Couple Therapy for Depression Competency Framework

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					Couple Therapy for Depression
Competency Framework



                                                       September 2010




1               IAPT Programme - Competency Framework for Interpersonal Psychotherapy (IPT)
Introduction
This document details the competences that staff delivering
Couple Therapy for Depression need to demonstrate to work
in IAPT services. The work to derive these competences was
commissioned by the Improving Access to Psychological
Therapies (IAPT) programme.

The updated NICE Guidelines for Depression (available at
www.nice.org.uk) indicate that these therapies can all be
effective treatments for depression, but not all therapies will
be effective for all patients. In November 2009, the IAPT
programme embraced this advice and committed to making
these therapies available in IAPT services.


The publication of the competency frameworks, for the
modalities additional to the previously published framework for
Cognitive Behavioural Therapy (CBT), is a key milestone for
the programme.

You can find out more about the Improving Access to
Psychological Therapies Programme and download all the
competency frameworks by visiting www.iapt.nhs.uk

While NICE recommends a range of interventions, based on a
wide-ranging evidence base, for the treatment of depression,
choice of therapy and treatment should be made at a local
level with the full involvement of the patient, supported by
good quality patient information.




2                                                             IAPT Programme - Competency Framework for Interpersonal Psychotherapy (IPT)
Couple Therapy for Depression

   Couple Therapy for Depression is a brief (20 session)                     seeing their relationship as constituting a third element that
   integrative treatment for depression for couples where there is           has the potential to supplement or diminish the resources of
   both relationship distress and depression in one or both                  each partner.      Therapists need to have the ability to
   partners. It has been developed by identifying best practice in           understand couple relationships as self-regulating systems
   a range of couple therapies as seen in random controlled                  while not losing sight of the individual impact on the system of
   effectiveness trials. Taken together these represent good                 each partner’s constitutional and characteristic profile
   clinical practice in the treatment of depression.                         (physical, psychological and relational). Therapists also need
                                                                             to have the ability to understand couple conflict as resulting
   Couple Therapy for Depression is specifically designed to                 from intrapsychic as well as interpersonal meanings, linking
   address presenting symptoms of depression and for delivery                individual perceptions and relationship ‘events’. In addressing
   within the context of the IAPT programme. It is an add-on skill           the complex strands of perspectives, actions and meanings
   to existing advanced competence in Couple Therapy.                        that constitute a couple’s experience, the therapist must be
   Couple therapy has a dual aim:                                            able to act in a manner that assures both partners that their
                                                                             position is recognised and respected, especially when that
       a)   to directly relieve the depressed feeling in the patient         position may be disagreed with.

       b)   to work on the precipitating and maintaining elements            Couple Therapy for Depression aims to improve the overall
            of the couple relationship that are known to have a              quality of a couple’s relationship as poor relationship quality is
            direct effect on the incidence of depression                     known to be a precipitating factor in depression.

   The model focuses on the relational aspects of depression
   and on factors that reduce stress and increase support within
   the couple. These are broken down into
         • Relieving stress and improving communication;
             Managing feelings and changing behaviour
         • Solving problems and promoting acceptance
         • Revising perceptions.

   The core of the model is the ability to implement couple
   therapy in a balanced manner that keeps the focus on the
   couple relationship without discounting the two individuals
   who comprise it. This is sometimes referred to as seeing the
   ‘couple as patient’, and requires a perspective that takes full
   account of how each partner acts on, and is acted on, by the
   other. By focusing on the interaction between partners, and by

   3                                                         IAPT Programme - Competency Frameworks for Non-CBT Therapies               Return to the
                                                                                                                                      Competency Map
Why identify competences?                                                applying their skills; to think not just about how to implement
                                                                         their skills, but also why they are implementing them.
The IAPT programme involves delivering high quality
treatments, and this requires competent practitioners who are            Beyond knowledge and skills, the therapist’s attitude and
able to offer effective interventions. Identifying individuals           stance to therapy are also critical – not just their attitude to the
with the right skills is important, but not straightforward.             relationship with the client, but also to the organisation in
                                                                         which therapy is offered, and the many cultural contexts within
Within the NHS, a wide range of professionals deliver                    which the organisation is located (which includes a
psychological therapies, but there is no single profession of            professional and ethical context, as well as a societal one). All
‘psychological therapist’. Most practitioners have a primary             of these need to be held in mind by the therapist, since all
professional qualification, but the extent of training in                have a bearing on the capacity to deliver a therapy that is
psychological therapy varies between professions, as does                ethical, conforms to professional standards, and which is
the extent to which individuals have acquired additional post-           appropriately adapted to the client’s needs and cultural
qualification training. This makes it important to take a                contexts.
different starting point, identifying what competences are
needed to deliver good-quality therapies, rather than simply
relying on job titles to indicate proficiency.

The development of the competences needs to be seen in the
context of the development of National Occupational
Standards (NOS), which apply to all staff working in health
and social care. There are a number of NOS that describe
standards relevant to mental health workers, downloadable at
the Skills for Health website (www.skillsforhealth.org.uk).

                    ----------------------------------
A competent clinician brings together knowledge, skills and
attitudes. It is this combination that defines competence;
without the ability to integrate these areas, practice is likely to
be poor.

Clinicians need background knowledge relevant to their
practice, but it is the ability to draw on and apply this
knowledge in clinical situations that marks out competence.
Knowledge helps the practitioner understand the rationale for

4                                                        IAPT Programme - Competency Frameworks for Non-CBT Therapies                Return to the
                                                                                                                                   Competency Map
Competency Map Explained

   The Competency Map                                                       Specific applications
   The competency map for each of the modalities organises the              Even within the same therapeutic approach there can be
   competences into a number of domains and shows the                       slightly different ways of assembling techniques into a
   different activities which, taken together, constitute each              ‘package’ of intervention. Where there is good research
   domain. Each activity is made up of a set of specific                    evidence that these different ‘packages’ are effective it makes
   competences. The maps show the ways in which the                         sense to describe them, so that clinicians know how these
   activities fit together and need to be ‘assembled’ in order for          specific intervention are delivered.
   practice to be proficient. The descriptions below give details of
   the competences associated with each of these activities.
                                                                            Metacompetences
   Generic Therapeutic Competences                                          Metacompetences are common to all therapies, and broadly
   Generic competences are employed in all psychological                    reflect the ability to implement an intervention in a manner
   therapies, reflecting the fact that all psychological therapies,         which is flexible and responsive. They are overarching,
   share some common features. For example, therapists using                higher-order competences which practitioners need to use to
   any accepted theoretical model would be expected to                      guide the implementation of therapy across all levels of the
   demonstrate an ability to build a trusting relationship with their       model.
   clients, relating to them in a manner that is warm, encouraging
   and accepting. They are often referred to as ‘common factors’.
                                                                            Competence Map Key:
                                                                             - The competences in each of the framework maps are colour coded
   Basic Competences
                                                                            under each of the headings above.
   Basic competences establish the structure for therapy and                 - The maps outline the competences under each heading and also group
   form the context and structure for the implementation of a               some key competences, that are fundamental components in
   range of more specific techniques. This domain contains a                demonstrating competence in that modality.
   range of activities that are basic in the sense of being
   fundamental areas of skill; they represent practices that
   underpin the modality.

   Specific Techniques
   These competences are the core technical interventions
   employed in the therapy. Not all of these would be employed
   for any one individual, and different technical emphases would
   be deployed for different problems.




   5                                                        IAPT Programme - Competency Frameworks for Non-CBT Therapies                   Return to the
                                                                                                                                         Competency Map
Couple Therapy for Depression (CTD)
              Generic therapeutic                  Basic couple therapy            Specific couple therapy       Specific adaptations of        Metacompetences
                competences                           competences                        techniques                couple therapy for

       Knowledge and understanding of            Knowledge/understanding          Ability to use techniques     Behavioural Couple         Generic metacompetences
       depression and mental health              of the basic principles of       that engage the couple
       problems
                                                                                                                Therapy
                                                 couple therapy
                                                                                                                                               Capacity to use clinical
                                                                                  Ability to use techniques                                    judgement when
       Knowledge of, and ability to operate      Knowledge of sexual                                            Marital Therapy for
                                                                                  that focus on relational                                     implementing therapy
       within, professional and ethical                                                                         Depression (MTD) Beach
                                                 functioning in couples           aspects of depression
       guidelines                                                                                               et al.., 1990.
                                                 Knowledge of depression          Ability to use techniques                                    Capacity to reflect critically
       Knowledge of a model of therapy,                                                                         Conjoint Marital               on the experience of
                                                 and the ways it manifests in     that reduce stress upon
       and the ability to understand and
                                                 couples                          and increase support within   Interpersonal                  therapy
       employ the model in practice,
       including the treatment of                                                 the couple, for example       Psychotherapy (IPT-CM )
       depression                                Knowledge and experience         through:                      Rounsaville et al, 1986.       Capacity to convey and
                                                 of working within a model                                                                     respond to interest, affect
       Ability to engage client                  of couple therapy                                              Coping Oriented Couple         and humour
                                                                                      improving                 Therapy (COCT)
                                                                                      communication             Bodenmann, G & Widmer,
       Ability to foster and maintain a good     Ability to assess the                                                                     Specific metacompetences
       therapeutic alliance, and to grasp        suitability of couple                                          K., 2008.
                                                                                      coping with stress
       the client’s perspective and ‘world       therapy for alleviating
       view’                                                                                                                                   Capacity to work reflexively
                                                 depression                           managing feelings
                                                                                                                                               with complex relational
       Ability to work with the emotional                                             changing behaviour                                       systems
                                                 Ability to identify and
       content of sessions                       manage risk
                                                                                      solving problems                                         Capacity to manage the
       Ability to manage endings                 Knowledge of and ability to                                                                   tension between competing
                                                                                      promoting acceptance
                                                 liaise with other services                                                                    duties of care
       Ability to undertake generic                                                   revising perceptions
       assessment (including relevant
       history and identifying suitability for   Ability to establish and                                                                      Capacity to work with
       intervention)                             convey the rationale for                                                                      difference and uncertainty
                                                 couple therapy
       Ability to assess and manage risk of                                                                                                    Capacity to apply different
       self-harm                                 Ability to initiate couple                                                                    levels of therapeutic
                                                 therapy                                                                                       response appropriately and
       Ability to work with difference                                                                                                         coherently
       (‘cultural competence’)                   Ability to maintain and
                                                 develop a therapeutic
       Ability to make use of supervision        process with couples

       Ability to use measures to guide          Ability to end couple
       therapy and monitor outcomes
                                                 therapy




   6                                                                            IAPT Programme - Competency Frameworks for Non-CBT Therapies                        Return to the
                                                                                                                                                                  Competency Map
Generic Competences

   Knowledge and understanding of depression and mental health                         •    An ability to draw on knowledge:
   problems                                                                                 • that a diagnosis of depression is based on the presence of a
     •    During assessment and when carrying out interventions, an ability                     subset of these symptoms
          to draw on knowledge of common mental health problems and                         • that of these symptoms, depressed mood; loss of interest or
          their presentation, particularly depression.                                          pleasure; and fatigue are central
       •   An ability to draw on knowledge of the factors associated with the               • that symptoms need to be present consistently over time (e.g.
           development and maintenance of mental health problems.                               DSM-IV-TR criteria specify two weeks, ICD-10 criteria specify
                                                                                                one month)
       •   An ability to draw on knowledge of the usual pattern of symptoms
           associated with mental health problems.                                     •    An ability to draw on knowledge of the diagnostic criteria for all
       •   An ability to draw on knowledge of the ways in which mental                      mood disorders (including minor depression/dysthmic disorder and
           health problems can impact on functioning (eg maintaining                        bipolar disorder) and to be able to distinguish between these
           intimate, family and social relationships, or the capacity to                    presentations
           maintain employment and study).
       •   An ability to draw on knowledge of the impact of impairments in             •    An ability to draw on knowledge of the incidence and prevalence
           functioning on mental health.                                                    of depression, and the conditions that are commonly comorbid
                                                                                            with depression
       •   An ability to draw on knowledge of mental health problems to
           avoid escalating or compounding the client’s condition when their
           behaviour leads to interpersonal difficulties which are directly            •    An ability to draw on knowledge of the patterns of remission and
           attributable to their mental health problem.                                     relapse/ recurrence associated with depression

