Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes.
BACKGROUND
The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented.


OBJECTIVE
This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes.


METHODS
Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up.


RESULTS
Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity.


CONCLUSIONS
The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.
a Department of Psychiatry and.
Andrea
A
Meier
b Departments of Psychiatry and Community & Family Medicine , Geisel School of Medicine at Dartmouth , Lebanon , NH .
Mark P
MP
McGovern
a Department of Psychiatry and.
Chantal
C
Lambert-Harris
c Dartmouth Psychiatric Research Center , Lebanon , NH .
Bethany
B
McLeman
d Dartmouth College, Lebanon , NH , and.
Anna
A
Franklin
c Dartmouth Psychiatric Research Center , Lebanon , NH .
Elizabeth C
EC
Saunders
e Department of Community & Family Medicine , Geisel School of Medicine at Dartmouth , Lebanon , NH , USA.
Haiyi
H
Xie
D000328:Adult; D002983:Clinical Competence; D015928:Cognitive Behavioral Therapy; D003376:Counseling; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D011446:Prospective Studies; D013313:Stress Disorders, Post-Traumatic / Q000150:complications* / Q000628:therapy*; D019966:Substance-Related Disorders / Q000150:complications* / Q000628:therapy*; D016896:Treatment Outcome
Addition therapy; clinician characteristics; evidence-based therapy; integrated psychosocial treatments; post traumatic stress disorder; therapist adherence and competence