Ethical Best Practice in an Evidence-Based Age
There were 2 presentations at this year’s annual American Psychological Association convention which were important to psychotherapists in particular. With the ever-growing challenge to prove efficacy of each and every treatment, healthcare providers and consumers alike face some confusion as to how much information is enough, or too much. Does every therapist need to give a long presentation about the relative proven efficacy of low-dose medication combined with verbal therapy — and 2 hours gardening per week? (I made up the last part, but hiking and fresh air were a popular cure for quite a long time in 19th Century Europe.)
Physicians are acutely aware of the need to know the research, and most ethical codes demand informed consent. Both health and mental health professionals provide information to their patients about effectiveness, efficacy, and other treatment options which may be equivalent.
Here is what a panel of distinguished psychologists and ethics experts had say, which for most present sounded both reasonable (i.e., not rigid to the point of possibly actually doing harm) and grounded in the true intent of ethics among most healers/therapists — to help.
Dr. Gerald Koocher, editor of Ethics and Behavior, and his fellow panelists addressed what has been the theoretical model of ethical practice for some time now: the 3-legged stool. Basically this model calls for treatment decisions to be based upon 1) Best research based evidence 2) clinical expertise 3) Patient context.
Aside from some conceptual difficulties with the 3 legged model in a figurative sense, it was noted that 2-legged stools (aka “benches”) can be even more sturdy, as can one good leg in strong concrete. So if life is a box of chocolates, ethics is a 3-legged stool.
So what’s important? Don’t providers now get that we need to base statements and decisions on sound evidence? Ah, but maybe it’s not that easy. Some real-world dilemmas are faced every day by clinicians who might be happy to follow a specific rule diligently, but what happens when life gets in the way of plans? And what about children?
Some important points include how “clients have preferences;” while “evidence” may show a combination of medication and therapy to be most effective for the most people, a parent may not want the medication part.
Therapists too may have preferences which can include ingrained but untenable allegiance to particular “schools” (for example trying to treat enuresis psychoanalytically, as opposed to providing a bell and pad, at risk of facing “symptom substitution”). One of the panelists asked where one might go to find every single situation and the evidence for best treatment for each. I followed up with this question, too. Answer: It’s not easy!
So, aside from the risks and benefits of “manualized” treatment — which has few advocates among practitioners I speak with — what is most important to keep in mind when trying to be both ethical and effective, using our skills, “evidence,” and judgment borne from experience? A great deal of importance must be assigned to the initial phase of outlining and agreeing to a course of treatment.
As Dr.Scott Lilienfeld described it, “We have a role as a clinician also as a persuader.” Dr. Koocher re-iterated a mantra shared by many: “The critical thing to evoke change is the therapeutic relationship.” This is not merely a fact borne from research, but a consideration in such cases where a client has a strong preference. Then again, as Dr. Nordal (of APA’s Practice Directorate) cautioned, “A client may not have a preference for something but it may be because they’re uninformed.” And thus informed consent is doubly important at the beginning of a therapeutic relationship.
Now I would like to add, for those who may think I was speaking about online therapy, I wasn’t. This is the type of consideration psychologists and other healthcare providers are constantly making. Face to face. Now imagine online interactions: still applicable, no? And this is why I am happy to be able to report on new evidence for online intervention efficacy, too!
I would like to segue briefly to a few uniquely online/digital age ethical points, made in the next symposium I attended, another ethics luminary with a continuing interest in 21st Century life, Dr. Jeffrey Barnett (past-ethics chair). I love his presentation title:
Ru red e 4 ths? The Practice of Psychology in the Digital Age
My very quick synopsis for here & now: Aside from being mindful that what goes up online is forever, as the prior panel emphasized, informed consent is (as the teens say) sooooo important! He shared some disclaimer forms covering “friending” policy upfront (informed consent!), and addressed the ethical aspects of Googling/researching a client or student without consent/discussion/reason. So much here: generational differences, FB privacy, positive use of the web in therapy sessions, impact of tweeting, so much more… Welcome to the 21st Century!
Fenichel, M. (2010). Ethical Best Practice in an Evidence-Based Age. Psych Central. Retrieved on February 12, 2016, from http://psychcentral.com/blog/archives/2010/08/21/ethical-best-practice-in-an-evidence-based-age/