DECISION MAKING AND PSYCHOTHERAPY INTEGRATION

Decision-Making and Psychotherapy Integration 1

Running head: DECISION MAKING AND PSYCHOTHERAPY INTEGRATION

Decision Making and Psychotherapy Integration:

Theoretical Considerations, Preliminary Data, and Implications for Future Research

Michele A. Schottenbauer, Carol R. Glass, & Diane B. Arnkoff

The Catholic University of America

Journal of Psychotherapy Integration (in press).


Abstract

In recent years, a number of publications have called for investigation of how psychotherapists make treatment decisions in clinical practice. This recommendation is particularly salient for psychotherapy integration, since studies consistently show that a plurality of American clinicians consider themselves to be either “eclectic” or “integrative” in theoretical orientation. Yet, the research on clinician decision making in psychotherapy is in its infancy. The current paper examines the need for decision-making research in psychotherapy integration, as well as aspects of psychotherapy integration that are targets for research and possible theoretical frameworks for understanding decision-making processes of integrative psychotherapists. A preliminary study provides data from practicing psychotherapists to illustrate these points. Finally, implications and directions for future research are discussed.


Decision Making and Psychotherapy Integration:

Theoretical Considerations, Preliminary Data, and Implications for Future Research

In the past decade, the need for research on clinician decision-making has been stressed repeatedly (e.g., NIMH, 1999; Street, Niederehe, & Lebowitz, 2000). These recommendations are particularly salient for psychotherapy integration, since studies consistently show that anywhere from one-third to two-thirds of American clinicians consider themselves to be either

“eclectic” or “integrative” in theoretical orientation (for a review see Glass, Victor, & Arnkoff,

1993). For instance, a recent survey found that 36% of clinical psychologists claim to be eclectic/integrative (Norcross, Hedges, & Castle, 2002). While most eclectic or integrative therapists state that they tend to use whatever works best for the client, they appear to use different combinations of theories and techniques, as well as different decisional processes to determine which theories and techniques to use (Garfield, 1994). For example, when a number of integrative clinicians were asked to create case formulations and treatment recommendations for sample clients in the Journal of Eclectic and Integrative Psychotherapy , there was little agreement among them (Giunta, Saltzman, & Norcross, 1991).

Not only does there appear to be much variance in the practice of integrative clinicians, but there is no empirical evidence as to what integrative clinicians do and how this differs from

“pure-form” therapies (Garfield, 1994; Glass et al., 1993). Psychotherapy integration is widely believed by experienced clinicians to improve the effectiveness of psychotherapy (Wolfe, 2001), and yet, despite a large theoretical and clinical literature, empirical research on psychotherapy integration has lagged behind (Arkowitz, 1997; Glass, Arnkoff, & Rodriguez, 1998; Goldfried &

Newman, 1992; Lambert, 1992 ; Norcross et al., 1993). Recently, however, a number of integrative therapies have gathered support in randomized clinical trials (see Schottenbauer,


Glass, & Arnkoff, 2005). Empirical investigation of whether psychotherapy integration works is necessary to support its use and discover its impact on clients (Norcross & Thomas, 1988). For instance, it is important to know whether psychotherapy integration is more useful to clients than the pure-form therapies that are routinely tested in efficacy studies (Stricker & Gold, 1996). It would also be useful to understand the process by which clinicians make decisions to deviate from pure-form therapies (Beutler, Consoli, & Williams, 1995; Glass et al., 1993, 1998).

The call for empirical research on how the decisions of practicing therapists leads to psychotherapy integration is not new. A recommendation from the NIMH workshop on psychotherapy integration stated that “conceptual and research efforts that investigate what practicing therapists of different orientations actually do should be carried out before integrative interventions are developed and researched” (Wolfe & Goldfried, 1988, p. 449). Although this recommendation was made over 15 years ago, the research called for has not yet been done. A number of authors have pointed out that research in the field to find out what practicing clinicians do is an important step before developing manualized treatments for randomized controlled trials (Arnkoff, Victor, & Glass, 1993; Carere-Comes, 2001), but once again, this research has not yet been completed.

One of the complications of studying psychotherapy integration is that there are so many ways in which clinicians carry it out. While psychotherapy integration can take many forms, perhaps the most common is assimilative integration, which exists when a clinician espouses a primary theoretical orientation and selectively integrates theoretical ideas or therapeutic techniques from one or more different theoretical orientations (Messer, 1992). While different authors disagree somewhat about the definition of assimilative integration, the most common definition is one in which assimilative integration “favors a firm grounding in any one system of

Decision-Making and Psychotherapy Integration 5 psychotherapy, but with a willingness to incorporate or assimilate, in a considered fashion, perspectives or practices from other schools” (Messer, 1992, p. 151). It is commonly believed that assimilative integration occurs when a clinician encounters difficult cases that do not respond to typical treatment, and that it is the result of a pragmatic attempt to improve effectiveness (McCullough & Andrews, 2001; Wolfe, 2001). If this is the case, then clinicians are in a sense “local clinical scientists” who are continually testing theories to maximize therapeutic effectiveness (Stricker, 1996; Stricker & Trierweiler, 1995), and in doing so are amassing important information that could be quite valuable to psychotherapy researchers and clinicians (McCullough & Andrews, 2001). Gathering data on what clinicians actually do would serve to better meet the clinician’s needs for research relevant to practice (Goldfried & Padawer,

1982; Goldfried & Wolfe, 1998).

