This study was supported by a research grant from the Hamilton Academic Health Sciences Organization. Dr. Susan Jack is supported by a New Investigator Personnel Award from the Institute of Human Development (Child and Youth Health, Reproduction and Child Health) within the Canadian Institutes of Health Research (CIHR). Dr. Gail McVey is supported by a Mid-Career Personnel Award from CIHR.
Decision-making processes for the uptake and implementation of family-based therapy by eating disorder treatment teams: A qualitative study
Article first published online: 14 SEP 2013
Copyright © 2013 Wiley Periodicals, Inc.
International Journal of Eating Disorders
Volume 47, Issue 1, pages 32–39, January 2014
How to Cite
Kimber, M., Couturier, J., Jack, S., Niccols, A., Van Blyderveen, S. and McVey, G. (2014), Decision-making processes for the uptake and implementation of family-based therapy by eating disorder treatment teams: A qualitative study. Int. J. Eat. Disord., 47: 32–39. doi: 10.1002/eat.22185
- Issue published online: 10 DEC 2013
- Article first published online: 14 SEP 2013
- Manuscript Accepted: 5 AUG 2013
- Manuscript Revised: 4 JUL 2013
- Manuscript Received: 4 MAR 2013
- evidence-based practice;
- implementation science;
- knowledge translation;
- Family-Based Treatment;
- evidence-based treatment
To explore the decision-making processes involved in the uptake and implementation of evidence-based treatments (EBTs), namely, family-based treatment (FBT), among therapists and their administrators within publically funded eating disorder treatment programs in Ontario, Canada.
Fundamental qualitative description guided sampling, data collection, and analytic decisions. Forty therapists and 11 administrators belonging to a network of clinicians treating eating disorders completed an in-depth interview regarding the decision-making processes involved in EBT uptake and implementation within their organizations. Content analysis and the constant comparative technique were used to analyze interview transcripts, with 20% of the data independently double-coded by a second coder.
Therapists and their administrators identified the importance of an inclusive change culture in evidence-based practice (EBP) decision-making. Each group indicated reluctance to make EBP decisions in isolation from the other. Additionally, participants identified seven stages of decision-making involved in EBT adoption, beginning with exposure to the EBT model and ending with evaluating the impact of the EBT on patient outcomes. Support for a stage-based decision-making process was in participants' indication that the stages were needed to demonstrate that they considered the costs and benefits of making a practice change. Participants indicated that EBTs endorsed by the Provincial Network for Eating Disorders or the Academy for Eating Disorders would more likely be adopted.
Future work should focus on integrating the important decision-making processes identified in this study with known implementation models to increase the use of low-cost and effective treatments, such as FBT, within eating disorder treatment programs. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:32–39)
While there has been increased attention placed on the use of evidence-based practice (EBP) within child and youth mental health organizations, there has been less focus on the decision-making processes involved in this endeavor. Not to be confused with evidence-based treatment (EBT), EBP is the process by which professional expertise and empirically sound research are combined to make intervention choices that will produce the best possible outcomes within a specified patient population. EBT, however, is an intervention or technique that has empirical evidence for its effectiveness in treating a particular illness or disorder within a research environment.[2, 3]
Although the conceptual tenants of EBP have been adopted broadly within human health and social services, the fidelity to EBTs in clinical practice is surprisingly low.[4-6] This is particularly the case among health professionals working with children and adolescents diagnosed with eating disorders.[7-9] Eating disorders can be serious and debilitating mental illnesses which are characterized by the psychological preoccupation with one's body weight and shape. Anorexia nervosa (AN) is one type of eating disorder that has been shown to have exceedingly serious physical, psychological, and social consequences; necessitating early and aggressive intervention upon recognition and diagnosis.
