Manualized therapy contrasts sharply with Dynamic Therapy LLC’s individualized therapeutic approach.

As the name suggests, manualized therapy follows steps and procedures as laid out in a manual. Although therapists do vary in how closely they adhere to the manual, the therapies have been developed to be practiced with little variation. By design, manualized treatment reduces the role of clinical judgment in psychotherapy.

Below:

• Standardization Over Individualization
• The Rise of Manualized Therapy
• Proponents & Detractors
  • Advocating for Manualized Therapy
  • Questioning the Evidence
  • The Evidence Against Evidence-Based Treatment
  • The Evidence Base for Non-Manualized Treatment
• Deciding Between Manualized & Individualized Treatment

Examples of therapies with highly detailed and regimented manuals include acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), eye movement desensitization and reprocessing (EMDR), and solution focused therapy (SFT), as well as an ever-growing list of other manualized treatments.

Standardization’s compatibility with empirical study has made manualized therapy the subject of many studies — so much so that the terms “manualized” and “evidence-based” are used interchangeably. Meanwhile, proponents of more individualized, psychodynamic approaches take exception, pushing back against the implication that psychoanalytic psychotherapy is not evidence based and pointing to flaws in studies that support manualized therapies.

Standardization Over Individualization

Yes, manualized therapy can allow for some degree of individualization. And an individualized, psychodynamic approach does adhere to certain standards. What’s different is where each approach puts its emphasis. Emphasizing standardization over individualization, manualized treatment generalizes human experience, codifies and quantifies symptoms, and specifies procedures.

Manualized treatment typically begins with a therapist conducting a diagnostic assessment by stepping you through a structured questionnaire. After tallying symptoms, the resulting diagnosis gives the practitioner a general idea of your situation. (It also enables the practitioner to get reimbursed by your health insurance company.) That diagnosis guides the practitioner to the applicable section of the manual. Based on the diagnosis, manuals delimit a set number and order of steps, specifying what a practitioner should say and do at each defined stage of treatment. Diagnosis also may guide the practitioner to templated treatment plans, scales for quantifying symptoms, and—based on symptoms and diagnosis—goals and “expected outcomes.” The use of worksheets and homework is common.

In contrast to individualized treatment—where your individual circumstances set the tone and tenor—the manual’s guidelines aim for consistency. The point is for each treatment to follow a standardized course, no matter the setting, no matter the practitioner’s experience, no matter the individual client.

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The Rise of Manualized Therapy

That generalization of experience and consistency of treatment makes manualized therapy attractive in institutional settings, to large clinics, and to health insurance companies, As a result, it continues to grow both in its use and in the variety of manualized therapies.

Institutional settings—such as veteran’s hospitals, psychiatric units, and other situations where high volume and high turnover prevent a high degree of individualization—value the emphasis on brevity and fixed procedures.

Large clinics rely on manualized therapies to be reasonably certain that recent graduates, having been trained to the manual, are delivering a consistent level of care.

Insurers also gravitate toward manualized treatment based on its generalization of individual experience, its diminished reliance on therapist judgement, its emphasis on brevity, and, significantly, its clear metrics for determining whether to reimburse and when to terminate treatment. For insurers, the use of manualized therapy simplifies the evaluation of effects that can be subtle, incremental, ephemeral, and sometimes known only to you. Compared to understanding the complexities of your life. it’s simpler to confirm that a practitioner is adhering to the manual’s sequence and number of steps.

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Proponents & Detractors

Although less effective for patients not easily sorted by their symptoms or characterized by a diagnosis, manualized therapies have been shown to be effective. This is especially true when measuring short term relief from specific symptoms. In the middle of is proponents and detractors, other clinicians and researchers see manualized treatment’s advantages and challenges.

Advocating for Manualized Therapy

Advocates of manualized therapy note several benefits reaped by reducing the role clinical judgement plays in the therapeutic process. They believe that shifting the emphasis from judgement to execution increases consistency of treatment, allows for greater accountability, simplifies training and supervision, shortens courses of treatment, and reduces costs. Support of manualized therapy hinges on its reputation as “evidence-based.”

Increased Consistency. The more closely a course of treatment follows a manual, the more likely it will be consistent with the next course of treatment. Plus, having reduced the role of clinical judgement—such consistency is likely to hold even when administered by novice practitioners.

That contrasts with an individualized approach which—by following the unique therapeutic relationship between two or more unique individuals—charts a course of treatment that is purposefully inconsistent.

Greater Accountability. Reducing the role of clinical judgement can result in greater accountability, at least as it relates to adherence to a manual. Within the free-flowing dynamic of an individualized approach, what a therapist says or does depends very much on the moment. Whether it was the “right” intervention requires an understanding of both therapist and patient, what was happening in that moment, and what, prior to that moment, has happened between them. It is easier to determine whether a practitioner followed the steps and intervened as directed by a manual.

Simplified Training & Supervision. A reduced need for clinical judgement winnows the knowledge needed to exercise that judgment. Traditionally, applying psychological theory—a key part of psychotherapy practice—has required deep understanding.  When judgement is a smaller part of the equation, applying theory becomes less about depth of comprehension and more about following directions. Training to a manual shortens the learning curve.

Shortened Treatment. As noted, treatment manuals typically lay out a finite, often low, number of sessions. Courses of CBT treatment, for example, range from 20 to as few as five sessions. DBT’s four modules can be completed in six months. EMDR’s eight phases take between six and twelve sessions. Solution-focused therapy takes an average of five sessions.

While the hope is that brief treatment will speed relief for suffering patients, the immediate and tangible result of brevity is that it costs less.

