Evidence-Based Practice in Psychology

APA Presidential Task Force on Evidence-Based Practice

BY: American Psychologist ● May–June 2006

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force’s report describes psychology’s fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider.

Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005.

Keywords: evidence-based practice; best available research evidence; clinical expertise; patient characteristics, culture, and preferences

From the very first conceptions of applied psychology as articulated by Lightner Witmer, who formed the first psychological clinic in 1896 (McReynolds, 1997), psychologists have been deeply and uniquely associated with an evidence-based approach to patient care. As Witmer (1907/1996) pointed out, “the pure and the applied sciences advance in a single front. What retards the progress of one, retards the progress of the other; what fosters one, fosters the other” (p. 249). As early as 1947, the idea that doctoral psychologists should be trained as both scientists and practitioners became American Psychological Association (APA) policy (Shakow et al., 1947).

Early practitioners such as Frederick C. Thorne (1947) articulated the methods by which psychological practitioners integrate science into their practice by “increasing application of the experimental approach to the individual case and to the clinician’s own ‘experience’” (p. 159). Thus, psychologists have been on the forefront of the development of evidence-based practice for decades.

Evidence-based practice in psychology is therefore consistent with the past 20 years of work in evidence-based medicine, which advocated for improved patient outcomes by informing clinical practice with relevant research (Sox & Woolf, 1993; Woolf & Atkins, 2001). Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) described evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (pp. 71–72).

The use and misuse of evidence-based principles in the practice of health care has affected the dissemination of health care funds, but not always to the benefit of the patient. Therefore, psychologists, whose training is grounded in empirical methods, have an important role to play in the continuing development of evidence-based practice and its focus on improving patient care.

One approach to implementing evidence-based practice in health care systems has been through the development of guidelines for best practice. During the early part of the evidence-based practice movement, APA recognized the importance of a comprehensive approach to the conceptualization of guidelines. APA also recognized the risk that guidelines might be used inappropriately by commercial health care organizations not intimately familiar with the scientific basis of practice to dictate specific forms of treatment and restrict patient access to care. In 1992, APA formed a joint task force of the Board of Scientific Affairs, the Board of Professional Affairs, and the Committee for the Advancement of Professional Practice.

The document developed by this task force—the Template for Developing Guidelines: Interventions for Mental Disorders and Psychosocial Aspects of Physical Disorders (hereinafter, Template) was approved by the APA Council of Representatives in 1995 (American Psychological Association, 1995).

The Template described the variety of evidence that should be considered in developing guidelines, and it cautioned that any emerging clinical practice guidelines should be based on careful systematic weighing of research data and clinical expertise. The Template noted that the successful construction of guidelines relies on the availability of adequate scientific and clinical evidence concerning the intervention being applied and the diagnostic condition being treated. . . . Panels (should) weigh the available evidence according to accepted standards of scientific merit, recognizing that the warrant for conclusions differs widely for different bodies of data. (p. 2)

Both the Template and the subsequent revised policy document that replaced it—the Criteria for Evaluating Treatment Guidelines (American Psychological Association, 2002)—were quite specific in indicating that the evidence base for any psychological intervention should be evaluated in terms of two separate dimensions: efficacy and clinical utility. The dimension of efficacy lays out criteria for the evaluation of the strength of evidence pertaining to establishing causal relationships between interventions and disorders under treatment. The clinical utility dimension includes a consideration of available research evidence and clinical consensus regarding the generalizability, feasibility (including patient acceptability), and costs and benefits of interventions.

The Template was used to examine a selection of available mental health treatment guidelines, and wide variation was found in the quality of the guidelines’ coverage of the relevant literature as well as the scientific and clinical basis, specificity, and generalizability of their treatment recommendations (Stricker et al., 1999). Even guidelines that were clearly designed to educate rather than to legislate, were interdisciplinary in nature, and provided extensive empirical and clinical information did not always accurately translate the evidence reviewed into the algorithms that determined the protocols for treatment under particular sets of circumstances. Psychologists have been particularly concerned about widely disseminated practice guidelines that recommend the use of medications over psychological interventions in the absence of data supporting such recommendations (Barlow, 1996; Beutler, 1998; Mun˜oz, Hollon, McGrath, Rehm, & VandenBos, 1994; Nathan, 1998).

The general benefits of psychotherapy had been established by meta-analytic reviews during the 1970s (Smith & Glass, 1977; Smith, Glass, & Miller, 1980). Nevertheless, a perception existed in many corners of the health delivery system that psychological treatments for particular disorders were either ineffective or inferior to pharmacological treatment. In 1995, the APA Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures, in an effort to promote treatments delivered by psychologists, published criteria for identifying empirically validated treatments (subsequently relabeled empirically supported treatments) for particular disorders (Chambless et al., 1996, 1998). This task force identified 18 treatments whose empirical support they considered to be well established on the basis of criteria that included having been tested in randomized controlled trials (RCTs) with a specific population and implemented using a treatment manual.

