• By Dartington SRU
  • Posted on Thursday 30th April, 2015

How team experience promotes implementation fidelity

Better results happen when therapists stick to the programme. So the question follows: what helps therapists adhere to treatment protocols? In a recent Swedish study of Multisystemic Therapy, the more experienced the team as a whole, the better the adherence.

In fact, the level of team experience mattered for adherence even when individual therapists’ levels of experience were taken into account. In other words, it seems that the “collective experience of the team members” makes the difference for fidelity – more so than the experience of each therapist individually.

It is now widely accepted that fidelity matters. Delivering an intervention according to specifications typically results in better outcomes. And so it was in this study. Multisystemic Therapy (MST) is designed to help teens who have serious antisocial behaviour. High therapist adherence to the MST protocols was related to a somewhat better chance of the youth living at home, engaging in school or work, and staying out of trouble with the law.

But the Swedish research team wanted to go one step further, and investigate what features promote better adherence. They found that adherence improved over time. Each year that teams were in the field, the average treatment adherence score rose. When a second wave of implementation began with new teams three years after the first, adherence was higher in the second wave than in the first.

The researchers conclude that the level of experience of teams – and the level of experience of the organisation as a whole – are more important for treatment fidelity than the experience of individual therapists.

The results suggest that better adherence relies, at least in part, on giving an intervention time to “bed in” with teams and organisations.

Adhering to the manual includes practicing important aspects of the treatment that are supposed to be consistent in all cases. In this study, the primary caregiver rated the therapist’s adherence on items such as “The therapist tried to understand how my family’s problems all fit together” and “My family knew exactly which problems we were working on.”

MST focuses on youth with severe behaviour problems, including criminal behaviour. The study included 973 families with youth aged 12-17 years who received MST over four to five months from child welfare authorities in Sweden.

Therapists are available to families around the clock. The intervention is delivered by a team of three to four therapists, one supervisor and one consultant. In this study, there were 68 therapists, 21 supervisors and four consultants in 10 teams. These teams were spread over two waves, beginning in 2003 and 2006.

Interestingly, individual therapists’ previous experience of delivering MST did not predict how well the intervention was implemented. But organisational experience and years of team activity did.

At the team level, one year of additional experience for the team resulted in almost a two-fold increase in adherence. At the organisation level, adherence was better in the second wave. These findings suggest that implementation is a process that improves over time.

The study echoes previous studies. It supports findings that adherence to important treatment components affects the results of treatment. By highlighting that implementation is likely to improve with experience of team and organisation, it has important implications. The earliest years of a new programme may not produce optimal results and studies in this period may fail to capture the greatest potential effects of the intervention.

Though important, the findings must be treated as exploratory due to methodological limitations. The study was retrospective and limited by data availability. It is unclear how well the measure of adherence could capture the differences among therapists. However, the study and the resulting hypothesis are valuable in highlighting the importance of promoting adherence to the crucial components of the treatment.


Löfholm, C. A., Eichas, K., & Sundell, K. (2014). The Swedish Implementation of Multisystemic Therapy for Adolescents: Does Treatment Experience Predict Treatment Adherence? Journal of Clinical Child & Adolescent Psychology. DOI: 10.1080/15374416.2014.883926

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