Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events

Evidence-based mental health interventions are inconsistently implemented in community settings. Many factors can interfere with practitioners’ implementation of evidence-based practices (EBPs), even when they are strongly motivated to use them (1). For example, supporting individuals who are in a state of crisis requires clinicians to make nuanced, contingent decisions while simultaneously regulating their own emotions (2, 3). This cognitive and emotional load can interfere with clinicians’ ability to implement EBPs.

Practitioners are typically trained in EBPs under low-stress conditions. The mismatch between the heightened emotional state of a real-life clinical encounter (hot state) and calm state when learning an EBP (cold state) is called the “hot-cold state empathy gap” (4). A growing body of research supports the importance of this gap in predicting physician and nurse behavior (5, 6). This gap has received little attention in mental health care and may contribute to inconsistent implementation of EBPs (7).

Here, we provide four examples of practitioners experiencing emotion dysregulation when attempting to implement evidence-based protocols in two community settings in which mental health treatment often is delivered: mental health clinics and schools. These examples come from our community-based field trials and observational studies (8–11). We discuss implications for developing training and supports that facilitate the implementation of EBPs during emotionally intense clinical interactions. Examples include community-based counselors working with neurodivergent adults, outpatient mental health clinicians working with individuals with anxiety or related disorders, elementary school special education teachers, and general elementary education teachers.

Examples of Practitioners’ Emotion Dysregulation

The first example of a practitioner experiencing emotion dysregulation in a practice setting comes from a 15-week intensive group counseling program for young adults who are autistic or have other developmental disabilities (8). All program participants are screened for clinically elevated emotion dysregulation; many have histories of suicidal thoughts and behaviors. Practitioners in this example included a licensed professional counselor and supervisor with >5 years of experience and two graduate trainees with 2 years of experience. Such practitioners complete training in a five-step, evidence-based protocol for emotion dysregulation that may occur during group counseling: identify that a client is in distress, interrupt the group activity to provide support, suggest an individualized strategy to complete together (12), practice the strategy together with the client until distress is reduced, and debrief after the client is emotionally regulated. Practitioners also were trained not to ask questions, not to place cognitive demands on the client, and not to enforce discipline or consequences while the client is experiencing dysregulation. The practitioners led community outings designed to elicit emotion dysregulation so that clients could practice newly learned skills (8, 12). In one such outing, the practitioners identified a client in distress (step 1) but did not interrupt the activity to provide support because of their own personal emotional reactivity to the client’s distress (steps 2–4). The licensed practitioner stated afterward, “[Because of the] level of distress I was feeling watching their distress, I couldn’t help everybody at the same time. I wish I would’ve stopped the activity.” In response to their own emotional reactivity, two other practitioners reverted to instinctual responses such as repeatedly asking clients, “Do you need to use a strategy?” Practitioners indicated that they were still too dysregulated after the outing to debrief with the participants and therefore did not complete step 5.

The second example involves community mental health clinicians working with people with psychiatric diagnoses such as anxiety, obsessive-compulsive, posttraumatic stress, and eating disorders (9). Years of clinical experience varied, but all clinicians were new to the EBP used. Clinicians were trained in exposure therapy to help clients learn to face fears and build distress tolerance. Delivering exposure therapy requires clinicians to assess patterns of avoidance that lead to impairment and distress, provide psychoeducation on avoidance and the need for intentional exposure practice, and guide the client to engage in exposure practices that support facing fears. The clinicians reported having anxious beliefs about exposure exercises “going wrong” before implementation. Their emotional reactivity in response to clients’ anxiety spiked during exposure practices. This reactivity resulted in failure to complete step 3; instead, the clinicians either halted exposure practices early or relied solely on arousal reduction strategies, such as relaxation, which runs counter to building distress tolerance.

The third example involves special education teachers who teach autistic students (10). The teachers had >3 years of teaching experience but little or no experience in supporting autistic students. Many of these students engage in aggressive behaviors, self-injury, or elopement to have their needs met or to escape undesirable situations. Evidence-based antecedent strategies include identifying the triggers and function of the challenging behavior, implementing strategies to prevent the behavior, reinforcing use of replacement skills, and modeling or prompting emotion regulation skills. Evidence-based consequent strategies include using safety management and deescalation or extinction or redirection skills and modeling or prompting emotion regulation skills. Instead of deploying these strategies when a student engaged in challenging behaviors, teachers were flustered. They forgot to model or prompt emotion regulation skills and acted in ways that indicate distress, which may escalate the situation or reinforce the challenging behavior.

