Development of Group Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments

Development of Group Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of Group Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments Justin C. Baker, Shannon Cain, Skyler D. Prowten, Laura Gunn, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8671387/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: Treatment fidelity is important for both research and clinical practice, including adapting new approaches for group delivery of Brief Cognitive Behavioral Therapy (G-BCBT) for suicide prevention. This study describes the development and preliminary field test of 12 fidelity assessment instruments (FAIs) for G-BCBT, for use in a non-inferiority trial comparing G-BCBT to Dialectical Behavioral Therapy (DBT) skills group. Method: This study included 141 active-duty service members (69 male, 72 female). Participants were randomized to one of two conditions with a total of 10 G-BCBT and 10 DBT group therapy cohorts. Twelve G-BCBT FAIs were developed (one per session) and used by two expert raters to evaluate G-BCBT fidelity. Results: Range of percent agreement was high among expert raters, with 86.3% of agreement scores exceeding 85%. Results for inter-rater reliability were mixed with several scores reflecting perfect agreement and others achieving fair to moderate levels of agreement. However, most inter-rater reliability metrics demonstrated less than chance levels of agreement, suggesting possible halo or ceiling effects. Conclusion: Initial field testing of G-BCBT FAIs provided mixed support for use. Recommendations to improve FAI use and inter-rater reliability metrics are discussed as well as directions for future research. Suicide Military Brief Cognitive Behavioral Therapy Fidelity Group therapy Introduction Clinical or Methodological Significance of this Article (2-3 sentences): Group-Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments (G-BCBT FAIs) provide a structured method for monitoring treatment fidelity. Monitoring treatment fidelity is relevant for both research and clinical practice to ensure treatments are delivered competently and as designed. The following study provides preliminary field evidence of the development and deployment of G-BCBT FAIs. Treatment fidelity most frequently describes how closely interventions follow the original design during clinical testing while remaining distinct from standard care or control methods (Borrelli, 2011; Hildebrand et al., 2012; Moncher & Prinz, 1991). Monitoring treatment fidelity has not always been common practice in clinical trials or field implementation (Moncher & Prinz, 1991). However, it is now a recommended practice, with clear guidelines and expectations to monitor treatment fidelity when conducting and evaluating behavioral health interventions (Bellg et al., 2004). In research, maintaining treatment fidelity serves the purpose of ensuring that any changes to the experimental intervention or treatment occur as intended (Cook et al., 2024; Moncher & Prinz, 1991). High treatment fidelity also helps one to better understand change mechanisms in an intervention and determine the actual degree the client was exposed to the specific treatment (Farmer et al., 2017). Moreover, higher fidelity is associated with improved internal and external validity, increasing the ability to generalize the findings to other settings (Borrelli, 2011). Intervention fidelity is also important for clinical practice (Bryant et al., 2025), as it aids in implementation and intervention update (Bellg et al., 2004; Gamarra et al., 2015; O’Shea et al., 2016). Perhaps the greatest benefit of fidelity assessment is its positive impact on treatment outcomes. For example, Gamarra et al. (2015) identified a significant relationship between higher safety plan quality and lower hospitalization rates in a sample of military veterans. In another study, higher fidelity to Cognitive Behavioral Therapy (CBT) for depression was linked with reduced depressive symptoms (Strunk et al., 2010). In a study of Cognitive Processing Therapy for Posttraumatic Stress Disorder (PTSD), researchers identified that higher therapist adherence and competence to the intervention resulted in greater decreases in symptoms of depression and PTSD (Marques et al, 2019). While fidelity assessment of interventions, especially within clinical trials, is an important matter, little research exists concerning how fidelity should be measured, particularly in the context of reducing suicide in the military. In the following sections, we outline military suicide rates and existing interventions, including Brief Cognitive Behavioral Therapy (BCBT; Bryan & Rudd, 2018; Rudd et al., 2015) and its recent group adaptation (Baker et al., 2023), to highlight the need for fidelity assessment. Finally, we describe the current state of BCBT fidelity assessment as a foundation for the present investigation of how fidelity is assessed in Group-Brief Cognitive Behavioral Therapy (G-BCBT; Baker et al., 2023). Military Suicide: Rates, Existing Treatments, and a Need for Fidelity Assessment Monitoring treatment fidelity is particularly important in the implementation and evaluation of treatments for suicide prevention among military service members. As the annual suicide rate among active-duty service members has gradually increased since 2011 (Department of Defense, n.d.), suicide among military service members is as an urgent public health and national security concern within the United States (U.S.). The rate of U.S. active-duty suicide (28.2/100,000) (Department of Defense, n.d.) is nearly double the rate of death by suicide in the U.S. civilian population (14.12/100,000; American Foundation of Suicide Prevention, 2025). However, robust interventions for suicidal thoughts and behaviors exist. Widely used therapies include the Collaborative Assessment and Management of Suicidality (CAMS; e.g., Jobes et al., 2012), Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT; Rudd et al., 2015), and Dialectical Behavioral Therapy (DBT; e.g., Goodman et al., 2021). Additionally, the Department of Veterans Affairs and Department of Defense (VA/DoD) created the Clinical Practice Guidelines for Assessment and Management of Patients at Risk for Suicide (VA/DoD, 2019, 2024). The guidelines highlight best therapeutic practices for military suicide prevention, such as cognitive-behavioral therapies, lethal means reduction, and problem-solving interventions. However, they make no mention of the importance of or methods for ensuring fidelity of treatment delivery. Further, Defense Health Agency and other treatment facilities experience challenges to fidelity in suicide-specific interventions, such as staffing shortages, lack of providers trained in the provision of such therapies, and patient deployment (VA/DoD, 2024; Tanielian, 2019). Thus, there exists an urgent and unmet need to address barriers to best ensuring fidelity to suicide prevention interventions in military settings. BCBT (Bryan & Rudd, 2018; Rudd et al., 2015) is a leading suicide prevention psychotherapy offering a foundation for fidelity assessment in clinical research and practice. Aligning with fluid vulnerability theory (Rudd, 2006), BCBT is a 12-session treatment grounded in the theory that an individual’s suicidal state results from the interaction of the individual’s deficits in emotion regulation and cognitive flexibility when faced with an activating event. BCBT has demonstrated efficacy in civilian outpatient settings via telehealth (Baker et al., 2024) and among active-duty service members and veterans (Bryan et al., 2025; Rudd et al., 2015). Emerging beyond outpatient treatment settings is recent evidence in the efficacy of a shortened version of BCBT for inpatient psychiatric patients (Diefenbach et al., 2024), and youth hospitalized for self-harm (Sinyor et al., 2020). Results from these trials suggest that BCBT is an effective treatment to reduce incidence of self-harm (Sinyor et al., 2020) and suicidal ideation and suicide attempts (Baker et al., 2024; Bryan et al., 2025; Diefenbach et al., 2024; Rudd et al., 2015). BCBT therapy fidelity ratings across existing studies are high. Research therapists delivering the intervention in the first trial of BCBT in military service members maintained > 90% fidelity ratings (Rudd et al., 2015) with similar fidelity ratings of 92.7% observed in the telehealth BCBT trial (Baker et al., 2024). Fidelity ratings for BCBT adapted to hospitalized youth were also high at 92% (Sinyor et al., 2020). However, fidelity ratings were not reported for the inpatient trial of BCBT or the most recent trial completed among veterans and military personnel (Bryan et al., 2025; Diefenbach et al., 2024). Importantly, existing studies are limited to fidelity ratings for individual BCBT therapy protocols. Group Brief Cognitive-Behavioral Therapy for Suicide (G-BCBT): Clinical Trial and Fidelity Assessment Baker and colleagues (2023) created a group adaptation of BCBT (G-BCBT). G-BCBT targets the same hypothesized mechanisms of action as BCBT (i.e., emotion regulation and cognitive flexibility; Bryan & Rozek, 2018) while leveraging the buffering effects of social support (Ogrodniczuk, Piper, Joyce, McCallum, & Rosie, 2002; Ogrodniczuk, Joyce, & Piper, 2003). The treatment was designed to address barriers to delivering suicide interventions among active-duty military personnel (e.g., provider shortages, patient deployment). Patients complete one individual intake session prior to beginning the twelve 90-minute weekly group sessions. G-BCBT is organized in three phases: (1) emotion regulation, (2) cognitive flexibility, and (3) relapse prevention. Sessions in phase one focus on teaching emotion regulation skills to patients in crisis, phase two focuses on teaching cognitive reappraisal skills, and phase three tests patient skill acquisition through successful navigation of imagined crisis scenarios. The G-BCBT protocol included development of Fidelity Assessment Instruments (FAIs). Twelve G-BCBT FAIs (one for each group therapy session) were adapted from existing BCBT fidelity rating forms to evaluate treatment adherence (Bryan & Rudd, 2018). G-BCBT FAIs were developed with the focus of ensuring treatment adherence throughout the study (Waltz, Addis, Koerner, & Jacobson, 1993). G-BCBT FAI items allowed raters to assess whether specific components of G-BCBT were completed for each session. Independent evaluators were expert licensed clinical social workers trained in crisis response planning (CRP) and BCBT. Evaluators scored items using a 3-item Likert scale indicating no, partial, or full credit for each listed item on the G-BCBT FAIs. A section for notes for each session was also included on the G-BCBT FAIs to help facilitate consultation and feedback during weekly consultation calls. The notes were not included in the scoring of the G-BCBT FAIs. The Present Study This current study focuses on the development of treatment fidelity rating forms for use in a non-inferiority trial comparing G-BCBT to DBT skills group (Baker et al., 2023). This paper focuses exclusively on the development of twelve G-BCBT FAIs that correspond with each session of the 12-session G-BCBT treatment. We proposed the following aims and hypotheses. Aim 1: Quantify overall G-BCBT FAI descriptive statistics. Hypothesis 1: G-BCBT FAI average scores and rates of agreement will be high across sessions. Aim 2: Establish inter-rater agreement in the use of G-BCBT FAIs. Hypothesis 2: G-BCBT FAI inter-rater reliability will be acceptable or higher across sessions. Methods Participants Participants included 141 active-duty service members (69 male, 72 female), who participated in a randomized non-inferiority clinical trial comparing G-BCBT to DBT skills group. Participants were randomized to receive either G-BCBT or DBT skills group, with a total of 10 G-BCBT groups and 10 DBT skills groups. There was an average of 8 participants randomized to each G-BCBT group and 7 participants to each DBT skills group. Briefly, prospective participants were recruited to participate in the trial from Naval Medical Center Portsmouth (NMCP; Baker, et al., 2023). Participants were eligible to participate in the clinical trial if they met the following inclusion criteria: (1) active duty service members, (2) between the ages of 18 to 65, (3) of treatment-seeking status in outpatient men­tal health or substance abuse rehabilitation clinics, and/or inpatient psychiatry discharge, or other NMCP pri­mary care and surrounding outpatient clinics (4) report current (within the past week) suicide ideation (e.g., score greater than two on the Scale for Suicide Ideation) and/or a suicide attempt within the past month (e.g., as assessed by the Self-injurious Thoughts and Behaviors Interview-Revised [SITBI-R]; Fox et al., 2020), (5) able to understand and speak English, and (6) able to complete the informed consent process. Participants were excluded if they had a psychiatric or medical condition that precluded them from providing informed consent or participating in outpatient treatment (e.g., psychosis, mania, acute intoxication requiring hospitalization). Retired service members and family/dependents of active-duty military personnel were not eligible for the study. All study procedures were approved by study site institutional review board. The non-inferiority trial comparing G-BCBT to DBT was preregistered at Clinicaltrials.gov (protocol REDACTED for anonymity). Therapist Training and Ongoing Consultation The two therapists hired to provide G-BCBT treatment were a licensed clinical social worker and licensed marriage and family therapist, both of whom completed training in military cultural competence, CRP, and BCBT. The two therapists were hired, onboarded, and fully credentialed as licensed mental health providers within the Department of Mental Health at NMCP to deliver both G-BCBT and DBT treatments within this trial. Therapists were interviewed and selected based on prior group therapy experience, ability to be credentialed within a military treatment facility, prior experience working with military populations, comfort and experience working with high-risk patients undergoing significant emotional distress, ability and familiarity with handling crises and possible hospitalization, willingness