Variables Relevant to Decision-Making Research in Psychotherapy Integration

Although it is clear that research on psychotherapy integration is necessary (Wolfe &

Goldfried, 1988), many problems arise in studying it. Most psychotherapy integration is so complex that it is difficult to derive testable hypotheses because it encompasses an infinite set of possible combinations of interventions (Arkowitz, 1997). For instance, decisions regarding treatment are not made at one time, but are often continually reevaluated throughout therapy

(Beutler et al., 1995). Client characteristics that affect the selection of appropriate treatment, such as diagnosis or personality variables, may change over the course of treatment and complicate research (Beutler, 1991; Safran, Greenberg, & Rice, 1988; Safran & Messer, 1997).

Two main directions for research emerge from the psychotherapy integration literature.

First, many authors agree that it is necessary to use methods that are geared to discovering what is unfolding in therapy, rather than studying one-time clinical decisions (Norcross et al., 1993;


Stricker & Gold, 1996). Second, authors agree that it would be highly useful to develop an empirically derived common theory of decisional processes for psychotherapists (Beutler &

Clarkin, 1990; Beutler et al., 1995; Street et al., 2000). To accomplish these goals, research that utilizes both qualitative and quantitative methods can provide more comprehensive, solid findings; quantitative research can investigate the hypotheses in a large population, while qualitative research can provide rich clinical detail and illustration of broad principles (Arnkoff,

Glass, Elkin, Levy, & Gershefski, 1996).

As noted above, psychotherapy integration presents problems to researchers because there are an infinite number of aspects that can be studied (Arkowitz, 1997). The current paper discusses several aspects of psychotherapy integration that are particularly salient for current research. These include the decision of when to integrate, meeting client goals, client perceptions of therapy, and client characteristics influencing psychotherapy integration.

Deciding When to Integrate

The literature indicates that clinicians may decide to integrate for a number of reasons.

First of all, clinicians may tend to integrate when progress reaches a standstill with a client and the therapist’s primary theoretical orientation does not seem to be addressing the problem adequately (Goldfried, Castonguay, & Safran, 1992; Norcross et al., 1996; Norcross & Newman,

1992). Clinicians believe that integration can improve the effectiveness of therapy in a number of ways, including helping clients meet treatment goals in a shorter amount of time, helping a wider range of clients, cutting costs of therapy, and meeting the needs of each client as an individual (Norcross et al., 1996). Whether these factors are consciously used by therapists to determine when to integrate, however, has not been tested empirically. Other factors that may be relevant to the decision of when to integrate include “individual patient differences, phase of

Decision-Making and Psychotherapy Integration 7 therapy, patient state, patient capacity for absorption of process, or related contextual problems”

(Marmar, 1990, p. 267). These or other factors relevant to the decision to integrate may appear during a session, and therefore a number of authors have stressed the importance of understanding the context in which decisions are made (Greenberg, 1991; Marmar, 1990;

Shoham-Salomon, 1990; Stiles, Shapiro, & Elliott, 1986).

Meeting Client Goals

Psychotherapy integration may be an avenue by which therapists intentionally reach out to clients, incorporating some of the client’s perspectives and values in order to better engage clients in the therapeutic process. Clients come to therapy with their own goals and worldviews, which may be very different from that of the therapist. For instance, Zuber (2000) found that patients describe their problems in very different ways, and that the way a patient describes his or her problems may affect what interventions a therapist would consider to be best for that patient. Glass and Arnkoff (1982) suggested that treatment might be more effective if attempts are made to work with the client’s major coping styles before helping him or her develop new ones. Likewise, Bonanno and Castonguay (1994) suggested that therapists suit interventions to a client’s mode of being, help the client develop new ways of being, and prevent worsening of unhelpful ways of being. A retrospective study of the NIMH Treatment of Depression

Collaborative Research Program found that clients were more likely to stay in therapy and develop a positive therapeutic alliance if their preferences matched the type of therapy to which they were randomly assigned (Elkin et al., 1999). It would be useful to investigate ways in which clinicians choose integrative techniques or theories in order to adjust to client preferences and to help meet the client’s goals, and how these relate to client retention and outcome.

Client Perceptions of Therapy


The role of client perceptions of therapy in clinician decision making is another area for potential research. Client perceptions of therapy are important because clients are responsible for coming to therapy each session; if a client does not perceive enough positive benefit from therapy, or perceives therapy as harmful, then these perceptions may result in termination. In short, clients need to perceive that their goals are being met in order to stay in therapy (Arnkoff et al., 1993). It is clear that client perceptions of therapy are an important, yet underinvestigated, area for research (Street et al., 2000), because understanding client perceptions could lead to the development of ways in which to better engage clients in therapy (Norcross et al., 1993).

Previous studies show that clients do not perceive interventions the same way as therapists do (e.g., Fuller & Hill, 1985, Llewelyn, 1988). Moreover, not all clients are alike, and variables such as the therapeutic alliance (i.e., the client’s perceptions of alliance) may depend partially on client characteristics (Bonanno & Castonguay, 1994). For instance, studies have shown that it is the client’s perceptions of empathy that is related to outcome, rather than the therapist’s or an observer’s perceptions (e.g., Beutler, Crago, & Arizmendi, 1986; Orlinsky &

Howard, 1986). Studies on client perspectives have shown that clients report a common core of helpful aspects of therapy (Paulson, Truscott, & Stuart, 1999), regardless of the therapeutic orientation of the therapist (Gershefski, Arnkoff, Glass, & Elkin, 1996). Few studies, however, have been conducted on the relationship between client preferences and outcome (Glass,

Arnkoff, & Shapiro, 2001).

Potential areas for exploration of client perceptions with regard to decision-making within psychotherapy integration include the impact of client feedback on therapist decision making. Since different clients can perceive the same intervention in varying ways, studies are necessary to understand the interface between therapist decisions (with their concomitant

Decision-Making and Psychotherapy Integration 9 intentions) and outcome (as perceived by the client), both within each client-therapist relationship and between clients. The tendency of a therapist to generalize rules for choosing psychotherapy integration with different clients is another potential topic of research.

