Implementation of Cognitive Enhancement Therapy: Preliminary Assessment of Barriers and Facilitators Using the Consolidated Framework for Implementation Research

Background and Purpose: Cognitive Enhancement Therapy (CET) is a cognitive remediation approach targeting the neurocognitive and social cognitive impairments prevalent in schizophrenia spectrum disorders. In clinical studies, CET has been successful in improving cognitive functioning, social adjustment, and other positive functional outcomes for both chronic and early course schizophrenia patients. Because the translation of evidence-based interventions, like CET, from controlled research settings to the broader community mental health system is an ongoing challenge, a systematic analysis of the implementation process and related constructs is crucial. To identify the barriers and facilitators in implementing CET in community settings, the current study uses the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis.

Methods: Thirteen individual 1-hour semi-structured interviews, guided by CFIR, were conducted via Zoom. Participants consisted of stakeholders who had experience with implementing CET in a community setting: five CET practitioner/coaches, three CET trainers, one site administrator, and four CET researchers/developers across six sites from three northeast states. The sample is predominately female (9 (69%)), all white, and ages ranged from 35 to 70. Recruitment was done through outreach to known community partners and snowball sampling. Interviews elicited participants’ opinions and perspectives on CET characteristics (i.e., evidence, complexity, adaptability), inner setting of their organization (i.e., workload, workplace culture, administrative and supervisory support), and process of implementation (planning, engagement, execution, and reflections). Interviews were recorded, transcribed, and coded using qualitative comparative analysis, guided by CFIR, to evaluate which areas were barriers and which were facilitators to the successful implementation of CET.

Results: While others successfully implemented CET, only one of the six sites has sustained implementation and continues to offer the intervention. Participants at this location appreciated the evidence-base of CET and its comprehensive manual (intervention characteristics), had strong support and commitment from supervisors and administration (inner setting), and expressed the presence of positive relationships between clinicians and clients. This site was also creative in establishing a reimbursement protocol for providing the innovative intervention. Participants at sites who did not sustain CET implementation tended to mention the length and complexity of the intervention, as well as inflexibility in modifying the intervention (intervention characteristics). Additional barriers included the long training process and difficulty recruiting clients (process). Those who had challenges in sustaining implementation also cited the rigid and productivity-focused mental health system, contributing to difficulty with reimbursements, heavy caseloads, little time for thinking about CET, and clinician burnout. Common themes across all participants were the observed effectiveness of CET, accounts of client successes, the now aging neurocognitive training software, and social cognition group exercise suggestions.

Conclusions and Implications: With this preliminary analysis we conclude that CET can be implemented into community settings, but requires commitment, collaboration, positive relationship-building, and creativity. Potential barriers related to moderness of training software and social cognition contexts can be easily addressed by researchers and developers of CET to improve user-friendliness and encourage engagement. Additional barriers related to the mental health system can be addressed with advocacy, community mental health partnerships, and policy change.