Therapist effects vary significantly across psychological treatment care sectors

Psychological intervention outcomes depend in part on the therapist who provides the intervention (a therapist effect). However, recent reviews suggest that therapist effects may vary as a function of the context in which care is provided and therefore should not be generalized beyond that context. This study statistically analysed therapist effect differences between care sectors delivering psychological interventions. The sample comprised routine clinical data from 26,814 patients (69% female; mean age 38) and 466 therapists in five care sectors: primary care, secondary care, university, voluntary, and workplace. Therapist effects were analysed using multilevel models and Markov chain Monte Carlo credible intervals. The therapist effect was significantly larger in primary care (8.4%) than in any other sector (1.1%–2.3%) except secondary care (4.1%), after controlling for explanatory baseline and process variables as well as accounting for differences between clinics. There were no other significant differences detected between care sectors. These findings support the hypothesis that differences in effectiveness between therapists vary depending on the context in which psychological treatment is provided. Differences in relative therapist impact can vary by a factor of 4–8 across treatment sectors. This should be considered in the application of research evidence, treatment planning, and the design and delivery of psychological care provision

Therapist and clinic effects in psychotherapy: a three-level model of outcome variability

Objective: The study aimed to 1) investigate the effect of treatment location on clinical outcomes for patients receiving psychological therapy (a clinic effect, akin to the concept of a therapist effect), and 2) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects. Method: The sample comprised 26,888 patients, seen by 462 therapists, across 30 clinics. Mean patient age was 38 years (69% female, 90% White, 92% planned ending). The dependent variable was patients’ post-therapy score on the Clinical Outcomes in Routine Evaluation – Outcome Measure. An incremental three-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects. Results: A three-level model with no explanatory variables detected a clinic effect of 8.2%, significantly larger than the therapist effect of 3.2%. Adding explanatory variables significantly reduced the clinic effect to 1.9% but did not significantly alter the therapist effect (3.4%). Patient-level symptom severity and employment status, and clinic-level percentage of White patients and healthcare sector explained the most clinic outcome variance and overall outcome variance. Conclusions: Substantial variability in clinical outcomes was found between clinics providing psychological therapy. Socioeconomic mix of patients explained significant proportions of variability at the clinic level but not the therapist level. Clinical implications include the need to go beyond the therapist-patient interaction in order to deliver effective psychological therapy. Future research is also needed to identify the mechanisms by which clinic and/or area-level factors impact on clinical outcomes

Innovative moments and poor outcome in narrative therapy

To analyse a poor outcome case of narrative therapy with a woman victim of intimate violence. Method: The Innovative Moments Coding System: version 1 was applied to all sessions to track the innovative moments (i-moments) in the therapeutic process. I moments are the narrative details that occur in psychotherapeutic conversations that are outside the influence of the problematic narrative. This research aims to describe the processes involved in the stability of meanings in psychotherapy through a dialogical approach to meaning making. Findings: Contrarily to what usually occurs in good outcome cases, re-conceptualization i-moments are absent. Moreover, two specific types of i-moments emerged with higher duration: reflection and protest. Qualitative analysis showed that the potential meanings of these i-moments were surpassed by a return to the problematic narrative. Conclusion: The therapeutic stability seems to be maintained by a systematic return to the problematic narrative after the emergence of novelties. This process was referred from a dialogical perspective as a mutual in-feeding of voices, one that emerges in the i-moment and another one that supports the problematic narrative, which is maintained by an oscillation between these two types of voices during therapy.This article was supported by the Portuguese Foundation for Science and Technology (FCT), by the Grant PTDC/PSI/72846/2006 (Narrative Processes in Psychotherapy, 2007-2010) and by the PhD Grant SFRH/BD/16995/2004

Multiple voices: A virtual discussion

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