A Psychotherapy Assessment Battery Based on Outcomes as Opposed to Efficacy (A Paradigm Including Internal Harmony).

Self-efficacy has been demonstrated repeatedly to be an important and even essential element for effectiveness in all health care. It is clear, however, that it can never be a substitute for real change in terms of physical and neurological functioning. The element in efficacy of personal expectations is always essential, must surely be present for health care effectiveness, but cannot be a substitute for real change in bodily functioning.

The initial work of Carl Rogers where accountability in health care was based on personality change in the client which was carried out at the Menninger Foundation, the University of Pennsylvania, and reviewed in The Annual Review of Psychology by Snyder (1950) represents the first scientific approach to assessing change in relation to psychotherapy. Then during the 1960s and 70s there was a focus on not whether psychotherapy works, but which specific procedures are more effective in dealing with specific problems (VandenBos, 1996; and Consumer Report, 1995). Beginning in the 1980s emphasis was placed on a comparison of different treatments for particular clinical problems. Highly detailed therapy manuals served as the basis for identifying treatment mode, and AXIS I from the DSM-IV served as the means for defining problem categories (American Psychiatric Association, 1994).

The 1995 Consumer Report

The Consumer Report (CR) (Seligman, 1995) represents a continuation of mental health services utilization research begun in 1960. The University of Michigan Survey Research Center conducted a survey of a representative cross sectional household sample of American 21 years of age and older based on area-sampling probability methods to evaluate the presence of psychological distress. Data were collected from 2,460 respondents during 90 minute interviews conducted in respondents' homes. For the 1995 CR study approximately 184,000 randomly selected CR subscribers received the form of the survey that included questions related to mental health services. The data was based on the 22,000 surveys returned of which 6,900 reported having sought help for emotional problems, which included all health care providers except for clergy. Most of the respondents who received psychological therapy were satisfied with their treatment and thought it had improved the quality of their lives. Moreover, the longer the treatment continued, the greater the level of satisfaction.

Efficacy Versus Effectiveness

The Consumer Report is said to have been focused largely on efficacy and being devoid of effectiveness (Reiss and Price, 1996). It should be noted, however, that effectiveness can not exist without personal satisfaction of individuals involved, and which always must include efficacy. This is true because the personal satisfaction of the patient is always a necessary requisite for success. The question of whether efficacy can exist without effectiveness is another matter; since persons involved in therapy typically have reality deviating problems, and false perceptions may be the rule.

The Cassel Assessment Battery

The Cassel assessment battery was designed specifically to evaluate change in relation to five factors that are critical in the effectiveness paradigm. They may be used in concert as a total battery, requiring less than three hours time of patient, or as individual tests or assessment instruments for assessing specific areas of human functioning and development.:

1. Global Functioning - The Global Functioning Test (GST),

2. Need Gratification - The Need Gratification Test (NEEDS),

3. Cognitive Feelings - The Cognitive Feeling Test (CFT),

4. Emotional Feelings - The Emotional Feeling Test (EFT), and

5. Voluntary Control - The Voluntary Control Test (RELAX).

Change in Personal and Social Demeanor

The first two assessment batteries have to do with cognitively oriented therapy, and where rational emotive elements characterize the process, Each one deals with a specific aspect of human functioning and development as clearly demonstrated by factor validity of 15 independently organized factors of the 16 part scores in the two tests.

The Global Functioning Test

The Global Functioning Test (GFT) (Cassel, 1993) is based largely on the Berkeley University longitudinal study where Block and Block followed a group of individuals for 14 years (from about 4 to 18 years of age) to determine the syndrome underlying deviant behavior, as opposed to the traditional studies concerned with symptoms (Cassel, 1992; and Shedler and Block, 1990). They found a syndrome under lying persons involved in deviant behavior characterized by ten different characteristics. That syndrome was present as early as 9 or 10 years of age, was present in the early teen years, and was there with the 18 year olds as well. It was characterized as follows:

1. Not dependable or responsive.

2. Not productive or able to get things done.

3. Guileful and deceitful (denial and distrust).

4. Unable to delay personal gratification

5. Rebellious and nonconforming (antisocial).

6. Pushed and stretched limits continuously.

7. Low aspirations (an absence of life goals).

8. Expressed hostile feelings directly to others.

9. Self indulged (not socially at ease).

10. Felt cheated and victimized by life.

This was followed by accountability concerns in relation to DSM-IV and health care where ten medical schools and thousands of medical doctors sought to develop accountability for health care. Here thirteen work groups with nearly 100 advisers sought ways to determine outcomes of health care. It was a project developed by The American Psychiatric Association, and represented the fourth revision of the project and involved more than 60 different organizations. A basic assessment in relation to DSM-IV has to do with Axis V : Global Assessment of Functioning, which involved: a. work place, b. school and/or learning, and c. Social and human relations.