to receive training in new treatment methods with ongoing clinical consultation, and aptitude for timely documentation. Both therapists were trained in BCBT and DBT treatment modalities through multi-day training workshops. Military cultural competence trainings were completed online through the American Insurance Trust (n.d.) and the Center for Deployment Psychology (n.d.). As this paper is solely focused on G-BCBT fidelity, only training in BCBT will be described. Therapists completed a two-day online synchronous training in BCBT, using established training curriculum based off the existing published manual (Bryan & Rudd, 2018). Training included an overview of theory, research, and best practices for treating high-risk suicidal individuals. Didactic exploration, video therapy demonstrations, and live role playing were included in the training as standard curriculum. Therapists were included in a workshop with other community mental health providers who were taking the training for continuing education units. In addition to this training in BCBT, therapists also received training specific to delivering BCBT in group format. The group adaptation is heavily based on the individual BCBT therapy manual (Bryan & Rudd, 2018). G-BCBT session outlines were developed for this trial to standardized group delivery of BCBT. G-BCBT session outlines were reviewed in six, one-hour weekly training sessions with the research therapists to discuss group adaptations for BCBT. Training focused on managing group dynamics and time, needed changes to homework assignments, and ways to conduct skill practices in a group format. Both therapists also completed preliminary mock group therapy sessions prior to enrollment of any study participants. Once participant enrollment began, therapists completed weekly consultation with the lead investigator and fidelity raters throughout the entire treatment delivery period of the trial. G-BCBT Treatment Intervention G-BCBT was adapted from the individual therapy BCBT manual (Bryan & Rudd, 2018). Like BCBT, G-BCBT follows a cognitive behavioral therapy paradigm to target skill deficits in emotion regulation and cognitive flexibility: two proposed mechanisms of action underlying vulnerabilities for suicide. Participants randomized to G-BCBT, completed a 90-minute individual intake session with one of the two research therapists. Participants then completed 12, 90-minute weekly group therapy sessions. The intake session for G-BCBT included BCBT components typically delivered during the first session of BCBT: the narrative assessment to assess suicide risk, development of a suicidal mode or case conceptualization to be used in treatment by the participant, and a tailored crisis response plan, a safety planning type intervention to mitigate risk of a future suicide attempt. Therapists also had the option of conducting lethal means safety counseling to reduce access to lethal means of suicide for the participant during this intake session. G-BCBT sessions followed a three-phased approach that organized sessions by proposed mechanisms of action: (1) emotion regulation, (2) cognitive flexibility, and (3) relapse prevention. Interventions introduced during the first phase of treatment included coping strategies such as mindfulness and relaxation training, psychoeducation for improving sleep hygiene, identifying a crisis support person and reasons for living, and building a survival kit to increase easy access to tangible reminders of hope. Phase two of G-BCBT focused on cognitive flexibility primarily through the introduction of worksheets designed around cognitive reappraisal strategies, including (1) ABC, (2) challenging questions, and (3) patterns of problematic thinking. Additional sessions in this phase also introduce coping cards and activity planning. The final or third phase of treatment, called relapse prevention, is focused on skills solidification and mastery. Group participants are tasked with demonstrating adequate skill use to navigate past and potential future suicidal crises with the goal of successfully thwarting future suicide attempts. Fidelity Assessment Instruments and Procedures A total of twelve G-BCBT FAIs, one for each group therapy session, were adapted from existing published fidelity rating forms for individual BCBT (Bryan & Rudd, 2018). G-BCBT FAIs were developed to ensure adherence to the treatment is maintained (Waltz, Addis, Koerner, & Jacobson, 1993). These FAIs are distinct from other therapy rating scales that may also measure therapist competence, or how skillful the therapist is in delivering the treatment (Waltz et al., 1993). G-BCBT FAI items were rated using the following rating scale 0 = no, 0.5 = partial , and 1 = yes , following the 3-point scale used in the original published fidelity rating forms. Each session G-BCBT FAI typically consisted of 1 subscale to rate the “Therapeutic Frame” which includes symptom/mood check, review/assigning homework, and agenda setting and an additional 1-2 subscales to rate the specific skills introduced in the session. As an example, the G-BCBT FAI for session 2 consisted of four-items for the Therapeutic Frame subscale, eight items for Skills Training: Sleep Disturbance subscale, and eight-items for Relaxation Training subscale, for a total max possible score of 20. FAI max scores differed by sessions. Session-by-session G-BCBT FAIs followed the prescribed treatment intervention order for G-BCBT (Baker et al., 2023), with items tailored specifically to the interventions introduced in each session. All twelve G-BCBT FAIs are included in the Online Supplemental. To establish initial treatment fidelity, all sessions were rated until fidelity scores averaged 85% or higher on two complete group therapy cohorts. Initial fidelity was established within the first two G-BCBT cohorts. For G-BCBT cohorts 3-10, 20% of sessions were randomly selected, controlling for session number (i.e., group sessions 1-12) to ensure each session number was reviewed at least four times. This was done to ensure adequate fidelity monitoring of the various interventions delivered among the 12 group therapy sessions. Fidelity scores for randomly selected cases from G-BCBT cohorts 3-10 remained at or above 85% for both raters. All sessions were rated by two independent evaluators. Independent evaluators were experienced licensed clinical social workers, who rated audio recorded group sessions using the developed G-BCBT FAIs. Evaluators received training in use of the G-BCBT FAIs from the lead investigator. Both independent evaluators participated in weekly consultation with the lead investigator and therapists to provide real time feedback to therapists during the trial. Consultation calls were supportive and fostered a culture of learning and attention to improving treatment fidelity. This allowed therapists to immediately incorporate any feedback into ongoing therapy sessions. Data Analysis Aim 1 was to quantify G-BCBT FAI descriptive statistics. We report overall percent agreement between coders, alongside other descriptive statistics. Percent agreement is included in Aim 1 because it is a poor metric of rater agreement (Aim 2) due to a failure to control for agreement by chance and a tendency toward over inflated values (Hallgren, 2012). Aim 2 focused on capturing inter-rater agreement in G-BCBT FAI ratings. We analyzed data at the subscale and total score levels for each G-BCBT group session FAI to ensure we had enough data points rated by coders; a higher number of rated observations increases the accuracy of inter-rater results (McHugh, 2012). We began with computing Cohen’s Kappa given its appropriateness for use with two raters and because it corrects for chance agreement (Sun, 2011). Cohen’s Kappa typically ranges from 0 to 1 but can yield negative values when the level of agreement is worse than what is anticipated by chance. In instances where a restricted range in ratings (i.e., using all one rating across all items) from any coder prevented Cohen’s tabulations, we employed Fleiss’ Kappa. Fleiss’ Kappa ranges from -1 (no agreement) to 1 (perfect agreement), where negative values indicate less than chance agreement and vice versa for positive values (Laerd Statistics, 2019). Magnitude of agreement for all inter-rater reliability values were determined in line with statistical conventions in the literature: 0 to .20 = slight, 0.21 to 0.40 = fair, 0.41 to .60 = moderate, 0.61 to 0.80 = substantial, and 0.81 to 1.00 = almost perfect (Royal & Hecker, 2016) Results There were no missing data, so missing data analysis and replacement techniques were unnecessary. Table 1 contains all descriptive statistics (Aim 1) and inter-rater reliability metrics (Aim 2). Hypothesis 1 was generally supported. Reviewing Table 1, average G-BCBT FAI subscale and total scores demonstrated ceiling effects, with ranges consistently on the higher end of each respective scale. Also, the overall range of percent agreement was high: 75-100%. Using the 85% metric as a cut-off, 38 of 44 (86.3%) of percent agreement scores exceeded acceptable levels of percent agreement. Results were highly mixed with regard to inter-rater reliability scores. Referring to Table 1, several scores achieved near perfect agreement, with a few others reaching fair to moderate levels of agreement. However, the majority (28/40, 70%) showed less than chance levels of agreement based on negative obtained Kappa values. Visual inspection of the data suggests the possibility of a halo or ceiling effect in which one rater did not deviate from the highest of three code choices. Discussion The overall purpose of this study was to present the G-BCBT FAIs, with an example of use in a field clinical trial. Given BCBT’s growing evidence (e.g., Baker et al., 2024; Bryan et al., 2025; Diefenbach et al., 2024; Rudd et al., 2015; Sinyor et al., 2020), a critical next step concerns articulation of implementation tools for various BCBT modalities. Considering the novelty of the G-BCBT FAIs, we focused testing on descriptive statistics (e.g., percent agreement) and inter-rater reliability to be consistent with initial tests of other fidelity assessment tools (e.g., Bryant et al., 2025; Martin et al., 2023). Developing and testing the G-BCBT FAIs is important given the limited literature (e.g., Bryant et al., 2025; Gamarra et al., 2015) validating fidelity tools for interventions in military active duty and veteran populations. Doing so also provides accessible instruments for further psychometric refinement and clinical use. Our initial test of the G-BCBT FAIs produced mixed support for the initial field implementation in the G-BCBT clinical trial (Baker et al., 2023). The first hypothesis was supported. Basic descriptive statistics such as percent agreement were robust (see Table 1). Yet, reliance merely on metrics of central tendency and overall agreement ignores important considerations in assessing intervention fidelity, potentially leading to overestimating the strength of agreement (McHugh, 2012). More robust hypothesis two Kappa-focused analyses yielded equivocal support for inter-rater reliability across G-BCBT FAIs (see Table 1). Several explanations can be hypothesized for the limited reliability, pointing to clear solutions and next steps in G-BCBT FAI development and usage. Low inter-rater reliability can result from a restricted range (Hallgren, 2012). Drawing on BCBT tools (Bryan & Rudd, 2018), the G-BCBT FAIs only have a 3-response option set (i.e., no, partial, yes). Moreover, consistent patterns from one rater raised the possibility of a ceiling or halo effect. In other words, one rater may have overgeneralized high ratings of performance to all ratings where an initial rating was highly positive (e.g., Laham & Forgas, 2022). Alternatively, a lack of or poorly executed training may lead to a lack of calibration of ratings (Hallgren, 2012). Finally, it is plausible that clinical delivery was exceedingly high, leading to relatively accurate ratings. Several possible solutions exist for the restricted range or halo and ceiling effects. First, in terms of measurement, the response range can be expanded to a 5-point Likert scale with refined anchors (Hallgren, 2012). Offering more nuances may promote careful rater observation and consideration of scale midpoints. Second, expert raters can conduct ratings in tandem or groups. Our study featured primarily individual raters conducting observations on their own. Evidence exists suggesting biases may be neutralized in group assessments, thereby resulting in stronger inter-rater reliability (Thomas et al., 2011). In a similar vein, G-BCBT FAI testing may benefit from a mixed-method approach whereby clinicians complete self-report fidelity ratings which are compared and discussed with expert raters. A fourth simple solution would be to use more than two raters to increase the likelihood of spread within the data. Finally, there may be a need for a more structured, detailed G-BCBT FAI training program that overtly addresses issues like response bias, clinical supervision dynamics, and creative implementation of the FAIs. As G-BCBT (Baker et al., 2023) and BCBT (Bryan & Rudd, 2018) may become more common treatments, fidelity tool use has several implications for clinical practice. First, findings from this study provide preliminary evidence for use of G-BCBT FAIs for tracking treatment fidelity. This is good news for supervisors and trainers who may want to use G-BCBT FAIs when helping trainees learn G-BCBT. Further, clinicians implementing G-BCBT for the first time may use these developed rating scales in self-reflective practice as feedback tools to improve treatment adherence and competence, which may result in improved treatment response for patients (Stirman et al., 2021). Similarly, trainees learning this treatment approach may want to watch their video recorded sessions and rate themselves. Watching sessions and completing fidelity ratings is a beneficial exercise to help trainees link interventions performed in session with the theory of the treatment. Lastly, fidelity ratings may provide a structured way for the therapist to consider alliance in group therapy and other potential group dynamics that may be affecting treatment (Alldredge, Burlingame, Yang, & Rosendahl, 2021). The present study possessed several limitations worth noting. First, G-BCBT FAIs were completed within the context of a randomized clinical trial (RCT) and may not generalize well to real world clinical practice settings. Additional research using the G-BCBT FAIs outside the context of RCTs is warranted. Second, the G-BCBT FAIs ratings were developed with a small sample size. There were two research clinicians who co-led each group therapy session and two expert raters that provided ratings throughout the trial. A more thorough evaluation of the developed G-BCBT FAIs with a larger sample size of therapists and raters should be undertaken in future studies. Lastly, this study was conducted at a military treatment facility and may not generalize outside military practice settings. Despite these limitations, this study provides an initial pilot test of the G-BCBT FAIs developed for use in a non-inferiority RCT. Future study should expand upon findings to evaluate how fidelity scores correlate with clinical outcomes, such as reductions in suicidal ideation or improved self-efficacy. Declarations Competing Interests Dr. Baker reported receiving personnel fees from Anduril LLC and grants from the Department of Defense outside the submitted work. Dr. Cramer reported receiving grants from the Department of Defense outside the submitted work. Dr. Khazem reported receiving personnel fees from Anduril LLC and grants from the Department of Defense and the University of Minnesota Press Test Division outside the submitted work. Remaining authors have no competing interests to declare.The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense nor the U.S. Government. CDR Grover is a military service member. