Staff Perspective: Modifying Evidence Based Treatment Protocols - Foolhardy Decisions or Strokes of Genius?

Staff Perspective: Modifying Evidence Based Treatment Protocols - Foolhardy Decisions or Strokes of Genius?

Are decisions to depart from a prescribed treatment format and content foolhardy or signs of ingenuity?  Working at a clinical training site, I will often get asked about possible modifications to treatment protocols or when it might be acceptable to deviate from a protocol.  This issue raises several important questions about clinical practice and the underlying factors that influence our choices when providing patient care.  To explore the issue of departing or making modifications to treatment protocols, I surveyed a panel of our CDP staff that has extensive experience in providing training and consultation on evidence based treatment protocols to get their feedback on the following questions.

What is a Treatment Protocol Modification?

Modifications can refer to any changes, both small and large, from the structure, content (i.e., specific interventions), or theory of a specific evidence based treatment protocol.  These changes can also be further classified into two basic categories of a priori or planned modifications and ad hoc modifications. With the first approach, there is something about a provider’s initial assessment that reveals behaviors that may interfere with treatment.  Based on this assessment, the provider modifies the treatment protocol accordingly to help the patient maximize the benefit of the active components of treatment.  For example, using audio recordings for cognitive processing therapy  (CPT) for homework assignments if the patient has severe arthritis making it difficult to write. The key here is that the decision to make a modification is done at the outset of treatment and is typically maintained throughout the course of treatment.  Ad hoc modifications are done when a patient may be experiencing some sort of difficulty with a particular aspect of a treatment protocol.  For example, titrating safety related behaviors and coping skills during in-vivo experiments.  Finally, modifications also include taking pauses in treatment, or interrupting treatment to focus on other issues.         

Common Reasons for Treatment Protocols Modifications

Although an infinite number of reasons likely exist to explain why providers deviate or make modifications to treatment protocols, I will summarize some common ones that our CDP staff has encountered. 

1)If one treatment works, than combining two must work even better.  An example of this is combing exposure interventions to cognitive processing therapy (CPT), or combining mindfulness interventions with either CPT or Prolonged Exposure (PE)

2)Making changes due to concerns about comorbid conditions like a substance use disorder.  An example of this is the deliberate exclusion of certain treatment components or homework assignments out of concern how it might impact a patient’s sobriety or recovery process.

3)Modifications to address limitations of patients. An example of this is using audio recordings instead of written worksheets for patients with low literacy skills, shortening PE sessions or combing CPT sessions due to time constraints.

4)Provider variables such as discomfort, habit, convenience or preference.  An example of this can be providers not spending enough time to review the relevant session content of a particular treatment protocol and assume that he or she is “covering everything,” or not covering certain themes as part of the CPT protocol because “it does not apply to the client.”

Treatment Protocol Modifications: Foolhardy Decisions or Strokes of Genius

The answer to this question is…it depends. The consensus from the CDP staff I surveyed was that some modifications are reasonable, warranted, and likely harmless in that they do not represent any major shifts away from the content or theory of a particular treatment protocol.  These modifications serve as a way to enhance or maximize the benefit of an active component of treatment.  Whether it is a planned modification or an ad hoc modification, these modifications can display the ingenuity of providers in addressing potential treatment barriers.  However, some modifications represent serious modifications from a protocol that may compromise the integrity, and therefore the effectiveness of the treatment.  For example, modifications made without consideration of underlying theoretical principles, regardless of the reason, are the greatest threat to outcome.  Regardless of any modification we make, no matter how minor, it is important to remember that it weakens the link between our treatment and the research that supports it.  So we need to be cognizant that we are not making so many minor modifications that we end up far removed from the original protocol and data supporting it. 

Tips for Getting Back on Track

Finally, I wanted to summarize the advice CDP staff offered about getting back on protocol.

  1. Take time to understand why you made the modification (e.g., due to comfort, avoidance, thought it would enhance treatment) and whether it makes sense with the theory of the treatment protocol.
  2. Process modification with patient, to include what might be necessary to return to the treatment protocol and evaluating the consequences of the different choices.
  3. If you have skipped over parts, return to those concepts first to ensure that the patient understands them and how they fit into the overall treatment approach.
  4. In the case of pauses or interruptions with treatment, the patient can be helped to understand the modification not as avoidance, or a statement about competence, but as a concession made so that treatment can continue when the interruption is over. Homework can be given in the interim to help maintain momentum and focus, and the impact behaviorally and cognitively can be minimized.

For more information about modifications to treatment protocols, please click on the link for a PFD document entitled: Protocol Modifications: When/Why/How by Dr. Kelly Chrestman.

Timothy Rogers, Ph.D.  is a Deployment Behavioral Health Psychologist for the Center for Deployment Psychology (CDP) at Joint Base San Antonio-Lackland Texas.  Prior to joining CDP in June 2014, Dr. Rogers served as an active duty psychologist in the United States Air Force from 2008 to 2014.  He deployed to Afghanistan in 2012 in support of Operation Enduring Freedom, establishing a new Combat Stress Clinic to provide mental health services for 3000 joint service personnel.