Despite the severe complications of AN and the fact that a number of authoritative bodies have published guidelines to effectively treat the child and adolescent AN population,[11-14] few health professionals follow these recommendations.[7-9] A recent review by Lilienfeld et al. (2013) documents the extent to which eating disorder practitioners do not use EBTs within their practice; and those who do, rarely do so with fidelity to the EBT model. For example, results from a large scale, cross-sectional survey of community physicians in London, England indicated that only 3.8% of the 236 participants reported using a published guideline or protocol when treating a patient with an eating disorder. Moreover, when physicians' self-reported treatment behaviors were compared to those recommended in the “best practice” guideline, physicians' treatment behaviors did not align with the empirically supported directions published in the guidelines. Qualitative research has shown similar results. In-depth interviews with clinicians in Canada indicate that while a number of clinicians reported following the principles of family-based treatment (FBT) in practice, none of clinicians did so with fidelity at the time of study.[7, 15]
In this article, we explore the EBP decision-making processes, as reported by therapists and their administrators, which are perceived to influence EBT implementation within their respective eating disorder treatment programs and larger organizational structures. The intent of this article is to present the constructs and processes important in EBP decision-making for pediatric eating disorder treatment services. Such findings may be useful for tailoring existing implementation models to effectively increase the uptake, use, and fidelity to EBTs in clinical practice.
Details concerning the design, sampling, and data collection strategy employed for the larger study in which this research is situated are reported elsewhere. Briefly, data come from a qualitative knowledge translation study that was informed by fundamental qualitative description, as described by Sandelowski (2000). This approach allows for a comprehensive exploration of individuals' experiences and perspectives about a phenomenon with which they are uniquely familiar. The utility of this design framework is in its ability to allow the identification of practical knowledge needed to address clinical challenges experienced by decision makers at different levels. This study was reviewed and approved by the Hamilton Health Sciences/McMaster Faculty of Health Sciences Research Ethics Board.
Both purposeful and maximum variation sampling were used to identify a sample of therapists and administrators involved in the treatment of those diagnosed with eating disorders as well as the decision-making practices within eating disorder treatment programs. For the first portion of the study, potential participants had to: (1) be a therapist providing psychotherapeutic intervention to children and adolescents under the age of 18 diagnosed with AN, and (2) have an ability to understand and speak English. For the second stage of the study, potential interview participants had to: (1) be employed as an administrator, supervisor, manager, or director of an eating disorder treatment program treating children and adolescents under the age of 18 diagnosed with AN, (2) have had at least one therapist from their program participate in the first study, (3) have a role in the treatment and administrative decision-making practices of the eating disorder treatment program (e.g., knowledge of program finances, staffing processes, treatment protocols), and (4) speak and understand English. Therapists and their administrators were recruited through an existing provincial network of eating disorder service providers within the province of Ontario, Canada. The provincial network includes clinicians working in a Ministry-funded, “no-fee-for-service” system of care that is located across rural, urban, suburban, academic, and non-academic settings that provide therapeutic intervention to individuals living across the province of Ontario. The 34 treatment programs residing within the network vary in relation to size and treatment focus, with programs ranging from having only one part-time dedicated eating disorder treatment provider to teams as large of 15 providers representing a range of professional designations (e.g., child and youth workers, psychiatrists, adolescent medicine specialists, and others) and full-time equivalent statuses. In addition, treatment programs range in their respective services, with some providing inpatient, day-patient, and outpatient treatment programs; and others only providing one of these three (see www.ocoped.ca). We emailed all contact persons listed on the “Intake Contacts for Referral List” which is housed on the ministry-funded provincial training program website to invite participation from those therapists and administrators meeting the inclusion criteria above. Given the diversity in the provincial eating disorder network membership, we estimated that a sample of 40 therapists and 10 administrators would lead to data saturation. It was felt that saturation of qualitative themes was possible with the small administrator sample size given the homogenous nature of the potential participants and the focused nature of the interview; namely that the administrator interview guide was informed and tailored following the completion of the therapist interviews.
Data were collected via individual semi-structured in-depth interviews. Each participant was invited to complete a single interview lasting approximately 60–90 min. The semi-structured interview for both the therapist and administrator samples were developed to explore key concepts relating to EBT implementation, specifically, the EBP knowledge transfer tenets in the Knowledge to Action framework developed by Graham et al. (2006) for moving research evidence into clinical practice.1 The interview guides were continually adapted to promote the deeper exploration of new concepts emerging across interviews and the administrator interview guide was informed by the results of the therapist portion of the larger study. Participants signed a consent form providing their permission to complete the interviews by telephone, to digitally record the interviews, and to transcribe the interviews verbatim. Field notes were completed by the interviewer to document emerging concepts requiring further elaboration or exploration, as well as the interviewer's perceptions about the quality, content, and process of the interview.