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.Research data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol. Author Contribution J.B. and L.R. are responsible for overall conceptualization of the manuscript. J.B., S.C., S.P., R.C., and L.K., wrote the main manuscript text. S.C., S.P., and R.C. completed data analysis. R.C., J.B., S.G., and L.G. acquired funding for the study. S.W., L.R., S.C., and J.B. provided supervision. C.C. and H.R. aided in the investigation. All authors reviewed the manuscript. Data Availability The data that support the findings of this study are available from the corresponding author, J.B., upon reasonable request. References Alldredge, C. T., Burlingame, G. M., Yang, C., & Rosendahl, J. (2021). Alliance in group therapy: A meta-analysis. Group Dynamics: Theory Research and Practice , 25 (1), 13–28. https://doi.org/10.1037/gdn0000135 American Foundation for Suicide Prevention (2025). Suicide statistics . https://afsp.org/suicide-statistics/ . Accessed on 11 Aug 2025. American Insurance Trust (n.d.). Military cultural competence: Providing effective assessment and treatment. https://thetrust.learnupon.com/store/2874375-military-cultural-competence-providing-effective-assessment-and-treatment Baker, J. C., Grover, S., Gunn, L. H., Charles, C., Rikli, H., Franks, M. J., Khazem, L. R., Williams, S., Ammendola, E., Washington, C., Bennette, M., Starkey, A., Schnecke, K., Cain, S., Bryan, C. J., & Cramer, R. J. (2023). Group brief cognitive behavioral therapy for suicide prevention compared to dialectal behavior therapy skills group for military service members: A study protocol of a randomized controlled trial. Bmc Psychiatry , 23 (1), 904. https://doi.org/10.1186/s12888-023-05282-x Baker, J. C., Starkey, A., Ammendola, E., Bauder, C. R., Daruwala, S. E., Hiser, J., Bauder, C. R., Daruwala, S. E., Hiser, J., Khazem, L. R., Rademacher, K., Hay, J., Bryan, A. O., & Bryan, C. J. (2024). Telehealth brief cognitive behavioral therapy for suicide prevention: A randomized clinical trial. JAMA Network Open , 7 (11), e2445913–e2445913. https://doi.org/10.1001/jamanetworkopen.2024.45913 Bellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., Ogedegbe, G., Orwig, D., Ernst, D., Czajkowski, S., & Treatment Fidelity Workgroup of the NIH Behavior Change Consortium. (2004). Enhancing treatment fidelity in Health Behavior Change Studies: Best practices and recommendations from the NIH Behavior Change Consortium. Health Psychology , 23 (5), 443–451. https://doi.org/10.1037/0278-6133.23.5.443 Borrelli, B. (2011). The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. Journal of Public Health Dentistry , 71 (s1), S52–S63. https://doi.org/10.1111/j.1752-7325.2011.00233.x Bryan, C. J., Khazem, L. R., Baker, J. C., Brown, L. A., Taylor, D. J., & Pruiksma K. E., Acierno. Larick, R., Baucom, J. G., Garland, B. R., E. L., & Rudd, M. D. (2025). Brief cognitive behavioral therapy for suicidal military personnel and veterans: The Military Suicide Prevention Intervention Research (MSPIRE) randomized clinical trial. JAMA Psychiatry . https://doi.org/10.1001/jamapsychiatry.2025.2850 . Published online. Bryan, C. J., & Rozek, D. C. (2018). Suicide prevention in the military: A mechanistic perspective. Current opinion in psychology , 22 , 27–32. https://doi.org/10.1016/j.copsyc.2017.07.022 Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention . Guilford. Bryant, W. T., Lange, T. M., Hilgeman, M. M., Bishop, T. K., Santa Ana, E. J., & Cramer, R. J. (2025). A clinician-based treatment fidelity tool for PRIDE in all who served. Translational Issues in Psychological Science , 11 (1), 80–89. https://doi.org/10.1037/tps0000418 Center for Deployment Psychology (n.d.). Military culture: Enhancing clinical competence course description. https://deploymentpsych.org/Military-Culture-Enhancing-Competence-Course-Description Cook, C., O’Halloran, B., Karas, S., Klopper, M., & Young, J. (2024). Treatment fidelity in clinical trials. Archives of Physiotherapy , 14 , 65–69. https://doi.org/10.33393/aop.2024.3128 Department of Defense (n.d.) Department of Defense annual report on suicide in the military: calendar year 2023. https://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf Diefenbach, G. J., Lord, K. A., Stubbing, J., Rudd, M. D., Levy, H. C., Worden, B., Sain, K. S., Bimstein, J. G., Rice, T. B., Everhardt, K., Gueorguieva, R., & Tolin, D. F. (2024). Brief cognitive behavioral therapy for suicidal inpatients: A randomized clinical trial. JAMA Psychiatry , 81 (12), 1177–1186. https://doi.org/10.1001/jamapsychiatry.2024.2349 Farmer, C. C., Mitchell, K. S., Parker-Guilbert, K., & Galovski, T. E. (2017). Fidelity to the Cognitive Processing Therapy Protocol: Evaluation of critical elements. Behavior Therapy , 48 (2), 195–206. https://doi.org/10.1016/j.beth.2016.02.009 Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview-Revised: Development, reliability, and validity. Psychological Assessment , 32 (7), 677–689. https://doi.org/10.1037/pas0000819 Gamarra, J. M., Luciano, M. T., Gradus, J. L., & Wiltsey Stirman, S. (2015). Assessing variability and implementation fidelity of suicide prevention safety planning in a regional VA healthcare system. Crisis: The Journal of Crisis Intervention and Suicide Prevention , 36 (6), 433–439. https://doi.org/10.1027/0227-5910/a000345 Goodman, M., Sullivan, S. R., Spears, A. P., Dixon, L., Sokol, Y., Kapil-Pair, K. N., Galfalvy, H. C., Hazlett, E. A., & Stanley, B. (2021). An open trial of a suicide safety planning group treatment: Project Life Force. Archives of Suicide Research , 25 (3), 690–703. https://doi.org/10.1080/13811118.2020.1746940 Hallgren, K. A. (2012). Computing inter-rater reliability for observational data: An overview and tutorial. Tutorials in Quantitative Psychology , 8 (1), 23–34. https://doi.org/10.20982/tqmp.08.1.p023 Hildebrand, M. W., Host, H. H., Binder, E. F., Carpenter, B., Freedland, K. E., Morrow-Howell, N., Baum, C. M., Doré, P., & Lenze, E. J. (2012). Measuring treatment fidelity in a rehabilitation intervention study. American Journal of Physical Medicine & Rehabilitation , 91 (8), 715–724. https://doi.org/10.1097/PHM.0b013e31824ad462 Jobes, D. A., Lento, R., & Brazaitis, K. (2012). An evidence-based clinical approach to suicide prevention in the Department of Defense: The Collaborative Assessment and Management of Suicidality (CAMS). Military Psychology , 24 (6), 604–623. https://doi.org/10.1080/08995605.2012.736327 Laerd Statistics (2019). Fleiss' kappa using SPSS Statistics. Statistical tutorials and software guides. https://statistics.laerd.com/spss-tutorials/fleiss-kappa-in-spss-statistics.php Laham, S. M., & Forgas, J. P. (2022). Cognitive illusions (3rd ed.). Routledge. Marques, L., Valentine, S. E., Kaysen, D., Mackintosh, M. A., De Silva, D., Ahles, L. E., Youn, E. M., Shtasel, S. J., Simon, D. L., N. M., & Wiltsey-Stirman, S. (2019). Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. Journal of Consulting and Clinical Psychology , 87 (4), 357–369. https://doi.org/10.1037/ccp0000384 Martin, M., Lachman, J. M., Murphy, H., Gardner, F., & Foran, H. (2023). The development, reliability, and validity of the Facilitator Assessment Tool: An implementation fidelity measure used in Parenting for Lifelong Health for Young Children. Child: Care Health and Development , 49 (3), 591–604. https://doi.org/10.1111/cch.13075 McHugh, S. (2012). Interrater reliability: the kappa statistic. Biochemia Medica , 22 (3), 276–282. Moncher, F. J., & Prinz, R. J. (1991). Treatment fidelity in outcome studies. Clinical Psychology Review , 11 (3), 247–266. https://doi.org/10.1016/0272-7358(91)90103-2 Ogrodniczuk, J. S., Joyce, A. S., & Piper, W. E. (2003). Changes in perceived social support after group therapy for complicated grief. The Journal of nervous and mental disease , 191 (8), 524–530. https://doi.org/10.1097/01.nmd.0000082180.09023.64 Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., McCallum, M., & Rosie, J. S. (2002). Social support as a predictor of response to group therapy for complicated grief. Psychiatry , 65 (4), 346–357. https://doi.org/10.1521/psyc.65.4.346.20236 O’Shea, O., McCormick, R., Bradley, J. M., & O’Neill, B. (2016). Fidelity review: A scoping. review of the methods used to evaluate treatment fidelity in behavioural change interventions. Physical Therapy Reviews , 21 (3–6), 207–214. https://doi.org/10.1080/10833196.2016.1261237 Royal, K. D., & Hecker, K. G. (2016). Understanding reliability: A review for veterinary educators. Journal of Veterinary Medical Education , 43 (1), 1–4. https://doi.org/10.3138/jvme.0315-030R Rudd, M. D. (2006). Fluid Vulnerability Theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 355–368). American Psychological Association. https://doi.org/10.1037/11377-016 Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E., & Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry , 172 (5), 441–449. https://doi.org/10.1176/appi.ajp.2014.14070843 Sinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C. J., Schaffer, A., Westreich, N., Ellis, J., Goldstein, B. I., Cheung, A. H., Selchen, S., Kiss, A., & Tien, H. (2020). Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: A pilot randomized controlled trial. Journal of Affective Disorders , 266 , 686–694. https://doi.org/10.1016/j.jad.2020.01.178 Stirman, S. W., Gutner, C. A., Gamarra, J., Suvak, M. K., Vogt, D., Johnson, C., Wachen, J. S., Dondanville, K. A., Yarvis, J. S., Mintz, J., Peterson, A. L., Young-McCaughan, S., & Resick, P. A. (2021). A novel approach to the assessment of fidelity to a cognitive behavioral therapy for PTSD using clinical worksheets: A proof of concept with Cognitive Processing Therapy. Behavior Therapy , 52 (3), 656–672. https://doi.org/10.1016/j.beth.2020.08.005 Strunk, D. R., Brotman, M. A., & DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behaviour Research and Therapy , 48 (7), 599–606. Sun, S. (2011). Meta-analysis of Cohen’s kappa. Health Services and Outcomes Research Methodology , 11 , 145–163. https://doi.org/10.1007/s10742-011-0077-3 Tanielian, T. (2019). Reducing Suicide Among U.S. Veterans: RAND Research Implications , RAND Corporation. Testimonies. United States. Retrieved from https://coilink.org/20.500.12592/mjqd0j . Accessed on 26 Aug 2025. Thomas, M. R., Beckman, T. J., Mauck, K. F., Cha, S. S., & Thomas, K. G. (2011). Group assessments of resident physicians improve reliability and decrease halo error. Journal of General Internal Medicine , 26 , 759–764. VA/DoD Clinical Practice Guideline. (2019). Assessment and Management of Patients at Risk for Suicide Work Group . U.S. Government Printing Office. Accessed 27 Nov 2021. VA/DoD Clinical Practice Guideline. (2024). Assessment and Management of Patients at Risk for Suicide Work Group . U.S. Government Printing Office. Accessed 13 Aug 2025. Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993). Testing the integrity of a. psychotherapy protocol Assessment of adherence and competence. Journal of Consulting and Clinical Psychology , 61 (4), 620–630. https://doi.org/10.1037/0022-006X.61.4.620 Tables Table 1. G-BCBT Fidelity Assessment Instrument Statistics by Session Session Subscale M ( SD ) Range Percent Agreement Cohen’s Kappa Fleiss' Kappa 1 Introduction 8.95 (.16) 8.5 – 9.0 44/45 = 97.8% - -0.01, p > .05 1 Group Therapy Commitment 5.90 (.21) 5.5 – 6.0 28/30 = 93% - -0.03, p > .05 1 Treatment Planning 6.45 (.69) 5.0 – 7.0 31/35 = 88.6% 0.30, p < .001 1 Session 1 Total Score 21.30 (.95) 19.0 – 22.0 103/110 = 93.6% 0.21, p < .001 2 Therapeutic Frame 4.00 (.00) No range 16/16 = 100% 1.00, p .05 2 Skill: Relaxation 7.69 (.70) 6.0 – 8.0 29/32 = 90.6% -0.02, p > .05 2 Session 2 Total Score 19.44 (1.24) 16.5 – 20.0 74/80 = 92.5% -0.02, p > .05 3 Therapeutic Frame 3.94 (.18) 3.5 – 4.0 15/16 = 93.8% - -0.03, p > .05 3 Skill: Mindfulness 7.19 (.88) 6.0 – 8.0 28/32 = 87.5% 0.45, p .05 3 Session 3 Total Score 18.50 (1.20) 17.0 – 20.0 67/80 = 83.8% 0.17, p > .05 4 Therapeutic Frame 5.00 (.00) No range 20/20 = 100% 1.00, p .05 4 Session 4 Total Score 14.88 (.23) 14.5 – 15.0 58/60 = 96.7% -0.02, p > .05 5 Therapeutic Frame 3.90 (.32) 3.0 – 4.0 19/20 = 95% - -0.03, p > .05 5 Skill: Survival Kit 7.40 (.94) 5.0 – 8.0 33/40 = 82.5% - -0.07, p > .05 5 Session 5 Total Score 11.30 (1.03) 9.0 – 12.0 52/60 = 86.7% - -0.06, p > .05 6 Therapeutic Frame 4.75 (.46) 4.0 – 5.0 20/20 = 100% 1.00, p .05 6 Session 6 Total Score 12.38 (.58) 11.5 – 13.0 48/52 = 92.3% 0.31, p < .01 7 Therapeutic Frame 4.00 (.00) No range 16/16 = 100% 1.00, p .05 7 Session 7 Total Score 10.50 (.89) 8.5 – 11.0 39/44 = 88.6% -0.04, p > .05 8 Therapeutic Frame 4.00 (.00) No range 20/20 = 100% 1.00, p .05 8 Session 8 Total Score 10.80 (.26) 10.5 – 11.0 51/55 = 92.7% -0.03, p > .05 9 Therapeutic Frame 3.88 (.35) 3.0 – 4.0 15/16 = 93.8% - -0.03, p > .05 9 Skill: Activity Planning 7.75 (.27) 7.5 – 8.0 28/32 = 87.5% -0.05, p > .05 9 Session 9 Total Score 11.63 (.52) 10.5 – 12.0 43/48 = 89.6% -0.03, p > .05 10 Therapeutic Frame 4.00 (.00) No range 16/16 = 100% 1.00, p .05 10 Session 10 Total Score 9.88 (.23) 9.5 – 10.0 38/40 = 95% -0.02, p > .05 11 Therapeutic Frame 4.00 (.00) No range 16/16 = 100% 1.00, p .05 11 Relapse Prevention Index Episode 5.81 (.53) 4.5 – 6.0 21/24 = 87.5% - -0.07, p > .05 11 Session 11 Total Score 14.75 (.53) 13.5 – 15.0 56/60 = 93.3% - -0.03, p > .05 12 Therapeutic Frame 3.88 (.23) 3.5 – 4.0 14/16 = 87.5% - -0.07, p > .05 12 Relapse Prevention Future Episode 6.69 (.88) 4.5 – 7.0 23/28 = 82.1% - -0.10, p > .05 12 Session 12 Total Score 10.56 (1.05) 8.0 – 11.0 37/44 = 84.1% - -0.09, p > .05 Notes: M = Mean; SD = Standard Deviation; Range = Range of possible scores on respective session subscale; Percent Agreement = Overall simple rate of agreement between two raters; Cohen’s Kappa Interpretation: 0-0.20 (Slight), 0.21-0.40 (Fair), 0.41-0.60 (Moderate), 0.61-0.80 (Substantial), and 0.81-1.00 (Almost Perfect) (see Royal & Hecker, 2016). Additional Declarations Competing interest reported. Dr. Baker reported receiving personnel fees from Anduril LLC and grants from the Department of Defense outside the submitted work. Dr. Cramer reported receiving grants from the Department of Defense outside the submitted work. Dr. Khazem reported receiving personnel fees from Anduril LLC and grants from the Department of Defense and the University of Minnesota Press Test Division outside the submitted work. Remaining authors have no competing interests to declare. