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feelings in the here-and-now of the therapeutic relationship, and how to facilitate an open
discussion about the rupture in a way that prevents unnecessary anxiety for the patient.
There has been greater interest among researchers and psychotherapists to
integrate relational and interpersonal interventions into various forms of psychotherapies
and to develop integrative forms of treatment manuals. The movement toward
psychotherapy integration has been charted in various traditions. For example, this
movement has been traced in psychoanalytic theory (Mitchell, 1988; Eagle, 1984), as
reflected among some integrative forms of psychodynamic and interpersonal therapies
(e.g., Wachtel & McKinney, 1992).
Likewise, the cognitive tradition has witnessed a reformulation in its
conceptualization of change toward an interpersonal perspective, with the recognition of
the alliance as a mechanism of change in its own right (e.g., Arnkoff, 1983; Goldfried,
1982; Jacobson, 1989; Safran, 1984a, 1984b). These changes have important implications
for future research, in terms of development of treatment manuals, as well as future
training of therapists in applying treatment manuals in ways that contribute to positive
treatment effects.
Research in therapist adherence to treatment manuals has yet to reach a
conclusion about the benefits of therapist adherence. Methodological and conceptual
problems with operationalizing treatment adherence pose barriers for researchers in this
area. Furthermore, there is evidence showing a link between therapists' adherence to
treatment manuals and problems in the alliance. Next, several issues that pertain to
treatment manuals are discussed. The review begins with a historical development of
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