What to do when manuals fail? The dual model of psychotherapy.

Although multicenter clinical trials have impressively attested to the efficacy of psychological interventions for common psychological disorders, some individual patients still do not profit from treatment. In this article, we present a theoretical model and some supportive results to explain this unsatisfactory state. Apart from early treatment dropout, some patients are not engaged in treatment and lack the prerequisite behavior (“patient basic behavior”) for successfully applying protocol-specified intervention techniques. According to the dual model of therapy, therapists have two tasks: to apply treatment techniques/procedures and to motivate patients for treatment by strengthening patient basic behavior if necessary. Our results show that therapists attend and react to therapeutic process problems by changing from a method-oriented treatment strategy to a process- or patient-oriented strategy. This change, however, occurs too soon, too often, and occasionally for the wrong reason. We must therefore develop empirically based criteria to inform therapists when to react, what to look for, and what to do to motivate the patient. We conclude that treatment outcome research and process research are both valuable and complementary aspects of psychotherapy research.