Introduction
Manualisation: fidelity and flexibility
Cognitive behavioural therapy (CBT) has one of the strongest evidence bases for supporting young people (YP) with emotional difficulties including anxiety and low mood (David-Ferdon and Kaslow, Reference David-Ferdon and Kaslow2008; Sigurvinsdóttir et al., Reference Sigurvinsdóttir, Jensínudóttir, Baldvinsdóttir, Smárason and Skarphedinsson2020). Most CBT research uses manuals: standardised guidelines about the theory, sequencing, content, and procedures of sessions (Kiesler, Reference Kiesler, Talley, Strupp and Butler1994; Marshall, Reference Marshall2009). While manualisation is favoured methodologically for maximising internal validity, some practitioners use a more judgement-based approach, where decision-making is based on personal experience and expertise (Nezu, Reference Nezu2020). In a survey of 317 US-based CBT practitioners, 11.4% reported frequently using manuals and 58.7% reported occasionally using manuals, suggesting manuals have a significant presence in practice (Becker et al., Reference Becker, Smith and Jensen-Doss2013).
The issue of manualisation provokes strong opinions among practitioners, going beyond treatment effectiveness and prompting reflection on professional identity (Addis and Krasnow, Reference Addis and Krasnow2000). Opponents typically resent the loss of flexibility and diminished importance of professional expertise, claiming manuals restrict practitioners’ ability to respond to idiosyncratic situations (Shedler, Reference Shedler2018). Proponents suggest manuals are informative, supportive and accessible, meaning professionals can be easily and widely trained to deliver effective interventions (Singla et al., Reference Singla, Raviola and Patel2018). A review comparing manualised with non-manualised forms of the same psychotherapy found two studies supporting non-manual superiority and four studies showing no difference (Truijens et al., Reference Truijens, Zühlke-van Hulzen and Vanheule2019). Judgement-based therapy practitioners are, however, more prone to decision-making flaws such as biases, heuristics and over-confidence (Miller et al., Reference Miller, Spengler and Spengler2015; Nezu, Reference Nezu2020).
Many studies see manualisation as a dialectic: either practitioners follow manuals with fidelity, or follow their judgement with flexibility. Most practitioners report modifying manuals (Durlak and DuPre, Reference Durlak and DuPre2008). This may be wise because, in a review of 47 studies, manual fidelity was not consistently associated with effectiveness (Truijens et al., Reference Truijens, Zühlke-van Hulzen and Vanheule2019). Kendall and Beidas (Reference Kendall and Beidas2007) argue for a compromise, ‘flexibility within fidelity’. This suggests, for example, that practitioners should always undertake exposure tasks during certain sessions, but the nature of exposure should address the individual’s anxiety, as judged by the practitioner. Chorpita et al. (Reference Chorpita, Daleiden and Weisz2005) describe a continuous manualisation scale, suggesting all facets of manuals could be varied to differing degrees. Keeping in mind the ultimate objective of improving outcomes for YP, the important issues are identifying which treatment components are crucial, which can or should be adapted, and how this should be done (Durlak and DuPre, Reference Durlak and DuPre2008).
Workbooks
Workbooks occupy a novel position in the fidelity–flexibility debate. Workbook authors describe workbooks as non-prescriptive collections of materials to help practitioners design and adapt psychological interventions (Stallard, Reference Stallard2002). One example of a CBT workbook is Think Good – Feel Good (TGFG) (Stallard, Reference Stallard2002, Reference Stallard2018). It is publicly available and widely used; a survey of Principal Educational Psychologists (EPs) in Scotland found that, of 21 services in which EPs delivered CBT, TGFG was used in 12 services (57%) (Greig et al., Reference Greig, MacKay and Ginter2019). TGFG contains background material on CBT, psychoeducational material, and worksheets exploring key concepts. It is accompanied by a Clinician’s Guide focusing on the CBT process (Stallard, Reference Stallard2005, Reference Stallard2021). TGFG chapters introduce thoughts, feelings and behaviours, before looking at controlling and changing each area. Other CBT workbooks for practitioners exist, such as ‘Coping Cat’, which is much more standardised than TGFG and has been subject to a considerable amount of controlled research to establish its efficacy (Podell et al., Reference Podell, Mychailyszyn, Edmunds, Puleo and Kendall2010).
