Psychotherapists’ perspectives on collaboration and stepped care in outpatient psychotherapy—A qualitative study

Objective
Stepped and collaborative care with outpatient psychotherapy as one treatment step is guideline-recommended for mental health care. To date, the experiences and evaluation of psychotherapists regarding collaboration and stepped care have been neglected. In order to improve collaborative mental health care, this qualitative study aimed at identifying psychotherapists’ perspectives and needs within collaboration and stepped care.
Methods
Semi-structured qualitative interviews with 20 German outpatient psychotherapists were conducted and analyzed applying thematic analysis. The analysis was realized in a recursive process to first identify themes and then relate these themes back to the research questions with regard to collaboration and stepped care.
Results
Collaboration mainly took place in small networks, with general practitioners and psychiatrists as the most important partners and psychotherapists wishing to intensify collaboration. Main barriers for collaboration were seen in deficient resources and remuneration and in a perceived lack of esteem by other medical specialties. Stepped care was appreciated for intensified collaboration and low-threshold access to care. Doubts were cast on its implementation within current health care conditions, worries concerned a primacy of economic principles instead of patient-orientation. Among further needs, psychotherapists demanded increased knowledge about psychotherapy, especially among general practitioners.
Conclusion
Psychotherapists expressed ambivalent attitudes towards stepped and collaborative care, substantially influenced by health care conditions and the perceived own standing among care providers. Psychotherapists’ needs within stepped care comprise intensified collaboration, sufficient time, personal and financial resources for collaboration and opportunities for a constructive interprofessional dialogue.

研究目标
以门诊心理治疗（outpatient psychotherapy）作为治疗环节之一的阶梯式协作照护（stepped and collaborative care），是精神卫生保健领域的指南推荐方案。迄今为止，心理治疗师针对协作与阶梯式照护的相关体验与评价尚未得到充分关注。为优化协作式精神卫生保健服务，本质性研究（qualitative study）旨在明确心理治疗师在协作与阶梯式照护中的视角与需求。

研究方法
本研究对20名德国门诊心理治疗师开展半结构化质性访谈（semi-structured qualitative interviews），并采用主题分析法（thematic analysis）进行编码分析。分析过程采用递归式流程：首先提炼核心主题，随后将所得主题与协作与阶梯式照护相关的研究问题进行关联验证。

研究结果
协作关系主要存在于小型网络中，全科医师（general practitioners）与精神科医师（psychiatrists）是最为核心的协作伙伴，心理治疗师普遍希望进一步强化协作。协作的主要障碍被认为是资源与薪酬不足，以及其他医学专科对其认可度低下。阶梯式照护因能够强化协作、提供低门槛照护而受到认可。但研究对象对现行医疗体系下该模式的实施可行性存有疑虑，担忧其会以经济原则优先，而非以患者为中心。此外，心理治疗师提出的诸多需求中，尤以提升其他从业者——尤其是全科医师——对心理治疗的认知水平最为迫切。

研究结论
心理治疗师对阶梯式协作照护持有矛盾态度，这种态度在很大程度上受医疗体系环境与自身在照护提供者群体中的认可度影响。心理治疗师在阶梯式照护中的需求包括：强化协作关系、保障充足的协作时间、个人与资金资源，以及开展建设性跨专业对话的机会。