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Assessing patient suitability for short-term cognitive

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Article in Cognitive Therapy and Research · February 1993

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Cognitive Therapy and Research, Vol. 17, No. 1, 1993

Assessing Patient Suitability for Short-Term

Cognitive Therapy with an Interpersonal Focus
Jeremy D. Safran 1
Adelphi University

Zindel V. Segal
University of Toronto

T. Michael Vallis
Dalhousie University

Brian F. Shaw
Toronto GeneralHospital and Universityof Toronto

Lisa Wallner Samstag

Beth IsraelMedical Center

In the current study, the development and initial validation of the Suitability
for Short-Term Cognitive Therapy (SSCT) interview procedure is reported. The
SSCT is an interview and rating procedure designed to evaluate the potential
appropriateness o f patients for short-term cognitive therapy with an
interpersonal focus. It consists of a 1-hour, semistructured interview, focused
on eliciting information from the patient relevant to nine selection criteria. The
procedures involved in the development of this scale are described in detail,
and preliminary evidence suggesting that the selection criteria can be rated
reliably is presented. In addition, data indicating that scores on the SSCT scale
predict the outcome of short-term cognitive therapy on multiple dependent
measures, including both therapist and patient perspectives, are reported. It is
concluded that the SSCT is a potentially useful scale for identifying patients

tAddress all correspondence to Jeremy D. Safran, The Derner Institute, Adelphi University,
Garden City, New York 11530.

23
0147-5916/93/0200-0023507.00/0 © 1993 Plenum Publishing Corporation
24 Safran, Segal, VaUis, Shaw, and Samstag

who may be suitable, or unsuitable, for the type of short-term cognitive therapy
administered in the present study.
KEY WORDS: patient selection;short-term therapy; predictingoutcome.

In the last 20 years there has been a strong trend toward the development
of short-term therapeutic approaches. Since not all patients can benefit
from short-term therapy, most of these therapeutic approaches emphasize
the importance of assessing the suitability of patients for treatment, prior
to the commencement of therapy (e.g., Davanloo, 1980; Malan, 1976;
Mann, 1973; Sifneos, 1972; Strupp & Binder, 1984).
While the development of short-term cognitive therapeutic ap-
proaches (e.g., Beck, Rush, Shaw, & Emery, 1979) has been quite important
in influencing the general trend toward brief-term therapeutic approaches,
cognitive therapists have traditionally placed less emphasis on the system-
atic evaluation of patient suitability than their psychodynamic counterparts.
There have been some criteria articulated by Beck et al. (1979) which are
relevant to the depressed patients who are suitable for cognitive therapy
(e.g., diagnosis of major depression, failure to respond to antidepressant
medication, variable mood reaction to environmental events). These crite-
ria, however, appear to be primarily concerned with the question of
targeting a subgroup of depressed patients for whom psychotherapy rather
than pharmacological intervention is indicated.
Two recent studies have attempted to clarify factors relevant to de-
termining patients' suitability for short-term cognitive therapy. Fennell and
Teasdale (1987) found that patients who responded positively to a written
treatment rationale and who reported a positive response to homework as-
signments benefited more from short-term cognitive therapy than those
who did not. Persons, Burns, and Perloff (1988) found the following factors
to be predictive of outcome: low initial scores on the Beck Depression In-
ventory, c o m p l i a n c e with h o m e w o r k assignments, and absence of
endogenous symptoms. They also found that premature termination was
more likely in patients with personality disorders. While these two studies
constitute an important starting point in the direction of clarifying relevant
predictors, they do not provide a systematic framework for evaluating pa-
tient suitability.
The present article reports preliminary reliability and validity data on
a systematic assessment procedure, developed for purposes of evaluating
patient suitability for the form of short-term cognitive therapy described
in Safran and Segal (1990). The Suitability for Short-Term Cognitive Ther-
apy (SSCT) assessment procedure consists of explicit suitability criteria and
Assessing Patient Suitability 25