                                                                                       •    An ability to draw on knowledge of factors which are associated
   Knowledge of depression                                                                  with an increased vulnerability to depression e.g.:
       •   An ability to draw on knowledge of the cluster of symptoms                       •   developmental risk factors (e.g. temperament)
           associated with a diagnosis of depression:                                       •   quality of early experience with parents or significant others
                                                                                            •   quality of relationships with partner, family and significant
               •   depressed mood most of the day                                               others
               •   marked loss of interest or pleasure in daily activities                  •   quality of current social relationships
               •   sleep problems                                                           •   social isolation
               •   loss of appetite and significant loss of weight                          •   major adverse life-events (e.g. childhood abuse or neglect,
               •   fatigue/exhaustion                                                           financial loss, unemployment, separation from a partner,
               •   difficulties getting to sleep or excessive sleep                             bereavement, retirement)
               •   psychomotor agitation (feeling restless or agitated) or                  •   major life-transitions (e.g. becoming a parent)
                   psychomotor retardation (feeling slowed down)                            •   acute and chronic physical illness (both in the client and in
               •   feelings of worthlessness or excessive guilt                                 significant others)
               •   low self-confidence
               •   difficulties in thinking/ concentrating and/or indecisiveness
               •   recurrent thoughts of death, suicidal ideation, suicidal
                   intent (with or without a specific plan)


   7                                                                 IAPT Programme - Competency Frameworks for Non-CBT Therapies                     Return to the
                                                                                                                                                    Competency Map
    •     An ability to draw on knowledge of the impact of depressive                         • recognition of the limits of competence and taking action to
          symptoms on the client’s functioning (e.g. in interpersonal and                       enhance practice through appropriate training/professional
          work domains), and the fact that difficulties in functioning can (in                  development
          turn) contribute to depressive symptoms                                             • protecting clients from actual or potential harm from
                                                                                                professional malpractice by colleagues by instituting action in
    •     An ability to draw on knowledge of the evidence for the                               accordance with national and professional guidance
          effectiveness of psychological and psychopharmacological
          interventions for depression, and their effectiveness in                            • maintaining appropriate standards of personal conduct for
          combination                                                                           self:
                                                                                                    a) a capacity to recognise any potential problems in
    •     An ability to draw on knowledge of the ways in which depression is                        relation to power and ‘dual relationships’ with clients, and
          conceptualised within the model of therapy being adopted                                  to desist absolutely from any abuses in these areas
                                                                                                    b) recognising when personal impairment could influence
Knowledge of, and ability to operate within, professional and ethical                               fitness to practice, and taking appropriate action (e.g.
guidelines                                                                                          seeking personal and professional support and/or
Knowledge of guidelines                                                                             desisting from practice)
    •     An ability to maintain awareness of national and local codes of
          practice which apply to all staff involved in the delivery of             Knowledge of a model of therapy, and the ability to understand and
          healthcare, as well as any codes of practice which apply to the           employ the model in practice, including the treatment of depression
          counsellor as a member of a specific profession.
                                                                                      •    An ability to draw on knowledge of factors common to all
    •     An ability to take responsibility for maintaining awareness of                   therapeutic approaches:
          legislation relevant to areas of professional practice in which the
          counsellor is engaged (specifically including the Mental Health                 •    supportive factors:
          Act, Mental Capacity Act, Human Rights Act, Data Protection Act).
                                                                                               o   a positive working relationship between counsellor and
Application of professional and ethical guidelines                                                 client characterised by warmth, respect, acceptance and
                                                                                                   empathy, and trust
        • An ability to draw on knowledge of relevant codes of professional
                                                                                               o   the active participation of the client
          and ethical conduct and practice in order to apply the general
          principles embodied in these codes to each piece of work being                       o   counsellor expertise
          undertaken, in the areas of:                                                         o   opportunities for the client to discuss matters of concern
            • obtaining informed consent for interventions from clients                            and to express their feelings
            • maintaining confidentiality, and knowing the conditions under
              which confidentiality can be breached
            • safeguarding the client’s interests when co-working with other
              professionals as part of a team, including good practice
              regarding inter-worker/ inter-professional communication
            • competence to practice, and maintaining competent practice
              through appropriate training/professional development

8                                                                   IAPT Programme - Competency Frameworks for Non-CBT Therapies                         Return to the
                                                                                                                                                       Competency Map
    •   learning factors:                                                      Ability to engage client
        o   advice
        o   correctional emotional experience                                    •    While maintaining professional boundaries, an ability to show
        o   feedback                                                                  appropriate levels of warmth, concern, confidence and
                                                                                      genuineness, matched to client need.
        o   exploration of internal frame of reference
                                                                                 •    An ability to engender trust.
        o   changing expectations of personal effectiveness
                                                                                 •    An ability to develop rapport.
        o assimilation of problematic experiences
                                                                                 •    An ability to adapt personal style so that it meshes with that of the
    •   action factors:                                                               client.
        o   behavioural regulation                                               •    An ability to recognise the importance of discussion and
                                                                                      expression of client’s emotional reactions.
        o   cognitive mastery
                                                                                 •    An ability to adjust the level of in-session activity and structuring of
        o   encouragement to face fears and to take risks
                                                                                      the session to the client’s needs.
        o   reality testing
                                                                                 •    An ability to convey an appropriate level of confidence and
        o   experience of successful coping                                           competence.
                                                                                 •    An ability to avoid negative interpersonal behaviours (such as
    •   An ability to draw on knowledge of the principles which                       impatience, aloofness, or insincerity).
        underlie the intervention being applied, using this to inform the
        application of the specific techniques which characterise the
        model.                                                                 Ability to foster and maintain a good therapeutic alliance, and to
                                                                               grasp the client’s perspective and world view’
    •   An ability to draw on knowledge of the principles of the
        intervention model in order to implement therapy in a manner
                                                                               Understanding the concept of the therapeutic alliance
        which is flexible and responsive to client need, but which also
        ensures that all relevant components are included.                       •    An ability to draw on knowledge that the therapeutic alliance is
                                                                                      usually seen as having three components:
                                                                                      •   the relationship or bond between counsellor and client
                                                                                      •   consensus between counsellor and client regarding the
                                                                                          techniques/methods employed in the therapy
                                                                                      •   consensus between counsellor and client regarding the goals
                                                                                          of therapy


                                                                                 •    An ability to draw on knowledge that all three components
                                                                                      contribute to the maintenance of the alliance.




9                                                              IAPT Programme - Competency Frameworks for Non-CBT Therapies                          Return to the
                                                                                                                                                   Competency Map
                                                                              Capacity to develop the alliance
Knowledge of counsellor factors associated with the alliance                    •    An ability to listen to the client’s concerns in a manner which is
                                                                                     non-judgmental, supportive and sensitive, and which conveys a
     •   An ability to draw on knowledge of counsellor factors which                 comfortable attitude when the client describes their experience.
         increase the probability of forming a positive alliance:
                                                                                •    An ability to ensure that the client is clear about the rationale for
         •   being flexible and allowing the client to discuss issues                the intervention being offered.
             which are important to them
                                                                                •    An ability to gauge whether the client understands the rationale for
         •   being respectful
                                                                                     the intervention, has questions about it, or is skeptical about the
         •   being warm, friendly and affirming                                      rationale, and to respond to these concerns openly and non-
         •   being open                                                              defensively in order to resolve any ambiguities.

         •   being alert and active                                             •    An ability to help the client express any concerns or doubts they
                                                                                     have about the therapy and/or the counsellor, especially where
         •   being able to show honesty through self-reflection                      this relates to mistrust or skepticism.
         •   being trustworthy                                                  •    An ability to help the client articulate their goals for the therapy,
                                                                                     and to gauge the degree of congruence in the aims of the client
     •   Knowledge of counsellor factors which reduce the probability of             and counsellor.
         forming a positive alliance:
         •   being rigid                                                      Capacity to grasp the client’s perspective and ‘world view’
         •   being critical                                                     •    An ability to apprehend the ways in which the client
         •   making inappropriate self-disclosure                                    characteristically understands themselves and the world around
                                                                                     them.
         •   being distant
                                                                                •    An ability to hold the client’s world view in mind throughout the
         •   being aloof                                                             course of therapy and to convey this understanding through
         •   being distracted                                                        interactions with the client, in a manner that allows the client to
                                                                                     correct any misapprehensions.
         •   making inappropriate use of silence
                                                                                •    An ability to hold the client’s world view in mind, while retaining an
                                                                                     independent perspective and guarding against identification with
                                                                                     the client




10                                                            IAPT Programme - Competency Frameworks for Non-CBT Therapies                           Return to the
                                                                                                                                                   Competency Map
                                                                                       Ability to work with emotional content of session
Capacity to maintain the alliance                                                        •    An ability to facilitate the processing of emotions by the client – to
                                                                                              acknowledge and contain emotional levels that are too high (eg
     •   An ability to recognise when strains in the alliance threaten the                    anger, fear, despair) and contact emotions when levels are too low
         progress of therapy.                                                                 (eg apathy, low motivation).
     •   An ability to deploy appropriate interventions in response to                   •    An ability to work effectively with emotional issues that interfere
         disagreements about tasks and goals:                                                 with effective change (e.g. hostility, anxiety, excessive anger,
                                                                                              avoidance of strong affect).
         •   an ability to check that the client is clear about the rationale for
             treatment and to review this with them and/or clarify any                   •    An ability to help the client access differentiate and experience
             misunderstandings.                                                               his/her emotions in a way that facilitates change.
         •   an ability to help clients understand the rationale for treatment
             through using/drawing attention to concrete examples in the               Ability to manage endings
             session.
                                                                                         •    An ability to signal the ending of the intervention at appropriate
         •   an ability to judge when it is best to refocus on tasks and goals                points during the therapy (e.g. when agreeing the treatment
             which are seen as relevant or manageable by the client (rather                   contract, and especially as the intervention draws to close) in a
             than explore factors which are giving rise to disagreement                       way which acknowledges the potential importance of this transition
             over these factors).                                                             for the client.
                                                                                         •    An ability to help client discuss their feelings and thoughts about
     •   An ability to deploy appropriate interventions in response to strains                endings and any anxieties about managing alone.
         in the bond between counsellor and client:
                                                                                         •    An ability to review the work undertaken together.
             •    an ability for the counsellor to give and ask for feedback
                                                                                         •    An ability to say goodbye.
                  about what is happening in the here-and-now interaction,
                  in a manner which invites exploration with the client.
             •    an ability for the counsellor to acknowledge and accept              Ability to undertake a generic assessment (including relevant history
                  their responsibility for their contribution to any strains in        and identifying suitability for intervention)
                  the alliance.
             •    where the client recognises and acknowledges that the                  •    An ability to obtain a general idea of the nature of the client’s
                  alliance is under strain, an ability to help the client make                problem.
                  links between the rupture and their usual style of relating            •    An ability to elicit information regarding psychological problems,
                  to others.                                                                  diagnosis, past history, present life situation, attitude about and
             •    an ability to allow the client to assert any negative                       motivation for therapy.
                  feelings about the relationship between the counsellor                 •    An ability to gain an overview of the client’s current life situation,
                  and themselves.                                                             specific stressors and social support.
             •    an ability to help the client explore any fears they have              •    An ability to assess the client’s coping mechanisms, stress
                  about expressing negative feelings about the relationship                   tolerance, and level of functioning.
                  between the counsellor and themselves.



