Advances in Fidelity Measurement for Mental Health Services Research: Four Measures
Abstract
Mental health intervention research requires clear and accurate specification of treatment conditions in intervention studies. Measures are increasingly available for community-based interventions for persons with serious mental illnesses. Measures must go beyond structural features to assess critical processes in interventions. They must also balance effectiveness, or adequate coverage of active treatment elements, with efficiency, or the degree to which measures may be used cost-effectively. The context of their use is changing with the emergence of new frameworks for implementation research and quality improvement. To illustrate a range of approaches, this article describes four recently developed fidelity measures: Cognitive Therapy for Psychosis Adherence Scale, Strengths Model Fidelity Scale, Illness Management and Recovery Program Fidelity Scale, and Tool for Measurement of ACT. The fidelity measures assess interventions in a range of treatment contexts from dyads to teams. Each measure focuses assessment resources on critical elements. Each has demonstrated coverage of its target intervention and satisfactory psychometric properties and is related to outcomes. Measures have been used for training, quality improvement, or certification. They assess domains and have uses beyond their nominal position in implementation and quality frameworks. This review of recent fidelity measures indicates that process components in community-based interventions can be effectively assessed. Omission of elements assessing potentially critical active treatment components poses risk to both research and practice until there is evidence to demonstrate that they are nonessential. Further development of fidelity measurement theory and approaches should proceed in conjunction with development of theory and methods in implementation science. (Psychiatric Services 63:765–771, 2012; doi: 10.1176/appi.ps.201100430)
Mental health intervention research requires clear and accurate specification of the independent variables that are actually operating in studies. For example, inferences about effects in experimental studies depend on fidelity: therapists' adherence to the intended treatment, their competence to apply it, and sufficient differentiation across conditions (1,2). Although empirical verification of fidelity has been reported infrequently in psychological treatment research (3), fidelity has recently received greater attention in research on community-based psychosocial interventions for persons with serious mental illnesses. These program-based interventions are inherently more complex and less amenable to full specification in manuals than interventions delivered by a single clinician; they often include elements related to the organization, caseload, types of treatments and other services provided, and interactions with other programs (4). Fidelity measurement strategies and measures have been developed and used for research and practice with a wide range of such programs (5–11).
The principal research uses of program fidelity measures are to monitor and ensure adherence to particular interventions and to identify their critical ingredients. They also serve as operational syntheses of prior research and as vehicles to disseminate information to the field about essential features of evidence-based practices (4). The demands of multiple uses pose significant challenges for the design of fidelity measures. One is selection of features to include. Critical ingredients are identified through theory and empirical research addressing the active mechanisms that are expected to yield intended outcomes. Because such ingredients might include multiple organizational levels, contributing mechanisms, and assessment points, program-based models present developers with a multitude of options. A second challenge is the need to balance effectiveness, or the degree to which fidelity measures and methods capture the essential features of an intervention reliably and validly, with efficiency, or the degree to which the tools can be applied cost-effectively such that the real gains from use in ordinary settings warrant the effort required to use them (12). Because of the complexity of treatments, contexts, and possible uses, developers of fidelity measures have made a wide range of choices in balancing effectiveness and efficiency.
Consideration of a number of conceptual frameworks within which fidelity measures operate suggests reasons for such variation. Within the classic structure-process-outcome quality framework (13), fidelity measures typically include both structure and process elements. Although fidelity measures have sometimes emphasized more accessible structural features—for example, group size and duration of treatment—less tangible processes may be essential to program integrity (7), and overemphasizing structure poses risks to both research and practice (14–16). Such misplaced emphasis can follow from weak theory, because fidelity measures have been described as representing program theory or theory of action of the intervention (14,17). What is included in a fidelity measure will thus depend on what actions are considered essential and at what level the intervention is defined. In some cases, this represents a departure from program theory as such, which specifies mechanisms of change, to include implementation theory, which specifies how a program is carried out (18).