There is currently scarce peer-reviewed research exploring usage of TGFG. Two unpublished dissertations involved delivering standardised programmes based on TGFG to 4th to 6th grade children with anxiety (Erhardt, Reference Erhardt2019) and Year 5 classes (Brightmore, Reference Brightmore2016). Both studies found equivocal results and had statistical weaknesses such as failing to establish stable baselines and undertaking several uncorrected tests. Moreover, by idiosyncratically designing standardised programmes, these studies limited their external validity. TGFG users could not easily replicate such standardised programmes and are discouraged from doing so by Stallard: ‘TGFG is not intended to be delivered systematically’ (Stallard, Reference Stallard2018; p. 26).
The current study
The concept of the workbook as a set of resources and guiding principles is under-explored in the research literature but potentially useful for practitioners. The current study focuses on TGFG as an example of a widely used workbook, considering how the format helps practitioners. This fits within the approach of implementation science, examining how interventions operate in practice and factors influencing outcomes (Bauer and Kirchner, Reference Bauer and Kirchner2020). The research question (RQ) is:
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How do practitioners use a CBT workbook to support therapeutic work with YP?
Method
This study used a one-phase, convergent mixed-methods design (Creswell and Clark, Reference Creswell and Clark2017; Jick, Reference Jick1979). Quantitative and qualitative data were collected simultaneously, analysed separately, then discussed jointly (Creswell and Clark, Reference Creswell and Clark2017; Morse, Reference Morse1991). Ethical approval was obtained from a university ethics committee in England.
Procedure
This study consisted of an online survey with closed and open questions, producing quantitative and qualitative data. A fixed, cross-sectional design was used, with a self-report survey administered once. The survey method was chosen to collect data from many participants, to explore how TGFG is typically used and the breadth of usage. The survey was piloted with three experienced TGFG users and minor alterations to question wording were made based on feedback. The survey was live between 9 November 2020 and 24 June 2021. See Appendix (in the Supplementary material) for the full survey. Questions addressed: ‘The support you provide’, ‘The YP with whom you work’, ‘Your use of TGFG’, ‘Your opinions on TGFG’, and ‘About you’. The survey was designed to strengthen construct validity: questions were short, avoided emotive language and jargon, avoided leading participants towards certain responses, and addressed specific issues (Barker et al., Reference Barker, Pistrang and Elliott2016; Bradburn et al., Reference Bradburn, Sudman and Wansink2004).
Participants
A purposive sampling strategy was pursued (Robson, Reference Robson2002). The sample population was practitioners with experience using TGFG to support YP. The inclusion criterion was that participants had used TGFG with YP aged 5–18, verified by an eligibility question. Participants gave informed consent for participation.
A priori power analysis was conducted with G*Power software (Faul et al., Reference Faul, Erdfelder, Lang and Buchner2007). The test family was χ2 and the parameters were a medium effect size, significance level of .05, and power of .8. Previous survey research with CBT practitioners (Becker et al., Reference Becker, Smith and Jensen-Doss2013) has found small–medium effect sizes (Cohen, Reference Cohen1988), with odds ratios up to 2.25 (95% CI [1.19–4.25]), justifying our assumption. The minimum desired sample size was 210 participants.
Of 271 organisations contacted, 69 (25.5%) confirmed sharing the survey. There were 1790 visits to the initial information page. Of 362 individuals who self-identified as eligible, 238 submitted responses. This gives a response rate of 13.3% from visits to the initial information page and a completion rate of 65.7% from individuals who self-identified as eligible. Participants were anonymous but demographic information was collected (Table 1). Although data were not collected on participants’ professional roles, 76.8% of organisations who confirmed sharing the survey were UK-based educational psychology services, suggesting that EPs constituted the majority of participants.
Table 1. Demographics of survey participants
Quantitative analysis
Chi-squared tests were conducted to compare responses. To meet the assumption of independence, only questions with single-choice responses were analysed: Questions 2, 3, 8, 9, 15 and 16. Data from Question 16 (Q16) were originally multiple choice but were edited to create a variable that could be analysed. Data from participants who only selected ‘self-taught’ or ‘general CBT training’ were re-coded to a single variable. Other data were disregarded.
