Assessing treatment integrity in acceptance and commitment therapy: Strategies and suggestions.

Abstract

Treatment integrity as it relates to psychotherapy outcome research refers to the degree to which a particular intervention is implemented in a competent manner with fidelity to the theoretical model and the specific processes and procedures specified in the treatment protocol (Nezu & Nezu, 2008). Treatment integrity typically involves two processes, adherence or fidelity to the manual, protocol, or treatment model, and competence or level of skill with which therapists deliver the specified treatment (Waltz, Addis, Koerner, & Jacobson, 1993). These constructs are related in that in order for a treatment to be delivered competently, adherence to the treatment is implied, but adherence to the treatment does not necessarily imply competence (Waltz et al., 1993). Treatment integrity is primarily viewed as a way to conduct a manipulation check to ensure that a treatment has been implemented appropriately. Without such assurance, treatment effects cannot be linked to the specific processes purported in the treatment model to be related to change. A well designed, reliable treatment integrity manual may also allow comparisons of treatments across settings, comparison of therapists across settings and studies, and provide important information for training and supervision procedures (Waltz et al., 1993). Integrity checks are also vital for randomized clinical trials, as an important tool to discriminate between different treatments (Kazdin, 2003; Nezu & Nezu, 2008). There is a small, but growing, body of literature in psychotherapy research that highlights the importance of assessing therapist adherence and competence in psychotherapy outcome studies and has examined these processes as predictors of outcomes themselves (e.g., Barber, Foltz, Crits-Christoph, & Chittams, 2004; Barber et al., 2006; McGlinchey & Dobson, 2003; Perepletchikova, Treat, & Kazdin, 2007). The relationship of adherence and competence to outcome is complex and conflicting. While some studies have shown that these variables predict positive outcomes (Barber, Crits-Christoph, & Luborsky, 1996; Barber, Liese, & Abrams, 2003; Carroll et al., 1998, 2000), meta-analyses of treatment outcome studies indicate that on the whole, they do not predict outcome (Webb, DeRubeis, & Barber, 2010). Such findings may highlight the importance of common (or nonspecific) factors, such as therapeutic alliance, treatment credibility and client's expectations given that a previous meta-analysis has indicated that common factors might be more influential for outcome across studies than treatment-specific factors (Wampold et al., 1997). However, Webb and colleagues postulate several reasons for their null findings, given that some individual studies have demonstrated direct significant effects of adherence on outcome (both in relation to and separate from therapeutic alliance). First, they postulate that the significant heterogeneity of effect sizes for adherence and competence in their analysis makes interpreting a nonsignificant mean effect size difficult, and that such disparate effect sizes between studies may be due to the fact that the methods used, problems treated, treatments applied, and the outcomes themselves were widely varied between studies in the meta-analysis. Webb and colleagues also postulate that, given evidence that certain methods within treatments tend to relate better to outcomes than others (e.g., problem focused cognitive therapy techniques; DeRubeis & Feeley, 1990; Feeley et al., 1999), the effect of adherence to effective components of treatments may be masked by adherence to less helpful components. Other researchers have attributed such lack of impact of treatment-specific processes on treatment outcomes in the cognitive-behavioral literature to the fact that only a minority of studies have actually assessed treatment integrity (Bhar & Beck, 2009; Perepletchikova, Hilt, Chereji, & Kazdin, 2009; Perepletchikova et al. …