Treatment manuals for the real world: Where do we build them?

Carroll and Nuro (this issue) outline a model for development of psychotherapy manuals that parallels the recently articulated stage model of psychotherapy research. The authors outline excellent considerations for treatment manuals in early, middle, and late stages of development. As manual testing moves from pilot studies and efficacy tests in university settings to transportability studies in clinical settings, the complexity of the manuals increases. These considerations also raise the broader question, however, of whether the stages of psychotherapy research as commonly implemented are best suited for developing treatments appropriate for “real-world” clinical settings. I suggest that all stages of research are perhaps better conducted in clinical as opposed to university settings. A change in research infrastructure would be challenging at first but could ultimately accelerate development of psychotherapy technologies.