Realizing the Promise: Strategic Dissemination and Implementation of CBT in Public and Private Health Care Systems

Although considered the gold standard psychological treatment for many mental and behavioral health conditions, Cognitive Behavioral Therapy (CBT) continues to be delivered at rates far below what research and expert recommendations suggest. Indeed, recent estimates suggest that as few as 5 percent of individuals with depression or anxiety receive CBT or other evidence-based psychotherapy (EBP). Despite the enduring under-use of CBT and other EBPs, psychopharmacotherapy for depression and anxiety has witnessed a dramatic increase in recent years.

We have strongly held that the enduring science-to-practice that has befallen CBT and other EBPs and prevented these treatments from taking center stage and achieving their true potential is in significant part due to limited focus on strategic implementation. Within clinical psychology, in particular, there has been a preoccupation on developing efficacious interventions, with almost no historical focus on the methods or mechanisms for how to implement treatments and promote their uptake (Karlin, in press).

Recognizing the need and opportunity for more fully realizing the potential of CBT and other EBPs, and the need to strategically address implementation process and context, the Department of Veterans Affairs (VA) has worked to implement, through a strategic process, more than 15 EBPs in what represents the nation’s largest implementation of EBPs now spanning over 13 years. This dissemination and implementation initiative, which has, in part, included the training of more than 11,000 staff in one or more EBPs, has been guided by a national, multi-level model accounting for barriers and facilitators at policy, provider, local systems, patient, and accountability levels (Karlin & Cross, 2014). Program evaluation results from this initiative reveal EBP training and implementation has been associated with large improvements among therapists, including improvements in therapist competencies and positive attitudes toward EBPs, and robust improvements in symptoms and quality of life among Veterans. Overall, these findings have provided for significant optimism for the feasibility and effectiveness of broad dissemination and implementation of EBPs and have suggested that the large science-to-practice divide no longer needs to be so wide and enduring.

Invigorated by the progress and impact of EBP dissemination and implementation in VA and the challenge of extending EBP implementation and systems change to other systems, particularly in the private sector where EBP dissemination and implementation has been more limited, we have held great interest and optimism for extending this work to other systems. Following the experience and impact of EBP dissemination and implementation in VA, Kaiser Permamente (KP), one of the nation’s leading health care providers serving more than 12.2 million members in eight states and the District of Columbia, elected to embark on a pilot initiative to promote the availability and delivery of EBPs, beginning in one region of the KP system. This initiative provides an opportunity to gain additional experience with and to evaluate whether EBP implementation would yield similar improvements in a private health care system context. Beginning with an initial pilot, which was subsequently expanded, we have worked to develop an initiative to disseminate and implement CBT for depression and co-occurring anxiety tailored to the KP system. This includes the development of a competency-based Kaiser Permanente CBT for Depression (CBT-D) Training Program tailored to the KP health care system and designed to serve as a self-sustaining system for promoting and sustaining CBT-D capacity, as well as system-level supports to promote successful implementation. Training included participation in a 2.5-day experientially-oriented workshop (foundational training) followed by participation in small-group, telephone-based consultation led by an expert CBT-D Training Consultant to promote full competency development and facilitate local implementation. Evaluation results reveal that training in and implementation of CBT within the KP system were associated with large increases in therapist preparedness to deliver CBT, including significant improvements in CBT knowledge, positive attitudes, and confidence and large improvements in general and specific CBT competencies, as well as clinically significant improvements in both depression and anxiety among patients, with results comparable to those experienced in VA. Although all participating clinicians were licensed mental health providers (many of whom expressed specific interest in CBT), few demonstrated minimum competency in CBT at the outset of training, further underscoring the need for competency-based training and strategic implementation of CBT. By the end of the training, all KP therapists trained achieved CBT competency. Furthermore, training led to significant improvements in overall skills as a therapist in addition to CBT-specific skills.

Significantly, an important and unique characteristic of the KP initiative involved careful emphasis on the individualization of training and treatment to maximize engagement and outcomes among therapists and patients, while also maintaining high fidelity to the CBT model. The significance of individualization – for engaging both therapists and patients – is something we (and those we have trained and treated) have come to increasingly appreciate in overseeing the training and treatment of many therapists and patients over the years and that we believed to be even more important in a very busy, private health care system like KP. As part of the individualized process of training, each training consultant completed a Therapist Progress Report for each therapist that addressed collaboratively identified strengths and weaknesses (baseline), specific training goals (baseline and updated at midpoint), and progress and opportunities for additional development (midpoint and end of training consultation). The individualization of treatment includesplacing important emphasis on the therapeutic alliance, a case conceptualization approach to treatment (including both cognitive and behavioral formulations to guide treatment), ongoing feedback to inform clinical decision-making, a focus on co-occurring anxiety, which is common among KP members, and use of a consistent session structure that prioritizes problems, fosters obtaining of feedback, includes an action plan for implementing and practicing a CBT skill, and increases the likelihood that progress is made toward the patient’s treatment goals.