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense nor the U.S. Government. CDR Grover is a military service member. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Research data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol. Supplementary Files GBCBTfidelityratinginstrumentsgroupsupplemental.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Mar, 2026 Reviews received at journal 09 Mar, 2026 Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor assigned by journal 29 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 22 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8671387","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587763744,"identity":"5abb9372-6f6d-4115-95ea-85bdcb959dbb","order_by":0,"name":"Justin C. Baker","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACxgYgkQBCPEDGB5gwD34tjA0wLYwziNGCsAioihmuEp8W5hnpzx883MGQx99z+Nhnm4q6xLXtBxgfvG3DY8WMHMOGxDMMxRJn25Jn55w5nLjtTAKz4Vz8WhgbEtsYEhvO8xgz57YdSNx2g4FNmhevlvSHYC3zz/N/ZrZsqwNpYf+NX0uCIVjLhrM9zMyMbcxgW5jxaul5YzgjsU2i2PDMMWPGnjOHjbedSWyWnHMOtxbD9vQHH3+22eTJnUl+zPCjok522/HDBz+8KcOjpQFMSaDY3IBbPRDI45UdBaNgFIyCUQACAJG0VnWUlvNSAAAAAElFTkSuQmCC","orcid":"","institution":"The Ohio State University Wexner Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Justin","middleName":"C.","lastName":"Baker","suffix":""},{"id":587763745,"identity":"379b8f75-582e-4c2f-a97c-9ae13132bfc4","order_by":1,"name":"Shannon Cain","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Shannon","middleName":"","lastName":"Cain","suffix":""},{"id":587763746,"identity":"e251c132-6d65-4845-857a-e6385a15245a","order_by":2,"name":"Skyler D. Prowten","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Skyler","middleName":"D.","lastName":"Prowten","suffix":""},{"id":587763747,"identity":"5cb389d1-9df1-4ef7-b197-e5b2b8a87e3e","order_by":3,"name":"Laura Gunn","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Gunn","suffix":""},{"id":587763748,"identity":"1d764e1b-08ce-4383-8728-1f4847fb9966","order_by":4,"name":"Sean Williams","email":"","orcid":"","institution":"The Ohio State University Wexner Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Sean","middleName":"","lastName":"Williams","suffix":""},{"id":587763749,"identity":"b2a926b0-55fb-4495-86af-e1555627cc96","order_by":5,"name":"Cindy Charles","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Cindy","middleName":"","lastName":"Charles","suffix":""},{"id":587763750,"identity":"0556031c-cf7f-41ba-9e16-51ae9dd22935","order_by":6,"name":"Heather Rikli","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Rikli","suffix":""},{"id":587763751,"identity":"9232907c-5c54-4452-aa73-40b0613c350d","order_by":7,"name":"Shawna Grover","email":"","orcid":"","institution":"Naval Medical Center Portsmouth","correspondingAuthor":false,"prefix":"","firstName":"Shawna","middleName":"","lastName":"Grover","suffix":""},{"id":587763752,"identity":"79755017-1321-4241-888c-2f7e66b7197f","order_by":8,"name":"Robert J. Cramer","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"J.","lastName":"Cramer","suffix":""},{"id":587763753,"identity":"9cb8a0c5-c19c-4542-a0dc-2a1e8cbfd29e","order_by":9,"name":"Lauren R. Khazem","email":"","orcid":"","institution":"The Ohio State University Wexner Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"R.","lastName":"Khazem","suffix":""}],"badges":[],"createdAt":"2026-01-22 15:25:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8671387/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8671387/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102296966,"identity":"8f3b592e-9008-4219-9a48-7c725a0deae5","added_by":"auto","created_at":"2026-02-10 10:23:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":749669,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8671387/v1/d4eacb7e-10ef-4350-b2ab-7b6082e971f9.pdf"},{"id":102220775,"identity":"66fc9cb7-e288-4fc8-ba99-c215b5dd05f1","added_by":"auto","created_at":"2026-02-09 13:43:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":59439,"visible":true,"origin":"","legend":"","description":"","filename":"GBCBTfidelityratinginstrumentsgroupsupplemental.docx","url":"https://assets-eu.researchsquare.com/files/rs-8671387/v1/3fb10cddf944d9e17b3b9c7a.docx"}],"financialInterests":"Competing interest reported. Dr. Baker reported receiving personnel fees from Anduril LLC and grants from the Department of Defense outside the submitted work. Dr. Cramer reported receiving grants from the Department of Defense outside the submitted work. Dr. Khazem reported receiving personnel fees from Anduril LLC and grants from the Department of Defense and the University of Minnesota Press Test Division outside the submitted work. Remaining authors have no competing interests to declare.\n\nThe views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense nor the U.S. Government. CDR Grover is a military service member. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.\n\nResearch data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol.","formattedTitle":"Development of Group Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical or Methodological Significance of this Article (2-3 sentences): Group-Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments (G-BCBT FAIs) provide a structured method for monitoring treatment fidelity. Monitoring treatment fidelity is relevant for both research and clinical practice to ensure treatments are delivered competently and as designed. The following study provides preliminary field evidence of the development and deployment of G-BCBT FAIs.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTreatment fidelity most frequently describes how closely interventions follow the original design during clinical testing while remaining distinct from standard care or control methods (Borrelli, 2011; Hildebrand et al., 2012; Moncher \u0026amp; Prinz, 1991). Monitoring treatment fidelity has not always been common practice in clinical trials or field implementation (Moncher \u0026amp; Prinz, 1991). However, it is now a recommended practice, with clear guidelines and expectations to monitor treatment fidelity when conducting and evaluating behavioral health interventions (Bellg et al., 2004). In research, maintaining treatment fidelity serves the purpose of ensuring that any changes to the experimental intervention or treatment occur as intended (Cook et al., 2024; Moncher \u0026amp; Prinz, 1991). High treatment fidelity also helps one to better understand change mechanisms in an intervention and determine the actual degree the client was exposed to the specific treatment (Farmer et al., 2017). Moreover, higher fidelity is associated with improved internal and external validity, increasing the ability to generalize the findings to other settings (Borrelli, 2011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntervention fidelity is also important for clinical practice (Bryant et al., 2025), as it aids in implementation and intervention update (Bellg et al., 2004; Gamarra et al., 2015; O’Shea et al., 2016). Perhaps the greatest benefit of fidelity assessment is its positive impact on treatment outcomes. For example, Gamarra et al. (2015) identified a significant relationship between higher safety plan quality and lower hospitalization rates in a sample of military veterans. In another study, higher fidelity to Cognitive Behavioral Therapy (CBT) for depression was linked with reduced depressive symptoms (Strunk et al., 2010). In a study of Cognitive Processing Therapy for Posttraumatic Stress Disorder (PTSD), researchers identified that higher therapist adherence and competence to the intervention resulted in greater decreases in symptoms of depression and PTSD (Marques et al, 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;While fidelity assessment of interventions, especially within clinical trials, is an important matter, little research exists concerning how fidelity should be measured, particularly in the context of reducing suicide in the military. In the following sections, we outline military suicide rates and existing interventions, including Brief Cognitive Behavioral Therapy (BCBT; Bryan \u0026amp; Rudd, 2018; Rudd et al., 2015) and its recent group adaptation (Baker et al., 2023), to highlight the need for fidelity assessment. Finally, we describe the current state of BCBT fidelity assessment as a foundation for the present investigation of how fidelity is assessed in Group-Brief Cognitive Behavioral Therapy (G-BCBT; Baker et al., 2023). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMilitary Suicide: Rates, Existing Treatments, and a Need for Fidelity Assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Monitoring treatment fidelity is particularly important in the implementation and evaluation of treatments for suicide prevention among military service members. As the annual suicide rate among active-duty service members has gradually increased since 2011 (Department of Defense, n.d.), suicide among military service members is as an urgent public health and national security concern within the United States (U.S.). The rate of U.S. active-duty suicide (28.2/100,000) (Department of Defense, n.d.) is nearly double the rate of death by suicide in the U.S. civilian population (14.12/100,000; American Foundation of Suicide Prevention, 2025). However, robust interventions for suicidal thoughts and behaviors exist. Widely used therapies include the Collaborative Assessment and Management of Suicidality (CAMS; e.g., Jobes et al., 2012), Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT; Rudd et al., 2015), and Dialectical Behavioral Therapy (DBT; e.g., Goodman et al., 2021). Additionally, the Department of Veterans Affairs and Department of Defense (VA/DoD) created the Clinical Practice Guidelines for Assessment and Management of Patients at Risk for Suicide (VA/DoD, 2019, 2024). The guidelines highlight best therapeutic practices for military suicide prevention, such as cognitive-behavioral therapies, lethal means reduction, and problem-solving interventions. However, they make no mention of the importance of or methods for ensuring fidelity of treatment delivery. Further, Defense Health Agency and other treatment facilities experience challenges to fidelity in suicide-specific interventions, such as staffing shortages, lack of providers trained in the provision of such therapies, and patient deployment (VA/DoD, 2024; Tanielian, 2019). Thus, there exists an urgent and unmet need to address barriers to best ensuring fidelity to suicide prevention interventions in military settings.\u003c/p\u003e\n\u003cp\u003eBCBT (Bryan \u0026amp; Rudd, 2018; Rudd et al., 2015) is a leading suicide prevention psychotherapy offering a foundation for fidelity assessment in clinical research and practice. Aligning with fluid vulnerability theory (Rudd, 2006), BCBT is a 12-session treatment grounded in the theory that an individual’s suicidal state results from the interaction of the individual’s deficits in emotion regulation and cognitive flexibility when faced with an activating event. BCBT has demonstrated efficacy in civilian outpatient settings via telehealth (Baker et al., 2024) and among active-duty service members and veterans (Bryan et al., 2025; Rudd et al., 2015). Emerging beyond outpatient treatment settings is recent evidence in the efficacy of a shortened version of BCBT for inpatient psychiatric patients (Diefenbach et al., 2024), and youth hospitalized for self-harm (Sinyor et al., 2020). Results from these trials suggest that BCBT is an effective treatment to reduce incidence of self-harm (Sinyor et al., 2020) and suicidal ideation and suicide attempts (Baker et al., 2024; Bryan et al., 2025; Diefenbach et al., 2024; Rudd et al., 2015).