Adapting Evidence-Based Psychotherapies While Maintaining Fidelity
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Purpose of review
Extensive resources have been devoted to implementing evidence-based psychotherapies (EBPs) to facilitate the best available treatments to clients. Yet, when treatment settings or client characteristics do not align with the contexts in which an EBP was developed and tested, adaptations may be indicated. The purpose of this article is to provide a summary of the adaptation literature and highlight key issues, using Cognitive Processing Therapy as an example throughout the paper.
Informed by the literature to date, we use Stirman and colleagues’ Framework for Reporting Adaptations and Modifications (FRAME) to organize current thinking and provide a guide for conceptualizing different types of adaptations. Broadly, we discuss (1) why adapt, (2) goals of the adaptation, (3) who is involved in the adaptation process, (4) when to adapt, (5) forms of adaptation, and (6) measurement and evaluation.
As effective interventions for PTSD are developed and identified, implementation in routine care settings will increase access for underserved populations, who may not have been well-represented in the research that originally established efficacy or effectiveness of the EBP. However, a careful process of EBP adaptation, informed by theory, research, and program-level evaluation, can result in successful implementation. Stakeholder-informed, carefully-evaluated adaptation can allow more individuals to benefit from treatment.
KeywordsModification Adaptation Cultural adaptation Implementation Treatment fidelity Cognitive Processing Therapy
This work was completed with support from the Veterans Health Administration. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the United States government, Stanford University, or other affiliates.
This project was supported by a grant from the National Institutes of Health (R01 MH106506).
Compliance with ethical standards
Conflict of interest
Drs. La Bash and Galovski have nothing to disclose. Dr. Wiltsey Stirman received grant funding from the National Institutes of Health (R01 MH106506), which partially supported this manuscript. Dr. Wiltsey Stirman has nothing else to disclose.
Human and animal rights and informed consent
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines). Informed consent was obtained from all individual participants included in the studies conducted by the study authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.Beutler LE, Howard KI. Clinical utility research: an introduction. J Clin Psychol. 1998;54(3):297–301.Google Scholar
- 2.Shadish WR, Matt GE, Navarro AM, Siegle G, Crits-Christoph P, Hazelrigg MD, et al. Evidence that therapy works in clincally representative conditions. J Consult Clin Psychol. 1997;65(3):355–65.Google Scholar
- 3.Barlow DH. The effectiveness of psychotherapy: science and policy. Clin Psychol Sci Pract. 1996;3(3):236–40.Google Scholar
- 4.Chambless DL, Hollon SD. Defining empirically supported therapies. J Consult Clin Psychol. 1998;66(1):7–18.Google Scholar
- 5.Persons JB, Silberschatz G. Are results of randomized controlled trials useful to psychotherapists? J Consult Clin Psychol. 1998;66(1):126–35.Google Scholar
- 6.American Psychological Association. Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD). Available at: https://www.apa.org/ptsd-guideline/ptsd.pdf2017.
- 7.International Society for Traumatic Stress Studies. Posttraumatic stress disorder prevention and treatment guidelines: methodology and recommendations. Available at: http://www.istss.org/getattachment/Treating-Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_PreventionTreatmentGuidelines_FNL-March-19-2019.pdf.aspx2018.
- 8.Baumann-Walker A, Cabassa L, Stirman SW. Adaptation in dissemination and implementation science. In: Brownson RC, Colditz GA, Proctor EK, editors. Dissemination and implementation research in health: translating science to practice. 2nd ed. New York: Oxford University Press; 2017. p. 286–300.Google Scholar
- 9.Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60(5):748–56.Google Scholar
- 10.Resick PA, Monson CM, Chard KM. Cognitive processing therapy for PTSD: a comprehensive manual: Guilford Publications; New York, New York, 2016.Google Scholar
- 11.Asmundson GJ, Thorisdottir AS, Roden-Foreman JW, Baird SO, Witcraft SM, Stein AT, et al. A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder. Cogn Behav Ther. 2019;48(1):1–14.Google Scholar
- 12.Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, et al. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the veterans health administration. J Trauma Stress. 2010;23(6):663–73.Google Scholar
- 13.Stirman SW, Gutner C, Crits-Christoph P, Edmunds J, Evans AC, Beidas RS. Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy. Implement Sci. 2015;10(1):115.Google Scholar