Conceptual justifications were made for each comparison to minimise the number of tests conducted and the possibility of Type I errors (Field, Reference Field2013). Q15 and Q16 were compared with the other four questions because it was hypothesised that practitioner experience and training levels would affect workbook usage. Q8 and Q9 were compared because it was hypothesised that practitioners who read from the workbook directly in sessions would be more likely to use worksheets. In larger contingency tables, all expected counts should be above 1, and no more than 20% should be below 5 (Field, Reference Field2013). To meet these assumptions, it was necessary to combine some responses. The Holm adjustment was made to correct for the increased risk of Type I error arising from multiple comparisons (Chen et al., Reference Chen, Feng and Yi2017; Holm, Reference Holm1979). Where omnibus chi-squared tests were significant, post hoc explorations were conducted by analysing standardised residuals (z) (Sharpe, Reference Sharpe2015). Standardised residual values of ±1.96 were considered statistically significant at p<.05. Cramér’s V (ϕ c) effect sizes are reported.
Qualitative analysis
Qualitative data were analysed using content analysis, which involves calculating frequencies of categories within qualitative data (Krippendorff, Reference Krippendorff2018). This method was chosen because survey data had little detail or contextualisation. We aimed to explore how practitioners typically use TGFG, which requires quantitative data showing proportions.
Content analysis involves data unitisation; a unit is an individual element that can be distinguished from other elements and counted (Krippendorff, Reference Krippendorff2004). Two ways of defining units were employed: categorical and thematic distinctions. For Q10 and Q11, a deductive coding process was followed, the focus was on manifest content of responses (Potter and Levine-Donnerstein, Reference Potter and Levine-Donnerstein1999), and categorical distinctions were made based on lists of worksheets and chapters in TGFG (Krippendorff, Reference Krippendorff2004). For the remaining data, an inductive coding process was followed, the focus was on latent patterns in responses (Potter and Levine-Donnerstein, Reference Potter and Levine-Donnerstein1999), and thematic distinctions were made based on the researchers’ judgement (Krippendorff, Reference Krippendorff2004).
Some responses contained multiple data units, which were coded separately. Responses were discarded if they were unclear or irrelevant. ‘Other’ responses were re-coded to original response options when appropriate.
The first author coded the whole dataset. An independent second coder analysed 10% of the dataset across four survey questions to establish inter-coder reliability, using the coding frame created by the first author (O’Connor and Joffe, Reference O’Connor and Joffe2020). Percentage agreement was M=85.5% (SD=11.1%, range: 75–100%); this was calculated by dividing the number of agreements by the number of decisions. Although percentage agreement does not take account of chance occurrence, it is considered an acceptable measure for nominal data when the coding task is straightforward (Feng, Reference Feng2014).
Following coding, themes and sub-themes were identified by the first author and validated by the second author to summarise the dataset (Braun and Clarke, Reference Braun and Clarke2006, Reference Braun and Clarke2022). This was an interpretive process that aimed to summarise the most important points in relation to the RQ; there were no standardised criteria for themes to consist of a certain number of codes.
Reflection
The researchers took a theoretical perspective of pragmatism (Creswell and Clark, Reference Creswell and Clark2017), which holds that knowledge should be useful and practical for human endeavour (Barker et al., Reference Barker, Pistrang and Elliott2016). Given the lack of previous research on TGFG, this study took an exploratory approach, meaning the researchers played an active role in designing data collection measures (Stebbins, Reference Stebbins2001). The researchers’ experiences and perspectives influenced data analysis; other researchers may have reached different conclusions based on the same data (Kvale, Reference Kvale1994). The primary researcher was a newly qualified EP, had four days’ CBT training, and had some experience using TGFG; the second researcher was an experienced EP.
Results
Descriptive statistics
The support you provide
Most practitioners use TGFG exclusively with individuals (75.11%). Very few use TGFG exclusively with groups (3.38%). The rest use it with both individuals and groups (21.52%). The most common average number of TGFG sessions is 4–6 (46.64%), with a sizeable proportion using 1–3 (20.59%) or 7–9 (19.3%), fewer using 10–12 (10.9%) or 13–15 (2.5%), and none using 16+.
The YP with whom you work
The youngest age of YP with whom TGFG is used is M=9.01 years (SD=2.26, range: 5–16). The average age is M=11.26 years (SD=2.03, range: 7–17). Practitioners use TGFG with YP with anxiety (96.2%), behaviours that challenge (64.1%), depression/low mood (60.8%), emotionally based school avoidance (39.2%), attachment difficulties (32.9%), difficulties with attention/hyperactivity (27.4%), and bullying/social exclusion (24.9%). Deciding whether TGFG is appropriate depends on the nature (87.4%) and severity (41.2%) of the YP’s difficulties; few practitioners use TGFG for all social-emotional difficulties (1.3%).
