Psychotherapy Development Research Center

Stage Model

The Stage model of psychotherapy development has had a major impact on drug abuse behavioral therapies since its initial formulation in the early 1990s. The Stage model details a systematic psychotherapy research approach that proceeds in three stages. Stage I involves pilot/feasibility testing, manual writing, training program development, and therapist fidelity or adherence and competence measure development for new and untested treatments. Stage II consists of controlled clinical trials to evaluate the efficacy of manualized and pilot tested treatments which have shown empirical promise in earlier Stage I studies and to determine mechanisms of action that may contribute to treatment outcomes. Stage III consists of studies to evaluate generalizability and implementation strategies for psychotherapies shown to be effective in at least two Stage II clinical trials. See Rounsaville, B. J., Carroll, K. M., and Onken, L. S. (2001). A stage model of behavioral therapies research: Getting started and moving on from Stage I. Clinical Psychology: Science and Practice, 8, 133-42.

The Center has been actively engaged in all three stages of psychotherapy development. Our Center has funded numerous Stage I projects that have covered a wide range of areas including: relational parent interventions for drug using mothers and fathers, motivational interviewing for dually diagnosed patients, development of adaptive brief re-engagement interventions for patients who drop out of treatment, contingency management for adolescent smoking, for patients with severe mental illness, and for compliance with goal-related activities in HIV-positive substance users, integrated substance abuse-domestic violence treatment, and fMRI studies involving the development of brain functional imaging drug abuse treatment outcome measures and the elucidation of CNS processes underlying stress response in cocaine abusers. Support of innovative Stage I projects has been a hallmark of the Center and the foundation for subsequent Stage II research.

The Center also has funded many Stage II projects. These projects include the integration of behavioral or behavioral and pharmacological treatments to maximize treatment effects (e.g., integrating contingency management and cognitive behavioral treatment for cocaine abusers, motivational enhancement therapy and contingency management for court referred marijuana users, and twelve step facilitation and disulfiram for cocaine-abusing methadone patients) and the investigation of mechanisms of action that underlie established empirically supported treatments (e.g., examining the efficacy of low-cost contingency management, changing reinforcement strategies for patients who begin treatment with cocaine-positive urinanalyses).

The Center also has been instrumental in developing materials and procedures necessary for Stage III research. Investigators in the Center have created manuals and training programs in cognitive behavioral therapy and twelve step facilitation. They also have refined the clinical trial training approach for preparing clinicians to implement a wide range of empirically supported treatments, including the use of the Yale Adherence and Competence System (YACS) for establishing, monitoring, and independently assessing therapist fidelity to several empirically supported treatments. Center spawned Stage III studies have included examining the effectiveness of different strategies to train community program clinicians in cognitive behavioral therapy, contingency management, twelve step facilitation, and motivational interviewing. Center investigators also have articulated goals and guidelines for Stage III research, including proposing a hybrid research model that combines elements of efficacy and effectiveness research and detailing implementation issues when using treatment manuals in community programs. See Carroll, K. M., & Nuro, K. F. (2002). One size can't fit all: A stage model for psychotherapy manual development. Clinical Psychology: Science and Practice, 9, 396-406 and Carroll, K. M., & Rounsaville, B. J. (2003). Bridging the gap between research and practice in substance abuse treatment: a hybrid model linking efficacy and effectiveness research. Psychiatric Services, 54, 333-39.

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