Balancing fidelity and adaption in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behavior Research and Therapy, 47, 946-953

Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215, USA
Behaviour Research and Therapy (Impact Factor: 3.85). 11/2009; 47(11):946-953. DOI: 10.1016/j.brat.2009.07.005


Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.

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    • "Increasingly, clinicians and researchers have begun to recognise the commonalities in cognitive and behavioural processes across different psychological disorders and their role in the development and/or maintenance in a range of symptoms, functioning and quality of life. Consequently, several prominent groups of researchers and clinicians have provided a range of benefits for moving towards a transdiagnostic approach to cognitive behavioural therapy (CBT; Craske 2012; Harvey et al. 2004; Hayes et al. 2013; Mansell et al. 2009; McHugh et al. 2009; McManus et al. 2010). Yet, the empirical, theoretical and clinical status of the transdiagnostic approach lags behind the ambitions of its supporters. "
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    ABSTRACT: Theorists have highlighted the commonalities in cognitive and behavioural processes across multiple disorders i.e. transdiagnostic approach. We report two studies that tested the psychometric properties of a new scale to assess these processes. The Cognitive and Behavioural Processes Questionnaire (CBP-Q) was developed as a 15-item measure. In Study 1, the CBP-Q was administered to a student (n = 172) sample with a range of standardised measures of the processes and symptom measures. Study 2 repeated the evaluation in a mixed clinical group (n = 161) and a community control group (n = 57). An exploratory factor analysis resulted in a 12-item version of the CBP-Q, consisting of a single factor. The measure demonstrated good internal consistency, test–retest stability and satisfactory convergent and divergent validity in both studies. Correlations with symptom-based measures showed increased engagement in these cognitive and behavioural processes to be associated with higher levels of symptomatology. The scale was elevated in the clinical relative to the community group and there were no differences in scores between broad diagnostic groupings (anxiety vs. mood vs. other). The CBP-Q has good psychometric properties. The findings are consistent with the transdiagnostic approach and indicate that a single, as yet unspecified factor may account for the shared variance across cognitive and behavioural maintenance processes.
    Cognitive Therapy and Research 01/2014; 39(2). DOI:10.1007/s10608-014-9641-9 · 1.70 Impact Factor
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    • "These processes fit within a broader Design, Implementation, Monitoring, and Evaluation (DIME) [31] methodology developed for identifying and addressing mental health problems in LMIC. Utilizing the Apprenticeship Model of training and supervision assisted in ensuring flexibility within fidelity, a topic of considerable importance in the implementation science literature [69,81,82]. This dual focus on flexibility and fidelity is increasingly being emphasized as an important aspect of provider satisfaction and adoption, as well a way to enhance the ability to provide interventions to diverse populations [83]. "
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    ABSTRACT: The need to address the treatment gap in mental health services in low- and middle-income countries (LMIC) is well recognized and particularly neglected among children and adolescents. Recent literature with adult populations suggests that evidence-based mental health treatments are effective, feasible, and cross-culturally modifiable for use in LMIC. This paper addresses a gap in the literature documenting pre-trial processes. We describe the process of selecting an intervention to meet the needs of a particular population and the process of cross-cultural adaptation. Community-based participatory research principles were implemented for intervention selection, including joint meetings with stakeholders, review of qualitative research, and review of the literature. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) was chosen as the evidence-based practice for modification and feasibility testing. The TF-CBT adaptation process, rooted within an apprenticeship model of training and supervision, is presented. Clinical case notes were reviewed to document modifications. Choosing an intervention can work as a collaborative process with community involvement. Results also show that modifications were focused primarily on implementation techniques rather than changes in TF-CBT core elements. Studies documenting implementation processes are critical to understanding why intervention choices are made and how the adaptations are generated in global mental health. More articles are needed on how to implement evidence-based treatments in LMIC.
    International Journal of Mental Health Systems 10/2013; 7(1):24. DOI:10.1186/1752-4458-7-24 · 1.06 Impact Factor
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    • "One of the primary goals of the gold standard supervision strategies is to improve clinician fidelity, as the research literature generally supports a link between model fidelity and client outcomes (e.g., [46,47]; see [48] for an exception) although the strength of the relation varies. Stronger associations between fidelity and outcomes are seen in effectiveness trials, likely due to required high fidelity in efficacy trials creating a floor effect [49]. The literature on the association between supervision and client outcomes is limited but important, as improved client outcomes are the ‘acid test’ for defining good supervision [50]. "
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    ABSTRACT: Evidence-based treatments for child mental health problems are not consistently available in public mental health settings. Expanding availability requires workforce training. However, research has demonstrated that training alone is not sufficient for changing provider behavior, suggesting that ongoing intervention-specific supervision or consultation is required. Supervision is notably under-investigated, particularly as provided in public mental health. The degree to which supervision in this setting includes 'gold standard' supervision elements from efficacy trials (e.g., session review, model fidelity, outcome monitoring, skill-building) is unknown. The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practices and test the impact of systematic implementation of gold standard supervision strategies on treatment fidelity and clinical outcomes.Methods/design: The study has two phases. We will conduct an initial descriptive study (Phase I) of supervision practices within public mental health in Washington State followed by a randomized controlled trial of gold standard supervision strategies (Phase II), with randomization at the clinician level (i.e., supervisors provide both conditions). Study participants will be 35 supervisors and 130 clinicians in community mental health centers. We will enroll one child per clinician in Phase I (N = 130) and three children per clinician in Phase II (N = 390). We use a multi-level mixed within- and between-subjects longitudinal design. Audio recordings of supervision and therapy sessions will be collected and coded throughout both phases. Child outcome data will be collected at the beginning of treatment and at three and six months into treatment. This study will provide insight into how supervisors can optimally support clinicians delivering evidence-based treatments. Phase I will provide descriptive information, currently unavailable in the literature, about commonly used supervision strategies in community mental health. The Phase II randomized controlled trial of gold standard supervision strategies is, to our knowledge, the first experimental study of gold standard supervision strategies in community mental health and will yield needed information about how to leverage supervision to improve clinician fidelity and client outcomes.Trial registration: NCT01800266.
    Implementation Science 08/2013; 8(1):89. DOI:10.1186/1748-5908-8-89 · 4.12 Impact Factor
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