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Introduction
Treatment fidelity or integrity refers to the extent to which a psychological treatment is implemented as intended (Fairburn and Cooper, 2011), and consists of both adherence and competence. Adherence is the extent to which a therapist delivers a therapy in accordance with the therapy model or manual. Competence is the skill with which a therapist delivers the therapy. Adherence and competence have been shown to be highly correlated (Barber et al., 2003), with a complex hierarchical relationship. Adherence is necessary but not sufficient for therapist competence, and competence is not sufficient without adherence (Waltz et al., 1993). Competence in therapy consists of adherence to the therapy, ability to engage a client and skilful use of treatment change strategies; as well as knowledge of when and when not to apply these strategies (Yeaton and Sechrest, 1981).
Measuring fidelity or integrity in cognitive behavioural therapy (CBT) is necessary for outcomes research to be meaningful. CBT has become one of the most prominent psychological therapies worldwide (Hofmann et al., 2012) due to its strong performance in outcome studies. Clearly, it is important to know that the therapy offered in these studies is actually CBT. Reliable and valid measures of competence in CBT are needed to establish treatment fidelity (Shafran et al., 2009) and these must be used with care: for example, a systematic review found that inter-rater reliability of the Cognitive Therapy Scale (CTS) or its revised version (CTS-R) is not often reported and when it is, the results are variable (Loades and Armstrong, 2016).
As the demand for CBT increases, commissioners, services, trainers and researchers all need effective methods to ensure that CBT is delivered with fidelity to the evidence base. CBT is recommended in the UK for many psychological difficulties [National Institute for Clinical Excellence, 2004, 2007, 2011, 2014a, 2014b; Scottish Psychological Therapy Matrix (National Health Service Education for Scotland, 2015); Matrics Cymru: Delivering Evidence-Based Psychological Therapy in Wales (National Psychological Therapies Management Committee, 2017)]. In England there has been a firm commitment for services to deliver CBT through the roll-out of the Improving Access to Psychological Therapies (IAPT) initiative (Clark, 2011). Commissioners and trainers responsible for disseminating CBT skills need effective methods to assess the impact of training on...