Ten generic competences to improve outcomes of cognitive behaviour therapy: evidence, postulated processes, and clinical implications

In the 18 years since higher-order, generic competences (metacompetences) were first identified to guide the implementation of cognitive behaviour therapy (CBT) across anxiety and depression, much evidence has accrued supporting these generic competences and identifying others. We describe 10 generic competences that can support therapists to deliver the strongest possible outcomes in CBT across different forms of psychopathology. In each case, the robustness of the evidence-base is reviewed, the theoretical processes that link the generic competence with improved outcome for the patient are considered, and practical suggestions are offered to the therapist. The ten generic competences include: balance firmness and empathy to ensure an effective working alliance; manage therapist discomfort to use effective techniques; push for early behavioural change; focus on (and respond to) session-by-session progress in therapy; require your patient (and service) to invest in an intensive start to therapy; complex presentations should initially be met with routine therapy, changing only where guided by evidence; deliver therapy competently rather than with rigid adherence; encourage the patient to argue for behavioural change; homework completion is critical for therapy to be effective; and positive outcomes require therapists who are well-trained and well-supervised. We provide recommendations for clinical practice and future research, recognising that this list will change and grow as new evidence accumulates.