Prescribing therapeutic interventions through Strategic Treatment Selection

Prescribing Therapeut ic Intervent ions Through Strategic Treatment Se l ec t ion

Lar ry E. Beu t l e r a n d B e n n y R. Mar t in , University o f California, San ta Barbara

This article describes the rationale and current research on Systematic Treatment Selection, a method for matching and fitting interventions to patients and patient problems. An efficient method of treatment planning must not only use effective and empirically tested procedures, but should take into account the fit of these procedures with important nondiagnostic information about the patient, and aspects of the patient's environment. The effort to transfer research-based treatment manuals to clinical practice has often failed because it requires therapists to give up procedures and theories that have been accepted on the basis of clinical experience and fails to consider ways in which patient qualities affect the fit of the treatment. Systematic Treatment Selection and its derivative, Pre- scriptive Therapy, seeks to overcome these difficulties by empirically defining general principles of treatment intervention and selection that cut across therapist theoretical orientation and capitalize on the selection and use of methods that are favored by the clinician.

W HAT interventions really help clients? Is a single- theory approach adequate for good client out-

comes, or is a generalized eclectic approach the better tool? How is it possible to empirically establish treatment efficacy? Is it possible to reliably observe and quantify differences of effects of treatments? Is it possible to tailor- make or custom-fit interventions to produce the best outcomes for clients? If so, what empirical support exists for such interventions, how might training be implemented, and what would be the principles a n d / o r strategies for such a structured integrated treatment?

Before responding to these questions, we provide a brief review of the history of psychotherapy. Next, we describe our current research program on Systematic Treat- ment Selection (STS) and Prescriptive Therapy (PT). The latter section explains the procedures applied in de- veloping PT as an outgrowth of STS. Lastly, we delineate the particular principles utilized in implementat ion of PT. It is our belief that clinicians need not learn entirely new theories and associated, new techniques; PT provides an opportunity for clinicians to more effectively use already-mastered techniques by applying them from a framework of empirically sound, flexible, and scientifically informed principles of intervention.

Hi s tor i ca l R e v i e w o f P s y c h o t h e r a p y

The application of psychotherapy to the many problems that affect people 's lives is largely a post -World War II phenomenon . The late 1940s and 1950s saw an expansion of the role of psychotherapy and of a climate that fostered an increase in the number of psychotherapists as

Cognitive and Behavioral Practice 7, I - 17, 2000 107%7229/00/1-1751.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

the federal government at tempted to address the voca- tional and mental-health needs of returning veterans. Psychologists and social workers, and eventually marital, behavioral, alcohol, and family counselors, were added to the list of experts in the treatment o f various mental and emotional problems, a list that had previously been the sole province of psychiatrists. An expanded list of diagnoses, often drawing their symptoms f rom experiences c o m m o n to normal people, b roadened the range o f problems that these professionals were called upon to address.

Over a period of 3 decades, the number of recognized and diagnosed problems expanded from approximately two dozen to well over 400. War neuroses, depression, chemical depen- dency, and, finally, the full array of diagnostic conditions came

The application of psychotherapy to the many problems that affect people's lives is largely a post-World War II phenomenon.

under the purview of the new army of mental health practitioners and psychotherapists.

As the number of available and practiced theories grew, so did disillusion with the original hope that one of these theories might hold the truth about how problems occurred and could be changed. By 1970, 50% of practicing psychologists had come to identify themselves as eclectic (Garfield & Kurtz, 1976), indicating that they had given up the effort to find a single-theory framework that was consistently valid as a way of viewing psychological problems. In subsequent years, more and more professionals came to forsake single-theory frameworks and instead adopted a poorly defined eclecticism as their pre- ferred model of practice (e.g., Norcross & Prochaska, 1988). As many as 70% of members o f some professional groups now identify themselves as eclectic in orientation

Z Beutler & Martin

and pract ice (Jensen, Bergin, & Greaves, 1990). These psychotherapists draw on intervent ions f rom several different t r ea tment models in o rde r to increase their ability" to address the widely different needs of those who seek their services.

As an inevitable result of introducing an expanded array of theories, there followed a decline in the consistency of how t reatment was conducted and an increase in the variety of techniques and procedures used. Theories and methods came to be appl ied according to varying standards and to equally ill<tefined groups of patients and problems. Thus, while psychotherapists had come to acknowledge the importance of integrating interventions across theoretical lines, this was accomplished quite unsystematically in the absence of an organizing, integrative theory.

By the mid-1970s, it became appa ren t that the diver-

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sit 3 ' of psychotherapy prac- tices, even within a given theoretical model , was too great to disentangle the effects of the different intervent ions used. Psychotherapy research of the late 1970s and 1980s emphas ized the need to reliably identify the componen t s of psychotherapeut ic treatments, to homogen ize pat ient groups to which t reatments were appl ied, and to compare models that were founded on different theoretical premises. To address these concerns, the Trea tment of Depression

Collaborative Research Project (TDCRP; Elkin, 1994) in- t roduced the use and compar ison of t rea tments con- dnc ted via s tandardized manuals , each reflecting a different theoret ical conceptual izat ion and a different array of interventions. These manuals were appl ied on a diagnos- tically h o m o g e n e o u s sample of patients, establishing diagnosis as the basis for g roup ing and identifying patients.

The use of manuals in support ive research is now accepted as a major cri teria for de t e rmin ing a proposal ' s acceptance for federal f lmding, for identifying those treatments that have received sufficient empir ical suppor t to warrant transfer to pract ice (Chambless et al., 1996; Chambless et al., 1998), and for de t e rmin ing what treatments should be inc luded in the curr iculum of major graduate t ra ining programs (Maki & Syman, 1997).

In spite of their several advantages, three problems with extant manuals have not been resolved.

1. Neither treatment manuals nor the theorie~ on which they. are based are sufficiently flexible to allow therapists to adapt a wide variety of treatment procedures to important non- diau~ostic states and needs (~particular patients.

All theories proscr ibe certain p rocedures while prescribing others. This is done on conceptual grounds ra ther than on empir ical ones. Indeed, it is likely that some of the proscr ibed intervent ions are effective in some circumstances and that some of the prescr ibed ones are ineffective. A maximally effective approach would be one in which the prescr ipt ion was made on the basis of pat ient qualities that had proven themselves to be predictive of a given t rea tment ' s effectiveness ra ther than on the basis of theoret ical rationales. The inflexibility of manuals to accomplish the task of fitting t reatments to pat ients was emphas ized by Anderson and Strupp (1996), who found that the most effective therapists depa r t ed from the manual ized rules when par t icular si tuations arose. From such findings, it is clear that s t ruc tured treat- merit manuals allow a n e e d e d degree of technical consistency, but they do so by sacrificing therapis t flexibility and creativity.

2. Manual-based training may actually increase the presence of antitherapeutic attitudes on the part of therapists.

Henry, Strupp, Butler, Schacht, and Binder (1993) found that therapists who were most compl ian t with the structure of using a manual to guide t rea tment were more rigid, angry, insensitive, and reject ing than those who were less compliant . Indeed, while increasing technical proficiency, manual-based t raining also seemed to reduce empath ic a t t unemen t and at t i tudinal readiness.

3. Comparisons of manualized therapies have failed to demonstrate that their distinguishing methods and theories translate to differences in outcomes among any of a wide variety of patient problems.

The selection of diagnosis as the cri teria on which to group patients and the use of manuals that are deve loped from a single (usually behavioral or cognitive) theory as the basis for s t ructur ing t rea tment have clearly lacked sensitivity to the cross-theory richness that under l ies clinical practice and the b read th of p rocedures that are used by man), skilled pract i t ioners. Nor does diagnosis as the pr inciple cri teria for pat ient selection capture the variations among pat ients that predispose them to benefi t f rom one or ano the r therapis t and therapeut ic approach.

Indeed, the weak evidence for the positive effects of clinician exper ience and training, as well as for the effects of most theoret ical models used in practice, has led some to suggest that we abandon a l together advanced psychotherapy t raining in techniques, procedures , and theories (e.g., Chris tensen & Jacobson, 1994). An alter- native may be to a t tend to the na ture of the events and environments to which individuals that represen t different characteristics and personali t ies respond, and then to construct t rea tments that mi r ro r and even exaggerate these enviromnents ra ther than p lann ing t rea tments solely from one or ano the r theory of psychopathology.

The conclusion that clinician exper ience and t ra ining

Prescribing Therapeutic Interventions 3

are i rrelevant may well pivot a round whe ther future prac- t i t ioners come systematically to apply t reatments that are responsive to the characterist ics of thei r pat ients even if these p rocedures are not valued by the clinician's pre- fe r red theory. In contrast to the b road scope usually valued by research programs, which strictly define pat ient response indicators as diagnost ic symptoms and criteria, clinicians tend to look at characterist ic in te rpersonal patterns and emot iona l response states as guides to making t rea tment decisions. These pa t ien t qualities, most of which are not cap tured in the diagnost ic nomencla ture , are used both to select some strategies and intervent ions and to avoid others.

Taken together, an effective t rea tment manual would guide the therapis t to adap t to pa t ien t differences and would demons t ra te that do ing so improves the a m o u n t of benef i t i nduced by t rea tment beyond that a t t r ibuted to single-theory models of in tervent ion and their associated manuals.

