The arrival of the Patient Protection and Affordable Care Act (ACA; H.R. 3590--111th Congress, http://www.govtrack.us/congress/bills/111/hr3590) has created long-overdue opportunities to grow the capacity of networks to deliver evidence-based care to those served by community behavioral health. As coverage for behavioral health and substance abuse services has substantially increased with the ACA, funding for treatment services will likely expand. A challenge to capitalizing on the ACA opportunity, however, is the underdeveloped state of evidence-based practices (EBPs) in community behavioral health. Efforts to implement EBPs in community behavioral health have moved to the forefront in the past decade, and Philadelphia has been at the leading edge of these efforts, beginning in 2007 with the Beck Initiative. This Initiative is a collaborative clinical, educational and administrative partnership that has successfully implemented cognitive behavioral therapy (CT) across a diverse group of community behavioral health care providers (agencies) in a range of settings. Flexibility has been a key factor in the success of this Initiative, allowing for an ongoing process of innovative solutions to the challenges inherent in matching science (for example, highly controlled studies and clinical trials research) to practice (the reality of community-based behavioral health care, in all of its complexities).
Goals of the Beck Initiative
In 2007, the Beck Initiative was established as a partnership among the Aaron T. Beck Psychopathology Research Center of the University of Pennsylvania, the Philadelphia Department of Behavioral Health and Intellectual Disability Services (DBHIDS), DBHIDS network providers and the individuals being served by the network. The Beck Initiative partners share two key goals: to improve of outcomes for people receiving services in the DBHIDS system and to share the successes and lessons learned with other networks in order to increase the understanding of these processes. To this end, the Beck Initiative has delivered 44 training programs to 35 provider agencies in Philadelphia, including almost 600 community behavioral health care workers. (Close to 200 additional professionals have attended informational workshops about CT in the network, including care managers and other DBHIDS employees.) Although the Beck Initiative has built on its successes in Philadelphia by broadening its partnership to include several other city- and statewide behavioral health systems, the original Philadelphia Beck Initiative has been the developmental proving ground for that success, and it continues to lead the edge of related innovations.
Development of a Flexible Training Model to Meet Diverse Needs
The network’s priorities have evolved over the course of the Initiative, which has required adapting both the training model and the core CBT concepts for diverse populations and levels of care. (For a detailed description of the training model, please see Creed, Stirman, Evans, & Beck, 2014). Originally, workshops were focused on training therapists in outpatient clinics to use CBT with individuals who were experiencing depression and suicidality. However, feedback from the therapists indicated that the focus on depression and suicide did not reflect the complexities experienced by the individuals they served. The Beck Initiative moved away from the disorder-specific model that had been traditionally used in clinical trials and instead embraced a trans-diagnostic approach that prepares therapists to use CT to meet the mission of the provider. Trainings are now tailored for the level of care and the population served including individuals across the life span in outpatient programs, school-based services, programs for individuals experiencing chronic homelessness, addictions services, assertive community treatment (ACT) teams, extended acute care units and services focused on gay, lesbian and transgendered adults. Services may be focused on depression, addiction, schizophrenia, recent incarceration, socioeconomic disadvantages and more. The Beck Initiative instructors are able to achieve this flexibility in their offerings by conceptualizing the training process as a true collaboration. The instructors bring expertise in CT to the table, and the therapists bring expertise in the provider’s mission and strategies and the common challenges of the individuals they serve. Rather than expecting the instructors to be expert in all populations and levels of care, we draw on the strengths of the therapists and ask them to partner with the instructors to identify strategies that will work in their work settings.
The network’s priorities have also shifted over time to include training for many levels of care beyond the outpatient clinics. This shift required a second innovation to shift the training focus from a traditional therapist-centered approach to one that would encompass the broader treatment milieu in settings like residential facilities, inpatient units and schools. The Beck Initiative team has developed strategies for infusing CT principles into the work of professionals who do not provide therapy (as it is traditionally defined), but who can help individuals move toward their recovery goals more effectively by using a CT framework for their work. For example, the Journey of Hope programs provide housing for individuals who have experienced chronic homelessness. The ACT teams use a multidisciplinary approach to provide comprehensive, community-based treatment and rehabilitation services to individuals with significant and chronic behavioral health needs. The team includes a range of services and specializations such as nursing, job coaching and assistance with housing in addition to more traditional behavioral health care. By including the entire team in CT training, a common language and way of delivering services is developed that helps team members to maximize their clinical opportunities. The lead clinician on the team may develop and share the case conceptualization for a specific individual in recovery, which would help each member of the team to understand the individual’s goals and challenges in the same light. For example, perhaps the individual is a man whose life experiences have led him to believe that people will always try to hurt him. When he refuses to take the medication that he has been prescribed, this conceptualization may lead the nurse to ask questions about whether he is worried that the medications may not be in his best interest. Once she and the man are able to understand his refusal in the same way, they may be better able to work toward a solution. If the housing specialist works with the same man, the case conceptualization may help him to identify and understand the man’s concerns about a potential new housing situation. (“I don't want to have a roommate. I can’t live with people!”) The conceptualization can lead to increased empathy toward the man’s beliefs, as well as creative strategies to help him overcome the challenges to meeting his goals.
Future Directions
The emphasis on EBPs continues to grow as the nation’s behavioral health systems respond to the mandates of the ACA, and flexibility and adaptability will likely be key to the successful implementation of these practices. The Beck Initiative offers a collaborative approach to meeting this need, resulting in increased accessible evidence-based care in the network. The successes in developing nontraditional, multidisciplinary approaches to delivering CT for a broad spectrum of challenges suggests that this model may offer opportunities to integrate evidence-based behavioral health care into other settings beyond the traditional therapy hour.
The development of a continuity of care across providers is an emerging opportunity to link behavioral health care and primary care. Using the ACT team example above, the potential for a common language and approach of CT across disciplines has been found to be feasible and powerful. When care providers share a common approach, they may find it much easier to collaborate on care, and individuals may have a much more cohesive, and perhaps even more successful, recovery experience.
Torrey A. Creed, Arthur C. Evans and Aaron T. Beck work in the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania. Arthur C. Evans also serves in the Philadelphia Department of Behavioral Health and Intellectual disAbility Services.
References
Creed, T. A., Stirman, S. S., Evans, A. C., & Beck, A. T. (2014). A model for implementation of cognitive therapy in community mental health: The Beck Initiative. The Behavior Therapist, 37(6), 56–64.