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Optimizing Fidelity of Empirically Supported Behavioral Treatments for Mental Disorders

NAMHC Concept Clearance


Varda Shoham, Ph.D.
Special Assistant to the Director
Division of Adult Translational Research (DATR)


This initiative aims to support research that will enhance the fidelity, and ultimately the effectiveness, of empirically supported behavioral treatments (ESBT) for mental disorders as implemented by community-based therapists. More specifically, it encourages research designed to develop and test: (a) methods for assessing theory-derived ESBT fidelity components; and (b) interventions that enhance and maintain the fidelity with which clinicians implement these ESBTs in community settings.


The recent National Advisory Mental Health Council’s workgroup report, From Discover to Cure: Accelerating the Development of New and Personalized Interventions for Mental Illnesses, calls for optimizing current treatments. The NIMH Strategic Plan also recognizes the need for improving interventions for people with mental disorders and for the effective application of these treatments in community-based practice.

Although efficacious behavioral treatments for many mental disorders exist, studies suggest that many patients in community settings do not receive these ESBTs as intended by the treatment developers. 1, 2, 3, 4 A major factor in the widely acknowledged science-to-service gap is treatment fidelity. The fidelity of an ESBT is essential in the delivery of psychosocial interventions, as the integrity of the treatment depends disproportionally on clinician behavior. What the clinician does and does not do (based on an ESBT manual) defines a multi-component independent variable—the treatment itself—encompassing domains such as adherence, competence, and differentiation from other treatments. While successful fidelity acquisition and maintenance is feasible in randomized efficacy trials, little is known about how to extend effective methods of ESBT training and fidelity maintenance to community practice.

A sharpened focus on treatment fidelity and its outcome-related components has the potential to advance knowledge on how ESBTs work and how to make them more efficient. For example, the complex, multi-component nature of some ESBT treatment packages may itself pose a barrier to successful community implementation. In the absence of specific knowledge about which components relate most essentially to behavior change, a common practice is to train therapists in all elements of the package, emphasizing active and inert components equally.

This funding initiative supports research aiming to develop treatment-specific, multi-component fidelity measures; to examine component-outcome relationships; and, to explore methods for enhancing and maintaining the most promising fidelity components. The ultimate goal of this initiative is to narrow the science-practice gap by making high-quality ESBTs more readily accessible to patients in the community.

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1 Carroll, K. & Rounsaville, B. (2007). A vision of the next generation of behavioral therapies, Addiction, 102, 850-862.

2 Herschell, A. (2010) Fidelity in the field: Developing infrastructure and measurement. Clin. Psychol. Sci. Prac. 17, 253-257.

3 Perepletchikova, F., Hilt, L. M., Chereji, E., & Kazdin, A. E. (2009). Barriers to implementing treatment integrity procedures. J. Consult. Clin. Psychol., 77, 212–218.

4 Santa Ana et al. (2008). What is usual about “treatment-as-usual”? J. Subs. Ab. Treat., 35, 369-379.