Although early in the process, the competency achievement rate of 100% among KP therapists compares very favorably to rates of competency attainment CBT training and implementation initiatives in public and private health care systems reported in the literature. We believe this is likely related to the significant focus on providing an individualized training experience to each therapist and to personalizing treatment application so that treatment is not seen or delivered in manner that is overly-rigid and that respects and promotes clinical decision-making and broad therapy skills.

Reflecting the overarching goal of establishing internal and self-sustaining CBT training and clinical capacity,the initiative has also included the development of extensive training and clinical materials for supporting sustainability and expansion. This includes a comprehensive KP CBT-D Therapist Manual (Brown & Karlin, 2017), which includes the full treatment protocol, case examples and dialogue, and all patient and provider forms and worksheets for implementing the treatment), as well as a CBT-D Training Consultant Manual and a CBT Training Consultant Rating Scale developed through an expert consensus process for rating and providing feedback to Training Consultants on their leading of training consultation sessions. Moreover, selected clinicians from the initial training cohort have been successfully trained to become internal KP CBT-D Training Consultants and have trained their first cohort of CBT-D training participants. Additional actions for promoting ongoing sustainability include the development of structured Peer Consultation groups (following formal training consultation groups) and the creation of a CBT-D Specialty Clinic—a designated work unit of CBT-D clinical champions with specific characteristics designed to facilitate the delivery of an episode of care and intended to make the treatment a more formal part of the treatment structure.

Finally, beyond the training and clinical impact, there are now data demonstrating CBT to yield cost offset, claims that in past years could be made inferentially for making a business case for CBT though required direct empirical examination to truly demonstrate. Recent research within KP found CBT for depression to be associated with a more than 90% probability of being cost effective over a 1 and 2 year period (Dickerson et al., 2018). This adds to research within the VA health care system documenting service and cost-offset of approximately 30-40% among Veterans receiving EBPs for PTSD (Myers et al., 2013; Tuerk et al., 2013).

In short, the experience with the KP CBT-D dissemination and implementation initiative is highly encouraging and provides additional support for CBT training and implementation in real-world settings, extending past work in public systems to the private system context. In light of the great need that exists to increase EBP delivery and mental health care quality across many private and public health care systems, it is essential that greater attention and resources be devoted to developing and deploying methods for broad scaling and sustaining of EBPs that include and maintain the integrity and essential elements of effective implementation. It is then will we be able to fully realize the promise of evidence-based, patient-centered, and feedback-informed mental health care.

Discussion Questions

  1. How can we promote individualization in EBP training and treatment for promoting engagement among clinicians and patients?
  2. How can we rapidly disseminate and implement EBPs across many public and private systems while also retaining the critical (and often labor intensive) elements of competency-based training and effective implementation?

ABOUT THE AUTHORS

Bradley E. Karlin, PhD, ABPP is Vice President and Chief of Mental Health and Aging at the Education Development Center, as well as Adjunct Associate Professor in the Department of Mental Health, Bloomberg School of Public Health at Johns Hopkins University. He is a Fellow of APA and a Past President of the Society of Clinical Psychology (Division 12, APA).

Thekla Brumder Ross, PsyD is a Behavioral Health Clinician in the Kaiser Permanente Care Management Institute and Northern California Division of Research. She is also a foundation of communications coach for medical students at The University of Colorado and a facilitator of Provider Share Workshops domestically and internationally in collaboration with Planned Parenthood Federation and The University of Michigan.

References Cited

Brown, G. K., & Karlin, B. E. (2017). Cognitive Behavioral Therapy for depression: A manual for Kaiser Permanente therapists.Philadelphia, PA: University of Pennsylvania and Waltham, MA: Education Development Center, Inc.

Dickerson, J. F., Lynch, F. L., Leo, M. C., DeBar, L. L., Pearson, J., & Clarke, G. N. (2018). Cost-effectiveness of Cognitive Behavioral Therapy for depressed youth declining antidepressants. Pediatrics, 141, e20171969. doi: 10.1542/peds.2017-1969

Karlin, B. E. (in press). Dissemination and implementation: The science and practice of bringing CBT to the clinical frontlines. In A. Wenzel (Ed.), APA Handbook of Cognitive Behavioral Therapy.Washington, DC: American Psychological Association Press.

Karlin, B. E., Brown, G. K, Jager-Hyman, S. Green, K. L., Wong, M., Lee, D. S., . . . Brumder Ross, T. (2018). Dissemination and implementation of Cognitive Behavioral Therapy for depression in the Kaiser Permanente health care system: Evaluation of initial training and clinical outcomes. Behavior Therapy.Advance online publication. doi: 10.1016/j.beth.2018.08.002

Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system. American Psychologist, 69, 19-33. doi: 10.1037/a0033888

Meyers, L. L., Strom T. Q., Leskela, J., Thuras, P., Kehle-Forbes, S. M., & Curry, K. T. (2013).  Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder. Military Medicine, 178, 95-99.

Tuerk, P. W., Wangelin, B., Rauch, S. A. M., Dismuke, C. E., Yoder, M., Myrick, H., . . . Acierno, R. (2013). Health service utilization before and after evidence-based treatment for PTSD. Psychological Services, 10, 401-409. doi:10.1037/a0030549

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