Demographics Characteristics
Qualitative interview participants were women (n=17, 100%), master’s level (n=17, 100%), predominantly licensed clinicians (n=11, 65%) with a mean age of 32.24 years (SD=9.74). The racial makeup of the sample was predominantly White (n =15, 88 %), with other participants identifying as Black or African-American (n=1, 5.88%) and Other (n=1, 6%). The majority identified as non-Latinx (n=13, 76%). See Table 2 for sample demographic characteristics.
Forty-one percent of participants reported using TNs with most or all of their TF-CBT clients in the past six months. Seventy-six percent of clinicians said it was “very likely” they would use TNs with their TF-CBT clients in the next six months.
Major Findings
Three broad themes emerged from our analyses of clinicians’ responses (see Appendix B for coding results and Table 3 for TN determinants, behavioral insights, and strategies).
Decision Complexity
Decision complexity refers to the dimensions of a decision problem. The more dimensions of the problem, the more complex it is (64). Behavioral insights suggest that more complex decisions lead clinicians to take longer to decide, to make more errors when they do, and to feel less confident in their decisions (65).
TN Determinants. Clinicians who were overwhelmed by the complexity (e.g., client psychosocial and symptom complexity, client developmental level, and the variety of therapeutic techniques available) cited it as a major barrier to TN use. They described a high level of uncertainty once several features of their clients did not map onto their schema of a typical TF-CBT client. Conversely, other clinicians were able to reduce the complexity of decisions through processes like staging (i.e., breaking the decision up into its essential parts) or using decision aids (66). Clinicians experienced in other EBIs described their skills as an asset, embracing the flexibility of the model.
Behavioral Insights. The TN determinants revealed several behavioral insights: choice overload/decision fatigue, base rate fallacy/mental models, and functional fixedness. Choice overload is a cognitive process in which people have difficulty making a decision when faced with many options. This phenomenon is related to decision fatigue, which describes how the more decisions clinicians make, the poorer their clinical judgement (67). When clinicians encounter clients with severe psychopathology, psychosocial stressors, and other challenges, they feel overloaded or fatigued. Other clinicians reported strategies such as accepting that TNs would not solve all of their clients’ problems, reframing their goals, or reducing their choices.
Clinicians who described that certain clients were better suited to creating TNs were potentially committing the base rate fallacy and revealed their specific mental models. The base rate fallacy arises when clinicians believe that aggregated data do not apply to individual clients. Mental models are people’s internal representations of a problem. Clinicians revealed that their vision of a “straight-forward” TF-CBT case is different from the cases they see. Functional fixedness captures clinicians’ perception that TNs can only be expressed in written form—the particular way they were trained to implement TNs. This prevents clinicians from integrating other clinical skills that would facilitate recovery. Clinicians who incorporated other techniques understood the purpose of the TN as a therapeutic tool beyond understanding how it is regularly implemented.
Implementation Strategies. We used EAST to develop an implementation strategy that would disrupt clinicians’ mental models and functional fixedness. Showing clinicians that peers working in similar contexts can use techniques from other EBIs (e.g., evidence-based play therapy) may prompt clinicians to have more flexible mental models while at the same time providing a leading example for how other EBIs can be incorporated into the implementation of TNs (68,69). This would enable clinicians who are more flexible to influence those who are less flexible. This strategy would involve clinicians who incorporate other EBIs into TNs to distribute stories or descriptive guides.
For clinicians who believe that certain client characteristics make TNs easier/harder, revealing mental models and choice overload, we generated a strategy in which supervisors show clinicians narratives of clients with challenging presenting symptoms, or who may seem ill-suited for TNs initially. This would provide a blueprint for clinicians with challenging clients. For clinicians who are concerned about their clients having their basic needs met, feeling helpless/hopeless, we designed a strategy to ease their burden. For clinicians with choice overload/decision fatigue relating to their clients’ severe psychopathology, we proposed a decision aid (such as a checklist, trauma hierarchy, or flowsheet) which uses the client’s clinical characteristics to guide TN priorities. Decision aids are behavioral insights-informed strategies for choice overload/decision fatigue (66).
Affective Experience
Invariably, implementing psychological EBIs can provoke intense emotions. Trauma therapy is well-known to cause clinicians distress. These emotions can, in turn, influence the quality of clinical decisions (70–72). Evidence also suggests that clinicians working in high poverty contexts tend to experience additional stress given the enormous needs of their clients and the feeling of powerlessness this can engender (73).
TN Determinants. Some clinicians described feeling overwhelmed by their clients’ economic hardships or by their clinical severity. Other clinicians described feeling distressed listening to graphic TNs or feeling afraid to push clients too far. Some indicated that the model is insufficiently concrete, leading them to feel anxious and uncertain. Many described not feeling rewarded for their uncompensated session planning and losing hope in clients’ improvement due to long treatment gaps or family disengagement. Contrary to clinicians who reported feeling overwhelmed by TNs (either due to their flexibility or their content), other clinicians reporting seeking guidance and support from their supervisors and reframing their perspective about TNs. Clinicians who might feel disappointed by inconsistent attendance instead created rules to ensure that clients would consistently attend.
