“The profession of speech therapy in Great Britain has never taken kindly to the construction of stereotyped programmes of treatment. It perceives therapy to be a creative process in which procedures are used with considerable selectivity.”
This introduction to Jennifer Warner, Betty Byers-Brown and Elspeth McCartney’s 1984 book ‘Speech therapy: a clinical companion’ makes me smile because I instinctively identify with it. Perhaps that is why it has taken me some time to come round to the idea that a manualised intervention is not the same thing as a stereotyped programme.
Health services researchers encourage practitioners to use published interventions which are accompanied by a manual and based on the findings of peer-reviewed research. If this research has been done well, and the theory behind the intervention is clear, it is easy to see the advantages. A manual has to include detailed information and instructions that help therapists and families think about important questions such as: who is it for? why can we expect it to work? how should we use it? what is the point of each component? how much can we adapt it? how can we record progress? how often does it have to be done to be effective?
The ‘What Works‘ database of interventions for children with speech, language and communication needs shows that relatively few are manualised. Moreover, the reports from the Better Communication Research Programme suggest a vagueness and lack of consistency in describing what we actually do with clients and why. Research efforts are therefore focused on better description of interventions. In my own unit, for example, Alex Pollock is doing some really interesting systematic review work by breaking reported interventions down into component parts and finding that we can usefully compare apples with pears (pp.1-17).
When we are discussing a potential practice change with colleagues, thinking about the principles of manualisation may actually help us to be more creative and selective. The TIDieR checklist and guide was published recently in an effort to improve the description of interventions in research reports. I’d be interested to know if it’s also useful in a practice context (see table 1).