[AVAPL Members] Re: How to Improve the Implementation of Evidence-Based Psychotherapy in the VA

  • From: "Kerns, Robert" <Robert.Kerns@xxxxxx>
  • To: "Adams, Kenneth (Ann Arbor)" <kmadams@xxxxxxxxxxxxx>, "members1@xxxxxxxxx" <members1@xxxxxxxxx>, VHA Psychology Internship Directors <VHAPID@xxxxxxxxxxx>, VHA Psychology Postdoctoral Training Directors <VHAPPTD@xxxxxxxxxxx>, VHA National Psychology Chiefs <VHANationalPsychologyChiefs@xxxxxxxxxx>, "Joan.Zweben@xxxxxxxx" <Joan.Zweben@xxxxxxxx>, "Armstrong, Keith" <Keith.Armstrong@xxxxxx>, "Lemle, Russell" <russell.lemle@xxxxxx>, V21SFC Psychologists <v21sfcpsychologists@xxxxxx>
  • Date: Wed, 4 Aug 2010 09:55:56 -0400

I want to speak out with a voice of strong support for the EBP initiative of 
the Office of Mental Health Services.  As a 32 year member of the VA psychology 
community, I have long been an advocate for Veterans' access to psychological 
treatments for which there is a strong empirical base that supports their 
efficacy.  I have been frequently dismayed at the failure of our system to 
assure that Veterans with anxiety disorders and depressive disorders, in 
particular, are offered behavioral, cognitive-behavioral, and interpersonal 
therapeutic interventions for which there is substantial evidence of efficacy, 
and even cost-effectiveness.  As a subtext, I'd like to see that this capacity 
building effort includes a focus on making these services available to Veterans 
as alternatives, and not just as complementary, to pharmacological approaches.  
Not surprisingly, I'd like to see a broadening of this initiative to include 
other domains of behavioral health, including pain management and sleep 
disorder treatment, to name just two examples.  

Of course, my strong support of EBM is not to mean that other psychological 
interventions with sufficient evidence should not be available.  However, I do 
believe that it is critical that our priority be to build our capacity to 
assure equitable access for Veterans to those therapies with the strongest 
empirical evidence.  I am enthusiastic about the VA's initiatives to expand the 
competencies of psychologists and others who can provide these interventions, 
and I am appreciative of OMHS's leadership in this regard.


Bob   


Robert D. Kerns, Ph.D.
National Program Director for Pain Management, Veterans Health Administration
Director, Pain Research, Informatics, Medical comorbidities, and Education 
(PRIME) Center, VA  
       Connecticut Healthcare System 
Professor of Psychiatry, Neurology and Psychology, Yale University

The PRIME Center/11ACSLG
Bldg 35A, Second Floor
VA Connecticut Healthcare System
950 Campbell Avenue
West Haven, CT 06516
Phone: 203-937-3841
Fax:  203-479-8126
Email: robert.kerns@xxxxxx

-----Original Message-----
From: Kenneth Adams [mailto:kmadams@xxxxxxxxxxxxx] 
Sent: Tuesday, August 03, 2010 7:11 PM
To: members1@xxxxxxxxx; VHA Psychology Internship Directors; VHA Psychology 
Postdoctoral Training Directors; VHA National Psychology Chiefs; 
Joan.Zweben@xxxxxxxx; Armstrong, Keith; Lemle, Russell; V21SFC Psychologists
Subject: [AVAPL Members] Re: How to Improve the Implementation of 
Evidence-Based Psychotherapy in the VA

Colleagues,

I want to own at least my fair share of the reflex response that we mental 
health and behavioral health providers do have when new fashions in care 
administration hit the (ground, fan, street ?, etc.). From sad experience, we 
have learned that our expertise doesn't count for (as) much compared to other 
"real" healthcare professions in the wider public. This is a general and 
historically justified Rodney Dangerfield complex Psychologists have a right 
to. 

But before indulging ourselves in the bathos of a hot-tub of pity; we should 
perhaps look at our colleagues, for example, in VA Dentistry. Their care 
discretion and options are sharply constrained by regulations promulgated by 
our ultimate employers, the American people as represented by Congress. It just 
must be hard on the heart of a VA Hygienist, Dentist or Oral Surgeon to know 
what must be done; but cannot be done. I must admit to remembering some years 
ago when one important element of an inpatient VA admission was really treating 
oral health; because nothing could be done in Dental Quarters as an outpatient. 

One could argue that our present regulatory environment with respect to care of 
all VA families is no less restrictive; with no less effect in our realm of 
care. 

But be that as it may.

In my opinion, in VA, Psychologists and Psychological practice have always been 
held in a higher regard. The company values what we do in ways that are not 
replicated in the private sector outside of the most prosperous care 
systems/entities. Even academic affiliates have often taken the expedient; if 
not more frankly the low road with respect to their honoring of the need for 
quality psychological assessment, treatment, and consultation services. 

At my own affiliate, The University of Michigan, when we owned our own managed 
care arm (M Care), we segregated access to all behavioral and mental health 
services from the regular portals of care; even unto not mentioning these 
services in the subscriber handbook, except in almost a footnote. Since the 
sale in 2007 of our M Care managed care arm to Blue Cross/Blue Shield of 
Michigan, there is no good change in that structure. I nominated this for the 
non-surprise of that year.

The point here, though, is that however much we may instinctively believe that 
the evidence based practice movement is designed (at least in part) to restrict 
services to veterans and strip professional judgment and options from us as a 
key caregiver community; this is not the case. At least with respect to what is 
going on with all realms of healthcare. 

