Empirically Supported Treatments (ESTs)

History

u Scientist practitioner model endorsed in 1949

u In 1952 Esynk stated that there was no evidence supporting effectiveness of psychotherapy (but there were only 24 outcome studies total!!)

u In 1960s there were some behavioral procedures that worked for a few specific problems

u In 80s and 90s research on effectiveness of psychotherapies was rampant (we could conduct meta-analyses that use many studies.

History

u In one meta-analysis of 475 studies Smith Glass and Miller (1980) found an effect size of .85

u In a review of the meta-analytic literature Lambert and Bergin (1994) found almost an entire standard deviation difference between clients receiving psychotherapy and those that were not.

u In 1993 Barlow (president of clinical psychology division of APA) established the Task Force on Promotion and Dissemination of Psychological Procedures (1995).

History

u This group produced a set of guidelines that specified both the criteria for evaluating efficacy of psychotherapy and the existing therapies that meet the evaluative criteria.

u Criteria designed to evaluate treatment efficacy (internal validity of outcome research) and not effectiveness (external validity)

u Effectiveness is very important and will be examined in the future

u Also criteria do not evaluate feasibility (how well can treatments be implemented) and efficiency (cost effectiveness)

u Most therapies developed and disseminated by psychologists (except Beck and Klerman)

History

u Three areas of accountability:

– 1) scientific

– 2) ethical

– 3) economic and political

Scientific Accountability

u We must determine empirically whether or not therapy “works”

u In principle there is no reason to believe that any type of psychotherapy cannot or should not be subjected to empirical validation

Scientific Accountability

u 5 criteria for judging that a treatment has been empirically supported:

u Must be compared to an adequate control group and must be found superior to a control group or equivalent to an already established treatment

u Must employ a manual for the specific treatment of individuals with well specified problems

u Has to be demonstrated as effective in at least two different studies (to be efficacious)

u Has to be shown to be effective in at least one study (possibly efficacious)

u To be classified as both efficacious and specific, the treatment must be shown to be superior to a placebo or to an alternative established treatment in at least two different research settings

Scientific Accountability

u The dependent variables that need to be assessed are:

– Magnitude of change

– The generality of change

– The universality of change

– The acceptability of the treatment

– Safety

– Stability

– Statistical significance

– Clinical significance

Scientific Accountability

u Sources of outcome data include:

– Patient self report

– Other’s reports

– Clinician judgment

– Diagnostic considerations

– Psychometric measurement

Ethical Issues

u Throughout our ethics code we are told we need to provide our patients with effective treatment

u There are two limitations:

– 1) right now treatments are limited for what types of problems they can solve and for what people – thus efficacy with one group of people does not imply efficacy with another group and

– 2) the limits of our current scientific methods

u There are also limitations to the DSM

Economic and Political Considerations

u Therapists who don’t practice supported therapies might be liable to malpractice

u If you don’t practice EST’s you may not be reimbursed by managed care

u Need to promote our methods but acknowledge their limitations

Implementation of EST’s

u Right now we are relying on the medical model

u Thus RCT are the standard means by which the efficacy of psychotherapy is evaluated

u Has been very successful in pharmacology research – people have transferred this information to psychotherapy research and now are even plotting dose-response curves

Implementation of ESTs

u But are RCT’s suitable for psychotherapy research??

u It is not generalizable, and it is prescriptive – but therapy cannot be prescribed like medicine

u Manualization will help with standardization – but still there is a lot of variability

u We are also basing our categorization of disorder on the DSM and we know that there is a lot of overlap between different diagnostic categories.

u However if we recruit a group that is too diagnostically pure – this seriously limits generalizability

Training in EST’s

u Need to have training

u Debate as to whether we should be trained in theory or in specific treatments

u Need basic courses before we can understand the principles behind EST’s

u This needs to be continued in our practicum training

ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

Effective date June 1, 2003.

General Principles

u General Principles, as opposed to Ethical Standards, are aspirational in nature.

u Intent is to guide and inspire psychologists toward the very highest ethical ideals of the profession.

5 General Principles

u Principle A: Beneficence & Nonmaleficence

u Principle B: Fidelity and Responsibility

u Principle C: Integrity

u Principle D: Justice

u Principle E: Respect for People's Rights and Dignity

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority

u If psychologists' ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists make known their commitment to the Ethics Code and take steps to resolve the conflict. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority.

1.04 Informal Resolution of Ethical Violations

u When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved.

1.05 Reporting Ethical Violations

u If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations, or is not resolved properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question.

2.01 Boundaries of Competence

u
(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

u (b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.

2.01 Boundaries of Competence (cont)

u (c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

u (d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.

2.01 Boundaries of Competence (cont)

u (e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.

u (f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.

