Implementing Evidence-Based Psychotherapies in Settings Serving Older Adults: Challenges and Solutions
Open accessAbstract
This Open Forum addresses challenges--insurance limitations, staff and setting limitations, and training and sustainability issues--in the implementation of psychotherapy interventions in settings serving older adults and provides solutions for ensuring that they have access to effective mental health services. There is considerable movement toward developing the geriatric mental health workforce, and it is important that these efforts include a discussion of implementation issues with regard to evidence-based psychotherapies as they are provided in services for aging populations.
AI snapshot
Written from the paper’s full text.
TL;DR
This commentary argues that although cognitive-behavioral, interpersonal, and problem-solving therapies are first-line, evidence-based options for late-life depression and anxiety, they remain poorly translated into aging-service settings. It catalogs reimbursement, workforce, organizational, and certification barriers and proposes policy, training, and technology-based remedies.
Key findings
The authors identify Medicare's low valuation of psychiatric services and its non-reimbursement of travel and telephone contact as core obstacles, noting that most evidence-based protocols require weekly 30–45 minute sessions that home-based providers cannot bill for efficiently. Staffing is a second barrier: bachelor's-level clinicians supervised by licensed professionals are a low-cost response to workforce shortages, but psychotherapy protocols assume providers with basic therapeutic skills, control over case mix, and adequate resources — conditions many aging agencies lack, and implementation would require organizational restructuring beyond administrative supervision. Certification is undermined by absent incentives, difficulty identifying clients willing to be recorded, insufficient supervision time, staff turnover requiring retraining, and fidelity drift over time (citing Fiander et al., 2003). Proposed solutions include ACA workforce and training incentives, APA clinician guidelines and the IOM geriatric workforce workgroup to define required credentials, manager training that holds staff accountable for timely certification, budgeting for ongoing consultation, and technology such as internet-based supervision, Skype observation, and computerized clinician support tools.
Methods
Narrative commentary synthesizing prior literature and the authors' own implementation experience; no study design, sample, or quantitative analysis is reported. The authors describe their experience implementing problem-solving treatment, observing that counties mandating certification within three months of rollout were more likely to have fully trained teams, and that organizations funding ongoing consultation sustained the practice better than those stopping investment after certification.
Limitations
The paper states no formal limitations. Evident from the text: it is a commentary rather than an empirical study, so the claims about certification mandates, incentives, and sustainability rest on the authors' informal field observations rather than controlled comparison; no sample sizes, effect estimates, or outcome data are provided for these assertions, and the cited supporting evidence is largely drawn from other service-delivery contexts (e.g., assertive community treatment).
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
0 of 12 cited sources checked · 0 supported · 0 flagged
- Findingnone given
Organizations that gave staff incentives to become certified overcame initial reluctance to learn a new psychotherapy.
“Organizations that have incentivized staff to become certified have overcome initial provider reluctance to learn a new psychotherapy.”
Quote in the paperNot a substantial claim - Findingnone given
In the authors' experience with problem solving treatment, counties that required providers to become certified within three months of program launch were more likely to have a fully trained team than counties without such mandates.
“In our experience implementing problem solving treatment, counties that have held providers accountable for becoming certified within three months of program roll out are more likely to have a fully trained team than counties without timely certification mandates.”
Quote in the paperNot a substantial claim - Premisecitation
Psychotherapy is regarded as a first-line treatment for mental health problems in later life.
“Psychotherapies for late life mental health problems are considered first-line treatments, but implementation of psychotherapy remains a significant challenge on multiple levels (Leslie, 2007).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Leslie, 2007
Not checked in the free run.
- Premisecitation
Cognitive-behavioral therapy is regarded as evidence-based for generalized anxiety.
“cognitive-behavioral therapy is an EBP for generalized anxiety (Wetherell, Gatz, & Craske, 2003).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Wetherell, Gatz, & Craske, 2003
Not checked in the free run.
- Premisecitation
Older adults frequently choose psychotherapy over medication.
“Older adults often prefer psychotherapy to medication, (Raue, Schulberg, Heo, Klimstra, & Bruce, 2009)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Raue, Schulberg, Heo, Klimstra, & Bruce, 2009
Not checked in the free run.
- Premisecitation
Psychotherapies have been inadequately moved into routine practice.
“yet like other care delivery innovations, psychotherapies have been poorly translate into practice (Pincus, 2010).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Pincus, 2010
Not checked in the free run.
- Interpretationreasoning
Technologies have greatly improved access to certification and technical assistance by enabling internet-based training, supervision, and fidelity evaluation.
“Access to certification and technical assistance has benefitted considerably from technologies by providing accessible training, supervision and fidelity evaluations through the internet.”
Quote in the paperNot a substantial claim - Interpretationreasoning
When aging service agencies try to deliver an evidence-based psychotherapy, the treatment may be ineffective partly because staff lack the resources and skills to conduct psychotherapy properly.
