A powerful way to recharge your practice

Paul Kettlewell, PhD, firmly believes that using the best science leads to the best practice. As director of clinical services at Geisinger Medical Center in Danville, Pennsylvania, he taught interns and postdocs how to use APA’s professional and clinical practice guidelines to inform their patients’ treatment.

“It is our obligation [as psychologists] to seek the evidence,” said Kettlewell, who is now retired and serving on APA’s Board of Professional Affairs, which helps to initiate and form committees that develop some of the guidelines. “And the guidelines condense the evidence in a much more efficient and thorough way than people can do on their own, which helps them practice more competently and with greater confidence.”

Besides their utility for students and clinicians, APA’s practice guidelines also help to educate other important parties—consumers, researchers, advocates, and policymakers, for example—on the most up-to-date findings and recommendations in a range of practice areas, said Claire Collie, PhD, director of quality assurance and improvement at the Veterans Administration (VA) Central Office and chair of the advisory steering committee for APA’s clinical practice guidelines. “They distill a massive amount of literature into clear-cut recommendations about the effectiveness of different treatments,” she said.

But the guidelines are only beneficial if people use them, she added.

“It’s like that old saying, ‘If a tree falls in the forest and no one hears it, does it make a sound?’” said Collie. “We’re not just interested in developing high-quality guidelines; we want to be sure they get out there and that people use them.”

There are two types of practice guidelines promulgated by APA. One is clinical practice guidelines, or CPGs; the other is professional practice guidelines, or PPGs. The names of these guidelines are similar enough to create some confusion, but they perform different and complementary functions. CPGs represent the latest vetted knowledge on how to treat specific conditions, while PPGs cover psychological practice with certain populations or in particular areas without focusing on specific disorders or treatments, said Lynn Bufka, PhD, ABPP, APA’s deputy chief of practice. As their names suggest, the aim of both types of guidelines is to provide information and ideas on how to improve one’s practice, but neither is mandatory, she added.

CPGs cover mental and behavioral health and related physical conditions that affect specific populations, such as depression across the life span or obesity and overweight in children and adolescents. They are based on a pre-established, rigorous, and comprehensive systematic review and evaluation process that follows the best practices outlined in Clinical Practice Guidelines We Can Trust opens in new window, standards developed by the Institute of Medicine (now the National Academy of Medicineopens in new window) in 2011. The process starts with an advisory committee that selects a diverse multidisciplinary panel of experts who come from varied research and practice backgrounds as well as patient representatives who are full members. In addition, it includes public comment periods that solicit input from psychologists, other health care providers, external organizations, consumers, families, and the public, as well as input from relevant APA sources including APA boards, committees, and staff. CPG panels make recommendations about first- and second-line treatments and make note of treatments that do not yet have sufficient evidence for a recommendation, said John McQuaid, PhD, ABPP, a member of the CPG advisory steering committee, chief of psychology at the VA Palo Alto Health Care System, and former chair of the APA depression CPG panel.

“[The CPGs] directly address some of the key challenges we have as providers: how to best match the needs of the people we serve to the resources and treatments that are available, and to do so in the most methodologically sound way possible,” he said.

PPGs, meanwhile, provide practical guidance and education to practitioners in areas that need greater attention and consolidation, including emerging areas of practice. Examples include providing optimal care for transgender and gender nonconforming people (PDF, 461KB)opens in new window; using telehealth in responsible, ethical, and practical ways; and providing psychological evaluations in child protection cases. They are not intended as a formal, rigorous literature review, but rather as general research- and practice-based guideposts on specific or general practice areas in need of further clarification, explained Amanda Jensen-Doss, PhD, a professor at the University of Miami and chair of a new PPG committee on measurement-based care, or using data from patient sessions to evaluate problems and progress.

“PPGs are really useful for providers who want to understand what to aspire to if they want to do a good job in the domain covered by one of these guidelines,” she said. While these guidelines cover a wealth of topics to date, APA is also considering ways to change aspects of their content and development to streamline the process and better meet practitioner needs in a timely fashion. An example is to include information that would help practitioners document “medical necessity,” a term becoming more frequently used by insurers to determine coverage.

A lot of time, effort, and expertise goes into producing both types of guidelines, all on a volunteer basis (see How are guidelines developed?). At present, both CPGs and PPGs can take several years to develop depending on factors including their scope, whether the guideline is new or an update, volunteer time, and public feedback. However, it is not clear how many psychologists are using them or if clinicians know the best way to apply them, guideline developers added. To address that, APA is conducting usage surveys with each CPG, using web analytics to monitor how often CPG pages are viewed and downloaded, and launching creative dissemination and implementation strategies such as improving website design to make the guidelines more accessible and usable and promoting them via social media, said Raquel Halfond, PhD, APA’s senior director of evidence-based practice and health equity.

In general, CPGs and PPGs are intended as one means of facilitating a good evidence-based practice—“an important tool in your clinical toolbox,” as Halfond put it. According to the evidence-based practice model established by APA, three components inform good clinical decision-making: use of the best research evidence; clinician expertise and judgment; and patient values, preferences, and individual characteristics. Combined, CPGs and PPGs offer a lot in terms of the model’s research and knowledge domain. For example, if a provider is treating an adolescent girl with depressive symptoms, consulting the CPG on depression in adolescents and the PPG on treating girls and women offers a broad lens on evidence-based treatment, she said.

