Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change.

Abstract

The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes. Method: Data were derived from a NIMH-funded implementationeffectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n ϭ 19) treated clients (n ϭ 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications. Results: Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelityconsistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms. Conclusions: The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention.

How community therapists describe adapting evidence‐based practices in sessions for youth: Augmenting to improve fit and reach

“…Whereas adaptations are often characterized in opposition to fidelity (i.e., fidelity‐inconsistent adaptations), adaptations can also be fidelity‐consistent, driving increased client buy‐in, client engagement, and fit with the client's specific needs and circumstances (Stirman et al, 2015). In fact, observational ratings of greater fidelity (i.e., adherence and competence) and fidelity‐consistent adaptations have both been associated with improved client outcomes in trauma treatment, suggesting that fidelity and adaptation might both beneficially impact clinical outcomes (Marques et al, 2019). Future studies are needed to further examine whether the adaptation‐fidelity tension indeed represents a false dichotomy.…”

“…Intervention developers and implementation researchers can work to optimize fit of EBPs for different contexts by first understanding how community therapists adapt EBPs. Despite the reality that EBPs are often adapted by community clinicians session by session, minimal research has identified the frequency, types, and predictors of EBP adaptations occurring within psychotherapy sessions during implementation as usual in community settings (Marques et al, 2019).…”

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

“…In that situation, it would be erroneous to simply conclude that the adaptation itself was the source of the poor performance of the treatment manual. Recent evidence suggests that both fidelity and adaptation may contribute to outcomes (Marques et al, ). Alternatively, an adaptation may not “hit the mark” and address the most central barriers to effectiveness.…”

“…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, ). For example, adaptations may be crucial to reducing health disparities, especially if the unmodified EBP would be ineffective or otherwise inappropriate for use with a historically underserved population (Bernal & Domenech Rodríguez, ; Cabassa & Baumann, ).…”

Client-level predictors of treatment engagement, outcome and dropout: moving beyond demographics

“…Providers were trained in CPT as part of a National Institute of Mental Health-funded (NIMH K23 MH096029-­01A1) implementation-­effectiveness hybrid pilot study of CPT for PTSD (for detailed description of the study design, please see ref29). Briefly, the study evaluated the feasibility and acceptability of adapting the CPT manual to be linguistically, culturally and contextually appropriate for a low-­income, diverse community population.…”