a semistructured interview designed to elicit information from the patient

relevant to the criteria (Safran, Segal, Shaw, & Vallis, 1990).
The selection criteria were designed to reflect the protocol for cog-
nitive therapy as represented in the work of Beck et al. (1979) as well as
some of the newer theoretical and technical developments that have taken
place in cognitive therapy in recent years. These include a greater emphasis
on the role of emotion in the change process (Foa & Kozak, 1986: Gui-
dano, 1987; Mahoney, 1991; Rachman, 1980; Safran & Greenberg, 1986),
a growing emphasis on the importance of the therapeutic relationship (e.g.,
Arnkoff, 1983; Beck, Freeman, & Associates, 1990; Jacobson, 1989; Safran,
1990a; 1990b; Young, 1990), and the recognition of the importance of de-
fensive information processing and interpersonal maneuvers for purposes
of reducing anxiety and maintaining interpersonal security (Beck et al.,
1990; Guidano, 1987; Liotti, 1987; Safran, 1990a). Those interested in a
more detailed and systematic description of these developments are re-
ferred to Safran and Segal (1990).
The development of the SSCT, including the selection of the specific
criteria and the development of the interview procedure, was guided by
two primary sources. The first was previous assessment procedures devel-
oped by short-term dynamic therapists (Malan, 1976; Mann, 1973; Strupp
& Binder, 1984). Sifneos (1972), for example, argued that the following
characteristics predict a good outcome in his approach: (1) above-average
intelligence; (2) a history of at least one meaningful relationship during
the patient's life; (3) the ability to interact well with the evaluator; (4) a
circumscribed chief complaint; and (5) motivation for change. Davanloo
(1980) suggested that patients who are appropriate for his approach to
short-term therapy should meet the following criteria: (1) the presence of
meaningful relationships in the past; (2) the ability to tolerate anxiety, guilt,
etc.; (3) a sense of psychological mindedness; (4) motivation to tolerate
the uncovering and working through of character problems; and (5) positive
responses to trial interpretations during a pretherapy evaluation interview.
By surveying the literature on short-term dynamic therapy in this fashion,
we were able to distill an initial list of potentially relevant selection criteria.
A second major guiding influence was Bordin's (1979) conceptuali-
zation of the therapeutic alliance as consisting of bond, goal, and task
components. Following this formulation, we reasoned that it was important
to clarify what the relevant tasks and goals are in short-term cognitive ther-
apy as an aid in determining specific patient characteristics which would
be more or less suited to this approach. In addition, we felt that it was
important to evaluate the patient's potential ability to form a good thera-
peutic bond within a short-term time frame, independent of the degree of
26 Safran, Segal, Vallis, Shaw, and Samstag

fit between his or her particular style and the specific tasks and goals of
short-term therapy.
Over a 5-year time period, we oscillated back and forth between the-
ory, observation of intake interviews, and evaluation of clinical outcome,
modifying both our selection criteria and our intake interviews as we be-
came clearer about what variables seemed to be most highly predictive of
outcome. Eventually we formalized nine selection criteria into a rating
scheme, and developed an accompanying interviewer manual. The rating
scale for each item consists of nine scale points: five detailed descriptive
anchors that are designed to increase reliability of ratings, and four nonan-
chored half-point ratings. The interviewer manual was designed to guide
the interviewer in probing for information required to make reliable ratings.
This interview was designed to be used in a clinically sensitive manner, and
the order of items probed can be modified to meet the demands of the
specific situation. It takes approximately 1 hour and is administered to the
patient prior to the commencement of therapy.
This interview was designed both to evaluate the patient's perception
of the relevance of the tasks and goals of short-term cognitive therapy as
described by the-interviewer, and to evaluate his or her ability to engage
in these tasks. This second feature of the interview is consistent with the
practice of administering "test interventions" during the assessment inter-
view, as suggested by short-term dynamic therapists such as Sifneos (1972)
and Davanloo (1980). The interview procedure, selection criteria, and se-
lection criteria rating scales are described in greater detail in Safran et al.
(1990).
A brief description of the nine selection criteria is as follows:

1. Accessibility of automatic thoughts. This item evaluates the

patient's ability to access negative, self-critical thinking related to
the problems he or she is experiencing.
2. Awareness and differentiation of emotions. This item identifies the
patient's ability to distinguish between different emotional
experiences, and to experience emotions relevant to his or her
problems in the therapeutic session. These abilities are believed
to be important in facilitating the process of accessing relevant
automatic thoughts.
3. Acceptance of personal responsibility for change. The acceptance
of personal responsibility for change item evaluates the extent to
which the patient views him/herself as a potential agent in the
change process, as opposed to a passive recipient of treatment
provided by the therapist.
Assessing Patient Suitability 27

