cpa-sm.gif (1004 bytes) DISCUSSION DOCUMENT

Empirically Supported Treatments in Psychology: Recommendations for Canadian Professional Psychology
Task Force on Empirically Supported Treatments (Section on Clinical Psychology of the Canadian Psychological Association)


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

As mentioned previously, the development of criteria for the recognition of empirically supported psychological treatments is beginning to have effects on the American training and practice domains. To date, the implications of this development in Canada are unclear. In this section, we identify and discuss some of the possible implications, particularly in the areas related to training, credentialing, practice, and research.

Before turning to these specific issues though, it is important to consider whether Canadian-American differences in legislative structures and health care systems renders the APA empirically supported treatment initiative irrelevant to professional psychology in Canada. One factor behind the development of the original APA Division 12 Task Force was the concern that, in a environment of managed health care, courts and legislative bodies would decide which forms of psychotherapy would be reimbursable. By developing criteria for determining whether a treatment has scientific support and a list of scientifically supported treatments, Division 12 hoped to be in a position to influence any debate about reimbursement that might take place outside of the profession of psychology (Beutler, 1998).

Although this specific concern is not relevant to the Canadian health care system, we do believe that the empirically supported treatment initiative is highly relevant to Canadian professional psychology. Historically, training and practice in psychology has been strongly influenced by numerous APA standards, codes, guidelines, and criteria. Despite the increasing trend for CPA to develop policies for Canadian psychology, the North American Free Trade Agreement is likely to ensure that American standards and practices exert at least some influence on the provision of psychological services in Canada (Dobson, 1995). Moreover, the trend toward the promotion of practice guidelines in health care is not simply an American phenomenon; indeed, the Canadian Medical Association is actively involved in the development and dissemination of many practice guidelines for Canadian physicians.

Quite apart from these issues, we believe that there is substantial merit in the APA initiative because it draws upon science in order to enhance psychological service. The initiative is a clear reflection of the basic tenet of the scientist-practitioner model, a model that is the core of all CPA and APA accredited clinical psychology training and internship programs in Canada. As the science of psychology develops, and as the health care system develops, it is imperative that professional psychology ensure that services are based on empirically informed "best practices" or "benchmarks" (cf. Adair, Paivio, & Ritchie, 1996; Cyr, King, & Ritchie, 1995; Sobell, 1996). In light of ongoing health care system restructuring, the ability of Canadian professional psychology to document the impact of psychological intervention should serve as a buffer against ill-informed attempts to reduce or limit access to psychological services.

Training Implications

Perhaps the most direct implication of empirical validation is in the area of training. The 1996 revision to the APA accreditation criteria included a specific requirement that training programs provide some attention to empirically supported treatments. Exactly how much training, and what type of training, however, is not specified in the criteria (see, however, Calhoun et al., 1998). As such, programs are given considerable latitude in the range and depth of training in empirically supported procedures. For example, a program may elect to provide training in only one such treatment, while offering all of its other training in interventions that lack such support. In contrast, another program may decide to offer its entire curriculum based around those treatments that are supported. Almost certainly, the distinction between two such programs will not only be with regard to the program's perspective on the importance of science in psychology, but likely will also reflect the dominant theoretical orientation within the training program. Most treatments that are currently recognized as having empirical support are either behavioral or cognitive-behavioral in nature; accordingly, the programs in which these orientations dominate will also be the programs most likely to endorse the training of students in empirically supported interventions. In this context, however, it is important to note that even among behaviorally oriented clinicians there is considerable disagreement regarding the appropriateness of using empirically supported treatments, as behavior therapy has a history of developing individually tailored interventions based on an idiographic assessment of each client (cf. Davison, 1998; Eifert, 1996; Evans, 1996).

Although exact data do not exist, the relative strength of behavioral and cognitive-behavioral training in Canada as compared to the United States is fairly clear. For example, the surveys by Hunsley and Lefebvre (1990) and by Warner (1991) can be contrasted with similar surveys from the United States. These comparisons suggest that Canadian clinical psychologists are more likely to endorse a theoretical orientation consistent with those orientations that are being empirically supported. It is perhaps for such reasons that some Canadian program directors have taken the position that there is nothing really new in the empirical validation/support movement for Canadian doctoral programs in clinical psychology (e.g. McMullen, 1996).

