Chapter X. Professional Affairs (Part 2)
WHEREAS the health care system in this country has been dramatically transformed in the last decade from a patient-focused system with an emphasis on the provision of adequate services to a market-driven system increasingly concerned about the cost of providing care to the nation's citizenry;
WHEREAS this transformation has been extremely far-reaching in its influence on all aspects of the health care delivery system and on all communities of interest, including health care professionals and purchasers and consumers of health care services;
WHEREAS all aspects of the profession of psychology are being affected by the changing health care system, including its practices, the education and training of psychologists, related research directions and psychology's objective of promoting human welfare;
THEREFORE BE IT RESOLVED That APA declares the changing health care system's impact on psychology and the public, with all its resulting challenges and opportunities, to be a matter of the highest priority and concern for the entirety of the Association.
WHEREAS "Serious mental illness" (SMI) has been defined by the Center for Mental Health Services (CMHS) in accordance with PL 102 321 (1992) to help identify those people who may receive mental health services from states under federal block grants; and that they are people who "have a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified by DSM IV, and that has resulted in functional impairments which substantially interfere with or limit one or more major life activities"; and whereas "severe emotional disturbance" refers to those mental illnesses with similar impact on children and adolescents;
WHEREAS the CMHS definition includes any mental disorders in DSM III or IV with exception of the "T codes, substance use disorders and developmental disorders, unless they co occur with another diagnosable SMI; and that all SMIs have episodic, recurrent or persistent features but vary in terms of severity and disabling effects; and that functional impairment is defined as difficulties that substantially interfere with or limit role functioning in one ore more major life activities including basic daily living skills (e.g., eating, bathing, dressing), instrumental living skills (e.g., managing money, maintaining a household, taking prescribed medication, or functioning in social, family, and vocational/educational contexts) and that adults who would have met the functional impairment criteria during the year without the benefit of treatment or other support services are considered to have a serious mental illness;
WHEREAS the Center for Mental Health Services reports that 5.4 million or 2.7 percent of the adult population have a "severe and persistent" mental illness, such as schizophrenia, bipolar disorder or major depression; and that more than 3 million children and adolescents have a severe emotional disturbance that undermines their present functioning and imperils their future (National Advisory Mental Health Council, 1990);
WHEREAS recovery from serious mental illness, once thought impossible, is being documented in research and demonstrated by the productive lives of an increasing number of recovered and recovering people who are open about their experience (Jamison, 1995; DeSisto, Harding, McCormack, Ashikaga, & Brooks, 1995); and there are many diverse paths through recovery (Bassman, 1997; Frese & Davis, 1997; Harding, Brooks, Ashikaga, Strauss, & Breier, 1987); and no one should be excluded from the possibility of a positive outcome or from services or education which would maximize recovery;
WHEREAS stigma and discrimination are most damaging to recovery and can unjustifiably foreclose opportunities for employment, housing, education, and other services;
WHEREAS the tendency of the lay public as well as some mental health professionals to define individuals as an illness or diagnosis and to use pejorative and dehumanizing terms contribute to the loss of hope, dignity, and self respect;
WHEREAS to be effective facilitators of recovery, it is essential for psychologists to understand how stereotypic and stigmatizing language, attitudes, and behaviors can demean and devalue people with mental illness and have an adverse impart on multiple aspects of functioning, such as self concept, relationships, self¬ esteem, self efficacy, and performance;
WHEREAS the Americans with Disabilities Act (ADA) protects people with mental disabilities and covers psychological training and employment; whereas in selecting applicants to psychology training programs and in hiring psychologists with a mental disability, the issue should be whether individuals can perform the work with reasonable accommodation; and whereas psychology training programs should be careful not to discriminate solely based on the fact or suspicion that students carry a diagnosis of mental illness, but rather to consider their potential to become proficient professionals and their possible future contributions to the field, taking note of the special insight, understanding, and practical experience they bring to their work;
THEREFORE BE IT RESOLVED:
that APA support efforts to eliminate stigma and discrimination against people with serious mental illness and children and adolescents with severe emotional disturbance, and to counter the negative attitudes and expectations that are often internalized by clients;
that APA, as stipulated in its Publication Manual, encourage psychologists to maintain the integrity of individuals as human beings by avoiding language that equates persons with their conditions (e.g., "the schizophrenics") and by using person first language in their publications (e.g., "people with schizophrenia");
that APA, in accordance with the spirit and requirements of the ADA, encourage state psychology boards to examine their state licensing requirements for the mental health disciplines to ensure that candidates for licensure are not disqualified solely on the basis of a diagnosis of mental illness;
that APA draft appropriate recommendations to assist psychology programs in screening, training, providing reasonable accommodation as needed, and when necessary, dismissing undergraduate and graduate students with mental disabilities in accord with the spirit and requirements of the ADA.
Bassman. R. (1997). The mental health system: Experiences from both sides of the locked doors. Professional Psychology: Research & Practice, 28, 238 242.
Bedell, J.R., Hunter, R.H. & Corrigan, P.W. (1997). Current approaches to assessment and treatment of persons with severe mental illness. Professional Psychology: Research & Practice. 28, 217 228.
