A Primer for the Design of Practice Manuals

Abstract

Treatment manuals are increasingly being used to guide interventions with individuals, families, groups, organizations, and communities. However, little is known about best practices in designing manuals. We describe a process that provides for the development of manuals and specifies the means by which manuals can be adapted for practice conditions and constraints. Manual development is conceptualized as comprising four systematic and recursive stages: (a) formulation, (b) revision, (c) differentiation, and (d) translation. We discuss issues and challenges in developing manuals that are responsive to a range of factors that influence social work practice, including advances in knowledge, the influence of evidence-based practice, the needs of individual clients, and contingencies linked to organizational policies, procedures, and leadership.

Keywords

manuals manual development manual design

Written manuals increasingly contribute to and, in some cases, directly guide social work practice. Some manuals provide guiding principles for delivering particular models of service, such as the nine principles that underpin multisystemic therapy for antisocial behavior in children (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009). Other manuals are more explicit or, perhaps, prescriptive in nature. They provide practitioners with sequences of detailed practice activities designed to address specific problems. For example, the Graduated Recovery Intervention Program describes a series of sequenced activities and exercises designed to promote recovery from a first episode of psychosis (Penn, Perkins, Mueser, Waldheter, & Cather, 2006). Still other manuals begin reflexively with content from client contact and evolve as new information is gathered. Today, as in no time before, social work practice is linked to the delivery of programs that prescribe specific content as well as preserve flexibility to respond to a variety of contingencies, including—as implied under evidence-based practice (EBP)—client preference.

Manuals frequently arise from efforts to design and develop new social and health programs (e.g., LeCroy, 2008). A practitioner’s discovery of innovative ways of working with clients, such as adding motivational interviewing to a supervision program in a drug court (G. Cuddeback, personal communication, November 22, 2011), may stimulate the development of a manual. Indeed, manuals are sometimes developed when interventions push the limits of existing practice. In the 1970s, the Homebuilders Program was designed by practitioners to reduce what was seen as excessive reliance on the out-of-home placement of children by child protective services in Tacoma, Washington (Kinney, Madsen, Fleming, & Haapala, 1977). The program began by providing brief, intensive in-home interventions immediately after maltreatment events; a manual was then developed to guide the training of new workers. Innovative programs also emerge as a part of intervention research (Fraser, Richman, Galinsky, & Day, 2009; Rothman & Thomas, 1994). Over time, researchers often revise program procedures and activities based on pilot tests and other data (e.g., Wilson et al., 2005). This article examines the process of manual development and describes a four-stage design and refinement model, emphasizing manual formulation and subsequent adaptation of program content for alternative populations and contexts in social work practice.

Manuals Are Embedded in the Broader Construct of Practice

Manuals are written guides to practice, but they do not constitute practice per se. Practice is far broader. The full scope of practice involves core skills in communication and a breadth of knowledge about human behavior, the environment, organizations, alternative practice methods, ethics, service systems, and social policy that can never be fully incorporated in a manual (Thyer & Myers, 2011). In addition, practice involves a range of skills in applying different strategies and techniques, including the ability to engage clients, assess problems, access resources, develop complementary strategies, sustain relationships, and select—often jointly with clients—a plan that best fits a complex, emergent situation. Practice is a multidimensional and constantly responsive construct that may involve the simultaneous use or sequencing of different manuals that articulate several interventions. In this context, manuals prescribe specific intervention procedures by building on the combined foundation of theory, evidence, professional training, ethics, and practice experience.

The increasing use of manuals has also been partly driven by funders and third-party payers that require agencies to use manuals, based on the assumption that manuals contribute to the fidelity with which services are delivered. For example, manuals are commonly used in implementing widely known, evidence-supported programs such as assertive community treatment (Marshall & Lockwood, 1998/2010; U.S. Department of Health and Human Services, 2008) and anger management (Reilly & Shopshire, 2002). Manuals are frequently used to prescribe activities that address particular risk factors or processes. For example, in juvenile justice, exposure to delinquent peers is viewed as a risk factor for delinquency, and thus, a manual might prescribe activities to increase association with prosocial peers.

