Skip to main content
SpringerLink
Log in

Treatment Manuals, Single-Subject Designs, and Evidence-Based Practice: A Clinical Behavior Analytic Perspective

  • Theoretical Article
  • Published:
The Psychological Record Aims and scope Submit manuscript

Abstract

Empirical support of procedures linked to processes of therapeutic change is emerging as an alternative foundation for evidence-based treatment development and selection in clinical psychology, in particular within cognitive-behavioral practice. Single-subject designs conducted with treatment manuals have contributed to the existing evidentiary base of research-supported treatment packages organized around psychiatric diagnoses, but as a rule have not been afforded the same status as randomized clinical trials. From a clinical behavior analytic perspective, single-subject experiments may be positioned to proportionately contribute more to emerging evidence-based practice that is itself more process focused, in particular if at least two recommended adjustments are made in how they are conducted. The first of these is to maximize efficacy and minimize rigidity in developing treatment manuals by creating them in a post-hoc rather than a-priori manner and with an emphasis on therapeutic procedures linked to specific processes. The second recommendation is that clinical behavior analysts routinely collect repeated process as well as outcome measures in conducting single-subject research.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. The terms “single-subject designs,” “single-subject experiments,” and “single-case research” will be used interchangeably throughout this article to refer to the systematic evaluation of the impact of manipulating one or more independent variables on the behavior of a single or small number of participants. Single-case research within behavior analysis is perhaps most closely epitomized by the A/B/A or withdrawal design, but also includes, but is not limited to, others such as multiple-baseline, alternating treatment, and changing-criterion designs (Barlow & Hersen, 1984).

  2. One possible distinction that could be made between protocols and manuals is that the former is more concerned with the timing and sequencing of when to introduce a specific therapeutic component or procedure (e.g., exposure or behavioral homework), whereas the latter focuses on the technical aspects of how to effectively implement a given procedure. Such a potential difference, however, would be largely based on their topographical or formal features, while obscuring their shared function of exerting control over therapists’ behavior. For this reason, the term “treatment manual” will be used to refer to written materials that when followed serve the ostensible purpose of increasing the desired impact of the therapists’ behavior on clients.

  3. The term “master chefs” is used here more colloquially (cf. Master Chef's Institute (n.d.)) to refer to individuals who are noted for creating and/or perfecting recipes often associated with a particular dish or cuisine (e.g., Emeril Lagasse). Their analogues in clinical psychology are scientist-practitioners who develop new treatment approaches and techniques. Within the focus of this article, the use of single-subject research in the development of metacognitve therapy is illustrative (Fisher & Wells, 2008; Wells et al., 2009).

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

    Book  Google Scholar 

  • American Psychological Association (APA) Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.

    Google Scholar 

  • Barlow, D. H., & Hersen, M. (1984). Single case experimental designs: Strategies for studying behavior change (2nd ed.). New York, NY: Pergamon.

    Google Scholar 

  • Barlow, D. H., Leitenberg, H., & Agras, W. S. (1969). Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization. Journal of Abnormal Psychology, 74, 596–601.

    Google Scholar 

  • Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford.

    Google Scholar 

  • Bevill-Davis, A., Clees, T. J., & Gast, D. L. (2004). Correspondence training: A review of the literature. Journal of Early & Intensive Behavior Intervention, 1, 13–26.

    Google Scholar 

  • Brown, A. (n.d.). Culinary quotes. Retrieved from http://chatteringkitchen.com/culinary-quotes/

  • Canadian Psychological Association. (2012). Evidence-based practice of psychological treatments: A Canadian perspective. (Report of the CPA Task Force on Evidence-Based Practice of Psychological Treatments). Ottawa, Canada: Author.

  • Castonguay, L. C., Schut, A. J., Constantino, M. J., & Halperin, G. S. (1999). Assessing the role of treatment manuals: Have they become necessary but nonsufficient ingredients of change. Clinical Psychology: Science & Practice, 6, 449–455.

