Evidence-Based Therapies Encounter Difficulty Transitioning Into Practice

“Even if you build it, they won't necessarily come,” said Patricia Resick, Ph.D., director of the Women's Health Sciences Division of the National Center for PTSD and the Veterans Affairs Boston Healthcare System.

Developing and testing new treatments for substance abuse and comorbid mental illness are difficult enough. Finding ways to get them into practice to help U.S. troops and veterans is often a more frustrating step, according to Resick and other speakers at a conference last month on substance abuse and comorbidities among military personnel and veterans.

The conference, which was held in Washington, D.C., was sponsored by the National Institute on Drug Abuse.

Disseminating any therapy takes more than publishing a protocol in some prestigious journal. Several speakers discussed therapeutic approaches that had successfully survived extensive trials but had not yet been adopted widely.

For instance, Stephen Higgins, Ph.D., a professor of psychiatry at the University of Vermont, told of successful trials of contingency management—not exactly a therapy, but a tool to reinforce it. Contingency management combines behavioral counseling with real-world rewards (like retail-store vouchers or cash payments) to encourage treatment adherence. Rewards increase with success, but if a patient tests positive for drugs or misses an appointment, the payoffs drop back to starting levels.

Kathleen Carroll, Ph.D., director of psychosocial research in the Division of Substance Abuse at the Yale University School of Medicine and affiliated with the VA Connecticut Healthcare System, has adapted cognitive-behavioral therapy for use on a computer, with an emphasis on learning and coping skills. Computerized therapeutic systems can be standardized and used anywhere, making them accessible for highly mobile or geographically distant military populations, she said. The system, which can be easily translated into other languages, can function as a stand-alone therapy, as an adjunct to live treatment, as a booster, or as a standardized behavioral platform for psychopharmacological studies.

Family members of military personnel and veterans also need help. William Fals-Stewart, Ph.D., a professor in the School of Medicine at the University of Rochester, has been studying behavioral couples therapy (BCT) when substance use disorders are involved. Substance abuse is often intertwined with other problems in a relationship, he said. When it becomes the dominant problem, partners think that stopping substance abuse will make everything right again, but sobriety just brings the earlier problems back to the foreground.

“Behavioral couples therapy seeks to harness the power of the marriage to improve substance use treatment outcomes,” he said.

Fals-Stewart uses a mixture of techniques: a recovery contract with partners, communications skills training, conflict resolution, and a recovery/relapse prevention plan. The approach has resulted in improved outcomes not only in abstinence but also in increased relationship satisfaction and reduced violence. Children do not directly take part in behavioral couples therapy. But those whose parents have done so showed less depression, anxiety, and acting out, and the children were less often victims of abuse or neglect.

Despite this record, counselors complain that BCT is “too hard” to learn and takes “too long” to do, said Fals-Stewart. So he trained ex-addicts as counselors and found that their treatment outcomes were the same as those of credentialed professional providers. He tested the program for six sessions against the usual 12, and again the outcomes were similar.

Difficulty in expanding tested therapies into wider use is not an uncommon problem, said session discussant Bruce Rounsaville, M.D., a professor of psychiatry at Yale and director of the VA Connecticut-Massachusetts Mental Illness Research Education and Clinical Center.

“If they were drugs, they would have already passed the FDA's requirement for two pivotal clinical trials,” he said. Some of the approaches discussed could be mutually reinforcing.

Contingency management, for instance, might well enhance engagement and compliance with cognitive-behavioral therapy, medications, or behavioral couples therapy, said Rounsaville. Alternatively, behavioral couples therapy might increase the durability of contingency management programs. But adoption of these and other apparently useful treatments has been slow.

Resick has been more fortunate than most, because her work setting in the VA allows for the possibility of a systemwide adoption of a medical practice by administrative decision. She has been testing and refining cognitive processing therapy for PTSD since 1988. After she joined the VA health system in 2003, she was frequently invited to speak about the treatment. Eventually, she asked her boss, “Can't we do something more systematic?”

The VA had funds available at just that moment and was under pressure to help troops returning from fighting in Iraq and Afghanistan. Further discussion led to a pragmatic approach to rolling out the therapy to VA facilities, said Resick. It would require systematically training as many therapists as possible, with close follow-up to build a community that could provide support for therapists.

By June 2006 Resick and her colleagues had developed a version of the CPT training manual for active-duty and veteran patients, a trainer's manual, a consultant's manual, and videos. From July 2007 to April 2008, they rolled out the program, holding 22 training conferences. Consultants provided 25 hours a week of phone backup, and advanced lectures were provided over the Web.

So far, 2,185 VA and Department of Defense personnel have been trained. However, to be fully accredited on the VA's provider roster, a therapist must undergo the training, participate in 10 consultant calls to discuss cases, and treat four cases under supervision.

Besides continuing to train providers, Resick said that the VA will evaluate the program to assure quality and fidelity to protocols, develop electronic records templates, and monitor implementation in practice.

She realizes that she has been more fortunate than other research colleagues on the panel.

“I was the squeaky wheel at the right moment,” she said.

Trying to get new psychotherapies into practice is not a straightforward process, said Rounsaville. Clinical trials go in stages just like pharmaceutical trials but have a few added quirks.

“Even the best ideas need to be tested in real-world settings and not just in the controlled settings of early-stage clinical trials,” he said. “Also, evidence-based treatments are developed in narrow patient populations and require a large number of specific skills and techniques for one disorder. It's daunting to learn.”

Furthermore, any given treatment package may consist of a package of four or five general strategies, and it is hard to know whether all of them are needed for efficacy. Psychotherapy researchers talk of“ dismantling,” testing the individual components of a therapy until they figure out what works and what doesn't—and with whom. That takes added time and resources.

Therapists have to be trained, raising questions of which training regimen for which type of treatment works best with which kind of therapist. Another problem is finding trainers and supervisors, he said. “Manuals and one-shot classes don't work.”

Clinicians have their biases too, said Rounsaville. “It's hard to get people to not do something they've learned well and have practiced for years.”

Overcoming limited resources and inertia on every level to disseminate a new therapy won't be easy.

“It's a slow process,” he said. “Perhaps the best place to start applying new evidence-based treatments is with students just beginning their professional training.” ▪