Introduction
A large body of research has shown cognitive behavioural therapies (CBT) to be effective in reducing symptoms and relapse rates across a range of psychological difficulties (Butler et al., Reference Butler, Chapman, Forman and Beck2006; Hofmann et al., Reference Hofmann, Asnaani, Vonk, Sawyer and Fang2012), prompting a drive to increase implementation of CBT into routine practice (Clark, Reference Clark2011; McHugh and Barlow, Reference McHugh and Barlow2010). Central to the success of CBT implementation programmes is the local adoption of evidence-based practices (EBP), an approach to making informed treatment decisions based on integration of the best available research evidence, therapists’ own expertise, and client values and characteristics (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006; Spring, Reference Spring2007). However, there are increasing reports of major gaps between what is known about effective CBT practice and what is actually implemented in routine practice, with evidence-based CBT (EB-CBT) often being unavailable or delivered sub-optimally (Dobson and Beshai, Reference Dobson and Beshai2013; McHugh and Barlow, Reference McHugh and Barlow2010; Shafran et al., Reference Shafran, Clark, Fairburn, Arntz, Barlow, Ehlers and Wilson2009). Indeed, even therapists who initially utilise EB-CBT may not continue to adopt such practices, a process known as ‘therapist drift’ (Waller and Turner, Reference Waller and Turner2016; Wilcockson, Reference Wilcockson2022). It is, therefore, important to better understand factors facilitating or impeding therapists in working within an EB-CBT framework, to promote ongoing successful implementation of CBT within routine practice.
Effective implementation of EBP requires a multi-level approach incorporating evidence-based policy and practice at the community, organisational, and practitioner level (Durlak and DuPre, Reference Durlak and Dupre2008; Greenhalgh et al., Reference Greenhalgh, Robert, MacFarlane, Bate and Kyriakidou2004). Pragmatic, educational, and attitudinal factors at each level influence adoption of EBP and facilitate or hinder the success of implementation programmes (Damschroder et al., Reference Damschroder, Reardon, Widerquist and Lowery2022; Dobson and Beshai, Reference Dobson and Beshai2013). At community level these include political and institutional policies, procedures, and regulations. Organisational level factors include cultural and functional climate, such as access to training and supervision, service delivery constraints, and goals and values of service leaders. Finally, at individual practitioner level factors are attitudes towards EBPs, knowledge and understanding of EBP, and practical issues. To date, studies have highlighted key barriers to the use of EB-CBT as pragmatic organisational factors (e.g. time constraints, high caseloads, lack of supervision, limited control over clinical schedules, poor communication with clinical leaders), and therapist attitudes (e.g. belief of centrality of the client, a preference for relying primarily on experience) (Gyani et al., Reference Gyani, Shafran, Myles and Rose2014; Gyani et al., Reference Gyani, Shafran, Rose and Lee2015; Kauth et al., Reference Kauth, Sullivan, Blevins, Cully, Landes, Said and Teasdale2010; Kjoge et al., Reference Kjoge, Turtumoyard, Berge and Ogden2015; Lewis and Simons, Reference Lewis and Simons2011; Stewart et al., Reference Stewart, Chambless and Baron2012; Wilcockson, Reference Wilcockson2022). Whilst this research is informative, it lacks a clear theoretical underpinning from which barriers and facilitators can be meaningfully identified and used to inform the development of theory driven intervention strategies to promote successful use of EB-CBT practices. The current research builds upon previous research by contextualising factors influencing the adoption of EB-CBT within a UK healthcare setting and drawing upon behaviour change theory to offer a more structured, theoretically driven approach to understanding and targeting mechanisms that influence EB-CBT implementation.
There is a need for multi-level, targeted, and specific strategies to address barriers to the adoption of EB-CBT and support therapists to work effectively within an EBP framework. Promoting the adoption of EB-CBT practices across organisations and services requires both individual and collective behaviour change. A behaviour change strategy grounded in implementation theory can identify barriers and facilitators, offering insights into the mechanisms of change and helping explain how individual and organisational factors influence the adoption of EB-CBT, thus guiding the development of targeted interventions and helping organisations allocate resources effectively (Eccles et al., Reference Eccles, Grimshaw, Walker, Johnston and Pitts2005). Several behaviour change tools have been developed to facilitate effective implementation of therapies into route practice.
The Capability, Opportunity, Motivation-Behaviour (COM-B) model and aligned Theoretical Domains Framework (TDF) implementation frameworks have been suggested as being well suited to developing complex interventions to reduce the gap between practice and evidence by providing a structured, theory-driven approach for identifying and addressing contextualised individual level and organisational factors influencing behaviour change in applied healthcare settings (French et al., Reference French, Green, O’Connor, McKenzie, Francis and Michie2012). The COM-B conceptualises behaviour as a function of an individual’s capabilities (individuals’ capacity to engage in behavioural modifications), opportunities (environmental factors that influence individual behaviours), and motivations (willingness for change) (Michie et al., Reference Michie, Van Stralen and West2011). The TDF expands on the COM-B model, identifying 14 theoretically driven sub-domains influencing behaviour: (1) knowledge, (2) skills, (3) memory, attention and decision processes, (4) behavioural regulation, (5) beliefs about capabilities, (6) social/professional role and identity, (7) beliefs about consequences, (8) emotions, (9) goals, (10) intentions, (11) reinforcement, (12) optimism/pessimism, (13) environmental context and resources, and (14) social influences (see Fig. 1 for an overview) (Cane et al., Reference Cane, O’Connor and Michie2012).
Map of the Theoretical Domains Framework (TDF) showing different types of individual barriers and facilitators therapists may experience when delivering evidence-based CBT. These are mapped onto the Capability, Opportunity, Motivation-Behaviour model (COM-B), indicating the key constructs required to allow therapists the opportunity to change behaviour. The figure was adapted from Michie et al., (Reference Michie, Van Stralen and West2011).