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBCBT therapy fidelity ratings across existing studies are high. Research therapists delivering the intervention in the first trial of BCBT in military service members maintained \u0026gt; 90% fidelity ratings (Rudd et al., 2015) with similar fidelity ratings of 92.7% observed in the telehealth BCBT trial (Baker et al., 2024). Fidelity ratings for BCBT adapted to hospitalized youth were also high at 92% (Sinyor et al., 2020). However, fidelity ratings were not reported for the inpatient trial of BCBT or the most recent trial completed among veterans and military personnel (Bryan et al., 2025; Diefenbach et al., 2024). Importantly, existing studies are limited to fidelity ratings for individual BCBT therapy protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup Brief Cognitive-Behavioral Therapy for Suicide (G-BCBT): Clinical Trial and Fidelity Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaker and colleagues (2023) created a group adaptation of BCBT (G-BCBT). G-BCBT targets the same hypothesized mechanisms of action as BCBT (i.e., emotion regulation and cognitive flexibility; Bryan \u0026amp; Rozek, 2018) while leveraging the buffering effects of social support (Ogrodniczuk, Piper, Joyce, McCallum, \u0026amp; Rosie, 2002; Ogrodniczuk, Joyce, \u0026amp; Piper, 2003). The treatment was designed to address barriers to delivering suicide interventions among active-duty military personnel (e.g., provider shortages, patient deployment). Patients complete one individual intake session prior to beginning the twelve 90-minute weekly group sessions. G-BCBT is organized in three phases: (1) emotion regulation, (2) cognitive flexibility, and (3) relapse prevention. Sessions in phase one focus on teaching emotion regulation skills to patients in crisis, phase two focuses on teaching cognitive reappraisal skills, and phase three tests patient skill acquisition through successful navigation of imagined crisis scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe G-BCBT protocol included development of Fidelity Assessment Instruments (FAIs).\u0026nbsp;Twelve G-BCBT FAIs (one for each group therapy session) were adapted from existing BCBT fidelity rating forms to evaluate treatment adherence (Bryan \u0026amp; Rudd, 2018). G-BCBT FAIs were developed with the focus of ensuring treatment adherence throughout the study (Waltz, Addis, Koerner, \u0026amp; Jacobson, 1993). G-BCBT FAI items allowed raters to assess whether specific components of G-BCBT were completed for each session. Independent evaluators were expert licensed clinical social workers trained in crisis response planning (CRP) and BCBT. Evaluators scored items using a 3-item Likert scale indicating no, partial, or full credit for each listed item on the G-BCBT FAIs. A section for notes for each session was also included on the G-BCBT FAIs to help facilitate consultation and feedback during weekly consultation calls. The notes were not included in the scoring of the G-BCBT FAIs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Present Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis current study focuses on the development of treatment fidelity rating forms for use in a non-inferiority trial comparing G-BCBT to DBT skills group (Baker et al., 2023). This paper focuses exclusively on the development of twelve G-BCBT FAIs that correspond with each session of the 12-session G-BCBT treatment. We proposed the following aims and hypotheses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAim 1: Quantify overall G-BCBT FAI descriptive statistics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHypothesis 1: G-BCBT FAI average scores and rates of agreement will be high across sessions.\u003c/p\u003e\n\u003cp\u003eAim 2: Establish inter-rater agreement in the use of G-BCBT FAIs.\u003c/p\u003e\n\u003cp\u003eHypothesis 2: G-BCBT FAI inter-rater reliability will be acceptable or higher across sessions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants included 141 active-duty service members (69 male, 72 female), who participated in a randomized non-inferiority clinical trial comparing G-BCBT to DBT skills group. Participants were randomized to receive either G-BCBT or DBT skills group, with a total of 10 G-BCBT groups and 10 DBT skills groups. There was an average of 8 participants randomized to each G-BCBT group and 7 participants to each DBT skills group. Briefly, prospective participants were recruited to participate in the trial from Naval Medical Center Portsmouth (NMCP; Baker, et al., 2023). Participants were eligible to participate in the clinical trial if they met the following inclusion criteria:\u0026nbsp;(1) active duty service members, (2) between the ages of 18 to 65, (3) of treatment-seeking status in outpatient men\u0026shy;tal health or substance abuse rehabilitation clinics, and/or inpatient psychiatry discharge, or other NMCP pri\u0026shy;mary care and surrounding outpatient clinics (4) report current (within the past week) suicide ideation (e.g., score greater than two on the Scale for Suicide Ideation) and/or a suicide attempt within the past month (e.g., as assessed by the Self-injurious Thoughts and Behaviors Interview-Revised [SITBI-R]; Fox et al., 2020), (5) able to understand and speak English, and (6) able to complete the informed consent process. Participants were excluded if they had a psychiatric or medical condition that precluded them from providing informed consent or participating in outpatient treatment (e.g., psychosis, mania, acute intoxication requiring hospitalization). Retired service members and family/dependents of active-duty military personnel were not eligible for the study. All study procedures were approved by study site institutional review board. The non-inferiority trial comparing G-BCBT to DBT was preregistered at Clinicaltrials.gov (protocol REDACTED for anonymity). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTherapist Training and Ongoing Consultation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two therapists hired to provide G-BCBT treatment were a licensed clinical social worker and licensed marriage and family therapist, both of whom completed training in military cultural competence, CRP, and BCBT. The two therapists were hired, onboarded, and fully credentialed as licensed mental health providers within the Department of Mental Health at NMCP to deliver both G-BCBT and DBT treatments within this trial. Therapists were interviewed and selected based on prior group therapy experience, ability to be credentialed within a military treatment facility, prior experience working with military populations, comfort and experience working with high-risk patients undergoing significant emotional distress, ability and familiarity with handling crises and possible hospitalization, willingness to receive training in new treatment methods with ongoing clinical consultation, and aptitude for timely documentation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth therapists were trained in BCBT and DBT treatment modalities through multi-day training workshops. Military cultural competence trainings were completed online through the American Insurance Trust (n.d.) and the Center for Deployment Psychology (n.d.). \u0026nbsp;As this paper is solely focused on G-BCBT fidelity, only training in BCBT will be described. Therapists completed a two-day online synchronous training in BCBT, using established training curriculum based off the existing published manual (Bryan \u0026amp; Rudd, 2018). Training included an overview of theory, research, and best practices for treating high-risk suicidal individuals. Didactic exploration, video therapy demonstrations, and live role playing were included in the training as standard curriculum. Therapists were included in a workshop with other community mental health providers who were taking the training for continuing education units. In addition to this training in BCBT, therapists also received training specific to delivering BCBT in group format. The group adaptation is heavily based on the individual BCBT therapy manual (Bryan \u0026amp; Rudd, 2018). G-BCBT session outlines were developed for this trial to standardized group delivery of BCBT. G-BCBT session outlines were reviewed in six, one-hour weekly training sessions with the research therapists to discuss group adaptations for BCBT. Training focused on managing group dynamics and time, needed changes to homework assignments, and ways to conduct skill practices in a group format. Both therapists also completed preliminary mock group therapy sessions prior to enrollment of any study participants. Once participant enrollment began, therapists completed weekly consultation with the lead investigator and fidelity raters throughout the entire treatment delivery period of the trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eG-BCBT Treatment Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;G-BCBT was adapted from the individual therapy BCBT manual (Bryan \u0026amp; Rudd, 2018). Like BCBT, G-BCBT follows a cognitive behavioral therapy paradigm to target skill deficits in emotion regulation and cognitive flexibility: two proposed mechanisms of action underlying vulnerabilities for suicide. Participants randomized to G-BCBT, completed a 90-minute individual intake session with one of the two research therapists. Participants then completed 12, 90-minute weekly group therapy sessions. The intake session for G-BCBT included BCBT components typically delivered during the first session of BCBT: the narrative assessment to assess suicide risk, development of a suicidal mode or case conceptualization to be used in treatment by the participant, and a tailored crisis response plan, a safety planning type intervention to mitigate risk of a future suicide attempt. Therapists also had the option of conducting lethal means safety counseling to reduce access to lethal means of suicide for the participant during this intake session. G-BCBT sessions followed a three-phased approach that organized sessions by proposed mechanisms of action: (1) emotion regulation, (2) cognitive flexibility, and (3) relapse prevention. Interventions introduced during the first phase of treatment included coping strategies such as mindfulness and relaxation training, psychoeducation for improving sleep hygiene, identifying a crisis support person and reasons for living, and building a survival kit to increase easy access to tangible reminders of hope. Phase two of G-BCBT focused on cognitive flexibility primarily through the introduction of worksheets designed around cognitive reappraisal strategies, including (1) ABC, (2) challenging questions, and (3) patterns of problematic thinking. Additional sessions in this phase also introduce coping cards and activity planning. The final or third phase of treatment, called relapse prevention, is focused on skills solidification and mastery. Group participants are tasked with demonstrating adequate skill use to navigate past and potential future suicidal crises with the goal of successfully thwarting future suicide attempts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFidelity Assessment Instruments and Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;A total of twelve G-BCBT FAIs, one for each group therapy session, were adapted from existing published fidelity rating forms for individual BCBT (Bryan \u0026amp; Rudd, 2018). G-BCBT FAIs were developed to ensure adherence to the treatment is maintained (Waltz, Addis, Koerner, \u0026amp; Jacobson, 1993). These FAIs are distinct from other therapy rating scales that may also measure therapist competence, or how skillful the therapist is in delivering the treatment (Waltz et al., 1993). G-BCBT FAI items were rated using the following rating scale \u003cem\u003e0 = no, 0.5 = partial\u003c/em\u003e, and \u003cem\u003e1 = yes\u003c/em\u003e, following the 3-point scale used in the original published fidelity rating forms.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Each session G-BCBT FAI typically consisted of 1 subscale to rate the \u0026ldquo;Therapeutic Frame\u0026rdquo; which includes symptom/mood check, review/assigning homework, and agenda setting and an additional 1-2 subscales to rate the specific skills introduced in the session. As an example, the G-BCBT FAI for session 2 consisted of four-items for the Therapeutic Frame subscale, eight items for Skills Training: Sleep Disturbance subscale, and eight-items for Relaxation Training subscale, for a total max possible score of 20. FAI max scores differed by sessions. Session-by-session G-BCBT FAIs followed the prescribed treatment intervention order for G-BCBT (Baker et al., 2023), with items tailored specifically to the interventions introduced in each session. All twelve G-BCBT FAIs are included in the Online Supplemental.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo establish initial treatment fidelity, all sessions were rated until fidelity scores averaged 85% or higher on two complete group therapy cohorts. Initial fidelity was established within the first two G-BCBT cohorts. For G-BCBT cohorts 3-10, 20% of sessions were randomly selected, controlling for session number (i.e., group sessions 1-12) to ensure each session number was reviewed at least four times. This was done to ensure adequate fidelity monitoring of the various interventions delivered among the 12 group therapy sessions. Fidelity scores for randomly selected cases from G-BCBT cohorts 3-10 remained at or above 85% for both raters. All sessions were rated by two independent evaluators.