The evolution of psychotherapy training: Reflections on manual-based learning and future alternatives

Although psychotherapists-in-training may rely significantly on their clinical intuitions when first beginning to practice therapy, they quickly discover that much more is required to conduct effective treatment. Increasingly over the past two decades, training manuals have been used to impart explicit guidelines to beginning psychotherapists. In addition, manuals offer a means for helping more experienced therapists to learn new approaches, while also allowing careful research on the relative efficacy of different psychotherapies. In some instances, manuals have been designed specifically to address troublesome transference and countertransference issues (e.g., Time-Limited Dynamic Psychotherapy; Strupp & Binder, 1984). But even manualized treatments that target hostile interactions between therapist and patient are sometimes of limited use in teaching therapists to work with difficult patients, as illustrated by the Vanderbilt II Psychotherapy Research Project. Experimental research on the distinctions between implicit learning and explicit learning (e.g., Lee & Vakoch, 1996) helps explain the constraints of manualized treatments. By relying on explicit, clearly articulated guidelines, treatments conducted in accordance with manuals may interfere with tacit reasoning processes. As a consequence of the strong emphasis that manuals place on explicit rules for treatment, this type of training can hinder the development of complex clinical judgments. Future generations of novice psychotherapists may benefit from training experiences that are designed to promote an integration of implicit and explicit learning.