    Google Scholar 

  • Chambless, C. L., & Hollon, S. D. (1998). Empirically supported therapies. Journal of Consulting & Clinical Psychology, 66, 7–18.

    Google Scholar 

  • Chambless, D. L., Sanderson, W. C., Shoham, V., Johnson, S. B., Pope, K. S., & Crits-Christoph, P. (1996). An update on empirically validated therapies. The Clinical Psychologist, 49, 5–18.

    Google Scholar 

  • Chaw, J. H. (2019). A comparison of two behavioral activation protocols. (Unpublished doctoral dissertation proposal), Wichita State University, Wichita, KS.

  • Christopher, P. J., & Dougher, M. J. (2009). A behavior-analytic account of motivational interviewing. The Behavior Analyst, 32, 149–161.

    PubMed  PubMed Central  Google Scholar 

  • Dobson, K. S., & Shaw, B. F. (1988). The use of treatment manuals in cognitive therapy: Experience and issues. Journal of Consulting & Clinical Practice, 56, 673–680.

    Google Scholar 

  • Eifert, G. H., Schulte, D., Zvolensky, M. J., Lejuez, C. W., & Lau, A. W. (1997). Manualized behavior therapy: Merits and challenges. Behavior Therapy, 28, 499–509.

    Google Scholar 

  • Embry, D. E., & Biglan, A. (2008). Evidence-based kernels: Fundamental units of behavioral influence. Clinical Child & Family Psychology Review, 11, 75–113.

    Google Scholar 

  • Ferster, C. B. (1972a). An experimental analysis of clinical phenomena. The Psychological Record, 22, 1–16.

    Google Scholar 

  • Ferster, C. B. (1972b). Psychotherapy from the standpoint of a behaviorist. In J. D. Keehn (Ed.), Psychopathology in animals: Research and clinical implications (pp. 279–303). New York, NY: Academic Press.

    Google Scholar 

  • Fisher, P. L., & Wells, A. (2008). Metacognitive therapy for obsessive-compulsive disorder: A case series. Journal of Behavior Therapy & Experimental Psychiatry, 39, 117–132.

    Google Scholar 

  • Forman, E. M., Chapman, J. E., Herbert, J. D., Goetter, E. M., Yuen, E. K., & Moitra, E. (2012). Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy. Behavior Therapy, 43, 341–354.

    PubMed  Google Scholar 

  • Garfield, S. L. (1996). Some problems associated with “validated” forms of psychotherapy. Clinical Psychology: Science & Practice, 3, 218–229.

    Google Scholar 

  • Ghaderi, A. (2006). Does individualization matter? A randomized trial of standard (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research & Therapy, 44, 273–288.

    Google Scholar 

  • Ghaderi, A. (2007). Logical functional analysis in the assessment and treatment of eating disorders. Clinical Psychologist, 11, 1–12.

    Google Scholar 

  • Hamilton, J. D., Kendall, P. C., Gosch, E., Furr, J. M., & Sood, E. (2008). Flexibility within fidelity. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 987–993.

    Google Scholar 

  • Harrington, M., & Velicer, W. F. (2015). Comparing visual and statistical analysis in single-case studies using published studies. Multivariate Behavioral Research, 50, 162–183.

    PubMed  PubMed Central  Google Scholar 

  • Hartmann, D. P., & Hall, R. V. (1976). The changing criterion design. Journal of Applied Behavior Analysis, 9, 527–532.

    PubMed  PubMed Central  Google Scholar 

  • Hayes, S. C. (1981). Single case experimental design and empirical clinical practice. Journal of Consulting & Clinical Practice, 49, 193–211.

    Google Scholar 

  • Hayes, S. C., Brownstein, A. J., Zettle, R. D., Rosenfarb, I., & Korn, Z. (1985). Rule-governed behavior and sensitivity to changing consequences of responding. Journal of the Experimental Analysis of Behavior, 45, 237–256.

