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Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Published online by Cambridge University Press:  24 October 2013

Jaime Delgadillo ,
Judith Gellatly  and
Simone Stephenson-Bellwood
Jaime Delgadillo*
Affiliation:
Leeds Community Healthcare NHSTrust, UK
Judith Gellatly
Affiliation:
University of Manchester, UK
Simone Stephenson-Bellwood
Affiliation:
Touchstone, Leeds, UK
*
Reprints requests to Jaime Delgadillo, Primary Care Mental Health Service, The Reginald Centre, Second Floor, 263 Chapeltown Road, Leeds LS7 3EX, UK. E-mail address: jaime.delgadillo@nhs.net
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Abstract

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Keywords

IAPTprimary carestepped caredecision making
Type
Research Article
Information
Behavioural and Cognitive Psychotherapy , Volume 43 , Issue 3 , May 2015 , pp. 328 - 341
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2013 

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