Academic journal article Journal of Cognitive Psychotherapy

Use of Treatment Manuals in Comparative Outcome Research: A Schema-Based Model

Academic journal article Journal of Cognitive Psychotherapy

Use of Treatment Manuals in Comparative Outcome Research: A Schema-Based Model

Article excerpt

The use of treatment manuals in clinical practice is purported to increase internal validity by ensuring specific, identifiable, and replicable treatments. In the present article, four factors in treatment manuals that should contribute to treatment integrity are singled out and addressed: (1) specification of model, (2) specification of relation between model and therapeutic practice, (3) circularity between model and actual practice, and (4) adoption of a natural attitude during therapy performance. Further, it is argued that theoretical contrast analyses and the accentuation of contrasting aspects in practice contribute to the differentiation of two or more treatments. A schema view of treatment manuals is developed and the implications for central issues in the field are inferred.

During the last decade there has been a dramatic increase in the development and use of treatment manuals. For instance, every published study of pure cognitive therapy since 1977 has adopted a manual (Dobson & Shaw, 1988). Dobson and Shaw (1988) point out two basic functions of manuals. First, they tend to increase internal validity by ensuring a specific, identifiable, and replicable treatment. Again, this increases the chances that the independent variable, the treatment, is actually delivered. Second, in manuals, one can equate extraneous factors like amount of therapy time which may represent a threat to internal validity.

To make a treatment identifiable, two aspects are important: treatment integrity and treatment differentiability: Treatment integrity refers to the extent to which the treatment is conducted according to the demands of the manual. Treatment differentiability refers to the extent to which the treatment is unique and can be differentiated from other treatment approaches.

Several issues have been raised in the context of using manuals. For instance, what is it to behave according to the demands of a manual? Do manuals actually prescribe/proscribe intervention behaviors, which is implied by Dobson and Shaw (1988), or should the relation between manual and therapy behavior be understood in another way? If the proper use of manuals involves adhering to prescriptions, then what about innovative interventions? Is it possible not to adhere to the protocol, but nevertheless behave consistently with the theory? It so, should innovations be prohibited, ignored, or welcomed?

The introduction of manuals has naturally led to attempts to measure adherence to manuals. Competency measures of how skillfully treatment is conducted have also been constructed. How feasible is it to separate these two kinds of measures? Could a therapist adhere fully to a manual, that is, perform the right type of therapist behaviors, but do it in a completely unskillful way?

Many treatment manuals have been published, but few authors have discussed general guidelines for what a manual should include to achieve its ends. In this article, I wish to develop a model for constructing and using manuals to achieve integrity and differentiability, particularly when comparing two treatments, and address the issues mentioned above. I will use my own work with manuals in the context of comparing cognitive therapy and guided mastery for panic disorder with agoraphobia as an example and as a basis for my considerations.

FACTORS CONTRIBUTING TO TREATMENT INTEGRITY

With regard to treatment integrity, we have found it important to outline an explicit theory of conditions that maintain the disorder, to make clear connections between theory of the disorder and aims, strategies, and techniques of treatment, to establish a circular relation between manual and actual practice, and to adopt a natural attitude during therapy performance.

Specification of Theory

We have tried to make our cognitive model of panic with agoraphobia as explicit as possible. This condition starts with a sudden and unexpected panic attack. …

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