Pausing a m o m e n t to review the foregoing historical perspective: We have moved from strict adhe rence to main-l ine theories to the recogni t ion of a need for an eclectic posture. Fur the rmore , it has been establ ished that in o rde r to know what is truly effective, one needs to govern the m a n n e r and amoun t of in tervent ion offered and to apply this t r ea tment to clients in a way that not only takes into account the b road symptoms ref lected in diagnoses, but also nondiagnos t ic factors, the na ture of the t rea tment relat ionship, and aspects of the clinician. Nondiagnost ic pa t ien t factors may include informat ion on how patients cope with the envi ronment , whether they internal ize or external ize anxiety, their levels of personal distress, and o ther re la ted factors. Trea tment planning can become a very complex process when one attends to both the various sources th rough which informat ion may be ga thered and the many specific variables affecting a client 's response to t reatment .

STS a n d PT

To help manage the complexi ty involved in t rea tment p lanning, Beut ler and Clarkin (1990) def ined a conceptual mode l emphasiz ing the value of using scientifically valid pr inciples of in tervent ion to guide t rea tment ra ther than relying on a finite set of techniques def ined by a theory. Beutler and Clarkin propose that the effects of treat- men t can be best unde r s tood not in terms of isolated techniques bu t as a complex, non l inea r interplay among pat ient , clinician, and environment . It is unlikely that a clinician can use a specific technique on every pa t ien t he sees and expect a consistent, cor re la ted reduct ion of symptoms or enhancement of t reatment outcome on every one. The effects of any technique d e p e n d on a host of factors, both within and outside of the patient . If one un-

ders tands the pr inciples under ly ing a given therapeut ic strategy and the outcomes to be expected, a cl inician may be gu ided th rough the morass of techniques, pa t ien t variables, and environmenta l considerat ions in o rde r to select an in tegra ted array of techniques that coalesce a round a consistent strategy and that fit the pa t ien t and therapis t ' s mutual rhythm. If the pr inciples are valid, then techniques can be selected f rom a variety of theoret ical posi- tions, and even b lended across theoret ical lines, in o rde r to enhance t rea tment gains. Thus, families of interventions may then serve a ta i lored purpose for each pat ient .

Beut ler and Clarkin 's (1990) mode l of t r ea tment plan- n ing suggests that each of four levels of t r ea tment decision (see Table 1) can be made efficiently by following principles of change that per ta in to specific domains or classes of pa t ien t variables within each level. The principles of change guide the clinician in ba lancing the importance of therapist , pat ient , and env i ronment factors and guides the selection of the intervent ions within these levels. The basic and dis t inguishing tenet of the STS mode l is that t r ea tment proceeds by complex reciprocal in terchanges among and within levels ra ther than as l inear accumulat ions of procedures .

To illustrate, it may be helpful to look at it this way. A bowler does no t a t t empt to de- liver the ball to the pins in the

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same way for all p in configurat ions or bowling alleys. She selects the po in t and m e t h o d of del iver ing the ball based on the n u m b e r and combina t ion o f pins r ema in ing in the lane and the condi t ion of the alley. The delivery is a skill and it is also an art, bu t she follows certain pr inciples even in the exercise of he r art. This is not a r a n d o m or u n p l a n n e d art. She aims he r ball at the target pins in the full knowledge that its speed, spin, and trajectory will de- te rmine where it hits and how many o the r pins will be affected by the throw. Before any impact , the tilt o f the lane and the texture of the terrain play thei r par t in the outcome. When the pins are struck, the force purveyed to the pins, air resistance, and humidi ty add or subtract from the final outcome. Therefore , a cascading interplay of factors affects what finally occurs. But, if the bowler knows the pr inciples of grip and ball release a t t endan t on each combina t ion of pins, and can est imate the inf luence of the envi ronmenta l forces, the l ike l ihood of affecting ou tcome is opt imized. While bowlers differ in the specific techniques used (e.g., grip, delivery point , n u m b e r o f

4 Beutler & Martin

Table I Levels of Decision Making

Level 1: Selection of Patient Predisposing Variables • diagnosis and symptom states • complexity, chronicity, and comorbidity • expectancies and other cognitive states • functional impairment and environmental support • subjective distress, level of self-esteem, and motivation • enduring trai~-like coping styles • level of trait-like resistance

Level 2: Selection of the Treatment Context • intensity/dose of treaunent--frequency and length • treatment setting • modality of treatment--pharmacological and psychosocial • format of treatment individual, group, couple, family

Level 3: Selection of Relationship Qualities and Interventions • therapeutic alliance • therapist skill and experience • therapist involvement--verbal activity • therapist background and ethnicity • therapist directiveness • therapist's use of symptom versus insight-oriented procedures • therapist's use of abreactive versus supportive techniques * therapist's theoretical model of treatment • setting contracts and agreements

Level 4: Selecting the Strategies and Techniques That Best Fit the Patient

• adapting the intensity of treatment to the level of impain-nent • fitting the modality of treatment to patient chronicity and

complexity • fitting the format of treatment to patient level of social support • fitting the model of treatment to the patient's diagnosis and

symptoms • fitting level of directiveness to patient defensiveness • fitting insight versus symptomatic goals to patient coping style • fitting abreactive versus supportive interventions to patient

distress and motivation

steps), they follow the same or similar principles of play (relationships of spin, trajectory, and course on outcome,

etc.). Thus, rather than selecting a technique because it is

r ecommended by a particular manual or guiding theory of psychopathology--a l inear re la t ionship- - the STS model proposes that the technique be one in which the clinician is well-versed and skilled at administering, but that it also is compatible with a particular patient 's style of coping and level of defensiveness. A given technique can be expected to have different effects, depend ing on who uses it on whom, how it is used in a given situation by a particular therapist, and the fit of the technique to the patient 's style of interacting. It may well have one effect when used by one therapist and another effect when used by another therapist if they are operat ing according to different strategic aims and according to different principles. Furthermore, a technique applied to a given symptom must be considered not just in terms of whether it

has been found useful in addressing the focal symptom, but also in terms of how it fits the patient 's particular style of interaction and how skillfully the therapist applies it to the in tended purpose. Specifically, the patient 's particular style of coping and interact ion influences whether techniques that facilitate insight or direct symptom change will exert the strongest effects.

All of this then depends on the availability of a set of guiding principles that directs the therapist 's use of strategies. The process of selecting techniques begins with an unders tand ing of a set of scientifically valid principles. This defines the nature of PT. In turn, p lann ing a constel- lation of interventions that constitutes an integrated, valid prescriptive therapy begins with an assessment of the key qualities that characterize the pat ient and dispose him or her to certain influences. This is the first level of decision making (Level 1) in systematic t reatment plan- n ing (Table 1). The pat ient qualities selected for evaluation in the STS model, patient predisposing variables, are those that have been related to outcome in extant scien- tific literature. The decisions that follow from an assess- men t of these pat ient predisposing variables bear on the other three levels of t reatment specificity: (Level 2) the context of t reatment--aspects of setting, intensity, modality (pharmacological, psychological, both, etc.) and format (group, individual, family, couple, drug class); (Level 3) the nature of the relationship to be developed and the interventions used by the clinician to enhance that rela- t ionsh ip-sk i l l , level of directiveness, relationship stance; and (Level 4) the strategies for fitting the t reatment to the specific nature of the pat ient - - theore t ica l goals, specific

techniques, etc. Various predict ion and t reatment models a t tend to

different combinat ions of these four levels, but do so with minimal a t tent ion to one or more of the levels. Thus, classical prognostic research is concerned only with the effect of pat ient predisposing variables on changes in symptoms and life funct ioning (Level 1 only); service delivery research attends to the relationship among pat ient predisposing variables, context (e.g., level of care) of treatment, and outcomes (Levels 1 and 2); pharmacological and other treatment-efficacy research concentrates on defining the pat ient predisposing variables that may be indicators of response to certain classes of medicat ion (e.g., SSRIs; Levels 1 and 3); and psychotherapy process research focuses on the effect of the t rea tment relationship and in- t reatment processes on outcome (Level 3 only). Even traditional eclectic and integrative approaches usually look for simple l inear effects, for example, seeking to establish the condit ions in which different t reatment models are likely to work best (Level 4 only).

Viewed through the eye of STS, these perspectives are all short-sighted and potentially misleading. A truly prescriptive therapy is one that takes into account the inter-


relat ionships a m o n g all four levels when p lann ing treatments and pred ic t ing t rea tment outcomes. Yet such a b road view is usually restr icted by clinician and investiga- tor pe rcep t ions - -which , by nature, affix to cer tain ideas and expec t a t i ons - - t ha t prevent the evolut ion of comprehensive t rea tment p lanning. Unfortunately, appl icat ions of such b road th inking are also cons t ra ined by real-world confines having to do with fund ing and sample sizes in research.