The COM-B model and TDF have been found to be predictive of a range of health behaviours and have been widely applied within qualitative research to support effective implementation of evidence-based healthcare practices by facilitating comprehensive assessment of behavioural determinants (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017; McGowan et al., Reference McGowan, Powell and French2020). These frameworks are particularly well-suited to support the implementation of complex evidence-based healthcare practices because they offer a comprehensive, theory-driven method for identifying and addressing the behavioural determinants of change (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017; McGowan et al., Reference McGowan, Powell and French2020). By integrating individual and contextual factors and demonstrating predictive utility across a wide range of health behaviours, they provide a robust foundation for designing targeted, effective implementation strategies. Applying COM-B and the TDF in this study therefore provides an integrative framework for understanding barriers and facilitators to the adoption of EB-CBT experienced by individual therapists, whilst also recognising the impact of the broader organisational and community contexts within which they are situated.
The current study used the COM-B and TDF to identify key determinants of UK therapists’ use of EB-CBT practices. Because it is important that implementation interventions are relevant and meaningful to the people they are aimed at, the study will focus on CBT therapists’ own views about the factors that influence the adoption of EB-CBT. Inductive themes will be mapped onto the TDF and COM-B frameworks to offer insight into the barriers and facilitators UK therapists perceive as inhibiting or enhancing the adoption of EB-CBT practices, thereby guiding the development of targeted, relevant, and acceptable implementation intervention strategies that promote successful use of EB-CBT practices.
The following research question was addressed within this exploratory study: what are the perceived barriers and facilitators to implementing EB-CBT reported by CBT therapists in the UK?
Method
Design
The study adopted a cross-sectional survey design to explore the opinions and experiences of implementing EB-CBT amongst UK therapists. This paper reports qualitative findings from open-ended survey questions to examine how therapists conceptualised EB-CBT practice and perceived barriers and facilitators to implementing EB-CBT. The Consolidated Criteria for Reporting Qualitative Research (COREQ-32) checklist was used to guide this qualitative investigation and reporting (Tong et al., Reference Tong, Sainsbury and Craig2018).
Materials
Drawing from a realist lens, a multi-method survey including five qualitative questions was developed to explore a varied range of therapists’ views about the factors perceived to influence the adoption of EB-CBT (Braun and Clarke, Reference Braun and Clarke2021; Wiltshire and Ronkainen, Reference Wiltshire and Ronkainen2021). First, participants were asked to explain what evidence-based practice meant to them. Second, they were asked to describe any factors they found helpful in supporting them to use EB-CBT in their practice and to explain how and why these were helpful. Third, they were asked to describe any barriers they experienced to using EB-CBT in their practice and to explain how and why these barriers hindered them. Fourth, they were asked to outline what they felt would help support the delivery of EB-CBT in their practice in the future. Fifth, they were asked to provide any other comments or experiences relating to the use of EB-CBT that they would like to share. Asynchronous survey responses were submitted at participants’ convenience; length of responses to questions ranged from two lines of text, to 15 lines of text.
Participants
Participants were therapists practising CBT (broadly defined as individuals who self-identified as using CBT within their clinical practice) based in the United Kingdom. Three recruitment methods were implemented. First, 1054 therapists who identified as practising CBT were contacted through public websites of professional therapeutic organisations (British Association for Behavioural and Cognitive Psychotherapies, British Association for Counselling & Psychotherapies, and British Psychological Society). Second, the study was advertised on social networks (Twitter and Facebook) and professional networks and societies (CBT-focused special interest groups, regional psychology networks, therapy today). Third, participants were asked to share information with other interested colleagues to support snowball sampling.
The survey was completed by 228 therapists. The majority described their primary form of therapeutic practice as cognitive behavioural (n=188). The remaining identified their therapeutic practice as including cognitive behavioural methods, but primarily as integrative (n=27), humanistic (n=4), psychodynamic (n=2), and ‘other’ (described as psycho-social model n=1; CBT informed physical rehabilitation; EMDR n=2, integrative/CBT n=1; third wave CBT n=1; trauma-focused CBT n=1). The sample consisted of therapists across 11 different professions: NHS Talking Therapies for Anxiety and Depression (NHS TTAD: formerly IAPT) high-intensity therapist (n=55), clinical psychologist (n=55), psychotherapist (n=31), CBT psychologist (n=25), psychological wellbeing practitioner (n=24), psychiatric nurse (n=18), counselling psychologist (n=12), counsellor (n=4), health psychologist (n=2), arts therapist (n=1), and social worker (n=1). In terms of highest level of qualification: 64 participants held a Doctoral degree, 84 held a Master’s degree, 66 held a Postgraduate Diploma, and 14 held a vocational health profession Bachelor’s degree. Participants primarily working context was in the National Health Service (n=164), private practice (n=47), charitable sector (n=7), academic institution (n=6) and ‘other’ (NHS-funded business n=2, dual NHS and private n=1, ministry of defence n=1). The sample consisted of 176 females and 51 males, with one participant preferring not to state gender. The mean age was 39.93 years (SD=11.88, range 23–74).
Procedure
Participants were invited to take part, with emails and advertisements including a summary of the study and a link to the online survey hosted by JISC Online Surveys. Participants completed an online information and consent form and an initial screening question confirming that they were a UK-based therapist who used cognitive behavioural interventions in their practice. Participants were offered a financial incentive in the form of a prize draw to win £50 vouchers. Ethical approval was granted by the University of Worcester Institute of Health and Society research ethics committee (ref. no. HCA16170014).
Analytical approach
Reflexive thematic analysis was conducted within a realist framework to identify factors that therapists perceived as barriers and facilitators to implementing EB-CBT (Braun and Clarke, Reference Braun and Clarke2021). Justification for adopting this approach to analysis was twofold. First, reflexive thematic analysis allowed flexibility in the iterative process of theme development, to hold space for codes and themes to develop and evolve as the researchers gained deeper understanding of the data. Second, the realist framework allowed the researchers to uncover objective truth beyond surface level interpretation of experiences and behaviours, by simultaneously acknowledging pre-existing assumptions and biases that may influence interpretation of the data to promote deep engagement with the analysis (Braun and Clarke, Reference Braun and Clarke2021).
