Tailoring Interventions to Clients:
Effects on Engagement and
Retention
Larry E. Beutler, Heidi Zetzer, and Elizabeth Yost
Drug abuse represents a major social and behavioral health problem.
National Institute of Drug Abuse (NIDA) statistics suggest that 37 percent
of the U.S. population has used illicit drugs (Smith 1992) and as many as
23 percent of the work force regularly do so in the workplace (Barabander
1993). Drug use in the workplace is not limited to benign, recreational
drugs. The NIDA estimates indicate that 3 percent of the work force
abuse heroin (Browne 1986) and over twice that figure abuse cocaine
(Abelson and Miller 1985). Chemical abuse affects family functioning,
work performance, and the health of newborn children (Levy and Rutter
1992). Of contemporary concern, opiate and cocaine abuse probably
represent the most significant problem because of their severe addictive
properties, the high likelihood of polydrug abuse among their users, and
the decline of social functioning that accompanies their abuse (Almog et
al. 1993). Three tasks face those who attempt to develop treatment
programs for drug abuse disorders: (1) developing procedures that
facilitate patient engagement in treatment, (2) developing procedures
that increase the likelihood of retention of individuals in treatment, and
(3) establishing the conditions under which even effective treatments
work best and least well. While this chapter will focus on the status of
research on the first two of these tasks, the last one cannot be ignored in
this process. This is true both because of the necessity of continually
testing the relationship between treatment engagement and dropout on
one hand and treatment efficacy on the other, and because there are
promising developments in the area of treatment efficacy that may
improve awareness of the significance of engagement and retention.
There is considerable contemporary interest in tailoring aspects of the
intervention to fit individual patient needs. Individualized treatments
offer the hope that sensitivity and specificity of interventions will
increase treatment retention and engagement rates as well as improve the
likelihood of clinical efficacy. Unfortunately, literature is sparse on the
application of tailored interventions to chemical abuse problems. Thus,
efforts to tailor handling of patients who suffer from these problems must
borrow and extract from research on other problems.
Two basic methods of matching treatments and patients have shown
enough promise in psychotherapy research to suggest that they may be
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transportable to research on chemical abuse treatment. The first of these
methods focuses on matching personal qualities (e.g., personalities,
backgrounds, beliefs, and other characteristics) of patients and therapists
to increase the likelihood that they will develop a working relationship
that will enhance therapeutic progress. The second seeks to match
specific treatment procedures or strategies to particular characteristics
and needs of patients. A brief review of the status of these matching
procedures may help in the assessment of their applicability to substance
abuse treatment research.
PATIENT-THERAPIST MATCHING AND THERAPEUTIC OUTCOMES
One way to tailor interventions to clients of different types is to match
them to therapists who represent the most appropriate fit. Such patienttherapist matching has a long tradition in psychotherapy, covering the
gamut of matching variables from sociodemographic characteristics to
value and belief systems. Indices of treatment engagement have included
patient preferences and satisfaction levels. One line of research, for
example, has suggested that some ethnic minority clients prefer to work
with counselors who are of the same race, but this finding tends to vary
according to the client’s ethnicity and his or her level of ethnic identity
development and acculturation (Parham and Helms 1981; Sanchez and
Atkinson 1983). Summaries of this research usually conclude that while
African-American clients prefer African-American therapists over white
therapists (Atkinson 1983; Harrison 1975; Sattler 1977), a preference for
an ethnically similar therapist is not as evident among other ethnic
minority groups (Atkinson 1983). Atkinson (1983) observed that
inattention to within-group differences and constricted ranges of
acculturation might have prevented the emergence of preferences as a
distinguishing effect of ethnic matching among nonblack minority groups.
Sanchez and Atkinson (1983) remedied some of these problems by
including level of acculturation as an independent variable in their
investigation of racial similarity and therapist preference. They found
that Mexican-American college students with strong commitments to the
Chicano culture preferred racially similar counselors, while those who did
not have strong cultural identities did not. Interestingly, however,
Vietnamese refugees (presumably not acculturated) showed no preference
for a racially similar counselor (Atkinson et al. 1984). Somewhat
stronger evidence has accumulated to suggest that patient-therapist ethnic
similarity is associated with lower dropout rates during therapy (Krebs
1971; Terrell and Terrell 1984; Yamamoto et al. 1967).
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Finally, therapist-patient socioeconomic status (SES) similarity has been
related to more positive perceptions of the therapist, but the relationship
between SES and either therapy process or outcome has not been investigated adequately.
