The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration.
Nina A Sayer, Shannon Wiltsey Stirman, Craig S Rosen, Shannon Kehle-Forbes, Michele R Spoont, Afsoon Eftekhari, Kathleen M Chard, Adam Kaplan, David B Nelson
{"title":"The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration.","authors":"Nina A Sayer, Shannon Wiltsey Stirman, Craig S Rosen, Shannon Kehle-Forbes, Michele R Spoont, Afsoon Eftekhari, Kathleen M Chard, Adam Kaplan, David B Nelson","doi":"10.1037/ccp0000832","DOIUrl":null,"url":null,"abstract":"<p><strong>Objective: </strong>This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs.</p><p><strong>Method: </strong>Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (<i>n</i> = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs.</p><p><strong>Results: </strong>Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (<i>p</i>s < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (<i>p</i> < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (<i>p</i> = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery.</p><p><strong>Conclusions: </strong>Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).</p>","PeriodicalId":15447,"journal":{"name":"Journal of consulting and clinical psychology","volume":" ","pages":"665-679"},"PeriodicalIF":4.5000,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10592522/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of consulting and clinical psychology","FirstCategoryId":"102","ListUrlMain":"https://doi.org/10.1037/ccp0000832","RegionNum":1,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2023/9/4 0:00:00","PubModel":"Epub","JCR":"Q1","JCRName":"PSYCHOLOGY, CLINICAL","Score":null,"Total":0}
引用次数: 0
Abstract
Objective: This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs.
Method: Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs.
Results: Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery.
Conclusions: Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
期刊介绍:
The Journal of Consulting and Clinical Psychology® (JCCP) publishes original contributions on the following topics: the development, validity, and use of techniques of diagnosis and treatment of disordered behaviorstudies of a variety of populations that have clinical interest, including but not limited to medical patients, ethnic minorities, persons with serious mental illness, and community samplesstudies that have a cross-cultural or demographic focus and are of interest for treating behavior disordersstudies of personality and of its assessment and development where these have a clear bearing on problems of clinical dysfunction and treatmentstudies of gender, ethnicity, or sexual orientation that have a clear bearing on diagnosis, assessment, and treatmentstudies of psychosocial aspects of health behaviors. Studies that focus on populations that fall anywhere within the lifespan are considered. JCCP welcomes submissions on treatment and prevention in all areas of clinical and clinical–health psychology and especially on topics that appeal to a broad clinical–scientist and practitioner audience. JCCP encourages the submission of theory–based interventions, studies that investigate mechanisms of change, and studies of the effectiveness of treatments in real-world settings. JCCP recommends that authors of clinical trials pre-register their studies with an appropriate clinical trial registry (e.g., ClinicalTrials.gov, ClinicalTrialsRegister.eu) though both registered and unregistered trials will continue to be considered at this time.