Practitioners can also keep in mind that there are many ways of using both types of guidelines—everything from taking a deep dive into a guideline to simply reading the summary recommendations or sections that are most relevant to them. The developers’ intent is to make each set of guidelines as user-friendly as possible, noted Sara Smucker Barnwell, PhD, a Seattle-based clinical psychologist and chair of the committee that is revising and updating the PPG on telepsychology, which is likely up for APA Council of Representatives review and approval in August 2024. Her committee is organizing the telepsychology update so that a person with a single question in mind can quickly find the section that addresses it. “We are laying out the document so it is accessible and written in forthright language, which is important because technology is a very jargon-heavy space,” she said.

Practitioners will also find useful a recent addition to the CPGs: decision-making tools that accompany each CPG and are included on each CPG web page. Inspired by similar decision aids used by the Department of Veterans Affairs, the tools are organized in a “decision tree” format that helps clinicians consider logical pathways for working with a given patient. The aids include embedded links to specific treatment recommendations, relevant professional practice guidelines to consult, and other resources. They also address the variety of considerations that inform evidence-based clinical decision-making, including patient preferences, shared decision-making, and multicultural factors, Halfond explained.

In the research realm, the guidelines can help researchers identify areas in high need of investigation, said Brandon Gaudiano, PhD, professor of psychiatry and human behavior at Brown University and vice-chair of the CPG advisory steering committee.

“The guidelines don’t just tell us what we know currently; they tell us what we don’t know, as well,” he said. “That can help researchers identify what they need to spend more time looking at.” That same information can serve as an advocacy tool, highlighting the gaps in the clinical research literature for funders in a rigorous, peer-approved way and showing why it is important to fill them for better patient care and the public good, he said.

Megan Loew, PhD, chair of APA’s Committee on Professional Practice and Standards, which helps to develop and make recommendations about professional practice guidelines, said she relies on the guidelines in her role as a behavioral health workforce researcher at the Minnesota Department of Health. “I work on a lot of state legislation research, so being able to lean on the APA guidelines to get the current consensus in the field is incredibly helpful,” she said. “They’re a good little cheat sheet, if you will.”

To that point, CPGs are designed to reach a wider audience than just psychologists, including other health professionals, policymakers, external organizations, and consumers, Gaudiano noted. In fact, because of the rigorous nature of their development, all of APA’s CPGs were initially included in national guideline repositories and clearinghouses as well as in the International Guidelines Library, a resource of the Guidelines International Network, a global organization dedicated to improving evidence-based guideline development and use.

Both types of guidelines are far from static, fixed entities: They are updated whenever new developments warrant a change, developers emphasized. There is a constant flow of new guidelines in development as well as updates to existing ones, with content determined via lengthy discussions among advisory board and committee members, APA staff, and public input about areas of greatest need, health equity considerations, and new findings in the literature. There is currently a CPG in the works for the treatment of chronic musculoskeletal pain in adults, due for APA Council of Representatives review and approval in August, and another planned on suicidal ideation and behavior in children and adolescents. (The systematic review for that CPG is being funded by the Agency for Healthcare Research and Qualityopens in new window based on APA’s nomination.)

Meanwhile, a number of PPGs are in various stages of planning, development, or revision, including one on measurement-based care, which developers emphasize is crucial because research shows that outcome-based measurement is an important piece of good evidence-based care but is complex and underutilized. “We’re trying to think about how to make this guideline clinically useful to practitioners who want to do this practice but who may not understand exactly what’s involved,” said Jensen-Doss. Another is the update to the telepsychology PPG, important both because of the many changes in technology that have taken place in the 10 years since the original guideline was released and because “at its core, telepsychology is about access and about bringing evidence-informed care to people who need it,” said Smucker Barnwell, the telepsychology committee’s chair.

Other newer PPGs include an update of the PPG on older adults, adopted by the council in February, and a new PPG on treating people who have experienced trauma, likely up for council approval in August.

In general, developers of both types take a forward-looking stance on guideline topics and execution. For example, they always consider the public health impact of a given topic, including how guidelines will address issues of health equity and patient vulnerability, a mission facilitated in part by assembling diverse guideline panels. Another example of progressive thinking is the CPG advisory committee’s plan to create more guidelines that cover broad physical or mental health areas relevant to a range of mental health conditions, such as the upcoming guidelines on musculoskeletal pain and suicide.

“We want to be more responsive to the fact that clinicians in the real world often work with patient populations that overlap or are not neatly defined,” said Gaudiano. In addition, the advisory committee wants to include more panel members with expertise in qualitative and mixed method designs and mechanisms of therapeutic change, both of which will add to the real-world relevance of the guidelines, he said.

An unforeseen gift of working on the guidelines, Gaudiano added, is that within a framework that is both rigorous and interdisciplinary, he has seen firsthand that psychological interventions are often the top treatment choice for a given condition. That’s the case “much more than the public knows, other health professionals know, or other organizations know.”

“Having these guidelines really allows us a platform to make the public and other health professionals more aware of who we are and what we do,” he said. “And ultimately, that is very good for psychology.”