From Cook to Culinarian: Going Beyond the Manual When Delivering Behavior Therapy to Treat Tourette Disorder

Abstract

In the case of Hiro, Dr. Jeremy Lichtman (2017, this issue) describes how he flexibly employed a manualized behavior therapy protocol to successfully treat a child's involuntary motor and vocal tics. In doing so, he raises interesting observations and questions regarding manualized psychotherapy treatment protocols, including their intended role, the need for "flexibility with fidelity," and the strengths and limitations of following manuals in a step-by-step fashion. In our commentary, we draw upon Dr. Lichtman's experience in treating Hiro to highlight what we see as the two most important factors in Hiro's treatment: (1) the therapist's firm grasp of the underlying theory behind behavior therapy for tics, which allowed for flexibility in treatment delivery without jeopardizing treatment fidelity, and (2) the importance of having a strong foundational clinical skill set prior to beginning treatment.

Mechanical/Algorithmic Versus Flexible/Creative Clinical Practice: How Underlying Principles Bridge the Gap

“…This training has provided me with the skills to understand, on a fundamental level, how to use new CBT manuals that I might encounter, as well as those skills needed to approach these manuals flexibly. Wellen and Himle (2017) thoroughly cover the importance of the underlying principles in the Comprehensive Behavioral Intervention for Tics (CBIT) model in their response to the Case of Hiro, which means there is not much more to say here. However, I would like to add a few comments.…”

“…As treatment progressed, I deemphasized the elements that were less useful in treatment and emphasized using the more effective components. It is important to recognize, as Wellen and Himle (2017) noted, that some parts of the manual were less relevant for the successful treatment of Hiro, a fact that I incorporated into my decision to shift the focus of treatment. The decision was guided by the treatment team's understanding of the most important elements of treatment from a principled perspective.…”

“…This question relates to Wellen and Himle's (2017) article regarding the importance of the underlying principles of CBT when using CBT treatments. Additionally, these first two questions more broadly relate to the dichotomy between what I would categorize as a mechanical/algorithmic approach versus a flexible/creative approach to psychotherapy.…”

“…My goal in writing this article is to find a middle ground between the mechanical/algorithmic and the flexible/creative approach to psychotherapy, as opposed to choosing one over the other. In this middle ground, maintaining fidelity with the "tried and true principles" (Wellen & Himle, 2017) together with the benefits of experience can inform the intuition and creativity of the practitioner to best be able to help their clients live meaningful lives.…”