Determination and Documentation of the Need for Practice Guidelines1
In August 2001, the American Psychological Association (APA) Council of Representatives approved as APA policy the "Criteria for practice guideline development and evaluation" (APA, 2002a), developed by the Board of Professional Affairs (BPA) Committee on Professional Practice and Standards (COPPS). The present document was developed in response to a request from the APA Board of Directors that BPA develop a document expanding on Section 2.2 of the Criteria, which indicates that practice guidelines should be written only when there is a clearly demonstrated and documented need. The Board of Professional Affairs further requested that COPPS consider the specific legal, public, and professional needs that may justify the development of guidelines and the related sources of documentation.
Developers of practice guidelines should review the Criteria carefully at the beginning of the project and frequently thereafter to help ensure consistency of the guidelines with APA policy. Note that this document is not intended to be a stand-alone document, but rather to be understood and used in the context of the Criteria. The intent of this document is to provide additional information to developers of guidelines related to the demonstration and documentation of the need for practice guidelines in the area of their interest.
1This document was developed by the Board of Professional Affairs Committee on Professional Practice and Standards (COPPS). Members of COPPS during the development of this document were Cynthia A. Sturm (chair, 2004), Kristin A. Hancock (chair, 2002 and 2003), Armand R. Cerbone, Victor de La Cancela, Mary A. Connell, William E. Foote, Michele M. Galietta, Larry C. James, (BPA member of COPPS 2004), Leigh W. Jerome (BPA member of COPPS, 2002 and 2003), Sara J. Knight, David C. Mohr, Carolyn M. West, and Philip H. Witt. COPPS is grateful for the support and guidance of BPA, particularly to BPA chairs Jalie A. Tucker (2004), Lisa R. Grossman (2003), and Sandra L. Shullman (2002). COPPS also acknowledges the contributions of APA staff members Geoffrey M. Reed, Christopher J. McLaughlin, Laura Kay-Roth, and Ernestine Penniman.
As it is used in APA policy, the term guidelines refers to statements that suggest or recommend specific professional behavior, endeavor, or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional and clinical situation. They are not definitive and are not intended to take precedence over the judgment of psychologists.
Practice guidelines consist of recommendations to professionals concerning their conduct and the issues to be considered in particular areas of psychological practice, in contrast to treatment guidelines, which provide specific recommendations about clinical intervention to be delivered to clients.2 The primary purpose of practice guidelines is to assist the practitioner in the provision of high quality psychological services by providing well-supported practical guidance and education in a particular practice area. Practice guidelines also "inform psychologists, the public, and other interested parties regarding desirable professional practices" (Criteria Section 2.5). APA policy, as stated in the Criteria and in previous documents, indicates that guidelines are not to be promulgated as a means of establishing the identity of a group or specialty area of psychology; likewise, they are not to be created with the purpose of excluding any psychologist from practicing in a particular area.
2Individuals or groups interested in developing or evaluating treatment guidelines are referred to the "Criteria for the evaluation of treatment guidelines" (APA, 2002b) for relevant APA policy.
COPPS has identified three categories of potential need for practice guidelines: 1) Legal and regulatory issues; 2) Public benefit; and 3) Professional guidance. While these distinctions are conceptually useful, the categories are likely to overlap in relation to the need for any particular guidelines document.
Legal and regulatory issues
Legal and regulatory issues in response to which practice guidelines may be written include:
Laws. Changes in state, federal, or international law or statutes may generate the need for practice guidelines. Guidelines are not written to interpret laws, which are mandatory and speak for themselves or are interpreted by the courts; however, in areas in which laws are silent, unclear, or conflicting, guidelines may assist psychologists in articulating recommended practices.
Court decisions and case law. Federal Circuit Court and the U.S. Supreme Court decisions may require changes in professional practice. For example, the U.S. Supreme Court decision in Daubert v. Merrill Dow Pharmaceuticals, 509 U.S. 579 (1993) prompted significant changes in how psychologists in affected jurisdictions prepare for and deliver expert opinions in court. Guidelines could educate psychologists about evidentiary requirements and how they can more effectively respond to them.
Professional interaction with the legal system. Psychologists are called upon to respond to demands from judges, lawyers, and administrative bodies. These demands may require the psychologist to provide information in the form of records or sworn testimony. For example, the "Guidelines for child custody evaluations in divorce proceedings" (APA COPPS, 1994) are intended to assist the practitioner to interact with the legal system, the family, and the child in a way that preserves ethical standards and clarifies professional roles. Guidelines can also provide education and information about specific legal concepts and requirements.
Changes in regulatory and administrative systems. Psychologists are subject to regulation by state licensing boards and federal health regulatory systems. Although the agencies that promulgate regulations sometimes write explanatory documents, there are areas in which regulations are silent or not fully explicated. In those cases, guidelines could be formulated to assist the psychologist to adapt existing practice and procedures to meet these standards. An example is record keeping, where regulations may be vague or even conflicting. Consequently, APA has developed record keeping guidelines (APA COPPS, 1993).
Guidelines may be written in order to benefit the public in ways that include:
Improved service delivery. Practice guidelines may be developed when substantial evidence emerges that service delivery models can be improved. Education concerning this information and its use may prompt psychologists to make positive changes in treatment or evaluation procedures. For example, "Guidelines on multicultural education, training, research, practice and organizational change for psychologists" (APA, 2003) and "Guidelines for psychological practice with older adults" (APA, 2004) provide a more sophisticated framework for service delivery to diverse populations.
