In addition, the IOM surveyed “APA members and other key stakeholders” about their recommendations for research priorities [survey now closed].

In its email request to members, APA wrote, “It is important that we communicate the significance of research that compares the effectiveness of different behavioral and psychosocial interventions with one another, as well as with medical interventions, or combinations of the two, for specific physical and mental health conditions.

We also believe it is important that comparative effectiveness research using medical interventions include behavioral and psychological outcome measures and that all interventions are sensitive to the possible effects of demographic variables (e.g., gender, race/ethnicity, and age) on treatment outcomes.

APA will continue to track the availability of economic stimulus funding for psychological research and related programs and will post information on our Web site in the coming weeks.”

My comments on these events are as follows.

(1) It is noteworthy that nowhere in APA’s information to its members or to the IOM is there an acknowledgment that “behavioral and psychosocial interventions” must be defined to include the human relationship variables now known to be the key “effective ingredients” of psychotherapy. I would like to remind APA that it will be essential to remain mindful of its own
Policy Statement on Evidence-Based Practice in Psychology. This is particularly so for the “Clinical Implications” of the Policy Statement:

”Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options. It is the treating psychologist who makes the ultimate judgment regarding a particular intervention or treatment plan. The involvement of an active, informed patient is generally crucial to the success of psychological services. Treatment decisions should never be made by untrained persons unfamiliar with the specifics of the case.

The treating psychologist determines the applicability of research conclusions to a particular patient. Individual patients may require decisions and interventions not directly addressed by the available research. The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBPP.

APA encourages the development of health care policies that reflect this view of evidence-based psychological practice.

There will be tremendous pressure in “clinical trials” during such “comparative effectiveness” research to resort to standardized, manualized “treatment.” APA must lead the way in reminding the IOM and all investigators that such methodology is a simplistic, simplified model adopted for the convenience of a research protocol, and that such methodology does not replicate the “real world” practice of psychotherapy.

In addition to results yielded by national level comparative effectiveness research, health policy informed by APA must require that the ultimate decision about psychological treatment is made by the psychologist in collaboration with an informed client.

Furthermore, a key focus of “comparative effectiveness” research must include protocols which examine the effectiveness of treatments applied mechanistically relative to those applied taking into account human relationship variables.

(2) Dr. Bray’s comments emphasize comparison of “…integrated systems of care comprised of interdisciplinary teams of medical and behavioral health providers versus routine medical care.” These of course are not the only, nor possibly even the most important, settings in which psychotherapy is provided. In this country, perhaps the vast majority of psychotherapy is provided in the independent, solo or small group practice setting. Consumers may well want the choice of seeing their psychologist in such settings or other locations than in medicalized “systems of care.” The question is how best to use what consumers attain in the independent practice setting in other places they receive care. Unless the APA and our “health care delivery system” is intent on wholesale abandonment of the solo or small group setting independent provision of psychotherapy, it would prudent to at least require comparative effectiveness research to investigate the effectiveness of provision of psychotherapy in various settings. Specifically, I would hope that APA would support comparative effectiveness research IN THE INDEPENDENT, SOLO AND SMALL GROUP SETTINGS, and other local, non-medicalized, non-industrialized, community-based settings, in comparison to larger “systems of care.”

(3) I want to thank the APA for its promise to “…continue to track the availability of economic stimulus funding for psychological research and related programs” and to post such information on its web site in the future. As called for in the letter posted here, I will be watching to see how APA helps bring such funding to solo- and small-group independently practicing psychologist in addition to large medical and research settings.