by Brendan Whitney, M.A., University of Iowa
In the field of psychological practice, there is often a debate over whether clinical practice is an “art” or a “science.” This generally arises when discussing the utility of “manualized” or “evidence-based” treatments. For example, some clinicians associate manualized treatments with being “cold”, and fear that their use (i.e., strictly following them “by the book”) may dampen the therapeutic alliance and reduce a clinician’s ability to work flexibly to address their clients’ unique needs (Lillienfeld et al., 2013; Nelson et al., 2006; Stewart et al., 2012). In sum, the use of these treatments may be viewed as too restrictive, taking the “art” out of clinical practice or aligning too closely to one specific theoretical orientation (e.g., cognitive-behavioral).
To many who train using these types of treatments, these criticisms may be confusing. Many clinicians who use empirically-supported manualized treatments feel that they require a significant level of creativity, flexibility, and client rapport (Forbat et al., 2016). However, when discussing this perspective with those skeptical of such treatments, it can often be difficult to have a productive conversation (Young et al., 2008). In particular, there is the possibility that the argument for using manualized treatments is interpreted as “pompous” or “pretentious” (Tavris & Aronson, 2007). Though this is not an exhaustive list, here are a few tips, based on my experience, that may be useful in refining conversations about manualized treatment.
1) Tone Down your Science Talk
I am sure you can imagine a time when you were presented with a swath of statistics and numbers and figures that went in one ear and out the other; perhaps you, like me, have a friend who studies asteroseismology and attempts to explain it to you using equations with little-to-no numbers. The way we present the rationale for manualized treatments is no different, and we must be cognizant about the audience we are presenting information to.
Often, we may find ourselves using science-based phrases like “research actually shows that…” followed by a smorgasbord of information that, particularly for those not well-versed in the area, may discourage practitioners from learning more about it (Backer, 2000; Lillienfeld et al., 2013). Depending on how the topic is presented, the argument may be interpreted as insulting, and may come off as an attack on one’s knowledge-base and intellect (Tavris & Aronson, 2007). The conversation may also quickly lead to an “us versus them” mentality in the listener’s mind (Lillienfeld et al., 2013; Young et al., 2008). The manner in which we communicate with others about what we practice when using evidence-based practices matters, and conversations must be held in ways that are comprehensible and that do not come off as patronizing.
2) “Manualized Treatments” are “Guided Treatments”
Manualized treatments may be perceived as therapeutic frameworks where the therapist is merely a “robot” reading out of a book (treating all clients as the same while following a specific “one-size-fits-all” approach). In turn, manualized treatments provide clinicians and patients with road maps that help guide them using tools and methods previously shown to be effective. (Lillienfeld et al., 2013).
When presented in this manner, a conversation about manualized treatment can take a completely different turn. For example, you can try and treat your patient’s anxiety by exposing them to their fears, but how do you do that? After collaborating with your patient on different activities they can engage in to confront their fears, how is the list organized? What experience should be confronted first, and what should be focused on during the experience? Rather than going in blind, treatment manuals and workbooks can help clinicians and patients organize and create strategies for change, like fear hierarchies (e.g., reviewing the Physical Sensation Test Form in Barlow and colleagues’ [2018] Unified Protocol manual]). Moreover, these manuals walk practitioners through how to explain why things are being done the way they are and how to effectively go about engaging with one’s fears. Overall, manualized treatments maintain utility in guiding the treatment process using techniques and worksheets that are empirically supported.
3) The Need for Creativity for Success
Similar to the robot example before, there is often a misconception about how exercises are implemented when using manualized treatments. Specifically, it can seem like the only way to administer an exercise is “by the book,” requiring the practitioner to follow a set script. This can further come off as though you are treating every patient as the same: that every patient with social anxiety must follow the same exposure hierarchy; that the same reinforcers in behavioral activation will be assigned to anyone. On the contrary, these conceptions cannot be farther from the truth.