Prescribed activities comprise both the defining and the limiting features of manualized programs. Even the most comprehensive manual is unlikely to address all aspects of practice, such as strategies for establishing therapeutic relationships, managing medications, tailoring activities for populations with physical or intellectual disabilities or low literacy, and providing concrete services (e.g., housing or health care) to promote treatment engagement and adherence over time (McCracken & Marsh, 2008). Manuals often lack sufficient detail for the case-by-case, individualized fit that characterizes advanced social work practice (Barth et al., 2011; Proctor & Rosen, 2008). In short, manuals are guides that practitioners must use with creativity and care. However, with these limitations, manuals are becoming an important and sometimes an expected element of practice.

Policy makers, social work educators, and practitioners broadly accept EBP as a means for providing more effective services (Thyer & Myers, 2011). Treatment manuals are often a component of empirically supported interventions involved in EBP. There has been vociferous debate on the use of manuals (e.g., Addis & Krasnow, 2000; Longhofer & Floersch, 2012) and clinical training in social work often does not teach the use of manualized EBT. Weissman et al. (2006), for example, found that 61.7% of a sample of 64 accredited master of social work programs did not require both classwork and clinical supervision in manualized EBT for training in psychotherapy. We believe, however, that the judicious use of manuals applied in the context of assessed, specific client needs is an important feature of practice and of the profession’s commitment to the transmission of knowledge through guidelines for practice (Howard & Jenson, 1999). This article proposes a model for developing practice manuals. Our aim is to outline a practice-sensitive, evidence-oriented process for designing and adapting manuals. We have focused on both the creative and the systematic activities that comprise manual development.

Developing Practice Manuals: Four Stages

Manuals are written guides to practice. Whether based on traditional interventions, practice innovations, research, or a combination, manual development can be conceptualized as four sequenced activities: (a) formulation, (b) revision, (c) differentiation, and (d) translation. Shown in Figure 1, this model of manual development is generally linear but it allows for iterative feedback loops to revisit earlier stages. We illustrate the stages of manual development by describing the Making Choices Program, which is a program designed to decrease aggression among elementary school-aged children. This program has appeared in several versions, including one for small groups and one for classrooms in schools. The Making Choices manual was developed over the course of several practice research projects.

Figure 1.

Activities across the stages of manual development. The stages are shown in sequence from left to right. Note that early stages remain active throughout the process and can be revisited.

Formulation: Writing It Down!

In the four-stage model of manual development (see Figure 1), the first set of activities involves outlining core constructs. Core constructs include knowledge, skills, or beliefs that are associated with broader factors targeted for change in intervention. As such, the core constructs begin to specify the deep structure of an intervention (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). That is, core constructs are the defining features of interventions. They constitute the fundamental active ingredients in an intervention. Implicitly, the specification of core constructs (e.g., skills or knowledge) makes an argument for why a program should affect distal outcomes, such as maltreatment or delinquency.

Introduction and rationale

The introduction to a manual should provide users with a short review of the program’s goals and core constructs, including a brief rationale stating the significance of the problem or issue. In addition, the introduction should outline the program based on an understanding of the needs and risk processes operating within the population. In other words, the introduction is based on a theory of the problem. Problem theory attempts to explain how a social or health problem arises and is sustained. Problem theory is informed by the theoretical, research, and practice literatures as well as unpublished insights drawn from practice experience. Building from the foundation of problem theory, the program theory or the “logic” of an intervention (i.e., what the intervention attempts to change) is determined.

Program theory specifies the targets of an intervention program from an understanding of the problem. Program theory is sometimes expressed as a logic model showing inputs, throughputs, outputs, and outcomes (see, e.g., Funnell & Rogers, 2011). Program theory emphasizes the role of mediators, which are the factors—the core constructs—that influence distal outcomes. To change mediators in the desired direction, programs often use activities that involve strengthening skills, building knowledge, and providing social support. For example, the relationship between peer rejection in childhood and aggressive behavior is thought to be partially mediated by the core construct of a child’s social–emotional skills. Social skills are malleable, and thus, social-emotional skills training might function protectively to reduce peer rejection and, in the long term, the risk of aggressive behavior. Program activities such as skills training can be thought of as the throughput that influences distal outcomes.