4. Compatibility with cognitive rationale. This item identifies the

extent to which the patient views the tasks and goals of short-term
cognitive therapy, as described by the therapist, as relevant.
Examples of relevant tasks include such activities as exploring the
r e l a t i o n s h i p b e t w e e n feelings and t h o u g h t s , testing out
expectations, doing homework assignments, and using the
t h e r a p e u t i c relationship as a vehicle for self-exploration.
Clarification of w h e t h e r the patient is able to establish a
r e a s o n a b l e goal to be accomplished within a s h o r t - t e r m
framework also provides important information (Fennell &
Teasdale, 1987; Persons et al., 1988).
5. Alliance potential." in-session evidence. This item measures the
patient's potential ability to form an adequate therapeutic alliance
within a short-term time frame, by evaluating the quality of the
i n t e r a c t i o n b e t w e e n the p a t i e n t and the interviewer. It
corresponds to the bond dimension of Bordin's conceptualization
of the alliance.
6. Alliance potential: out-of-session evidence. This item gauges the
bond dimension of the therapeutic alliance on the basis of
information about the patient's previous relationships. An
attempt here is made to evaluate whether the history of the
patient's previous relationships provides evidence that he or she
is able to establish a relatively trusting relationship within a
s h o r t - t e r m time f r a m e . Of p a r t i c u l a r r e l e v a n c e h e r e is
information about previous therapeutic relationships.
7. Chronicity of problems. The chronicity of problems item gauges
the duration of the presenting problem. The hypothesis here is
that more chronic, long-term problems may reflect the presence
of enduring dysfunctional characterological styles that may not
be amenable to change in short-term therapy.
8. Security operations. This item evaluates the extent to which the
patient employs defensive information processing strategies or
interpersonal maneuvers to reduce his or her anxiety level
(Sullivan, 1953). Although the concept of security operations is
not a part of traditional cognitive therapy theory, there is a
growing recognition by cognitive therapists of the role that these
types of self-protective strategies play in psychological dysfunction
(e.g., Guidano & Liotti, 1983; Mahoney, 1991; Safran & Segal,
1990). This dimension gauges the extent to which the intensity
of the patient's security operations will interfere with a reasonable
amount of self-exploration within a short-term context.
28 Safran, Segal, Vallls, Shaw, and Samstag

. Focality. Focality refers to the patient's ability to maintain a

problem focus. This is particularly important in a short-term
approach where time is limited.
This study represents an attempt to evaluate the utility of the SSCT.
A number of specific methodological and conceptual issues are addressed.
First, the interrater reliability of the scale is determined, using trained rat-
ers. Second, the predictive validity of the scale is evaluated by using
pretreatment SSCT ratings to predict outcome in cognitive therapy. Third,
the relationship between the nine dimensions of the SSCT and a self-report
measure of the therapeutic alliance (the Working Alliance Inventory or
WAI; Horvath & Greenberg, 1986) is examined in order to provide pre-
liminary evidence regarding the construct validity of the SSCT. It is
hypothesized that the alliance potential: in session evidence item of the SSCT
will correlate significantly with the WAI, since they are in theory tapping
similar dimensions, despite the difference in rater perspectives. The other
items of the SSCT, in contrast, should provide information which is non-
redundant (i.e., uncorrelated) with the WAI. Finally, a comparison of SSCT
scores is made between patients accepted for cognitive therapy and those
patients not accepted for cognitive therapy in order to provide preliminary
norms that may be of some clinical utility.

