An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: a modified Delphi study

ABSTRACT

Designing new approaches to delivering cognitive behavioural therapy (CBT) requires an understanding of the key components. This study aimed to establish an expert consensus on the effective components of CBT for depressed adults. An international panel of 120 CBT experts was invited to participate in a modified Delphi study. Thirty-two experts participated in round 1; 21 also provided data in round 2. In round 1, experts rated the effectiveness of 35 content and process components. A priori rules identified components carried forward to round 2, in which experts re-rated items and final consensus items were identified. Consensus was achieved for nine content components (ensuring understanding; developing and maintaining a good therapeutic alliance; explaining the rationale for CBT; eliciting feedback; identifying and challenging avoidant behaviour; activity monitoring; undertaking an initial assessment; relapse prevention methods; homework assignments); and three process components (ensuring therapist competence; scheduling sessions flexibly; scheduling sessions for 45–60 mins). Five of the twelve components identified were generic therapeutic competences rather than specific CBT items. There was less agreement about the effectiveness of cognitive components of CBT. This is an important first step in the development of novel approaches to delivering CBT that may increase access to treatment for patients.

KEYWORDS:

• Cognitive behavioural therapy
• component analysis
• consensus
• Delphi study
• depression

Acknowledgments

We are grateful to the experts who participated in our survey. We thank Vivien Jones for providing administrative support, and Eloisa Colman for facilitating the set-up of the study. We are also grateful to a number of colleagues who are involved with the INTERACT study as co-applicants but who have not participated in drafting this manuscript: Rachel Churchill, David Coyle, Simon Gilbody, Paul Lanham, Glyn Lewis, Una Macleod, Irwin Nazareth, Steve Parrott, Katrina Turner, Nicky Welton, and Catherine Wevill. We also thank Steve Hollon for his helpful comments on an earlier draft of this manuscript. This study was conducted in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a UKCRC Registered Clinical Trials Unit (CTU), which as part of the Bristol Trials Centre, is in receipt of National Institute for Health Research CTU support funding. Study data were collected and managed using REDCap (Research Electronic Data Capture, Harris PA et al., J Biomed Inform. 2009 Apr; 42(2): 377-81) hosted at the University of Bristol.

Disclosure statement

CW is President of the British Association for Behavioural and Cognitive Psychotherapies—a charity that advocates the use of CBT. He is also Director of a company (Five Areas Ltd) that markets CBT training and low intensity interventions. The other authors have no competing interests to declare.

Supllementary material

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Additional information

Funding

This study is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research (Integrated therapist and online CBT for depression in primary care, RP-PG-0514-20012). All research at Great Ormond Street Hospital NHS Foundation Trust and UCL Great Ormond Street Institute of Child Health is made possible by the NIHR Great Ormond Street Hospital Biomedical Research Centre. This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.