3.A.2
Choosing a treatment: evidence, fit, readiness and cost
ASPPB's competency statement 3.A.2: Factors related to treatment/intervention decision-making (e.g., relevant research, matching treatments/interventions to assessment/diagnoses, diversity considerations, societal context, cost-benefit analysis, readiness to change, knowledge and use of allied services)
Choosing a treatment weighs several factors at once: research on what works for the problem, how well a treatment matches the assessment and diagnosis, the person's identities, culture and circumstances, their readiness to change, the costs and benefits of each option, and services others can provide. Evidence-based practice integrates these rather than applying a treatment simply because it has trial support. The aim is the option most likely to help this person, offered in a form they will accept and can reach.
Key ideas
- Matching to assessment
- The diagnosis and formulation narrow the field to treatments tested for that problem; severity, risk, comorbidity and medical factors can change the order or call for combined care. Research, clinical expertise and patient characteristics all bear on the choice (APA Presidential Task Force, 2006).
- Readiness to change
- The transtheoretical model describes precontemplation, contemplation, preparation, action and maintenance (Prochaska and colleagues, 1992). Across 76 studies, the further along the stages clients were before treatment, the better their outcomes (Krebs and colleagues, 2018).
- Diversity and societal context
- APA's Multicultural Guidelines use a layered ecological model: identity is shaped by culture, language, religion, social class, immigration status, ability and experiences of marginalization, within community and institutional contexts that affect access and fit (Clauss-Ehlers and colleagues, 2019).
- Cost-benefit analysis
- Economic evaluations compare options: cost-effectiveness analysis reports cost per unit of a health outcome, cost-utility analysis uses quality-adjusted life years, and cost-benefit analysis values both costs and outcomes in money (Drummond and colleagues, 2015).
- Stepped care and allied services
- Stepped care begins with the least intensive effective option and steps up those who do not improve; its benefits depend on low-intensity care being nearly as effective and acceptable (Bower and Gilbody, 2005). Physicians and community services may also belong in the plan.
Worked example
A 52-year-old bus driver has feared for two years that his headaches mean a brain tumor; normal scans reassure him for only a few days. He searches symptoms online every night. His health plan covers ten sessions, and he is 'thinking about' therapy but doubts that talking can help a physical problem.
- Assessment points to health anxiety. A meta-analysis of 19 trials found cognitive behavior therapy (CBT) for health anxiety moderately to largely effective, with therapist-guided internet CBT comparable to face-to-face CBT (Axelsson and Hedman-Lagerlöf, 2019).
- He is in contemplation, so begin by exploring his doubts and offering a rationale that takes his physical worry seriously, rather than pressing for behavior change in the first week.
- Cost and access: ten covered sessions fit a brief CBT course, the same review judged CBT for health anxiety probably cost-effective, and guided internet CBT could fit around his shifts.
- Allied services: with his consent, agree with his physician on scheduled visits rather than repeated tests on demand, since reassurance seeking is part of what maintains health anxiety in the cognitive model (Salkovskis and Warwick, 1986).
The best choice fits the evidence, the person's readiness and means, and the other services already in his life.
Check yourself
Which statement best describes evidence-based practice in psychology as APA's 2006 policy defines it?
Sources
- APA Presidential Task Force on Evidence-Based Practice (2006), Evidence-based practice in psychology, American Psychologist (PMID 16719673), Policy statement and definition
- Prochaska, DiClemente and Norcross (1992), In search of how people change: Applications to addictive behaviors, American Psychologist (PMID 1329589), The stages of change
- Krebs, Norcross, Nicholson and Prochaska (2018), Stages of change and psychotherapy outcomes: A review and meta-analysis, Journal of Clinical Psychology (PMID 30335193), Abstract; readiness and outcome across 76 studies
- Clauss-Ehlers, Chiriboga, Hunter, Roysircar and Tummala-Narra (2019), APA Multicultural Guidelines executive summary: Ecological approach to context, identity, and intersectionality, American Psychologist (PMID 30762387), Abstract; the layered ecological model
- Drummond, Sculpher, Claxton, Stoddart and Torrance (2015), Methods for the Economic Evaluation of Health Care Programmes, Fourth Edition, Chapter 1, forms of economic evaluation
- Bower and Gilbody (2005), Stepped care in psychological therapies: access, effectiveness and efficiency, British Journal of Psychiatry (PMID 15630118), Abstract; results and conclusions
- Axelsson and Hedman-Lagerlöf (2019), Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes, Expert Review of Pharmacoeconomics and Outcomes Research (PMID 31859542), Abstract; pooled effect, internet CBT and cost-effectiveness
- Salkovskis and Warwick (1986), Morbid preoccupations, health anxiety and reassurance: a cognitive-behavioural approach to hypochondriasis, Behaviour Research and Therapy (PMID 3753387), The role of reassurance in maintaining health anxiety