The Global Functioning Test (GFT) was based on both the Berkeley longitudinal study and the Axis V of DSM-IV. The author sought to incorporate the basic essentials for an individual in a democracy, "The interdependence of independent individuals." The GFT has two separate parts with the first one, Personal Maturity, dealing with independence; and the second is Social Integration. It is concerned with the interdependence element. It is a cognitively oriented assessment instrument with 200 true/false type items, using 25 in each of eight different part scores. It is used primarily to develop an ego-ideal for the future guidance of individuals based on the present ego-status as reflected in the GFT (Cassel, 1986).

Part I - Personal Maturity:

Self Esteem                 EST
Religion                    REL
Assertiveness               ASS
Survival                    SUR

Total Score Part I - PERMAT

Overall Total Score GLOBAL

Part II - Social Integration:

5. Common Elements          COM
6. Sympathy                 SYM
7. Withdrawal               WIT
8. Anxiety                  ANX

Total Score Part II - SOCINT

The Need Gratification Test

In 1949 The New York Times Magazine reported a study designed to determine the greatest contributions to society from 1900 to 1950; from the Victorian to the Atomic Age (Commager, 1949). The second most important contribution was considered to be "mass production" by Henry Ford, the third was "relativity theory" by Einstein; the fourth, was "passive resistance: by Mahandas Ghandi; and then "the radio and "communication with electronic magnetic waves" by Gugliama Marconi, then "microbe healers" by Walter Reed. The single most important contribution, however, was "free association" by Sigmund Freud, and which was later described by Leon Festinger (1957) as "cognitive dissonance" (a feeling of unpleasantness) when needs are present. By others it was characterizes as like the old family physician talking to the little boy, saying "Where does it hurt? Put your finger where it hurts," and that when needs are present they create "cognitive dissonance" (representing hurts).

Human behavior is designed by the individual to gratify personal needs, and when lower level needs are present in large amounts, higher level needs seldom if ever have a chance to be recognized. Using the theory described by Festinger, The Need Gratification Test is designed to assess the presence of needs in eight different areas of one's life space. For example, a question like "Is your home warm and friendly?" If the answer is "No." it means that it hurts in the area of the home, and that needs are present. It is clear that when excessive needs are present, individuals are unable to be effectively involved in any other activity (Cassel, 1984). The NEEDS test is comprised of two sections with eight part scores

Part I - Internal & Personal World:

1. Home                     HOM
2. Religion                 REL
3. Social                   SOC
4. Survival                 SUR

Total Part I - IPTOT

Part II External & Impersonal World:

5. School                   SCH
6. Travel                   TRA
7. Sports                   SPO
8. Money                    MON

Total Part II - EITOT

Overall NEEDS Total - NEETOT

Harmony of One's Inner States

The three other tests in the assessment battery all use The Cassel Bio-Sensors which is comprised of four different biofeedback instruments interfaced with a computer (Cassel, 1996; Epstein, 1994; Cacioppo and Tassinary, 1990). Each one of these instruments are designed to assess an important and critical function in relation to the individual, and are always used in concert in the evaluation process. All four readings from these instruments are converted by the computer to common scores ranging from 0 to 100; so that a score of 50 on any one of them (EMG, GSR, TEM, or PUL) is comparable to a 50 on any other instruments. Since the finger temperature (TEM) measures the presence of the sympathetic syndrome (emergency state), with the colder finger depicting emergency state presence, it is reversed; so that all higher scores depict increased functioning in the respective areas. The four different areas being assessed are as follows:

1. EMG - electromyograph - a continuous record of the intrinsic electrical activity associated with muscle contraction and kinesthesia (swish of skirt and blink of eye).

2. GSR - galvanic skin conduction - associated with pleasant and unpleasant olfactory stimuli and affect intensity (full range of emotions and discerning of truth).

3. TEM - finger temperature - valid measure of the presence of a functioning sympathetic syndrome, the "fight or flight pattern," or an emergency state.

4. PUL - pulse rate - a general measure of functioning and associated with perceived stress load, personal commitment, and caring.

