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Empirical Examinations of Modiﬁcations and Adaptations to Evidence‐Based

Psychotherapies: Methodologies, Impact, and Future Directions
Article in Clinical Psychology Science and Practice · November 2017

DOI: 10.1111/cpsp.12218
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Empirical Examinations of Modifications and Adaptations
to Evidence-Based Psychotherapies: Methodologies,
Impact, and Future Directions
Shannon Wiltsey Stirman , National Center for PTSD, Stanford University
Jennifer M. Gamarra, University of California
Brooke A. Bartlett, University of Houston
Amber Calloway, University of Massachusetts Boston
Cassidy A. Gutner, National Center for PTSD, VA Boston Healthcare System, Boston University
School of Medicine
This review describes methods used to examine the Key words: adaptation, empirically supported treat-
modifications and adaptations to evidence-based psy- ment, evidence-based, implementation, modification,
chological treatments (EBPTs), assesses what is known psychotherapy. [Clin Psychol Sci Prac 24: 396–420,
about the impact of modifications and adaptations to 2017]
EBPTs, and makes recommendations for future research Policymakers and mental health systems have devoted
and clinical care. One hundred fourteen primary studies substantial resources and attention to the implementa-
tion of evidence-based psychosocial treatments (EBPTs)
and three meta-analyses were identified. All studies
and interventions. However, many researchers and
examined planned adaptations, and many simultane-
clinicians have raised questions about their fit and
ously investigated multiple types of adaptations. With
effectiveness for individuals with characteristics typically
the exception of studies on adding or removing specific
seen in routine care settings. These potential differences
EBPT elements, few studies compared adapted EBPTs
include comorbid mental health diagnoses that were
to the original protocols. There was little evidence that not included or addressed in the original studies, insuf-
adaptations in the studies were detrimental, but there ficient insurance coverage for the required number of
was also limited consistent evidence that adapted pro- sessions, and differences in culture, literacy, or other
tocols outperformed the original protocols, with the patient characteristics and circumstances. Challenges in
exception of adding components to EBPTs. Implications delivering EBPTs in the context of routine care set-
for EBPT delivery and future research are discussed. tings include replicating the timing of sessions (often
twice a week in randomized controlled trials) and
delivering session content as specified in the manuals.
In efforts to address these contextual challenges,
which are not present in the original, well-controlled
Address correspondence to Shannon Wiltsey Stirman,
National Center for PTSD and Stanford University, 795 trials that established treatment efficacy, clinicians in
Willow Road, NC-PTSD 334, Menlo Park, CA 94025. E- routine care settings commonly modify and adapt pro-
mail: sws1@stanford.edu. tocol treatments (Aarons, Miller, Green, Perrott, &
Bradway, 2012; Cook, Dinnen, Thompson, Simiola, &
doi:10.1111/cpsp.12218
© 2017 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
396 All rights reserved. For permissions, please email: permissions@wiley.com.
Schnurr, 2014; Stirman, Calloway, et al., 2013). Modifi- systematically derived modifications, could result in
cation is a term used to describe planned or unplanned diminished treatment response (Blakely et al., 1987;
changes made to an EBPT protocol or its delivery in Cohen et al., 2008). Previous reviews that have consid-
an attempt to improve the fit, engagement, or effec- ered the relationship between treatment fidelity and adap-
tiveness of the treatment (Stirman, Gutner, Edmunds, tation have argued for a middle ground, wherein “flexible
Evans, & Beidas, 2015). Adaptation is a form of modi- fidelity” allows for minor, planned adaptations that do not
fication that is planned or purposefully made to the compromise core elements of the treatments (Forehand,
design or delivery of an intervention, often with the Dorsey, Jones, Long, & McMahon, 2010; Kendall & Bei-
intention to retain fidelity to the fundamental elements das, 2007). Others have suggested development of transdi-
or spirit of the intervention (Lee, Altschul, & Mow- agnostic treatment protocols as a means to balance
bray, 2008; Stirman, Miller, Toder, & Calloway, 2013; between fidelity and flexibility, through delivery of clini-
Stirman et al., 2015). Literature on the modification of cally indicated elements of evidence-based treatments to
EBPTs to date has not always differentiated between populations with a variety of presenting problems and
adaptations that are carefully planned and monitored diagnoses (McHugh, Murray, & Barlow, 2009).
for their impact on symptom change (Chambers, Glas- Although related to treatment fidelity, modification
gow, & Stange, 2013; Lee et al., 2008) and modifica- and adaptation are unique constructs. Treatment fidelity
tions that occur less systematically and without has been defined as adherence to the key intervention
planning (Stirman et al., 2015), although the extent components and competence (skill with which the
and impact of planned and unplanned changes may be intervention is delivered), as well as treatment receipt,
very different. There is some evidence that modifica- and differentiation from other treatments (Gearing
tions may be common in routine care settings (Aarons, et al., 2011; Schoenwald et al., 2011). Any therapy that
Miller, et al., 2012; Cook, Dinnen, Thompson, et al., has been investigated in an efficacy study has an associ-
2014). For example, Cook, Dinnen, Thompson, et al. ated fidelity assessment instrument, required for rigor-
(2014) found that therapists reported tailoring EBPTs, ous clinical trials, that specifies elements that are
integrating them with other approaches, removing ele- believed (or, at times, empirically demonstrated) to be
ments of the treatments, and changing the length of central to the interventions. However, fidelity assess-
the sessions or the protocols when delivering them in ment, which focuses on the delivery of central aspects
inpatient treatment settings. Similarly, therapists sur- of the intervention, may fail to capture certain types of
veyed by Lau et al. (2017) reported tailoring (modify- modifications or adaptations, such as minor changes to
ing how the treatment or materials were presented), terminology or language, changes to the length of the
integration of other strategies, reordering treatment ele- session or protocol, or the use of elements that are nei-
ments, removing components, and changing the length ther prescribed nor proscribed. Furthermore, many
of the sessions or protocol. Aarons, Green, et al. (2012) fidelity assessment instruments do not assess treatment
and Aarons, Miller, et al. (2012) identified a variety of differentiation and therefore may not detect integration
adaptations in routine care that were provider-, pro- or the addition of other treatment elements. Thus, fide-
gram-, and consumer-driven. Some such changes may lity assessment alone may provide limited understanding
be relatively minor and may not be expected to have of whether different types of alterations are detrimental,
an appreciable impact on clinical outcomes, but others nondetrimental, or enhancements to the treatment pro-
might depart significantly from the original protocol. tocol (Stirman et al., 2012; Zvoch, 2009).
