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VA Training in Evidence-Based Psychotherapies

VA Training in Evidence-Based Psychotherapies. Background. In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001)

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VA Training in Evidence-Based Psychotherapies

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  1. VA Training in Evidence-Based Psychotherapies VAPTC EBP Presentation

  2. Background • In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001) • The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004) • The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country VAPTC EBP Presentation

  3. Goals of VA Training in EBPs • To train VA staff from multiple disciplines in evidence-based psychotherapies • To augment psychotherapies already being offered in VA medical centers VAPTC EBP Presentation

  4. VA Dissemination and Trainingin EBPs • Cognitive Behavioral Therapy (CBT) for Depression • Acceptance and Commitment Therapy (ACT) for Depression • Cognitive Processing Therapy (CPT) for PTSD • Prolonged Exposure (PE) for PTSD • Social Skills Training (SST) for severe mental illness (SMI) • Integrative Behavioral Couple Therapy (IBCT) • Family Psychoeducation (FPE) • Behavioral Family Therapy (BFT) • Multi-Family Group Therapy (MFGT) VAPTC EBP Presentation

  5. EBP Presentations for Interns and Postdoctoral Fellows • VA EBP rollout training has been focused on staff • VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows VAPTC EBP Presentation

  6. Goals of these EBP Presentations • To provide a basic working knowledge of each of the rollout EBPs • To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement VAPTC EBP Presentation

  7. Limitations • This presentation will not provide equivalent training to the EBP rollouts • This presentation will not provide the skills to implement the treatment without further training and supervision VAPTC EBP Presentation

  8. Cognitive Processing Therapy CPT slides are adapted from a presentation by Kathleen M. Chard, Ph.D.

  9. COGNITIVE PROCESSING THERAPY (CPT) IS…

  10. FORMATS FOR CPT

  11. CPT IN THE VA

  12. A Focus on Cognitive Theory of PTSD

  13. A Focus on Cognitive Theory of PTSD

  14. A Focus on Cognitive Theory of PTSD

  15. SOCIAL COGNITIVE THEORY OF PTSD Beliefs Trauma ≈ 15

  16. ASSIMILATION - PRE-EXISTING POSITIVE BELIEFS It is a just world People can be trusted Beliefs Trauma I am in control I must have done something bad to deserve this ≈ It is my fault STUCK I could have prevented this 16

  17. ASSIMILATION - PRE-EXISTING NEGATIVE BELIEFS Trauma I am a bad person People cannot be trusted I deserved it I knew I shouldn’t have trusted him/her ≈ Beliefs STUCK See, I have no control I have no control over anything 17

  18. OVER-ACCOMMODATION I was unsafe Trauma I was powerless I am in control I have no control at all ≈ Beliefs STUCK The world is completely unsafe The world is safe 18

  19. ACCOMMODATION A bad thing happened to me Trauma I was unsafe I was powerless Good people do bad things Bad things happen to good people RECOVERY Beliefs I have power over many things, but not all things I can take steps to protect myself, but no one is 100% safe 19

  20. IDENTIFYING STUCK POINTS Undoing, (“if only, should have”) guilt or blame about trauma Conclusions, implications of trauma (“never, always, no one”, all re: 5 themes)

  21. Stuck points are usually: 21

  22. So what about emotions?

  23. So how does CPT work?

  24. RESEARCH ON CPT There have been four randomized clinical trials of CPT and several effectiveness studies. See the manual for the exact references. Randomized Clinical Trials • Rape victims (Resick et al., 2002, JCCP) • Child sexual abuse (Chard, 2005, JCCP) • Veterans (Monson et al., 2006, JCCP) • Rape and assault (Resick et al., 2008, JCCP) 24

