Development and Preliminary Analysis of a Scale to Assess Client Characteristics that Influence Clinical Decision-Making

Clinical decision-making is a hallmark of clinical psychology, psychiatry, and psychotherapy, being a core skill in mental health responsiveness (Norcross & Goldfried, 2019; Norcross & Wampold, 2019). Recent empirical research suggests that variance in psychotherapy outcomes can be attributed to patient variables (30%), therapeutic relationship (15%), intervention methods/techniques (10%), individual therapist variables (7%) and other factors (3%) such as therapeutic setting. The other 35% is attributable to unexplained variance (Norcross & Wampold, 2019). These generic research factors at a higher level of abstraction encompass several concrete elements that, at a lower level of abstraction, can be differentiated into basic therapeutic elements (e.g., strategies, goals, and tasks) related to interactions between patient and therapist (Goldfried, 2019). Within patient variables, several meta-analytic studies revealed a cluster of patient characteristics and behaviors that showed to be consistently associated with psychotherapy outcomes (Beutler et al., 2005, 2018; Flückiger et al., 2018; Krebs et al., 2018; Levy et al., 2018). In this sense, these patient variables might be candidates for the development of a new assessment measure focused on clinical decision-making, which is the aim of this study.

Previous instruments have focused on clients’ preferences that were thought to be related to psychotherapy outcomes. The Cooper-Norcross Inventory of Preferences (CNIP, Cooper & Norcross, 2016) is a self-report instrument designed to assess patients’ preferences regarding therapist directiveness, emotionality, time orientation and support/challenge. The Therapy Personalisation Form (TPF, Bowen & Cooper, 2012) is an assessment instrument with two forms, one for the assessment phase and the other for the therapy sessions with 20 semantic differential items focused on the client’s preferences for therapist activities. The Psychotherapy Preferences and Experiences Questionnaire (PEX, Sandell et al., 2011) is a 29-item measure focused on the assessment of how individuals evaluate therapist activities, therapist characteristics, and client activities as beneficial to them. The Counseling Preference Form (CPF, Goates-Jones & Hill, 2008) is a self-report measure that asks patients to rate 10 therapists which activities they prefer that counselors use in counseling sessions. Similarly, The Preference for College Counselling Inventory (PCCI, Hatchett, 2015) is a 90-item instrument that asks patients for therapist characteristics, therapist activities, and client activities. These assessment instruments were almost focused on patients’ preferences rather than patient variables, and this aspect may support the need for a new measure focused on patients’ variables associated with psychotherapy outcomes.

Furthermore, metanalytic studies refer to such patient variables as the specific traits, behaviors, and therapeutic timings that research showed to be associated with psychotherapy outcomes (Norcross & Wampold, 2019). The variables are emotional stability (severity and complexity), therapeutic alliance, motivational stage, reactance level, coping style and attachment style. However, the stages of psychotherapy are not derived from metanalytic studies and are referred to as one core domain for clinical decision-making (Vasco et al., 2018). Emotional stability depends on the severity and complexity of the problem and is directly associated with emotional suffering and long-lasting dysfunctional patterns (Beutler et al., 2005). The therapeutic alliance is defined as the emotional bond and articulation between tasks and goals between the patient and psychotherapist (Flückiger et al., 2018). The motivational stage is the readiness for change that people experience at each moment in time to pursue transformational actions (Krebs et al., 2018). Reactance level is the specific way that individuals react to psychotherapeutic proposals (Beutler et al., 2018). Coping styles are individuals’ internalization or externalization tendencies in dealing with distress, emotional pain, and suffering (Beutler et al., 2011). Attachment style is the characteristic and recurring pattern of thoughts, feelings, and behaviors that individuals exhibit when forming emotional bonds with significant others (Levy et al., 2018). Finally, stages of psychotherapy are the sequential stages that individuals enter during the psychotherapy process (e.g., stage one– alliance formation and bonding, stage two-consciousness awareness, stage three—meaning-making, stage four –regulation of responsibility, stage five—repairing actions, stage six—consolidation of change and stage seven—anticipation of the future and relapse prevention), which are significant to specific patient acquisitions (Vasco et al., 2018). Despite this empirical evidence, no single assessment instrument is specifically designed to gauge these constructs within a unified measure, even though research has consistently demonstrated their strong correlation with psychotherapy outcomes (Norcross & Wampold, 2019).

The main idea of the CDMI is to have a measure that can rapidly assess several clinical constructs related to psychotherapy outcomes. For instance, if a patient has an internalizing coping style, clinicians should focus on insight/restructuring strategies, while clinicians should focus more on behavioral tasks if a patient has an externalizing coping style (Beutler et al., 2005, 2018). Another example is, if a patient has difficulties in forming secure attachments, the clinician should focus more on the relational domains of therapy. Therapeutic strategies are expected to match the patient’s styles and needs by correctly assessing these constructs. Developing a new measure encompassing several clinical decision-making constructs may not only be a cost-effective reduction in time, but it may also function as a relevant unified instrument based on various empirical evidence.

Several constructs were selected to start the CDMI validation process. Previous research has emphasized several significant constructs associated with symptomatology and psychological distress, that may relate to clinical decision-making.