Behavioral Insights. These determinants revealed several behavioral insights: risk/loss aversion, fear avoidance/ostrich effect, lack of reinforcement, helplessness/hopelessness, base rate fallacy/mental models, and functional fixedness. Risk/loss aversion is the tendency to prefer avoiding losses to acquiring similar gains. Clinicians may perceive the risk of conducting TNs as more salient than the benefits they offer. 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. Clinicians may avoid implementing TNs because they are difficult—clinicians may not be as skilled in TN delivery as they are in other practices. Clinicians may fear doing something that makes them feel incompetent. Some described dreading TN details because they are graphic and potentially produce vicarious traumatization.
Positive reinforcement describes the increased frequency of behaviors when they result in rewards. Some clinicians described not feeling rewarded for their work, specifically for uncompensated TN preparation (e.g., session planning), as well as for their sustained attempts to help clients whose treatment was often derailed by more acute needs (e.g., psychosocial stressors). Despite clinicians’ attempts to implement TNs, due to factors outside of their control (such as clients’ crises that lead to missing sessions) they described feeling insufficiently rewarded—i.e., clients were not getting better. This lack of reinforcement may have led them to feel less inclined to attempt to implement TNs. Persistent lack of reinforcement led clinicians to experience helplessness and hopelessness about their clients’ progress and disappointment that TNs were not a panacea. Some clinicians avoided experiencing the lack of reinforcement, helplessness, and hopelessness by managing their expectations and reframing their goals.
Clinicians who described being able to manage their expectations and goals for clients viewed TNs as easier to implement, and displayed less risk/loss aversion, fear avoidance, and helplessness/hopelessness. They understood that they could not solve everything in their clients’ lives, which may have allowed them to reframe their expectations and mitigate the potential lack of reinforcement. Some clinicians reported seeking support and encouragement from their supervisors, reaffirming the rationale of TNs to themselves, and planning ahead to ensure that clients did not consistently lose momentum. Clinicians’ strategies to seek positive reinforcement from their supervisors/agencies enabled them to feel rewarded for their efforts irrespective of the forces outside of their control.
Implementation Strategies. For clinicians who reported anxiety about the flexibility of the narrative, we generated an implementation strategy that would prevent this anxiety and provide concrete assistance to narrow the possibilities. We suggested the development of a toolkit or workbook of resources for TNs, serving as both a template and a toolkit of creative ideas. Some TF-CBT clinicians cited already using templates as helpful in alleviating their anxiety. Given that this anxiety appears to stem from an intolerance of uncertainty, providing concrete tools for clinicians can assuage their worries (74).
For clinicians who reported losing momentum due to clients’ inconsistent attendance, we developed a strategy that would reduce the frustration and worries of clinicians by incentivizing clients to attend session with financial compensation and arranged transportation. This would indirectly address the affective experience of clinicians by making it less likely that clients miss sessions. For clinicians who experience significant emotional distress about TNs (i.e., worrying that clients will decompensate or that the details will be difficult for them to hear), we generated implementation strategies to directly address clinicians’ anxieties through supportive techniques. One strategy involves using clinical supervision more therapeutically, acknowledging that clinicians also experience secondary traumatic stress. One technique that can be employed in group supervision is to do an imaginal exposure to feared outcomes (e.g., a client decompensating), effectively treating clinicians’ anxieties (75,76). We also generated a peer consultation model strategy where clinicians can support one another and discuss challenging cases. These practices would be incorporated into the supervision model (creating a default) which would reduce the effort of clinicians to seek support independently. The social element of the supervision and consultation models would make it more likely that clinicians feel supported and not alone. Assigning a case manager to provide support around clients’ basic needs would enable clinicians to focus on their therapeutic work and eliminate their worries that they should be prioritizing non-therapeutic casework. Equipped with the knowledge that their clients would be cared for, this strategy would help clinicians feel less hopeless about their clients’ prospects.
Agency Norms
The final broad theme was agency norms—the social norms of clinicians’ agency leaders, supervisors, and peers. Evidence suggests that social norms strongly influence behavior (77).
TN Determinants. Clinicians reported that if it was standard practice to use TNs in their agencies, clinicians would employ TNs. When agency leaders, supervisors, and colleagues did not prioritize TNs, clinicians reported that they were less likely to use TNs.
Behavioral Insights. Agency norms reveal the behavioral insight that clinicians are influenced by the default bias and social norms. Clinicians prefer the current state of affairs, or the default 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. Clinicians are influenced by others at their agency who do or do not use TNs.
Implementation Strategies. To address social norms and default bias, we generated an implementation strategy that makes use of the electronic health records clinicians typically use to record progress notes. Agencies and supervisors would create templates in the electronic health record that would require clinicians to describe their attempts to implement TNs. Clinicians would be prompted to write a justification if they did not attempt a TN in session with the knowledge that their supervisors would see the note. Establishing a default ensures that the standard practice is to use TNs, and, further, it creates a social norm that everyone at the agency implements TNs. Strategies prompting clinicians to provide justification embedded in electronic health records have been effective at increasing the use of other EBIs in medical settings (78).