The Development of the STS
There has always been an implicit belief among mental health practitioners, and especially among psychotherapy researchers, that there is some optimal or “best fit” between a given collection of interventions and the characteristics of a particular patient. The most usual tactic for exploring this illusive “fit” has been based on a model derived from pharmacology and medicine, the randomized clinical trial (RCT). While RCT research designs are good for assessing the effects of pure treatment packages, isolated techniques, and specified groups of interventions, these designs are not adequate for identifying and blending the many extra-therapy and non-diagnostic contributors to outcome that comprise the more part of treatment. A “treatment”, in the area of mental health, must be considered to extend beyond the particular methods applied. It includes these, and also important qualities of the person who applies these techniques, the receptivity and preferences of the person who is subjected to these procedures, and the quality of the interactions that comprise the medium through which the procedures are applied.
The STS system comes from a different perspective than that from which efficacy studies derive. Instead of simply constructing and testing another rationally-based treatment to add to the 400+ already in existence, Beutler and colleagues, over the years, have inspected patients, clinicians, and treatments at more micro levels than that subsumed either by the theoretical model used or by the diagnosis of the patient on which it is applied. Instead, we have been drawn to inspect research through a lens than identifies dimensions of patient, therapist, treatment, and relationships, that optimally fit together and that induce positive effects, regardless of the model of treatment from which these qualities were conceived. Thus, a growing number of scholars have joined the effort to match specific therapeutic technologies with equally specific non-diagnostic patient dimensions.
Rather than representing a new therapy model, Systematic Treatment Selection was conceived and has remained a method of circumventing the narrow theoretical models and proscriptive lists of procedures and techniques that traditionally have characterized rationally-derived approaches that comprise the fields of psychotherapy and the clinical experiments that have comprised much of psychotherapy research. In contrast to these rational, theory-based approaches, the empirical approach of the STS has ensured that it is an open system in which all research-grounded dimensions of patients, therapists, processes, and treatments could be incorporated as available research was able to articulate the principles that underlay their application. As a result, the principles that comprise the application engine of the STS can be modified and extended almost limitlessly, with the major consideration being only that the characteristics and matching dimensions employed: (1) are well founded in sound research methodology, (2) can be reliably measured, (3) can be articulated as either common or specific principles, and (4) successfully predict a patient=s or a group of like-patients= course of treatment, prognosis, and outcome.
As the STS system identifies the classes or types of procedures and principles that should guide treatment, the Prescriptive Therapy that derives from this planning is varied in order to both fit the proclivities of the clinician and to conform to the particular needs of each patient. STS, as a planning system, directs the clinician to think about and measure a given patient=s status on a dynamic blend of dimensions that are all research-informed and grounded. Prescriptive Therapy, as an application of these research-informed principles, can focus on different types of problems and different settings, challenging the clinician to develop ways of reliably tailoring the application of the research-informed principles of STS for the unique needs of particular patients (e.g., Beutler & Harwood, 2000; Housley & Beutler, in press; Norcross & Beutler, in press).
Cross Cultural Applications of the STS Dimensions
Since its inception, there has been great interest in testing the concepts and principles that have been derived on a North American, English speaking culture to other cultures. Initial comparisons of North American and European samples were very encouraging. In this study, a sample of anxious and depressed patients from the Bern (Switzerland) Psychotherapy Research program was studied utilizing a randomized clinical trial design. Coping style significantly predicted the differential value of symptom focused (behavior therapy) and insight focused (client-centered therapy) interventions. Likewise, resistant sensitivity was differentially predictive of the value of these directive and non-directive procedures.
Likewise applications to Spanish speaking samples in Europe and South America have suggested the cohesiveness of the measurement procedures, and recent tests of predictive validity have been very promising.
