Our ever-growing knowledge base for psychotherapy in general and CBT (and related therapies) in particular is the result of many decades of research on principles of human functioning and change. As a field, we have tested and found support for the benefits of teaching our clients skills such as: (1) planning and enacting behavioral activities that boost their sense of accomplishment, enjoyment, and connection, (2) approaching (rather than avoiding) uncomfortable situations that can improve their sense of self-efficacy and expand their life experiences, (3) being self-aware of physiological sensations in a way that allows for a reduction in hyper-arousal, (4) being self-aware of thoughts in a way that allows for cognitive flexibility and perspective-taking, (5) enacting problem-solving to reduce impulsivity and improve one’s life situation, (6) mindfulness, self-soothing and self-compassion methods to moderate dysregulated emotions and promote positive states of mind, (7) communication and assertiveness skills to improve interpersonal relationships, and others. These are categories of interventions in CBT that have produced so many positive outcomes across a range of clinical problem areas (Hayes & Hofmann, 2018).
Therapists are trained to deliver the above (and related) interventions to their clients to meet their individual needs, and to teach their clients to self-apply psychological skills for long-term maintenance. Imparting these interventions is part of what is known as the “functional competencies” of therapists, to go along with such related competencies as possessing diagnostic and case conceptualization skills. It is also important for us to mention the “foundational competencies” of therapists that underlie the above, such as respect for the scientific method, alliance-building skills, self-assessment and self-correction, and cross-cultural humility (Iwamasa & Hays, 2019), among others (see Newman, 2010).
Now that we have briefly summarized the competencies of the CBT therapist, what do we mean by the term meta-competencies? Loosely defined, the term “meta-competencies” refers to those qualities or characteristics that therapists bring to bear on their interactions with clients that maximize the positive impact and staying power of the interventions so that clients find therapy to be memorable, inspirational, and a catalyst for further growth (Whittington & Grey, 2014).
CBT takes a psycho-educational approach to psychotherapy, therefore it is apropos to consider the notion that to some extent therapists are in fact teachers. If we think back to our school days, we recognize that many teachers more or less competently followed a similar rubric (perhaps analogous to a therapy protocol), but some teachers were more memorable and positively influential than others (hence, they possessed greater meta-competencies). What were some of the qualities that those teachers exhibited that helped us not only to learn, but to value learning, and how can we relate these qualities to the meta-competencies of conducting CBT? We may hypothesize that the educational process works best when teachers challenge their students to think for themselves, while still offering guidance if the students struggle. Such teachers may be seen as somewhat demanding, but never demeaning, and they typically demonstrate confidence in their students’ capacity to learn, trying to instill in their students greater belief in themselves. These teachers bring life to the subject material through interesting stories, creative use of language, clarity of communication, and by encouraging lively dialogue on the subject at hand. They show genuine interest in what they are teaching – shown in part by their energy, engagement, and preparedness – and try to inculcate this level of interest in their students so they will want to continue to learn long after their coursework with the particular teacher in question is complete.
We can see how the above readily relates to the tasks that comprise competency and meta-competency in CBT. We take an evidence-based set of procedures and deliver them with a keen understanding of the sensibilities and needs of the client, based in part on having done our homework about the client’s learning history, and in part by paying close attention to the client’s verbal and non-verbal reactions in session so that we are “in tune” with them. We serve as role models for thoughtfulness, composure, sincerity, self-reflection, and perseverance. We practice congruence by utilizing for ourselves the same psychological skills we endeavor to impart to our clients (Bennett-Levy et al., 2015). This not only improves our skill set through repetition, but provides us with enhanced empathy for the clients’ experiences in utilizing interventions, and boosts our hopefulness about therapeutic change because we undergo it ourselves.
The following is a non-exhaustive list of the characteristics we may call meta-competencies – qualities that are not always mentioned in CBT treatment protocols but that play significant roles nonetheless. Some of these meta-competencies have an extensive and ever-growing evidence base (e.g., repairing ruptures in the therapeutic alliance), and some have considerably less of a data base (e.g., matters of timing in delivering interventions), but let us take a glance at some of these hypothesized factors just the same:
- Interweaving the therapeutic relationship with case conceptualization and interventions: The positive power of therapy is amplified when therapists can weave together their conceptual understanding of their clients’ background and current life situation into their manner of interacting with the clients in the here and now (thus being able to express accurate empathy), along with introducing and explaining interventions that fit the needs of the clients and make sense to them.
- Juggling multiple lines of discussion across sessions and within sessions: For maximum breadth of coverage of relevant agenda items, therapists have to keep track of multiple topics, goals, and life circumstances of their clients. Therapists who areorganized, attentive, and adept at “connecting the dots” can address a broad range of client concerns, doing so without ever getting too far off track or losing sight of the central themes being addressed. Being prompt and thorough with clinical documentation assists this process.
- Having an interdisciplinary fund of knowledge: When therapists have a range of personal interests, are well-read, are “students of life,” and learn from each of their clients, they continually improve their ability to connect with their clients by alluding to relevant subject material that clients find personally interesting and compelling (e.g., regarding current events, history, arts and literature, the substance of the client’s profession, the details of the client’s hobbies, the language and customs of the client’s culture, etc.).
- Valuing self-reflection, self-correction, and personal growth: When therapists self-reflect on their work, this is considered a foundational competency in doing psychotherapy. When therapists value thoughtful self-reflection and self-correction as a way of life, it is a meta-competency that helps them develop and mature as human beings, which in turn assists them in their work (see Bennett-Levy et al., 2015).
