This document summarizes a mixed-methods study examining the relationship between mental health therapists' attitudes towards evidence-based practices (EBPs), perceptions of organizational factors, and degree status. The study found that doctoral-level therapists with positive attitudes reported more autonomy, while those with less positive attitudes reported requirements to use CBT and lack of time. Non-doctoral therapists reported lack of resources, space, funding, and regular client access as barriers. Managerial support was a facilitator for all therapists. The study provides insight into implementation challenges faced in community clinics from front-line perspectives.

1. Non-Doctoral;
Positive Attitudes
• Confidence in
implementing CBT
• Lack of space and
resources to implement
as intended
• Funding
Non-Doctoral;
Positive Attitudes
• Confidence in
implementing CBT
• Lack of space and
resources to implement
as intended
• Funding
Background
• Ecological approaches to dissemination and implementation (DI) recommend
consideration of the relationship between individual- and organizational-level (IOL)
factors associated with DI of evidence-based practices in mental health (EBPs;
Damschroder et al., 2009).
• Two potentially important individual-level therapist variables are therapist degree status
(i.e., doctoral versus non-doctoral) and attitudes (Aarons, 2006). Research illustrates
that educational background may be related to therapist attitudes towards EBPs
(Aarons, 2004). Limited research has examined the relationship between educational
background and therapist perception of organizational environment. Previous work
indicates doctoral therapists may endorse differences in perceptions of organizational
environment including adequacy of resources and motivation for change compared to
non-doctoral counterparts (Downey et al., 2012)
• Further research is needed to examine the relationship between degree status, attitudes
towards EBPs, and perception of organizational factors. This is especially salient given
that previous work has focused on attitudes of those with doctoral degrees even though
most community mental health clinic (CMHC) therapists do not have doctoral degrees
• Calls for a mixed-methods approach in implementation science cite the need for a more
nuanced understanding of implementation issues faced in the community (Palinkas et
al., 2011)
• The current study uses a mixed-methods design to examine the intersection of
quantitative data (i.e., attitudes as measured by the Evidence-Based Attitudes Scale;
Aarons, 2004) with qualitative themes around implementation barriers and
organizational factors emergent from semi-structured interviews conducted with
therapists who participated in training for an EBP of the treatment of child anxiety,
cognitive-behavioral therapy (CBT; Beidas et al,. 2012).
Methods
Stratified Themes
Doctoral; Positive: “As a psychologist…”; “My current practice…”; “I implemented the
program…but within my system”
Doctoral; Less Positive: “I have been able to apply the concepts from training, even if I don’t
have enough time in the work setting to actually do full kind of Coping Cat treatment”.
Non-Doctoral; Positive: “…(adequate training gave) me the confidence and the tools to
be able to identify who CBT would work for and then the tools to be able to actually
implement it with someone”.
Non-Doctoral; Less Positive: “In…our structure we generally see people when they’re here (in
the medical setting) and so they often aren’t willing to commit to come in regularly outside of
that (medical treatment)”.
Universal Themes
• Managerial support (including supervision, openness, educated management, materials, and
passive assent to therapist practice) as a facilitator of implementation
• Setting (e.g., school or medical) as a facilitator of or barrier to implementation
Discussion
• The present study provides information on barriers and organizational factors in therapists;
stratified by doctoral status and attitude level. Doctoral-level therapists with positive attitudes
were more likely to report autonomy and ownership whereas doctoral-level therapists with less
positive attitudes reported required usage of CBT and lack of time for therapy as intended.
Striking divergence existed between doctoral level therapists with differing attitudes. Non-
doctoral therapists reported funding and lack of space and resources as a barrier; non-doctoral
therapists with positive attitudes reported more confidence in their use of CBT.
• Given that the overwhelming majority of providers in the community are non-doctoral level,
these findings suggest the reality of CMHCs from the perspective of front-line providers.
CMHCs tend to have high rates of turnover which may be due to lower organizational climate
and culture (Glisson and James, 2002). One possible explanation for the differences we found
between doctoral and non-doctoral providers is their level of autonomy. Interventions that
increase autonomy for non-doctoral providers may increase satisfaction towards their
organization and attitudes towards EBPs which may result in increased provision of EBPs.
• Limitations include: therapists volunteered for initial training study, the self-report of attitudes,
barriers, and organizational-level factors, the inclusion of graduate students in doctoral status,
and potentially a third variable of setting as a determinant of organizational-level factors and
attitudes.
• Future directions include exploration of other qualitative themes (e.g., adaptation of EBPs) and
stratifying by other quantitative measures (e.g., the Organizational Readiness for Change) as
well as stratifying by professional type (e.g., psychologist, psychiatrist, social worker, nurse).