A more recent model of implementation research, with primary domains of intervention strategies, implementation strategies, and three types of outcome domains—implementation, service, and client—would place fidelity as one of a number of implementation outcomes (19). However, some fidelity measures, including two described here, have addressed implementation features in three or four of these five domains. This implementation research framework itself draws on a model for assessing change at four levels: individual, group or team, organization, and larger system and environment (20). Again, fidelity measures can span multiple levels. Finally, a recent heuristic model for ensuring quality of implementation of evidence-based practices proposes four main strategic categories: policy and administration, training and consultation, team operations, and program evaluation (21). Fidelity assessment is placed in the last category, but it can also support other strategies.
In this article, we describe four recently developed fidelity measures for community-based interventions for people with serious mental illness to illustrate a range of approaches within this context. Overall they reflect advances in effective measurement of critical processes, but they differ in terms of where and how they focus within those frameworks for theory, quality, and implementation. These measures are summarized in Table 1 and listed along a continuum of complexity of program levels.
Recent measures of service fidelity
Cognitive Therapy for Psychosis Adherence Scale
Between 25% and 40% of people with a schizophrenia spectrum disorder experience persistent psychotic symptoms (22,23), which are associated with high levels of distress and functional impairment, as well as increased vulnerability to relapse (24,25). To address this problem, cognitive-behavioral therapy (CBT) for psychosis was adapted based on the principles of CBT initially developed for the treatment of depression and anxiety (26,27). These principles emphasize treatment components, such as “normalizing” psychotic symptoms, teaching effective coping strategies for persistent symptoms, and critically examining and challenging thoughts and beliefs underlying psychotic symptoms (28–30). Over the past two decades, more than 30 randomized controlled trials have evaluated the effects of CBT for psychosis, and results indicate significant reduction of psychotic, negative, mood, and social anxiety symptoms (31). CBT for psychosis is a recommended treatment for schizophrenia, both in the most recent guidelines from the National Institute for Health and Clinical Excellence in Great Britain (32) and in recommendations from the Schizophrenia Patient Outcomes Research Team in the United States (33).
To evaluate therapist adherence to the elements of CBT for psychosis defined by Fowler and colleagues (29), Startup and colleagues (34) developed the Cognitive Therapy for Psychosis Adherence Scale (CTPAS), which includes 12 items, each rated on 7-point Likert scales, with assessments based on audiotapes of treatment sessions. Ratings on the scale pertain to specific therapist behaviors, such as “assessing psychotic experiences” and “validity testing.” Startup and colleagues (34) demonstrated that reliable ratings could be obtained with the CTPAS. A principal components factor analysis indicated two factors, corresponding to focus on problems and focus on delusions. This scale was used to document therapist fidelity to CBT for psychosis in two clinical trials (35,36).
The CTPAS was subsequently revised (R-CTPAS) by adding nine items and changing the rating scale to provide separate ratings of therapist adherence to the CBT for psychosis model and the frequency of specific therapist activities (37). Adherence is conceptualized as competent delivery of therapist activities described in the manual (29), as defined by practices that are individualized to the client's presenting problems, matched to the client's understanding, and carried out collaboratively. Frequency items are recorded for specific therapist activities, regardless of whether the activities are adherent to the manual or not. High interrater reliability ratings were obtained. A principal components factor analysis of the presence of specific therapist activities demonstrating adherence to the model yielded three factors corresponding to “engagement and assessment,” “relapse prevention,” and “formulation and schema work.” Concurrent validity was shown by demonstrating moderate associations between ratings on the CTPAS and the Cognitive Therapy Scale (38), which was developed to evaluate fidelity to CBT for depression. The CTPAS has been used to ensure adherence of therapists delivering CBT for psychosis in randomized controlled trials (39) and to compare the skills of clinicians working on a research project with those in routine clinical practice (37).
