Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Nina A Sayer, Shannon Wiltsey-Stirman, Craig S. Rosen, Nancy C. Bernardy, Michele Spoont, Shannon M. Kehle-Forbes, Afsoon Eftekhari, Kathleen M. Chard, David B Nelson

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The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients’ treatment experience and outcomes is referred to as “therapist effects.” The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%–3.1% of the variance in early dropout and adequate dose. For CPT, patients’ odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Original languageEnglish (US)
JournalJournal of Traumatic Stress
StateAccepted/In press - 2021

Bibliographical note

Funding Information:
This research was supported by the U.S. Department of Veterans Affairs, Health Services Research and Development (HSR IIR 17–178 to Nina A. Sayer. The sponsor was not involved in any aspect of the study's design and conduct; data collection, management, analysis, or interpretation of data; or in the preparation, review, or approval of the manuscript. The findings and conclusions presented in this manuscript are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or HSR&D.

Publisher Copyright:
Published 2021. This article is a U.S. Government work and is in the public domain in the USA

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