As a therapist, do you know what your interventions are? What they consist of? What the different components are (who does what to whom to what end)? What their benefits are, as well as the harms?
Or do you doubt your interventions, question yourself, feel unclear about what it is you are actually providing? Do you wonder what your interventions are really made of, even question whether they are doing much good at all? Quite a while ago I found myself in this second group. Feeling like a non-believer, a doubter (dare I say, a fraud?).
If you too find yourself in this second group, take solace: “The problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.” (Bertrand Russell).
Today, over a decade after my doubting started, I find myself in a world where the most credible thinking around non-drug interventions starts with a strong appreciation that we need to question our interventions. As a field, we have increasingly come to realise that we have tended to gloss over some key questions about our interventions, and just jump in to using them. We use them before we even really knew what they are. We don’t pay enough attention to questions like “what is this intervention actually made of?” and “how do I believe this intervention will lead to the outcomes I am trying to achieve?”.
In 2000, the UK Medical Research Council published its first guidance on how the international multidisciplinary research community should approach non-drug interventions . This guidance recognises that non-drug interventions are complex: they have many moving parts that can be difficult to pin down and define, the relationships between the parts can be messy, and the pathways from the parts to the outcomes can be difficult to specify. The MRC guidance is also very clear that despite these challenges we must try to be clearer about our interventions.
Since its publication, the MRC guidance has been elaborated , and additional parts have been added (e.g. the process evaluation guidance  ). From when I first read the guidance in 2005 to today, I consider it and its added parts as the most fundamental and important methodology document for anyone doing any research into therapy interventions. I also think that if we as a clinical community took on board some of its basic tenets the quality of our thinking around our interventions would hugely improve – and would put us in a genuine position to lead health interventions across research and practice.
One key element of the guidance is the development of cumulative theory. In the simplest way this means we need to be very clear about our ideas before we start applying them. This may be ideas about the problem, e.g. being specific and having evidence about who exactly is affected, in what way, and the factors playing a role). This may be ideas about the solution, e.g. specific solutions that might make things better, the use of these solutions in different situations, and barriers to implementing the solutions. So all quite practical questions.
The MRC guidance argues we need to take these questions as seriously as the question of “does this intervention work?”. This is so that we have clarity (a good theory!) about the problem and possible solutions, and a good foundation for thinking about out intervention. So for those who think theory has little benefit for practice, keep in mind that “There is nothing more practical than a good theory.” (Kurt Lewin).
So, here is the stall set up. Below is a running order for the haggling – but feel free to bring your own goods along and offer them up too so we’ll get a lively discussion =).
Running order for questions:
1) How clear do you feel on your interventions: what they are made of, and what ideas and evidence there is about the problems and solutions?
2) Have you come across the MRC guidance? Have you used it? What do you make of it?
3) How much, and in what ways, do you currently think about and seek evidence about the problems you are trying to address (as opposed to evidence about the interventions)?
4) How much do you consider each component within your intervention (how specific are you?), and form hypotheses about how each component targets the outcome?
5) What one thing can you do to become clearer about the interventions you use? How will this help you and the patients?
 Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. London: Medical Research Council; 2000.
 Craig P, Dieppe P, Macinture S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: new guidance. London: Medical Research Council; 2008.
 Moore G, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. London: MRC Population Health Science Research Network; 2014.
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