On the Topic of Treatment Integrity

[Clin Psychol Sci Prac 18: 148–153, 2011] Treatment integrity, also known as treatment fidelity, is integral for empirical testing of intervention efficacy, as it allows for unambiguous interpretations of the obtained results. Ensuring treatment integrity is also important for dissemination of evidence‐based practices and quality improvement of services. However, in the examination of the relationship between treatment integrity and treatment outcome, it is important to consider that treatment integrity may be a proxy variable for other variables impacting therapeutic change (e.g., characteristics of intervention, clients, setting, and therapist). Considerations on examining the association between integrity and outcome are discussed. Further, recommendations on the level to which treatment integrity needs to be addressed in psychotherapy research and clinical practice are provided.     

Development and Initial Psychometrics for a Therapist Competence Instrument for CBT for Youth Anxiety

Therapist competence is an important component of treatment integrity. This article reports on the development and initial psychometric assessment of the Cognitive-Behavioral Treatment for Anxiety in Youth Competence Scale (CBAY-C), an observational instrument designed to capture therapist limited-domain competence (i.e., competence in the delivery of core interventions and delivery methods found in a specific psychosocial treatment program) in the delivery of the core practice elements in individual cognitive-behavioral treatment (ICBT) for youth anxiety. Treatment sessions (N = 744) from 68 youth participants (M age = 10.60 years, SD = 2.03; 82.3% Caucasian; 52.9% male) of the same ICBT program for youth anxiety from (a) an efficacy study and (b) an effectiveness study were independently scored by 4 coders using observational instruments designed to assess therapist competence, treatment adherence, treatment differentiation, alliance, and client involvement. Interrater reliability—intraclass correlation coefficients (2,2)—for the item scores averaged 0.69 (SD = 0.11). The CBAY-C item, scale, and subscale (Skills, Exposure) scores showed evidence of validity via associations with observational instruments of treatment adherence to ICBT for youth anxiety, theory-based domains (cognitive-behavioral treatment, psychodynamic, family, client centered), alliance, and client involvement. Important to note, although the CBAY-C scale, subscale, and item scores did overlap with a corresponding observational treatment adherence instrument independently rated by coders, the degree of overlap was moderate, indicating that the CBAY-C assesses a distinct component of treatment integrity. Applications of the instrument and future research directions discussed include the measurement of treatment integrity and testing integrity-outcome relations.     

Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective

[Clin Psychol Sci Prac 17: 1–30, 2010]
Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.     

Treatment Integrity and Differential Treatment Effects

Bhar and Beck (2009) examined the extent to which treatment integrity procedures were implemented in studies comparing psychoanalytic psychotherapies and cognitive-behavioral therapies. Consistent with other reports on attention to treatment integrity in psychotherapy research, the authors noted that most of the evaluated studies did not adequately implement treatment integrity procedures. This highlights methodological neglect of treatment integrity and a need to amend errors in monitoring the independent variables under investigation. This commentary considers how Bhar and Beck's investigation affects the dodo bird verdict that all psychotherapies are presumed to be of equal efficacy. Further, ways to examine the treatment integrity of process-oriented treatments (e.g., humanistic, psychoanalytic) are discussed.     

Interventions for alcohol-related offending by women: a systematic review

Treatment programmes specifically for women offenders are under-developed. A systematic review of studies that could inform interventions for alcohol-related offending by women is reported. Three questions were addressed: 1) What is the most up to date knowledge of ‘what works’ with females who commit alcohol-related offences? 2) What are the identifiable risk-needs factors for non-alcohol dependent women who commit offences involving alcohol misuse? 3) Are there differences between male and female alcohol-related offending? Four studies addressed the effectiveness of psychosocial interventions; three addressed identifiable risk-needs; and 19 addressed differences between male and female offenders' alcohol-related offending. Heterogeneity of these studies precluded meta-analyses, and so a narrative synthesis method was used. There is insufficient evidence to answer the question of what treatment works with women who commit alcohol-related offences. Drunk-driving is most widely studied, and women offenders appear to have more psychosocial problems than men. Alcohol increases the likelihood of violence for both men and women, and, while the mechanisms whereby alcohol increases the likelihood of violence are likely the same in men and women, the effect may be moderated by gender-associated issues. Again, women offenders appear to have more psychosocial problems than men. Implications for developing interventions are discussed.     

