4 - (IOP 39) Feasting on Flexibility: Proposing a Practical Framework for Tailoring Evidence-based Treatments in Clinical Contexts

Evidence-based treatments (EBTs) have shown efficacy across various diagnoses in controlled settings; yet EBTs are not consistently implemented in clinical settings and often discontinued after initial adoption. One possible explanation may be that the protocols typically tested under controlled conditions with single presenting issues in laboratory settings may not obviously align with the diverse and evolving needs of clients in front-line service settings. This sense of misalignment contributes to the "efficacy-effectiveness gap", illustrating the challenges clinicians may face in confidently integrating EBTs into their practice. While fidelity to EBTs helps maintain treatment integrity, clinicians need to flexibly use EBTs to meet individual client needs, yet rarely receive guidance.
To address this gap, we build on previously proposed frameworks, such as Lau’s (2006) selective and direct approach and Stirman’s (2013) content and contextual modification approach, and propose a guiding framework for flexibly adapting EBTs in real-time while maintaining fidelity, drawing on the analogy of EBT manuals as "cookbooks." Just as chefs rely on their culinary skills to customize recipes without sacrificing the fundamental ingredients of a dish, clinicians need practical strategies to tailor EBTs to individual client needs while preserving the core principles of the treatment.
FEAST stands for five domains: Fitness, Engagement, Accessibility, Standard treatment principles, and Therapeutic alliance. While the five domains are presented as distinct for clarity, they are interconnected in practice. For instance, addressing treatment fit can simultaneously enhance therapeutic alliance and engagement. To further illustrate this, we conducted a scoping review of literature on tailoring Behavioral Parent Training, one of the most well-studied EBTs, to identify practical strategies for meeting diverse families’ needs. For instance, we synthesized practical strategies on improving fit and establishing therapeutic alliance across various demographic and cultural backgrounds, increasing engagement by enhancing internal motivations, and improving accessibility for families facing logistical barriers. Our findings demonstrate how the goals outlined in the FEAST framework may guide clinicians to implement EBTs in ways that are more compatible with clients’ unique contexts and needs.
This review provides clinicians with a structured yet flexible framework, FEAST, to increase the flexibility of EBTs while maintaining fidelity and highlight practical strategies clinicians can use to tailor case conceptualization and treatment as outlined in the FEAST framework. By addressing situational, contextual, and systemic factors (e.g., health disparities) that influence clients’ needs, FEAST bridges the gap between universal principles of cognitive behavioral therapy and the diverse realities of real-world practice through a person-centered lens.