Qualitative content analysis procedures and the constant comparative technique guided the coding and synthesis of the interview data. The detailed steps for the process used in this study are described elsewhere. Generally, line-by-line coding was completed by the first author (MK), with a codebook of themes, codes, and their definitions created and refined through reading the transcripts multiple times. The second author, JC, independently coded 20% of the transcripts to ensure integrity of data analysis. Disagreements in coding were resolved through standard consensus-making methods used in qualitative research, with all transcripts re-coded following the consensus meetings. All coding was completed in a qualitative data analysis software program (Nvivo 8, QSR International Pty, Version 8, 2008).
Table 1 describes the characteristics of the 51 participants in this study. In total, 40 therapists and 11 administrators from eating disorder treatment programs participated in this study. The average age of the therapists was 43.8 years, with 37 (92.5%) of these participants identifying as female. The majority of therapists (n = 30, 75%) indicated that they had been working with patients under the age of 18 and diagnosed with AN for five or more years; and 31 of 40 therapists reported working in an outpatient setting as part of their work. The administrator sample was slightly older, with an average age of 49.8 years and the majority of these individuals had worked in their current role for 15 years or less (Table 1). The entire administrator sample identified as female and most participants (n = 10, 90.0%) had completed graduate programs. Administrators indicated working in leadership roles with therapists treating children and adolescents struggling with eating disorders for an average of 9.3 years.
|Sample Characteristic||Therapists N (%)||Administrators N (%)|
|Age (years)||(Avg. = 43.8)||(Avg. = 49.8)|
|35 or less||11 (27.5)||1 (9.1)|
|36–45||11 (27.5)||1 (9.1)|
|46–55||12 (30.0)||5 (45.5)|
|56–60||6 (15.0)||4 (36.4)|
|Level of education|
|Graduate degree||35 (87.5)||10 (90.9)|
|Undergraduate degree||3 (7.5)||1 (9.1)|
|College diploma||2 (5.0)||0 (0)|
|# of years in current role||(Avg. = 6.0)||(Avg. = 9.5)|
|Less than 5||17 (42.5)||3 (27.3)|
|5–10||15 (37.5)||2 (18.2)|
|10–15||6 (15.0)||3 (27.3)|
|15 or more||2 (5.0)||3 (27.3)|
|# Years in practice (therapists)/in leadership position (administrators)with AN patients||(Avg. = 7.7)||(Avg. = 9.3)|
|Less than 5||10 (25.0)||3 (27.3)|
|5–10||19 (47.5)||3 (27.3)|
|10–15||8 (20.0)||2 (18.2)|
|15 or more||3 (7.5)||3 (27.3)|
Therapists and administrators identified a “multi-staged decision-making process” for engaging in EBP. In addition, participants identified two factors contributing to the successful adoption and use of EBTs in practice; namely maintaining “an inclusive change culture” and “making the case” for practice change. Present in all 51 interviews, these main themes varied in their degree of importance for each interviewee but were persistent within and across interviews. What follows is a description of these three over-arching themes and their major sub-themes.
Therapists and their administrators identified a multi-staged decision-making process for EBT implementation. In total, interviewees identified seven stages or components of decision-making that would inform the delivery of an EBT within their respective programs, including: (1) individual exposure to the EBT, (2) team exposure to the EBT, (3) evaluating the EBT evidence, (4) determining program fit, (5) training in the EBT model, (6) using the EBT in practice with supervision, and (7) evaluating the EBT in their programs.
From a practical standpoint, interviewees highlighted that implementation of any EBT is unlikely to occur if programs are unaware of its existence. Therapists and administrators acknowledged the difficulty in being up-to-date with the current literature on EBTs when their own clinical caseloads were so demanding. For this reason, clinicians often do not have the time to seek out information on new or emerging best practices within the eating disorder treatment field. This is compounded by the perception that the current intervention choices within their programs are working; which is informed by both anecdotal and program evaluation evidence. Second, exposing the whole team to the new EBT model is an important second step to decision-making. Participants indicated that their teams have policies in place for discussing practice changes, which include exposing the staff to the proposed EBT at clinical rounds, team program retreats, or program planning days. In response to being asked about making changes in practice, one administrator stated,
It would be suggested by someone, whether it's a front-line staff member, a manager, or director of services, it would then go to the team.