“When aging service agencies attempt to implement an evidence-based psychotherapy, they may find the treatment ineffective partly because their staff lacks resources and skills needed to conduct psychotherapy appropriately.”
Quote in the paperSubstantial claim- Rests on an assumption: With few exceptions, psychotherapies are designed for providers who have basic psychotherapy skills, control over their case mix, and the resources needed to deliver the treatment.
- Rests on an assumption: Many aging service providers work in settings with limited resources and large, complex caseloads.
- Premisecitation
Computerized support tools for clinicians are a promising way to ensure treatment fidelity.
“Other promising technologies for ensuring fidelity to treatment include the use of computerized support tools for clinicians (Craske, et al., 2009).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Craske, et al., 2009
Not checked in the free run.
- Interpretationreasoning
Implementing evidence-based psychotherapy would require substantial organizational restructuring for many aging service agencies that have only administrative supervision.
“The implementation of EB psychotherapy would require considerable organizational restructuring for many aging service agencies that do not have supervision beyond administrative review.”
Quote in the paperSubstantial claim - Interpretationreasoning
Implementing and sustaining psychotherapies in systems of care for older adults is difficult but not impossible.
“The implementation and sustainability of psychotherapies into systems of care that serve older adults is challenging but not impossible.”
Quote in the paperSubstantial claim- Rests on an assumption: Most evidence-based psychotherapies are designed to require weekly sessions lasting 30 to 45 minutes.
- Rests on an assumption: Many aging service providers deliver care in patients' homes.
- Rests on an assumption: Many insurers do not reimburse the weekly travel required for home-based psychotherapy, which makes delivery inefficient and often unavailable.
- Rests on an assumption: Medicare does not reimburse telephone contact.
- Rests on an assumption: Most aging service settings do not offer incentives for certification in an evidence-based psychotherapy.
- Rests on an assumption: Certification usually consists of a training workshop followed by observational review of cases.
- Rests on an assumption: In community settings, certification can be complicated by difficulty finding cases willing to be audiotaped, insufficient time for supervision, and staff turnover requiring retraining and re-certification, all without a Medicare reimbursement incentive.
- Rests on an assumption: Poor long-term fidelity results from insufficient ongoing support from evidence-based practice experts and insufficient accountability from insurers and organizational leaders for following treatment guidelines.
- Rests on an assumption: Training programs seldom offer ongoing consultation and may add another cost barrier.
- Premisecitation
Clinicians' treatment fidelity often declines over time.
“An additional complication is clinicians’ treatment fidelity will often drift over time (Fiander, Burns, McHugo, & Drake, 2003).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Fiander, Burns, McHugo, & Drake, 2003
Not checked in the free run.
- Premisecitation
Organizations that include the costs of ongoing consultation and technical assistance sustain a new practice better than those that stop investing after certification.
“Further, organizations that factor in costs of on-going consultation and technical assistance sustain the new practice better than those who stop investment after certification (Aarons, Sommerfeld, Hecht, Silovsky, & Chaffin, 2009).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Aarons, Sommerfeld, Hecht, Silovsky, & Chaffin, 2009
Not checked in the free run.
- May combine two claims. 8
- Classified as probably not a substantial claim. 1
May combine two claims.
PremisecitationPolicy and system-level factors, including Medicare's low valuation of psychotherapy and psychiatric services, clinician training, and insufficient technical assistance for treatment fidelity, complicate implementing and maintaining psychotherapies in aging services.
“The implementation and maintenance of psychotherapies in these settings is complicated by a number of policy and system-level issues (Mancini et al., 2009), such as the under valuing of psychotherapy/psychiatric services by Medicare, clinician training, and lack of technical assistance to sustain treatment fidelity.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Mancini et al., 2009
Not checked in the free run.
May combine two claims.
PremisecitationCognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy are regarded as evidence-based for depression in later life.
“Cognitive-behavioral therapy, interpersonal therapy and problem solving therapy are considered evidence-based (EBP) for late life depression (Mackin & Arean, 2005)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Mackin & Arean, 2005
Not checked in the free run.
May combine two claims.
InterpretationreasoningThe main limitations for implementing psychotherapies in aging services are the needed provider skills and the organizational culture of many aging service organizations.
“Two of the major limitations in the implementation of psychotherapies within aging services are the skill sets required to implement them effectively, and the organizational culture of many aging services.”
Quote in the paperSubstantial claim- Rests on an assumption: In some senior service agencies, bachelor's-level clinicians provide mental health services under a licensed professional who can bill Medicare only when directly providing the service.
- Rests on an assumption: With few exceptions, psychotherapies are designed for providers who have basic psychotherapy skills, control over their case mix, and the resources needed to deliver the treatment.