In the absence of empirical evidence, implications of In contrast to modification and adaptation, the impact
modification to EBPT protocols have been the subject of of aspects of treatment fidelity on clinical outcomes has
debate. Although some have argued that adaptation is to been examined in numerous investigations, reviews, and
be expected and may improve treatment effectiveness and a meta-analysis (Barber, Triffleman, & Marmar, 2007;
sustainability in routine care settings (Chambers et al., DeRubeis, Gelfand, Tang, & Simons, 1999; Strunk,
2013), others have cautioned that changes to evidence- Brotman, & DeRubeis, 2010; Strunk, Brotman, DeRu-
based interventions, particularly unplanned or less beis, & Hollon, 2010). Whether fidelity is necessary to
MODIFICATIONS TO EVIDENCE-BASED PSYCHOTHERAPIES WILTSEY STIRMAN ET AL. 397

produce good clinical outcomes has been the subject of the research literature range broadly from slight changes
debate, particularly in light of a meta-analysis that con- in terminology or delivery of the same content in dif-
cluded that overall, fidelity did not appear to be predic- ferent languages (tailoring), to removal of core compo-
tive of symptom changes (Webb, DeRubeis, & Barber, nents or integration with other interventions (Chu &
2010). Although some limitations to the primary studies Leino, 2017; Stirman, Miller, et al., 2013). Moreover,
included in this analysis (e.g., use of an average fidelity modifications can be made to the content of the inter-
score rather than a session-by-session assessment of fide- vention (e.g., removing, changing, or adding elements
lity and of symptoms that would allow temporal prece- of the intervention) or the context in which it is deliv-
dence of fidelity to be established) may have obscured a ered (e.g., delivered in groups or in different treatment
potential relationship, some individual, rigorously settings; Chu & Leino, 2017; Stirman, Miller, et al.,
designed studies have concluded that there is a relation- 2013). Others have pointed out the importance of dis-
ship for specific interventions (Feeley, DeRubeis, & Gel- tinguishing between proactive and reactive forms of
fand, 1999; Strunk, Brotman, & DeRubeis, 2010; modification and adaptation (Moore et al., 2013; Stir-
Strunk, Brotman, DeRubeis, & Hollon, 2010). Some man, Miller, et al., 2013) and adaptations made to
studies have also identified a nonlinear relationship improve theoretical versus logistical fit (Moore et al.,
between fidelity and treatment outcome. For example, 2013). Adaptations have also been grouped into cate-
Barber et al. (2006) identified a curvilinear relationship gories such as enhancing/expanding, simplifying/reduc-
between adherence and treatment outcome, such that ing (Lau et al., 2017), and fidelity-consistent and
higher and lower levels of adherence were associated fidelity-inconsistent (Stirman et al., 2015), although
with poorer outcomes in treatment for cocaine depen- how different types of adaptations would be categorized
dence than moderate levels of adherence. Hogue et al. in terms of fidelity would depend on the nature of a
(2008) examined the impact of adherence in multidi- specific intervention. The varied nature of the changes
mensional family therapy for adolescents with externaliz- to EBPTs can have very different implications for out-
ing behaviors and found a linear relationship between comes of interest. Although some might facilitate
adherence and outcomes for externalizing problems, but implementation and sustainability by improving the fit
moderate levels of adherence were associated with the between the intervention, the target population, and
stronger outcomes for internalizing behaviors. Collec- the context into which an EBPT is introduced, they
tively, these findings have potential implications for may also erode treatment integrity or compromise clini-
modification of EBPTs. If the highest levels of adherence cal outcomes (Kennedy, Mizuno, Hoffman, Baume, &
are not in fact essential to produce good clinical out- Strand, 2000). One meta-analysis comparing novel
comes, it is possible that modification may not negatively interventions, standard protocols, and adapted protocols
impact clinical outcomes. Competent treatment delivery found a trend-level advantage for adapted psychosocial
may in fact require at least minor adaptations to meet interventions when compared to standard interventions
patient needs or ensure that patients are able to under- in terms of improving effectiveness (Sundell, Beelmann,
stand and benefit from the skills and interventions that Hasson, & von Thiele Schwarz, 2016), but it included a
are delivered (Roth & Pilling, 2008). However, to date, variety of intervention types and did not examine speci-
much of the consideration of modifications to EBPTs fic types of adaptations. As Bell, Marcus, and Goodlad
has consisted of theoretical articles about planned adapta- (2013) demonstrated in their reconsideration of a meta-
tion, descriptions of planned adaptations, and investiga- analysis that showed no effects associated with adding or
tions of the impact of specific types of adaptations to removing components of psychotherapies (Ahn &
EBPTs that were set forth at the beginning of a study. Wampold, 2001), grouping different types of adapta-
More recently, some have attempted to categorize tions can mask differences in outcomes. Other than Bell
adaptation and modifications (Baumann, Cabassa, & and colleagues’ careful effort to assess the impact of add-
Stirman, 2017; Hill, Maucione, & Hood, 2007; Moore, ing or removing treatment components, there is little
Bumbarger, & Cooper, 2013; Stirman, Miller, et al., empirical guidance about whether certain modifications
2013). Descriptions of modifications and adaptations in to EBPT should be avoided or encouraged.
398 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V24 N4, DECEMBER 2017
Although potentially informative, a full and careful used, highlight strengths and limitations in the research
assessment of the impact of each different type of mod- to date, and summarize and synthesize findings from
ification on clinical outcomes for each and every EBPT research on different forms of modifications to EBPT
would clearly be expensive, time consuming, and content. Therefore, this review will not include articles
impractical. Therefore, looking toward the existing lit- that summarize recommendations for adaptations or
erature may result in some guidance regarding the state descriptions of planned adaptations that do not include
of the research on EBPT modification and important clinical outcome data. Additionally, unless the content
directions for future research. Over the course of the of the EBPTs was also adapted, this review does not
development of the literature on EBPTs, some studies examine the impact of contextual-level modifications
have been conducted to investigate adapted interven- such as delivery of an EBPT to a new population or in
tions. Although there have been some reviews that a different format or setting. We define EBPTs as treat-
have considered the relationship between adherence ments that have demonstrated efficacy in at least one
and flexible application of EBPT elements (Forehand adequately powered randomized controlled trial or
et al., 2010; Kendall & Beidas, 2007; McHugh et al., multiple smaller controlled studies. Because decisions to
2009), and meta-analytic reviews of three specific implement treatments in routine care weigh clinical
forms of adaptation (Bell et al., 2013; Nieuwsma et al., demand with the body of existing research evidence
2012), there has yet to be a critical review of the study and treatments may be used for populations for which
designs and methodologies used in such research or the they have not specifically been studied, we employed
findings related to many of the specific forms of modi- less stringent criteria for treatments that warranted
fication. Therefore, the goals of this systematic review inclusion in our review than those for empirically
are (a) to identify the types of modifications and adap- supported treatments (Chambless & Hollon, 1998),
tations that have been investigated and characterize the which require additional research evidence for specific
reasons that different forms of modification were made, populations.
(b) to examine the methodologies used in previous
research on modifications, (c) to better understand Search Strategy
what is known about the clinical impact of specific We searched the literature for articles published or in
types of modifications to the content of EBPTs, and press before January 2017 that investigated modified or
(d) to make recommendations for future research and adapted EBPT protocols. We searched the following
current efforts to implement EBPTs in clinical practice databases: MEDLINE, ISI, PsycINFO, Academic
settings. Although we expected that most published Search Premier, Health Source, ERIC, PubMed, and
studies would focus on planned adaptations, we also Google Scholar, using the terms “modify*” or
searched for any studies that investigated the impact of “adapt*” or “cultural adaptation” or “dismantling” and
unplanned modifications that occurred during routine “evidence-based psychosocial treatment,” “evidence-
care. By reviewing these studies, limitations in knowl- based psychotherapy,” “psychotherapy,” “cognitive-
edge about some types of changes to EBPTs may be behavioral therapy,” and the names of specific com-
revealed. Additionally, although interventions and tar- monly studied mental health disorders (major depres-
get populations may vary, patterns of methodological sive disorder, PTSD, anxiety and eating disorders,
limitations, gaps in the literature, and patterns of find- schizophrenia, bipolar disorder, conduct disorder, bor-
ings may emerge when the implications of the research derline personality disorder). We also employed a
on specific types of modifications are examined across snowballing strategy to search the reference sections of
the existing literature. articles that we identified as well as theoretical papers,
studies, and reviews that discussed adaptations to
METHOD EBPTs (Bell et al., 2013; Benish, Quintana, & Wam-
Scope pold, 2011; Chu & Leino, 2017; Forehand et al., 2010;
The intent of this review is to provide a critical over- Hall et al., 2016; Kendall & Beidas, 2007; McHugh
view of the research methodologies that have been et al., 2009; Stirman, Miller, et al., 2013). The authors

reviewed abstracts and full-text articles when necessary Strunk, Brotman, DeRubeis, & Hollon, 2010), if they
to determine their eligibility for this review and dis- focused on prevention rather than treatment
cussed any differences of opinion regarding inclusion (e.g., Kennedy et al., 2000), if they described or sug-
with the study team. Care was taken to be as thorough gested adaptations without providing data on clinical
as possible in identifying studies, but it is possible that outcomes (e.g., Kaysen et al., 2013), if they reported
some studies were missed due to inconsistencies in on adaptations for a single case (e.g., Graham-LoPresti,
terms used to describe changes to EBPTs in the litera- Gautier, Sorenson, & Hayes-Skelton, in press), or if
ture. the intervention was delivered to an individual other
Inclusion criteria for articles were as follows: (a) the than the identified patient (e.g., caregiver or parenting
article described one or more modifications made to a interventions; Parra-Cardona et al., 2017). Meta-ana-
specified, manualized psychotherapeutic treatment that lyses were also examined to determine whether the
had previously demonstrated efficacy or effectiveness included studies met inclusion criteria for this review,
for a DSM-III or DSM-IV diagnosis in at least one and each eligible study included in the meta-analysis
well-designed study and/or met APA Division 12 cri- was coded.