In addition to a rationale that describes a program theory, the introductory section of manuals might include summaries of research results, reviews of complementary interventions (that can be used to augment impact), and guidelines for staff qualifications. In addition, this section can include discussion of strategies for dealing with common problems (e.g., clients who arrive agitated or intoxicated) and suggestions for promoting fidelity to program activities.

Program goals and activities

Following the introduction, program goals and activities must be specified. This step often includes description of

the specific objectives, content, and format of sessions;

the number of sessions per topic;

the length of sessions; and

the practice processes and skills required for successful implementation.

Making Choices was designed for implementation with groups of children. To provide practice tips on implementation, we included an explanation of the stages of group development in the manual introduction and wove information on group development into session content (Fraser, Nash, Galinsky, & Darwin, 2000). Similarly, throughout the manual for the Graduated Recovery Intervention Program (Penn et al., 2006, 2011; Waldheter et al., 2008), Penn and his colleagues described engagement strategies for building relationships with people recovering from serious mental illnesses.

In many manuals, sessions are sequenced and structured according to substantive goals related to distal outcomes. Figure 2 presents an outline for part of a lesson from Making Choices that focuses on understanding emotions. Notice that the lesson plan outlines objectives, describes lesson activities, and lists essential materials. In addition to specifying required content, lesson plans often include tips and options for supplemental activities or choices of alternate activities that are based on the intended settings for the intervention. Illustrated in Figure 2, the manual also includes a discussion of practice constraints. For a school-based program such as the Making Choices program, national or regional guidelines for curriculum content define the bounds of teaching goals and activities. In the United States, every state has a Standard Course of Study (SCS) that guides curricular content in public schools. At a micro-social level, the SCS is the policy context in which interventions must fit. Shown in Figure 2, the objectives of the session are linked to SCS Language Arts (LA) guidelines. This SCS link anchors the session content in the policy context, which can affect program support. The constraints presented by different settings should be considered during the formulation phase.

Figure 2.

Sample of program content from the Making Choices program: Session on emotions (Activity 1).

Revision: Rethinking and Rewriting

The second stage of manual development is revision (see Figure 1). Typically, revisions are based on feedback from practitioners who have used the manual, clients who have participated in the intervention, experts in the field who have reviewed the manual, and, when intervention research is involved, data from pilot testing and efficacy trials (Carroll & Rounsaville, 2008). Often, the richest information for making revisions comes through (a) feedback from practitioners and their clients and (b) critical reviews from experts. Revisions are warranted when material is inadequate to convey the desired concepts, such as instances in which practitioners or participants find content confusing. When data are collected, the results from mediation analyses can be helpful for defining areas in which new or revised content is needed (e.g., MacKinnon, 2008). These analyses can be undertaken in both efficacy trials (i.e., small controlled trials) and effectiveness trials (i.e., larger controlled trials; see Flay, 1986, for a review of efficacy vs. effectiveness trials).

During the revision stage, developers reconsider program content. Some activities might be designated as essential to program integrity, whereas the choice to use nonessential or supplemental activities can be left to the discretion of practitioners. This specification of core content provides a foundation for practitioner training. (Note. Core content is not the same as core constructs. The term content refers to activities). In addition, specification of core content serves as a base for identifying fidelity criteria that denote what must be done to ensure that an intervention is carried out as intended.

The goal of revision is to sharpen the focus and flow of content and program materials. Information from intervention agents, program participants, experts, and administrators is used to make modifications to content, session format, or the number of sessions allotted to a particular issue.

Differentiation: Adapting Content for the Intended Setting and Population

The third stage of manual development is differentiation (see Figure 1). Differentiation involves enriching content related to variations in the practice settings and target populations for which a manual is intended. Important elements of differentiation include an evaluation of the core constructs as well as the activities to ensure that they apply to subpopulations. Pilot-test data might indicate that a manual needs revision to include content relevant to certain subpopulations in the intended setting. For example, feedback from teacher focus groups conducted as part of a pilot test of Making Choices suggested the need to strengthen the program content on socially aggressive behavior to better address aggressive behavior among girls.

