Manual-Based Treatment in Clinical Psychology Research Paper

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The practice of psychotherapy has seen dramatic and sweeping changes since the 1950s. One of the most dramatic changes impacting the delivery and dissemination of speciﬁc psychotherapeutic service has been the development of detailed explanatory manuals for complex psychological treatments. More recently client ‘workbooks’ are available that guide the client through therapeutic direction. The main function of these treatment manuals is to, ‘outline the procedures, techniques, and strategies which comprise an accept-able implementation of a given [psychotherapeutic approach]’ (Luborsky and DeRubeis 1984, p. 7) and to make the process of psychotherapy more accessible to clients and clinicians alike. Typically these manuals describe session-by-session strategies for speciﬁc problems such as depression or phobias for therapists to follow.

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Many changes in the ﬁeld have led to the impetus for speciﬁc treatment manuals to be developed including the demand for ‘good and better research,’ in which the therapeutic intervention is speciﬁed for all to examine, and the burgeoning of the hegemonic man-aged behavioral healthcare system. In response to these many demands, the number of manuals has proliferated. Although the psychotherapeutic community has positively received the majority of manuals, some front-line clinicians raise objections to this approach, stating, among other objections, that manuals damage the therapeutic relationship, and that clinical innovation is restricted (Addis et al. 1996). Despite these obstacles, treatment manuals appear entrenched in the forefront of clinical psychology.

1. Developmental History Of Treatment Manuals

The initial impetus for the development of treatment manuals came from psychotherapy researchers who in the early 1960s began to test broadly the eﬀectiveness of speciﬁc treatments in controlled outcome studies. Looking to demonstrate successfully that psychological interventions could withstand rigorous scientiﬁc investigation, similar to that of existing pharmacological treatments (Luborsky and DeRubeis 1984), scientist–practitioners realized that they needed treatment tools that would allow for systematic replication and comparison. Wilson (1996) more speciﬁcally pointed out that treatment manuals sought to eliminate any ‘error’ associated with ‘clinical judgment’ or intuition that might cause one therapist to behave in a substantially diﬀerent manner from another. Thus, to study the eﬀectiveness of these therapies, treatments were condensed into manuals that could then be reviewed and used across studies. Many researchers hoped that by utilizing treatment manuals, presented in this fashion, psychological interventions would be able to withstand the methodological constraints of research protocols. More speciﬁcally, ‘treatment manuals help support the internal validity of a given study by ensuring that a speciﬁc set of treatment procedures exists, that procedures are identiﬁable, and that they can be repeated in other investigations’ (Dobson and Shaw 1988, p. 675). This is in contrast to the conduct of treatment outcome research prior to manualization, in which speciﬁc therapeutic techniques were often not explained and thus could not be compared to other treatments or be replicated by other investigative groups. As a consequence, the use of a treatment manual is currently a prerequisite to receive federal funding for psycho-therapy research in many countries.

Another push to develop speciﬁc treatment manuals came from the development of the Agency for Health Care Policy and Research (AHCPR) in the United States in 1989. The sole purpose of this Agency was to facilitate identiﬁcation of the eﬀectiveness of speciﬁc strategies for speciﬁc disorders, with the aim of increasing the quality and reducing the cost of health-care (Barlow 1996). One major mechanism of accomplishing this goal was the creation of clinical practice guidelines that explicitly articulate the optimal strategies for assessing and treating a variety of psychological problems. Treatments recommended in these clinical practice guidelines are typically based on two speciﬁc factors: (a) eﬃcacy; or internal validity of the speciﬁc treatment, the determination of which is based on the results of a systematic evaluation of the intervention in a controlled setting, and (b) eﬀectiveness; or clinical utility of the treatment, which is based on the feasibility, generalizability, and cost-eﬀectiveness of the intervention actually being delivered in a local setting. Based on these equally important and rigorous bases of evidence, the development of treatment manuals that could produce the necessary evidence was encouraged. As a result, manual-based treatments have been incorporated as one of the major components of evidence-based service delivery (Strosahl 1998).

2. Manualized Treatment In Behavioral Health Care Settings

One of the ﬁnal steps in the progression of manual-based treatments is their incorporation into managed care treatment settings. Strosahl (1998) points out that these manuals are especially appealing to these settings because they are essentially an easily discernable roadmap for the most appropriate way to implement clinical practice guidelines. Within managed care organizations, where psychotherapy must demonstrate: (a) its overall eﬀectiveness, (b) may be limited to a certain number of sessions, and (c) increasingly is delivered by practitioners with less than doctoral degrees, treatment manuals are embraced for their ability to facilitate the delivery of empirically sup-ported treatments at lower costs. Treatment manuals increasingly are also adopted because they aid in the training of master’s level clinicians.