teria for strong or modest support (Chambless & Hol-
lon, 1998)—we used the description of the treatments Coding Strategy
and the summary of research reported on those treat- Studies were classified by study design, type of change
ments from the articles to make a determination of made to the EBPT, and study findings. We categorized
whether they met this criterion, and when necessary, study designs based on previous categorizations of stud-
conducted a further literature search to determine ies that have been used to establish feasibility, efficacy,
whether treatments met this criterion; (b) the article possible efficacy, or effectiveness of psychotherapy
included sufficient detail about one or more content- interventions (Carey & Stiles, 2015; Chambless & Hol-
level modifications to facilitate coding; (c) the article lon, 1998; Najavits, 2003; Weersing & Hamilton,
employed a case series or record review, within-sub- 2005). Types of adaptations and modifications were
jects design, open trial, nonrandomized comparison, identified using a framework and coding system of
benchmarking, randomized controlled trial, or disman- modifications and adaptations to evidence-based psy-
tling design, or included a meta-analysis of studies that chotherapies (see Table 1 for definitions of each; Stir-
individually would have been eligible for the review; man, Miller, et al., 2013). Additional information
(d) the article presented clinical outcome data; and (e) collected from each study included intervention stud-
at least some portion of the intervention was intended ied, target population, adaptation type(s), sample size,
to be delivered directly to the identified patient (rather comparison group, a summary of key results, and the
than exclusively to a parent, caregiver, or teacher). information necessary to derive bias-corrected effect
Modifications could be either adaptations (i.e., inten- sizes. Raters trained together on the coding system by
tional, planned changes that typically included an effort reviewing and discussing operational definitions, rating
to preserve fidelity) or changes that were made without five articles per week separately and discussing them in
premeditation during the delivery of the intervention. weekly meetings over one month, at which time, rater
We also included studies that reported on clinical out- agreement was 92%. Subsequently, individual raters
comes data that were collected in routine care settings. reviewed articles for potential inclusion and coded arti-
Although some more recently developed interventions cles that met inclusion criteria. Three raters then
were created to allow a high degree of flexibility and reviewed the coding for all of the articles. If questions
adaptability (e.g., Barlow et al., 2011; Weisz et al., arose about inclusion or appropriate codes, the team
2012), studies of these treatment protocols were not achieved consensus through discussion.
included in the review unless specific content-level
adaptations were made to those protocols. Articles were Calculation of Effect Sizes
excluded if they assessed fidelity but did not describe Using the data available in the published studies, we
adaptations (e.g., Strunk, Brotman, & DeRubeis, 2010; calculated Hedge’s g, which corrects for small sample
resulting from a snowballing approach. One hundred
Table 1. Definition and number of specific types of content-level
modifications eighty-eight of those articles met our exclusion criteria
(64 were not research studies; 12 were single case
Content-Level descriptions; 87 were not applied to specific psychoso-
Modification Definition N
cial disorders, did not use an evidence-based protocol,
Tailoring Minor alteration of aspects of a treatment 49 or there was not enough information to discern the
without significant changes or removal of core
treatment elements evidence base for the specific protocol that was used;
Removinga Implementing an EBPT without one or more 41
distinct elements described in the original
five did not contain content-level modifications; and
protocol 20 did not present sufficient data, results, or specific
Addinga Including one or more distinct treatment 40
components that are not part of the original information about modifications). One hundred four-
EBPT protocol teen original studies met inclusion criteria for this
Shortening Decreasing the number of sessions that are 25
(protocol)b,c delivered (without removing treatment review. All of the articles described planned adapta-
components)
Shortening Decreasing the amount of time allocated for 1112 tions. We did not identify research on modifications
(session)b EBPT sessions that were not planned or that occurred in routine care
Lengthening Increasing the number of sessions in the EBPT 8
(protocol)b,c protocol (without adding treatment conditions without prespecified guidelines for accept-
components)
Lengthening Increasing the amount of time allocated for EBPT 6
able adaptations. Therefore, hereafter, we refer to the
(session) sessions changes that were identified in the articles as adapta-
Integrating The infusion of a different, established 3
therapeutic approach into an EBPT throughout tions. Table 1 indicates the number of studies that
the duration of the protocol included each type of adaptation, along with a defini-
Repeating Elements that are normally prescribed or 2
conducted once during a protocol are used tion for each type of adaptation. Some adaptations and
more than once
Reordering Elements are delivered or completed in a 2 modifications specified in the Stirman, Miller, et al.
different order than originally specified in the (2013) framework, such as substitution of a different
protocol
Loosening Elements that are intended to structure 1 element in place of an element specified in the proto-
intervention sessions do not occur as prescribed
by the protocol
col, were not the subject of investigation in any studies
identified for this review. Detailed findings regarding
Note. Original studies are included in the counts provided; meta-analyses study size, study design, effect sizes, and confidence
are not included in this table. aMany studies included multiple adapta-
tions, and the total number of articles in this table will not match the intervals, and whether the comparison was pre-to-post,
total number of studies identified for review. bEight studies shortened
both sessions and protocol. cTwo studies allowed for flexible length, thus adapted protocol compared to a control or alternative
shortening and lengthening the protocols. treatment, or to the original protocol can be found in
online Table S1.
size and, in contrast to Cohen’s d, uses a weighted
pooled standard deviation, for the main outcome Study Design and Methodology
described in each study, with 95% confidence intervals Forty-four studies made multiple content-level adapta-
(results are included in Table S1). Whenever possible, tions to the EBPT, and 45 included content-level
we calculated the effect sizes based on comparisons to adaptations as well as contextual adaptations. The
the original protocols or controls, and when those data remainder reported on the impact of a single adapta-
were not available, pre–post effect sizes were com- tion. Three studies provided clinicians with guidelines
puted. Table S1 specifies whether between-condition for adaptation and allowed them to make the prespeci-
or pre–post effect sizes were calculated. When data fied adaptations on a case-by-case basis. Fifty (44%)
were reported, but were insufficient to compute effect included a comparison to the standard protocols; others
sizes, we noted this in Table S1 and summarized the were open trials or comparisons to control conditions.
relevant results found in the articles. One study tested noninferiority of an adaptation as
compared to a standard protocol. We identified three
RESULTS meta-analyses that included studies that met our inclu-
Our search resulted in 302 articles for abstract review, sion criteria: two on shortened/brief interventions
with 154 resulting directly from searches and 142 (Cape, Whittington, Buszewicz, Wallace, &

Underwood, 2010; Nieuwsma et al., 2012), and one added components, but only 15 did not include other
study that separately examined the impact of adding adaptations. Eighteen of these studies compared a stan-
and removing components (Bell et al., 2013), which dard protocol to an adapted protocol, although sample
was a reanalysis of an earlier meta-analysis on compo- sizes varied and individual studies may not have been
nent studies (Ahn & Wampold, 2001). Other meta- powered to detect significant differences between stan-
analyses on adaptation contained fewer studies that met dard and adapted conditions. Few occurred in routine
our inclusion criteria (Benish et al., 2011; Hall et al., care settings, and those that did used open trial designs
2016; Sundell et al., 2016). Studies that were included or compared to usual care. Our review of these studies
in these meta-analyses and that met our inclusion crite- identified additions to protocols that served a variety of
ria are individually summarized in Table S1. purposes, including efforts to enhance treatment out-
The majority of the studies that compared adapted comes or to address unique patient characteristics.
to standard protocols focused on adding or removing Bell et al. (2013) included 36 studies that added
components. Few studies of other forms of adaptation components, 23 of which met inclusion criteria for this
made comparisons to original protocols, and many review. These studies, which compared standard and
studies included multiple types of adaptations. Thus, it adapted protocols, typically added cognitive-behavioral
is not possible to isolate the impact of most types of components in an effort to enhance the effectiveness of
specific adaptations on clinical outcomes, or to conduct the intervention. Five studies included in the Bell et al.
a rigorous meta-analysis for individual adaptations, meta-analysis also tailored treatment in some way. The
other than those that have been the subject of meta- meta-analysis concluded that small but significant
analyses that we include in our review (Bell et al., effects were found for primary outcomes for the
2013; Cape et al., 2010; Nieuwsma et al., 2012). adapted interventions compared to the original proto-
However, the variation in research design and settings cols, and the effects increased slightly at follow-up.
in which the studies were conducted allows for consid- That pattern remained consistent when we individually
eration of the type of study design and nature of adap- examined the subset of 23 studies that met our inclu-
tations that need to be studied to yield clinically useful sion criteria.
results for different types of adaptations. Other studies that were not included in the Bell
In the following sections, the review results are et al. (2013) meta-analysis varied in design and in the
organized by the type of content-level adaptation spec- purpose of the adaptations (summaries of the designs,
ified in the articles. Within each section, we describe populations, and effect sizes can be found in Table S1).
