This is the largest examination to date of barriers to adoption of psychotherapies in terms of number and range of mental health providers surveyed. Content analysis indicated that there were five higher order themes: clinician attitudes, client characteristics, contextual or institutional factors, training issues and other, with sub-themes under training issues being the most frequently cited barriers. There are a few significant effects of demographic and practice variables on obstacles, but the effect sizes for most were negligible. These findings overlap somewhat with other published studies, even though most assessed barriers to evidence-based rather than new treatments (Aarons 2004
; Nelson et al. 2006
; Pagoto et al. 2007
; Varra et al. 2008
Insufficient time to choose, learn, practice, master, refine, and integrate new skills was by far the most frequently endorsed barrier in the adoption of new treatments. It appears as if lack of time may place training for new treatments lower on the clinicians’ professional and personal priorities list when there is no urgent need for a new treatment. Things that take precedence mentioned by participants include “seeing too many clients”, barely having time for anything more than “to put out fires”, building and enlarging one’s practice, and one’s family demands.
Affordability of new training is also emphasized. Given that the cost of training often include tuition or conference fees, travel and lodging expenses and possibly loss of income during time away from practice or work it is not surprising that this is a serious hindrance to adoption of new treatments even for those working in institutional settings. Absence of affordable local training opportunities accompanied by a lack of ongoing supervision while refining new skills seem to contribute to a sense of frustration when one feels a need for more training but has no easy way of getting it. Additionally follow-up training appears to be just as important as initial training, with many practitioners voicing that they have difficulty finding a local mentor, an expert, or even a qualified colleague, for supervision while one is honing his/her new skills. Contrary to expectation that clinicians working in institutions may have an easier time getting free training through their organizations, we did not find significant differences between the institutional and private groups with regard to either time, cost, or training/supervision for refining one’s skills (ranked first, second, and third, respectively, by both groups). However, clinicians in institutional settings appear to have a slightly easier time with local training, ranking this obstacle sixth rather than fourth as private practitioners do, although again, the difference between the two groups was insignificant.
There is some overlap between Aarons’ (2004)
findings and ours, despite important methodological differences between the two studies. Aarons (2004)
investigation was theory-driven and relied on a predetermined set of items, while this study was based on open-ended responses. Aarons used quantitative analysis to find underlying factors, while in this study qualitative content-analysis was utilized to identify common themes. And, most importantly, all participants in Aarons’ study were providers from publicly funded programs in one region in California who worked in child and adolescent mental health services, while our participants included practitioners from a wide range of practice settings within the US and Canada. Namely, more than half of our participants were in private practice and most provided psychotherapy to a wide age range. Thus, by including private practitioners this study we may have achieved a sample more representative of a larger general clinician population (Robiner 2006
Our themes did not form the same groupings as Aarons’ (2004) factors from his predetermined items, and only a few of the items were similar in both studies. Perhaps, this difference is due to divergence in assessed constructs, that is attitudes vs. barriers, and the nature of treatments addressed (evidence based practices only vs. all new treatments). The overlapping items included insufficient training, lack of acceptance, and support by colleagues, belief that therapy is more than a set of techniques, and institutional requirements. In Aarons’ study, requirements by agency had the highest mean, but in our study institutional restrictions and lack of institutional support were less important (ranked sixth). This is partly because Aarons’ sample was restricted to only those working in institutional settings. In our sample those working in institutional settings were 25 times more likely to feel institutional restrictions and lack of institutional support compared to private practitioners, although this effect was small. This obstacle was ranked fourth in those clinicians working in institutional settings, compared to 23rd ranking in private practitioners. Thus, unlike Aaron’s results, in this study, even when institutional settings are considered alone, institutional obstacles still rank lower on the barriers list than time, cost, and the lack of training. This may surprising as those practicing in institutions typically do not have to pay out of pocket for educational trainings and usually are paid their salaries when in training.
Unlike Aarons, who found that interns show more positive attitudes towards new treatments, our results demonstrate the opposite and only for one attitudinal variable, that is less experienced clinicians are more likely to question efficacy or applicability of treatment for particular client population, although the association was negligible. We also found, though again the associations were negligible, that clinicians with doctoral degrees compared to those holding other degrees had more reserved attitudes towards new treatments with regard to their efficacy and were more likely to believe that therapy did not equal the sum of the techniques. Aarons, on the other hand, reports that participants with higher educational attainment showed more positive attitudes towards treatments, however, only for intuitively appealing ones.
