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Brief Reports   |    
Community Mental Health Provider Modifications to Cognitive Therapy: Implications for Sustainability
Shannon Wiltsey Stirman, Ph.D.; Amber Calloway, B.A.; Katherine Toder, B.A.; Christopher J. Miller, Ph.D.; Andrea K. DeVito, B.A.; Samuel N. Meisel, B.A.; Regina Xhezo, M.S.; Arthur C. Evans, Ph.D.; Aaron T. Beck, M.D.; Paul Crits-Christoph, Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200456
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Dr. Wiltsey Stirman is affiliated with the Women’s Health Sciences Division, Veterans Affairs (VA) National Center for PTSD at the VA Boston Healthcare System, and with the Department of Psychiatry, Boston University, 150 S. Huntington Ave. (116B3), Boston, MA 02130 (e-mail: sws@bu.edu). Ms. Calloway is with the Department of Psychology, University of Massachusetts, Boston. Ms. Toder, Dr. Beck, and Dr. Crits-Christoph are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Dr. Miller is with the Center for Healthcare, Organization, and Implementation Research, VA Boston Healthcare System. Ms. DeVito and Mr. Meisel were with the Department of Psychiatry, Boston University, when this research was conducted. Ms. Xhezo and Dr. Evans are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services.

Copyright © 2013 by the American Psychiatric Association


Objective  This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.

Methods  A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.

Results  Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.

Conclusions  Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client’s needs or to the clinician’s therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.

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Table 1Modifications and adaptations to cognitive therapy by community mental health providersa
Table Footer Note

a A total of 175 modifications were identified by 27 therapists. Thirteen modifications that were identified in the interviews did not contain sufficient detail to be rated.



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