In 1995, our research group at the University of Cali- fornia embarked on a novel effort to inspect the complexity of the t r ea tment process within the complex cross-theory mode l ou t l ined by Beutler and Clarkin (1990). The objectives of these efforts were to identify how well the various models o f selecting and p lann ing t r ea tment might fit a relatively large and varied data set. This research and its f indings have been summar ized in some detail by Beutler, Clarkin, and Bongar (2000). They are re i te ra ted here in abbrevia ted form.

An Apt i tude Trea tment In terac t ion (ATI) research mode l provides a genera l f ramework within which our research program works to define the relevance and mean- ingfulness of pa t ien t and t r ea tment variables (Shoham- Salomon, 1991; Snow, 1991). ATI research has also provided a workable list o f pa t ien t d imensions and qualities that may exer t a media t ing effect on therapeut ic change (e.g., Beutler & Clarkin, 1990; Frances, Clarkin, & Perry, 1984; Norcross & Goldfr ied, 1992; Orlinsky, Grawe, & Parks, 1994; Prochaska, 1984; Str iker & Gold, 1993). A part ia l r ende r ing o f this list is i l lustrated in Table 1. How- ever, research to date has not provided assurance that these d imensions are uni formly predict ive or that they re- main relevant when inf luenced by o the r variables on the list. Our research g roup ini t ia ted a systematic test and compar i son of the variables represen t ing each of the four levels (out l ined in Table 1). The result ing research study c o m b i n e d randomized trials and di rec t observat ion of more naturalist ic t rea tments and a modes t array of pa- t ient variations.

O u r research sought to compare t reatments given to more- and less-improved pat ients in o r d e r to ascertain meaningful differences. We fur ther sought to identify the techniques a n d / o r strategies that were effective a m o n g clients who varied a long certain pa t ien t dimensions, doc- umen t ing their characterist ics quantitatively and qualita- tively. Ultimately, we sought to construct f rom our obser- vations a set of pr inciples to guide t rea tment but that would also provide room for clinician discret ion and creativity as app l ied to specific si tuations and patients.

In a simplif ied form, the tasks r equ i red by our objectives were fourfold:

1. Identify which pa t ien t p red ispos ing variables are the most p romis ing for t r ea tmen t selection.

2. Translate these specific pa t ien t variables into a reliably ident if iable set of constructs that can be measured in a variety of ways in o r d e r to provide equiv- a lent scores across studies that vary in me thods and procedures .

3. Construct a measure of t r ea tment in tervent ions and qualities, at each level in the Beut ler and Clarkin (1990) model , to identify the level of match occur r ing between pat ient ' s p red ispos ing quality and the indica t ing t r ea tment decis ion or activity.

4. Test models of l inear and complex change by directly compar ing them in a large and varied data set.

Select ing Pat ient Pred ispos ing Variables Extensive l i terature reviews and careful selection of

ident i f ied pa t ien t characterist ics and t r ea tment d imensions were conduc ted over a pe r iod of several years to ini- tiate the task of identifying promis ing pa t ien t variables that were impl ica ted in t r ea tment ou tcomes (Beutler, 1979; Beutler, Engle, Shoham- Salomon, et al., 1991). The list of p a t i e n t / c l i e n t variables sub- sequently was e x p a n d e d and then modi f ied th rough a complex process of reviewing addi t ional l i terature, discussing concepts, and then pi lot testing our decisions for reliability on new studies as they were publ i shed (Beutler, Goodr ich , Fisher, & Williams, 1999; Beut- ler, Wakefield, & Williams, 1994). After conceptual ly sim- i lar variables were c o m b i n e d

Ultimately, w e sought to

construct a set of principles to gu ide treatment that would also provide room for clinician discretion and creativity.

and variables that did not consistently pred ic t t r ea tmen t ou tcomes were e l iminated, the result was a list o f fewer than a dozen pa t ien t variables that we d e t e r m i n e d to be impl ica ted in effective t r ea tment decisions, as j u d g e d by a large a m o u n t of clinical research l i terature (Beuder & Berren, 1995; Beuder, Consoli, & Williams, 1995; Gaw & Beutler, 1995). The ref ined list of variables is inc luded in Table 1. The r ema in ing tasks were in i t ia ted in the course of an empir ica l effort to cross-validate the importance of these variables in p red ic t ing t r ea tment ou tcomes (Beuder et al., 2000).

Measuring Pat ient Variables The cross-validation study, conduc ted on a total sam-

ple of 289 patients, drew from three different geographi- cal locations and represen ted five di f ferent research projects. Because these samples were drawn from differ- en t sources, the da ta available on them varied. We selected archival data sets for study that inc luded a variety of state and symptom measures, inc luding measures that

6 Beutler & Martin

would seem to allow the assessment of the pat ient predisposing variables that we had defined as relevant to predicting t reatment outcome and matching with treatment. These measures relied heavily on patient self-report and we sought, through a series of multiple regression procedures, to construct methods for translating relevant scores from all of these measures into common scores that reflected the targeted constructs and that made the various data sets comparable.

The use of different measures for assessing the targeted constructs, and assessing their comparison by con- structing equivalence scores fi'om the application of

statistical algorithms, are inefficient methods of deter- min ing pat ient predisposing variables across studies and methodologies. Not only is precision lost when scores are translated into equivalence, but the measures are not designed specifically to assess the variables that have been empirically related to t reatment planning. For that rea- son, a related purpose of this project was to develop a more refined, self-contained, and efficient method for measuring the designated pat ient predisposing variables (within a single measurement device) and to do so in a way that could be applied to varied data sets and various clinical situations. The STS Clinician Rating Form (Fisher, Beutter, & Williams, 1999), the result of these efforts, was used in the research reported here to supple- men t the use of standardized self-report measures (e.g., MMPI, MCMI, EPI), but our research cont inues to ex- plore (at this writing) its use as a separate and self-sustain- ing method for efficiently measuring treatment-relevant

pat ient variables. The STS Clinician Rating Form is applied by criteria-

trained and experienced clinicians, based on the varying types of data available on a given patient at intake, including intake interviews and psychological tests. Its advantage is that it allows clinicians to use the materials for intake assessment that are most familiar to them and then capitalizes on this familiarity by asking clinicians to sum- marize their interpretat ions and impressions through a common set of questions that can be administered via an interactive computer program. ,&s note& in the current study, the STS Clinician Rating Form was used to supple- men t formal psychological tests that defined patient- t reatment matching variables (flmctional impairment , distress, coping style, resistance, etc.) when test scores were missing. Missing scores occur either because of pa- t ient noncompl iance with self 'report or because some constructs were simply excluded f iom considerat ion in the research protocols. In either case, we considered it impor tant to avoid the resultant, potential bias by inserting a score from the STS Clinician Rating Form. This maximized patient representat ion in the analysis, allow- ing all patients who received t reatment and outcome assessment in the sample to be used (_984 of the 289 origi-

nal patients in the samples), and avoided potential biasing effects. Replacement of missing scores in this way ensured relative score equivalence so that the entire sample of patients could be utilized. Technical details about the psychological tests used and the methods of con- structing equivalence scores to assess the various constructs from these different measures have been described elsewhere and need not be repeated in this paper

(Beutter et al., 2000). Dimensions assessed by the rating form or by the psy-

chological tests employed in the various studies included the areas of funct ioning observed in our literature review to be implicated in t reatment outcome (functional impairment, subjective distress, social support, problem complexity, resistance level, and coping style) as well as specific problem areas (e.g., depression, suicidal risk, self-esteem), various diagnostic disorders, and areas of social impai rment (e.g., family, partner, work, legal).

Measuring Standard Treatment Processes A corresponding measure tapping the effects of the

actual therapy env i ronment and a t tendant relationship dynamics was developed. The STS Therapy Process Rat- ing Scale rates contextual and process dimensions of therapy identified in our review of qualities that inter- acted with patient variables. Ratings were applied by trained graduate s tudent raters. In addi t ion to not ing the mode (amount and type of psychoactive medications) and format (dosage, frequency, length) of treatment, this ins t rument allows indication of whether the t reatment is group, indMdual , couple, or family based, and logs ad- junctive treatments and consultations.

For the application of this ins t rument , we elected not to describe t reatment procedures by theoretically derived terms. Instead, we developed labels that described general aspects or qualities of treatment, borrowing these from a review of the extant t reatment manuals and fidel- it}, measures in contempora D" use. These dimensions were identified by i nde pe nde n t raters and then, through consensual discussions, a common set of dimensions was extracted on which t reatment models could be profiled. These dimensions consisted of such variables as individual versus mult iperson treatment, amoun t of psychosocial intervention, amoun t of antidepressants prescribed, t reatment intensity (length and frequency, symptom versus thematic focus, t reatment that sought directly to change symptomatic behavior versus t reatment that sought change through insight and awareness), level of directiveness, level of clinician verbal activity, level of skill, and therapeutic alliance. The nature and strength of the therapeutic alliance was assessed by incorporat ing a formal measure, the Penn Psychotherapy Alliance Scale (Luborsky, Crits-Christoph, Alexandm, Margolis, & Co- hen, 1983), of the nature of the working relationship.


