Richard Ruth, PhD
The intent of this article is to explicate some ethical considerations facing practicing psychologists in the era of evidence-based practices (EBPs) and to frame productive ways of thinking through such questions. At first blush, this may seem like an odd intellectual enterprise: Would not reliance on EBPs imply that a psychologist was practicing ethically, or, at least, that many potential ethical problems were less likely to occur? As I hope to demonstrate, the answer is not so obvious.
THE PSYCHOLOGIST AS A PROFESSIONAL
The Preamble of the American Psychological Association’s (2002) Ethical Principles of Psychologists and Code of Conduct begins, “Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others...” What does the term “professional” mean in this context, and why is there a need for such a term to accompany the characterization of knowledge as scientifically based?
Ethical practice involves not just keeping up with the scientific literature - although that is an essential for all practicing psychologists - but participating in the life of our profession, preferably actively and proactively rather than passively and reactively. As we will go on to see, applying ethical principles to new and evolving real-world dilemmas inevitably forces the profession to think through complexities unforeseen in earlier eras; the precedents and collective experience of the profession go on to shape how we understand and react to future ethical dilemmas. When we face new phenomena, such as changing healthcare reimbursement schemes or previously unfamiliar disorders, and want to identify ethical and effective ways to respond, we are ill-served by trying to think through the ethical implications on our own, and well served by participating in the collective conversations in our profession. Reading articles about ethics in professional publications, attending professional meetings where cutting-edge ethics issues are being discussed, and turning to organizational resources when we face a problem that stumps us are always useful strategies.
UNDERPINNINGS OF THE PSYCHOLOGY ETHICS CODE
The APA Ethics Code is an intentional mix of aspirational principles and enforceable standards (Behnke, 2006) based on the recognition that psychological practice is fluid, evolving, complex, and inherently conflictual. The Code, by its very structure, forces us to recognize that many situations we face in everyday practice are not as straightforward or unambiguous as they may seem on the surface, so that our ethical thinking needs to be oriented not toward searching for the right way, but identifying the most important among the competing ethical values and coming to a reasonable next step.
Dr. A is a scientist-practitioner clinical psychologist in private practice. She completed her internship five years ago. Her training, in graduate school and after, emphasized evidence-based cognitive-behavioral treatments of anxiety, depression, and adjustment disorders, and she has done research on empirically supported behavioral treatment for the acute effects of trauma. She is new to the community where she practices and needs to build a practice that can sustain her family’s economic needs. She receives a referral from a colleague, involving a prospective adult patient with a history of incestuous abuse; the patient also has a history of major depression, past substance abuse, and complex family dysfunction. Dr. A has never treated a patient like this before, but the colleague assures Dr. A that, as a local trauma specialist, Dr. A is well positioned to treat this patient.
In thinking through the ethical questions the referral presents, Dr. A considers the aspirational principles that “[p]sychologists strive to benefit those with whom they work and take care to do no harm” (Principle A) and that “[p]sychologists exercise reasonable judgment and take precautions to ensure that...the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practice” (Principle D). However, her ethical thinking begins, but does not stop, there. Taking account of her legitimate needs to develop her range of clinical expertise and earn a living, and her desire to serve the community in which she practices, she might then try to balance these aspirations with the standards that “[p]sychologists provide services...with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (Standard 2.01a) and “[p]sychologists take reasonable steps to avoid harming their clients/patients . . . and to minimize harm where it is foreseeable and unavoidable” (Standard 3.04) (American Psychological Association, 2002).
Dr. A is competent in and committed to using only EBPs, but she cannot assume from her research and clinical experience that an approach to chronic and complex trauma would parallel her experience working with acute trauma symptoms. Nor should she automatically preclude herself from taking on a referral where her background and interests situate her to be of valuable service to a patient in need. Possibilities for obtaining relevant additional training, consultation and supervision would need to be weighed.
The current version of the APA ethics code is crafted with practitioners’ realities and needs very much in mind (Behnke, 2004). If Dr. A uses ethical thinking to help orient and structure her self-assessment, including both strengths and limitations in her abilities, to treat the full spectrum of trauma-related and other problems in the patient who has been referred to her, she may find creative and ethical ways of balancing her aspirations to be of service and build a practice with the competing demands of required standards. For instance, if she is working in a region with a wide variety of available psychological resources, she may use the referral as an opportunity to build her network with clinicians in neighboring locales with experience and interest in the spectrum of trauma treatment, and consider either passing on the referral to a colleague more experienced with complex trauma or finding a supervisor to support her work with this patient. If Dr. A is practicing in an area where the prospective patient has few other treatment options, Dr. A may conclude that the requirement to minimize harm is best served by making her services available to the patient, while at the same time enlisting supports that could equip her to do a competent job and taking care to negotiate the patient’s informed consent.