Measures
Degree status was operationalized as doctoral (i.e., participants with a completed doctoral degree
such as PhD, PsyD, EdD, MD, or DO and graduate students enrolled in doctoral
programs at baseline) or non-doctoral (i.e., participants not having completed a doctoral
degree such as MA, MS, MFT, RN, BA)
Evidence-Based Practice Attitude Scale (EBPAS; Aarons 2005) measured individual-level therapist
variables (i.e., appeal, requirements, openness and divergence). The total score was used to
stratify our qualitative data.
• Appeal refers to the extent to which a therapist will adopt a new practice if it is intuitively
appealing
• Requirements refer to the extent to which a therapist will adopt a new practice if required
by the organization or legally mandated
• Openness is the extent to which a therapist is generally receptive to using new
interventions
• Divergence is the extent to which a therapist perceives research-based treatments as not
useful clinically
Semi-structured interviews (Stirman et al., 2012) were used to generate qualitative themes.
Questions were open-ended and follow-up probes were included to tailor the interview to
the participants’ responses and to elicit information about participant experiences and
perceptions implementing CBT. Example questions directly dealing with the intersection
of implementation barriers and organizational factors were:
• How are specific elements of CBT working in your practice (i.e., exposures)?
• What types of policies, procedures, or characteristics of your agency make it either easier or more difficult
to use CBT?
• Is there anything management could or should to support the use of CBT? How do they show support?
• What do you feel you would need to keep using CBT or what would you need to change for you to use
it more?
Procedures
• Therapists in the Philadelphia metropolitan area volunteered to receive training in CBT for
child anxiety. Attitudes and demographics were measured prior to training (see Beidas et
al., 2012)
• Semi-structured interviews (approximately 45-60 minutes) and the EBPAS were conducted
2-years later with a sample of therapists who participated in the training study
Results
Analysis
• Interviews were digitally recorded, transcribed, and coded with a comprehensive scheme
developed for the study through a consensus line-by-line reading of 8 transcripts. Separate
codes were established for implementation barriers and organizational factors (Beidas et al
2013)
• Interviews segments coded for organizational factors and/or barriers were stratified by
provider type and high/low EBPAS total score (Mean = 3.04 ; Median = 3.00) using QSR
NVIVO 10 software
• We conducted data analysis by extracting universal themes reported by all participants and
then themes stratified by attitude and doctoral status
The intersection of attitudes and organizational factors by provider type in
dissemination and implementation of an evidence-based practice for child anxiety:
A mixed methods approach
Margaret Mary Downey, BA1
; Mark Gallagher, BA1
; Jessica Watkins1
; Prianna Pathak1
; Julie Edmunds, MA2
; Phillip Kendall, PhD2
; and Rinad Beidas, PhD1
1
University of Pennsylvania Perelman School of Medicine, Center for Mental Health Policy and Services Research
2
Temple University, Department of Psychology
Funding for this research project was supported by the following grants from the National Institutes ofFunding for this research project was supported by the following grants from the National Institutes of
Mental Health: Beidas (F31 MH083333; K23 MH099179); Kendall (F31 MH083333; U01Mental Health: Beidas (F31 MH083333; K23 MH099179); Kendall (F31 MH083333; U01
MH063747). Invaluable training and consultation provided by Shimrit Kedden of the University ofMH063747). Invaluable training and consultation provided by Shimrit Kedden of the University of
Pennsylvania Mixed Methods Research Lab.Pennsylvania Mixed Methods Research Lab.
Doctoral;
Positive Attitudes
•Autonomy
• Ownership over
position
Doctoral;
Positive Attitudes
•Autonomy
• Ownership over
position
Doctoral; Less
Positive Attitudes
•Required use of CBT
•Lack of time for
therapy as intended
Doctoral; Less
Positive Attitudes
•Required use of CBT
•Lack of time for
therapy as intended
Non-Doctoral; Less
Positive Attitudes
• Lack of regular access
to clients
• Lack of space and
resources to implement
as intended
• Funding
Non-Doctoral; Less
Positive Attitudes
• Lack of regular access
to clients
• Lack of space and
resources to implement
as intended
• Funding
Participants
N = 50
92.0% Female
Ages: 23 - 75 (M = 35.09, SD = 10.85)
Race/Ethnicity:
Caucasian 74.0 %
African-American 8.0%
Asian 8.0 %
Other 4.0 %
Clinical Experience:
0 to 372 months (M = 69.59, SD = 86.85)
Degree Status:
Non-Doctoral = 28; Doctoral = 22
Education:
64.0 % had a master’s degree
18.0 % enrolled in a graduate program
6.0 % had a doctorate in philosophy
4.0 % had a medical degree
4.0 % had a doctorate in psychology
4.0 % had a doctorate in education