Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy

Do therapists who deliver therapist-assisted Internet-delivered Cognitive Behaviour Therapy (ICBT) adhere to specific behaviours when delivering this service? What is the quality of the therapeutic assistance provided in ICBT? Do raters agree on therapist competence in delivering ICBT and what factors are associated with greater therapist competence with this mode of delivery?  These questions were addressed in the current paper. ICBT is often accompanied by therapeutic emails, but there has been a paucity of research on the nature of these emails and therapeutic assistance provided.

In face-to-face cognitive behaviour therapy (CBT) attention has been given to therapist fidelity, which involves examining therapist adherence to therapeutic guidelines as well as examining the quality of therapy delivered. This research has yielded important findings that enhance understanding of CBT and facilitate training and supervision.

To date, there has been a lack of research on therapist fidelity in ICBT. This may reflect that therapist assistance is viewed as less important than the presentation of structured materials in ICBT, but also that no scales exist to assess therapist assistance in ICBT. We contend that it is very important to assess therapist fidelity in ICBT to better understand how therapists deliver ICBT across settings, the circumstances that influence therapist fidelity, to draw inferences about the relationship between therapist behaviours and outcomes as well as to aid training and supervision.

The current paper describes the development and evaluation of an ICBT Therapist Rating Scale (ICBT-TRS). The scale was designed to measure adherence to and quality of a number of therapist behaviours that we recommend to therapists who deliver ICBT. These therapist behaviour are also generally consistent with descriptions of ICBT therapist assistance reported in the literature. More specifically, the scale assesses the following nine therapist behaviours: Builds Rapport, Seeks Feedback, Provides Symptom Feedback, Provides Psychoeducation, Facilitates Understanding, Praises Effort, Encourages Practice, Clarifies Administrative Procedures, and Communicates Effectively. In the paper, we describe each behaviour, along with examples of inadequate and competent performance. We used the ICBT-TRS to rate 706 emails sent by 39 therapists to 91 patients. We then examined the inter-rater reliability, internal consistency, face validity, and concurrent validity of the scale.

Results showed that the ICBT-TRS had high inter-rater reliability and internal consistency. Promisingly, among the 39 therapists, most behaviours were identified as being present in emails and were rated as high quality. Nevertheless, the scale highlighted some areas where therapist-assistance could be improved (e.g., facilitating patient understanding, encouraging practice). Supporting the validity of the ICBT-TRS, ratings were higher when patients were more engaged in ICBT and among therapists who specialized in ICBT and had a psychology background. Overall, the ICBT-TRS has considerable potential to facilitate ICBT clinical training. This study highlights the need for further investigation into therapist fidelity in ICBT. Multiple directions for research are described.

Read the full paper: Hadjistavropoulos, H. D., Schneider, L. H., Klassen, K., Dear, B. F., & Titov, N. (2018). Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy. Cognitive Behaviour Therapy. doi:10.1080/16506073.2018.1457079

Heather Hadjistavropoulos
Luke Schneider








Photo by: Andri Koolme

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