Your use of TGFG
Most practitioners do not read directly from TGFG during sessions, instead using it as a prompt/reminder (40.7%). Of those who read directly from the workbook, most share it with the child (17.4%) rather than keeping it to themselves (0.4%). Some only use TGFG outside sessions, as a planning aid (36.4%). Most practitioners use worksheets during sessions (79.7%). Some use worksheets for homework (6.4%). Some do not use worksheets (7.2%).
Your opinions on TGFG
The most helpful aspects of TGFG are worksheets (80.2%), use as a planning aid (80.2%), introductory CBT chapters (46%), characters (43.9%), and ‘Helpful Tips’ sections (31.6%). Some participants use TGFG as a ‘manual’ to read from (19.8%). Aspects practitioners think YP find engaging are worksheets (84.1%), characters (45.8%), ‘Helpful Tips’ sections (28.2%), and reading directly from the workbook (8.4%).
Inferential statistics
Table 2 summarises the chi-squared tests conducted.
Table 2. Summary of tests conducted, chi-squared values (χ2) and significance levels (p)
There was a significant association between years of experience and whether TGFG was used with individuals or groups, χ 2 (3)=15.199, p=.002, ϕc=.254. Participants with 6–10 years of experience were significantly more likely to use TGFG with groups than expected (z=2.6, p=.009). There was not, however, a consistent linear relationship between years of experience and likelihood of using TGFG with groups.
There was a significant association between years of experience and type of training, χ 2 (3)=13.253, p=.004, ϕc=.289. Participants with 0–2 years of experience were significantly more likely to be self-taught using TGFG (with no formal CBT training) than expected (z=2.1, p=.036). Being self-taught was associated with having less experience.
There was a significant association between how participants used TGFG within sessions and type of training, χ2 (2)=15.34, p<.001, ϕc=.315. Self-taught participants were significantly more likely to read directly from the workbook than expected (z=2, p=.046) and significantly less likely not to read directly from the workbook than expected (z=–2.3, p=.021).
The association between how participants used TGFG within sessions and whether they used worksheets closely approached significance (the adjusted threshold was p=.007), χ2 (2)=9.458, p=.009, ϕc=.21. The majority of respondents used worksheets. These respondents were distributed across workbook groupings in line with chance expectation. Of those who did not use worksheets, fewer than would be expected by chance read directly from the workbook (z=–2.2, p=.028).
Content analysis
The number of ‘Other’ responses ranged from 3 for Q12, to 48 for Q7. For Q7, 18 codes were defined, the most of any question with pre-defined response options. Open response questions attracted many responses: 160 for Q10, 161 for Q11, and 100 for Q14. For Q14, 55 codes were defined, showing the relative richness of the dataset. Across all questions, 24 responses were re-coded to original response options and 56 responses were excluded for being unclear or irrelevant. Themes and sub-themes are summarised in Table 3.
Table 3. Themes and sub-themes about how practitioners use a CBT workbook
Theme 1: Decision-making
This theme describes practitioners’ criteria for deciding whether to use TGFG: ‘presenting difficulty’, YP’s ‘understanding’, YP’s ‘motivation’, and ‘systemic support’.
Practitioners described using TGFG with YP who have at least 16 ‘presenting difficulties’. ‘Other’ responses were autism, obsessive compulsive disorder, anger, trauma, bereavement, Tourette’s syndrome, and selective mutism. Almost all respondents selected multiple options, suggesting TGFG is seen as a ‘go to’ tool for supporting social-emotional difficulties. Although 2/3 respondents use TGFG with YP exhibiting behaviours that challenge, just two respondents selected this as their only response. One practitioner articulated, ‘Although the referral may be about challenging behaviours there is often an underlying social emotional need and the workbook can help to address this’.
Regarding ‘understanding’, practitioners consider general ability levels, developmental age, ability to understand CBT concepts, reflection and metacognitive skills, ability to make conceptual links, whether the YP has learning difficulties, expressive language skills, and literacy skills. Only three responses referred to chronological age as a criterion, suggesting developmental maturity is more important. Respondents did not refer to standardised assessments for judging children’s skills, suggesting these are qualitative judgments.
‘Motivation’ was only mentioned in six responses and explained by one practitioner as ‘wanting to change’.
‘Systemic support’ was seen as a bureaucratic bottleneck. Twelve practitioners reported schools being reluctant to allow extended therapeutic work because it was an inefficient use of practitioner time. Practitioners described other adults supporting YP beyond the intervention, including the availability of school staff and the quality of familial support.