reasons that the adaptations were made and the nature Three studies examined the inclusion of additional cog-
of the adaptations, discuss the findings, and comment nitive-behavioral interventions to cognitive-behavioral
on the study design. Within this general organizational protocols (Cloitre et al., 2010; M€ ortberg, Clark, Sun-
framework, studies are grouped by treatment and/or din, & Aberg Wistedt, 2007; Schulte, K€ unzel, Pepping,
population. Table S1 contains details about each study’s & Schulte-Bahrenberg, 1992; Sportel, de Hullu, de
design, sample size, population, and outcomes. We dis- Jong, & Nauta, 2013), and two studies added compo-
cuss implications for clinical practice and consider nents to address childhood sexual abuse (Chard, 2005;
whether the designs of the studies in the review reflect Cloitre et al., 2010). Four studies included a distinct
the way adaptations are typically made in clinical prac- intervention at a specified point in the protocol
tice, noting limitations and future directions for (Chard, 2005; Cloitre et al., 2010; M€ ortberg et al.,
research. 2007; Sportel et al., 2013), and the other allowed clini-
cians to add interventions at any point in the protocol
RESULTS AND DISCUSSION FOR SPECIFIC ADAPTATIONS (Schulte et al., 1992). These different approaches
Adding Components yielded different results. Greater latitude resulted in
Adding refers to the addition of one or more distinct poorer outcomes (Schulte et al., 1992), and a more cir-
treatment components that are not part of the original cumscribed or sequenced addition of elements was
EBPT protocol. Forty investigated protocols with associated with large pre–post effects (Chard, 2005;
Cloitre et al., 2010) or a small effect in favor of a con- suggested an advantage to the standard group in one
trol (Sportel et al., 2013). A small effect was found in study (Burrow-Sanchez & Wrona, 2012), although
favor of the standard individual protocol compared to a an interaction suggested that the adapted protocol
group protocol that added a different form of exposure yielded better results for a subgroup. In the other
(M€ ortberg et al., 2007). Due to multiple modifications study, there was a small effect in favor of the adapta-
made in the M€ ortberg et al. study, however, whether tion (Kohn et al., 2002). In future comparisons
this difference was due to the change to an intensive between standard protocols and those that add mod-
group format or due to the nature of the form of ules to address specific cultural considerations, it will
exposure that was added cannot be determined. be particularly important to sufficiently power the
Studies that focused on adolescents added compo- research to examine moderating factors such as level
nents designed to foster parental involvement or to of acculturation.
address additional clinical issues. These studies identified In combination, these findings suggest that in the
significant benefits (medium to large pre–post effect absence of clear guidance regarding additions to a speci-
sizes) to the modified protocol when compared to usual fic protocol, any additions made to EBPTs in routine
care or in the context of within-subjects designs and care should be discrete, well defined, and based on sound
open trials. However, the only two studies that com- theory and understanding of the target population.
pared adapted and standard protocols for depressed ado- Symptom measures should be used before and after any
lescents identified a small effect in one study, and no sessions in which content is added, and, if possible,
effect in a larger, subsequent trial (Clarke, Rohde, benchmarked against data for the standard protocol to
Lewinsohn, Hops, & Seeley, 1999; Lewinsohn, Clarke, inform decisions about the clinical utility of adaptation
Hops, & Andrews, 1990). Five studies investigated an for individual patients or specific populations.
adapted dialectical behavior therapy (DBT) for adoles-
cents that included additional components, along with Integration
other forms of adaptation. Some of these studies added In contrast to adding a distinct, theoretically consistent
elements to address diagnoses (e.g., eating disorders, component to a treatment for a limited number of
bipolar disorder) other than borderline personality disor- sessions, integration is the infusion of a different thera-
der (Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, peutic approach into an EBPT throughout the dura-
& Miller, 2008), and others were added to address other tion of the protocol. Three studies integrated cultural
needs or differences between the study population and or spiritual healing practices into the interventions,
the population with which the EBPT was originally although only one compared the adapted protocol to
tested (e.g., Charlton & Dykstra, 2011). Because these a standard protocol (Barrett, 1998), and the other two
studies were all open trials and case series, their outcomes studies also tailored the interventions (Bradley et al.,
support feasibility but do not shed light on the relative 2006; Venner et al., 2016). The Venner et al. (2016)
benefits of adapted and standard DBT. However, the study was a small pilot that integrated two psychoso-
single study that employed a benchmarking approach cial interventions. Barrett’s (1998) study infused a fam-
indicated that when adapted DBT was delivered to ily component throughout a group CBT intervention
adults in routine care with added components, the effects for adolescents with anxiety and identified a small
were within the range of those found in published clini- effect in favor of the adapted protocol. The studies
cal trials of the standard intervention (Comtois, Elwood, included in this review integrated a single additional
Holdcraft, Smith, & Simpson, 2007). approach, whereas studies suggest that therapists often
Studies that added modules to tailor treatments to pick and choose EBPT elements to integrate into their
racial and ethnic minority populations (Burrow-San- preferred treatment modality (Cook, Dinnen, Simiola,
chez & Wrona, 2012; Kohn, Oden, Mu~ noz, Robin- Thompson, & Schnurr, 2014; Stirman, Calloway,
son, & Leavitt, 2002) were characterized by low et al., 2013) or use a more eclectic approach (von
sample sizes and were likely underpowered to detect Ranson & Robinson, 2006; Stirman, Calloway, et al.,
differences from the original protocol. Effect sizes 2013; Wallace & von Ranson, 2012). Additional

studies on integration of other, and perhaps multiple, elements remains to be studied. Particularly because
common psychotherapeutic modalities (e.g., client- research indicates that these are fairly common occur-
centered, Gestalt, dynamic, family systems) are needed rences in routine clinical practice, it is important to
to understand how this practice impacts clinical out- understand and potentially provide guidance regarding
comes. decisions to remove such elements from treatment in
routine care settings (Cook, Dinnen, Thompson, et al.,
Removing EBPT Elements 2014; Lau et al., 2017; Stirman, Calloway, et al.,
Removing refers to implementing an EBPT without 2013). Additionally, to inform whether more stream-
one or more distinct original elements. Forty-one stud- lined forms of EBPTs are viable, effective options for
ies examined removal of EBPT elements, with 28 of routine care settings, future dismantling studies should
them comparing the adapted and standard protocol. test for noninferiority of treatments that remove speci-
The meta-analysis conducted by Bell et al. (2013), fic elements associated with greater burden on the cli-
which included 30 of these studies, identified neither a ents or therapists.
positive nor negative overall effect associated with Although most of the evidence does not suggest that
removing components of treatment protocols. The removing certain components from EBPTs diminishes
other studies we identified supported this conclusion. clinical outcomes, decisions to remove elements in
Importantly, the dismantling studies were designed to routine care should include careful consideration of the
determine whether single, specific central components theory behind the treatments and the original theoreti-
of treatment protocols that were either hypothesized to cal rationale for including the element. Also, the ways
be essential or nonessential components (e.g., eye in which specific patient characteristics might interact
movement, progressive muscle relaxation, exposure, with each treatment element should be considered. If
written trauma accounts) were necessary to yield results studies are not available to inform the removal of ele-
that were comparable to the full protocol. The results ments, the use of single case designs, consistent moni-
were intended to determine whether the protocols toring of progress, and benchmarking may be useful in
could be streamlined to remove elements that were not providing further guidance for individualized treat-
active components or to remove elements that may be ments.
more challenging to implement. In contrast, most stud-
ies that we reviewed beyond the meta-analysis gener- Tailoring EBPT Protocols
ally combined removal of components with other Tailoring refers to the relatively minor alteration of
adaptations, and seven of these additional studies aspects of a treatment without significant changes or
included other adaptations as well. Notably, none of removal of core treatment elements. There are several
the studies that we reviewed represented certain ele- ways in which therapists may tailor a treatment. Exam-
ments that are typically removed in routine care, such ples include changing the language in which the inter-
as components that are conceptualized as supporting vention is delivered; modifying the terminology,
cognitive-behavioral treatment like agenda setting, examples, or metaphors provided to patients to illus-
homework, or clinical worksheets (Cook, Dinnen, trate concepts; or making changes to handouts or
Thompson, et al., 2014; Stirman, Calloway, et al., assignments to make them more appropriate for the
2013). However, one study did remove a culturally population. These types of adaptations are common in
incongruent component, while still finding a large routine care settings (Aarons et al., 2012; Cook, Din-
effect in favor of the adapted intervention over a con- nen, Simiola, et al., 2014; Cook, Dinnen, Thompson,
trol intervention (Murray et al., 2013; Murray, Skaven- et al., 2014; Stirman, Calloway et al., 2013; Stirman,
ski, & Kane, 2015). Previous studies that have Miller et al., 2013), and may be examples of a form of
examined the use of components, such as homework, “flexible fidelity” that has been advocated in the litera-
have typically been process studies rather than studies ture (Forehand et al., 2010; Kendall & Beidas, 2007).