Despite evidence that therapeutic engagement (e.g., therapist preference
and treatment retention) is enhanced by the assignment of a racially
similar therapist to minority patients, the extent to which this similarity
or dissimilarity affects engagement in the therapy process is far from
clear (Atkinson and Schein 1986). About half the studies examined by
Atkinson and Schein (1986) support the hypothesis that patient-therapist
ethnic similarity can enhance certain qualities of the therapy process,
including the working relationship, and at times even lead to improved
therapy outcomes. The other half of the research studies in those
authors’ review found no relationship among these factors.
It may be, however, that ethnic similarity is not the important variable in
studying the cultural fit of patients and therapists. Perhaps a broader
dimension of shared cultural values would provide a better test of the role
of ethnicity and background in psychotherapy change among certain
disenfranchised groups. In the most systematic effort to address this
latter issue, Smith and colleagues (1980) assigned an index of cultural
similarity to each of the 475 studies in their meta-analysis of
psychotherapy outcome, based upon the degree to which client and
therapist samples shared a common educational, economic, and upwardly
mobile history. An effect size of only 0.10 was obtained using this
variable, suggesting that little variance in outcomes could be attributed to
similarity of culturally derived attitudes.
There is also little evidence in contemporary literature to indicate that
gender similarity, age similarity, or physical ability similarity have an
effect on psychotherapeutic engagement, relationship enhancement, or
treatment outcome (Atkinson and Schein 1986), though patients,
regardless of their status on these dimensions, tend to prefer female
(Stricker and Shafran 1983), middle-aged (Simon 1977), and physically
disabled therapists (Brabham and Thoreson 1973; Mitchell and
Frederickson 1975).
Collectively, these findings suggest both that different ethnic groups
respond differently to demographically similar therapists and that sharing
certain attitudes, rather than simply demographic background, may be
more important in facilitating patient engagement and commitment.
This con-clusion may be seen as supportive to the position, often taken
in chemical abuse treatment programs, that therapists who share the
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patient’s history of substance abuse may be better able to provide help
than therapists who do not have a history of chemical abuse. The results
of research on this topic have shown some support for this view, at least
for enhancing the therapeutic alliance (Argeriou and Manohar 1978;
Lawson 1982). For example, Lawson (1982) found that counselors who
were in alcohol recovery were judged by their alcoholic patients to show
higher regard and greater unconditionality than counselors without
alcohol problems. Results regarding attrition and outcome in these
treatment programs are not available. Nonetheless, this work raises the
importance of considering patient and therapist fit along dimensions of
personality and attitude.
Viewing literature on broad personality dimensions reveals evidence of
some relationship between the degree of patient-therapist similarity and
the strength of the therapeutic relationship (Atkinson and Schein 1986).
Though not replicated extensively in contemporary research, similar
personality styles, as measured by the Myers-Briggs Type Indicator, have
been associated with improved treatment retention rates (Mendelsohn and
Geller 1963, 1965). However, treatment duration does not necessarily
indicate treatment benefit. For example, Swenson (1967) found that
dissimilarities on the specific dimensions of dominance and submission
were directly related to treatment gains. Likewise, several reviews
conclude that dissimilar, rather than similar, personality traits are
associated with better outcomes and greater patient satisfaction levels
(Atkinson and Schein 1986; Beutler 1981).
Therapist conceptual level is another personality trait that has been the
focus of both theoretical and empirical work over several years. Unlike
findings related to dominant and submissive traits, however, this research
generally supports the value of patient-therapist similarity. Similarity in
conceptual level has been particularly related to retention in treatment
(Holloway and Wampold 1986; Lamb 1977; McLachlan 1972; Stein and
Stone 1978). For example, Hunt and colleagues (1985) explored the
effects of cognitive style match among consecutive admissions to the
University of Washington Psychiatric Outpatient Clinic. They found
that 60 percent of the premature terminations occurred in mismatched or
dissimilar dyads while only 24 percent occurred in dyads with similar
cognitive styles. Among clients who continued therapy, similar dyads
were associated with more symptomatic changes at the end of 12 weeks
of treatment than dissimilar dyads, an effect that disappeared quickly
when mismatched groups caught up to the similar group. These findings
suggest that similarity of cognitive style facilitates retention in therapy
and may even speed improvement in the early sessions of therapy.
