Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

Abstract

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Reframing implementation science to address inequities in healthcare delivery

“…Based on the diffusion of innovation theory, an "[EBI] almost never fits perfectly in the organization in which it is being embedded", suggesting that adaptations to the intervention and/or the context of practice are critical to the implementation process [60]. Adaptations are thoughtful modifications made to the intervention with the goal of improving their fit with a given context [61,62]. Multiple models and methods have been developed and used to inform the adaptations of EBIs [63][64][65].…”

“…Standardizing the tracking process of modifications done to the intervention, implementation strategies and to the context will help us build the knowledge base of what is being adapted, who is adapting, how, when, and why adaptations are being made [76]. Documenting adaptations can be done through a variety of methods, such as direct observations, checklists, key informant self-reports, semi-structure interviews, focus groups, review of charts, intervention manuals, project documents, and/or meeting minutes [62,74]. Tracking can occur as adaptations are being planned, in-real time, and/or retrospectively [76].…”

Implementing evidence‐based treatment protocols: Flexibility within fidelity.

“…Content modifications (e.g., tailoring, condensing, extending, re-ordering) are also examples of ways that protocols can be implemented flexibly, but only when the decision-making takes into account therapist knowledge, patient characteristics, and available research evidence. In their review, Stirman et al (2017) found that the few studies that actually compared adapted and non-adapted treatments found that outcomes were generally comparable, suggesting that protocols may not be as fragile as sometimes suggested. Relatedly, Goldstein, Kemp, Leff, and Lochman (2012) provide guidance for a step-by-step approach to appropriately adapting protocols for new populations.…”

“…In short, the benefit of employing a protocol is most evident when it is used with flexibility and within fidelity rather than as a set of strict requirements to which the therapist is expected to rigidly adhere. As emphasized by Stirman et al (2015), Stirman, Gamarra, Bartlett, Calloway, and Gutner (2017) and Stirman, Miller, Toder, and Calloway (2013), there is a distinction between fidelity-consistent and fidelity-inconsistent modifications to protocols. Modifications are defined as planned or unplanned changes to the content or delivery of a protocol (Stirman et al, 2015).…”

Depression self-management in people with epilepsy: Adapting project UPLIFT for underserved populations

“…The current RCTs for Blacks and Hispanics being implemented will advance the science of adaptation of EBIs and may bolster the proposition that adapted EBIs can retain the original program's effects or not have diminishing results [66]. The science of cultural adaptations is nascent; more research is needed to understand not only the adaptation process, but also the adoption, recruitment and engagement of diverse communities; and sustainability of adapted EBIs [67].…”