The APA ethics code makes at least four different references to the centrality of informed consent to our ethical thinking. Standard 3.10 specifies that the requirement to obtain informed consent extends across the full range of psychologists’ activities, needs to be communicated meaningfully and effectively, and needs to be documented. Standard 9.03 requires that the psychologist present informed consent, in diagnostic and testing situations, in a way that is candid, specific, confidential and thorough-going; in no way is this to be a pro forma procedure. Standard 10.01 requires that, with respect to therapy, psychologists have a proactive responsibility to address with patients in some depth the nature and process of treatment, alternatives to the proposed course of treatment, and potential risks as part of the process of obtaining truly informed consent. Standards 7 and 8 discuss ways informed consent applies to teaching, supervision, and research situations as well (American Psychological Association, 2002).
The APA ethics code makes provision for the inevitable difficulties that arise in applications in everyday professional life. There is guidance for what to do in emergencies, with minors whose parents hold their rights, with those incapable of giving consent, and with procedures that rely on necessary elements of deception and ambiguity. For example, while a practitioner of transference-based treatment would not be expected to “front load” a therapy with detailed information about the workings of this unconscious process, a general discussion of what the patient might anticipate would be indicated.
For EBPs only studied in laboratory settings with carefully controlled patient selection and treatment procedures, informed consent suggests the need to make this known to a patient being seen under different conditions in a community setting. In a professional climate that values the rapid dissemination of new discoveries, limitations on a treatment’s applicability to persons of specific ages, gender, sexual orientation, ethnicity, social class background, or disability status, which may not yet have been determined through adequate research, may also be discussed near the beginning of a proposed course of treatment.
Dr. B, a researcher-clinician, studies short-time psychodynamic psychotherapy for anxiety disorders. His part-time practice specializes in this treatment, and his expertise is known to colleagues and the public in the community in which he practices. The parents of an Asian-American early adolescent, who is dealing with the anxiety of coming out as gay, consult Dr. B. The parents are comfortable with their son’s emerging sexual orientation. They are interested in Dr. B treating their son because they believe that the prospect of treatment that offers a quick resolution of the young man’s anxiety will be most valuable to him. Dr. B does not have specific experience working with Asian-Americans or gay teenagers in the process of coming out, but he has worked with many persons of diverse ethnic and cultural backgrounds and with many adolescents. From what the parents tell him, he believes his approach has good chances of being helpful to the young man.
Dr. B is a member of his state psychological association. After receiving the initial inquiry from the parents, he seeks consultation from the association’s ethics committee to help him think through the issues he may confront in undertaking this treatment. Equipped with what he learns from this consultation, he sets up an initial meeting with the parents. While treating their request with empathy and projecting the confidence he feels in his treatment approach and skills, he is also candid with the parents about the limited research on the use of his method with Asian-Americans, and with gay males. He discusses with them alternative approaches they might consider and identifies local resources experienced in providing gay-affirmative therapy and working with Asian-Americans. He offers information about what can be expected to happen in the treatment approach he practices. He offers the parents a return appointment to discuss any questions or concerns they have, after they have a chance to consider with each other what he has explained to them.
Dr. B’s positive but nuanced approach to the parents’ request is respectful of the ethical considerations likely to present if the parents refer their son to him. He has considered the circumstances provided for in Standard 10.01b: “When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation.” (American Psychological Association, 2002). He is also modeling a considerate, thoughtful attitude that augurs well for his ability to build a productive therapeutic relationship with the young man and his family, and models values of autonomy, reflection, empowerment, and collaboration that will likely contribute to the effectiveness of the course of therapy being considered.
THE ROLE OF NON-SPECIFIC EFFECTS
A variety of lines of evidence are causing our field to re-consider its views about the positive and ubiquitous role of non-specific effects in psychological treatments. Mintz (2005), a psychiatrist actively involved in psychotherapy, psychopharmacology, and teaching, has written about the strong roles that the doctor-patient relationship and the patient’s positive expectations play in outcomes of psychopharmacological interventions. In an extensive review of thousands of research studies, Norcross et al. (2002) have demonstrated that relationship factors account for much of the effect of psychotherapies of diverse kinds. Impressive bodies of evidence, including neuroscientific evidence (Benedetti et al., 2005), document that non-specific effects can be powerful and clinically useful, in medical as well as mental health conditions (Talbot, 2000, provides a useful summary).
