Study Finds No Link Between Therapist CBT Skill and Patient Outcomes

A study showed therapists in routine psychiatric care delivered cognitive-behavioral therapy (CBT) with adherence and competence.1

“Previous research suggests that therapist adherence is often low, with insufficient use of treatment protocols in clinical practice and non-supported treatment modifications even in controlled settings,” wrote investigators, led by Hillevi Bergvall, from the Centre for Psychiatry Research at Karolinska Institutet.

An earlier study found that among 317 CBT therapists, only 11% reported frequently using protocols, and 30% reported never using them.2 In another study, community-based therapists reported only using the prescribed CBT interventions a few years following their CBT training.3 Investigators sought to examine the delivery quality of CBT in routine psychiatry care for depression and anxiety, looking at therapist adherence and competence, as well as therapy effectiveness.1

The study included 23 therapists who recruited 85 patients with a depression or anxiety disorder from 2 routine psychiatric outpatient clinics in Stockholm, Sweden between August 2018 and February 2020. Therapists all had received university-level basic CBT training and licensed clinical psychologists (excluding 2 resident psychologists).

The therapists were mostly female (75.9%), had an average age of 31.1 years, and had an average of 2.4 years of clinical experience delivering CBT on top of CBT supervision for 2.0 years. The therapists treated a mean of 3.7 patients, ranging from 1 – 11.

Patients were included if they had a principal diagnosis of MDD (14.1%), OCD (29.4%), PTSD (10.6%), generalized anxiety disorder (27.1%), panic disorder (12.9%) or social anxiety disorder (5.9%) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). They were excluded if they had acute suicidal ideation, current substance use disorder, and concurrent psychological treatment.

Investigators developed The Therapist Adherence to Cognitive-Behavioral Therapy Scale (TACBT) instrument to assess therapist adherence to generic CBT techniques and procedures. To develop this, they reviewed many CBT protocols and reviewed research on therapist adherence to CBT from established instruments, such as the Multitheoretical List of Therapeutic Interventions, the Collaborative Study Psychotherapy Rating Scale, and the Cognitive-Behavioral Therapy Adherence Scale.

TACBT includes structure, conceptualization, behavioral techniques, and cognitive techniques. The instrument also had different versions for patients, therapists, and observers, although patient and therapist versions are nearly identical.

Patients received a median of 18.5 sessions of CBT (interquartile range [IQR], 13.0 – 24.0). Before and after CBT, patients rated symptoms, functional impairment, and global health. Observers assessed therapist adherence during CBT, and patients and therapists assessed therapist adherence using TACBT.

In 95.3% of patient records, therapists reported using specific CBT protocols for different psychiatric disorders. 20% of patients received additional treatments targeting a comorbid diagnosis and had a median of 21.0 sessions (IQR, 17.5 – 26.5), compared with 17.5 sessions for single treatments (IQR, 12.8 – 22.5) (P = .061).

Patients viewed therapist adherence as high, therapists as moderate to high, and observers as moderate. Structural and conceptual items received greater scores than behavioral and cognitive items. Patients and therapists had low agreement of ratings of complete treatments (ICC, -0.14; 95% confidence interval [CI], -0.35 to -0.10).

Most therapists showed competence in CBT, with a mean score of 40.5 on the competence score on the Cognitive Therapy Scale-Revised. 75% passed the competence threshold, which was a total core of ≥ 36 points. The study revealed a therapist’s competence level is not significantly correlated with years of CBT experience (P = .077), years receiving CBT supervision (P = .080), or age (P = .522).

Patients had significantly improved depression or anxiety symptoms following CBT (Cohen’s ds, 0.80 – 1.36). However, symptom improvements were not linked to patient symptom duration, number of psychiatric diagnoses, therapist, therapist CBT experience, therapeutic alliance, or psychiatric clinic.

Across all symptom measures, 67.1% improved, 4.7% deteriorated, and 16.5% remained the same. 11.8% had incomplete data for all symptom measures.

“While potential areas for quality improvement would be increased use of behavioral and cognitive techniques, and competence development for a few of the therapists, this study did not provide any support that they will affect patient outcomes,” investigators wrote.

References

1. Bergvall H, Linde J, Alfonsson S, Sunnhed R, Barber JP, Lundgren T, Andersson G, Bohman B. Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders. BMC Psychiatry. 2024 Dec 4;24(1):887. doi: 10.1186/s12888-024-06328-4. PMID: 39633319; PMCID: PMC11616186.
2. Webb CA, DeRubeis RJ, Barber JP. Therapist adherence/competence and treatment outcome: a meta-analytic review. J Consult Clin Psychol. 2010;78(2):200–11. https://doi.org/10.1037/a0018912.
3. Becker EM, Smith AM, Jensen-Doss A. Who’s using treatment manuals? A national survey of practicing therapists. Behav Res Ther. 2013;51(10):706–10. https://doi.org/10.1016/j.brat.2013.07.008.