The fourth example comes from reported experiences of elementary school teachers, who typically have at least several students with attention-deficit hyperactivity or other disorders in their classroom (11). On average, teachers in this example had a master’s-level degree and 10 years of experience and were moderately familiar with the evidence-based protocol. To prevent students from engaging in disruptive behaviors, or in response to disruptive behaviors, the evidence-based protocol is to identify students who need individualized behavior support, apply individualized antecedent- and consequence-based interventions for those students (e.g., high rates of praise for behavioral improvement), and use a daily report card or similar targeted intervention to provide students with feedback and reinforcement on specific behavioral goals. Instead of using these EBPs when a student showed disruptive behavior, teachers often felt overwhelmed, frustrated, or angry. These emotional responses led to teachers using punishment-based responses, reacting inconsistently to students’ behaviors, and forgetting daily report cards.

Key Themes Across Examples

Practitioners reported that their heightened emotions interfered with their ability to recall an EBP; they instead responded in ways that were inconsistent with EBPs. Practitioners showed variation in training and experience, and many were new to the practice of interest, suggesting that emotional reactivity can inhibit implementation of new practices regardless of previous training and experience. Practitioners in all the examples had received extensive training in the relevant evidence-based protocol, had successfully implemented the protocol in less emotionally charged situations, and indicated their willingness to use such protocols.

Suggestions to Improve Implementation During Emotionally Intense Clinical Events

Training, Professional Development, and Continuing Education

Didactic training in cold states is not likely to succeed when practitioners must use new skills in challenging settings. Simulation training allows practitioners to practice protocols in emotional states similar to those they will experience in the field (13, 14). We developed a training protocol that includes rapid-fire practice of emotionally intense or feared clinical scenarios with timed group problem solving (14). This practice integrates principles from exposure therapy to elicit practitioners’ most feared clinical scenarios, followed by targeted, tailored practice (e.g., imaginal exercises, tailored simulations, or role-plays) to regulate their own emotions (9, 14). Such strategies may equip the practitioner with skills to use the evidence-based protocol during emotionally charged hot-state situations.

In-the-Moment Supports: Checklists, In Vivo Supervision, and Digital Reminders

Safety checklists can prevent adverse events in settings where practitioners must make quick decisions under duress (15). Checklists comprise lists of requirements, steps to complete, and aspects to consider in making a decision. Checklists can be tailored for frequent and infrequent emotionally intense events and for emergencies. Mental health teams can build checklists together and place them where they are readily available to clinicians and other practitioners when needed.

On-call support and coaching through stressful clinical encounters may also support mental health and other practitioners in implementing EBPs. These in vivo supports can encourage practitioners to reflect on their own thoughts, emotions, and behaviors that are affecting optimal implementation. Real-time electronic clinical decision support tools and reminders have shown efficacy in emergency health care, leading to greater fidelity to EBPs and better patient outcomes (16). Like checklists, these types of tools could augment and support practitioners’ use of EBPs when a situation demands such use (17).

Conclusions

Emotionally intense clinical encounters pose barriers to EBP implementation for practitioners at all levels of training and experience. Practitioners must manage their own emotional reactivity and their clients' reactivity and must navigate the tension between adherence to EBPs and adaptively responding in ways that are not detailed in the EBP protocol (7). Yet, training and implementation plans rarely consider the hot-cold state empathy gap as a barrier to implementation. Although the examples in this Open Forum were derived from real clinical vignettes and interviews, we posit that this barrier to skillful EBP implementation is relevant to many emotionally intense clinical encounters, such as with patients experiencing first-episode psychosis or chronic suicidal thoughts and behaviors. Simulation-based training and in vivo practice are promising options to better prepare mental health practitioners before an emotionally intense clinical encounter. Learning new skills during times when a practitioner’s emotional state is dysregulated that match situations in the clinic or similar settings will better translate to optimal implementation. Tailored checklists and on-call or remote coaching for practitioners provide immediate supports to help practitioners remember steps when they themselves are emotionally dysregulated. These efforts could go a long way toward helping motivated clinicians implement interventions successfully and are therefore worthy of further study.