3. Speciﬁc Treatment Manuals

The earliest treatment manuals were based on behavioral treatment techniques (Dobson and Shaw 1988). These treatments were the logical outgrowth of behavior therapy’s de-emphasis of therapist variables in favor of speciﬁc procedures (Parloﬀ 1998). Non-behavioral varieties of treatment manuals are currently available, although behavioral and cognitive behavioral techniques tend to predominate. The majority of treatment manuals do not adhere to more traditional psychotherapy models, which tend to emphasize a more individualized theory-based under-standing of underlying patient problems (Wilson 1996). Rather, most manuals target the speciﬁc di-agnostic categories speciﬁed by DSM-IV. For ex-ample, speciﬁc manuals exist for a wide variety of anxiety disorders including panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia. Most of these manuals utilize cognitive and behavioral techniques with an emphasis on identifying and challenging maladaptive cognitions and eliminating behaviors that serve to increase and maintain anxiety. Other manuals with a cognitive behavioral emphasis include treatments for bulimia nervosa, weight reduction, stress reduction, depression addictive behaviors, and sexual dysfunction.

As noted above, other forms of therapy have been manualized into speciﬁc books such as interpersonal psychotherapy for depression (IPT), which stresses the alleviation of destructive interpersonal patterns that are maintaining depressive mood, and Dialectical Behavior Therapy (DBT) for borderline personality disorder which draws on cognitive-behavioral techniques and eastern philosophy. More recently, important new treatments for bipolar disorder and schizophrenia, featuring family systems therapy directed at emotional lability in these families, have been developed. All of these treatments have received empirical support and are also incorporated into many aspects of clinical practice guidelines.

4. Pros And Cons Of Treatment Manuals

One distinct advantage of treatment manuals is that they have been shown to be eﬀective in controlled treatment outcome studies (Barlow and Hofmann 1997, Nathan and Gorman 1998). Thus, when practitioners implement techniques they can do so with the conﬁdence that they are delivering services that have a high probability of success. Furthermore, manuals guide clinicians to use strategies that are spelled out and are clearly discernable.

Wilson (1996) points out that treatment manuals can reduce the errors that might be associated with unrestrained clinical judgment. ‘What is typically overlooked, however, and what research on human judgement so clearly documents, is that individualized clinical judgement can just as easily produce worse results than standardized treatments, by introducing errors and inappropriate strategies that are not part of manual-based treatments’ (Wilson 1996, p. 302). Manuals, however, outline speciﬁc techniques to be used in each session, which have been created by systematic investigation, rather than relying upon clinical judgment to choose a session topic.

Due to their structure, treatment manuals may also facilitate a more highly focused and eﬃcient therapy. With a limited number of sessions and speciﬁc goals and strategies outlined for each of these sessions, Wilson (1998) suggests that this more focused approach may actually lead to a more active engagement in therapy for patients.

Treatment manuals also make it easier to train and supervise therapists in speciﬁc clinical techniques and strategies (Calhoun et al. 1998). By providing nascent clinicians and supervisors with speciﬁc guidelines and techniques to monitor, treatment manuals streamline the learning process and delineate a speciﬁc set of therapeutic skills to be learned. This in turn may lead to a greater aptitude and ability for learning therapeutic techniques in general, and a larger armentarium of clinical skills.

Treatment manuals, as structured interventions, can also help clinicians deliver therapy in a brief and in many cases non-traditional format (Craske et al. 1995). For example, even a very brief and unstructured intervention for patients presenting to an emergency room with panic attacks may be eﬀective if delivered early enough to less severe patients (Swinson et al. 1992). Considering the high prevalence rates of clinical and subclinical mental disorders in primary care settings (Fifer et al. 1994) such interventions are clearly cost eﬀective.

Finally, utilization of treatment manuals can pro-mote innovation in the delivery of clinical services. That is, when highly speciﬁed treatments are delivered, and assuming appropriate outcomes measures are collected, clinical administrators can determine when a speciﬁc treatment is working and for whom. In the case of failures either individually or systematically, it will then be clear that innovations to the treatment program are needed and should be incorporated and evaluated.