that randomized patients into standard or adapted con- In this review, 49 studies of tailored interventions were
ditions. Thus, the impact of the removal of such identified. However, only eight were compared to
standard protocols, and all of them included additional tailoring was necessary to optimize benefits, the
forms of adaptation. research demonstrates feasibility and potential effective-
Some studies, none of which included comparisons ness of culturally adapted protocols, and very little evi-
to a standard intervention, tailored EBPTs to address dence of detrimental effects. Meta-analyses of cultural
factors such as delivery to populations of different ages adaptations of a variety of preventive and psychosocial
or diagnostic characteristics. For example, some open interventions (some of which are EBPTs for psycho-
trials investigated EBPTs with tailored homework and logical disorders and some of which are not) also
written materials, such as handouts, to meet the needs yielded equivocal results or small effects, depending on
of specific populations (e.g., Charlton & Dykstra, 2011; the nature of the intervention, populations, and adapta-
Goldstein, Axelson, Birmaher, & Brent, 2007; Salbach- tions (cf. Benish et al., 2011; Hall et al., 2016). To
Andrae et al., 2008), and these adaptations consisted fully understand the impact of tailoring to increase the
largely of simplification of the terminology or the cultural relevance to specific populations, future studies
homework. Others tailored content somewhat more would need to be fully powered to compare tailored
extensively to address issues experienced by depressed and standard interventions and detect potential interac-
adolescents in different contexts (Mufson, Weissman, tions with level of acculturation and other factors
Moreau, & Garfinkel, 1999; Shelton, Kesten, Zhang, (Cardemil, 2010).
& Trestman, 2011), such as inpatient or correctional Given the numerous differences in populations and
settings, and tested them using within-subjects designs settings for which established EBPTs may need to be
(Shelton et al., 2011) or compared them to wait-list tailored, it is not feasible, and may not be desirable, to
controls (Mufson et al., 1999). Finally, in some open conduct fully powered comparisons of standard and tai-
trials, EBPT content was tailored before delivery to lored adaptations to establish the benefits of tailoring
different age groups or diagnostic populations (e.g., for each and every context. As Lau (2006) suggests,
Fleischhaker et al., 2011; Katz, Cox, Gunasekara, & assumptions that tailoring and adapting interventions is
Miller, 2004; Salbach-Andrae et al., 2008; Stark, Rey- always necessary may not be correct. However, at
nolds, & Kaslow, 1987). times, local practice evaluation data may indicate that
A number of studies tailored EBPTs to align them tailoring is warranted, and tailoring without removal of
with cultural needs and values. However, only two core elements of treatments may reflect good clinical
small pilot studies compared the tailored intervention care. For example, if engagement in, or degree of
to a standard intervention (Burrow-Sanchez & Wrona, understanding of a standard EBPT protocol is lower
2012; Pan, Huey, & Hernandez, 2011), with one find- for specific subpopulations, it may be important to
ing evidence of a small effect in favor of the standard consider tailoring the intervention while collecting
protocol, and the other indicating a large effect in favor practice-level data to determine whether the adapta-
of the adapted protocol (results detailed in Table S1). tions are having the desired impact on treatment
Both studies also found preliminary evidence of a mod- engagement and other outcomes. In other circum-
erating effect for acculturation or ethnic identity, sug- stances, knowledge of the population will dictate
gesting that future research should be adequately whether tailoring elements of the protocol is appropri-
powered to determine for whom tailoring to increase ate or necessary. For example, handouts, homework,
cultural relevance may be most necessary. Studies that and certain concepts may need to be tailored when lit-
compared adapted protocols to control groups or other eracy, language of origin or fluency, education levels
interventions (Bass et al., 2013; Murray et al., 2015; (Bass et al., 2013; Kaysen et al., 2013; Schulz, Resick,
Rossell o & Bernal, 1999) also found evidence that tai- Huber, & Griffin, 2006; Valentine et al., 2017), or the
lored interventions yielded large pre–post effects (Miller presence of developmental disabilities (Charlton &
et al., 2011), as did open trials (Interian, Allen, Gara, & Dykstra, 2011) suggest that an unmodified protocol
Escobar, 2008; Kanter, Santiago-Rivera, Rusch, Busch, would not meet the needs of, or could not be under-
& West, 2010; Murray et al., 2015). Although the stood or utilized by the population. In such cases, the
studies were not designed to determine whether current evidence and recommendations from the field

(Chambers et al., 2013; Chu & Leino, 2017; Forehand EBPT protocol (often without adding or removing
et al., 2010; Stirman, Miller, et al., 2013) suggest treatment components, although those studies that did
preserving core elements of the protocols while so are noted below). In addition to studies that short-
making adjustments to language, terminology, and ened or lengthened the protocol, two studies allowed a
complexity, and tracking clinical data as these changes variable protocol length, meaning protocols could be
are implemented. shortened or lengthened. Eleven studies shortened ses-
sions, and five examined lengthened sessions in the
Repeating Sessions or Session Material context of a shortened, intensive protocol. One study
A code for repetition was assigned when either the condensed the protocol (lengthened sessions and com-
content of a full session or session elements were pleted the protocol in fewer sessions) to accommodate
repeated or extensively reviewed in a manner that is the distance that participants traveled for the study
not consistent with instructions in the standard proto- (Murray et al., 2015). Descriptions of these studies and
col. Repetition may be a common strategy in routine their effect sizes can be found in Table S1. Notably,
care settings, as clinicians may deem it necessary to the adapted studies did not vary the treatment length
ensure that patients understand certain concepts and by more than 50% of the sessions in the original proto-
materials before advancing in the treatment. However, col; that is, the studies did not investigate highly abbre-
very little research has been conducted to assess the viated protocols or long-term EBPT protocols.
impact of repetition. Two studies investigated adapted Conversely, many individuals who receive psychother-
protocols that included repetition, although in both apy in routine care settings receive far fewer sessions
studies, other adaptations were also made. In a ran- than specified in EBPT protocols (Spoont et al., 2014)
domized study, Lynch, Morse, Mendelson, and Robins or engage in longer-term care, even when receiving
(2003) adapted DBT for depressed older adults and treatments that are conceptualized as more structured,
combined it with medications and compared it to med- short-term therapies. Thus, further investigation of the
ication alone in a small trial (n = 34). In addition to impact of EBPTs delivered in timeframes and contexts
shortening both the sessions and the protocol length that are typical of routine care is needed to better
and removing some sessions, the researchers repeated understand the magnitude of the benefits that can be
the full protocol so that participants were exposed to expected under these circumstances. Below, we
all skills training material twice, and found evidence of describe conclusions that can be drawn based on differ-
a medium effect in favor of the adapted protocol. In ent approaches to adjusting protocol length.
the other study, an open trial of STAIR for PTSD
(Levitt, Malta, Martin, Davis, & Cloitre, 2007), repeat- Variable Protocol Length. Although in routine care
ing earlier aspects of treatment was at the discretion of settings the number of sessions attended varies widely
the therapist, and it is unclear how many study partici- (Connolly-Gibbons et al., 2011), few studies have
pants repeated session elements. Although very little allowed flexibility in terms of session length. Only one
research has been conducted on repetition, it is likely randomized controlled trial examined the efficacy of a
that the impact of repeating sessions or specific treat- variable length intervention for PTSD and compared it
ment elements varies widely based on individual or to a symptom-monitoring condition (MCPT; Galovski,
population needs. Practice-based research data, in con- Blain, Mott, Elwood, & Houle, 2012; N = 100). In
junction with measures of fidelity to assess whether the this study, clinicians determined when treatment should
repetition comes at the expense of other key treatment end based on each individual’s progress toward a priori
elements, may be useful for exploring outcomes associ- defined end-state criteria, and engaged in shared deci-
ated with repetition of protocol elements. sion making with patients regarding termination. An
earlier open trial of STAIR for PTSD (2007) similarly
Adaptations to Protocol and Session Length allowed clinical latitude in the number of sessions, but
Adaptations to protocol and session length include in contrast to the Galovski et al. (2012) study, investi-
increases or decreases in the number of sessions in the gators allowed not only nonprotocol sessions (which
were also allowed by Galovski et al., 2012), but also compared to usual care (Barnhofer et al., 2009).
the repetition and removal of sessions and materials. In Although many of the shortened protocols examined
both studies, large pre-to-post effects were demon- in this study did not remove treatment elements, it is
strated. Together, results suggested that in the context important to note that different outcomes may occur
of EBPT protocols for PTSD, patients recover at dif- depending on whether shortening is accomplished by
fering rates, and that flexibility in the number of ses- removing some session materials as opposed to com-
sions offered may be appropriate. Further research on pressing all EBPT elements into fewer sessions.