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As the contradictory findings from these studies on conceptual level and
dominance-submissiveness would suggest, it is difficult to generalize from
any one variable within the domains of personality and belief systems to
others, even within similar domains. No single conclusion is warranted
that applies to a broad range of beliefs or personality characteristics
regarding whether similarity or difference is more facilitative of
retention, engagement, or outcome in psychotherapy. However, a
relatively consistent theme does emerge to suggest that increasing
patient-therapist similarity on a wide variety of these variables over the
course of therapy is associated both with indicators of engagement and
improvement. For example, Foon (1985, 1986) reported that among a
diagnostically heterogeneous group of 78 adult outpatients and their 21
therapists, end-of-therapy similarity of locus of perceived control, but
not pretreatment similarity, was positively associated with improvement,
indicating that convergence of client-therapist perceptions is a factor in
achieving benefit. Patient-therapist convergence has been a particularly
consistent observation in research on patient belief and value systems, a
conclusion that partially reflects and has been supported by a relatively
large series of studies from the authors’ laboratory (Beutler et al. 1991a).
Six critical qualitative reviews of this research have all concluded that
clients tend to adopt the personal values of their therapists during the
course of successful psychotherapy, independently of the type of problem
presented (Atkinson and Schein 1986; Beutler 1981; Beutler and Bergan
1991; Beutler et al. 1991b; Kelly 1990; Tjelveit 1986). According to
these reviewers, patients who become converted to the therapist’s beliefs
or values have good outcomes. A review of the six most
methodologically sound studies on this topic (Kelly 1990) suggests that
value conversion may be related most closely to therapist ratings of
improvement, but the effect, nevertheless, does extend to the outcomes
assigned by external raters and the patients themselves.
A second generalizable, but somewhat weaker, conclusion also emerges
from this literature. Three of the six reviews (Beutler 1981; Kelly 1990;
Tjelveit 1986) inspected the relationship between initial therapist-client
similarity and subsequent improvement, noting that initial dissimilarity of
client and therapist values was associated with the subsequent adoption of
the therapists’ values and beliefs.
None of the six qualitative reviews reached a clear determination as to
whether initial global value similarity or dissimilarity is more conducive to
client improvement. Likewise, Foon (1985, 1986) found that initial
patient-therapist similarity on the dimension of perceived locus of
control was not predictive of treatment outcome. It appears that while
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global value and personality convergence are associated with positive
outcomes, and while initial dissimilarity on these global dimensions is
associated with convergence, neither global value/belief similarity nor
dissimilarity are consistent predictors of treatment response (Beutler
1981; Tjelveit 1986).
Some effort has been devoted to looking at and comparing specific value
and personality characteristics within the patient-therapist dyad that will
identify a pattern of initial similarities and dissimilarities that will relate
to positive treatment outcomes. Such a pattern, if identified, could serve
as a template for assigning patients to therapists with whom they would
work well. Some relatively weak but promising conclusions seem to be
emerging from this literature. The findings indicate that psychotherapy
improvement may be enhanced by a complex pattern of similarity and
dissimilarity between client and therapist belief and value systems (e.g.,
Beutler et al. 1974; Cheloha 1986). In the authors’ laboratory, a series of
studies has suggested that treatment success is enhanced when clients and
therapists are similar in the relative value placed upon such qualities as
wisdom, honesty, intellectual pursuits, and knowledge (e.g., Arizmendi et
al. 1985; Beutler et al. 1974). At the same time, client-therapist
discrepancies in the value placed on personal safety (Beutler et al. 1978),
interpersonal values, social status and friendships (Arizmendi et al. 1985;
Beutler et al. 1974, 1983) have been found to facilitate improvement. At
least some of these findings have been supported by independent research
programs (Charone 1981; Cheloa 1986).
In sum, while demographic similarity and conceptual level appear to be
related to dropout, value conversion and a complex pattern of individual
belief and value similarities and dissimilarities appear to be related to
improvement. To date, however, none of these lines of research has
inspected retention and improvement rates within drug-abusing populations. Typically, patient samples have been diverse outpatient groups
with very heterogeneous problem types. The research to date is
promising, especially in its implications to retention rates. It provides a
fertile field in which treatment retention rates among chemical abuse
patients might be explored. Clearly, more research on the types of
similarity dimensions that are positively, nonsignificantly, and negatively
associated with different types of retention and improvement will be
necessary to apply these promising relationships to problems of chemical
abuse.
