3.C.2
Adapting treatment to the person and the response
ASPPB's competency statement 3.C.2: Use relevant factors (e.g., client preferences, responses to treatments/interventions, individual/diversity considerations) to adapt or change treatments/interventions
Treatments are adapted when the client's culture, values, development, abilities or circumstances call for it, or when monitoring shows too little response. Good adaptation keeps a treatment's core elements and changes how they are delivered: language, examples, pace, format or who takes part. When an adequate trial has not helped, the plan changes more deeply, to a different or added treatment. Culturally adapted interventions have outperformed unadapted versions of the same interventions.
Key ideas
- Flexibility within fidelity
- Deliver a manual's core components faithfully while tailoring examples, pacing and emphasis to the client, so that adaptation does not drop what makes the treatment work (Kendall and colleagues, 2008).
- Cultural adaptation
- Changing language, concepts, goals and methods to fit clients' culture. Across 78 studies, culturally adapted interventions outperformed unadapted versions of the same intervention, g = .52 (Hall and colleagues, 2016).
- Religion and spirituality
- Therapy can draw on a client's religious or spiritual beliefs when the client wishes. In additive trials, accommodated therapies reduced distress as much as standard versions and improved spiritual well-being more (Captari and colleagues, 2018).
- Development and ability
- For clients with cognitive, sensory or other disabilities, adapt format and access, such as concrete steps, more practice, written or visual aids and involvement of supporters the client chooses (APA Guidelines for Assessment and Intervention With Persons With Disabilities, 2022).
- Nonresponse
- When an adequate trial has not helped, revisit the formulation with the client and consider a different evidence-based treatment, an added one or a referral, rather than more of the same; monitoring is meant to prompt exactly this collaboration (Lambert and colleagues, 2018).
Worked example
A 58-year-old woman in CBT for depression is devout and active in her congregation. In session 5 she says that challenging her thoughts feels like arguing with her faith, and she has stopped the thought records. Her depression scores have not changed.
- Treat the impasse as information: ask how her faith understands suffering and hope, and which of her beliefs comfort or trouble her.
- Keep the core of CBT, examining thoughts and scheduling valued activity, but draw on her beliefs as resources, for example by asking how a teaching she trusts would answer the thought 'I am worthless.'
- Schedule valued activities that connect to her faith community, such as returning to the choir, which serve both activation and her own goals.
- Recheck scores over the next sessions; if there is still no change after a fair trial, revisit the formulation and discuss other treatments with her.
Adapt the delivery to the person while keeping the active ingredients, and change the treatment itself when an adequate trial fails.
Check yourself
When religiously accommodated therapy was compared with the same therapy without accommodation, what did Captari and colleagues (2018) find?
Sources
- Kendall, Gosch, Furr and Sood (2008), Flexibility within fidelity, Journal of the American Academy of Child and Adolescent Psychiatry (PMID 18714195), Whole article
- Hall, Ibaraki, Huang, Marti and Stice (2016), A Meta-Analysis of Cultural Adaptations of Psychological Interventions, Behavior Therapy (PMID 27993346), Abstract; adapted versus unadapted versions
- Captari, Hook, Hoyt, Davis, McElroy-Heltzel and Worthington (2018), Integrating clients' religion and spirituality within psychotherapy: A comprehensive meta-analysis, Journal of Clinical Psychology (PMID 30221353), Abstract; additive studies
- American Psychological Association (2022), Guidelines for Assessment and Intervention With Persons With Disabilities, Guidelines on intervention and accommodation
- Lambert, Whipple and Kleinstäuber (2018), Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring, Psychotherapy (PMID 30335463), Abstract; purpose of feedback