As mentioned earlier, the organizing or core constructs are the deep structure of an intervention (Resnicow et al., 2000). In the differentiation stage, the foremost consideration is the extent to which the deep structure is applicable to subpopulations within the target population and whether changes in setting require new approaches. Program activities—sometimes called the surface structure—should be adapted only after it has been established that the core constructs have relevance. For example, when the Making Choices program was introduced into schools, which was a variation in setting from the community agencies where the program was initially developed, we determined that the core constructs would be unaffected by changing the intervention agents from trained clinicians to classroom teachers. However, the change in setting required changes to the surface structure. The treatment manual was realigned to meet the expectations and needs of classroom teachers. We removed the clinical language that was familiar to social workers (the former intervention agents), linked lessons to academic achievement, and created optional activities for the classroom, cafeteria, and playground settings where teachers interact with children.

When intervention research is involved in manual development, differentiation often arises from analyses of moderators; that is, creating statistical models to explore how social and demographic factors alter the relationship between program participation and outcomes (Videka, 2003). Among others, potential moderators include age, gender, race/ethnicity, income, marital status, population density, language fluency, religion, sexual orientation, and cumulative risk. If a subpopulation does not appear to be responding to content (i.e., engagement and outcomes for a subpopulation are not comparable to those for other groupings), then the program developers must determine (a) if the core constructs are relevant to the subgroup; (b) if additional constructs or risk processes are disrupting intervention activities; and (c) if content should be altered to increase fit with the subpopulation. If the developers determine the deep structure is relevant to a subpopulation, differentiation need focus only on altering wording or presentations so that constructs are conveyed in easily understood ways. If additional risk processes are identified, the needs of particular subgroups might require that the developers add new content, which would necessitate a return to the formulation phase. We assume that the recipients of these services will be engaged in a feedback process that informs the relevance and fit of the intervention. It is this continuous process of reexamination that makes manual development recursive and iterative.

Translation: Extending Beyond the Intended Setting and Population

Translation constitutes the final stage of manual development and refers to a general process in which program materials are modified for new settings or extended to new populations (See Figure 1). Arguably, the translation of programs to new settings and populations is the most uncertain and debated stage of manual development. In this use, translation describes the interpretive activities needed to prepare a manual or other materials (e.g., recruitment brochures) for use in settings or with populations that might not have been anticipated in the program’s original design. In the health sciences, translation refers to taking knowledge from “the bench to the bedside”—that is, the adaptation of findings from basic, bench-top studies to applications in clinical settings. In the arts and humanities, translation is often used to mean a literal interpretation from one language to another. In intervention science, the term translation is increasingly used to describe the means of making information and activities culturally understandable in a new setting or with a new population. Translation often occurs without the involvement of the manual developers. Critics argue that the extrapolation of original materials beyond settings and populations similar to those involved in the development of the manual (e.g., applied beyond the available research evidence) is likely to compromise a proven program’s effectiveness (Elliott & Mihalic, 2004).

Under ideal conditions, a program would be used only in the settings for which it was intended and with only the populations on which it was successfully implemented or validated. However, because it is not feasible to undertake rigorous testing in all situations in which an intervention might provide social benefits, proven programs will inevitably be extrapolated to populations and settings for which no effectiveness data are available. Anticipating this extrapolation, we and others have argued that manuals must specify core content that is mandatory and that addresses the core constructs foundationally related to outcomes (e.g., Carroll & Nuro, 2002).

Two kinds of adaptations

If extrapolation is inevitable, translation should involve at least two kinds of adaptations: those directed at the setting and those directed at the program. The setting must be examined for fit with the program, and the program must be examined for fit with the setting. Coadaptation of the program and setting should preserve core manual content and ready a setting for a program innovation. For example, when the Homebuilders program was adopted by child welfare agencies in many states across the country, a large number of the settings had to be adapted (Institute for Family Development, 2010). A key Homebuilders strategy was to provide services in the home immediately after a child maltreatment report. To do this, Homebuilders workers had to be available at any time during the week or weekend. Agencies that operated on a traditional 8 a.m. to 5 p.m. work schedule were forced to adapt their personnel policies to permit flex work hours. Without this setting adaptation, the Homebuilders program could not have been implemented with fidelity (Kinney, Haapala, & Booth, 1991).