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndependent evaluators were experienced licensed clinical social workers, who rated audio recorded group sessions using the developed G-BCBT FAIs. Evaluators received training in use of the G-BCBT FAIs from the lead investigator. Both independent evaluators participated in weekly consultation with the lead investigator and therapists to provide real time feedback to therapists during the trial. Consultation calls were supportive and fostered a culture of learning and attention to improving treatment fidelity. This allowed therapists to immediately incorporate any feedback into ongoing therapy sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eAim 1 was to quantify G-BCBT FAI descriptive statistics. We report overall percent agreement between coders, alongside other descriptive statistics. Percent agreement is included in Aim 1 because it is a poor metric of rater agreement (Aim 2) due to a failure to control for agreement by chance and a tendency toward over inflated values (Hallgren, 2012). Aim 2 focused on capturing inter-rater agreement in G-BCBT FAI ratings. We analyzed data at the subscale and total score levels for each G-BCBT group session FAI to ensure we had enough data points rated by coders; a higher number of rated observations increases the accuracy of inter-rater results (McHugh, 2012). We began with computing Cohen\u0026rsquo;s Kappa given its appropriateness for use with two raters and because it corrects for chance agreement (Sun, 2011). Cohen\u0026rsquo;s Kappa typically ranges from 0 to 1 but can yield negative values when the level of agreement is worse than what is anticipated by chance. In instances where a restricted range in ratings (i.e., using all one rating across all items) from any coder prevented Cohen\u0026rsquo;s tabulations, we employed Fleiss\u0026rsquo; Kappa. Fleiss\u0026rsquo; Kappa ranges from -1 (no agreement) to 1 (perfect agreement), where negative values indicate less than chance agreement and vice versa for positive values (Laerd Statistics, 2019). Magnitude of agreement for all inter-rater reliability values were determined in line with statistical conventions in the literature: 0 to .20 = slight, 0.21 to 0.40 = fair, 0.41 to .60 = moderate, 0.61 to 0.80 = substantial, and 0.81 to 1.00 = almost perfect (Royal \u0026amp; Hecker, 2016)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere were no missing data, so missing data analysis and replacement techniques were unnecessary. Table 1 contains all descriptive statistics (Aim 1) and inter-rater reliability metrics (Aim 2). Hypothesis 1 was generally supported. Reviewing Table 1, average G-BCBT FAI subscale and total scores demonstrated ceiling effects, with ranges consistently on the higher end of each respective scale. Also, the overall range of percent agreement was high: 75-100%. Using the 85% metric as a cut-off, 38 of 44 (86.3%) of percent agreement scores exceeded acceptable levels of percent agreement. Results were highly mixed with regard to inter-rater reliability scores. Referring to Table 1, several scores achieved near perfect agreement, with a few others reaching fair to moderate levels of agreement. However, the majority (28/40, 70%) showed less than chance levels of agreement based on negative obtained Kappa values. Visual inspection of the data suggests the possibility of a halo or ceiling effect in which one rater did not deviate from the highest of three code choices. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall purpose of this study was to present the G-BCBT FAIs, with an example of use in a field clinical trial. Given BCBT’s growing evidence (e.g., Baker et al., 2024; Bryan et al., 2025; Diefenbach et al., 2024; Rudd et al., 2015; Sinyor et al., 2020), a critical next step concerns articulation of implementation tools for various BCBT modalities. Considering the novelty of the G-BCBT FAIs, we focused testing on descriptive statistics (e.g., percent agreement) and inter-rater reliability to be consistent with initial tests of other fidelity assessment tools (e.g., Bryant et al., 2025; Martin et al., 2023). Developing and testing the G-BCBT FAIs is important given the limited literature (e.g., Bryant et al., 2025; Gamarra et al., 2015) validating fidelity tools for interventions in military active duty and veteran populations. Doing so also provides accessible instruments for further psychometric refinement and clinical use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Our initial test of the G-BCBT FAIs produced mixed support for the initial field implementation in the G-BCBT clinical trial (Baker et al., 2023). The first hypothesis was supported. Basic descriptive statistics such as percent agreement were robust (see Table 1). Yet, reliance merely on metrics of central tendency and overall agreement ignores important considerations in assessing intervention fidelity, potentially leading to overestimating the strength of agreement (McHugh, 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore robust hypothesis two Kappa-focused analyses yielded equivocal support for inter-rater reliability across G-BCBT FAIs (see Table 1). Several explanations can be hypothesized for the limited reliability, pointing to clear solutions and next steps in G-BCBT FAI development and usage. Low inter-rater reliability can result from a restricted range (Hallgren, 2012). Drawing on BCBT tools (Bryan \u0026amp; Rudd, 2018), the G-BCBT FAIs only have a 3-response option set (i.e., no, partial, yes). Moreover, consistent patterns from one rater raised the possibility of a ceiling or halo effect. In other words, one rater may have overgeneralized high ratings of performance to all ratings where an initial rating was highly positive (e.g., Laham \u0026amp; Forgas, 2022). Alternatively, a lack of or poorly executed training may lead to a lack of calibration of ratings (Hallgren, 2012). Finally, it is plausible that clinical delivery was exceedingly high, leading to relatively accurate ratings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral possible solutions exist for the restricted range or halo and ceiling effects. First, in terms of measurement, the response range can be expanded to a 5-point Likert scale with refined anchors (Hallgren, 2012). Offering more nuances may promote careful rater observation and consideration of scale midpoints. Second, expert raters can conduct ratings in tandem or groups. Our study featured primarily individual raters conducting observations on their own. Evidence exists suggesting biases may be neutralized in group assessments, thereby resulting in stronger inter-rater reliability (Thomas et al., 2011). In a similar vein, G-BCBT FAI testing may benefit from a mixed-method approach whereby clinicians complete self-report fidelity ratings which are compared and discussed with expert raters. A fourth simple solution would be to use more than two raters to increase the likelihood of spread within the data. Finally, there may be a need for a more structured, detailed G-BCBT FAI training program that overtly addresses issues like response bias, clinical supervision dynamics, and creative implementation of the FAIs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;As G-BCBT (Baker et al., 2023) and BCBT (Bryan \u0026amp; Rudd, 2018) may become more common treatments, fidelity tool use has several implications for clinical practice. First, findings from this study provide preliminary evidence for use of G-BCBT FAIs for tracking treatment fidelity. This is good news for supervisors and trainers who may want to use G-BCBT FAIs when helping trainees learn G-BCBT. Further, clinicians implementing G-BCBT for the first time may use these developed rating scales in self-reflective practice as feedback tools to improve treatment adherence and competence, which may result in improved treatment response for patients (Stirman et al., 2021). Similarly, trainees learning this treatment approach may want to watch their video recorded sessions and rate themselves. Watching sessions and completing fidelity ratings is a beneficial exercise to help trainees link interventions performed in session with the theory of the treatment. Lastly, fidelity ratings may provide a structured way for the therapist to consider alliance in group therapy and other potential group dynamics that may be affecting treatment (Alldredge, Burlingame, Yang, \u0026amp; Rosendahl, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The present study possessed several limitations worth noting. First, G-BCBT FAIs were completed within the context of a randomized clinical trial (RCT) and may not generalize well to real world clinical practice settings. Additional research using the G-BCBT FAIs outside the context of RCTs is warranted. Second, the G-BCBT FAIs ratings were developed with a small sample size. There were two research clinicians who co-led each group therapy session and two expert raters that provided ratings throughout the trial. A more thorough evaluation of the developed G-BCBT FAIs with a larger sample size of therapists and raters should be undertaken in future studies. Lastly, this study was conducted at a military treatment facility and may not generalize outside military practice settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Despite these limitations, this study provides an initial pilot test of the G-BCBT FAIs developed for use in a non-inferiority RCT. Future study should expand upon findings to evaluate how fidelity scores correlate with clinical outcomes, such as reductions in suicidal ideation or improved self-efficacy. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eDr. Baker reported receiving personnel fees from Anduril LLC and grants from the Department of Defense outside the submitted work. Dr. Cramer reported receiving grants from the Department of Defense outside the submitted work. Dr. Khazem reported receiving personnel fees from Anduril LLC and grants from the Department of Defense and the University of Minnesota Press Test Division outside the submitted work. Remaining authors have no competing interests to declare.The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense nor the U.S. Government. CDR Grover is a military service member. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that \u0026ldquo;Copyright protection under this title is not available for any work of the United States Government.\u0026rdquo; Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person\u0026rsquo;s official duties.Research data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.B. and L.R. are responsible for overall conceptualization of the manuscript. J.B., S.C., S.P., R.C., and L.K., wrote the main manuscript text. S.C., S.P., and R.C. completed data analysis. R.C., J.B., S.G., and L.G. acquired funding for the study. S.W., L.R., S.C., and J.B. provided supervision. C.C. and H.R. aided in the investigation. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, J.B., upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlldredge, C. T., Burlingame, G. M., Yang, C., \u0026amp; Rosendahl, J. (2021). Alliance in group therapy: A meta-analysis. \u003cem\u003eGroup Dynamics: Theory Research and Practice\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(1), 13\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/gdn0000135\u003c/span\u003e\u003cspan address=\"10.1037/gdn0000135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Foundation for Suicide Prevention (2025). \u003cem\u003eSuicide statistics\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://afsp.org/suicide-statistics/\u003c/span\u003e\u003cspan address=\"https://afsp.org/suicide-statistics/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 11 Aug 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Insurance Trust (n.d.). \u003cem\u003eMilitary cultural competence: Providing effective assessment and treatment.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://thetrust.learnupon.com/store/2874375-military-cultural-competence-providing-effective-assessment-and-treatment\u003c/span\u003e\u003cspan address=\"https://thetrust.learnupon.com/store/2874375-military-cultural-competence-providing-effective-assessment-and-treatment\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker, J. C., Grover, S., Gunn, L. H., Charles, C., Rikli, H., Franks, M. J., Khazem, L. R., Williams, S., Ammendola, E., Washington, C., Bennette, M., Starkey, A., Schnecke, K., Cain, S., Bryan, C. J., \u0026amp; Cramer, R. J. (2023). Group brief cognitive behavioral therapy for suicide prevention compared to dialectal behavior therapy skills group for military service members: A study protocol of a randomized controlled trial. \u003cem\u003eBmc Psychiatry\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 904. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-023-05282-x\u003c/span\u003e\u003cspan address=\"10.1186/s12888-023-05282-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker, J. C., Starkey, A., Ammendola, E., Bauder, C. R., Daruwala, S. E., Hiser, J., Bauder, C. R., Daruwala, S. E., Hiser, J., Khazem, L. R., Rademacher, K., Hay, J., Bryan, A. O., \u0026amp; Bryan, C. J. (2024). Telehealth brief cognitive behavioral therapy for suicide prevention: A randomized clinical trial. \u003cem\u003eJAMA Network Open\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(11), e2445913\u0026ndash;e2445913. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamanetworkopen.2024.45913\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2024.45913\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., Ogedegbe, G., Orwig, D., Ernst, D., Czajkowski, S., \u0026amp; Treatment Fidelity Workgroup of the NIH Behavior Change Consortium. (2004). Enhancing treatment fidelity in Health Behavior Change Studies: Best practices and recommendations from the NIH Behavior Change Consortium. \u003cem\u003eHealth Psychology\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(5), 443\u0026ndash;451. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0278-6133.23.5.443\u003c/span\u003e\u003cspan address=\"10.1037/0278-6133.23.5.443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorrelli, B. (2011). The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. \u003cem\u003eJournal of Public Health Dentistry\u003c/em\u003e, \u003cem\u003e71\u003c/em\u003e(s1), S52\u0026ndash;S63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1752-7325.2011.00233.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1752-7325.2011.00233.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryan, C. J., Khazem, L. R., Baker, J. C., Brown, L. A., Taylor, D. J., \u0026amp; Pruiksma K. E., Acierno.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarick, R., Baucom, J. G., Garland, B. R., E. L., \u0026amp; Rudd, M. D. (2025). Brief cognitive behavioral therapy for suicidal military personnel and veterans: The Military Suicide Prevention Intervention Research (MSPIRE) randomized clinical trial. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamapsychiatry.2025.2850\u003c/span\u003e\u003cspan address=\"10.1001/jamapsychiatry.2025.2850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published online.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryan, C. J., \u0026amp; Rozek, D. C. (2018). Suicide prevention in the military: A mechanistic perspective. \u003cem\u003eCurrent opinion in psychology\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e, 27\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.copsyc.2017.07.022\u003c/span\u003e\u003cspan address=\"10.1016/j.copsyc.2017.07.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryan, C. J., \u0026amp; Rudd, M. D. (2018). \u003cem\u003eBrief cognitive-behavioral therapy for suicide prevention\u003c/em\u003e. Guilford.