Understanding therapist variables: an analysis of online cognitive behavioural therapy transcripts

OBJECTIVES- Cognitive behavioural therapy (CBT) is a psychological therapy that is widely recommended for the treatment of depression and anxiety disorders. The variance in recovery rates for CBT in England’s Improving Access to Psychological Therapy (IAPT) programme has received much attention, with some services reporting recovery rates as low as 18%. One of the variables that account for clinical outcome are therapists. Without access to therapy transcripts it has been difficult to assert which therapist variables are associated with outcome. The purpose of this research is to use the therapy transcripts of 200 IAPT therapists in order to understand which therapist variables are associated with clinical outcome. METHOD- This research used a naturalistic observational study design to understand the relationship between clinical outcomes and therapist variables. The therapy transcripts of 200 High Intensity IAPT therapists, who had provided CBT online using synchronous written communication, were rated by 6 highly experienced CBT therapists. The raters used the revised version of the Cognitive Therapy Scale to assess therapist competence and used the transcripts of 3 whole episodes of care to rate adherence to an evidence-based protocol. The data were analysed using correlation, regression and loglinear models. RESULTS- This research found that not all therapists deliver CBT with fidelity to the model (competence) or adherence to a protocol. Where this was evident, therapist competence and therapist adherence were related to clinical outcome at the ≤ 0.05 level. Therapist age, gender, core profession, years of experience or method of training were not related to outcome CONCLUSION- Process-outcome research in IAPT has, to date, been unable to access the therapy transcripts of large numbers of therapists. This is the first time that this has been possible to use therapy transcripts to understand the relationship between clinical outcome and therapist competence and adherence to an evidence-based protocol. This new way of conducting psychological therapy research provides a unique contribution to knowledge and will have a significant impact on professional practice in relation to how CBT therapists are supported to improve patient outcomes in the context of IAPT.