Why We Need Evidence-Based Psychotherapy Practice Guidelines

William C. Sanderson, PhD


Medscape General Medicine. 2002;4(4) 

In This Article

Practice Guidelines

Practice guidelines represent the first step in attempting to bridge the gap between science and practice. As noted by Howard and Jensen,[13] "numerous studies indicate that guidelines can increase empirically based practice and improve clients' outcomes." Practice guidelines increase our accountability by promoting those treatments with the most efficacy.

Several authors have raised important concerns and criticisms regarding the identification of empirically supported therapies.[14,15,16] In fact, I agree that there are difficulties and risks in establishing psychotherapy guidelines -- or any treatment guidelines, for that matter.[17] However, I strongly disagree with the premise that the development of evidence-based psychotherapy guidelines is "self destructive behavior, the consequences of which will degrade our calling far worse than anything government or managed costs corporations will ever conceive.[15] To the contrary, it is my opinion that the failure to develop treatment guidelines will result in psychotherapists being our own worst enemy.[11] Unfortunately, to date, psychotherapists have not taken an active role in promulgating guidelines. Recognizing the importance of treatment guidelines, other organizations such as the American Psychiatric Association have accelerated the development process. Indeed, as noted by Dr. Harold Pincus,[17] who has been a member of a committee overseeing the development of the American Psychiatric Associations guidelines, "in the absence of standards, what is cheapest is best. . . . Evidence-based guidelines developed by professional organizations assist clinicians in asserting professional values in the face of economic pressures."

From my vantage point, the question is not whether we should develop treatment guidelines whenever possible, but instead, have we already missed the boat? The danger in not creating our own guidelines is obvious from Persons and colleagues'[18] analysis of the Agency for Health Care Policy and Research[19] and American Psychiatric Association[20] reports. Essentially, Persons and colleagues[18] concluded that both guidelines understate the value of psychotherapy; and in particular, the American Psychiatric Association's guidelines do not reflect a balanced assessment of the available empirical evidence supporting cognitive, behavioral, brief psychodynamic, and group psychotherapy. Clearly, having "other" groups (ie, those not primarily involved in providing and evaluating psychotherapy) construct guidelines is not in psychotherapists' best interest.

Of course, there are risks and drawbacks to developing guidelines. But these do not outweigh the benefits. In my opinion, many of these concerns are not unique to psychotherapy, but are inherent in the complexities of applying research findings to the treatment of any disorder, whether it be a psychological intervention, medication, or surgical procedure. Treatment guideline development is an evolving process, driven by existing data. It appears as though much of the concern expressed about the development of guidelines is due to a misunderstanding of guidelines. Consider the Statement of Intent in the Preface of the American Psychiatric Association's Guidelines[20]:

This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available from an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.

Thus, guidelines are not strict criteria. Exceptions are appropriate whenever necessary to meet the needs of a specific patient. However, any modification should be justified by a "compelling professional rationale."