Collectively, the reliabili ty of this ins t rument is relatively good ( in ter ra ter agreements were consistently above 80%) for assessing relevant d imensions of treatment. For the purposes of def in ing the d imensions used in the STS Therapy Process Rating Scale, we cons idered t r ea tment variables to be adequate ly def ined if they could be reliably j u d g e d to be present . In the case of some variables, like g roup versus individual therapy or intensity of t rea tment , this was easy. The psychotherapy process dimensions that were def ined as fitt ing with a pat ient variable were cons idered viable if they were app l ied by a manual and were descr ibed in sufficient detail as to rate them reliably by t ra ined raters.

Validating the Predictions The combina t ion of p rocedures f rom formal psycho-

logical tests, s upp l emen ted by the STS Clinician Rating Form, and a long with the STS Therapy Process Rating Scale, genera ted a c o m m o n data set for the four samples used in this study. In addi t ion, a c o m m o n methodolog i - cal feature of all the samples was the inclusion of the Beck Depression Inventory (BDI) as an ou tcome measure. Moreover, two of the samples had received the Hami l ton Rating Scale for Depression as an ou tcome measure. For pat ients who failed to comple te the BDI, a statistically der ived r ep lacemen t score was ext rac ted from the STS Clinician Rating Form that was readmin is te red at the end of t rea tment . Once again, this allowed all patients who received more than one t r ea tment session to be inc luded in the analysis.

The analyses for this pro jec t were based on three archival and one prospective data sets. This resul ted in a c o m m o n set of pa t ien t and t rea tment variables be ing ident i f ied in a final sample of 284 pat ients with a variety o f specific p roblems and diagnoses, but all of which were character ized by mild to modera te levels of distress and dysphoria.

Sample #1. This sample was compr i sed of pat ients who were seeking services at a university-affiliated, ou tpa t i en t menta l heal th t ra ining clinic. All pat ients were ambula- tory outpat ients present ing with n o n - s u b s t a n c e abuse pr imary diagnoses, average intel lectual ability, and the ability to read at a sixth-grade level or above. This sample consisted of 54 individuals who actually received treat- men t and comple ted usable ou tcome evaluation on at least one ou tcome variable.

This was a t rea tment as usual (TAU) sample in that no effort was made to structure or cont ro l the therapy outside of the usual supervision that was provided to each therapis t by independen t , professional psychologists f rom the local communi ty who r ema ined b l ind to the nature of the study. All t r ea tment sessions were v ideotaped and two sessions were randomly selected from the initial and subsequent series of five sessions. Patients were eval-

ua ted at the end of 10 t r ea tment sessions (the mean n u m b e r of sessions in the clinic) and 1 m o n t h later. Ninety pe rcen t of the qualif ied individuals who were a p p r o a c h e d within the pe r iod of screening agreed to part ic ipate .

Sample #2. One h u n d r e d and five individuals who en- te red a federal ly funded study on the t r ea tment o f alcohol ism (Beutler, Patterson, et al., 1994) compr i sed the second sample. The sample was recru i ted f rom a variety of substance-abuse t r ea tment p rograms in the local com- munity. They underwen t initial t e l ephone screening followed by a computer-assisted diagnost ic interview by a t ra ined clinician and comple t ed self-report quest ion- naires to assess dr ink ing patterns, personality, and personal history. This informat ion was used to establish the diagnoses and substance-use patterns.

The par t ic ipants ( identif ied a l coho l -dependen t pa- t ient and significant other) in this sample were r andomly assigned to one of two s t ructured and manual ized treatments: cognitive therapy for a lcohol ic couples (Wake- field, Williams, Yost, & Patterson, 1996) and family- systems therapy (Rohrbaugh, Shoham, Spungen, & Stein- glass, 1995). They were followed th rough 20 sessions of active t r ea tment and a 1-year follow-up per iod. All sessions were v ideotaped and 2 sessions were r andomly selected f rom the first and last th i rd of the t reatment . The individuals who were assigned to t r ea tment and on whom at least one ou tcome measure was comple t ed (BDI, HRSD, or STS Ou tcome Rating) were used in this study.

Sample #3. This sample consisted of 63 individuals who were reliably d iagnosed as having major depressive d i sorder (Beutler, Engle, Mohr, et al., 1991). These individuals were recru i ted and t rea ted as par t of a randomized clinical trial study of cognitive, exper ient ia l , and self- d i rec ted therapies. Prospective pat ients were sc reened by t e lephone and then assessed by an i n d e p e n d e n t clinician and subjected to a variety of s tandardized interviews and tests to assure compl iance with depressive diagnost ic and severity criteria. Those who were initially on psychoactive medica t ion were withdrawn (n = 15) p r io r to comple t ing the intake materials that were used in the cur ren t study.

Individuals in this sample received one of two g roup therapies or an individually conduc ted self-directed therapy (S/SD). The group therapies consisted of cognitive therapy (Yost, Beutler, Corbishley, & Allender, 1986) and an exper ient ia l therapy fashioned on pr inciples of gestalt therapy (Daldrup, Beutler, Engle, & Greenberg , 1988). The therapies were all manual ized and m o n i t o r e d for therapis t compl iance with process criteria, and the treatments were des igned to vary systematically in level of directiveness and symptomat ic versus conflictual focus. All g roup sessions were v ideotaped and two sessions were randomly selected from early and late sessions to serve as process data for this project .

8 Beutler & Martin

Sample #4. This sample was comprised of depressed adults over the age of 60 and was extracted from two separate research studies performed by the Palo Alto Veter-

ans Administrat ion Geropsychiatry program. Two treat- men t groups were extracted from one study (Thompson, Gallagher-Thompson, Hanser, Gantz, & Steffen, 1991) and one t reatment group was extracted from another study at the same site (Thompson, Gallagher, & Brecken- ridge, 1987). The samples in these studies were all drawn from the same geographic area, were selected on the basis of identical selection criteria, and were all randomly assigned to the various treatments unde r study. We randomly selected 62 patients for the current study on whom BDI or STS outcome ratings were completed. These individuals all had usable audio or videotapes of two treat- men t sessions and an intake session. The participants represented three t rea tment conditions: Desipramine therapy (n = 20), cognitive therapy (n = 22), and psychodynamic therapy (n = 20), all of which were moni tored and conducted according to a manual .

Procedures The t rea tment sample of 284 patients ranged from 17

to 79 years of age, was predominant ly female, and was moderately impaired on functional measures. The treat-

Our in teres t w a s

no t in w h a t t y p e or

brand of t r e a t m e n t

worked. Ins tead,

w e w e r e

concerned with

the fit b e t w e e n

certain therapist-

initiated activities

and object ives

on the o n e hand,

and patient

characteristics on

the other.

ments inc luded medication, group cognitive therapy, individual cognitive therapy, psychodynamic therapy, ex- periential therapy, and self- directed therapy, all of which were implemented via structured manuals, and a therapy- as-usual condi t ion that was not conducted in such a structured fashion. For the current purposes, however, our inter- est was not in what type or b rand of t reatment worked. Instead, we were concerned with the fit between certain therapist-initiated activities and objectives on the one hand and pat ient characteristics on the other. The interventions that we inspected, therefore, were cross-cutting

classes of procedures. Thus, for all patients who entered t reatment and completed at least one post-entry assess- men t period, we obtained audio- or videotapes of two t reatment sessions. These sessions were rated to deter- mine the nature of the in-session activity of the therapist. These latter ratings were made by independent ly trained graduate students using the STS Therapy Rating Scale

and were extracted from two therapy sessions, respectively drawn from the first and last third of t rea tment sessions.

Doctoral clinicians rated all intake data for all patients blindly, with checks to ensure reliability, using the STS Clinician Rating Form. These ratings were used, in various select samples, both to test the psychometric qualities of this ins t rument (Fisher et al., 1999). Moreover, the common ratings are now being used to validate the predictive value of these clinician rat ings compared to the predictive constructs based on pat ient self-reports.

Results and Discussion We will not detail the complex structural equation-

analytic procedures used in this study. However, an illus- tration may help one not as familiar with statistical procedures to grasp the nature of these analyses: A creek may

overflow its banks. If it has been a stormy, rainy winter, one can conclude that the extra rain prompted the flooding. However, other factors could have contr ibuted to the flooding as well, such as a mudslide, a broken mainl ine water pipe, a leaking dam, and so forth. If engineers wish to guard against flooding, they may do a study of the local geography and come up with even more possible contributors to the flooding.

Hence, the more elements that are considered in a plan for solving a problem, the better the outcome, because many factors contr ibute to a final solution. Roughly, Structural Equat ion Modeling (SEM) attempts to discover the contr ibut ion of various predicted patterns of relationships among variables and classes of variables and t reatment outcomes. It is a method of identifying the pat tern of patient, treatment, and pat ient by t reatment matching factors that contr ibute to the final outcome. As

will be noted in the following discussion, there are various arrangements of mixes and matches that reflect how each may contr ibute to outcomes. The analyses allowed us to compare the six different models that have been used to unders tand and develop t reatment plans.

1. Prognosis Model, which at tempted to fit pat ient intake variables to predict ion of outcomes;

2. Managed Health Care Model, which assessed the impact of context (intensity, mode, format) on outcome;

3. Common Factors Model, which explored common relationships between therapist activity, qualities of the relationship, and outcomes;

4. Patient-Treatment Matching Model, which explored fitting patient and therapist variables with outcomes at the level of the individual therapist;

5. Technical Eclectic Therapy Matching Model drawn from Beutler (1983); and the more complex

6. STS Model, which included assessment of the cascading effect of factors related to context, therapist, and relationship factors as well as therapy matching.


