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Assessing Treatment Integrity in Personalized CBT: The Inventory of Therapeutic Interventions and Skills

Cognitive behavioral therapy (CBT) is a highly effective form of psychotherapy applied to treat a range of mental illnesses including, but not limited to, depression, anxiety, somatic symptom disorders, substance use disorders, trauma-related disorders and eating disorders. CBT originated as an application of psychological research on learning theory to the treatment of mental illnesses. Originally, behaviorism focused on individual’s learned behavioral reactions to stimuli and their modification (e.g., exposure treatment for phobias) to alleviate symptoms (behavior therapy, so-called “first wave”). Later, concepts emerged, which postulated that how we interpret situations and the beliefs we have about ourselves, others, and the world influence our behavior and emotions. In this “second wave” of CBT, methods applied in behavior therapy were extended to include cognitive techniques (i.e., identifying and modifying dysfunctional automatic thoughts and core beliefs). This phase of CBT development saw the proliferation of evidence-based, disorder-specific treatment manuals and efforts to standardize the treatment of mental illnesses.

Further, in the last two decades several newer developments have influenced how CBT is practiced today. First, within the so-called “third wave” of CBT, new treatment protocols have been developed, which integrate classic CBT concepts and interventions with theories and methods from other psychotherapeutic approaches, including psychodynamic and humanistic therapies, as well as eastern traditions (i.e., Buddhism). These often transdiagnostic (i.e., not disorder-specific) treatments therefore go beyond the classic behavioral and cognitive components of CBT to include interpersonal and emotion-focused elements as well as mindfulness-based interventions. As a result, the diversity of CBT has continuously increased. Second, psychotherapy research has put much effort into identifying change factors common to all psychotherapies, resulting in an increased focus on such factors (e.g. therapeutic relationship) across therapeutic approaches. Finally, the research focus has begun to shift from the average response of a group of patients receiving a given treatment to the response of individual patients. More and more treatment services are implementing routine outcome monitoring and feedback systems to monitor patient progress and adapt the treatment strategy as needed to improve individual results. This development supports the evidence-based personalization and flexible adaptation of treatments, moving away from standardized, manualized treatments. This move towards personalization also increases the diversity of CBT practice.

In psychotherapy research, treatment integrity investigates whether the treatment was implemented as intended and its assessment is necessary to attribute treatment effects to the given treatment and increase transparency (i.e., we have to know what and how the therapist actually did to be able to properly interpret treatment results). However, the increasing diversity of CBT presents a challenge to the assessment of treatment integrity. We therefore developed and tested the Inventory of Therapeutic Interventions and Skills (ITIS), which is an adaptation and extension of previously existing CBT adherence and competence scales, with the aim being able to adequately assess treatment integrity in modern, personalized CBT via video ratings.

We described the development process and presented the new instrument, including results from its initial application at a university outpatient clinic. First, we reported information on the frequency of interventions and the level of skills in the observed treatments. We then investigated agreement between raters who applied the new instrument and found inter-rater reliability to be good and largely independent of raters’ clinical experience (graduate students vs. post-graduate clinicians). We also examined the instrument’s item structure and found that the items assessing therapists’ skills seemed to measure an underlying global skill level. We also found aspects of treatment integrity assessed with the ITIS to be associated with the therapeutic relationship and the session outcome as reported by the patient, which suggests that the ITIS may capture aspects of therapists’ interventions and skills that are associated with how positively patients’ perceive therapy. We further discuss strengths and limitations of the study and implications for future research as well as clinical training and practice.

Read the full paper: Boyle, K., Deisenhofer, A.K., Rubel, J.A., Bennemann, B., Weinmann-Lutz, B., & Lutz, W. (in press). Assessing treatment integrity in personalized CBT: The inventory of therapeutic interventions and skills. Cognitive Behaviour Therapy. doi: 10.1080/16506073.2019.1625945

photo by: Mike Cohen

Pictured: Kaitlyn Boyle

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