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