The Progressive Cascading Model (PCM) is a competency-based approach for training novice therapists inexposure therapy techniques. It involves multiple tiers of experiential learning tailored to the trainee’s skill level.
Trainees first observe treatment sessions, then act as therapy aids assisting more senior clinicians in carrying out exposures. As competencies develop in areas like case conceptualization and exposure delivery, trainees take on roles as junior co-therapists, independent therapists, and eventually supervisors mentoring the more junior trainees.
Throughout the process, trainees receive layered supervision and feedback from both licensed providers and peers at various stages of the cascading model.
The PCM aims to provide an intensive yet scalable framework for graduate students to gain competency in evidence-based exposure methods through modeling, social learning principles, and individualized supervision to enhance disseminating these techniques into community practice after graduation.
illustration of a man holding a clipboard and a spider in a container. a woman in front of him cowering in fear of the spider.
Key Points
Rationale
Exposure therapyis a highly efficacious treatment for anxiety disorders, yet many therapists fail to implement it or do so suboptimally in community settings (Higa-McMillan et al., 2016; Hipol & Deacon, 2013).
Researchers believe insufficient graduate-level training in exposure techniques significantly contributes to this problem (Shafran et al., 2009; Weissman et al., 2006).
The Progressive Cascading Model (PCM) was developed as a competency-based method to train novice therapists in exposure therapy (Balkhi et al., 2016), but empirical evaluation of its effectiveness was still needed.
Method
Forty-two trainee therapists completing a 5-6 month rotation at aspecialty OCD clinicwere trained in the PCM model.
The PCM utilizes experiential and social learning theory across increasing trainee responsibility tiers. It begins with didactics on exposure therapy principles and debunking myths.
Trainees then observe sessions, act as exposure aids to experienced clinicians, then junior co-therapists before independent practice and supervision roles.
Procedure
The 42 trainees completed rotations averaging 5-6 months where they implemented exposure therapy. Trainees treated approximately 11 OCD patients each, though exposure hours are unknown.
Patients typically had severeOCD(Yale-Brown scores of 26-27) and around one comorbid condition like depression.
Trainees worked with a mix of around six youth and five adult patients across their rotation. Cotherapy with a supervisor occurred constantly for 26% of trainees, often for 52%, sometimes for 19%, and rarely for 2% – allowing for layered supervision.
Sample
Mostly female psychology graduate students and pre/post-doctoral fellows in clinical psychology programs, with an average age of 27 years old.
Measures
Trainees reported on exposure therapy behaviors, beliefs about exposure, and personal sensitivities before and after training:
Statistical Measures
Repeated-measures MANOVAs were used to assess pre-post changes on target variables and differences based on trainee experience level.
Results
Insight
The Progressive Cascading Model significantly improved the quality of exposure therapy delivery and attitudes/sensitivities related to utilizing exposure techniques among trainee therapists.
After going through the PCM program, trainees reported that they delivered exposures more effectively – they used more methods to intensify the exposures and confront patients’ fears thoroughly. They also relied less on cautious behaviors that weaken exposures or make patients too comfortable.
Beyond real therapy skills, the PCM also improved the trainees’ own comfort levels and attitudes about exposure techniques.
Their worries, doubts, or hesitations about using exposure went way down after observing mentors and trying it themselves. Things like feeling disgusted or avoiding triggers didn’t get in the way as much anymore.
Strengths
Limitations
Implications
The PCM model utilizes experiential and social learning theory to provide layered levels of exposure therapy training tailored to trainees’ needs.
The data suggest it can enhance competency in exposure techniques regardless of prior experience. This has important implications for dissemination, given graduate school is a critical time for shaping therapists’ attitudes and utilization of treatments.
The PCM provides a roadmap for competency-based education in exposure therapy that training programs could readily implement.
If results hold in larger controlled trials, graduate programs should consider implementing this competency-based training model to increase the use of this efficacious yet rarely utilized treatment.
Clinics with expertise in exposure therapy could provide supervised PCM rotations. Future research should examine the sustainability of gains post-training and feasibility across diverse service settings.
Note: The PCM was developed at a clinic which specializes in OCD treatment, thus future research will need to test how well this training model translates to other clinical populations that warrant exposure therapy.
References
Primary reference
Reid, A. M., Guzick, A. G., Balkhi, A. M., McBride, M., Geffken, G. R., & McNamara, J. P. H. (2017). The progressive cascading model improves exposure delivery in trainee therapists learning exposure therapy for obsessive-compulsive disorder.Training and Education in Professional Psychology, 11(4), 260–265.https://doi.org/10.1037/tep0000159
Other references
Balkhi, A. M., Reid, A. M., Guzick, A. G., Geffken, G. R., & McNamara, J. P. H. (2016). The progressive cascading model: A scalable model for teaching and mentoring graduate trainees in exposure therapy.Journal of Obsessive-Compulsive and Related Disorders, 9, 36–42.https://doi.org/10.1016/j.jocrd.2016.02.005
Higa-McMillan, C. K., Kotte, A., Jackson, D., & Daleiden, E. L. (2016). Overlapping and non-overlapping practices in usual and evidence-based care for youth anxiety.The Journal of Behavioral Health Services & Research. Advance online publication.https://doi.org/10.1007/s11414-016-9502-2
Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming: A survey of practicing psychotherapists.Behavior Modification, 37(2), 170–188.https://doi.org/10.1177/0145445512458794
Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M. G., & Wilson, G. T. (2009). Mind the gap: Improving the dissemination of CBT.Behaviour Research and Therapy, 47(11), 902-909.https://doi.org/10.1016/j.brat.2009.07.003
Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., Fitterling, H., & Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work.Archives of General Psychiatry, 63(8), 925–934.https://doi.org/10.1001/archpsyc.63.8.925
Keep Learning
Here are some suggested discussion questions for a course focused on therapist training and dissemination of evidence-based treatments:
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
