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TMatch: Client/Therapist Matching Based on

Client Diagnosis for Therapist Treatment Emphasis

The Principle of Matching Treatments to Diagnoses

For almost 50 years, psychotherapy researchers have been attempting to find interactions between diagnoses and systems of therapy that would indicate that certain methods of therapy were more effective than other methods for particular diagnoses. There is a well-supported movement within the psychotherapy establishment to list empirically supported treatments (EST's) which have been shown by research to work for specific diagnoses (Task Force on the Promotion and Dissemination of Psychological Procedures, 1995). After a thorough examination of the utility of using EST's for matching, I concluded that for TMatch, with a couple minor exceptions described below, they are not directly useful for matching clients to therapists. The primary reasons for this conclusion are the following:

  1. EST's are based on studies that don't match clinical practice (Silberschatz in Persons and Silberschatz, 1998). EST's are in almost every case based on random controlled trials (RCT's), in which therapists follow manuals during their treatments. This may match reality for recently trained cognitive or behavioral therapists, but it certainly doesn't match reality for psychodynamic therapists, humanistic therapists, or experienced therapists of any type (Bohart, 2000; Strupp & Anderson, 1997). In addition, in RCT's the clients are homogeneous in ways not normally seen clinically, clients are randomly assigned to therapists (Goldfried & Wolfe, 1998), therapists are trained and observed by researchers (DeRubeis & Crits-Cristoph, 1998), and therapies are all relatively short term and have set lengths that are independent of the results of the therapy (Goldfried & Wolfe, 1998).
  2. A consistent finding from psychotherapy research is that the outcome of therapy is independent of the method of therapy for any diagnosis (Robinson, Berman, & Neimeyer, 1990; Stiles, Shapiro, & Elliot, 1986;). This is commonly called the "Dodo bird verdict" after a race in Alice in Wonderland (Carroll, 1865/1960) in which the Dodo bird declared "Everybody has won, and all must have prizes."
  3. The common factors, not techniques, are mainly what is curative in therapy. That is, the curative elements of psychotherapy reside primarily in factors they all have in common (Assay & Lambert, 1999; Hubble, Duncan, & Miller, 1999). If therapy is curative primarily through these common factors, then EST's are very misleading in implying that different methods and techniques should be used for different diagnoses. Some examples of these common factors are the instillation of hope (Frank and Frank, 1991;), clients' capacity for self-healing (Tallman and Bohart, 1999), and the relationship between the clients and therapists (Rogers, 1957), usually called the therapeutic alliance.

The Exceptions: Two Methods of Matching Treatments to Diagnosis

There were two methods of matching treatments to diagnosis that are so widely accepted that I did add them to the matching. They were that clients with phobias, agoraphobia and OCD should be matched to therapists who either use exposure techniques or refer to other therapists who use them, and clients with sexual dysfuncion should be matched to therapists who use certain behavioral techniques for these problems, or refer to other therapists who use them.

Client Assessments: Agoraphobia, Phobias, or OCD

Time and space considerations meant that specific diagnoses of these client conditions could not be made. Therefore, the decision was made to approximate the existence of these conditions from the rating on the Anxiety scale on the Brief Symptom Inventory 18, which was incorporated into TMatch. This means that 6 questions designed to assess anxiety in general were used to approximate whether clients had the specific symptoms listed for this criterion. This is obviously not satisfactory as a complete solution for this type of assessment.

Client Assessments: Sexual Problems

The assessment of clients' sexual problems was made with a combination of two questions:

  1. Is a sexual problem part of the reason you want to see a therapist? (Yes, No).
  2. (Only appears if answer to question 1 is Yes). How important is this problem compared to the other reasons you want to see a therapist? (1 = Very unimportant, 2 = Relatively unimportant, 3 = Somewhat Important, 4 = Very Important, 5 = Most Important).

Therapist Assessments: Exposure Treatments for Anxiety Problems

The assessment of therapists using exposure treatments for anxiety problems, or collaborating with other therapists who specialize in exposure treatments, was made with two questions, listed together under the heading "For your clients with anxiety disorders such as agoraphobia, phobias, or OCD."