Analysis was conducted by three researchers (KM, EW, and KS) and followed Braun and Clarke’s (2021) reflexive TA guidelines, integrating an initial inductive data-driven approach, followed by a deductive theory-driven mapping of themes (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017; McGowan et al; Reference McGowan, Powell and French2020). Data from across the qualitative survey responses were pooled and analysed together. Researchers worked independently to identify and code initial descriptive features in the data, capturing key elements associated with adoption of EB-CBT. Researchers then worked together to review these descriptive codes for similarity in meaning to create interpretative codes that captured more nuanced meaning associated with adoption of EB-CBT practices. Interpretative codes were then clustered according to common underpinning meaning into potential themes to construct more coherent theme structures. Clusters were re-assessed, reviewing whether the meaning attributed overlapped with one another. This re-assessment continued alongside review of the data based on the codes applied and the original data set, until a final thematic framework was agreed by all researchers. Inductive themes were then deductively labelled as barriers or facilitators and were mapped to a pre-defined matrix, consisting of the over-arching capability, opportunity, and motivation domains within the COM-B model (Michie et al., Reference Michie, Van Stralen and West2011) and the 14 sub-domains within the TDF (Cane et al., Reference Cane, O’Connor and Michie2012). In moving from an inductive to a deductive approach, all themes mapped onto the theoretical matrix as they had been identified inductively, with no amendments or re-construction of themes required. Two themes were mapped to the framework in tandem to ensure agreement across researchers in the mapping strategy. Subsequent mapping was conducted independently, with researchers meeting regularly to discuss the process and any challenges identified. Themes that were mapped in different domains by researchers were discussed to establish consensus.
Reflections on the analytical process
The research team acknowledges that our professional training, disciplinary backgrounds, and shared commitment to evidence-based CBT (EB-CBT) shaped the design, analysis, and interpretation of this study. The project emerged from a collective aim to support more effective implementation of EB-CBT in routine practice and was conducted by a team of academic researchers with experience in qualitative research and varied but complementary areas of expertise. KM is a Senior Lecturer whose research focuses on the implementation of EB-CBT in routine care settings. EW is a Health Psychologist (DHealthPsy) with experience delivering CBT in NHS TTAD services and a particular interest in applying behaviour change models in clinical contexts. KS is a Senior Lecturer in occupational psychology and LR-D is a Senior Lecturer in psychology and education. Both are Chartered Coaching Psychologists with expertise in workplace and educational settings.
Our academic and professional experiences likely influenced our conceptualisation of EB-CBT and our analytic interpretations, including a shared belief in the value of evidence-based practice in healthcare and in organisations. These perspectives, while offering insight into the topic, also present a potential for bias, which we sought to acknowledge through regular team discussion and critical reflection during engagement with the data, conduct of the analysis, and theoretical application. Given the relatively small size of the professional field, some members of the research team had pre-existing working relationships with a small number of participants (e.g. through shared workplaces). We acknowledge that this may have influenced participants’ decisions to participate or shaped the content of their responses.
Results
Inductive analysis of CBT therapists’ accounts identified ten perceived barriers and eight perceived facilitators to the use of EB-CBT. Nine themes fell within therapist (i.e. CBT ‘provider’) level (see Fig. 2) and nine within organisational level (i.e. stemming from the broader healthcare system) (see Fig. 3). Themes were deductively mapped onto a combined matrix including the COM-B and TDF. A summary of each theme is presented below, with an overview and illustrative quotations in Table 1.
Perceived therapist (i.e. CBT ‘provider’) level barriers and facilitators impacting the use of evidence-based CBT practice aligned to the Theoretical Domains Framework (TDF).
Perceived organisational level (i.e. stemming from the broader healthcare system) barriers and facilitators impacting the use of evidence-based CBT practice. Themes are aligned to the Theoretical Domains Framework in brackets (TDF domain).
Summary of perceived barriers and facilitators linked to the Theoretical Domains Framework (TDF) and the Capability, Opportunity, and Motivation-Behaviour model (COM-B) as determinants of use of evidence-based CBT practice with illustrative quotations
1 Quotations marked with an ellipsis . . . represent removal of text from the quotation.
2 Theoretical Domains Framework (TDF).
3 Capability, Opportunity, and Motivation-Behaviour model (COM-B).
Capability (COM-B)
Within the COM-B capability system, three linked TDF domains (knowledge, skills, and behavioural regulation) were described.
Knowledge (TDF)
Knowledge refers to an awareness of the existence of something (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017). Lack of knowledge at individual therapist and organisational level were identified as barriers.
Barrier – A narrow view of EBP (therapist level)
This theme captures a lack of consensus about what it means to work within an EBP framework. Well-accepted definitions typically highlight EBP as being a decision-making process drawing upon ‘three pillars’: research evidence, clinical expertise, and client needs and preferences (Spring, Reference Spring2007). Although some therapists spoke of the need for balancing research evidence with client needs or clinical expertise, therapists rarely expressed this integrated view of EBP. Instead, many therapists reported a much narrower view of EBP, dominated by the research component. Evidence-based practice was not only equated with the application of research to practice, but there was also a sense for some that working in a way that was not ‘proven’ P4 by a large body of research to be effective would be disapproved of or prohibited.
Barrier – Lack of guidance (organisational level)
This theme refers to perceived gaps in EB-CBT guidance, which sometimes left therapists feeling unsure of the most appropriate ways of working. This was particularly the case in relation to populations requiring adaption from standard CBT protocols (e.g. children and young people, people with learning disabilities, older adults), more complex presentations (e.g. co-morbidity, eating disorders, long-term health conditions), and novel CBT approaches (e.g. third-wave, transdiagnostic). When working in these areas, therapists highlighted the need to work outside of clear EB-CBT guidance. This involved drawing on broader knowledge for ‘filling in the blanks’ P7 and making adaptations to ‘off the shelf’ P206 interventions. Participants who felt they did not have the experience or broader knowledge needed to work in this way were left without a clear understanding of when, how, and why such adaptations should be made.
Skills (TDF)
Skills includes abilities or proficiencies acquired through practice (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017). Two facilitators identified refer to skills developed by therapists, which therapists felt supported the use of EB-CBT.
Facilitator – Research literacy (therapist level)
This theme reflects research literacy skills required to access, make sense of, and apply research evidence and guidelines within clinical practice. These skills include knowing how to search and access appropriate literature, critically reviewing articles and guidelines, and understanding the process of research evidence development. These skills were acquired through postgraduate training, involvement in research, and research-informed supervision.
