Manualized Behavior Therapy

Historical Context

At least initially, the primary aim of developing and implementing manualized therapies was to improve the evaluation of particular treatment strategies and entire treatment programs. Indeed, manuals served to specify in abbreviated form the nature of the treatment and articulate in detail how it was to be delivered. Thus, researchers would have available a precise and standardized clinical methodology that could be used in the evaluation of a particular treatment's efficacy. In addition, manuals provided researchers with the opportunity to standardize training of a specific treatment so as to increase the chance that the therapy would be delivered in the manner designated by, and consistent with, the theoretical underpinnings of the approach. Today, the development and utilization of manualized therapies reflects an important breakthrough in the larger history of developing and evaluating psychosocial treatments for psychopathology specifically and psychological dysfunction more generally.

Reasons for Implementing Treatment Manuals

With the advantage of hindsight, it is easy to identify a number of key reasons why manualized therapies originally emerged in the midto late 1970s. Prior to having standardized treatment methods and procedures, researchers often were left in the dark in regard to how a particular treatment was delivered. In the best-case scenario, questions about the effects of a clinical trial could be directed at how well a particular treatment was delivered. In the worstcase scenario, it was possible to question whether a particular treatment was really delivered at all or at least whether the key components of that therapy were implemented. Other types of common concerns were aimed at issues such as whether the therapy under investigation was delivered in a consistent fashion across study participants. Still other concerns were aimed at how well the results could be replicated across independent research sites. All of these questions, and others similar to them, essentially reflect questions of treatment integrity. A prerequisite for adequately addressing questions of treatment integrity from a scientific standpoint is to have a methodology that identifies the treatment of interest and guides its delivery in a step-by-step manner. In fact, treatment manuals are virtually a de facto requirement in treatment efficacy research.

Today, the development and utilization of manualized behavior therapies have far exceeded the boundaries of research circles. Indeed, the use of manuals in clinical contexts with no clear research objectives has been spurred on by health care policy changes demanding that psychological services follow guidelines for relatively brief treatments that have an empirical basis for outcome. Also, treatment manuals often are used as a basis for training psychologists and other mental health professionals in training programs, and they have become increasingly involved in clinical practice. Thus, despite the fact that manuals have helped to improve the quality of largescale clinical trials in accordance with their original intended purpose, it is perhaps not surprising that they have been the subject of controversy and intense debate. In fact, the use of treatment manuals has called attention to clinical issues that strike at the very heart of what treatment should be considered clinically useful and in what contexts it should be implemented.

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