- Rests on an assumption: Many aging service providers work in settings with limited resources and large, complex caseloads.
May combine two claims.
PremisecitationManagers who successfully implement new practices learn the model, seek staff feedback, hold staff accountable for training, and explain why the intervention was chosen.
“Successful managers who implement new practices learn the model, solicit feedback from their staff, hold staff accountable for being trained in the intervention, and are clear about why the intervention was selected. (Choi, 2009)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Choi, 2009
Not checked in the free run.
Probably not a substantial claim: may not pass S2 (checkable), S4 (based).
InterpretationreasoningSeveral policy and practice innovations can improve access to high-quality psychotherapy for older adults.
“Although the implementation of psychotherapy is challenging, there are a number of policy and practice innovations that can facilitate access to high quality psychotherapy for older adults.”
Quote in the paperNot a substantial claim- Rests on an assumption: The Affordable Care Act brings changes in national policy and funding for psychotherapy and opportunities to expand the workforce through incentives, education, and training grants.
- Rests on an assumption: The American Psychological Association has recently appointed a task force to develop clinician guidelines for treating mental illnesses, especially psychotherapy across demographic and age groups.
- Rests on an assumption: The Institute of Medicine Geriatric Workforce Development in Mental Health workgroup is a policy forum that could help define the credentials clinicians need to deliver evidence-based practices successfully.
- Rests on an assumption: Training programs for middle-level managers in aging services on implementing evidence-based practices effectively are showing promising results.
May combine two claims.
InterpretationreasoningUsing providers without master's degrees is a low-cost response to the shortage of professionals who can work with older adults, but it creates difficulties for implementing evidence-based psychotherapy.
“Although using non Master’s-level providers results in a low-cost solution to the dearth of professionals who can work with older adults, it creates other problems implementing evidence-based psychotherapy.”
Quote in the paperSubstantial claim- Rests on an assumption: In some senior service agencies, bachelor's-level clinicians provide mental health services under a licensed professional who can bill Medicare only when directly providing the service.
May combine two claims.
PremisecitationMedicare and other insurers undervalue psychiatric and psychotherapy services and do not reimburse certification in geriatric subspecialties.
“A significant limiting factor in the implementation of EBPs is the undervaluing of psychiatric services, and lack of recognition in reimbursement for certification in geriatric subspecialties by insurers such as Medicare (Moran, 2010).”
- Also stated in: § Undervaluing Psychotherapy Services · plain
“Additionally, the value placed by Medicare on psychotherapy services is minimal.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Moran, 2010
Not checked in the free run.
- Also stated in: § Undervaluing Psychotherapy Services · plain
May combine two claims.
InterpretationreasoningConsequently, few clinical trainees choose to work with older adults, producing a shortage in the U.S. workforce for older people's needs.
“As a result few clinical trainees elect to work with older adults, leading to a deficit in the U.S. workforce serving the needs of older people.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationTelephone-based psychotherapy has high acceptability and effectiveness comparable to in-person treatment.
“Although research has pointed to high acceptability and comparable effectiveness of telephone-based psychotherapy (which makes treatment delivery more efficient), (Mohr, Carmody, Erickson, Jin, & Leader, 2011)”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Mohr, Carmody, Erickson, Jin, & Leader, 2011
Not checked in the free run.
The paper relies on this without support.
Most evidence-based psychotherapies are designed to require weekly sessions lasting 30 to 45 minutes.
“By design most EBPs require weekly visits that are 30-45 minutes long.”
The paper relies on this without support.
Many aging service providers deliver care in patients' homes.
“Many aging service providers work in the patient’s home.”
The paper relies on this without support.
Many insurers do not reimburse the weekly travel required for home-based psychotherapy, which makes delivery inefficient and often unavailable.
“However, the weekly travel involved is not reimbursed by many insurers, making the delivery of psychotherapy inefficient and ultimately unavailable.”
The paper relies on this without support.
Medicare does not reimburse telephone contact.
“Medicare does not reimburse for telephone contact.”
The paper relies on this without support.
In some senior service agencies, bachelor's-level clinicians provide mental health services under a licensed professional who can bill Medicare only when directly providing the service.
“In some senior service agencies, bachelor’s level clinicians provide an array of mental health services under the supervision of a licensed professional who can bill Medicare if directly providing the service.”
The paper relies on this without support.
With few exceptions, psychotherapies are designed for providers who have basic psychotherapy skills, control over their case mix, and the resources needed to deliver the treatment.
“With few exceptions, psychotherapies are developed for providers with basic psychotherapy skills (e.g., how to establish therapeutic rapport), for those who have control over their case-mix and have the resources needed to provide the treatment.”
The paper relies on this without support.
Many aging service providers work in settings with limited resources and large, complex caseloads.
“Many aging service providers work in settings with limited resources and large, complex caseloads.”
The paper relies on this without support.
