Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators

We selected 17 participants (four administrators, three supervisors, and ten clinicians) from five community mental health clinics that did not routinely implement structured evidence-based psychotherapies. The clinics were participating in a study examining the feasibility and acceptability of alternative approaches to supporting implementation of IPSRT. We invited all clinic administrators and supervisors to be interviewed; we randomly selected clinicians to participate from among all clinicians at the clinics who had experience treating patients with bipolar disorder and who would also be participating in the subsequent study. All selected individuals consented to participate in this qualitative investigation.

Approximately one month before IPSRT training began, we conducted 30-minute semistructured interviews with study participants regarding the clinic’s readiness to implement IPSRT. Participants were primarily women (N=14, 82%;), and the majority (N=10; 59%) had been in their current clinic positions for less than five years. Two participants (12%) had been in their current position for five to ten years, two for 11 to 20 years (12%), and three (18%) for 21 to 30 years.

Interviews were audio recorded and transcribed, followed an interview guide, and focused on anticipated facilitators and barriers in implementing IPSRT in an outpatient clinic. A codebook was developed on the basis of an iterative reading of the transcripts. Once coders reached thematic consensus, a finalized codebook was created that contained both a question-specific coding approach and global qualitative themes that emerged from the text. The themes were then applied by two experienced analysts, who independently identified themes generated from responses or that emerged through the global thematic analysis. Coding disagreements were adjudicated through discussion. The University of Pittsburgh and RAND Institutional Review Boards approved the study.

Below we describe the key themes that emerged from the interviews regarding both perceived barriers to and perceived facilitators of implementing IPSRT, provide illustrative quotations, and indicate whether the theme was more common among a specific type of participant.

The major anticipated barriers to implementing IPSRT fell into three main categories: logistical challenges to engaging clients, challenges in the transition from training to practice, and time constraints.

The anticipated barriers cited most commonly were logistical challenges to engaging clients. Administrators were substantially more likely than clinicians to express this concern. Interviewees anticipated being unable to engage clients in IPSRT as intended because they felt IPSRT would require regular and routine visits. One clinician related, “We have about a . . . 63% show rate for clients, so I can really get started and into something and then, for whatever reason, Jane Doe stops showing up for her appointments.” A supervisor at the same clinic discussed frequent client no-shows, explaining that mental disorders and limited financial and social resources challenge clients’ ability to adhere to recommended treatment. According to the supervisor, “Attendance is not always stellar. . . . A lot of it has to do with the severity of their illnesses, with their socioeconomic situation, with their ability to acquire transportation.” At a different clinic, an administrator described as a potential barrier the detailed personal tracking required by IPSRT, considering clients’ resistance to change. “It [tracking of social rhythms] is a change for some of the individuals . . . coming in for services,” according to the administrator. “What they may be used to and what they may be asked to track, to look at, things like that. And that’s always a barrier—getting individuals to [accept] change.”

Both clinicians and administrators commonly expressed concern about their ability to apply newly acquired knowledge of IPSRT to their clinical practice. Concerns ranged from the therapy “getting lost” in busy daily clinical activities to worries that it would not be implemented smoothly because fellow clinicians were reluctant to adopt new treatment approaches. Participants often lacked confidence that they would learn enough about IPSRT to use it appropriately. One said, “The biggest barrier is learning it and then sitting down and practicing it with clients. I think that there’s always that step in between. You know, it’s fine to say ‘Yes, I’m trained, I got some training in it,’ but I’m not sure how to use it well enough to use it with clients.” Some participants also expressed concern that changing treatment protocols could be difficult, either for themselves or for others. For example, one said, “There’s at least one [clinician] in the training group [who isn’t open to trying new things]. It’s not so much about trying new ideas; it’s just change in general.”

Likewise, some supervisors worried about supporting clinicians in implementing IPSRT and making the therapy a regular part of the clinic’s practice. According to one supervisor, “After the . . . training it’s still a little fuzzy on how we will get support if we need it. . . . We can support our staff and do clinical supervision from this model’s perspective. I think we’ll be able to learn this model pretty quickly, and probably be able to do clinical supervision. . . . But that could be a barrier if we [supervisors] don’t have access to ongoing support ourselves . . . just keeping it alive and making sure that folks are using it. And, going forward, as we have some staff turnover . . . how would we get new people up to speed?”

Having insufficient time to master and implement IPSRT was a common theme among both administrators and clinicians, given competing demands such as routine clinical activities and transitioning to electronic health records. As one supervisor noted, “Time is a factor. We’re all under the gun for productivity, to return phone calls, trying to do consults with the doctors . . . being pulled in different ways. It’s going to take definitely time to do [IPSRT], and time is always an issue here. . . . I could probably come to work for a whole week and not see a client and still have plenty to do.” An additional concern was how contracted clinicians, who are paid only for providing clinical services, would be compensated for learning and practicing IPSRT.

The most commonly identified facilitator of successful implementation was support at the clinic level in the form of supervision specific to IPSRT or group discussions of and consultations on use of IPSRT. Continued support from clinic staff and other clinicians was also viewed as a necessary, and potentially critical, follow-up to training and handouts, but it was mentioned more commonly by administrators and supervisors than by clinicians. One clinician observed, “But [in addition to the training] . . . I’m also a really big fan of having handouts for a quick referral back, too. . . . I [also] like the idea of having . . . booster sessions as far as homing in on those skills, so we could use . . . just kind of problem-solving groups where people can talk about areas that they’ve had trouble with. I think that they’re helpful in learning a new method.” Some participants envisioned support specific to IPSRT, and others imagined incorporating support into already existing clinical supervision. “[Clinicians] have weekly individual therapy and also have weekly supervision in terms of groups,” said one clinical supervisor. “We also do a lot of peer support. So if we know this is going to be a focus for individuals who suffer from bipolar [disorder], we can continue to encourage one another to keep using this . . . peer support, along with the team supervision.”

