Evidence-based practice in psychology

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force's report describes psychology's fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005.     

How does evidence-based practice in psychology work? – As an ethical demarcation

Evidence-based practice in psychology (EBPP) is ordinarily understood to demarcate between legitimate and illegitimate psychotherapy practice, based upon the epistemic demarcation distinguishing scientific from non-scientific knowledge. EBPP emphasizes the value of effective and efficient interventions identified through randomized controlled trials and cost-benefit analyses. Basing the template for choice of action or strategy on randomized controlled trials and cost-benefit analyses create a deceptive appearance of ethical neutrality. However, there is an implicit ethical demarcation at work in EBPP, which favors a non-articulated specific position in normative ethics. More particularly, evidence-based practice in psychology is structured according to a utilitarian framework, severely limiting the kinds of ethical perspectives available to assess psychotherapy practice. The latter point is illustrated through a new mode of delivering psychotherapy services called “Internet-based guided self-help” (IBGSH). In EBPP the only relevant ethical question is to what extent any intervention, such as IBGSH, is effective and efficient. Some of the limiting effects of the ethical, utilitarian, demarcation are showcased by presenting three alternative ethical perspectives by which psychotherapy practice in general and IBGSH in particular can be analyzed. The analysis concludes that EBPP is not suited to ethically regulate the practice of psychotherapy.     

Improving Medicare coverage of psychological services for older Americans

Professional psychology's ability to meet older Americans' psychological needs and to simultaneously thrive as a profession will be closely tied to the federal Medicare program over the coming decades. Despite legislative changes in the 1980s providing professional autonomy to psychologists and expanding coverage for mental health services, Medicare coverage policies, reimbursement mechanisms, and organizational traditions continue to limit older Americans' access to psychological services. This article describes how psychologists can influence Medicare coverage policy. Specifically, the authors examine widely unrecognized policy processes and recent political developments and analyze the recent creation of a new Medicare counseling benefit, applying J. W. Kingdon's (1995) well-known model of policy change. These recent developments offer new opportunities for expanding Medicare coverage of psychological services, particularly in the areas of prevention, screening, and early intervention. The article provides an analysis to guide psychologists in engaging in strategic advocacy and incorporating psychological prevention and early intervention services into Medicare. As Medicare policy entrepreneurs, psychologists can improve the well-being of millions of Americans who rely on the national health insurance program and, in so doing, can help shape the future practice of psychology.     

Exploring the Why of Psychologist Misconduct and Malpractice: A Thematic Analysis of Court Decision Documents

Objective: To identify reasons for misconduct and misconduct amongst Australian psychologists. Method: During the 5‐year period from 2008 to 2013, 42 psychologists across 41 cases were found guilty of misconduct and malpractice by civil and administrative courts across Australia. The court decision documents were analysed using Braun and Clarke’s ( 2006 ) qualitative methodology to explore themes relating to the court’s objective, the psychologist’s subjective, and the authors’ interpretive causal reasons transgressing psychologists engaged in misconduct and malpractice. Results: Explanations given by psychologists for misconduct and malpractice behaviours included the use and abuse of legal and illicit substances, addiction behaviours, and impairment due to mental disorder or unresolved trauma. A number of other reasons identified by the courts and by the authors from the evidence cited in the published court decision documents are also discussed. Possible contributing factors for why misconduct and malpractice behaviours occurred coalesced into three themes: the externalisation of responsibility for personal actions and behaviours, a lack of objectivity concerning why such behaviours occurred, and an inability to understand how personal circumstance affected the provision of ethical services to clients. Conclusion: (a) The complexity of situations and scenarios surrounding psychologist malpractice can be simplified for the benefit of designing interventions by applying Glass’ ( 2003 ) concept of the “slippery slope.” (b) Court records have benefit as detailed data, but could be augmented for greater value with a simple and easily completed additional coversheet of background and demographic data.     

The evidence missing from evidence-based practice

Comments on the report by the APA Presidential Task Force on Evidence-Based Practice entitled Evidence-based practice in psychology. Regrettably, the task force report was largely silent on three critical issues. As a consequence, it omitted much of the evidence necessary for a complete picture of evidence-based practice. First, the task force report did not operationalize "evidence." Second, the task force report did not address the crucial problem of iatrogenic treatments. Third, the task force report said little about the necessity for ongoing objective evaluation of clinical cases, which is critical to ethically responsible services. Current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so. Rather than waiting for the resolution of competing views on the matter, psychologists bear an ethical obligation to offer evidence-informed services. Three critical steps that were largely neglected by the task force report can go far toward helping psychologists honor that commitment: (a) providing a clearer operationalization of scientific evidence, (b) using current research to rule out the use of potentially harmful methods, and (c) using objective criteria to evaluate all of their cases on an ongoing basis. These steps, in turn, clarify the menu of options available to therapists, help protect clients from harm, and offer the advantage of allowing clinicians to contribute to the growing body of knowledge about what does and does not work in psychotherapy.     

