The current study provided data on the sustained adoption of an evidence-based treatment, problem-solving therapy (PST), among 40 clinicians trained to a high degree of proficiency. Most of the PST-trained clinicians surveyed reported using PST in their clinical practices either frequently or occasionally, and many reported having modified PST according to patient preferences and characteristics. Our findings extend the results of an earlier study, in which nearly all of a group of 11 family medicine residents trained in PST reported they continued to use PST three years after receiving training, often in modified form [15
Limitations of the present study include its small sample size, moderate response rate, and reliance on clinicians' self-reported behavior. Given that almost 90% of clinicians in our study had been trained in PST as part of a research study, it is possible that our sample may have been more highly motivated than clinicians without this background to continue using an evidence-based approach like PST after training. It is also possible that clinicians who responded to the survey were more likely to use PST than those who did not respond. Nevertheless, there was considerable variability within our sample concerning clinicians' theoretical orientation, years of experience, and the manner in which clinicians chose to apply PST in their clinical practices. Indeed, it was interesting that so many clinicians reported modifying PST despite their research background.
Tailoring an evidence-based treatment according to client needs and preferences, as well as provider expertise and resources, is consistent with the principles of evidence-based behavioral practice. Evidence-based behavioral practice, or EBBP, has been described as a process whereby clinical judgment and client-specific needs are integrated with empirical evidence concerning various treatment approaches in the selection and application of interventions [16
]. If, as our results suggest, modification of a structured treatment protocol is common, it may be useful for trainers and supervisors to explicitly discuss how to individualize EBTs for diverse clients while maintaining fidelity to the treatment's core components (cf. the use of a modular approach to training, [17
]). Trainers might emphasize the rationale and empirical justification for each component of an EBT so that clinicians can judiciously apply or adapt each component. For example, the empirical evidence supporting the use of “homework assignments” in behavioral therapies [18
], including PST [15
] might be used to reinforce the rationale for asking clients to work on solving problems outside of sessions.
Feedback from clinicians with experience using the treatment in the field, such as that provided by the clinicians in our survey, may help to identify treatment components that are easier or more difficult to implement and provide rich examples of creative applications of core components [19
]. For example, several PST-trained clinicians noted that they had developed new homework forms to meet the needs of the client and/or setting. In future studies, it would be useful to elicit specific examples of the ways clinicians had adapted PST. The questionnaire could be modified to focus on each of the seven steps of PST in turn, asking about ease and frequency of use as well as examples of modifications they have made to those steps. We might acquire a more objective, in-depth understanding of sustained adoption of PST by observing video or audio tapes of therapy sessions recorded months or years after training. In addition, we might track other factors that may influence implementation, such as characteristics of the clinical population or the setting in which the treatment is provided (cf., [2
Our results provide initial support for the IMPACT training model as a means to promote sustained adoption of PST, but must be replicated in larger studies where adherence and modifications to the structured protocol are assessed objectively. Given the documented scarcity of research on what happens to evidence-based treatments after dissemination [4
], the current study represents an initial attempt to “follow” an EBT into regular clinical practice. Effective dissemination and implementation of EBTs depend on an understanding of how the therapists who will ultimately deliver those treatments respond to and use the training they receive.