Coursey, R.D., Alford, J., & Safarjan, W. (1997). Significant advances in understanding and treating serious mental illness. Professional Psychology: Research & Practice, 28, 205 216.
DeSisto, M. J., Harding, C.M., McCormack, R.V., Ashikaga, T., & Brooks, G.W. (1995). The Maine and Vermont three decade studies of serious mental illness. British Journal of Psychiatry, 167, 331 342.
Frese, F.J. & Davis, W.W. (1997). The consumer/survivor movement, recovery, and consumer professionals. Professional Psychology: Research & Practice, 28, 243 245.
Harding, C.M., Brooks, G.W., Ashikaga, T., Strauss, J.S., & Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, 1: Methodology, study sample and overall status 32 years later. American Journal of Psychiatry. 144, 718 725.
Jamison, K. R. (1995). An unquiet mind: A memoir of moods and madness. NY: Alfred A. Knopf.
Marsh, D.T., & Johnson, D.L. (1997). The family experience of mental illness: Implications for intervention. Professional Psychology: Research & Practice, 28, 229 237.
National Advisory Mental Health Council. (1990). National plan for research on child and adolescent mental disorders (DHHS Publication No. ADM 90 1683). Washington, DC: US Government Printing Office.
WohIford, P. (1994). National perspectives on clinical training for psychological services. In D.T. Marsh (Ed.), New directions in the psychological treatment of serious mental illness (pp. 3 20). Westport, CT: Praeger.
Practice parameter: Screening and diagnosis of autism
Criteria for evaluating treatment guidelines
Criteria for practice guideline development and evaluation
Policy on challenges to the doctoral standard for psychology
Encouragement and assistance to State Psychological Associations (SPAs) and state licensing boards to move to single level doctoral licensure.
Active consulting to SPAs in states that have dual level licensure.
Encourage the recognition of individuals holding terminal masters degrees in psychology under existing or new state statutes, provided that such statutes do not recognize, regulate or govern the title or practice of psychology, and do not use the term “psychological” in defining the title or scope of practice for such persons.
Convening exploratory meetings focusing on issues involving education, training and credentialling, at the Consolidated meetings with the Board of Directors, Committee for the Advancement of Professional Practice, Board of Professional Affairs, Board of Educational Affairs, American Psychological Association of Graduate Students, the Association of State and Provincial Psychology Boards and other relevant groups.
Health service psychologists as primary health care providers
APA reaffirms its commitment to the designation of health service psychologists as primary health care providers in relevant federal, state, and local regulations, and in federal funding programs designated for primary care practitioners. APA views this as a long-term goal in pursuit of which a variety of actions have already been undertaken and will continue to be undertaken as strategic openings and opportunities can be made available.
WHEREAS outpatient civil commitment (OCC) is increasingly used in courts and civil commitment venues across the country (Swartz & Monahan, 2001);
WHEREAS people with serious mental illness and resulting psychological disabilities are the individuals most subject to imposition of involuntary mental health services, including OCC (Swartz & Monahan, 2001);
WHEREAS people with such disabilities have the same rights to personal liberty as other citizens (Stefan, 2001);
WHEREAS psychological disabilities may impair the ability of individuals to appreciate threats to their well-being, placing them at risk for homelessness, incarceration, premature death, suicide, and vulnerability to violence (Swartz & Monahan, 2001);
WHEREAS there is heated controversy about the legitimacy of OCC, the criteria by which it should be applied, the relevant clinical methods and standards of professional practice, and the relative value of alternatives (Petrila, Ridgely & Borum, 2003);
WHEREAS people with behavior disorders severe enough to reach the dangerousness criterion should have access to psychological and behavioral interventions designed to treat the specific behaviors (Spaulding, Sullivan & Poland, 2003);
WHEREAS key issues concerning OCC can be effectively addressed through application of the principles of psychological science and the findings of psychological and psycholegal research (Spaulding, Poland, Elbogen & Ritchie, 2000);
WHEREAS people with serious mental illness have a right to the resources and services generated by psychological research and practice (Van Houton, Axelrod, Bailey & Favell, 1988);
WHEREAS all people have a right to the opportunity for recovery, namely, full participation in society to the best of their ability (Stefan, 2001);
WHEREAS issues regarding OCC, and broader issues of services for people with serious mental illness, will only be resolved in the context of a comprehensive, accessible, and responsive system of care that focuses on improved quality of life rather than mere symptom reduction (Petrila, Ridgely & Borum, 2003);
WHEREAS a key ingredient in recovery from serious mental illness is making choices for oneself and developing skills necessary to make those choices (Anthony and Liberman, 1992);
WHEREAS clinical application of psychological methods (including neuropsychological, behavioral, sociocognitive, and functional assessments and interventions) hold substantial promise for enhancing skill development, including skills relevant to recovery from serious mental illness and skills relevant to making competent personal choices (Spaulding, Sullivan & Poland, 2003);
WHEREAS resolution of controversies regarding OCC will require consideration of people’s rights; their uniqueness and diversity; the disabilities associated with serious mental illness; and the sometimes competing values of personal liberty, public safety, and the public’s interest in providing for those who cannot provide for themselves (Petrila, Ridgely & Borum, 2003);
WHEREAS women and members of minority racial and ethnic groups are especially vulnerable to discrimination in adjudication and treatment related to involuntary incarceration and treatment (Stefan, 1996);
WHEREAS women and members of minority racial and ethnic groups tend to receive less or lower quality mental health services (Thornicroft, Davides & Leese, 1999);
WHEREAS members of other stigmatized groups may also be vulnerable to discrimination in adjudication and treatment related to involuntary incarceration and treatment;
WHEREAS involuntary treatment raises special concerns about gender, ethnic or minority status, or membership in other stigmatized groups for the practitioner (Mindell, 1993; Baker, 1999);
WHEREAS it is the role of mental health scientists and practitioners to advocate for due process and appropriate legal representation and counsel, to advise the court through briefs or testimony, and to seek therapeutic benefits in application of the law (Daicoff & Wexler, 2003);
WHEREAS mandating involuntary mental health services is a legal, not a clinical process; except in cases of dire emergency, it is never the role of any mental health practitioner, of any discipline, acting in the role of caregiver, to make decisions that infringe upon a person’s right to consent to services. Moreover, as specified in the APA Ethics Code, psychologists are required to respect the rights of individuals to self-determination and autonomy, and to act in accordance with the requirements for informed consent to therapy and related procedures.
