Some APA members have asked me why I have chosen to sponsor an APA Presidential Initiative on Evidence-Based Practice (EBP) in Psychology, expressing fears that the results might be used against psychologists by managed-care companies and malpractice lawyers.
To respond, I would start by drawing attention to the larger societal context in which we live. The EBP movement in U.S. society is truly a juggernaut, racing to achieve accountability in medicine, psychology, education, public policy and even architecture. The zeitgeist is to require professionals to base their practice to whatever extent possible on evidence. Thus, psychology needs to define EBP in psychology or it will be defined for us. We cannot afford to sit on the sidelines.
In fact, EBP in psychology is already being defined for us. We learned about the impact of EBP in psychology on Medicaid-funded state mental health programs last March at the APA State Leadership Conference. The APA Div. 12 (Society of Clinical Psychology) lists of "empirically validated" (later "empirically supported") treatments have been referenced by a number of local, state and federal funding agencies, which are beginning to restrict reimbursement to these treatments, as are some managed-care and insurance companies. The Div. 12 lists were developed using rigorous scientific criteria, which, I believe, were too narrow. Not taken into account were some of the broader strands of psychological research evidence (such as effectiveness research) and the other two pillars of what the Institute of Medicine (IOM) has defined as the foundation of evidence-based practice, namely clinical expertise and patient values. Moreover, the requirement of a treatment manual excluded many forms of therapy from consideration.
This presidential initiative aims to affirm the importance of attending to multiple sources of research evidence and to assert that psychological practice based on evidence is also based on clinical expertise and patient values. The mission of the APA Presidential Task Force on Evidence-Based Practice in Psychology is three-fold, corresponding to the three components of the IOM definition of EBP:
To consider how a broader range of research evidence, one that inclusively considers multiple research designs, research in public health, health services research, and health-care economics, should be integrated into a definition of EBP in psychology.
To explicate the application and appropriate role of clinical expertise in treatment decision-making, including a consideration of the multiple streams of evidence that must be integrated by clinicians and a consideration of relevant research regarding the expertise of clinicians and clinical decision-making.
To articulate the role of patient values in treatment decision-making, including a consideration of the role of ethnicity, race, culture, language, gender, sexual orientation, religion, age and disability status, and the issue of treatment acceptability and consumer choice.
This Presidential Initiative Task Force includes 18 scientists and practitioners from a wide range of employment settings, theoretical orientations, APA constituencies, and ethnic heritages. Their areas of expertise include: clinical expertise and decision-making; health services research; public health and consumer perspectives; treatment outcome and process research; full-time practice; clinical research and diversity; health-care economics; and EBP research/training and applications (see roster). The task force first met in October and is working hard to form a consensus statement that APA can use to influence health-care policy, which will likely have an impact on the landscape of practice and payment for services. To be honest, I was pleasantly surprised and very impressed with how effectively the task force members worked to hear each others' perspectives and seek common ground.
The charge of the task force is to develop two documents. The first will be a policy statement for APA governance action, which will be circulated widely for comment, and have its first review at the Consolidated Board and Committee meetings in March. The second will be a position paper with targeted messages for health-care decision-makers, payers and the media, supporting a broad conceptualization of evidence-based practice in psychology.
If we do not take on this task, the challenge will not magically disappear. Rather, someone else will dictate what treatments are acceptable and what types of evidence are privileged. We will have MORE leverage with insurers, courts and policy-makers when APA has a clear statement asserting that we are a science-based profession and preserving the right for psychologists to make the final, evidence-informed decisions in clinical practice.
2005 Presidential Task Force on Evidence-Based Practice
Ronald F. Levant, EdD, Chair
Carol D. Goodheart, EdD, Co-chair
David H. Barlow, PhD
Karina W. Davidson, PhD
Jean Carter, PhD
Kristofer J. Hagglund, PhD
Steven D. Hollon, PhD
Frederick L. Newman, PhD
Josephine D. Johnson, PhD
John C. Norcross, PhD
Laura C. Leviton, PhD
Doris K. Silverman, PhD
Alvin R. Mahrer, PhD
Brian D. Smedley, PhD
Bruce E. Wampold, PhD
Brian T. Yates, PhD
Drew I. Westen, PhD
Nolan W. Zane, PhD