Comparable numbers of administrators or supervisors and clinicians felt that during the initial implementation phase, IPSRT use would be enhanced by decreasing productivity requirements or paying for time spent studying the new approach. Reimbursement for time spent learning IPSRT was particularly salient in clinics with a majority of contract clinicians. In those clinics, the need to spend unreimbursed time learning IPSRT or consulting with others was viewed as a potential implementation barrier. Recognizing reimbursement as a critically important issue, all clinics planned to compensate clinicians for training time, but none had yet developed plans to decrease productivity requirements or provide payment for posttraining activities.

Both administrators and clinicians often stressed the importance of gaining sufficient understanding of IPSRT during training, with special focus on strategies to facilitate treatment use and usability. “Getting a good basic understanding of it in initial training,” as one administrator explained, was an essential foundation. Several participants also discussed specific information about IPSRT that would be helpful, such as its most common benefits for patients and its similarities to and differences from other therapies used in the clinic. Obtaining practical knowledge of how to conduct IPSRT was also commonly mentioned. As one clinician related, “As much as [the training] can be, ‘What’s going to be the benefit and how do I use this with a client sitting in front of me?’ and not, ‘Here’s what the data say, here’s all the good things it can do.’ But to actually say to people, ‘This is how you use this, this is how you facilitate this technique. This is how you use some of these things.’ A lot of things talk about the research benefits, but they don’t actually tell clinicians how to use them.”

Numerous participants also discussed a need for readily accessible, highly usable reference materials, both for themselves and clients, to refresh or supplement what participants had learned in training and to help explain IPSRT to patients, monitor progress, or both.

We found that despite strong and supportive leadership, staff anticipated a number of potential challenges to successfully implementing IPSRT. Many of the factors identified are consistent with prior implementation studies; however, we are unaware of prior studies identifying concerns about high rates of client no-shows or studies reporting that overall, clinicians, administrators, and supervisors expressed convergent beliefs about barriers to and facilitators in implementing an evidence-based therapy.

Adequate training and knowledge related to the intervention, competing time demands, and sufficient peer and supervisor support have all been identified as factors influencing effective implementation (6,7). Decreased productivity requirements and adequate reimbursement were also commonly cited issues (5) because clinicians are often less productive while mastering a new intervention. Administrators and supervisors were aware of this challenge. However, none of the clinics in our study had made plans to address the issue.

Community mental health clinics commonly operate on very thin margins, often reimbursed at very low rates for each service unit provided. As a result, high service volume is a priority for both the organization and for individual clinicians. Lowering productivity requirements to allow clinicians to master new interventions is challenging. Payers and community mental health organizations will need to address this issue thoughtfully and directly if they wish to enhance the capacity of the community mental health workforce to implement effective mental health therapies.

Concern about how client attendance rates could affect adherence to IPSRT and, implicitly, therapists’ ability to master the approach was also cited as a potential implementation barrier. Although the implementation literature identifies a good fit between intervention and setting as an important factor for successful intervention implementation (8), we are unaware of studies explicitly identifying inconsistent client attendance as a barrier to implementing evidence-based psychotherapies. No-show rates are often high in community mental health outpatient settings, in the range of 35%−50% (9). Further research is needed to better understand how inconsistent client attendance may affect the implementation and effectiveness of therapies in community outpatient clinics. However, given the strong concern about the issue expressed by study participants, intervention developers may consider incorporating tools and strategies to address this challenge.

Our findings must be viewed within the context of the study limitations. We interviewed 17 individuals from five community mental health centers in a large mid-Atlantic state, centers where organizational leadership had committed to implementing IPSRT as part of a federally funded implementation study. Additional issues may have arisen if the interviewees had been from organizations without such leadership commitment, had more or less experience implementing evidence-based psychotherapies, or worked in states with a less robust specialty mental health system. Although new themes related to IPSRT implementation ceased to emerge among the last participants interviewed, other themes may have arisen had there been more interviewees, interviewees from other organizations, or interviewees from other geographic regions. Finally, this study was part of a larger study examining alternative approaches to feasibly and efficiently implement IPSRT in community mental health settings. The goal of this study was to better understand the implementation of an evidence-based therapy within common community mental health setting constraints rather than support implementation during the study period. Findings from subsequent study stages will help community mental health providers make informed choices regarding how best to implement evidence-based psychotherapies and other interventions.

Despite these limitations, our findings contribute to the evolving literature regarding implementation of evidence-based psychotherapies in community settings. These therapies have the potential to extend the reach and improve the quality of care to many individuals with mental health needs, but “a sound program will not produce the desired results if it is implemented poorly” (10). Ensuring effective implementation is complicated, requiring a thorough understanding of facilitators and barriers. Our finding that clinicians and administrators often share the same concerns about implementation should facilitate the development of materials and approaches designed to address them. However, the impact of high no-show rates on treatment adherence when introducing evidence-based psychotherapies into community settings constitutes a newly identified concern. Implementation planning efforts can use preimplementation periods to identify barriers that were previously unidentified or that are potentially unique to the participating delivery system (11) as well as to engage a broad range of delivery system stakeholders in discussions about the potential benefits of effective intervention implementation.

However, our findings also demonstrate that awareness of important implementation challenges does not always precipitate actions to address them. Evidence-based practices deserve evidence-based implementation (12). Approaches such as learning collaboratives are increasingly used to support mental health intervention implementation in community settings (13), but further research is needed to understand whether learning collaboratives (13,14) and other implementation interventions (15) change behaviors in a way that supports effective and sustainable evidence-based psychotherapies.