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

  • From: "Kimbell, Anne-Marie" <Anne-Marie.Kimbell@xxxxxx>
  • To: <members1@xxxxxxxxx>
  • Date: Wed, 11 Aug 2010 10:19:52 -0500

Would someone please provide information about this monthly Psychology 
conference call so that we will be able to call in? This is the first I have 
heard about this call.

Thank you!

Anne-Marie Kimbell

 

From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Burk, Jeffrey P.
Sent: Tuesday, August 10, 2010 7:38 PM
To: Nicholson, Karen J.; Junginger, John A.; Joan.Zweben@xxxxxxxx; Lemle, 
Russell
Cc: members1@xxxxxxxxx; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC 
Psychologists; Armstrong, Keith
Subject: [AVAPL Members] Re: How to Improve the Implementation of 
Evidence-Based Psychotherapy in the VA

 

I'll leave it to others to debate many of the issues presented in this e-mail 
chain. But I do want to comment on the issue of transparency.

Transparency is a two-way street. VACO can do (and frankly has done) a lot to 
answer the questions raised, but all of us have to do our part to hear the 
message. Most of these questions have been asked, answered, and discussed many 
times in many forums. If you're not dialing in to the monthly Psychology 
conference call (and typically only 30-50 of us do), then you're missing a 
wonderful opportunity to hear the latest news from and interact with VACO. If 
you don't go to the annual VA Psychology Leadership Conference (and fewer than 
200 of us do) or the VACO meeting at the annual APA Convention (and typically 
fewer than 75 of us do), then you're missing out on some great opportunities. 
We really do have to be in the forest to hear the tree fall.

Jeff

-------------------------- 
Sent from my BlackBerry Wireless Handheld 

 

________________________________

From: Nicholson, Karen J. 
To: Junginger, John A.; 'Joan.Zweben@xxxxxxxx' <Joan.Zweben@xxxxxxxx>; Lemle, 
Russell 
Cc: 'members1@xxxxxxxxx' <members1@xxxxxxxxx>; VHA Psychology Postdoctoral 
Training Directors; VHA Psychology Internship Directors; VHA National 
Psychology Chiefs; V21SFC Psychologists; Armstrong, Keith 
Sent: Tue Aug 10 19:24:57 2010
Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA 

I have read with great interest what seem to be increasingly stronger reactions 
to something that I believe started out as a call for greater 
clarity/transparency in the process that eventually identified the first five 
EBP rollouts. I have to confess that I have been tempted way before this to 
enter my opinion into the fray but the process of bringing in new interns to 
our program has been too time consuming to allow me to give in to the 
temptation.  What the heck—I’ll take a stab. Dinner can wait a bit. . .

 

I am not sure how these EBPs were identified exactly. What we know is that they 
are evidence based. I don’t think anyone has said anything is particularly 
wrong with evidence based practices or endorsing them. The problem that some 
have stated is that other EBPs might be overlooked. It seems simple enough to 
me that either the process was transparent or it wasn’t; only the committees 
who chose these will be able to put that argument to rest by providing 
information on how the decision came to be for those who want to know but 
somehow have not been so informed to date (including myself, I admit).

 

I agree that VACO has every right to develop special productivity measures to 
encourage their mental health staff to provide the best psychotherapeutic 
interventions for their veterans. However, I have to state here that I can’t 
think of anything more misguided than tying these therapies to awards to the 
therapists via “workload credits”. This would certainly invite interventions 
that have more to do with making money than what is actually the right choice 
for patients. In addition, although VACO seems to be spending all this money on 
these particular rollouts, the benefits (i.e., training opportunities) have not 
yet trickled down to many of us who have a great deal invested in our veterans’ 
therapy, not to mention what we invest in our training of future psychologists.

 

Regarding “cookie cutter” treatments, I disagree that this is a figment of 
psychologist’s imagination that incites us to cry out like Chicken Little about 
the sky falling when it is really blue with puffy clouds. I know I have 
witnessed investments in manualized treatments and trainings that have 
certainly given short shrift to the therapeutic relationship. It is something 
which I have experienced in many newly trained, recent graduates of doctoral 
programs. That is, they have been taught a great deal about specific techniques 
but much less about how to handle those patients who don’t fit neatly into the 
box or how to develop the rapport that might help the patient engage in an EBP 
about which they are ambivalent. That’s what (I think) some folks in the mental 
health field are concerned about and have seen first-hand, especially when 
training new folks coming into internship programs now—the lack of critical 
thinking about the relational aspect of the therapeutic enterprise. Indeed, one 
of the interns I trained recently confessed that none of her supervisors has 
ever asked her how she felt about any of her patients or explored her emotional 
reactions with respect to the therapy. I hate to add that I started asking and 
noted that she was not alone in this lack of experience. So, this is very 
disheartening to me—“proficiency” in examining patient’s automatic thoughts but 
no thoughts given to interpersonal process at all. 

