Cognitive Behavior Therapy Treatment Fidelity in Clinical Trials: Review of Recommendations

Background: Over a number of decades, Cognitive Behavior Therapy has evolved and been modified by various theorists and researchers. Concerns regarding the integrity of cognitive and behavioral treatment in research studies, including fidelity, competence, and treatment differentiation, have been raised. Ensuring adequate treatment fidelity and competency is a prerequisite to have a reliable measure of the independent variable and having confidence in the corresponding statistical conclusions. Objective: To review the extant literature on the topic of treatment fidelity and consolidate recommendations that would be relevant to researchers and practitioners of Cognitive Behavior Therapy. Results: Adequate fidelity data is not typically reported in psychotherapy outcome studies. This decreases confidence in the conclusions of these studies, and in the conclusions of meta-analytic analyses that involve these studies. Several studies have consistently demonstrated that assuming treatment fidelity or competence is problematic. Conclusion: Previous recommendations are compiled and reemphasized. Individual psychotherapists are encouraged to seek competency-based certifications (e.g., through the Academy of Cognitive Therapy) to verify competency and fidelity of Cognitive Behavior Therapy practice. Researchers are encouraged to utilize direct-observational methods to ensure fidelity of practice and reliability of the independent variable. Due to concerns about demand characteristics and possible inflation of fidelity estimates, it is strongly recommended that expertly trained, blind raters who are not dependent on the project or organization be used to assess the fidelity and competency of clinical practice. Additionally, it is recommended that journal editors require inclusion of fidelity data from manuscripts that are seeking publication.