How to Bend but Not Break an Empirically Supported Treatment for Anxiety in Youth

This chapter addresses the treatment of youth anxiety. Cognitive behavioral therapy (CBT) for youth anxiety, as illustrated by the Coping Cat program, is implemented flexibly based on considerations including age/developmental level, co-occurring disorders, socioeconomic status, and cultural factors to enhance outcomes. For fidelity, the program adheres to key components: building rapport, providing psychoeducation about anxiety, addressing anxious self-talk, conducting exposures, assigning homework, and providing rewards/praise. The essential components, however, are applied with flexibility. Ultimately, research is needed to evaluate strategies to increase continued fidelity to the core components of treatment. Peer consultation and supervision may be valuable for maintaining fidelity while flexibly applying the program to a specific client.

Post-Traumatic Stress Disorder Treatment with Adults

This chapter describes the theoretical models behind evidence-based post-traumatic stress disorder (PTSD) treatments and the importance of adhering to the model of PTSD treatment when making adaptations to treatment protocols. We review modifications that might be made for both exposure-based and cognitive-based treatment approaches, rooted in their respective underlying theories. We also describe modifications to the delivery of treatment (e.g., number and duration of treatment sessions, method of treatment delivery, and location where treatment is delivered). Throughout the chapter, we emphasize that decisions regarding modifications should aim to foster mechanisms of change, based on theoretical models, and implemented to maximize treatment outcomes.

Empirically Supported Treatment for Obsessive-Compulsive Disorder

This chapter assesses which treatment should be chosen as the first-line intervention for obsessive-compulsive disorder (OCD). Cognitive Behavioral Therapy (CBT) involving Exposure Plus Response Prevention (ERP) is the treatment with the most empirical support, and its effects appear to be both robust and durable. The chapter then reviews the data on predictors and moderators of differential ERP outcomes. Contemporary ERP manuals emphasize the following core procedures: (1) psychoeducation; (2) hierarchy development; (3) in vivo and imaginal exposure; (4) response prevention; and (5) relapse prevention. The chapter looks at situations in which clinical circumstances dictate a deviation or modification of the protocol from the way these procedures are described in the manual or customarily implemented—being flexible while maintaining fidelity. Therapist experience appears to play a role in how comfortable clinicians are in being flexible, and how successful they are likely to be when they do so.

Treatment of Chronic Pain

Chronic pain is a highly prevalent condition that causes substantial impairment in many domains of life. Recent advances in pain research have elucidated the many biological, psychological, and social factors that can contribute to and impact the subjective experience of pain. In addition to treating patients using medications to manage pain, psychological treatments have now been developed and tested and found to significantly improve the severity of pain and the negative mood that often accompanies pain, as well as disability and impairment. Cognitive behavioral approaches are now considered the “gold standard” psychological treatment for pain. To maximize their efficacy, however, these treatments are not implemented rigidly; rather, they are tailored to the particular needs of the patient. This chapter covers the essential treatment components for pain and offers therapists ideas for effectively tailoring treatment to individual patients, so that pain treatment can be implemented flexibly, but with fidelity.

Flexible Principles for the Treatment of Adult Worry

This chapter outlines various empirically supported cognitive-behavioral strategies driven by current understanding of worry-related mechanisms that may be implemented in the treatment of chronic worry. Excessive and uncontrollable worry is reliably observed across anxiety disorders, and it is most evident in generalized anxiety disorder (GAD), of which it is the cardinal symptom. At present, achieving treatment fidelity for cognitive behavioral therapy (CBT) for excessive worry requires cognitive restructuring—wherein targets can range from challenging overestimation of likelihood, severity of negative outcomes, or metacognitive beliefs about worry—and exposure, either in vivo or imaginal, as a means to provide extinction learning around feared outcomes involving uncertainty or aversive emotional experiences. It also requires behavioral experimentation through which worry-related cognitions are tested and challenged through “real-life” experiences, which may involve stimulus control/worry postponement; explicit removal of safety behaviors throughout all components of treatment; and incorporation of strategies to enhance problem orientation. Using a case formulation-driven approach, these elements can be flexibly applied in a systematic, responsive, and data-driven manner to target the deficits present in the individual.