Two recent studies have produced particularly interesting findings with respect to Asian populations. In a study of how patient coping style, one of the central STS dimensions, may be used as a differential treatment indicator raised the question raised the question of a “cultural coping style” that may predispose those in different countries to be optimally affected by different patterns and mixes of treatment. A simultaneous study of normal Asian-Americans confirmed a strong tendency for these groups to prefer therapies that had certain qualities of discourse and focus. These studies have now led to a widespread study that is designed to validate the STS and test it among patients in four Asian cultures—Korea, Japan, Shanghai, and Taiwan. The data gathering procedure is being coordinated to allow comparisons among cultures as well as to develop tailored assessment procedures for each specific cultural group as predictors become identified. The overall plan of the study is proceeding in four phases:
Phase #1—Alpha test of the inner life items with 150-200 people representing students, normal citizens, throughout the region. In this Phase, we will try to get some degree of representativeness, but we will not specifically seek to either include or exclude people who are in some mental health treatment. Also in this phase, we will try to get information about any medical, medication, or psychological counseling that they are getting or have gotten in the past, including a rating of whether it was helpful. After Phase #1 data are gathered, PGSP will analyze the reliabilities (each site may want to do this as well and apply their own procedures). We will recommend changes in the items and the addition of new items based on this analysis.
Phase #2—Beta testing will be initiated with a sample of 150-200 people who are in mental health treatment at each site. This should be a relatively representative sample of people in counseling, though they may also be taking medication and seeking medical treatment as well. Before we start this phase, we will need to put together a questionnaire that asks about the counseling that they are receiving —how directive, what the therapist does, therapist style, quality of relationship, etc. PGSP will put together a form to recommend to each site. Each site will translate and change the form to fit their needs and will add items to address areas and questions of particular interest to the on site leaders. In particular, there may be dimensions or patient and treatment characteristics that are of interest to each site (e.g., shame, collectivist values, etc.) that we want to include in the items at this point. These items will be added to the end of the form and tested. We will then want to have each person who completes the Inner Life form, complete it at least one more time at least a month later. We will try to get as many of the 150-200 people in this sample to give us at least 2 responses and many more times, if possible. When the Beta data are gathered, PGSP will analyze these data (each site may also want to analyze). PGSP will look again at reliabilities and will make final recommendations for changes to the items. We will also analyze hypotheses about predictors of outcome (change on the two administrations) using the therapist evaluation to define therapy dimensions of directiveness, insight-behavioral focus, emotion focused vs problem focused, etc. We will try to test hypotheses about (1) patient predictors, 2) treatment/therapist predictors, 3) relationship predictors, and 4) Patient-treatment fit predictors.
Phase #3 —Web Translation. For this phase, we will begin the translation of the narrative reports and will add language for adding new dimensions to the inner life form that prove to be important in Phase #2. This phase will be focused on developing a web-based assessment system like the www.innerlife.com site now in English.
Phase #4—cross validation phase. We will seek to gather as much information and as many responses as possible, on both the therapist form and the innerlife form, and do cross-validation studies to inspect differences across countries and patterns of similarity.
Thus, the movement to identify research-based principles, rather than research supported theories and models, has gained ground in the past several years. For example, in 2003 a joint task force (comprised of 45 scholars) of the American Psychological Association’s Division 12 and the North American Society for Psychotherapy Research was formed to identify what cross-cutting principles of treatment could be extracted from extant research literature to guide treatment among depressed, anxious, chemically abusing patients and those with personality disorders. The results were published in 2006. The joint task force found sufficient research evidence to expand and refine the initial list of 18 principles to a list of over 60 research-informed principles that were extractable to clinical practice. Whereas the earlier list did not differentiate among the treatments for different disorders, nearly half of the principles identified by the joint task force were specific to the treatment of one of four problem areas discussed (depression, anxiety, personality disorders, substance use disorders). In the extension of these principles, we are currently seeking to both expand the array of principles that help us understand and predict effectiveness and generalize to other cultures and groups, both diagnostic and non-diagnostic. The work and progress of the STS represents maintaining a delicate balance between predictors that indiosyncratic to particular groups and those that generalize across groups and peoples.