Although the claim that Canadian clinical psychologists are more likely than their American counterparts to be trained in and practice behavioral and/or cognitive-behavioral approaches seems to have face validity, it is not at all clear to what extent this international difference may apply to other practice domains in professional psychology. Further, although the overall difference between Canadian and American programs may exist, we do not know the extent to which some specific Canadian programs may disregard or even eschew the need for training in empirically supported treatments. Such data would be valuable in determining future trends in Canadian training programs, and could be useful for licensing and accreditation bodies in Canada.

It seems likely that if CPA accreditation criteria were modified so that some attention to training in empirically supported treatments was required, the effect on most clinical psychology training programs and internships would be minimal. It is our impression that all Canadian doctoral programs already offer some training in treatments that are considered empirically supported. Indirect evidence, based on a recent survey of directors of clinical training in doctoral programs and predoctoral internships conducted by the Canadian Council of Professional Psychology Programs, suggests that most programs strongly endorse the importance of training in empirically supported treatments (Alden et al., 1996). Any such changes to accreditation criteria are, therefore, unlikely to place undue burden on programs to alter their training. Rather, the changes may provide programs an opportunity to highlight for their students, the profession, and the public the precise manner in which professional training is based on scientific evidence. Given the range of orientations represented, and the nature of services provided in Canadian internships, we are less certain about the impact of such a requirement on internship settings. Clearly some internships would have little difficulty fulfilling this requirement, whereas for others, perhaps because of the nature of the services provided (e.g., psychogeriatric, forensic or correctional services, palliative care), it might prove more difficult.

Credentialing Implications

To our knowledge, no Canadian regulatory board has adopted a requirement that licensed professionals demonstrate training (let alone proficiency) in empirically supported procedures, either at the time of entry into the profession, or as a continuing education requirement. As such, although there is nothing in the current Canadian credentialing system that prohibits the recognition of practitioners who are trained, or who seek continuing education in empirically supported treatments, there is no particular incentive for electing to do so.

It is our perspective that, although one of the major advantages of generic credentialing of psychologists in Canada is that all areas of psychological practice fall under a single legislative and regulatory rubric, such a credentialing system also places real limits on the ability to advance credentialing requirements within specific areas of the discipline and profession. For example, it is likely the case that if speciality licensing existed in Canada, it would be possible to put into place, for a speciality of clinical psychology, a requirement for training in empirically supported treatments. This would be possible because, based upon our knowledge of Canadian doctoral programs in Clinical Psychology, the necessary foundational training would be available in the vast majority of programs. In the absence of such specialist licensing, however, such a credentialing requirement may be very difficult to implement across the broad domain of professional psychology.

One effect that the empirically supported treatment initiative is having in the area of credentialing operates outside of the formal licensing/registration process in the area of self-declared speciality credentialing. It has been possible for some time for a practitioner to self-identify as a "group therapist," "cognitive therapist," marital and family therapist," and so on. These labels typically reflect advanced training in a given area, and are useful in carving out practice niches. To the extent that some treatments may be recognized as having more status or support than others by virtue of being empirically supported, these self-declarations of expertise become more problematic. As the public may begin to seek out empirically supported treatments or to believe that better care is associated with these treatments, practitioners with or without the requisite training may begin to declare competency in these treatments. Not surprisingly, some of the originators of these treatments are now becoming concerned about the misuse of certain self-designations, and the negative impact these labels may have on the treatment, when used by untrained practitioners. As a specific example, the developers of cognitive therapy are in the process of developing a credentialing system for cognitive therapists for these very reasons.

