Alternative Options for Promoting Evidence-Based Practice

The work by Division 12 of APA is only one of a number of recent efforts to promote the use of scientific data in determining optimal services for patients or clients. The generic term for this increasing trend among health care professions is evidence-based practice. As we describe below, although formats used to promote increased accountability through the use of scientific findings may vary, all have in common the goal of ensuring that people seeking treatment receive services that are informed by research findings.

In the United Kingdom, the National Health Service recently commissioned a report for use in their strategic policy review of psychotherapy services. This review of the efficacy of psychological interventions was submitted to the Department of Health and a book based on these findings was published (Roth & Fonagy, 1996). As with the Division 12 initiative, the scope of the review was very broad. In many instances, the conclusions drawn by the authors were similar to those reached by the Division 12 Task Force. However, it is informative that the basis for Roth and Fonagy’s designation as empirically supported (or, to use their term, validated) was much more lenient than the Division 12 criteria. Specifically, they required: (i) replicated demonstration of superiority of a treatment to a control or another treatment condition or a single high quality randomized control trial, (ii) availability of a clear description of the therapeutic method that was of sufficient clarity to be used for training purposes (preferably but not necessarily a manual), and (iii) a clear description of the patient group who received the treatment.

Roth and Fonagy provided detailed reviews of the treatment literature which culminated in their listing of treatments with demonstrated efficacy. Additionally, they provided a number of suggestions for training and provision of services that in some cases parallel, and in others go beyond those made by the Division 12 Task Force. For example, like the Division 12 Task Force, they suggested that (i) professional organizations maintain a list of supported treatments, (ii) training in supported procedures should occur in professional training programs, (iii) clinicians should develop skills in these procedures through continuing education efforts, and (iv) comprehensible information about effective treatments should be available to the public. Additionally, though, they also called for (i) greater attention to the development of monitoring procedures, such as quality assurance procedures and outcome evaluation strategies, to ensure that high quality, effective services are provided in clinical settings and (ii) the involvement of professional organizations in the development of clinical practice guidelines or protocols that integrate research findings with current practice activities and options.

The use of clinical practice guidelines is perhaps the most common approach to encouraging evidence-based practice, and medical associations have been actively developing such guidelines for a host of disorders for many years. With practice guidelines, the practitioner is provided with current information on the nature of a disorder or problem and is encouraged to use specific interventions that have been demonstrated to be effective in clinical trials. In many areas these guidelines are seen as the backbone of effective and ethical service delivery, and the guidelines are the primary way in which evidence-based care can be provided by the individual practitioner (Clinton, McCormick, & Besteman, 1994; Edmunds, 1996; Rizzo, 1993; Strosahl, 1996). Recently, efforts have been made by various agencies to develop such guidelines for mental health problems. For example, the American Psychiatric Association has been publishing practice guidelines in the American Journal of Psychiatry for the past few years; similarly the American Academy of Child and Adolescent Psychiatry publishes practice guidelines in the Journal of the American Academy of Child and Adolescent Psychiatry. Practice guidelines are not just the product of specific professional organizations, though. There is a long tradition in several countries of government-supported agencies or working groups that work on practice guidelines. In New Zealand and Australia, for example, the Quality Assurance Project has published several guidelines for the treatment of mental health disorders in the Australian and New Zealand Journal of Psychiatry. In the United States, the government sponsored Agency for Health Care Policy and Research has produced a number of guidelines, including a practice guideline on the treatment of depression that has been the source of controversy within professional psychology (see Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994 for details).

One of the more recent developments within organized psychology in the United States has been a push to move beyond simple lists of supported treatments to work on the development of practice guidelines for mental health services. The importance of organized psychology’s involvement in the development of guidelines cannot be understated, for representation during the drafting of guidelines is essential if professional psychology is to play a central role in the provision of mental health services (Barlow, 1996a, b; Nathan, 1998). The Association for Advancement of Behavior Therapy and the American Association of Applied and Preventive Psychology have sponsored two national summits on the development of scientifically based practice guidelines in behavioral health. A steering committee has been struck to develop a Practice Guidelines Coalition (PGC) that will lead to principles, that in turn will lead to specific strategies for the adoption of practice guidelines in specific patient population areas (Hayes, 1997). Appendix B provides a summary of the key organizing principles that have been suggested for practice guidelines, based upon the June, 1997 summit meeting.

In 1993, the APA struck a Task Force on Psychological Intervention Guidelines chaired by Dr. David Barlow. The report of this task force was not a specific practice guideline, but rather a generic template for developing practice guidelines (Task Force on Psychological Interventions Guidelines, 1995). The general approach taken by the task force was that all practice guidelines should be based on a careful weighing of research data and clinical expertise, and that the resultant guidelines should include considerations based on two axes. The first axis includes a rigorous evaluation of the scientific evidence for interventions aimed at addressing the target problem or disorder -- this is similar to the approach taken by the Division 12 Task Force. The second axis involves the consideration of the applicability and feasibility of use of the intervention in the treatment setting. This second axis, dealing with clinical utility, allows the panel developing the practice guideline to build into the guideline considerations based on the generalizability of the extant treatment research. To aid in the development of treatment guidelines, this task force also included a number of helpful organizationally based recommendations that focus on forming a panel to develop a practice guideline. Appendix C contains the recommendations outlined in the task force report.

Although an excellent template, the suggestions of the Task Force on Psychological Intervention Guidelines represent, in many ways, a unnecessarily limited approach to practice guidelines. Although obviously essential to a guideline, a review of the treatment literature is a relatively narrow definition of evidence-based practice. If the purpose of a practice guideline is to produce scientifically based psychological service in a context of quality assurance and accountability, then several other issues are highly relevant. For example, practice guidelines could draw upon foundational knowledge in psychology, including research on normal human functioning and psychopathology, to guide the assessment and treatment of a given disorder. Data on etiological factors and contextual factors that may maintain or exacerbate the disorder could also be presented in the guideline. Based on prior research, suggestions could also be made regarding the assessment of (i) the target disorder or problem and (ii) common psychosocial problems that tend to co-occur with the target problem. Additional factors that should be considered in the development of the treatment plan and the monitoring of the treatment could also be presented. Embedded within this larger empirically based context, information on empirically supported treatments could serve to provide "default" options that should be considered for all patients/clients. Then, based upon consultations with the patient/client and other considerations outlined in the guideline, alternative options could be developed should the "default" treatment prove to be ineffective or unacceptable to the patient/client.

Next: Implications of the Empirically Supported Treatment Task Forces for Clinical Psychology in Canada

 

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