How Practitioners Can Systematically Use Empirical

Evidence in Treatment Selection

Larry E. Beutler, Carla Moleiro, and Hani Talebi

University of California, Santa Barbara

Contemporary concerns with empirically supported treatments emphasize the differences in outcomes that are associated with reliably delivered
treatments, representing different models and theories. This approach often
fails to address the fact that there is no consensus among scientists about
whether there are enough differences between and among treatments to
make this effort productive. There is a considerable body of data that
suggests that all treatments produce very similar effects. This article reviews
these viewpoints and presents a third position, suggesting that identifying
common and differential principles of change may be more productive
than focusing on the relative value of different theoretical models. 2002
Wiley Periodicals, Inc. J Clin Psychol 58: 11991212, 2002.
Keywords: psychotherapy; outcome; integration; empirically supported
treatments; health care

Although most practitioners report that they value the importance of science in defining
what types of procedures are most effective in psychotherapy, relatively few of the procedures and models that are actually used in clinical practice are supported by a body of
empirical research (Beutler, Williams, Wakefield, & Entwistle, 1995). These paradoxical
findings may be partially attributed to the difficulties encountered when practitioners
attempt to extract practical and usable procedures from extant scientific research. Even
for one who is deeply imbued in statistical procedures and nuances, it is very difficult to
know what research findings really mean at the level of practice. What evidence is necessary to justify altering the nature of ones practice and to ensure the use of only effective procedures? While there is a large body of psychotherapy research available (e.g.,
Bergin & Garfield, 1994), the results of published studies are often contradictory and
confusing. In the face of this confusion, it seems impossible to integrate the results from
diverse studies and to reach conclusions about the relative value of a very wide array of
Correspondence concerning this article should be addressed to: Larry E. Beutler, Department of Education,
Counseling/Clinical/School Psychology Program, University of California, Santa Barbara, CA 93106.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(10), 11991212 (2002)

2002 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10106

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differently labeled and named treatments, all applied to a dizzying array of mental health
conditions.
Each clinician who embarks on the task of conducting a research-informed practice
is faced with a dilemma of reconciling two contrary but credible viewpoints that exist
among research scientists. On the one hand, a body of research has identified particular
techniques and whole models of psychotherapy that are responsible for a significant and
predictable portion of therapeutic change and outcome. The nature of this research emanates from a model of research and a concomitant criteria of decision making that have
been successfully applied to the identification of effective pharmacological treatments,
the Randomized Clinical Trial (RCT). This RCT model of research consists of randomly
assigning patients to either a defined package of interventions under some brand name
(e.g., Cognitive Therapy, Psychodynamic Therapy) or to a minimal treatment, placebo
control, or a no-treatment comparison condition. A comparison of outcomes allows one to
determine the degree to which benefit is a product of factors that distinguish the control
and experimental treatments. That is, it concentrates on identifying the effects of what are
called specific treatment factors.
Specific factors are differentiated from more general or common factors that characterize or derive from the context in which treatment is offered. These common factors
include patient expectations, the offer of help, attention, and a host of relational and
placebo factors that are part of the act of delivering a credible treatment. These common contributors to treatment may be embodied within the treatment itself, be a product
of the particular personality or style of the therapists, or derive from the hopes and fears
that the patient brings to the treatment. Common factors are those qualities of treatment
that are embodied in all credible treatments.
Scientists and clinicians have generally and differentially debated the relative value
of specific and common treatment factors as the basis for building practice guidelines.
Those who place their faith in the salience of specific factors assume that some models or
approaches to intervention are better than others and, accordingly, focus on the differences that exist among different brands of treatment. These differences are assumed to be
reflected in both processes (i.e., what is done in the treatment itself ) and outcomes (i.e.,
in the amount or type of benefit experienced). This specificity view assumes that the most
useful platform on which to develop treatment guidelines and standards of care is that
which is defined by different brands or theories of treatment (e.g., Cognitive Therapy vs.
Psychodynamic Therapy). This specificity model is especially preferred by those practitioners and scientists who are concerned with the danger of proliferating unresearched
and potentially dangerous practices. As a result, authors and practitioners within this
perspective have invested considerable effort in identifying which of the 400 models
and brands of psychological treatments that are available to practitioners meet some more
or less specified standard of empirical support.
The philosophy of specific effects is embodied and typified in the work of the Task
Force on the Identification and Dissemination of Empirically Validated Treatments (EVT),
formed by the Division of Clinical Psychology (Division 12) of the American Psychological Association (APA) in 1993. This initial Task Force report and its more recent
renditions have provided the most specific foundations for defining Empirically Supported Treatments (ESTs; Chambless & Hollon, 1998). The Task Force was formed as a
byproduct of a desire among the Board of Directors of the Society of Clinical Psychology
(Division 12) to reliably and objectively determine the scientific status and credibility of
the various psychotherapies. It derived out of growing concerns with the dissemination of
controversial interventions (e.g., recovered memory, thought field therapy, rebirthing therapy) and from external, sociopolitical pressures deriving from insurance carriers who pay