  25. CAPS SEVERITY PRE- AND POST-TREATMENT (TREATMENT COMPLETERS)

  26. BDI SEVERITY PRE- AND POST-TREATMENT(TREATMENT COMPLETERS)

  27. CHARD (2007): EFFECTIVENESS OF CPT IN VA RESIDENTIAL PROGRAM • 7-week residential program • CPT conducted twice a week in individual and group treatment • 23 other hours of psych. programming • Pre-post data on 154 residents, 122 men and 32 women admitted as cohorts of 12 • Next slides compare this program with the RCT with veterans by Monson et al. (2006) Chard, Unpublished data

  28. CINCINNATI RESIDENTIAL PROGRAM * ** N= 140 77 142 61 139 73

  29. PCL (MADISON) AND CAPS (CINCINNATI) ACROSS ERAS Madison Cincinnati

  30. Some other findings of note… 1. Long-term follow-up of a clinical trial comparing CPT and PE. Patricia A. Resick, Lauren WilliamsRobert Orazem and Cassidy Gutner ISTSS & ABCT, Nov., 2005

  31. LONG TERM FOLLOW-UPS • Follow-up conducted at five+ years post-treatment (M= 6 yrs, range 5-10) • 171 women were in the intent-to-treat sample • We did not locate 25 and 3 were deceased • Of the 143 we located: 17 refused to participate (12%) 2 were located but were not appropriate • We conducted at least the diagnostic interviews on 124 and have complete assessments on 119 • 88% participation rate

  32. CPT AND PE “CROSS-SECTIONAL”(INTENT-TO-TREAT) CPT, N= 83 55 50 41 63 PE, N= 88 55 51 39 64

  33. CPT & PE ITT ON PTSD DIAGNOSIS AT PRE-TREATMENT AND LONG TERM

  34. COGNITIVE PROCESSING THERAPYSESSION BY SESSION Cognitive Processing Therapy Veteran/Military Version Resick, P. A., Monson, C. M., & Chard, K. M. (2008) Produced by VA Office of Mental Health, VA National Center for PTSD/ VA Boston Healthcare System and Cincinnati VA Medical Center

  35. CPT VERSUS CPT-C?FACTORS THAT INFLUENCE THE CHOICE • Patient may have a personal preference • More available research • Account writing and sharing full details might be therapeutic • Patient is wiling to write an account • Patient states he has little or no memory of the event due to avoidance (writing acct may help recover the details) • Time is not a factor • Therapist believes that the patient needs to express avoided emotions. • Patient may have a personal preference • Patient really has no recollection of the event • Patient refuses to write account • Impending redeployment/not enough time for full protocol • Therapist discomfort with written account component • Less overall time available, want more time to develop cognitive skills • Conceptualization of case warrants more cognitive restructuring • Conducting group therapy

  36. PROGRESSION THROUGH WORKSHEETS

  37. PHASE 1. PRE-TREATMENT ASSESSMENT ANDPRE-TREATMENT ISSUES

  38. PRE-TREATMENT ISSUES

  39. OTHER PRE-TREATMENT ISSUES:CPT FOR WHOM AND WHEN

  40. PRETREATMENT ISSUES- RATIONALE AND BUY-IN THERAPIST TASKS

  41. RECOMMENDED ASSESSMENT MEASURES

  42. STRUCTURING SESSIONS

  43. STRUCTURING SESSIONS (CONT.)

  44. PHASE 2. EDUCATION REGARDING PTSD, THOUGHTS, AND EMOTIONS

  45. SESSION 1. SYMPTOMS AND RATIONALE

  46. SESSION 1. SYMPTOMS AND RATIONALE

  47. SESSION 1. SYMPTOMS AND RATIONALE

  48. SESSION 2. IMPACT STATEMENT

  49. A-B-C Sheet Date: ___________ patient #: ______ ACTIVATING EVENT BELIEF CONSEQUENCE A B C“Something happens” “ I tell myself something” “I feel something” Is it reasonable to tell yourself “B” above? _____________________ _________________________________________________________ What can you tell yourself on such occasions in the future? ________________________________________ _____________________________________________________________________________

  50. SESSION 3. EVENTS, THOUGHTS & EMOTIONS

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