 

I am all about changing with the times to provide the greatest degree of relief 
from suffering for our veterans. Maybe that’s why it seems insulting that those 
who are engaging in dialogue that questions whether we are headed in the 
“right” direction or have some misgivings about what seems like an avalanche of 
support for a limited number of treatments are being seen as anti-research or 
anti-change. That doesn’t seem quite fair, especially in a profession that 
prides itself on critical thinking, especially as it applies to research 
review. 

 

I hope the dialogue can remain open. I’m not sure this is going to be easy. I 
already caught myself saying “ouch” out loud several times, empathizing with 
Russell Lemle and others who followed, calling to light what they see as flaws 
in this particular system. I appreciate their efforts to clarify the thinking 
behind these initiatives.

 

Karen 

 

Karen Nicholson, Ph.D.

Staff Psychologist

Assistant Director of Training,

Psychology Internship Program

James A Haley Veterans Hospital

13000 Bruce B. Downs Blvd. #116B

Tampa, FL  33612

813-972-2000 ext. 6726

 

 

 

 

From: Junginger, John A. 
Sent: Tuesday, August 10, 2010 3:46 PM
To: 'Joan.Zweben@xxxxxxxx'; Lemle, Russell
Cc: 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC 
Psychologists; Armstrong, Keith
Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA

 

It seems to me that VACO has every right to develop special productivity 
measures, both in recognition of the additional effort involved in 
administering EBPs and as an incentive for their adoption by local sites. The 
thing is, if you’re going to put this kind of time, effort and $ into what many 
of us see as an extremely worthwhile initiative, you’d better have some carrots 
in place to make participation immediately worthwhile for the service 
providers. 

 

As for Dr. Zweben’s other points:

 

·         I don’t have a good enough sense of the collaborative process to 
comment, but the process certainly has been transparent—at least from our lofty 
view here in Central Iowa. If that’s not the opinion of others, then maybe 
another summary of the selection process in this forum would be helpful.

·         CBT, PE, CPT, ACT & SST all have solid empirical support—no mystery 
there, …and this from a person who loves a good mystery. Thus, the statement 
that treatments with weak evidence were selected while others with strong 
evidence were omitted seems a bit misleading. Which EBPs with similarly strong 
empirical support were overlooked?

·         Hard to argue with any proposal of a multi-site effectiveness study 
conducted on VA populations for a variety of EBPs. But, honestly, how realistic 
is that? Patricia Resick briefly reviewed for us last week the compelling 
evidence for CPT for Veterans with PTSD, so that’s one bit of relevant 
information that should not be ignored in these exchanges. I also think it’s an 
arguably small leap-of-faith to expect demonstrably positive outcomes with the 
other EBPs included in the VACO rollout given their strong empirical support 
for other populations. 

*       The MH profession never did degenerate to “cookie cutter” treatment, so 
there’s really no risk of returning; it’s one of those bogeymen we’re often 
warned about, but which never seem to appear. Maybe more to the point, EBPs are 
nothing if not “individualized.” That is, their parameters, elements of focus 
and treatment paths are continually adjusted to fit the characteristics of the 
problem being addressed. Don’t know how this cookie cutter myth took hold, but 
it’s time to dismiss it out-of-hand.
*       I can see how an emphasis on empirically supported treatments might be 
inferred as a de-emphasis on the therapeutic relationship. But (and I’m going 
out on a limb here), has any of us ever heard an EBP advocate dismiss the 
therapeutic relationship? Really? If anything—and this certainly was true of 
the VACO EBP rollout last year in Nashville—EBP advocates seem to go out of 
their way to acknowledge its importance. So, while I’m willing to admit that 
maybe I haven’t noticed some slights to the therapeutic process, they must have 
been few and far between and clearly are not representative of evidence-based 
philosophy or policy.

