Clinical Skills in Core and Specific Streams

When we began talking about CAPA in 2005 we realised that we needed a skills framework to be able to describe and think about the various skill sets and skill levels of clinicians in a team and of the whole team. There weren’t any whole service skill frameworks that used the ideas of segmenta- tion, so we created the idea of the ABCD’ S skills (the Alphabet Skills).

This is a framework that allows us to think about the basic skill domains in a predominantly therapeutic service – CAMHS. Other services may have skill sets that overlap with this and may want to add their own. For example cultural competence in New Zealand is such a core issue that they added this to some of their skill set thinking and in adult mental health services there are the skills

of medication, psychiatric assessment and mental health assessments that might also be thought about in this way. In fact, any skill that the service needs can be added to this framework.

These are the ABCD’S skills:

  • Assessment
  • Behavioural
  • Cognitive
  • Dynamic and
  • Systemic.

Any individual clinician may have these skills or some of them. They may also have these at core or advanced level.

Traditional Specialist

A traditional Specialist skills pattern might look like the diagram.

Traditional

This staff member has Advanced level skills in assessment (say autism assessment using a structured tool such as the ADI and ADOS) and in systemic therapy (probably a senior systemic therapist). They could be used in family therapy teams, to do autism assessments and in Core Partnership work using systemic skills. However, they could not be used in a broader way in Core Partnership (for example to do some behavioural work or CBT) and so would be a less flexible member of the workforce.

Extended Core Skills

In the graph below we have shown that now this member of the team has had their skills in the other three domains improved such that they could function at a core level.

Extended

Now we can use them in flexible ways in core work.

They could use their advanced skill at a lower intensity or their core skill at an appropriate intensity.

This is shown by the circled area on the diagram. This single modality core work of average duration is placed in the Core Partnership segmentation.

Core Skills in Advanced

Note that in the diagram to the left the clinician is using their advanced skills at lower intensity…

Core Skills only

…and in this diagram they are using some of their core trained skills at lower intensity without having advanced skills in that modality. Both are single modality core work.

The same member of staff shown below can also now do core work using multimodal integrative skills across several domains.

Core Skills only

For example, integrating elements of dynamic, cognitive and systemic therapy in the treatment of a distressed patient with anxiety who might have another family member with depression (parent or partner). They will not be using a single modality but selecting skills and techniques from their range of modalities that best suits the patient’s needs and goals (and in this example supporting the intervention in the family context). This is shown by the circled skills in the graphic below.

Caution

This is not the recommended skill distribution in CAPA. It is an example to show the effect of ex- tending these core skills by training. In reality few members of the team will have skills across all the clinical skill domains and in fact this is probably not necessary. What is required is that there are enough skills across the team so that the needs of the service users can be met from within the service. This is a bit more of a patchwork quilt of skills at different levels than it is bringing everybody up to exactly the same standard.

An example of Skills in CBT

There is a national framework for CBT in England. This model describes different layers of intensity. In CAPA terms we describe this as low intensity equivalent to core CBT and high-intensity equivalent to advanced CBT skills.

The skills of core CBT could be the ability to explain model, structure sessions, use homework and review homework.

High Intensity (Advanced) CBT in Specific Partnership will use all of those skills as well as techniques for specific conditions such as OCD. These extra techniques could include Socratic questioning/guided discovery, identification of automatic thoughts/assumptions/beliefs and problem specific competencies e.g. in Exposure and Response Prevention for OCD (Dept. of Health, 2007b).

We encourage you to think about what are core and advanced skills competencies in your own team.