Data demonstrating very low fidelity in CBT among clinicians in community settings comes from a project exploring what constitutes ‘treatment as usual’ as part of two large multisite clinical trials evaluating Motivational Interviewing (MI) (Miller & Rollnick, 1991, 2002) and Motivational Enhancement Therapy (MET) for individuals seeking treatment for substance use disorders. In these two studies, clinicians working in community treatment settings who volunteered to participate in the protocols were randomized to either (1) a condition in which they were trained and supervised to deliver MET or MI with substance using individuals, or (2) continue to deliver the ‘standard treatment’ they usually would in that setting (treatment-as-usual, or TAU) (Ball et al., 2007; Carroll, Martino, et al., 2009). As a means of developing a fidelity rating system to evaluate implementation of MET/MI versus TAU in those trials, the 66 volunteer clinicians from the 11 participating sites were surveyed as to their usual theoretical orientation and techniques when working with clients at that site. Multiple orientations were endorsed, including 12-Step/disease concept, reality therapy, MI/MET, client centered, psychodynamic, and experiential; however, the
