One Size Cannot Fit All: A Stage Model for Psychotherapy
Manual Development
Kathleen M. Carroll and Kathryn F. Nuro, Yale University School of Medicine
There has been controversy surrounding the roles and
value of psychotherapy manuals in clinical practice since
their inception. It has been underrecognized that the ap-
propriate roles and content of manuals should evolve
with the stage of development of a given treatment. This
article proposes a stage model in which manuals are seen
as evolving with the level of development of the treat-
ment, from the basic outlines necessary for preliminary
evaluation of the treatment in early pilot studies (stage I),
to highly defined guidelines that demark the internal and
external boundaries of treatment for efficacy studies
(stage II), and finally to elaborated systems appropriate
for use with diverse clinical populations (stage III). We
propose guidelines for the content of manuals at the var-
ious stages, as well as strategies for developing “clinician-
friendly” manuals to facilitate broader use of empirically
supported treatments.
Key words: treatment manuals, stage model, empiri-
cally supported treatments. [Clin Psychol Sci Prac 9:396–
406, 2002]
The development of treatment manuals, which specify
behavioral therapies and provide guidelines for their im-
plementation, revolutionized psychotherapy research (Lu-
borsky & DeRubeis, 1984). Now virtual requirements in
treatment efficacy research (Chambless & Hollon, 1998),
manuals are more frequently being used as a basis for
training psychologists in clinical programs (Beutler, 1999;
Address correspondence to Kathleen M. Carroll, Psychotherapy
Development Center, Division of Substance Abuse, Yale Uni-
versity School of Medicine, 950 Campbell Avenue (151D),
West Haven, CT 06516. E-mail: kathleen.carroll@yale.edu.
 2002 AMERICAN PSYCHOLOGICAL ASSOCIATION D12
Maki & Syman, 1997). Manuals are also increasingly pres-
ent in clinical practice as changes in the health care system
exert greater pressure on clinicians to define and evaluate
the effectiveness of services they provide (Addis, Wade, &
Hatgis, 1999).
Nonetheless, many manuals, including those that spec-
ify psychotherapies with extensive levels of empirical sup-
port, have met only mixed enthusiasm and acceptance by
the clinical community. Existing treatment manuals have
been criticized on several grounds, including (1) limited
applicability to the wide range of populations and problems
regularly encountered in clinical practice (Abrahamson,
1999; Elliot, 1998; Foxhall, 2000; Henry, 1998; Norcross,
1999), (2) excessive emphasis on technique with inade- AQ1
quate focus on the working alliance and other important
common elements of treatment (Addis et al., 1999; Binder
et al., 1993; Dobson & Shaw, 1988; Elliot, 1998; Fonagy,
1999; Henry, 1998; Silverman, 1996), (3) restriction of
clinical innovation and the clinical expertise of the thera-
pist (Addis et al., 1999; Castonguay, Schut, Constantino, & AQ2
Halperin, 1999; Elliot, 1998; Henry, 1998; Norcross, 1999;
Wolfe, 1999), and (4) feasibility when the manual is imple-
mented by clinicians of great diversity regarding experi-
ence, discipline, and clinical expertise (Addis et al., 1999).
Empirically supported treatments fail to find their way
into clinical practice for a number of reasons. For ex-
ample, even a highly flexible and sophisticated manual is
not likely to be adopted by clinicians if the treatment it
describes is not feasible, cost-effective, or acceptable to
the clinical community. Conversely, however, if a novel
treatment is practical and appealing to clinicians (see Fish-
bein, 1995; Fonagy, 1999), a well-written manual may fa-
cilitate its acceptance.
One strategy for addressing some of these criticisms and
encouraging broader use of treatment manuals in clinical
396
practice might be to view manual development not as a
single event but as a series of progressive stages, with each
successive stage addressing more complex clinical issues. A
major recent innovation in behavioral therapies develop-
ment was the articulation of a “stage model” of behavioral
therapies development (Onken, Blaine, & Battjes, 1997).
This sequence of research on new treatments was con-
ceived to facilitate a comparatively rapid and systematic
development of promising treatments from merely “good
ideas” to validated, effective, well-defined treatments with
guidelines for choosing the patients, providers, and settings
most associated with optimal outcomes (Rounsaville, Car-
roll, & Onken, 2001). Stage I consists of pilot/feasibility
testing, initial manual writing, training program develop-
ment, and adherence/competence measure development
for new and untested treatments. Stage II consists princi-
pally of controlled clinical trials to evaluate efficacy of
manualized and pilot-tested treatments that have shown
promise or efficacy in earlier studies. Studies in this stage
may also be devoted to evaluating mechanisms of action or
effective components of treatment. Stage III consists of
studies to evaluate transportability of treatments (e.g., effi-
cacy of the treatment in diverse populations, systematic
evaluation of different means of training therapists, estima-
tion of cost-effectiveness) whose efficacy has been demon-
strated in at least two stage II trials (Rounsaville et al.,
2001).
