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Original Investigation
June 9, 2021

Effect of Matching Therapists to Patients vs Assignment as Usual on Adult Psychotherapy Outcomes: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychological and Brain Sciences, University of Massachusetts, Amherst
  • 2Department of Psychology, University at Albany, State University of New York, Albany
  • 3Psychological and Behavioral Consultants, Beachwood, Ohio
  • 4Outcome Referrals Inc, Framingham, Massachusetts
JAMA Psychiatry. 2021;78(9):960-969. doi:10.1001/jamapsychiatry.2021.1221
Key Points

Question  Can assigning patients to therapists with empirically determined strengths in treating the patients’ specific mental health problem(s) (ie, measurement-based matching) improve the outcomes of naturalistic psychotherapy compared with case assignment as usual?

Findings  In this 2-arm, double-blind randomized clinical trial including 48 therapists and 218 outpatients, measurement-based matching promoted significantly greater reductions in patients’ general symptomatic and functional impairment, global psychological distress, and domain-specific impairment on patients’ most elevated presenting problem over 16 weeks postintake.

Meaning  In this study, mental health care was enhanced by prospectively assigning patients to empirically good-fitting therapists, which requires minimal disruptions within a mental health care system.


Importance  Psychotherapists possess strengths and weaknesses in treating different mental health problems, yet performance information is rarely harnessed in mental health care (MHC). To our knowledge, no prior studies have tested the causal efficacy of prospectively matching patients to therapists with empirically derived strengths in treating patients’ specific concerns.

Objective  To test the effect of measurement-based matching vs case assignment as usual (CAU) on psychotherapy outcomes.

Design, Setting, and Participants  In this randomized clinical trial, adult outpatients were recruited between November 2017 and April 2019. Assessments occurred at baseline and repeatedly during treatment at 6 community MHC clinics in Cleveland, Ohio. To be eligible, patients had to make their own MHC decisions. Of 1329 individuals screened, 288 were randomized. Excluding those who withdrew or provided no assessments beyond baseline, 218 patients treated by 48 therapists were included in the primary modified intent-to-treat analyses.

Interventions  Therapist performance was assessed pretrial across 15 or more historical cases based on patients’ pre-post reporting across 12 problem domains of the routinely administered Treatment Outcome Package (TOP). Therapists were classified in each domain as effective (on average, patients’ symptoms reliably improved), neutral (on average, patients’ symptoms neither reliably improved nor deteriorated), or ineffective (on average, patients’ symptoms reliably deteriorated). Trial patients were randomly assigned to good-fitting therapists (matched group) or were assigned to therapists pragmatically (CAU group). There were multiple match levels, ranging from therapists being effective on the 3 most elevated domains reported by patients and not ineffective on any others (highest) to not effective on the most elevated domains reported by patients but also not ineffective on any domain (lowest). Therapists treated patients in the matched and CAU groups, and treatment was unmanipulated.

Main Outcomes and Measures  General symptomatic and functional impairment across all TOP domains (average z scores relative to the general population mean; higher scores indicate greater impairment), global distress (Symptom Checklist-10; higher scores indicate greater distress), and domain-specific impairment on each individual’s most elevated TOP-assessed problem.

Results  Of 218 patients, 147 (67.4%) were female, and 193 (88.5%) were White. The mean (SD) age was 33.9 (11.2) years. Multilevel modeling indicated a match effect on reductions in weekly general symptomatic and functional impairment (γ110 = −0.03; 95% CI, −0.05 to −0.01; d = 0.75), global distress (γ110 = −0.16; 95% CI, −0.30 to −0.02; d = 0.50), and domain-specific impairment (γ110 = −0.01; 95% CI −0.01 to −0.006; d = 0.60), with no adverse events.

Conclusions and Relevance  Matching patients with therapists based on therapists’ performance strengths can improve MHC outcomes.

Trial Registration  ClinicalTrials.gov Identifier: NCT02990000

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