Training cognitive behavioural therapy practitioners in New Zealand: from University to clinical practice.

The present study evaluated the transfer of skills taught in a Cognitive Behavioural Therapy training programme to work practice. Seventy-three past trainees from varying mental health professions completed self-report questionnaires exploring key aspects of transfer. The results showed that, overall, there was a moderate degree of perceived transfer and a high degree of confidence in using CBT techniques. Statistically significant differences in transfer scores were found between groups with different current therapeutic approaches, age groups of clients, and therapy formats. Significant positive correlations were found between the transfer outcome and two variables: perceived confidence in using the CBT skills, and the perceived impact of the CBT training on skills and knowledge. The most helpful factors and influential barriers in the transfer of CBT training were identified. Results were consistent with findings from previous CBT studies and Goldstein and Ford's (2002) theory of the transfer process. Limitations and strategies to enhance the transfer of training are highlighted.

**********

The 'transfer of training' issue is a well-documented and researched phenomenon (Heaven, Clegg & Maguire, 2006). Even if trainees acquire high quality skills during training, there is no guarantee that they will apply those skills correctly, or at all, in the work setting (Jahr, 1998). In the clinical context, transfer of training is of paramount concern as many efficacious and/or promising psychosocial treatments do not necessarily transfer from the clinical research environment (Corrigan & McCracken, 1997; Milne, Dudley, Repper & Milne, 2001). For instance, in one study, the implementation of four different behaviour programmes was evaluated, and none were adopted successfully (Stolz, 1981). Another study found that only 10% of training expenditure could be expected to be transferred to the workplace (Georgenson, 1982).

The majority of research investigating training in cognitive behavior therapy (CBT; Beck, Rush, Shaw & Emery, 1979) has focused on evaluating the competence of trainees (Freihelt & Overholser, 1997; Kingdon, Tyrer, Seivewright, Ferguson & Murphy, 1996; Shaw et al., 1999). The results of previous studies evaluating the transfer of a variety of CBT training programs show an improvement in knowledge acquisition and competence, and that the majority of trainees successfully transfer skills from training (Ashworth, Williams & Blackburn, 1999; Freiheit & Overholser, 1997; Hull & Swan, 2003; Milne, Keegan et al., 2000; Myles & Milne, 2004). It is argued that there is a need to extend the analysis of CBT training to include transfer as a follow-up assessment of competency (Milne, Baker, Blackburn, James & Reichelt, 1999). This need stems from research demonstrating that measures of knowledge in treatment techniques are not a sufficient and reliable indicator of clinicians' behaviour change in the clinical setting (Reid & Whitman, 1983; Whitman, Scibak & Reid, 1983).

Taking this into account, a sample of 90 mental health professionals who attended a 12 week CBT training course were found to have a significant increase in use of nearly all CBT techniques between three months pre-training and the three months post training (Myles & Milne 2004). In another study, a sample of 40 clinical psychology graduates used significantly more CBT techniques at the end of a nine-month CBT training practicum than at the beginning (Freiheit & Overholser 1997). The trainees in Milne, Keegan et al. (2000) also reported significant improvements in their use of learned skills in CBT and other psychosocial interventions for severe mental illness across time, persons, settings, and behaviour. A limitation of several of these studies is the use of an oversimplified pre-post design to evaluate changes in use of CBT skills.

In contrast, some studies showed less successful results of transfer. For example, Kavanagh et al. (1993) assessed the implementation of CBT family interventions for schizophrenia, and found that only 18% had applied their learned skills with more than three different clients, demonstrating poor transfer of skills. Furthermore, a written quiz indicated that 70% of these trainees did not even display a minimal recall of the cognitive therapy material covered in training to competently apply it in practice. Another study showed that although consultant psychiatrists are getting increasing amounts of formal training in CBT, many are unable to incorporate the techniques into everyday practice due to medically-related time constraints around such issues as diagnostic assessment and drug treatment (Le Fevre & Goldbeck, 2001).

Factors in the Transfer Process: Barriers and Strategies