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for the services. Accordingly, the Division 12 Task Force turned to studies that had randomly assigned patients to treatments that were governed and guided by treatment manuals as a way of standardizing the nature of the treatments received.
Although the resulting list of empirically supported treatments were explicitly not
intended to serve as guidelines, the use of standard manuals and the implied judgment
against unlisted treatments provided some level of comfort to insurance administrators
who were grappling with the problems of selecting, from among an unwieldy number of
treatments and patients, those that should be covered by insurance policies.
After their first report in 1995 (Task Force on Promotion and Dissemination of Psychological Procedures, 1995), two addendum reports were published (Chambless et al.,
1996; Chambless et al., 1998) that identified models or brand names of treatments that
met the defined criteria as being efficacious for treating particular problems, largely as
represented by discrete patient diagnoses. To date, more than 11 independent, but overlapping lists of empirically validated treatments have been created. Collectively, these
lists identify 108 different therapeutic manuals for adult clients and 35 for child/
adolescent clients that have been found to work with 51 different diagnostic categories of
the DSM-IV-R (Beutler, Harwood, et al., in press; Chambless & Ollendick, 2001).
Contrast this latter concentration to that of a second group of scientists and practitioners who have directed their attention to identifying the common factors that are associated with psychotherapy outcome. Authors and practitioners within this perspective have
been drawn by the relative absence of significant differences when various treatment models have been compared head-to-head (Wampold et al., 1997). This result has been documented in the literature as The Dodo Bird verdict (All have won and all must have prizes),
after a summary of extant comparative psychotherapy literature established that all
psychotherapies were, overall, equally effective (Luborsky, Singer, & Luborsky, 1975).
Whether discussed as common or nonspecific factors, terms that are usually used interchangeably in the literature, these cross-cutting qualities of treatment have been repeatedly shown to be among the largest contributors to outcome in therapy, both positive and
negative (Norcross & Newman, 1992). Among other things, these common factors include
the expectations that one might hold about treatment, the perceived charisma of the therapist, and the healing role of the evolving relationship between patient and therapist, itself.
Practitioners and scientists who are disposed to focus on what treatments have in
common have been vocal critics of the efforts to identify specific treatments that are
effective (e.g., Garfield, 1996; Silverman, 1996; Wampold, 1997). Most of these critics
of specificity focus on the confounding and complexity of effects that are observed when
one applies research-derived treatment manuals to comparative studies of different treatments. They point out that requiring therapists to follow research-derived manuals imposes
an impossible level of rigidity and devalues the roles of creativity and spontaneity. They
also express considerable concern that any prioritizing of treatments based on random
assignments to manual-driven research methods will necessarily favor treatments that are
easily manualized, whether or not these treatments are really effective. Accordingly, most
of the lists are dominated by cognitive and behavioral models of interventions.
Those who adopt a viewpoint of nonspecificity point out that a failure to meet criteria of efficacy based on some count of the number of studies that have obtained significant findings can come to favor a particular approach either because of the absence of
research or from the presence of research that has obtained negative findings. In turn,
treatments that are highly structured, symptom focused, and short-term are more easily
manualized than others, and thereby are the most frequently studied.
It is argued that the vagaries and complexities of clinical practice require clinicians
to be more flexible, eclectic, and creative in the development and application of inter-

