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

  • From: "Mirch-Kretschmann, Susan" <Susan.Mirch-Kretschmann@xxxxxx>
  • To: <members1@xxxxxxxxx>
  • Date: Fri, 13 Aug 2010 11:38:08 -0700

Thank you - well said!

Sue

 

From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Junginger, John
A.
Sent: Tuesday, August 10, 2010 12:46 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: [AVAPL Members] 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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