Strengths Model Fidelity Scale
The purpose of the strengths model of case management, first formulated in the early 1980s, is to help people with psychiatric disabilities to attain the goals that they set themselves by identifying, securing, and sustaining the range of resources, both environmental and personal, that are needed to live, play, and work in a normally interdependent way in the community (40). The focus is on individual and community strengths and assets in the service of goal achievement. The strengths model has been the subject of four experimental or quasi-experimental studies (41–44) and five nonexperimental studies (45–49). Results have been consistently positive, with reduction in symptoms and improved social functioning being the most frequent findings. This body of research has been criticized for small samples and the varied measures employed (50). Of particular concern is the lack of systematic monitoring of intervention implementation.
The impetus to develop a Strengths Model Fidelity Scale (SM-FS) was threefold. First, future research on the strengths model needed a reliable method for monitoring implementation of the intervention. Second, the mental health authority in Kansas created an enhanced Medicaid reimbursement rate for providers who delivered high-fidelity strengths model case management, and other states were pursuing similar arrangements. They needed a reliable method for ascertaining fidelity. Third, because the idea of strengths-based practice has gained such currency, there was a need to distinguish between the rhetoric of programs and actual practice.
The SM-FS contains three major domains: structure (for example, caseload size and use of group supervision), supervision (for example, field mentoring and review and feedback on the use of clinical tools), and clinical practice (for example, use of the strengths assessment and personal recovery plan, use of naturally occurring community resources, and hope-inducing behavior) (51). The measure uses the 5-point anchored-scale format used in many fidelity measures (11). Possible scores range from 11 to 55, with 45 defined as good fidelity. It uses multiple sources of data, including case records; interviews with consumers, case managers, and supervisors; and direct observation of practice. SM-FS has face validity with expert item reviews.
One study showed the predictive validity of SM-FS for team performance in terms of consumer outcomes (52). The core outcomes included psychiatric hospitalization, competitive employment, involvement in higher education, and independent living. Fidelity reviews were conducted at baseline and then every six months during the first 18 months of implementation. Each review was conducted by at least two consultant-trainers. Interrater reliability (intraclass correlation) between the two raters of the fidelity scale was .97, representing a high level of agreement. Internal consistency (Cronbach's alpha) for the 11 items was .98. Consumer outcomes were reported by the participating team case managers when fidelity reviews occurred. The data contained 14 case management teams representing ten agencies serving an average of 953 consumers over an 18-month period who were diagnosed as having a serious mental illness. The study found that consumer outcomes improved over time and that the improvement was explained by the increase in the fidelity score, which indicated predictive validity. Concurrent correlations between the fidelity score and outcomes were in the expected directions, which also supported the associations between fidelity and outcomes.
Illness Management and Recovery Program Fidelity Scale
The illness management and recovery (IMR) program was developed to teach illness self-management skills to people with severe mental illness (53). A comprehensive review of illness self-management strategies was first conducted that identified five empirically supported interventions: psychoeducation, behavioral tailoring for medication adherence, development of a relapse prevention plan, coping skills training, and social skills training to improve social support (54). These strategies were then incorporated into a comprehensive, integrated program that included ten different “modules” or topic areas aimed at teaching illness self-management strategies to help clients achieve personally meaningful recovery goals. The IMR program can be implemented either individually or in groups, and completion generally requires four to five months of twice-weekly meetings or nine to ten months of weekly meetings.
The IMR Fidelity Scale (IMR-FS) was developed to evaluate the adherence of clinicians to the principles of the IMR program. In contrast to the R-CTPAS, which focuses on evaluating the fidelity of individual clinicians to the CBT for psychosis treatment model, the IMR-FS focuses on evaluating the fidelity of an overall program (that is, all the clinicians together) to the principles and defining elements of IMR. The IMR-FS includes 13 items, each rated on 5-point behaviorally anchored scales, that tap a combination of specific structural aspects regarding how the program should be delivered (number of people in sessions, program length, comprehensiveness of curriculum, and provision of handouts), the provision of specific empirically supported components in IMR sessions (psychoeducation, behavioral tailoring, relapse prevention plan, coping skills training, and social skills training), and adherence to specific principles that guide implementation of the overall IMR program (goal setting and follow-up; use of educational, motivational, and cognitive-behavioral teaching strategies; and involvement of significant others). Ratings are usually conducted by two assessors on the basis of a combination of inspection of charts; meetings with clinicians, clients, and supervisors; and direct (limited) observation of IMR sessions.