Facilitator – Formulation skills (therapist level)
This theme relates to the acquisition, development, and maintenance of formulation skills, which were felt to be central in guiding implementation of evidence-based techniques appropriate to individual client needs and preferences. Therapists reported that a carefully considered and co-constructed formulation provided a way of applying theoretical understanding of CBT principles to make sense of and explain a particular individual client’s difficulties. This offered both clients and therapists ‘a shared map’ P227 which could be drawn upon to guide therapy. The formulation gave therapists confidence to work flexibly within an evidence-based framework, balancing research evidence and guidelines with responsiveness to client needs. Therapists highlighted the importance of developing and then maintaining formulation skills to prevent ‘robotic’ P179 application of interventions or drift away from EB-CBT. Experiential training and supervision, clinical feedback, and modelling by experienced therapists all helped to foster formulation skills.
Behavioural regulation (TDF)
Two behavioural regulation strategies aimed at managing or changing actions (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017) were identified as facilitating EB-CBT, one externally driven and the other internally driven.
Facilitator – External monitoring (organisational level)
This theme reflects the facilitative role of supportive service or organisational level monitoring of practice, such as service evaluation, accreditation reviews, and other ‘continuing professional development’ reporting activities. This external monitoring prompted and encouraged ongoing self-reflection on current ways of working, including whether these were in alignment with up-to-date evidence-based guidance. Monitoring also highlighted further support and development needs.
Facilitator – Guided self-reflection (therapist level)
This theme includes a number of self-directed strategies for reflecting on implementation of evidence-based practice. These included protecting time and space away from hectic and busy work schedules for engaging in reading, training, reflecting, and informed decision making. Peer support and supervision were also seen as a supportive context for self-reflection. Routine outcome monitoring; self, peer, and supervisor feedback on recorded sessions; and use of role-plays within supervision were particularly drawn upon to support self-reflection.
Opportunity (COM-B)
Within the COM-B opportunity system, one TDF domain (environmental context and resources) was described.
Environmental context and resources (TDF)
This domain includes any situational or environmental circumstances encouraging or discouraging skill development, independence, social competence, or adaptive behaviour (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017). Three facilitators and four barriers fell within this category.
Facilitator – Community of practice (organisational level)
This theme illustrates the importance of a supportive learning community in facilitating engagement with evidence-based practices. Networks of trusted peers and colleagues came together to offer mutual support, both in person and online. These spaces were used for sharing ideas, research, materials, discussing cases, overcoming obstacles, practising skills and group reflection. They were most beneficial when senior leadership from within the organisation actively encouraged and supported participation.
Facilitator – Knowledge through resources (organisational level)
This theme reflects the crucial role of access to evidence-based practice resources. This included research articles and conference attendance, which supported up-to-date knowledge of current evidence and guidance. Treatment manuals and guidelines about how to implement EB-CBT treatments were highlighted as especially helpful. Case studies and practice magazines were also deemed useful resources for sharing clinical knowledge and experience.
Facilitator – Access to training and supervision (organisational level)
Central within this theme is access to good quality training and supervision. This was understood to be informed by research evidence and guidance, encouraging of self-reflection, providing opportunities for experiential learning, and offering support and feedback from more experienced therapists. Such training and supervision helped therapists focus, reflect, problem-solve, avoid drifting from best practice, consider new up-to-date ways of working, build confidence, and feel inspired. A solid foundation of training and access to supervision was seen as fundamental when first developing understanding and skills in EB-CBT. Therapists also highlighted the importance of ongoing and regular access to quality training and supervision.
Barrier – Complex research and guidelines (organisational level)
Barriers were faced by therapists in finding relevant and good quality resources from the plethora of information available. The complex way in which research evidence and guidelines were presented, the varying quality of information, and the conflicting viewpoints made it difficult to draw meaningful conclusions, with therapists left feeling unsure how to apply these ideas to their clinical practice.
Barrier – Barriers to accessing knowledge (organisational level)
Therapists highlighted facing significant barriers in terms of having the time and ability to access research and guidance to inform their EB-CBT. Research paywalls and a lack of published manuals and materials made it more difficult and time consuming to keep up-to-date with and understand how to implement the evidence base.
Barrier – Lack of training and supervision (organisational level)
Therapists within private, NHS, and charitable settings felt it was difficult to maintain evidence-based practice without regular, consistent, and high-quality training and supervision from an experienced and supportive CBT oriented therapist. Yet these vital developmental opportunities were often not available due to accessibility (e.g. time and location of training or supervision), resource implications (e.g. financial costs and time to attend), availability (e.g. lack of experienced or CBT oriented supervisors), or lack of service-level support.
Barrier – Service constraints (organisational level)
A variety of service constraints were highlighted within this theme, all of which meant that therapists felt they were left with no choice but to do ‘what is possible’ P9, rather than what they considered best practice. This included offering fewer treatment sessions, feeling compelled to move people along in therapy, and not implementing some techniques (e.g. behavioural experiments and exposure-based interventions). A combination of limitations on the number, length, and location of sessions within the service, high caseload demands, and a focus on targets created a challenging environment which left some therapists feeling pressured and overwhelmed. The issue of suitability of referrals was highlighted as particularly challenging. Therapists felt that a ‘one size fits all’ approach compelled them to work with clients they did not feel met suitability criteria for their service, or for whom they did not feel CBT was appropriate for. Within some settings this was further compounded by a lack of encouragement and at times even discouragement from colleagues, supervisors, and management to work within an EB-CBT framework.
Motivation (COM-B)
Within the COM-B motivation system, two TDF domains (beliefs about consequences and reinforcement) were described.
Beliefs about consequences (TDF)
Four themes reflect beliefs and preferences held by therapists which served as barriers to EB-CBT. These fell within the beliefs about consequences domain, referring to beliefs about truth, reality, or validity about outcomes of a particular behaviour in each situation (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017).
Barrier – Perception of rigidity (therapist level)
This theme reflects the belief that EB-CBT involves working within rigid and inflexible protocols, manuals, and guidelines which fail to account for the client’s needs and goals and therefore can damage the therapeutic relationship. It was felt that sometimes a softer, more personalised, and less structured approach that focused on building a strong therapeutic alliance was needed and that this was not possible within the rigidity of an evidence-based practice framework.