THEREFORE BE IT RESOLVED that psychologists should continue to promote and engage in development of evidence-based clinical methods for determining risk and dangerousness, including risk associated with accepting or not accepting mental health services.
BE IT FURTHER RESOLVED that psychologists should continue to promote and engage in development of clinical methods for determining competence to make specific judgements and decisions, including decisions about whether to accept and/or participate in mental health services.
BE IT FURTHER RESOLVED that psychologists should continue to promote and engage in development of clinical methods for reversing the disabilities of serious mental illness and enhancing recovery, including those disabilities that incur risk and dangerousness, as well as those disabilities that compromise competent decisions and choices about accepting and/or participating in mental health services.
BE IT FURTHER RESOLVED that when people with mental illness exhibit dangerous behavior, psychologists trained in the direct treatment of behavioral dysfunction can enhance positive outcomes by providing consultation and treatment for the specific behaviors.
BE IT FURTHER RESOLVED that psychologists should continue to promote and engage in development of clinical methods that help people participate to the maximum extent in legal processes that affect their lives.
BE IT FURTHER RESOLVED that psychologists should continue to promote and conduct rigorous research on the interaction of clinical and legal processes, with the objective of making those processes maximally accessible to and beneficial for people with serious mental illness.
BE IT FURTHER RESOLVED that psychologists should continue to promote and conduct rigorous research on the various forms of and alternatives to involuntary commitment, including OCC, limited guardianship, and advance directives, to determine their relative costs, outcomes, and benefits.
BE IT FURTHER RESOLVED that psychologists should continue to promote and engage in development of clinical assessment methods that address and inform the legal processes that mandate involuntary mental health services, and should promote development of legal processes that make optimum use of information generated by psychological assessments.
BE IT FURTHER RESOLVED that psychologists should continue to support and promote social policy that ensures accessibility of services that enhance recovery, including comprehensive biopsychosocial rehabilitation, for all people, regardless of gender or membership in racial, ethnic or other stigmatized and vulnerable groups.
BE IT FURTHER RESOLVED that psychologists should continue to support and promote professional training and education in the treatment of serious mental illness, including the ethical, clinical, and legal considerations involved in involuntary services, and the impact of gender or membership in racial, ethnic or other stigmatized and vulnerable groups.
BE IT FURTHER RESOLVED that psychologists should continue to support and promote public education and other strategies for eliminating the prejudice and stigmatization of serious mental illness, including public attitudes related to involuntary services.
BE IT FURTHER RESOLVED that psychologists should continue to support and promote consumer empowerment, citizen advocacy, collaboration, and other strategies for enhancing the role of people with serious mental illness in mental health services, policy, and law.
BE IT FURTHER RESOLVED that psychologists should continue to participate, as scientists, practitioners, educators and citizens, in the ongoing public discourse that weighs competing values and imperatives in formulation of law and social policy about involuntary mental health services.
BE IT FURTHER RESOLVED that psychologists should continue to vigorously promote the view that involuntary services and related infringements on individual liberty can only be mandated through legal processes, not by mental health professionals acting as caregivers. However, psychologists also should assertively provide professional expertise and consultation to legal and judicial authorities in order to ensure that legal processes and decisions are appropriately informed by scientific and clinical considerations.
Allen, M. & Smith, V.F. (2001). Opening Pandora’s box: The practical and legal dangers of involuntary outpatient commitment. Psychiatric Services, 52, 342-346.
Anthony, W. A., & Liberman, R. P. (1992). Psychiatric Rehabilitation. In R. P. Liberman (Ed.), Handbook of psychiatric rehabilitation (pp. 95-126). New York: Macmillan.
Baker, K. (1999) The importance of cultural sensitivity and therapist self-awareness when working with mandatory clients. Family Process 38, 55-67.