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryant, W. T., Lange, T. M., Hilgeman, M. M., Bishop, T. K., Santa Ana, E. J., \u0026amp; Cramer, R. J. (2025). A clinician-based treatment fidelity tool for PRIDE in all who served. \u003cem\u003eTranslational Issues in Psychological Science\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 80\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/tps0000418\u003c/span\u003e\u003cspan address=\"10.1037/tps0000418\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenter for Deployment Psychology (n.d.). \u003cem\u003eMilitary culture: Enhancing clinical competence course description.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://deploymentpsych.org/Military-Culture-Enhancing-Competence-Course-Description\u003c/span\u003e\u003cspan address=\"https://deploymentpsych.org/Military-Culture-Enhancing-Competence-Course-Description\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook, C., O\u0026rsquo;Halloran, B., Karas, S., Klopper, M., \u0026amp; Young, J. (2024). Treatment fidelity in clinical trials. \u003cem\u003eArchives of Physiotherapy\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e, 65\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.33393/aop.2024.3128\u003c/span\u003e\u003cspan address=\"10.33393/aop.2024.3128\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Defense (n.d.) \u003cem\u003eDepartment of Defense annual report on suicide in the military: calendar year 2023.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf\u003c/span\u003e\u003cspan address=\"https://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiefenbach, G. J., Lord, K. A., Stubbing, J., Rudd, M. D., Levy, H. C., Worden, B., Sain, K. S., Bimstein, J. G., Rice, T. B., Everhardt, K., Gueorguieva, R., \u0026amp; Tolin, D. F. (2024). Brief cognitive behavioral therapy for suicidal inpatients: A randomized clinical trial. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e, \u003cem\u003e81\u003c/em\u003e(12), 1177\u0026ndash;1186. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamapsychiatry.2024.2349\u003c/span\u003e\u003cspan address=\"10.1001/jamapsychiatry.2024.2349\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarmer, C. C., Mitchell, K. S., Parker-Guilbert, K., \u0026amp; Galovski, T. E. (2017). Fidelity to the Cognitive Processing Therapy Protocol: Evaluation of critical elements. \u003cem\u003eBehavior Therapy\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(2), 195\u0026ndash;206. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.beth.2016.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2016.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., \u0026amp; Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview-Revised: Development, reliability, and validity. \u003cem\u003ePsychological Assessment\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(7), 677\u0026ndash;689. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/pas0000819\u003c/span\u003e\u003cspan address=\"10.1037/pas0000819\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamarra, J. M., Luciano, M. T., Gradus, J. L., \u0026amp; Wiltsey Stirman, S. (2015). Assessing variability and implementation fidelity of suicide prevention safety planning in a regional VA healthcare system. \u003cem\u003eCrisis: The Journal of Crisis Intervention and Suicide Prevention\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(6), 433\u0026ndash;439. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1027/0227-5910/a000345\u003c/span\u003e\u003cspan address=\"10.1027/0227-5910/a000345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman, M., Sullivan, S. R., Spears, A. P., Dixon, L., Sokol, Y., Kapil-Pair, K. N., Galfalvy, H. C., Hazlett, E. A., \u0026amp; Stanley, B. (2021). An open trial of a suicide safety planning group treatment: Project Life Force. \u003cem\u003eArchives of Suicide Research\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 690\u0026ndash;703. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13811118.2020.1746940\u003c/span\u003e\u003cspan address=\"10.1080/13811118.2020.1746940\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHallgren, K. A. (2012). Computing inter-rater reliability for observational data: An overview and tutorial. \u003cem\u003eTutorials in Quantitative Psychology\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(1), 23\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.20982/tqmp.08.1.p023\u003c/span\u003e\u003cspan address=\"10.20982/tqmp.08.1.p023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHildebrand, M. W., Host, H. H., Binder, E. F., Carpenter, B., Freedland, K. E., Morrow-Howell, N., Baum, C. M., Dor\u0026eacute;, P., \u0026amp; Lenze, E. J. (2012). Measuring treatment fidelity in a rehabilitation intervention study. \u003cem\u003eAmerican Journal of Physical Medicine \u0026amp; Rehabilitation\u003c/em\u003e, \u003cem\u003e91\u003c/em\u003e(8), 715\u0026ndash;724. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/PHM.0b013e31824ad462\u003c/span\u003e\u003cspan address=\"10.1097/PHM.0b013e31824ad462\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJobes, D. A., Lento, R., \u0026amp; Brazaitis, K. (2012). An evidence-based clinical approach to suicide prevention in the Department of Defense: The Collaborative Assessment and Management of Suicidality (CAMS). \u003cem\u003eMilitary Psychology\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(6), 604\u0026ndash;623. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/08995605.2012.736327\u003c/span\u003e\u003cspan address=\"10.1080/08995605.2012.736327\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaerd Statistics (2019). Fleiss' kappa using SPSS Statistics. Statistical tutorials and software guides. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://statistics.laerd.com/spss-tutorials/fleiss-kappa-in-spss-statistics.php\u003c/span\u003e\u003cspan address=\"https://statistics.laerd.com/spss-tutorials/fleiss-kappa-in-spss-statistics.php\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaham, S. M., \u0026amp; Forgas, J. P. (2022). \u003cem\u003eCognitive illusions\u003c/em\u003e (3rd ed.). Routledge.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarques, L., Valentine, S. E., Kaysen, D., Mackintosh, M. A., De Silva, D., Ahles, L. E., Youn, E. M., Shtasel, S. J., Simon, D. L., N. M., \u0026amp; Wiltsey-Stirman, S. (2019). Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e87\u003c/em\u003e(4), 357\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/ccp0000384\u003c/span\u003e\u003cspan address=\"10.1037/ccp0000384\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin, M., Lachman, J. M., Murphy, H., Gardner, F., \u0026amp; Foran, H. (2023). The development, reliability, and validity of the Facilitator Assessment Tool: An implementation fidelity measure used in Parenting for Lifelong Health for Young Children. \u003cem\u003eChild: Care Health and Development\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(3), 591\u0026ndash;604. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/cch.13075\u003c/span\u003e\u003cspan address=\"10.1111/cch.13075\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcHugh, S. (2012). Interrater reliability: the kappa statistic. \u003cem\u003eBiochemia Medica\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(3), 276\u0026ndash;282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoncher, F. J., \u0026amp; Prinz, R. J. (1991). Treatment fidelity in outcome studies. \u003cem\u003eClinical Psychology Review\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(3), 247\u0026ndash;266. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0272-7358(91)90103-2\u003c/span\u003e\u003cspan address=\"10.1016/0272-7358(91)90103-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgrodniczuk, J. S., Joyce, A. S., \u0026amp; Piper, W. E. (2003). Changes in perceived social support after group therapy for complicated grief. \u003cem\u003eThe Journal of nervous and mental disease\u003c/em\u003e, \u003cem\u003e191\u003c/em\u003e(8), 524\u0026ndash;530. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.nmd.0000082180.09023.64\u003c/span\u003e\u003cspan address=\"10.1097/01.nmd.0000082180.09023.64\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgrodniczuk, J. S., Piper, W. E., Joyce, A. S., McCallum, M., \u0026amp; Rosie, J. S. (2002). Social support as a predictor of response to group therapy for complicated grief. \u003cem\u003ePsychiatry\u003c/em\u003e, \u003cem\u003e65\u003c/em\u003e(4), 346\u0026ndash;357. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1521/psyc.65.4.346.20236\u003c/span\u003e\u003cspan address=\"10.1521/psyc.65.4.346.20236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Shea, O., McCormick, R., Bradley, J. M., \u0026amp; O\u0026rsquo;Neill, B. (2016). Fidelity review: A scoping.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ereview of the methods used to evaluate treatment fidelity in behavioural change interventions. \u003cem\u003ePhysical Therapy Reviews\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(3\u0026ndash;6), 207\u0026ndash;214. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10833196.2016.1261237\u003c/span\u003e\u003cspan address=\"10.1080/10833196.2016.1261237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoyal, K. D., \u0026amp; Hecker, K. G. (2016). Understanding reliability: A review for veterinary educators. \u003cem\u003eJournal of Veterinary Medical Education\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(1), 1\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3138/jvme.0315-030R\u003c/span\u003e\u003cspan address=\"10.3138/jvme.0315-030R\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudd, M. D. (2006). Fluid Vulnerability Theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T. E. Ellis (Ed.), \u003cem\u003eCognition and suicide: Theory, research, and therapy\u003c/em\u003e (pp. 355\u0026ndash;368). American Psychological Association. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/11377-016\u003c/span\u003e\u003cspan address=\"10.1037/11377-016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E., \u0026amp; Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. \u003cem\u003eAmerican Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e172\u003c/em\u003e(5), 441\u0026ndash;449. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ajp.2014.14070843\u003c/span\u003e\u003cspan address=\"10.1176/appi.ajp.2014.14070843\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C. J., Schaffer, A., Westreich, N., Ellis, J., Goldstein, B. I., Cheung, A. H., Selchen, S., Kiss, A., \u0026amp; Tien, H. (2020). Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: A pilot randomized controlled trial. \u003cem\u003eJournal of Affective Disorders\u003c/em\u003e, \u003cem\u003e266\u003c/em\u003e, 686\u0026ndash;694. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2020.01.178\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2020.01.178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStirman, S. W., Gutner, C. A., Gamarra, J., Suvak, M. K., Vogt, D., Johnson, C., Wachen, J. S., Dondanville, K. A., Yarvis, J. S., Mintz, J., Peterson, A. L., Young-McCaughan, S., \u0026amp; Resick, P. A. (2021). A novel approach to the assessment of fidelity to a cognitive behavioral therapy for PTSD using clinical worksheets: A proof of concept with Cognitive Processing Therapy. \u003cem\u003eBehavior Therapy\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(3), 656\u0026ndash;672. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.beth.2020.08.005\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2020.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrunk, D. R., Brotman, M. A., \u0026amp; DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(7), 599\u0026ndash;606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun, S. (2011). Meta-analysis of Cohen\u0026rsquo;s kappa. \u003cem\u003eHealth Services and Outcomes Research Methodology\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 145\u0026ndash;163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10742-011-0077-3\u003c/span\u003e\u003cspan address=\"10.1007/s10742-011-0077-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanielian, T. (2019). \u003cem\u003eReducing Suicide Among U.S. Veterans: RAND Research Implications\u003c/em\u003e, RAND Corporation. Testimonies. United States. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://coilink.org/20.500.12592/mjqd0j\u003c/span\u003e\u003cspan address=\"https://coilink.org/20.500.12592/mjqd0j\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 26 Aug 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas, M. R., Beckman, T. J., Mauck, K. F., Cha, S. S., \u0026amp; Thomas, K. G. (2011). Group assessments of resident physicians improve reliability and decrease halo error. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e, 759\u0026ndash;764.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVA/DoD Clinical Practice Guideline. (2019). \u003cem\u003eAssessment and Management of Patients at Risk for Suicide Work Group\u003c/em\u003e. U.S. Government Printing Office. Accessed 27 Nov 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVA/DoD Clinical Practice Guideline. (2024). \u003cem\u003eAssessment and Management of Patients at Risk for Suicide Work Group\u003c/em\u003e. U.S. Government Printing Office. Accessed 13 Aug 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaltz, J., Addis, M. E., Koerner, K., \u0026amp; Jacobson, N. S. (1993). Testing the integrity of a.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003epsychotherapy protocol Assessment of adherence and competence. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e(4), 620\u0026ndash;630. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0022-006X.61.4.620\u003c/span\u003e\u003cspan address=\"10.1037/0022-006X.61.4.620\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. G-BCBT Fidelity Assessment Instrument Statistics by Session\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eSession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSubscale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003ePercent Agreement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eCohen\u0026rsquo;s Kappa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFleiss\u0026apos; Kappa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIntroduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e8.95 (.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e8.5 \u0026ndash; 9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e44/45 = 97.