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ventions than is possible when one relies on treatment manuals and rigid research designs
as the bases of evidence. Some authors have pointed to evidence that following rigid
treatment manuals may even lead to unexpected negative effects, including a general loss
of interpersonal and therapeutic skill (Henry et al., 1993). Moreover, controlled trials
designs raise questions about the clinical utility (transferability and cost-efficiency) of
reported findings (e.g., Wampold et al., 1997).
Even if one were conservatively to accept the validity of various lists of empirically
supported treatments, and to eliminate from the list the redundant and overlapping treatments, a clinician would have to be knowledgeable in over 70 treatment models to be able
to respond effectively to a varied clientele in clinical practice (Beutler, 2000a). In contemporary research it is not unusual for training to take in excess of one year before one
is considered to be proficient. Thus, attaining initial proficiency in a sufficient number of
treatments to be effective in a varied practice setting is a daunting task even if one does
not consider the need to maintain proficiency once achieved (Beutler, 2000b). It is unlikely
that either practicing clinicians or managed health care companies will commit the resources
necessary to ensure that there is a sufficient large cadre of practitioners available to
represent the various methods and manuals identified as efficacious.
On the other hand, basing treatments on the use of common factors and relationship
qualities are also imbued with problems. Although repeated observations have been made
about the existence of therapeutic commonalities, little progress has been made in improving psychotherapy based on them (Norcross & Newman, 1992; Norcross et al., 1995) or
even in identifying and defining them (Castonguay, 1993; Grencavage & Norcross, 1990;
Norcross et al., 1995). Terms like common factors and nonspecific variables have
been generally regarded as referring to undefined and sometimes undefinable aspects of
the therapeutic relationship. For example, Grencavage and Norcross (1990) identified
five overlapping ways in which common factors have been described or used in the
literature: (a) client characteristics (e.g., positive expectations, initial client distress, helpseeking behavior); (b) therapist qualities (e.g., warmth, empathic understanding, socially
sanctioned healer, expertise and other positive descriptors); (c) change processes (e.g.,
opportunity for catharsis/ventilation, provision of a rationale, emotional/interpersonal
learning, persuasion, modeling, reality testing, education/information); (d) treatment structure (e.g., use of techniques/rituals, a healing setting, communication, roles); and (e)
therapeutic relationship (development of an alliance, transference, engagement).
The factors most often identified as common are those connected with the therapeutic alliance (Grencavage & Norcross, 1990; Norcross et al., 1995). Other variables
within this same class that are often cited are clients positive expectations, therapists
facilitative skill, the provision of an acceptable treatment rationale, and the acquisition by
the patient of new behaviors. There is insufficient evidence, however, to assume that the
therapeutic relationship operates identically in all forms of psychotherapy or with all
clients, nor is there reason to believe that all types of therapy make use of the various
factors defined as common, to an equal extent (Norcross & Newman, 1992; Norcross
et al., 1995). With the exception of a recent effort (Hubble, Duncan, & Miller, 1999), it
seems fair to say that there is little agreement and empirical research on the real commonalities among the therapeutic common factors, and, without such accord and research,
it seems difficult to apply these variables effectively in clinical practice.
Systematic Treatment Selection and Prescriptive Psychotherapy
Given such extant differences among the effective attributes of psychotherapy and the
opinions of equally credible scientists about what constitutes effective psychotherapy, it

