Implementing evidence‐based treatment protocols: Flexibility within fidelity.

Abstract

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

Infant mental health home visiting therapists’ fidelity to the Michigan IMH‐HV model in community practice settings

“…More experienced therapists may also recognize that flexibility and responsivity to in‐the‐moment, and often unexpected, needs and issues are necessary to sustain the therapeutic relationship; as a result, they may be more likely to prioritize such over a planned agenda or curriculum expectation. This is consistent with the notion that flexibility is, in fact, an indicator of fidelity for relationally oriented therapies (e.g., CPP; Lieberman et al., ) and that “flexibility within fidelity” is optimal for achieving the best clinical intervention outcomes (Kendall & Frank, ). As long as such adaptations do not interfere with the provision of model key ingredients, prior findings suggest that such flexibly applied treatments are associated with lower dropout rates and better outcomes (Forgatch, Patterson & DeGarmo, ).…”

“…The findings also highlight that partial fidelity to a therapeutic model in a community practice setting may still lead to beneficial outcomes, such as increases in parental reflective functioning and positive caregiving behavior. These results suggest that flexibility may, in fact, be desirable so long as there is adherence to a model's core components (Kendall & Frank, ); flexibility may even be considered an aspect of fidelity in some models (Lieberman, Ghosh Ippen, & Van Horn, ).…”

Iterative Decision‐making for Evaluation of Adaptations (IDEA): A decision tree for balancing adaptation, fidelity, and intervention impact

“…This debate also includes adaptations, defined as a planned, proactive type of modification. On the one hand, there is an understanding that EBPs must be delivered with some level of fidelity (i.e., in a manner, that is, consistent with the design or intent of said EBP; Eke, Neumann, Wilkes, & Jones, ; Kendall & Frank, ; McKleroy et al, ; Stirman et al, ). On the other hand, there is growing recognition that adaptations to EBPs are not only common (Aarons et al, ; Chambers & Norton, ; Wiltsey Stirman et al, ), but may be essential to maximizing clinical effectiveness in certain settings and populations (Chambers, Glasgow, & Stange, ; Iwelunmor et al, ; Marques et al, ; Stirman et al, ).…”

Alternative psychotherapies: Conceptual elucidation and epidemiological framework.

“…Even though due to probability distribution actuarial prediction does not work for all patients, it offers the greatest warranty to the majority of them and facilitates uncertainty reduction during clinical decision-making (Egisdottir, White, Spengler, Maugherman, Anderson, & Cook, 2006). Nevertheless, the disparity between the statistical approach of researchers and individualized clinical practice hinders the use of group-based findings and leads many clinicians to demand more flexibility to implement research outcomes (Nelson, Steele, & Mize, 2006;Kendall & Frank, 2018).…”