In each case, we tested specific hypotheses that had been derived f rom our review of research l i terature and a t t empted to distill the findings in a finite set of treat- men t p lann ing principles. In so doing, we selectively ana- lyzed and ref ined the tests unti l we found a pa t te rn of relat ionships a m o n g the variables ident i f ied as relevant by the t rea tment mode l be ing tested and that accoun ted for the maximal predic t ion. This resul ted in some variables be ing c o m b i n e d with others as it was de t e rmined that they measured similar under ly ing constructs. But, in each case, the f ramework of the mode l was kept intact. Follow- ing is a br ie f descr ip t ion of the results with each treat- men t plan deve lopmen t model .

Prognostic Model The Prognost ic Model relies on pa t ien t predic tors of

outcomes. A test of its validity simply assesses the interre- lat ionships a m o n g our array of pa t ien t predispos ing variables (see Level 1 of the STS mode l in Table 1) and outcomes. In our analysis, la tent constructs emerged f rom the measures of pa t ien t variables to descr ibe three general clusters that were in te r re la ted and associated in various ways with good outcome: social impa i rmen t (R = - . 3 5 ) , distress (R = .44), and complexi ty /chronic i ty . The lat ter variable actually affected the previous two variables, which, in turn, affected outcome.

Social impa i rmen t would increase or decrease with levels of social isolation, f ami ly / in te rpe r sona l problems, and social support . As these became problemat ic , the pa- t ient 's prognosis decl ined. On the o the r hand, pa t ien t distress was positively re la ted to the magni tude of im- p rovement and was indexed by low self-esteem, high external indices of distress, and cl inician-judged turmoi l and discomfort . In short, if a cl ient expe r i enced h igher subjective distress, lower self-esteem, and objectively observed turmoil , the outcomes were general ly greatly improved.

A comorb id personal i ty disorder, elevated scores on the MMPI, and a history of r ecu r ren t p rob lems def ine p rob lem complexi ty and chronicity. Interestingly, com- p lex i ty /chronic i ty was positively associated with bo th of the o the r two p red ic to r variables. Tha t is, individuals with complex and chronic p rob lems were likely to be both highly distressed and socially impaired . This gave them a mixed prognosis. Thus, while chronici ty and complexi ty may help us pred ic t the presence of bo th distress and social impai rment , they do not directly relate to prognosis or magni tude of improvement .

Managed Health Care Model The second m o d e l tested pa ra l l e l ed the efforts of

hea l th care organiza t ions to def ine pa t i en t quali t ies that will lead to be t t e r ou tcomes if given cer ta in ma t ched lev-

els of care (see Beut le r et al., 2000). This m o d e l ident i - fies the re la t ionships a m o n g pa t i en t variables, t reat- m e n t con tex t (Level 2 of the STS model ; see Table 1), and outcomes . To test this model , we cons t ruc ted ma tch scores based u p o n c o n t e m p o r a r y dec is ional cr i ter ia between pa t i en t p red i spos ing variables (Level 1) and contextual variables (Level 2). Matched scores i nd i ca t ed the degree to which ou tcomes were improved when (a) i m p a i r m e n t level was used as an ind ica to r for psycho- pha rmaco log ica l in tervent ion; (b) c h r o n i c i t y / c o m p l e x - ity was used as an ind ica to r for p sychopharmaco the rapy ; (c) c omp le x i t y / c h ron i c i t y was also used as an ind ica to r for g roup o r family the rapy (as o p p o s e d to individual therapy) ; and (d) i m p a i r m e n t was used as an ind ica to r for increas ing t r ea tmen t intensi ty ( length and frequency o f t r ea tmen t ) .

The results found that the first three of the foregoing variables collectively p red ic ted the amoun t of t r ea tmen t benef i t (R = .39). However, the severity of the p rob l em did no t prove to be a stable indica tor for increas ing the intensity o f t rea tment . This lat ter result may be a little sus- pect, however, since the range of t r ea tment intensifies r ep resen ted was no t widely distr ibuted. Most t rea tments were short- term, varying in length of sessions more than in terms o f absolute n u m b e r of sessions (all t rea tments were u n d e r 20 sessions in length) .

To cross-check these results in more h o m o g e n e o u s and cont ro l led samples, we conduc ted separate analyses of Sample #3 (Albanese, 1998) and Sample #4 (Sando- wicz, 1998) data. Sample #3 included three treatments that differed in p l a nne d intensity (short versus long sessions) and Sample #4 inc luded a systematic compar i son of psychosocial and pharmacologica l (ant idepressant) treat- men t modali t ies. F rom the perspective o f the Managed Heal th Care Model we ob ta ined two findings in these analyses: (1) initial level of pat ient impa i rmen t and severity was positively re la ted to benef i t if the intensity o f treat- men t was high ( longer sessions and conduc ted by a professional), but not if it was not; (2) level o f impa i rmen t was also a p red ic to r of the effectiveness of Des ipramine but not of psychotherapy, a l though the two t rea tments had equivalent effects, overall.

These f indings general ly suppor t the conclusions that the level of care, inc luding the use of g roup therapy, intensive t reatments , and psychopharmaco the rapy are in- d ica ted by the presence of c o m p l e x / c h r o n i c p rob lems and high levels of social impai rment .

Common Factors Model The third mode l tested was the C o m m o n Factors

Model. It p roposed that ou tcome would be e n h a n c e d in p ropo r t i on to the therapist ' s skill level, involvement, and the quality of the therapeut ic all iance (variables f rom Level 3 of the STS Model; Table 1). Indeed , these vari-

10 Beutler & Martin

ables coalesced a round a c o m m o n factor of therapy process and all collectively con t r ibu ted to the pred ic t ion of t rea tment benef i t (R = .17).

These f indings are general ly consistent with the conclusions of major l i terature reviews on the role of therapy re la t ionship (e.g., Beutlen Machado, & Neufeldt, 1994; Lamber t , Okiishi, Finch, &Johnson , 1998) and alliance. However, they add new data in suggesting that therapis t involvement and skill also are very helpful to patients. While this makes logical sense, it has se ldom been directly studied.

Treatment Procedures Model The four th mode l tested was more complex than the

foregoing therapis t model . It looked at interact ions be-

The STS model

proved to have the

most complex but

comprehensive fit

with the data,

combining the

positive features

of several of the

other models. In

most respects,

the contributors

to each of the

other models

remained intact.

tween pat ient predisposing variables (Level 1 of the STS model; Table 1) and therapist activity variables (Level 3 variables; Table 1). The specific process variables cons idered inc luded therapist directiveness, therapis t focus on symptoms versus insight, and therapist use of abreactive versus support ive techniques.

In this model , the use of abreactive strategies and the use of directive intervent ions both cont r ibu ted to a common construct of "therapist action" but had virtually no re la t ionship to positive outcomes. Indeed , none of the therapist activities a lone con- t r ibuted to benefit . This find- ing general ly is consistent

with the observat ion that most procedures , as embod ied in different therapeut ic models, p roduce equivalent outcomes. In short, what the therapis t does in the session does not by itself p roduce notable change, whether he or she is be ing support ive or del iberately a t t empt ing to stir the client 's emotions.

Technical Eclectic Therapy Matching Model The Technical Eclectic The rapy Matching Model was

des igned to exp lore the possibility that the failure of procedures to affect ou tcome may be because they work only with cer tain people . The Technical Eclectic Model , original ly deve loped by Beut ler (1983), p roposed that cer tain matches between therapis t p r o c e d u r e and pa- t ient qualit ies would be beneficial . Specifically, the mode l suggests the following: pa t ien t cooperat iveness is

an ind ica tor for the use of directive intervent ions, while s t rong defensiveness or uncoopera t iveness suggests use of nondirec t ive interventions; low pa t ien t arousal is an indica tor for the use of abreact ive intervent ions, while high pa t ien t arousal indicates the use of more suppor t - ive techniques; and pa t ien t in ternal iza t ion is an indica- tor for ins ight-or iented procedures , while external iz ing individuals would r e spond be t te r to symptom-removal procedures .

Results failed to confi rm the hypotheses. While the various matching pat terns were in tercorre la ted , they did not significantly cont r ibute to t rea tment outcome. This model proved to be too simplistic to lend itself to treat- men t predict ion.

STS Model The last mode l tested was the STS, as ou t l ined by Beut-

lei" and Clarkin (1990). This mode l incorpora ted aspects of each of the o ther models. Thus, it was the most complex of the models tested (see Figure 1).