We propose a parallel stage model for the development
of treatment manuals. This model posits that the apparent
disconnect between researchers and clinicians regarding
manuals (see Addis & Krasnow, 2000) may reflect in part
that treatment researchers tend to develop and dissemi-
nate manuals appropriate for stage I and stage II research;
however, to facilitate broader dissemination of effective
treatments, all-too-rare stage III manuals that focus on the
needs of clinicians treating diverse groups of patients are
needed. This model recognizes that the purposes and
roles and, therefore, content of manuals should evolve
with the stage of development of a given treatment. We
note that the development of many manuals essentially
stops at stage I or early stage II, while effective dissemina-
tion to the clinical community is likely to require ongo-
ing efforts involving the synthesis of process and outcome
data from several trials to extend the manual to be of use
to clinicians applying the treatment to broader popula-
tions and settings. We propose guidelines for the content
of manuals at the stages of development, as well as strate-
STAGE MODEL OF MANUALS • CARROLL & NURO
gies for developing “clinician-friendly” manuals to facili-
tate greater use of empirically supported treatments in
clinical practice (see Street, Niederehe, & Lebowitz,
2000).
EVOLVING ROLES OF MANUALS
The fundamental purpose of a psychotherapy manual is
to specify a treatment and provide guidelines to therapists
for its implementation. However, manuals have been de-
scribed as having myriad potential roles: providing a
means for objective comparisons of different psychother-
apies, setting standards for training and evaluation of ther-
apists, providing a means of linking treatment process to
outcome, defining treatment goals, establishing clinical
care standards, fostering replication of clinical trials, facil-
itating transfer of promising treatments from research to
clinical settings, reducing variability in outcome due to
therapist effects, and many more (see Castonguay et al.,
1999; Crits-Christoph et al., 1991; Kazdin, 1995; Lubor-
sky & DeRubeis, 1984; Moras, 1993; Rounsaville, O’Mal-
ley, Foley, & Weissman, 1988).
A psychotherapy researcher in the nascent stages of de-
veloping a novel therapy would be overwhelmed with
this daunting list, particularly if he or she failed to recog-
nize that what a given manual can do depends very much
on the current level of empirical support for the treatment
it specifies. That is, manuals serve different functions as
the development of a treatment moves from stage I
(where the critical role of the manual is to define the
treatment in broad strokes for preliminary evaluation of
feasibility and efficacy) to stage II (where the manual can
be used as the basis for training therapists, reducing the
magnitude of therapist effects in clinical efficacy trials,
sharpening the distinction between therapies, dismantling
treatment elements, or linking process to outcome) to
stage III (where the manual may be used to evaluate the
treatment clinicians applied to diverse patient popula-
tions, as well as to foster replications of clinical trials in
other settings) and ultimately to broad dissemination to
the clinical community (through serving as a component
of clinical care standards or practice guidelines, as well as
a tool used in training of clinicians). Table 1 provides an
overview of the roles of manuals across stages, evolving
from the essential “bare bones” of stage I to a highly de-
tailed, elaborate, clinically sophisticated version in stage
III and beyond. This stage model presumes that psycho-
therapy manuals develop over time with accumulated
397
Table 1. Overview of roles of manuals by stage of treatment development
Stage Purpose Focus
I Preliminary evaluation of Pilot/feasibility trials
feasibility and efficacy
II Randomized clinical trials Efficacy trials
III Transportability & dissemination Effectiveness trials
to clinical community
clinical experience, but, more important, with process
and outcome data.
This model is not, however, predicated solely on wide-
spread acceptance of the stage model of therapy develop-
ment. We have merely attempted to codify a logical
sequence of manual development and to emphasize that
treatment manual development should not stop with the
versions of manuals used in stage II efficacy trials. Never-
theless, just as an important benefit of the stage model of
treatment development is that it fostered support for
treatment development and pilot studies in stage I and
dissemination studies in stage III (see Onken et al., 1997),
articulation of a parallel model for manual development
may foster greater recognition of the need to support the
development of stage III manuals to foster broader use of
manuals in clinical practice. Moreover, we recognize that
this process is likely to result not in the distribution of dis-
crete stage I/stage II/stage III manuals for a given treat-
ment but rather in successive editions of the manual over
several years.
