Treatment standardization

Psychotherapy efficacy research, like pharmacotherapy research, requires that the treatment be standardized. Such standardization serves two related purposes. First, from a clinical point of view it is necessary that the treatment be clearly specified, so that any conclusions about differential treatment efficacy can be translated into clear treatment recommendations. From a research point of view, treatment standardization allows studies to be replicated. In addition, by making the delivery of a treatment more standardized, differences between therapists and the statistical problems that result from the non-independence that 'therapist effects' introduce can be avoided.(!0)

Standardization of pharmacological interventions is relatively straightforward—a per-day dosage (or range of dosages) is set in advance. But for psychotherapy, how can something so complex as patient-therapist dialogue be standardized? The central ingredient in standardization of a psychosocial treatment is a treatment manual. A psychotherapy manual describes the treatment in detail, with case examples and instruments for psychotherapists. Some treatment manuals, particularly those coming from a cognitive-behavioural perspective, present a highly systematized step-by-step programme which therapists follow over the course of therapy. The relative success of treatment manuals in standardizing psychotherapy has been supported by a meta-analysis, (L1) which documented that studies employing treatment manuals had fewer outcome differences between therapists compared with studies that did not employ treatment manuals. Thus, when a treatment manual is used, therapists appear to produce relatively more uniform outcomes. In contrast, when no treatment manual is used, therapists differ considerably in their typical outcomes with patients; suggesting that different therapists are likely to be conducting sessions in discrepant ways, some therapists producing more favourable outcomes and other therapists producing less favourable outcomes.

Treatment standardization, however, does not simply translate to the use of a treatment manual. A variety of steps are needed to ensure that therapists are delivering the intended treatment (Table...2), including: the careful selection of therapists; training of therapists in the intended modality using a treatment manual; certification of therapists based upon their adherence to the treatment model during training; and continuing adherence and competence monitoring of therapists during a clinical trial.

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Table 2 Steps involved in the standardization of psychotherapy for outcome research

Concerns have been raised about the 'treatment manual' concept applied to less directive treatments such as psychodynamic therapy. The belief is that session-by-session manuals would remove the essence of good psychotherapy, and good dynamic therapy in particular, by making treatment artificially rigid and taking away the necessary clinical flexibility and creativity. Psychodynamic treatment manuals, (12,,13> however, are perhaps better described as 'guides', which specify the principles of treatment but do not overly constrain the necessary clinical flexibility and creativity. The flexibility of treatment is fully retained through the principle of tailoring the treatment intervention to the specific idiosyncratic issues that are salient for each patient. The actual learning of the practice of treatment is accomplished through supervision in the application of the treatment manual. Because dynamic treatment manuals are less like 'cookbooks', there may be a greater reliance on the supervision process compared with perhaps more straightforward behavioural treatments.

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