2.03 Maintaining Competence

u Psychologists undertake ongoing efforts to develop and maintain their competence

3.04 Avoiding Harm

u Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable

3.05 Multiple Relationships

u (a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

u A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

u Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

3.07 Third-Party Requests for Services

u When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (e.g., therapist, consultant, diagnostician, or expert witness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality.

3.10 Informed Consent

u (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code.

3.10 Informed Consent

u (c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding

4.01 Maintaining Confidentiality

u Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship

4.02 Discussing the Limits of Confidentiality

u (a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.

u (b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.

u (c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

4.06 Consultations

u When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation.

6.05 Barter With Clients/Patients

u Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative

8.01 Institutional Approval

u When institutional approval is required, psychologists provide accurate information about their research proposals and obtain approval prior to conducting the research. They conduct the research in accordance with the approved research protocol.

9.02 Use of Assessments

u (a) Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques.

u (b) Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.

u (c) Psychologists use assessment methods that are appropriate to an individual's language preference and competence, unless the use of an alternative language is relevant to the assessment issues.

9.04 Release of Test Data

u (a) The term test data refers to raw and scaled scores, client/patient responses to test questions or stimuli, and psychologists' notes and recordings concerning client/patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data. Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release. Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law.

u (b) In the absence of a client/patient release, psychologists provide test data only as required by law or court order.

10.01 Informed Consent to Therapy

u
(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers

10.02 Therapy Involving Couples or Families

u (a) When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist's role and the probable uses of the services provided or the information obtained.

Sex with Patients

u 10.05 Sexual Intimacies With Current Therapy Clients/Patients
Psychologists do not engage in sexual intimacies with current therapy clients/patients.

u 10.06 Sexual Intimacies With Relatives or Significant Others of Current Therapy Clients/Patients
Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.

u 10.07 Therapy With Former Sexual Partners
Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies.

10.08 Sexual Intimacies With Former Therapy Clients/Patients

u (a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

u (b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient.

10.10 Terminating Therapy

u (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

u (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

u (c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

Ethical Vignette - 1

Dr Hope Charity, the clinical psychologist, had just completed six structured sessions of systematic desensitization for Mr Gold, a solicitor, for management of work-related anxiety. Mr Gold, a handsome man whom she quite liked, was otherwise well-adjusted. Two weeks after the termination of their successful therapeutic venture, Mr Gold sent Dr Charity a bunch of red roses, and a note conveying his thanks and an invitation to dinner and the opera. She found that she really wanted to accept the invitation. If she did, would she be violating ethical guidelines? If so, why?

Ethical Vignette 2

You are in independent practice. A young male client attends for behavioral modification. He tells you he has met a nice girl and wants to settle down. He has recently quit being a member of a notorious biker gang. He gives you details of his involvement in various anti-social acts including a vicious beating which you recall was covered by the media about 12 months ago when a reward was offered for information leading to the conviction of the perpetrator. What are your ethical obligations?

Ethical Vignette - 3

A clinical psychologist, Dr Hope Charity, was treating a young woman aged 22 years for Post-Traumatic Stress Disorder following an armed holdup in the workplace. You have performed several assessments and conducted 10 weeks of psychotherapy. One of the woman’s colleagues is taking the employer to court and the lawyer has subpoenaed Dr. Charity’s assessment protocols and therapy records to demonstrate that this incident caused a great deal of trauma to members of the workplace. The patient does not want her records released. What should Dr Charity do?

Ethical Vignette - 4

You have discovered that your friend and colleague, a clinical psychologist in partnership with a medical practitioner, is collaborating with the doctor (ie using medical receipts and provider numbers) to gain Medicare benefits for his psychology clients. What would you do?

Ethical Vignette - 5

You are in independent practice and have been contacted by a solicitor for an insurance company who has asked you to undertake a neuropsychological assessment of a child client who is claiming compensation. You are told that you would then be required to appear in Court as an expert witness. Although you have had no prior experience or training in neuropsychological assessments, you have recently purchased an expensive and comprehensive battery of tests which would be more than sufficient for the undertaking. Is this ethical – why or why not?

Ethics Vignette - 6

The non-custodial parent of an eight year old boy asks a psychologist to assess his functioning. The parent involved has not discussed this with the child's mother. It is to be done without knowledge or permission of the custodial parent. Should he be encouraged to discuss this with her? If he does not, should you do so? And if this assessment reveals the need for an intervention, should this be discussed with the custodial parent? If so, by whom?

Ethics Vignette - 7

You are counseling a gay man who has tested as HIV positive. He has not told his lover, with whom he is not practicing safe sex. His lover is known to have tested negative for the virus. Your client is afraid to tell his lover because he fears that he may be rejected by him. You feel that this decision puts the lover at considerable risk, and you feel responsible for this. Do you have a duty to warn?