MATCHING PROCEDURES TO PATIENT NEEDS
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Efforts to define various psychotherapy methods that are effective either
for those with a common diagnosis, such as drug abuse, or with a specific
symptom, such as depression, have largely concluded that all psychotherapy approaches produce similar mean effects (e.g., Beutler et al.
1986; Lambert et al. 1986; Smith et al. 1980). The studies that support
these conclusions are largely based on a randomized clinical trials
methodology that has been borrowed from psychopharmacological
research. The methodology of this research paradigm is to study a single,
diagnostically homogeneous sample of patients and to compare the
efficacies of one or more packaged, reliably applied, and brand-named
treatments. In this paradigm, nondiagnostic patient characteristics are
usually studied as a secondary, post hoc variable when, as is usually the
case, no significant differences are observed between two packaged
treatments.
Depression and its various subtypes have been the target of most studies
of psychotherapy. Fortunately, there are reasons to believe that there
are links between depression and substance abuse that will allow this body
of research to transfer to chemical-abusing populations. For example,
depres- sion is a frequent coexisting condition both in drug abuse and
during drug withdrawal (Weiss et al. 1992). Whether cause or
consequence, the coexistence of drug abuse and depressive symptoms
suggests that psycho- behavioral interventions that are effective in
treating depression also may be effective treatments for chemical abuse.
Because of the demands of randomized clinical trials research, a number of
well-established treatments of depression also have evolved, many of
which are potentially transportable to the area of chemical abuse. For
example, mounting evidence suggests that even in the case of endogenous
depression, the condition most often thought to be weighted toward the
role of biological precipitators, manualized forms of cognitive therapy are
effective in both relieving depression and preventing its recurrence
(Corbishley et al. 1990; Jarrett et al. 1990; Simons and Thase 1992).
Moreover, cognitive therapy, though initially formulated and manualized
as a treatment for depression (Beck et al. 1979), in recent years has
successfully been adapted as a treatment both for drug abuse (Wright et al.
1993) and alcoholism (Wakefield et al., in press).
Similarly, treatment manuals based upon relationship-oriented therapies
(both psychodynamic and interpersonal models) have been successfully
extrapolated from research on the treatment of depression and anxiety
disorders for application in the treatment of opiate abuse (McLellan et al.
1983; Rounsaville et al. 1987). The use of manuals within the context of
the usual clinical trials research model is well adapted to revealing which
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systematic therapies are effective in treating specific diagnostic groups,
but is of limited value for assessing questions of matching treatments to
patients. Nonetheless, the translations of established manuals to
chemical- abusing populations have provided a foundation for
explorations of the conditions under which different psychotherapies and
psychotherapy procedures are maximally effective.
The effort to fit treatments—variously called "eclectic," "integrative,"
and "prescriptive" psychotherapies—to patients has evolved largely in
the last decade. Two approaches to matching patients to treatments have
been employed in these prescriptive models. One has been to develop
different manualized therapies for patients with different diagnostic
conditions. In this approach, an effort is made to construct a theoryconsistent therapy that can be applied in a somewhat different form to
several different and diagnostically distinct patient groups. The
foundation studies for this method usually concentrate on demonstrating
the clinical efficacy of each within the patient samples for which it was
designed rather than on comparing the efficacy of the different manuals.
A second approach to matching patients to treatments has been to define
characteristics of treatment procedure and strategy that distinguish
different theoretical approaches to psychotherapy, and then to identify
the patient characteristics on which these procedures are differentially
effective. The foundation studies for this approach to prescriptive
matching have been those in which two or more manualized therapies are
applied to two or more patient groups. Rather than being selected solely
on diagnostic grounds, the patient groups for this approach usually are
stratified on the basis of a variable that is thought on empirical or
theoretical grounds to be differentially responsive to the therapies studied.
Differentiating aspects of each treatment are related to differential
efficacy on the diverse samples of patients, yielding conclusions about
those treatment characteristics that best fit the patient characteristics. In
these studies, the patient characteristics of interest are often extradiagnostic in nature.
While the first approach works within a single theoretical system to
develop variations that fit different diagnostic groups, a major aim of the
latter approach is to develop guidelines for mixing and combining
procedures from across theoretical models to maximally tailor
interventions to specific patient characteristics that are not captured well
in diagnosis. Both types of studies provide leads to indicate the patient
and treatment dimensions that will make the most effective matches.
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STATUS OF INTEGRATIVE TREATMENTS
To compare the relative value of the two prescriptive treatment methodologies described above, Beutler and Crago (1987) compared studies that
used a variety of methodologies to calculate the percentages of explained,
within-subject variance accounted for by each approach— different
treatment models applied to patients with different diagnoses versus
contrasting treatment models applied to nondiagnostic patient variables.
