Modeling changes in distress in a psychotherapy training setting from a middle-income country: A three-level analysis

OBJECTIVE: This study explored change in distress during psychotherapy in a training setting from a middle-income country, examining client demographics and between-therapist variability. METHOD: Participants were 220 adults attending ≥5 sessions. Most were women (66.82%); aged 18-62 (Mean = 23.48 [22.61, 24.42], SD = 6.90). Distress was assessed with the CORE-10. Two- and three-level models with linear, quadratic, and logarithmic time functions were compared. Three-level models were fit with and without adjustment for first score, age and gender. Higher initial distress was associated with higher symptom levels across sessions but did not moderate the rate of improvement over time. Therapist effects were small but statistically significant (longitudinal: 2.9%; pre-post: 1.4%). Pre-therapy gender differences were not statistically significant; however, men improved faster initially. Age showed no statistically significant association with pre-therapy distress. CONCLUSION: Clients showed early improvements that decelerated and between-therapist differences were small after accounting for baseline distress. Findings suggest that strengthening early engagement and attending to possible gender-related differences in early response may help inform service delivery in middle-income countries, although these strategies were not directly tested in the present study.