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Prescriptive Psychotherapy

General Description

Larry Beutler and his associates have been researching matching patients with therapeutic techniques for over 20 years. In their latest version of their theory, the primary patient characteristics analyzed are resistance, coping style, level of experienced distress, and level of functional impairment. To a lesser extent, they analyze the patient characteristics of problem complexity and social support. They have developed a system of adapting therapy to these patient characteristics, which they now call Prescriptive Psychotherapy. Because Prescriptive Psychotherapy recommendations involve matching patient and therapy characteristics in prescribed ways, these recommendations can also be used to match clients to therapists by matching these patient characteristics to therapists' preferred or usual therapy methods. These patient characteristics are described below.

Resistance is the tendency to resist external demands. In therapy, this would indicate the tendency of a client to refuse to cooperate and change, rather than comply with the therapist. Beutler and associates believe that the less client resistance is activated, the better the outcome for therapy. They suggest that therapy directiveness should be inversely related to client resistance. Based on their reviews of outcome studies of the interaction between client resistance and therapist directiveness, they recommend that the more resistant the client, the less therapist control, structure and directiveness there should be. Beutler and associates particularly recommend paradoxical interventions for clients with high resistance.

Coping style refers to the way in which a client copes with stress and interacts with other people. Beutler and associates have focused on what they believe is the most relevant aspect of coping style, which is the difference between externalization and internalization. Externalizing people blame other people or external objects for their behavior or problems, while internalizing people blame themselves. Beutler et. al believe these are enduring traits in people, in whom one of these coping styles predominate to various degrees. They characterize externalizers as socially active, aggressive, and undercontrolled, with tendencies to overindulge, overreact, avoid confronting problems, and with excessive behavior that leads to interpersonal problems. Internalizers tend to be over-controlled, self-critical, shy, withdrawn, worried, and inhibited. For externalizing patients, treatments are recommended that focus on external behavior or on changing symptoms, independently from any introspection by the patients. For internalizing patients, treatments are recommended that emphasize insight, self-knowledge, self-understanding, awareness, and emotional arousal.

Beutler and associates believe clients' levels of distress and impairment are important for therapy because there are ideal amounts of emotional stress for patients in therapy, based on their levels of distress and impairment at various times. Beutler et. al believe therapists should increase or decrease affective arousal during therapy based on these levels in order to maintain a level of arousal intense enough to motivate the client to change, but not so intense that it defeats the therapy. They suggest that clients with low levels of distress and impairment may in general be best suited for therapy that treats symptoms only, as they may have little motivation for anything deeper. These theories seem to suggest that clients with low levels of distress and impairment should be matched to therapists whose treatments involve high levels of emotional intensity, and vice versa. For example, Beutler and associates suggest experiential methods for unmotivated patients. Finally, they suggest that patients with extremely high levels of distress and impairment be given therapy at first that emphasizes support and anxiety reduction.

Beutler and associates suggest that simple problems, or problems that are situation specific, may be easily solved with therapy that focuses on symptom relief. Complex problems may require therapy that is broader. In addition, they maintain that the more complex clients' problems, and the less social support they have, the higher their levels of distress and impairment will be. This implies that the same suggestions for matching clients with treatments based on levels of distress and impairment described in the section above could also be used to match clients with treatments based on problem complexity and level of social support.

Other researchers have made similar recommendations for problem complexity. For example, Richards (1999) suggests time limitations in therapy are less indicated for clients with complex problems, or clients without much social support. This suggests that therapy for these clients should be less oriented toward immediate symptom relief, and more oriented toward depth. In addition, Addis and Jacobson (1996) found that the more possible reasons clients gave for being depressed, the worse they did in action oriented treatment. This would support the idea that complex problems, or lots of problems, require more therapy depth than directly trying to change behavior.

These suggestions were combined into the recommendation that the more complex clients' problems, and the less social support they have, the more they should be matched with therapy that is less action oriented, and that has the possibility of increased depth over time.

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Addis, M. E., & Jacobson, N. S. (1996). Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. Journal of Consulting and Clinical Psychology, 64, 1417-1424.

Beutler, L. E., Arizmendi, T. G., Crago, M, Shanfield, S., & Hagaman, R. (1983). The effects of value similarity and clients' persuadability on value convergence and psychotherapy improvement. Journal of Social and Clinical Psychology, 1, 231-245.

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., & Clarkin, J. F. (1990). Systematic treatment selection. New York: Brunner/Mazel.

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.

Beutler, L. E., Mohr, D. C., Grawe, K., Engle, D., & MacDonald, R. (1991). Looking for differential treatment effects: Cross-cultural predictors of differential psychotherapy efficacy. Journal of Psychotherapy Integration, 1, 121-141.

Beutler, L. E., Rocco, F., Moleiro, C. M., & Talebi, H. (2001). Resistance. Psychotherapy, 38 (4), 431-436.

Richards, B. M. (1999). Brief dynamic counseling: Making the right choice. Psychodynamic Counseling, 5(3), 285-300.