The value of the two approaches was assessed against a base rate
expectation of 10 percent, the amount of variance attributable to
different treatment types when patient variables are not considered. The
base rate figure of 10 percent was derived from a variety of research
reviews of comparisons of different psychotherapy models (Lambert
1989; Lambert and DeJulio 1978; Smith et al. 1980).
The comparisons indicated that the interaction effects attributable to
combinations of psychotherapy types by patient diagnoses increased the
amount of outcome variance accounted for from 10 to 15 percent, a very
modest increase over the base rate of 10 percent. This finding confirmed
the suggestion (Howard 1989) that even in manualized treatments of
diagnostically homogeneous patient groups, the variability of outcomes
among treatments is very broad. In any defined and uniformly applied
treatment, there appears to be a relatively large number of patients who
get better and a smaller but substantial number who do not. Apparently,
diagnostic variables are insufficient to reduce the wide variance in
outcomes that are secured by all treatments.
When Beutler and Crago considered studies that matched patients and
treatments in ways other than through patient diagnosis or brand-named
therapies, they had more success in establishing the presence of
differential effects among treatments. Matching treatments to select
nondiagnostic variables increased the amount of attributable variance to
an average of 30 percent, and some variables accounted for as much as 60
percent of the variance in patient responses.
Some patient variables that have been found to interact most successfully
with treatment procedures are coping styles (Beutler 1979; Beutler and
Mitchell 1981; Sloane et al. 1975), levels of resistance (Beutler et al.
1991c, 1991d; Shoham-Salomon and Hannah 1991), cognitive
organization (McLachlan 1972), and aspects of problem severity and
distress (Imber et al. 1990; Luborsky et al. 1985).
Promising Matching Dimensions
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Drawing from studies representing each of the foregoing approaches, an
inspection of the most promising findings suggests that:
• Experiential therapies often are more effective than cognitive
and dynamic therapies either when used early in treatment or when
applied to those who are insufficiently distressed about their problems
to support emotional growth (Beutler and Mitchell 1981; Greenberg
and Safran 1987; Mohr et al. 1990; Orlinsky and Howard 1986);
• Nondirective and paradoxical interventions are more effective
than therapist-directed ones among patients with high levels of
pretherapy resistance (i.e., resistance potential or reactance) (Beutler
et al. 1991c, 1991d; Forsyth and Forsyth 1982; Shoham-Salomon and
Hannah 1991); and
• Therapies that target cognitive and behavior changes are more
effective among impulsive, externalizing patients than those that
attempt to facilitate insight. The latter effect has often proven to be
reversed among patients with internalizing coping styles (Beutler et
al. 1991c, 1991d; Calvert et al. 1988; Sloane et al. 1975).
All of these relationships have been found to be sufficiently robust to be
revealed in a variety of diagnostic disorders. Thus, they carry
implications for the prescription of psychotherapeutic strategies and
procedures that are extracted and combined across theoretical models (see
Beutler and Consoli 1992; Beutler and Hodgson 1993; Gaw and Beutler
1995). The robust effect of many of these parameters suggests that
combined treatments, based upon these relationships, may be applicable
to chemical abuse dependencies as well as to a variety of mental health
disorders.
On a more negative note, even the best among the available research
studies on this topic have oversimplified the complexity of matching
patients and treatments. With few exceptions, the long-term effects of
these variables on relapse and efficacy have not been investigated.
Neither has research, to date, investigated the interdependence and joint
effects of two or more patient and treatment dimensions operating at
once. The best studies include only one or two manualized variations of
therapy procedure as applied to a group of patients who are selected to
vary along a single dimension. No study to date has had the resources to
address the implications of assigning a treatment package composed of
several interventions to patients who vary on several indicators/
contraindicators at once.
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The importance of considering multiple patient and treatment parameters
at once cannot be overstated. Even manualized treatments, if they are
not sensitive to the complexities of individual proclivities and the
treatments with which they fit (and this includes most contemporary
manuals), may unintentionally include treatment components for a given
patient that are offsetting when applied to a patient who embodies a
constellation of characteristics that do not fit. For example, the positive
effects of cognitive therapy applied to an externalizing patient may be
offset by the limited effective-ness of this same therapy with patients
who have high levels of resistance to therapist leadership or control.
