Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary

Abstract

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

Applying the Theoretical Domains Framework to Develop an Intervention to ‘Re-implement’ Parent–Child Interaction Therapy (PCIT)

“…Relatedly, coaching parents to use time-out was emotionally evocative for several clinicians, and their colleague appeared to provide direct or indirect scaffolding to enhance their emotion regulation. This finding is in keeping with suggestions that clinicians’ anxiety relating to delivery of exposure-based tasks (e.g., within Cognitive Behavioural Therapy-based treatments for anxiety) ought to be better accounted for in implementation research and practice (Becker-Haimes et al, 2022 ; Deacon & Farrell, 2013 ).…”

Therapist Anxious Distress and Avoidance of Implementing Time-Out

“…Therapists should potentially be trained specifically to manage their own anxious distress during treatment. In fact, developing implementation interventions that address therapist distress, such as helping therapists learn to manage their own anxious reactions, has been recommended [14,38]. A recent study found that 12 therapists who underwent experiential training reported improved attitudes towards exposure, one underused EBI [39].…”

“…Therapist anxiety has been proposed as an additional factor impacting the uptake of EBIs [14,15]. In fact, preliminary research has suggested that higher rates of therapist anxiety, measured in one study as intolerance of uncertainty, are related to decreased use of evidence-based interventions, specifically exposure-based and behavioral experiments [16].…”

“…Children's emotions can become heightened, crying and screaming when time-out is implemented for the first time, eliciting an urge to end the time-out in order to appease the dysregulated child. Because delivering time-out can induce temporary anxiety for the child, caregiver, and therapist, it is an ideal intervention through which to study the role of therapist anxiety in implementation and potential maladaptive avoidance [14].…”

Editorial: Implementation of evidence-based treatments for child anxiety and related disorders across diverse contexts

“…Using insights from implementation science, or the scientific study of how to increase the use of EBPs in routine clinical settings to improve care quality ( 14 ), the past few decades have seen advances in efforts to understand the major barriers leading to the underutilization of Ex-CBT. Identified barriers range from concerns about the complex nature of the intervention itself ( 15 ) and poor marketing of Ex-CBT to practicing clinicians and families ( 16 ), negative beliefs and misconceptions about Ex-CBT held by clinicians ( 17 – 20 ), organizational constraints and intervention delivery challenges ( 21 , 22 ), and systemic barriers related to factors such as reimbursement rates and limited funding for specialized training ( 23 ). These implementation barriers also occur alongside historical underrepresentation of marginalized and minoritized individuals in clinical treatment trials and limited attention to ways of culturally tailoring treatments to increase engagement and effectiveness.…”