Fidelity may be defined as the extent to which delivery of an intervention adheres to the protocol or program model originally developed. Fidelity measurement has increasing significance for evaluation, treatment effectiveness research, and service administration. Yet few published studies using fidelity criteria provide details on the construction of a valid fidelity index. The purpose of this review article is to outline steps in the development, measurement, and validation of fidelity criteria, providing examples from health and education literatures. We further identify important issues in conducting each step. Finally, we raise questions about the dynamic nature of fidelity criteria, appropriate validation and statistical analysis methods, the inclusion of structure and process criteria in fidelity assessment, and the role of program theory in deciding on the balance between adaptation versus exact replication of model programs. Further attention to the use and refinement of fidelity criteria is important to evaluation practice.

Assertive community treatment (ACT) is a complex community-based service approach to helping people with severe mental disorders live successfully in the community. Effective replication of the model and research on critical elements require explicit criteria and measurement. A measure of program fidelity to ACT and the results of its application to fifty diverse programs are presented.

Alcohol use disorders are common comorbid conditions in schizophrenia, and their presence is associated with poor adjustment and poor treatment response. Standard alcohol assessment instruments have not been validated for use with schizophrenic patients, and several authors have questioned the validity of these patients' self-reports. A reliable and valid screening procedure for assessing alcohol use is needed. The present study used the following three methods to evaluate a rural sample of 75 outpatients with DSM-III-R schizophrenia or schizoaffective disorder: (1) clinical records; (2) research interviews using standard alcohol assessment instruments; and (3) case managers' ratings. In addition, consensus diagnoses, determined by combining information from all three methods with intensive case reviews, were used to determine the sensitivity and specificity of the other approaches. As expected, clinical evaluations frequently missed alcohol problems. Research interviews and case managers' ratings differentiated between alcoholic and nonalcoholic schizophrenic patients and were highly correlated. Case managers' ratings, which incorporated longitudinal observations of behavior and collateral reports as well as interview data, were more sensitive measures of current alcohol use disorders than research interviews. Subjects frequently manifested alcohol-related problems that interfered with community adjustment without the full dependence syndrome, suggesting that schizophrenic patients may be particularly vulnerable to negative effects of alcohol.

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.

Participants were 54 clients with serious psychiatric disorders and 21 clinical case managers. Clients' serious psychiatric disorders included Axis I diagnoses, such as schizophrenia and bipolar disorder. This study examined how attachment states of mind of both clients and case managers influenced the effectiveness of therapeutic relationships and client functioning. Client and case manager attachment states of mind interacted in predicting the working alliance and client functioning. Specifically, clients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers. These findings highlight the importance of clinicians and clients being matched in ways that balance their interpersonal and emotional strategies.