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

  • From: "Long, Stephen [Northport]" <Stephen.Long@xxxxxx>
  • To: "members1@xxxxxxxxx" <members1@xxxxxxxxx>, "Lemle, Russell" <russell.lemle@xxxxxx>, VHA Psychology Postdoctoral Training Directors <VHAPPTD@xxxxxxxxxxx>, VHA Psychology Internship Directors <VHAPID@xxxxxxxxxxx>, VHA National Psychology Chiefs <VHANationalPsychologyChiefs@xxxxxxxxxx>
  • Date: Thu, 23 Sep 2010 14:32:47 -0400

Hello, Chris.

Do you have more complete citations of those publications you mentioned?

I'm not having any luck finding them?

From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Crowe, Chris
Sent: Thursday, September 23, 2010 1:36 PM
To: members1@xxxxxxxxx; 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

A great question in and of itself. Luckily there is a literature that speaks to 
this.

*         Training in general principles does not result in sustainable change 
in clinical practices. Clinicians continue to do what they have done (Oxman et 
al. 1995).

*         Even competency training in an EBT without ongoing consultation 
drifts back to treatment as usual. (see Lockman et al 2009.)  And the outcome 
of the treatment as usual in this study was no better than control conditions.  
So if the clinicians internalized key principles it didn't make a difference in 
outcome.

*         Even if this approach did work, the science is not at the point of 
identifying which components (principles) in a given protocol are necessary and 
sufficient.


Terrific discussion.
Thanks.

From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Long, Stephen 
[Northport]
Sent: Thursday, September 23, 2010 12:57 PM
To: members1@xxxxxxxxx; 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

A continued, Aloha to all (from a different  island and a different  ocean  -- 
Long Island, NY in the beautiful Atlantic).

Kathleen's message is a example of why I have rejoined AVAPL.

This discussion is critically important.

The issues addressed in one of  Kathleen's questions are particularly salient:

"...Why [have] any particular treatments...[been] named as opposed to a more 
general principle being stated which would allow practitioners to base their 
practice (not their "treatments") on sound psychological tenets, seeking 
evidence which supports their practice (so the language about evidence-based 
would be explicitly included), and allowing the treatment to be 
patient-centered (which also should be explicitly stated) in the way that the 
IOM and the APA Reports indicated.

From: avaplmembers-bounce@xxxxxxxxxxxxx 
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of McNamara, Kathleen M.
Sent: Thursday, September 23, 2010 5:53 AM
To: Lemle, Russell; members1@xxxxxxxxx; VHA Psychology Postdoctoral Training 
Directors; VHA Psychology Internship Directors; VHA National Psychology Chiefs; 
members1@xxxxxxxxx
Subject: [AVAPL Members] Re: How to Improve the Implementation of 
Evidence-Based Psychotherapy in the VA

Aloha, All -
       I have been following the very cogent responses to Russell's initial 
e-mail on this topic, and have very much appreciated the depth of the 
discussion from many of you.  As those of you know who have heard me speak on 
this issue at the Leadership Conference and at the Convention VACO Meeting, I 
am less concerned about the fact that we are advocating for evidenced-based 
treatments (though I wish we were discussing evidenced-based practice), and 
much more concerned about the issues which others have also raised in this 
discussion since Russell's posting:  (1) transparency and the selection process 
for inclusion of the limited treatments which are explicitly named in the 
Uniform MH Services Handbook, and (2) implementation, more generally.  The 
first point on the limiting of those treatments which are explicitly named at 
this time again reached a level of concern for me as I was reviewing literature 
for the completion of a chapter I am writing for a book on Veterans Health 
Care, with a particular focus for my invited chapter being ethnic, racial and 
cultural factors in health care for veterans. The process of reviewing the 
literature pointed to the obvious fact that we have a peer-review process for 
journal publications that intends to provide us with the most scientifically 
sound evidence for various psychological issues - with treatments being among 
the issues in those refereed journals.  The review also highlighted the fact 
that the literature contains many studies which are examples of the differences 
across minority groups in the treatment provided, as well as the response to 
treatment.   So, the question raised in this e-mail discussion about how these 
particular treatments were included and others are not is a critical one for 
those of us in the practice arena to address. I consider the question a little 
more broadly:   why any particular treatments were named as opposed to a more 
general principle being stated which would allow practitioners to base their 
practice (not their "treatments") on sound psychological tenets, seeking 
evidence which supports their practice (so the language about evidence-based 
would be explicitly included), and allowing the treatment to be 
patient-centered (which also should be explicitly stated) in the way that the 
IOM and the APA Reports indicated.  With regard to the differences already 
noted in the literature for minority groups, the evidence is clearly not 
complete and not in published (refereed) form yet on the named treatments, and 
the National Center for PTSD - Pacific Islands Division has a number of very 
significant research studies on-going in this area.  So, I am looking forward 
to our discussion during the call this morning (afternoon for East Coast).
   The implementation concerns remain  significant areas about which the 
Psychology Leadership in the field need to be providing input and feedback to 
VACO.  I noted that Toni mentioned that the Handbook was undergoing revisions, 
and I hope that our call today addresses the language will be included so that 
there is a clearer statement of how the intent of having practice be based in 
psychological evidence can be achieved.  I look forward to hearing how the 
input from the various meetings and phone calls will be incorporated into the 
revision process.
    While the above issues would have priority, at some point (in a future call 
would be fine) it would be great to hear how VACO has followed up to work with 
APA President Carol Goodheart's  Task Force working on her Presidential 
initiative on Outcomes, what is being discussed in that Task Force and how the 
VA's input is being received.  Dr. Goodheart's invitation to have a 
representative from the VA working with that group is such a great opportunity 
to show that  VA  Psychology has much to offer and is often on the forefront of 
research such as this!
    I am eager to hear our discussion today, and again hope that the concerns 
about transparency and implementation of a broader concept of evidence-based 
practice are addressed.
     Aloha.

From: Lemle, Russell
Sent: Monday, August 02, 2010 11:22 AM
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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