Daicoff, S. & Wexler, B. (2003) Therapeutic jurisprudence. In A. Goldstein (ed.) Handbook of psychology: Forensic psychology, Vol. 11 (pp. 561-580).
Mindell, J. (1993) Issues in clinical psychology. Madison WI: Wm. C. Brown.
Morse, S. J. (1987). Treating crazy people less specially. West Virginia Law Review, 90, 353-385.
Munetz, M.R. & Frese, F.J. (2001). Getting ready for recovery: Reconciling mandatory treatment with the recovery vision. Psychiatric Rehabilitation Journal, 25, 35-42.
Petrila, J., Ridgely, M.S. & Borum, R. (2003) Debating outpatient commitment: Controversey, trends and empirical data. Crime and Delinquency 49: 157-172.
Reisner, R., Slobogin, C., & Rai, A. (1999). Law and the mental health system: Civil and criminal aspects (3rd ed.). St. Paul, MN: West Group.
Ridgely, M.S., Borum, R., & Petrila, J. (2001). The effectiveness of involuntary outpatient treatment: Empirical evidence and the experience of eight states. Santa Monica, CA: RAND.
Saks, E. R., & Behnke, S. H. (1999). Competency to decide on treatment and research: MacArthur and beyond. Journal of Contemporary Legal Issues, 10, pp. 103-129.
Schopp, R. F. (2001). Competence, Condemnation, and Commitment: An Integrated Theory of Mental Health Law. Washington, D.C.: American Psychological Association.
Schopp, R. F. (2003). Outpatient civil commitment: A dangerous charade or a component of a comprehensive institution of civil commitment? Psychology, Public Policy, and Law, 9, 33-69.
Spaulding, W., Johnson, D., & Coursey, R. (2001). Combined treatments and rehabilitation of schizophrenia. In M. Sammons & N. B. Schmidt (Eds.), Combined treatments for mental disorders (pp. 161-190). Washington DC: American Psychological Association.
Spaulding, W., Poland, J., Elbogen, E., & Ritchie, J. (2000). Therapeutic juripsrudence in psychiatric rehabilitation. Thomas M. Cooley Law Review, 17, 135-170.
Spaulding, W., Sullivan, M., & Poland, J. (2003). Treatment and rehabilitation of severe mental illness. New York: Guilford.
Steadman, H.J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., & Robbins, P.C. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52, 330-336.
Stefan, S. (1996) Issues relating to women and ethnic minorities in mental health treatment and law. In B. Sales & D. Shuman (eds.) Law, mental health, and mental disorder. Belmont, CA: Brooks Cole (pp.240-278).
Stefan, S. (2001) The Americans With Disabilites Act and its impact on mental health systems. In S. Stefan (ed.) Unequal rights: Discrimination against people with mental disabilites and the Americans With Disabilites Act. Washington DC: American Psychological Association.
Swartz, M. & Monahan, J. (2001) Special Section on Involuntary Outpatient Commitment: Introduction. Psychiatric Services 52: 323-324.
Swartz, M.S., Swanson, J.W., Hiday, V.A., Wagner, H.R., Burns, B.J., & Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52, 325-329.
Thornicroft, G., Davides, S. & Leese, M. (1999) Health service research and forensic psychiatry: A black and white case. International Review of Psychiatry 11, 250-257.
Van Houton, R., Axelrod, S., Bailey, J. & Favell, J. (1988) The right to effective behavioral treatment. Journal of Applied Behavior Analysis 21: 381-384.
Wallace, C.J., Liberman, R.P., Kopelowicz, A., & Yaeger, D. (2001). Psychiatric Rehabilitation. In Gabbard, G.O. (Ed.), Treatment of Psychiatric Disorders, 3rd Edition (pp. 1093-1112). Washington: American Psychiatric Publishing Co.
Winnick, B. (2003) Outpatient commitment: A therapeutic jurisprudence analysis. Psychology, Public Policy & Law 9:107-144.
Determination and documentation of the need for practice guidelines
Evidence-based practice in psychology
Evidence-based practice in psychology1 (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.2 This definition of EBPP closely parallels the definition of evidence-based practice adopted by the Institute of Medicine (2001, p. 147) as adapted from Sackett and colleagues (2000): “Evidence based practice is the integration of best research evidence with clinical expertise and patient values.” The purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention.
Best Research Evidence
Best research evidence refers to scientific results related to intervention strategies, assessment, clinical problems, and patient populations in laboratory and field settings as well as to clinically relevant results of basic research in psychology and related fields. A sizeable body of evidence drawn from a variety of research designs and methodologies attests to the effectiveness of psychological practices. Generally, evidence derived from clinically relevant research on psychological practices should be based on systematic reviews, reasonable effect sizes, statistical and clinical significance, and a body of supporting evidence. The validity of conclusions from research on interventions is based on a general progression from clinical observation through systematic reviews of randomized clinical trials, while also recognizing gaps and limitations in the existing literature and its applicability to the specific case at hand (APA, 2002). Health policy and practice are also informed by research using a variety of methods in such areas as public health, epidemiology, human development, social relations, and neuroscience.