    Google Scholar 

  • Hayes, S. C., & Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behavioral Assessment, 14, 345–365.

    Google Scholar 

  • Hayes, S. C., & Hofmann, S. G. (2018). Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. Oakland, CA: Context Press.

    Google Scholar 

  • Hayes, S. C., Hofmann, S. G., Stanton, C. E., Carpenter, J. K., Sanford, B. T., Curtiss, J. E., & Ciarrochi, J. K. (2019). The role of the individual in the coming era of process-based therapy. Behaviour Research & Therapy, 117, 40–53.

    Google Scholar 

  • Hayes, S. C., Long, D. M., Levin, M. E., & Follette, W. C. (2013). Treatment development: Can we find a better way? Clinical Psychology Review, 33, 870–882.

    PubMed  Google Scholar 

  • Hayes, S. C., Nelson, R. O., & Jarrett, R. B. (1986). Evaluating the quality of behavioral assessment. In R. O. Nelson & S. C. Hayes (Eds.), Conceptual foundations of behavioral assessment (pp. 463–503). New York, NY: Guilford.

    Google Scholar 

  • Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford.

    Google Scholar 

  • Hayes, S. C., Zettle, R. D., & Rosenfarb, I. (1989). Rule-following. In S. C. Hayes (Ed.), Rule-governed behavior: Cognition, contingencies, and instructional control (pp. 191–220). New York, NY: Plenum.

    Google Scholar 

  • Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–111.

    PubMed  Google Scholar 

  • Hilliard, R. B. (1993). Single-case methodology in psychotherapy process and outcome research. Journal of Consulting & Clinical Psychology, 61, 373–380.

    Google Scholar 

  • Hofmann, S. G., & Hayes, S. C. (2018). The history and current status of CBT as an evidence-based therapy. In S. C. Hayes & S. G. Hofmann (Eds.), Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy (pp. 7–21). Oakland, CA: Context Press.

    Google Scholar 

  • Hoyer, J., Colic, J., Pittig, A., Crawcour, S., Moeser, M., Ginzburg, D., et al. (2017). Manualized cognitive therapy versus cognitive-behavioral treatment-as-usual for social anxiety disorder in routine practice: A cluster-randomized controlled trial. Behavior Research & Therapy, 95, 87–98.

    Google Scholar 

  • Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

    Google Scholar 

  • Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive-behavioral treatment of depression. Journal of Consulting & Clinical Psychology, 64, 295–304.

    Google Scholar 

  • Kaplan, B. J., Giesbrecht, G., Shannon, S., & McLeod, K. (2011). Evaluating treatments in health care: The instability of a one-legged stool. BMC Medical Research Methodology, 11, 65–72.

    PubMed  PubMed Central  Google Scholar 

  • Kaptchuk, T. J. (2001). The double-blind, randomized, placebo-controlled trial: Gold standard or golden calf? Journal of Clinical Epidemiology, 54, 541–549.

    PubMed  Google Scholar 

  • Kazdin, A. E. (1998). Treatment manuals in clinical practice: Introduction to the series [Special section]. Clinical Psychology: Science & Practice, 5, 316–362.

    Google Scholar 

  • Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27.

    PubMed  Google Scholar 

  • Klepac, R. K., Ronan, G. F., Arnold, K. D., Belar, C. D., Berry, S. L., Christoff, K. A., et al. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral Training. Behavior Therapy, 43, 687–697.

    PubMed  Google Scholar 

  • Kohlenberg, R. J., Bolling, M. Y., Kanter, J. W., & Parker, C. R. (2002). Clinical behavior analysis: Where it went wrong, how it was made good again, and why the future is so bright. The Behavior Analyst Today, 3, 248–253.

    Google Scholar 

  • Kratochwill, T. R., & Levin, J. R. (Eds.). (1992). Single-case research design and analysis: New directions for psychology and education. Hillsdale, NJ: Lawrence Erlbaum Associates.