Every aspect of care is being considered through this admittedly parallax view 
of cost versus patient health and welfare. One of the last areas that many 
would think subject to the "evidence based" standard is actually one of the 
first; namely surgery. Now this can be for a lot of incremental reasons in the 
VA. 
But evidence based practice governs not only surgical privileges, but also 
surgical performance and outcomes.

Now that may be because that - more than many medical specialties - doing bad 
surgeries gets noticed. But this is another conversation for another time. 

Now, in my opinion, if we get at the front of this parade we can begin to 
rightfully claim more of our heritage as a Scientist-Practitioner profession.  
Not just another professional practice tribe "just practicing".
You need reasons and evidence to support your claim to a unique role in VA.  
Otherwise, may I ask how what you do differs from a GS-11 staff social work 
colleague? Can you explain that? To your Chief of Staff? Your Director? 

I think that what Russell is asking is for the best and fuller expression and 
elaboration of EBP. That's reasonable on a prima facie basis. What he is also 
asking are challenging questions "at the point of the spear".
I'd like to appeal to our leaders to respond as a management and a care 
community. 

Finally, as an interesting (and at this point almost historical note) I offer 
the attached paper whose dateline is 1999.
Regarding that "new" development of evidence based practice.

We are not alone. 

With best regards,

Ken Adams
VA Ann Arbor


>>> "Burda, Philip C      (MIAMI VA)" <Philip.Burda@xxxxxx> 8/3/2010 4:15 PM >>>
I wonder how much of this emphasis on  "evidence based" therapies is political 
since most of these complexities would not be issues for non-mental health 
providers.  Requiring that VA staff provide Veterans only with "evidence based 
psychotherapy" would seem to be a very good thing to folks who are not well 
versed on the topics discussed here.  

 

From: Lemle, Russell
Sent: Tuesday, August 03, 2010 4:11 PM
To: 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC 
Psychologists; 'Joan.Zweben@xxxxxxxx'; Armstrong, Keith
Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA

 

I appreciate the numerous responses to my proposal, including a dozen private 
ones so far.  I encourage  continued discussion of these important issues.

Russell

 

From: Lemle, Russell
Sent: Monday, August 02, 2010 2:22 PM
To: 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC 
Psychologists
Subject: How to Improve the Implementation of Evidence-Based Psychotherapy in 
the VA

 

How to Improve the Implementation of Evidence-Based Psychotherapy in the
VA: Increase Transparency, Equitability and Efficacy

 

Since the San Antonio VA Psychology Leadership Conference in May, there have 
been a series of email exchanges about the direction of evidenced-based 
psychotherapy in the VA. I would like to further that discussion and raise 
several critical issues.

 

The utilization of EBPs within the VA is an unquestionably important goal. 
However, I am gravely concerned that some of the methods for reaching that goal 
are taking us in the opposite direction - i.e. toward the curtailment of VA 
clinicians' ability to choose from the broad array of effective evidence-based 
interventions. The difficulty started when the Uniform Mental Health Services 
Handbook embraced a narrow, limited subset of VA-preferred evidence-based 
psychotherapies (without revealing the criteria for their selection). The 
Handbook conveyed the implication that these specific treatments were the only 
ones that satisfied the standard of being "evidence-based." 

 

More significantly, a new VA policy -- RVU Productivity Incentives -- is being 
deliberated that would discourage the use of non-sanctioned treatments, 
including efficacious ones. From what I understand, this plan will grant 
clinicians 25% greater workload credit for rendering a VA-preferred 
psychotherapy than for rendering another psychotherapy of the same duration. If 
you use VA-preferred psychotherapies, you reach your annual productivity quota 
much quicker. That buys you time to do other activities and as someone with 
higher total workload numbers, you will be evaluated as being "more 
productive." Using other evidence-based treatments will result in having to 
work additional hours to attain your quota.

 

In my view, Productivity Incentives -- like some of the other methods of 
promoting EBP in the VA -- take us on an errant course. They purposely aim to 
increase the use of the few VA-preferred psychotherapies and curb all other 
approaches, including those with a strong evidence basis. Yet, it is clear from 
the research that there are many treatments beyond the officially sanctioned 
ones that are equally effective -- and sometimes superior -- for alleviating 
the target disorders and problems. In addition, attending to clinician and 
patient factors in treatment selection is well known to improve outcomes. When 
we can choose from a wider selection of psychotherapies, we are able to provide 
the most effective treatment for our patients. This was the conclusion of the 
APA's Task Force on Evidence-Based Psychotherapy.

 

I therefore propose that VACO champion the use of all evidence-based 
psychotherapy approaches and then let clinicians use their clinical judgment as 
to which treatment would be most effective. Four particular actions would 
enable that to occur:

1.     VACO should make transparent the specific "evidence-based"
criteria that were used to select the UMHS handbook psychotherapies and 
disseminated roll-outs (e.g. ACT, CBT, CPT, IBCT, PE, etc.).  

2.     This criteria should be equitably applied to all psychotherapies.
VACO should inform the field that every treatment -- whether or not mentioned 
in the UMHS Handbook -- that meets this standard would be explicitly endorsed 
as an equally suitable "Evidence-Based Psychotherapy."

3.     "Fidelity to Evidenced-Based Psychotherapy" and "Access to
Evidence-Based Psychotherapy" should be assessed for all psychotherapy 
treatments that meet the criteria, not just for disseminated treatments.

4.     Productivity incentives should be applied far more broadly than
just for using VA-preferred psychotherapies.   

I hope that these suggestions prompt continued dialogue about how VACO can 
promote the full armamentarium of evidence-based approaches.  

 

Russell Lemle, PhD

Psychology Director, San Francisco VA Medical Center

 

 

 

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