Tourette and Trichotillomania

This chapter explores the treatment of trichotillomania (TTM; also referred to as hair pulling disorder) and Tourette disorder (TD). TTM and TD exist in separate diagnostic categories but exhibit functional similarities and respond to similar treatments. The chapter reviews the characteristics of each disorder. It then describes habit reversal training (HRT) and function-based interventions, which serve as core therapeutic elements in the treatment of both TTM and TD. The chapter also discusses additional treatment strategies that occur as part of standard protocols for both disorders, before looking at the treatment efficacy research. It considers the key features of the manual-based treatments (behavior therapy protocols), as well as ways these protocols can be flexibly implemented for those with TTM and TD. Finally, consistent with the call for “flexibility within fidelity,” the chapter provides an example of a flexible implementation of these treatments.

Introduction

Do research findings apply to an individual case? Although the answer is yes, we are tempted to think that an individual case, for whatever reason, is somehow an exception (we fall prey to a cognitive processing error). We can be flexible when applying an empirically supported treatment (EST). Research findings typically carry more weight than the “features” of the individual. Take the client’s features into account and apply the known-to-be-effective treatment with flexibility... flexibility within fidelity.

Cognitive Behavioral Therapy for Social Anxiety Disorder

This chapter discusses the efficacy of cognitive behavioral therapy (CBT) for the treatment of social anxiety disorder (SAD). SAD is a mental health condition marked by impairment and distress across a number of social situations. Manual-based, workbook-driven protocols for CBT for SAD hold promise for promoting evidence-based practice across clinical settings. Not only does the protocol offer a structured framework to guide therapists through therapy sessions, but it also provides clients with their own set of resources to bolster what is learned in the therapy room and bring it into their daily lives. These materials emphasize the importance of a person-centered approach to treatment that can be applied flexibly and adapted to the needs of the individual client. Although key components of the treatment are required for fidelity, there is substantial flexibility built into the structure of the protocol and each component, including the number of treatment sessions, the approach to cognitive restructuring, the content of the fear and avoidance hierarchy, the focus of exposure exercises conducted in session and as homework assignments, as well as how comorbid psychological disorders are addressed.

Flexible Applications of Family-Based Therapy for Youth with Bipolar Spectrum Disorders

Bipolar spectrum disorders (BPSD) affect approximately 3.9% of youth and are associated with meaningful impairments across social, academic, and family domains. Early psychosocial treatment, in conjunction with psychotropic intervention, can ameliorate the negative impact of symptoms by equipping youth and their families with knowledge and skills to promote understanding and management of the disorder, leading to improved short- and long-term outcomes. Family-focused treatment for adolescents (FFT-A), family-focused cognitive behavioral therapy (CFF-CBT), and psychoeducational psychotherapy (PEP) represent a well-established class of manual-based interventions that have been found to improve mood symptoms and family functioning through the use of family psychoeducation and skill building. We detail and discuss the core components of these interventions, with a specific focus on how treatment components can be successfully adapted and delivered to ensure an individualized approach for optimal care. Flexibility is further illustrated by a depiction of ways in which PEP has been adapted to meet practical needs of families and clinicians while maintaining fidelity to the intervention.

The Coping Power Program for Children with Aggressive Behavior Problems

Flexible adaptations of the Coping Power Program have been made for the delivery of the program. Coping Power is a structured, manualized cognitive-behavioral program, with components for children and parents designed to alter targeted mechanisms that contribute to children’s aggressive behavior problems. The program originated as a targeted prevention program, delivered in school settings, but also has been applied and tested in clinical settings. The contextual social-cognitive model is described, followed by a brief description of program components, of fidelity assessment, and of results from several initial randomized controlled efficacy studies. The bulk of the chapter describes two types of adaptations of the program. The first adaptation is evident in a field trial study of real-world school counselors’ use of the program, and was affected by the intensity of training that counselors received and by their own characteristics and the characteristics of their work setting. Appropriate and inappropriate adaptions were observed, with appropriate adaptations illustrating the concept of flexibility within fidelity. The second type of adaptation involves efforts to optimize the program and to test planned changes. The chapter describes evaluations of planned adaptations to the length of the program (including Internet components), to program targets through inclusion of mindfulness training, to delivery of the program in group versus individual formats, and to a variety of changes made in the structure and cultural relevance of the program in international adaptations.