Barrier – Doubts about flawed evidence (therapist level)
This theme highlights a lack of confidence in the quality, rigour, and relevance of research evidence, reducing therapists’ motivation to engage with research evidence and use it to inform their practice. Concerns centred on a perceived lack of effectiveness research, lack of lived experience research, lack of long-term follow-up, lack of transparency, and failure of replicability. Therapists particularly noted that research was reductionist and focused too heavily on diagnosis, thus failing to reflect the complexity of clients in clinical reality. The resources available within research trials was also felt to be unrepresentative of the clinical organisations within which therapists worked.
Barrier – Belief that EBP is not client centred (therapist level)
This theme reflects therapists’ belief that EB-CBT is not always ‘patient-centred’ P197. Therapists reported that clients’ expectations of CBT therapy, aversion to techniques deemed unhelpful or unnecessarily challenging, and poor previous experiences of CBT sometimes meant that clients were reluctant to engage in EB-CBT therapy. This made working within evidence-based practice guidelines challenging. For some, this prohibited working within an EB-CBT framework at all, as this approach was not seen as aligning with client preferences, goals, and values.
Barrier – Preference for intuitive eclecticism (therapist level)
This theme characterises the belief that clinical intuition should be the primary driver for treatment decisions and that this is not always possible within the framework of EB-CBT practice. Some therapists preferred to rely on their clinical judgement and experience to work with an individual in a way that draws upon a range of therapeutic modalities and treatment techniques. This eclectic, or integrative approach to therapy was preferred over working exclusively within an EB-CBT framework.
Reinforcement (TDF)
Reinforcement increases the probability of a response through a relationship between the response and resulting rewards, incentives, or punishment (Atkins et al., Reference Atkins, Francis, Islam, O’Connor, Patey, Ivers and Michie2017). One facilitative theme was identified as providing reinforcement for EB-CBT.
Facilitator – A tried and tested method (therapist level)
This theme illustrates a range of experiences that reinforce working within an evidence-based practice framework. Personal experience of seeing positive change in clients was a rewarding and satisfying experience that promotes continued use of EB-CBT. Similarly, seeing research evidence also increased confidence in using these ways of working as they are ‘tried and tested’ P184. In contrast, therapists reflected that when they had drifted from using evidence-based practice in the past, this was sometimes unhelpful for clients and thus encouraged them to return to evidence-based practice.
Discussion
This study provided a theoretically driven approach to exploring barriers and facilitators associated with the adoption of evidence-based cognitive behavioural therapy practices (EB-CBT) within a UK healthcare setting. Inductive analysis identified ten barriers and eight facilitators, which were deductively mapped onto the Capability, Opportunity, Motivation-Behaviour (COM-B: Michie et al., Reference Michie, Van Stralen and West2011) and Theoretical Domains Framework (TDF: Cane et al., Reference Cane, O’Connor and Michie2012) to identify key determinants affecting EB-CBT practice. These factors can be categorised as falling at the individual therapist (i.e. CBT ‘provider’) and organisational level (i.e. stemming from broader healthcare systems). At the therapist level, barriers included knowledge of EBP and beliefs about consequences of EB-CBT (perceptions of rigidity, flawed evidence, lack of client centredness, preference for intuitive eclecticism). Therapist facilitators included skills in research literacy and formulation, guided self-reflection as a behaviour regulation strategy, and reinforcement through positive outcomes. Organisational barriers included limited EBP guidance and environmental context issues (complexity of research/guidelines, difficulty accessing knowledge, lack of training/supervision, service constraints). Organisational facilitators included external monitoring as a behavioural regulation strategy and environmental context issues (fostering communities of practice, gaining knowledge through resources, access to training/supervision).
Individual therapist level factors
Therapists in this study, like those in previous research (Gyani et al., Reference Gyani, Shafran, Myles and Rose2014; Safran et al., Reference Safran, Abreu, Ogilvie and DeMaria2011), preferred decision-making based on clinical experience over research, citing concerns about research quality and relevance as well as a preference for drawing intuitively on clinical experience from across modalities. This mistrust of research evidence is concerning, as attitudes toward research correlate with delivering empirically supported treatments (Speers et al., Reference Speers, Bhullar, Cosh and Wootton2022). Therapists in this study also identified research literacy as a factor supporting their use of EB-CBT. More firmly embedding research literacy across all levels of therapist education may help address this mistrust, by better equipping therapists with the critical scientific reasoning required to become autonomous and informed research consumers who can actively engage in evidence-based practices (Norcross et al., Reference Norcross, Hailstorks, Aiken, Pfund, Stamm and Christidis2016). However, researchers must also directly address therapist concerns by making research more relevant, accessible, and practice-oriented and therefore bridging the research–practice gap evident within CBT. Bridging this gap may require a paradigm shift in research focus (towards transdiagnostic processes; mechanisms of action; efficacy of specific therapeutic techniques; implementation research), method (collecting longitudinal data to monitor individual patient trajectories; using innovative causal inference methods), process (participatory approaches involving non-scientists; fostering reciprocal practice research links), and dissemination (clearer reporting; user-friendly clinician-focused guidelines; and increased sharing of findings across stakeholders) (Berg et al., Reference Berg, Schemer, Kirchner and Scholten2024; Dobson and Beshai, Reference Dobson and Beshai2013; Shafran et al., Reference Shafran, Clark, Fairburn, Arntz, Barlow, Ehlers and Wilson2009).
Therapists reported common beliefs that EB-CBT is rigid, inflexible, and non-client-centred (Gyani et al., Reference Gyani, Shafran, Rose and Lee2015; Speers et al., Reference Speers, Bhullar, Cosh and Wootton2022), reflecting broader scepticism about the clinical decision-making process. This scepticism may stem partly from a perceived lack of EBP guidance, as highlighted in this study. Some therapists also equated EB-CBT solely with research, suggesting misunderstandings about its framework and providing an explanation as to why some felt reticent to work within a framework perceived as restrictive, undervaluing therapist experience, and lacking flexibility to meet individual client needs. Yet this restrictive view is not reflective of original descriptions of the ‘three pillars’ approach to EB decision-making, which integrates clinical expertise and client needs or preferences with the best available evidence (Spring, Reference Spring2007). While EBP training is a core component of the scientist-practitioner model in professional psychology and CBT programs, its coverage varies across graduate training (Hunsley, Reference Hunsley2007). This study highlights the need to strengthen training in higher-order metacompetencies, such as formulating relevant questions, acquiring and appraising evidence, integrating client context and preferences with available resources, and continuously assessing outcomes (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006; Roth and Pilling, Reference Roth and Pilling2007; Spring, Reference Spring2007). Given the variability in training routes for CBT therapists in the UK, embedding these competences in continuing professional development and supervision is essential.