There were more similarities between our large-scale investigation and another qualitative study (Nelson et al. 2006
), a small focus group investigation of barriers. These are limited practitioner time due to heavy caseload, lack of training and supervision, economic restrictions such as reimbursement, client resistance and complex client presentation. Similar to Pagoto et al. (2007)
survey of 37 practitioners, lack of time and money for training, a part of their logistical concerns surrounding implementation and issues with obtaining training were identified barriers in our study. In addition, our investigation found further support for the barriers identified in Varra et al. (2008)
investigation of 59 substance abuse counselors. However, the frequency of the endorsement of these barriers was relatively low in our sample possibly due to restriction of their sample to a narrow subspecialty within the broader mental health field. Also similar to Schmidt and Taylor (2002)
, we found that clinicians were concerned about applicability of new techniques to specific client populations, although only 3% of clinicians in our study mentioned it.
There are several limitations of the present study that should be noted. The most important is the indeterminate view and participation rates of the web-based data collection, putting into question the generalizability of findings to the greater mental health workforce. However, similar to a large investigation of psychotherapists using a snowballing technique (Orlinsky et al. 2001
), the various disciplines and treatment settings represented in this dataset give it ecological validity. Indeed, this study may have better captured a broad range of the psychotherapy field than studies targeting specific professional populations, particular practice settings or geographical regions. The fact that the findings here identify and verify other published studies in a much larger and presumably representative sample is noteworthy.
Implications for Dissemination
These results provide important insights into the nature of issues which interfere with implementation of innovative treatments, perhaps including empirically-supported treatments and evidence-based practices. These findings may help to re-establish priorities in the implementation process. For example, although important, clinician’s opinion of new treatments and even its suitability to one’s views or to clients’ needs are secondary to such issues as lack of time, affordability of training, and opportunities to gain confidence in new skills by refining them in advanced training and supervision. Moreover, the results here indicate that lack of time dramatically outweighs all other barriers. If taken at face value, clinicians appear to have little time to devote to learning to apply new treatments, a potentially lengthy and complicated process. In order to better understand the limited time issue, future investigations could include additional indices to assess objective indicators rather than self-reported access to training or, at least, include questions about actual training opportunities offered at work settings, their duration, and cost. This would help to clarify whether there are actually limited training opportunities in organizations, or “lack of time” is merely an umbrella justification for unwillingness to or disinterest in adopting a new treatment. However, severe lack of time may also indicate a larger issue for the mental health workforce, such as heavy caseloads and limited time to write notes, prepare for sessions, and attend meetings. Perhaps the lack of time in institutional settings is due to limited funding for additional staff positions or need for a larger caseload due to low reimbursement rates imposed by managed care. Clearly if lack of time is indeed a substantial issue for practitioners in implementing new practices, institutional settings would need to carve out time for attending training, practicing new techniques and receiving supervision, and ongoing consultation in order to encourage sustained implementation of new practices.
Past dissemination strategies have included distributing summaries of information about new treatments (Haynes and Haines 1998
). In view of findings presented here, it is questionable whether this strategy would be effective since many clinicians admitted not having time for even reading about new treatments. Moreover, research articles, treatments manuals, and various internet-based media would have less impact on clinicians as we found in the study of factors influencing clinicians’ adoption of new treatments (Cook et al. (2008
)). Clinicians seem to prefer to acquire this information through interpersonal channels, such as mentors or peers.
The full list of the barriers identified in this study can be used to anticipate problem areas that may arise during various stages and levels of implementation. For eg., for those working in institutional settings, administrative support is required to protect sufficient time for clinicians to immerse themselves in learning a new treatment and implement it with clients on a trial basis (Schmidt and Taylor 2002
). Time is particularly important when disseminating research-based treatments as many manualized treatments require a greater frequency and regularity of sessions than is common in many practice settings (Addis et al. 1999
Reaching clinicians in private practice likely requires different strategies. For e.g., on-line interactive training with ongoing online supervision could be more affordable and could address the needs of those practicing in the rural areas. It could also address another important obstacle, reducing time necessary for travel to the training sites.