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

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) Understand the key barriers UK therapists perceive as hindering the implementation of evidence-based CBT practices. (2) Understand the key factors UK therapists perceive as facilitating and enhancing the implementation evidence-based CBT practices. (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) Consider theoretically driven implementation interventions which could be used to target identified individual and organisational factors to improve sustained adoption of EB-CBT.