As reported in previous research (e.g. Addis and Krasnow, Reference Addis and Krasnow2000; Waller et al., Reference Waller, Mountford, Tatham, Turner, Gabriel and Webber2013), some therapists in this study were reluctant to follow protocols, manuals, and guidelines they perceived as rigid and inflexible. Addressing these concerns may require greater emphasis on formulation skills when working with guidelines. CBT case formulation involves therapist and client working together to develop a coherent set of theory-routed explanatory inferences about factors causing and maintaining client’s presenting issues, thus guiding appropriate adaptation of interventions to individual client needs, context, and preferences while maintaining fidelity to core CBT principles (Kuyken et al., Reference Kuyken, Padesky and Dudley2011). Therapists in this study reported that formulation skills allowed them make decisions about when, how, and why to adapt current EB-CBT guidelines. Despite being a core CBT competency (Roth and Pilling, Reference Roth and Pilling2007), some therapists in this study reported that formulation skills were insufficiently covered in larger-scale national CBT training programmes. Previous research emphasised the need for ongoing training and targeted supervision to enhance formulation training in larger scale CBT training courses (Zivor et al., Reference Zivor, Salkovskis and Oldfield2013) and this study adds further weight to this argument.
Therapists in this study highlighted guided self-reflection as a facilitator to EB-CBT, involving self-monitoring strategies such as goal setting, action planning, and feedback from peers and supervisors to track, manage, and adjust their use of EB-CBT. In line with best practice guidelines, relationship-based support and development opportunities within supervision can enhance these behavioural regulation strategies by facilitating collaborative goal setting, ongoing practice monitoring, and corrective feedback (Milne, Reference Milne2017). Experiential learning including live feedback strategies may be particularly effective in promoting behaviour change by providing instant performance-based feedback tailored to individualised therapist goals (Alfonsson et al., Reference Alfonsson, Parling, Spännargård, Andersson and Lundgren2018).
Engaging in ongoing monitoring of CBT treatments within practice-based datasets can boost therapists’ motivation to adopt EB-CBT (Hogue et al., Reference Hogue, Henderson, Dauber, Barajas, Fried and Liddle2008; Loeb et al., Reference Loeb, Wilson, Labouvie, Pratt, Hayaki and Walsh2005). Participants in this study were more motivated to use EB-CBT after witnessing its beneficial effects firsthand. According to the COM-B model, motivation and behaviour are mutually reinforcing (Michie et al., Reference Michie, Van Stralen and West2011), meaning positive experiences with EB-CBT increase motivation to continue using it. If therapists see EB-CBT as relevant and useful, their motivation and intention to apply it in practice will increase (Van Eerde et al., Reference Van Eerde, Tang and Talbot2008). Providing easy access to routine outcome measures and training in their use can encourage regular monitoring, enabling therapists to track clinical changes and reinforce positive outcomes for both clients and therapists alike (Jonášová et al., Reference Jonášová, Čevelíček and Doležal2024).
Organisational level factors
Therapists in this study highlighted the importance of resources like clinician-facing guidelines, research articles, and case studies for maintaining up-to-date EB-CBT knowledge. However, these resources were often inaccessible due to paywalls, limited clinician materials, complex systems, and technical research findings. Access to published articles varies based on the subscription budgets of academic institutions or healthcare services (Lawson and Meghreblian, Reference Lawson and Meghreblian2015). Restricted access to scientific knowledge increases social and economic inequalities for therapists and their clients, creating a need for greater transparency and open access to research findings and supporting clinical materials (Cheng and Hampson, Reference Cheng and Hampson2008). Research findings should be presented in user-friendly formats and synthesised into clear guidelines, which can be actively promoted to therapists through media promotion, high-traffic websites, and specialist magazines in a range of easy to access and digest formats such as podcasts, blogs, webinars, and mobile apps (Forman et al., Reference Forman, Gaudiano and Herbert2016). Training providers and accrediting bodies, such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP), could play a useful role in sharing and promoting these resources.
Therapists in this study reported that regular, research-informed, experiential, feedback-informed training and supervision from experienced CBT therapists facilitated EB-CBT. Benefits included improved focus, self-reflection, problem-solving, confidence, exploration of innovative approaches, inspiration, and prevention of therapist drift. However, as the most effective model, format, or dosage of training and supervision remains unclear (Alfonsson et al., Reference Alfonsson, Parling, Spännargård, Andersson and Lundgren2018; Henrich et al., Reference Henrich, Glombiewski and Scholten2023), the optimal way for training and supervision to support EB-CBT is uncertain. Research suggests that ongoing, interactive, experiential training and supervision supports therapists in maintaining competences required to deliver EB-CBT gained within initial training (Henrich et al., Reference Henrich, Glombiewski and Scholten2023; Rakovshik and McManus, Reference Rakovshik and McManus2010). While didactic methods may effectively convey theory, skills-based experiential strategies such as modelling, role-play, and corrective feedback are likely required to support ongoing skilful delivery of EB-CBT (Bearman et al., Reference Bearman, Weisz, Chorpita, Hoagwood, Ward and Ugueto2013). Ongoing supervision is needed alongside training to promote adoption of EB-CBT (Henrich et al., Reference Henrich, Glombiewski and Scholten2023; Schoenwald et al., Reference Schoenwald, Mehta, Frazier and Shernoff2013) and supports the intention to transfer knowledge from training, with supervisor attitudes predicting uptake of EB practices by supervisees (Speers et al., Reference Speers, Bhullar, Cosh and Wootton2022) and supervisory support impacting motivation and perceived importance of EB-CBT for supervisees (Salas and Cannon-Bowers, Reference Salas and Cannon-Bowers2001). Given the importance CBT therapists place on supervision in supporting clinical decision making (Gyani et al., Reference Gyani, Shafran, Myles and Rose2014), supervision may also be used to scaffold decisions about when, how, and why to adapt evidence-based CBT interventions in practice, facilitating flexible fidelity. This study particularly highlights the need for this support for therapists with less knowledge, experience, or confidence, as well as those working within complex or novel areas which lack clear research evidence or practice guidelines.
