Efforts to disseminate empirically-supported treatments (ESTs) are receiving unprecedented support as the potential public health benefit of better access to effective mental health care has received increased recognition (e.g., Insel, 2009
; President’s New Freedom Commission, 2004
). Internationally, large-scale initiatives are underway and evaluation of the most effective procedures for disseminating and implementing treatments is ongoing. One of the most pertinent questions at this stage is that of transportability – the degree to which treatments that demonstrate efficacy in controlled research designs can be utilized in front line service provision settings with similar benefits. Studies of treatment effectiveness suggest that it is possible to see gains similar to those observed in efficacy trials (e.g., Clark et al., this issue; Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000
; Persons, Bostrom, & Bertagnolli, 1999
; Nadort et al., this issue; Wade, Treat, & Stuart, 1998
); however, other studies have shown attenuation of treatment effects in service provision settings (e.g., Burns et al., 2002
; Henggeler et al., 1997
). Indeed, the conditions necessary for successful implementation outside of research settings are not well understood and studies of effectiveness differ in the degree to which they utilize procedures similar to those used in controlled research trials.
Many factors reflecting differences between clinical research and clinical practice settings may impact the transportability of treatments, such as organizational factors (see Backer, Liberman, & Kuehnel, 1986
; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005
). A critical component of efficacy trials is the degree to which treatments are administered competently and as intended. Since the development of more clearly defined psychological treatments in the 1970s and 1980s, treatment fidelity has emerged as an important methodological consideration in the empirical evaluation of interventions. Specifically, the degree to which interventions are administered as intended and in a reliable manner impacts both the internal validity and the external validity of these studies and has implications for the ability to attribute symptom changes to the intervention and to replicate and disseminate treatments (see Moncher & Prinz, 1991
; Perepletchikova, Treat, & Kazdin, 2007
Intensive procedures for training, supervision, and ongoing monitoring are employed to maximize fidelity in efficacy trials. Indeed, many efficacy studies will set a priori standards for sufficient fidelity such that cases for which this standard is not met are not included in data analysis (see Behar & Borkovec, 2003
). Although such stringent standards can be employed in these controlled settings, training in the context of dissemination efforts presents a particular challenge. The process of training is costly, and traditionally utilized methods for dissemination (i.e., workshops) are not sufficient to effectively train clinicians (see Oxman, Thomson, Davis, & Haynes, 1995
; Sholomskas et al., 2005
; VandeCreek, Knapp, & Brace, 1990
). Indeed, because of the cost associated with supervision, feedback, and fidelity monitoring, many dissemination programs do not include these procedures in their implementation efforts. The degree to which this is damaging, or even potentially fatal, to both the acute success and long-term sustainability of implementing ESTs remains unclear. This is further complicated by the potential benefits of adaptation.
Given the high levels of control needed to conduct efficacy research, interventions inevitably require some level of adaptation in order to be used in service provision settings, where contextual factors influence the feasibility of such controls. In fact, adaptation is not only an expected response to the use of a new innovation, but actually facilitates adoption and prevents drift (Rogers, 2003
). Although adaptation may facilitate adoption rates and transportability to heterogeneous clinical settings, it may also attenuate or compromise the effectiveness of interventions through altering the conditions in which they were tested. With the recent proliferation of efforts to disseminate ESTs in the absence of a “gold standard” procedure for this process, the appropriate balance of fidelity and adaptation is a particularly important and timely research question.
Although the introduction of treatment manuals provided an unprecedented opportunity for the standardization and dissemination of psychological treatments (see Luborsky & DeRubeis, 1984
), substantial criticism of manualized interventions remains (e.g., Addis & Krasnow, 2000
; Barlow, Levitt, & Bufka, 1999
). Furthermore, despite the presence of treatment manuals for years, the dissemination of these treatments is spotty. Acknowledgement of the limitations of traditional manualized treatments and advances in basic research have led to the development of novel treatment strategies that introduce flexibility to the structure of ESTs. Transdiagnostic or principle-based treatments aim to treat similar disorders using interventions that may target underlying processes (e.g., negative affect) or that utilize decision-rules to determine the use and dose of components based on individual symptom presentations. These treatments introduce opportunities for flexibility in manualized treatments by allowing for greater heterogeneity of clinical presentation and providing opportunities to adapt the intervention to the individual patient. As such, these treatments may facilitate a balance between fidelity and flexibility that maximizes the benefits of both.
This paper will provide a critical review of the importance of fidelity and adaptation in the dissemination and implementation of ESTs. First, the literature on the association between treatment fidelity and outcomes will be reviewed. Second, we will discuss the promise of the burgeoning area of development of transdiagnostic, modular, and principle-based treatments for providing a framework that facilitates a balance between fidelity and adaptation and may provide a particularly cost-effective modality for the dissemination of ESTs. Finally, the importance of fidelity and flexibility for successful dissemination and implementation efforts will be discussed (for review of this issue in substance abuse prevention, see Backer, 2001