EBPTs for other disorders, and on characteristics of Although results of the meta-analysis on removing
patients who may benefit from adapted lengths, will treatment components indicate that some treatment
also be useful in guiding clinical practice. components may be removed without detrimental
effects on clinical outcomes (Bell et al., 2013), the
Shortening the Protocol. Shortening the protocol combined impact of removing elements and shortening
refers to reducing the number of sessions that are deliv- protocols may differ. Thus, additional research compar-
ered. A review on brief psychotherapies for depression ing standard to adapted interventions, and considering
included a meta-analysis on five studies of brief CBT whether treatment is compressed or elements are
(Nieuwsma et al., 2012). Another meta-analysis exam- removed to accomplish shortening of protocols, is rec-
ined studies of brief CBT and problem-solving therapy ommended. Decisions to shorten protocols in routine
(Cape et al., 2010) for depression and anxiety disorders care should be made in conjunction with real-time data
in primary care. Twenty-five additional studies exam- on individual symptoms and functioning.
ined shortened EBPT protocols, and six compared
them to standard protocols. Three studies investigated Lengthening the Protocol. Lengthening refers to the
abbreviated DBT protocols using a comparison group addition of more sessions to an EBPT. Eight studies
(Katz et al., 2004; Rathus & Miller, 2002) or an open investigated lengthened interventions, but all studies
trial (Salbach-Andrae et al., 2008). Only four studies that adapted protocol length included additional
did not include other adaptations. For example, in adaptations. One RCT (Schulte et al., 1992) length-
addition to tailoring, some studies increased the fre- ened a protocol for specific phobias to accommodate
quency of sessions or shortened the sessions. One small the addition of other treatment elements that could
open trial demonstrated a large effect for shortened be added at clinicians’ discretion. Contrary to the
CBT for panic disorder and agoraphobia, although it hypothesis that more flexible delivery would result in
did not include a control condition or a benchmarking better outcomes, a medium effect in favor of the
€ 1999).
strategy (Westling & Ost, standard protocol compared to the adapted one was
Several studies investigated abbreviated treatments found. Despite the addition of sessions to accommo-
for depression. Results of the meta-analyses suggested date clinical latitude in delivering additional cogni-
small effects for studies of brief CBT or problem- tive-behavioral elements, the results suggest that
solving therapy (PST) for depression or for mixed elements required in the protocol may not have been
depression and anxiety (Cape et al., 2010; Nieuwsma delivered at an adequate dose or intensity. This
et al., 2012), but larger effects on brief CBT for anxi- stands in contrast to the findings from Galovski et al.
ety disorders delivered in primary care settings (Cape (2012), which suggest that some patients experience
et al., 2010). Some of the PST studies also shortened additional benefits when a protocol is lengthened and
the duration of the therapy sessions. These studies did care is taken to deliver an adequate dose of the key
not include comparisons to standard-length protocols, elements of a therapy.
although authors noted that the effects for depression Variations in treatment length are common in
were smaller than those found for full-length protocols routine care settings due to a variety of factors, such
(Nieuwsma et al., 2012). Not included in these meta- as insurance reimbursement policies, program capac-
analyses were a study on mindfulness-based cognitive ity, and patient needs. Designs that isolate the impact
therapy (MBCT), which demonstrated a large effect of changing the length of a protocol can provide

clinically useful information. The results provided by delivered to provide an intensive EBPT. Notably, all
Galovski et al. (2012), which described the propor- of the intensive interventions preserved all core ele-
tion of patients who achieved remission and good ments of CBT. Following a promising small feasibility
end-state functioning after a shortened, standard, or study (Ehlers et al., 2010), Ehlers et al. (2014) con-
lengthened protocol, are a good model for develop- ducted an RCT comparing a standard cognitive ther-
ing processes to make decisions about protocol apy for PTSD protocol and an emotion-focused
length, and for providing results that can guide treat- therapy condition to an intensive, adapted seven-day
ment planning. protocol with two, 90–120 min sessions per day (as
opposed to one 60-min session per week). Intensive
Shortening Session Duration. Our review identified cognitive therapy achieved faster symptom reduction
12 studies that examined the impact of shortening the and comparable overall outcomes to standard cognitive
length of sessions. In eight studies for depression, therapy, with both protocols outperforming supportive
which were included in a meta-analysis (Nieuwsma therapy. These findings suggest that intensive treat-
et al., 2012), the sessions were shortened in the context ments for PTSD can be beneficial, although replication
of abbreviated treatment protocols. Only one study that is necessary. Additionally, research has been conducted
we identified (Nacasch et al., 2014) was a randomized on intensive EBPT protocols for anxiety disorders.
comparison to the standard protocol. In the studies we One study compared weekly and intensive CBT for
reviewed, sessions were shortened for different reasons pediatric obsessive–compulsive disorder and found a
that may have different clinical implications. For exam- small to medium effect in favor of the adapted condi-
ple, sessions were shortened in the van Minnen and tion, although the difference between groups was not
Foa (2006) study due to feasibility related to restrictions significant (Storch et al., 2007). Studies of panic disor-
on reimbursement for 90-min sessions. The same der also demonstrated large reductions in panic symp-
research question was examined in a more recent, ran- toms, with one study demonstrating effects that were
domized noninferiority study (Nacasch et al., 2014), similar to those demonstrated in previous RCTs (Dea-
and together, these studies suggest that the benefits of con & Abramowitz, 2006; Evans, Holt, & Oei, 1991).
imaginal exposure for PTSD may be experienced even One RCT also demonstrated that results of an inten-
in abbreviated sessions. Charlton and Dykstra’s (2011) sive, group-based CBT for social anxiety resulted in
study shortened sessions to address feasibility of deliver- smaller effects than that seen in an individual CBT
ing DBT to a population with intellectual disabilities comparison, possibly because the group format made it
and included additional adaptations, but it was not more difficult to tailor exposures to individual patients
designed to determine the relative benefits of this (M€ ortberg et al., 2007). An additional limitation to the
approach as compared to a longer session. Studies that study by M€ ortberg and colleagues is that it relied on
examine the impact of abbreviated sessions have impor- self-report, rather than interviewer-assessed outcomes.
tant implications for routine care outpatient settings, Finally, an open trial in a partial hospitalization pro-
where clinicians are rarely able to provide or bill for gram also provided preliminary evidence of benefits
over an hour with individual patients. Thus, particu- resulting from a CBT for depression protocol that was
larly when an intervention specified a session length adapted for intensive treatment, but it similarly relied
that exceeds an hour, studies of shortened sessions on program evaluation data (Christopher, Jacob, Neu-
would be highly clinically relevant, and noninferiority haus, Neary, & Fiola, 2009).
studies could be conducted to determine whether Although most of these results suggest that intensive
shortening results in inferior outcomes to the long ses- interventions can result in symptom change that is sim-
sions required in standard protocols. ilar in magnitude to standard protocols, in some cases,
further replication is needed. In the case of social anxi-
Lengthening Sessions and Compressing the Protocol ety, further study is needed to determine whether an
(Intensive Protocols). Some studies have abbreviated intensive individual intervention could overcome the
the number of days or weeks over which a protocol is shortcomings of the group-based intensive protocol
that has been tested. Additionally, it might be useful to protocols, when compared to the original format,
identify characteristics of patients who are most likely yielded small, if any, effects. With respect to specific
to need or benefit from intensive protocols in future adaptations, the studies reviewed here and in Bell and
research. Implications of these findings for routine care colleagues’ (2013) previous meta-analysis suggest that
in outpatient settings are not certain, as some clinicians when additions are discrete, well defined, and based on
may lack the flexibility to schedule individuals for sound theory and an understanding of the population
longer, more frequent sessions (Stirman, 2014). How- for which the intervention is being adapted, they may
ever, they could represent a promising approach for result in better outcomes than standard protocols.
inpatient or intensive day programs. Although most studies demonstrated benefits to patients
who received tailored interventions, few tested or
GENERAL DISCUSSION AND RECOMMENDATIONS demonstrated benefits over and above standard proto-
Although previous reviews have examined the impact cols, and most such studies comprised small sample
of certain forms of modification or considered the rela- sizes. Large effects, comparable to original protocols,
tionship between flexibility and fidelity in the delivery were typically seen for EBPTs that were adapted for
of EBPTs, to date, there has not been an examination intensive delivery, although intensive group-based
of the impact of a variety of forms of modifications to interventions resulted in a magnitude of change that
EBPTs, or a critical review of the research methodolo- was lower.
