This special series focuses upon the ways in which research on treatment integrity, a multidimensional construct including assessment of the content and quality of a psychosocial treatment delivered to a client as well as relational elements, can inform dissemination and implementation science. The five articles for this special series illustrate how treatment integrity concepts and methods can be applied across different levels of the mental health service system to advance dissemination and implementation science. In this introductory article, we provide an overview of treatment integrity research and describe three broad conceptual models that are relevant to the articles in the series. We conclude with a brief description of each of the five articles in the series.

Measures of treatment integrity are needed to advance clinical research in general and are viewed as particularly relevant for dissemination and implementation research. Although some efforts to develop such measures are underway, a conceptual and methodological framework will help guide these efforts. The purpose of this article is to demonstrate how frameworks adapted from the psychosocial treatment, therapy process, healthcare, and business literatures can be used to address this gap. We propose that components of treatment integrity (i.e., adherence, differentiation, competence, alliance, client involvement) pulled from the treatment technology and process literatures can be used as quality indicators of treatment implementation and thereby guide quality improvement efforts in practice settings. Further, we discuss how treatment integrity indices can be used in feedback systems that utilize benchmarking to expedite the process of translating evidence-based practices to service settings.

Quality control methods, including therapist trainingI and supervision procedures, are used to establish and maintain fidelity to a psychosocial intervention. The effectiveness and efficiency of these methods impact both the validity of research on intervention effects and the success of dissemination and implementation in routine care contexts. Quality control methods utilizing active training strategies and review of observational treatment session data are more effective than the methods that rely on passive learning. The purpose of this review was to catalogue the use of an array of quality control methods in studies of evidence-based psychosocial treatments, to evaluate how often the most potentially effective and efficient methods have been used, and to evaluate the variability in the use of these methods across different treatment models, client populations, or clinical settings. The results indicate that the most effective methods have been used to implement fewer than a quarter of the treatments studied. Variability across treatment contexts is presented and implications for future research are discussed.

The role of clinical supervision in the larger-scale implementation of effective mental health treatments has begun to attract attention in effectiveness research and implementation science. Clinical supervision approaches demonstrated to support the implementation of effective treatments could provide a fruitful basis for adaptation to the contours and implementation of other interventions. The adaptation of the Multisystemic Therapy supervision model to support the implementation of an innovative, experimental mental health service model called Links to Learning is described. An observational study provides the platform for consideration of the extent to which the Links supervision model was implemented as intended and of challenges to Links implementation illuminated by the supervision process. Implications are considered for research on supervision as a tool to effect the implementation and outcomes of effective treatment and service models in community practice contexts.

Although the science of disseminating empirically supported behavioral treatments has made remarkable advances, the ultimate goal of dissemination—sustaining the implementation of evidence-based practices (EBPs) in usual care with a high degree of fidelity—remains challenging. This article presents a rationale and guidelines for transitioning from conventional purveyor-driven dissemination methods to intramural quality assurance procedures that can be maintained with routine agency resources. Three innovations for localizing EBP quality assurance are described: adaptation of observational fidelity methods for therapist self-report and supervisor observation of EBPs, process control benchmarking methods for continuous tracking of EBP fidelity strength and consistency, and development of intramural clinical expertise grounded in local management of EBP implementation and outcome data. These innovations exemplify a fundamentally empirical approach to sustaining quality EBP implementation in frontline settings.

This article presents a broad-based framework for evaluating integrity, defined as the structured comparison of observed values (i.e., what did happen) with expected values (i.e., what should happen), across various domains (e.g., practices, outcomes) for the purposes of informing key questions in system contexts (e.g., Is a practice being done properly? How well is it working?). We discuss the application of integrity in serving the goals of the scientific and service systems and potential sources for observed and expected values. An expanded framework regarding integrity analysis is presented detailing multiple domains of measurement (e.g., outcomes, activities, and resources), types of analysis (e.g., across vs. within units), and levels of analysis (e.g., event, episode, multi-episode). Other possible applications of integrity analysis in service systems and ongoing dissemination and implementation efforts are also discussed.

Treatment fidelity and the stage model.

It has been proposed that one way of strengthening the effects of evidence-based treatments for youth in service clinics is to improve treatment integrity in these settings. Four assumptions related to this recommendation are evaluated in light of findings from effectiveness studies. The absence of evidence on links between treatment integrity and treatment outcome in effectiveness trials makes it difficult to estimate the potential benefits of many of the proposed quality control strategies. Incremental changes in methods to improve treatment integrity in service clinics must be considered in the context of structural barriers to implementation.

This commentary reflects on issues related to linking the conceptual frame for treatment fidelity presented in the special issue articles to the most current thinking on treatment fidelity within the emerging field of implementation science. The commentary presents several aspects of treatment fidelity in implementation science that generally were not discussed or addressed in the special issue articles, such as the placement of treatment fidelity as only one among several critical implementation outcomes, the relationship of treatment fidelity to design elements such as external validity as well as internal validity, and the importance of considering implementation issues in the measurement of treatment fidelity even in the earlier stages of efficacy and effectiveness research. The excellent in-depth discussion of treatment fidelity in the special series is a promising start to linking this critical concept to the emerging field of implementation science.

The structure, organization, management, and design of the mental health system are changing profoundly as new healthcare policies reshape its configurations. This special issue is a call to action for the mental health services research field. The articles represent an important attempt to identify specific concepts, constructs, and findings from psychosocial treatment research about fidelity and integrity of treatment and align them with healthcare quality. However, the current structure and processes for deriving quality indicators place other demands on the extant research base. These will challenge this migration unless changes are made in leadership around consistent measurement strategies, payment mechanisms to support quality, and attention to technological infrastructure development. The mental health services research field should be proactive. Pediatric issues need special attention, especially as applied to community-based services for children and their families.