Manualized Treatments

Written by: Dan Mortenson, PhD

What is a “manualized treatment”? And why do people have strong opinions of it?

I have a complicated “love/hate” relationship with the topic I’ll be discussing today: manualized therapeutic treatments.  This is when a more structured manual is used to help guide therapy using a more regimented, chapter based approach to directing treatment.  It’s based on research and created in a way to help maximize reliability so that different providers can be providing the same quality of care across settings and amongst clients.

Much of my conflict here stemmed from my introduction to them when I was a graduate student learning about different approaches to therapy.  I was torn between the idea of having treatment tailored to the unique needs of the individual and also the importance of having them be based in solid empirical research.  Both of these ideas appealed to different parts of my brain but I struggled with how they could ultimately fit together and still work.  Ultimately though, I’ve come to appreciate how something like a manualized approach to treatment can make a lot of sense as long as it’s approached flexibly while still respecting the core elements.

Dan’s Recurring Nightmare

The scenario that my mind always goes to is if I’m the one starting therapy.  I imagine meeting my new therapist, sharing all my intimate secrets, being at my most vulnerable and asking, “Can you help me?” only to have a workbook offered to me.  “That’s it?”  How can some workbook encapsulate all that has made my life so difficult recently?  How can this relatively small book you can order online hold the key to what has been such an issue?”

The answer to this is honestly that it doesn’t even come close.  But that’s not the point of it.  Treatment manuals are there to serve as a guide and some of it might be a slam dunk and other parts may not really apply.  When at their best, they can help to lay out the theoretical framework of what you’re going through, give you an idea of what’s going on with the current research, and then outline some ideas and exercises that can help you to better manage.  It’s helpful to take the perspective that it’s there to provide ideas and new perspectives to help complement the journey you’re going through with a therapist rather than to be the end goal.

Get Modular

The solution for me came down to how treatment could be balanced out by having some core elements that are important to form a solid backbone to therapy so that it can be reliable but also allow for customization.  In a sense, this is a “mix and match” approach akin to having a core entree on the menu but allowing for it to be customized in how it’s prepared and what kind of side dishes come along with it to complete the meal.

The key word that helps to clarify how manualized treatments can be most useful for me is “modular.”  This means that often the best research-based forms of therapy have different elements or “modules,” some of which are at the core and apply to pretty much everyone, but there are others that can be supplemental and can be modified as needed.

Some bonus modules may apply depending on the issues at hand.  For example, if someone is seeking treatment for health anxiety, there will be core modules involving working to understand where the anxiety comes from, how it affects the brain, how it can lead to questions centered around uncertainty, and ultimately how we can build skills to help better deal with the ambiguity present here.  Further modules will likely involve identifying core beliefs, thought patterns, identify avoidance behaviors, and set goals aimed at approaching anxiety based situations more effectively.  But if it turns out there are more depressive symptoms present or issues involving social skills that can add a further layer of difficulty then these can also be addressed with further modules in treatment.  That way we can balance out having the core modules to provide a solid background for everyone with having other modules emphasized as needed to help with the tailoring to individual needs that is so important to making therapy effective.

Works in Progress

What’s helped to allow me to coexist with the presence of a manual in treatment is knowing how it can best be incorporated and allow for treatment to respect the core tenets while still making room for flexibility.  Manuals are also always works in progress, so if there are parts which are modified accordingly to fit with the issues at hand, this is part of how therapy works, too.  Although therapy is more complicated than a set of instructions, it can still be helpful to have a manual as a guide and way of reminding yourself of the basics for when you’re feeling lost at sea.  But just know that there’s always room for critique and adding on to what’s there because manuals, just like people, are perpetual works in progress.