Counselling Older Adults Living in Residential Aged Care Settings: Four Illustrative Case Studies

The role of psychologists and other mental health professionals in long‐term care settings is undefined in Australia. Graduate psychology students receive little training in clinical geropsychology, and residential aged care providers do not routinely employ psychologists within such settings. Further, despite high rates of depression, neurocognitive problems, and other mental health problems, residents are rarely referred for evidence‐based psychological treatment. This article presents four case studies showing how psychology services may be employed in such settings within the context of a postgraduate psychology placement programme. These case studies emphasise the importance of engagement, the use of flexible and individualised treatment approaches, and the involvement of family and professional carers in the provision of psychological services. Psychology services in residential settings can have a positive impact on the care of older adults and their families.     

The practice of psychology in rural communities: potential ethical dilemmas

The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas.     

Psychological re-evaluations: A survey of practices and perceptions of school psychologists

The practice of psychologically re-evaluating students receiving special education services has been mandated by P.L. 94–142 and further operationalized by state departments of education. Intuitively, such a requirement appears sound, for psychologists occasionally make mistakes, children change over time, and efficacy of special education services is variable. Yet given the other mandated practices, such as yearly IEP updates, and the fact that many school psychologists spend a majority of their time testing, we wondered how important three-year psychological re-evaluations are considered by school psychologists. In the present study 40 psychologists across four states were surveyed concerning their perceptions and practices regarding re-evaluations. The psychologists' responses to a 16-item questionnaire indicated that re-evaluations comprised a substantial portion of their evaluations, involved a considerable amount of time, and were perceived as an important check on a child's diagnosis and placement. Re-evaluations and initial evaluations were described as involving nearly identical tests and related activities.     

Integrating consultation and program evaluation in school psychology

Consultation approaches to providing psychological services are widely used by school psychologists. Recently, the need for school psychologists to be proficient in educational program evaluation has been recognized. The present paper discusses how school psychologists can use their existing consultation skills as an approach to program evaluation. The integration of consultation skills with evaluation results in an approach to program evaluation that is particularly useful where program goals and objectives are broad and nonspecific (as in many educational innovations). Also, the consultation approach to evaluation is easier for school psychologists to blend with their other roles in schools than the assessment-oriented evaluator role of some evaluation models. The consultation approach to evaluation is illustrated using a federally sponsored training program for school teachers and administrators.     

Integrating remotely accessible information services into psychology instruction and research

Wide-area computer networks provide a wealth of information services that have the potential to alter the approach toward scholarship taken by both students and researchers. Although it can be argued that the translation of information from hard copy to a publicly accessible electronic form has developed slowly, the total volume of text-based information that has been digitized is already staggering. Two major challenges facing psychologists wishing to develop their skills in network use are to identify and locate pertinent information that is accessible, and to find an easy way to retrieve it. This paper is an attempt to provide an overview of network resources and services that may be of particular interest to psychologists and psychology students. Its focus is on how to learn more about the available information services, as well as how to make access as user friendly as possible.     

Functional communication training: From efficacy to effectiveness

Functional communication training (FCT; Carr & Durand, 1985) is a common function‐based treatment in which an alternative form of communication is taught to reduce problem behavior. FCT has been shown to result in substantial reductions of a variety of topographically and functionally different types of problem behavior in children and adults (efficacy). The extent to which these reductions maintain in relevant contexts and result in meaningful changes in the lives of those impacted (effectiveness) is the focus of this paper. This review evaluates the degree to which FCT has been established as an evidence‐based practice in psychology (EBPP) according to the definition set out by the American Psychological Association's 2005 Presidential Task Force on Evidence‐Based Practice. Our review finds overwhelming evidence in support of FCT as an efficacious treatment but highlights significant limitations in support of its effectiveness. In order to also be recognized as an EBPP, future research on FCT will need to focus more closely on issues related to home, school, and community application, feasibility, consumer satisfaction, and more general and global changes for the individual.     

Integrating Web-Based Applications into Aged Care: Two Case Studies and Discussion

In anticipation of the growing need for adequate mental health care for older adults in residential aged care facilities, psychologists are challenged to overcome several barriers that impede the uptake and delivery of their services in such settings. Information and communication technologies (ICT) have strong potential to overcome some of these barriers by supporting the delivery of evidence-based psychosocial treatments for common psychogeriatric issues. This paper presents two case studies that illustrate when and how psychologists can use various ICT applications (e.g., tablet devices, web-based applications) integrated with cognitive behavioural and reminiscence-based therapies. Both case studies demonstrate that ICT can effectively support the therapeutic alliance, enhance therapeutic engagement, and individualize treatment delivery to accommodate the needs of elderly patients. It is hoped that these case studies will encourage clinicians to consider using ICT to augment therapy with their elderly patients.     