Metacognition defined as a set of higher-order mental abilities related to identification, decentration, self-reflection, and mastery was previously associated with symptomatology (Faustino et al., 2021a; Semerari et al., 2003). Nevertheless, another metacognitive model (Wells & Matthews, 1994; Wells, 2009), can be used to explore if these results are stable. However, the Metacognitions Questionnaire 30 (MCQ-30, Wells & Cartwright-Hatton, 2004) is focused on metacognitive beliefs, which is a specific form of metacognitive variables and in the present study, we believe that a broader notion of metacognition can be an asset to perform a preliminary analysis of the CDMI. Cognitive fusion (as a measure of psychological inflexibility), cognitive reappraisal, and expressive suppression have been associated with symptomatology (Faustino, 2021), attachment styles (Gardner et al., 2020), and emotional instability (Carlo et al., 2012). Interpersonal problems have been associated with difficulties in forming alliances and secure attachment (Wong & Pos, 2014). Finally, coping states of mind which may be regarded as state-like manifestations of coping mechanisms were previously associated with symptomatology (Faustino et al., 2021b) and therapeutic alliance (Black et al., 2013). Therefore, based on this previously documented evidence, these constructs were selected to explore the convergent and divergent validity in the present study. The core idea behind the development of this measure is that if the therapist adopts his intervention according to the patient's characteristics, this will increase responsiveness. Decisions can be taken as a function (but not adhered to) of the degree of emotional suffering, of the therapeutic relational posture due to the attachment style, of the strategies centered on the coping style and of the actions centered on the motivational level. In this sense, from a transtheoretical perspective different variables of symptomatology, cognition, emotion regulation, coping, and interpersonal behaviors were selected based on previous research related to the variables measured by the CDMI.

This study focuses on the development and preliminary psychometric study of the CDMI through an Exploratory factor Analysis, convergent, divergent, and predictive validity with theoretically related constructs. To our knowledge, this is the first attempt to develop a clinical decision-making instrument based on empirical data. Therefore, we expected that the CDMI has a unidimensional structure (H1). Expressive suppression, symptomatology, interpersonal problems, coping mechanisms, and cognitive fusion are expected to correlate negatively with all CDMI constructs showing convergent validity (H2). Metacognition is a higher-order intrapsychic cognitive construct different from some CDMI constructs, namely, stages in psychotherapy, therapeutic alliance, and emotional stability. Therefore, metacognition is expected to not correlate with these variables, showing evidence of divergent validity (H3). Finally, CDMI variables are expected to have predictive value on symptomatology, interpersonal problems, and cognitive fusion (variables related to psychotherapy outcome).

Study aims were achieved, which was to start a preliminary study of the CDMI. This is just the initial study, and much work must be done. Developing an empirically based instrument to help clinicians make decisions is not an easy task. We regard this effort as the beginning of a line of research focused on the CDMI. Hypothesis one was not confirmed. The CDMI showed a two-factor solution, however, both factors had a low internal consistency, which result from the confluence of different constructs. In this sense, a unidimensional scale was computed to explore further validation. Nevertheless, to some extent, the two-factor solution (therapeutic engagement and clinical styles) matches the underlying variables. Clinical decision-making takes into consideration several psychological variables that are very different, and this is reflected in the study instrument (Beutler et al., 2005). For instance, stages in psychotherapy or motivational level differ from attachment and reactance. However, they are still correlated, so a unidimensional factor structure may be adequate to represent the theoretical assumptions of the CDMI. As detailed before, single-item measurements seem to be sufficient if the construct is clearly described (Freed, 2013). Despite our effort to match this principle, exploring the constructs contained in the CDMI through multi-item measurement is also plausible. Both versions need to be studied simultaneously to explore validity criteria.

Hypothesis two was partially confirmed; however, the results were mostly aligned with theoretical predictions. Only expressive suppression did not correlate with stages in psychotherapy, therapeutic relationship, motivational level, and emotional stability. A previous study showed that expressive suppression does not differentiate between non-clinical and clinical samples (Faustino, 2021), which is why it did not correlate with the specific variables associated with the psychotherapy process (e.g., therapeutic relationship). However, all other variables were significantly correlated. For instance, it was expected that symptomatology and interpersonal problems were correlated with emotional stability, therapeutic relationships, and attachment styles because these variables were associated previously (Gardner et al., 2020; Wong & Pos, 2014). Also, it was expected that coping mechanisms and cognitive fusion were correlated with emotional stability and coping styles, first because of the previous studies (Faustino, 2021; Faustino et al., 2021b) and the similarities between coping mechanisms and coping styles. Therefore, matching theoretical assumptions implies, to some extent, some preliminary evidence of convergent validity.

Divergent validity was explored through correlations between constructs that were somewhat different from the CDMI variables. Metacognition did not correlate with stages in psychotherapy, therapeutic alliance, and emotional stability, confirming the third hypothesis. Metacognition as defined by Semerari et al. (2003) and measured by the MSAS (Pedone et al., 2007) seems to be very different from these CDMI variables, such as stage in psychotherapy, therapeutic relationship, and emotional stability. In this sense, these results match previous theoretical assumptions and may be considered as preliminary evidence of divergent validity.

Finally, it was expected that some of the CDMI variables showed predictive value on symptomatology, interpersonal problems, and cognitive fusion. Only a few variables showed predictive value, non-confirming the fourth hypothesis. However, these results may imply that some CDMI variables (e.g., emotional stability and attachment style) have predictive value on other clinical variables, which makes them relevant for clinical decision-making and differentiated targets for psychological interventions (Faustino & Vasco, 2020b, 2020c).

Preliminary results suggest that the CDMI showed the potential to become a reliable instrument to help clinicians in tailor interventions to patients’ specifications. This assessment instrument may offer a cost-effective choice in the decision-making process while being a coherent empirical-based instrument. Nevertheless, more research is required to explore the psychometric properties of the CMDI before it can be used as a reliable measure.