Similarly, a therapist asserted,
I do work with a team. So it does come down to the whole team making decisions together.
Upon having the team exposed to the proposed EBT model, interviewees indicated that their teams would then undergo an assessment of the evidence pertaining to the proposed EBT (step 3) and determine program fit between the proposed EBT and what currently is delivered in their program practice (step 4). All 11 administrators reported that staff have dedicated time to read the most recent and relevant research for their practice; however, these scholarship activities are not monitored. When a potential shift in clinical practice presents itself, all of the relevant literature pertaining to the EBT is reviewed by the team, both for its effectiveness and to discern the important components of the EBT for implementation. For example, one administrator stated,
If we heard about it, we would read the literature and assess for ourselves if we thought it was workable given our clientele, given our team and given the way that we do things.
Some interviewees reported that the evidence and EBT components would be evaluated in relation to what their program currently delivers, the current staff context and whether staff could take on the model given their current commitments, skill level, and caseload. One administrator exemplifies these concerns with the following:
One barrier may be just sort of trying to make it fit with the current staff compliment that you have and what to do if you find out that you have people with differently matched skills.
Therapists echoed these concerns. Many reported that although their programs allow for professional development time, rarely are work hours used for these purposes. If asked to learn and implement a new EBT, therefore, therapists indicated that something would need to “give.” When asked about opportunities to learn about EBTs, one therapist said the following,
Time is an issue because when it comes down to it, am I going to see the next client who's waiting or am I going to have an hour to read more of the manual, well I'm going to see the next client who's waiting.
Following a determination of program fit, therapists and administrators recognized the need for therapists to undergo training in the EBT (stage 5), which would then be followed by therapists' use of the EBT model in everyday practice under supervision (stage 6). Specifically, 95% of therapists and 100% of the administrators indicated that they and their staff would need further training in the FBT model and that training is a seminal component to the implementation of any EBT model in practice. When asked about the type of training that should be provided, an administrator said,
They have to have some clear understanding theoretically, but they also have to be able to—all the practicalities of it have to be shared with them and how it is actually done. And they need some someone to be able to recommend some changes to what they are doing.
Similarly, therapists had preferences for segmented training programs where a number of training sessions in relation to the EBT model would be held over a 1 year time period, allowing therapists to practice what they learned at the previous training session and then come back for more training and subsequent application. One therapist captured this preference when they stated,
I think for me 4 sessions or whatever over a year. We've done that type of training before. They allowed us to go back to work, practice these techniques, roll them around in our heads a little bit, think about how they'll fit our clients, and then we're ready to go back for our next sessions. That would be ideal.
Therapists and administrators commented on the importance of having clinical supervision following training in order to monitor their use of the EBT in practice, indicating that without some form of supervision, therapists are likely to stray from fidelity to FBT or any EBT model. Preferences for supervision were identified as someone who is well versed in the clinical application of the EBT so that they can be assured that new model users are meeting the requirements of the manualized approach. Supervision was seen both as a support and as a resource to ensure that therapists are implementing the model as suggested by the evidence.
In addition to clinical supervision and monitoring fidelity to the EBT, participants indicated that the use of the model should be evaluated in relation to patient outcomes (step 7). Ten of the 11 administrators identified program evaluation research as playing a seminal role in their program decisions, with 39 of 40 therapists also identifying program evaluation as an important influence in their treatment decision-making.
Inclusive Change Culture
All interviewees identified the importance of an inclusive change culture as an important factor in EBT adoption and implementation within pediatric eating disorder treatment services. Participants operationalized inclusiveness as engaging all program staff in the change process, from front-line practitioners to those in leadership positions. Some participants went as far as to identify this inclusive change culture as a “way of working” that their program has explicitly aimed for, while most were more implicit about this “norm” of program operations. For example, when asked to speak to the process of adopting new EBTs into their program, an administrator said the following,
We work really hard at moving forward as a team. It has taken us a number of years to be able to create that culture and be able to have open conflict with one another to say what we agree with and disagree with.
