The Role of Therapy Delivery and Clinic Organizational Factors in Explaining Therapist Effects for Trauma-Focused Psychotherapies in the Veterans Health Administration

• Published in: Journal of consulting and clinical psychology Vol. 91; no. 11; pp. 665 - 679
• Main Authors: Sayer, Nina A., Wiltsey Stirman, Shannon, Rosen, Craig S., Kehle-Forbes, Shannon, Spoont, Michele R., Eftekhari, Afsoon, Chard, Kathleen M., Kaplan, Adam, Nelson, David B.
• Format: Journal Article
• Language: English
• Published: Arlington American Psychological Association 01-11-2023
• Subjects: Caseloads; Chart reviews; Clinical effectiveness; Dropping out; Female; Government Agencies; Health; Health Care Delivery; Health Maintenance Organizations; Health status; Human; Male; Meaning; Military hospitals; Military Veterans; Organizational effectiveness; Organizational factors; Patients; Post traumatic stress disorder; Psychotherapy; Recovery; Social workers; Therapists; Therapy; Trauma; Veterans; Women; trauma-focused psychotherapies; treatment outcomes; therapist effects; dropout; implementation
• ISSN: 0022-006X; 1939-2117; 1939-2117
• DOI: 10.1037/ccp0000832

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.
What is the public health significance of this article?
In routine care, some therapists were more effective than others at retaining patients in trauma-focused psychotherapy. Specifically, approximately one in four patients dropped out among therapists in the best performing quartile, while almost four in five patients dropped out among therapists in the worst performing quartile. Because patients who dropped out from a trauma-focused psychotherapy generally did not demonstrate clinically meaningful improvement or recovery, identification of modifiable factors that enhance therapists' ability to reduce dropout is critical. Our findings suggest that interventions to reduce the time between sessions and enhance clinic support for delivery of trauma-focused psychotherapy have the potential to reduce the difference in dropout rates between high and low performing therapists.