Client Characteristics

A number of client characteristics may influence a therapist’s decision to integrate. One of the main questions facing psychotherapy researchers is patient matching: “are there particular persons, problems, diagnoses, or psychological characteristics for which this therapy can be empirically demonstrated to be most effective?” (Stricker & Gold, 1996, p. 54). Research has shown that there may be interactions between patient characteristics and particular interventions

(Beutler & Consoli, 1992). Beutler and Clarkin (1990) reviewed the literature to find criteria for matching, including diagnosis, patient expectations, coping ability, personality, environmental stressors/resources, therapist-patient compatibility, response to role induction, reactance level, readiness to change, and breadth of pathology. More recent research has shown that variables relevant to choosing therapeutic techniques can be grouped into four categories, including patient predisposing variables, treatment context, relationship qualities and interventions, and selection of the strategies and techniques that best fit the patient (Beutler & Martin, 2000).

There has been a call for the development of algorithms for making treatment decisions based on client characteristics (Arkowitz, 1992; Beutler, 1991; Shoham-Salomon & Hannah,

1991), and several theoretical models for treatment matching have been proposed (e.g., Beutler et al., 1995; Bonanno & Castonguay, 1994; Lazarus, 1989; Prochaska & DiClemente, 1986), but

Decision-Making and Psychotherapy Integration 10 the large number of variables involved (about 1.5 million possible interactions, by one count) make comprehensive empirical tests of matching impossible (Lampropoulos, 2001).

Even if comprehensive studies of treatment matching would be feasible, they would have crucial flaws. While clients may appear to be similar in one respect, it is not uncommon for them to have different factors contributing to that same problem (Collins & Messer, 1991).

What is more, client characteristics can change over the course of treatment, requiring the clinician to constantly reevaluate treatment decisions (Beutler, 1991; Rice & Greenberg, 1984;

Safran et al., 1988; Safran & Messer, 1997). Thus, it becomes virtually impossible to study treatment matching comprehensively. Yet, the issue of treatment matching is a problem with which clinicians deal every day. Research aimed at understanding how clinicians deal with the problem of treatment matching would be useful in order to develop general guidelines for matching based on clinical wisdom.

Possible Theoretical Frameworks for Decision-Making Processes of Integrative Psychotherapists

The above questions regarding psychotherapy integration can be subsumed under the primary issue of clinical decision-making. Research on decision making has included a wide variety of methods, from early studies centered on the accuracy of diagnostic judgments and utility theory (e.g., Slovic & Lichtenstein, 1971; Tversky & Kahneman, 1973), to a more recent focus on information processing (e.g., Feltovich, Johnson, Moller, & Swanson, 1984; Johnson et al., 1981). Yet another promising contemporary theory, bounded rationality (Gigerenzer, 2001), has not yet been applied to the area of decision making in clinical psychology. The benefits and shortcomings of each of these are considered in turn.

Decision Analysis and Utility Theory


Subjective utility theory, the dominant theory of decision making for the past three centuries, consists of analyzing decisions through investigating all possible outcomes, assigning probabilities of success to each, and rationally choosing the best (Hastie, 2001). Its benefits include that it is systematic and unambiguous (Elwyn, Edwards, Eccles, & Rovner, 2001).

Decision analysis and utility theory have been applied in a wealth of studies to examine clinical judgment and decision-making using brief case conceptualizations or neatly packaged decision problems. Much of this research has focused on faulty heuristics and distortions in clinical reasoning (e.g., Dumont, 1993; Grove & Meehl, 1996; Ross & Nisbett, 1991), and is based on the work of Tversky and Kahneman (1973). Research from this point of view has shown that clinical psychology experts are biased, lack validity and reliability, and are unaware of their shortcomings (for a review, see Shanteau, 1992).

Studies based on utility theory, however, are flawed in that they do not approximate reallife situations well (Elstein, 1988; Hastie, 2001). First, these studies assume that each possible choice and its corresponding probability of success is evident on the onset of the task. In complicated situations such as psychotherapy integration, however, new possibilities for interventions may emerge over time, and their apparent likelihoods of success may change as new information is gathered. Second, decision analysis and utility theory assume there is one correct answer. In psychotherapy, however, there is no one correct answer; for instance, various psychotherapies have been shown to have similar outcome and may in many ways be equivalent

(Smith, Glass, & Miller, 1980). On a more subtle level, research is beginning to show that decision making is inherently not a rational task in the way previously specified by decision analysis and utility theory. Newer research has shown that emotion is not just a problem or incentive encountered by the decision-maker, but a vital variable that can influence the decision-

Decision-Making and Psychotherapy Integration 12 making process itself (Luce, Bettman, & Payne, 1997). Utility theory also ignores contextual factors such as social intelligence (Ortmann & Gigerenzer, 1997). Due to its shortcomings, utility theory is not an ideal theory for understanding the complexities of psychotherapy as conducted by real clinicians (Elstein, 1988). Two contemporary theoretical frameworks show the most promise: information processing and bounded rationality.

Information Processing

Information-processing theory is a promising approach to studying psychotherapy because it utilizes symbolic and qualitative reasoning (Elstein, 1988). Information processing analyzes transcripts from experts to understand “what knowledge structures, cognitive operations, and rule structures are necessary and sufficient to reproduce the observed clinical reasoning” (Elstein, 1988, p. 19). This sort of approach is particularly important for areas in which decisions need to be reevaluated as time goes on. Concepts that are central to the information-processing approach include serial vs. parallel processing, attention, and strategies

(Massaro, 1993).