Guidelines for a Stage I Treatment Manual
The overall goals of the initial stage of treatment develop-
ment are to specify the treatment and provide an initial
evaluation of its feasibility and efficacy. Thus, at this stage,
the treatment developer often has in mind only a general
outline of the treatment and a rough conception of the
major contents of sessions. Table 2 provides a general out-
line for a stage I manual that would define the boundaries,
basic structure, and preliminary contents of a treatment at
a level minimally sufficient for a preliminary pilot study
aimed at evaluating its feasibility and efficacy. It may not
be necessary or appropriate to include lengthy descriptions
for each of these topics in any single manual (as brevity is
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V9 N4, WINTER 2002
Principal Roles of Treatment Manual
Initial specification of treatment techniques, goals, and format
Initial specification of theoretical active ingredients
Specifications of standards for training and supervision of therapists
Specification of unique versus common elements
Discrimination from comparison/control approaches
Discrimination from other approaches for the disorder
Evaluation of treatment process
Provide detailed guidelines for implementation of the treatment
with diverse patient groups and in a range of clinical settings
Provide guidelines for tailoring treatment to different patient subgroups
Explicate limits of treatments effectiveness
always a virtue in treatment manuals). Treatment develop-
ers may find it helpful to consider each of these issues in
order to more thoroughly define new treatments.
Very briefly, a bare-bones stage I manual should cover
the overview, description, and theoretical justification of
the treatment; a conception of the nature of the disorder
or problem the treatment targets; the theoretical mecha-
nisms of change; the goals of the treatment; a description
of how the treatment may be similar to or different from
other existing treatments for the disorder (as a means of
highlighting its unique elements); and specification of the
treatment’s defining characteristics.
Other elements critical to a stage I manual include
defining the treatment’s overall structure, including dura-
tion, format (e.g., group vs. individual), intensity (num-
ber and length of sessions in a given week), level of
flexibility versus structure, session format, and so on. De-
tailed guidelines for the conduct and goals of sessions as
well as major content areas to be conveyed to the patient
should also be provided. Special attention should be de-
voted to clarifying and defining elements of the treatment
likely to distinguish it from the control or comparison ap-
proach to which it may be contrasted in an initial pilot
feasibility/efficacy study.
The model Waltz and colleagues (1993) describe for
delineating treatments in terms of four defining charac-
teristics (unique and essential elements, essential but not
unique elements, recommended elements, and proscribed
elements) is an excellent one for defining psychotherapies
at all stages. This model is valuable in helping treatment
developers sharpen the distinctive features of a given
treatment, in training therapists by highlighting the essen-
tial defining elements of the approach, and in developing
efficient adherence/competence rating systems.
398
Table 2. General outline for a stage I manual
Section Content Area
I. Overview, description, A. General description of
and rationale the approach
B. Background and rationale
for the treatment
C. Theoretical mechanism
of action
II. Conception of the A. Etiological factors
disorder or problem
B. Factors believed to be
associated with behavior change
C. Agent of change (e.g., patient,
therapist, group affiliation)
D. Case formulation
E. How are the disorder/symptoms
assessed by the therapist?
III. Treatment goals A. Specification determination
of treatment goals
B. Evaluation of patient goals
C. Identification of other
target behaviors and goals
D. Negotiation of change
in goals
IV. Contrast to other A. Similar approaches
approaches
B. Dissimilar approaches
V. Specification of A. Unique and essential elements
defining interventions B. Essential but not unique
elements
C. Recommended elements
D. Proscribed elements
VI. Session content Explication of unique &
essential elements
VII. General format A. Format for delivery
B. Frequency and
intensity of sessions
C. Flexibility in content
D. Session format
E. Level of structure
F. Extra-session tasks
For example, several of our manuals have incorporated
this system; we include sections that, grouped under each
of Waltz’s four categories, provide definitions and detailed
examples of the specific interventions and processes con-
sidered to be (1) unique and essential to the treatment and
thus necessary in all sessions (e.g., provision of skills train-
STAGE MODEL OF MANUALS • CARROLL & NURO
Issues To Be Addressed
Overview of treatment and goals
Theoretical rationale
Empirical underpinnings of treatment
Rationale for application of this treatment to this population
Brief summary of hypothesized mechanisms of action, critical “active ingredients”
Summary of treatments’ conception of the forces or factors that lead to the
development of the disorder in a particular individual
According to treatment/theory, what factors or processes are thought to be
associated with change or improvement in the problem or disorder?