Therapists were more implicit in their dialogue about an inclusive change culture. Instead, therapists identified team buy-in and administrator buy-in as important factors in the practice change process, but did not allude to this need for “inclusivity” as an over-arching culture for change. For example, one therapist insisted that treatment planning would be much more difficult if the model proposed was not supported by her team members. When asked about the important factors impacting her ability to adopt and implement EBTs, this therapist stated,
Definitely our treatment team. If they're not on board then that makes it a little bit difficult to formulate a treatment plan that they don't believe in.
All 40 therapists reported having autonomy in their choice of therapeutic interventions, but when asked what barriers may prevent them from adopting and implementing EBTs in practice, 36 of the 40 therapists indicated that their administrator would need to buy into the model and that, without their support, it would be difficult to shift their current practice.
Similarly, therapists felt that administrator allowances for EBT model variation within clinical practice could be contributing to their inconsistent fidelity to EBT interventions. One therapist stated,
We have, I think, a lot of leeway in terms of the work that we do. Nobody's breathing down your neck and saying you have to do it this way…but at the same time maybe makes it so that we don't jump on things as quickly as we could or should.
So pervasive was the notion of an inclusive change culture that administrators indicated they would never push for EBT adoption or implementation without consulting their team, and this was in spite of each administrator indicating that they had the decision-making authority to do so. Often times, these leaders reported that such an authoritative approach just would not make sense. One administrator exemplified this point with the following,
Theoretically I could make the decision by myself. That makes no sense to me. No, I would never come to a place where I was making a decision without having had extensive consultation with the mental health team.
Making the Case
Participants related the over-arching multi-staged decision-making process and having an inclusive change culture as the context from which they make the case for EBT adoption and implementation within their organization. Participants reported that change to needs to demonstrate foreseeable benefits to the client population, and when a good case for change is not made, suggested changes are unlikely to be endorsed by larger program decision-makers and staff.
Similarly, participants commented on the trend for health programs to provide EBTs and that therapists and administrators can use this trend to their advantage when advocating for practice change when an EBT is concerned. For example, one participant put it this way,
And the fact that it's [FBT] the only treatment that has evidence for adolescents, right? If admin knew that the only treatment that was proven to be effective was not being used in their center, like, that would be embarrassing.
Participants also identified the Ontario Provincial Network for Eating Disorders as an important authoritative body in EBT use and the implementation of EBP, and that if the Network endorsed FBT as the treatment of choice for adolescents under the age of 18, then this likely would make advocacy for practice change easier. Similarly, many administrators indicated that support from the Academy for Eating Disorders would support their adoption of the EBT model. In response to this question, an administrator said the following,
So, you know, when we have the Provincial Network supporting it, when you can have the Academy of Eating Disorders supporting it, you can go through and say these are the standards of care.
The primary objective of this study was to examine the decision-making processes involved in EBT uptake and EBP implementation within the context of pediatric eating disorder treatment services and, in particular, the decision-making processes involved in the implementation of FBT, an empirically supported EBT. Participants' identified a multi-staged decision-making process which influences their provision of EBP and the implementation of EBTs, and FBT more specifically. Of particular relevance to these processes was the development and maintenance of an inclusive change culture which respects the roles of therapists and administrators in the delivery of EBTs to children and their families, but also the need to make a case for practice change that is grounded in evidence and the pursuit of better outcomes. Each of these considerations also needs to be made while simultaneously acknowledging staff workload and program context.
The EBP decision-making processes discussed in this study map onto those discussed in the general child and youth mental health literature, but add to our understanding about the unique EBT implementation needs of therapists and decision-makers working in the pediatric eating disorder treatment field. For example, the multi-staged National Implementation Research Network (NIRN) model of implementation stipulates five successive stages in successful EBT implementation: exploration and adoption, program installation, initial implementation, full operation, and innovation. Our results resonate with each of the NIRN stages of implementation in that participants felt that they and their teams first need to be exposed to the EBT, assess the evidence for the model and determine program fit (NIRN exploration/adoption stage), train their staff in the EBT model (NIRN program installation stage), implement the EBT (NIRN initial implementation and full-operation stages), and continually consider the role of sustainability throughout the planning and implementation process, namely through providing fidelity checking and supervision. In this regard, EBT does not become ingrained within EBP without a thorough consideration of practice context.
