2019 HSR&D/QUERI National Conference
4089 — Modification of cognitive-behavorial therapy for chronic pain
Lead/Presenter: Alan McGuire, COIN - Indianapolis
All Authors: McGuire AB (Center for Health Information and Communication, Richard L. Roudebush VAMC), Henry, N (Department of Psychology, Indiana University Purdue University Indianapolis), Marina Kukla (Center for Health Information and Communication, Richard L. Roudebush VAMC) Marianne Matthias (Center for Health Information and Communication, Richard L. Roudebush VAMC) Matt Bair (Center for Health Information and Communication, Richard L. Roudebush VAMC) Mindy Flanagan (Center for Health Information and Communication, Richard L. Roudebush VAMC) Sarah Bauer (Center for Health Information and Communication, Richard L. Roudebush VAMC) Jessica Carter (Center for Health Information and Communication, Richard L. Roudebush VAMC) Jennifer Murphy (James A Haley VAMC
This study examined modifications to cognitive-behavioral therapy for chronic pain (CBT-CP) within the Veterans Health Administration (VHA). More specifically, we describe use of CBT-CP in the field (e.g., penetration, completion percentage); describe the type and extent of modifications; and examine the relationship between therapist characteristics and modifications.
An online survey, based on Stirman and colleagues (2013) framework, of therapists who completed the VHA CBT-CP certification. Data were analyzed descriptively and predictors of modification using Pearson's correlations.
One hundred and forty therapists responded and met inclusion criteria. Therapists reported providing individual CBT-CP to about 7 Veterans (M = 7.4, SD = 13.3) and about 6 Veterans in groups (M = 5.7, SD = 12.5). Therapists attempted CBT-CP with less than half of Veterans with chronic pain (M = 48.1, SD = 36.0). Most therapists reported modifying CBT-CP (n = 98, 86.0%) and a plurality reported modifying CBT-CP for over 80% of Veterans seen (n = 36, 37.1%). When asked about the percentage of Veterans for whom specific types of modifications are made, only 10-20% of therapists reported making any given type of modification for the majority of Veterans. Of those reporting some modification, the plurality reported not planning modifications at all (n = 32, 22.9%), while about a fifth reported planning "always" (n = 27, 19.3%). Reports of more modification were associated with more planning (r = .37, p < .001) and less use of the manual (r = -.49, p < .001). Psychologists modified more (mean = 2.8) than master's level therapists (mean = 2.3, t(111) = 2.08, p = .04). Modification did not differ based on setting (VAMC vs. CBOC), clinic (primary care, specialty pain, and general) or therapist time in the field.
Trained and certified therapists report small modifications to a majority of Veterans' courses of CBT-CP. It is possible that many therapists make modifications based on immediate clinical judgment rather than systematic or premeditated modifications. However, conclusions based on self-reported data should be made with caution.
VHA training and certification process may ensure high program fidelity; however, additional research and training on when to modify is needed.