gies used to investigate their impact. The purpose of
this systematic review was therefore to describe the Gaps in the Literature
design and findings of the current empirical literature Our review also resulted in the identification of a
on adaptations to EBPTs, to identify gaps in the litera- number of gaps in the existing empirical literature
ture, to discuss methodological considerations, and to regarding adaptations. Although studies that investigate
make recommendations for future research for the flexible, modular treatments (Weisz et al., 2012) or cir-
study of modifications to EBPTs. Additionally, when cumscribed adaptations (Galovski et al., 2012) prove
possible, based on study findings, a goal of this review important specific guidance about the degree of flexi-
was to make recommendations regarding adaptation bility with which treatment elements can be applied, it
when implementing EBPTs in clinical practice settings. is critical to explicitly examine the impact of other
Most open trials and comparisons of adapted protocols forms of modification that are commonly made in rou-
demonstrated feasibility and symptom improvements, tine care. The research that we identified in this review
but it is important to note that “file drawer” studies focused almost exclusively on adaptations that were
suggesting negative results for adaptations may not have planned for the purposes of the study, and as such,
been published, potentially resulting in an overly opti- some forms of adaptation as they occur in typical prac-
mistic assessment of the benefits of delivering adapted tice may not be adequately represented in the litera-
EBPT protocols. ture. A number of different modifications, including
Although we had originally planned to conduct a integration, substitution of different elements for estab-
random-effects meta-analysis to examine the impact of lished EBPT components, loosening session structure,
different forms of adaptation, we were unable to do so and reordering of EBPT elements have not been ade-
due to the dearth of controlled studies that were quately investigated, although there is some evidence
designed to compare adapted and nonadapted protocols that these types of changes occur in routine care (Aar-
for adaptations other than shortening, adding, and ons, Green, et al., 2012; Aarons, Miller, et al., 2012;
removing, which had already been examined in recent Cook, Dinnen, Simiola, et al., 2014; Cook, Dinnen,
meta-analyses. However, we are able to draw several Thompson, et al., 2014; Lau et al., 2017; Stirman, Cal-
conclusions that should be considered both when mak- loway, et al., 2013; Stirman, Miller, et al., 2013).
ing choices to adapt EBPTs in routine care and when Similarly, although providers who were interviewed
designing future research. With few exceptions, the in one study indicated that they loosened the structure
research that we reviewed suggested that adapted and occasionally drifted from a cognitive therapy

approach before returning to the intervention (Stirman, Recommendations for Future Research
Calloway, et al., 2013), no studies have specifically Although RCTs are a methodologically rigorous way to
investigated the impact of these changes to treatment examine many questions regarding the effectiveness of
protocols. In studies that did allow “nonprotocol” ses- adaptation and modifications to EBPT protocols, there
sions for emergent life events, clinicians were instructed are drawbacks to relying solely on this strategy. Utilizing
to approach issues discussed in session within the gen- RCTs to investigate the impact of certain individual
eral framework specified by the protocol, an approach adaptations, even those common in routine care, may
that may differ from routine care (Guan et al., 2017). be less efficient and feasible due to the sheer variety of
The meta-analysis by Bell et al. (2013) indicated that EBPT interventions, populations, and adaptations that
removal of certain protocol elements did not impact exist, as well as the large sample sizes that may be
results, which has implications for implementation in required to detect meaningful differences in outcomes
routine care settings, as it may be easier to train clini- between adapted and original protocols. It is highly
cians in simplified protocols. However, almost no stud- unlikely that many such studies would be funded in the
ies examined the impact of removal of key cognitive- current funding context. Furthermore, available data
behavioral elements such as homework or session suggest that clinicians often make multiple adaptations
agenda, which is not always included in routine care to interventions when delivering them in routine care
settings (Stirman, Calloway, et al., 2013; Stirman, (Aarons, Miller, et al. 2012; Cook, Dinnen, Simiola,
Miller, et al., 2013; Thompson, Simiola, Schnurr, Stir- et al., 2014; Stirman, Calloway, et al., 2013), which
man, & Cook, 2016). make the design of RCTs to determine the unique
Other adaptations that are commonly found in rou- impact of specific adaptations complex and impractical.
tine care settings, such as adapting the length of proto- Adaptive and factorial clinical trial approaches to clinical
cols or sessions and tailoring the intervention to meet trials, such as SMART (Sequential Multiple Assignment
the needs of specific populations, have been somewhat Randomized Trial) and Multiphase Optimization Strat-
better represented in the literature. Many of the adap- egy (MOST) designs (Buscemi et al., 2017; Chow,
tations made for specific populations appeared to be 2014), can also facilitate rigorous evaluation of adapta-
made in an effort to apply treatments to different diag- tion (Baumann, Cabassa, & Stirman, 2017). SMART
nostic populations than those for whom they were designs, also called adaptive designs, involve a sequence
originally developed, or to foster engagement, increase of decision rules that operationalize whether, how, or
relevance, and enhance outcomes for individuals with when and how (i.e., based on which measures) the
specific demographic characteristics. Surprisingly, out- dosage (i.e., frequency, duration, and/or amount), type,
side of studies on DBT, relatively few studies investi- or delivery of treatment is effective for those receiving
gated adaptations made specifically to address the intervention. These studies are designed such that
comorbidity. The development and testing of protocols participants can be re-randomized at decision points
that specifically address commonly co-occurring diag- based on their response to the adapted intervention,
noses such as PTSD and substance abuse (Foa et al., without compromising the integrity of the study (Almi-
2013; Kaysen et al., 2014) are important advances in rall & Chronis-Tuscano, 2016; Chow, 2014). The Mul-
the literature. However, due to the relatively high rates tiphase Optimization Strategy (MOST framework
of comorbidity in routine care and questions about involves first identifying strategies to address a specific
how to apply EBPTs when comorbid diagnoses are need, and then conducting pilot work before evaluating
present, further research on whether, when, and how the overall effect of the intervention (Collins, Murphy,
to adapt protocols to address comorbidity is necessary. & Strecher, 2007). This design is useful for identifying
Furthermore, studies on modular and transdiagnostic promising adaptations before conducting a full evalua-
protocols (Barlow et al., 2011; Fairburn et al., 2009; tion. Microtrials can also be used to evaluate the benefits
Weisz et al., 2012) can provide critical information on of discrete treatment elements prior to a larger-scale
application of cross-cutting EBPT strategies to address adoption of an adaptation (Leijten et al., 2015). To bet-
multiple psychiatric conditions. ter examine adaptation as it occurs in routine care,
RCTs could compare a standard protocol to a condition identified treatment elements that could not be
in which clinical latitude in making adaptations to a removed without impacting outcomes (Barlow, Craske,
protocol is permitted. The study by Schulte et al. (1992) Cerny, & Klosko, 1989; Craske, Brown, & Barlow,
is a good example of a study of this nature, as is a study 1991). Removing a relaxation component from a treat-
by Jacobson, Schmaling, Holtzworth-Munroe, and Katt ment for PTSD may have a very different impact than
(1989) that was not included because it focused on mar- removing another cognitive or behavioral component,
ital therapy rather than a therapy for a specific disorder. and yet clinicians appear to be less likely to deliver the
Although other studies gave clinicians latitude in apply- exposure and cognitive components (Thompson et al.,
ing a circumscribed set of adaptations (Galovski et al., 2016; Wilk et al., 2013). Practice-based studies that
2012; Levitt et al., 2007), some of the adaptations that randomize patients into conditions in which a single
are seen in routine care (Cook, Dinnen, Thompson, element, such as relapse prevention or cognitive
et al., 2014; Stirman, Calloway, et al., 2013) were not restructuring, is added, integrated, or removed can add
represented in this research. By providing real-time data to the literature on what forms of adaptations are effec-
on adaptations that are made to address issues that are tive in specific populations and contexts, and the find-
most common in particular clinical settings, practice- ings may be more convincing to clinicians.
based studies and process research can complement Furthermore, even when a study is designed to allow
guidance provided by RCTs and shed light on the for clinical latitude in making adaptations, assessing the
impact of adaptations that occur in routine care (Cham- types that were made in each session in conjunction
bers & Norton, 2016). This information can contribute with corresponding symptom assessment can facilitate
to an empirical basis for selecting, modifying, or remov- an examination of whether certain types of adaptations
ing strategies described in EBPT protocols. Although result in session-by-session or overall symptom change,
some populations may benefit from stricter adherence using analytic strategies such as latent variable analysis
while others may experience more improvement from or piecewise regression models.