Our own results differ from others in that rarely do knowledge users and their decision makers actually request the research evidence relating to an EBT, as reading this information is often perceived to be too time consuming or inaccessible.[22, 23] Reasons for devoting time to this process among our participants were given by their desire to learn about the potential benefits of the proposed EBT and how the EBT fits within their current program operations, demonstrating an informed approach to EBP decision-making.
The importance of an inclusive change culture in implementation processes has also been reported in the general child and youth mental health literature,[24, 25] as has the importance of inclusive leadership models. However, the explicit reluctance of administrators to commit to EBT adoption and implementation without staff support, as well as the importance placed on program evaluation despite not routinely implementing EBT, is novel.
Our findings resonate with what Damschroder et al. (2009) identify as important components for EBT implementation. Specifically, Damschroder et al.'s (2009) Consolidated Framework for Implementation Research speaks to the specific characteristics of the organization that need consideration during EBT implementation, including EBT characteristics, characteristics of the organization's inner and outer setting, therapist characteristics, and characteristics of the implementation process. Thus, while each of these domains of EBT implementation will be consistent to every implementation endeavor, our results suggest that the process for EBT implementation extends well beyond the purview of a single clinician and is likely to be implicitly driven by a number of factors within a program or organization. We stand to learn a great deal from any research which monitors the implementation of EBTs within specialized pediatric eating disorder treatment services, as well as the constructs impacting the use of the EBT in practice and inform EBP decision-making.
Limitations of this study include the nature of our sample and their recruitment. We aimed to engage a purposeful sample of therapists and their administrators within pediatric eating disorder treatment services in Ontario. Although both samples represented professionals working in rural, urban, suburban, academic, and nonacademic service centers, those involved in private practice were not recruited for this study. Similarly, the small number of administrator interviews can be viewed as a limitation of the study. The smaller administrator sample precluded our ability to provide information about the participants' professional designation, as providing this information could lead to the identification of participants. We believe the small administrator sample is reflective of the everyday challenges in working in human services, where decision-makers rarely have additional time to participate in research activities above their current clinical and administrative commitments. However, we have confidence in our data's representation of the variation of clinical eating disorder treatment services and decision-making processes across Ontario. Finally, and most notably, the content of our therapist and administrator interviews focused on one specific manualized EBT model—family based-treatment—and for this reason, may limit the generalizations we can make about EBT implementation in relation to other treatment models within and across eating disorder treatment contexts. Despite this information, our team feels that results from our work are informative for clinicians, administrators and/or programs undertaking any EBT implementation endeavor; whereby many, if not all, of the constructs and implementation processes identified by our study participants can be tailored to assist any program's implementation needs.
This qualitative description of therapist and administrator perspectives on EBT implementation is the first to provide insight on the decision-making processes involved in the uptake and implementation of EBTs, and FBT more specifically, within the pediatric eating disorder treatment field. Data from our study provide support for those constructs and domains of implementation found to be important in the EBT and EBP implementation literature. More generally, our results provide support for the field testing of implementation models in the pediatric eating disorder treatment services. Future work should focus on incorporating our findings into EBT implementation models and meta-theories that have been successful in other human service areas and identify how these models can assist in increasing EBT adoption, implementation, and fidelity within pediatric eating disorder treatment services. Such investigation, in addition to those evaluating implementation of other EBTs in eating disorder practice, will assist in assuring that evidence-based and low-cost treatments which are shown to produce the best possible outcomes are effectively and efficiently translated into clinical practice.
The authors appreciate the time that each study participant devoted to sharing their experiences and clinical expertise with the research team. They thank Joanne Savoy who conducted the therapist interviews for this study.
Note: Both the Therapist and Administrator Interview Guide(s) are available by contacting the primary author at firstname.lastname@example.org.
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