It is designed specifically to assess harmony in one's inner space using a biosocial approach to apply system theory in health care. It is favored for use in relation to wellness of an individual where somatization disorders prevail, estimated to occur in 75 percent of all visits for health care (Davies and Wickramasekera, 1996). Technological advances in bioelectronics, imaging procedures, and laboratory computing have made it possible to record internal feeling signals for building a meaningful bridge from our physiological system to psychological meaning with increasing accuracy, and The Cassel Bio-Sensors is designed for this purpose.

The Cognitive Feeling Test (CFT)

Here The Cassel Bio-Sensors is used to assess the role of four basic feelings in relation to dominant brain activity in a 20 minute test. Using guided imagery a cognitively structured milieu makes use of "cognitive dissonance" (feelings of discontent) to assess eight different areas of one's life space; which are precisely the same as for The Need Gratification Test; so that meaningful comparisons might be made with the two different worlds of cognitive feeling and thinking (Cassel, 1985b; 1987; and 1991). Five questions pertinent to each of the eight areas are asked one-at-a-time, and while the individual is answering each question in secret to self, changes occurring in the four feeling areas are being recorded in the computer (Cassel, 1989). The GFT Profile depicts the findings for the different scores in a meaningful manner.

Harmony in one's inner space is based on the degree to which the four critical feelings being assess in concert depart from a typical pattern. The typical pattern, not unlike with a concert orchestra, includes the middle 68 percent of such measures; so that scores above 84 or below 16 represent departure from norm, and are atypical in nature. The specific scores departing from norm serve as basis for nature of feeling/s involved in the departure; or as the basis for any disharmony. In a marriage or maybe a funeral, for example, planned expectations are always involved in the interpretation; not unlike in a sympathy orchestra playing Mozart or Bach.

The Emotional Feeling Test (EFT)

Here The Cassel Bio-Sensors is used to assess non-dominant brain activity using the four modalities of the instrument precisely the same as for the CFT. The CFT and the EFT are designed as companion tests that provide clinical inferences for both hemispheres of the brain. The CFT for dominant brain activity where typically logical reasoning prevails, and with full veto power over the non-dominant brain activity, and the EFT for non-dominant brain where largely emotional feelings are involved. Here the social milieu is structured by use of five carefully selected pictures in each of the eight different areas. These eight areas are precisely the same as in the CFT and the NEEDS test; so that meaningful comparisons may be made; not unlike in a symphony orchestra (Cassel, 1978; Rogers, 1979; Strupp and Howard, 1992; and Weiner, 1992).

Each picture is on the screen for precisely 10 seconds. During this time the individual is asked to rate in secret to self each picture on a ten point scale as to how pleasing it is; where 8, 9 or 10 is highly pleasing; and 1, 2, or 3 are the opposite - non-pleasing pictures. Harmony in relation to the EFT is believed to be associated with crisis states or emotional scars from earlier life that linger in one's unconscious and are depicted by the EFT Profile. Here, like in the CFT, scores departing form the typical norm data (above 84 or below 16) represent the presence of disharmony just as for the CFT.

The Voluntary Control Test (RELAX)

The Voluntary Control Test (RELAX) is a fifteen minute test designed to assess the degree of voluntary control of an individual in relation to both the dominant and nondominant brain areas (Cassel, 1985a; Norris, 1986; and Sapolosky, 1994). For the first six minutes the individual is given specific instructions on how to relax and control bodily functions. Guided imagery is used based on the "Fehmi" technique - Imagine that you hand is getting heavy and warm! While the individual is trying to follow precisely the instructions as given, assessments are being made by the computer to determine the degree of voluntary control demonstrated.

For the second six minutes, no specific instructions are provided, and the individual is asked to try to relax using own best methods. During this period Chinese music is played. Since no instructions are given, and in a milieu bathed in music background, it is presumed that the nondominant brain prevails. Thus, we have a comparison between verbal oriented instructions and free flowing self-directed activity.

The interpretation of the RELAX Profile is based on the degree to which the data for the four separate functions are maintained within the average range for 68 percent of data. The absence of voluntary control being depicted by feelings outside of the typical range; above 84 or below 16 on the scales ranging from 0 to 100. The absence of voluntary control is further depicted by the nature of modality scores deviating from the norm.

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Russell N. Cassel, Ed.D., ABPP, FABP, Professor University of Wisconsin, Retired,

Correspondence concerning this article should be addressed to Dr. Russell N. Cassell, 1362 Santa Cruz Court, Chula Vista, California 91910-7114.