Theme 2: Workbook usage
This theme concerns practical ways practitioners use TGFG.
Outside the therapeutic space (where interactions with YP occur), TGFG is used as a planning aid by 80% of practitioners, supporting them in terms of efficiency (practicalities in preparing an intervention) and understanding (education or revision of concepts). This includes explaining CBT concepts, structuring practitioners’ thinking, reminding practitioners what to cover, providing ready-to-use resources, and inspiring creativity. Positive aspects include TGFG’s convenience, range of resources, structure, and accessibility.
A few practitioners (5%) use TGFG systemically, copying worksheets for teaching assistants (TAs), sharing the workbook for school staff to read from as a ‘manual’, supporting delivery of staff training, explaining CBT to parents, and sharing resources with parents to act as ‘co-therapists’. One practitioner felt too busy to carry out the work themselves; another provided supervision to TAs. One practitioner noted, ‘Lots of my schools use it already with children’.
Inside the therapeutic space, nearly two-thirds of practitioners bring the TGFG workbook and around 80% bring worksheets, showing supplementary resources are commonplace in therapeutic spaces. An important pedagogical use of TGFG involves completing worksheets. One practitioner summarised the impact of worksheets as ‘[they] begin to take the “inside” thoughts/feelings to a more concrete and objective state for the YP. Something about seeing it in black and white, written down helps with cognitive diffusion and supports appraisal’. The most substantial and consistent finding was that practitioners value supplementary resources with a cognitive focus above those with emotional or behavioural foci. The six cognition-focused chapters are the six most used and 9/10 of the most-used worksheets come from these chapters. One practitioner noted, ‘Children often want management strategies (at the end of the workbook) and to understand why they feel the way they feel (starting chapters)’. Cognitive resources contribute to self-understanding, which YP value, forming a foundation for practical ‘management strategies’.
‘Making therapeutic progress’ involved developing shared understanding, eliciting core beliefs, and prompting extended discussions. Although there were few such responses, they conveyed a sense that TGFG could function beyond pedagogy, actively contributing to more complex constructs such as self-reflection, self-understanding, and insight, such as, ‘helps the practitioner and the client conceptualise their difficulties and work to a shared understanding of how to move forward’.
‘Engaging YP’s interest’ was considered important for building therapeutic alliance. Practitioners saw worksheets, ‘Helpful Tips’ and TGFG ‘Characters’ as both helpful and engaging to the same degree. Only 28% of practitioners considered ‘Helpful Tips’ engaging; these are concise summary statements of chapters that provide pedagogical efficiency. Just 7% considered reading from TGFG engaging (despite 20% considering it helpful). One way of closing this gap between practitioners finding ‘reading aloud’ more helpful than engaging could be to focus on reading ‘Helpful Tips’ rather than longer passages, as they require less focus time and are more memorable. Their sparse use might result from being dotted throughout chapters, thus requiring more effortful searching out compared with self-contained worksheets.
One distinct aspect of worksheets is that they are interactive, requiring active participation from YP, which likely contributes to being perceived as engaging (84%). Practitioners feel the most engaging worksheets are those involving visuals and drawing, perhaps because they engage multiple sensory modalities (Clark and Paivio, Reference Clark and Paivio1991). One practitioner described the benefit of a child-centred approach for avoiding complacency, ‘[I] try to approach the text afresh, keeping the child’s needs in mind rather than my favourite resources’. From Q10, 62% of worksheets across all editions of TGFG were considered engaging, including: ‘What thinking errors do you make?’ (33 references), ‘The magic circle’/‘The negative trap’ (20), and ‘Thought/Feelings thermometer’ (17). From Q11, 85% of chapters across all editions of TGFG were considered useful including ‘Thinking Errors’ (46), ‘Thoughts, feelings, and what you do’ (27), ‘Automatic thoughts’ (26), and ‘Balanced thinking’ (20).
Theme 3: Workbook reflections
This theme concerns reflections on how TGFG should form part of therapeutic interventions: ‘Flexibility’ explores the degree to which interventions should be run prescriptively, ‘Adaptability’ explores the degree to which individual resources should be modified, and ‘Risks and limitations’ explores potential challenges with using TGFG.
Regarding ‘Flexibility’, several practitioners described their approach as ‘dip in and out’. Some use TGFG resources within other CBT-based approaches. Some create bespoke interventions by combining TGFG with other therapeutic approaches, such as personal construct psychology, and acceptance and commitment therapy. This gives an impression of pragmatism, taking what works from TGFG and leaving what does not. This approach was the most commonly mentioned response to Q14 (20 occurrences).
