Top

Administration and Policy in Mental Health and Mental Health Services Research

Open Access 02-04-2024 | Psychotherapy | Original Article

Therapist-Level Moderators of Patient-Therapist Match Effectiveness in Community Psychotherapy

Authors: Alice E. Coyne, Michael J. Constantino, James F. Boswell, Averi N. Gaines, David R. Kraus

Published in: Administration and Policy in Mental Health and Mental Health Services Research

Abstract

Based on patient-reported outcomes data analyzed at the provider level, there is evidence that psychotherapists can possess effectiveness strengths and weaknesses when treating patients with different presenting concerns. These within-therapist differences hold promise for personalizing care by prospectively matching patients to therapists’ historical effectiveness strengths. In a double-masked randomized controlled trial (RCT; NCT02990000), such matching outperformed pragmatically determined usual case assignment—which leaves personalized, measurement-based matching to chance—in naturalistic outpatient psychotherapy (Constantino et al., JAMA Psychiatry 78:960–969, 2021). Demonstrating that personalization can be even more precise, some research has demonstrated that the strength of this positive match effect was moderated by certain patient characteristics. Notably, though, it could also be that matching is especially important for some therapists to achieve more effective outcomes. Examining this novel question, the present study drew on the Constantino et al. (JAMA Psychiatry 78:960–969, 2021) trial data to explore three therapist-level moderators of matching: (a) effectiveness “spread” (i.e., greater performance variability across patients’ presenting problem domains), (b) overestimation of their measurement-based and problem-specific effectiveness, and (c) the frequency with which they use patient-reported routine outcomes monitoring in their practice. Patients were 206 adults, randomized to the match or control condition, treated by 40 therapists who were crossed over conditions. The therapist variables were assessed at the trial’s baseline and patients’ symptomatic/functional impairment and global distress were assessed regularly up to 16 weeks of treatment. Hierarchical linear models revealed that only therapist effectiveness spread significantly moderated the match effect for the global distress outcome; for therapists with more spread, the match effect was more pronounced, whereas the match effect was minimal for therapists with less effectiveness spread. Notably, two therapist-level covariates unexpectedly emerged as significant moderators for the symptomatic/functional impairment outcome; for clinicians who consistently treated patients with higher versus lower average severity levels and who relatedly treated a higher proportion of patients with primary presenting problems of substance misuse or violence, the beneficial match effect was even stronger. Thus, measurement-based matching may be especially potent for therapists with more variable effectiveness across problem domains, and who consistently treat patients with more severe presenting concerns or with particular primary problems, which provides further precision in conceptualizing personalized care.

Available only for authorised users

As noted, a neutral classification is not inherently negative, as it can mean a therapist helps their average patient in a given problem domain improve to roughly the expected degree (Constantino et al., 2021). However, to the extent a patient believes a therapist is highly effective at treating their presenting problem, such an outcome may still be somewhat misattuned to the patient’s expectation.

See Supplemental Table 1 for descriptive statistics for each of the 12 domain-specific problems on the TOP at baseline by case assignment condition.

Notably, once assigned to the match condition, the level of matching was not randomly determined. Rather, from a shortlist of clinicians who were empirically matched at any level, a project coordinator worked their way through the list, from highest to lowest match level, to assign a therapist who met other necessary conditions for a given patient (e.g., had an opening, accepted their insurance; Constantino et al., 2021).

The remaining 36.1% of CAU patients were empirically unmatched.

Although more complex outcome change patterns (e.g., quadratic, cubic) are common in psychotherapy data, due to the variability in treatment lengths, many patients did not have enough timepoints to inform such complex trajectories. Therefore, consistent with the primary outcome paper for this trial (Constantino et al., 2021), we focused only on linear outcome change.

Due to variability in treatment lengths within this trial, we conducted a sensitivity analysis for the therapist effectiveness spread moderator with time centered at week 11 (the average treatment length in the sample). The cross-level interactive effect remained significant for both weekly global distress reduction and global distress level at week 11 (ps < .05). Full results available upon request of first author.

Boswell, J. F., Constantino, M. J., Coyne, A. E., & Kraus, D. R. (2022). For whom does a match matter most? Patient-level moderators of evidence-based patient-therapist matching. Journal of Consulting and Clinical Psychology, 90(1), 61–74. https://doi.org/10.1037/ccp0000644CrossRefPubMed

Boswell, J. F., Constantino, M. J., Kraus, D. R., Bugatti, M., & Oswald, J. M. (2016). The expanding relevance of routinely collected outcome data for mental health care decision making. Administration and Policy in Mental Health and Mental Health Services Research, 43(4), 482–491. https://doi.org/10.1007/s10488-015-0649-6CrossRefPubMed