What is the hypothesized agent of change?
Who, or what, is thought to be responsible for change in the disorder?
What is the conceptual framework around which cases are formulated and understood?
Therapist strategy for assessment of the disorder/problem
Specification of any standardized assessment to be used
Specification of principal treatment goals
Determination of primary versus secondary goals
Strategies for prioritization of goals, goal-setting with patient
Strategies the therapist uses to identify and evaluate patient goals
Clarification of other problem areas that can be targeted as secondary goals of the
treatment versus those that must be handled outside of the treatment
Strategies for renegotiation of goals as treatment progresses
What are the available treatments for the disorder or problem that are most similar to this
treatment? How do these differ from this treatment?
What treatments for the disorder or problem are most dissimilar to this approach?
What are the specific active ingredients, which are unique and essential to this treatment?
What interventions are essential to this treatment but not unique?
What interventions or processes are recommended but not essential or unique?
What interventions or processes are prohibited or not characteristic of this treatment?
What interventions may be harmful or countertherapeutic in the context of this treatment?
Where appropriate, detailed, session-by-session content with examples and vignettes
Individual, group, family, mixed
If group, closed- or open-ended format?
How often do sessions occur? How long are sessions?
How many sessions should be delivered over what period of time?
Are there essential versus “elective” content areas?
Is there flexibility in sequencing session content areas?
Length of sessions
Guidelines for within-session structure
Does the therapist set an agenda for each session? Is this done collaboratively?
How structured are the sessions? What determines the level of structure in this treatment?
Who (therapist or patient) talks more?
Are extra-session (e.g., homework) tasks a part of this treatment?
What is the purpose of extra-session tasks?
How are specific tasks or assignments selected?
How does the therapist present a rationale for the tasks?
How does the therapist assess patient implementation of tasks?
How does the therapist respond to the patient’s completion of
an assignment? How is it integrated into the work of therapy?
How does the therapist respond to the patient’s failure to complete an assignment?
ing in cognitive-behavioral therapy [CBT] for substance
use disorders); (2) essential but not unique (e.g., defining
sessions goals); (3) recommended (e.g., monitoring sub-
stance use through urinalysis); and (4) proscribed (e.g., ex-
tensive self-disclosure) (see Carroll, 1998, for examples).
In turn, delineation of the treatment in this way facilitates
399
development of adherence/competence rating systems,
for any intervention in the four categories may be used to
evaluate the therapist’s fidelity in monitoring the treat-
ment. For example, using a unique and essential item
from CBT, an adherence item might be “To what extent did
the therapist teach or model specific skills during this ses-
sion?” A competence item might be “How effectively did
the therapist teach or model specific skills during this ses-
sion?” (see Carroll et al., 2000). In addition, we use the
interventions defined as “unique and essential” and “essen-
tial but not unique” as the basis of our therapist checklist
systems (Carroll, Nich, & Rounsaville, 1998), in which
therapists learning the approach are encouraged to self-
monitor through completing a brief checklist of critical
intervention items after each session (and to share these
and compare them with supervisors’ ratings) (see Carroll,
1998, for examples).
Guidelines for a Stage II Manual
At this stage, the treatment researcher has typically gained
some experience with the treatment through one or more
pilot studies. Thus, experience with the training and su-
pervision of therapists to conduct the treatment, review
of session tapes, and analysis of process and outcome data
can be used not only to elaborate the content areas in stage
I but also to address additional areas difficult to articulate
without substantial clinical experience with the treatment.
Thus, a stage II manual would be sufficiently comprehen-
sive to serve as the basis of a larger randomized controlled
trial. Table 3 outlines additional topics to be included at
this stage. These include guidelines for troubleshooting—
that is, strategies for managing common clinical problems
in the course of treatment, such as missed sessions, low
motivation for treatment, exacerbation of symptoms, and
strategies for managing major transitions or clinical choice
points in the treatment. Stage II manuals should also in-
clude a description of the role of nonspecific (common)
elements of treatment, their importance to the nature of
the treatment, and their relationship to unique or specific
aspects of the treatment, with particular emphasis on the
role and the importance of the therapeutic alliance. Man-
uals at this stage of development should also address the
compatibility of the treatment with other commonly used
approaches including permissible adjunctive treatments
(see Rounsaville, Weiss, & Carroll, 1999). Again, clear dif-
ferentiation of the treatment from the control or compar-
ison conditions to which it may be compared in a stage II
(efficacy) trial is essential.