11                                                                     IAPT Programme - Competency Frameworks for Non-CBT Therapies                           Return to the
                                                                                                                                                            Competency Map
     •       An ability to help the client identify/select target symptoms or                           o    even where accurate systems of prediction are
             problems, and to identify which are the most distressing and which                              employed these will incorrectly identify a substantial
             the most amenable to intervention.                                                              number of individuals as possible suicides
         •      An ability to help the client translate vague/ abstract complaints                •   that because most risk factors relate to long-term risk they
                into more concrete and discrete problems.                                             are less helpful in prediction in the short-term or immediate
                                                                                                      clinical situation
         •      An ability to assess and act on indicators of risk (of harm to self
                or others and the ability to know when to seek advice from                    •   An ability to draw on knowledge that individuals with a history of
                others).                                                                          prior suicide have a markedly elevated risk of self-harm
         •      An ability to gauge the extent to which the client can think
                about themselves psychologically (e.g. their capacity to reflect              •   An ability to draw on knowledge of factors associated with an
                on their circumstances or to be reasonably objective about                        elevated risk of self-harm that apply across the population:
                themselves).                                                                      • childhood adversity
         •      An ability to gauge the client’s motivation for a psychological                   • experience of a number of adverse life-events (including
                intervention.                                                                         sexual abuse)
         •      An ability to discuss treatment options with the client, making                   • a family history of suicide
                sure that they are aware of the options available to them, and                    • a history of self-harm
                helping them consider which of these options they wish to                         • seriousness of previous episodes of self-harm
                follow.
                                                                                                  • previous hospitalisation
         •      An ability to identify when psychological treatment might not be
                                                                                                  • mood disorders
                appropriate or the best option, and to discuss with the client
                                                                                                  • substance use disorder
                (e.g. the client’s difficulties are not primarily psychological, or
                the client indicates that they do not wish to consider                            • a diagnosis of personality disorder
                psychological issues) or where the client indicates a clear                       • anxiety disorder (particularly PTSD)
                preference for an alternative approach to their problems (e.g. a                  • a psychotic disorder (e.g. a diagnosis of schizophrenia or
                clear preference for medication rather than psychological                             bipolar disorder)
                therapy).                                                                         • presence of chronic physical disorders
                                                                                                  • bereavement or impending loss (where psychological
Ability to assess and manage risk of self-harm                                                        problems preceded the bereavement)
                                                                                                  • relationship problems and relationship breakdown
         •   An ability to draw on knowledge of indicators of self–harm, and to                   • severe lack of social support
             integrate research/actuarial evidence) with a structured clinical                    • socio-economic factors e.g.
             assessment and the exercise of professional judgment in                                   o      people who are disadvantaged in socio-economic
             appraising risk                                                                                  terms
                                                                                                       o      people who are single or divorced
         •   An ability to draw on knowledge of the limitations of using risk                          o      people who are living alone
             factors to predict self-harm:                                                             o      people who are single parents
              • that risk factors identify high risk groups rather than
                  individuals
              • that because suicide is a relatively rare event it is difficult to
                  predict at the level of the individual:


12                                                                       IAPT Programme - Competency Frameworks for Non-CBT Therapies                        Return to the
                                                                                                                                                           Competency Map
     •   An ability to draw on knowledge that individuals with depression             •    An ability to draw on knowledge that the risk of suicide is elevated
         have a significantly elevated lifetime risk of suicide                            if the following factors are present, and the person:
                                                                                            • has a history of previous attempts
     •   An ability to draw on knowledge that the risk of suicide is highest                • used a violent method in their attempt
         relatively early in a depressive episode, and less likely during                   • left a suicide note
         periods of remission                                                               • is older (45 and over)
                                                                                            • is male
     •   An ability to draw on knowledge that hopelessness (negative                        • is living alone
         expectations of the future) may be a more important marker of                      • is separated, widowed or divorced
         risk than the severity of depression                                               • is unemployed
                                                                                            • is in poor physical health
     •   An ability to draw on knowledge that the combination of
         depression, hopelessness and continuing suicidal intent                      •    An ability to undertake an assessment which aims
         represents a marker of elevated risk
                                                                                           • to understand the social, psychological and motivational
                                                                                               factors specific to the act of self-harm
     •   An ability to assess the client’s strengths and resources by
                                                                                           • to assess the degree of suicidal intent:
         asking them about:
                                                                                           • to assess current suicidal intent and hopelessness
         • external resources (e.g. relationship with care services, self
                                                                                           • to assess current mental health and social needs
             help groups, local associations)
         • supportive relationships (e.g. a partner or close friend who
                                                                                      •    An ability to convey a nonjudgmental and tolerant attitude when
             they trust and can confide in)
                                                                                           discussing self-harm with the client
         • personal resources (e.g. ability to suggest ways of managing
             their present difficulties)
                                                                                      •    An ability, where required, to ask direct questions to clarify an
         • previous patterns of coping (i.e. how they coped with
                                                                                           understanding of the attempt, and the extent of suicidal intent
             potentially stressful events in the past)
                                                                                      •    An ability to work with the client to develop a detailed sequential
Assessing risk in individuals who have self-harmed
                                                                                           account of the period leading up to self-harm, in order to identify
                                                                                           the events which precipitated it
     •   An ability to draw on knowledge that the risk of suicide is
         particularly elevated in the three months following attempted
         suicide, and that this risk remains elevated in the longer-term.




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                                                                                                                                                      Competency Map
     •   An ability to work with the client in order to assess the degree of           •    An ability to identify and manage ethical issues in relation to risk
         suicidal intent e.g.:                                                              management e.g.:
          • whether the event was impulsive or planned
          • whether the client was alone, whether someone was present                       •    the management of actively suicidal clients who refuse
              or within easy access, whether the client was likely to be                         intervention
              found soon after the attempt                                                  •    decisions regarding the involvement of relatives
          • whether any steps were taken either to prevent or to ensure
              discovery                                                                •    An ability to ensure that (so far as is possible) the client is
          • if alcohol or drugs were taken prior to or during the attempt,                  involved in decisions regarding any actions to be taken to
              and the intent and/or impact of taking these substances on                    manage risk
              the attempt
          • client’s expectations regarding the lethality of the drugs or              •    An ability to draw up an appropriate plan of action which specifies
              injury                                                                        the ways in which risk will be managed, and is tailored to the
          • presence of a suicide note (including recorded and text                         needs of the individual
              messages)
          • the client’s efforts to obtain help after the event                        •    Where there is a clear risk of repetition, an ability to draw up a
                                                                                            plan which is maintained over an extended period (e.g. 3 months)
     •   An ability to ask about previous acts of self harm (including the                  and which includes:
          circumstances and the level of intent)
                                                                                            •    frequent access to a therapist when needed
Use of standardised scales to assess risk of self-harm                                      •    home treatment when necessary
   •    An ability to draw on knowledge that if a standardised risk                         •    telephone contact
        assessment scale is used to assess risk, this should be used only                   •    outreach (which include active follow-up when appointments
        to aid in the identification of people at high risk of repetition of                     are missed)
        self-harm or suicide

     •   An ability to administer and interpret standardised measures for              •    An ability to liaise with and refer to any relevant colleagues and
         assessing suicidality and hopelessness (e.g. Suicide Intent Scale,                 services who need to be involved in delivering the plan of action,
         Suicide Assessment Checklist, Beck Hopelessness Scale (etc))                       or who need to be aware of its content

Management of risk of self-harm                                                        •    Where plans for the management of risk are compatible with the
                                                                                            maintenance of the therapeutic contract, an ability to integrate the
     •   An ability to draw on knowledge of local and national protocols                    management of risk with the current intervention
         (e.g. NICE 2004) for the management of self-harm, and an ability                   • an ability to make appropriate modifications to a treatment
         to ensure that actions taken comply with these protocols                               contract in order to ensure that it includes elements focus on
                                                                                                the management of risk (e.g. a problem-solving orientation
     •   An ability to draw on knowledge of relevant legislation (e.g.                          focused on identifying potential crises and the strategies for
         Mental Health Act, Mental Capacity Act) when considering                               avoiding or resolving these)
         admission of a client who is considered to represent a significant
         risk to themselves (but is not willing to receive treatment)


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                                                                                                                                                         Competency Map
         •   An ability to seek supervision and/or consult with colleagues in                  this potential for disadvantage that makes it important to focus on
             relation to decisions regarding risk-management                                   this area
                                                                                         •     An ability to draw on knowledge that clients will often be a
Ability to maintain a record of assessments and plans for managing                             member of more than one “group” (for example, a gay man with
risk                                                                                           disabilities, or an older adult from a minority ethnic community),
                                                                                               and that as such, the implications of different combinations of
                                                                                               difference needs to be held in mind by therapists
         •   An ability to maintain a clear and detailed record of any
             assessments and of decisions regarding plans for managing risk,             •     An ability to maintain an awareness of the potential significance
             in line with local protocols for recording clinical information                   for practice of social and cultural difference across a range of
         •   An ability to communicate (verbally and in writing) with relevant                 domains, but including:
             clinicians and services in order ensure that all individuals or                     • ethnicity
             services involved in the management of risk are appropriately                       • culture
             informed                                                                            • class
              • an ability to draw on knowledge of the conditions under                          • religion
                   which confidentiality can be breached in support of the                       • gender
                   management of risk, and the national and profession-specific                  • age
                   guidance which addresses this issue                                           • disability
                                                                                                 • sexual orientation
Ability to work with difference (cultural competence)
                                                                                         •     For all clients with whom the therapist works, an ability to draw
Although it is common (and appropriate) to think about ‘difference’ in                         on knowledge of the relevance and potential impact of social and
relation to specific demographic groups, this may be a somewhat narrow                         cultural difference on the effectiveness and acceptability of an
perspective. There are many ways in which both therapists and their                            intervention
clients could be ‘different’, partly because some areas of difference will not
be immediately apparent, and also because it is the individual’s sense of
                                                                                         •     Where clients from a specific minority culture or group are
their difference that is important. On this basis almost any therapeutic
                                                                                               regularly seen within a service, an ability to draw on knowledge
encounter requires the therapist to consider the issue of difference.
                                                                                               of that culture or area of difference
In what follows the term ‘culture’ is sometimes used generically, so (for
                                                                                         •     An ability to draw on knowledge of cultural issues which
example) referring to an intervention as ‘culturally sensitive’ means that
                                                                                               commonly restrict or reduce access to interventions e.g.:
the intervention is responsive to the demographic group to which it is
applied.                                                                                        • language
                                                                                                • marginalisation
                                                                                                • mistrust of statutory services
     •       An ability to draw on knowledge that the term ‘difference’ refers to               • lack of knowledge about how to access services
             the individualised impact of background, lifestyle, beliefs or                     • different cultural concepts, understanding and attitudes
             religious practices                                                                   about mental health which affect views about help-seeking,
     •       An ability to draw on knowledge that the demographic groups                           treatment and care
             included in discussion of ‘difference’ are usually those who are                   • stigma, shame and/or fear associated with mental health
             potentially subject to disadvantage and/or discrimination, and it is                  problems (which makes it likely that help-seeking is delayed
                                                                                                   until/unless problems become more severe

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                                                                                                                                                        Competency Map
          •   stigma or shame and/or fear associated with being                      •     An ability to discuss with the client the ways in which individual
              diagnosed with a mental health disorder                                      and family relationships are represented in their culture (e.g.
          •   preferences for gaining support via community contacts/                      notions of the self, models of individuality and personal or
              contexts rather than through ‘conventional’ referral routes                  collective responsibility), and to consider the implications for
              (such as the GP)                                                             organisation and delivery of therapy

     •   An ability for therapists of all cultural backgrounds to draw on an         •     An ability to ensure that standardised assessments/ measures
         awareness of their own group membership and values and how                        are employed and interpreted in a manner which is culturally-
         these may influence their perceptions of the client, the client's                 sensitive e.g.:
         problem, and the therapy relationship                                              • if the measure is not available in the client’s first language,
                                                                                                an ability to take into account the implications of this when
     •   An ability to take an active interest in the cultural background of                    interpreting results
         clients, and hence to demonstrate a willingness to learn about                     • if a bespoke translation is attempted, an ability to cross-
         the client’s cultural perspective(s) and world view                                    check the translation to ensure that the meaning is not
                                                                                                inadvertently changed
     •   An ability to work collaboratively with the client in order to                     • if standardisation data (norms) is not available for the
         develop an understanding of their culture and world view, and                          demographic group of which the client is a member, an
         the implications of any culturally-specific customs or                                 ability explicitly to reflect this issue in the interpretation of
         expectations, for:                                                                     results
           • the therapeutic relationship
           • the ways in which problems are described and presented                  •     An ability to draw on knowledge of the conceptual and empirical
               by the client                                                               research-base which informs thinking about the impact of cultural
                         o an ability to apply this knowledge in order to                  competence on the efficacy of psychological interventions
                             identify and formulate problems, and
                             intervene in a manner that is culturally                •     Where there is evidence that social and cultural difference is
                             sensitive, culturally consistent and relevant                 likely to impact on the accessibility of an intervention, an ability to
                         o an ability to apply this knowledge in a manner                  make appropriate adjustments to the therapy and/or the manner
                             that is sensitive to the ways in which                        in which therapy is delivered, with the aim of maximising its
                             individual clients interpret their own culture                potential benefit to the client
                             (and hence recognises the risk of culture-              •     An ability to draw on knowledge that culturally-adapted
                             related stereotyping)                                         treatments should be judiciously applied, and are warranted:
                                                                                             • if evidence exists that a particular clinical problem
     •   An ability to take an active and explicit interest in the client’s                       encountered by a client is influenced by membership of a
         experience of difference:                                                                given community
          • to help the client to discuss and reflect on their experience                    • if there is evidence that clients from a given community
              of difference                                                                       respond poorly to certain evidence-based approaches
          • to identify whether and how this experience has shaped the
              development and maintenance of the client’s presenting
              problems