Making a Case for Treatment Integrity as a Psychosocial Treatment Quality Indicator for Youth Mental Health Care

Measures of treatment integrity are needed to advance clinical research in general and are viewed as particularly relevant for dissemination and implementation research. Although some efforts to develop such measures are underway, a conceptual and methodological framework will help guide these efforts. The purpose of this article is to demonstrate how frameworks adapted from the psychosocial treatment, therapy process, healthcare, and business literatures can be used to address this gap. We propose that components of treatment integrity (i.e., adherence, differentiation, competence, alliance, client involvement) pulled from the treatment technology and process literatures can be used as quality indicators of treatment implementation and thereby guide quality improvement efforts in practice settings. Further, we discuss how treatment integrity indices can be used in feedback systems that utilize benchmarking to expedite the process of translating evidence‐based practices to service settings.     

Integrity in Mental Health Systems: An Expanded Framework for Managing Uncertainty in Clinical Care

This article presents a broad‐based framework for evaluating integrity, defined as the structured comparison of observed values (i.e., what did happen) with expected values (i.e., what should happen), across various domains (e.g., practices, outcomes) for the purposes of informing key questions in system contexts (e.g., Is a practice being done properly? How well is it working?). We discuss the application of integrity in serving the goals of the scientific and service systems and potential sources for observed and expected values. An expanded framework regarding integrity analysis is presented detailing multiple domains of measurement (e.g., outcomes, activities, and resources), types of analysis (e.g., across vs. within units), and levels of analysis (e.g., event, episode, multi‐episode). Other possible applications of integrity analysis in service systems and ongoing dissemination and implementation efforts are also discussed.     

Treatment adherence and illness self-management: introduction to the special issue

The current issue is devoted broadly to research on treatment adherence and chronic illness self-management behavior. As the prevalence of chronic illness increases, the pervasive problem of treatment nonadherence is increasingly viewed as having a major impact on treatment outcomes, public health and healthcare costs, making this issue particularly timely. Sixteen articles spanning an array of topics are presented; articles include empirical studies, statistical simulations, systematic reviews, and theoretical commentaries. Studies conducted with diverse patient populations (e.g., chronic headache, diabetes, end-stage renal disease, HIV, hypertension, severe obesity), samples (e.g., adolescents, ethnic/racial minorities, low-income adults, parents, spousal dyads), and designs (e.g., cross-sectional, longitudinal assessment, randomized controlled trial), are represented. This issue highlights psychosocial factors associated with nonadherence, promising interventions to promote adherence, and state-of-the art methods for the study of illness self-management. We hope these articles engender even more high quality, methodologically rigorous research in this important subfield of behavioral medicine.     

Feasibility and preliminary outcomes from a pilot study of a brief psychological intervention for families of children newly diagnosed with cancer

OBJECTIVE: To report initial feasibility and outcome from a pilot study of a new three-session intervention for caregivers of children newly diagnosed with cancer, Surviving Cancer Competently Intervention Program-Newly Diagnosed (SCCIP-ND). METHOD: Nineteen families (38 caregivers) were randomly assigned to SCCIP-ND or treatment as usual subsequent to learning of their child's illness. The study design included pre- and 2-month postintervention assessments, with state anxiety and posttraumatic stress symptoms as outcomes. Feasibility was based on therapist feedback and supervision, program evaluations, and data from study-tracking procedures. RESULTS: SCCIP-ND appears to be an acceptable intervention that can be used successfully with caregivers over the first few months after diagnosis. Recruitment and retention data document feasibility but also highlight challenges. Preliminary outcome data show changes in the desired direction [e.g., reduced anxiety and parental posttraumatic stress symptoms (PTSS)]. CONCLUSIONS: The pilot data are supportive of the value and challenges of developing evidence-based family interventions in pediatric psychology.     

Client variables and the behavioral treatment of recurrent tension headache: A metaanalytic review

Meta-analysis revealed that in studies evaluating behavioral treatments for tension headaches, the treatment outcome has varied with the client samples (e.g., age, gender, referral source) that have been used but not with the treatment procedures (e.g., type of behavioral intervention, length of treatment, whether or not efforts were made to facilitate transfer of training) or the research designs (e.g., internal validity, explicitness of diagnostic criteria) that have been used. Mean client age proved the best predictor of treatment outcome, accounting for 30% of the outcome variance following behavior therapy. Significantly poorer outcomes have also been reported in recent studies than were reported in early studies. These findings suggest that (1) outcomes obtained with behavioral interventions have been less dependent upon the treatment variables that have been the primary focus of research attention than upon characteristics of client samples and (2) behavioral interventions may be less effective in reducing headache activity than has previously been assumed.Preparation of this article was supported in part by National Institute of Mental Health Grant MH37464 to Kenneth A. Holroyd.     