Good interrater reliability has been shown for the IMR-FS, which was also found to be sensitive to change over two years after training and consultation in the IMR program across 12 community mental health centers participating in the National Implementing Evidence-Based Practices project (11). The IMR-FS has also been used to document fidelity to the IMR model in three randomized controlled trials comparing IMR with usual services (55–57). Of interest, in one of these studies IMR was implemented at 12 sites, of which nine showed high fidelity to the IMR program (56). When analyses were restricted to the nine high-fidelity sites, somewhat stronger effects were found than in the intent-to-treat analyses that included all 12 sites.
Validation work on the IMR-FS has yet to be conducted, although several possible approaches are possible. Research could be conducted to evaluate whether total scores on the IMR-FS at different agencies providing the IMR program are related to improvements in domains targeted by the program, such as illness self-management, hospitalization, or functioning. In addition, research could evaluate whether ratings on some of the items of the IMR-FS are significantly related to independent fidelity measures tapping the same constructs. For example, one would expect that higher scores on the IMR-FS item on motivational teaching strategies would be related to greater clinical competence on the motivational interviewing subscale of the Yale Adherence and Competence Scale (58).
The Tool for Measurement of ACT
Assertive community treatment (ACT) was developed as a comprehensive program to provide the full array of treatments, services, and supports needed by persons with severe mental disorders and significant psychiatric disabilities to establish and maintain fulfilling lives in the community (59,60). The program is the single point of responsibility for enrolled consumers; has a small caseload of approximately 100 consumers shared across multidisciplinary team of ten to 12 members; and provides highly individualized, integrated services in vivo, whenever, wherever, and for as long as needed in consumers' daily lives. The model incorporates carefully specified procedures to track and respond to consumer needs, deploying staff as needed. As definitions for optimal treatment and expectations for treatment goals have changed over time, the practice of ACT has also evolved, incorporating other evidence-based practices in treatment (10) within an overall recovery orientation (61).
After preliminary fidelity measures were developed (6,62), the Dartmouth Assertive Community Treatment Scale (DACTS) (7), although developed for a particular study (63), became the standard fidelity measure for ACT and has been used widely in studies (11,64,65). Because it was available before publication of the first ACT manual (60) and had a clear and accessible format and protocol, it was frequently used as a guide to implementing the program despite the authors' assertions that some key processes were not assessed. Although not problematic in its original application (66), the scale's emphasis on structural features and omission of some critical process risked weaker implementation and research inferences elsewhere, especially as the ACT model evolved.
The Tool for Measurement of ACT (TMACT) (16) was designed to address these issues. It assesses use of evidence-based practices—for example, supported employment and integrated treatment for co-occurring disorders—within the ACT model, includes items addressing consumer recovery orientation, and strengthens measurement of team functioning. It has 47 items in six subscales that define operations and structure, core team, specialist team, core practices, evidence-based practices, and person-centered planning and practices. A protocol specifies the fidelity assessment process and provides interview questions, rules for scoring all items, and formats for collecting data and providing feedback. Items on each evidence-based practice are derived from respective full fidelity scales (11). ACT staff function as both specialists and generalists informed by others' specialist services, so staff roles are assessed relative to other staff as well as to consumers. Recovery orientation is built into items assessing person-centered planning and practices and is more generally reflected throughout the measure in assessing the focus of treatment and interactions with consumers.
DACTS and TMACT scores were compared for ten teams over 18 months (16). Significant differences between the two measures varied over time and were a function of lower fidelity in key areas not measured by the DACTS, confirming the TMACT as a more comprehensive and higher standard than the DACTS and as more sensitive to change.
