"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
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
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
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
"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
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
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." ▪