Demographics Characteristics
Participants who completed the initial survey about therapists’ beliefs regarding the TN were predominantly female (n=60, 92.3%), master’s level (n=61, 93.8%), licensed (n=34, 52.3%) therapists with a mean age of 34.26 years (SD=10.62). The racial makeup of the sample was as follows: white (n=47, 72.3%), black (n=11, 16.9%), other (n=6, 9.2%), Asian (n=4, 6.2%), American Indian or Alaska Native (n=1, 1.5%), and Native Hawaiian or Other Pacific Islander (n=1, 1.5%). The majority identified as non-Hispanic or Latino (n=49, 75.4%). In the initial survey, 47.7% of therapists reported that they did not use TNs with patients receiving TF-CBT over the last 6 months. Participants who completed the qualitative interviews were all female (n=17, 100%), master’s level (n=17, 100%), predominantly licensed therapists (n=11, 64.71%) with a mean age of 32.24 years (SD=9.74). The racial makeup of the sample was predominantly white (n =15, 88.24%), with other participants identifying as black (n=1, 5.88%) and other (n=1, 5.88%). The majority identified as non-Hispanic or Latino (n=13, 76.47%). Analyses comparing demographic characteristics of those who did and did not complete qualitative interviews showed that the two groups did not differ on any characteristics except likelihood of using TNs with the majority of patients receiving TF-CBT; participants who completed qualitative interviews were significantly more likely to report planning to use TNs in the next six months, t(43.57) = -3.73, p = .001. See Table 1 for the demographic characteristics of the sample.
Application of Behavioral Insights
Figure 1 summarizes the iterative process we used to analyze the qualitative interviews and to generate our final results. Step 1 generated 53 barriers and facilitators, coded in the therapists’ own language. In Step 2, we organized these 53 barriers and facilitators into 11 broad themes using a thematic analysis. In Step 3, coders further reduced, distilled, and synthesized the barriers and facilitators into 36 barriers and facilitators under the 11 broad themes. In Step 4, the codes were mapped onto behavioral insights, and resulted in 18 behavioral insights organized under three broad themes, which the experts validated in Step 5. In Step 6, coders mapped the 18 behavioral insights (organized under three broad themes) onto 9 EAST-informed implementation strategies. Table 3 displays the final list of three broad themes that organize the final set of hypothesized barriers and facilitators; the barriers and facilitators coded in the therapists’ language; the behavioral insights that correspond to them; and behavioral insights-informed implementation strategies generated from this process. Exemplar quotes from therapists are also included in the table to demonstrate the data we used to generate these hypothesized barriers, facilitators, behavioral insights, and implementation strategies.
Decision Complexity
Barriers and Facilitators. One theme that emerged relates to the complexity of TN decision-making. Some therapists reported that any aspect of complexity that was introduced into the decision-making process (e.g., client psychosocial stressors, client symptom and trauma severity, client developmental level, or integrating other therapeutic techniques) all make the TN more challenging to implement. Therapists appeared to display an inflexible understanding of the TN. Hypothesized barriers along this theme were: “Doing the trauma narrative means I can’t incorporate other therapeutic modalities,” “Some clients make it hard,” “My clients need to have their basic needs met before they can do the trauma narrative and therefore, what I do doesn’t matter in the grand scheme of things,” and “My clients have more severe psychopathology or complex trauma.”
Conversely, some therapists reported strategies to manage, reframe, or reduce the complexity to facilitate TN implementation (i.e., “I have to prioritize which traumas to treat; I can’t do everything and take the client’s lead on this,” “I can’t do everything for a kid and my agency gives me leeway to take more time with my clients who have a lot of psychosocial stressors,” and “I reframe what my client’s goals are based on their needs”). Therapists experienced in other EBPs described this as an asset (“I can incorporate other evidence-based practice techniques when it is clinically relevant”).
Application of Behavioral Insights. These barriers and facilitators all revealed several behavioral insights about therapists’ decision-making to use the TN. These include: “choice overload/decision fatigue,” “lack of reinforcement,” “helplessness/hopelessness,” “base rate fallacy/mental models,” and “functional fixedness.” As is described in Table 2, choice overload is a cognitive process in which people have a difficult time making a decision when faced with many options. This phenomenon is highly related to decision fatigue, which describes the fatigue and impairment people experience the more decisions they make. When therapists encounter patients with severe psychopathology, psychosocial stressors, and other challenges, they feel overloaded or fatigued, which is a barrier. Other therapists reported strategies such as a reframing their goals for their clients, accepting that the TN would not solve all their clients’ problems, thereby discovering methods to reduce their choices.