Discussion
Advances in research on community-based interventions will depend in part on advances in our ability to measure whether they are being delivered as intended. The fidelity measures described above for four intervention models for people with severe mental disorders represent improvements in this respect. Although all of these measures include structural elements, they also include assessment of specific processes demonstrated or hypothesized as critical to successful delivery of the intervention. They were designed for use in a number of research purposes, such as validating inclusion of sites or practitioners in studies, indicating the strength of the intervention, or identifying critical ingredients. And their intended uses go beyond research: one or more is used to accredit programs for enhanced reimbursement rates, to certify individual clinicians, or as a tool for training and quality improvement.
The measures differ in important respects, following from differences in program and implementation theory underlying their respective interventions. At the programmatically simplest level, the CBT for psychosis intervention is specified strictly in terms of dyadic interaction. At the other extreme of programmatic complexity, the ACT model includes specifications for program-level structures and processes theoretically required to ensure optimal delivery of services at the dyadic level. Current fidelity measurement as exemplified by these recent measures expands beyond the respective niches suggested by recent frameworks for implementation science and quality improvement (19–21).
This broad practical and conceptual scope in what we currently define as fidelity measurement suggests an important future need. There are calls for refinement in program and implementation theory, as well as development of measures of implementation fidelity (17,19). The field would gain from greater clarity in concept and definition. The term “fidelity” has merit as representing a general concept, but we would benefit from articulation of a typology of fidelity measurement linked to emerging frameworks for implementation and quality.
The role of fidelity measures in research could also be better clarified. For example, McGrew (67) faulted the TMACT authors for including items that had not been individually demonstrated to predict outcomes in ACT. The authors' response was that fidelity measures had rarely been prevalidated at the item level and that the TMACT was just the sort of refinement of program theory called for on the basis of related evidence and necessary to move the science of this intervention forward (17,68). Further consideration of this issue is warranted.
Validation is a related need. The four measures described here have made variable use of one or more of the approaches described by Mowbray and colleagues (14)—reliability, structural analysis, known groups, convergent validity, and outcome prediction; but these must be used judiciously. Internal consistency, for example, may apply poorly to measurement of domains that do not represent a single underlying construct, outcome prediction may be uninformative or misleading when program variation is insufficient, and overall test-retest and interrater reliability may present practical challenges for programwide assessments. However, several of these, especially convergent validity, could more routinely apply to measure components. And validation of choice of method would be important and feasible in complex programs, for example, by evaluating program-level items against aggregated results from individual-level items.
In the absence of the suggested theoretical and empirical work it would be difficult to judge the respective choices made within the four fidelity measures in balancing effectiveness and efficiency. Respective descriptions and the information presented in Table 1 indicate an adaptation of both coverage and methods to the domains assessed. In the normal scientific context of testing and refinement, increasing effectiveness should also yield improved efficiency over time. All four entail considerable effort, albeit of varying types, suggesting the importance of additional work to quantify the value added and establish cost-effectiveness. How much effort in fidelity assessment is warranted, and to what degree of precision, is unclear. However, there is substantial evidence that higher fidelity is generally correlated with better outcomes; establishment of high fidelity early on should yield substantial benefit. Even a full TMACT assessment with consultative feedback requires less than .5% of the annual effort of a team, a modest marginal cost for expected treatment improvement from assessment of either a new team or one showing intermediate performance, and there is reasonable concern and some evidence that diluted fidelity measurement in an environment of complex incentives may weaken both practice and research findings (16,68). Further work is needed on development of low-risk strategies for titration of ongoing fidelity assessment efforts (64).
Conclusions
Fidelity measurement in mental health services research is at a promising if uncertain point. New measures are being developed to measure and guide fidelity of emerging and enhanced practices in serving persons with serious mental illnesses in the community. Four recent measures illustrate this progress. At the same time, the context of use is rapidly changing as an emerging implementation science begins to articulate frameworks for addressing the compelling translational challenge of developing the necessary knowledge to establish and maintain evidence-based practices in usual care settings. Further refinement and clarification of the science and practice of fidelity measurement, along with an expanded view of its useful place in these frameworks, should be a part of that development.
