The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration.

IF 4.5 1区 心理学 Q1 PSYCHOLOGY, CLINICAL Journal of consulting and clinical psychology Pub Date : 2023-11-01 Epub Date: 2023-09-04 DOI:10.1037/ccp0000832
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
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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).

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治疗提供和临床组织因素在解释退伍军人健康管理局以创伤为重点的心理治疗师效果中的作用。
目的:本研究估计了两种以创伤为中心的心理治疗师治疗(TFP)的辍学和临床有效性的治疗师效应(TE)大小,并评估了治疗提供和临床组织因素是否解释了观察到的TE。方法:参与者包括来自137个退伍军人健康管理机构的180名治疗师(54.4%为心理学家,42.2%为社会工作者)和1735名至少完成两次TFP治疗的患者(24.7%为女性;27.2%为有色人种)。结果是辍学(<8次TFP治疗),对于一个子样本(n=1273),基于创伤后应激障碍DSM-5(PCL-5)评分检查表,有临床意义的改善和恢复。治疗师水平的预测因素是通过调查、手动图表审查和管理数据确定的。多层次模型估计TE。结果:超过一半(51.2%)的患者退出,退出的患者不太可能达到有临床意义的改善或恢复标准(p<0.001)。根据病例组合和TFP类型进行调整后,治疗师占退出的原因不明方差的5.812%(p<.001)。表现最好的四分位数中的45名治疗师的平均辍学率为27.0%,而表现最差的四分位中的45位治疗师的平均退学率为78.8%。当治疗师的平均疗程天数、依从性、实施氛围和工作量被添加到多水平模型中时,治疗师之间的差异减少到2.031%(p=.140)。TE对临床意义的改善和恢复无显著意义。结论:针对治疗提供和临床组织的干预措施有可能减少治疗师之间TFP脱落的差异,从而使更多的患者保持足够长的时间来体验临床益处。(PsycInfo数据库记录(c)2023 APA,保留所有权利)。
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CiteScore
9.00
自引率
3.40%
发文量
94
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.
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