METHOD
Subjects
All subjects were outpatients referred to the Cognitive Therapy Sec-
tion at the Clarke Institute of Psychiatry, Toronto, a clinic offering
short-term cognitive therapy for either depressive or anxiety based disor-
ders. Diagnoses followed the Diagnostic and Statistical Manual of Mental
Disorders (3rd ed., rev.) (DSM-III-R; American Psychiatric Association,
1987) categories and were formulated on the basis of information compiled
during the clinical interviews and from the intake assessment battery meas-
ures. Forty-two clinic patients served as the treated sample, of whom 52%
were men and 48% were women. Ages ranged from 23 to 62 years, with
a mean age of 37.20 years (SD = 10.25). In addition, 45% of the sample
were married or had remarried, while 40% were single and 8% were either
separated or divorced (this information was unavailable for three of the
patients in this group). Twenty-two patients, evaluated for cognitive therapy
but not accepted into treatment, made up the nonaccepted sample. Of this
group, 54.5% were men and 45.5% were women with a mean age of 38.52
years (SD = 9.59); 14% were married or had remarried, 36% were single
Assessing Patient Suitability 29

and 18% were divorced (information regarding marital status was unavail-
able for seven patients in the nonaccepted sample).

Procedure

Prior to treatment, all subjects were administered the 1-hour semis-

tructured interview designed to elicit information relevant to rating the
suitability criteria. The five interviewers who participated in the study all
underwent extensive training in the interviewing and rating procedure, and
employed the SSCT interview manual and rating scales provided in Safran
et al. (1990). Three of the five interviewers were at the Ph.D. level, while
the other two were at the M.A. level. Interviewers' experience with the
selection procedure ranged from 1 to 5 years.
Following the interview, all interviewers rated their patients on the
nine SSCT dimensions, using the 9-point rating scales provided in Safran
et al. (1990). All patients then completed an intake battery consisting of
the Symptom Checklist-90 (SCL-90; Derogatis, 1977), the Millon Multiaxial
Clinical Inventory (MCMI; Millon, 1982), the Beck Depression Inventory
(BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Automatic
Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980), and the Dysfunc-
tional Attitudes Scale (DAS; Weissman & Beck, 1978). A final measure,
completed independently by both therapists and patients, consisted of 100-
point scale ratings of target complaints (Battle et al., 1966). For this
measure, patients were asked to identify three target complaints prior to
beginning therapy, which they rated for severity on a 100-point scale.
Therapists independently rated the same target complaints identified by
the patient. The three target complaint ratings made by patients and thera-
pists were then averaged to provide a mean target complaint rating frofn
both perspectives.
The mean BDI score from subjects at intake was 19.32 (SD = 8.52),
and the mean score on the global severity index of the SCL-90 was 50.36
(SD = 7.45). Pretreatment scores on the other symptom measures are re-
ported in Table IV.
At this point the case was discussed with the clinic team, and a de-
cision was made either to admit the patient to short-term cognitive therapy
or to refer him or her to some other treatment modality (e.g., long-term
psychotherapy and/or pharmacotherapy). Although this step narrowed the
range of patients accepted with respect to potential degree of suitability,
it was considered necessary for clinical reasons. This decision was not based
on the suitability criteria in any absolute sense. No specific cutoff scores
on any of the dimensions or on the overall suitability rating were employed,
30 Safran, Segal, Vallis, Shaw, and Samstag

and additional information such as psychometric testing and variables not

explicitly addressed by the SSCT influenced the decision. Since, however,
team members were familiar with the results of the SSCT, it is likely that
they influenced the decision to some extent. Although no precautions were
taken to ensure that therapists were blind to patients' SSCT scores, it was
not customary for therapists to make use of this information in any sys-
tematic way, and it is unlikely that therapists recalled the scores or that
the scores influenced their treatment of the patients.
Patients who were accepted for treatment were assigned to therapy
with either the SSCT interviewer or another therapist. This decision was
made exclusively on the basis of therapist availability. Therapy consisted
of a 20-session protocol of cognitive therapy. The treatment incorporated
the standard cognitive practices of exploring and challenging automatic
thoughts and dysfunctional attitudes. This focus was augmented with an
emphasis on employing the therapeutic relationship for exploring and chal-
lenging dysfunctional beliefs (e.g., Arnkoff, 1983; Goldfried, 1982;
Jacobson, 1989; Safran, 1990a; 1990b; Safran & Segal, 1990).
The Working Alliance Inventory (Horvath & Greenberg, 1986) was
administered to all patients following the third session of therapy. At ter-
mination, patients were administered the same battery completed at intake.
In addition, both patients and therapists independently provided a global
success rating on a 100-point scale. Finally, therapists and patients inde-
pendently rated the target complaints that had been selected by patients
at intake, and mean termination target complaint ratings were calculated
from both patient and therapist perspectives. Eight patients, who dropped
out of treatment prior to session 8, were excluded from the data analysis.
All other patients completed the 20-session protocol.