- Viewing ruptures in the therapeutic alliance as opportunities to do problem-solving. Being adept at forming and maintaining good therapeutic alliances is an important competency. Having a positive outlook about repairing alliance ruptures is a meta-competency whereby therapists model the valuable attitude, “We can work it out.” This meta-competency is related to the ability to demonstrate grace under pressure (Muran & Eubanks, 2020), as therapists may need to maintain a pleasant and hopeful demeanor even in the face of criticism and pessimism expressed by clients. Therapists who welcome the opportunities presented by doing interpersonal problem-solving will enhance both their own and their clients’ interpersonal resiliency and satisfaction.
- Communicating clearly: Therapy is largely a verbal medium. Therapists express empathy, provide psycho-education, share their reflections and conceptualizations, and provide direction in how to implement a wide range of interventions. These are all important competencies in conducting therapy. What makes them meta-competencies is the therapist’s ability to be maximally comprehensible in communicating all of the above, so that clients more readily grasp and retain what the therapist is saying, without having to strain or otherwise work too hard to focus or keep track. Therapists who extensively read, write, and give academic presentations gain a lot of practice in being clear communicators.
- Possessing a good sense of timing: Admittedly, this is subjective and difficult to measure. It can refer to the therapist’s cadence of verbal delivery such that what they are saying provides extra emotional emphasis (similar to the methods of skilled stand-up comedians, stage actors, and orators) or it can refer to knowing when to say something in particular, and when to wait.
- Having facility in using metaphors, imagery, stories, and hypothetical questions to make the messages of therapy more vivid and compelling. Sometimes it is indeed the case that a picture (or a metaphor) is worth a thousand words (Hackmann et al., 2011; Stott et al., 2010). Similarly, a lesson of therapy embedded in an interesting vignette can make a lasting impact, Likewise, thought-provoking hypothetical questions can maximize the power of guided discovery (Newman, 2000; Waltman et al., 2021).
- Knowing how and when to use the best of your personality, including humor and judicious use of self-disclosure. It is a meta-competency when therapists are adept at “using themselves,” such as by having a knack for introducing good-natured mirth and irreverent humor into a session (Linehan, 1993), and perhaps by knowing how to appropriately share one’s own feelings and experiences in the service of bonding with clients and helping them feel better understood (Farber, 2006).
- Having a good memory and using it in the service of creating continuity across sessions, and inspiring clients to remember the lessons of therapy in return. For example, when therapists remember what clients said many sessions ago, they serve as role models for clients to remember what their therapists have said. To make therapy more memorable, we can use methods of “memory support” (Harvey et al., 2016) and we can demonstrate that the clients themselves are memorable.
The above-mentioned meta-competencies may be viewed as tied to the concept of “therapist effects,” referring to personal qualities and habits that make some therapists “better” than others, regardless of modality or theoretical orientation of the therapy being delivered (Castonguay & Hill, 2017). A key question is whether (and/or to what degree) these meta-competencies can be learned through formal training, and/or perhaps via personal growth endeavors (including going through therapy as clients) (see Whittington & Grey, 2014). These are intriguing questions, reminding us that maximizing the efficacy of our psychological treatments is inextricably tied to improving our capabilities as therapists in delivering these treatments.
References
Bennett-Levy, J., Thwaites, R., Haarhoff, B., & Perry, H. (2015). Experiencing CBT from the
inside out: A self-practice, self-reflection workbook for therapists. Guilford Press.
Castonguay, L. G., & Hill, C. E. (Eds.) (2017). How and why are some therapists better than
others? American Psychological Association.
Farber, B. A. (2006). Self-disclosure in psychotherapy. Guilford Press.
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in cognitive
therapy. Oxford University Press.
Harvey, A. G., Lee, J., Smith. R. L., Gumport, N. B., Hollon, S. D., Rabe-Hesketh, S., et al.
(2016). Improving outcomes for mental disorders by enhancing memory for treatment. Behaviour Therapy and Research, 81, 35-46.
Hayes, S. C., & Hofmann, S. G. (2018) (Eds.). Process-based CBT: The science and core
clinical competencies of cognitive behavioral therapy. New Harbinger Publications.
Iwamasa, G. Y., & Hays, P. A. (Eds.) (2019). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). American Psychological Association.
Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder.
Guilford Press.
Muran, J. C., & Eubanks, C. E. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.
Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational,
functional, and supervisory aspects. [For the Special Section on Psychotherapy Competencies and Supervision of Trainees]. Psychotherapy: Theory, Research, Practice, Training, 47(1), 12-19.
Newman, C. F. (2000). Hypotheticals in cognitive psychotherapy: Creative questions, novel
answers, and therapeutic change. Journal of Cognitive Psychotherapy: An
International Quarterly, 14(2), 135-147.
Stott, R., Mansell, W., Salkovskis, P., Lavender, A., & Cartwright-Hatton, S. (2010). Oxford
guide to metaphors in CBT. Oxford University Press.
Waltman, S. H., Codd, R. T. III, McFarr, L. M., & Moore, B. A. (2021). Socratic questioning
for therapists and counselors: Learn how to think and intervene like a cognitive
behavior therapist. Routledge.
Whittington, A., & Grey, N. (Eds.) (2014). How to be a more effective CBT therapist:
Mastering meta-competencies in clinical practice. Wiley Blackwell.