Studies on the efficacy of EBPs need to demonstrate that the effects the treatments under study produce are not primarily attributable to non-specific effects of the patient being in a healing environment; a relationship with an empathically attuned clinician; hope and optimism about positive outcomes; and beliefs about the efficacy of a treatment receiving research attention. These objectives are not easily accomplished, and those researching the outcomes of EBPs struggle creatively to meet the challenge.
A psychologist providing EBPs - particularly a relatively newly developed treatment - incurs an ethical obligation not to overstate the promise of the treatment, especially in comparison to more traditional treatments that share common features with the newer treatment. Modesty about the potential benefits of a treatment, when presented with professionalism and compassion, can boost grounded and informed treatment participation by patients, and may also have the effect of encouraging greater patient awareness and greater patient responsibility for active, collaborative participation in treatment efforts. This stance is in line with the ethical principle that psychologists orient our interventions toward the most optimal benefit for those with whom we work (Principle A; American Psychological Association, 2002).
Dr. D’s PhD is in clinical psychology; she is licensed in her state and credentialed as a health service provider by the National Register. However, she has not practiced in many years. A university-based neuroscience researcher, she has been interested in mirror neurons (Rizzolatti & Craighero, 2004). In the past two years, she has developed and tested a mindfulness-based approach to the reduction of depressive symptoms, based on discoveries from her research. Dr. D. has begun seeing patients as part of an ongoing research study that looks at whether her treatment can produce sustained improvements in patients with treatment-refractory depression.She has treated Ms. E, who was referred to her by a local psychologist with a humanistic orientation who has seen Ms. E in long-term treatment. Ms. E obtained excellent results from her work with Dr. D. In the second-to-last session with Dr. D, Ms. E talks about how helpful the treatment has been - it has given her relief beyond what her work with her long-term psychotherapist offered her, and she is grateful. Dr. D, while appreciative of Ms. E’s comments, reminds her of the many gains her long-term treatment has afforded.
It is unlikely that Dr. D’s comments attenuated the impact of her helpful intervention with Ms. E. Dr. D. acknowledges Ms. E’s long-term psychotherapy may have been very helpful, perhaps because of non-specific factors, and thus does not preclude the possibility that Ms. E. may gain additively from continuing treatment with her therapist, or may consider the possibility of seeking further help from that therapist at a future point.
AVOIDING FALSE AND DECEPTIVE STATEMENTS
Psychologists take integrity very seriously. Our ethics code treats high levels of honesty and accuracy about what we do both as an aspirational principle - “Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact.” (Principle C) - and as enforceable standards - “Psychologists do not knowingly make public statements that are false, deceptive, or fraudulent concerning their... practice...” (Standard 5.01a) and “Psychologists do not make false, deceptive, or fraudulent statements concerning...the scientific or clinical basis for, or results or degree of success of, their services...” (Standard 5.01b) (American Psychological Association, 2002).
These values commit psychology intentionally to a basis of practice different from expediency and accommodation to market-driven pressures, and make it incumbent upon practicing psychologists to take seriously the autonomy of our professional judgments. While our ethics code recognizes that psychologists must respect organizational realities and cannot take unrealistic views of our professional degrees of freedom, we are required to frame our statements to those we serve in a considered, balanced way. As healthcare providers, we want our patients, in their relationships with us, to be trusting and open, and the confidence and professional assurance we project is essential to this; but our ethics code emphasizes that a basis for this is that the information we provide about our services is held to a high standard of accountability.
Telling a patient that a proposed course of treatment is empirically supported by randomized clinical trails (RCTs) would be a necessary but perhaps not a sufficient basis for ethical practice. While it would not be appropriate to go into depth of detail about effect size, replication, generalizability, and other concerns, neither can we over simplify or distort inherent complexities of the treatment process (“if you follow my instructions carefully, you are sure of success”), or give in to temptations to use testimonial-type advertisements (“many of my clients tell me this treatment has been the most helpful approach they have ever tried”).
Dr. F is a well trained and experienced psychologist and is employed by a managed care organization as a clinician. The organization has gained a large share of the local behavioral health market because it provides low-cost coverage. In order to do this, the organization has investigated a variety of evidence-based treatments for acute disorders, is explicit in its benefit plans that there are limited numbers of treatment sessions available to individuals they cover based on the organization’s standards of medical necessity (chronic conditions are excluded from coverage), and has instructed its employees to follow specific manualized protocols of proven efficacy for the treatment of presenting conditions. Clinicians are thoroughly trained in the approaches the organization approves for use. The organization’s policies and procedures are reiterated at intake to patients with psychological disorders.