Despite these many advantages, a sizeable segment of practicing clinicians object to the notion of treatment manuals, pointing out the many disadvantages in the delivery of what has been called derisively, robot-like therapy (Parloﬀ 1998). For example, dissenters have argued that randomized controlled trials, utilized to validate most manualized treatments, exclude patients with co-morbid diagnoses, among other constraints, and that the results of these types of research studies inherently have limited applicability to ‘real-world’ settings (Bologna et al. 1998). These same individuals note that highly structured, manualized psychological interventions used in clinical trials cannot generalize to practice settings where psycho-therapy is often applied more ﬂexibly and adapted to meet the needs of the patients, who may present with multiple problems (Barlow 1996). This set of objections is based on the fundamental idea that the scientiﬁc method, as it is known, is incapable of proving the eﬀectiveness or ineﬀectiveness of psycho-therapy, and that some alternative methodological approach to psychotherapy research is preferable. These are important criticisms that cannot be ignored. But Wilson (1998) outlines how there are signiﬁcant and important diﬀerences between the use of treatment manuals in therapy protocols and their use in clinical practice, with the latter context allowing for greater ﬂexibility. Furthermore, the beginning of much needed research in this area suggests generalizability of manualized treatments to front line clinical settings despite high co-morbidity and a diverse population base (Barlow et al. 1999).

Other clinicians bemoan that structured treatment manuals will compromise the integrity of the therapeutic relationship and thus interfere with the therapy process (Garﬁeld 1996). For example many of these clinicians fear that manualized therapy may reduce the therapy process to mechanized and robotic delivery of techniques, thereby eliminating the importance of the therapist as a clinical tool. Further, innovation and the development of unique and creative strategies will be stagnated by reliance on prescribed treatment strategies. Parloﬀ (1998) summarized these sentiments by stating that many saw the reliance on actuarial decision making over honed clinical judgment as ‘perverse.’ Many clinicians also feel hindered by having to adhere to a speciﬁc set of goals for a given session, and prefer to rely on their own judgment to guide them. However, Wilson (1996) notes, ‘if clinical artistry is taken to connote such necessary therapeutic elements as developing a therapeutic relationship and engaging patients in the change process, then treatment manuals do not obfuscate it—rather they demand it’ (p. 305). It can also be assumed that even though the therapist utilizing a treatment manual is encouraged to deliver the techniques outlined, within this delivery they are also encouraged to rely on their own personal skills to convey the therapy to the patient (Dobson and Shaw 1988). Finally, the data indicate that therapists engaged in manualized treatments in clinical practice can form strong alliances (Addis et al. 1996). Simply because the therapist has to spend a segment of time conveying speciﬁc therapeutic techniques does not mean that they are not building alliances with their patients. Furthermore, a great deal of time is allotted in manual-based therapies to emphasize alliance building. Examples include such strategies as identifying client and therapist expectations for treatment and eliciting client feedback (Addis et al. 1996).

Criticisms of treatment manuals also encompass the belief that manuals may undermine successful case formulation. That is, many clinicians argue that manual-based treatments will be less eﬀective because these approaches assume that all individuals with a given disorder are uniform and have the same symptoms for the same reasons (Wilson 1996). As such, these techniques will ‘miss the boat’ for a certain subset of patients and will attempt to treat them with techniques that are not applicable. The fact that manuals do not allow for clinical exploration that might lead to the discovery of what works for patients with dissimilar etiology is a commonly expressed concern that may lead to diminished treatment innovation. In fact, treatment manuals do emphasize the current symptom picture over past development processes and idiosyncratic etiology. But research has yet to suggest that therapeutic attention to past developmental processes contributes in a substantial way to the amelioration of the disorder.

Many of these criticisms of manualized treatment have some validity and will be grist for the research mill. Research on the eﬀectiveness or external validity of therapeutic interventions will be the ground on which these competing ideas will be evaluated and tested.

5. The Future Of Structured Treatment Manuals

The science and practice of psychotherapy has under-gone comprehensive shifts in the 1990s, none arguably more central than the proliferation of semistructured treatment manuals. In this era of treatment guidelines, best practice algorithms, and behavioral healthcare management organizations, treatment manuals increasingly are being embraced. Despite objections, and lingering doubts, treatment manuals have many merits, with demonstrated eﬃcacy the principal at-tribute. As psychotherapeutic services become more integrated with other forms of healthcare in the twenty-ﬁrst century, treatment manuals with demonstrated outcomes may become the preferred method of nondrug interventions, and ‘formularies’ of eﬀective psychological treatments may begin to appear in mental health services or managed behavioral health-care organizations. In this context, research will progress to address the reasonable concerns that have arisen regarding the implementation of these strategies.

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