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V9 N4, WINTER 2002
A particularly crucial component of a stage II manual
is explication of procedures and standards for therapist se-
lection, training, and supervision. These include defini-
tion of the level of training and expertise of clinicians
likely to implement the treatment competently. The man-
ual should also describe the minimal training standards for
therapists, such as (for example) the didactic and experi-
ential training each therapist must complete before treat-
ing patients in a clinical trial, as well as the goals, intensity,
and format of the supervision.
Also essential is clarification of the process by which
the therapists’ adherence and competence in delivering
the treatment is evaluated—for example, through an ob-
jective rating system (e.g., Barber, Krakauer, Calvo, Bad-
gio, & Faude, 1997; Carroll et al., 2000; DeRubeis,
Hollon, Evan, & Bemis, 1982; Hill, O’Grady, & Elkin,
1992). Clearly, the manual should serve as the foundation
for the adherence/competence rating system, for if an in-
tervention is not clearly defined in the manual, it will not
likely be manifest in the treatment. Thus, to more clearly
define the manual developers’ intentions regarding thera-
pist adherence and competence, there should be a clear
correspondence between the detailed rating guidelines
for adherence/competence and the description of the key
critical interventions in the manual. In other words, the
manual should specify what the therapists should be
“shooting for” in terms of adherence and competence.
Guidelines for a Stage III Treatment Manual
Ideally, prior to the development of a stage III manual,
several efficacy trials will have evaluated the treatment
among diverse clinical samples. Thus, the treatment de-
veloper can better articulate how the treatment should, or
should not, vary when applied to different populations.
Process and outcome data will be available that may in-
form guidelines regarding the limits of the applicability of
the treatment to some patient groups, that is, whether the
effectiveness of the treatment varies across clinical sub-
types and whether the treatment should not be applied to
individuals with specific characteristics (e.g., through pa-
tient profiling) (see Beutler, 1999; Moras, 1993). Detailed
guidelines regarding how assessment instruments can help
clinicians tailor the treatment to the specific patient sub-
groups may also be provided (see Beutler, 1999).
The treatment may have been evaluated using a wider
range of therapists than in the stage I or early stage II tri-
als, and the treatment developer may have a sense of the
additional training and supervision required if more di-
400
Table 3. General outline of additional areas to be addressed in a stage II manual
Section Content Area
I. Elaborated rationale Empirical evidence
supporting effectiveness
of this approach
Variations by subgroups
II. Troubleshooting Strategies for dealing with
common clinical problems
III. Managing transitions Guidelines for clinical
decision-making through
stages of treatment
IV. Nonspecific or A. Patient-therapist
common aspects of relationship
treatment
B. Relationship of common
and unique elements
V. Compatibility with A. Permissibility and limits
other treatments of adjunctive treatments
B. Role of self-help groups
VI. Therapist selection, A. Therapist selection
training, supervision
B. Therapist training
C. Therapist supervision
VII. Clinical care Specification of guidelines
standards for managing clinical issues
verse, less experienced or committed clinicians are to im-
plement the treatment adequately.
Thus, a stage III manual would be viable only after the
completion of several clinical trials and the resultant accu-
mulation of process and outcome data for a variety of
patient populations. Such a manual would require that
STAGE MODEL OF MANUALS • CARROLL & NURO
Issues To Be Addressed
Summary of data on effectiveness of this population, process findings
Did preliminary or pilot studies suggest variability in outcome across different patient groups?
Specific guidelines for therapist handling of common issues such as: patient lateness,
missed sessions, recurrent crises, poor motivation, relapse, intoxication, failure to
implement extra-session tasks
Are these strategies “generic” or highly specific to this type of treatment?
How does the therapist assess the patient’s readiness to move on to a new stage of
the treatment?
How does the therapist determine whether to repeat/review old material or move on?
How does the therapist deal with an apparent clinical impasse?
How does the therapist assess core issues to be targeted during treatment?
How are shifts in the treatment introduced?
How does the therapist handle issues related to termination, including determination of
readiness for termination?
What is the ideal therapist role in this treatment (educator, collaborator, teacher, peer,
adviser)? What is the patient’s role?
What is the nature of the optimal or ideal patient-therapist relationship?
How important is the therapeutic relationship to the outcome of the treatment?
How important are relationship issues relative to other aspects of the therapy?
Strategies the therapist uses to develop desired relationship
Strategies the therapist uses to address poor or weak therapeutic relationship
What is the nature of the relationship between unique and common elements?
What distinguishes“good” session of this treatment from a poor one?
What adjunctive treatments (e.g. medications, family therapy, case management)
are permitted, encouraged, or even prohibited?
