APA practice guidelines raise questions

By James Bradshaw, Senior Editor
May 29, 2018 - Last updated: May 27, 2018

psychology clinical practice guidelinesWashington, D.C. – APA is preparing two sets of practice guidelines, which has many psychologists confused on what the difference is and others concerned that the results may be misapplied by insurers or licensing boards.

Those concerns carried over from the March 9-10 meeting of the Council of Representatives to the overlapping March 10-13 Practice Leadership Conference.

The agenda item that raised questions concerned nine months that leadership, staff and a consultant had been working on “development of a Professional Practice Guideline facilitating the implementation of Clinical Practice Guidelines.”

In essence, professional guidelines are just that: recommendations for maintaining professionalism with patients or clients, such as taking into account cultural differences. In a related matter, it was noted that work also is being done on “a revision of Multicultural Guide-lines for the 21st Century.”

The clinical guidelines concern the working nuts-and-bolts of practice, such as outlining which approaches work best for particular patients and disorders.

The council item was informational and didn’t require a vote but it led to much discussion, which carried over to the leadership conference.

Joseph J. Coyne, Ph.D., who serves on the APA board of directors as chair of the Council Leadership Team, said the guidelines must be carefully drafted to reassure practitioners.

“Thousands of members are expressing concern,” Coyne said.

The primary concerns are that the clinical guidelines will not be inclusive enough and the professional guidelines may include too much, particularly in “aspirational” goals.

Problems many members foresee with the clinical guidelines, which cover treatment recommendations for various disorders, were epitomized in complaints about clinical guidelines for treatment of PTSD that were adopted last year. Those guidelines listed various treatments, such as CBT, as evidence-based in showing effectiveness.

But, psychoanalysis, which is an accepted treatment for PTSD under guidelines of VA hospitals, and other psychodynamic approaches, were omitted from the APA guidelines. Psychologists who practice those treatments are concerned that insurers would interpret that as grounds to deny payment.

The New Jersey Psychological Association, spurred by complaints from 75 members, issued a statement questioning the guidelines and urging that they be reconsidered.

The fear concerning the professional guidelines is that some licensing boards may adopt the wording in regulations without regard to the “aspirational” limits intended.

For example, the description of aspirational general principles of conduct in the APA Code of Ethics specifies that, in contrast to ethical standards, such principles “do not represent obligations and should not form the basis for imposing sanctions.”

Among those general principles is this statement: “Special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.”

If such broad but well-meaning statements are contained in the professional standards, many practitioners fear that a disgruntled patient could file a complaint under subjective interpretations impossible to defend against.

In a leadership conference session on clinical practice guidelines, members were told the guidelines are not meant to be all-inclusive or to impose inflexible “manualized treatment.” Instead, they were told, practitioners should tailor treatment to needs, relying on education and expertise to make modifications.

Jana Martin, Ph.D., CEO of The Trust, said the important thing is to document decisions with notes on why particular treatment methods were used and how and why they might have been modified.

That would include documenting why a method was chosen that may not have been included in the written standards, Martin said.

Lisa R. Grossman, JD, Ph.D., expressed the doubt many members have about the guidelines when she asked what APA would do to make certain insurance companies don’t abuse whatever wording is adopted.

The question received no direct answer.

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