Using community-based participatory research to identify potential interventions to overcome barriers to adolescents’ healthy eating and physical activity

Using a community-based participatory research approach, we explored adolescent, parent, and community stakeholder perspectives on barriers to healthy eating and physical activity, and intervention ideas to address adolescent obesity. We conducted 14 adolescent focus groups (n = 119), 8 parent focus groups (n = 63), and 28 interviews with community members (i.e., local experts knowledgeable about youth nutrition and physical activity). Participants described ecological and psychosocial barriers in neighborhoods (e.g., lack of accessible nutritious food), in schools (e.g., poor quality of physical education), at home (e.g., sedentary lifestyle), and at the individual level (e.g., lack of nutrition knowledge). Participants proposed interventions such as nutrition classes for families, addition of healthy school food options that appeal to students, and non-competitive physical education activities. Participants supported health education delivered by students. Findings demonstrate that community-based participatory research is useful for revealing potentially feasible interventions that are acceptable to community members.     

Therapists' adherence and competence and treatment discrimination in the NIDA Collaborative Cocaine Treatment Study

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study was designed to assess the efficacy of four different psychosocial interventions (cognitive therapy, supportive-expressive dynamic therapy, and individual and group drug counseling) for cocaine dependence. This report addresses the treatment integrity and discriminability of the three individual treatments. Therapists' adherence and competence for all three individual treatments during early and late sessions were rated reliably by three sets of independent expert judges (one set of expert clinicians for each treatment condition). Results indicated that therapists and counselors made use of the therapeutic techniques described in their respective treatment manuals rather than those from different treatment manuals. Thus, treatments were easily discriminable by the independent judges.     

Between‐therapist and within‐therapist differences in the quality of the therapeutic relationship: effects on maladjustment and self‐critical perfectionism

The relationship between therapeutic outcome and a patient‐reported measure of the Rogerian conditions of positive regard, empathy, and genuineness was decomposed into between‐therapist effects and within‐therapist effects using multilevel modeling. Data were available for 157 depressed outpatients treated by 27 therapists in the cognitive‐behavioral therapy, interpersonal therapy, or placebo with clinical management conditions of the Treatment of Depression Collaborative Research Program (Elkin, 1994 ). Consistent with prior findings of significant between‐therapist variability in outcome (e.g., Baldwin, Wampold, & Imel, 2007 ), patients whose therapists provided high average levels of the perceived Rogerian conditions across the patients in their caseloads experienced more rapid reductions in both overall maladjustment and depressive vulnerability (self‐critical perfectionism). Within each therapist's caseload, differences between patients in perceived Rogerian conditions had weaker effects. The results underline the importance of differences between therapists as determinants of outcome in the treatment of depression. © 2010 Wiley Periodicals, Inc. J Clin Psychol: 66:1–17, 2010.     

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

Despite the vast literature supporting the efficacy of stimulant medication in the treatment of attention-deficit/hyperactivity disorder (ADHD), several limitations of pharmacological treatments highlight the clear need for effective psychosocial treatments to be identified. A large evidence base exists for behavioral interventions, including parent training and school interventions, which has resulted in their classification as "empirically validated treatments." Additionally, social skills training with generalization components, intensive summer treatment programs, and educational interventions appear promising in the treatment of ADHD. Given the chronic impairment children with ADHD experience across multiple domains of functioning, multimodal treatments are typically necessary to normalize the behavior of these children. The state of the ADHD treatment literature is reviewed, important gaps are identified (e.g., treatment for adolescents), and directions for future research are outlined within a developmental psychopathology framework.     

Intervention Format and Delivery Preferences Among Young Adult Cancer Survivors

Background

Young adult cancer survivors face a number of increased medical and psychosocial risks, including an increased risk of cardiovascular disease and emotional distress. Although behavioral strategies, such as exercise, may diminish some of these risks, few behavioral interventions have been developed for this population.

Purpose

As a first step toward developing interventions specifically for young survivors, we conducted a qualitative study of their intervention-related preferences. A key objective was to identify the preferred format for delivering interventions (e.g., face-to-face, online).

Method

In-depth, semi-structured individual interviews were conducted with 20 young adult cancer survivors between the ages of 18 and 39. This research was conducted in Rhode Island, USA.