Avoidance of harm. The development of practice guidelines may be supported where there is empirical evidence or professional consensus of bias, discrimination or harm to clients. For example, the development of "Guidelines for psychotherapy with lesbian, gay, and bisexual clients" (American Psychological Association Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Task Force, 2000) was prompted by evidence of inappropriate treatment of gay, lesbian, and bisexual clients.
Emerging, underserved, or vulnerable client populations. Practice guidelines may be developed to meet the psychological needs of emerging, underserved, or vulnerable client populations. Emerging populations may include client groups identified by shifting demographics, such as new immigrant populations. Underserved groups may include certain rural, homeless or undocumented immigrant individuals. Vulnerable populations are those less able to advocate for themselves with regard to access and utilization of health services. Vulnerable populations may include minors, older adults, people with AIDS, victims of interpersonal violence, prison inmates, individuals with serious mental illness and/or substance dependence, or other groups or individuals who may be compromised by adverse circumstances or conditions.
Public policy initiatives. Practice guidelines may be developed to assist psychologists in responding to public policy initiatives, for example, prevention of school violence, depression or alcohol screening, and promotion of positive health behaviors.
Guidelines may offer professional guidance in relation to issues such as:
Development of new technology. The development of new technology may necessitate reevaluation or reconsideration of existing processes and procedures. For example, the increasing use of electronic communication and transmission of medical records may require psychologists to modify their practices concerning control and confidentiality of records.
New, expanded, or complex multidisciplinary roles. Psychologists may require guidance in providing novel services or working in new contexts or emerging areas of practice. For example, advances in genetic testing have led to new areas of multidisciplinary collaboration and service delivery for psychologists. Guidelines may assist psychologists in clarifying their roles and maintaining professional autonomy.
Advances in theory and science. Advances in psychological theory and science may lead to the development of new approaches with which psychologists need guidance. For instance, theory and science related to sexual orientation led, in part, to the development of practice guidelines in this area.
Professional risk management issues. Practice guidelines may be developed in response to professional risk management issues. For example, APA guidelines on record keeping may protect psychologists in the absence of clear guidance from state and federal regulations.
The need for a set of practice guidelines must be well established. In addition, each guideline must be supported by specific documentation. The document as a whole and each of its component guidelines must be accompanied by an explicit rationale and supporting evidence appropriate to the guideline's range of application. It is expected that guidelines approved as policy by APA will have relevance to a significant segment of APA membership.
Developers of guidelines are expected to describe each source of evidence used in guideline formulation so that a reader can evaluate the guidelines' evidentiary base. Documentation of empirical and broad based professional consensus in developing guidelines will protect against the appearance of unwarranted advocacy for particular policy positions or theoretical perspectives, or restrictive attempts to regulate professional behavior and judgment.
The basis for establishing and documenting need will depend on the impetus for the particular set of guidelines. For example, guidelines developed for legal or regulatory reasons will have different types of evidentiary support than guidelines developed for professional reasons. In all instances, guideline developers should make a thorough effort to be comprehensive and representative in their selection of theoretical and empirical sources and consider the positions of other relevant stakeholders as applicable. Developers should examine relevant evidence, including that which may contradict their point of view. Direct empirical support for recommending specific professional behavior is always a strong form of evidence, though it is not always available.
In some areas, expert professional consensus is the strongest form of evidence. A variety of forms of information may be important to determine professional consensus, depending on the nature of the guideline being developed. These include, but are not limited to, agreement among recognized subject matter experts, practitioner surveys, incidence of inquiries to APA or other professional or regulatory bodies, reviews of professional literature, and general agreement among psychologists regarding responsible professional conduct.
It is essential that practice guidelines provide a clear rationale for focusing on a singular topic under consideration separately from the rest of psychological practice. Guidelines that focus on a particular client population or characteristic must explain why and how psychological practice with this population is sufficiently different from sound practice with all clients to justify separate guidelines. Guidelines could potentially be written for any number of client characteristics (e.g., age, gender, sexual orientation, religion, ethnicity). Good psychological practice requires that practitioners be sensitive to all these client characteristics and their interactions, and it is generally not clinically useful to conceptualize clients' problems according to a singular person attribute. While evidence of past and present injustice in the broader sociocultural context is likely to be relevant, it is not sufficient as a justification for practice guidelines. Guidelines statements should have adequate documentation and provide clear examples of recommended professional practice.
The developers of guidelines must consider the broader implications and range of applications of guidelines, which are likely to extend beyond the unit or group by which they are developed. In some instances, guidelines may affect groups outside the profession of psychology (e.g., other health professionals, test developers, public stakeholders) and developers should consider this in developing guidelines. In these cases, a broader development and review process that solicits comment from individuals and groups outside APA is appropriate.
Guidelines that make reference to a single theoretical perspective or a narrow body of literature are potentially less useful than guidelines that integrate multiple perspectives. The wider the intended application of guidelines, the more incumbent it is on their developers to integrate perspectives from across (and outside) the profession. For example, the scope of the "Guidelines on multicultural education, training, research, practice and organizational change for psychologists" (APA, 2003) required the integration of a broad base of evidence and perspectives, whereas the "Guidelines for psychological evaluations in child protection matters" (APA, 1999) were appropriately based on a narrower range of evidence and expertise. APA is a large organization representing psychologists from myriad theoretical perspectives functioning in a broad array of professional settings. The process for development, revision and dissemination of guidelines allows for input from that range of views to be considered by guideline developers. In order to be adopted by the APA Council of Representatives, guidelines must have strong support across constituencies.
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