Serial processing involves the sequential analysis of information, while in parallel processing different lines of processing can occur simultaneously (Massaro, 1993). These concepts become particularly interesting with regard to the possible interactions between parallel and serial processing (Schweickert, 1992; Sternberg, 1975). For assimilative integrationists, it would be interesting to find out how their original primary theoretical orientation and newer theoretical or technical imports affect the flow of their information processing. For instance, an information-processing approach could clarify whether clinicians consider one treatment possibility at a time, or whether their original primary theoretical orientation interacts with newer techniques they have learned.


The concepts of attention and strategies are also important aspects of informationprocessing theory. Attention refers to control over cognition, within the context of constraints and limitations on cognitive abilities (Shiffrin, 1988). An important question is whether integrative psychotherapists focus on wider ranges of concepts than pure-form clinicians.

Alternatively, it may be that the number of concepts any therapist can focus on at one time is rather fixed by the limits of human computational capacity, so integrative therapists may focus on a similar number but more varied concepts during psychotherapy.

Strategies consist of cognitive efforts to maximize task performance (Massaro, 1993).

Techniques in which a single strategy or a mixture of strategies can be identified and analyzed

(Yantis, Meyer, & Smith, 1991) are highly relevant to psychotherapy integration. It would be interesting to find out whether clinicians utilizing psychotherapy integration use more strategies, or more complex strategies, than clinicians using pure-form therapies. The ways in which integrative clinicians combine strategies from different forms of therapies would also be an important topic to consider.

A variety of findings from information theory studies are relevant to psychotherapy integration. For instance, experts have been found to have well-organized knowledge, although they may use the same decision-making strategies as novices (Elstein, 1988). They tend to structure problems that present as vague, limit and focus data collection, evaluate using categories or coding schemes, have ideas for what to do if certain tactics do not work, and are vigilant for unusual conditions. Moreover, they tend to sort information by being on the lookout for “prototypic” characteristics, by distinguishing “signal” from “noise,” and by bounding and simplifying problems (Elstein, 1988).


One researcher who has examined psychotherapist decision-making using informationprocessing techniques is Caspar (1995, 1997). His research utilizes an in-depth reconstructive technique to analyze the process that goes on in a therapist’s mind. After a therapy session, he asks the therapist to describe what he or she was thinking during the first 15 minutes of a session three times: first, without additional stimulation (free recall), then with a transcript to provide minimal stimulation of memories, and finally, with a videotape that provides additional stimulation. This is a lengthy process; it takes half a day for the therapist to review 15 minutes.

Caspar (1995) found that thought processes differ both according to primary orientation and experience level; in addition, a therapist’s attention to data (i.e., verbal vs. nonverbal) during the session may vary according to these variables. For instance, psychoanalysts tended to think more interpretive and evaluative thoughts with implicit causal relations, while behavior therapists tended to think in more inductive, causal, and intuitive terms. Experienced therapists planned information gathering more carefully, processed information more selectively, and thought in more automatic and complex ways than inexperienced therapists. Based on Caspar’s findings, decision-making processes among assimilative integrationists may be expected to vary according to their primary theoretical orientation. However, there should also be some similarities among experienced assimilative integrationists, in that they should demonstrate some of the concepts that Elstein (1988) describes as characteristics of experts.

Bounded Rationality

While the information processing approach described above has proved fruitful, there is another contemporary theory that has yet has not been applied to decision-making in psychotherapy: bounded rationality. Bounded rationality is a concept coined by Simon (1955,

1956) and expanded in recent years by researchers such as Gigerenzer (2001); it acknowledges

Decision-Making and Psychotherapy Integration 15 the practical limits on decision-makers, including resources such as time, knowledge, and computational capacity, and attempts to explain how people can make decisions quickly and efficiently to meet specific goals in the presence of both internal and external demands

(Gigerenzer, 2001). In these ways, it differs significantly from traditional utility theory, in which unlimited resources, information, knowledge of probabilities, and time were assumed to be available to the decision maker, and in which an optimal decision was thought to exist

(Gigerenzer, 2001).

A central component of bounded rationality is satisficing, which consists of “[s]trategies that successfully deal with conditions of limited time, knowledge, or computational capacities”

(Gigerenzer, 2000, p. 167). Satisficing is closely linked to the use of fast-and-frugal heuristics, which include ways of quickly gathering information and then making decisions based on this knowledge, using limited computational capacity. Satisficing and fast-and-frugal heuristics clearly apply to clinical decision making because they include the limits inherent to the clinical decision-making task: limited time and computational capacity with which to make a decision, limited knowledge of the client and psychotherapeutic techniques, and an unknown number and types of possible client reactions to an intervention.

Although specific heuristics are different, they are made up of similar building blocks: search rules, stopping rules, and decision rules. Search rules include rules about determining alternative routes of action and gathering cues with which to evaluate the various alternatives.

For an integrative psychotherapist, alternatives include the various options for intervention, and cues would include any perceived variables associated with patient characteristics, preferences, setting, etc. that are related to the choice of alternatives. An example of client cues is the concept of client markers, i.e., behavior that the therapist takes as an indication that the time is

Decision-Making and Psychotherapy Integration 16 right for a particular intervention (Rice & Greenberg, 1984). Client markers and the ideal therapist response have been found to vary according to therapist orientation (Messer, 1986).

Understanding these differences may be key to understanding how psychotherapy integration works in real clinical settings (Safran & Messer, 1997).

