From the late 1760’s through 1780, Captain James Cook and his small fleet had fantastic adventures. His ships were small with relatively light crews who did not have particularly good health practices (this was the late 1700’s, so we’ll give them a pass since toothpaste and masculine-scented body wash weren’t invented yet). Yet, they circumnavigated the globe multiple times, visiting exotic locations like Hawaii, New Zealand, Australia, Tahiti, and Alaska. Captain Cook and his crew are mostly remembered for their intrepid voyages and consequent additions to English sea charts, but they also achieved something even more remarkable for sailors at the time: almost none of them died of scurvy (Berwick, 2003) . How did he do it? He forced everyone on his ships to eat sauerkraut every day.
Sailors don’t really need to worry about scurvy these days, but scurvy killed more sailors than all battles, storms, diseases, or any other cause between the 16th and 17th centuries according to Jason Allen Mayberry. Think about that for a moment: Scurvy was the undisputed, leading cause of death for sailors in the Age of Sail. Mayberry reports that, during the 7 Years War (1754-1763), approximately 72% of all enlisted sailors died from disease (most likely scurvy) while less that 1% died from wounds related to combat.
When I read these statistics and other estimates of lives lost to scurvy, I was shocked. I thought, “If they only knew about vitamin C, so many sailors could have been saved.” The maddening fact is that the cure for scurvy was known at the time, albeit not widely disseminated. Even before James Lind conducted his clinical trial comparing multiple interventions for scurvy (he proposed foods containing vitamin C such as citrus fruit and sauerkraut) and published his results in 1753, some English sea captains already advocated the use of citrus fruit to prevent and treat scurvy (Kerr, 2009). Sir Gilbert Blaine attempted to persuade the Royal Navy to begin using citrus fruit to treat scurvy with little initial success (Blane, 1781). It wasn’t until Blane was appointed “Physician of the Royal Navy” that he would have the power, influence, and opportunity to replicate Lind’s experiment and, ultimately, affect policy. Sailors participating in Blane’s “effectiveness study” were provided with lemon juice (cut with rum, water, and sugar, of course) on a voyage to India, resulting in the observation that none of the sailors died of scurvy. Following this voyage, it was mandated that all sailors in the Royal Navy would have access to lemon juice. Nearly 50 years passed from the time Lind piloted the evidence-based treatment for scurvy and the Royal Navy implemented the practice.
Now, it would be unfair to say that physicians and early medical researchers had unequivocal evidence for the cure of scurvy at the time. It’s also important to note that “humorism” was the leading theoretical orientation of the day (not at all humorous, given that bloodletting was a major practice informed by this philosophy) and that it was likely difficult for clinicians to reconcile their beliefs with innovative ideas. Furthermore, the “mechanism of action” that accounted for the efficacy of citrus fruit and sauerkraut (vitamin C) was unknown and would not be discovered until 1930 by Albert Szent-Gyorgi. Citrus fruit was also not as widely available as it is today. To be sure, there were barriers to implementing the evidence-based treatment for scurvy. Despite all these barriers, the cure for scurvy was eventually made widely available.
Somehow, Captain Cook managed to implement the treatment for scurvy some 30 years before the rest of the Royal Navy caught up, saving the lives of most of his sailors. Cook had the reputation of being a man who was fond of innovations and, by all accounts, was a man who had the power and influence to implement his wishes, at least in his small sphere of influence (Berwick, 2003). On a larger scale, Sir Blane used his power and influence to affect the lives of all sailors in the Royal Navy, and the rest, as the saying goes, is history.