RESULTS
Reliability of the Rating Scales
Interrater reliability was evaluated by selecting a subsample of 11
SSCT interviews, and having these interviews independently rated by three
judges. Of the 11 interviews, 6 were selected from patients admitted to
treatment and 5 were selected from patients who had not been accepted.
The major criterion for interview selection was adequacy of the interview
(in the sense of adhering to the SSCT procedure outlined in Safran and
Segal, 1990). Raters prepared for the reliability study with intensive train-
ing, involving viewing of SSCT interviews and detailed reviewing of ratings
made. Ratings of the 11 SSCT interviews were made from audiotapes. Spe-
cific items were rated by starting at the low anchor of the 9-point scale for
Assessing Patient Suitability 31

Table I. Interrater Reliability of Three

Raters Using the Suitability for
Short-Term Cognitive Therapy
Interview (N = 11)a
SSCT item ICC coefficient
1. ACCESS .82
2. AWARE .75
3. ACCEPT .77
4. COMPAT .86
5. INALL .81
6. OUTALL .80
7. CHRON .98
8. SECUR .76
9. FOCAL .46
aNote: ACCESS = accessibility of
a u t o m a t i c thoughts; A W A R E =
awareness and d i f f e r e n t i a t i o n of
emotion; ACCEPT = acceptance of
personal responsibility for change;
C O M P A T = c o m p a t i b i l i t y with
cognitive rationale; INALL = in-session
alliance potential; OUTALL =
o u t - o f - s e s s i o n alliance p o t e n t i a l ;
CHRON = cbronicity of problems;
SECUR = security operations; FOCAL
= focality. SSCT = Suitability for
Short-Term Cognitive Therapy; ICC =
intraclass correlation.

e a c h i t e m a n d , if t h e r a t e r ' s j u d g m e n t j u s t i f i e d it, m o v i n g up the scale until

an a p p r o p r i a t e s c o r e was o b t a i n e d . This m e t h o d o f v a l u e a l l o c a t i o n is simi-
lar to t h a t u s e d with o t h e r r a t i n g scales, such as t h e G l o b a l A s s e s s m e n t o f
F u n c t i o n i n g Scale ( D S M - I I I - R ; A P A , 1987). I n t r a c l a s s c o r r e l a t i o n ( I C C )
c o e f f i c i e n t s for t h e s e r a t e r s w e r e c a l c u l a t e d f o r e a c h i t e m s e p a r a t e l y , a n d
a r e p r e s e n t e d in T a b l e I. E x a m i n a t i o n o f t h e r e s u l t i n g I C C c o e f f i c i e n t s in-
d i c a t e s t h a t all items, with t h e e x c e p t i o n o f locality, w e r e r a t e d with high
reliability.

Validity of the Rating Scales

T w o t y p e s o f validity o f p a r t i c u l a r i m p o r t a n c e for a scale such as t h e

S S C T , w h i c h u l t i m a t e l y w o u l d b e u s e d to d e t e r m i n e t r e a t m e n t suitability,
a r e c o n s t r u c t a n d p r e d i c t i v e validity. P r e l i m i n a r y d a t a a d d r e s s i n g t h e s e is-
sues w e r e c o l l e c t e d .
32 Safran, Segal, Vallis, Shaw, and Samstag

Table II. Correlations Between Mean Suitability Rating and Termination Scoresa
Outcome measures M SD df r