Therapists who felt that certain clients were more suited to the TN revealed their tendency to commit the “base rate fallacy” and their tendency to employ specific “mental models.” The base rate fallacy refers to when therapists believe that aggregated data do not apply to individual patients. Mental models are people’s internal representations of a problem. Therapists revealed that their understanding of a “straight-forward” TF-CBT case is different from the types of clients they see. In terms of their mental models, therapists who felt like they could incorporate other techniques were able to understand the abstract principle of the TN—the purpose it serves as a therapeutic tool—and not the particular or concrete way it is taught in training—often as a written narrative. Therapists who reported an ability to include other techniques in TN implementation displayed different mental models than therapists who felt constrained to the written narrative form. Therapists’ perception of the TN as rigid relates to the phenomenon of “functional fixedness.” Functional fixedness describes, therapists’ perception that the TN can only be used in the way it is traditionally used (i.e., in written form). This mental block prevents therapists from integrating their other clinical skills that would help clients heal from trauma.
Therapists described not feeling rewarded for their work. Positive reinforcement is a well-established principle, which describes the increased frequency of behaviors when they result in rewards. Therapists reported not feeling rewarded for the uncompensated work they do to prepare for the TN. Some therapists suggested that despite their attempts to implement the TN, due to factors outside of their control (e.g., the client’s psychosocial stressors, clients missing sessions) they felt insufficiently rewarded for their work, and therefore less inclined to attempt the TN. This continued lack of reinforcement led some therapists to experience helplessness and hopelessness about their clients’ progress as well as disappointment that the TN does not solve all their clients’ challenges. Some therapists managed to avoid experiencing the lack of reinforcement by managing their expectations and reframing their goals for clients. These therapists avoided feeling helpless and hopeless about the TN.
Behavioral Insights Informed Implementation Strategies We generated some examples of a broader set of implementation strategies that would target these behavioral insights. Given the functional fixedness and mental models displayed by therapists, we used EAST to develop an implementation strategy that would enable therapists who are more flexible to influence those who are less flexible. This strategy to “make it social and attractive” would involve therapists who incorporate other EBPs into their TN to distribute stories/guides describing how they do this. For therapists who believe that certain clients make the TN easier/harder, revealing mental models and choice overload, we designed a strategy to “make it easy” by having supervisors or TF-CBT trainers show therapists narratives of clients with challenging presenting symptoms, or who may seem ill-suited for the narrative initially. For therapists who are concerned about their clients having their basic needs met, feeling helpless or hopeless, we designed a strategy to “make it easy.” Assigning a case manager or lay peer specialist to provide support around their clients’ basic needs would enable therapists to focus on their therapeutic work, while shifting the task of case management to another individual. For therapists who had choice overload/decision fatigue relating to their clients’ severe psychopathology and multiple traumas, we designed a strategy to “make it easy” by developing a decision aid (such as a checklist, trauma hierarchy, or flowsheet) which uses the patient’s symptoms and other clinical characteristics to guide TN priorities.
Therapist Affective Experience
Barriers and Facilitators. Another broad theme that emerged was therapists’ affective experiences either preparing for or completing the TN. Some therapists reported that preparing to implement the TN made them anxious (“The flexibility makes me anxious,” “Implementing the trauma narrative comes with risks—patients can decompensate”) whereas others reported that the experience of the TN itself was an emotional challenge (“The trauma narrative is gory and difficult to hear”). Other therapists reported that they did not feel rewarded for attempting to do the TN because clients often miss sessions (“I lose momentum when clients do not consistently attend”).
Therapists cited various facilitators to improve their affective experiences. Contrary to therapists who reported feeling anxious about the flexibility or about hearing the TN, other therapists reporting seeking guidance and support from their supervisors and reframing their perspective about the TN (“I receive support and resources from my supervisor,” “I receive encouragement from my supervisor that assures me that clients are resilient,” and “I understand the rationale of the TN and can withstand the gory details”). Therapists who might feel dismayed by inconsistent attendance instead created rules to ensure that clients would consistently attend (“I plan ahead to emphasize consistency of attendance”).