The example of the cure for scurvy has been cited by researchers interested in understanding the process by which innovative ideas such as evidence-based treatments are disseminated (e.g., Rogers, 1995; Sobel, 2016). Much like in the case of scurvy, the assumption of “appropriability” (the notion that clinicians will automatically adopt new technologies solely on the basis of published, empirical support. Basically, “if you build it, they will come.”) does not seem to apply to mental health treatments (Stirman, Crits-Christoph, & DeRubeis, 2004). There are many different models of dissemination that have been proposed, highlighting the complexity of the barriers that modern day scientists encounter when attempting to bring their innovations from the lab to the clinic. For example, psychological treatments for PTSD with strong empirical support (e.g., Prolonged Exposure Therapy and Cognitive Processing Therapy) have been around for over two decades but have certainly not become “standard practice” for the majority of clinicians, especially those who have not had access to expensive and time-consuming training opportunities. The good news is that CDP and other organizations (e.g., the Department of Veterans Affairs) are actively working toward developing sustainable models of evidence-based psychotherapy (EBP) implementation or #LemonSolutions. There are avatars of “Sir Gilbert Blane” among us, for sure, and “lemons” are definitely on their way. But how long are these efforts going to take, and how many Service members and Veterans will miss out on the opportunity to receive EBP in the meantime?
The “top down” approach used to shift organizations toward making EBP part of standard practice is not likely to have impact on clinicians in private practice or in smaller organizations that do not have the resources or motivation necessary to make a similar shift. This is why EBP-inclined clinicians need to find their “inner Captain Cook.” I am not proposing that we all leave our clinics and set sail for Hawaii (unless, of course, one of our readers wants to fund that trip, in which case I would be happy to climb aboard), but I am suggesting that we work to spread the use of EBP by our own efforts. Let’s call this strategy “micro-dissemination.” Perhaps we can motivate our colleagues to consider adopting EBP by sharing success stories, actively seeking opportunities to be “champions” for the use of EBP, starting local consultation groups (have a “lunch and learn,” people will do almost anything for free food), lending out treatment manuals, or dragging them to an EBP training with us.
Sometimes we overlook the small opportunities for change, thinking that small opportunities are not significant. That is a mistake. In a qualitative study conducted by Stewart, Stirman, and Chambliss (2012), several clinicians indicated that the suggestions of respected colleagues were more important in making decisions about adopting innovations than peer-reviewed research articles by important experts. Here is a quote from that paper that illustrates this point, “I’m like so many other clinicians where we talk to each other, and someone reports a technique and says ‘try this’—it doesn’t depend on whether there’s a lot of data on it or not, but if it makes sense to me, and someone I respect recommends it, I’ll try it (p.106).” It’s fine to think “big” when you are Sir Gilbert Blane, but you need to think “small” when you are Captain Cook.
I often commiserate with my fellow trainers and consultants about the difficulties we encounter when trying to disseminate EBP. The conversation usually gravitates toward discussions of #LemonsSolutions. I wonder what would happen if we spend more time talking about #SauerkrautSolutions.
So what do you think? Even if lemons are on the way, could we be willing to eat sauerkraut in the meantime?
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The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Andrew Santanello, Psy.D is a licensed, clinical psychologist and CBT trainer at the Center for Deployment Psychology. Dr. Santanello joined CDP after over a decade of service in the Veterans Health Administration where he was a staff psychologist in the Trauma Recovery Program.
Berwick, D. (2003). Disseminating innovations in health care. Journal of the American Medical Association, 289,1969-1975.
Blane, Gilbert (1781). A short account of the most effectual means of preserving the health of seamen : particularly in the Royal Navy.
James Lind (1753). A Treatise of the Scurvy in Three Parts
Kerr, Gordon (2009). Timeline of Britain, Canary press.
Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: Free Press.
Sobell, L.C., Bridging the gap between scientists and practitioners: The challenge before us – Republished Article, Behavior Therapy (2016), doi:10.1016/j.beth.2016.11.007
Stirman, S., Crits-Christoph, P. & DeRubeis, R. (2004). Achieving successful dissemination of empirically supported psychotherapies: A synthesis of dissemination theory. Clinical Psychology: Science and Practice,11, 343–359.
Stewart, R., Stirman, S., & Chambliss, D. (2012). A qualitative investigation of practicing psychologists’ attitudes toward research-informed practice: Implications for dissemination strategies. Professional Psychology: Research and Practice, 43, 100 –109