Thus, comparisons of two or more treatments may fail to reveal
important differences within diagnostically homogeneous groups because
these groups include patients who have counterbalancing but unassessed
differences in indicating characteristics.
Extracting from research on the patient-treatment dimensions previously
identified, it is conceivable that treatment outcomes could be maximized
among substance abusers by fitting specific procedures from several
different treatment models to the unique combination of extradiagnostic
characteristics that is presented by the individual patients (e.g., combining
the symptom focus of cognitive therapy with the arousal-induction
procedures of relationship-oriented therapies for use with an
externalizing, nondistressed patient). This is an area where research is
needed.
Selecting the most promising combinations of procedures from among
those valued by the several hundred available theories (Corsini 1981)
requires that several patient and treatment dimensions be varied at once.
The complexity of patient and treatment variables (e.g., Lazarus 1981;
Orlinsky and Howard 1986; Parloff et al. 1978) makes it unlikely that
studies in which one brand of psychotherapy is pitted against another,
without regard for the patient characteristics that fit and fail to fit with
these treatments, will yield much information about treatment efficacy.
ILLUSTRATIVE RESEARCH
For descriptive purposes, findings that have been obtained and the
implications of some patient-therapy matching components will be
illustrated. For example, in a prospective test of the independent effects
of two matching dimensions among depressed outpatients, Beutler and
colleagues (1991c) selected manualized therapies that contrasted in
defined ways to provide greater and lesser fits to patients varying in
coping style and resistance potential.
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Following 20 sessions of treatment, therapies that were directive and
therapist-guided were found to have opposite effects from a therapy that
was designed to be self-directed and nondirective when contrasting patient
groups were studied. Resistance-prone patients did poorly in the directive
therapies but well in the nondirective/self-directed therapy, while patients
who were not prone to high levels of resistance did comparatively better
with the directive therapies than the nondirective one. This finding was
independently crossvalidated on a sample of anxious and depressed
patients at the University of Bern utilizing a variety of alternative
measures of defensive anxiety (Beutler et al. 1991d).
Corollary work (Horvath 1989; Seltzer 1986; Shoham-Salomon et al.
1989; Shoham-Salomon and Rosenthal 1987) has confirmed the
conclusion that trait-like indicators of resistance may be a specific
indicator for the use of nondirective, paradoxical, and self-help
procedures. Shoham-Salomon and colleagues (1989) have demonstrated
that college students who were predicted to be highly resistant by voice
tone measures became worse when they were directly told to change
habits of procrastination. However, paradoxical assignments (i.e.,
"observe but don’t change your habits") resulted in a decrease in
symptoms. Confirmations in different populations (Shoham-Salomon
and Jancourt 1985) suggest that either low directive or paradoxical (don’t
change) instructions are indicated for patients judged to have high
propensities for resistance, while directive assignments are
contraindicated (Forsyth and Forsyth 1982).
Studying a second dimension, Beutler and colleagues (1991c) found that a
therapy that was designed to directly induce a change in symptoms of
depression worked more effectively among patients who had adopted
impulsive and other externalizing coping styles, but it was relatively
ineffective among those who were prone to internalize conflict and to be
excessively self-reflective. In contrast, therapies that were designed to
provoke self-awareness and insight worked best among internalizing
individuals but relatively less well among those who externalized their
conflicts and acted out.
Outcomes. Outcome analyses revealed that two of three outcome
measures were affected differently across treatments as a function of
patient coping style. The symptom-focused procedures of cognitive
therapy exerted their strongest effects among depressed patients who
exhibited externalizing coping styles. Less impulsive, depressed patients
did best with the insight-oriented procedures of a client-centered therapy.
This finding was subsequently independently crossvalidated on a sample of
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depressed and anxious subjects at the University of Bern, utilizing a
variety of alternative measures of externalization (Beutler et al. 1991c).
Relapse. Another finding emerged from these studies that is important
to the development of matching dimensions. Beutler and colleagues
(1993) tabulated followup data from the completed study of depression.
They found that while relapse rates for depressed patients in all
treatments were very low (averaging 12 percent) over a 1-year period,
return of clinically significant depressive symptom levels was a function
of interactional matches between type of treatment and patient
characteristic. Externalizing patients in cognitive therapy had lower
relapse rates than either externalizing patients in the other treatment
conditions or than nonexternalizing patients in cognitive therapy. In
contrast, nonexternalizing patients in two insight-oriented psychotherapies had lower relapse rates than nonexternalizing patients in
cognitive therapy. Likewise, high-resistance patients in directive,
cognitive, and experiential therapies relapsed at a higher rate than
resistant patients in a nondirective therapy. Low-resistance patients in
directive therapies also relapsed at a relatively low rate.