- 14.Lee SJ, Altschul I, Mowbray CT. Using planned adaptation to implement evidence-based programs with new populations. Am J Community Psychol. 2008;41(3–4):290–303.Google Scholar
- 15.Stirman SW, Miller CJ, Toder K, Calloway A. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement Sci. 2013;8(1):65.Google Scholar
- 16.Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013;8(1):117.Google Scholar
- 17.Gearing RE, El-Bassel N, Ghesquiere A, Baldwin S, Gillies J, Ngeow E. Major ingredients of fidelity: a review and scientific guide to improving quality of intervention research implementation. Clin Psychol Rev. 2011;31(1):79–88.Google Scholar
- 18.Schoenwald SK, Garland AF, Chapman JE, Frazier SL, Sheidow AJ, Southam-Gerow MA. Toward the effective and efficient measurement of implementation fidelity. Adm Policy Ment Health Ment Health Serv Res. 2011;38(1):32–43.Google Scholar
- 19.Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101(11):2059–67.Google Scholar
- 20.Dusenbury L, Brannigan R, Falco M, Hansen WB. A review of research on fidelity of implementation: implications for drug abuse prevention in school settings. Health Educ Res. 2003;18(2):237–56.Google Scholar
- 21.Fixsen DL, Naoom SF, Blase KA, Friedman RM. Implementation research: a synthesis of the literature. Tampla: National Implementation Research Network, University of South Florida; 2005.Google Scholar
- 22.Bass JK, Annan J, McIvor Murray S, Kaysen D, Griffiths S, Cetinoglu T, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368(23):2182–91.Google Scholar
- 23.••Marques L, Valentine SE, Kaysen D, Mackintosh MA, De Silva D, Louise E, Ahles EM, Youn SJ, Shtasel DL, Simon NM, Wiltsey-Stirman S. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. J Consult Clin Psychol. 2019;87(4):357–369. This study examines the relationships among modifications to evidence-based interventions and therapist adherence and competence in routine care settings.Google Scholar
- 24.Stirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14(1):58.Google Scholar
- 25.Lau AS. Making the case for selective and directed cultural adaptations of evidence-based treatments: examples from parent training. Clin Psychol Sci Pract. 2006;13(4):295–310.Google Scholar
- 26.Barrera M, CaStro FG. A heuristic framework for the cultural adaptation of interventions. Clin Psycol Sc Pr. 2006;13(4):311–316. https://doi.org/10.1111/j.1468-2850.2006.00043.x.
- 27.Galovski TE, Blain LM, Mott JM, Elwood L, Houle T. Manualized therapy for PTSD: flexing the structure of cognitive processing therapy. J Consult Clin Psychol. 2012;80(6):968–81.Google Scholar
- 28.Chard KM. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol. 2005;73(5):965–71.Google Scholar
- 29.••Roscoe JN, Shapiro VB, Whitaker K, Kim BE. Classifying changes to preventive interventions: applying adaptation taxonomies. The journal of primary prevention. 2019;40(1):89–109. This is a review of several frameworks for understanding, classifying, and reporting adaptations, with each then used to classify the adaptions made in treatment study. It provides a nice overview of the ways in which adaptations can be categorized as well as a real-world example of what each framework can offer. Google Scholar
- 30.Valentine SE, Borba CP, Dixon L, Vaewsorn AS, Guajardo JG, Resick PA, et al. Cognitive processing therapy for Spanish-speaking Latinos: a formative study of a model-driven cultural adaptation of the manual to enhance implementation in a usual care setting. J Clin Psychol. 2017;73(3):239–56.Google Scholar
- 31.Feingold ZR, Fox AB, Galovski TE. Effectiveness of evidence-based psychotherapy for posttraumatic distress within a jail diversion program. Psychol Serv. 2018;15(4):409–18.Google Scholar
- 32.Stirman SW, Calloway A, Toder K, Miller CJ, DeVito AK, Meisel SN, et al. Community mental health provider modifications to cognitive therapy: implications for sustainability. Psychiatr Serv. 2013;64(10):1056–9.Google Scholar
- 33.Schulz PM, Huber LC, Resick PA. Practical adaptations of cognitive processing therapy with Bosnian refugees: implications for adapting practice to a multicultural clientele. Cogn Behav Pract. 2006;13(4):310–21.Google Scholar
- 34.Cook JM, Dinnen S, Thompson R, Simiola V, Schnurr PP. Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation. J Trauma Stress. 2014;27(2):137–43.Google Scholar
- 35.Stirman SW, Gamarra JM, Bartlett BA, Calloway A, Gutner CA. Empirical examinations of modifications and adaptations to evidence-based psychotherapies: methodologies, impact, and future directions. Clin Psychol Sci Pract. 2017;24(4):396–420.Google Scholar
- 35.••von Thiele Schwarz U, Förberg U, Sundell K, Hasson H. Colliding ideals – an interview study of how intervention researchers address adherence and adaptations in replication studies. BMC Med Res Methodol. 2018;18(1):36 This study reviews the most common factors impacting the decision to adapt a treatment as well as the most common types of adaptions made to treatments in replication studies. It also discusses the tensions that can impact the reporting of adaptions in the scientific literature.Google Scholar