In her first treatment session with Ms. G, a patient with a diagnosed panic disorder, Dr. F explains the proposed course of treatment, including available alternatives (e.g., medication, seeking other therapy outside the plan’s coverage). Ms. G is dubious. She had openended, exploratory psychotherapy several years earlier, while she was a college student. While the therapy did not prevent her from developing severe panic symptoms subsequently, she enjoyed her past therapy experience, and does not find it easy to embrace the different treatment being proposed. Dr. F, feeling committed to her organization and its treatment approach, tells Ms. G, “Research has shown that the approach I am describing to you is more effective for your symptoms than the kind of therapy you had in the past. I am confident that, within 12 sessions, you will be feeling much better.”
From an ethical vantage point, there is nothing inherently wrong with what the managed care organization in this scenario has set out to do, or with Dr. F’s choice to embrace, become trained in, and limit her practice to manualized treatment protocols. Indeed, she and her organization have taken a number of admirable ethical steps, including making their policies explicit, communicating them effectively, making time to discuss the proposed treatment with Ms. G in order to clarify her informed consent, and explaining the proposed course of treatment and possible alternatives.
Where Dr. F may be at risk of an ethical misstep is with regard to her overstatement of the results of the research establishing the efficacy of the proposed course of treatment, and unless Dr. F is familiar with literature on the efficacy of the past treatment, she should not make comparative statements. Her offer of professional assurance that the treatment will succeed for Ms. G within a specific time frame seems exaggerated. Had Dr. F been more circumspect in her statements, and seen her professional role as offering what she is able to offer and describing it clearly, rather than as a forceful advocate for her organization’s specific approach, her ethical stance would have been better grounded, and the likelihood of beginning the treatment based on an agreed upon understanding between psychologist and patient would have been more firmly established.
LOOKING TOWARD THE FUTURE
One of psychology’s strengths is the ongoing conversation among our science, our practice experience, and our ethical concerns. The rise of the EBPs movement, in my view, can be an impetus, and not an obstacle, to this big tent aspect of our profession. For this to succeed, however, it is important that all concerned avoid the kind of oversimplified or reductionistic thinking that has always been inimical to psychological practice, and think together carefully about all the implications, most especially the ethical implications, of our profession’s re-assertion of our historic commitment to the empirical basis of what we do.
As I hope I have demonstrated, EBPs do not make our ethical decision-making any less complex. To the contrary, it opens up new ethical questions that we will have to weigh and consider carefully.
As a basis for this to succeed, both organized psychology and individual psychologists will have to increase efforts to create mechanisms to increase the bidirectional information flow between science and practice. Practitioners should consider the research that most actively pertains to their practice, and take responsibility for ensuring an adequate intake of scientific information, available in traditional forms, such as books, journals, and conferences, and less traditional forms, such as online resources and listservs. Researchers have an affirmative obligation, in my view, to participate in active dialogues with practitioners, so that they can track what happens when their discoveries are implemented in real world situations - potentially, an important incubator for new scientific discoveries.
It is likely that traditional ethical concerns, such as informed consent and avoiding false and deceptive statements, will continue to frame ethical considerations in the era of the EBPs. At the same time, discoveries in cognitive science and new research methodologies seem likely to change the way we think through some of these considerations. New concerns - such as speaking with patients clearly about differences between treatment-specific and non-specific effects, maintaining our professional autonomy in the face of market pressures, and addressing clearly and directly the empirical basis of our practice - require our attention.
Richard Ruth, PhD, is Associate Professor of Clinical Psychology at the Center for Professional Psychology at The George Washington University, and a member of the faculty and the steering committee of the Child and Adolescent Psychotherapy Program at the Washington School of Psychiatry, both in Washington, DC. He also maintains a private practice in clinical psychology in Wheaton, Maryland. Dr. Ruth has been a Registrant since 1998.
American Psychological Association Statement
Policy Statement on Evidence-Based Practice in Psychology The following statement was approved as policy of the American Psychological Association (APA) by the APA Council of Representatives during its August, 2005 meeting.
Reprinted with permission*
Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.2 This definition of EBPP closely parallels the definition of evidence-based practice adopted by the Institute of Medicine (2001, p. 147) as adapted from Sackett and colleagues (2000): “Evidence-based practice is the integration of best research evidence with clinical expertise and patient values.” The purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention.