APPLICATIONS TO SUBSTANCE ABUSE
With the exception of Project MATCH (alcohol abuse), randomized
clinical trials of psychotherapy for either depression or substance abuse
have not mirrored the integrative effort that characterizes clinical
practice. Kazdin (1983, 1986) has suggested that comparative studies of
packaged psychotherapies must be accompanied by dismantling and
combining strategies to refine the potency of interventions. The authors
believe that a variety of psychotherapies have now adequately
demonstrated their clinical efficacy and that more specific combined
strategies are now needed to define the dimensions of differential
treatment selection. However, without prospective, hypothesis-driven
research designs, the accumulation of empirical knowledge is likely to be
slow (Goldfried and Padawer 1982).
There have been several interesting studies of substance abuse that have
used aspects of treatment matching to look at ways of enhancing
treatment efficacy. Most notable among these, from the authors’
perspective, have been those of Kadden and colleagues. Kadden and
colleagues (1990) evaluated the relative effects of interactional
(insight/interpersonal therapy) and skills training (symptomatic/
behavioral) aftercare groups among 96 inpatient alcoholic patients who
were differentiated by their propensities toward sociopathic behaviors (an
externalizing quality). Interactional therapy proved to be most
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efficacious among those with low sociopathic qualities—more
internalizing—while behavioral skills training was most efficacious among
those with high sociopathic qualities. After 2 years, results were obtained
that paralleled the findings of Beutler and colleagues (1991d) on patients
with major depression. Cooney and coworkers (1991) found that longterm relapse rates were also associated with matches of therapy and
patient types. Correctly matched groups produced less relapse and better
long-term gains than did poorly matched patients.
Though consistent with the research on depression, these latter findings
have not received universal support among substance abusers. For
example, Woody and colleagues (1985) found that sociopathy did not
differentiate between those patients in a methadone maintenance
program who responded to cognitive therapy and those who responded to
an insight-oriented therapy. In this study, however, the measure of sociopathy was categorical and diagnosis specific rather than being continuous
and symptomatic. Moreover, it was obtained by clinician ratings rather
than self-report. Thus, it is likely that the elements of coping style
reflected in this measure were different and more diagnosis specific than
measures used in studies of coping style.
Woody and colleagues (1983) did find some results that bear on the effort
to discover indicators and contraindicators for types of intervention.
They investigated the role of problem severity and level of impairment as
a con-tributor to differential outcomes of psychotherapies versus drug
counseling. They found that methadone-maintained, opiate-abusing
patients with severe problems did better in professionally run
psychotherapy programs. In contrast, those with less severe problems of
opiate abuse were able to benefit from less intensive drug counseling.
Alterman and colleagues (1991) have incorporated these findings and
others into a systematic set of suggestions for the differential treatment
of substance abusers.
The authors’ research group (Beutler et al. 1993) is currently
implementing a research program that was designed to demonstrate the
advantages of matching patient characteristics with psychotherapeutic
techniques. The program compares the differential effectiveness of
family systems couples therapy (Rohrbaugh et al. 1995) and cognitivebehavioral couples therapy (Wakefield et al., in press) in treating men or
women with a primary "Diagnostic and Statistical Manual of Mental
Disorders," 3d ed. revised (DSM-III-R) (American Psychiatric Association
1987) diagnosis of alcohol abuse or dependence. The participants are
engaged in 20 sessions of treatment with their partners over a period of 6
months. In addition to evaluating the efficacy of the two treatments in
98
reducing or eliminating alcohol intake, improving the quality of the
couple’s relationship, and alleviating psychological symptomatology, the
authors are also examining the differential effects of treatment for men
with two different drinking styles (episodic versus steady), two different
coping styles (internalizing versus externalizing), and varied levels of
interpersonal reactance. It is hoped that the importance of some of these
variables in both the selection of systems- versus symptom-focused
treatments and the application of other intervention strategies that
distinguish the treatments will be confirmed.
This study reflects the authors’ belief that the field is ripe for developing
methods of combining treatment procedures across theoretical models.
