Patterns of therapist variability: Therapist effects and the contribution of patient severity and risk.
Observační studie
Typy studií podle spolehlivosti
Od nejspolehlivějšího po nejméně spolehlivý.
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Souhrn více studií (meta-analýza, systematický přehled)
nejspolehlivější obraz, jaký dnes máme. -
Randomizovaný pokus (RCT)
lidé byli rozděleni náhodně, takže rozdíl lze přičíst zásahu. -
Porovnání skupin
skupiny se porovnaly, ale bez náhodného rozdělení; naznačuje účinek. -
Pozorování nebo rozhovory ← tahle studie
popisuje, co se děje a co spolu souvisí; příčinu to neukáže. -
Názor odborníků, teorie nebo jeden případ
nic se neměřilo na skupině lidí, jde o zkušenost a výklad.
Typ studie říká, jak byla udělaná, ne jak velký byl účinek.
Klasika
Jak nová je studie
Podle roku vydání; klasika stojí stranou.
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Nový výzkum
vyšla letos nebo loni. -
Zavedené
vyšla předloni nebo dřív. -
Klasika ← tahle studie
práce, na které obor staví.
Stáří neříká, jak je studie spolehlivá. To říká typ studie.
Ve zkratce
The authors studied 119 therapists and 10,786 clients in UK primary care therapy services. They found that about 6.6% of the variation in client outcomes was linked to which therapist a client saw. That difference was much larger for clients who started therapy with more severe symptoms.
Celý souhrn studie Context · Findings · Implications · Co nepřeceňovat
Context
The study used routine data from National Health Service primary care counselling and psychological therapy services in the UK. The data covered clients referred between 2000 and 2008. Clients were included if they were 18 or over and had at least two one-to-one sessions. They also needed a planned ending and outcome scores before and after therapy. The final sample was 10,786 clients seen by 119 therapists. Clients averaged 42.1 years old, and 71.5% were women. Therapists entered the study only if they had 30 or more clients and returned outcome measures for at least 90% of them. Clients completed the CORE-OM, a 34-item self-report measure of wellbeing, symptoms, functioning and risk. This was an observational study of routine practice, not a randomised trial. The authors used multilevel modelling to separate client factors from therapist factors.
Findings
The authors report a therapist effect of 6.6%. This means about 6.6% of the remaining difference between clients was linked to the therapist. Without the therapist risk caseload variable, the figure was 7.8%. The therapist effect was not fixed. It was around 1% to 2% for clients with very low symptom scores. It rose to about 10% as client severity increased. So for more severe clients, outcome depended more on which therapist they saw. Individual therapist recovery rates ranged from 23.5% to 95.6%, with a mean of 58.8%. The model identified 21 therapists (17.7%) as above average and 19 (16.0%) as below average. The other 79 (66.4%) did not differ reliably from average. Among clients who started above the clinical cut-off, 76.5% recovered with above-average therapists. With below-average therapists, 46.1% recovered. Deterioration rates were 0.5% and 1.6% respectively. When the authors removed the 19 least effective therapists, the therapist effect fell to 4.6%. Overall recovery rose from 61.6% to 64.9%. The authors estimate that 265 more clients would have recovered with average therapists. Higher client severity predicted poorer outcomes. A higher average risk score in a therapist's caseload also predicted poorer outcomes. Caseload severity without risk did not predict outcomes.
Implications
The authors suggest that services should monitor outcomes at the therapist level, not just service-wide. They also recommend managing caseloads, especially the number of high-risk clients each therapist carries. Careful allocation of more severe clients may matter most. The study does not show what makes some therapists more effective. Routine data held little information about therapists themselves. The evidence also does not settle whether training, supervision or adherence to protocol would reduce these differences. Be careful with simple rankings. Recovery rate ranges overlapped a lot between groups. Some average therapists had lower recovery rates than some below-average therapists. The authors note limitations. Only clients with planned endings were included, which may inflate overall effectiveness. Results apply to experienced therapists who treated 30 or more clients. Clients who dropped out were not examined.
Co nepřeceňovat
Do not read the 6.6% figure as a fixed share of your own results. Do not rank therapists on raw recovery rates alone, because the ranges overlapped heavily. The study included only clients with planned endings, so it may overstate recovery. It cannot tell you which training or supervision changes would close the gap between therapists.
Zdroje
- Saxon, David, Barkham, Michael (2012). Patterns of therapist variability: Therapist effects and the contribution of patient severity and risk. Journal of Consulting and Clinical Psychology. https://doi.org/10.1037/a0028898