Quality assessment of cognitive-behavioural therapy: competence, adherence, and clinical outcomes

Background

Quality of care is essential in disseminating cognitive-behavioural therapy (CBT). Yet, little is known about how therapists acquire CBT competence, to what extent CBT is delivered as intended and with skill in routine psychiatric care, and if delivered CBT improve the health of patients with common psychiatric disorders, including depression, anxiety disorders, posttraumatic stress disorder, and obsessive-compulsive disorder.

Research aims

The aim was to examine the quality of CBT in practice. We formulated four main hypotheses: 1) therapists are competent in delivering CBT, both following training and in clinical practice, 2) therapists adhere to CBT procedures and techniques in routine psychiatric care, 3) CBT is delivered with desired clinical outcomes in terms of symptom reduction, functional ability, and global health, and 4) therapist competence and adherence is associated with clinical outcomes.

Methods

We conducted three observational studies, with longitudinal and cross-sectional designs. Competence was assessed by observers, based on sessions with standardised patients (Studies I and II). Adherence was assessed by observers, therapists, and patients (Study II), or patients only (Study III). Outcomes were based on patient reports of symptoms, function, and global health (Study II) or of perceived improvement and treatment satisfaction (Study III). Statistical analysis included non-parametric tests (Kruskal-Wallis, Mann-Whitney U, Spearman and Kendall's rank correlations), parametric tests (Pearson correlation, one-way ANOVA), reliable change index, and linear mixed models.

Results

First, we found that therapist competence improved after CBT training (Cohen's d effect size = 1.94). A competence threshold was passed by 72% (n = 46/64) after training and 76% (n = 22/29) in routine practice. More competent therapists tended to underestimate their performance, while less competent therapists made more accurate self-assessments.

Second, therapist adherence was moderate to high in routine psychiatric care, across perspectives (patients, therapists, and observers), subscales, and diagnoses. Adherence ratings were higher from patients than therapists and for structure/conceptualisation than behavioural/cognitive techniques. Moreover, therapist adherence ratings were higher among patients treated for panic disorder compared to those treated for depression, generalised anxiety disorder, or obsessive-compulsive disorder.

Third, patients improved significantly across outcomes (ds = 0.80 - 1.36) and 67% (n = 57/85) demonstrated reliable clinical improvement, while 5% reliably deteriorated (n = 5/85). Moreover, patients reported high degrees of perceived symptom improvement and treatment satisfaction.

Finally, there was a moderate correlation between therapist adherence and patient-rated improvement (Kendall's ts rank correlation coefficient = . 37 -. 38, ps < . 001). Still, neither adherence nor competence was related to clinical outcomes based on validated outcome measures.

Conclusion

In conclusion, CBT was delivered with high quality. Overall, therapists demonstrated competence and adherence, and patients showed clinical improvements. However, there were exceptions, including instances of below- threshold competence, non-adherence, and nearly a third of patients who did not appear to benefit from treatment. The potential association between competence/adherence and patient improvement remains unclear, possibly due to methodological limitations including limited statistical power.

List of scientific papers

I. Bergvall, H., Ghaderi, A., Andersson, J., Lundgren, T., Andersson, G., & Bohman, B. (2023). Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students. Behavioural and Cognitive Psychotherapy. https://doi.org/10.1017/S1352465822000686

II. Bergvall, H., Linde, J., Alfonsson, S., Sunnhed, R., Barber, J. P., Lundgren, T., Andersson, G., & Bohman, B. (2024). Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders. BMC Psychiatry, 24:887. https://doi.org/10.1186/s12888-024-06328-4

III. Bergvall, H., Andersson, G., Lundgren, T., & Bohman, B. Therapist adherence to cognitive-behavioural therapy and quality of care from a patient perspective. [Submitted]