Global success ratings

Therapist 61.90 18.11 40 .340
Patient 66.05 21.38 36 .30b
Target complaint ratings
Therapist 43.98 16.69 33 -.53 c
Patient 43.56 20.23 33 -.33 (p<.06)
BDI 10.13 8.10 29 -.39 b
A T Q frequency 64.69 26.06 29 -.44 b
Degree of belief 61.56 23.16 29 -.52 a
DAS total score 135.44 41.18 29 -.34
MCMI anxiety 76.18 19.66 30 -.42 b
Major depression 51.88 12.70 30 -.46 a
Dysthymia 73.15 20.37 30 -.37 b
SCL-90 GSI 42.41 10.07 29 -.29
aNote: Pearson correlations were calculated between mean suitability scores and global success
ratings; partial correlations were calculated with posttherapy scores on all other measures,
controlling for pretherapy scores. Sample sizes ranged between 32 to 42 depending on amount
of missing data. BDI = Beck Depression Inventory (Beck et al., 1961); ATQ = Automatic
Thoughts Questionnaire (Hollon & Kendall, 1980); DAS = Dysfynctional Attitudes Scale
(Weissman & Beck, 1978); MCMI = Millon Clinical Multiaxial Inventory (Miilon, 1982);
SCL-90 = Symptom Checklist-90, GSI = global severity index (Derogatis, 1977).
bp < .05.
~p < .001.
< .01.

As a preliminary attempt to evaluate the construct validity of the

SSCT procedure, we examined its relationship to a self-report measure of
the therapeutic a l l i a n c e - - t h e Working Alliance Inventory (Horvath &
Greenberg, 1986). The WAI was administered to patients in the accepted
for treatment group at the end of the third therapy session. Separate cor-
relations were calculated between the total score of the WAI and each of
the items and mean score of the SSCT measure. The only significant cor-
relation was with the in-session alliance dimension of the suitability
interview, r(15) = .57, p < .05. This suggests that the therapeutic alliance
rating based on in-session evidence emerging in the suitability interview
was related to the therapeutic alliance as assessed from the patient's per-
spective on the WAI, and provides preliminary evidence relevant to the
convergent validity of this dimension. It also suggests that the other eight
dimensions provided information which was nonredundant with a self-re-
port measure of the therapeutic alliance.
Second, data bearing on the predictive validity of the suitability in-
terview were analyzed by calculating Pearson correlations between the
mean of the suitability ratings and the global success ratings, and by cal-
Assessing Patient Suitability 33

culating partial correlations (controlling for pretherapy severity level) with

the outcome measures administered before and after therapy. (A negative
partial correlation indicates that the better the SSCT score, the greater the
reduction in symptomatology shown on that measure.) These data are re-
ported in Table II. There were significant correlations between the mean
SSCT and both the therapists' and patients' global success ratings. The par-
tial correlation between the mean SSCT score and therapists' mean target
complaint ratings was also significant; the partial correlation with patients'
mean target ratings approached significance.
The mean SSCT score also correlated significantly with outcome as
measured by a number of psychometric tests. As indicated in Table II, sig-
nificant correlations were found with the BDI, both the frequency and
degree of belief subscales of the ATQ, and the anxiety, major depression,
and dysthymia subscales of the MCMI. All correlations indicated that high
pretreatment SSCT ratings were associated with greater overall symptom
reduction over treatment. Correlations with the DAS and the SCL-90
(global severity index), although not significant, were in the same direction
as the other measures.
An analysis was then conducted comparing SSCT scores of the 42
patients accepted into therapy (M = 3.92, SD = .52) to those of the 22
patients not accepted into treatment (M = 2.84, SD = .63). The results of
a Hotelling's T2 test revealed that those patients accepted into treatment
had, overall, significantly higher SSCT scores than those not accepted, T 2
(9, 46) = 5.82, p < .001. A series of univariate t-tests subsequently revealed
that all SSCT item scores, with the exception of item seven (chronicity),
were significantly different between the accepted and nonaccepted groups.
Results are reported in Table III.
The results of a Hotelling's T 2 test comparing accepted vs. nonaccep-
ted patients on personality and symptomatology measures administered at
intake are presented in Table IV. The two groups did not differ significantly
overall, T 2 (10, 53) = 0.99, n.s., nor was there a significant difference be-
tween groups on any of the outcome assessment measures.