Although all of the efforts towards specialty designations to date are based in the United States, it is highly unlikely that nationality will be a barrier to Canadian practitioners who seek such designation. Nonetheless, the development of lists of "qualified" (and therefore, by default, unqualified) practitioners may have an effect on the dissemination and practice of certain treatments in both countries. As these systems develop, it will be important for organized professional psychology in Canada to monitor such effects. Previously, a joint Canadian Psychological Association/Council of Provincial Associations of Psychology task force recommended that a framework for developing speciality designations be developed using national standards and procedures (Service, Sabourin, Catano, Day, Hayes, & MacDonald, 1989, 1994). In light of the APA move toward requiring training in empirically supported treatments for clinical psychology programs, should such a framework be developed, it will be critical that it is sensitive to the issues raised above. Failing this, it may be necessary to put in place a mechanism by which organized Canadian professional psychology can determine which American-based specialty-based designations or credentials should be recognized in Canada.

Practice Implications

There is little doubt that the movement towards empirically supported and evidence-based approaches will have an effect on the practice of psychology in the United States. There are already concerns in the practice community that managed care companies may limit their coverage of psychological services to those that have empirical support in an effort both to control costs and to recognize demonstrably effective treatments (Sleek, 1997). In a related vein, an organization called the National Association for Consumer Protection in Mental Health Practices has used the task force reports to bolster their call for legislation that prohibits government reimbursement for any therapy that has not been proven effective by outcome research (Hinnefeld & Newman, 1997).

To date, we know of no effort in any Canadian jurisdiction to limit funding of psychological services to those that use empirically supported treatments. Although there are some service units in Canada that explicitly employ only empirically supported treatments, such programs are the exception rather than the rule in Canada.

The observation that service units do not often explicitly rely on supported interventions is perhaps surprising in the overall Canadian context of limited and/or shrinking health budgets. As a matter of public policy in Canada, it may be prudent for ministries of health to begin to consider directing funding toward those programs that promote effective approaches to specific patient problems. This approach is largely consistent with the population-based approach to health services that exists in most areas of Canada, and could be integrated into an overall health service strategy. Moreover, it is also consistent with advocacy principles stemming from the Mississauga Conference on Professional Psychology (Dobson & King, 1995) inasmuch as it promotes the use of empirically grounded knowledge regarding the potential contributions of psychology to the health of Canadians.

As described previously, a major development in the United States has been a push to develop practice guidelines for mental health services. To our knowledge, there has been no participation from any Canadian organization in any of the meetings involving professional psychology in the development of such practice guidelines. Further, to our knowledge, there is no comparable effort under way in Canada for mental health services. Given the potential importance of the adoption of empirically supported treatment listings and practice guidelines, it may be prudent for CPA, or at least those sections of the association that see value in this movement, to participate in practice guideline development meetings. For example, representatives of Division 12 of APA attended the summits on the development of scientifically based practice guidelines in behavioral health (as did representatives of both the APA and the American Psychological Society), and we believe that Canadian involvement in subsequent summits may well be important for the optimal development of practice in Canada, as well as for the ongoing cross-fertilization of Canadian and American professional psychology. Alternatively, CPA and interested sections could work with other health professions in Canada to develop practice guidelines for psychosocial interventions.

Research Implications

At present, much of the research on empirically supported treatment is based on treatments provided to samples of American patients. As minority cultural groups are under-represented in such research, there are concerns within the Division 12 Task Force that the results of the research may not be generalizable to American minority groups (Chambless et al., 1996). Because this type of generalizability concern is also evident in a number of areas of psychological and biomedical research, the American National Institutes of Health now require that all intervention research funded by the agency use a research sample that is representative of the ethnic composition of the population in the region where the research is to be conducted.

If the results of psychotherapy research, including both efficacy and effectiveness studies, are to serve as a basis for determining Canadian public policy regarding service delivery, it is imperative that the research be broadly generalizable. To this end, given the differing cultural composition of Canada and the United States, it is important that decisions regarding Canadian health care services be based, as much as possible, on studies using representative samples of Canadian participants. Unfortunately, there is only a very limited infrastructure in Canada to support psychotherapy research. For example, although the Medical Research Council funds research on clinical trials (i.e., efficacy research) there are ongoing concerns about the extent to which research that is not biomedical in nature will be funded by the council. Additionally, although the National Health and Research Development Program of Health Canada funds research on health service delivery systems, the base budget for this program is extremely limited. If Canadian professional psychology is to participate in the development of practice guidelines, much will need to be done to improve the infrastructure supporting Canadian treatment research.

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