Adaptation of the setting

Taking into account both setting and program features, translation should occur at the organizational level, as happened with Homebuilders. The fit of a setting to a program is assessed in terms of staff expertise and training, leadership, organizational climate, personnel policies, and work culture. In addition, extraorganizational contingencies that could promote implementation, such as the availability of a reimbursement mechanism for a new program, should be considered. From the perspective of coadaptation, factors affecting overall program achievement, such as successful recruitment of program participants, faithful program implementation by staff, and adherence to the program by participants, may be as much a function of preparing the agency for the program as preparing the program for the population.

Coadaptation involves strengthening the fit of an agency to a program, and the fit of a program to the setting, including—often—a new population. This is a tall order. Change from “practice as usual” requires that agency management and social workers approach the implementation of a new program with willingness to (a) give up previously comfortable practice methods; (b) become proficient in unfamiliar methods or use familiar methods in new ways; and (c) create organizational processes and structures that support a new program. From this perspective, much of the activity related to translation is beyond the scope of manual development per se. It is organizational development.

Adaptation of program content

Translation of program materials should preserve core content because that content addresses core constructs. If the core constructs and content are changed, then the essential features or deep structure that make a program effective are likely to be compromised. Given the risk of compromising effectiveness, is translation possible? Yes, conditionally. In our view, valid program adaptation involves (a) translating existing program materials (e.g., ensuring that the material is at a culturally congruent level); (b) using available evidence to identify potential new risk processes in the target population; and (c) formulating content to address newly identified risk processes. Thus, when new constructs are identified, a return to the formulation phase is necessary (Castro, Barrera, & Martinez, 2004).

In the absence of new risk processes, translation should focus on the addition, modification, or deletion of content and activities. Barrio and Yamada (2010) described two levels of cultural translation: (a) a surface strategy that responds to ethnocultural and interpersonal styles by adapting program content and (b) a deeper translation that further incorporates “values, traditions, and practices consistent with the worldview and help-seeking patterns of the cultural group” (p. 484). In translating program materials at the surface level, literal translation from one language to another alone is not enough. Translation must also occur at the semantic level where the meaning of a sentence is conveyed in culturally relevant expressions or colloquialisms. Ideally, translation should be done by a team of linguists with cultural knowledge at the idiomatic level.

The challenges of deeper translation are often underestimated. Finding the right colloquial metrics includes initial translation, back translation, review by experts, and retranslation. Our experience with the translation of Making Choices for China is illustrative of the kinds of changes needed when a program manual is applied in a different cultural environment. The U.S.-based Making Choices manual was translated to Chinese and then independently back-translated to ensure accuracy. A group of seven faculty members in social work and psychology from Nankai University in Tianjin, China, worked with U.S. counterparts to find idiomatic expressions that conveyed core ideas in Chinese. After determining from research in China that the social information-processing skills taught in Making Choices operate in children in China as they do in children in the United States (i.e., the core constructs were relevant), the manual was revised to reflect the unique nature of Chinese schools and the culture in which the children are raised. Lessons were adapted for cultural congruence. For example, a role-play activity that required familiarity with baseball was replaced with a role-play that referred to soccer. New material was added to account for ways that classrooms in China differ from those in the United States. Content was reviewed by Chinese experts in child development and by governmental officials. Because a high percentage of China’s children come from urban areas where the one-child policy has influenced family size, a novel risk factor was identified and a new three-lesson unit was formulated—a return to Stage 1, Formulation—and added to the manual (Making Choices Research Group, 2011). This unit addressed situations commonly encountered by children from single-child households with two working parents. Finally, an adapted and reformulated manual was presented at a public hearing in Beijing and 10 experts from across China were invited to comment. This hearing completed a translation process that focused on conveying program content at the semantic level and, further, on formulating new content that was uniquely tailored to Chinese culture (Making Choices Research Group, 2011).