Reduced Costs. Brevity is just one way manualized treatment can reduce costs. The consistency achieved by reducing the role of clinical judgement, for example, permits administration by lower-paid practitioners. Simplified accountability also makes it easier to verify that, at a minimum, novice practitioners are following the manual. Simplified training, meanwhile, means less time and money spent on preparing practitioners to see clients.

Evidence Based. Promoters acknowledge that, for these benefits to matter, manualized therapy has to benefit clients. To validate its use, supporters site studies that, they say, make manualized treatment “evidence-based.” In fact, to promote its use, manualized therapy is more often called “evidence-based treatment.”

Empirical support, say proponents, makes manualized therapy the “gold standard.” One meta-analytic review of 26 studies, for example, concluded that CBT should be considered, “at least for patients with anxiety and depressive disorders.”  Meanwhile, a review of 106 meta-analyses maintains that “the evidence-base of CBT is very strong.” Another review of indicators of efficacy and effectiveness of evidence-based treatments coded 750 treatment protocols from 435 studies to find “large numbers of evidence-based treatments applicable to anxiety, attention, autism, depression, disruptive behavior, eating problems, substance use, and traumatic stress.”

Calling manualized treatment “evidence based” works to imply that non-manualized therapy is not evidence based. Not only do critics of manualized therapy take exception to this, they question the evidence that purports to support manualized treatment.

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Questioning the Evidence

Yes, say critics of manualized therapy, briefer treatment, reduced costs, and the rest are all desirable. But, they ask, where’s the evidence for evidence-based therapy?

Calling the studies that support manualized treatment “bad science,” critics point to flaws in statistical modeling and data analysis, flaws in population sampling, and flaws in experimental design. Even before digging into empirical validity, some call out the limitations of empirically-supported treatment. One contributor to Psychology Today likens manualized treatment to “teaching to the test.” Another notes that, while the evidence for “evidence-based therapy” is real, its relevance often is not.

By looking closely at what the evidence actually says, these detractors question whether brevity, accountability, consistency, and savings, ultimately result in healing.

Flawed Statistical Modeling & Data Analysis. Many studies, say critics, offer only weak support for manualized treatment.

A study’s findings may be “statistically significant,” for example, but, at the same time, be clinically meaningless. One such study’s statistically significant findings—showing that CBT recipients scored only 1.2 points higher than the control group on a 54-point scale—did not actually reflect significant improvement in its subjects’ lives.

What’s more, say critics, a fuller analysis of published data would account for the “publication bias” that favors studies with positive rather than negative results.

Flawed Population Sampling. Population sampling methods routinely screen-out about two-thirds of a study’s potential test subjects. Typical criteria—which exclude those with a diagnosable personality disorder, meet criteria for more than one diagnosis, or who are deemed unstable or suicidal—result in a population sample much different than those actually seeking therapy.

Flawed Experiment Design. Empirical studies arrive at their conclusions by comparing outcomes of test subjects with those of a control group. The problem is that treatments for control groups may not reflect viable alternatives to the manualized therapy under investigation. In one study comparing CBT against psychodynamic outcomes, the control group received a constrained version of psychodynamic psychotherapy from inexpert graduate students. In another study, the control group received no psychotherapy at all.

The limitations of randomized control designs, concluded one researcher, mean that empirical studies “work best for those symptom-focused approaches to psychotherapy that can be manualized and applied in essentially the same manner across patients who share a certain uncomplicated diagnosis.”  Another researcher, citing limitations on the external validity of psychotherapy efficacy studies, cautions against “uncritical acceptance of empirically supported treatments.”

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The Evidence Against Evidence-Based Treatment

Publication bias notwithstanding, critics point out that data challenges superiority of manualized psychotherapy. Studies questioning the superiority of manualized treatment do get published.

A meta-analysis of 17 studies, for example, demonstrated the questionable efficacy of manualized psychological treatments. Another meta-analysis “fail[ed] to provide corroborative evidence for the conjecture that CBT is superior.” Concluded one systematic review, “manualized treatment is not empirically supported as more effective” and “it should not be promoted as being superior to non-manualized psychotherapy.” As reflected in the title of a meta-analysis of 70 studies, “The effects of cognitive behavioral therapy as an anti-depressive treatment is falling.”

Other meta-analyses questioned the efficacy of the third wave of behavioral therapies such as DBT and ACT, demonstrated CBT’s poor performance in 53 comparative outcome studies, and expressed doubts about the empirical status of empirically supported psychotherapies.

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The Evidence Base for Non-Manualized Treatment

Meanwhile, proponents of more individualized, psychoanalytic approaches bristle at the implication that non-manualized psychotherapy is not evidence-based.

They counter that ample empirical evidence does, indeed, demonstrate the efficacy of psychodynamic psychotherapy. Meta-analyses comparing various therapies, for example, show that psychodynamic therapy routinely meets or exceeds the effect sizes of CBT, medication, and of psychotherapy in general. Another systematic review of empirical evidence concluded that manual-based treatment is not superior to non-manualized psychotherapy.

The evidence base supporting non-manualized treatment includes meta-analyses comparing the effectiveness of psychodynamic therapy and CBT, demonstrating the effectiveness of long-term psychodynamic psychotherapy, suggesting that psychodynamic therapy is as efficacious as other empirically supported treatments, and showing how bioscience demonstrates the effectiveness of psychodynamic psychotherapies.

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Deciding Between Manualized &
Individualized Treatment

The reality is that two, seemingly opposed claims can be true at the same time.

Yes, many patients have reported success following a course of manualized treatment. As noted above, empirical support is strongest for manualized therapies that focus on a single symptom and on uncomplicated diagnoses.

Others, however, have been frustrated by manualized therapy’s standardization and predictability. They find that they respond better to an individualized therapeutic approach that charts a course based on their unique needs and focused on understanding them as an individual.

Determining which approach is right for you comes from understanding what manualized therapy is and how it works.

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