DISCUSSION
The data presented provide preliminary evidence supporting the re-
liability, construct validity, and predictive validity of the SSCT. Eight of
the nine suitability dimensions were rated reliably by three independent
raters. The one exception was the focality dimension, which yielded an in-
traclass correlation of only .46. The lowered reliability here may have
reflected some confusion by the raters over whether focality should be in-
terpreted as the patient's ability to focus in session in a task-oriented
34 Safran, Segal, Vallis, Shaw, and Samstag

Table IlL Comparison of SSCT Item Scores in the Accepted and Nonaccepted Groupsa
Accepted Nonaccepted

SSCT item M SD M SD t (1, 54)

1. ACCESS 3.68 .79 2.47 .80 5.240

2. AWARE 3.36 .80 2.32 .87 4.34 b
3. ACCEPT 3.65 .88 2.71 1.32 3.16c
4. COMPAT 3.89 .73 Z44 1.20 5.55b
5. INALL 3.74 .78 2.85 1.07 3.50b
6. OUTALL 3.24 1.08 2.38 1.27 2.60d
7. CHRON 2.74 1.09 2.27 1.17 1.47
8. SECUR 3.55 .85 2.50 .97 4.08 b
9. FOCAL 3.76 .78 2.77 .92 4.15 b

aNote: Sample sizes range from 40 to 42 in the accepted group and from 19 to 22 in the
nonaccepted group due to missing data. ACCESS = accessibility of automatic thoughts;
AWARE = awareness and differentiation of emotion; ACCEPT = acceptance of personal
responsibility for change; COMPAT = compatibility with cognitive rationale; INALL =
in-session alliance potential; OUTALL = out-of-session alliance potential; CHRON =
chronicity of problems; SECUR = security operations; FOCAL = focality. SSCT =
Suitability for Short-Term Cognitive Therapy.
bp < .001.
~p < .01.
< .05.

Table IV. Comparison of Symptom Severity Measures at Intake Assessment for the
Accepted and Nonaccepted Groupsa
Accepted (n = 42) Nonaccepted (n = 22)
Outcome measures M SD M SD t (1, 62)

Target complaint ratings

Therapist 75.28 7.32 75.38 7.18 0.00
Patient 81.01 9.66 84.60 7.99 1.50
BDI 19.36 8.52 20.14 10.66 0.32
ATQ frequency 83.50 24.42 81.91 30.79 0.22
Degree of belief 82.04 24.14 83.29 32.11 0.17
DAS total score 152.43 40.46 143.14 42.21 0.86
MCMI anxiety 90.14 19.81 83.23 25.87 1.19
Major depression 61.40 10.51 59.82 14.93 0.49
Dysthymia 86.26 18.11 82.09 25,11 0.76
SCL-90 GSI 50.36 7.45 52.14 12.73 0.71
aNote: All the t values are nonsignificant. BDI = Beck Depression Inventory (Beck et al.,
1961); ATQ = Automatic Thoughts Questionnaire (Hollon & Kendall, 1980); DAS =
Dysfynctional Attitudes Scale (Weissman & Beck, 1978); MCMI = Millon Clinical Multiaxial
Inventory (MiUon, 1982); SCL-90 = Symptom Checklist-90, GSI = global severity index
(Derogatis, 1977).

f a s h i o n o r t h e i n t e r v i e w e r ' s ability to e x t r a c t a focal t h e m e u n d e r l y i n g t h e

patient's symptom picture (the way in which locality is conventionally de-
Assessing Patient Suitability 35

fined in most short-term dynamic schemes, e.g., Malan, 1976: Sifneos,

1972). Despite the fact that the item was explicitly anchored in a fashion
consistent with the first definition (see Safran et al., 1990), this type of
confusion emerged at various points during the training period and may
have persisted subsequently. Whether these or other factors decreased the
reliability of the item will have to be clarified and resolved in future re-
search.
Preliminary evidence relevant to the construct validity of the SSCT
is provided by the fact that only the in-session alliance dimension correlated
significantly with the WAI. This provides preliminary evidence relevant to
the convergent validity of the in-session alliance item and suggests that the
other eight dimensions provide information which is nonredundant with
the WAI, a self-report measure of the alliance. Further, predictive validity
of the SSCT was found with respect to a wide range of outcome measures
from both therapist and patient perspectives.
Overall, SSCT scores were demonstrated to differentiate the accepted
group from the nonaccepted group, whereas the two groups were not sig-
nificantly different from each other with respect to initial personality and
symptomatology scores. These findings suggest that the SSCT procedure is
measuring something distinct from severity of presenting pathology. While
eight of the nine SSCT items discriminated the accepted from the nonac-
cepted groups, there was no significant difference between groups on the
chronicity item, indicating that further questions need to be explored re-
garding the potential importance of this particular item to the scale. It may
be that chronicity of the problem is a less useful selection criterion than
the other dimensions.
The current results compare favorably with other attempts to predict
outcome. For example, Marmar, Horowitz, Weiss, and Marziali (1986) re-
ported correlations in the range of .27 to .35 for the external judge's version
of the Therapeutic Alliance Rating System, and found that, while there
was some consistency in predicting global ratings of outcome, specific meas-
ures of symptom change were difficult to predict.
Horvath and Greenberg (1986) found that the WAI, while predictive
of patient posttherapy reports of change, was not predictive of symptom-
specific measures. Saunders, Howard, and Orlinsky (1989) found that their
Therapeutic Bond Scales, rated from the patient's perspective, correlated
only .19 with therapy outcome as assessed through rater evaluations of
clinic files.
The finding that the mean SSCT score correlated significantly with
both global and symptom-specific measures from both therapist and patient
perspectives is thus encouraging. Moreover, the ability to predict change
36 Safran, Segal, Vallis, Shaw, and Samstag

