To the Editor: A study by Mancini and colleagues (1) published in the February issue examined facilitators and barriers to faithful implementation of assertive community treatment. Although the authors did not discuss the question of what makes ACT effective, their findings raise the issue. ACT's effectiveness is usually ascribed to faithful implementation of the model, but as the authors show, faithful implementation is associated in turn with a series of favorable contextual factors: good alignment between state financing mechanisms and the model, expert technical assistance, effective middle and upper management, strong team leadership, skilled staff with low turnover, and a culture that supports change.
Such favorable factors might be associated with good clinical outcomes regardless of the model being used. Would it not therefore be more parsimonious to ascribe a team's clinical success to these factors without the intervening variable of "fidelity"? As the authors note "high-fidelity teams were generally composed of more competent staff, and this overall competence, as opposed to specific actions or skill sets, appeared to be responsible for implementation success." It would hardly be surprising that the same "overall competence" that produces "implementation success" might produce clinical success, even at the expense of fidelity to the ACT model. In their article, the authors seem at times to take this tack. For example, they are critical of the "lengthy, detailed, and comprehensive approach to fidelity monitoring" used by one state, even though it was associated with higher fidelity on multiple ACT components. Is fidelity good except when it is bad?
Their findings are better understood in light of the view that psychotherapy's benefits are not due to the specific ingredients of any model but to the nonspecific elements that are embedded in all therapies but better transmitted by some therapists (2). Wampold (3) has provided compelling meta-analytic evidence that the efficacy of individual psychotherapy is explainable by such common factors as the placebo effect, working alliance, allegiance, and therapist effects. Perhaps it is these factors and the contextual factors described by Mancini and colleagues, such as financing mechanisms and strong management, and not fidelity to the specific components of ACT, that mediate its clinical benefits.
Dr. Luchins is affiliated with the Department of Psychiatry, Jesse Brown Veterans Affairs Medical Center, Chicago.
Mancini AD, Moser LL, Whitley R, et al: Assertive community treatment: facilitators and barriers to implementation in routine mental health settings. Psychiatric Services 60:189–195, 2009
Frank JD, Frank JB: Persuasion and Healing: A Comparative Study of Psychotherapy, 3rd ed. Baltimore, Johns Hopkins University Press, 1991
Wampold BE: The Great Psychotherapy Debate: Models, Methods and Findings. Mahwah, NJ, Erlbaum Associates, 2001