April, 2006; Dikla Kerem (chip8@013.net)
Advantages and Disadvantages of Making Procedures in Clinical and Research Work
Clinical research and applications have been both blessed and plagued by procedures. In their best form, procedures are clear prescriptions for a sequence of effective diagnostic and therapeutic treatments to be initiated by the clinician. This mechanistic approach has proved itself many times in both the basic and clinical sciences. First, the process of formulating procedures distills the essence of the method and the reason for success from distracting situational irrelevancies. Second, it allows researchers to leverage the experience earned by others in successful cases and hands them solutions in a form ready-to-apply. Third, successful clinical procedures provide in turn measures of validity and reliability for the theory from which they were derived. As such they catalyze the development of basic research suitable for applications.
However, procedures have proved much more useful in chemical, and biological treatments, than in mental therapies. That state of affairs has increased the perceived pressure on practitioners to deliver well-formed and generally applicable therapeutic procedures, or else be deemed by others as operating on the basis of intuition alone.
In spite of appearances, procedures fail to supply the clinician’s needs due to their very nature. First, procedures are sequences of causes (treatments) and their resulting effects. For the clinician, that implies that the outcome (impact) of a treatment can always be evaluated before the next one is applied. However, mental life is influenced by factors at multiple levels (biological, social, and chemical) all co-interacting in complex ways. Consequently, evaluation of the effects of treatments in the sequence is in most cases impractical. Second, as action sequences, procedures are relatively rigid and lose their effectiveness with large inter-client variability, situational differences, and unexpected outcomes. Third, procedures are unidirectional, implying a treatment is invoked by the therapist and applied to the client. However, in mental health applications, most of the treatment process is done by the client on himself/herself and their environments, leaving the therapist to guide/supervise the treatment instead of leading (“causing”) it.
The solution to the shortcomings of procedures in therapy has been provided by the formulation of guiding principles. Principles are general statements that remain true in spite of variation in details. As such they allow the application of knowledge across situations and individuals and the description of the client’s state across levels of observation. They provide guidance to clinicians in unfamiliar cases by specifying invariant facts about the interaction of the client with his/her environment and response to treatment. These invariant properties can then serve as landmarks in the development and application of treatments strategies. Unlike procedures, strategies describe a manner of approaching therapy and how to cope with unexpected change, rather than dictating implementation details.
However, due to their generality, principles run the risk of reducing to a mere collection of rule-of-thumbs, if not complied into a converging set of consistent factual statements. Principle-based manuals may then provide the necessary tool in which principles can be coordinated and optimized by the collective experience of practitioners and researchers a like. It seems that the interdependence of clinical researchers and practitioners is accentuated in the challenge posed by the development of principled manuals. It is only in this collaboration that we may hope to find the tools to translate our general understandings into effective therapy.
© 2006. Nordic Journal of Music Therapy. All right reserved. This page was last updated by Rune Rolvsjord March 30, 2006.