Episode 5: When to deviate from the manual

***Claire**: Hi Isabelle!

**Isabelle**: Hi Claire! Good to see you.

**Claire**: Good to see you as well. Today, we're diving into an interesting topic: manualized interventions and when it's okay to deviate from them. This is particularly relevant for those just starting out in the therapy space.

**Isabelle**: Absolutely. Manualized interventions are quite common in many workplaces. They often involve structured workbooks based on various types of interventions, with CBT manuals being among the most prevalent. When you're beginning your career as a therapist, having a guidebook or a structured approach to interventions can be very helpful.

**Claire**: Yes, it's very common to rely on these structured methods initially. However, as we gain experience, we might notice situations where our clients don't seem to be engaging with or benefiting from the manualized approach. This can lead us to wonder: when should we stick to the manual, and when is it appropriate to be more flexible?

**Isabelle**: Exactly. It's about finding that balance between maintaining structure and being creative and flexible in our approach. Recognizing the signs of when to adhere strictly to the manual and when to deviate is crucial.

**Claire**: Right. For instance, in my early days, I started using manualized interventions, especially since my background was heavily focused on assessment. Using a manualized program provided a comforting structure—it laid out what was to be covered each week, which can be reassuring for new therapists. Knowing what’s coming next allows you to focus on delivery rather than creating the content on the spot.

**Isabelle**: Most definitely. When we're just starting out, it's natural to lean on these manuals. I used to think of them almost like having a teacher in the room. The manual provided a clear, black-and-white direction: discuss this topic now, then ask the client open-ended questions about it. It gave a sense of security and direction.

**Claire**: I remember those moments of uncertainty during a session when the conversation would pause, and I’d think, “What do I do next?” Having the manual to fall back on was a real safety net. Isabelle, I’d tell myself, “Everything’s okay; just move on to the next page.” It was incredibly handy in those early years.

**Isabelle**: Absolutely. The question of "What do I do next?" can cause a lot of anxiety, especially when we’re starting out. We often feel the pressure to add value or to provide something substantial to the client. With more experience, we realize we are always giving something to the client, whether we’re delivering a structured intervention or not.

**Claire**: That’s so true. There’s a significant emphasis on delivering interventions, especially during psychology training. Structured interventions are highly encouraged through case reports and guided by frameworks like the Medicare guidelines. Being well-versed in these structured approaches is important, and manualized programs provide a solid introduction to them.

**Isabelle**: Definitely. However, a phenomenon often emerges, sometimes sooner than we expect. We might be following the manual with a client and suddenly notice nonverbal cues or even explicit feedback indicating that the approach isn’t working for them or isn’t meeting their needs in that particular session.

**Claire**: Yes, exactly. One size does not fit all. These programs are usually very clearly structured, leaving little room for deviation. So, when we sense it isn’t working, we need to consider what to do next.

**Isabelle**: Right. I think it’s important to discuss how we’ve seen or experienced using manuals in a more flexible manner. Claire, could you share some observations from your experience?

**Claire**: Sure. I used to work as a supervisor in a service where manualized programs were routinely delivered. Part of my role involved observing intervention sessions. I remember two sessions that particularly stood out to me. In one session, the therapist adhered very strictly to the manual. Despite this, the session didn’t seem effective; it felt like the manual's rigid structure wasn’t resonating with the client. We discussed afterward how we might approach things differently and began considering when it might be appropriate to deviate from the manual.

**Isabelle**: That makes sense. And what about the other session?

**Claire**: In the other session, the therapist quickly set the manual aside when it was clear it wasn’t working for the client. The session became much more flexible and dynamic, and it turned out to be incredibly effective. The content was similar, but the delivery was adaptable to the client's needs. These contrasting experiences highlighted the importance of being attuned to the client's response and needs, rather than strictly following the manual.

**Isabelle**: That’s a great observation. It really shows that clients might need a more individualized approach. Sometimes the structure of the manual is just what they need, but other times, flexibility is key.