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                                                                                                                                                       Competency Map
                                                                                               •       An ability to use feedback from the supervisor in order further to
         •        Where the therapist does not share the same language as                              develop the capacity for accurate self-appraisal.
                  clients, an ability to identify appropriate strategies to ensure and
                  enable the client’s full participation in the therapy
                   • where an interpreter/advocate is employed, an ability to                Capacity for active learning
                        draw on knowledge of the strategies which need to be in                •       An ability to act on suggestions regarding relevant reading made
                        place for an interpreter/advocate to work effectively and in                   by the supervisor, and to incorporate this material into clinical
                        the interests of the client                                                    practice.
                                                                                               •       An ability to take the initiative in relation to learning, by identifying
Ability to make use of supervision
                                                                                                       relevant papers, or books, based on (but independent of)
                                                                                                       supervisor suggestions, and to incorporate this material into
             •      An ability to hold in mind that a primary purpose of supervision                   clinical practice.
                    and learning is to enhance the quality of the treatment clients
                    receive.
                                                                                             Capacity to use supervision to reflect on developing personal and
An ability to work collaboratively with the supervisor                                       professional role
    •       An ability to work with the supervisor in order to generate an
                                                                                               •       An ability to use supervision to discuss the personal impact of the
            explicit agreement about the parameters of supervision (e.g.
                                                                                                       work, especially where this reflection is relevant to maintaining the
            setting an agenda, being clear about the respective roles of                               likely effectiveness of clinical work.
            supervisor and supervisee, the goals of supervision and any
            contracts which specify these factors).                                            •       An ability to use supervision to reflect on the impact of clinical
                                                                                                       work in relation to professional development.
             •      An ability to help the supervisor be aware of your current state
                    of competence and your training needs.
             •      An ability to present an honest and open account of clinical             Capacity to reflect on supervision quality
                    work undertaken.                                                               •      An ability to reflect on the quality of supervision as a whole,
     •           An ability to discuss clinical work with the supervisor as an active                     and (in accordance with national and professional guidelines)
                 and engaged participant, without becoming passive or avoidant, or                        to seek advice from others where:
                 defensive or aggressive.                                                                  •    there is concern that supervision is below an acceptable
     •           An ability to present clinical material to the supervisor in a                                 standard
                 focussed manner, selecting the most important and relevant                                •    where the supervisor’s recommendations deviate from
                 material.                                                                                      acceptable practice
                                                                                                           •    where the supervisor’s actions breach national and
Capacity for self-appraisal and reflection                                                                      professional guidance (e.g. abuses of power and/or
     •           An ability to reflect on the supervisor’s feedback and to apply                                attempts to create dual (sexual) relationships)
                 these reflections in future work.
     •           An ability to be open and realistic about your capabilities and to
                 share this self-appraisal with the supervisor.
                                                                                             Ability to use measures to guide therapy and to monitor outcomes


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                                                                                                                                                                      Competency Map
                                                                                                 measured) and reliable (i.e. reasonably consistent with how
Knowledge of measures                                                                            things actually are)

     •   An ability to draw on knowledge of commonly used                               Ability to integrate measures into the intervention
         questionnaires and rating scales used with people with
         depression                                                                         •    An ability to use and to interpret relevant measures at appropriate
                                                                                                 and regular points throughout the intervention, with the aim of
Ability to interpret measures                                                                    establishing both a baseline and indications of progress

     •   An ability to draw on knowledge regarding the interpretation of                    •    An ability to share information gleaned from measures with the
         measures (e.g. basic principles of test construction, norms and                         client, with the aim of giving them feedback about progress
         clinical cut-offs, reliability, validity, factors which could influence
         (and potentially invalidate) test results)                                         •    An ability to establish an appropriate schedule for the
                                                                                                 administration of measures, avoiding over-testing, but also aiming
     •   An ability to be aware of the ways in which the reactivity of                           to collect data at more than one timepoint
         measures and self-monitoring procedures can bias client report
                                                                                        Ability to help clients use self-monitoring procedures
Knowledge of self-monitoring
                                                                                            •    An ability to construct individualised self-monitoring forms, or to
     •   An ability to draw on knowledge of self-monitoring forms                                adapt ‘standard’ self-monitoring forms, in order to ensure that
         developed for use in specific interventions (as published in                            monitoring is relevant to the client
         articles, textbooks and manuals)
                                                                                            •    An ability to work with the client to ensure that measures of the
     •   An ability to draw on knowledge of the potential advantages of                          targeted problem are meaningful to the client (i.e. are chosen to
         using self-monitoring                                                                   reflect the client’s perceptions of the problem or issue)
           • to gain a more accurate concurrent description of the
               client’s state of mind (rather than relying on recall)                       •    An ability to ensure that self-monitoring includes targets which are
           • to help adapt the intervention in relation to client progress                       clearly defined and detailed, in order that they can be
           • to provide the client with feedback about their progress                            monitored/recorded reliably

     •   An ability to draw on knowledge of the potential role of self-                     •    An ability to ensure that the client understands how to use self-
         monitoring:                                                                             monitoring forms (usually by going through a worked example
          • as a means of helping the client to become an active,                                during the session)
              collaborative participant in their own therapy by identifying
              and appraising how they react to events (in terms of their                Ability to integrate self-monitoring into the intervention
              own reactions, behaviours, feelings and cognitions))                           • An ability to ensure that self-monitoring is integrated into the
                                                                                                 therapy, ensuring that sessions include the opportunity for regular
     •   An ability to draw on knowledge of measurement to ensure that                           and consistent review of self-monitoring forms
         procedures for self-monitoring are relevant (i.e. related to the
         question being asked), valid (measuring what is intended to be                     •    An ability to guide and to adapt the therapy in the light of
                                                                                                 information from self-monitoring


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                                                                                                                                                            Competency Map
Basic Competences

   Knowledge and understanding of the basic principles of couple                                    including their capacity to adapt and change over time.
   therapy
                                                                                           •   An ability to draw on knowledge to understand developmental
        •   An ability to draw on knowledge and experience to establish and                    factors that contribute to shaping the dynamics of couple
            maintain a balanced position in relation to the couple, in order to:               relationships, for example:
             • focus attention on their relationship, rather than either                         • the effects of family of origin, childhood and earlier
                 partner, as the means of achieving change;                                          partnership experiences on each partner’s assumptions
             • provide a framework for understanding and managing                                    about and expectations of their relationship;
                 presenting concerns.                                                            • the restructuring of couple and family relationships
                                                                                                     occasioned by predictable life events such as the birth of a
        •   An ability to draw on knowledge to understand the nature of the                          child;
            commitment that underpins a couple’s relationship and                                • the restructuring of couple and family relationships
            contributes to shaping its dynamics, including:                                          occasioned by unpredictable life events such as
             • the feelings the partners may have for each other, their                              unemployment, illness, or bereavement;
                  understanding of why they chose each other, and their                          • the potential for past relationship conflicts, and ongoing
                  sense of being (or not being) a couple;                                            commitments resulting from them (such as parenting or
             • the conscious and unconscious expectations, assumptions,                              financial responsibilities), to affect the process of re-forming
                  beliefs and standards they may share (or differ about) with                        family life with a new partner.
                  regard to their relationship;
             • the role of external factors (such as religious affiliation,                •   An ability to draw on knowledge to understand contextual factors
                  ethnicity and other social grouping) on their choice of                      that contribute to shaping the dynamics of couple relationships,
                  partner and support for their partnership.                                   for example:
                                                                                               • the influence of culture and ethnicity on each partner’s
        •   An ability to draw on knowledge to understand interpersonal                             assumptions about and expectations of their relationship;
            factors that contribute to shaping the dynamics of couple                          • the potential for social constructions of gender to shape
            relationships, for example, the effects of:                                             assumptions about roles and responsibilities in the couple;
              • potentially different understandings and levels of awareness                   • the effects of socio-economic factors such as employment,
                  between partners about their roles, responsibilities and                          relocation, and redundancy on couple and family
                  expected behaviour;                                                               relationships.
              • the degree of fit or misfit within the couple over such matters
                  as what constitutes a comfortable distance in their                  Knowledge of sexual functioning in couples
                  relationship, or how feelings are managed;
              • the degree of fit or misfit within the couple over the values,             •   An ability to draw on knowledge of factors that may influence
                  beliefs and meanings each partner brings to interpreting                     sexual functioning, for example:
                  events occurring inside and outside their relationship;                      • physiological factors such as hormone levels, medication,
              • the degree to which each partner is aware of and                                  addictive substances, debilitating illness and ageing;
                  responsive to the other’s feelings, intentions and states of                 • psychological factors, such as:
                  mind, especially in stressful situations;                                        • major current life stressors;
              • their communication skills, including their capacity to give,                      • past experiences of sexual inhibition or trauma (for
                  ask for and accept support from each other;                                           example, prohibitive sexual attitudes, ignorance, abuse);
              • the rigidity or flexibility with which partners interact together,             • current relationship difficulties.


   19                                                                  IAPT Programme - Competency Frameworks for Non-CBT Therapies                          Return to the
                                                                                                                                                           Competency Map
                                                                                                and vulnerability to abuse.
     •    An ability to draw on knowledge of the main sexual dysfunctions
          in women and men and available psychosexual, pharmacological              Knowledge and experience of working within a model of couple
          and mechanical/surgical treatment options for:                            therapy
     erectile and ejaculatory/anorgasmic difficulties in men;
     vaginismus, dysparaneuia and anorgasmia in women;                                  •   An ability to draw on knowledge and experience to be able to
     reduced sexual drive and desire in women and men.                                      work within a recognised model of couple therapy that is based
                                                                                            on:
Knowledge of depression and the ways it manifests in couple                                 • a coherent conceptual framework for understanding couple
relationships                                                                                   relationships;
                                                                                            • an externally validated programme of couple therapy training
     •   An ability to draw on knowledge about the clinical manifestations                      and supervised practice;
         of depression, including:                                                          • evidence of efficacy.
         • biological symptoms of depression, such as loss of sleep,
             appetite, weight and sex drive;                                        Ability to assess the suitability of couple therapy for alleviating
         • psychological symptoms of depression, such as poor                       depression.
             concentration, sadness, low self esteem, guilt, reduced
             coping capacities and suicidal thoughts.                                   •   An ability to create an environment that facilitates exploring the
                                                                                            couple’s relationship, for example by:
     •   An ability to draw on knowledge about non-organic factors that                     • providing a protected time and predictable setting for
         might predispose towards, precipitate and maintain depression,                        meetings with both partners;
         including the effects of:                                                          • conveying impartiality towards the partners and in relation to
         • support, or lack of it, from partner, family and friends;                           outcomes;
         • the interaction between partners on symptomatic roles (for                       • conveying interest in each partner, both as individuals and as
             example, a partner’s response to the depressed partner’s lack                     part of a couple;
             of assertiveness, interest and competence, and the impact of                   • exploring each partner’s definitions of and perspectives on the
             that response on the depressed partner);                                          presenting problem in an even-handed way;
         • developmental factors, including a history of insecure                           • demonstrating sensitivity towards the fear that the therapist
             attachment, loss or abuse;                                                        may favour one or other partner because of gender, race or
         • life events, such as the birth of a baby (in potentially triggering                 other differentiating factors;
             puerperal and postnatal depression), bereavement, and other                    • focusing on the couple relationship rather than on either of the
             stressful occurrences (such as reversals in health, work or                       partners.
             financial security);
         • social constructions of gender, which may increase                           •   An ability to structure the assessment of the couple relationship,
             vulnerability for those (most often women) who are financially                 for example by:
             dependent, vulnerable to abuse, emotionally expressive and                     • providing information about the processes of assessment and
             carrying undue caring responsibilities;                                             couple therapy;
         • social exclusion on minority groups (such as the disabled or,                    • setting and maintaining boundaries relating to the time and
             in some cultures, those of homosexual orientation), which can                       place of sessions;
             aggravate, sometimes punitively, stress that undermines self-                  • initiating an exploration of the relationship’s strengths,
             confidence and self-esteem, and increases social isolation                          problems and potential;


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                                                                                                                                                    Competency Map
         •   setting clear ground rules for the assessment and any offer of                    within the relationship.
             couple therapy.
                                                                                       •   An ability to formulate and test hypotheses about the functional
     •   An ability to screen for psychotic depression, bi-polar disorder or               significance of depression, for example:
         other psychotic conditions, through:                                              • as a means of securing help for the relationship, or of
         • taking a mental health history of the depressed partner;                            coercing a partner into treatment;
         • ascertaining recent or current treatments received for                          • as a means of communicating about the emotional
             diagnosed conditions (including medication);                                      significance of life events, asserting relationship rules,
         • gauging the depressed partner’s degree of contact with                              punishing past misdemeanours, regulating distance, securing
             reality;                                                                          care, or registering protest;
         • seeking expert advice for help in the screening process where                   • as a means of discouraging any change in the partners’ roles
             necessary.                                                                        and relationships;

