A Glimpse into the 'Black Box': Which Elements of Consultation in an EBP are Associated with Client Symptom Change and Therapist Fidelity?

Background: Consultation is an implementation strategy that improves delivery and clinical outcomes for Cognitive Processing Therapy (CPT), an evidence-based practice (EBP) for posttraumatic stress disorder (PTSD). However, little is known about the specific components of consultation that influence the fidelity of treatment delivery or clinical outcomes. Methods: The current study examined whether specific activities performed during CPT consultation meetings were associated with better fidelity to the CPT protocol among 60 newly trained therapists or improved clinical outcomes among 135 clients treated by these therapists. Consultation activities that fall under three broad categories (discussion of the application of CPT to individual cases, review/feedback on fidelity, and technical difficulties) were measured by consultant checklists for each consultation session. Treatment fidelity (adherence to the protocol and competence of delivery) was rated by trained observers for a random sample of therapists' CPT sessions following consultation. The self-reported PTSD Checklist-IV assessed PTSD symptom change. Results: Multilevel regression analyses indicated that higher therapist consultation attendance predicted a greater decrease in their clients' PTSD symptoms and that attendance was not associated with observer-rated treatment fidelity. Discussion of the application of specific CPT strategies was the only consultation activity that was significantly associated with greater improvement in PTSD symptoms. Lastly, no consultation activities were significantly associated with treatment fidelity. Conclusions: Our findings suggest that specific consultation strategies such as emphasizing the discussion of the application of specific CPT strategies to individual cases during consultation meetings may be effective in improving the clinical outcomes of CPT.