Why is “fidelity” important in Evidence-Based Treatment?

By: Dr. Cheri Shapiro

One common question often asked by treatment providers and organizations about evidence-based interventions involves program fidelity.  Treatment integrity or fidelity refers to implementing an intervention in the way that it was intended to be delivered. This means not adding or deleting program elements, and not creating combinations of programs or program elements.

Why is this so important?  If intervention content is changed, we cannot be confident that our clients can achieve the outcomes that have been found for the program (this is, such changes mean that the program becomes different, and this “new” program has not been tested to see if the effects are the same).

Yet, one important concept identified by many researchers such as Philip Kendall, Rinad Biedas, Matthew Sanders, and Trevor Mazzucchelli is flexibility within fidelity.  How can evidence-based programs be delivered in a way that is true to the model, but allowing practitioners the ability to make modifications based on client capacities and needs?

The first place to look for guidance is the manual that guides treatment delivery of the program.  What have the intervention developers said on this topic?

A second consideration is common sense.  Remember, all evidence-based interventions come with one thing – the ability of the intervention provider to make decisions based on practical considerations.  For example, in my work, we have found a need to make changes in the length of time it took to deliver a manualized, evidence-based intervention.  In this instance, delivering a 10-session intervention in client homes typically took many more home visits to complete (15 in one study and 17 in another).  The program content was not changed, but the process, in this case time, was.  The changes in the number of home visits to complete the intervention was based on client need.

A third source of guidance is from your peers and supervisors.  Consulting with colleagues who have experience with the intervention and the client population can be invaluable in helping to address questions about ways to deliver material in a flexible way that honors program integrity.

Finally, if a program is to be delivered in a way that is different from how it is intended to be delivered, several considerations arise. First, informing clients about what intervention they are getting is critical; if it is different from the evidence-based version in some way, the differences and reasons for the differences should be clearly explained. Clients should have voice in choosing whether to receive this revised version of the intervention.

Second, collecting information or data on client outcomes becomes even more important.  Will the revised program result in the desired outcomes?  Collecting information in these types of cases can help us stay on track to support our clients in achieving their desired outcomes.  After all, this is why they have come to us for support.

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