Researchers and practitioners should join together to ensure that the research available on psychological practice is both clinically relevant and internally valid. It is important not to assume that interventions that have not yet been studied in controlled trials are ineffective. However, widely used psychological practices as well as innovations developed in the field or laboratory should be rigorously evaluated and barriers to conducting this research should be identified and addressed.
Psychologists’ clinical expertise encompasses a number of competencies that promote positive therapeutic outcomes. These competencies include a) conducting assessments and developing diagnostic judgments, systematic case formulations, and treatment plans; b) making clinical decisions, implementing treatments, and monitoring patient progress; c) possessing and using interpersonal expertise, including the formation of therapeutic alliances; d) continuing to self-reflect and acquire professional skills; e) evaluating and using research evidence in both basic and applied psychological science; f) understanding the influence of individual, cultural, and contextual differences on treatment; g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; and h) having a cogent rationale for clinical strategies. Expertise develops from clinical and scientific training, theoretical understanding, experience, self-reflection, knowledge of current research, and continuing education and training.
Clinical expertise is used to integrate the best research evidence with clinical data (e.g., information about the patient obtained over the course of treatment) in the context of the patient’s characteristics and preferences to deliver services that have a high probability of achieving the goals of treatment. Integral to clinical expertise is an awareness of the limits of one’s knowledge and skills and attention to the heuristics and biases--both cognitive and affective--that can affect clinical judgment. Moreover, psychologists understand how their own characteristics, values, and context interact with those of the patient.
Patients’ Characteristics, Values, and Context
Psychological services are most effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences. Many patient characteristics, such as functional status, readiness to change, and level of social support, are known to be related to therapeutic outcomes. Other important patient characteristics to consider in forming and maintaining a treatment relationship and in implementing specific interventions include a) variations in presenting problems or disorders, etiology, concurrent symptoms or syndromes, and behavior; b) chronological age, developmental status, developmental history, and life stage; c) sociocultural and familial factors (e.g., gender, gender identity, ethnicity, race, social class, religion, disability status, family structure, and sexual orientation); d) environmental context (e.g., institutional racism, health care disparities) and stressors (e.g., unemployment, major life events); and e) personal preferences, values, and preferences related to treatment (e.g., goals, beliefs, worldviews, and treatment expectations). Some effective treatments involve interventions directed toward others in the patient’s environment, such as parents, teachers, and caregivers. A central goal of EBPP is to maximize patient choice among effective alternative interventions.
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.3 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.
American Psychological Association. (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57, 1052-1059.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.
An expanded discussion of the issues raised in this policy statement, including the rationale and references supporting it, may be found in the Report of the 2005 Presidential Task Force on Evidence-Based Practice, available online at http://www.apa.org/practice/ebpreport.pdf.
To be consistent with discussions of evidence-based practice in other areas of health care, we use the term patient to refer to the child, adolescent, adult, older adult, couple, family, group, organization, community, or other populations receiving psychological services. However, we recognize that in many situations there are important and valid reasons for using such terms as client, consumer or person in place of patient to describe the recipients of services.
For some patients (e.g., children and youth), the referral, choice of therapist and treatment, and decision to end treatment are most often made by others (e.g., parents) rather than by the individual who is the target of treatment. This means that the integration of evidence and practice in such cases is likely to involve information sharing and decision-making in concert with others.
Guidelines for psychological practice with girls and women
Record keeping guidelines
Reclaim the distinctiveness of the term "psychology"
Authors of APA communications and publications are strongly encouraged to use the terms “psychology,” “psychological” and “psychologists” when referring specifically to the activities of psychologists. However, in many contexts, good judgment may determine that alternative terms be used. The aim of this motion is to reclaim the distinctiveness of the term psychology, not to be divisive with fellow health-care professions. Of course, in other contexts outside of APA, such as clinical work, psychologists may well use generic terms.
Avoid use of generic terms (e.g., clinician, intervention, therapy, assessment) in professional communications when referring to psychologists and psychological activities.
Use generic terms only as necessary in public information publications to introduce concepts to consumers. Use “psychological” terms in subsequent references as often as possible.
Employ generic terms in only those situations referring to the activities of members of multiple mental health professions.
Adopt brand recognition of psychology; for example, “psychotherapy” in place of “therapy,” “psychological disorder” in place of “disorder,” “psychological assessment” or “neuropsychological assessment” (as appropriate) in place of “assessment,” “psychological treatment” in place of “treatment,” and “psychological counseling” in place of “counseling.”
APA principles for health care reform
Everyone should have coverage that provides affordable health care for all basic services.
Basic health care services eliminate the artificial distinction between “mental” and “physical” health, recognize the inseparable relationship between mental and physical well being, and offer access to treatment for “mental health conditions” equivalent in all respects to access for “physical health conditions”.
Basic health care services include the psychological treatment of physical conditions in order to maximize rehabilitation and quality of life.
Basic health care services include appropriate prevention services that address the role that behavior plays in seven out of the ten leading causes of mortality and morbidity.
