Key Factors to Maintaining Treatment Fidelity in an Improving Access to Psychological Therapies (IAPT) Model of CBT

The aim of this contribution is to provide evidence and greater theoretical understanding of the relationship between key factors that maintain treatment fidelity in CBT, outside of research settings. This spans decades in CBT training, supervision and practice, contributing new terms, concepts, models and clinical recommendations. The series culminates by focusing on Improving Access to Psychological Therapies (IAPT). A coherent body of work emerges, when an ‘empirically-grounded clinically interventions’ approach is applied. This uses practice-based research, pilot data and preliminary studies, combined with original empirical evidence.

Aims are achieved by defining and appraising five topics - Treatment Fidelity, Service-Model Fidelity, Training, Clinical Supervision and Service Framework. Once their key functions are established, their inter-relatedness emerges. The rationale has a basis in findings that clinical outcomes in research do not always translate into services, despite insignificant demographic differences and more experienced practitioners in services. This hypothesises, services with more variables that increase treatment fidelity to known interventions, will be linked to superior clinical outcome. Whilst drilling deeper into key concepts at one level, the overarching theme remains the tension between outcome research in CBT and its failure to translate into standard clinical services. This historical lack of replication was a factor in the modernisation agenda of IAPT. Three broad recommendations and implications for future research are concluded from the series.

First, adhering to a High Dose Narrow/Bandwidth (HD/NB) model (Cromarty 2016), increasing the dose of the primary intervention allows IAPT practitioners to closer match treatment fidelity and clinical outcomes of research trials. The Australian IAPT contributions explicitly showcase this, supporting the hypothesis that services with increased treatment fidelity yield superior clinical outcomes.

Secondly, HD/NB interventions must be supported by Service-Model Fidelity (Cromarty 2016). The delivery system in which HD/NB principles operate is equally important. This recommendation for integrating clinical improvement and service-redesign models, notes Treatment Fidelity is not guaranteed in clinical services with training, supervision and best-practice alone. Placed within an optimised service model such as IAPT, the joint strengths of key variables are amplified. Further research on service model being a possible factor of improved clinical outcome is recommended.

Thirdly, if known problems translating research into clinical practice persist, additional research closing the gap, can originate from the clinical practice! CBT has an actual empirical basis in clinical observation with additional theoretical aspects, researching and treating numerous variables, including psychosocial and psychological processes. CBT clinical practice possesses several overlapping features with single-case methodology. Small scale, service-based studies allow convenient samples, with high inference and low numbers. They have high clinical and face validity with the ability to study individual change processes. The advent of IAPT services allows a more robust two-way process to augment controlled research. They are ideal grounds for translating research findings into services due to inexorably linked variables, combining to improve treatment fidelity. This constitutes a continual two-way process by recipient IAPT services increasing the empirical basis of practice-based research. This can contribute back into the wider evidence base to inform future large-scale research.