    Google Scholar 

  • Last, C. G., Barlow, D. H., & O’Brien (1983). Comparison of two cognitive strategies in treatment of a patient with generalized anxiety disorder. Psychological Reports, 53, 19–26.

  • Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification, 25, 255–286.

    PubMed  Google Scholar 

  • Lilienfeld, S. O., Lynn, S. J., & Bowden, S. C. (2018). When evidence-based practice isn’t enough: A call for science-based practice. The Behavior Therapist, 41, 42–47.

    Google Scholar 

  • Luborsky, L., & DeRubeis, R. J. (1984). The use of psychotherapy treatment manuals: A small revolution in psychotherapy research style. Clinical Psychology Review, 4, 5–14.

    Google Scholar 

  • Marques, C. (1998). Manual-based treatment and clinical practice. Clinical Psychology: Science & Practice, 5, 400–402.

    Google Scholar 

  • Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York, NY: Norton.

    Google Scholar 

  • Matthews, B. A., Shimoff, E., Catania, A. C., & Sagvolden, T. (1977). Uninstructed human responding: Sensitivity to ratio and interval contingencies. Journal of the Experimental Analysis of Behavior, 27, 453–467.

    PubMed  PubMed Central  Google Scholar 

  • McKnight, D. L., Nelson, R. O., Hayes, S. C., & Jarrett, R. B. (1984). Importance of treating individually-assessed response classes in the amelioration of depression. Behavior Therapy, 15, 315–335.

    Google Scholar 

  • Miller, W. R., & Rollnick, S. R. (2012). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford.

    Google Scholar 

  • Papageorgiou, C., & Wells, A. (1998). Effects of attention training on hypochondriasis: A brief case series. Psychological Medicine, 28, 193–200.

    PubMed  Google Scholar 

  • Paronson, B. S., & Baer, D. M. (1992). The visual analysis of data, and current research into the stimuli controlling it. In T. R. Kratochwill & J. R. Levin (Eds.), Single-case research design and analysis: New directions for psychology and education (pp. 15–40). Hillsdale, NJ: Lawrence Erlbaum Associates.

    Google Scholar 

  • Ruiz, F. J., Flórez, C. L., García-Martín, M. B., Monroy-Cifuentes, A., Barreto-Montero, K., García-Beltrán, D. M., et al. (2018). A multiple-baseline evaluation of a brief acceptance and commitment therapy protocol focused on repetitive negative thinking for moderate emotional disorders. Journal of Contextual Behavioral Science, 9, 1–14.

    Google Scholar 

  • Ruiz, F. J., Riaño-Hernández, D., Suárez-Falcón, J. C., & Luciano, C. (2016). Effect of a one-session ACT protocol in disrupting repetitive negative thinking: A randomized multiple-baseline design. International Journal of Psychology & Psychological Therapy, 16, 213–233.

    Google Scholar 

  • Sackett, D. L., Strauss, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence based medicine: How to practice and teach EBM (2nd ed.). London, UK: Churchill Livingston.

    Google Scholar 

  • Schulte, D., Künzel, R., Pepping, G., & Schulte-Bahrenberg, T. (1992). Tailor-made versus standardized therapy of phobic patients. Advances in Behaviour Research & Therapy, 14, 67–92.

    Google Scholar 

  • Shadish, W. R. (2014). Statistical analyses of single-case designs: The shape of things to come. Current Directions in Psychological Science, 23, 139–146.

    Google Scholar 

  • Shimoff, E., Catania, A. C., & Matthews, B. A. (1981). Uninstructed human responding: Sensitivity of low-rate performance to schedule contingencies. Journal of the Experimental Analysis of Behavior, 36, 207–220.

    PubMed  PubMed Central  Google Scholar 

  • Skinner, B. F. (1953). Science and human behavior. New York. NY: Free Press.

