Abstract
The extent to which therapist adherence to guidelines and clinician skill or competence may play a role in the prediction of therapeutic outcomes remains inconclusive. This systematic literature review and meta-analysis considers whether adherence or competence predicts youth outcome in child and adolescent psychotherapy, and whether there are any identifiable factors which moderate the strength or direction of this relationship. A systematic literature search identified 35 studies in 52 papers. The studies contained 29 effect sizes for the relationship between adherence and outcome, while nine effect sizes were extracted for competence, and a further five effects measured a composite of adherence and competence constructs, referred to as fidelity in this report. The meta-analysis indicated a small but significant relationship between therapist adherence and outcome, although the small size of effect suggests that outcomes are likely to be more strongly associated with factors other than adherence. No significant relationship was identified between competence or composite fidelity and outcome. Although variance was observed in effect sizes, no significant moderation by client group, intervention type, or implementation measure informant was identified. Further study is needed to understand the specific circumstances under which adherence and outcome are related.
Highlights
Treatment fidelity is often used to refer to a range of processes involved in model delivery
A recent meta-analysis has indicated a relationship between integrity and outcome in intervention for juvenile antisocial behaviour [19]. These findings suggest, in line with inferences drawn based on individual studies, that implementation may be associated with outcome in some child and adolescent intervention approaches but not others
Three separate meta-analyses tested the relationship between therapist adherence, competence or composite fidelity and youth outcome in child and adolescent psychotherapy, and whether this relationship was moderated by client group, intervention modality or implementation measure informant
Summary
Treatment fidelity is often used to refer to a range of processes involved in model delivery The classification of this construct varies across studies, often including characteristics such as dosage and differentiation [1], as well as the two processes which are the focus of the present investigation, therapist adherence and competence. Proponents of manualised models or empirically supported treatments (ESTs) argue that variability in outcomes when transporting interventions from research settings could be attributed to variable therapist adherence or competence, rather than failures in the therapeutic model. This suggests that the key to transporting findings from well-controlled efficacy studies to everyday clinical settings is to ensure high levels of therapist adherence and competence in the delivery of the therapeutic model [3]
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