A case study approach to delivering and evaluating services by a school psychologist

Two interrelated problems in delivering school psychological services by one school psychologist acted as a motivating force behind this study: the problem of how to plan and render services to a school system where the ratio of students to school psychologists is high, and the problem of how to determine the degree of effectiveness of these services. This study describes an approach which consisted of three distinct services rendered by a school psychologist. Evaluative measurements of the services were made in two areas: the effect of the services on the ongoing operations of the system, and the evaluation of the services by school personnel exposed to the services directly or indirectly. The relative merits and the limitations of such an approach are discussed.     

The current status of clinical geropsychology in Australia: A survey of practising psychologists

Little recent objective evidence exists to qualify past concerns regarding the low numbers of psychologists working with older adults in Australia. The present study reports on figures from two surveys of Australian psychologists, finding that of the 1,699 psychologists surveyed, only 6% specialise in treating older adults. This figure is comparable to those from studies conducted overseas, where more training and employment opportunities are available. Reasons for such low figures are explored together with recommendations to meet the future demand for psychological services as the proportion of elderly adults within the Australian population increases.     

Perceptions of school psychology services from a staff perspective

This investigation examined how staff in an elementary school district perceived their school psychologists and how these perceptions differed across components of service and staff groups. We developed a School Psychological Service Questionnaire and then analyzed responses from regular education teachers, special education teachers, principals, and school psychologists in an urban school district. Although the findings are numerous, most noteworthy are, first, that consumer groups in the district had different perceptions than school psychologists about how school psychologists allocate their time and how this time should be allocated in the future. Second, consumer perceptions of school psychologists' knowledge generally were favorable. Third, in terms of domains appropriate for involvement by school psychologists, a factor analysis of consumer ratings revealed three relatively clear dimensions of recommended service provision — special education activities, interpersonal or school-climate activities, and administrative responsibilities. Fourth, the helpfulness of school psychologists, as perceived by consumers, related positively to frequency of contact. Fifth, differences in perception of school psychological services were evident across staff groups. Finally, comparisons between master's level and doctoral level school psychologists suggested numerous differences in how the staff perceived these service providers.     

Aging and mental health in the decade ahead: what psychologists need to know

Until relatively recently, most psychologists have had limited professional involvement with older adults. With the baby boomers starting to turn 65 years old in 2011, sheer numbers of older adults will continue to increase. About 1 in 5 older adults has a mental disorder, such as dementia. Their needs for mental and behavioral health services are not now adequately met, and the decade ahead will require an approximate doubling of the current level of psychologists' time with older adults. Public policy in the coming decade will face tensions between cost containment and facilitation of integrated models of care. Most older adults who access mental health services do so in primary care settings, where interdisciplinary, collaborative models of care have been found to be quite effective. To meet the needs of the aging population, psychologists need to increase awareness of competencies for geropsychology practice and knowledge regarding dementia diagnosis, screening, and services. Opportunities for psychological practice are anticipated to grow in primary care, dementia and family caregiving services, decision-making-capacity evaluation, and end-of-life care. Aging is an aspect of diversity that can be integrated into psychology education across levels of training. Policy advocacy for geropsychology clinical services, education, and research remains critical. Psychologists have much to offer an aging society.     

Single payers and multiple lists: must everyone get the same coverage in a universal health plan?

In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both more efficient and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits.     

The Ethical Ideologies of Psychologists and Physicians: A Preliminary Comparison

The ethical ideologies of psychologists (who provide health services) and physicians were compared using the Ethics Position Questionnaire. The findings reveal that psychologists tend to be less relativistic than physicians. Further, we explored the degree to which physicians and psychologists report being influenced by a variety of factors (e.g., family views) in their ethical decision making. Psychologists were more influenced by their code of ethics and less influenced by family views, religious background, and peer attitudes than were physicians. We argue that these differences reflect the varied professional cultures in which practitioners are trained and socialized.     

The ethical ideologies of psychologists and physicians: a preliminary comparison

The ethical ideologies of psychologists (who provide health services) and physicians were compared using the Ethics Position Questionnaire. The findings reveal that psychologists tend to be less relativistic than physicians. Further, we explored the degree to which physicians and psychologists report being influenced by a variety of factors (e.g., family views) in their ethical decision making. Psychologists were more influenced by their code of ethics and less influenced by family views, religious background, and peer attitudes than were physicians. We argue that these differences reflect the varied professional cultures in which practitioners are trained and socialized.