The Case for Evidence-Based Psychotherapy Treatment Guidelines

WILLIAM C. SANDERSON, Ph.D.* One contemporary issue in the area of psychotherapy which has received increasing attention concerns the advantages and disadvantages of treatmentguideline development.1-3 The discussion of treatment-guideline development appears to be fueled, for the most part, by changes in the healthcare delivery system in the United States. It seems safe to say that in the past, practitioners of many forms of psychotherapy were less concerned than now about scientific evaluation and accountability. Accountability was desirable, but not necessary. However, the need for accountability has sharply increased, as treatments without supporting efficacy data are unlikely to survive. Indeed, as noted by Trabin,4 "the development of an accountable, science-based model of behavioral healthcare may be catalyzed on a broad scale by competitive pressures from the marketplace and from government" (p. 8). Recognizing the importance of establishing a body to identify and promote empirically supported psychotherapeutic treatments, the Division of Clinical Psychology (Division 12) of the American Psychological Association assembled a Task Force to accomplish the goal.5 Based upon a specific review process, a list of empirically supported treatments was identified.5 The Task Force report acknowledged that the list is never final, and must be maintained and updated on a regular basis to include new data as they emerge (in fact, the recent list represents the third "update"). During a time of sweeping healthcare changes, the list represents a crucial step in the identification and promotion of proven-effective psychotherapies, with the overall mission of making these treatments more widely available.6 Several authors have raised important concerns and criticisms7-9 regarding the identification of empirically supported therapies. In fact, I agree that there are difficulties and risks in establishing psychotherapy guidelines-or any treatment guidelines for that matter.lo 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"8 (p. 136). To the contrary, it is my opinion that the failure to develop treatment guidelines will result in psychotherapists being our own worst enemy.3 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, Dr. Harold Pincus,lo who has been a member of a committee overseeing the development of the American Psychiatric Associations Guidelines has noted: "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" (p. 45). From my vantage point, the question is not whether or not 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, Thase, and Crits-Christoph's11 analysis of the AHCPR12 and American Psychiatric Association report.13 Essentially, they conclude that both guidelines understate the value of psychotherapy and, in particular, the American Psychiatric Association's Guidelines does not reflect a balanced assessment of the available empirical evidence supporting cognitive, behavioral, brief psychodynamic, and group psychotherapy. Clearly, having "other" groups (i.e., those not primarily involved in providing and evaluating psychotherapy) construct guidelines is not in psychotherapists' best interest. Of course, there are risks and drawbacks in developing guidelines. …