Evolution of the Treatment Integrity Concept: Current Status and Future Directions

Abstract

This special series on treatment integrity is a timely and salient contribution to the fields of intervention science in general and school psychology in particular. Theoretical and empirical developments regarding the concept of treatment integrity have lagged behind advances in the development, delivery, and validation of evidence-based interventions. The guest editors, Lisa Sanetti and Tom Kratochwill, have done the field a valuable service by providing a set of outstanding articles detailing major conceptual and empirical issues, some resolved and many unresolved, in the area of treatment integrity. At the heart of the importance of treatment integrity to intervention science is that empirical demonstration of measurable changes in a dependant variable (e.g., behavior or academic achievement) must be attributable to systematic and controlled manipulations in the independent variable (i.e., the treatment). In the absence of objective and documented specification of an independent variable (i.e., operationally defined), as well as accurate independent variable application (i.e., treatment integrity), incontrovertible conclusions regarding the relation between a treatment and behavior change are not possible (Gresham, 1989; McIntyre, Gresham, DiGennaro, & Reed, 2007: Moncher & Prinz, 1991). The concept of treatment integrity cuts across a diversity of fields involved with providing treatments or interventions to individuals. In medical treatments, the concept of treatment compliance or treatment adherence is an important and problematic issue. In the field of nutrition, the concept of dietary adherence is important for successful outcomes. In the fields of rehabilitation and substance abuse, the term program implementation captures the concept of treatment integrity. In clinical psychology, a common term for this concept is treatment fidelity. Finally, in the field of applied behavior analysis, the concept of procedural reliability is commonly used to refer to treatment integrity. Despite variations in terminology across these diverse fields, the concern that treatments or interventions are delivered as prescribed or intended is of utmost importance to document that changes in individuals' functioning (medical, nutritional, psychological, or behavioral) are from those treatments and from extraneous variables. Treatment integrity is usually conceptualized as involving three dimensions: (a) treatment adherence, or the degree to which an intervention is implemented as planned or intended; (b) interventionist competence, or the interventionist's skill and experience in implementing a particular treatment; and (c) treatment differentiation, or the extent to which interventions differ on critical dimensions (Nezu & Nezu, 2008; Perepletchikova, Treat, & Kazdin, 2007). Conceptually, treatment adherence represents a quantitative dimension of treatment integrity in that it can be measured in terms of the number of critical treatment components that are implemented. Therapist competence might be conceptualized as more of a qualitative dimension of treatment integrity because it reflects how well treatment procedures are delivered. Finally, treatment differentiation represents theoretical distinctions between different aspects of two or more treatments. The relationship between treatment adherence and interventionist competence is somewhat clouded because competence presupposes adherence, but adherence does not presuppose competence (McGlinchey & Dobson, 2003). One can adhere to a particular intervention with perfect integrity yet do so in an incompetent manner. A breakdown in treatment integrity in this case would dictate training and feedback to ensure a more competent delivery of a treatment. A breakdown in adherence would dictate performance feedback and training in key components of an intervention plan. Recent Estimates of Treatment Integrity Reporting As indicated by numerous intervention studies, the assessment and reporting of treatment integrity is uncommon in the intervention literature. …

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