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    The Dialectics of Manual-Based Treatment
    Jim Pretzer · 7/26/99 at 10:28 pm ET

    Michael Addis and colleagues have an interesting discussion titled "The Dialectics of Manual-Based Treatment" in the Summer 1999 edition of the Behavior Therapist which I recommend highly. After explaining Dialectics and applying a dialctical perspective to some apparent dichotomies related to manual-based treatment, they present a nice analysis of some of the "sticking-points" encountered in using treatment manuals. The following is adapted from Figure 2 in their article:


    Adhering to the manual VS Flexibly adapting it to meet the needs of individual clients


    • Am I too focused on the uniqueness of this client and forgetting that the treatment works for a range of people with similar problems?


    • Am I too focused on adhering to the manual and not allowing myself to modify it as I see necessary for this client?


    • Possible Synthesis:

      • How does the manual provide a general framework for treating this individual?

      • What aspects of this particular individual facilitate my use of the treatment manual?

    • Moving Through Contrasts:

      • How can I adhere to the treatment as much as possible?

      • How can I flexibly modify the treatment as necessary?


    Utilizing therapeutic techniques VS Creating and maintaining a strong therapeutic alliance


    • Am I so concerned with adherence to the manual that I'm not attending to my relationship with the client?


    • Am I so concerned with maintaining rapport that I'm not utilizing the techniques described in the manual?


    • Possible Synthesis:

      • What type of therapeutic alliance can I create with this client to facilitate using these techniques?

      • How can using these techniques strengthen my alliance with this client?

    • Moving Through Contrasts:

      • How can I make sure to create the conditions for a strong alliance with my client?

      • How can I make sure to implement effective techniques as described in the manual?


    Believing in the treatment and expecting to be helpful VS Recognizing that my client may not improve as much as I would like


    • Am I feeling so much pressure for this client to improve that I am unwilling to accept his/her current level of progress?


    • Am I so demoralized by the client's lack of improvement that I have stopped communicating belief in the treatment?


    • Possible Synthesis:

      • How does my client's level of improvement enhance my understanding of this treatment?

      • How can I use my understanding of this treatment to better help this client and similar ones in the future?

    • Moving Through Contrasts:

      • How can I accept that this client may not improve as much as I would like?

      • How can I maintain confidence in the treatment and convey this to my client?

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