Page 1 of 13http://spider.apa.org/ftdocs/ccp/2000/april/ccp682331.html 8/30/2000A National Survey of Practicing Psychologists' Attitudes Toward Psychotherapy Treatment Manuals Michael E. AddisDepartment of Psychology Clark University Aaron D. KrasnowDepartment of Psychology Clark University ABSTRACTThere has been considerable debate and little empirical data on the role of psychotherapy treatment manuals in clinical practice. Attitudes toward treatment manuals are a potentially important determinant of how likely practitioners are to use manual-based treatments in clinical practice. A total of 891 practicing psychologists nationwide were surveyed about their attitudes toward treatment manuals and their ideas about the content of manuals. Practitioners held widely varying attitudes toward treatment manuals, and ideas about what constitutes a manual were associated with attitudes in a predictable way. Recommendations are made for how to gather more useful information about practitioners' attitudes toward the many changes affecting current models of clinical practice. This research was supported by a faculty development award from Clark University and by Grant R29 MH57778 from the National Institute of Mental Health. Correspondence may be addressed to Michael E. Addis, Department of Psychology, Clark University, 950 Main Street, Worcester, Massachusetts, 01610. Electronic mail may be sent to [email protected] Received: March 8, 1999 Revised: July 2, 1999 Accepted: July 12, 1999 Psychotherapy treatment manuals reflect both the conflicts and the promises associated with the changes occurring in our field. Manuals are powerful because they touch on issues central to our identities. What is psychotherapy, and how do we conceptualize our roles as health care professionals? Manuals also spark controversies over ownership (Who should be able to conduct psychotherapy?) and accountability (Are practitioners ethically obligated to use only empirically supported psychotherapies?). Finally, manuals reflect and contribute to epistemological differences between and within practitioners, researchers, clinical administrators, and other parties concerned with psychotherapy outcomes. For example, what is the role of controlled science versus clinical experience in constituting the knowledge base of our field? The primary impetus for the evolution of treatment manuals was the need to enhance internal validity in comparative psychotherapy outcome studies ( Luborsky & DeRubeis, 1984 ; Waltz, Addis, Koerner, & Jacobson, 1993 ). For example, in the National Institute of Mental Health—sponsored Treatment of Journal of Consulting and Clinical Psychology © 2000 by the American Psychological Association April 2000 Vol. 68, No. 2, 331-339 For personal use only--not for distribution.Page 2 of 13http://spider.apa.org/ftdocs/ccp/2000/april/ccp682331.html 8/30/2000Depression Collaborative Research Program, therapists were trained to adhere to manuals for cognitive versus interpersonal therapy for depression. When the results demonstrated no outcome differences between the treatments, documented therapist adherence to the treatment manuals in both treatments ruled out a number of alternative interpretations ( Elkin et al., 1989 ). As similar studies continued to document the efficacy of treatments for a range of disorders, researchers and practitioners naturally became interested in the effectiveness of these same treatments in clinical practice (e.g., Addis, 1997 ; Barlow, 1994 ; Seligman, 1995 ; Wade, Treat, & Stuart, 1998 ). Wilson (1995 , 1996 ) drew on the research on clinical versus actuarial prediction ( Dawes, Faust, & Meehl, 1989 ; Meehl, 1954 ) to argue that use of empirically based treatments in clinical practice should improve therapists' average client outcomes. Consistent with his position, there is accumulating evidence that adherence to an empirically supported, manual-based treatment is associated with positive outcomes for a range of disorders ( DeRubeis & Feeley, 1991 ; Foley, O'Malley, Rounsaville, Prusoff, & Weissman, 1987 ; Frank, Kupfer, Wagner, McEachran, & Cornes, 1991 ; Schulte, Kunzel, Pepping, & Schulte-Bahrenberg, 1992 ). However, there are also some studies suggesting that manuals may have deleterious effects under some conditions ( Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996 ; Henry, Butler, Strupp, Schacht, & Binder, 1993 ). Researchers are only beginning to explore when, how, and why treatment manuals have different effects in clinical practice. In the meantime, the very idea of a psychotherapy treatment "manual" runs counter to traditional ways of conceptualizing the individual therapist and the therapeutic process. Flexibility, clinical judgment, and tailoring treatment to what therapists perceive as the unique needs of individual clients have long been considered the hallmarks of a skilled clinician. Thus, manuals have been criticized for promoting adherence to single theoretical perspectives ( Goldfried & Wolfe, 1998 ), overemphasizing technique at the expense of theory ( Silverman, 1996 ), ignoring the role of the individual therapist ( Garfield, 1996 , 1998 ), and relying on diagnostic categories that draw attention away from the complexities of individual life situations ( Fensterheim & Raw, 1996 ). The majority of these criticisms have been voiced by outspoken practitioners and researchers publishing in clinical and scientific journals. Absent are any data on how the majority of practitioners feel toward psychotherapy treatment manuals. Nevertheless, it is practitioners who are the potential users of treatment manuals and the ones who will ultimately determine whether manuals make helpful contributions to clinical practice. The purpose of the present study was to survey a large national sample of practitioners regarding their attitudes and beliefs about the role of psychotherapy treatment manuals in clinical practice. We were concerned with three major questions. First, what do practitioners think a psychotherapy treatment manual is? From a research perspective, treatment manuals are typically thought of as describing relatively structured interventions in the context of an articulated theory of change ( Addis, 1997 ; Dobson & Shaw, 1988 ). Nevertheless, during the pilot phase of our study, we found that some practitioners had not even heard of treatment manuals and others had radically different conceptions from our own (e.g., a treatment manual is an arbitrary
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