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

  • From: "Padin, Edgardo (VHACLE)" <Edgardo.Padin@xxxxxx>
  • To: <members1@xxxxxxxxx>
  • Date: Fri, 24 Sep 2010 12:08:23 -0400

Almost as if you have questions about the sanctity of the RCT Model?

 

From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Tan, Gabriel
Sent: Thursday, September 23, 2010 1:14 PM
To: members1@xxxxxxxxx
Subject: [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Based Psychotherapy in the VA

 

I concur with the points brought out by Kathy. I believe the
scientist-practitioner tradition should guide our decisions along with
the RCT model currently so popularly held as sacrosanct  by many.  

 

From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of McNamara,
Kathleen M.
Sent: Thursday, September 23, 2010 4:53 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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