When you go to therapy, you expect your therapist to provide effective treatment. For conditions like depression and anxiety, Cognitive Behavioral Therapy, or CBT, has decades of research showing it works. But here's a problem: just because a therapy is proven effective doesn't mean every therapist delivers it as intended.
Health systems have invested billions of dollars to train therapists in CBT and other evidence based treatments. Yet some research suggests many providers don't implement these treatments the way they're supposed to. This creates a need for quality monitoring to make sure patients are getting the care that actually helps.
The traditional way to check if therapists are doing CBT correctly involves having trained experts listen to audio recordings of therapy sessions and rate how well the therapist performed. This "gold standard" approach has major downsides. It's extremely time consuming, requires extensive training, and can feel invasive to both therapists and clients who may not want their sessions recorded and reviewed.
Researchers wanted to find a more practical solution. They tested whether materials that therapists already create during normal therapy sessions could be used to assess quality instead. These materials include worksheets that clients fill out during sessions and checklists that therapists complete about what they covered.
The study involved 87 therapists and 137 clients across multiple mental health clinics. Researchers compared three different ways of assessing therapy quality: ratings based on client worksheets, ratings based on therapist checklists, and traditional observer ratings of recorded sessions.
The results revealed some interesting patterns. When it came to measuring how competently therapists delivered CBT skills, ratings based on worksheets matched up well with the traditional observer ratings. Therapist checklists also aligned with observer ratings when measuring whether therapists covered the right content.
Perhaps most notably, only the therapist checklists showed a relationship with actual patient improvement. When therapists reported higher adherence on their checklists, clients showed greater reductions in depression symptoms over time. Surprisingly, the traditional observer ratings of quality didn't predict symptom improvement at all.
The study also found that reviewing routine materials took significantly less time than having trained experts review audio recordings. This makes the approach much more feasible for busy mental health clinics with limited resources.
These findings could change how mental health systems monitor the quality of therapy. Instead of the expensive and intrusive process of recording and reviewing sessions, clinics could use materials that therapists and clients already create as part of normal care. This would make quality monitoring more sustainable and less burdensome.
The research suggests that checking whether therapists are using the right techniques (competence) through client worksheets, and verifying they're covering the right content through therapist checklists, could provide meaningful quality assurance. This approach respects the time constraints of real world clinical settings while still maintaining accountability for delivering effective care.
For patients, this could mean better assurance that they're receiving therapy that follows proven methods. For therapists, it means less intrusive monitoring that fits more naturally into their workflow. And for healthcare systems, it offers a way to maintain quality standards without the prohibitive costs of traditional monitoring methods.
The study opens the door to more practical approaches to ensuring that the therapy people receive actually matches what research has shown to work. In a field where resources are often stretched thin, finding ways to monitor quality that don't add excessive burden could help more people access truly effective mental health care.
Gatley, D., Millar‐Sarahs, V., Brown, A., Brooks, C. P., & Matcham, F. (2025). Understanding Early Treatment Response in Brief CBT for Nonunderweight Eating Disorders: A Mixed Methods Study. International Journal of Eating Disorders, 58(3), 518-530.
