3.B.4
Explaining why: the rationale for a recommendation
ASPPB's competency statement 3.B.4: Provide evidence-based rationale for treatment/intervention decisions, recommendations, and opinions to clients or others as indicated
Clients, families, referrers and courts often ask why a psychologist recommends one course over another. A good rationale states the recommendation, the evidence behind it and how strong that evidence is, how it applies to this person, the alternatives including no treatment, and the likely benefits and risks. It also answers the worry behind the question. Explaining well is part of informed consent and keeps the decision with the client.
Key ideas
- Informed consent to therapy
- Psychologists inform clients as early as feasible about the nature and anticipated course of therapy, fees, involvement of third parties and limits of confidentiality, with time for questions (APA Ethics Code, Standard 10.01a; CPA Code, Principle I).
- Treatments still developing
- When generally recognized techniques and procedures have not been established, clients are told of the treatment's developing nature, potential risks, available alternatives and the voluntary nature of participation (APA Ethics Code, Standard 10.01b).
- Strength of evidence in plain numbers
- Say what kind of evidence supports the advice, such as replicated trials or a guideline, and give absolute figures. The number needed to treat, the inverse of the absolute risk reduction, is more meaningful for decisions than relative risk (Cook and Sackett, 1995).
- Answering the real worry
- A question often carries a fear about harm, stigma or cost. Shared decision making starts by supporting the person and eliciting their goals, then compares options openly (Elwyn and colleagues, 2017).
- Opinions to others
- Recommendations and opinions given to referrers, schools or courts rest on information and techniques sufficient to support them (Standard 9.01a), and reports include only information germane to their purpose (Standard 4.04a).
Worked example
The parents of an 11-year-old with Tourette disorder ask why the psychologist recommends the Comprehensive Behavioral Intervention for Tics (CBIT). They fear that teaching him to notice his tics will make them worse, and a relative has told them that holding tics in makes them 'rebound' later.
- State the recommendation and its evidence: in a randomized trial of 126 children aged 9 to 17, 52.5% of those receiving CBIT were much or very much improved, against 18.5% receiving supportive therapy and education (Piacentini and colleagues, 2010).
- Answer the fear of worsening with data: in that trial, tic worsening was reported for 4% of all the children, and 87% of available responders still showed benefit six months later.
- Address the rebound belief: in a small experimental study, tic rates after suppression ended were higher than during suppression but lower than at baseline, which argues against a rebound (Himle and Woods, 2005).
- Lay out the alternatives: a neurology guideline lists watchful waiting, CBIT and medication, chosen together after weighing benefits and harms (Pringsheim and colleagues, 2019). Then ask what they think.
A rationale answers the family's actual fear with evidence they can weigh and leaves the decision with them.
Check yourself
A psychologist proposes a treatment for which generally recognized techniques and procedures have not been established. Under the APA Ethics Code, what must the client be told beyond the usual elements of consent?
Sources
- American Psychological Association (2017), Ethical Principles of Psychologists and Code of Conduct (2002, amended 2010 and 2016), Standards 4.04(a), 8.01, 9.01(a), 10.01(a) and 10.01(b)
- Canadian Psychological Association (2017), Canadian Code of Ethics for Psychologists, Fourth Edition, Principle I, Respect for the Dignity of Persons and Peoples: informed consent
- Cook and Sackett (1995), The number needed to treat: a clinically useful measure of treatment effect, BMJ (PMID 7873954), Abstract
- Elwyn, Durand, Song and colleagues (2017), A three-talk model for shared decision making: multistage consultation process, BMJ (PMID 29109079), Results; team talk
- Piacentini, Woods, Scahill and colleagues (2010), Behavior therapy for children with Tourette disorder: a randomized controlled trial, JAMA (PMID 20483969), Abstract; results
- Himle and Woods (2005), An experimental evaluation of tic suppression and the tic rebound effect, Behaviour Research and Therapy (PMID 16159587), Abstract
- Pringsheim, Okun, Müller-Vahl and colleagues (2019), Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders, Neurology (PMID 31061208), Abstract; results