The STS mode l proved to have the most complex but comprehens ive fit with the data, combin ing the positive features of several of the o ther models. In most respects, when all variables were tested together, the contr ibutors to each of the o the r models r ema ined intact. The three except ions were the C o m m o n Factors Model, the Treat- men t Procedure Model, and the Technical Eclectic Model. Factors from these three models c o m b i n e d to re- veal a significantly con t r ibu t ing interact ion. In sum, while certain factors by themselves showed no signifi- cance, when several factors were p laced together, it was found that the combina t ion of them p r o d u c e d a be t te r "fit" with ou tcome data. Specifically, the findings indi- cated that match ing distinctive strategies with par t icular pa t ien t characteristics and qualities facili tated and activated the quality of the therapeut ic work, inc luding aspects of the therapeut ic process, and both provided inde- p e n d e n t cont r ibu t ion to outcome. This f inding salvages the matching variables p roposed in the Technical Eclec- tic Model, but in a un ique way. It points to the "fit" between strategies and patients as an activating mechanism of change. To the degree that therapy process activities are par t of a c o m m o n factor that includes o ther therapy process factors, it is the systematic match that makes the largest contr ibut ion. Simply stated, systematically matching pat ient characterist ics with intervent ions in the mi- lieu of therapis t activities contr ibutes greatly to the treat- men t outcome.

Drawing on our previous creek-f looding example , if one could trace the amoun t of leakage f rom the dam, measure the soil erosion a n d / o r the rainfall in inches pe r hour, each of those measures would possibly have a d d e d or subtracted from the flood. If forces such as u p r o o t e d trees or soil erosion were also creat ing a crack in the dam,

Prescribing Therapeutic Interventions I I

Direc- tivcness

1.00

Therapy Process

Arousal I Reactance Match

1.00 -3.4:

-.09

I I='1 I 1.00

Impairment X

Mode

Chronicity X

Mode

I Format X

Chronicity

1.00

.61

.39

-1.26

1.0o

Outcome

27

BDI Change

Depression I Change

00• Low Self Esteem

1.

Low ] S o c i ~ Clinician- I Social Distress " Observed

Supoort -.25 Distress

• ._ ~ , . 9 ~

Isolation -.2 Distess

~ . 3 0

[ Chr°nicity I [ # MMPI Seales>65 Personality I Disorder

Figure 1. Total systematic treatment selection model.

then it would be possible to combine these factors into one overall contributor. Something on that order has been described above, when social impairment, distress, therapy process, and therapy match are identified (but only interactively) as carrying the bulk of the explanation for differing outcomes.

The remainder of this paper describes a psychotherapy that incorporates principles derived from the preced- ing research. We will describe the guiding objectives of PT, the kind of training needed, the types of strategies used, the principles upon which they are based, and the levels of training employed in implementation of PT for systematic treatment planning.

Guiding Objectives of PT

The results of the above analysis confirmed our as- sumption that it is advantageous to individualize the interventions given to clients by methods that cut across and integrate the methods of different theoretical models of treatment. Some practitioners have used intu- ition, born of innate and acquired interpersonal understanding, to bridge theoretical disciplines; others have made use of manualized treatment, departing from these by inserting theory-incongruent methods when they be- lieve that this will help. Because these methods of filling in the missing or weak aspects of a theoretical technique

1Z Beutler & Martin

with interventions borrowed from other theories is largely impressionistic and subjective, they vary widely from clinician to clinician. A set of guiding principles to direct this cross-theory selection would help the clinician without sacrificing their use of favored techniques. What we have in the STS model is an opportuni ty to better moni to r such interchanges.

PT is a t rea tment manual (Beutler & Harwood, 2000) that is based on identified principles rather than techniques; it allows therapists to select interventions using an empirically derived rationale based on the methods of

O u r PT t r a i n i n g

c e n t e r s o n t h e

d e v e l o p m e n t o f s ix

k e y s t o b e c o m i n g

a n e f f e c t i v e

p s y c h o t h e r a p i s t :

• a t t i tudes • knowledge • tools • t echn iques • t ime • creat ive imaginat ion

STS (Beutler & Clarkin, 1990). STS attempts to define a method of fitting strategies and techniques to patient needs and proclivities, based upon scientifically established assumptions in psychotherapeutic practice. It provides a model for selecting interventions to accommodate a variety of patient qualities and characteristics. In this process, it advocates using multicom- p o n e n t methods of intervention derived from a variety of systematic approaches to psychotherapy. Like all available

prescriptive t rea tment models, the STS model eschews comprehensive clinical theories of either psychopathology or of psychotherapy as guides to intervention. In- stead, it focuses on identifying individual patient characteristics that lend themselves to clearly del ineated t rea tment strategies. As individual clients will differ in the type and degree of characteristics, the t reatment plan must be custom-made. In its cur rent rendit ion, STS focuses on def ining general and empirically validated principles that logically lead to differential t rea tment strategies. These strategies can be implemented with a wide variety of techniques and procedures, varying in their particular use, and varying as a funct ion of the particular strengths of individual clinicians.

We are currently in the third year of a funded project designed to see if we can develop a cross-cutting treat- men t and train therapists in the application of PT among a group of comorbid chemical abusive and depressive patients. PT is based on the principles defined in our analysis of the STS model. Two sets of principles are at the core of the development of PT. The first set applies to principles of training, the second set to principles of therapeutic change.

Principles of Training In our current project, we initially instigated and pilot-

tested a t raining program in PT that emphasizes cue rec-

Table 2 Principles of Training

Six Keys to Therapeutic Effectiveness 1. Attitudes of respect, optimism about the patient's potential for

growth and change, empathic sensitivity, curiosity, and self- a w a r e n e s s .

2. Knowledge of lO principles of therapeutic change. 3. Tools of psychotherapy include the psycholo~cal assessment

procedures, materials, environment, setting, and equipment that are necessary for a patient to establish a sense of safety and predictability in the treatment environment.

4. Techniques are used but vary as a function of the explanatory theory, and past training of the therapist.

5. Time is inherendy related to therapist skill. The skillful therapist is able to time interventions and permits the patient the time necessary to change.

6. hnagination and creativity provide the foundation for flexibility. The application of established principles to new and novel environments is the epitome of therapeutic art.

ognition, unders tand ing the principles of change, and the flexible application of strategies and techniques that are consistent with these principles. Our PT training cen- ters on the development of six keys to becoming an effective psychotherapist: attitudes, knowledge, tools, techniques, time, and creative imaginat ion 1 (Table 2).

1. Effective therapy begins with attitudes o f respect, op-

timism about the patient 's potential for growth and change, empathic sensitivity, curiosity, and self- awareness. These attitudes are the foundat ion for the interpersonal and listening skills that are the nucleus of the powerful heal ing forces that con- tribute to the benefits of all forms of effective psychotherapy.

2. To maximize the power of psychotherapy, one must have a sound unders tand ing or knowledge of funda- mental principles of change in addit ion to appropriate therapeutic attitudes. Knowledge of the principles that guide clinical change is impor tant but never subsumes or replaces, in importance, therapeutic attitudes such as respect and caring.

3. The tools of psychotherapy include the psychological assessment procedures, materials, environment , setting, and equ ipmen t necessary for a pa- t ient to establish a sense of safety and predictability in the t reatment environment .

4. The techniques of psychotherapy are allowed to vary as a funct ion of the explanatory theory and past

1These keys to success were borrowed from an unlikely source. They were extrapolated, with thanks, from Parelli's (1992) descrip- tion of the successful natural horseman. The first author has found many parallels between the nonpunitive, relationship-oriented methods that have become central to modern methods of "natural" animal training and the desirable attributes of a skilled psychotherapist. Parelli's keys to success are among these parallels.


training of the therapist. Training also provides examples and t raining in technique expansion, as well, with emphasis on those that might be used to implement the principles of change. We view tools and techniques to be the basis of therapist skill, but skill also includes the therapist 's willingness to modify and alter the interventions applied in a flexible fashion.

5. Time is the fifth key to success and also is inherent ly related to therapist skill. The skillful therapist is able to time interventions and permits the pat ient the time necessary to change.

6. The therapist 's attitudes, knowledge, skills, and t iming come together through the use of creative imagination. Imaginat ion is the creative foundat ion of flexibility. The application of established principles to new and novel envi ronments is the epitome of therapeutic art and flexibility.

These six keys are applied within a three-tier system of training. The training is designed to ensure that clinicians learn to identify the pat ient cues that reliably signal the presence of treatment-relevant traits and states, assess the levels at which these qualities occur, and select and fit therapeutic interventions to these qualities and levels:

1. At the first level, therapists are taught basic principles of change derived from empirically established relationships across a variety of theories.

2. At the second level, therapists are taught strategies of inf luence that derive from these principles and that distinguish among the treatments that are effective with different groups of patients.

3. At the third level, therapists are taught some repre- sentative bu t nonexhaustive techniques and procedures for carrying out the strategies.

The difference between this and previous approaches is that the focus is on the principles and strategies rather than on specific techniques. Techniques are considered to be both very flexible as applied to various objectives and (within some limits) interchangeable. Thus, unlike most approaches that emphasize the techniques of intervent ion--- interpretat ion, two-chair work, reinforcement , e tc . - - the PT that arises from STS urges therapists to learn the principles and strategies. They use their own array of techniques and their own imaginat ion to develop a t reatment plan that is consistent with these principles.

