A brief report on the evidentiary bases of APA’s clinical practice guidelines by the ASC for clinical practice guidelines

Science is ever evolving. A mission of the Advisory Steering Committee (ASC) for development of clinical practice guidelines is to guide the field in its efforts to continue developing and disseminating evidence about psychotherapy and other interventions. APA’s clinical practice guidelines (CPGs) represent the state of the literature and provide recommendations to guide high-quality clinical care. This report was created to complement the ASC’s establishment of CPGs in developing and disseminating evidence about psychotherapy and other interventions.

This report is intended to encourage attention toward current evidence while acknowledging the state of psychotherapy science and two distinct but inherent limitations of our current processes and evidentiary base:

• systemic barriers and potential biases that exist in recognizing or generating evidence about therapy approaches and treatment strategies with culturally diverse populations; and
• biases against diverse psychotherapy orientations, scientific methodologies, and their findings.

In this way, psychologists and related disciplines are encouraged to increase research activities that engage with varied cultures and rigorous methodologies (e.g., quantitative, qualitative, and mixed methods research) from a wider array of orientations that will further strengthen the science of psychotherapy for a broader range of individuals.

We also highlight actions that the ASC is taking to advance guideline development processes in light of these limitations, intending to enhance the utility of the guidelines. The following report is presented to acknowledge the complexity of the research landscape, to aid in the interpretation of evidence and the absence of evidence, and to provide recommendations to guide future research efforts so as to improve the state of evidence in the field.

Historical limitations in research methodology, systems-level inequities, and disciplinary perspectives raise concerns for the application and generalizability of traditional research findings to culturally diverse populations (e.g., American Psychological Association [APA], 2015; 2017; 2021a).

There are barriers and biases in examining the use of treatments for culturally diverse populations. These include:

• the inadequacy of reporting, inclusion, and focused examination of culturally diverse participants within systematic randomized controlled trial (RCT) studies of psychotherapy efficacy, effectiveness, and during-treatment process (notably related to gender, sexual orientation, race, and ethnicity; e.g., Geller et al., 2011; Schick et al., 2022; Schmaling, 2022);
• a history of Western psychotherapies to be developed by and for White, upper and middle class populations, and for lower socioeconomic groups to be served by less experienced therapists using simplified and less bona fide treatments (Goodman, 2016);
• the reasonable skepticism of societally minoritized and underserved communities to participate in psychological research given the history of racism and ethnocentrism in the past studies (e.g., Winston, 2020);
• ongoing racism and a lack of cultural understanding that pathologizes Native people’s values rather than encouraging culturally adapted treatments and culturally responsive practices, including those that focus on broader theory-common factors (Gone, 2021; Wendt et al., 2022);
• the history of racism and antisemitism that has been intertwined in the marginalization of certain theoretical orientations (Yakushko, 2021);
• the definition of therapy success solely as symptom reduction, which may not address the needs, trajectories, and preferences of populations that have experienced multiple forms of trauma, for example (Boswell et al., 2015);
• the use of diagnostic categories that have been embedded in many forms of social stigma and are potentially problematic in terms of race (Dodd, 2015), ethnicity (Green et al., 2012), gender (Robles et al., 2022), and sexuality (Goldhill, 2015); and
• race-ethnicity gaps disadvantaging researchers of color, and the methods they may select, in obtaining grant funding (Laurer & Bernard, 2023).

In the face of these barriers, APA (2021b) has resolved to “encourage psychologists and trainees to consider the limitations of White Western-oriented clinical practice, and gain awareness of other healing approaches emanating from Indigenous and other non-Western and cultural traditions… [and] to learn and update new information on racism in diagnosis and clinical practice, and on the pursuit of equity, diversity, and inclusion in health service psychology, including psychological testing and assessment, while fostering practice based in culturally relevant evidence” (p. 4).

In addition, the ASC encourages researchers to incorporate into their research methodology procedures that allow them to: report on their samples’ cultural characteristics, recruit participants who identify as culturally diverse, conduct analyses to evaluate their responses to treatments, examine diverse treatments and outcomes, use caution when applying diagnostic criteria to minoritized populations, and understand the limitations of disseminating treatments and treatment strategies that have yet to be tested for underrepresented populations.

The research cultures across diverse psychotherapy orientations have distinctive roots and values (e.g., Hill & Corbett, 1993; Lutz et al., 2021). While some therapy traditions that have historically prioritized experimental research on symptoms and syndromes—which have positioned them in alignment with the values, language, and discourse used within health-focused national research funding bodies—other approaches (e.g., psychodynamic/psychoanalytic, feminist/multicultural, humanistic/existential approaches) have developed from different sets of values that may not have prioritized the same methods, symptom change outcomes, or diagnostic criteria from the American Psychiatric Association’s (2022) Diagnostic and Statistical Manual of Mental Disorders (5^th ed., text rev.) in their conceptualization.