Criteria for the evaluation of quality improvement programs and the use of quality improvement data
Guidelines for child custody evaluations in family law proceedings
INTRODUCTION: The traditional view of serious mental illness, especially psychotic disorders, is that they have at best a stable course with chronic disability and poorer-than-premorbid functioning, and at worst a chronic deteriorating course. As a result, treatment has typically focused on symptom reduction and relapse prevention, and has been characterized by low expectations with little focus on issues such as living environment, relationships, work, and education. This is now changing. A wealth of data now indicate that the majority of people with serious mental illness eventually improve significantly over time, and can have independent lives that include striving for personal meaning and enhanced quality of life through active efforts in the above domains (e.g., relationships, work), regardless of whether symptoms are present or not. Moreover, research indicates that these areas are important sources of self-esteem for consumers, and are some of their most highly rated goals for treatment. In addition, federal and state agencies are now recommending that the paradigm for treatment of serious mental illness shift away from symptom-oriented care, to this more comprehensive view of how treatment can be envisioned. This new vision for foci of treatment, informed by long-term outcome data suggesting that it is realistic, has been labeled recovery-oriented treatment. It is important to note that the concept of recovery-oriented care does not assume a specific etiology for serious mental illness, nor does it recommend or contraindicate any specific treatments. Rather, it is a vision for a person-based approach to treatment, and a method of treatment delivery that is sensitive to consumer-defined goals and recognizes the need to at tend to a range of psychological factors (e.g., identity, self-esteem) as part of an expanded definition of what a positive outcome represents. In the resolution below, a detailed set of points is reviewed to clarify the definition of, and rationale for, the concept of “recovery.” This is followed by recommendations regarding how APA can help to promote this concept and thereby influence both how treatment is provided and the outcomes that are achieved.
WHEREAS as noted in the APA Resolution on Stigma and Discrimination against People with Serious Mental Illness and Severe Emotional Disturbance (1999), the Center for Mental Health Services reports that 5.4 million or 2.7 percent of the adult population has a "severe and persistent" mental illness, such as schizophrenia, bipolar disorder or major depression;
WHEREAS the Center for Mental Health Services (CMHS, 1993), in accordance with PL 102 321 (1992), has defined serious mental illness (SMI) as “a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified by DSM-IV, and that has resulted in functional impairments which substantially interfere with or limit one or more major life activities;”
WHEREAS, as stated in the APA Resolution on Stigma and Discrimination against people with Serious Mental Illness and Severe Emotional Disturbance (1999), the CMHS definition further notes that “functional impairment is defined as difficulties that substantially interfere with or limit role functioning in one or more major life activities including basic daily living skills (e.g., eating, bathing, dressing), instrumental living skills (e.g., managing money, maintaining a household, taking prescribed medication, or functioning in social, family, and vocational/educational contexts) and that adults who would have met the functional impairment criteria during the year without the benefit of treatment or other support services are considered to have a serious mental illness;”
WHEREAS, APA has previously endorsed a resolution on Stigma and Discrimination against People with Serious Mental Illness and Severe Emotional Disturbance (1999);
WHEREAS, a proficiency which contains language clearly expressing a recovery orientation in the Assessment and Treatment of Serious Mental Illness has been recognized by APA;
WHEREAS the concept of “recovery” is a core theme in the President’s New Freedom Commission Report (2003), which states that: 1) “the system is not oriented to the single most important goal of the people it serves-the hope of recovery;” 2) “the system should foster recovery, resilience, and independence;” and 3) “Research and personal testimony confirm that “recovery from mental illness is real: there are a range of effective treatments, services, and supports to facilitate recovery;”
WHEREAS recovery has been defined as “A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993);
WHEREAS the process of recovery includes “that people overcome the effects of being a mental patient - including rejection, poverty, substandard housing, isolation, unemployment, loss of valued social roles and identity, loss of sense of self and purpose in life, and the iatrogenic effects of involuntary hospitalization, medication and other treatments - in order to retain, or resume, some degree of control over their lives” (Davidson, O’Connell, Tondora, Staeheli, & Evans, 2005);
WHEREAS recovery involves “a redefinition of one’s illness as only one aspect of a multi-dimensional sense of self capable of identifying, choosing, and pursuing, personally meaningful goals and aspirations despite continuing to suffer the effects and side effects of mental illness” (Davidson, et al., 2005);
WHEREAS the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a National Consensus Statement on Mental Health in which it defined recovery as a "journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential" (SAMHSA, 2005);
WHEREAS the Department of Veterans Affairs is changing its regulations and practice standards to implement recovery-oriented care;