Another key component of fast-and-frugal heuristics is stopping rules, or one or more simple criteria that need to be met in order for the search for alternatives and cues to be stopped and a decision made. One example of a stopping rule is criterion A for depression from the

DSM-IV-TR, which requires five of nine positive characteristics (American Psychiatric

Association, 2000); thus, once a clinician discovers a client has five of these characteristics, he or she can stop searching for information in order to make a diagnosis. Stopping rules depend on the aspiration level, or the level that is deemed as a suitable solution meeting certain criteria, which can be adjusted during the search. For instance, a therapist may be about to stop gathering information about diagnosis until the client mentions cutting; at this point, the therapist may begin to probe for more details to evaluate other diagnostic possibilities. Decision rules are heuristics used to make decisions in limited time, based on the limited information acquired during the search for alternatives and cues. A therapist is generally limited to once-a-week, 50minute sessions, during which a limited amount of information about a client can be obtained.

The theory of bounded rationality considers three basic elements relevant to the decision-making task: psychological plausibility, ecological rationality, and domain specificity.

Following the presentation of the basic elements of the theory, the concept of the "adaptive toolbox" and research support are discussed.

Psychological plausibility. Psychological plausibility refers to the way in which people actually reason when time, knowledge, computational capacity, and other resources are limited.


This includes an examination of cognitive and emotional factors working within the decisionmaker’s mind that affect the decision-making process (Gigerenzer, 2001). It includes all of the factors described above, such as search rules, stopping rules, and decision rules. It is important to note that emotions have also been found to play an important role in decision making.

Research on emotions in bounded rationality has found that emotions affect decision making through restricting the range of options and focusing attention (Hanoch, 2002). For integrative psychotherapists, psychological plausibility refers to the ability of the therapist to make treatment decisions, including the information and treatment options available to the therapist, the temporal and practical limitations on the therapist during treatment, and the therapist’s limited computational capacity to calculate probable outcomes of various treatment routes.

Ecological rationality. Ecological rationality considers whether the decision-making process is adaptive, that is, it meets the demands of the environmental conditions in which the decision-maker resides. This includes an examination of the match between a heuristic and the environment in which it is used, how well heuristics generalize to different situations or environments (robustness), and the way in which social norms, social imitation, and social emotions are incorporated when dealing with other humans (Gigerenzer, 2001). The social contexts in which decisions are based play an important role in ecological rationality. When evaluating decisions using bounded rationality, decision makers do much better than as expected by traditional utility theory (Ortmann & Gigerenzer, 1997).

Ecological rationality is central to therapy, in that there is a continual interplay between the client and the therapist in which each adjusts to the other (Pole & Jones, 1998). In psychotherapy integration, where the primary goal of integration in the mind of most therapists is to best meet the needs of the client (Garfield, 1994), ecological rationality becomes a key feature.


Domain specificity. Domain specificity refers to the situation-specific nature of heuristics

(Gigerenzer, 2001). While heuristics are made up of general building blocks, each heuristic is tailored to its situation. For therapists who practice assimilative integration, domain specificity refers to the extent to which specific heuristics for assessment and treatment generalize from client to client. This may be related to the degree to which therapists integrate, with what types of clients they integrate, and the use of integration over time with one client as the client changes during therapy.

Adaptive toolbox. One of the aspects of bounded rationality that seems to apply particularly well to psychotherapy integration is the notion of an adaptive toolbox, which is a set of strategies and heuristics for dealing with various problems (Gigerenzer, 2001). As psychotherapists are trained in various techniques and work with various clients, they begin to develop strategies for dealing with clients. Some of these strategies may be more relevant to certain patients, diagnoses, or situations than others (Beutler, 1991). These sets of strategies can be thought of as an adaptive toolbox, which therapists bring to each new therapy situation.

Psychotherapy integration can be thought of as having more tools in the toolbox, or a larger set of heuristics for assessment and treatment from which to draw. In addition, psychotherapy integration may be associated with having a more flexible heuristic that allows for seeking out novel alternative treatment solutions when cues appear inconsistent with previously available options.

The adaptive toolbox is also useful in helping understand the ways clinicians deal with multiple goals and possible incommensurability between goals (e.g., Selten, 1998). Often in psychotherapy, the therapist is presented with different therapeutic goals, all of which can not be cannot be achieved at the same time or in the same manner, and the therapist must choose

Decision-Making and Psychotherapy Integration 19 between them (Beutler, 1991). In this situation, the therapist must decide upon the most important proximal goal or goals and the ways in which they can be achieved. Strategies in the adaptive toolbox are not aimed at determining the best way of doing things, because one best strategy does not exist (Gigerenzer, 2001). This especially is the case when multiple, sometimes incompatible goals or cues exist, or when the cues, reasons, alternatives, or consequences of actions are not known, as is usually the case in psychotherapy.

Research support. Various research has supported bounded rationality. For instance,

Gigerenzer and Goldstein (1996) found that bounded rationality heuristics were more effective for describing decision-making than utilitarian models. Other studies have found support for bounded rationality, with the caveat that there are situational differences in the way it is employed (Bröder, 2000; Newell & Shanks, 2003). While these studies have been conducted on tasks remote from the therapeutic consulting room (guessing the population of cities, estimating the similarity of objects and cues, and purchasing stock), recent applications of bounded rationality to medical decision making point to its promise in the clinical realm (Elwyn et al.,

2001).

Implications, Preliminary Data from Practicing Psychotherapists, and Directions for Future Research

Both bounded rationality and information-processing theory appear to be adequate theories to describe clinician decision making. While these two theories approach the same problem in intrinsically different ways, there is also some conceptual overlap between the two.


For instance, the information-processing concept of attention, which includes an understanding of the limits of human capacities, is similar to the concept in bounded rationality of searching for alternatives and cues and making decisions with limited time and computational ability.

Likewise, the information-processing emphasis on strategies shares some common ground with heuristics, in that both attempt to describe the ways in which people go about making decisions.

Despite these general similarities, there are important differences in how these two approaches can help researchers understand how integrative psychotherapists make decisions.