As a result, the existing literature is characterized by societal values that do not reflect all constituent groups. This limiting of methodological perspectives has led to barriers for many approaches in accruing and examining the kind of evidence typically considered in systematic reviews. These barriers include:

• the research cultures of therapies historically centering process and qualitative research, which has led them to develop epistemologically distinct evidentiary bases that emphasize the demonstration of change processes within their treatments (Maxwell & Levitt, 2023) rather than comparisons between treatments and/or control conditions in experimental studies;
• the tendency for funding efficacy or effectiveness trials that are tied to health and diagnoses, in contrast to the alternative approaches that prioritize other processes and outcomes for understanding the problems that they treat (e.g., Dodd, 2015; McWilliams, 2011; Raskin, 2019);
• the tendency for efficacy or effectiveness trials to focus on symptom change as the sole or primary outcome, rather than to assess other outcomes on which a therapy might focus or have as central aims (for instance the evaluation of increased self-determination for humanistic therapies, or increased insight for psychodynamic therapies; Levitt et al., 2005; Bland, 2022);
• the tendency of the National Institute of Mental Health (NIMH) not to fund studies that fail to align with traditional psychiatric nosology (Leichsenring & Steinert, 2017), which stymies research on these therapies;
• given their relative lack of grant funding histories, researchers from those orientations more rarely serve on grant review boards or have input into calls for proposals that would be appropriate for the distinctive concerns/values of therapists in these approaches (Elliott, 1993; Leichsenring et al., 2018); and
• the decreasing diversity of faculty in grant-competitive programs who study psychotherapeutic approaches. Numbers of faculty who are not focused on symptoms and syndromes are low and are structurally unable to produce similar quantity of research (see Heatherington et al., 2012; Levy & Anderson, 2013 on these shifting proportions over time).

With few faculty in these programs, replication studies on these approaches are then even more challenging to produce. As a result of these cumulative barriers, many therapy orientations may not have been able to or desired to gain access to funds needed to produce evidence of efficacy that would be admitted into consideration for CPGs under the current best practice guideline development standards (e.g., National Academy of Medicine, formerly the Institute of Medicine).

Continuing to advance the evidence base and disseminate information about treatments that may help or harm are guiding principles of APA’s clinical practice guideline development work. Documenting the forms of therapy and treatment that have produced evidence of efficacy and comparative efficacy is an essential contribution to psychological science. When there is evidence that a treatment is not helpful or is demonstrably harmful, there is a need to educate consumers and/or find ways to improve a poorly performing treatment, perhaps by conducting more refined and sophisticated studies or by consulting what we know about therapeutic change processes that are already known to work.

APA’s clinical practice guideline development process and the work of the ASC serve an important public good by identifying these treatments and providing feedback to the field and to consumers. The following recommendations build upon that work by articulating the systems-level changes and research foci needed for a broader assessment of diverse therapy approaches and the application of psychotherapy approaches to historically underrepresented clients.

Recommendations for developing evidence regarding cultural diversity

The APA encourages psychologists and other mental health clinicians to develop a discerning lens with which to understand psychotherapy research not limited by the influence of White Western-oriented practice traditions (APA, 2021b). This behooves researchers to conduct studies that consider social and ecological factors, values, worldviews, and the unique needs of populations of interest (Prilleltensky, 1997). Furthermore, this involves designing inclusive, methodologically pluralistic research, capturing nuanced differences in how various groups perceive, experience, and respond to therapeutic interventions.

To this end, there is a need for researchers to be equitable in their recruitment methods, ensuring the experiences of historically underrepresented participants are substantively represented (Paquin et al., 2019). The report notes the distinction between having evidence that a treatment is ineffective, ineffective for historically excluded and underserved populations, or less effective compared to other interventions, and the absence of evidence regarding a treatment’s applicability to specific populations and/or the inability to evaluate it in a way that aligns with that group’s values (e.g., Wendt et al., 2022). In the former cases, CPGs will serve as a protective public service by conducting a critical review of evidence and then making this evidence clear. In latter cases, there is a need to develop systems that create more opportunities for research with diverse populations, so that clients may select from a range of effective therapy approaches that meet their needs and values and that have strong evidence.