    Google Scholar 

  • Skinner, B. F. (1969). Contingencies of reinforcement: A theoretical analysis. New York, NY: Appleton-Century-Crofts.

    Google Scholar 

  • Skinner, B. F. (1974). About behaviorism. New York, NY: Knopf.

    Google Scholar 

  • Smith, R., & Rennie, D. (2014). Evidence-based medicine: An oral history. JAMA, 311, 365–367.

    PubMed  Google Scholar 

  • Society of Clinical Psychology. (n.d.). Treatment target: Depression. Retrieved from https://www.div12.org/diagnosis/depression/

  • Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3–23.

    Google Scholar 

  • Thase, M. E., & Wright, J. H. (1991). Cognitive-behavior therapy manual for depressed inpatients: A treatment protocol outline. Behavior Therapy, 22, 579–595.

    Google Scholar 

  • The Master Chefs' Institute (n.d.) What is a certified chef? Retrieved from https://www.masterchefs-llc.com/about-us/what-is-a-certified-master-chef/

  • Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science & Practice, 22, 317–338.

    Google Scholar 

  • Truijens, F., Hulzen, Z.-v., & Vanheule, S. (2018). To manualize, or not to manualize: Is that that still the question? A systematic review of empirical evidence for manual superiority in psychological treatment. Journal of Clinical Psychology, 75, 329–343.

    PubMed  Google Scholar 

  • Tschacer, W., & Ramseyer, F. (2009). Modeling psychotherapy process by time-series panel analysis (TSPA). Psychotherapy Research, 19, 469–481.

    Google Scholar 

  • Twohig, M. P., & Crosby, J. M. (2010). Acceptance and commitment therapy as a treatment for problematic internet pornography viewing. Behavior Therapy, 41, 285–295.

    PubMed  Google Scholar 

  • Villatte, J. L., Vilardaga, R., Villatte, M., Vilardaga Plumb, J. C., Atkins, D. C., & Hayes, S. C. (2016a). Acceptance and commitment therapy modules: Differential impact on treatment processes and outcomes. Behavior Research & Therapy, 77, 52–61.

    Google Scholar 

  • Villatte, M., Villatte, J. L., & Hayes, S. C. (2016b). Mastering the clinical conversation: Language as intervention. New York, NY: Guilford.

    Google Scholar 

  • Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome. Journal of Consulting & Clinical Psychology, 78, 200–211.

    Google Scholar 

  • Wells, A., Fisher, P., Myers, S., Wheatley, J., Patel, T., & Brewin, C. R. (2009). Metacognitive therapy in recurrent and persistent depression: A multiple-baseline study of a new treatment. Cognitive Therapy & Research, 33, 291–300.

    Google Scholar 

  • Wilson, G. T. (1998). Manual-based treatment and clinical practice. Clinical Psychology: Science & Practice, 5, 363–375.

    Google Scholar 

  • Wulfert, E., Greenway, D. E., & Dougher, M. J. (1996). A logical functional analysis of reinforcement-based disorders: Alcoholism and pedophilia. Journal of Consulting & Clinical Psychology, 64, 1140–1151.

    Google Scholar 

  • Zettle, R. D., & Hayes, S. C. (1987). Component and process analysis of cognitive therapy. Psychological Reports, 61, 939–953.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychology, Wichita State University, Wichita, KS, 67260-0034, USA

    Robert D. Zettle

Authors
  1. Robert D. Zettle
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert D. Zettle.

Ethics declarations

There are no potential conflicts of interest to disclose or declare. Because this article is not an empirical study, ethical standards involving informed consent and research involving human participants and/or animals are not applicable.

Availability of Data and Materials

Not applicable.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zettle, R.D. Treatment Manuals, Single-Subject Designs, and Evidence-Based Practice: A Clinical Behavior Analytic Perspective. Psychol Rec 70, 649–658 (2020). https://doi.org/10.1007/s40732-020-00394-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40732-020-00394-2

Keywords

Search

Navigation