Constantino, M. J., & Muir, H. J. (2024). Can we harness therapist effects for therapeutic benefit? In F. T. L. Leong, J. L. Callahan, J. Zimmerman, M. J. Constantino, & C. F. Eubanks (Eds.), APA handbook of psychotherapy: Evidence-based practice, practice-based evidence, and contextual participant-driven practice., (Vol. 2, pp. 243–254). American Psychological Association. https://doi.org/10.1037/0000354-016

Constantino, M. J., Boswell, J. F., Coyne, A. E., Muir, H. J., Gaines, A. N., & Kraus, D. R. (2023). Therapist perceptions of their own measurement-based, problem-specific effectiveness. Journal of Consulting and Clinical Psychology, 91(8), 474–484. https://doi.org/10.1037/ccp0000813CrossRefPubMed

Constantino, M. J., Boswell, J. F., Coyne, A. E., Swales, T. P., & Kraus, D. R. (2021). Enhancing mental health care by matching patients to providers’ empirically derived strengths: A randomized clinical trial. JAMA Psychiatry, 78(9), 960–969. https://doi.org/10.1001/jamapsychiatry.2021.1221CrossRefPubMed

Coyne, A. E. (2024). Therapist performance report cards: Do clinicians differ in their specific effectiveness? In F. T. L. Leong, J. L. Callahan, J. Zimmerman, M. J. Constantino, & C. F. Eubanks (Eds.), APA handbook of psychotherapy: Evidence-based practice, practice-based evidence, and contextual participant-driven practice., Vol. 2. (pp. 227–242). American Psychological Association. https://doi.org/10.1037/0000354-015

Coyne, A. E., Constantino, M. J., Ouimette, K. A., Gaines, A. N., Atkinson, L. R., Bagby, M., Ravitz, P., & McBride, C. (2022). Replicating patient-level moderators of CBT and IPT’s comparative efficacy for depression. Psychotherapy, 59(4), 616–628. https://doi.org/10.1037/pst0000458CrossRefPubMed

Johns, R. G., Barkham, M., Kellett, S., & Saxon, D. (2019). A systematic review of therapist effects: A critical narrative update and refinement to review. Clinical Psychology Review, 67, 78–93. https://doi.org/10.1016/j.cpr.2018.08.004CrossRefPubMed

Kraus, D. R., Bentley, J. H., Alexander, P. C., Boswell, J. F., Constantino, M. J., Baxter, E. E., & Castonguay, L. G. (2016). Predicting therapist effectiveness from their own practice-based evidence. Journal of Consulting and Clinical Psychology, 84(6), 473–483. https://doi.org/10.1037/ccp0000083CrossRefPubMed

Kraus, D. R., Castonguay, L. G., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implications for accountability and patient care. Psychotherapy Research, 21(3), 267–276. https://doi.org/10.1080/10503307.2011.563249CrossRefPubMed

Kraus, D. R., Seligman, D. A., & Jordan, J. R. (2005). Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The treatment outcome package. Journal of Clinical Psychology, 61(3), 285–314. https://doi.org/10.1002/jclp.20084CrossRefPubMed

Preacher, K. J., Zhang, Z., & Zyphur, M. J. (2016). Multilevel structural equation models for assessing moderation within and across levels of analysis. Psychological Methods, 21(2), 189–205. https://doi.org/10.1037/met0000052CrossRefPubMed

Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). SAGE Publications.

Rosen, C. S., Drescher, K. D., Moos, R. H., Finney, J. W., Murphy, R. T., & Gusman, F. (2000). Six and ten-item indexes of psychological distress based on the symptom checist-90. Assessment, 7(2), 103–111. https://doi.org/10.1177/107319110000700201CrossRefPubMed

Snow, R. E. (1991). Aptitude-treatment interaction as a framework for research on individual differences in psychotherapy. Journal of Consulting and Clinical Psychology, 59, 205–216.CrossRefPubMed

Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639–644. https://doi.org/10.2466/02.07.17.PR0.110.2.639-644CrossRefPubMed

Wampold, B. E., & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In L. G. Castonguay, M. Barkham, & W. Lutz (Eds.), Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 301–330). Wiley.

Zack, S. E., Castonguay, L. G., Boswell, J. F., McAleavey, A. A., Adelman, R., Kraus, D. R., & Pate, G. A. (2015). Attachment history as a moderator of the alliance outcome relationship in adolescents. Psychotherapy, 52(2), 258–267. https://doi.org/10.1037/a0037727CrossRefPubMed

Title: Therapist-Level Moderators of Patient-Therapist Match Effectiveness in Community Psychotherapy
Authors: Alice E. Coyne
Michael J. Constantino
James F. Boswell
Averi N. Gaines
David R. Kraus
Publication date: 02-04-2024
Publisher: Springer US
Keyword: Psychotherapy
Published in: Administration and Policy in Mental Health and Mental Health Services Research
Print ISSN: 0894-587X
Electronic ISSN: 1573-3289
DOI: https://doi.org/10.1007/s10488-024-01360-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Therapist-Level Moderators of Patient-Therapist Match Effectiveness in Community Psychotherapy

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content