Application of Behavioral Insights. These barriers and facilitators revealed several behavioral insights about therapists’ decision-making to use the TN. These include: “risk/loss aversion,” “fear avoidance/ostrich effect,” “lack of reinforcement,” “helplessness/hopelessness,” “base rate fallacy/mental models,” and “functional fixedness.” As is described in Table 2, risk/loss aversion is the tendency to prefer avoiding losses to acquiring similar gains. Therapists may perceive the risk of conducting the TN as more salient than the benefits it offers. Fear avoidance is the tendency to avoid thoughts or actions that cause people fear. The Ostrich effect is a related phenomenon; it describes people’s tendency to ignore obvious, often negative, information because it is inconvenient or anxiety-inducing. Therapists may avoid implementing the TN because it is difficult for them—they may not be as skilled in the TN as they are in other practices. Therapists may not want to do something that makes them feel incompetent or nervous. Some described fearing TN details because they are challenging to hear and potentially traumatic. As with the barriers and facilitators relating to decision complexity, some therapists reported feeling little reinforcement for their work and helpless and hopeless about their clients’ prospects.
Therapists who were able to manage their expectations and goals for their clients tended to see the TN as easier to implement, and displayed less risk/loss aversion, fear avoidance, and helplessness/hopelessness. Many indicated that they understood they could not solve everything in their clients’ lives, reframing their expectations and mitigating the potential lack of reinforcement. Some therapists reported seeking support and encouragement from their supervisors, reaffirming the rationale of the TN to themselves, and planning ahead to ensure that clients do not consistently lose momentum. Therapists’ strategies to seek positive reinforcement from their supervisors/agencies involved seeking it outside of the client’s progress. This allowed therapists to feel rewarded for their efforts irrespective of the forces outside of their control.
Behavioral Insights Informed Implementation Strategies. These behavioral insights led to the design of various implementation strategies that would help shape therapists’ affective experiences to increase TN implementation. For therapists who reported anxieties about the flexibility of the narrative, we generated an implementation strategy that would “make it easy,” by developing a toolkit or workbook of resources for the TN, serving as both a template and a toolkit of creative ideas. Some TF-CBT therapists cited already using templates as a facilitator. For therapists who reported losing momentum due to clients’ inconsistent attendance, we designed a strategy to “make it attractive and easy” by incentivizing clients to attend session with financial compensation and arranged transportation. This would indirectly address the affective experience of therapists by making it less likely that clients miss sessions. For therapists who worry about the TN being risky (i.e., clients decompensating), we generated an implementation strategy to make it “easy and social.” This strategy involves using clinical supervision to do an imaginal exposure about a patient decompensating, effectively treating the anxiety of the therapists. For therapists who reported that the TN can be gory and difficult to hear, we generated a strategy that would “make it social,” i.e., develop a peer consultation model where therapists can support one another and discuss challenging cases.
Agency Norms
Barriers and Facilitators. The final theme that emerged from the interviews related to norms at different mental health agencies. Some therapists reported that most therapists at their agencies don’t do TF-CBT or supervisors don’t prioritize TF-CBT, which makes it challenging for them to implement the TN. At other agencies all therapists use TF-CBT and supervisors expect to discuss the TN during supervision.
Application of Behavioral Insights. Barriers and facilitators relating to agency norms reveal the behavioral insight that therapists are influenced by the “default bias” and “social norms.” The default bias describes people’s preference for the status quo. In this case, therapists prefer the current state of affairs, or the current practices they typically use in their clinical work. This default is taken as a reference point, and any change from that baseline is perceived as less preferable and sometimes aversive. “Social norms” arise when people do something primarily because others like them do. Therapists may feel that if others at their agency do not use the TN, they won’t either. Conversely, if others at their agency are using the TN, they would be more likely to implement it.
Behavioral Insights Informed Implementation Strategies. To address social norms and default bias, we generated an EAST-informed implementation strategy to “make it easy and social.” This strategy makes use of the electronic health records therapists typically use to record treatment progress notes. Agencies and supervisors would create templates in the electronic health record that require therapists to describe their attempt to implement the TN. Therapists would be prompted to write an extensive justification if they do not attempt the TN in session. Establishing a default practice ensures that the status quo is to use the TN, and creates a social norm that everyone at the agency implements the TN. The health record accountable justification will be effective at prompting therapists to explain why they didn’t use the TN with the knowledge that their supervisor will view this explanation. Strategies prompting clinicians to provide “accountable justifications” embedded in electronic health record notes have been effective at increasing the use of other EBPs in medical settings (24).