     •   An ability to establish the presence of relationship problems,                •   An ability to engage the couple in identifying and assessing
         either preceding or concurrent with the partner’s depression, and                 interpersonal factors that may contribute to depression and the
         to assess how couple discord might contribute to causing and/or                   couple’s concerns, for example:
         maintaining the condition, including:                                             • communication patterns, such as repeated criticism and
         • the timing of the onset of depressive symptoms;                                     complaint;
         • the timing of the onset of any relationship problems;                           • interactive processes, such as cycles of withdrawal and
         • reactions of the non-depressed partner to depressive                                pursuit;
             symptoms, including whether s/he has experienced them too;                    • affective cycles, such as the escalation of anger or
         • the impact of depression on home life, including parenting                          depression.
             and work roles;
         • levels of support and tolerance from significant others outside             •   An ability to identify factors that maintain problematic patterns of
             the couple, both in terms of the acceptability of the condition               relating, for example:
             and perceived stigma.                                                         • the contribution of each partner to the couple’s difficulties;
                                                                                           • the potential risks for each partner of not maintaining their
     •   An ability to assess the rigidity of the depressive symptom, and to                   presenting concerns.
         identify the main areas of relationship difficulties associated with
         depression, for example:                                                      •   An ability to engage the couple in identifying and assessing
         • the depressed behaviour of one partner being directed                           developmental factors that may contribute to the couple’s
             towards the other, but not towards other people;                              concerns, for example by inviting:
         • low levels of companionable time partners spend in each                         • an account of each partner’s history of family and attachment
             other’s company;                                                                  experiences;
         • asymmetry within the partnership, for instance where the                        • an account of each partner’s perspective on the history of
             depressed person constantly diminishes their value and self-                      their relationship;
             regard in relation to their partner;                                          • a review of their presenting concerns within the meaningful
         • the non-depressed partner expressing less hostility and                             context of their relationship histories.
             frustration than they might be feeling;
         • the degree of rigidity with which the depressed partner might               •   An ability to recognise and address individual needs that may
             be persisting in a comparatively limited and ‘disabled’ role                  conflict with relationship goals, for example by:


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                                                                                                                                                      Competency Map
         •   gauging each partner’s level of commitment to the
             relationship and to couple therapy, including any differences
             there may be between them;                                             Ability to liaise with other services
         •   identifying incapacitating individual conditions, such as acute
             or chronic depression, and, if necessary, arranging for these              •   An ability to draw on knowledge about the salient network of
             to be addressed alongside or independently of couple                           services and when to liaise with other service providrs, for
             therapy;                                                                       example:
         •   providing separate as well as conjoint assessment meetings,                    • when statutory requirements need to be complied with (such
             ensuring these are conducted in ways that do not disturb the                       as child protection);
             couple’s trust in therapist impartiality.                                      • when the risk of domestic violence is high;
                                                                                            • when there are major changes in the clinical picture (such as
     •   An ability to engage partners in working with complex boundary                         a marked exacerbation of depressive symptoms).
         issues, for example:
         • the disclosure to the therapist in an individual session of an               •   An ability to make appropriate referrals.
             ongoing or past secret extra-marital sexual relationship.
                                                                                    Ability to establish and convey the rationale for couple therapy
     •   An ability to identify factors in the couple’s presentation that are
         amenable to change and the resources available to the couple to                •   An ability to establish for each partner the rationale for focusing
         achieve this, for example by:                                                      on their relationship as a means of addressing depression and
         • focusing on the strengths of their relationship;                                 their other presenting concerns, for example by demonstrating
         • inviting the partners to identify challenges they have                           how their:
             successfully overcome together as a couple.                                    • negative patterns of relating may create, maintain and
                                                                                                exacerbate these concerns;
Ability to identify and manage risk                                                         • positive patterns of relating, either in the present or the past,
                                                                                                might be mobilized to alleviate them.
     •   An ability to apply to couples knowledge about the risk of suicide,
         self harm, domestic violence, and other violence towards/abuse                 •   An ability to integrate different aspects of the assessment
         of vulnerable adults and children, including:                                      experience when making dynamic formulations of the couple’s
         • their nature, impacts, prevalence, indicators, contexts and                      relationship difficulties.
              socio-legal implications;
         • theories about causative and risk factors.                                   •   An ability to work with couples in achieving collaborative
                                                                                            formulations about, or understandings of, their problems, their
     •   An ability to work within the policies and protocols laid down by                  strengths and the therapy strategies that are appropriate to their
         Strategic Health Authorities with regard to such risks.                            needs.

     •   An ability to draw on knowledge of the above areas to establish:               •   An ability to work collaboratively with the partners to draw up a
         • whether the couple relationship is an appropriate site for                       therapy plan with clear, specific and achievable goals to which
            addressing depression and the partners’ other presenting                        they can agree and subscribe.
            concerns;
         • what safeguards might need to be put in place before offering                •   An ability to agree with the couple a risk assessment and
            therapy.                                                                        management plan where this is needed, and to liaise with other


22                                                                  IAPT Programme - Competency Frameworks for Non-CBT Therapies                        Return to the
                                                                                                                                                      Competency Map
         practitioners to implement it.                                                  •   An ability to frame interventions in ways that take account of
                                                                                             knowledge that:
Ability to initiate couple therapy                                                           • all close relationships contain personal incompatibilities that
                                                                                                may find expression in depressive symptoms and relationship
     •   An ability to engage both partners early on:                                           concerns;
         • in the knowledge that with depression comes easy                                  • reactions to such symptoms and concerns can be as
             demoralisation and early abandonment of treatment;                                 problematic as the symptoms or concerns themselves;
         • in avoiding precipitating the sense of failure or hopelessness                    • attempts to change depressive symptoms or relationship
             commonly present in depression, either within the depressed                        concerns can consequently be a problem for couples as well
             partner or the couple;                                                             as a solution;
         • in supporting each other to collaborate together in addressing                    • accepting what cannot be changed may in itself constitute an
             sources of stress external to their relationship.                                  important change.

     •   An ability to build and balance collaborative alliances between:                •   An ability to establish and maintain momentum for change within
         • the therapist and each partner;                                                   the couple’s relationship, for example through remaining focused
         • the therapist and the couple as a unit;                                           on the relationship in the face of individual concerns.
         • the partners in their relationship with each other.
                                                                                         •   An ability to motivate couples to read any manuals or self-help
     •   An ability to mediate between partners, for example by:                             guides that are associated with the therapy.
         • avoiding taking sides or being drawn into an adjudicatory role;
         • avoiding forming a coalition with either partner against the                  •   An ability to motivate and help couples to understand, complete
            other.                                                                           and evaluate between-sessions tasks that might be designed as
                                                                                             part of the therapy.
     •   An ability to identify and work with differences between the
         partners in exploring relationship difficulties, including being able       Ability to maintain and develop a therapeutic process with couples.
         to:
         • validate their different definitions, experiences and                         •   An ability to structure the therapeutic process, for example by:
             perceptions of their problems;                                                  • scheduling sessions, maintaining time boundaries, staying on
         • value the positive potential of these differences for the                            task and avoiding being sidetracked;
             relationship;                                                                   • helping partners to formulate and prioritise their agendas for
         • explore possible meanings associated with these differences                          change;
             for the partners and their relationship.                                        • holding in focus the negotiated goals of therapy;
                                                                                             • maintaining the therapeutic ‘conversation’ by:
     •   An ability to identify, understand and explore the emotional bonds                      • moving in and out of engagement with each partner;
         underlying the partners’ attachment to each other, including:                           • encouraging partners to speak directly to each other.
         • strengths and vulnerabilities in their relationship;
         • their respective responses to roles they assume in relation to
            each other;
         • the feelings each partner has for and generates in the other,
            and how these are expressed.



23                                                                   IAPT Programme - Competency Frameworks for Non-CBT Therapies                       Return to the
                                                                                                                                                      Competency Map
                                                                                       •   An ability to review the progress of therapy, for example by
     •   An ability to manage the boundary of the couple therapy, in                       identifying what has been achieved, what remains to be achieved
         relation to:                                                                      and what cannot be achieved.
         • any other therapy partners might be undergoing;
         • out of session contact with either or both partners;                        •   An ability to identify with the couple feelings associated with
         • behaviour within or outside therapy that might compromise                       ending, including the ways these can be expressed indirectly, for
             confidentiality or safety.                                                    example through:
                                                                                           • recurrences of presenting problems, or the emergence of new
     •   An ability to help couples learn about areas where they may have                     difficulties within the partnership that call into question the
         insufficient knowledge or skills, for example by working with them                   wisdom of ending;
         to create conditions in which they can be:                                        • requests from the couple to end early or precipitately, which
         • taught;                                                                            may serve to avoid difficult feelings associated with ending.
         • practised in and outside sessions;
         • applied to other domains of their lives.                                    •   An ability to prepare couples for the likelihood of a recurrence of
                                                                                           depressive symptoms and the need to plan for that eventuality,
     •   An ability to integrate the content of sessions into relationship                 for example by considering:
         themes, using these to promote understanding in the couple, for                   • extending therapeutic support through follow-up meetings;
         example by:                                                                       • other possibilities of outside help.
         • identifying overarching themes that link specific conflicts (for
            example, identifying the difficulty balancing the need for                 •   An ability to liaise about the ending appropriately with
            intimacy and autonomy that runs through different arguments                    practitioners who made the referral for couple therapy, and to
            between the partners);                                                         refer on to other services where required and agreed.
         • using themes to encourage the couple’s understanding of
            their problems;
         • providing a sense of hope through helping partners deepen
            their understanding of their relationship.

     •   An ability both to participate in and observe interactions in the
         couple.
     •   An ability to move between engaging each partner directly and
         working with the relationship between them.

Ability to end couples therapy

     •   An ability to terminate therapy in a planned and considered
         manner, including being open to revising a planned ending.

     •   An ability to act with discretion and awareness that timescales are
         different for different individuals, and that timetables can be
         disrupted by events.



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                                                                                                                                                     Competency Map
Specific Competences

   Ability to use techniques that engage the couple.                                             constructing agendas collaboratively;
                                                                                             •   recapitulating and checking out key communications made
        •   An ability to form and develop a collaborative alliance with each                    during sessions;
            partner and to enlist their support for relationship-focused                     •   encouraging couples to describe events and episodes in
            therapy, for example by:                                                             active rather than passive terms (for example, asking ‘how did
            • responding empathically in order to validate the experience of                     you make that happen?’ rather than ‘how did that happen?’);
                each partner, especially their emotional experience;                         •   creating openings for new relational experiences (for
            • accepting and exploring each partner’s reservations about                          example, through collaboratively setting homework
                engaging in couple therapy;                                                      assignments);
            • gauging when and whether separate sessions are needed to                       •   being clear and sensitive about the rationale for any
                engage each partner in the therapy, or to overcome an                            homework assignment, and following up on how it is
                impasse;                                                                         experienced as well as whether it has been completed.