Regarding ‘Adaptability’, practitioners alter resources to suit YP’s interests, to address specific mental health issues, to make resources more interactive and practical, to make resources more engaging and visual, and to differentiate for YP’s understanding levels.
Most survey respondents who discussed ‘Flexibility’ and ‘Adaptability’ saw these as positive attributes. However, some respondents highlighted risks that could detrimentally affect therapeutic practice. One wrote, ‘I recall being surprised that one could leapfrog through the activities. On one hand this enables flexibility, on the other it risks adults making decisions that assume secure knowledge in one area that the child would need to successfully access an activity’. Another wrote, ‘Makes me shake my head when I think about practitioners doing “a bit of CBT” and pulling out TGFG’. These responses highlight the risks of flexibility, suggesting that the accessible nature of TGFG might unintentionally encourage sub-optimal CBT practice. Taking a ‘dip in and out’ approach might under-estimate the cumulative nature of CBT, where certain concepts are foundational and should be understood prior to tackling other concepts. Similar reasoning is used in the response, ‘there is a lot in the book – whilst on the face of it this is good, a lot of the nuance of “good quality” CBT can be lost’. The number of resources available could be overwhelming. Moreover, practitioners might rely on concrete resources to the detriment of interpersonal skills, ‘the main thing is the skills and values that the therapist holds and their ability to develop a therapeutic relationship. Less about the resource – this just provides helpful stimuli for discussion’.
Discussion
This study explored how practitioners use a CBT workbook, TGFG, to support therapeutic work. These data are valuable given the paucity of existing research about CBT workbooks, providing a practice-based perspective to compare against recommendations from controlled trials.
The prevailing view is that TGFG is not a manual to be followed prescriptively; this fits with how Stallard recommends TGFG is approached (Stallard, Reference Stallard2018; p. 26). Practitioners described pragmatically incorporating TGFG’s CBT resources with other therapeutic approaches. From one perspective, pragmatism could be described as defying evidence-based practice in favour of practitioner judgement. From another perspective, it is taking an applied scientific approach to practise, testing and combining different approaches based on what works for individuals in unique circumstances (Barker et al., Reference Barker, Pistrang and Elliott2016; Fonagy et al., Reference Fonagy, Cottrell, Phillips, Bevington, Glaser and Allison2005). Future research could evaluate the effectiveness of pragmatic approaches and how they are perceived by practitioners.
The degree to which practitioners use TGFG flexibly was related to levels of experience and training. Practitioners self-taught using TGFG were statistically more likely to have the least experience and to read directly from TGFG, compared with practitioners with formal CBT training. As the survey was cross-sectional, no claims are made for causality. Either experience, training, or both, might lead practitioners to develop skills and confidence so they grow less reliant on reading directly from TGFG. TGFG remains useful to the most experienced practitioners, as the largest group of survey respondents had 11+ years of experience. Experience was not statistically related to number of sessions, worksheet usage, or workbook usage.
A significant relationship has previously been found between therapist adaptability and child engagement (r=.25, p=.05), which in turn was significantly related to positive outcomes (Chu and Kendall, Reference Chu and Kendall2009). Across 20 courses of CBT, 87.5% of sessions involved manual content being adapted, most commonly to match YP’s interests or abilities. A recent systematic review of 538 patients across three non-hierarchical study designs identified small, significant associations (r=.15, 95% CI [.06–.23], p<.001) between positive outcomes and therapist integrity, a measure of how practitioners use skill and judgement to differentiate prescribed therapeutic methods (Power et al., Reference Power, Noble, Simmonds-Buckley, Kellett, Stockton, Firth and Delgadillo2022). The current findings suggest workbook resources are adapted as manuals are. Nonetheless, 20% of respondents found it helpful to read directly from TGFG without adaptation, perhaps because certain sections are perceived as high quality or convenient.
