It seems like we often fail to clearly differentiate between the Empirically Supported Treatments (ESTs) that are being rolled out and Evidence Based Practice. It would be wise for us to be attentive to the differences as we work to provide the best services possible. The attached 2005 APA Task Force report has been mentioned before and is worth reading if you aren't familiar with it. This report is excellent at attending to the balance needed in the arguments being made in this discussion. What seems to be clear to me (and others responding) is that we want to engage in Evidence Based Practice - not simply offer ESTs regardless of whether they are most appropriate for all veterans. Kristin J.P. Rodzinka, Ph.D. | Clinical Psychologist | MST Coordinator | Co-Director of Training, Psychology Internship Program | Dayton VA Medical Center | 4100 W. 3rd Street | Dayton, OH 45428 | (937) 268-6511 x1079 | Fax: (937) 267-5385 From: Burda, Philip C (MIAMI VA) Sent: Tuesday, August 03, 2010 4:16 PM To: Lemle, Russell; 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training Directors; VHA Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC Psychologists; 'Joan.Zweben@xxxxxxxx'; Armstrong, Keith Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy in the VA I wonder how much of this emphasis on "evidence based" therapies is political since most of these complexities would not be issues for non-mental health providers. Requiring that VA staff provide Veterans only with "evidence based psychotherapy" would seem to be a very good thing to folks who are not well versed on the topics discussed here. From: Lemle, Russell Sent: Tuesday, August 03, 2010 4:11 PM To: 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training Directors; VHA Psychology Internship Directors; VHA National Psychology Chiefs; V21SFC Psychologists; 'Joan.Zweben@xxxxxxxx'; Armstrong, Keith Subject: RE: How to Improve the Implementation of Evidence-Based Psychotherapy in the VA I appreciate the numerous responses to my proposal, including a dozen private ones so far. I encourage continued discussion of these important issues. Russell From: Lemle, Russell Sent: Monday, August 02, 2010 2:22 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