Evidence-based treatment and therapist drift

Central and North West London NHS Foundation Trust and Institute of Psychiatry, King's College London, London, United Kingdom.
Behaviour Research and Therapy (Impact Factor: 3.85). 11/2008; 47(2):119-27. DOI: 10.1016/j.brat.2008.10.018
Source: PubMed


Cognitive-behavioural therapy (CBT) has a wide-ranging empirical base, supporting its place as the evidence-based treatment of choice for the majority of psychological disorders. However, many clinicians feel that it is not appropriate for their patients, and that it is not effective in real life-settings (despite evidence to the contrary). This paper addresses the contribution that we as clinicians make to CBT going wrong. It considers the evidence that we are poor at implementing the full range of tasks that are necessary for CBT to be effective--particularly behavioural change. Therapist drift is a common phenomenon, and usually involves a shift from 'doing therapies' to 'talking therapies'. It is argued that the reason for this drift away from key tasks centres on our cognitive distortions, emotional reactions, and use of safety behaviours. A series of cases is outlined in order to identify common errors in clinical practice that impede CBT (and that can make the patient worse, rather than better). The principles behind each case are considered, along with potential solutions that can get us re-focused on the key tasks of CBT.

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Available from: Glenn Waller, Jan 08, 2014
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    • "Even among CBT-oriented psychologists with strong interest and training in behavioral treatments and a commitment to EBP in principle, exposure therapy in particular is not completely accepted or widely used (Becker et al., 2004). Waller (2009) discusses this reluctance to use exposure, which he speculates is related to therapists' own anxiety, avoidance, and safety behaviors. He found that more anxious therapists, as measured by the Brief Symptom Inventory—Anxiety Scale, were less likely to use CBT techniques when treating patients with eating disorders (Waller et al., 2012). "
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    ABSTRACT: Despite the overwhelming evidence that the behavioral components of cognitive-behavior therapies (CBTs) are critical for patient improvement, particularly in the case of anxiety disorders, there remains a wide gap between science and practice in their consistent use. In particular, exposure therapy for anxiety is under-used, even among self-proclaimed cognitive-behavior therapists. Some have speculated that this under-use is related to therapist discomfort with and avoidance of the temporary increase in distress that patients often experience during exposure therapy, and the secondary distress that this may cause in therapists themselves. Recent studies have begun to examine therapist characteristics that are associated with the use of evidence-based psychotherapies, but this research has focused on evidence-based practice as a whole rather than on specific interventions such as exposure, and have not addressed therapist psychological variables. We examined the role of therapists׳ experiential avoidance in the hypothetical use of exposure-based interventions to treat fictional patients for whom exposure therapy is clearly indicated. A total of 172 therapists watched simulated therapy intake sessions and were asked to designate the percentage of time they would allot toward various therapeutic modalities, including exposure. Results suggested that participants exhibiting higher experiential avoidance tended to allot less time to exposure therapy for the fictional patient. Additional therapist personality factors, such as intuitive personality style and attitudes toward evidence-based treatments, were associated with self-reported use of exposure therapy as well.
    Journal of Contextual Behavioral Science 12/2014; 4(1). DOI:10.1016/j.jcbs.2014.12.002
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    • "administering their own versions of the intervention, rather than the one that was manualized and tested (Shafran et al., 2009; Waller, 2009). An internet intervention, once tested and found successful, can be offered to the public without any changes and alterations, greatly increasing the likelihood that its effectiveness in the community will be very similar to the one observed during the trial, even if it is offered worldwide to thousands of users (which is possible with unsupported interventions). "
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    ABSTRACT: Internet interventions provide an option for those who either cannot or choose not to engage with traditional treatments. Most research on internet interventions involves guided or supported interventions. However, unsupported interventions offer considerably more scalability and cost-effectiveness, which makes them attractive for large-scale implementation. In this study, 309 participants recruited via Google AdWords entered an unsupported cognitive-behavioral internet intervention for depressive symptoms. To maximize the ecological validity of the study, participants received no incentives or live contact with study personnel. Furthermore, the study was open to individuals at any level of depressive symptoms, and all participants received the active intervention. The main outcome measures were depressive symptom level and self-efficacy in managing depressive symptoms. At follow-up, depression scores were significantly lower than baseline scores at each follow-up point (1, 2, 4, and 7 months), with pre-post effect sizes ranging from medium to large. Follow-up depression self-efficacy scores were significantly higher than baseline scores at each follow-up point, with pre-post effect sizes in the medium range. The results remained significant when analyzing only participants with depression scores indicative of a presence of a major depressive episode; results likewise remained significant when employing the conservative last observation carried forward convention, even in the presence of high attrition observed in this study. The results illustrate the potential of unsupported internet intervention to address the health needs of the global community.
    Internet Interventions 09/2014; DOI:10.1016/j.invent.2014.09.002
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    • "Another characteristic that has been considered is the emotional component of therapist 'drift' (Waller, 2009). In particular, there is evidence that clinicians who are more anxious are less likely to deliver the more effective elements of CBT for the eating disorders (Brown, Mountford, & Waller, submitted for publication; Waller, Stringer, et al., 2012). "
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    ABSTRACT: Despite research supporting the effectiveness of evidence-based interventions in the treatment of eating disorders, those interventions are under-utilised in routine clinical practice, possibly due to clinicians' concerns about delivering the relevant techniques. This study examined what elements of therapy clinicians worry about when delivering cognitive-behavioural therapy (CBT) for the eating disorders, and what clinician variables are associated with such concerns. The participants were 113 clinicians who used individual CBT with eating disorder patients. They completed a novel measure of concerns about delivering elements of CBT, as well as demographic characteristics and a standardised measure of intolerance of uncertainty. Clinicians worried most about body image work and ending treatment, but least about delivering psychoeducation. Their concerns fell into four distinct factors. Older, more experienced clinicians worried less about delivering the CBT techniques, but those with greater levels of prospective and inhibitory anxiety worried more about specific factors in the CBT techniques. Clinicians' capacity to tolerate uncertainty might impair their delivery of evidence-based CBT, and merits consideration as a target in training and supervision of CBT clinicians.
    Behaviour Research and Therapy 04/2014; 57C(1):38-42. DOI:10.1016/j.brat.2014.04.003
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Questions & Answers about this publication

  • Kate Muse added an answer in Psychotherapy:
    How to bridge the gap between research and clinical practice in psychotherapy?
    We built up interesting concepts like scientists-practitioner models, evidence based practice or empirical supported therapy. But especially in psychotherapy including behavior therapy the problems are ongoing. Many clinicians express the feeling that research results are often irrelevant to them or too hard to understand. We have a debate about manuals, about modalities, about specific versus common factors, about the clinical relevance of RCTs and meta analysis … In talking with researchers and clinicians there seems to be a long lasting large distance between researchers and clinicians. The question seems extremely relevant, and the danger too loose contact is not banned. I remember very interesting meetings with David Orlinsky on SPR congresses more than 15 years ago, where this problem was discussed. But has the situation changed in the meantime?
    Kate Muse
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