  1. With how many of these clients do you use systematic desensitization or exposure treatments? (Range = 1-5, 1 = All clients, 5 = No clients).
  2. How often do you collaborate with other therapists who specialize in systematic desensitization or exposure treatments by referring your clients with these disorders to them? (Range = 1-5, 1 = Usually, 5 = Never).

Therapist Assessments: Behavioral Treatments for Sexual Problems

The assessment of therapists using behavioral treatments for sexual problems, or collaborating with other therapists who specialize in behavioral treatments, was made with two questions, listed together under the heading "For your clients with sexual performance problems."

  1. With how many of these clients do you use behavioral treatments? (Range = 1-5, 1 = All clients, 5 = No clients).
  2. How often do you collaborate with other therapists who specialize in behavioral treatments by referring your clients with these disorders to them? (Range = 1-5, 1 = Usually, 5 = Never).

Future Use of Client Diagnosis for Matching

Results of Study: Client Assessments

As explained above, TMatch had no direct way of assessing the diagnoses listed for this matching criterion. In addition, none of the clients in the study had sexual problems. It is obvious that both these areas of assessment would have to be expanded if these matching criteria were retained.

Results of Study: Therapist Assessment of Exposure Treatments for Anxiety

On Question 1, although almost all therapists answered in the middle range, between "Most clients" and "Few clients," the range of anwers was discriminatory enough to be able to differentiate the therapists. On Question 2, there was a very strong cluster of answers around 4, which was "Seldom." It appears that therapists do not tend to collaborate in respect to these treatments for anxiety disorders. Therefore, this question was not useful.

Results of Study: Therapist Assessment of Behavioral Treatments for Sexual Problems

On Question 1, answers were similar to those for exposure treatments described above. On Question 2, most therapist answered between "Often" and "Seldom", and this question did differentiate therapists to some degree, although the range was small. This could be from the effect of therapists being reluctant to answer questions at the extreme ends. Because there were only 5 choices, the answers were almost all 2, 3, or 4.

Results of Study: Matching in General

There was some indication from the study that matching on the criterion of exposure treatments for anxiety has some potential to be useful. There were no clients with major sexual problems in the study, so the second matching criterion couldn't be tested.

The Next Step for Matching on These Criteria

Therapist questions about use of these techniques should have the number of choices expanded from 5 to at least 7, to give a wider range of answers. The question about collaboration on exposure treatments for anxiety should be deleted. These two matching criteria should be retained and continued to be tested, as they seem to have some potential to be useful and effective.


For more information, email Kenneth Frankel, Ph.D.

References

Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller, (Eds.), The heart and soul of change. Washington, D.C.: American Psychological Association.

Bohart, A. (2000). A passionate critique of empirically supported treatments and the provision of an alternative paradigm. Paper distributed at Conference of the Society for Psychotherapy Research, June, 2000.

Carroll, L. (1960). Alice's adventures in wonderland. New York: Penguin Putnam. (Original work published 1865).

DeRubeis, R.J. & Crits-Cristoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.

Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore: Johns Hopkins University Press.

Goldfried, M. R., & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66(1), 143-150.

Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999). Introduction. In M. A. Hubble, B. L. Duncan, & S. D. Miller, (Eds.), The heart and soul of change (pp. 1-19). Washington, D.C.: American Psychological Association.

Robinson, L. A., Berman, J. S., & Neimeyer, R. A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49.

Rogers, C. R. (1957). The necessary and sufficient conditions of psychotherapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

Stiles, W. G., Shapiro, D. A., & Elliot, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 1-8.

Strupp, H. H., & Anderson, T. (1997). On the limitations of therapy manuals. Clinical Psychology: Science and Practice, 4, 76-82.

Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in and dissemination of empirically-validated psychological treatments. The Clinical Psychologist, 49, 3-23.

Tallman, K., & Bohart, A. C. (1999). The client as a common factor: Clients as self-healers. In M. A. Hubble, B. L. Duncan, & S. D. Miller, (Eds.), The heart and soul of change (pp. 91-131). Washington, D.C.: American Psychological Association.