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is not surprising that clinicians are highly prone to accept personal opinion over scientific
evidence (Garb, 1998). Yet, because clinical experience as a sole criteria of whether a
practice is effective may lead to both unethical and dangerous practices (Beutler, 2000a;
Beutler, Bongar, & Shurkin, 1998; Singer & Lalich, 1996), we believe that another, scientifically based standard is needed by which clinicians can select and use researchinformed treatments (Beutler, 2000a). The Systematic Treatment Selection (STS) model
(Beutler & Clarkin, 1990; Beutler, Clarkin, & Bongar, 2000) offers a way of achieving a
level of integration that rises above discourse about specific research methodologies,
patient diagnoses, and theories of psychotherapy.
The STS model attempts to achieve integration among perspectives by planning a
tailored intervention that is driven by research-informed principles that cut across both
different theories of change and variations that exist among specific techniques (Beutler
& Harwood, 2000; Beutler, Clarkin, et al., 2000). By linking the practice of psychotherapy to cross-cutting principles of change, rather than to either techniques or causal theories, STS acknowledges that there is not a one-to-one correspondence between a given
problem and the effectiveness of a specific technique just as there is not a single theory
that encompasses all effective techniques (Beutler, Alimohamed, Moleiro & Romanelli,
in press). In this system, therapists would not be required to learn either a large number of
different treatment models or an entirely new theory of psychopathology and intervention. Rather, by selecting classes of intervention based on research findings, therapists
would be able to stack their interventions with techniques with which they are most
effective and comfortable, drawing both from their own experience and from a set of
research-informed principles of therapeutic change.
Both STS and Prescriptive Therapy (PT; Beutler & Harwood, 2000), an application
of the STS treatment decision model to individual psychotherapy, have an established
empirical foundation and a set of guiding directives. Included among these are certain
competencies that are expected of the therapist who follows the systems:
1. Having an attitude that is conducive to establishing and maintaining a therapeutic
relationship/alliance characterized by warmth, optimism, acceptance, and genuine interest;
2. Having the therapeutic knowledge of principles of change that guide the
applications;
3. Having the therapeutic skill to implement effective techniques and tools in a safe,
therapeutic environment;
4. Being sensitive to the demands and uses of time in selecting interventions, withdrawing pressure, providing support, and waiting for change.
5. Using creative imagination to create and use procedures that fit good treatment
principles when established techniques are not available.
Following these keys to effective application, the STS model is able to integrate the
contribution of both nonspecific factors and specific qualities of the psychotherapeutic
process. The therapists attitude fosters those qualities common to all effective psychotherapies; the therapists knowledge of principles of change allows him or her to use
specific forces that effect change; the therapists attitude and knowledge together foster
the development of skill through the selection of appropriate techniques and tools. To
these are added the forces of time sensitivity and creativity that allow optimal ability to
adapt to new situations. The therapist/clinician seeks to know the most recent results
from empirical literature that can be applied to practice through empirically derived transtheoretical principles.

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Background to STS
The history of the development of the STS system has drawn from many resources. Early
authors (e.g., Sigmund Freud, Carl Rogers, Fritz Perls, Victor Frankl) who came to eschew
reliance on the dominant theory of the time, or to follow charismatic leaders solely because
they were charismatic, laid the initial foundation to integrative and eclectic thought. Later
writers and practitioners who specifically rejected the notion of a single-theory model of
psychotherapeutic change (e.g., Frederick Thorne, Arnold Lazarus, Arnold Goldstein)
built the early structure of technical and pragmatic eclecticism. More recent authors (e.g.,
Hal Arkowitz, Marvin Goldfried, Paul Wachtel, John Norcross, Barry Wolfe, James
Prochaska) placed the nuance on the eclectic structure, developed and differentiated among
various models of eclecticism, and initiated a movement to conduct research on integrated and combined treatments. Systematic Treatment Selection (Beutler & Clarkin,
1990) arose specifically as an effort to integrate among integrative approaches. Specifically, it sought to incorporate and integrate principles from common factors eclecticism
(Garfield, 1980), transtheoretical eclecticism (Prochaska, 1984), individual psychotherapy (Beitman, 1987), Multi-Modal Psychotherapy (Lazarus, 1976), differential
therapeutics (Frances, Clarkin, & Perry, 1984), and systematic eclectic psychotherapy
(Beutler, 1983).
Acknowledging these previous efforts and their common objectives, as well as the
competing models from which they derive, Beutler and Clarkin (1990) proposed approaching treatment planning from a perspective that is guided more by empirical and structured
perspective than by theory. The STS model formulated by these authors attempted to
incorporate the best from all available eclectic theories. Although prior attempts to improve
treatment effects by homogenizing patient groups around common diagnoses had by and
large failed, they noted that several lines of both research and clinical practice had begun
to examine ranges of patient response and levels of adaptation as indices of factors that
moderated and mediated the effects of various interventions. The result was a multilevel
model of treatment planning, called Systematic Treatment Selection (STS), that incorporated prognostic variables, relationship considerations, interventions, and the fit of interventions to particular patient proclivities.

