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In the case of Hiro, Dr. Jeremy Lichtman (2017, this issue) describes how he flexibly employed a manualized behavior therapy protocol to successfully treat a child’s involuntary motor and vocal tics.  In doing so, he raises interesting observations and questions regarding manualized psychotherapy treatment protocols, including their intended role, the need for "flexibility with fidelity," and the strengths and limitations of following manuals in a step-by-step fashion. In our commentary, we draw upon Dr. Lichtman’s experience in treating Hiro to highlight what we see as the two most important factors in Hiro’s treatment: (1) the therapist’s firm grasp of the underlying theory behind behavior therapy for tics, which allowed for flexibility in treatment delivery without jeopardizing treatment fidelity, and (2) the importance of having a strong foundational clinical skill set prior to beginning treatment

From Cook to Culinarian: Going Beyond the Manual When Delivering Behavior Therapy to Treat Tourette Disorder