For permitted treatment adjuncts, are there limits on their frequency or intensity?
Especially for substance abuse treatments, or those where peer- or community-based
alternatives are available, how are these handled within the treatment (e.g. neutrally,
supportively)?
Education, training, credential, and experience requirements for therapists
Ideal personal characteristics of therapists
Components and goals of training, training materials available
Issues to be covered in didactic training
Number, nature of training cases required
Standards for therapist initial certification
Common problems encountered in training
Standards for determination of therapist adherence and competence
Explication of ratings systems and assessments of therapist adherence and competence
Education, credential, experience, and training requirements of supervisors
Recommendations for frequency, type (group, individual), goals, content and intensity
of supervision
Strategies to address therapist drift in treatment delivery
Strategies to help therapists balance adherence and competence
Strategies for supervision sessions; use of videotapes and rating systems
How does the therapist assess symptoms use that may have occurred since the
last session?
How does the therapist assess treatment progress?
How does the therapist respond to lack of progress or clinical deterioration?
How does the therapist assess and respond to expressions of suicidal or homicidal ideation?
How does the therapist respond to a contradiction between a patient’s self-report of
symptoms and a collateral source?
treatment guidelines be, essentially, translated from the
“ideal conditions” of research to the “reality” of clinical
work (Wolfe, 1999). As suggested in Table 4, a stage III
manual would provide empirically informed guidance to
therapists regarding how the treatment may be adapted for
patients typically encountered in clinical settings, defining
401
Table 4. General outline of additional areas to be addressed in a stage III manual
Section Content Area
I. Issues related to Specification of variations
patient diversity in the treatment for
managing different types of
patient groups, including
limits of the treatment
with particular groups
II. Program diversity Variability of resources
III. Implementation by Training and supervision
therapists with diverse
range of disciplines
and experience
the limits on flexibility in tailoring the treatment to meet
individual patient needs, and offering strategies for tailor-
ing the treatment to different settings, formats, and inten-
sities. A critical component here might be the inclusion of
guidelines and examples regarding how the therapist
might determine that, in altering the treatment to meet
the needs of a particular patient, it no longer adequately
approximates the treatment defined in the manual (and
thus may have limited efficacy).
A critical component in stage III manual development
is attention to how the manual may be used by clinicians
of greater diversity than those who typically deliver treat-
ment in randomized efficacy trials. Thus, while assump-
tion of basic psychotherapy skills, extensive experience
with the patient population, and familiarity with the the-
oretical basis of a given treatment might be assured when
therapies are implemented solely by therapists trained in
efficacy trials, stage III manuals will need to articulate, or
at least set minimal standards for, these basics of therapy.
DEVELOPING THERAPIST-FRIENDLY MANUALS
Any treatment manual represents at best a detailed guide-
line, or set of instructions, for a highly complex task. Thus,
the clearer, more specific, and more detailed those instruc-
tions are, the more likely the treatment as practiced will re-
flect the intention of the treatment’s originators and foster
greater consistency in treatment delivery and quality.
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
Issues To Be Addressed
Managing patients with comorbid disorders, including (as appropriate) depression,
anxiety and posttraumatic stress disorders, antisocial personality disorder,
concurrent substance use, psychotic disorders, cognitive impairments
Managing patients who have concurrent medical problems
Managing patients who are homeless, have few psychosocial supports
Managing patients who are mandated for treatment
Managing patients who are not motivated for treatment
Managing patients from different cultures, ethnic backgrounds
Managing other patient types commonly encountered in this population
Delivering treatment in a range of settings, time frames
Managing issues such as imposed length of treatment, # of sessions, and so on
Managed care and third-party reimbursement issues
Managing delivery of treatment in a range of treatment frameworks
Common problems involved in training novice therapists to use this approach
Common problems encountered in training experienced therapists to use this approach
Common problems encountered in training therapists with a commitment to a particular
orientation to treatment, or conversely to a more eclectic approach
Strategies to help avoid therapist “drift” from adherence to jargon and active ingredients
of the treatment
Learning tools available (e.g., training videotapes, suggested background reading in
theoretical basis of treatment)
Therapists may feel more comfortable and competent in
delivering a treatment if they believe the manual can en-
hance, rather than limit, their clinical expertise (Addis &
Krasnow, 2000; Addis et al., 1999; Fonagy, 1999; Seligman,
1998). The following recommendations are intended to
help treatment researchers develop more clinician-friendly
manuals by anticipating common criticisms.
