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

Fidelity monitoring is crucial for successful implementation of evidence-based practices, buttraditional methods such as observation and video recording are impractical for routine mentalhealth care due to their high resource demands. A reliable, low-burden fidelity (adherence andcompetence) assessment can be helpful in improving the sustained implementation of cognitivebehavioral therapies (CBTs). This study evaluated two pragmatic alternatives to the time andcost-intensive “gold standard” observer ratings based on session recordings to assess fidelity inCognitive Processing Therapy (CPT). We assessed the feasibility of clinician-completedadherence checklists and ratings of clinical worksheets that were completed during sessions inpublic and private mental healthcare settings by a diverse sample of patients with significanttrauma histories and their therapists. We also examined whether fidelity ratings using theseapproaches were associated with observer ratings of fidelity and with subsequent PTSDsymptom change. Results indicated high overall rater agreement for adherence and competenceon CPT worksheets and session recordings. We found significant associations among traditionalobserver ratings of adherence and our two low-burden alternatives for assessing adherence.Clinician-completed adherence checklists were also associated with subsequent symptomchange. Checklists and worksheets required substantially less time to rate than sessionrecordings. Overall, checklists and worksheets emerged as reliable and feasible methods forfidelity assessment, potentially diminishing the necessity for time- and labor-intensive fidelityratings based on session recordings. Our findings suggest a scalable approach for integratingfidelity monitoring and support into policies aimed at enhancing the accessibility andeffectiveness of evidence-based care.