Information processing is more descriptive in a general sense; it can provide insight into what goes on in a psychotherapist’s mind. In this way, it is more valuable for describing the flow of information and providing general strategies for sorting through that information. While bounded rationality also can help understand variables associated with the process (search, stop, and decision rules), it is more focused on the decision-making process itself. Studying psychotherapist decision making utilizing bounded rationality may help elucidate some of the fast-and-frugal heuristics employed by clinicians (If X, then do Y), which may have more implications for research and education. Bounded rationality also takes into account the environment in which decisions take place. This emphasis on ecological rationality and on social interaction includes aspects that are very relevant to the decisions made in psychotherapy.

While both information-processing and bounded rationality approaches may contribute significantly to the understanding of psychotherapist decision making, the implications of utilizing bounded rationality are considered in more depth here.

Studies of clinician decision making guided by the theory of bounded rationality could answer a number of important questions. First, what are the internal decision-making processes underlying clinicians’ selections of therapy interventions? This question includes determining

Decision-Making and Psychotherapy Integration 21 the alternatives readily available to therapists, the cues therapists seek in order to decide among alternatives, and the rules therapists use to decide when to stop looking for information and make treatment decisions. It also includes the fast-and-frugal heuristics that clinicians utilize when making decisions. A second question pertains to how clinicians’ decisions interface with the therapy environment (e.g., patient needs, setting, etc.). In therapy, there is a constant interplay between the client and the therapist, in which each adjusts to the other over time. Investigating ecological rationality in the social context of therapy would involve evaluating whether the decisions of the therapist to intervene on a moment-to-moment basis, as well as on a longer-term basis, are meeting the needs of the client. A third question relates to how a clinician’s scripts for decision-making processes transfer across client and situation. This would involve studying a clinician’s decision making with a number of clients with differing characteristics and across a number of sessions for each client to determine how much transfer occurred, both between clients and across sessions as clients changed. In order to begin to test some of these hypotheses, a preliminary study was conducted.

Preliminary Research with Practicing Psychotherapists

An initial study was conducted to gather preliminary data concerning Gigerenzer’s

(2001) theory as discussed in this paper, as part of a larger study on therapist-reported treatment of clients who experienced trauma.

Participants. The sample consisted of psychotherapists who completed an online questionnaire, including an open-ended question on decision-making in the context of client lack of improvement ( N = 171). Of these, two did not report their theoretical orientation, and were thus not included in the analyses. Clinicians were primarily from the United States (87%) and the majority were female (64%). Fifty percent had Ph.D. degrees, with the remainder holding an


M.A. or M.S. (12%), M.S.W. (11%), M.D. (9%), Psy.D. (9%), or other (9%) degree. Most worked in clinical psychology (54%), with social work (10%), counseling psychology (10%), psychiatry (9%), counseling (6%), marital and family therapy (2%), nursing (1%), pastoral counseling (1%) and other (7%) professions also represented. Most (61%) had completed advanced psychotherapy training, 15% were psychoanalysts, and 6% were currently in psychoanalytic training.

Procedure.

Psychotherapists were recruited via e-mails and professional psychotherapy organization list-servs and were directed to a webpage with questionnaires. Those who gave informed consent were asked a number of questions about their professional background, and then presented with a short case summary of a client who had experienced trauma. In addition to other measures not used in the present study, they were asked an open-ended question about what they would do if they saw this hypothetical client for a certain length of time and improvement and/or generalization of treatment gains did not occur.

Qualitative analyses were conducted on these data, including determining whether “pure-form” therapists reported implementing any techniques from outside their orientation if treatment gains did not occur, and whether or not they were as flexible when hitting a roadblock as therapists who reported themselves as primarily integrative therapists. For the purposes of this study, “pure-form” therapists were those who indicated that their primary orientation was one of several brand-name therapies, including p sychodynamic/psychoanalytic, behavioral or cognitive-behavioral, humanistic/experiential, family systems, or EMDR. Participants were also asked to rate their adherence to each of these theoretical orientations on a scale from 1 to 5, as well as to rate to what extent their work with clients was typified by an eclectic/integrative approach.


Coding categories. A coding manual was developed with 16 categories (see Table 1).

Categories 1 though 6 were developed to code explicit mention of techniques from specific types of psychotherapy. More general options, such as “exploring the client’s past,” which could be associated with a specific type of psychotherapy but is not exclusive to that form of psychotherapy, were given their own categories. Qualitative responses were coded by two raters, who were trained and reached excellent inter-rater reliability with kappa of .81.

Results. The intervention indicated most commonly among clinicians of all theoretical orientations was reassessment of the client, the client’s environment and motivation, or the therapist’s conceptualization of the client’s problems (see Table 2). The next most frequently mentioned category was refer to a different psychotherapist or a different therapy modality.

Third was consult with colleague(s) and/or obtain further education, followed by non-specific change or addition of treatment while staying in therapy with current therapist, and fifth, consider medication. Few respondents chose a specific technique, such as psychodynamic psychotherapy, cognitive-behavioral treatment, EMDR, psychoeducation, experiential techniques, or another specific approach.

For the largest two groups of clinicians, CBT ( n = 61) and psychodynamic ( n = 62), chisquare tests were run to determine if the number of clinicians endorsing specific techniques differed between groups. Analyses could be conducted only on categories 2, 6, 7, 8, 9, 10, 11,

12, and 14, because no cells had an expected count of less than 5 on these items. Results showed a significant difference between groups only for category 9, considering medication.

Psychodynamic clinicians were more likely to consider medication than CBT clinicians,

 2 =

4.77, p = .04.