 

VACO’s EBP rollout mostly is a “Bang for the Buck” proposition (wouldn’t you 
say?) And, as with all such propositions, it’s easy to second guess the 
numerous decisions that had to be made. That can be useful, but only to the 
extent that it helps move along the effort to deliver EBPs to our Veterans.

 

John

 

From: Joan E. Zweben, Ph.D. [mailto:Joan.Zweben@xxxxxxxx] 
Sent: Monday, August 09, 2010 8:44 PM
To: Lemle, Russell
Cc: members1@xxxxxxxxx; VHA Psychology Postdoctoral Training Directors; VHA 
Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC 
Psychologists; Armstrong, Keith
Subject: Re: How to Improve the Implementation of Evidence-Based Psychotherapy 
in the VA

 

Dear Colleagues,

I am writing to urge delay and open discussion of proposed RVU Productivity 
Incentives that would discourage the use of a broad range of efficacious 
treatments that have not been officially sanctioned.  Crucial steps in the 
science appear to have been omitted.  These include describing current outcomes 
as a baseline, conducting effectiveness studies to examine whether the list of 
treatments selected actually improve outcomes significantly for the VA patient 
population, and an examination of whether the level of improvement warrants the 
costs of implementation.  Instead, it appears that the push for implementation 
goes beyond what is supported by the research. I am in support of Russell 
Lemle’s proposal to include a wide range of efficacious treatments until these 
basic parameters have been established.  

 

I have been a part time substance abuse psychologist at the San Francisco VAMC 
for over 35 years.  In the rest of my work life, I am the Executive Director of 
East Bay Community Recovery Project in Oakland.  EBCRP has been part of NIDA’s 
Clinical Trials Network since 2002.  I have been on the CTN National Steering 
Committee throughout that time and am currently its Co-Chair.  Throughout my 
long career, I have published both books and articles intended to foster the 
utilization of research findings by clinicians.  This is a topic near and dear 
to my heart, and I am very concerned about the direction the VA has taken.  
Here are my concerns:

 

*       The process was neither collaborative nor transparent.  This is 
guaranteed to create many problems in implementation, not the least of which is 
undermining confidence whether treatment outcomes will actually be improved.

 

*       Treatments with weak evidence were selected while others with strong 
evidence were omitted.  Without transparent criteria and an open process, the 
rationale is mysterious and there is too much room for personal preferences of 
the decision makers.

 

*       To my knowledge, there are no multi-site effectiveness studies 
conducted on VA populations for the designated treatments, so we don’t know 
much about the level of improved outcomes that can be expected.  In general, 
effectiveness is reduced when treatments are implemented in real world 
situations, and in many case, the effect sizes in the random assignment studies 
are modest.  How was it determined that the effect sizes were worth the 
transition costs?

 

*       The “pick from this list” approach stifles innovation and rigidifies 
the treatment system.  It can promote a return to cookie-cutter treatment, 
rather than individualized treatment.

 

*       It appears that no attention has been given to the consistent research 
finding that the therapeutic relationship has a more powerful influence than 
any specific intervention in determining outcomes.

 

The key question remains, how will we know if we will get better outcomes than 
some programs get now?

 

An alternative approach is to look at our current outcomes, determine which 
programs have the best outcomes (excluding the possibility to significant 
differences in patient characteristics) and examine what they are doing that is 
working. A clear understanding of program strengths and weak spots also allows 
administrators and clinical staff to select from the array of evidence-based 
interventions or treatments to bring improvement in needed areas.  NIATx 
(www.NIATx.net <http://www.niatx.net/> ) offers a simple process to help 
program units identify problems, make a plan for improved services, evaluate 
and fine tune that plan.

 

I also suggest including experts such as William R. Miller, Ph.D., Tom 
McLellan, Ph.D., and Dean Fixsen, Ph.D. if this has not already been done.  
They have vast experience looking at the implementation of EBPs in the 
community and would have much wisdom to contribute to this process.

 

Sincerely,

 

Joan Zweben, Ph.D.

Staff Psychologist, San Francisco VAMC

 

Executive Director

East Bay Community Recovery Project; Oakland, CA.

 

Clinical Professor of Psychiatry, University of California, San Francisco.

 

         

         

 

-- 
Joan E. Zweben, Ph.D.
714 Spruce Street
Berkeley, CA 94707
 
Phone: (510) 526-4442
Fax: (510) 527-6842

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