Acknowledgments and disclosures
This research was supported in part by grants R01 MH064662 and R01 MH077210 from the National Institute of Mental Health.
The authors report no competing interests.
References
1.
Moncher FJ, Prinz RJ: Treatment fidelity in outcome studies. Clinical Psychology Review 11:247–266, 1991
2.
Waltz J, Addis ME, Koerner K, et al.: Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. Journal of Consulting and Clinical Psychology 61:620–630, 1993
3.
Perepletchikova F, Treat TA, Kazdin AE: Treatment integrity in psychotherapy research: analysis of the studies and examination of the associated factors. Journal of Consulting and Clinical Psychology 75:829–841, 2007
4.
Bond GR, Evans L, Salyers MP, et al.: Measurement of fidelity in psychiatric rehabilitation research. Mental Health Services Research 2:75–87, 2000
5.
Brekke JS, Test MA: A model for measuring the implementation of community support programs: results from three sites. Community Mental Health Journal 28:227–247, 1992
6.
McGrew JH, Bond GR, Dietzen L, et al.: Measuring the fidelity of implementation of a mental health program model. Journal of Consulting and Clinical Psychology 62:670–678, 1994
7.
Teague GB, Bond GR, Drake RE: Program fidelity in assertive community treatment: development and use of a measure. American Journal of Orthopsychiatry 68:216–232, 1998
8.
Henggeler SW, Pickrel SG, Brondino MJ: Multisystemic treatment of substance-abusing and-dependent delinquents: outcomes, treatment fidelity, and transportability. Mental Health Services Research 1:171–184, 1999
9.
Becker DR, Smith J, Tanzman B, et al.: Fidelity of supported employment programs and employment outcomes. Psychiatric Services 52:834–836, 2001
10.
Torrey WC, Drake RE, Dixon L, et al.: Implementing evidence-based practices for persons with severe mental illnesses. Psychiatric Services 52:45–50, 2001
11.
McHugo GJ, Drake RE, Whitley R, et al.: Fidelity outcomes in the national implementing evidence-based practices project. Psychiatric Services 58:1279–1284, 2007
12.
Schoenwald SK, Garland AF, Chapman JE, et al.: Toward the effective and efficient measurement of implementation fidelity. Administration and Policy in Mental Health 38:32–43, 2011
13.
Donabedian A: The quality of care: how can it be assessed? JAMA 260:1743–1748, 1988
14.
Mowbray CT, Holder M, Teague GB, et al.: Fidelity criteria: development, measurement, and validation. American Journal of Evaluation 24:315–340, 2003
15.
Matejkowski J, Draine J: Investigating the impact of housing first on ACT fidelity. Community Mental Health Journal 45:6–11, 2009
16.
Monroe-DeVita M, Teague GB, Moser LL: The TMACT: a new tool for measuring fidelity to assertive community treatment. Journal of the American Psychiatric Nurses Association 17:17–29, 2011
17.
Bickman L: Summing up program theory. New Directions for Evaluation 87:103–112, 2000
18.
Rogers PJ: Theory-based evaluations: reflections ten years on. New Directions for Evaluation 114:63–67, 2007
19.
Proctor EK, Landsverk J, Aarons GA, et al.: Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health 36:24–34, 2009
20.
Shortell SM: Increasing value: a research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Medical Care Research and Review 61(suppl 3):12S–30S, 2004
21.
Monroe-DeVita M, Morse G, Bond GR: Program fidelity and beyond: multiple strategies and criteria for ensuring quality of assertive community treatment. Psychiatric Services, Apr 15, 2012;
22.
Carpenter WT, Buchanan RW: Schizophrenia. New England Journal of Medicine 330:681–690, 1994
23.
Silverstein ML, Harrow M: First rank symptoms in the post acute schizophrenic: a follow-up study. American Journal of Psychiatry 135:1418–1426, 1978
24.