**Claire**: Exactly. It’s crucial to assess individual characteristics and preferences before starting with a manualized approach. For instance, considering whether the client is comfortable with reading and writing is fundamental. Even if they are literate, we should assess whether a written text format is something they find engaging and effective. We can do this during the initial sessions by discussing the rationale for using the workbook and checking in with them about their preferences and comfort levels.

**Isabelle**: That’s so important. We want our clients to be on board with the intervention method. Some clients thrive with structure and are diligent about homework, making them ideal candidates for manualized interventions. However, that’s not the case for everyone. Conducting an initial assessment to understand what works best for each client can be incredibly helpful.

**Claire**: Absolutely. Assessing clients' literacy, comfort in writing, and how they express themselves can guide us in choosing the right approach. Some people are more comfortable expressing themselves verbally, while others prefer writing things down. Understanding where our clients are coming from is so helpful. For instance, a client who feels anxious might prefer something to focus on other than face-to-face conversation. Conversely, I’ve had experiences where a client seemed comfortable in conversation, but when I introduced the workbook we had discussed, their body language changed, and they became quiet.

**Isabelle**: That’s interesting. What did you do in that situation?

**Claire**: I had to check in with the client. I asked, "How are you feeling about doing this right now? I sense this might not be something you're engaging with." The client immediately responded, "Yes, can we please put this away? This isn't working for me." Later, I found out that using the workbook reminded them of unpleasant educational experiences, which explained their discomfort.

**Isabelle**: That’s such a great example of being attuned to your client. Even though they didn’t say it explicitly, you picked up on their cues. Some clients will be assertive and say they don’t want to do something, but others might comply out of people-pleasing tendencies. It’s essential to be aware of these dynamics so we don’t unintentionally reinforce them.

**Claire**: Exactly. For some clients, having a workbook can be a good distraction or a way to engage with the material. But as therapists, we need to use our intuition. This means being attuned to the client's feelings in the room, even if we can’t explicitly describe what we’re picking up. Signs of discomfort or disengagement are cues that it might be time to set the manual aside, ask open-ended questions, reflect, and validate what the client is experiencing.

**Isabelle**: That’s such good advice. When in doubt, returning to basic counseling skills like active listening, reflecting, and holding space for the client can be very effective. We don’t always need a worksheet to provide meaningful support.

**Claire**: Exactly. These moments where the structured plan doesn’t work are invaluable. They teach us to be adaptive and flexible, essential qualities in therapy. Experiencing this early on helps shape us into therapists who can navigate the ever-changing nature of therapy sessions.

**Isabelle**: Yes, it’s all about being attuned to our clients' needs. While structure can be comforting, especially when we’re new, learning to be guided by the client can be a profound learning experience. Some clients communicate their needs clearly, making it easier for us to connect and adjust. But what about clients who are more withdrawn, less communicative, or unclear about their goals?

**Claire**: Absolutely. In those cases, we might need to take a step back, go at their pace, and meet them where they’re at. It’s all about that wonderful person-centered approach.

**Isabelle**: Exactly. When we reduce or set aside some of the structure imposed by a manual or by us as therapists, we often return to a more person-centered approach. This ties into individual differences, both in clients and therapists. Some therapists thrive on structure and feel more comfortable with a clear, laid-out session plan. For others, like myself, a more organic process works better, where we let the client's needs guide us, even if that means meandering a bit along the way.

**Claire**: I’m enjoying this discussion, Isabelle. It’s fascinating to reflect on how we’ve developed as clinicians over the years. We’ve talked about starting with manualized workbooks and interventions, but over time, we tend to gravitate towards what feels authentic to us—our strengths, characteristics, and personalities. It’s crucial not to compare ourselves to others and recognize that different clients will resonate with different styles.

**Isabelle**: Absolutely. That’s why it’s important for clients to know they don’t have to stick with one therapist if it’s not a good fit. Sometimes it takes trying several therapists before finding the one that really matches their needs. We encourage therapists to be authentic to themselves, and the right clients will find them.

**Claire**: Yes, the fit is so important. In my practice, I usually have a 15- to 20-minute conversation with potential clients to discuss how I work and see if it aligns with what they’re looking for. I ask them about their needs and explain my approach. For example, if someone is looking for a highly structured CBT therapist and that’s not my style, I’m happy to refer them to a colleague who excels in that area. Conversely, if someone says they’ve tried structured approaches and they’re seeking something different, we discuss that further to ensure a good fit from the start.

