Treatment selection: What do we know? - summary of an article by Vervaeke & Emmelkamp in the European Journal of psychological assessment

European Journal of psychological assessment 14, 50-59
Vervaeke, G. A., & Emmelkamp, P. M. (1998)
Treatment selection: What do we know?

Treatment selection is seldom the topic of study and guidelines for the practitioner concerning treatment selection have rarely been formulated.

Treatment selection as an enhancement of the first phase of psychotherapy

When is psychotherapy indicated?

Psychotherapy leads to statistically significant and clinically meaningful effects in a variety of patients compared to untreated patients.
There are little research data to help the practitioner decide which patient should not be treated.

• Authors suggest that psychotherapy may not be necessary for individuals with a history of good adjustment and who are currently under stress because of common difficulties in life
• There is some consensus among therapist that patients who refuse to become involved in the basic process of psychotherapy are poor candidates for psychotherapy
• Patients for whom specific problem-effective psychotherapy has not yet been developed may not benefit from psychotherapy

Deterioration in psychotherapy was particularly frequently found in borderline patients and schizophrenics.
The problem with studies in this area is that it is not clear whether the negative effects are due to the specific type of patients or to the specific type of psychotherapy.

Factors related to discontinuation of treatment

• Most clients remain in therapy for relatively few sessions
  The number of sessions expected by the patients before the start of psychotherapy is the best predictor of the subsequent actual number of sessions
• Client motivation, desire for therapy, and expectations of change may have more to do with prompting the patient to become initially involved in therapy than directly influencing the therapeutic process or its outcome
• The use of psychological test variables to predict continuation in psychotherapy has not been very successful
• No clear relationship between length of time in therapy, age, sex, and psychiatric diagnosis and psychotherapy continuation is found
  There is some evidence for and inverse relationship between social class and educational level, and length of time in therapy
• Mutuality of patient and therapist perspective may be related to staying in therapy
  • A direct enquiry into the importance of client and therapist preferences concerning psychotherapy-relevant variables at the start of psychological treatment
  • Congruency concerning locus of blame enhances continuation
  • A cognitive match between client and therapist enhances self-exploration and openness to learn and results in less premature termination

Therapeutic alliance

A number of patient characteristics have been identified that can be assessed before the start of therapy, and that affect establishment of a good working alliance later on.

• The quality of interpersonal relationships of the patient evaluated by the therapist
• The absence of extreme interpersonal behaviours
• Friendly-submissive interpersonal problems
• The patient’s verbal skills
• Capacity to express appropriate affect
• Ability to respond to interpretations
• Patient motivation
• Attachment bonds with parents

These factors all contribute positively toward building a good working alliance.

Factors that are likely to develop a bad working alliance

• Extreme hostility
• Many somatic complains
• Difficulty in maintaining social relationships or having poor family relationships prior to commitment of therapy

The severity of a patient’s symptoms appear to have little impact on the ability to develop a good alliance.

Compatibility between patient and therapist concerning interpersonal hostile behaviour were found to be crucial to the development of a positive working alliance.

Treatment selection variables inferred from outcome research

Sociodemographic variables

As to the variables social class, age and gender only a few specific relationships with outcome of therapy have been reported.

Degree of disturbance and related variables

Individuals with more serious levels of disturbance have poorer outcomes.
Psychological health-sickness was moderately related to outcome of therapy.
The sicker the patient the harder it will be to make therapeutic gains.

Match of patient and therapist

• Gender similarity may enhance therapeutic change among female clients, especially among rape victims
• Efforts to match therapist and clients on global personality dimensions or to predict therapeutic effects from global therapist personality measures appear to be fruitless
• A match between patient and therapist along the patient dimension of autonomy and the therapist dimension of directivity is related to final outcome.
  Submissive patients treated by non-directive therapist profit less from therapy than when treated by directive therapist.
  Interpersonal compatible styles between therapist and client may be indicative of whether or not psychotherapy will proceed in a positive direction
• Psychotherapy success has been found to be enhanced when clients and therapists are
  • Similar in the relative value placed upon such qualities as wisdom, honesty, intellectual pursuits and knowledge
  • Different in the value placed on personal safety, interpersonal goals of treatment, social recognition and friendships.
  • The therapist’s ability to communicate within the patient’s value framework, or the mutual acceptability seems to be more important than the particular values held be both therapist and patient

Patient characteristics and type of therapy

When differences between traditional scholarly methods are found, they often favour cognitive or behavioural approaches across a variety of patient diagnostic categories.

When problems are less discrete and more diffuse, there is no evidence that cognitive-behaviour therapy is more effective than other approaches.

• Analytically and experiential oriented therapist exert their strongest effects on patients with internalizing coping styles
  Less effective in working with patients whose coping styles are characterized by acting out patterns.
• Behaviourally oriented therapists obtained the most positive effects on patients who were identified as relying on externalizing coping styles.

A client’s general openness and interest in inner experience may be a useful predictor of success in experimental psychotherapy.

Patient diagnoses and type of therapy

Depression

• Mild to moderate non-psychotic levels of depression can be treated effectively with brief individual behavioural, cognitive and interpersonal therapies and imipramine plus clinical management.
• More severely depressed patients were more effectively treated by use of imipramine and clinical management

Cognitive therapy is the most effective.

Better social functioning predicted a superior response to interpersonal therapy.
Low cognitive dysfunction superior response to cognitive-behavioural therapy and to imipramine.

Perfectionism is negative for treatment outcome.

Individualized treatment that matched the problems of the patient is not more effective than a mismatched treatment.

Anxiety disorders

There is no clear-cut relationship between personality disorders and outcome of therapy.

Guidelines for treatment selection

The choice of methods that can detect relevant pretherapy characteristics within the domain of interpersonal skills and intapersonal dynamics recommended.
A match between patient and therapist on the following dimensions should be considered to enhance treatment effectiveness.
Matching on interpersonal compatible styles between therapist and client may also enhance outcome.
Matching on cognitive style and locus of blame seems to enhance continuation.
Gender similarity of patient and therapist may enhance therapeutic change among female clients especially among rape victims.

Suggestions with respect to the attitude during treatment selection

• The attitude has to be directed at facilitating the therapeutic alliance with includes explicit attention to possible difficulties in the therapeutic interaction during the first encounter
  • A thematically focus on the here-and-now
  • A challenging and rather distant, then intimate, attitude
  • A negotiation based intervention strategy based on expectations and preferences of both
• The attitude has to include an openness for discussion with the patient concerning potential problems to engage in a relationship with the therapist