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Table 3 Results from the behavioral insights informed analysis of interview data

From: Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making

Broad theme TN determinant Evidence from interview Behavioral insights Potential implementation strategy
Decision Complexity (i.e., dimensions of clinicians’ decisions) Decision complexity surrounding the incorporation of other evidence-based interventions 4: “I feel like sometimes I might get a little bit stuck in the structure part and have a little bit of a harder time figuring out how to be flexible.” Functional Fixedness
Mental Models
Distribute stories/guides from similar clinicians (or peers) describing how they incorporate EBP with existing therapy routines.
8: “I’m getting trained in Theraplay which is an evidence-based play therapy practice and because of the age group I’m working with right now I feel like that’s very helpful … I also employ, obviously, a lot of art therapy techniques”
Decision complexity surrounding client characteristics 17: “I find older children tend to be easier to do trauma narratives with than younger kids. I have a 4-year-old right now and it’s been kind of a process to figure out how to adapt TF-CBT to do a narrative with them. And then I also work with a 6 year old who doesn’t read yet, so I definitely feel like it’s easier when a kid is more verbal, and is of age to read on his own.” Base Rate Fallacy /Mental Models
Choice Overload/
Decision fatigue
Show clinicians narratives of kids with challenging presenting symptoms, or who may seem ill-suited for the narrative initially.
10: “[My client is] juvenile justice-involved, and they said like her IQ’s 76 and verbal comprehension is by far her lowest competency, so that’s helped us reframe our whole therapeutic approach. We’re just doing so much more attachment-oriented things with her mom, who’s also intellectually disabled. And so it’s like this kid needs it.”
Decision complexity surrounding client psychopathology and/or complexity of trauma. 10: “[Barriers:] Cases where there’s just like a lot of complex trauma. They were sexually abused, and they witnessed someone kill someone, and domestic violence. You’re like, how am I going to ever get to all of these things? Which ones are the things that are worth prioritizing?” Base Rate Fallacy/Mental Models
Choice Overload/
Decision Fatigue
Develop a decision aid (such as a checklist, trauma hierarchy, or flowsheet) which uses the client’s symptoms and other clinical characteristics to guide trauma narrative priorities.
16: “I guess [I prioritize] just going based off of what they were sharing and prioritizing interventions to meet what they identified as bothering them the most.”
17: “I’ve had one kid who has had one singular trauma and it’s kind of been a process where we’ve really been able to follow TF-CBT to a T, it’s kind of progressing as expected and so forth.”
Clinician Affective Experience (i.e., emotions of the clinician) Clinician affective experience of the structure and/or flexibility of TF-CBT 14: I think maybe a template or something that can be given to clinicians to... you know, like “this chapter is about me” or, I don’t know, something to make it more user friendly. To feel like even though it’s unstructured, there’s some parameters around it.
Interviewer: from your experience supervising, do you find that some therapists have more or less difficulty with the unstructured aspect of it?
14: Definitely. And I feel their own hesitation and worries about doing it creates … it takes longer to get there for their clients, and that’s not ok.
Risk Aversion
Fear Avoidance
Develop a toolkit or workbook of resources for each module that makes it easy to be creative, while also being a template for those who are unsure as to how to implement the narrative.
14: “I love the lack of structure, cause I’m creative”
14: “I know some of my staff that I supervise have [faced a lot of challenges]. Sometimes it’s more of this unstructured creativity part that they do not feel like they have the skill to do. One of the worries is where is it going to go, and if it goes somewhere we don’t want it to go, is that too much? We talked about the avoidance for me.”
11: “My supervisor is really helpful, my co-worker is really helpful. Also, I just go back the material, like a cheatsheet I keep with me.”
Clinician affective experience of client attendance 2: “Not only do gaps in attendance interrupt the therapeutic process, but some of my clients might have other behavioral issues, or other mental health issues, like poor recall, or they might be dealing with ADHD, so it’s almost like you’ve got to start over again” Lack of Reinforcement
Incentivize clients to attend session with compensation and arrange transportation to bring the client to session.
