American Psychological Association

118th Annual Convention
San Diego, August 12-15 2010

Ethics and Evidence-Based Practice
L-R: Drs. Katherine Nordal, Scott Lilienfeld, Mitchell Prinstein, Bruce Chorpita, Gerald Koocher

Is it Unethical to Conduct Nonevidence-Based Practice?

This event was skillfully moderated by Dr. Mitchell Prinstein, directing important questions for today's practitioners towards a panel of experts including Drs. Katherine Nordal (APA's Practice Directorate head), Scott Lilienfeld, Bruce Chorpita, and Gerald Koocher (editor, Ethics and Behavior).

This is quite a dense and passionately debated topic, "evidence-based treatment", with ethical and "best" practice requiring this, but with tension arising from the options that have arisen, such as rigid, "manualized treatments" or the prospect of no treatment at all where there's not a body of documented solid "evidence". Hugely important topics, which cannot all be covered here, but hopefully this will provide a flavor of the issues and concerns as discussed by those present today.

Dr. Koocher and others referenced the extant model of APA policy regarding evidence based practice, seeing a "3 legged stool" that not everyone fully subscribes to but which basically calls for awareness of 1) Best research based evidence 2) clinical expertise 3) Patient context

Dr. Koocher was blunt: he'd like to throw out this blind allegiance to a 3-legged stool, noting as a point of fact that a bench does very well on 2 legs, just as a well-cemented one-leg chair can be solid. With a tripod model, each of the individual legs bear scrutiny.

Some important points include how in the real world "clients have preferences" so that while evidence may show a combination of medication and therapy to be most effective, a parent may not want the medication part. Therapists too may have preferences which can include ingrained but untenable allegiance to particular "schools" (for example trying to treat enuresis psychoanalytically, as opposed to providing a bell and pad, at risk of being called guilty of "symptom substitution".)

Dr. Chorpita asked how the 3 legged stool works if a proposed treatment is "not on the list". [I later asked where one might even find such a list - it is not easy!]

What if a seemingly effective treatment is "in front of us" but it's not proven? Dr. Lilienfeld recalled Paul Meehl's observation of therapy being a "hybrid between practice and art" and agreed with Dr. Chorpita's point about the importance sometimes of "local evidence".

Dr. Nordal agreed with Dr. Koocher's earlier comments: "The best prescribed care in the world can go nowhere", as with a patient simply being non-compliant, and thus it is important to note "clients' preferences combined with our understanding of what's best for that particular patient". [Some discussion of appropriate treatment for enuresis ensued, given context and facts, such as age, etc.]

Dr. Koocher re-iterated a mantra shared by many over the years: "The critical thing to evoke change is the therapeutic relationship". This is not merely a fact borne from research, but a consideration in such cases where a client has a strong preference. The importance of a truthful, meaningful informed consent process was underscored.

Dr. Lilienfeld agreed and reminded us: "We have a role as a clinician also as a persuader". [E.g., encouraging a proven treatment, fully informing of risks, etc.] Dr. Nordal added, "A client may not have a preference for something but it may be because they're uninformed."

And thus informed consent is doubly important at the beginning of a therapeutic relationship, both to be educative as to what evidence exists, as well as honest about the risks and expectations should the client decide to begin a professional relationship which is founded on honesty and best practice tenets.

Dr. Koocher repeated a point about "the value of human judgment" and recalled struggles over the pressures to develop treatment manuals, ultimately suggesting at times that one "read our manual and adapt your techniques to a specific client, as you know how to do. We treat real people in the real world and they all look very different."

Dr. Prinstein (moderator) asked: "What do we say to a clinician for 20-30 years, who says 'I know the debate but I know my community and what I'm doing is definitely helpful'?" Dr. Koocher responded that "the 1/2 life of a doctorate is 7-8 years", i.e., "half of what you learned is obsolete". This person may need to ask if they're practicing appropriately, as in being aware of best practice through continuing education.

In addition (bearing on the isolated or entrenched clinician), Dr. Nordal commented that "one of the most dangerous things is clinicians who don't have contact with colleagues. CE is one way to do this. Isolation - and maybe big egos - can get some psychologists in trouble."

Dr. Koocher added that it's not just psychologists who make mental health treatment decisions, and it is the case that "most psychiatrists under 40 have not had psychotherapy training". So if someone walks in, say for ODD, most likely they leave with a prescription, and without any discussion of parent training. The question then becomes, how does one disseminate the "evidence"? Not only to psychologists but to allied professionals and general public, in addition to CE? [Continuing Education]

Following the presentation I spoke briefly with Drs. Koocher and Nordal, and then an APA practice leader to whom I was directed, in my search for the aforementioned, iconic "list" or even a database of what is considered "evidence based best-practice", across diagnoses, contexts, etc. Nothing online was named, but one recommendation was the APA (print) publication, "Treatments that Work". (Is it on Kindle?)

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INDEX OF 2001 APA Convention Articles:
Behavioral Telehealth | E-biz of Mental Health | 2001: A Cyberspace Odyssey

INDEX OF 2002 APA Convention Articles:
CyberSex & Cyber-Infidelity | Beck & Ellis 2002 | Behavior Therapy | CyberPsychology | E-Ethics

2003 Convention Highlights: Full Text | Beck 2003 | Quality of Online Health Info | Sternberg's Vision

2005 Convention Highlights:   Opening Session | Pioneers of Behavior Therapy
Distinguished Elders of Psychotherapy | Legends Discuss Psychology | Online Clinical Work | Town Hall Meeting

2006 Convention Highlights:
Opening | Online Psychotherapy & Research | Psychological Vital Signs | Advances in Cognitive Therapy
Brok on Chaplin | Conversation with Aaron T. Beck - 2006 | Dr.Phil | 21st Century Ethics | Media: Town Hall '06

2007 Convention Highlights:
Humanizing an Inhumane World | Opening Session | Albert Bandura | Linehan, on Suicide
Psychology's Future | Conversation with Aaron T. Beck - 2007 | Evil, Hate, & Horror

2008 Convention Highlights:
Grand Theft Childhood | Opening | Malcolm Gladwell | College Success, Love, Hate, More | My Life With Asperger's
My Space, You Tube, Psychotherapy, Relationships... | Aaron T. Beck - 2008 | The Mind and Brain of Voters

2009 Convention Highlights:
Internet: Pathway for Networking, Connecting, and Addiction | Opening | Virtual Psychology & Therapy | Q&A with Zimbardo
Seligman: Positive Education | Future of Internet Media | Sex, Love, & Psychology | How Dogs Think

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