Although the goal was to identify treatments with evidence for efficacy comparable to the evidence for the efficacy of medications—and, hence, to highlight the contribution of psychological treatments—the Division 12 Task Force report sparked a decade of both enthusiasm and controversy. The report increased recognition of demonstrably effective psychological treatments among the public, policymakers, and training programs. At the same time, many psychologists raised concerns about the exclusive focus on brief, manualized treatments; the emphasis on specific treatment effects as opposed to common factors that account for much of the variance in outcomes across disorders; and the applicability to a diverse range of patients varying in comorbidity, personality, race, ethnicity, and culture.

In response, several groups of psychologists, including other divisions of APA, offered additional frameworks for integrating the available research evidence. In 1999, APA Division 29 (Psychotherapy) established a task force to identify, operationalize, and disseminate information on empirically supported therapy relationships, given the powerful association between outcome and aspects of the therapeutic relationship such as the therapeutic alliance (Norcross, 2001). APA Division 17 (Society of Counseling

Psychology) also undertook an examination of empirically supported treatments in counseling psychology (Wampold, Lichtenberg, & Waehler, 2002). The Society of Behavioral Medicine, which is not a part of APA but has a significantly overlapping membership, has recently published criteria for examining the evidence base for behavioral medicine interventions (Davidson, Trudeau, Ockene, Orleans, & Kaplan, 2003). As of this writing, we are aware that task forces have been appointed to examine related issues by a large number of APA divisions concerned with practice issues.

At the same time that these groups within psychology have been grappling with how best to conceptualize and examine the scientific basis for practice, the evidence based practice movement has become a key feature of health care systems and health care policy. At the state level, a number of initiatives encourage or mandate the use of a specific list of mental health treatments within state Medicaid programs (e.g., Carpinello, Rosenberg, Stone, Schwager, & Felton, 2002; Chorpita et al., 2002; see also Reed & Eisman, 2006; Tanenbaum, 2005). At the federal level, a major joint initiative of the National Institute of Mental Health and the Department of Health and Human Service’s Substance Abuse and Mental Health Services Administration focuses on promoting, implementing, and evaluating evidence-based mental health practices within state mental health systems (e.g., see National Institutes of Health, 2004). The goals of evidence-based practice initiatives to improve quality and cost-effectiveness and to enhance accountability are laudable and broadly supported within psychology, although empirical evidence of system-wide improvements following their implementation is still limited. However, the psychological community—including both scientists and practitioners—is concerned that evidence-based practice initiatives not be misused as a justification for inappropriately restricting access to care and choice of treatments.

It was in this context that 2005 APA President Ronald F. Levant appointed the APA Presidential Task Force on Evidence-Based Practice (hereinafter, Task Force). The Task Force included scientists and practitioners from a wide range of perspectives and traditions, reflecting the diverse perspectives within the field. In this report, the Task Force hopes to draw on APA’s century-long tradition of attention to the integration of science and practice by creating a document that describes psychology’s fundamental commitment to sophisticated evidence-based psychological practice and takes into account the full range of evidence that policymakers must consider. We aspire to set the stage for further development and refinement of evidence- based practice for the betterment of psychological aspects of health care as it is delivered around the world.1

1 The Task Force limited its consideration to evidence-based practice as it relates to health services provided by psychologists. Therefore, other organizational, community, or educational applications of evidence-based practice by psychologists are outside the scope of this report. Further, the Task Force was charged with defining and explicating principles of evidence-based practice in psychology but not with developing practice guidelines for individual psychologists or with other forms of implementation.

In its first two meetings, through an iterative process of small working groups and subsequent review and revision of all drafts by the entire group, the Task Force achieved consensus in support of draft versions of its two primary work products: a draft APA policy statement and a draft report. The draft documents were circulated widely, with a request for review and comment to the APA Council of Representatives, boards and committees, divisions, and state and provincial psychological associations. Notice of the documents’ availability for review and comment by members was published in the APA Monitor on Psychology and publicized on the front page of the APA Web site. A total of 199 sets of comments were submitted by groups and by individual members. Each of these comments was reviewed and discussed by the Task Force in a series of conference calls. At its final meeting, the Task Force achieved consensus on revised versions of the proposed APA policy statement and the current report.

References

American Psychologist, P. 271-285, May–June 2006

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