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There were three matching recommendations for this criterion. First, clients with low levels of distress and impairment should be matched to therapists whose treatments involve high levels of emotional intensity, and vice versa. Second, clients with extremely high levels of distress and impairment should be matched to therapists whose therapy at first emphasizes support and anxiety reduction. Finally, clients with more severe problems should be matched to more structured therapy.
Clients were assessed for distress and impairment by combining their scores on the Global Severity Index (GSI) of the Brief Symptom Inventory 18 (BSI 18) with their answers to two additional questions. The BSI 18 is an extremely short version of the Symptom Checklist 90, which is a widely accepted instrument for assessing client symptoms. The BSI 18 evaluates clients on the three symptom dimensions of Somatization, Depression, and Anxiety, and on a combination of all three of these, the Global Severity Index. I purchased 50 copies of the BSI 18, more than enough for my study, and then transferred this instrument into the first version of TMatch, which was just used for this one study. The two additional questions were added specifically for assessment of distress and impairment. They were:
Therapist emotional intensity was assessed through two questions, and how therapists answered one question from the Help-Ways questionnaire, which asked them to order and rate 7 different possible ways of helping clients.
The treatment recommendation that clients with high levels of distress and impairment should be given therapy that at first emphasizes support and anxiety reduction is probably a recommendation for treatment that cannot be usefully translated into a recommendation for a therapist. Therapists probably cannot be differentiated on this dimension, since it is probable that almost all therapists try at the beginning of therapy to be supportive for clients with high levels of distress and impairment, and try to reduce their anxiety. However, despite this pessimism, I tried anyway to assess a difference among therapists on this quality with the one "help-way" [clients] develop more hope that they can solve their problems,and Question #2 from the section just above, which was chosen because it contains the word "supportive."
This assessment was made through two questions:
This assessment worked adequately for this first preliminary version of TMatch. Client Level of Distress and Impairment, on a scale created for TMatch of -11 (minimum distress) to +11 (maximum distress) had a mean of -0.75 with sd = 5.38. The mean was close to zero, indicating the scale was fairly well-balanced. However, the standard deviation was smaller than would have been liked, indicating a strong tendency for clients to answer away from extreme ends.
The total ratings for therapist emotional intensity, on a scale created for TMatch, had a range of -14 (lowest) to +14 (highest). The mean for all therapists was 3.06, with sd = 5.63. This shows a rather strong tendency for therapists to see their therapy as having high emotional intensity. If all therapies have reltively high emotional intensity, then this would be a recommendation for matching therapy that does not translate well to matching therapists.
For this assessment, on a scale created for Tmatch of -11 to +11, the mean was 0.26 with sd = 3.84. This shows very little variation, with almost all therapists being more or less neutral (neither low nor high). However, this assessment is slightly suspect. The question about hope is out of place in the list of help-ways, and is a rather indirect way of asking about focus on support. The second question was included because the left side has the word "supportive." However, this question is too complex and indirect to be very useful for determining therapists' tendencies to be supportive. For example, therapists could be extremely sensitive to providing support for high distress clients, yet also feel that their therapy involved novel thinking. None of these questions asked about anxiety reduction.
The direct question about amount of structure in therapy did produce some useful variability, although therapists tended toward believing their therapy had relatively low amounts of structure. The qualititative part of this study indicated that a problem with this question was that the term "struture" is not clearly defined or understood. People have an immediate reaction to this concept, but on deeper examination, are not in agreement as to what it means. The question about how much therapy was planned ahead was not very useful, as there was a strong tendency for therapists to think that they did not plan where their therapy was going ahead of time, and the level of planning ahead is only indirectly related to structure anyway.
This matching criterion had enough success that it should be improved and tried again.
Because of the difficulties with therapist assessment explained above, this matching criterion was completely unsuccessful.
The assessment of structure had too many inadequacies and problems for this criterion to be adequately tested. Although there was some indication that this criterion is effective, there was also some indication from the qualitative part of this study that some clients with a lot of distress may prefer a lack of structure, and prefer depth over immediate symptom relief.
For all three recommendations in this criterion, the assessment of client distress and impairment needs to be improved. This assessments appeared to be somewhat accurate for extremely distressed clients and clients with no distress, but not very accurate for clients near the middle of the range. The Brief Symptom Inventory (BSI) is not complete enough to give a clear indication of this assessment, as it only looks at anxiety, somatic problems, and depression. If somatic symptoms are very low, it lowers the overall Global Severity Index on this instrument. The additional two questions for this assessment also need some improvement. Clients were slightly confused by the question about how severe their problems were during the past 7 days, that is, why the last 7 days were so important. Asking about just the past 7 days was used to match the instructions in the BSI, which was on the previous page of the client questionnaire. It was assumed that there was a very good reason for asking about just the past 7 days, since the BSI is such a well-tested and accepted instrument. In spite of this, in the future this question should be made more general, not limited to just the past 7 days.
Therapist assessment of amount of emotional intensity in therapy should be improved, and then this criterion tried again. The first question to answer is if there is enough difference in therapists' usual emotional intensity in therapy to make this a usable therapist trait for matching. As I have said repeatedly on this web site, a useful suggestion for therapists to modify their treatments does not necessarily translate into a difference among therapists that is large enough to be used for thrapist matching.
This matching recommendation should probably be abandoned. The reason is that there is no evidence that there is a way to assess therapists on the amount of support and anxiety reduction they provide to clients with high levels of distress and impairment. Therapists may vary on this quality only to the extent that some therapists are better than others, since all therapists probably try to give support and anxiety reduction to clients with high levels of distress and impairment. If some evidence arises to the contrary, and if a valid method becomes available for assessing this quality, then this matching criterion would be worth trying again.
This matching recommendation should be tried again. Because of the problems with assessment of structure, this efficacy of this criterion could not be tested. What is needed for further testing is a valid method of describing and assessing structure in therapy. However, as explained above, there were some indications that some clients with a lot of distress may prefer a lack of structure, and prefer depth over immediate symptom relief. These clients might be better matched to therapists who do not have a lot of structure. Perhaps the answer is to only match clients with a lot of distress to therapists with a lot of structure if the clients do not express a specific preference for therapy with depth over time and lack of structure. This would add a second level of matching to TMatch. That is, the assessment for one criterion would affect how the matching for another criterion was done.
The next step for client-therapist matching based on the principles of Prescriptive Psychotherapy would be to integrate the assessment instruments (and quantitative information) developed by Larry Beutler and his associates into a matching system, or to develop a matching system from scratch using these instruments and information. Click the link above for a more complete discussion of this subject, or click here.
To Contact Kenneth Frankel, Ph.D., Click Here.
Beutler, L. E., & Consoli, A. J. (1992). Systematic eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried, (Eds.), Handbook of psychotherapy integration (pp. 264- 299). New York: Basic Books.
Beutler, L. E., & Harwood, T. M. (2000). Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press.
Derogatis, L. R. (2001). Brief symptom inventory 18: Administration, scoring, and procedures manual. Minneapolis, MN: NCS Pearson.