Ethical Issues in Treatment Selection Northern Arizona University Timothy C. Thomason

Ethical Dilemmas Most Often Encountered by APA Members Results of a national sample of APA members: – Confidentiality – Multiple relationships – Payment sources, plans, and methods – Academic/Research/Forensic issues – Conduct of colleagues – Sexual issues – Assessment – Questionable or harmful interventions - Pope & Vetter

APA Ethical Principles Related to Treatment Selection Principle A: Beneficence and Nonmaleficence “Psychologist strive to benefit those with whom they work and take care to do no harm.” Implication: Treatments that may be unsafe or ineffective should be avoided.

APA Ethical Standards Related to Treatment Selection, cont “Psychologists’ work is based upon established scientific and professional knowledge of the discipline.” Implication: Treatments that have good evidence of their effectiveness should be considered the treatments of choice.

APA Ethical Standards, cont. 2.01(c) Boundaries of Competence Psychologists provide services in areas only within the boundaries of their competence. Psychologists planning to provide services involving techniques or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

APA Ethical Standards, cont. 201 (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 from harm.

APA Ethical Standards, cont Informed Consent to Therapy “When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation.”

ACA Code of Ethics (2014) C.7.a. Scientific Basis for Treatment “When providing services, counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation.”

ACA Code of Ethics (2014), cont. C.7.b. Innovative Theories and Techniques “When counselors use developing or innovative techniques/procedures/modalities, they explain the potential risks, benefits, and ethical considerations of using such techniques/procedures/modalities.”

ACA Code of Ethics (2014), cont. C.7.c. Harmful Practices “Counselors do not use techniques/procedures/modalities when substantial evidence suggests harm, even if such services are requested.”

American Medical Association Principles of Medical Ethics E-3.01 Nonscientific Practitioners “It is unethical to engage in... treatment which has no scientific basis and is dangerous....”

Suppose You Have a Client with OCD What treatment would you use to help them?

Evidence-Based Treatments for OCD Exposure and Response Prevention Cognitive Therapy

Suppose You Have a Client with PTSD What treatment would you use to help them?

Evidence-Based Treatments for PTSD Prolonged Exposure Present-Centered Therapy Cognitive Processing Therapy

Suppose You Have a Client with Generalized Anxiety Disorder What treatment would you use to help them?

Evidence-Based Treatment for Generalized Anxiety Disorder Cognitive and Behavioral Therapies

Suppose You Have a Client with Depression What treatment would you use to help them?

Evidence-Based Treatments for Depression Behavior Therapy/Behavioral Activation Cognitive Therapy Cognitive Behavioral Analysis System Interpersonal Therapy Problem-Solving Therapy Self-Management/Self-Control Therapy

Low Usage of Evidence-Based Treatments Many psychologists use techniques and treatments that have little or no evidence of their safety or effectiveness. Many psychologists do not use evidence-based treatments even for conditions that clearly benefit from them.

Examples of Empirically Supported Treatments CBT for anxiety disorders ERP for OCD CPT for PTSD BA for depression MI for substance abuse IP for eating disorders REBT for depression ACT for anxiety DBT for BPD

Usage of EBP National survey of psychologists in 2000: 47% said they never used evidence-based treatment manuals. Only 6% said they used them often. National survey of psychologists in 2004: Most did not use exposure techniques for anxiety. National survey of psychologists in 2007: Most said they rely on their clinical experiences to decide treatment rather than research evidence.

Usage of EBP, cont. National survey of psychologists in 2007: Majority said they often use non-evidence based techniques. National survey of psychologists in 2008: 30% said they use controversial and unsupported techniques at least sometimes in their practice. National survey of social workers in 2009: 76% said they used at least one “novel unsupported therapy” within the past year.

Usage of EBP, cont. The results of a survey of ACA Members in 2011 found that 43% said that using techniques that are not theory or research based is ethical; 56% said it is unethical. National survey of psychotherapists in 2012: 42% said they used or were inclined to use unsupported “energy meridian therapies.”

What is Evidence-Based Practice? APA definition: “Evidence-based practice is the integration of research with clinical expertise in the context of the client’s characteristics, culture, and preferences.” This definition gives clinicians plenty of leeway.

Guidelines to Select Treatments Base treatment selection on pragmatic grounds. Select evidence-based treatments when possible. Avoid treatments with little evidence of safety or effectiveness.

Examples of Empirically Supported Treatments (APA Div. 12) Acceptance and Commitment Therapy Behavioral Activation for Depression Cognitive Behavioral Therapy Dialectical Behavior Therapy for BPD Cognitive Therapy for Depression Exposure and Response Prevention for OCD Interpersonal Therapy

Examples of ESTs, cont. Motivational Interviewing Psychoanalytic Therapy for Panic Disorder Psychoeducation for Bipolar Disorder Rational Emotive Behavior Therapy Schema-Focused Therapy Short-Term Psychodynamic Therapy Social Skills Training for Schizophrenia

APA List of Research-Supported Psychological Treatments

Current Status of EBP Most states are implementing strategies to support the use of evidence-based practices. They equate EBP with lists of specific treatments for specific disorders. Reimbursement is contingent on adherence to officially sanctioned therapies. Miller, Hubble, Chow, & Seidel (2013). The outcome of psychotherapy. Psychotherapy, 50(1),

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