***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Does higher level of individualization increase treatment efficacy ? Fifty patients with bulimia nervosa were r and omized into either manual-based ( focused ) or more individualized ( broader ) cognitive behavioral therapy guided by logical functional analysis . Eating disorders Examination and a series of self-report question naires were used for assessment at pre- , and post-treatment as well as at follow-up . Both conditions improved significantly at post-treatment , and the results were maintained at the 6 months follow-up . There were no statistically and clinical ly significant differences between the two conditions at post-treatment with the exception of abstinence from objective bulimic episodes , eating concerns , and body shape dissatisfaction , all favoring the individualized , broader condition . Both groups improved concerning self-esteem , perceived social support from friends , and depression . The improvements were maintained at follow-up . Ten patients ( 20 % ) did not respond to the treatment . Notably , a majority of non-responders ( 80 % ) were in the manual-based condition . Non-responders showed extreme dominance of rule-governed behavior , and lack of contact with actual contingencies compared to responders . The study provided preliminary support for the superiority of higher level of individualization ( i.e. broader CBT ) in terms of the response to treatment , and relapses . However , the magnitude of effects was moderate , and independent replications , with blind assessment procedures , and a larger sample sized are needed before more clear cut conclusions can be drawn UNLABELLED Although associations with outcome have been inconsistent , therapist adherence and competence continues to garner attention , particularly within the context of increasing interest in the dissemination , implementation , and sustainability of evidence -based treatments . To date , research on therapist adherence and competence has focused on average levels across therapists . With a few exceptions , research has failed to address multiple sources of variability in adherence and competence , identify important factors that might account for variability , or take these sources of variability into account when examining associations with symptom change . OBJECTIVE ( a ) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and ( b ) examine the relationship between adherence/competence and symptom change . METHOD R and omly selected audiotaped sessions from a r and omized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence . Patients completed a  self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment . RESULTS Significant between- and within-therapist variability in adherence and competence were observed . Adherence and competence deteriorated significantly over the course of treatment . Higher patient interpersonal aggression was associated with decrements in both adherence and competence . Neither adherence nor competence predicted subsequent panic severity . CONCLUSIONS Variability and " drift " in adherence and competence can be observed in controlled trials . Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients OBJECTIVE This study explores the relationships between therapist variables ( cognitive behavioral therapy [ CBT ] competence , and CBT adherence ) and clinical outcomes of computer-assisted CBT for anxiety disorders delivered by novice therapists in a primary care setting . METHODS Participants were recruited for a r and omized controlled trial of evidence -based treatment , including computer-assisted CBT , versus treatment as usual .  Therapists ( anxiety clinical specialists ; ACSs ) were nonexpert clinicians , many of whom had no prior experience in delivering psychotherapy ( and in particular , very little experience with CBT ) . Trained raters review ed r and omly selected treatment sessions from 176 participants and rated therapists on measures of CBT competence and CBT adherence . Patients were assessed at baseline and at 6- , 12- , and 18-month follow-ups on measures of anxiety , depression , and functioning , and an average Reliable Change Index was calculated as a composite measure of outcome . CBT competence and CBT adherence were entered as predictors of outcome , after controlling for baseline covariates . RESULTS Higher CBT competence was associated with better clinical outcomes whereas CBT adherence was not . Also , CBT competence was inversely correlated with years of clinical experience and trended ( not significantly , though ) down as the study progressed . CBT adherence was inversely correlated with therapist tenure in the study . CONCLUSIONS Therapist competence was related to improved clinical outcomes when CBT for anxiety disorders was delivered by novice clinicians with technology assistance . The results highlight the value of the initial training for novice therapists as well as booster training to limit declines in therapist adherence This study evaluated the short-term effectiveness of cognitive-behavioral treatment ( CBT ) for substance abuse delivered in a community setting . At entry into outpatient community substance abuse treatment , participants ( N = 252 ) were r and omly assigned to 3 conditions : high-st and ardization CBT , low-st and ardization CBT , and treatment as usual . Treatment consisted of 12 weekly individual therapy sessions . There was a significant decrease in substance use from baseline , with participants reporting being abstinent on 90 % of within-treatment days and 85 % of days during the 6 months posttreatment . However , there were no significant differences in outcomes across conditions . Findings do not support the hypothesis that disseminating CBT to community setting s will improve outcomes and suggest that st and ard substance abuse counseling may be more effective than previously thought Although r and omized controlled trials examining the efficacy of attachment-based interventions have been increasing in recent years , adequate measurement of treatment integrity , integrity- outcome associations , and mechanisms of change has been rare . The aim of this investigation was to conduct a rigorous test of proposed mechanisms of change in the Mothers and Toddlers Program ( MTP ) treatment model , a 12-session , attachment-based individual therapy for substance-using mothers of children birth to 3 years of age . The MTP aims to improve maternal reflective functioning ( RF ) and representation quality ( RQ ) to bring about second-order change in maternal caregiving behavior . Following guidelines from M.K. Nock ( 2007 ) , it was hypothesized that ( a ) therapist adherence to unique MTP treatment components would uniquely predict improvement in RF and RQ and that ( b ) improvement in RF and RQ would function as unique mechanisms of change ( when compared with other potential mechanisms-reduction in depression and increase in abstinence from drug use ) in the improvement of caregiving behavior . Findings supported each hypothesis , confirming the proposed mechanisms of the treatment model . However , improvement in maternal depression also uniquely predicted improvement in caregiving behavior . Results