WHEREAS the Department of Justice is promoting recovery-oriented care;
WHEREAS the Joint Commission has incorporated standards that address recovery oriented services for persons with severe mental illness;
WHEREAS the National Association of State Mental Health Program Directors (NASMHPD) issued a report supporting recovery-oriented care in 2004 (NASMHPD/NTAC, 2004);
WHEREAS states, agencies, and other organizations have published guidelines for recovery-oriented care (e.g., Connecticut DMHAS, 2006; Onken, Dumont, Ridgway, Dornan, & Ralph, 2002; Sainsbury Centre for Mental Health, 2004; Young, Forquer, Tran, Starzynski, & Shatkin, 2000);
WHEREAS, as noted in the APA Resolution on Outpatient Civil Commitment (2004), all people have a right to the opportunity for recovery, namely, full participation in society to the best of their ability;
WHEREAS numerous longitudinal research studies indicate that the majority of people with SMI can improve their functional status and move into valued social roles (e.g., spouse, employee, student) over time (e.g., Bleuler, 1978; Ciompi, 1980; DeSisto, Harding, McCormick, Ashikaga, & Brooks, 1995a,b; Harding, Brooks, Ashikaga, Strauss, & Breier, 1987; Harrow et al., 2005; Huber, Gross, & Schuttler, 1975; Huber, Gross, Schuttler, & Linz, 1980; Jablensky, Sartorius, Ernberg, Anker, Korten, Cooper et al., 1992; Ogawa, Miya, Watarai, Nakazawa, Yuasa, & Utena, 1987; Sartorius, Jablensky, & Shapiro, 1977; Tsuang, Woolson, & Fleming, 1979);
WHEREAS these longitudinal data supporting recovery from SMI are consistent with findings that even people diagnosed with schizophrenia who have spent years in state hospitals and are considered treatment-refractory can be discharged to live back in the community after receiving intensive social-learning based inpatient services (Corrigan & Liberman, 1994; Paul & Lentz, 1977; Silverstein, Wong, Wilkniss, Bloch, Smith, Savitz, et al., 2006);
WHEREAS short term outcome data (1-2 years) also support the idea that recovery is possible (Edwards, Maude, McGorry, Harrigan, & Cocks, 1998; Gitlin, Nuechterlein, Subotnik, Ventura, Mintz, Fogelson, et al., 2001; Maslin, 2003; Loebel, Lieberman, Alvir, Mayerhoff, Geisler, & Szymanski, 1992; Whitehorn, Richard, & Kopala, 2004);
WHEREAS converging data on positive long-term outcomes of people with serious mental illness, and on the personal meanings of recovery have come from countries all over the world (Cohen, Patel, Thara, & Gureje, 2008; Jablensky et al. 1992; Ng, Pearson, Lam, Law, Chiu, & Chen, et al. 2008; Sartorius et al. 1977; Warner, 1983);
WHEREAS despite the general similarities in outcomes and subjective experiences related to recovery in different countries, cultural variation in the expression of serious mental illness and attitudes towards serious mental illness exist, and these must be taken into account in conceptualizing and implementing recovery-oriented care for individual persons;
WHEREAS recovery for some individuals or groups involves religious coping as a way to maintain control of their lives (Yangarber-Hicks, 2004). Research has shown that patterns of religious coping differ between ethnic groups (Bhui et al., 2008);
WHEREAS life challenges associated with recovery are common human experiences that require resilience. Resilience across cultures involves resolving tensions in relationships and cultural adherence (Ungar et al., 2007). Resilience is “...both a characteristic of the individual…and a quality of …environment which provides the resources necessary for positive development despite adverse circumstances” (Ungar et al., 2007);
WHEREAS the “research and clinical literature on resilience has focused largely if not exclusively on individual personality traits and coping styles, and has neglected to explore all possible sources and expressions of resilience in individuals and groups. For many ethnic minorities, traditional notions of resilience, shaped largely by middle class European and North American values, may not capture culturally more familiar modes of positive adaptation to adverse and traumatic experience” (Tummala-Nara, 2007);
WHEREAS research indicates that recovery is not an inevitable outcome of SMI, but that it is a function of the availability of comprehensive and coordinated psychological interventions (e.g., Harding et al., 1987b);
WHEREAS despite the existence of evidence-based practices, there are often environmental barriers to accessing potentially beneficial services. Moreover, the research literature suggests that these disparities are more severe for minorities and people of lower socioeconomic status, and that general disparities in health care lead to people with SMI dying, on average, 25 years earlier than expected. In addition, women with schizophrenia are more likely to have experienced severe trauma (e.g., physical or sexual abuse) and to have comorbid post-traumatic stress disorder, and therefore to be at risk for especially poor outcomes and further comorbidity (e.g., substance abuse) if this is not diagnosed and treated;
WHEREAS although most people with SMI will experience a significant improvement in functioning over the long term, some people will need long-term intensive treatment and supports and continue to experience significant disability; even in these cases, however, recovery-oriented principles, such as shared decision making, and a focus on multiple dimensions of outcome may improve quality of life;
WHEREAS most discussions of recovery focus on subjective experience as the domain that is most critical for promoting recovery, the extent of recovery is likely to be significantly affected by community and societal values regarding mental illness, and the extent to which people undergoing a process of recovery are accepted as valued members of their communities and the society at large.