Validation of the STS

Over a period of ten years, Beutler, Clarkin, and many of their colleagues (e.g., Beutler &
Consoli, 1992; Beutler, Mohr, Grawe, Engle, & MacDonald, 1991; Beutler, Wakefield, &
Williams, 1994; Gaw & Beutler, 1995) were able to refine the original list of patient and
treatment variables and to extract from extant research those that were most promising
for treatment planning. In the most recent rendition of the STS model, the authors initiated a three-step process of validating their model. The first step in this process was to
initiate a series of extensive and comprehensive reviews of research literature (Beutler,
Clarkin, & Bongar, 2000; Beutler, Goodrich, Fisher, & Williams, 1999) in an effort to
narrow and refine the list of potential patient variables and corresponding treatment qualities to a manageable number.
In the second step of this research procedure, Beutler, Clarkin, and Bongar (2000)
sought to establish a measurable set of matching parameters that promised to increase the
benefits associated with treatment. The initial literature reviews resulted in the identification of six patient and problem characteristics that have been found to relate either to
patient prognosis or to moderate different types of treatment. These variables included

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functional impairment, subjective distress, social support, complexity/comorbidity, resistance, and coping skills (Beutler, Clarkin, et al., 2000).
Research on each of these variables had also suggested that a corresponding and
mediating quality of treatment tended to enhance the effects of the patient qualities alone.
It was determined that these mediating qualities of treatment could be reliably classified
into groups or families of intervention, each of which tended to interact with these patient
and problem characteristics. These classes of intervention included such things as the
treatment mode (pharmacotherapeutic and psychosocial methods), the format (individual, group, family), the intensity of treatment (length, variety, frequency, etc.), and several
classes of specific interventions (level of therapist guidance and control, insight vs. symptomatic focus, level of abreaction, and support).
Collectively, this body of research suggested that instead of striving to identify a
single, invariant treatment that was effective for a particular diagnostic condition, patient
and problem characteristics could be used effectively to select classes of interventions,
from among a wide variety of treatment models, that might best fit different patients.
Thus, these research-defined patterns could be used to construct an individually tailored
treatment plan for each patient.
Consequently, measures were developed to provide a uniform assessment of both the
patient qualities and the families of interventions. The STS Clinician Rating Form
(Beutler, 2001; Fisher, Beutler, & Williams, 1999) is a computer interactive, clinicianbased measure of both the six identified treatment planning variables and several indicators of improvement, the latter of which are plotted over time against a normative projection
indicating course of treatment. The computer administration identifies the six patient
qualities and then utilizes empirically established algorithms to recommend treatment
parameters. This is expressed in a ready-made, narrative treatment plan for applying
prescriptive psychotherapy (PT). The assessment is administered by intake clinicians
after the intake interview and after reviewing all available intake assessment procedures,
but a patient self-report version is also under development.
The STS Therapy Rating Scale (STRS; Malik, Beutler, & Moliero, 2000) is completed by trained external raters and identifies both aspects of the treatment format and
context and aspects of the therapeutic process. Treatment is identified as being of psychosocial, pharmacological, or mixed mode and of taking place in a group, individual, or
family/couple format. It is also rated as to the type of setting, the probable length, and the
frequency of treatment sessions. Beyond these qualities of treatment, the ratings also
provide estimates of the relative levels of directive versus nondirective interventions, of
symptom-oriented versus insight procedures, and the use of abreactive versus supportive
procedures. The extant review suggested that certain patterns existed between the use of
these various intervention styles, modes, and formats, on one hand, and patient and problem qualities, on the other.
The third step in the validation process (Beutler, Clarkin, et al., 2000) was to extract
the hypotheses garnered from the reviews of past research and subject these to independent cross-validation on a diagnostically mixed sample of outpatients. The samples were
drawn from the archival records of three large research projects representing a very wide
range of manualized treatments, diverse patient samples, therapists with varied training
and experience, and dispersed geographical settings. A prospective sample of patients
was also included that were treated by usual clinical methods rather than manualized
treatments. The treatments thus varied in theoretical model, intensity and length, setting,
modality, format, and degree of structure.
A set of 15 hypotheses were developed about what patient, therapy, and patient
therapy combinations would be related to improvement. Thirteen of these hypotheses