underscore the potential value of attachment-based parenting interventions for improving mother-child relations and the importance of providing these interventions in clinic setting s where mothers have access to comprehensive care ( e.g. , psychiatric services ) Abstract This modest clinical pilot study was intended to provide preliminary data on the effects of hypnotic inductions tailored to an irritable bowel syndrome patient at each session compared to Palsson ’s manualized protocol . Patients ( N = 8) who had not previously responded to any form of treatment were assigned r and omly to either a tailored or manualized induction condition . Other than pretesting for hypnotizability , the procedure followed for the manualized group ( n = 4 ) was exactly as prescribed by O. Palsson ( 1998 ) . The identical procedure was used for the other 4 patients except that the inductions were individualized . All 8 patients showed favorable responses to treatment immediately posttreatment and at 10-month follow-up . Only the tailored group showed no incapacitating pain at posttreatment but greater emotional stress than the manualized group . The tailored group continued to improve and showed better results than the manualized group at 10 months , and the posttreatment emotional distress was significantly attenuated OBJECTIVES Treatment failure is a common phenomenon , but little is known about the reasons . Therapeutic alliance , therapist adherence , and therapist competence are considered important aspects of treatment success and formed the focus of the current investigation . DESIGN Three r and omized controlled trials for the treatment of depression , social phobia , and hypochondriasis were the basis of the current study . METHODS The role of therapeutic alliance , as well as therapist adherence and competence , were investigated in 61 patients , which were classified either as treatment failure or as treatment success . Process variables were evaluated by independent raters on the basis of videotapes of the first three treatment sessions . RESULTS Therapists ' adherence and therapeutic alliance differed significantly between successful treatments and those classified as failures , whereas therapists ' competence did not . In cross-sectional analysis , we found a moderating effect of adherence with alliance on treatment outcome , indicating that the better the therapeutic alliance , the stronger the effect of adherence on treatment outcome . Moreover , higher therapists ' competence was found to affect treatment outcome positively , only mediated by therapeutic alliance . Higher therapists ' adherence affected treatment outcome positively , only mediated by the competence-alliance relationship . In additional longitudinal analyses , we found evidence that the therapeutic alliance within one session influences therapists ' adherence and competence in the subsequent session , but not the other way around . CONCLUSIONS Therapeutic alliance proved to be an important variable for the prediction of treatment failure . Furthermore , in our longitudinal analyses , we found evidence that the therapeutic alliance is a precondition for the adherent and competent implementation of therapeutic techniques , which questions the results of our cross-sectional analysis and of previous research . PRACTITIONER POINTS Clinical implication s Treatment failure is associated with a lower therapeutic alliance in cognitive-behavioural treatment .  Therapeutic alliance seems to be an important precondition for the adherent and competent implementation of therapeutic techniques . Therapeutic alliance should be monitored during psychotherapeutic treatment . Caution s or limitations Results are limited to cognitive-behavioural therapy and may not be representative for other treatment approaches . Process analyses are based on highly st and ardized r and omized controlled trials and may not be generalizable to routine care This article provides a critical review of the assumptions and findings of studies used to establish  psychotherapies  as empirically supported . The attempt to identify empirically supported therapies ( ESTs ) imposes particular assumptions on the use of r and omized controlled trial ( RCT ) methodology that appear to be valid for some disorders and treatments ( notably exposure-based treatments of specific anxiety symptoms ) but substantially violated for others . Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported . The authors recommend changes in reporting practice s to maximize the clinical utility of RCTs , describe alternative method ologies that may be useful when the assumptions underlying EST methodology are violated , and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies OBJECTIVE Therapist adherence has been shown to predict clinical outcomes in family therapy . In prior studies , adherence has been represented broadly by core principles and a consistent family ( vs. individual ) focus . To date , these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinical ly relevant outcomes over the course of treatment . In this study , the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents who received brief strategic family therapy  within a multisite effectiveness study . METHOD Participants were 480 adolescents ( age 12 - 17 ) and their family members , who were r and omized to the Brief Strategic Family Therapist treatment condition ( J. Szapocznik , U. Hervis , & S. Schwartz , 2003 ) or treatment as usual . The adolescents were mostly male ( 377 vs. 103 female ) and Hispanic ( 213 ) , whereas 148 were White , and 110 were Black . Therapists were also r and omly assigned to treatment condition within agencies . RESULTS Results supported the proposed factor structure of the adherence measure , providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy . Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinical ly relevant ways and that therapist adherence was associated with engagement and retention in treatment , improvements in family functioning , and reductions in adolescent drug use . CONCLUSIONS Clinical implication s and future research directions are discussed , including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy OBJECTIVE Previous research has found that therapist adherence to concrete , problem-focused cognitive therapy ( CT ) techniques predicts depressive symptom change ( e.g. , Feeley , DeRubeis , & Gelf and , 1999 ) . More recently , Strunk , DeRubeis , Chui , and Alvarez ( 2007 ) demonstrated that in-session evidence of patients ' use of CT skills was related to a lower rate of relapse in the year following CT for depression . The current investigation attempts to integrate and extend these findings within 2 separate sample s of patients and therapists . METHOD Drawing from the CT sample s ( N = 105 , mean age = 40 years , female = 62 % , White = 82 % ) of 2 published r and omized clinical trials of depression treatment , we conducted analyses to examine whether therapist adherence to concrete CT techniques ( Collaborative Study Psychotherapy Rating Scale ) and the quality of the 
    Output:
    
Manualized treatment is not empirically supported as more effective than nonmanualized treatment .