Discussion and implications from bounded rationality theory. The current study asked clinicians what they would do if their treatment for a particular client did not result in the client’s improvement in the expected amount of time. Interestingly, few clinicians responded that they would try techniques from specific theoretical orientations. Rather, clinicians most often responded that they would reassess the client, the client’s environment and motivation, or the therapist’s conceptualization of the client’s problems. Examining this finding through the lens of bounded rationality, we could ask whether this answer has ecological rationality (e.g., does it meet the demands of the environment). In this case, the answer is affirmative; if a client is not making progress in the expected amount of time, reassessing the situation meets the demand of the treatment contract, which implies that the purpose of the therapy relationship is to effect change in the client. We could also ask whether the decision has psychological plausibility (e.g., what are the cognitive and emotional factors related to the reasoning, what are the decision rules involved, etc.). Examining psychological plausibility is outside the bounds of the current study, however, since it would be necessary to know more about the mental process that went into the decision process. With regard to domain specificity, we could ask whether the decision to reassess would occur for only the client in this study, or for certain types of clients, or for all clients, but we would need additional studies to answer this question. Finally, with regard to the notion of the adaptive toolbox, we could note that the clinician’s decision to reassess, and the specific methods that he or she might use, would depend on the clinician’s adaptive toolbox of assessment techniques (e.g., what are their assessment skills and abilities).

In our preliminary study we found that second most often, clinicians responded that they would refer the client to a different psychotherapist or different therapy modality. From the perspective of bounded rationality, this raises the question as to whether clinicians decide that

Decision-Making and Psychotherapy Integration 25 they do not have the tools in their adaptive toolbox to solve the problems of that particular client and therefore refer. If this is the case, perhaps the argument could be made that clinicians in the community ought to be encouraged to learn a wider number of techniques, so as to have more techniques to intervene with difficult clients. Another question is whether they would refer all clients who do not make progress in the expected time (domain specificity), or whether there were specific characteristics of this client that are related to their decision to refer. Additionally, did the clinicians choose to refer because they are inferring a poor client-therapist fit (ecological rationality)? Client-therapist fit is thought to be an important variable in psychotherapy (Scheidt, et al., 2003); if this is factoring into their decision, then further studies could examine which relational variables are relevant to the decision-making process that leads to referral

(psychological plausibility).

From the perspective of psychotherapy integration, it is interesting that when clinicians indicated that they would change their techniques, they most often indicated a theoretically nonspecific change or addition to treatment rather than endorsing the use of techniques from a major

“name brand” of therapy. This might suggest that clinicians in the community prefer “common factors,” or elements of therapy that are found in many therapies, and that “common factors” may make up much of clinicians’ adaptive toolbox. If so, is this because they have found these factors to be more effective than specific techniques? More research is needed to flush out the reasons why clinicians in the community might prefer non-specific techniques to “name brand” therapies. It is possible that clinicians did not endorse CBT techniques because either they are already employing these techniques and they are not already working, or they are not cognitivebehavioral in their orientation and even when that’s not working they don’t know enough about

CBT to try it. In particular, it is interesting that relatively few clinicians indicated that they

Decision-Making and Psychotherapy Integration 26 would employ cognitive-behavioral or EMDR techniques with difficult clients, since those types of “pure-form” therapy have been backed by the most empirical evidence to date. The reason for this divide would be an apt area for further research.

In summary, more research is needed to understand the decisions that practicing psychotherapists make when they hit roadblocks, in order to tap into clinicians’ practical wisdom, and in order to improve therapeutic outcomes. Bounded rationality provides insights into understanding some of these processes, as well as pointing the way for areas of future research.

Future Directions for Research on Integrative Decision-Making Employing Bounded Rationality

Better appreciation of the applicability of bounded rationality to clinician decision making is necessary in order to develop a more comprehensive model of clinical decision making in psychotherapy practice that then can be tested in a larger sample. Qualitative research would be particularly helpful in this regard (e.g., Hill, Thompson, & Williams, 1997). For instance, a series of qualitative studies could ask clinicians to report how they decide on specific interventions for particular clients. Initial qualitative studies could be done in several ways: 1) an interview about their practices in general, 2) an interview about specific decisions made with one of their actual clients, or 3) an interview about decisions they would make to treat a patient presented in a standardized form, such as on videotape or in a script. The interview would inquire in general about therapists’ decision-making process, and qualitative analyses would be used to determine if any themes arose in their responses. Similar research on web-based decision-making among youth (Agosto, 2002) found common domains in their explanations, including time constraints (imposed or self-generated), cognitive constraints (e.g., information overload, outcome overload), physical constraints (e.g., exertion, discomfort), and strategies for

Decision-Making and Psychotherapy Integration 27 satisficing (e.g., reduction of data, attraction to known elements, termination rules, acceptance).

In a social decision-making environment such as psychotherapy, emotions may also have an important role in clinician decision making.

Initial qualitative studies could facilitate the generation of standardized measures of clinician decision making. Future studies could utilize standardized measures to gather information on a large-scale basis about the use of clinical heuristics. This research on clinician decision making could have important implications with regard to education. A clear understanding of psychotherapists’ decision making could result in the development of psychotherapy manuals that would better be able to teach clinicians effective ways for flexibly meeting client needs, as well as offering a venue for teaching these effective methods of mental health treatment to new clinicians.

In conclusion, more research on clinical decision making in psychotherapy integration is needed. Contemporary theories such as bounded rationality and information processing hold great promise for facilitating the understanding of clinician decision-making. Applying these theories to clinical decision-making will take time and effort, but may have important implications for understanding the process of psychotherapy and improving training and the quality of care.


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Table 1

Coding Categories: What Would You Do If Improvement Did Not Occur?

1. Psychodynamic psychotherapy. Code if the therapist specifically mentions

“psychodynamic” or “psychoanalytic,” or if specific techniques commonly associated with any of these are recommended (e.g., interpretation).