Issues In Manual Development and Manual-Based Practice

Emerging from advances in practice, the movement toward EBP, and changes in public policies, manuals have gradually become an important part of social work. Manuals were first developed in medicine and subsequently used by cognitive behavioral researchers in the social sciences. Today manuals inform practice in many settings and professions, and they are not constrained to a particular theoretical perspective. As the use of manuals has expanded, a number of challenges and issues have emerged.

Selecting a Manual

Selecting a manual is by no means easy, especially as the number of manuals is increasing. The choice of a particular manual should be based on several factors such as suitability for the population and agency, evidence of effectiveness of the program in which the manual is used, and feasibility of adaptation when surface structures need to be altered. A manual should be usable by agency personnel. That is, the manual should be matched to the education and professional orientation of staff. Training should be available. Both the cost of manuals and training must fall within an agency’s fiscal resources and possible modes of operation. A key factor in selection is that the manual should target the perceived risk factors within the intended population. Evidence of effectiveness is perhaps the strongest indication for selection. If data show that a program is effective, then a manual from the program should earn a high priority for selection.

Making Changes in a Manual

The extent to which manuals can be revised and adapted by practitioners is hotly debated. How much can a manual be altered and still retain its status as a part of an evidence-supported program? There are no clear answers to this question. Changing aspects of surface structure, content or activities, or the frequency and length of implementation may retain the basic features of a program, as long as changes are not extensive. Even in research projects practitioners adapt and individualize interventions to fit the interaction between clients and workers, and the circumstances of a client’s life. Good practice is never rote and this holds as well when manuals are used.

Selecting portions of a manual with relevance to a new setting is commonplace. However, choosing only parts of a manual could compromise deep structure if core content or activities are eliminated. As we have noted, when aspects of deep structure are changed, it is necessary to return to a formulation phase of manual development. In addition to changes made by practitioners, manuals are often updated by developers. Reviews of manuals should continue throughout their use and should involve constant scans of the literature. New data from basic and applied research may have implications for the formulation of deep structure constructs. New findings may also have implications for practice theory and policy directives.

Prescriptive Activities Versus Guidelines: How Much Training?

Yet another knotty issue is the extent to which manualized programs require extensive training and supervision. When more generalized guidelines, such as those associated with multisystemic family treatment, are employed, they afford much greater latitude in the selection of intervention activities as compared with the prescriptive content in many cognitive-behavioral manuals. When problems are complex and populations are diverse, guidelines provide flexibility in selecting intervention activities that match the needs and preferences of clients. Implicitly, guideline-based manuals rely on the practitioner to understand the deep structure of a program and to be skilled in developing strategies consistent with that structure. In this sense, guidelines place greater reliance on the experience, expertise, and training of the practitioner. As a result, compared with prescriptive programs that contain detailed descriptions of core content, programs based on guidelines may require more extensive professional training, development, and supervision.

Another issue concerns the use of terms when written practice resources are used. The term “standardization” is sometimes used—almost pejoratively—to describe manualized or prescriptive elements of treatments. However, it is not always clear whether this refers to a written manual or to a generally understood protocol of treatment based on a theory of change. There is a need for further clarification of concepts such as standardization and individualization in the context of EBP.

Implementation Science: Manuals in the Context of Practice Innovation

Indeed, the uptake of evidence-supported interventions in practice is a focal issue in the emerging field of implementation science. Studies suggest that a variety of factors beyond the control of social workers influence the infusion of interventions into practice (for more information on implementation science, see Damschroder et al., 2009; Raghavan, Bright, & Shadoin, 2008). In addition to the availability of a program manual and training, factors influencing the uptake of evidence-supported treatments include public policies that support new programming, leadership that is responsive to emerging issues, organizational cultures that foster innovative thinking and experimentation, a host of extra-agency influences that affect the regulatory environment in which agencies are embedded, and the availability of funding for evidence-supported programs.

The Effectiveness of Manuals?