17: “It was really hard for clients and families to really be able to retain the information when there were gaps between the different skills we were learning as well as the gradual exposure that’s so paramount when you’re doing a narrative. And then it was also harder to see that hope of the more and more you do narrative and gradual expose the less distressed a kid is while hearing it and that was not really happening because there is too long of a period in between.”
13: “You explain the attendance contract. You say this is really important and the reasons why we’re doing trauma work. This is something that has to be built upon. You have to practice it. You’re coming every week to make sure the skills are being set, and if you’re not being consistent, then it is really hard to move forward.”
Clinician affective experience of the possibility of clients decompensating. 1. [Clinician reported that in the middle of the session she decided against doing the TN because the caregiver relapsed on substance abuse problems.] Interviewer: “What do you think would have happened if you had just gone forward with using the trauma narrative with that patient against your clinical gut?”
Clinician: Probably a break in the relationship. Some transference would have probably . . . Yeah.
Risk Aversion Use clinical supervision to do an imaginal exposure about a client decompensating.
8: “That was something I really got supervision with my supervisor from and she was kind of supporting me in that and I felt like he was a kid that I could pull more from and really push whereas other kids again, I don’t know if I would be that comfortable doing that.”
Clinician affective experience of hearing the gory and difficult details of the trauma narrative. 14: “The murder part, the shooting that he witnessed was the goriest thing I’ve ever heard.” Fear Avoidance/
Ostrich Effect
Develop a peer consultation model where clinicians can support one another and discuss challenging cases.
5:“The intensity of asking the specifics, just the acuteness in the moment when someone’s telling a story, you know … This idea that we’re sharing a story; we pass around stories; we learn from this. There are so many examples of how narratives are so healing and art in the world.”
Clinician affective experience surrounding the clients’ social context and resource depravation 3: “They are constantly . . . they were displaced for a long time, and they are constantly about to be displaced. I feel like she is at a point right now, where it’s not . . . we could process the trauma with mom, but I don’t think that what’s happening for him substantiates doing TF-CBT.” Lack of Reinforcement
Mental Models
Assign case managers to provide support around basic needs so clinician can focus on clinical/therapeutic work
10: “Look, we cannot get to this deeper work until Mom stops kicking the kid out of the house and locking the door.”
5: “But dad threatened him with a gun, so that shook up everything that we were doing … In those moments, I switch hats: I go into DV counselor mode and then immediately go into safety planning and really working hard with the parent to make sure we’re supporting whatever they need to do … We haven’t been able to get back on track with the components, and … we haven’t . . .been doing trauma narrative even though technically with the timing I should be doing that now.”
5: “And, you know, I’ve been meeting with him [my client] way longer than TF-CBT suggests. Really, since February, and I feel a lot of that is building that rapport … He, after seven months, was able to do the trauma narrative and talk about what happened, but it really did take that long, and I think sometimes the impression in the [TF-CBT supervision] call’s is that this is short-term, you know. Bam, bam, bam. You’re doing all the things, and they’re done and cured … This really showed me the amount of trust that you have to engender in your clients in order for it to be effective … I’m lucky because my agency does give me a lot of leeway … But just the mentality around, ‘we should be doing short-term intervention.’ Right?. . . every kid has a different time line
Agency Norms (i.e., social norms and practices at the workplace) Norms related to whether clinicians, supervisors, or agency leaders do or do not prioritize TF-CBT. 1:“We recently just . . . I think devoting time specifically to talking about TF-CBT is a barrier. I think the administrative piece takes precedent sometimes, and sometimes the clinical work or—I don’t want to say the quality of the clinical work but—the supervision of the clinical work, sometimes can get lost in the administrative piece.” Social Norms
Default Bias
Supervisors set an expectation that implementing the trauma narrative is a default by using templates in the Electronic Health Record, with a prompt for clinicians to make an accountable justification if they did not attempt the trauma narrative in session.
8: “I guess if I were to go to another organization where TF-CBT was not so heavy, maybe I would stray away from it … maybe if I were to go into private practice, I don’t know how much I’d use them … yeah, if I changed jobs, or went to private practice something like that I might not do it to the extent that I am.”
8: “Where I work we do employ TF-CBT, that’s kind of what they do there. So I do a trauma narrative with every single kid.”