2. Cognitive-behavioral treatment. Code if “CBT,” “behavior therapy,” “DBT,” or specific interventions commonly associated with any of these are recommended (e.g., exposure to anxiety hierarchy).

3. Eye Movement Desensitization and Reprocessing (EMDR). Code if “EMDR” is specifically mentioned.

4. Psychoeducation. This category includes adding elements of didactic information to the treatment, or referring the client to psychoeducational material or experiences of any sort.

The therapist may give the client information directly in sessions, or may give the client reading material or refer him or her to a program.

5. Experiential techniques. Code this category if experiential or Gestalt therapy are mentioned, or if specific techniques commonly associated with any of these are recommended (e.g., 2-chair technique).

6. Other specific approach recommended. Code this if a specific treatment that is not psychodynamic, CBT, EMDR, or experiential is recommended (e.g., “dance therapy”).

7. Non-specific change or addition of treatment, while staying in therapy with current therapist. Code this category if change is non-specific (e.g., “change approach”), if a nontheoretical treatment is recommended. Code if they recommend a change in intensity or frequency of the current treatment (e.g., more sessions, take a break, etc.).

8. Consult with colleague(s) AND/OR obtain further education. This category includes the therapist consulting with an expert or with colleagues, or with a supervisor. Also code this category if the therapist indicates he/she would seek further education, including independent reading, taking classes or workshops, or enrolling in some other educational program for therapists.


9. Consider medication. Therapist mentions considering any form of medication, including prescription and non-prescription medicines. This category includes referring client for medication consult.

10. Refer to a different psychotherapist, or a different therapy modality that would imply a different psychotherapist (e.g., inpatient treatment). Code this category if the therapist specifically mentions the referral with the implication of terminating therapy with current therapist, or if therapist considers a referral. Referring to a psychiatrist for medication is

NOT coded in this category, unless it is made clear that the current therapy would be terminated upon the referral to a psychiatrist.

11. Explore the client’s past. Any mention of exploring the client’s past. Could include childhood issues, previous trauma, or other historical events. Anything “previous” to therapy counts as the past.

12. Explore therapeutic relationship. Any mention of the therapeutic relationship or working alliance.

13. Explore the client’s relationships outside therapy. Any mention of the client’s relationships outside therapy, or “relationship issues” stated in a general way.

14. REASSESS client, client’s environment and motivation, or therapist’s conceptualization of client’s problems. Code issues in this category if assessment or reassessment is mentioned. The statement may ALSO be coded in another specific category above if the therapist mentions assessing concepts related to a particular therapeutic viewpoint. For example, if the therapist mentions “reassessing the client’s early childhood”, it would be coded BOTH in category 11 and category 14. But if the therapist states “reassess the client” it is considered nonspecific and coded only in category 14.

15. Other. Code this category if the information provided does not fit in any other category.

Always code this category if the therapist states that their clients always improve, or “this has never happened to me.”

16. No Changes. Code this category if the therapist implies they would continue doing the same treatment.

Table 2

Number and percentage of clinicians reporting interventions for a client who is not improving, by clinician's predominant theoretical orientation

Suggested Strategies

Cognitive

Behavioral

( n = 61) dynamic

(

Psychon = 62) (

EMDR n = 12)

Family

Systems

( n = 4)

Humanistic

( n = 9)

Integrative/

(

Eclectic n = 17) (

Other n = 4)

1. Psychodynamic psychotherapy 2

(3.3%)

1

(1.6%)

1

(11.1%)

1

(5.9%)

2. Cognitive-behavioral treatment 10

(16.4%)

6

(9.7%)

1

(8.3%)

3. Eye Movement Desensitization and

Reprocessing (EMDR)

1

(1.6%)

2

(16.7%)

1

(25.0%)

1

(5.9%)

4. Psychoeducation

5. Experiential techniques

6. Other specific approach recommended 5

(8.2%)

1

(1.6%)

1

(1.6%)

11

(17.7%)

1

(8.3%)

1

(25.0%)

1

(5.9%)

7. Non-specific change or addition of treatment, while staying in therapy with current therapist

8. Consult with colleague(s) AND/OR obtain further education

9. Consider medication

10. Refer to a different psychotherapist, or a different therapy modality

11. Explore the client’s past

12. Explore therapeutic relationship

13. Explore the client’s relationships outside therapy

14. Reassess client, environment and motivation, or therapist’s conceptualization of problems

15. Other

18

(29.5%)

22

(36.1%)

11

(18.0%)

28

(45.9%)

22

(35.5%)

21

(33.9%)

22

(35.5%)

28

(45.1%)

2

(16.7%)

5

(41.7%)

4

(33.3%)

2

(16.7%)

2

(50%)

1

(25.0%)

1

(25.0%)

6

(9.8%)

9

(14.8%)

5

(8.2%)

6

(9.7%)

7

(11.3%)

2

(3.2%)

43

(70.5%)

42

(67.7%)

6

(50.0%)

1

(8.3%)

10

(83.3%)

1

(25.0%)

1 1 3

2

(22.2%)

3

(33.3%)

4

(44.4%)

3

(33.3%)

1

(11.1%)

5

(55.5%)

3

(17.6%)

2

(50.0%)

6

(35.3%)

5

(29.4%)

6

(35.3%)

3

(75.0%)

2

(50.0%)

3

(17.6%)

1

(5.9%)

1

(5.9%)

13

(76.5%)

2

(50.0%)

2

16. No Changes

(1.6%)

3

(4.9%)

(1.6%)

3

(4.8%)

(25.0%)

1

(8.3%)

(11.8%)

1

(5.9%)

DECISION MAKING AND PSYCHOTHERAPY INTEGRATION

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