As an illustration, some manuals for acceptance and commitment therapy (ACT; Polk et al., 2016) utilize the “ACT matrix,” which is used to help the patient and therapist understand 1) the patient’s values in life, 2) the feelings and thoughts they experience that move them away from their values, 3) the behaviors in which the patient engages that are counter to their values, and 4) the behaviors in which they engage (or would like to) that are congruent with their values. While the procedure of going through the matrix is generally the same with every patient (i.e., moving through the four areas listed above), each person will present their own personal values, reactions to distress, behaviors to avoid feelings of distress, and goal-directed behaviors that move them towards a life in line with their values. The manual itself will guide the practitioner through these conversations, but the exercise ultimate relies on the practitioner’s skillset (e.g., active listening, empathy) to help the patient craft their unique matrix.
Although some manuals may list some specific exercise to use (e.g., interoceptive exposures like breathing through a straw or spinning in a chair; Craske & Barlow, 2007), it is crucial that the exercise aligns with the patient’s specific needs. Even when patients meet criteria for the same categorical disorder, the exercises presented in evidence-based manuals need to be tailored to the patient’s struggle. A clinician’s goal is to collaborate with the patient in discovering which exercises will be most beneficial for them to practice, and to creatively discover how best to implement them. Clinicians must think of new ways to approach exercises, even when working with multiple clients diagnosed with the same condition.
Wrapping Up
In short, there are a variety of ways to talk about manualized treatments that describe their balance between art and science in psychological practice. If we want to truly disseminate our research beyond our labs, we inevitably need to step outside of our academic lives and engage with community partners in conversations about the biases against empirically supported treatment modalities (Becker et al., 2009). In doing so, especially when talking to individuals who know less about empirically-supported manualized treatments, it may be useful to: 1) cut back on the science/stats terminology, 2) talk about “manualized” treatments as “guided” ones, and 3) discuss the need for creativity in implementing these guided treatments.
________________________________________________________________
References
Backer, T. E. (2000). The failure of success: Challenges of disseminating effective substance abuse prevention programs. Journal of Community Psychology, 28, 363-373. https://doi.org/10.1002/(SICI)1520-6629(200005)28:3<363::AID-JCOP10>3.0.CO;2-T
Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Latin, H. M., Ellard, K. K., Bullis, J. R., Bentley, K. H., Boettcher, H. T., & Cassiello-Robbins, C. (2018). Unified protocol for transdiagnostic treatment of emotional disorders (2nd ed.). Oxford University Press.
Becker, C. B., Stice, E., Shaw, H., & Woda, S. (2009). Use of empirically supported interventions for psychopathology: Can the participatory approach move us beyond the research-to-practice gap? Behaviour Research and Therapy, 47(4), 265-274. https://doi.org/10.1016/j.brat.2009.02.007
Craske, M. G., & Barlow, D. H. (2007). Mastery of your anxiety and panic: Therapist guide (4th ed.). Oxford University Press.
Forbat, L., Black, L., & Dulgar, K. (2015). What clinicians think of manualized psychotherapy interventions: Findings from a systematic review. Journal of Family Therapy, 37(4), 409-428. https://doi.org/10.1111/1467-6427.12036
Lillienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33(7), 883-900. https://doi.org/10.1016/j.cpr.2012.09.008
Nelson, T. D., Steele, R. G., & Mize, J. A. (2006). Practitioner attitudes toward evidence-based practice: Themes and challenges.
Polk, K. L., Schoendorff, B., Webster, M., Olaz, F. O. (2016). The essential guide to the ACT matrix: A step-by-step approach to using the ACT Matrix Model in clinical practice. Context Press.
Stewart, R. E., Chambless, D. L., & Baron, J. (2012). Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments. Journal of Clinical Psychology, 68(1), 8-23. https://doi.org/10.1002/jclp.20832
Tavris, C. & Aronson, E. (2007). Mistakes were made (but not by ME): Why we justify foolish beliefs, bad decisions, and hurtful acts. Houghton Mifflin Harcourt.
Young, J., Connolly, K. M., & Lohr, J. M. (2008). Fighting the good fight by hunting the Dodo Bird to extinction: ABCT’s Dissemination Effort. The Behavior Therapist, 31(5), 97-100. Retrieved from http://www.abct.org/docs/PastIssue/31n5.pdf
Disclaimer: The views and opinions expressed in this newsletter are those of the authors alone and do not necessarily reflect the official policy or position of the Psychological Clinical Science Accreditation System (PCSAS).