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

Abstract

AbstractBased 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.