Principles of Therapeutic Change The second set of principles (Table 3) applies to the

mechanisms of therapeutic change. In the first year and a half of the current study, we conducted a thorough literature search to identify a set of hypothetical bu t general principles that may govern t rea tment selection without

Table 3 Ten Principles of Therapeutic Change

Relationship Principles 1. Therapeutic change is greatest when the therapist successfully

conveys trust, acceptance, acknowledgment, and respect for the patient and does so in an environment that both supports risk and provides maximal safety from criticism.

2. Therapeutic change is most likely when the patient is realistically informed about the probable length and effectiveness of the treatment and has a clear understanding of the roles and activities that are expected during the course of treatment.

Adjusting Level of Treatment 3. Therapeutic change is most likely and maximal when the

intensity of treatment is consistent with the patient's level of psychological and functional impairment.

Differential Treatment Change 4. Therapeutic change is most likely when the patient is exposed

to the objects or targets of behavioral and emotional avoidance.

5. Therapeutic change is greatest when the internal or external focus of the selected interventions parallel the external or internal methods of avoidance that are characteristically used by the patient to cope with stressors.

6. Therapeutic change is most likely if the initial focus of change efforts is to alter disruptive symptoms.

7. Therapeutic change is most likely when the therapeutic procedures do not evoke therapeutic resistance.

8. Therapeutic change is greatest when the directiveness of the intervention is either inversely correspondent with the patient's current level of resistance or authoritatively prescribes a continuation of the symptomatic behavior.

9. The likelihood of therapeutic change is greatest when the patient's level of emotional stress is moderate, neither being excessively high nor excessively low.

10. Therapeutic change is greatest when a patient is confronted with avoided behaviors and experiences to the point of raising emotional distress until problematic responses diminish or extinguish.

sacrificing therapist flexibility in the selection of explanatory frameworks and techniques (Beutler et al., 2000). We successfully identified and then cross-validated 18 principles of effective treatment. From these, we extracted 10 principles that apply specifically to the na ture of psychotherapy, and these have been incorporated into PT.

Specifically, we identified two principles that direct the development of the t reatment relationship and eight cardinal principles of change that can be used to guide the application of treatments in a selective manner . These principles facilitate the therapist 's efforts to adapt each t reatment plan to fit the un ique pat tern of characteristics of particular patients. We will use some of these latter principles to illustrate the flexibility that may be possible while practicing within the cross-theory guidelines they represent.

The 10 principles of therapeutic change are as follows:

14 Beutler & Martin

1. Therapeu t ic change is greatest when the therapis t successfully conveys trust, acceptance, acknowledgment , and respect for the pat ient and does so in an environ- men t that both supports risk and provides maximal safety from criticism.

2. Therapeu t i c change is most likely when the pat ient is realistically i n fo rmed about the p robab le length and effectiveness of the treatment, is provided with suppor t and comfort, and has a clear unders tanding of the roles and activities that are expected dur ing the course of treatment.

These pr inciples of re la t ionship deve lopment are relatively self-explanatory. Accordingly, the il lustrations of flexibility are be t te r made as we look at the principles that guide specific t rea tment selection.

3. High funct ional impa i rmen t indicates the need for a relatively intensive t reatment . The flexibility of this pr incip le can be i l lustrated by cons ider ing the variety of ways in which t rea tment intensity, might be increased.

Changing the sett ing to be more or less restrictive, increasing the f requency of sessions, increasing the length of sessions, a l ter ing the intensity by using group or individually focused t reatments , and supp lement ing therapy with homework assignments, collateral contact, or sup- p lementa ry p h o n e call contacts, are examples of the lati- tude available to the therapist ' s discretion.

4. Therapeu t ic change is most likely when the pat ient is exposed to the objects or targets of behavioral and emot iona l avoidance.

5. Therapeu t ic change is greatest when the internal or external focus of the selected intervent ions parallel the external or in ternal methods of avoidance that are characteristically used by the pa t ien t to cope with stressors.

To apply these principles, a behavior therapist may identify external objects of avoidance and use in-vivo exposure to activate pr inciple #4, while an in terpersonal or re la t ionship-or iented therapis t may activate pr inciple #4 by a here-and-now focus on daily problems and relationship, and activate pr inciple #5 by identifying a dynamic theme or life narrative as a po in t of focus. In somewhat similar fashion, a cognitive therapis t may focus on identifying automat ic thoughts and exposing the pat ient to feared events in response to pr incip le #4 and may moni- tor and activate schematic injunct ions to activate principle #5.

6. Therapeu t ic change is most likely if the initial focus of change efforts is to al ter disruptive symptoms.

Principle #6 may be evoked by a re la t ionship therapist by a t t end ing to here-and-now issues and by a behavior or cognitive therapis t by moni to r ing and res t ructur ing urges and o ther cognitions.

7. Therapeut ic change is most likely when the therapeut ic p rocedures do not evoke therapeut ic resistance.

8. Therapeu t ic change is greatest when the directiveness of the in tervent ion is e i ther inversely co r r e sponden t

with the pat ient ' s cur ren t level of resistance or the therapist authoritat ively prescribes a cont inuat ion of the symptomatic behavior.

Within all theoret ical frameworks, there are sugges- tions for handl ing and minimizing pa t ien t resistance. In a behavioral t radi t ion, these may include pat ient-gener- a ted behavioral contracts or behavioral exchange programs; in a systems framework they may involve prescribing the symptoms and refraining; and in the t radi t ion of re la t ionship therapy they may involve acceptance, ap- p roach and retreat , and evocative support .

9. The l ikel ihood of therapeut ic change is greatest when the pat ient ' s level of emot iona l stress is modera te , ne i ther be ing excessively high nor excessively low.

All therapeut ic schools catalog p rocedures that con- front and p rocedures that suppor t or structure. Provid- ing structure and suppor t as well as behavioral and cognitive stress m a n a g e m e n t p rocedures can serve to reduce immedia te levels of disruptive emot ion while confronta- tional, experient ia l , and open -ended or uns t ruc tured p rocedures tend to increase arousal.

10. Therapeut ic change is greatest when a pa t ien t is conf ron ted with avoided behaviors and exper iences to the po in t of raising emot iona l distress unti l p roblemat ic responses diminish or extinguish.

This is the simple pr inciple of exposure and extinc- tion. It can be activated th rough repea ted in te rpre ta t ion of a consistent dynamic theme or th rough in vivo exposure training, again d e p e n d i n g on a therapist 's proclivities and the m a n n e r in which the o the r pr inciples are being addressed. Our t ra ining p rogram is des igned to help therapists learn to apply these principles in a flexible fashion and within the context of the appl ica t ion of a wide variety of therapeut ic techniques with which the therapis t may be familiar.

As a therapis t a t tempts to apply these pr inciples to real patients, it will be impor tan t to adap t all of these procedures at once. The effective therapis t must adap t not only to the pat ient ' s re la t ionship expecta t ions but to the pa- t ient 's level of emot iona l intensity, defensiveness, and coping style. Translated to the level of strategies, at a minimal level, an effective strategy for t rea tment will:

• provide a safe and respectful env i ronment • expose the pa t ien t e i ther to the external precipi ta-

tors of the symptom or to in ternal exper iences that are avoided

• adap t level of t r ea tment to the level of pa t ien t impa i rmen t

• adop t e i ther a directive or a nondirect ive role with the pat ient to lead him or her toward act ion and change

• provide e i ther suppor t or confronta t ion and exposure to fit the pat ient ' s level of emot ional distress, a


complex process that requires the therapist to move flexibly among treatment procedures as the patient changes.

Summary and Conclusions

Several conclusions are possible from the findings and principles presented in this paper. This research on the STS model suggests that we may be underestimating the power of psychotherapy by oversimplifying the ways in which we study it. This is truly exciting because it suggests that the use of techniques and procedures, as well as the development of artistic skill, are dependent on the training and supervision that is provided in training.

Of equal delight to the first author is the general support these data provide for the STS model of Beutler and Clarkin (1990). Albeit, aside from demonstrating the value of a model of Beutler and Clarkin's derivation, these results point to the fallibility of Beutler's (1983) original eclectic psychotherapy. This latter model was overly simplistic and failed to acknowledge the complexity of the relationship of technique and fit with other aspects of the therapy process and relationship when con- structing the predictive equation.

Of major import are the implications of these findings for research methodology. The findings strongly suggest that, while predictive, simple treatment matching based on either patient self-report or on initial problem and symptom presentations--the most usual type of prognostic model used in managed health care planning (e.g., Butcher, 1990; Orlinsky et al., 1994)--in the absence of direct observation and sequential monitoring of skillfully applied interventions are doomed to produce less-than- optimal and less-than-desirable, not to mention misleading, results. This would also be true of treatment matching attempts based on other myths of treatment simplicity. In this, perpetuation of such unidirectional and linear research hypotheses will produce inconsistent and low- power results that are destined to reinforce what have come to be operational myths in managed health care planning: that psychotherapy is a simplistic treatment that can be conducted effectively without benefit of special expertise; that experience and sensitivity to contextual nuance are unimportant; and that the avenue to personal nirvana is best sought through better biochemistry.

In contrast, our findings tell us that psychotherapy may require very high technical expertise, experience, and skill, including the ability to interact with and take advantage of computer technology to help guide one through the morass of cascading influences, in the level of complexity needed, and the cognitive flexibility to bridge theories and methods (Beutler et al., 2000; Fisher et al., 1999).