**Isabelle**: That’s great advice, Claire. Having that initial conversation helps set expectations and ensures a better match. Even if it’s not a perfect fit after a session or two, it’s important for clients to know they have the option to change therapists.

**Claire**: Exactly. This kind of intake or screening process is vital. It allows both the therapist and the client to feel each other out and see if it’s going to work. In private practice, we often have more flexibility to choose our clients compared to community-based settings, where clients are usually allocated to us.

**Isabelle**: Yes, private practice does offer that flexibility. It’s wonderful to hear how you’ve structured your practice to prioritize the client-therapist fit, which is crucial for effective therapy. Ensuring a good fit from the start is important because I don't want to be working with a client who needs a different approach than what I can offer. That wouldn’t be beneficial for them or for me. However, in other settings, like community mental health or rehab, we often don't get to choose our clients—they're allocated to us. In those cases, we hope to make the fit work, but it can be more challenging since we can't pre-screen clients the same way we can in private practice. Especially when clients are paying privately or through Medicare, I want to make sure their sessions count.

**Claire**: Absolutely. Your point about making every session count is so important. It’s interesting to reflect on how we've evolved from using manualized treatments to adopting more integrative and flexible approaches. Like you, Isabelle, I lean towards a more person-centered and organic therapy style. However, in recent months, I completed training in brief solution-focused therapy, which I initially thought wasn't for me.

**Isabelle**: That's fascinating! Brief solution-focused therapy is quite manualized, right? I remember learning about it during my clinical master's program and thinking it wasn’t my style either. But it’s great to hear that you've found it useful, especially in your work at a drug and alcohol community clinic where it’s an evidence-based intervention for that population.

**Claire**: Yes, it is quite structured and repetitive. While it may not seem flexible, I find ways to adapt it to make it more client-centered. It’s been a valuable tool for certain clients. Before starting, I introduce the rationale and ensure I have their buy-in, which is crucial for any manualized approach.

**Isabelle**: It’s a nice reflection on how our perceptions can change. We might initially resist certain interventions, but with time and experience, we see their value. For instance, EMDR is another manualized therapy that follows a set protocol, yet requires creativity and flexibility, especially with complex trauma cases where things don’t always go as planned.

**Claire**: Exactly. EMDR starts with a clear protocol, and while learning, it’s essential to stick to the manual. However, as we become more proficient, we can adapt and be more attuned to our clients' needs, which often requires flexibility. Similarly, in psychodynamic therapy, there isn’t a manual per se, but a framework provides a guide while allowing room for individual client differences.

**Isabelle**: I love the distinction between frameworks and manuals. Frameworks offer guidance without the rigidity of manuals, allowing us to be flexible and responsive to our clients. As we become more familiar with a technique, like EMDR, we can move beyond strict adherence to the manual and be more adaptive, which is crucial for being attuned to our clients rather than forcing them into a preset structure.

**Claire**: Exactly. Even with a structured approach, having a clear guide or framework is crucial. We want to ensure we have a solid formulation and direction in our therapy. It’s about balancing structure with creativity, flexibility, and intuition to meet our clients' needs effectively.

**Isabelle**: So, to summarize, it’s okay to deviate from the manual when necessary. Adhering rigidly can sometimes be counterproductive. Manuals are designed to provide a comprehensive process, but accommodating the client’s needs should always come first. I believe most practitioners would agree that some deviation in the client's best interest is both welcomed and encouraged.

**Claire**: Absolutely. This discussion on manualized interventions has been enlightening. It’s essential to reflect on our practices and be open to adapting our approaches to better serve our clients.

**Isabelle**: Indeed. Thanks, Claire, for this insightful deep dive into manualized interventions. It’s always great to explore these topics and challenge our assumptions.

**Claire**: Thank you, Isabelle. I’m looking forward to our next conversation.

**Isabelle**: Me too. Thanks to everyone for listening. See you next time!

**Claire**: Goodbye!

[Music fades out]