in the ATQ, which measures a construct congruent with cognitive therapy

theory, is encouraging.
In addition, it should be remembered that a number of patients who
were felt to be extremely unsuitable for short-term cognitive therapy were
screened out of the study for clinical reasons. This screening procedure
restricted the range of suitable and unsuitable patients (as confirmed by
the finding of significant differences in the SSCT scores of accepted and
nonaccepted groups), and may thus have attenuated the size of the corre-
lations. This finding of significant differences between accepted and
nonaccepted groups cannot be taken as a direct confirmation of the pre-
dictive validity of the SSCT, since SSCT ratings and admission decisions
were not made completely independently. Nevertheless, the data in Table
III may be useful to readers in terms of providing SSCT norms for patients
who were evaluated to be clearly unsuitable on the basis of a number of
pieces of information (e.g., case formulation, psychometric testing, diagno-
sis). Finally, administering the SSCT during the first meeting with the
patient rather than the third meeting (as is customary for therapeutic al-
liance measures), presents an important clinical advantage.
The fact that SSCT interviews and ratings were not, in all cases, con-
ducted by the therapists who ultimately treated the patients is a factor
confounding the interpretation of the results. It is possible, for example,
that SSCT interviews and ratings conducted by therapists, rather than in-
dependent intake workers, would provide better predictions of outcome.
First, SSCT interviews conducted by therapists would provide a more ac-
curate sample of the interactional style which would be specific to a
particular therapist-patient dyad. Second, SSCT ratings made by therapists
would potentially correlate more highly with therapist ratings of therapy
outcome, because of shared method variance. A third possibility is that
therapist-rated SSCT interviews may correlate more highly with therapist
measures of outcome than independent evaluater ratings of SSCT because
SSCT ratings may bias therapists' perceptions of outcome.
While the ability of therapists to conduct their own SSCT interviews
is useful from the perspective of everyday clinical practice, the use of thera-
pists as SSCT raters presents a potential confound in the context of a
controlled study. Since the current sample was not large enough to permit
a separate analysis of interview ratings made by therapists and independent
intake workers, we were unable to assess the impact of having both SSCT
ratings and outcome evaluations conducted by therapists. It will thus be
essential to address this issue in future research.
While we have reported normative data for those patients accepted
and not accepted for treatment, at this stage of the SSCT's development
there is not sufficient justification for making clinical decisions regarding
Assessing Patient Suitability 37

patient suitability for treatment on the basis of absolute cutoff scores. Fu-
ture research is required to replicate the present findings with other patient
samples and with other cognitive therapy protocols. There appears to be
a general movement in the field toward broadening the practice of cognitive
therapy in the direction of the interpersonally focused protocol employed
in the present study, especially as the treatment of personality disorders
becomes a prominent concern (e.g., Beck et al., 1990). Further research
will be required, however, to determine how useful the SSCT is for a more
traditional cognitive therapy protocol, such as that employed in the NIMH
Treatment of Depression Collaborative Study (Elkin et al., 1989), and in
what way it may need to be adapted for various treatment protocols. It
will also be important to determine whether the SSCT is useful in evalu-
ating which patients receive differential benefit from cognitive therapy,
rather than other treatments (e.g., psychodynamic therapy).

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