Anticipate Real-World Problems
Treatment manuals sometimes describe theoretically com-
pelling and elegant approaches that bog down quickly in
the complex realities of treating challenging patients who
present with multiple problems. Some manuals, particu-
larly those for stages I and II, are written as if for ideal pa-
tients without comorbid psychopathology or concurrent
problems. Clearly, manuals geared only toward ideal or un-
complicated patients will likely be of limited clinical util-
ity. Moreover, while therapist adherence is likely to be high
with comparatively easy or uncomplicated patients, adher-
ence is likely to be poorer with more impaired, sympto-
matic, challenging patients who often (directly or indirectly)
pressure therapists to deviate from manual guidelines
(Foley, O’Malley, & Rounsaville, 1987). Manuals that an-
ticipate that some patients will be challenging, poorly mo-
tivated, ambivalent, resistant, inarticulate, or cognitively
impaired and that provide explicit guidance for addressing
these issues are more likely to foster adherence, consistency,
• V9 N4, WINTER 2002 402
and perhaps even greater effectiveness than manuals that do
not address these issues (Carroll & Nuro, 1997).
Provide Troubleshooting Guidelines
In research and clinical practice, few treatments proceed
without at least some difficulties. Because therapists may
be more likely to deviate from manual guidelines and
“borrow” from other familiar approaches when they en-
counter clinical challenges, clinician-friendly manuals
anticipate and provide guidance for common clinical prob-
lems. Ideally, guidelines should be provided for handling
these common problems in a manner consistent with the
theoretical background and goals of the treatment. Spe-
cific guidelines are particularly helpful for handling late-
ness to sessions, missed sessions, patients whose lives are so
consumed by crises that the work of the therapy may be
hampered, patients with low levels of motivation to
change or engage in treatment, and so on. Furthermore,
manuals should also provide guidelines for referring the
patient to another treatment when these problems have
vitiated the current one.
Don’t Ignore the Basics
Therapists frequently have misconceptions about manuals
(Addis & Krasnow, 2000; Addis et al., 1999). Rather than
viewing manuals as detailed “blueprints” that define the
treatment and guide the therapist, some therapists per-
ceive them as therapeutic straitjackets. In reviewing video-
taped training sessions of clinicians who are new to
manual-guided therapies, we have seen therapists grasp
their arms behind their chairs or sit on their hands, as if
they felt their hands were literally “tied” by the perceived
constraints of the manual. Some clinicians are concerned
that manuals overemphasize technique, thereby negatively
affecting the therapeutic alliance, and that manuals are not
flexible enough to meet the needs of patients with co-
morbid disorders (Addis et al., 1999, Fonagy, 1999).
Though therapists’ anxieties usually abate during train-
ing as they become more confident in the treatment and
their own experience, manuals themselves can directly
confront apprehension by clarifying the balance between
adherence and clinical judgment. For example, in any
therapy, a therapist must first establish rapport, formulate
the case, agree on treatment goals, and build a working al-
liance. However, some manuals (particularly those at stage
I or early stage II) fail to explicitly point out the impor-
tance of these prerequisite fundamental tasks of treatment
STAGE MODEL OF MANUALS • CARROLL & NURO
and instead emphasize specific techniques over competent
delivery of those techniques. The crucial importance of
clinical competence should not be ignored in treatment
manuals. While there is emerging consensus that manuals
can enhance adherence, whether manuals can adequately
foster, or even convey, competence is much less clear (and
hence an important empirical question). Nevertheless,
some attempt to specify competent implementation of a
given intervention is likely to be very helpful for thera-
pists (e.g., an example from CBT might be the therapist’s
focusing on the patient mastering only one or two care-
fully selected new skills).
Thus, a clinician-friendly manual should attempt to
articulate definitions of therapist competence (in addition
to adherence) in the conduct of the treatment at all stages
of development, specify the role of common elements of
treatment and how they are to be balanced with treat-
ment-specific techniques, define the fundamental re-
quirements and indicators of progress before each new
stage or technique is undertaken, and provide strategies
for addressing difficulties in the therapeutic alliance. Ad-
dis and colleagues (1999) point out that articulating and
emphasizing the techniques that strengthen the therapeu-
tic alliance is a potential strategy for countering percep-
tions that manual-guided treatments undervalue the role
of the alliance at the price of effectiveness.
Clarify Choice Points
Therapists conducting manual-guided treatments fre-
quently face a wide array of possible interventions and
strategies, often with comparatively little guidance about
which intervention to select at different phases of treatment.
