Judith S. Beck, PhD, President, Beck Institute for Cognitive Behavior Therapy
Three Case Examples
I gave “Client A” the diagnosis of Major Depressive Disorder, Single Episode, Severe (according to DSM-5 TR). He was spending most of the day sitting on his couch, immersed in painful, negative thoughts. He had isolated himself and was avoiding any activity that he predicted would be difficult or energy-depleting. He was doing little self-care, including eating regular meals, going to bed at a reasonable hour, cleaning his apartment, and interacting with friends and family. He responded quite favorably to standard CBT for depression interventions, as demonstrated to be effective in randomized controlled trials, including behavioral activation and identifying, assessing, and responding to his automatic thoughts.
“Client B” also met full criteria for Major Depressive Disorder, single episode, but of moderate severity. She held unrealistically high expectations for herself and maintained a busy schedule, working sixty hours a week and caring for her four young children, despite her depression. She needed the opposite of behavioral activation. She needed to learn to accept the reality of her depression, view it as temporary, and adjust her schedule and the demands she placed on herself. Using the same treatment plan with Client B would have proven ineffective.
“Client C” likewise carried the diagnosis of Major Depressive Disorder. At least part of her depression was related to being continually passed over for promotions at work, despite having excellent evaluations. An examination of this problem revealed that systemic racism was probably associated with her lack of advancement at her workplace. Re-attributing what she saw as her own failure to the broader framework of discrimination enabled her to become empowered to take steps to find a better job elsewhere.
These three examples illustrate how the same diagnosis can often require vastly different approaches—and how using treatment manuals for every client simply won’t work.
Did CBT emphasize treatment manuals when it was first developed?
No. In the foundational book, Cognitive Therapy of Depression (1979), Aaron Beck, MD, and colleagues asserted that treatment plans based on an individualized cognitive case conceptualization or formulation for each client is essential for effective treatment. After reviewing the literature, Wilson (1997) concluded treatment manuals are inadequate when clients have complex problems.
Why, then, do so many therapists use one-size-fits-all treatment manuals?
Wilson (1997) noted that treatment manuals are essential for randomized controlled trials to assure that treatment across subjects has fidelity and validity. But manualized treatment has not been shown to be superior to non-manualized treatment. Truijens et al (2018) assessed six studies that compared manualized and non-manualized treatment and eight meta-analyses that indirectly assessed the effect sizes of manual-based treatment and control groups. None of the six studies demonstrated that therapists who used manuals were more effective than those who didn’t. Three of the meta-analyses found that therapists who used manuals had better outcomes than those who didn’t but five did not.
What should therapists do instead?
Rosen and Davison (2003) assert that therapists should use the empirically supported principles (ESPs) described in treatment manuals, including mechanisms of change, when developing treatment plans. Therapists in clinical practice need to view each client as an individual. Effective treatment requires understanding their specific core beliefs, automatic thoughts, behavioral coping strategies, barriers to change, dynamics of key relationships, their history and current functioning. Therapists also need to consider a range of individual characteristics, including their age, developmental level, gender and gender identity, cognitive functioning, medical conditions, culture, race, socio-economic and education levels, and degree of the impact (if there is one) of systemic racism, violence, and other trauma.
In addition, when developing individualized treatment plans, therapists need to consider clients’ unique aspirations and values, their strengths, talents, personal qualities, achievements, interests, positive relationships, positive aspects of their history and current functioning, their internal and external resources, and adaptive cognitions and coping strategies. Therapists then need to incorporate these attributes into their treatment plans to help clients build motivation, resilience, and a sense of empowerment and self-efficacy (J. Beck, 2021).
What are some other problems when relying on treatment manuals?
Manuals rarely include enough guidance on how to build very strong therapeutic relationships and how to understand and repair ruptures when they arise. In fact, adhering too closely to the protocol in a treatment manual may interfere with the therapist’s ability to notice, and then respond appropriately to clients’ negative affect shifts.
Manuals usually include only the standard techniques of a psychotherapy, and they don’t tell you how, when, and why to integrate techniques from other evidence-based psychotherapies into treatment. For any given client, for example, I will use cognitive and behavioral techniques, but I may also use recovery techniques, and techniques from Dialectical Behavior Therapy, Acceptance and Commitment Therapy, Interpersonal Psychotherapy, Compassion-Based Psychotherapy, psychodynamic psychotherapy (the latter especially when I’m treating someone diagnosed with a personality disorder), and many more.
And, by and large, manuals do not adequately address the problem of clients’ lack of progress or response.
Is there a rationale for using treatment manuals in specific circumstances?
Yes! A number of World Health Organization programs, based on randomized controlled trials, successfully train lay counselors from various international communities to use manuals when working with individuals who require therapeutic intervention. These individuals, though, are not delivering psychotherapy as we understand it in the United States. They are effectively using cognitive behavioral interventions in the context of supportive relationships. And novice therapists who are still in training may benefit from following a treatment manual—if they use it flexibly and make adaptations based on a comprehensive case formulation. Manuals may also be useful when non-professional staff are providing group psychoeducational training.
Treatment manuals can offer structure and guidance, especially for novice clinicians and lay counselors, but effective therapy depends on the therapist’s ability to respond flexibly and tailor treatment to each client’s unique circumstances. Truly effective CBT therapists approach each client as a unique individual with their own history, challenges, strengths, and values—and plan treatment accordingly.
References:
Wilson, G. T. (1997). Treatment manuals in clinical practice. Behaviour Research and Therapy, 35(3), 205–210. https://doi.org/10.1016/S0005-7967(96)00115-1
Rosen, G. M., & Davison, G. C. (2003). Psychology should list empirically supported principles of change (ESPs) and Not Credential Trademarked Therapies or Other Treatment Packages. Behavior Modification, 27(3), 300–312. https://doi.org/10.1177/0145445503027003003
Truijens, F., Zühlke-van Hulzen, L., & Vanheule, S. (2019). To manualize, or not to manualize: Is that still the question? A systematic review of empirical evidence for manual superiority in psychological treatment. Journal of Clinical Psychology, 75(3), 329-343. https://doi.org/10.1002/jclp.22712
Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond. New York, NY, USA: Guilford Press.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G (1979). Cognitive therapy of depression (pp. 153-203). New York, NY, USA: Guilford Press.