MIRECC / CoE

Research to Practice | Balancing Fidelity and Adaptation While Implementing Brief CBT in Primary Care

Summary by Sonora Hudson, MA and Darius B. Dawson, PhD

An article by VA and MIRECC investigators used the Dynamic Adaptation Process model to examine 18 providers’ experiences trying to maintain fidelity yet allow adaptability during implementation of brief cognitive behavioral therapy (bCBT) for depression and anxiety in primary care clinics. Under this model, adaptations during implementation can occur in patient-emergent issues, provider skills and abilities, available resources, provider knowledge, and organizational changes.

Participants (licensed psychologists, psychology fellows and interns, licensed clinical social workers and physician assistants) were delivering mental health services at two VA medical centers implementing bCBT in primary care clinics for patients with heart failure and/or chronic obstructive pulmonary disease who were experiencing elevated anxiety and/or depression. Although providers could adapt peripheral components of the standardized modules, they were required to maintain high fidelity to key components of bCBT.

Researchers interviewed providers using a semi-structured, open-ended interview guide, then performed two phases of qualitative analysis:

• In the first phase, a medical anthropologist and clinical psychologist used directed content analysis to code categories of responses.
• In phase two, implementation data (aspects of treatment fidelity, level of provider adherence to treatment protocol, how providers modified and/or deviated from the protocol and how providers chose to deliver treatment, for example) were extracted from the Atlas.ti database by one analyst, who then manually sorted them into categories before having them reviewed by the second analyst.

The main themes outlining the tension between adherence/flexibility were as follows:

• Adaptations associated with providers’ skills and abilities (how providers responded to the patient’s desire to engage in bCBT) – providers simplified language and paced delivery of content when necessary but had difficulty dealing with patients’ dislike of homework;
• Adaptations associated with patient-emergent issues – providers were challenged by having to help patients deal with “larger” issues outside the realm of bCBT but tried to provide resources for additional help or expand the behavioral activation session;
• Adaptations associated with available resources – providers had to try to maximize time, challenging since time was a critical element in the clinics and patients sometimes missed scheduled appointments; phone delivery was an option.

Key findings of this study, thought to be the first to report adaptations made to delivery of an evidence-based practice in a primary care setting, suggest that the critical factors guiding provider delivery and adaptations were the therapeutic relationship, individual patient factors, and system-level factors such as time and scheduling availability. Provider knowledge and organizational changes were not sources of adaptation in this study.

Time was a very important resource driving provider adaptations. Allowing more time to reschedule missed appointments might aid in implementation efforts. Visit https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987469/ to read this article.

*MIRECC affiliates in bold

Citation: Mignogna J, Martin LA, Harik J, Hundt NE, Kauth M, Naik AD, Sorocco K, Benzer J, & Cully J (2018). “I had to somehow still be flexible”: Exploring adaptations during implementation of brief cognitive behavioral therapy in primary care. Implementation Science, 13, 76.

Last updated: April 14, 2020