Clinician-friendly manuals should define important transi-
tion points in therapy (e.g., managing transitions between
early to middle stages of treatment or from a treatment fo-
cused solely on a single principal goal to greater focus on
secondary problems) and provide direction to therapists for
managing them. Decision trees for determining a patient’s
stage in treatment and readiness to move on may also be
helpful to therapists and may minimize excessive drift or
overly aggressive interventions. Provision of clinical rules of
thumb, or general strategies the therapist can use to organ-
ize complex treatments and maintain appropriate treatment
goals, is likely to enhance the usefulness of a manual. An
excellent example of this approach is the use of the core
conflictual relationship theme method (Luborsky & Crits-
Christoph, 1990) to focus dynamically oriented therapies.
403
 Build in Flexibility and Clarity for Required and Optional
Elements
Some manuals may give the impression that “all interven-
tions are created equal,” that key interventions should be
delivered in the same format and order in all sessions, re-
gardless of the patient’s readiness or individual needs. This
is, in fact, rarely so. Treatment developers usually expect
some interventions in all sessions and some in only se-
lected sessions, depending on the needs of each patient.
AQ3 Therapist-friendly manuals have built-in flexibility and
clarify the essential, active ingredients of the therapy that
must be delivered in some or all sessions versus those that
are optional or indicated only for specific patients or in
particular circumstances. Again, the classification devel-
oped by Waltz and colleagues (1993) for defining treat-
ments is an excellent framework for describing the
expected salience and intensity of interventions.
Specification of strategies to tailor the treatment to
meet the needs of different patient types is critical in
clinician-friendly manuals. Examples include the distinc-
tion between “core” versus “elective” sessions in the cog-
nitive-behavioral and twelve-step facilitation treatments
in Project MATCH (Kadden et al., 1992; Nowinski,
Baker, & Carroll, 1992), the four problem types of
interpersonal psychotherapy (IPT) (Klerman, Weiss-
man, Rounsaville, & Chevron, 1984), or the personality
types in Beck’s schema-based approach for personality
disorders (Beck & Freeman, 1990).
Furthermore, therapist-friendly manuals clarify which
interventions or behaviors are proscribed in the therapy
and provide feasible “substitutes.” That is, if a commonly
used therapeutic intervention is proscribed within a treat-
ment manual, manual developers should provide an alter-
nate intervention as a substitute. Finally, clarity regarding
possible negative effects or countertherapeutic interven-
tions is likely to enhance the helpfulness of a manual to
therapists (Moras, 1993). Clarity regarding counterthera-
peutic interventions is a critical aspect of treatment defi-
nition and is particularly important if a treatment is to be
used by relatively novice therapists.
Include Summaries and Outlines
Given the many complex and sometimes competing de-
mands on therapists during the therapy hour, therapists
may find it helpful to refer to brief session summaries or
outlines to remind them of a few key points to be con-
veyed. This may be particularly useful in treatments with a
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V9 N4, WINTER 2002
more didactic focus, where a number of issues are to be
covered in a given session. Similarly, treatment outlines to
which therapists may refer just before a session may cue
them to key elements to convey during the session (Car-
roll & Nuro, 1997). As stage III manuals may become in-
creasingly complex and sophisticated, it will be essential to
provide “navigation” tools such as outlines, indexes, sum-
maries, and flow sheets to help clinicians maintain focus.
We have also found it useful to provide therapists with
detailed “therapist checklists,” which are essentially a
therapist self-report version of our adherence/compe-
tence ratings systems (Carroll et al., 1998, 2000). Thera-
pist checklists may encourage clinicians to self-monitor
their delivery of key features of the treatment, in addition
to providing a useful strategy for reminding therapists
of critical defining strategies of a given treatment and
thus preventing drift in treatment implementation over
time.
SUMMARY
The limited use of manual-driven, empirically validated
treatments in clinical practice is a complex issue and
clearly will require much more than clinician-friendly
manuals. Some challenges are inherent in the nature of
manuals themselves, which systematize, codify, and often
reduce flexibility in a complex and highly variable pro-
cess. However, some of these issues might be addressed in
part by adoption of the stage model of treatment manual
development proposed here. Treatment manuals should
meet the needs of therapists implementing the treatment
in highly controlled efficacy trials as the needs of clini-
cians implementing the treatment in diverse clinical set-
tings. Recognition that a “one size fits all” approach is
inappropriate for psychotherapies, as well as psycho-
therapy manuals, may be an important step in bridging
the divide between research and practice.
ACKNOWLEDGMENT
Support was provided by the National Institute on Drug Abuse
grants P50-DA09241 and K05-DA00457 (Carroll).
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Received February 13, 2001; revised May 18, 2001; accepted
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