Mueser KT, Douglas MS, Bellack AS, et al.: Assessment of enduring deficit and negative symptom subtypes in schizophrenia. Schizophrenia Bulletin 17:565–582, 1991
25.
Racenstein JM, Harrow M, Reed R, et al.: The relationship between positive symptoms and instrumental work functioning in schizophrenia: a 10-year follow-up study. Schizophrenia Research 56:95–103, 2002
26.
Beck AT, Emery G, Greenberg RL: Anxiety Disorders and Phobias: A Cognitive Perspective. New York, Basic Books, 1985
27.
Beck AT, Rush AJ, Shaw BF, et al.: Cognitive Therapy of Depression. New York, Guilford, 1979
28.
Beck AT, Rector NA, Stolar N, et al.: Schizophrenia: Cognitive Theory, Research, and Therapy. New York, Guilford, 2009
29.
Fowler D, Garety P, Kuipers E: Cognitive Behaviour Therapy for Psychosis: Theory and Practice. Chichester, United Kingdom, Wiley, 1995
30.
Morrison AP, Renton JC, Dunn H, et al.: Cognitive Therapy for Psychosis: A Formulation-Based Approach. New York, Brunner-Routledge, 2004
31.
Wykes T: Review: cognitive remediation improves cognitive functioning in schizophrenia. Evidence Based Mental Health 11:117, 2008
32.
Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care. National Collaborating Centre for Mental Health, Clinical Guideline 82. London, British Psychological Society and Royal College of Psychiatrists, 2010
33.
Dixon LB, Dickerson F, Bellack AS, et al.: The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin 36:48–70, 2010
34.
Startup M, Jackson M, Pearce E: Assessing therapist adherence to cognitive-behaviour therapy for psychosis. Behavioural and Cognitive Psychotherapy 30:329–339, 2002
35.
Durham RC, Guthrie M, Morton RV, et al.: Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms: results to 3-month follow-up. British Journal of Psychiatry 182:303–311, 2003
36.
Startup M, Jackson M, Bendix S: North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: outcomes at 6 and 12 months. Psychological Medicine 34:413–422, 2004
37.
Rollinson R, Smith B, Steel C, et al.: Measuring adherence in CBT for psychosis: a psychometric analysis of an adherence scale. Behavioural and Cognitive Psychotherapy 36:163–178, 2008
38.
Vallis TM, Shaw BF, Dobson KS: The Cognitive Therapy Scale: psychometric properties. Journal of Consulting and Clinical Psychology 54:381–385, 1986
39.
Garety PA, Fowler DG, Freeman D, et al.: Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. British Journal of Psychiatry 192:412–423, 2008
40.
Rapp CA, Goscha RJ: The Strengths Model: Case Management With People With Psychiatric Disabilities, 2nd ed. Oxford, United Kingdom, Oxford University Press, 2006
41.
Modrcin M, Rapp C, Poertner J: The evaluation of case management services with the chronically mentally ill. Evaluation and Program Planning 11:307–314, 1988
42.
Macias C, Kinney R, Farley OW, et al.: The role of case management within a community support system: partnership with psychosocial rehabilitation. Community Mental Health Journal 30:323–339, 1994
43.
Macias C, Farley OW, Jackson R, et al.: Case management in the context of capitation financing: an evaluation of the strengths model. Administration and Policy in Mental Health 24:535–543, 1997
44.
Stanard RP: The effect of training in a strengths model of case management on client outcomes in a community mental health center. Community Mental Health Journal 35:169–179, 1999
45.
Rapp CA, Chamberlain R: Case management services to the chronically mentally ill. Social Work 30:417–422, 1985
46.
Rapp CA, Wintersteen R: The strengths model of case management: results from twelve demonstrations. Psychosocial Rehabilitation Journal 13:23–32, 1989
47.
Ryan CS, Sherman PS, Judd CM: Accounting for case management effects in the evaluation of mental health services. Journal of Consulting and Clinical Psychology 62:965–974, 1994
48.