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.01, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eGroup Therapy Commitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5.90 (.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e5.5 \u0026ndash; 6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e28/30 = 93%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTreatment Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.45 (.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e5.0 \u0026ndash; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e31/35 = 88.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.30, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 1 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e21.30 (.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e19.0 \u0026ndash; 22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e103/110 = 93.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.21, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16/16 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Sleep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.75 (.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.5 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e29/32 = 90.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Relaxation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.69 (.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.0 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e29/32 = 90.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.02, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 2 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e19.44 (1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e16.5 \u0026ndash; 20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e74/80 = 92.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.02, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.94 (.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3.5 \u0026ndash; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e15/16 = 93.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Mindfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.19 (.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.0 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e28/32 = 87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.45, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Support Person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.38 (.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.5 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e24/32 = 75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.11, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 3 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e18.50 (1.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e17.0 \u0026ndash; 20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e67/80 = 83.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.17, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e20/20 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00,\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Reasons for Living\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e9.88 (.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e9.5 \u0026ndash; 10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e38/40 = 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 4 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e14.88 (.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e14.5 \u0026ndash; 15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e58/60 = 96.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.02, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.90 (.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3.0 \u0026ndash; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e19/20 = 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Survival Kit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.40 (.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e5.0 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e33/40 = 82.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.07, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 5 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e11.30 (1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e9.0 \u0026ndash; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e52/60 = 86.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.06,\u003cem\u003e\u0026nbsp;p\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.75 (.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4.0 \u0026ndash; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e20/20 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: ABCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.63 (.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.5 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e28/32 = 87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 6 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e12.38 (.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e11.5 \u0026ndash; 13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e48/52 = 92.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.31, \u003cem\u003ep\u003c/em\u003e \u0026lt; .01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16/16 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Challenge Questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.50 (.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4.5 \u0026ndash; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e23/28 = 82.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.07, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 7 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e10.50 (.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e8.5 \u0026ndash; 11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e39/44 = 88.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.04, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e20/20 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Patterns of Problematic Thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.80 (.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6.5 \u0026ndash; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e31/35 = 88.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.04, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 8 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e10.80 (.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e10.5 \u0026ndash; 11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e51/55 = 92.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.88 (.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3.0 \u0026ndash; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e15/16 = 93.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Activity Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e7.75 (.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e7.5 \u0026ndash; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e28/32 = 87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.05, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 9 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e11.63 (.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e10.5 \u0026ndash; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e43/48 = 89.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16/16 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSkill: Coping Cards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5.88 (.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e5.5 \u0026ndash; 6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e22/24 = 91.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.04, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 10 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e9.88 (.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e9.5 \u0026ndash; 10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e38/40 = 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.02, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.00 (.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eNo range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16/16 = 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eRelapse Prevention Consent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.94 (.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4.5 \u0026ndash; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e19/20 = 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eRelapse Prevention Index Episode\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5.81 (.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4.5 \u0026ndash; 6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e21/24 = 87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.07, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 11 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e14.75 (.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e13.5 \u0026ndash; 15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e56/60 = 93.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.03, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTherapeutic Frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.88 (.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3.5 \u0026ndash; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e14/16 = 87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.07, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eRelapse Prevention Future Episode\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.69 (.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4.5 \u0026ndash; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e23/28 = 82.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.10, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSession 12 Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e10.56 (1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e8.0 \u0026ndash; 11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e37/44 = 84.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.09, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: \u003cem\u003eM\u003c/em\u003e = Mean; \u003cem\u003eSD\u003c/em\u003e = Standard Deviation; Range = Range of possible scores on respective session subscale; Percent Agreement = Overall simple rate of agreement between two raters; Cohen\u0026rsquo;s Kappa Interpretation: 0-0.20 (Slight), 0.21-0.40 (Fair), 0.41-0.60 (Moderate), 0.61-0.80 (Substantial), and 0.81-1.00 (Almost Perfect) (see Royal \u0026amp; Hecker, 2016).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cognitive-therapy-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cotr","sideBox":"Learn more about [Cognitive Therapy and Research](http://link.springer.com/journal/10608)","snPcode":"10608","submissionUrl":"https://www.editorialmanager.com/cotr/default.aspx","title":"Cognitive Therapy and Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Suicide, Military, Brief Cognitive Behavioral Therapy, Fidelity, Group therapy","lastPublishedDoi":"10.21203/rs.3.rs-8671387/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8671387/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: Treatment fidelity is important for both research and clinical practice, including adapting new approaches for group delivery of Brief Cognitive Behavioral Therapy (G-BCBT) for suicide prevention. This study describes the development and preliminary field test of 12 fidelity assessment instruments (FAIs) for G-BCBT, for use in a non-inferiority trial comparing G-BCBT to Dialectical Behavioral Therapy (DBT) skills group.\u003c/p\u003e\n\u003cp\u003eMethod: This study included 141 active-duty service members (69 male, 72 female). Participants were randomized to one of two conditions with a total of 10 G-BCBT and 10 DBT group therapy cohorts. Twelve G-BCBT FAIs were developed (one per session) and used by two expert raters to evaluate G-BCBT fidelity.\u003c/p\u003e\n\u003cp\u003eResults: Range of percent agreement was high among expert raters, with 86.3% of agreement scores exceeding 85%. Results for inter-rater reliability were mixed with several scores reflecting perfect agreement and others achieving fair to moderate levels of agreement. However, most inter-rater reliability metrics demonstrated less than chance levels of agreement, suggesting possible halo or ceiling effects.\u003c/p\u003e\n\u003cp\u003eConclusion: Initial field testing of G-BCBT FAIs provided mixed support for use. Recommendations to improve FAI use and inter-rater reliability metrics are discussed as well as directions for future research.\u003c/p\u003e","manuscriptTitle":"Development of Group Brief Cognitive Behavioral Therapy Fidelity Assessment Instruments","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 13:43:52","doi":"10.21203/rs.3.rs-8671387/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T18:12:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T09:32:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T16:12:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74935897381899720670360405641423398747","date":"2026-02-09T09:27:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68527104704289509371742691335150856110","date":"2026-02-04T21:19:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T18:17:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-29T11:17:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T11:10:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cognitive Therapy and Research","date":"2026-01-22T14:57:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cognitive-therapy-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cotr","sideBox":"Learn more about [Cognitive Therapy and Research](http://link.springer.com/journal/10608)","snPcode":"10608","submissionUrl":"https://www.editorialmanager.com/cotr/default.aspx","title":"Cognitive Therapy and Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5e48981f-5aab-4dd8-ab14-cd072bf0c6e9","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T01:25:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 13:43:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8671387","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8671387","identity":"rs-8671387","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}