Manuals per se are neither effective nor ineffective. Outside of research enterprise, they are an important practice tool that contributes to training and implementation (Castro et al., 2004; Chambless & Ollendick, 2000). Manuals describe programs that may or may not be effective. They are closely allied with practice research where, in order to make causal inferences about the effectiveness of an intervention, it was essential to standardize the independent variable, that is, the practice methods being evaluated. When practitioners are well trained and supervised in the delivery of a program, whether the program is manualized may have little impact on clinical outcomes. In a meta-analysis of 77 evaluations of parenting training programs, Kaminski, Valle, Filene, and Boyle (2008) found no evidence that manualized programs produced larger effect sizes than nonmanualized programs (see also Ghaderi, 2006; Jacobson et al., 1989). Simply using a manual may promote fidelity, but based on current data, the argument that manuals increase effectiveness is not well supported. This may occur because practitioners involved in research projects, whether using manuals or not, tend to be well versed in the interventions under scrutiny.

Developing Manuals That (Better) Fit Social Work Practice

As they are currently developed, many manualized programs conform poorly to practice. Historically, many manuals were developed as a part of clinical trials where clients with several clinical problems, or comorbidities, were screened from samples. This was done to isolate the impact of the core content of programs on singular social problems. From a research perspective, this made sense. The presence of comorbidities confounds the interpretation of program effects.

The practice of selecting research participants on the basis of one-and-only-one social or health problem has had an unintended consequence. It has produced a plethora of manuals that fit particular disorders and conditions without fitting the complexity of everyday practice, where comorbidities are commonplace. The ideal participant in research has one clearly defined problem, whereas the typical client in practice often has overlapping and ill-defined problems. An emerging challenge in practice research is to develop and test multielement interventions that better fit practice. This type of treatment package research would use multiple manuals or one integrated manual to cover a range of conditions and provide for the design of flexible intervention or care plans that are configured from evidence-supported programs, the practice experience of the practitioners, and the preferences of clients (see, e.g., Fraser, Day, Galinsky, Hodges, & Smokowski, 2004).

Developing Practice Principles and Theories of Change

Finally, we have emphasized problem and program theory because together they constitute the theory of change related to whatever intervention is being manualized. In the long run, the challenge is not merely to create more manuals or even more multielement manualized programs. Rather, it is to distill practice principles that will guide the development of advanced practice where evidence-supported interventions can be flexibly configured to meet changing client needs and environmental conditions (Thyer & Pignotti, 2011; Westen, Novotny, & Thompson-Brenner, 2004).

Summary

In this article, we have traced the design and development of program manuals. We have described four stages in the formulation, revision, differentiation, and translation of program materials. The process of manual development can be—and often is—integrated with intervention research. At the formulation stage, activities involve identifying core constructs and specifying program content, whether at the individual, group, family, organizational, or community levels. During revision and differentiation, data from program participants and practitioners are used to refine content and nuance activities. Translating program content for new populations and settings is perhaps the most debated stage of manual development. The extrapolation of manuals to new groups or novel environments presents a variety of challenges, even when core constructs remain applicable.

These challenges notwithstanding, manuals are an emerging element of social work practice. References for dozens of new manuals are included in Information for Practice (http://ifp.nyu.edu/category/guidelines-plus/) and publishers are beginning to create practice manuals book series (e.g., http://www.routledge.com/books/search/keywords/treatment_manuals/, http://www.oup.com/us/catalog/general/series/TreatmentsThatWork/). Prescriptive manuals tend to include rationales rooted in theory, goals targeting skills, knowledge, or other constructs (e.g., self-efficacy or social support), and sequences of learning activities. Both the Graduated Recovery Intervention Program in mental health and Making Choices in school social work provide research reviews and detailed programming, including suggestions for tailoring content on the basis of client characteristics. Similar to maps, manuals provide information about the practice terrain. However, no manual by itself constitutes practice or ensures that an intervention will be effective. When coupled with professional training and supervision, manuals inform service delivery and offer a promising means for strengthening practice outcomes.

Footnotes

Authors’ Note

This article was invited and accepted by the editor.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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