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There were two matching recommendations for this criterion. The first was that clients with simple problems should be matched to therapy that focuses on symptom relief, and clients with complex problems should be matched to therapy that is broader and focuses more on depth. The second recommendation was that the more complex clients' problems, the less social support they have, and the worse their early relationships were, the more they should be referred toward therapy that is less action oriented, is less time-based on a small fixed number of sessions, and has the possibility of increased depth over time.
I do not yet have an elegant method for assessing problem complexity. For the first version of TMatch, I approximated problem complexity by the total number of problems clients had, as assessed by all the parts of TMatch. For example, for one area of matching, TMatch assessed whether clients had alcohol or drug problems. If they had both of these problems, that had increased the number of problems, and thus (it was assumed) the problem complexity.
Clients' amount of social support was assessed with four questions specifically created for TMatch for this assessment:
The quality of clients' early relationships was assessed with one question created specifically to assess this quality: How good were your early (childhood) relationships with your family?
The assessment of therapists' emphasis on symptom relief versus their emphasis on depth was made through how therapists answered a questionnaire that asked them to order and rate 7 different possible ways of helping clients (the Help-Ways questionnaire), and through two additional questions:
Therapist action orientation, or amount of emphasis on action, was assessed through one question, and on how therapists answered two questions from the Help-Ways questionnaire, which asked them to order and rate 7 different possible ways of helping clients.
It was assumed that assessing therapists for therapy that was less time based on a small fixed number of sessions, and that had the possibility of increased depth over time was essentially the same as assessing for longer term therapy, since therapy that lasted longer would automatically have the possibility of increased depth over time. The assessment for long-term emphasis of therapy was made with a combination of two questions relating to therapy complexity, one question directly related to therapy depth, and a section of direct questions asking therapist about their preference for length of therapy. The questions about complexity were added because it was assumed that complex therapy would require more time. This Long-Term Emphasis questionnaire was used for several different purposes in TMatch.
The method used was an extremely indirect and inexact measure of problem complexity, as it only counted a few specific problems, and left out any direct questions on this subject. To get a true rating of problem complexity, it would be necessary to assess problem complexity directly, by determining how many problems clients actually had, and also possibly the complexity of each individual problem.
Based on the four questions used for this assessment, there was a strong tendency for clients and pilot testers to have a large amount of social support: some family members and friends who care a lot about them and would do a lot to help them. Either the questions had very low validity, or the people in the study did have a lot of social support. Perhaps the large amount of social support for these participant clients was because they were from a relatively affluent geographic area.
Assessment of clients' early relationships were with one direct question, which was answered by most clients in the direction of these relationships being not very good. This is probably reasonable for clients seeking therapy.
The assessments of therapist action orientation seemed to work quite well. Therapists were usefully differentiated on this assessment, and the assessments matched their self-described styles of therapies (e.g., cognitive-behavioral therapists rated very high on action orientation).
This assessment seemed to work quite well. For this first version of TMatch, this rating had a possible range of -18 (shorter term emphasis) to +18 (longer term emphasis). For all therapists, the mean was 3.32 with sd = 7.10. Thus almost all answers were between -4 and +10. This seems to accurately reflect the position of the therapists who took the questionnaire, who tended to be psychodynamic or use other systems interested in more depth therapy (e.g., existential therapists).
Although this was only a first preliminary version of TMatch, this particular assessment did seem to be valid, with psychodynamic therapists being rated toward the insight (depth) direction, and cognitive therapists being rated toward the symptoms direction. It is unlikely that this same assessment will be used in the future, but at least this first version of TMatch has shown that therapists can be usefully differentiated on this dimension.
The recommendation that clients with simple problems should be matched to therapy that focuses on symptom relief, and clients with complex problems should be matched to therapy that is broader and focuses more on depth, was not successful. In fact, there were indications that often the opposite matching recommendations would apply. For example, sometimes clients who have simple problems that aren't severe might be going to therapy for exploration and depth, and therefore should not have therapy that is focused on symptom relief. In addition, it seems intuitively that the more complex a client's problems, the more distress and impairment the client would have. The more distress and impairment clients have, the more it seems they would need some immediate symptom relief, which again is the opposite of the matching recommendation. Finally, the study indicated that there was a tendency for clients with simple problems to like more exploratory therapy, and for clients with the relatively more complex problems to want more focus on their symptoms.
The matching criterion that the more complex clients' problems, the less social support they have, and the worse their early relationships were, the more they should be referred toward therapy that is less action oriented, was also not supported by the study. As with the recommendation described above, there was a tendency for clients with complex problems to have high distress and impairment, and to need immediate action to alleviate these symptoms. In addition, there was a tendency for clients with simple problems to have less distress and impairment, and to be more interested in exploratory therapy as opposed to immediate action. This would leave the recommendation that clients with low social support and bad early relationships be matched to less action oriented therapy. Although there was no direct evidence for or against this recommendation in this study, this recommendation doesn't make sense from the standpoint that clients with low social support and bad early relationships would tend to have more distress and impairment, and thus would seem to need more immediate action to alleviate their symptoms, not more exploratory therapy.
The remaining recommendation is that clients with more complex problems, less social support, and worse early relationships, might need longer therapy. This seems intuitively obvious, although there was no way to test it in this study. Clients with these qualities would probably be the clients with the most distress and impairment. It does seem obvious that the more complex clients' problems are, the more therapy they might need. Therefore, the conclusion is that this one aspect of the matching should be tested in a future study. That is, clients should be assessed for problem complexity, and the more complex their problems, the more they should be matched with therapists who tended to have longer term therapy. However, to use this criterion, a better way to assess client problem complexity is required. One possibility for making this assessment is to ask clients to select from a list of problems.
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.
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Beutler, L. E., Brookman, L., Harwood, T. M., Alimohamed, S., & Malik, M. (2001). Functional impairment and coping style. Psychotherapy, 38(4), 437-442.
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.