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were supported and were supplemented by adjacent findings regarding treatment of patients
in crises in order to construct a set of 18 principles that could be used to guide treatment.
These principles identified the patient, treatment, and patienttherapist combinations that
were associated with improvement under different conditions and specified both a way of
identifying patients who were likely to get better when treated and the conditions that
maximized potential benefit for even difficult to treat patients (Beutler, 2000a). These
guidelines were formulated within a revised form of the original (Beutler & Clarkin,
1990) STS model, that looked both at levels of interventions and critical decision points.
A Summary of the Refined STS Model
The STS model is founded on two main premises:
1. Fitting a patient to a particular mix of interventions is likely to be better achieved
by attending to specific characteristics of the problem (e.g., impairment, chronicity), nondiagnostic traits (e.g., resistance patterns, coping style), and the context
(e.g., social support levels, level of distress evoked) than by describing patients
primarily in terms of global, diagnostic labels.
2. Specific functional classes of interventions (e.g., directive vs. nondirective, insightoriented vs. symptom-oriented, abreactive vs. supportive) are likely to be more
conducive to the task of tailoring treatments to individual patients than selecting
among different, global brands of treatment.
Confirming the nascent view that treatment could be functionally configured within
a perspective of levels, this latter research (Beutler, Clarkin, & Bongar, 2000) distinguished four interactive and sequential decision points. More importantly, treatment decisions were established as possessing an accumulating effect. Correspondingly, single
conclusions regarding treatment implied increased uncertainty within this framework;
the efficacy of decisions was best thought to mirror an interwoven network of influences
of each decision on the others.
The first stage of the decision process, as reviewed by Beutler, Clarkin, & Bongar
(2000), involves a measurement of the patient predisposing qualities that both foretell
varying prognoses and serve to reconcile the results of disparate treatments. The STS
Clinician Rating Form is one way of accomplishing this, but other standardized tests are
also useful (Gaw & Beutler, 1995). Relevant neoteric literature implies that, at minimum,
these qualities should incorporate aspects of normal adjustment (i.e., coping/interpersonal
style), attention to the patients environment (i.e., role demands), and aspects of the problem presented (i.e., distress, impairment).
The context of treatment comprises the second stage of decision-making within this
systemic backdrop. This subdivision encompasses the extent (i.e., intensity) of treatment
required (including whether professional care is necessary at all), the mode of treatment
(medical vs. nonmedical), treatment procedure (multiperson vs. individual), and optimal
treatment setting (inpatient, partial care, vs. outpatient). Although conventional practice
relies on patient diagnosis to make these decisions, Beutler, Clarkin, & Bongar (2000)
suggest that variables such as level of functioning, chronicity, and co-morbidity with
personality disorder (complexity) may be additional indicators of varying treatment context (Beutler & Harwood, 2000).
At this level of decisional process, there are several areas in which treatments are
selected and modified to fit certain qualities of the patient and problem. For example, the
length and intensity of treatment may be adjusted to fit the functional impairment, com-