- 36.••Sundell K, Beelmann A, Hasson H, von Thiele Schwarz U. Novel programs, international adoptions, or contextual adaptations? Meta-analytical results from German and Swedish intervention research. J Clin Child Adolesc Psychol. 2016;45(6):784–96 This is a review of intervention studies in two European countries and categorizes several types of adaptation and their level of effectiveness, providing guidance on when adaptations should be considered.Google Scholar
- 38.Kaysen D, Lindgren K, Zangana GAS, Murray L, Bass J, Bolton P. Adaptation of cognitive processing therapy for treatment of torture victims: experience in Kurdistan, Iraq. Psychol Trauma Theory Res Pract Policy. 2013;5(2):184–92.Google Scholar
- 39.Schulz PM, Resick PA, Huber LC, Griffin MG. The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. Cogn Behav Pract. 2006;13(4):322–31.Google Scholar
- 40.Morland LA, Mackintosh M-A, Greene CJ, Rosen CS, Chard KM, Resick P, et al. Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. J Clin Psychiatry. 2014;75:470–6.Google Scholar
- 41.Peterson AL, Foa EB, Blount TH, McLean CP, Shah DV, Young-McCaughan S, et al. Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: design and methodology of a randomized clinical trial. 2018;72:126–136.Google Scholar
- 42.Bryan CJ, Leifker FR, Rozek DC, Bryan AO, Reynolds ML, Oakey DN, et al. Examining the effectiveness of an intensive, 2-week treatment program for military personnel and veterans with PTSD: results of a pilot, open-label, prospective cohort trial. J Clin Psychol. 2018;74:2070–81.Google Scholar
- 43.Peterson AL, Resick PA, Mintz J, Young-McCaughan S, McGeary DD, McGeary CA, et al. Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD. Contemp Clin Trials. 2018;73:27–35.Google Scholar
- 44.Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatr. 2005;162(2):214–27.Google Scholar
- 45.Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry: Interpersonal and Biological Processes. 2008;71(2):134–68.Google Scholar
- 46.Twamley EW, Jak AJ, Delis DC, Bondi MW, Lohr JB. Cognitive symptom management and rehabilitation therapy (CogSMART) for veterans with traumatic brain injury: pilot randomized controlled trial. J Rehabil Res Dev. 2014;51(1):59–70.Google Scholar
- 47.Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, Thomas KR, Boyd B, Norman SB, Lang AJ, Keller AV. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2019;90(3):333–41. https://doi.org/10.1136/jnnp-2018-319315
- 48.Galovski TE, Harik JM, Blain LM, Elwood L, Gloth C, Fletcher TD. Augmenting cognitive processing therapy to improve sleep impairment in PTSD: a randomized controlled trial. J Consult Clin Psychol. 2016;84(2):167–77.Google Scholar
- 49.Kozel FA, Motes MA, Didehbani N, DeLaRosa B, Bass C, Schraufnagel CD, et al. Repetitive TMS to augment cognitive processing therapy in combat veterans of recent conflicts with PTSD: a randomized clinical trial. J Affect Disord. 2018;229:506–14.Google Scholar
- 50.Resick PA, Galovski TE, Uhlmansiek MOB, Scher CD, Clum GA, Young-Xu Y. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol. 2008;76(2):243–58.Google Scholar
- 51.Zalta AK, Held P, Smith DL, Klassen BJ, Lofgreen AM, Normand PS, et al. Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD. BMC Psychiatry. 2018;18(1):242.Google Scholar
- 52.Walter KH, Dickstein BD, Barnes SM, Chard KM. Comparing effectiveness of CPT to CPT-C among US veterans in an interdisciplinary residential PTSD/TBI treatment program. J Trauma Stress. 2014;27(4):438–45.Google Scholar
- 53.Nixon RD, Bralo D. Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD. Behav Ther. 2019;50(1):155–64.Google Scholar
- 54.Nixon RD, Bralo D. Using explicit case formulation to improve cognitive processing therapy for PTSD. Behav Ther. 2018.Google Scholar
- 55.Pérez D, Van der Stuyft P, del Carmen Zabala M, Castro M, Lefèvre P. A modified theoretical framework to assess implementation fidelity of adaptive public health interventions. Implement Sci. 2016;11(1):91.Google Scholar
- 56.Barrera M, Berkel C, Castro FG. Directions for the advancement of culturally adapted preventive interventions: local adaptations, engagement, and sustainability. Prev Sci. 2017;18(6):640–8.Google Scholar
- 57.Chambers DA, Norton WE. The adaptome: advancing the science of intervention adaptation. Am J Prev Med. 2016;51(4):S124–S31.Google Scholar
- 58.Martin P, Murray LK, Darnell D, Dorsey S. Transdiagnostic treatment approaches for greater public health impact: implementing principles of evidence-based mental health interventions. Clin Psychol Sci Pract. 2018;25(4):e12270.Google Scholar
- 59.Gutner C, Presseau C. Dealing with complexity and comorbidity: opportunity for transdiagnostic treatment for PTSD. Curr Treat Options Psychiatr. 2019;6:2.Google Scholar