To support this aim, researchers of various psychotherapeutic approaches are encouraged to critically examine their treatments in ways that will inform this evidence base and encourage the field and research funding agencies to broaden their conceptualizations of psychological health and to support culturally diverse and community-based approaches to both quantitative and qualitative research. It is recommended that funding systems recommit their attention to diversity in grant development and review processes. With these changes, there may be renewed interest from psychotherapy researchers in culturally diverse settings to apply for funding as well as the development of new bodies of evidence.

The ASC has adjusted its guideline document template (APA, 2023) to direct CPG panels to specifically consider cultural diversity in terms of development of guidelines, implementation considerations and recommendations for research. These new types of recommendation statements will also give the panels greater opportunity to address issues of equity, diversity, and inclusion. This process will encourage CPG panels to deliberately seek research that includes and/or is focused upon culturally diverse populations.

These efforts will result in a more comprehensive evaluation of psychotherapy as it is practiced with diverse clients. It will allow CPG panels to both ensure that searches for evidence are more inclusive and to make recommendations to the field about types of culturally-based research that are needed in each area to stimulate growth.

Recommendation for developing evidence regarding diversity in psychotherapy orientation values

The ASC encourages psychotherapy researchers from all psychotherapeutic approaches to conduct sophisticated efficacy, effectiveness, and/or change process studies and to collect evidence about their therapies in a manner that is aligned with the values of the theoretical orientations they study. There is an important difference between having evidence that a treatment does not work, or does not work as well as other treatments, as compared to lacking evidence about a treatment due to systemic barriers regarding the theoretical diversity of faculty, the values of theoretical orientations, and the outcomes, epistemological perspectives and methods they employ. In the former cases, the CPGs conduct a critical review of evidence and then by communicating this evidence, they serve a protective public service. In latter cases, there is a need to develop systems that create more opportunities for research on diverse therapy approaches, so that clients have a range of effective therapy approaches supported by evidence from which to select to meet their needs and values.

To support that, the ASC recommends that researchers increase attention to underrepresented therapy approaches and that changes be made to research funding systems to allow diverse therapies to honor their value systems and conceptualizations of psychotherapy as well as collect the types of evidence (e.g., RCTs) that are evaluated in CPGs. We encourage funding systems to deliberately pay attention to theoretical orientation diversity in grant development and review processes, and to expand the methodological approaches and conceptualizations of psychological health in calls for research proposals.

In this process, funding agencies are encouraged to conscientiously consider the types of outcomes, processes, evidence, and research designs used to support the values of a wide range of therapy approaches. For instance, research designs may include but not be limited to the repurposing of the RCT to isolate effective treatment adaptations and identity-focused treatment personalization efforts, task analytic and process measure studies to identify change processes, qualitative and mixed methods research to study therapists’ and clients’ experiences, as well as integrative, quantitative, and qualitative meta-analyses and systematic reviews to synthesize the available research findings.

With these changes, the field may better reflect the values, goals, and epistemological perspectives of diverse therapy cultures and clients and could generate new interest in applying for funding and new forms of evidence that could deepen our knowledge of how psychotherapy functions (Levitt et al., 2024).

To that end, APA CPG panels are further encouraged to consider empirical evidence beyond intervention efficacy by the ASC’s revised review template (APA, 2023). Specifically, the template directs a review of the breadth of available quantitative and qualitative research (including mixed method) that address change processes and outcomes (at the micro or postsession level and macro or posttreatment level), as well as meta-analytic research that demonstrates the relation of interventions or approaches to established treatments.

This broadened approach can lead to a more integrated consideration of the three types of information that support evidence-based psychotherapy (APA, 2021c)—relying on (1) an evidentiary base that reflects the experimental evidence on psychotherapy outcomes along with (2) evidence on psychotherapy change processes from both quantitative studies (including, but not limited to, experimental designs) and qualitative studies that reflect clients’ treatment values and preferences and (3) that reflect clinicians’ expertise and clinical decision-making processes (APA, 2006; Berg, 2019).

The joint consideration of outcomes and change processes will result in a more comprehensive review of psychotherapies that are practiced in the field, the strengthening of guidelines through their grounding in pluralistic methods, and the broadened implementation by a wide range of clinicians to the betterment of their clients. The ASC values the deliberate fostering of research from diverse theoretical perspectives and with diverse populations.

Starting with the adoption by the APA’s Council of Representatives of the CPG on posttraumatic stress disorder in February 2025, the introductory section of this brief report, followed by a link to it and its reference, will be placed at the beginning of future CPGs. ASC members anticipate that it will be reviewed and updated approximately every 10 years, or earlier if there are significant developments.