Therapist Report of Adaptations to Delivery of Evidence-Based Practices Within a System-Driven Reform of Publicly Funded Children's Mental Health Services

Objective: This study examined clinical adaptations reported by community therapists to multiple evidence-based practices (EBPs) currently implemented in children's mental health services. Based on an item set informed by Stirman and colleagues' model (2015), 2 factors emerged describing Augmenting adaptations and Reducing/Reordering adaptations. We used multilevel modeling to examine therapist-and practice-level predictors of therapist reports of each type of adaptation. Method: Data were drawn from an online survey, including a novel therapist report measure of EBP adaptations, completed by 572 therapists (89.2% female, M-age = 37.08 years, 33.4% non-Hispanic White) delivering EBPs in the context of a system-driven, fiscally mandated implementation effort. Results: Analyses revealed that the 2 types of therapist adaptations (Augmenting and Reducing/Reordering) could be readily discriminated, with therapists reporting significantly more Augmenting than Reducing/Reordering adaptations. Therapists of Hispanic/Latino ethnicity and with fewer years of experience reported more extensive Augmenting adaptations, but no therapist background characteristics were associated with Reducing/Reordering adaptations. Therapists' general attitudes that EBPs diverged from their personal approach to therapy were associated with reporting more Augmenting and Reducing/Reordering adaptations. In contrast, negative perceptions toward the specific EBP predicted Reducing/ Reordering adaptations, but not Augmenting adaptations. Conclusions: Community therapist reports suggest that most adaptations undertaken involve engaging with the practice to augment the fit of the EBPs for local contexts; however, when practices were perceived negatively, therapists were more likely to make adaptations reducing or rearranging components. What is the public health significance of this article? Increased efforts have focused on implementing EBPs in publicly funded mental health settings, but research is needed to understand the inevitable process of community therapists' adaptation of practices. This study is the first to identify how therapist reported adaptations vary across multiple EBPs within a mental health system reform. Findings suggest most therapists report augmenting EBPs to fit the local context, whereas adaptations reducing or rearranging EBP components are less common but more likely when therapists hold a negative view of the EBP.