“I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care

Abstract

BackgroundPrimary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice.MethodsA multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes.ResultsProviders described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment).ConclusionsThe therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery.Trial registrationClinicalTrials.gov, NCT01149772Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0768-z) contains supplementary material, which is available to authorized users.

Importance of congruence between communicating and executing implementation programmes: A qualitative study of focus-group interviews.​

“…Hybrid design studies are susceptible to exposing the potential tensions inherent in real-world implementation processes of EBTs and their impacts on their application (21,22). For instance, some elements of the original intervention may require adjustment to the real-world setting, thereby risking impaired e cacy (21).…”

The use of brief cognitive behavioral therapy interventions in the treatment of chronic non-cancer pain in the primary care setting

“…Provider and setting type were the first themes to emerge from the literature. Nine of the twelve articles found that CBT interventions, in particular those that were brief and/or adaptable, were successfully employed within the primary care setting by providers who did not have specific mental health intervention training (Aschim et al, 2011;Broderick et al, 2014;Buysse et al, 2011;Funderburk et al, 2011;Hoifodt et al, 2011;Junquist et al, 2010;Lewis et al, 2013;Mathieson et al, 2013;Mignogna et al, 2018). Mixed findings regarding the efficacy of CBT interventions delivered in PC settings by PCPs was found in one of the twelve articles, though several contributing factors led to these mixed findings; these will be described further below (Dorflinger et al, 2016).…”

“…Of the twelve articles included in the review, six were conducted in the USA (Broderick et al, 2014;Buysse et al, 2011;Funderburk et al, 2011;Lewis et al, 2013;Mignogna et al, 2018;Richmond et al, 2015); two in Norway (Mathieson et al, 2013;Aschim et al, 2011), one in New Zealand (Junquist et al, 2011); and three from the above countries as well as Australia and the United Kingdom (Knoerl et al, 2015;Hoifodt et al, 2011;Dorflinger et al, 2016). These settings represent similar and relevant sociopolitical, healthcare system, and cultural demographics as Canada.…”

“…The research methods used in the articles are further detailed in the literature matrix and include: three primary randomized control trials (Broderick et al, 2014;Buysse et al, 2011;Junquist et al, 2010), three systematic reviews of RCTs (Hoifodt et al, 2011;Dorflinger et al, 2016;Richmond et al, 2015); one integrative literature review (Knoerl et al, 2015); one pre-post design study (Mignogna et al, 2018), two case-control studies (Funderburk et al, 2011;Mathieson et al, 2013) and two cross-sectional studies (Lewis, 2013;Aschim et al, 2011). All studies were assessed for evidence levels based on Melnyk and Fineout-Overholt's (2015) work, and ranked from one to seven (See Appendix D).…”

“…These changes did not require additional funding, education, or clinic time, but rather a reorganization of the day-to-day office scheduling. Adapting the primary care setting so that CBT sessions were organized and had sufficient time for consultations and therapy allowed for effective CBT delivery (Aschim et al, 2011;Mignogna et al, 2018). Strategies for reorganization included: scheduling CBT sessions for the last office hours on a particular day, blocking off certain time on certain days of the week, and organizing support staff to prevent session interruptions (phone calls, questions, etc.).…”