Despite perceived benefits, the quality and availability of supervision for therapists in both training and practice settings is variable (Speers et al., Reference Speers, Bhullar, Cosh and Wootton2022). Concerns about insufficient access to training and supervision have been previously identified as barriers to EBP (Pagoto et al., Reference Pagoto, Spring, Coups, Mulvaney, Coutu and Ozakinci2007; Stewart et al., Reference Stewart, Chambless and Baron2012) and were echoed in this study across private and NHS, clinical and training settings. Therapists in this study highlighted several obstacles, including limited time, accessibility, resource constraints, supervisor availability, and insufficient service-level support. Developing supportive organisational cultures and managerial backing is crucial, as these factors influence prioritisation and implementation of training and supervision within clinical settings (Zammel and Hashana, 2023). A research priority should be enhancing evidence around effective training and supervisory practices to provide decision makers with evidence to support greater financial investment. Given training methods differ greatly in their cost profiles (Henrich et al., Reference Henrich, Glombiewski and Scholten2023), exploring more cost-effective, accessible, less intensive training options is also necessary.
Therapists in this study identified several workplace conditions hindering EB-CBT, including limitations on the number, length, and location of sessions within the service, high caseloads, target-focused work, and pressure to treat clients who may not meet suitability criteria. Previous research has highlighted similar barriers, including lack of control over clinic schedules, conflicts with other duties, and lack of time with clients (Kauth et al., Reference Kauth, Sullivan, Blevins, Cully, Landes, Said and Teasdale2010). Such service level restrictions imposed by wider healthcare systems (NHS Trusts, Clinical Commissioning Groups) and local services may limit the degree therapists feel able to deliver EB-CBT, particularly in terms of treatment duration and use of time-intensive or practically complex techniques like behavioural experiments and exposure-based interventions. Such concerns about sub-optimal CBT delivery due to service limitations have been voiced by UK CBT practitioners (e.g. Roscoe, Reference Roscoe2019). Thus, it seems essential to foster supportive organisational climates that promote the importance of EB-CBT and rewarded therapists for engaging skilfully in EB-CBT practices (Williams et al., Reference Williams, Becker-Haimes, Schriger and Beidas2022). A positive climate promotes clinician engagement with EB-CBT, improving attitudes towards it and increasing both self-reported and observed use of EBP (Powell et al., Reference Powell, Mandell, Hadley, Rubin, Evans and Hurford2017; Williams et al., Reference Williams, Ehrhart, Aarons, Marcus and Beidas2018). Participants in this study also highlighted the role of supportive communities of practice in promoting EB-CBT. Organisations can foster this climate through policies, procedures, and reward systems that encourage EB-CBT behaviours. This may involve structures that support a culture of continuous learning, set individual learning goals, provide personal development opportunities, offer chances to apply acquired skills, reinforce learning achievements, provide constructive feedback, and facilitate social and peer support (Banerjee et al., Reference Banerjee, Gupta and Bates2017; Cheng and Hampson, Reference Cheng and Hampson2008). Leadership training strategies should also be adopted within postgraduate psychology training provision to ensure policies and procedures are implemented and communicated appropriately by clinical leaders to foster positive shared climate perceptions, especially as therapists take on more leadership roles (Hunt et al., Reference Hunt, Schmitz, Vail and Opperman2024; Williams et al., Reference Williams, Becker-Haimes, Schriger and Beidas2022).
External oversight and evaluation can support EB-CBT by offering feedback that identifies areas for additional skill development and reinforcing positive behaviours. Waller and Turner (Reference Waller and Turner2016) argue that there is a need for increased monitoring of therapists’ adherence to EBP throughout their careers to prevent therapist drift. Although there are concerns such monitoring could be seen as punitive, therapists in this study found external oversight from services and accrediting bodies to be helpful for self-reflection and motivation. UK CBT therapists value non-mandatory BABCP accreditation (Parkinson and Marks, Reference Parkinson and Marks2017), and this study underscores the role of such professional bodies in supporting EB-CBT. External oversight involving formal evaluation of behaviour in the form of competence assessments based on direct observation of therapists’ skills within treatment sessions or role-plays may be particularly beneficial in providing reinforcement, corrective feedback, and identifying training needs (Muse et al., Reference Muse, Kennerley and McManus2022).
Limitations
Whilst an inductive approach examining therapists’ views about what influences adoption of EB-CBT supports development of meaningful implementation interventions, it is important to recognise potential inaccuracies associated with self-reported use of EB-CBT (Hogue et al., Reference Hogue, Dauber, Henderson and Liddle2014). A qualitative survey was used to explore therapists’ views. Whilst this method of data collection facilitates inclusion of views across a broader and more diverse sample of therapists, this method can compromise depth of data obtained.
The study employed a broad recruitment strategy to promote inclusivity of therapists working across diverse clinical contexts and professional roles, reflecting the varied settings in which CBT is delivered and providing an over-arching understanding of how implementation barriers and facilitators operate in practice. However, this inclusive approach also introduces variety and ambiguity in the sample in relation to CBT training, qualifications, and practice. Although most therapists held a postgraduate qualification (n=214, 94%), the professional training completed by therapists was variable. The sample was predominantly NHS TTAD therapists (HIT n=55, 24%; PWP n=24, 11%) and clinical psychologists (n=55, 24%). However, a number of therapists identified their current profession as psychotherapist (n=31, 14%), counsellor (n=4, 2%), and CBT psychologist (n=25, 11%). Given that these professional titles are not protected, there is variability in training, qualifications, and scope of practice among therapists who self-identify with these titles. As the survey did not prompt therapists to indicate more specific details of their EB-CBT training and professional body affiliation this depth of information was not captured. Participants predominantly worked in the NHS (n=164, 72%) and private practice (n=47, 21%), with academic and charitable sectors being less well represented. There is an increasing trend towards therapists identifying their therapeutic orientation as integrative (Norcross et al., Reference Norcross, Karpiak and Lister2005), which is also reflected in our sample (n=27, 12%). Integrative practice is conceptualised in diverse ways, encompassing theoretical integration, technical eclecticism, assimilative integration, and the common factors approach (Feixas and Botella, Reference Feixas and Botella2004; Finnerty and McLeod, Reference Finnerty and McLeod2019). Given this conceptual ambiguity, the degree to which integration reflects evidence-based delivery of interventions in a theoretically coherent way that aligns with the empirical grounding is unclear. Ultimately the sample recruited will have shaped the barriers and facilitators reported in this study. As therapists across professional backgrounds and clinical settings may differ in their approach to EB-CBT (Gyani et al., Reference Gyani, Shafran, Myles and Rose2014; Stewart et al., Reference Stewart, Chambless and Baron2012; Wilcockson, Reference Wilcockson2022), future research could usefully explore and unpick the way in which these experiences and contexts influence Therapists views towards and adoption of EB-CBT practices.