Most aging service settings do not offer incentives for certification in an evidence-based psychotherapy.
“Most aging service settings do not provide incentives for certification in an evidence-based psychotherapy.”
The paper relies on this without support.
Certification usually consists of a training workshop followed by observational review of cases.
“Certification typically involves participation in a training workshop, followed by observational review of cases.”
The paper relies on this without support.
In community settings, certification can be complicated by difficulty finding cases willing to be audiotaped, insufficient time for supervision, and staff turnover requiring retraining and re-certification, all without a Medicare reimbursement incentive.
“Although certification can be inexpensive in direct costs, the certification process in community settings can be complicated by the inability of clinicians to identify cases willing to be audiotaped, lack of extra time for supervision, and staff turnover requiring retraining and re-certifications, all to be done without a reimbursement incentive from Medicare.”
The paper relies on this without support.
Poor long-term fidelity results from insufficient ongoing support from evidence-based practice experts and insufficient accountability from insurers and organizational leaders for following treatment guidelines.
“Suboptimal long-term fidelity is due to lack of ongoing support from EBP experts, and lack of accountability from insurers and from organizational leadership for following treatment guidelines.”
The paper relies on this without support.
Training programs seldom offer ongoing consultation and may add another cost barrier.
“While training programs are available, these programs rarely have opportunities for ongoing consultation and may impose another cost barrier.”
The paper relies on this without support.
The Affordable Care Act brings changes in national policy and funding for psychotherapy and opportunities to expand the workforce through incentives, education, and training grants.
“The Patient Protection and Affordable Care Act (ACA) heralds changes in both national policy and funding for psychotherapy, and opportunities to grow the workforce through incentives, education and training grants.”
The paper relies on this without support.
The American Psychological Association has recently appointed a task force to develop clinician guidelines for treating mental illnesses, especially psychotherapy across demographic and age groups.
“One promising development is the American Psychological Association’s recently appointed task force to develop clinician guidelines for treatment of mental illnesses, particularly psychotherapy for all demographic and age groups.”
The paper relies on this without support.
The Institute of Medicine Geriatric Workforce Development in Mental Health workgroup is a policy forum that could help define the credentials clinicians need to deliver evidence-based practices successfully.
“The Institute On Medicine (IOM) Geriatric Workforce Development in Mental Health workgroup is another policy forum that could be help in defining the credentials needed for clinicians to successfully delivery EBPs.”
The paper relies on this without support.
Training programs for middle-level managers in aging services on implementing evidence-based practices effectively are showing promising results.
“Training programs for middle-level managers in aging services on the effective implementation of EBPs are showing promising results.”
The paper relies on this without support.
Many older adults avoid mental health settings because of stigma attached to mental health care.
“In addition, many older adults do not seek care in mental health settings because of the stigma associated with mental health care.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Real-world implementations of behavioural treatments result in poor fidelity of treatment delivery.
“Behavioural treatments such as cognitive behaviour therapy may have some advantages over medications (e.g., cost-effectiveness over long-term follow-up13), but real-world implementations result in poor fidelity of treatment delivery14,15 and compromised adherence.16,17”
From Precision clinical trials: a framework for getting to precision medicine for neurobehavioural disorders (2021) · cites this paper as [15]
The citation lists haven’t been fetched yet
References 13 · Cited by 33
Research works printed but not linked: 1
- 10.1176/ps.2009.60.2.189 · DOI
- Authors
- Arean, P. A., Raue, P. J., Sirey, J. A., & Snowden, M.
- Affiliations
- Dr. Arean is affiliated with the Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave., Box F-0984, San Francisco, CA 94143 (e-mail: ).
- Weill Cornell Medicine (US)
- University of Washington (US)
- Venue
- Psychiatric Services
- Published
- 2012-06
- Volume
- 63
- Issue
- 6
- Pages
- 605-607
- ISSN
- 0022-1597 (ISSN-L)
- 1075-2730
- 1557-9700
- PMC
- PMC3643294
- OpenAlex
- W2047096592
- Semantic Scholar
- a96c3ac76a8f26bdd76bce1e82ca64b59bd80927
- Cited by
- 33
- References
- 13
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 3 · 2023: 1 · 2022: 3 · 2021: 1 · 2020: 2 · 2019: 7 · 2018: 1 · 2017: 4 · 2016: 1 · 2015: 4 · 2014: 3 · 2012: 1
- FWCI
- 2.91
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Psychiatric Services (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R01MH075900, R01MH079265, K24MH074717)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Keywords
- evidence-based psychotherapy, older adults, geriatric mental health, implementation barriers, insurance coverage, mental health professionals, employee training, service sustainability, access to mental health care
- MeSH terms
- Workforce, Aged, Mental Disorders, Health Services Accessibility, Humans, Mental Health Services, Psychotherapy, Evidence-Based Medicine
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