By combining aspects of different treatments into a single treatment
package based upon the patient indicators revealed in these studies, it may
be possible to improve treatment efficacy far over that obtained using
manualized, single-theory models. In support of this conclusion, several
recent theoretical and methodological articles have appeared in the
literature advocating a search for treatment by patient interaction
dimensions. A special series in the April 1991 "Journal of Consulting and
Clinical Psychology" was devoted to aptitude by treatment interaction
(ATI) in psychotherapy and posed some methodological suggestions as
well as advocating for an integrative, conceptual position. Likewise,
several textbooks of eclectic and integrative models of psychotherapy
have been published in recent years and are well received (Norcross 1986,
1987; Norcross and Goldfried 1992; Striker and Gold 1993). This level of
activity indicates that this is both an exciting and fruitful area of
investigation, and one with many potential applications, including
applications to drug and alcohol abuse.
Recommendations
In this chapter, treatment research studies on a variety of patient and
diagnostic conditions have been reviewed in an effort to find some
dimensions that may be extrapolated to the treatment of substance abuse
disorders. The focus of the review has been on efforts to match patients
either to specific therapists or to types of psychosocial treatments to
reduce dropout rates and increase treatment-related gains. It is impressive
that there is a growing body of research demonstrating meaningful, but
largely extradiagnostic, differences in the types of patients for whom
different treatment strategies and methods are effective.
Moreover, the advent of treatment manuals from randomized clinical
trials research, and the demonstration that some treatment strategies and
procedures from these manuals are more effective than others when
99
applied to distinguishable patient groups, have laid the foundation for
combining some of the procedures used in a variety of treatments in order
to tailor therapies to the needs of different chemical abusers.
Collectively, the review of literature suggests several promising directions
for future research.
1. Patient-therapist similarity on various aspects of background and
demographic variables appears to slow the rate and frequency of
premature termination. Some of these variables, most notably gender
and ethnic similarity, may also contribute to reductions in focal
symptoms. In the case of drug abuse, this literature suggests that
retention in treatment and declining use of drugs may be enhanced by
selecting and assigning therapists whose backgrounds are similar to
those of patients. The mechanism of this action is uncertain, but at
least conceptually it is associated with the patient’s ability to identify
with the therapist and to find the therapist to be a credible and
believable individual.
2. Aspects of patient and therapist dissimilarity may also be important,
especially for facilitating symptomatic change. For example, the
patient’s ability to accept and adopt the therapist’s general view of
life appears to be associated with improved functioning, especially as
rated by the therapist. Concomitantly, the presence of contrasting
attitudes and values between therapist and patient seems most
conducive to the emergence of this conversion process.
3. Certain patterns of initial patient-therapist similarity and dissimilarity
of viewpoint and personality also are conducive to facilitating
improvement, irrespective of the process of attitude convergence.
Similarity of cognitive conceptual level, social values, and intellectual
values, combined with dissimilarity of interpersonal needs for
closeness or ascendence, appear to be an optimal pattern.
4. Defining a fit between patient characteristics and therapy procedures
also appears to be possible. Among the best studied patient-therapy
dimensions are the effects of matching patient coping style to the
symptom or insight orientation of the therapy. Impulsive,
charactero-logical patients seem to do best in behavioral and
cognitive therapies, while overcontrolled, internalizing patients do
best with insight-oriented therapies.
5. Similarly, it appears that patients who have strong tendencies to resist
external control through oppositional behaviors do best when treated
100
with nondirective and paradoxical therapies. Conversely, patients
who exhibit more cooperative and less resistant reactions to external
demands are likely to benefit from therapies led and directed by the
therapist.
6. Therapies that combine a number of procedures from several different
models in order to accommodate both the patient’s coping style and
level of interpersonal resistance may be maximally effective. This
cross-theory eclecticism may entail a number of other dimensions, as
well, with the expectation that it may have increasing effects on
symptom reduction. Combining patient-therapist assignment and
patient-therapy treatment selection may create an opportunity to
both decrease dropout rates and to increase treatment efficacy.
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ACKNOWLEDGMENT
Work on this chapter was supported by grant no. AA 08970 from the
National Institute on Alcoholism and Alcohol Abuse awarded to Larry
Beutler (PI), Theodore Jacob, and Varda Shoham (co-PIs).
108
AUTHORS
Larry E. Beutler, Ph.D.
Professor of Education and Psychology
Heidi Zetzer, Ph.D.
Project Coordinator
Elizabeth Yost, Ph.D.
Visiting Associate Professor
Couples Alcoholism Treatment Project
Counseling/Clinical/School Psychology Program
Department of Education
University of California
Santa Barbara, CA 93106
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