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

  • From: "Zeiss, Antonette" <Antonette.Zeiss@xxxxxx>
  • To: "Lemle, Russell" <russell.lemle@xxxxxx>, <members1@xxxxxxxxx>, "VHA Psychology Postdoctoral Training Directors" <VHAPPTD@xxxxxxxxxxx>, "VHA Psychology Internship Directors" <VHAPID@xxxxxxxxxxx>, "VHA National Psychology Chiefs" <VHANationalPsychologyChiefs@xxxxxxxxxx>, "V21SFC Psychologists" <v21sfcpsychologists@xxxxxx>
  • Date: Mon, 9 Aug 2010 15:00:42 -0400

I appreciate Russell's thoughtful suggestions and the interest his
message has generated.  I have invited Russell to present his
suggestions verbally at the upcoming OMHS Update meeting this Friday at
APA, during the 1-3 session, and he has generously agreed to do so.  I
would like to use that time for him to review his ideas, for the group
to discuss VA efforts to disseminate and utilize evidence-based
psychotherapies, and for OMHS staff to discuss some pending plans on
this front.  I think this should be an interesting and mutually
informative discussion.

 

I look forward to seeing many of you at the meeting - 1-3 in the
Manchester Grand Hyatt, Elizabeth Ballroom F.  We have other important
topics on the agenda as well, and Jeff Burk also will have the 3-5 slot
to review Hybrid Title 38 updates.  Safe travels to San Diego.

 

Toni

 

Antonette.Zeiss, Ph.D. 

202 461-7347

Antonette.Zeiss@xxxxxx

 

From: Lemle, Russell 
Sent: Monday, August 02, 2010 5:22 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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