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plexity, and chronicity of the patients problem. Likewise, the relative balance of psychosocial and medical interventions may depend on chronicity and complexity (comorbidity) and the use of multiperson interventions may be a function of the impairment
level, chronicity, and the level of social support.
Fulfilling the aforementioned requisite leads to the third level of the STS model
enhancements to the treatment relationship and the selection of effective and powerful
therapeutic procedures. This level of decision includes selecting compatible therapists
and relationship facilitation coupled with the selection of clinical interventions that exert
a positive are quite consistently straightforward effect on patient changefor example,
treatment contracting, focusing on symptom changes first, etc. (Beutler, Clarkin, & Bongar, 2000). Three different factors affect this level of the treatment model: (a) how well
the patient and therapist share certain background and attitudinal similarities (arguably
an acutely inconstant variable in most treatment settings); (b) the power of various interventions as used by a particular clinician (i.e., identifying procedures that are particularly
compatible with the personal style and skill of a given therapist); and (c) the development
or facilitation of the professional alliance between the counselor and client.
The fourth and most refined level of the decision model involves selecting and then
tailoring specific interventions and techniques to fit the particular proclivities and needs
of the client. Clearly, the preceding can only occur after the clinician comprehensively
accounts for the relationship that characterizes and is compatible with a particular therapeutic dyad. Three patient and therapy characteristics have been identified at this level
as comprising well-fitting treatment (Beutler & Harwood, 2000). Specifically, therapists
are more likely to provide effective treatment when the level of applied directiveness is
inversely consistent with their patients level of resistance, if the relative balance of
symptom removal/skill building procedures to insight-oriented procedures is consistent
with the dominance of externalizing (stimulation seeking, impulsive, acting out) to internalizing (self-punitive, introverted, emotional withholding) coping styles, and if the utilization of support versus abreactive sensitization procedures inversely correspond with
the level of initial distress.
While most contemporary efforts at identifying effective treatments still are directed
at identifying interventions that are effective either within a given diagnostic group or
across all varieties of patients, the STS model seeks to draw the focus to aspects of patient
behavior that serve as either indicators or contra-indicators for various classes of intervention. Ultimately, this model has been designed to successfully bring consistency to the
shifting inclinations of the clinician by identifying certain propensities of the client,
changing the treatment procedure only when client characteristics begin to change.
Treatment Guidelines in Systematic Treatment Selection
The procedures for making sequential decisions at each of the four levels described in the
foregoing section have been consolidated into a set of principles. These principles are
designed to aid the clinician to accommodate to differences in treatment setting, patient
characteristics, environments, and theoretical models. These principles are designed to
allow the clinician to apply a verifiable and research-informed treatment from any of a
number of theoretical models, while avoiding the necessity of learning an endless number
of empirically supported treatments. Rather than attempting to identify specific techniques for each possible combination of symptoms, these principles allow the therapist to
select, create, and modify extant techniques in order to accommodate the endless variety
of patients and problems that might be presented. Thus, the creativity and flexibility of
the clinician is protected.

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The 18 guiding principles defined by Beutler and colleagues (Beutler, 2000; Beutler,
Clarkin, & Bongar, 2000; Beutler & Harwood, 2000; Beutler, Moleiro, Malik, & Harwood, 2000) are divided into those that help the clinician determine when the basic
treatment requirements are being provided as well as how to optimize treatment. Basic
guidelines are defined as principles of treatment that can be successfully applied by a
diverse group of clinicians, adhering to different intervention models, without specific
training or monitoring to ensure the accuracy of their utilization (Beutler, Clarkin, &
Bongar, 2000). These basic guidelines serve to predict and alter the natural trajectory of
a patients condition as well as enhancing the probability that a patient might improve by
adjusting the level and sequencing of interventions, regardless of the specific psychotherapy procedures used. Basic guidelines for managing treatment decisions imply that a
pattern of patient and problem features serve to influence the selection of patients who
will ultimately most profit from treatment.
The application of the Reasonable and Basic principles of treatment to identify
prognosis, level of care, and risk reduction have been defined as follows (Beutler,
Clarkin, & Bongar, 2000).
Prognosis
1. The likelihood of improvement (prognosis) is a positive function of social support level and a negative function of functional impairment.
2. Prognosis is attenuated by patient complexity/chronicity, and by an absence of
patient distress. Facilitating social support enhances the likelihood of good outcome among patients with complex/chronic problems.
Level and Intensity of Care
3. Psychoactive medication exerts its best effects among those patients with high
functional impairment and high complexity/chronicity.
4. The likelihood and magnitude of improvement are increased among patients
with complex/chronic problems by the application of the multiperson therapy.
5. Benefits correspond to treatment intensity among functionally impaired patients.
Risk Reduction
6. Risk is reduced by careful assessment of risk situations in the course of establishing a diagnosis and history.
7. Risk is reduced and patient compliance is increased when the treatment includes
family intervention.
8. Risk and retention are optimized if the patient is realistically informed about the
probable length and effectiveness of the treatment and has a clear understanding
of the roles and activities that are expected of him or her during the course of the
treatment.
9. Risk is reduced if the clinician routinely questions patients about suicidal feelings, intent, and plans.
10. Ethical and legal principles suggest that documentation and consultation are
advisable.
Optimal guidelines, as opposed to basic guidelines, speak to more precise themes of
treatment. Monitoring of these guidelines, unlike that of basic guidelines, requires direct

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observation of the in-session activities of a clinician-therapist (Beutler, Clarkin, & Bongar,