Kisthardt W: The impact of the strengths model of case management from the consumer perspective, in Case Management: Theory and Practice. Edited by, Harris M, Bergman H. Washington, DC, American Psychiatric Association, 1993
49.
Barry KL, Zeber JE, Blow FC, et al.: Effect of strengths model versus assertive community treatment model on participant outcomes and utilization: two-year follow-up. Psychiatric Rehabilitation Journal 26:268–277, 2003
50.
Chamberlain R, Rapp CA: A decade of case management: a methodological review of outcome research. Community Mental Health Journal 27:171–188, 1991
51.
Rapp CA, Goscha RJ: The Strengths Model: Case Management With People With Psychiatric Disabilities, 3rd ed. New York, Oxford University Press, 2012
52.
Fukui S, Goscha R, Rapp CA, et al.: Strengths model case management fidelity scores and client outcomes. Psychiatric Services 63:708–710, 2012
53.
Gingerich S, Mueser KT: Illness Management and Recovery Implementation Resource Kit, revised ed. Rockville, Md, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2010
54.
Mueser KT, Corrigan PW, Hilton D, et al.: Illness management and recovery for severe mental illness: a review of the research. Psychiatric Services 53:1272–1284, 2002
55.
Färdig R, Lewander T, Melin L, et al.: A randomized controlled trial of the illness management and recovery program for schizophrenia. Psychiatric Services 62:606–612, 2011
56.
Hasson-Ohayon I, Roe D, Kravetz S: A randomized controlled trial of the effectiveness of the illness management and recovery program. Psychiatric Services 58:1461–1466, 2007
57.
Levitt A, Mueser KT, DeGenova J, et al.: A randomized controlled trial of illness management and recovery in multi-unit supported housing. Psychiatric Services 60:1629–1636, 2009
58.
Carroll K: A general system for evaluating therapist adherence and competence in psychotherapy research in the addictions. Drug and Alcohol Dependence 57:225–238, 2000
59.
Stein LI, Test MA: Alternative to mental hospital treatment: I. conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry 37:392–397, 1980
60.
Allness DJ, Knoedler WH: The PACT Model of Community-Based Treatment for Persons With Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up. Arlington, Va, National Alliance for the Mentally Ill, 1998
61.
Silverstein SM, Bellack AS: A scientific agenda for the concept of recovery as it applies to schizophrenia. Clinical Psychology Review 28:1108–1124, 2008
62.
Teague GB, Drake RE, Ackerson TH: Evaluating use of continuous treatment teams for persons with mental illness and substance abuse. Psychiatric Services 46:689–695, 1995
63.
Drake RE, McHugo GJ, Clark RE, et al.: Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial. American Journal of Orthopsychiatry 68:201–215, 1998
64.
McGrew JH, Stull LG, Rollins AL, et al.: A comparison of phone-based and on-site assessment of fidelity for assertive community treatment in Indiana. Psychiatric Services 62:670–674, 2011
65.
Bond GR, Salyers MP: Prediction of outcome from the Dartmouth Assertive Community Treatment Fidelity Scale. CNS Spectrums 9:937–942, 2004
66.
McHugo GJ, Drake RE, Teague GB, et al.: Fidelity to assertive community treatment and client outcomes in the New Hampshire Dual Disorders Study. Psychiatric Services 50:818–824, 1999
67.
McGrew JH: The TMACT: Evidence based or eminence based? Journal of the American Psychiatric Nurses Association 17:32–33, 2011
68.
Teague GB, Moser LL, Monroe-DeVita M: Established and emerging elements in the TMACT: measuring fidelity to an evolving model. Journal of the American Psychiatric Nurses Association 17:17–29, 2011
Figures and Tables
Information & Authors
Information
Published In
Cover: Girl With Ball, by Roy Lichtenstein, 1961. Oil on canvas. Gift of Philip Johnson. The Museum of Modern Art, New York. Digital image © The Museum of Modern Art/Licensed by SCALA/Art Resource, New York.
History
Published online: 1 August 2012
Published in print: August 2012
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).