Perspective on Practice
I want to introduce you to a new practice-science collaboration: the development of treatment guidelines. Support for this initiative has been growing within APA's practice governance community. There was a lot of energy around this issue at the 2009 APA Presidential Summit on the Future of Psychology Practice among visionary leaders within and outside psychology, and treatment guidelines development emerged from the summit as a high priority.
During the 1990s, numerous other professional organizations and agencies began to develop treatment guidelines that pertain to specific disorders. However, APA chose not to do so, for very good reasons at the time. Instead, APA focused on practice guidelines, which consist of "recommendations to professionals concerning their conduct and the issues to be considered in particular areas of psychological practice." These cover a range of topics from record-keeping, to working with gay, lesbian, bisexual and transgender clients to child custody evaluations.
What is now very evident is that treatment decisions for patients with psychological disorders are primarily based upon guidelines developed by medicine/psychiatry. Few treatment guidelines reference psychotherapy; when they do, psychotherapy is usually secondary to medical interventions. Because APA has not promulgated guidelines that reflect the effectiveness of psychological interventions, it should come as no surprise that medically based guidelines have become the de facto standard for treatment, even when psychological interventions may be as effective or even superior to pharmacological interventions for psychological disorders or patient populations.
Treatment guidelines are a way to translate psychology's best scientific evidence into best clinical practice. They represent the best judgment of a team of experienced clinicians and methodologists who have critically reviewed the scientific evidence for the treatment of a particular disorder and who use information from those evidence reviews and other sources to make specific recommendations for treatment interventions. Guidelines can inform best practices, offer a framework for clinical decision-making, and provide a benchmark for evaluating treatment outcomes. Guidelines benefit patients when they have better outcomes, fewer ineffective interventions, and more consistent care. Psychologists can use guidelines to make more informed clinical decisions and to support patient access to appropriate services for psychological and substance-use disorders. Guideline development can also help us to better understand the kinds of research in which we need to engage to even better inform clinical practice.
It is also important for clinicians to understand what guidelines are not. Guidelines are not performance measures, legal precedents or standards, or recipes for cookbook or manualized treatments. They do not obviate the need to tailor treatment to the individual. Consistent with APA's definition of evidence-based practice as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences," guidelines are not the sole determinant of the choice of interventions. Guidelines do not trump professional judgment. Psychologists must always act in a manner that they believe will best serve their patient's needs and best interests.
So where do we go from here? APA can no longer afford to be silent where treatment guidelines are concerned. We need to have a significant impact on how treatment decisions are made for the patients psychologists treat. We have a solid scientific foundation that undergirds the intervention approaches we have developed for many psychological disorders. It is time for APA to do more to ensure that our science contributes in a meaningful way to improving the care of people with mental health and substance-abuse disorders.
As always, I hope this column stimulates your thinking and I encourage you to e-mail me with your questions, concerns or ideas about treatment guidelines.