This study captured influences on the broad constellation of inter-related behaviours involved in EB-CBT. This approach aligns with behaviour change research examining complex health interventions involving sequential delivery of multiple discrete components over time in a way that is individually tailored (De Leo et al., Reference De Leo, Bayes, Bloxsome and Butt2021). Although less precise in behavioural terms, this approach offers broad insights into factors influencing the adoption of EB-CBT across a range of settings. However, it may also be fruitful to explore whether unique barriers and facilitators influence adoption of discrete EB-CBT practices which may be under-used in clinical practice (e.g. use of exposure interventions, use of behavioural experiments, imagery work, etc.).
Conclusions
The barriers and facilitators identified in this study offer insights into challenges that need to be addressed and best practices that can be leveraged to enhance the uptake of EB-CBT. At the individual therapist level, interventions should focus on developing therapists’ capability and motivation to work within an EB-CBT framework. Capability-enhancing strategies should promote higher-order knowledge of evidence-based decision-making, strengthen research literacy and formulation skills, and encourage guided self-reflection. To enhance motivation, a paradigm shift towards more relevant, accessible, and practice-oriented research may be needed within research to addresses concerns about research flaws, perceptions of EB-CBT as rigid or non-client-centred, and a preference for intuitive eclecticism. Enhancing opportunities for routine outcome monitoring may also improve motivation by supporting reflection on positive outcomes of EB-CBT. At the organisational level, collaborative efforts from leaders, policymakers, and funding bodies are crucial to enhance therapists’ capability and opportunity to engage in EB-CBT. Organisations must improve access to understandable research and practice-based resources, enhance access to high quality training and supervision, foster a supportive organisational climate, and facilitate supportive external monitoring of EB-CBT practices.
Given the complex interactions between individual therapists and their organisational environments in shaping EB-CBT adoption (Becker-Haimes et al., Reference Becker-Haimes, Williams, Okamura and Beidas2019), multi-level intervention strategies are likely to be more effective in driving lasting practice changes. Furthermore, as factors that influence the adoption of EB-CBT practices are likely to differ between therapists within different service contexts (Fixsen, Reference Fixsen2005), combined interventions which target the specific set of barriers and facilitators evident within that unique service context may be more effective than generic interventions (Kauth et al., Reference Kauth, Sullivan, Blevins, Cully, Landes, Said and Teasdale2010). The use of implementation facilitators to conduct bespoke needs assessments and implement individualised strategies to support change efforts may, therefore, be a cost-effective and pragmatic method of enhancing EB-CBT practices (Kauth et al., Reference Kauth, Sullivan, Blevins, Cully, Landes, Said and Teasdale2010).
Key practice points
-
(1) Barriers therapists identified as inhibiting use of EB-CBT were understanding of evidence-based decision making, scepticism about EB-CBT, a preference for intuitive eclecticism, limited or complex research/guidelines, difficulty accessing knowledge, lack of training/supervision, and service constraints.
-
(2) Facilitators therapists identified as enhancing their use of EB-CBT were research literacy and formulation skills, guided self-reflection, seeing positive outcomes, external monitoring, fostering communities of practice, gaining knowledge through resources, and access to training/supervision.
-
(3) Strategies to enhance individual therapists’ capability and motivation to engage in EB-CBT could include enhancing higher-order knowledge of evidence-based decision-making; strengthening research literacy and formulation skills; encouraging guided self-reflection; enhancing routine outcome monitoring; and making research more relevant, accessible, and practice-oriented.
-
(4) Organisational level strategies to enhance therapists’ capability and opportunity to engage in EB-CBT could include improving access to understandable research and practice-based resources; availability of high-quality training and supervision; fostering a supportive organisational climate; and external monitoring.
Data availability statement
The dataset generated and analysed during the current study is not publicly available for three reasons: first, informed consent was not obtained to share data in this way; second, due to the sensitive nature of the data; third, publication of participant answers in full risks identifying research participants and their working contexts.
Acknowledgements
We would like to thank our participants for giving their valuable time and for sharing their experiences and opinions. We would also like to acknowledge Linda Sundvik’s involvement and input to the project during her time as a vacation research assistant at the University of Worcester.
Author contributions
Kate Muse: Conceptualization (lead), Data curation (equal), Formal analysis (lead), Funding acquisition (lead), Investigation (lead), Methodology (lead), Project administration (equal), Writing - original draft (lead); Elaine Walklet: Conceptualization (equal), Data curation (equal), Formal analysis (equal), Funding acquisition (equal), Investigation (equal), Methodology (equal), Project administration (equal), Writing - original draft (supporting); Kazia Anderson: Data curation (equal), Formal analysis (equal), Investigation (equal), Project administration (equal), Writing - review & editing (supporting); Laura Rees-Davies: Data curation (equal), Investigation (equal), Project administration (equal), Writing - review & editing (supporting).
Financial support
This research was funded by the University of Worcester Institute of Health and Society Research Outputs Facilitation Fund. The funding source did not have any direct involvement in the study design, data collection, analysis, or writing of this report.
Competing interests
The authors declare none.
Ethical standards
Authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS and informed consent from participants was obtained.
Comments
No Comments have been published for this article.