        •   An ability to form and develop an alliance with the couple as a          Ability to use techniques that focus on relational aspects of
            unit, for example by:                                                    depression
            • reframing any presentation of individual problems in
                relationship terms;                                                      •   An ability to focus on and reduce negative cycles of influence
            • focusing attention on shared as well as separate concerns;                     between depression and couple interactions, for example by:
            • supporting the partners’ sense of themselves as being part of                  • educating couples about potential links between depression
                a unit as well as two individuals.                                              and stressful patterns of relating in the couple;
                                                                                             • gathering in broader aspects of the couple’s relationship and
        •   An ability to promote a collaborative alliance between the partners                 focusing on these (for example, concentrating on their roles
            in the couple, for example by:                                                      as parents as well as partners);
            • using empathic questioning to help the partners explore and                    • inviting the depressed partner to assume the caring role
                 reappraise their respective positions;                                         normally occupied by her or his partner;
            • encouraging the partners to address each other directly,                       • asking the depressed partner to help her or his partner to
                 rather than the therapist being drawn into a role as mediator                  express feelings;
                 or interpreter.                                                             • supporting the depressed partner in being assertive;
                                                                                             • discouraging blaming and denigration;
        •   An ability to engender hope about the therapeutic process, for                   • encouraging partners to maintain routines, surroundings and
            example by:                                                                         relationships that provide them with a sense of familiarity and
            • expecting neither too little nor too much about what can be                       security;
               achieved and by when;
            • engaging constructively with problematic issues;                           •   An ability to review interpersonal roles in the couple relationship,
            • encouraging, recognising and reflecting back positive cycles                   especially with regard to care giving and care receiving, for
               of interaction in the couple;                                                 example by:
            • reinforcing achievements by marking and celebrating positive                   • using family life-space techniques (such as sculpting or
               change.                                                                          button/stone games) to enable partners to represent how
                                                                                                roles are divided between them, including any changes that
        •   An ability to instigate therapeutic change, for example by:                         have taken place;
            • encouraging shared responsibility for the therapy by                           • encouraging each partner to depict graphically the amount of


   25                                                                IAPT Programme - Competency Frameworks for Non-CBT Therapies                         Return to the
                                                                                                                                                        Competency Map
             time and energy they believe they spend carrying out these                            • made available for reflecting on in the therapy;
             roles, including any changes that have taken place;                              •   providing opportunities for each partner to imagine what they
         •   using genograms to investigate family-of-origin roles;                               think might happen if existing roles and relationship patterns
         •   reviewing how roles were allocated in previous partnerships;                         were to change;
         •   highlighting similarities and differences between each partner
             in terms of their cultural expectations;                                 Ability to use techniques that reduce stress upon and increase
         •   investigating how their audit of relationship roles compares             support within the couple:
             with what each partner expects and desires;
         •   identifying areas where changes might be achieved.                       Improving communication
                                                                                          • An ability to teach listening skills, for example by:
     •   An ability to consult with the couple about their interaction, for                  • encouraging partners to listen actively (clarifying but not
         example by reflecting back observations about:                                          debating what is being said) in a manner that supports and
         • recurring patterns of relating between the partners;                                  validates the speaker;
         • ways in which each partner and the couple use their therapist;                    • encouraging partners to summarise and reflect back what
         • any relevance this might have to their relationship concerns.                         they have heard, especially in relation to key issues voiced;
                                                                                             • discouraging either partner (or their therapist) from making
     •   An ability to generate and test hypotheses that explain depressive                      unfounded assumptions about communications.
         symptoms through the relational contexts in which they occur, for
         example by:                                                                      •   An ability to teach disclosing skills, for example by:
         • offering thoughts about the possible functions of symptomatic                      • encouraging direct rather than ambiguous statements;
            behaviour for each partner;                                                       • encouraging the expression of appreciation, especially before
         • highlighting the roles played by each partner and others in                           raising concerns;
            creating and maintaining depressive symptoms, and exploring                       • softening the way concerns are introduced and voiced;
            possible reasons for these;                                                       • discouraging ending on a criticism when positive statements
         • describing interactive patterns that may maintain depressive                          are made;
            symptoms.                                                                         • promoting ‘I’ statements (rather than ‘We’ or ‘You’ statements
                                                                                                 that attribute meanings and intentions to others);
     •   An ability to challenge repetitive sequences, for example by:                        • encouraging concise, specific and relevant speech;
         • interrupting monologues, or cycles of accusation, rebuttal and                     • encouraging expression of information about feelings as well
            counter-accusation;                                                                  as reports of thoughts and experiences.
         • exploring possible functions performed by such repetitive
            sequences for each partner and the couple;                                    •   An ability to use exploratory techniques to aid communication, for
         • suggesting alternative behaviours or ways of communicating.                        example by:
                                                                                              • using open-ended questioning;
     •   An ability to offer possibilities for altering interactions, for example             • extending the issue being discussed;
         by:                                                                                  • using silence while actively and supportively listening.
         • tracking and reflecting back observations about patterns of
             relating and their possible purposes for each partner and the                •   An ability to use explanatory techniques to aid communication, for
             couple;                                                                          example by:
         • replaying and highlighting key interactions so they can be:                        • clarifying what has been said;
              • more directly be experienced in the session;                                  • providing feedback about a communication;

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                                                                                                                                                       Competency Map
         •   reconstructing the content of a message, especially where                   •   using questions, hypotheses, and/or reflections that can
             contradictions may be embedded within it.                                       evoke emotions within the session in the service of then
                                                                                             making them intelligible to each partner;
Coping with stress:                                                                      •   using pacing and softening techniques to create safety in
    • An ability to help partners cope with their own and each other’s                       evoking emotion;
       stress, for example by:                                                           •   heightening awareness of the link between physiological
       • enhancing a sense of safety by encouraging each partner to                          arousal and emotional states (for example, by using bio-
           talk first about low-level stressors that are removed from                        feedback methods);
           home before going on to talk about higher-level stressors that                •   teaching individual self-soothing techniques;
           may be closer to home;                                                             • when possible, inviting and enabling partners to help
       • encouraging the speaking partner to identify what they might                            each other implement self-soothing techniques;
           find helpful in coping with the stress;                                       •   heightening emotions, in a controlled and safe way within the
       • enabling the listening partner to offer empathic support for the                    session by repeating key phrases to intensify their impact.
           speaker in disclosing what they are finding stressful, and any
           specific needs they may have in order to cope with the stress;            •   An ability to work with partners who amplify the expression of
       • encouraging the speaking partner to provide empathic                            emotion, for example by:
           feedback on their experience of being supported;                              • bounding the expression of emotion within sessions;
       • repeating these sequences with the partners changing                            • helping partners differentiate between their emotional states:
           speaker and listener roles;                                                       • as experienced in themselves;
       • maintaining fairness and equity in the balance of speaker and                       • as observed by others;
           listener roles to ensure neither partner is privileged in either              • helping them to clarify when unexpressed emotional states
           role.                                                                            might underlie expressed emotion (for instance when
                                                                                            unexpressed fear underlies the expression of anger);
Managing feelings:                                                                       • promoting containment of upset in one domain of life to
   • An ability to encourage the expression and reformulation of                            prevent it infiltrating other domains;
       depressive affect, for example by:                                                • curtailing statements of contempt through opening up
       • supporting the expression of depressed feelings, and the                           explorations of its impact and underlying emotions;
           partner’s reactions to depressed feelings, and encouraging                    • helping partners to establish useful boundaries around
           acceptance of them;                                                              emotional expression, for example through:
       • exploring past and present experiences of loss that may                              • scheduling mutually agreed times and places in which
           account for these feelings, which provide a framework for                                to discuss feelings, especially those associated with
           acknowledging and understanding them;                                                    painful experiences, whether shared or separate;
       • facilitating mourning.                                                               • encouraging partners to accept the importance of other
                                                                                                    relationships (such as friends and relatives) to provide
     •   An ability to work with partners who might minimise expressions                            additional emotional support, and to reduce
         of emotion, for example by:                                                                unmanageable pressure on the relationship, while also:
         • normalising emotional experience;                                                  • identifying and agreeing upon mutually acceptable
         • describing emotions in language that is both accessible and                              boundaries (such as, for example, mutually agreed
             meaningful to the couple;                                                              sexual or financial limits to other relationships).
         • validating and promoting acceptance of both existing and
             newly-experienced feelings of each partner;                             •   An ability to work with mismatches between partners’ emotional

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                                                                                                                                                  Competency Map
         responses and meanings, for example by:                                                 •    focusing on increasing the frequency of
         • building awareness between partners of:                                                    positive exchanges
               • their different attitudes, histories and experiences with                       • rather than on diminishing negative
                    expressing specific emotions;                                                     exchanges;
               • their different attitudes towards introspection, self-                     •   helping each partner to generate a list of specific, positive,
                    disclosure and exploration of feelings;                                     non-controversial things they could do for the partner;
         • accepting and processing mismatches of emotional                                 •   helping the partner to whom the list is directed to develop the
             expression and responsiveness;                                                     list;
         • helping translate each partner’s respective meanings of the                      •   conducting a staged approach in which:
             other’s behaviours;                                                                 • requests from partners are simple and clear,
         • helping the couple reach clearer shared understandings of                             • complaints from and about partners become wishes,
             each other’s responses and meanings.                                                • specific, reciprocal, achievable changes are negotiated
                                                                                                      and worked at together, and
     •   An ability to provide empathic support, for example by:                                 • progress is monitored by all participants;
         • tracking the emotions of each partner, as signalled within                       •   encouraging the reciprocation of positive behaviour.
            sessions through verbal and non-verbal cues;
         • tuning into and validating emotional experience, for example                 •   An ability to instigate an increase in positive behaviour that does
            by responding sensitively and robustly;                                         not depend on reciprocation, for example by:
         • focusing on patterns of relating that disrupt emotional                          • enabling partners to identify and achieve specific changes
            connection, and promoting their repair through reprocessing                         they want to make in themselves irrespective of whether their
            sequences as experienced by each partner;                                           partner reciprocates, including:
         • reframing the emotional experiences of partners to make                               • changes of a broad nature, such as improving the
            them intelligible and acceptable to each other.                                          emotional climate of the relationship through being more
                                                                                                     available to share time;
Changing behaviour:                                                                              • changes with a specific focus, such as the manner in
   • An ability to hold collaborative discussions to establish and assist                            which concerns are raised;
       in achieving agreed upon and specific goals, including:                              • encouraging partners to predict how changes in their own
       • helping couples identify and set their own goals for the                               behaviour might have a positively reinforcing effect upon their
           therapy;                                                                             partner:
       • establishing the rules and procedures for achieving these                               • exploring how this prediction looks to the partner;
           goals;                                                                                • exploring their own and their partner’s response to
       • when appropriate, contracting with either or both partners to                               initiating such change;
           refrain from specific behaviour (for instance, behaviour that                    • identifying and articulating relationship themes and meanings
           has been agreed-upon as dangerous);                                                  for each partner that lie behind specific behaviour.
       • exploring why behavioural agreements entered into by the
           partners have worked or failed to work, and reviewing goals in
           the light of this.                                                       Solving problems:
                                                                                        • An ability to create and nurture shared systems of meaning within
     •   An ability to instigate an increase in reciprocated positive                       the couple as a prelude to addressing problems, for example by:
         behaviour, for example by:                                                         • encouraging partners to talk to each other about respective
         • noting such behaviour in the couple and:                                             hopes and fears they have about their relationship, especially

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                                                                                                                                                      Competency Map
             when they feel upset or threatened;
         •   establishing and noting, to underline their intentional nature,           •   An ability to help couples find a solution to identified specific
             the partners’ daily rituals of connecting with each other (over               problems through sequentially:
             meal times, shared activities and so on);                                     • defining problems;
         •   identifying ways, and noting their intentional nature, in which               • brainstorming potential positive alternatives to current
             partners already are supported by each other in their shared                     problematic behaviour;
             roles (parenting, home maintenance and so on);                                • evaluating the pros and cons of those alternatives;
         •   facilitating the emergence and recognition of a shared                        • negotiating alternatives;
             relationship story:                                                           • identifying the components of a contract;
              • noting how it clarifies and sustains the values and                        • forming an explicit (when appropriate, written) contract.
                   meanings the partners have in common.
                                                                                   Promoting acceptance:
     •   An ability to help couples define problems in ways that can limit            • An ability to work with couples in ways that respect each partner’s
         complaint or criticism, for example by encouraging partners to:                  experience of depression, for example through:
         • use specific examples when raising potentially contentious                     • educating the couple about depression:
            issues;                                                                            • naming and explaining the symptoms of depression,
         • convey why the problem is important to them;                                        • allowing depression to be viewed as an illness, and
         • include clear statements about how the problem makes them                               thereby
            feel.                                                                              • reducing feelings of guilt or blame associated with the
                                                                                                   condition;
     •   An ability to provide a structured and stepped approach to                       • accepting the couple’s reality of the depressed partner as
         problem-focused discussions, for example by:                                         patient:
         • separating the process of sharing thoughts and feelings from                        • especially in the early stages of therapy, and
             discussions about the way in which decision-making and                            • simultaneously helping the non-depressed partner play a
             problem-solving will proceed;                                                         supportive role;
         • developing communication skills before applying them to                        • accepting the reality of both partners’ depression when this is
             problem-solving;                                                                 the case, and the limitations on what each can do for the
         • starting with low conflict before proceeding to high conflict                      other in the short term;
             issues;                                                                      • engaging the supportive abilities of the non-depressed
         • addressing one problem at a time;                                                  partner, for example by involving him or her in:
         • avoiding being sidetracked;                                                         • helping the depressed partner:
         • discouraging disagreements when there is insufficient time to                            • prioritise tasks,
             address them.                                                                          • undertake manageable social activities,
                                                                                                    • be assertive;
     •   An ability to enable partners to try out different approaches to                           • recognise dysphoric symptoms;
         managing conflict, for example by:                                                         • seek out situations that can relieve such symptoms;
         • enacting arguments in the safety of the therapy session;                            • evaluating and managing the patient’s depressive
         • interrupting enacted arguments to explore alternative                                   symptoms, including the need for either social stimulus
            approaches;                                                                            and/or medication;
         • encouraging pretend or controlled arguments outside                                 • relating to the depressed partner as ‘more than his or her
            sessions.                                                                              depression’, to help reduce the effects of depression.

