Balancing Outcomes and Processes: Curriculum Design in CBT Training
Although there is little agreement on an operational definition of a curriculum (Wiles, 2009), various authors have proposed a number of associated factors, ranging from a broad understanding (e.g., “All the learning which is planned and guided by the school, whether it is carried on in groups or individually, inside or outside of school” (Kerr, 1968)) to attempts at breaking down its constituent components. For example, these include the planned and received curricula, formal and informal curricula, and the concept of the hidden curriculum (Kelly, 2009). These concepts revolve around the idea of the intended delivery of learning, and an expectation of how it might be received by students, as well as the unintended consequences of this process.
Product/Outcomes-Focused Curricula
The popularity and prominence of product-focused curricula has increased over the course of the 20th and 21st centuries, emphasising the tangible outcome of a course of study. Typically, these products are measurable, behavioural outputs that the course has been designed to produce. Tyler (1949) offered a framework for planning a curriculum that focuses on outcomes.
Tyler’s Four Questions
1. What educational purposes should the school seek to attain?
2. What educational experiences can be provided that are likely to attain these purposes?
3. How can these educational experiences be effectively organized?
4. How can we determine whether these purposes are being attained?
As we can see, this framework places immediate focus on ‘educational purposes’. However, it neglects context. It could be argued that the nature of an educational purpose varies depending on specific contextual factors—such as the differences between teaching engineering versus philosophy—and broader influences, for example, recent changes in the financial responsibilities of students in higher education in the UK and the resulting power dynamics between institution and the student‐consumer (Bunce, Baird & Jones, 2016). Furthermore, Tyler’s four questions illustrate that the educational experiences are designed, organised, and evaluated solely to achieve the predetermined educational purposes. This reduces all aspects of the curriculum to merely achieving pre-defined characteristics.
Critics argue that this reductionism results in behaviour modification rather than genuine education (Kelly, 2009). In the context of psychotherapy, it is argued that demonstrating a behavioural competency—for example, performing an intervention with a client—fails to capture the full range of necessary cognitive, emotional, and interpersonal competencies (Sharpless & Barber, 2009). Thus, behaviour modification is insufficient unless students are also educated on the full range of skills, knowledge, and attitudes required.
Furthermore, a linear relationship is assumed, where specific inputs produce measurable outputs. This discounts the possibility that developing skills and knowledge is not a linear process. As Inskipp & Proctor (1993) note, the journey toward competency is a cyclical process, requiring new experiences and self-awareness, as well as a redefinition of one’s own competency within a given context. In considering the context of psychotherapy once again, we might note that the benchmark for competency is low early in a therapist’s career, but it is likely to be redefined after 20 years. Similarly, applying the same knowledge and skills with traumatised refugees and clients with an autism spectrum condition requires flexibility in defining competency.
Because the focus of this curriculum style is on the product of a course of study, both students and teachers may place too much emphasis on the outcome rather than on fostering a motivation and passion for learning, which can be a central focus of a curriculum. Furthermore, the prescriptive nature of the course limits the freedom of both students and teachers. Although the concept of learning styles is outdated (Rohrer & Pashler, 2012), the individual differences among students and teachers, and the interactions between them, are vital in developing learning.
When considering the criticisms of the outcome/product-focused curriculum, the main issue may be its application as a general model for curriculum planning across all educational contexts. There are instances, such as when managing risk, where the product of training is very clear—patient safety—where the questions asked by the therapist accurately assess the risk, and the interactions between therapist and patient help to reduce it. If such training neglects the wider context of the therapist and patient, as well as the full range of competencies (not merely behavioural ones), then the quality of clinical decision‐making and patient–therapist interactions will be limited.
Process-Focused Curricula
A process-focused curriculum emphasises the development and understanding of the student. Education is viewed as a set of developmental processes that the curriculum promotes, and its direction is provided by guiding principles:
“The essence of the process approach is that what is derived from what are stated as overall aims is not a series of short-term goals or objectives but rather a detailing of the principles which are inherent in those aims and which are to inform and guide subsequent practice” (Kelly, 2009)
Thus, the design and implementation of teaching content and activities are underpinned by these aims, and the interaction between students and teachers focuses on fostering student development in line with these aims. The distinguishing feature is that there is no single, prescriptive path for student development within this curriculum; rather, the focus is on the learning processes required, rather than on the behavioural outcomes, to achieve the curriculum’s aims.
Smith (1996, 2000) offers a more practical view of how a process-driven curriculum looks in action.
Process-Focused Curriculum in Action (Smith; 1996, 2000)
Teachers enter particular schooling and situations with:
an ability to think critically, in-action
an understanding of their role and the expectations others have of them, and
a proposal for action which sets out essential principles and features of the educational encounter.
Guided by these, they encourage conversations between, and with, people in the situation out of which may come thinking and action.
As with the product-focused curriculum, the process-focused curriculum has some key criticisms when applied. Firstly, the lack of rigour allows for variability in the product of the educational programme. This is perhaps most troublesome when educational and professional standards come together for professionally recognised qualifications (for example, postgraduate courses needing to comply with minimum training standards set by the British Association for Behavioural and Cognitive Psychotherapies - BABCP - in order to achieve accreditation). From this, we can assume that employers would need to trust that two postgraduate diplomas offer a similar level of quality. As the education process is entrusted to more people, possibly on individual courses, then the ‘product’ becomes more diverse, leading to issues in routine practice. To continue using the psychotherapy context: without standardisation of the outcomes of a course of study, it wouldn’t be possible to guarantee that each course teaches the necessary knowledge and skills, thus undermining the principles of evidence-based practice - that each patient receives the most appropriate and empirically supported treatment protocol.
From this, the process of developing students rather than delivering knowledge, relies on the proficiency of teachers to do this. How does one measure a teacher’s skill and knowledge when the measure of success is development rather than attainment? This issue will perhaps continue to be difficult as the product-focus of education becomes more entrenched.
Efforts at reconciling the two models of curriculum are considered ineffective due to the incompatibility of the approaches with one another. Rather than the best of both worlds, the inadequacies of each are inherited in amalgamating the approaches (Kelly, 2009). If we consider this, and psychotherapy once again, it leaves us with some questions to consider:
Is one form of curriculum more effective in teaching psychotherapy than any other?
How can the strengths of a process-focused approach be incorporated into a curriculum while still maintaining professional standards?
How can we ensure that essential behavioural competencies are achieved as an outcome of the psychotherapy course, while also fostering the development of emotional, cognitive, and interpersonal competencies that are less easily measured?