2000). Optimal guidelines serve to highlight specific arenas of treatment that demand
direct monitoring and observation of therapy as well as specialized instruction on the part
of the attending clinician. Optimal principles bear on the processes of treatment, addressing the therapeutic relationship, the general role of exposure and extinction processes,
sequencing of interventions, and the differential use of psychotherapeutic interventions
as follows.
Relationship Principles
1. Therapeutic change is greatest when the therapist is skillful and provides trust,
acceptance, acknowledgment, collaboration, and respect for the patient and does
so in an environment that both supports risk and provides maximal safety.
2. Therapeutic change is most likely when the therapeutic procedures do not evoke
patient resistance.
Principles of Exposure and Extinction
3. Therapeutic change is most likely when the patient is exposed to objects or targets
of behavioral and emotional avoidance.
4. Therapeutic change is greatest when a patient is stimulated to emotional arousal
in a safe environment until problematic responses diminish or extinguish.
Principle of Treatment Sequencing
5. Therapeutic change is most likely if the initial focus of change efforts is to build
new skills and alter disruptive symptoms.
Differential Treatment Principles
6. Therapeutic change is greatest when the relative balance of interventions either
favors the use of skill building and symptom removal procedures among patients
who externalize or favor the use of insight and relationship-focused procedures
among patients who internalize.
7. Therapeutic change is greatest when the directiveness of the intervention is either
inversely correspondent with the patients current level of resistance or authoritatively prescribes a continuation of the symptomatic behavior.
8. The likelihood of therapeutic change is greatest when the patients level of emotional stress is moderate, neither excessively high nor excessively low.
Conclusions and Final Comments
To date, efforts to define treatment guidelines and to identify empirically supported
treatments have resulted in lists of procedures and theory-based manuals that are inordinately inflexible and require extensive amounts of training to apply in a mixed clinical
setting. Moreover, the evidence to support the value of learning exhaustive lists of procedures and whole treatment theories or to differentially apply these theories to different
diagnostic populations is weak at best. It is difficult to justify the expenditure of energy
required to learn procedures that account for no more than 10% of the variance in

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Journal of Clinical Psychology, October 2002

outcome (Lambert, 1992; Shapiro & Shapiro, 1982; Wampold, in press; Smith, Glass, &
Miller, 1980).
Systematic Treatment Selection poses an alternative to sole reliance either on different
theoretical models or on the nonspecific effects of the treatment relationship. It also is
designed to circumvent the need for therapists to learn a host of new theories to support the
proliferating array of empirically supported treatments. STS provides a set of principles that
cut across theoretical lines and diagnostic labels. These reflect general principles of
change and serve as guidelines for the practitioner to develop comprehensive treatment plans.
Although the principles provided by STS have been derived from a large body of scientific
research and then cross-validated through independent investigation, they by no means are
proposed as being either an exclusive or exhaustive list of potential principles. They are,
however, representative and promising principles that seem quite capable of helping
clinicians in the field deal with the complexity of problems that face them with a minimal
amount of need to learn ever increasing lists of specific techniques and theories.
That is not to say that these principles are easy to apply. Their application depends on
the ability of clinicians to assess accurately, various patient qualities. This, in turn, assumes
that clinicians have the training to go beyond diagnostic evaluation to assess aspects of
the patients life style, coping style, interpersonal behavior, and intimate functioning. To
assist in this process, we have provided guidelines about how familiar measurement and
assessment procedures can be used to identify such qualities as patient impairment level,
social support, problem complexity/chronicity, coping style, trait and state-like resistance, and level of motivational distress (Beutler, Clarkin, et al., 2000; Beutler & Harwood, 2000; Gaw & Beutler,1995). In addition, we have developed observational
instruments both to help clinicians organize their impressions within the STS framework
and to evaluate the fit of psychotherapeutic processes to patient needs (Beutler, in press;
Fisher et al., 1999). The STS Clinician Rating Form (Fisher et al., 1999) has also been
adapted to a computer interactive system that both provides a narrative treatment plan
and tracks patient progress, comparing these latter results to normative data reflecting
expected progress (Beutler, in press). All of these efforts are designed to further the
general objective of translating empirical findings into forms that are useable by clinicians. This movement is consistent with our general objectives of deriving a sound scientific base for practice that also capitalizes on the creative ability and clinical wisdom of
the practitioner.
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