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                                                                                                                                                        Competency Map
             •   assisting the depressed partner to manage their condition                    (as compared with actual) criticism;
                 for themselves.                                                          •   drawing attention to self-reinforcing problematic predictions
                                                                                              and assumptions.
     •   An ability to help partners empathically connect with each other
         around their concerns by:                                                    •   An ability to reduce blame and stimulate curiosity in the partners
         • eliciting vulnerable feelings from each partner that may                       about their own and each other’s perceptions, for example
             underlie their emotional reactions to their concerns;                        through:
         • encouraging them to express and elaborate these feelings;                      • ‘circular’ questioning (questioning that highlights the
         • conveying empathy and understanding for such feelings;                             interactive nature of each partner’s behaviour on the other);
         • helping each partner develop empathy for the other’s                           • ‘Socratic’ questioning (questioning that re-evaluates the logic
             reactions through modelling empathy toward both partners.                        behind existing positions in order to create an alternative,
                                                                                              more functional logic);
     •   An ability to help the couple empathically connect with each other               • encouraging partners to ‘read’ what their partner is thinking
         in distancing themselves from their concerns, for example by                         and feeling through:
         helping partners:                                                                     • picking up verbal and non-verbal cues and messages;
         • step back from their concerns and take a descriptive rather                         • listening to feedback about the accuracy of these
              than evaluative stance towards it;                                                   readings;
         • describe the sequence of actions they take during                              • imagining the effects their behaviour and feelings have on
              problematic encounters to:                                                      their partner, and to accept and reflect on feedback from their
               • build awareness of the triggers that activate and escalate                   partner about this.
                  their feelings;
               • consider departures from their behaviour and what might              •   An ability to use techniques that increase the partners’
                  account for such variations;                                            understanding of their own and each other’s vulnerability to
         • generate an agreed name for problematic repetitive                             cognitive distortion, for example by encouraging them to:
              encounters to help them call ‘time out’.                                    • identify recurring behaviour and feelings that might act as
                                                                                             flashpoints for each partner in their relationship;
     •   An ability to help the couple develop tolerance of responses that                • explore the contexts in which they arise;
         the problem can trigger, for example by:                                         • encourage reflection across relationship domains about
         • helping partners identify positive as well as negative functions                  similar experiences and reactions.
             served by problematic behaviour;
         • using desensitising techniques to reduce the impact of                     •   An ability to engage the curiosity of partners about possible links
             problematic behaviour (such as practising arguments in                       between their current relationship perceptions and past
             sessions).                                                                   developmental experiences, for example by:
                                                                                          • taking a thorough family and relationship history for each
Revising perceptions:                                                                         partner, or facilitating this to emerge in the context of the
    • An ability to observe and reflect back on observations of                               therapeutic process, that includes attachment patterns,
        seemingly distorted cognitive processing, for example through:                        events and themes;
       • marking selective inattention;                                                   • using devices such as family genograms to identify cross-
       • encouraging partners to check out the validity of attributions                       generational family meanings, norms, and/or expectations,
           they make about each other;                                                        especially with regard to relationship roles and scripts;
       • encouraging partners to check out the validity of perceived                      • allowing embedded roles, scripts, themes, and patterns that


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                                                                                                                                                    Competency Map
             might contribute to distortions in the representation of
             relationships to emerge and be worked with;                              •   An ability to apply developing formulations to achieve changes in
         •   linking past attachment themes and problematic experiences                   perception, for example by:
             with current perceptions and predictions.                                    • working through past attachment difficulties, disappointments
                                                                                              and losses;
     •   An ability to develop shared formulations of central relationship                • making accessible and accepting feared
         themes, for example by:                                                              emotions/experiences, and encouraging new ways that
         • exploring the transference of representations of past                              partners can be with each other;
            attachment patterns, roles and affects into current couple                    • providing the context for a corrective emotional experience
            and/or therapy relationships, and helping the couple                              that encourages each partner to feel secure with each other.
            distinguish between past and present meanings and realities;
         • exploring the therapist’s own emotional and behavioural
            responses, both to each partner and to the couple itself:
             • to identify affects and experiences that may reflect and
                   resonate with those of the couple;
         • to make connections between the affective experiences of
            each partner and their therapist to build understanding from
            shared experience.

     •   An ability to identify and make links between specific arguments
         and central relationship themes, for example by highlighting:
         • meanings, thoughts and feelings that accompany escalating
            arguments;
         • recurring tensions over the need for intimacy and autonomy;
         • conflicts that are structured around issues of dominance and
            submission;
         • roles that rooted in gender or cultural expectations that might
            be uncomfortable for one or other of the partners;
         • past attachment experiences that might be creating anxieties
            and fears.

     •   An ability to reframe events, actions, feelings or interactions to
         provide alternative, more positive and/or functional meanings to
         those posited by one or both partners in order to change
         perceptions of what is going on in the relationship, for example
         by:
         • reconceptualising a partner’s perceived negative motivations
             as misguided or misfired attempts to be supported by and/or
             supportive of the other;
         • emphasising the desire of partners to enable rather than
             disable each other.


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                                                                                                                                                  Competency Map
Specific Adaptations

                                                                                                     IBCT) about their problems and about their forthcoming
   Traditional behavioural couple therapy (TBCT)                                                     treatment.

   Source: Jacobson, N. & Margolin, G. (1979) Marital therapy: Strategies             Ability to give feedback to the couple (offer a rationale)
   based on social learning and behavior exchange principles. New York:                    • An ability (for TBCT) to focus on feedback which emphasises the
   Brunner/Mazel. Supplemented by Jacobson, N. S., & Christensen, A.                           strengths of the couple and delineates specific problem areas that
   (1994). Traditional behavioral couple therapy manual. Unpublished                           could be the target for later communication and problem-solving
   manuscript, University of Washington.                                                       efforts.
                                                                                           • An ability (for IBCT) to focus on broad themes in the conflicts
   Couples were also given reading during the communication-training                           between partners rather than on particular problematic issues:
   segment of the therapy: Gottman, J. M., Notarius, C., Markman, H., &                          • an ability to formulate the couple's difficulties in terms of the
   Gonso, J. (1977) A couple's guide to communication. Champaign, IL:                                differences between them, in terms of:
   Research Press.                                                                                    • the understandable (though often ineffective or self-
                                                                                                          defeating) actions that each has taken;
   Integrative behavioural couple therapy (IBCT)                                                      • the natural emotional reactions that each experiences.
   Traditional TBCT relied for its effectiveness on the ability of couples to                    • an ability to describe the couple’s realistic strengths;
   accommodate and collaborate with each other. Aware that many couples                          • an ability to convey hope that examination may lead to a
   could not do this, and that conflict could have positive as well as negative                      greater understanding of each other's emotional reactions
   effects, Jacobson and Christensen developed the model to incorporate                              and to a greater closeness.
   ‘acceptance’ as a central focus for couples with irreconcilable differences.
                                                                                      TBCT
   Source: Jacobson, N. & Christensen, A. (1998). Acceptance and change               Knowledge
   in couple therapy: A therapist's guide to transforming relationships. New             • An ability to draw on knowledge that TBCT aims to promote
   York: Norton.                                                                             positive change in couples through direct instruction and skill
                                                                                             training.
   Couples were also asked to read Christensen, A. & Jacobson, N. (2000).                • An ability to draw on knowledge of the three primary treatment
   Reconcilable differences. New York: Guilford Press.                                       strategies employed in TBCT (behavioural exchange,
                                                                                             communication training and problem-solving).
   Components of TBCT and IBCT:
                                                                                      Behavioural exchange
   Ability to assess the couple’s difficulties
                                                                                         • An ability to direct efforts to increase mutual, positive behavioural
        • An ability to draw on knowledge that the initial stages of both                    exchange.
            TBCT and IBCT usually comprises four sessions of assessment
                                                                                         • An ability to help each partner to generate a list of specific,
            followed by feedback:
                                                                                             positive, noncontroversial behaviours that they could do for the
              • an initial session (attended by both partners) to assess                     partner;
                  presenting problems and obtain a brief relationship history
                                                                                             • an ability to help the partner to whom the list is aimed to
                  of the couple;
                                                                                                   develop this list.
              • two sessions (attended by each partner separately) to
                                                                                         • An ability to encourage each spouse to perform activities from the
                  assess presenting problems and obtain an individual history
                                                                                             list in an effort to increase mutual positive reinforcement.
                  from each partner;
              • a joint session to obtain additional information, and to              Communication training
                  provide the couple with feedback (appropriate to TBCT or

   32                                                                 IAPT Programme - Competency Frameworks for Non-CBT Therapies                          Return to the
                                                                                                                                                          Competency Map
     •   An ability to teach partners both speaking and listening skills.                      invalidated by the other's reaction in the session).
     •   An ability to help partners develop their speaking skills (for               •   An ability to employ three major strategies to promote emotional
         example, by focusing on “I” statements and teaching partners to                  acceptance:
         specify their emotions and behaviour (e.g. “I feel disappointed                   • “empathic joining” around the problem;
         when you come home late without calling” vs. “you are so selfish                  • “unified detachment” from the problem;
         and inconsiderate”).                                                              • building tolerance to some of the responses that the
     •   An ability to help develop their listening skills (for example, by                    problem can trigger.
         learning to paraphrase or summarize the other's message).
                                                                                      •   An ability to help the couple employ a strategy of “empathic
Problem-solving skills                                                                    joining” around the problem:
    • An ability to help couples to:                                                        • an ability to elicit vulnerable feelings from each spouse that
        • define problems;                                                                      may underlie their emotional reactions to the problem;
        • generate positive alternatives to current problem behaviour;                      • an ability to encourage partners to express and elaborate
        • evaluate the pros and cons of those alternatives;                                     these feelings;
        • negotiate alternatives;                                                                • an ability to communicate empathy for having these
        • implement and evaluate planned change.                                                      understandable reactions;
                                                                                            • an ability , by adopting this stance toward both partners, to
IBCT                                                                                            help each partner develop empathy for the other’s reactions.
Knowledge
   • An ability to draw on knowledge that IBCT is designed to enhance                 •   An ability to help the couple employ a strategy of “unified
       TBCT by adding a focus on emotional acceptance.                                    detachment” from the problem:
   • An ability to draw on knowledge that IBCT assumes:                                    • an ability to help the couple to step back from the problem
         • that all close relationships are characterised by some                              and take a descriptive rather than evaluative stance toward
              genuine incompatibilities, and the reactions to problem                          the issue;
              behaviour are often as problematic as the behaviour itself;                  • an ability to help the couple engage the couple in an effort
         • that direct change efforts are often as much a problem for                          to describe the sequence of actions they take during their
              couples as they are a solution.                                                  problematic pattern:
   • An ability to draw on knowledge that IBCT focuses more on the                              • to specify the triggers that activate and escalate their
       emotional reactions of partners to the difficulties they encounter in                          emotions;
       their relationships and less on the active solutions they can take                       • to consider variations of their patterned behaviour and
       to resolve these difficulties;                                                                 what might account for these variations (e.g., a typical
         • an ability to draw on knowledge that this stance is especially                             struggle over their child was less intense because they
              relevant for what seem to be insoluble problems.                                        had felt close to each other earlier);
                                                                                                • to generate a name for their problematic pattern.
Application
    • An ability to maintain a focus on salient incidents that:                       •   An ability to help the couple build tolerance to some of the
         • have occurred recently (e.g. an argument the previous                          responses that the problem can trigger;
            night);                                                                         • an ability to engage the couple in an analysis of the positive
         • will soon occur (e.g. a forthcoming trip to stay with the family                    functions as well as the negative functions of their
            of one partner);                                                                   differences and their problematic behavioural patterns;
         • or are occurring in the session (e.g., one partner feels                         • an ability to encourage the couple to deliberately engage in


33                                                                IAPT Programme - Competency Frameworks for Non-CBT Therapies                        Return to the
                                                                                                                                                    Competency Map
              the problem behaviour during the session or at home, so                          •   promoting couple cohesion;
              that each partner can become more aware of the pattern                           •   encouraging the acceptance of emotional expression;
              and take it less personally.                                                     •   increasing actual and perceived coping assistance;
                                                                                               •   supporting positive self-esteem;
     •   An ability to make use of the direct change efforts employed in                       •   increasing spousal dependability;
         TBCT.                                                                                 •   deepening intimacy and mutual confiding.