BEST RESEARCH EVIDENCE
Best research evidence refers to scientific results related to intervention strategies, assessment, clinical problems, and patient populations in laboratory and field settings as well as to clinically relevant results of basic research in psychology and related fields. A sizeable body of evidence drawn from a variety of research designs and methodologies attests to the effectiveness of psychological practices. Generally, evidence derived from clinically relevant research on psychological practices should be based on systematic reviews, reasonable effect sizes, statistical and clinical significance, and a body of supporting evidence. The validity of conclusions from research on interventions is based on a general progression from clinical observation through systematic reviews of randomized clinical trials, while also recognizing gaps and limitations in the existing literature and its applicability to the specific case at hand (APA, 2002). Health policy and practice are also informed by research using a variety of methods in such areas as public health, epidemiology, human development, social relations, and neuroscience.
Researchers and practitioners should join together to ensure that the research available on psychological practice is both clinically relevant and internally valid. It is important not to assume that interventions that have not yet been studied in controlled trials are ineffective. However, widely used psychological practices as well as innovations developed in the field or laboratory should be rigorously evaluated and barriers to conducting this research should be identified and addressed.
Psychologists’ clinical expertise encompasses a number of competencies that promote positive therapeutic outcomes. These competencies include a) conducting assessments and developing diagnostic judgments, systematic case formulations, and treatment plans; b) making clinical decisions, implementing treatments, and monitoring patient progress; c) possessing and using interpersonal expertise, including the formation of therapeutic alliances; d) continuing to self-reflect and acquire professional skills; e) evaluating and using research evidence in both basic and applied psychological science; f) understanding the influence of individual, cultural, and contextual differences on treatment; g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; and h) having a cogent rationale for clinical strategies. Expertise develops from clinical and scientific training, theoretical understanding, experience, self-reflection, knowledge of current research, and continuing education and training. Clinical expertise is used to integrate the best research evidence with clinical data (e.g., information about the patient obtained over the course of treatment) in the context of the patient’s characteristics and preferences to deliver services that have a high probability of achieving the goals of treatment. Integral to clinical expertise is an awareness of the limits of one’s knowledge and skills and attention to the heuristics and biases - both cognitive and affective - that can affect clinical judgment. Moreover, psychologists understand how their own characteristics, values, and context interact with those of the patient.
PATIENTS’ CHARACTERISTICS, VALUES, AND CONTEXT
Psychological services are most effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences. Many patient characteristics, such as functional status, readiness to change, and level of social support, are known to be related to therapeutic outcomes. Other important patient characteristics to consider in forming and maintaining a treatment relationship and in implementing specific interventions include a) variations in presenting problems or disorders, etiology, concurrent symptoms or syndromes, and behavior; b) chronological age, developmental status, developmental history, and life stage; c) sociocultural and familial factors (e.g., gender, gender identity, ethnicity, race, social class, religion, disability status, family structure, and sexual orientation); d) environmental context (e.g., institutional racism, health care disparities) and stressors (e.g., unemployment, major life events); and e) personal preferences, values, and preferences related to treatment (e.g., goals, beliefs, worldviews, and treatment expectations). Some effective treatments involve interventions directed toward others in the patient’s environment, such as parents, teachers, and caregivers. A central goal of EBPP is to maximize patient choice among effective alternative interventions.
Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options. It is the treating psychologist who makes the ultimate judgment regarding a particular intervention or treatment plan. The involvement of an active, informed patient is generally crucial to the success of psychological services. Treatment decisions should never be made by untrained persons unfamiliar with the specifics of the case. The treating psychologist determines the applicability of research conclusions to a particular patient. Individual patients may require decisions and interventions not directly addressed by the available research. The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBPP. APA encourages the development of health care policies that reflect this view of evidence-based psychological practice.
American Psychological Association. (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57, 1052-1059.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National
Academy Press.Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.
1 An expanded discussion of the issues raised in this policy statement including the rationale and references supporting it may be found in the Report of the Presidential Task Force on Evidence-Based Practice available online at http://www.apa.org/practice/ebpreport.pdf.
2 To be consistent with discussions of evidence-based practice in other areas of health care, we use the term patient to refer to the child, adolescent, adult, older adult, couple, family, group, organization, community, or other populations receiving psychological services. However, we recognize that in many situations there are important and valid reasons for using such terms as client, consumer or person in place of patient to describe the recipients of services.
3 For some patients (e.g., children and youth), the referral, choice of therapist and treatment, and decision to end treatment are most often made by others (e.g., parents) rather than by the individual who is the target of treatment. This means that the integration of evidence and practice in such cases is likely to involve information sharing and decision-making in concert with others.
* American Psychological Association, Task Force on Evidence-Based Practice. (2005, August). Policy statement on evidence-based practice in psychology. Retrieved April 5, 2007, from http://www.apa.org/practice/ebp.html. Copyright by the American Psychological Association.