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

  • From: "Resick, Patricia A" <Patricia.Resick@xxxxxx>
  • To: "'members1@xxxxxxxxx'" <members1@xxxxxxxxx>
  • Date: Wed, 4 Aug 2010 09:56:28 -0400

I would like to make a small response to the comment below.  First, I can't 
speak to any of the other roll-outs on other disorders, but the PTSD 
treatments, CPT and PE, were developed and tested on very traumatized clients.  
They were never "much selected".  I would be happy to send you the articles on 
CPT so that you can see that for yourself.  Second, we do have some 
effectiveness data.  Kate Chard and her colleagues from the Cincinnati VA 
published CPT data across 31 different therapists (including trainees) from 
their outpatient clinic in a recent issue of the Journal of Traumatic Stress.  
They included data from everyone (101 veterans) who completed at least 1 
session of CPT, not just treatment completers.  On average the Vietnam veterans 
had a 20 point drop in their PTSD scores on the CAPS and the OEF/OIF veterans 
averaged a 40 point drop.  Like the Monson et al. clinical trial of CPT in VA, 
40% of the Vietnam veterans were PTSD negative at posttreatment.  The Monson et 
al. study did not include recent veterans.  This Chard et al. report indicated 
that 59% of the OIF/OIF veterans no longer met PTSD criteria at posttreatment.  
These are real clinical improvements that affect their functioning and lives.

Patricia A. Resick, Ph.D.

From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Tan, Gabriel
Sent: Tuesday, August 03, 2010 9:54 AM
To: members1@xxxxxxxxx; Zinnbauer, Brian, VHACIN; Bateman, Guy D.; Lemle, 
Russell; VHA Psychology Postdoctoral Training Directors; VHA Psychology 
Internship Directors; VHA National Psychology Chiefs
Subject: [AVAPL Members] Re: How to Improve the Implementation of 
Evidence-Based Psychotherapy in the VA

I fully agree and endorse Dr Lemle's position.

Sometimes we forget that controlled efficacy research typically utilizes a much 
selected groups of subjects and that efficacy does not equal effectiveness. If 
alternative therapies are not supported, we will inevitably discourage creative 
approaches which could develop into EBP of the future.


Gabriel Tan, PhD, ABPP
Psychologist, Pain Management Program
Anesthesiology Care Line, Michael E DeBakey VA Medical Center

Associate professor, Departments of Anesthesiology, Psychiatry and Behavioral 
Sciences, & Physical Medicine and Rehabilitation, Baylor College of Medicine



From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Junginger, John A.
Sent: Tuesday, August 03, 2010 8:13 AM
To: Zinnbauer, Brian, VHACIN; Bateman, Guy D.; Lemle, Russell; 
members1@xxxxxxxxx; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs
Subject: [AVAPL Members] Re: How to Improve the Implementation of 
Evidence-Based Psychotherapy in the VA

VACO's criteria for identifying evidence-based psychotherapies are pretty 
standard-no news there. The more heroic effort, IMO, is the one to standardize 
VA-sponsored training to help ensure adequate levels of treatment fidelity. 
Without that standardization of training, I don't see how we achieve those same 
levels of fidelity with evidence-based psychotherapies not included in the 
current roll-out.

So, while it may appear to be common sense to champion all evidence-based 
psychotherapies, I don't have a problem with special consideration given to 
those that we specifically train.

From: Zinnbauer, Brian, VHACIN
Sent: Tuesday, August 03, 2010 7:54 AM
To: Bateman, Guy D.; Lemle, Russell; 'members1@xxxxxxxxx'; VHA Psychology 
Postdoctoral Training Directors; VHA Psychology Internship Directors; VHA 
National Psychology Chiefs
Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA

I completely agree as well

Brian Zinnbauer, Ph.D.
Acting Chief, Psychology Program
Acting Director, Psychology Training Program
Assistant Chief, Homeless and Therapeutic Work Division
Cincinnati VAMC
office (859) 572-6777
cell (513) 266-1962



From: Bateman, Guy D.
Sent: Tuesday, August 03, 2010 8:53 AM
To: Lemle, Russell; 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training 
Directors; VHA Psychology Internship Directors; VHA National Psychology Chiefs
Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA

I strongly endorse Dr. Lemle's analysis and proposals.


Guy Dean Bateman, Ph.D.
Lead Clinical Psychologist
Mental Health Service Line
VAMC St. Cloud, MN
320-252-1670 ext. 6205

"A man dies when he refuses to take a stand for that which is true."  Martin 
Luther King, Jr.

From: Lemle, Russell
Sent: Monday, August 02, 2010 4:22 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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