A Comparison of Pragmatic and Scalable Strategies to Assess Fidelity to Cognitive Processing Therapy in Routine Care Settings

Abstract

Fidelity monitoring is crucial for successful implementation of evidence-based practices, but traditional methods such as observation and video recording are impractical for routine mental health care due to their high resource demands. A reliable, low-burden fidelity (adherence and competence) assessment can support the implementation of cognitive behavioral therapies (CBTs). This study evaluated two pragmatic alternatives to the time and cost-intensive "gold standard" observer ratings based on session recordings to assess fidelity in Cognitive Processing Therapy (CPT). We assessed the feasibility of clinician-completed adherence checklists and ratings of worksheets that were completed during sessions in public and private mental healthcare settings by a diverse sample of patients with significant trauma histories and their therapists. We also examined whether fidelity ratings using these approaches were associated with observer ratings of fidelity and with subsequent PTSD symptom change. Results indicated high overall rater agreement for adherence and competence on CPT worksheets and session recordings. We found significant associations among traditional observer ratings of adherence and our two low-burden alternatives for assessing adherence. Clinician-completed adherence checklists were also associated with subsequent symptom change. Checklists and worksheets required substantially less time to rate than session recordings. Overall, checklists and worksheets emerged as reliable and feasible methods for fidelity assessment, potentially diminishing the necessity for time- and labor-intensive fidelity ratings based on session recordings. Our findings suggest a scalable approach for integrating fidelity monitoring and support into policies aimed at enhancing the accessibility and effectiveness of evidence-based care.

Keywords: cognitive processing therapy; evidence-based practices; fidelity; implementation; posttraumatic stress disorder.