School of Health and Related Research (ScHARR), University of Sheffield.
Clinical Psychology Unit, Department of Psychology, University of Sheffield.
J Consult Clin Psychol. 2019 Apr;87(4):345-356. doi: 10.1037/ccp0000388.
The study aimed to (a) 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 (b) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects.
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' posttherapy score on the Clinical Outcomes in Routine Evaluation-Outcome Measure. An incremental 3-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects.
A 3-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 health care sector, explained the most clinic outcome variance and overall outcome variance.
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 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. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
本研究旨在（a）调查治疗地点对接受心理治疗患者的临床结局的影响（一种类似于治疗师效应的诊所效应），以及（b）评估个体和总体人口统计学和过程变量对诊所和治疗师效应的影响。
该样本包括 26888 名患者，由 462 名治疗师在 30 个诊所中治疗。患者的平均年龄为 38 岁（69%为女性，90%为白人，92%计划结束治疗）。因变量是患者在常规评估-结果测量中的治疗后得分。构建了一个递增的 3 水平多层模型。马尔可夫链蒙特卡罗估计为诊所和治疗师效应创建了 95%概率区间。
在没有解释变量的 3 水平模型中，检测到 8.2%的诊所效应，显著大于 3.2%的治疗师效应。添加解释变量显著降低了诊所效应至 1.9%，但并未显著改变治疗师效应（3.4%）。患者水平的症状严重程度和就业状况，以及诊所水平的白种人比例和医疗保健部门，解释了大部分诊所结果的变异性和总体结果的变异性。
在提供心理治疗的诊所之间，发现临床结果存在很大的差异。患者的社会经济构成解释了诊所水平变异性的很大比例，但不能解释治疗师水平的变异性。临床意义包括需要超越治疗师-患者的互动，提供有效的心理治疗。还需要进一步研究，以确定诊所和/或地区层面的因素对临床结果的影响机制。（PsycINFO 数据库记录（c）2019 APA，保留所有权利）。
