Evidence-based patient-psychotherapist matching improves mental health care

In first-of-its kind research led by a University of Massachusetts Amherst psychotherapy researcher, mental health care patients matched with therapists who had a strong track record of treating the patients' primary concerns had better results than patients who were not so matched.

In addition, this "match effect" was even more beneficial and pronounced for patients with more severe problems and for those who identified as racial or ethnic minorities.

The findings are published in JAMA Psychiatry and the Journal of Consulting and Clinical Psychology.

"One of the things we've been learning in our field is that who the therapist is matters," says lead author Michael Constantino, professor of clinical psychology and director of the Psychotherapy Research Lab, who seeks to understand the variability of outcomes among patients receiving mental health treatment. "We've become very interested in this so-called therapist effect. Earlier on, there was a heavier emphasis on what the treatment was as opposed to who was delivering it."

Constantino and colleagues have discovered, for example, that psychotherapists possess relative strengths and weaknesses in treating different types of mental health problems. Such performance "report cards" hold promise, then, for personalizing treatment toward what therapists do well.

The researchers conducted a randomized clinical trial involving 48 therapists and 218 outpatients at six community clinics in a health care system in Cleveland, Ohio. They used a matching system based on how well a therapist has historically treated patients with the same concerns. The matching relied on a multidimensional outcomes tool called the Treatment Outcome Package (TOP), which assesses 12 symptomatic or functional domains: depression, quality of life, mania, panic or somatic anxiety, psychosis, substance misuse, social conflict, sexual functioning, sleep, suicidality, violence and work functioning. The matched group was compared to a group of patients who were case-assigned as usual, such as by therapist availability or convenience of office location.

"By collecting TOP data from enough patients treated by a given therapist, this outcomes tool can establish the domains in which that therapist is stably effective (historically, on average, their patients' symptoms reliably improved), neutral (historically, on average, their patients' symptoms neither reliably improved nor deteriorated), or ineffective(historically, on average, their patients' symptoms reliably deteriorated)," the paper states.

To qualify for matching, the therapists had to have completed a minimum of 15 cases with patients who had completed the TOP before and after treatment. For the trial, neither the patients nor the therapists knew if they had been matched or were case-assigned as usual. "We think there would be an even stronger positive impact if the patients knew they were empirically well-matched versus assigned by chance," Constantino says. "Such knowledge might cultivate more positive expectations, which are generally associated with better therapy outcomes."

Post-therapy reports by patients showed that those in the matched group experienced significantly greater reductions in general impairment compared with those who were randomly assigned a therapist. "We showed that with this matching system you can get a big bump in improvement rates," Constantino says.

The finding that the improvement in the matched group was even greater among people who identified as racial or ethnic minorities may provide a way to address and improve mental health care access and quality in traditionally underserved populations, Constantino says.

The JAMA Psychiatry paper concludes, "Notably, the good fit in this study came not from changing what the therapists did in their treatment, but rather who they treated. Capitalizing on whatever it is that a therapist historically does well when treating patients with certain mental health problems, the current data indicate that our match system can improve the effectiveness of that care, even with neither therapist nor patient being aware of their match status."