adapted protocols (Jacobson et al., 1989; Schulte et al., Designs that allow within- and between-subject
1992; Strunk, Brotman, & DeRubeis, 2010; Strunk, comparisons (e.g., ABA designs) can be useful for inves-
Brotman, DeRubeis, & Hollon, 2010; Williams et al., tigating certain adaptations such as adding, removing,
2014), practice-based investigations to determine cir- and loosening structure. When the removal of specific
cumstances under which flexibility is and is not indi- aspects of the treatment would have a significant impact
cated would also be clinically useful. on the feasibility of delivery in a particular setting, a
Attention to study design, in practice-based research noninferiority study design may also be appropriate. In
or future trials, can result in greater clarity regarding the examining clinical outcomes, benchmarking method-
impact of modifications to EBPTs. The types of adap- ologies are typically more informative than open trials
tations that are made should be carefully characterized or case series, and in routine care settings, rapid cycle
because, as illustrated by the different meta-analytic testing strategies can also be employed to inform deci-
strategies employed by Ahn and Wampold (1999) and sions about whether adaptations should be made in
Bell et al. (2013), the impact of specific adaptations can specific contexts (Chambers et al., 2013). Finally, to
be obscured when different types are examined better guide the process of adaptation in routine care, it
together. Even within the different forms of adaptation is also important to understand whether outcomes differ
that we have examined, the nature and content of the when changes are carefully planned in advance after
adaptations may vary and may have implications. For examining practice-level data and the existing literature
example, some studies showed that adding response versus when they are made in session, on an individual
prevention for exposure yielded additional benefits basis as challenges to EBPT delivery arise (Moore et al.,
(Hiss, Foa, & Kozak, 1994), and other studies showed 2013). In contrast to the studies in this review, there is
that certain treatment elements could be removed evidence to suggest that in routine care settings, many
without negatively impacting outcomes (Jacobson adaptations are reactive and made for logistical rather
et al., 1996; Resick et al., 2008). Yet some studies than theoretical reasons (Aarons, Green, et al. 2012;

Aarons, Miller, et al., 2012; Cooper et al., 2016; Stir- may be greater for adapted interventions. If symptom
man, Calloway et al., 2013; Stirman, Miller et al., outcomes are not degraded substantially, such additional
2013). Studies that are designed to allow tests of moder- consideration may justify adaptations even if their impact
ation may also shed light on whether adaptations may on symptoms alone does not. Understanding what out-
be more or less useful for individuals with specific char- comes are critical to key stakeholders and assessing those
acteristics. The potential moderating influence of factors outcomes can better inform implementation of EBPTs
that might suggest that adaptations are necessary should in routine care settings.
also be taken into account when designing methods and Despite the importance of examining the existing
analysis to examine the impact of adaptations or modifi- literature that has investigated the impact of adaptations
cations in process research. The timing of data collection of EBPTs on patient outcomes, there are several limita-
and identification of adaptations should be carefully tions to the current study. The first is the potential for
considered in order to establish temporal precedence of the “file drawer” effect, which may have resulted in a
an adaptation when investigating its relationship to bias toward publication of studies with positive results.
changes in symptoms, functioning, or other outcomes, We caution against decisions to implement adaptations
and to facilitate analyses to explore mediation and mod- that have not been more rigorously investigated, partic-
eration. ularly without an evaluation plan. Another limitation is
Although large-scale research may not be feasible in the possibility that our search strategy did not capture
every case, it may be the appropriate and necessary all relevant studies. Despite our use of systematic
strategy to address some questions regarding adaptation review search strategies, some studies that contained
and modification. For example, using methodologies to adaptations may not have been captured in our search,
aggregate evidence from different trials would produce due to the use of different terminologies, a lack of
large samples and common measures to evaluate what emphasis on adaptations in the methods sections or
forms of adaptations have worked for whom. Such abstracts, or insufficient descriptions of the adaptations
strategies have been used to examine variations of that precluded accurate coding. Additionally, some pri-
interventions targeting obesity (Belle et al., 2016; Tate mary sources did not provide sufficient information to
et al., 2016). Other potential strategies include use of calculate bias-corrected effect sizes. The number and
dashboards to track adaptations and outcomes metrics, design of the primary studies that were identified for
and could support the evaluation of multiple trials or most adaptations did not allow for the application of
practice-based research on adaptation (Chambers & rigorous meta-analytic strategies that would yield more
Norton, 2016; Rith-Najarian, Daleiden, & Chorpita, firm conclusions about the impact of different forms of
2016). Larger-scale research, including the pooling of adaptation. This study also did not focus on all present-
practice-based data collected using common method- ing problems, on non-EBPTs, on preventive interven-
ologies, would allow a better understanding of whether tions, or on interventions such as parenting programs,
specific patient-related factors that may drive the need which have been the focus of other reviews (Baumann
to adapt are moderators of outcomes, and whether the et al., 2015). Although some context-level adaptations,
adaptations themselves predict outcomes of interest such as the delivery of EBPTs in settings other than
(Baumann, Cabassa, & Stirman, 2017). those for which they were originally tested, were rep-
Even if specific differences are not found in terms of resented because they accompanied the content-level
symptom change, there may be other contextual reasons adaptations that we reviewed, the current review does
to adapt treatments, such as increasing acceptability, fea- not include a comprehensive review of contextual
sibility, engagement, accessibility, patient satisfaction, adaptations. Particularly because the context of treat-
cost, and efficiency (Chen, Olin, Stirman, & Kaysen, ment delivery can drive adaptation (Aarons, Green,
2017). Thus, data beyond symptom measurement should et al., 2012; Aarons, Miller, et al., 2012; Chen et al.,
be collected in future adaptation studies. For example, 2017), studies of this nature can further inform imple-
therapist and patient satisfaction with the standard and mentation efforts that include adaptations to the setting,
adapted treatments have generally not been reported but mode of delivery, population, and treatment provider.
CONCLUSIONS B., & Chaffin, M. J. (2012). Dynamic adaptation process
It is well established in both implementation theory and to implement an evidence-based child maltreatment
research that clinicians adapt and modify EBPTs when they intervention. Implementation Science, 7. https://doi.org/10.
use them in routine care settings. This review described 1186/1748-5908-7-32
limitations in the design of studies to date that make it diffi- Aarons, G. A., Miller, E. A., Green, A. E., Perrott, J. A., &
cult to determine the implications of most types of adapta- Bradway, R. (2012). Adaptation happens: A qualitative case
study of implementation of the Incredible Years evidence-
tions on clinical outcomes, and highlighted gaps in the
based parent training program in a residential substance
existing research literature. Although relatively few studies
abuse treatment program. Journal of Children’s Services, 7,
demonstrated clear improvements when adapted protocols
233–245. https://doi.org/10.1108/17466661211286463
were compared to standard protocols, we found little evi- Ahn, H., & Wampold, B. E. (2001). Where oh where are
dence that most adapted protocols were associated with the specific ingredients? A meta-analysis of component
substantial degradation in clinical outcomes. However, few studies in counseling and psychotherapy. Journal of
studies investigated adaptations and combinations of adapta- Counseling Psychology, 48, 251–257. https://doi.org/10.
tions in routine care contexts. Further investigation of clini- 1037/0022-0167.48.3.251
cal latitude, practice-based research, and additional Almirall, D., & Chronis-Tuscano, A. (2016). Adaptive
comparisons of adapted and standard EBPTs can provide interventions in child and adolescent mental health. Journal
much-needed guidance on when, for whom, and how of Clinical Child & Adolescent Psychology, 45, 383–395.
adaptations should be made to EBPTs. https://doi.org/10.1080/15374416.2016.1152555
Barber, J. P., Gallop, R., Crits-Christoph, P., Frank, A.,
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Effort on this work was partially supported by National M. (2006). The role of therapist adherence, therapist
competence, and alliance in predicting outcome of
Institute of Mental Health Grants R21 MH 099169 and
individual drug counseling: Results from the National
R01 MH 106506 (Stirman) and K23 MH 103396 (Gut-
Institute on Drug Abuse Collaborative Cocaine Treatment
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NIH/VA-sponsored Training Institute for Dissemina- org/10.1080/10503300500288951
tion and Implementation Research in Health and the Barber, J. P., Triffleman, E., & Marmar, C. (2007).
Implementation Research Institute (R25 MH080916). Considerations in treatment integrity: Implications and
These entities had no role in the study design, collection, recommendations for PTSD research. Journal of Traumatic
analysis, or interpretation of the data, writing the manu- Stress, 20, 793–805. https://doi.org/10.1002/jts.20295
script, or the decision to submit the article for publica- Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S.
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in recurrent depression: A randomized dismantling trial.
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Empirical Examinations of Modiﬁcations and Adaptations to Evidence‐Based

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