Evidence-based interventions are active areas of research in psychology. Their discussion has been extensive in the area of psychotherapy or psychosocial treatments. There are now many forms of psychotherapy that have solid empirical evidence in their behalf. The individual studies and reviews ordinarily might be comfortably tucked in for restful sleep. With ongoing debates and the entrance of managed care and reimbursement agencies into the mix, many of us have insomnia.
The debate within psychology pertains to the extent to which results from highly controlled clinical trials can be extended to clinical practice and decision-making in clinical practice and how research, expertise and judgment are combined. The constructive features of the debate-both research and practice, could do better and more to improve patient care. Also, there is the promise of some eventual synthesis, for devotees of Hegel and his dialectic.
Too few receive our services
The debate too often omits the concrete and contextual issues that have to do with patient care. As a concrete example, my clinical research and work is with children referred for aggressive and antisocial behavior (conduct disorder), the most frequent basis of clinical referrals of children (one-third to one-half of cases) and one of the most costly mental health problems in the United States. There are now at least a half a dozen psychosocial interventions with strong evidence (multiple replications with clinical populations) in their behalf. We can debate issues about these all day. At issue: It is very difficult to obtain one of these treatments in everyday clinical work. One context related to the debate is that our internal discussions are somewhat moot if we cannot deliver our treatments that do have evidence.
As a broader context, we know that approximately 67 percent of the children and adolescents in the United States in need of psychological services do not receive them. The rates are higher when the focus is on children of color and children living in rural areas (communities with fewer than 3,000 people, not connected to an urban area). With conservatively one in five children in community samples meeting criteria for at least one psychiatric disorder, the number of children we are not reaching is enormous. In short, the clinical-research debate on whether a treatment is sufficiently established or established in a way to justify its use in clinical work ignores the less nuanced issue-most people in need of services receive none.
Much more is needed to redress the critical problem of delivering services. All sorts of efforts are needed and at different levels to provide the best services and on a scale that will have impact on the incidence and prevalence of mental health problems. Individual (one-to-one) treatment will always have a role but not permit delivery on the scale that is needed. Emerging are evidence-based treatments using self-help manuals, the Internet, CD-ROM and virtual reality. Telehealth (use of electronic information and telecommunication technologies to provide long-distance care and to train and supervise others to deliver care) and cell phones too can play a role in treatment (e.g., prompting therapeutic homework assignments, serving as a therapeutic tether when needed).
Dissemination of our treatment advances requires intervention at broader levels. APA is active on multiple fronts. For example, the mental health parity bill passed by the Senate extends coverage to mental health and seeks to reduce barriers to treatment and access to services. APA's Practice Directorate participated in ongoing negotiations with bill sponsors and other key Senate policy-makers, provided actuarial analyses, built coalitions, and provided language and drafts to move the bill forward. As another example, APA through various committees (e.g., Committee on Rural Health, Committee for the Advancement of Professional Practice) and APA's Education Directorate are engaged in several state-level activities to increase the number of positions for psychologists so that additional resources are available. These psychologists would work at community health centers and extend treatment to underserved rural areas.
These brief examples out of scores that could be provided convey critical areas of APA work that not only informs pertinent bodies (e.g., Congress, state agencies) about our work, but develops ongoing collaborations so that our findings can make a difference. This is critical-science and scientific findings are not a matter of "build it and they will come." Ensuring the benefits of our work requires a special team that can take our findings and move from the red zone to the end zone. APA programs, staff and members score points to help the public and in so doing increase the likelihood that our findings will have palpable impact.
Letters to the Editor
- Send us a letter