As for the issue of empirically based decision making,

these findings argue persuasively for the need for empirical guidelines. Linear logic is too simple and fails to add stability. With the exception of the Prognostic Model and Managed Health Care Model, the simple, linear models that we tested produced inconsistent, unstable, or weak findings. The power of patient predisposing factors alone should be clear and failure to account for these when we study therapy process or therapist factors or therapy procedures is destined to be misleading.

While these latter two models can be used effectively by health care planners, optimally efficient, empirically based decision making will require more complex decisions. These decisions will probably require some technical support to make meaningful algorithms for a given patient. The use of computer- generated predictions makes sense.

The aforementioned need for computer technology to assist in bringing to bear algorithmic cascading of various factors going into planning for treatment does exist in the form of STS software presendy being marketed and undergo- ing refinement. The software utilizes a large database of patient/client variables, treatment dimensions and strategies, and generates a printed report. A clinician can input

This r e s e a r c h o n

t h e STS m o d e l

s u g g e s t s t h a t

w e m a y b e

u n d e r e s t i m a t i n g

t h e p o w e r o f

p s y c h o t h e r a p y b y

o v e r s i m p l i f y i n g

t h e w a y s in w h i c h

w e s t u d y it.

information from gathered assessments and clinical interview to which algorithmic processing is applied utilizing the appropriate database. However, it must be em- phasized that such software does not leave the clinician without his or her work to do. In fact, as has been men- tioned earlier, training and supervision are still essential.

Support for the STS model raises the need to focus on the development and training of treatments that incorpo- rate these principles. With this in mind, we have described the development of PT (Beutler & Harwood, 2000), utilizing 10 principles that guide the therapist in the selection and application of interventions. The principles, in turn, are empirically grounded and research based, designed to help the clinician select techniques from his or her own armamentarium that can be applied to patients with defined levels of receptivity. The applica- tions of these principles are designed to allow for a high degree of freedom and flexibility on the part of the therapist. Procedures and techniques have different proper- ties depending on who is using them and how they are in- troduced. Thus, while we consider the principles to be sound and relatively inviolate, the selection of specific procedures will depend on the clinician's experience,

16 Beutler & Martin

skill level, a n d fami l ia r i ty wi th specif ic p r o c e d u r e s . I t is

w i t h i n th is f r a m e w o r k t h a t we be l i eve t h a t s o m e h o p e

rests fo r e n s u r i n g f lexibi l i ty in s tud ies o f i n t e g r a t e d t rea t -

m e n t . To p r a c t i t i o n e r s , t h e r e is t h e o p p o r t u n i t y to use

t h e i r k n o w l e d g e a n d e x p e r t i s e s t ra teg ica l ly to p l a n t reat-

m e n t a l o n g c o m p a r a b l e g u i d e l i n e s wi th o t h e r t h e r a p i s t s

whi le a t t h e s a m e t i m e e x e r c i s i n g t h e i r p r e r o g a t i v e to

" p r e s c r i b e " t he i n t e r v e n t i o n s a n d " c h a n g e p r e s c r i p t i o n "

in a c c o r d wi th s igns a n d s y m p t o m s p r e s e n t e d by t h e i r

"pa t i en t . "

To e m p l o y a s i m p l e analogy, a f a rmer , a h o r t i c u l t u r a l -

ist, o r t h e h o m e g a r d e n e r knows t h a t ever)" p l a n t spec ies

d i f fers f r o m a n o t h e r in t e r m s o f t h e a t m o s p h e r i c cond i -

t ions a n d qua l i t i e s o f soil t hey n e e d in w h i c h to grow a n d

f lour i sh . However , e a c h i n d i v i d u a l g r o w e r p r e s e n t s t he

p lan t s , a r r a n g e s t h e p lan t s , a n d p r e f e r s va r ious p l a n t s o n

t h e basis o f p a r t i c u l a r values. Th i s is t h e i r creat iv i ty a n d

t h e basis o f c o n s i d e r a b l e flexibility. In sp i te o f t he se dif-

f e r e n c e s o f p r e f e r e n c e a n d style, t he k n o w l e d g e a b l e

g r o w e r accep t s c e r t a i n c l i m a t e a n d soil c o n d i t i o n s as op-

t ima l fo r a g iven p l a n t a n d all fo l low c e r t a i n g u i d e l i n e s

w i t h o u t th is s t r u c t u r e i n t e r f e r i n g wi th t he g rower ' s sense

o f creat ivi ty a n d a u t o n o m y .

C o n s i d e r i n g p a t i e n t cha rac t e r i s t i c s f r o m the s ta r t in

p r e s c r i b i n g i n t e r v e n t i o n s is r e a s o n a b l e . A d d i n g in t he

t h e r a p i s t ' s s ense o f t he c l i en t ' s i n t e r p e r s o n a l style a n d

o t h e r e m o t i o n s ta tes is p r u d e n t . Dev i s ing a t r e a t m e n t

p l a n t h a t c o m b i n e s su f f i c i en t s t r u c t u r e a n d creat ivi ty in

d e a l i n g wi th e a c h p a t i e n t s i t u a t i o n is s o u n d p rac t i ce .

T h e s e key c o m p o n e n t s l ead to a r e l a t i o n s h i p b e t w e e n cli-

n i c i a n a n d c l i e n t t h a t will b e o p t i m a l in p r o v i d i n g w h a t

t h e p a t i e n t needs .

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Audi tory Hallucinat ions 17

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Address correspondence to Larry E. Beutler, Counseling/Clinical/ School Psychology Program, Department of Education, Santa Barbara, CA 93106.

Received: January 4, 1999 Accepted: April 29, 1999

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

A Self-Control Skills Group for Persistent Auditory Hallucinations

L a w r e n c e M. P e r l m a n , M a i m o n i d e s Med ica l Center B r u c e A. H u b b a r d , Cognit ive Hea l th Group

A self-control skills group was developed to help schizophrenic clients cope with persistent auditory hallucinations. Nine clients were provided with a variety of coping strategies for shifting attention away from hallucinations. Seven reported improved symptom control Matching skill complexity to functional level may yield optimal treatment benefit.

T HIS PAPER descr ibes the d e v e l o p m e n t o f a symptom-

m a n a g e m e n t g r o u p for c l ients with pers i s ten t audi-

tory ha l luc ina t ions . T h e g r o u p moda l i ty was c h o s e n to

e n h a n c e eff ic iency a n d to be cons i s ten t with the psychiat-

ric day- t r ea tmen t progi-am format . Several pract ical ap-

p r o a c h e s to s u p p l e m e n t i n g p h a r m a c o t h e r a p y for audi-

tory ha l luc ina t ions can be f o u n d in the l i t e ra ture

(Fa l loon & Talbot, 1981; K i n g d o n & Turk ing ton , 1993;

Tar r ie r e t al., 1993). T h e mos t cons i s ten t l ine o f investiga- t ion is based on a se l f -control mode l .

S e l f - C o n t r o l S k i l l s f o r H a l l u c i n a t i o n s

N u m e r o u s d e m o n s t r a t i o n s o f t he e f fec t iveness o f a

se l f - con t ro l a p p r o a c h in h e l p i n g pa t i en t s c o p e wi th au-

Cognitive and Behavioral Practice 7, 17-2 I , 2000 107%7229/00/17-2151.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

d i t o ry h a l l u c i n a t i o n s have b e e n r e p o r t e d in s ing le case s tudies . Se l f - con t ro l skills fo r m a n a g i n g a u d i t o r y hal lu-

c ina t i ons involve the i n t r o d u c t i o n o f a c o m p e t i n g sig-

na l tha t i n t e r f e r e s wi th h a l l u c i n a t i n g . T h e t h e o r e t i c a l r a t i o n a l e is ba sed o n the c o m m o n l y a c c e p t e d a s sump- t ion tha t a t t e n t i o n a l r e s o u r c e s a re f ini te . W h e n they a re

p r o b l e m a t i c , h a l l u c i n a t i o n s e n g a g e a l a rge p o r t i o n o f cogn i t i ve capacity. A c o m p e t i n g s ignal tha t d e m a n d s at-

t e n t i o n a l r e s o u r c e s r e d u c e s t he a t t e n t i o n a l capac i ty ava i lab le fo r ha l l uc ina t i ons . Essentially, t he c l i e n t f inds

a n o t h e r o b j e c t o f focus wi th wh ich to d i s t rac t h i m - o r h e r s e l f f r o m h a l l u c i n a t i n g . H a l l u c i n a t i o n s a re dis- p l a c e d f r o m the f o r e f r o n t o f awareness a n d b e c o m e b a c k g r o u n d noise . Whi l e t he s y m p t o m m a y n o t be

e l i m i n a t e d , its d e b i l i t a t i n g ef fec ts o n b e h a v i o r can be m i n i m i z e d .

Specif ic a t t en t iona l shif t ing s t rategies closely m o d e l

m e t h o d s e m p l o y e d in o t h e r cogni t ive behav io ra l t reat-

m e n t p rograms . T h e y r ange f r o m s imple d ivers ionary ac-

Prescribing therapeutic interventions through Strategic Treatment Selection

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