There are several conjectural explanations for why cognition-focused resources were the most used. It could reflect that cognitive insight is at the heart of achieving change through CBT, so is prioritised for consideration (Kaplan et al., Reference Kaplan, Thompson and Searson1995). It could reflect that cognitive concepts are difficult to explain and hard to understand (Verduyn, Reference Verduyn2000), and are easily confused with feelings (Belsher and Wilkes, Reference Belsher, Wilkes, Wilkes, Belsher, Rush and Frank1994), so physical resources make ideas tangible and concrete. It could reflect that cognitive elements are distinctive to CBT in comparison with other therapeutic approaches, so resources with emotional or behavioural foci are available elsewhere. Given that this study did not measure outcomes, all that can be concluded is that practitioners favour the use of cognition-focused resources; future research could explore why. YP themselves often identify behavioural elements of CBT as of increased importance, perhaps because they want to see tangible evidence of change (Jones et al., Reference Jones, Hassett and Sclare2017). Insight can be gained by analysing the most-used worksheet, ‘What thinking errors do you make?’, as an example. This questionnaire narrows down a generic list of thinking errors to those relevant to individuals. The worksheet trades open discussion for systematic choices, helping practitioner and YP focus on pertinent information, reducing cognitive load for processing novel information, and providing insight (Schnotz and Kürschner, Reference Schnotz and Kürschner2007). The worksheet facilitates strengths-based consideration of ways YP do not make thinking errors, enabling practitioners to challenge narratives of hopelessness (Zimmerman, Reference Zimmerman2013). The worksheet has boundaries (i.e. questions to answer) so can be completed, leading to a sense of achievement which could enhance motivation.
TGFG was most commonly used with late primary school and early secondary school age-groups. There is a significant rise in emotional difficulty prevalence during early adolescence (NHS, 2018) along with a rise in metacognitive and self-reflective skills (Veenman and Spaans, Reference Veenman and Spaans2005). Few practitioners discussed the importance of YP being motivated to engage in interventions. Many YP themselves identify that achieving positive change requires attending sessions persistently, despite the challenging nature of CBT (Jones et al., Reference Jones, Hassett and Sclare2017). Practitioners may be under-estimating the importance of motivation. Almost all practitioners work with YP with anxiety and 61% work with YP with depression. ‘Anxiety disorders’ are over three times more prevalent among 5- to 19-year-olds than ‘depressive disorders’ (NHS, 2018) but there is strong evidence supporting CBT with both populations (David-Ferdon and Kaslow, Reference David-Ferdon and Kaslow2008; Sigurvinsdóttir et al., Reference Sigurvinsdóttir, Jensínudóttir, Baldvinsdóttir, Smárason and Skarphedinsson2020). In contrast, the evidence base for CBT addressing ‘challenging behaviours’ is weaker, with a review of 24 studies tentatively finding CBT had a small–medium effect on episodes of challenging behaviour (Ho et al., Reference Ho, Carter and Stephenson2010). The fact that nearly 2/3 practitioners work with YP with ‘challenging behaviours’ may reflect the high prevalence of ‘behavioural disorders’ among YP (NHS, 2018) and the fact that this challenges school staff, leading to referrals for professional support (Anderson, Reference Anderson1997).
Over two-thirds of practitioners used TGFG for 1–6 sessions, at the lower end of the 5–20 CBT sessions recommended by the NHS (2019). A survey of how EPs conduct therapeutic interventions found that the two most common barriers were ‘limitations of service time allocation model’ and ‘service capacity’ (Atkinson et al., Reference Atkinson, Bragg, Squires, Muscutt and Wasilewski2011). A study of adults with panic disorders found a consistent decrease in outcome symptom severity as a function of sessions attended, up to at least six sessions, which was maintained at 12-month follow-up (Craske et al., Reference Craske, Roy-Byrne, Stein, Sullivan, Hazlett-Stevens, Bystritsky and Sherbourne2006). There is a tricky balance between practitioners providing support broadly to enable fair access (British Psychological Society, 2018) and acknowledging that positive therapeutic outcomes take time.
From the current sample (which likely consisted primarily of EPs), 20% were exclusively self-taught from TGFG and only 2% had training specifically about TGFG. For that 20%, TGFG was not an adjunct but the foundation of knowledge and practice. Among registered psychological practitioners, some argue that initial training courses provide the requisite skills to undertake CBT (Squires, Reference Squires2010). In a survey of Scottish EP services, 57% felt EPs were ‘well’ or ‘very well’ equipped to deliver therapeutic interventions through initial training (Greig et al., Reference Greig, MacKay and Ginter2019). However, given that TGFG is publicly available, no training is required to use it. On one hand, this encourages broad access to something potentially helpful and supports practitioners in myriad ways. On the other, it could give people false confidence that they can help someone without necessarily possessing interpersonal therapeutic skills or working within support systems such as supervision (Dunsmuir and Leadbetter, Reference Dunsmuir and Leadbetter2010).