Results

Participants identified advantages and disadvantages to a variety of intervention formats including: telephone-based, print-based, computer-based, and several types of face-to-face interventions. The dominant theme that emerged was that interventions developed for young adult cancer survivors should take into account their multiple competing needs and obligations (e.g., work, family). Two closely related subthemes were: (1) the importance of developing interventions that are convenient and (2) the need for interventions that provide social support. Interventions for this population may be most successful if they take into account these themes.

Conclusion

Data indicate that young adult cancer survivors have some unique needs (e.g., multiple competing demands of young adulthood) and preferences (e.g., comfort with remotely delivered interventions) that differentiate them from older cancer survivors. Thus, young survivors would be best served by interventions designed to specifically target this population.     

Psychosocial health risk factors and resources of medical students and physicians: a cross-sectional study

Background  

Epidemiological data indicate elevated psychosocial health risks for physicians, e. g., burnout, depression, marital disturbances, alcohol and substance abuse, and suicide. The purpose of this study was to identify psychosocial health resources and risk factors in profession-related behaviour and experience patterns of medical students and physicians that may serve as a basis for appropriate health promoting interventions.     

Psychosocial treatment of late-life generalized anxiety disorder: current status and future directions

Although generalized anxiety disorder (GAD) was once an understudied illness, there has been an increase in research on the disorder over the past several years. A subset of studies has focused on the psychosocial treatment of late-life GAD. It was initially expected that cognitive behavior therapy (CBT) would prove to be the most effective treatment for GAD in the elderly. Although group format CBT has outperformed no-treatment control conditions in some studies, the existing body of work does not clearly indicate the superiority of CBT over alternative interventions [e.g., supportive therapy (ST)]. Trials of individual format CBT have tested augmented or otherwise nonstandard versions of the therapy. Therefore, it may not be appropriate to assume a smooth transfer of CBT benefits across age groups in the treatment of GAD. This review summarizes and discusses the current state of psychosocial interventions for late-life GAD, including group and individual format CBT, limitations of existing research, and suggestions for future directions.     

No need to worry: the promising future of child anxiety research

Looking ahead, we review two themes concerning the treatment of youth anxiety: treatment personalization and its dissemination and implementation (DI). Anxious youth can be effectively treated, but not all youth respond, suggesting the need to further adapt, or personalize, interventions for nonresponders. Treatment personalization may benefit from increased knowledge of social phobia, modular and transdiagnostic treatments, and active mechanisms of change. Further, despite the availability of efficacious treatments, they remain underutilized in the community. DI needs to overcome concerns regarding treatment manuals, social and organizational factors, therapist training, and reaching underserved populations. Finally, computer-based programs can facilitate dissemination through both treating anxious youth and training therapists.     

Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations

This article examines how bipolar symptoms emerge during development, and the potential role of psychosocial and pharmacological interventions in the prevention of the onset of the disorder. Early signs of bipolarity can be observed among children of bipolar parents and often take the form of subsyndromal presentations (e.g., mood lability, episodic elation or irritability, depression, inattention, and psychosocial impairment). However, many of these early presentations are diagnostically nonspecific. The few studies that have followed at-risk youth into adulthood find developmental discontinuities from childhood to adulthood. Biological markers (e.g., amygdalar volume) may ultimately increase our accuracy in identifying children who later develop bipolar I disorder, but few such markers have been identified. Stress, in the form of childhood adversity or highly conflictual families, is not a diagnostically specific causal agent but does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. A preventative family-focused treatment for children with (a) at least one first-degree relative with bipolar disorder and (b) subsyndromal signs of bipolar disorder is described. This model attempts to address the multiple interactions of psychosocial and biological risk factors in the onset and course of bipolar disorder.     

Treatment Integrity of Studies That Compare Short-Term Psychodynamic Psychotherapy With Cognitive-Behavior Therapy

In their meta-analysis, Leichsenring, Rabung, and Leibing (2004) found that short-term psychoanalytic psychotherapy (STPP) and cognitive-behavior therapy (CBT) were equally efficacious. However, they did not examine whether the treatments were delivered as intended. In our review of nine studies comparing STPP and CBT, we found that most did not adequately implement treatment integrity procedures. Leichsenring and colleagues' contention that CBT and STPP are equally efficacious is therefore based on studies without adequate procedures to monitor treatment adherence or therapist competence. The neglect of treatment integrity procedures in these studies leaves open the possibility that the absence of comparative treatment effects may be due to the manner in which the treatments were operationalized.