WHEREAS as noted in the APA Resolution on Outpatient Civil Commitment (2004), a key ingredient in recovery from serious mental illness is making choices for oneself and developing skills necessary to make those choices (Anthony & Liberman, 1992);
WHEREAS as noted in the APA Resolution on Outpatient Civil Commitment (2004), clinical application of psychological methods (including neuropsychological, behavioral, sociocognitive, and functional assessments and interventions) holds substantial promise for enhancing skill development, including skills relevant to recovery from serious mental illness and skills relevant to making competent personal choices (Spaulding, Sullivan, & Poland, 2003);
WHEREAS recovery-oriented interventions such as supported employment, supported housing, and supported education have demonstrated greater effectiveness than traditional interventions for people with SMI (Drake & Bellack, 2005; Mueser, Clark, Haines, Drake, McHugo, Bond, et al., 2004);
WHEREAS the integration of psychological interventions with interventions seen as paradigmatic of recovery can lead to outcomes that are superior than with either intervention alone (e.g., cognitive rehabilitation, when added to supported employment, significantly improves vocational outcomes for people with SMI compared to supported employment alone) (McGurk, Mueser, Feldman, Wolfe, & Pascaris, 2007);
WHEREAS recovery-oriented care is consistent with evidence-based treatment (Bond, Salyers, Rollins, Rapp, & Zipple, 2004; Frese, Stanley, Kress, & Vogel-Scibilia, 2001);
WHEREAS psychologists are well qualified by training and experience, as well as well positioned in both service delivery and policy development roles, to promote such transformation and champion the adoption of recovery-oriented services, including training staff in, and delivery of recovery-oriented interventions in mental health settings;
WHEREAS research conducted by psychologists has identified psychological constructs that are involved in the recovery process (e.g., hope, self-efficacy, self-determination, empowerment, changing personal narratives) (e.g., Lysaker, Lancaster, & Lysaker, 2003; Roe 2001, 2003), and that can form the basis for more effective psychological therapies;
WHEREAS reliable and valid assessment instruments to assess individual staff members on the extent to which they have adopted a recovery orientation, and to assess agencies’ growth towards recovery oriented services, are now increasingly used (e.g., Campbell-Orde, Chamberlin, & Leff, 2005; Chinman, Young, Rowe, Forquer, Knight, & Miller, 2003; O'Connell, Tondora, Croog, Evans, & Davidson, 2005; Ridgway & Press, 2004);
WHEREAS recovery is now routinely the subject of books; articles in scientific journals in the fields of psychology, nursing, and psychiatry, articles in consumer-oriented publications such as Schizophrenia Digest, and papers given at local, national, and international conferences;
WHEREAS the American Psychological Association has yet to develop or issue a position on the concept of recovery as it applies to SMI;
THEREFORE BE IT RESOLVED that the American Psychological Association (APA) endorses the concept of recovery as it applies to SMI.
BE IT FURTHER RESOLVED that APA will issue a position statement noting this endorsement, and that this statement will be actively promulgated to the public and appear on the APA website.
BE IT FURTHER RESOLVED that APA will work toward increasing the attention to promoting data-driven views on the realities of long-term outcomes for people with serious mental illness, and to the importance of consumer-defined and community reintegration-centered goals in conceptualizing treatment, in graduate and post-graduate training.
BE IT FURTHER RESOLVED that psychologists be encouraged to continue to promote the development, implementation, and rigorous evaluation of recovery-oriented services.
BE IT FURTHER RESOLVED that, consistent with the principles of recovery, that these efforts involve consumer input and other forms of active collaboration with consumers.
BE IT FURTHER RESOLVED that psychologists be encouraged to support and promote staff training and public education efforts designed to increase awareness of recovery-oriented concepts and treatment.
BE IT FURTHER RESOLVED that psychologists be encouraged to support and promote efforts at stigma reduction, with the understanding that the extent of recovery is partly a function of the degree to which people with SMI are accepted as valued individuals in their communities.
BE IT FURTHER RESOLVED that psychologists be encouraged to conduct further research on the outcomes of recovery-oriented interventions.
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Cohen, A., Patel, V., Thara, R., & Gureje, O. (2008). Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin, 34, 229-244.
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Connecticut Department of Mental Health and Addiction Services (2006). Practice guidelines for recovery-oriented behavioral health care. Retrieved from http://www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf, February 1, 2008.
Corrigan, P. W., & Liberman, R. P. (1994). Behavioral therapy in psychiatric hospitals. New York: Springer.
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Model Act for State Licensure of Psychologists (PDF, 111KB)
Guidelines for psychological evaluations in child protection matters
Guidelines for psychological practice in health care delivery systems
Guidelines for the evaluation of dementia and age-related cognitive change
(Also included in Section XII: Public Interest.)
Guidelines for the practice of parenting coordination
Specialty Guidelines for Forensic Psychology
Specialty Guidelines for Forensic Psychology (PDF, 146KB)
Also see the in-progress clinical treatment guidelines development.
Guidelines for prevention in psychology
Guidelines for prevention in psychology (PDF, 495KB)
Guidelines for psychological practice with older adults
Guidelines for the practice of telepsychology
About the Council Policy Manual
This is Chapter X (Part 2) of the Council Policy Manual, which contains the current policies of the American Psychological Association. The organization of the manual follows the same major subject headings and sequence that is used in the agenda books of the Council of Representatives. Council actions are listed in chronological order with the earliest dated policies coming first. For more information, visit the Council Policy Manual table of contents.