Limitations
This study was not pre-registered; doing so could have helped identify and resolve methodological and analytical weaknesses (Dirnagl, Reference Dirnagl2020). Several questions (such as Q6 and Q7) elicited many ‘Other’ responses, suggesting the original options were reductive. If all respondents had a broader range of options to choose from originally, data collection would have been more comprehensive. This could have been addressed by piloting the survey more widely. Whilst the intention was for responses to remain anonymous, collecting data on ethnicity, professional role, and biological sex would have facilitated further cross-group comparisons and demographic analyses. More stringent inclusion criteria around practitioners having a specified amount of experience using TGFG (e.g. number of cases worked with) could have facilitated more informed viewpoints, although the intention of the study was to gain a realistic perspective of how TGFG is used in practice, which includes less experienced practitioners. The self-selected sampling procedure could have caused bias of respondents who were particularly interested in using TGFG, restricting the external validity of the results (Barker et al., Reference Barker, Pistrang and Elliott2016). Although multiple response questions gave respondents greater flexibility and facilitated analysis of response combinations, these questions could not be converted to variables for statistical cross-group comparisons.
Practice recommendations
CBT workbooks have various uses for practitioners across the range of experience working with YP. Within sessions, practitioners can use worksheets, ‘Helpful Tips’, characters, and reading directly from a workbook to help explain CBT content, build rapport, and engage YP. Outside sessions, practitioners can use workbooks as planning resources, providing practical efficiency and background understanding. Workbooks can be used flexibly, in combination with other therapeutic approaches, and resources can be adapted to suit YP’s interests and needs. However, practitioners should acknowledge the limitations of flexibility, ensuring that workbook-based CBT does not become an exercise in completing worksheets to the detriment of developing the interpersonal relationship. Alliance is an important variable in achieving change from psychotherapy and is related to positive outcomes with an average effect size of .24 (Castonguay et al., Reference Castonguay, Constantino and Holtforth2006). Practitioners should consider how to negotiate referrals effectively; tensions may exist between the evidence base for CBT effectiveness and pressure from schools to work with children considered disruptive or to keep interventions short. Practitioners who are exclusively self-taught using TGFG may consider whether further training could benefit their practice; a simple first step would be to read the Clinician’s Guide.
Conclusion
This exploratory study focused on practitioners’ views of how a CBT workbook (TGFG) is useful as a therapeutic adjunct. TGFG is employed by practitioners across the range of experience and is considered useful inside and outside the therapeutic space. Outside, practitioners use TGFG to plan sessions and revise CBT concepts. Inside, practitioners use TGFG worksheets (particularly those with a cognitive focus) to explain content, make therapeutic progress, and engage YP. Practitioners described adapting worksheets to simplify them or personalise them to YP’s interests. Practitioners described taking a pragmatic approach to therapeutic delivery, ‘dipping in and out’ of TGFG and combining CBT with other therapeutic approaches based on professional judgement. This study had several methodological limitations which limit external validity. However, it is hoped that this study’s exploratory findings about an under-researched but widely used therapeutic adjunct (the workbook) will support future research about how TGFG is used by other professionals (such as teachers), how other CBT workbooks are used, and other methodological approaches such as video microanalysis of therapeutic interactions involving workbooks (De Jong et al., Reference De Jong, Bavelas and Korman2013).
Key practice points
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(1) TGFG is used by practitioners across the range of experience; it may be especially useful for boosting the confidence of novices.
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(2) TGFG is considered useful by practitioners both inside and outside the therapeutic space, for planning sessions and completing worksheets with YP.
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(3) Practitioners commonly take a pragmatic approach to adapting resources and combining CBT with other therapeutic modalities.
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(4) Resources explaining cognitive elements of CBT are the most used.
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(5) Supplementary resources (i.e. worksheets) can help to explain content, build rapport, and engage YP.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1754470X23000338
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
None.
Author contribution
James Redburn: Conceptualization (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Writing – original draft (lead), Writing – review & editing (lead); Ben Hayes: Conceptualization (supporting), Methodology (supporting), Supervision (lead), Writing – review & editing (supporting).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
Ethical considerations were reviewed in line with the British Psychological Society (BPS) code of conduct and those drawn from the British Association for Counselling and Psychotherapy (BACP) Ethical Framework to inform best research practice. This study received approval from University College London Research Ethics Committee by an independent panel made of a team of academics in November 2020 (Ethics Code: 18753/001). All participants provided informed consent and agreed for the results to be published.
Open access
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