                                                                                     •   An ability to draw on knowledge of the main treatment strategies
MARITAL THERAPY FOR DEPRESSION (MTD)                                                     used in TBCT:
Source: Beach, S., Sandeen, E. & O’Leary, K. (1990) Depression in                        • behavioural exchange;
marriage: A model for etiology and treatment. New York: Guilford.
                                                                                         • communication training;
                                                                                         • cognitive restructuring;
MTD is a modification of TBCT, specifically adapted to treat depression.
Based on the ‘marital discord model’ of depression, which focuses on the                 • problem-solving.
role of stress and social support in triggering and protecting against
depression, it aims to reduce stressful transactions in marriage and             Application:
enhance social support between the partners. Its effectiveness was                   • An ability to draw on knowledge that assessment for MTD usually
associated with ongoing marital problems that preceded depression, but                   comprises at least two sessions, where partners are seen
the need for supportive couple interventions in the absence of this                      together and separately, to satisfy the following conditions:
chronology was justified on the basis that depression restricted positive                • the risk of suicide or suicidal gestures is low;
interactions between partners even when there was no reported                            • the depressed partner has received a thorough diagnostic
relationship problem.                                                                        assessment and is not bi-polar;
                                                                                         • the presence of marital discord has been clearly established;
Knowledge:                                                                               • marital discord appears to play an aetiological or maintaining
   • An ability to draw on knowledge that MTD aims to promote                                role in the depression;
       positive change in couples through:                                               • there are no hidden agendas that caution against the offer of
      • administering the therapy in a structured manner;                                    marital therapy (for example, low commitment, or the desire
      • mediating the therapeutic alliance with both partners;                               for divorce).
      • re-educating the couple about depression and relationships;
      • modelling approaches and skills;                                             •   An ability to draw on knowledge that MTD usually comprises
      • celebrating positive change.                                                     three phases over approximately 15 sessions:
                                                                                         • an initial phase that aims rapidly to eliminate major stressors
     •   An ability to draw on knowledge about the marital discord model                     and enhance couple cohesion, caring and companionship;
         of depression, in which marital discord:                                        • a mid-therapy phase that focuses on the ways partners
         • increases stress in the relationship, which can result in or                      communicate, solve problems and interact on a day-to-day
             exacerbate depression;                                                          basis;
         • reduces support from the relationship, which can have similar                 • a concluding phase that prepares the couple for termination.
             effects;
         • is treated by the therapist working to reduce stress and                  •   An ability to apply depression-specific knowledge and techniques,
             increase support from the couple’s relationship, and so                     for example:
             prevent or mitigate depression by:                                          • evaluating the role of the relationship in eliciting and/or
                                                                                              maintaining depression;

34                                                               IAPT Programme - Competency Frameworks for Non-CBT Therapies                      Return to the
                                                                                                                                                 Competency Map
         •   seeing the couple together;                                                   depression, in which marital disputes:
         •   increasing awareness of each partner’s agency in relation to                  • provide an important aspect of the interpersonal context for
             the other;                                                                       precipitating and maintaining depression;
         •   combating negative self statements;                                           • are understood as resulting from discordant role expectations
         •   increasing positive events;                                                      in the couple relationship;
         •   identifying relationship factors that increase or lessen                      • form the focus of therapeutic attention.
             depression;
         •   setting therapeutic contingencies at realistic levels (for                •   An ability to draw on knowledge of the main treatment strategies
             example, in relation to complying with homework).                             used in IPT-CM:
                                                                                           • accepting depression as a clinical disorder;
     •   An ability to apply behavioural, communication, cognitive and                     • limiting set goals and timescales;
         problem-solving couple therapy techniques to the therapeutic                      • encouraging an exploratory, patient-led process;
         process.                                                                          • promoting understanding within and between partners;
                                                                                           • focusing on the relationship between marital disputes and
                                                                                              depression.
Conjoint Marital Interpersonal Therapy (IPT-CM)
Source: Rounsaville, B., Weissman, M., Klerman, G. & Chevron, E. (1986)            Application:
Manual for conjoint marital interpersonal psychotherapy for depressed                  • An ability to draw on knowledge that IPT-CM usually comprises
patients with marital disputes (IPT-CM). Yale University School of                         three phases over approximately 3-6 months of weekly sessions:
Medicine. Unpublished.                                                                     • an initial phase that aims to evaluate and manage depressive
                                                                                               symptoms by:
IPT-CM is a specific treatment for clinically depressed partners with marital                   • evaluating the identified patient’s depression, including
disputes. On the basis that an increase in couple discord is the most                              the need for medication;
commonly reported life stress preceding the onset of clinical depression,                       • educating the couple about depression and ways of
and that an intimate, confiding relationship provides robust protection                            managing it;
against depression, the IPT-CM model engages couples in renegotiating                           • identifying marital disputes;
role expectations as a means of reducing symptoms and improving
                                                                                                • explaining the rationale for the marital treatment;
interpersonal processes. The primary focus is on achieving sustained
                                                                                                • determining the relationship between depression and
change through helping couples gain a richer understanding of the
                                                                                                   marital disputes;
problem in their relationship.
                                                                                                • performing an interpersonal inventory;
Knowledge:                                                                                      • setting the treatment contract;
   • An ability to draw on knowledge that IPT-CM aims to promote                           • a middle phase that focuses on renegotiating marital roles by:
       positive change in couples through promoting understanding of                            • structuring sessions through repeatedly tying new
       the interpersonal context of depression, specifically to:                                   material to central themes and targeted problem areas;
       • facilitate a reduction of depressive symptoms and remission                            • identifying options for role change;
           of acute depressive episodes;                                                        • facilitating communication and role renegotiation;
       • promote the renegotiation of role relations between the                           • a concluding phase that prepares the couple for termination
           partners.                                                                           by:
                                                                                                • discussing termination explicitly;
     •   An ability to draw on knowledge about the IPT-CM model of                              • encouraging discussion about the loss of treatment;


35                                                                 IAPT Programme - Competency Frameworks for Non-CBT Therapies                      Return to the
                                                                                                                                                   Competency Map
             •   fostering feelings of competence and accomplishment;                     •   enhancing the ability to cope as a couple;
             •   discussing future treatment needs.                                       •   sensitising the couple to issues of mutual fairness, equity and
                                                                                              respect;
     •   An ability to apply specific IPT-CM techniques to the therapeutic                •   improving couple communication;
         process:                                                                         •   improving the couple’s problem-solving skills.
         • conducting communication analyses;
         • promoting acknowledgement and acceptance of affect;                    Application:
         • negotiating and structuring behaviour change;                              • An ability to draw on knowledge that COCT usually comprises up
         • making interpretations (especially clarification);                             to 20 hours of sequenced therapy sessions in which:
         • encouraging exploration.                                                       • an initial session focuses on:
                                                                                               • analysing the presenting problem;
Coping Oriented Couple Therapy (COCT)                                                          • taking an oral history from each partner in the presence
Source: Bodenmann, G & Widmer, K. (2008) Coping-oriented couple                                   of the other;
therapy. Fribourg: Institute for Family Research and Counselling,                         • a middle phase focuses in sequence on:
University of Fribourg. Unpublished German edition. Developed from                             • reciprocity training and improving the repertoire of
Bodenmann, G. & Shantinath, S. (2004) The couples coping enhancement                              positive experiences;
training (CCET): A new approach to prevention of marital distress and                          • communication training;
coping. Family Relations 53 (5): 477-484.                                                      • problem-solving training;
                                                                                               • enhancing couple coping through partners expressing
In addition to promoting better couple communication through teaching                             their own stress and supporting each other in managing
speaking and listening techniques, COCT focuses on promoting improved                             their stress;
individual and couple coping skills through partners being helped to                           • learning to accept what cannot be changed;
communicate about and respond to their own and each other’s stress.                       • a concluding phase focuses on preparing the couple for
                                                                                              termination.
Knowledge:
   • An ability to draw on knowledge that COCT aims to promote                        •   An ability to apply traditional and integrative behavioural couple
       positive change in couples through acquiring new adaptive                          therapy techniques to the therapeutic process:
       skills/behaviours and strengthening existing ones.
                                                                                          • reciprocity training;
                                                                                          • communication skills training;
     •   An ability to draw on knowledge about the COCT stress model of
                                                                                          • problem-solving training;
         couple dissatisfaction, in which stressors external to the couple:
                                                                                          • stress management training;
         • reduce the time they spend together;
                                                                                          • promoting emotional acceptance.
         • erode communication and intimacy between partners;
         • increase health problems, and consequently add to the
            couple’s burdens;
         • result in mutual alienation and increased stress from within
            the relationship.

     •   An ability to draw on knowledge of the main treatment strategies
         used in COCT:
         • improving individual stress management capabilities;


36                                                                IAPT Programme - Competency Frameworks for Non-CBT Therapies                        Return to the
                                                                                                                                                    Competency Map
Metacompetences

   Generic metacompetences                                                            Specific metacompetences

   Capacity to use clinical judgement when implementing therapy.                      Capacity to work reflexively within complex relational systems

   Capacity to work with assessment and termination in ways that recognise            A capacity continuously and actively to monitor the system of therapeutic
   ambiguities contained in these processes as well as the needs of different         alliances (i.e. therapist to each partner, therapist to couple, and partner to
   couples.                                                                           partner), especially when they are threatened or out of balance, and to
                                                                                      reflect on and work with disruptions to the system as and when they occur.
   Capacity to recognise and work with relevant clinical material that is not
   directly, verbally or consciously acknowledged by the partners.                    Capacity to manage the tension between competing duties of care

   Capacity to approach each couple as unique, requiring a tailored approach          Capacity to manage conflicting confidentiality claims, for example the
   that attends to:                                                                   disclosure of unprotected sex and/or HIV to an unknowing partner.
         each partner’s specific personality, current circumstances and life
         experiences;                                                                 Capacity to work with difference and uncertainty
         those of their therapist;
         the interaction between those participating in the therapeutic               Capacity to work with the competing realities of partners:
         process.                                                                        validating both;
                                                                                         privileging neither;
   Capacity to reflect critically on the experience of therapy                           and engaging with the potential function and meanings of difference.

   Capacity to adapt and develop practice in the light of the experience of a         Capacity to entertain feelings associated with not understanding and
   therapy, and the experience of other practitioners using similar and               knowing about aspects of the couple’s experience, without losing
   different therapeutic models.                                                      confidence in what is known and understood, in order to:
                                                                                          encourage an attitude of curiosity in the couple for exploring their
   Capacity to recognise the limits of one’s abilities and knowledge, and to              experience;
   learn from the experience of others (for example through supervision,                  avoid taking precipitate action in the face of anxiety;
   consultation and continuing professional development).                                 resist internal and external pressures to share observations,
                                                                                          interpretations or hypotheses prematurely;
   Capacity to convey and respond to interest, affect and humour                          resist adhering to a single, fixed interpretation or hypothesis by being
                                                                                          open to the couple’s ideas and responses;
   Capacity to draw on authentic responses to promote emotional                           ensure, through collaborating in this way, that there is convincing
   connection, for example by judging:                                                    evidence;
      the function of humour in a session, and whether and how to respond                 assess whether sharing an interpretation or hypothesis is likely to be
      to it;                                                                              helpful.
      when it might be therapeutically useful to make a personal disclosure
      and being able to do so appropriately, for instance to validate an
      experience or cement an alliance.




   37                                                                 IAPT Programme - Competency Frameworks for Non-CBT Therapies                          Return to the
                                                                                                                                                          Competency Map
Capacity to use different therapeutic approaches appropriately and
coherently.

A capacity to select from, integrate and move between different
therapeutic models and techniques to provide a coherent and appropriate
therapeutic response to the different and changing needs of couples, for
example by:
    applying a graded model of intervention tailored to the nature and
    severity of the couple’s areas of concern;
    exploring behavioural contracting, communication and conflict
    management skills in conjunction with more complex, in-depth work,
    and determining the appropriate level on which to work;
    drawing on other, more complex approaches, such as insight-oriented
    ones, where the couple can both benefit from and work with a deeper
    understanding of underlying developmental factors that may be
    interfering with their relationship;
    focusing on accepting limitations for the partnership set by factors
    within, between and external to the partners as a means of increasing
    relationship satisfaction.




38                                                             IAPT Programme - Competency Frameworks for Non-CBT Therapies     Return to the
                                                                                                                              Competency Map
Acknowledgments
The work to devise the competences in this document was led
by:

        •    Christopher Clulow
        •    Susannah Abse
        •    Nick Turner




39                                                 IAPT Programme - Competency Frameworks for Non-CBT Therapies     Return to the
                                                                                                                  Competency Map

				
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