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.

    • "Second, the patient needs to engage in the therapy, rather than simply attending sessions. As stated previously (Waller, 2009), it is always important to remember that CBT is most likely to be effective when it is a 168-h-a-week therapy, where 1 h is coaching by the therapist as to how to change and the other 167 h are used to implement those lessons in the outside world. The danger is that the patient attends therapy sessions (for 1 h a week) rather than undertaking the therapy fully (the remainder of the week), in the mistaken belief that attending sessions is the equivalent of 'doing therapy'. "
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    ABSTRACT: Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.
    No preview · Article · Jan 2016 · Behaviour Research and Therapy
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    • "A common finding is that therapists use exposure-based methods relatively rarely, despite their extensive empirical support (Harned et al., 2013). It has been suggested (Waller, 2009) that this failure to use some well-evidenced therapeutic tools is the result of the clinician engaging in safety behaviors, because the avoidance of such methods (with their likelihood of temporarily raising patients' anxiety) makes the clinician feel more positive in the short term. "
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    ABSTRACT: Psychological therapists commonly fail to adhere to treatment protocols in everyday clinical practice. In part, this pattern of drift is attributable to anxious therapists being less likely to undertake some ele- ments of evidence-based therapies e particularly the exposure-based elements. This study considers what facets of anxiety (cognitive, behavioral, physiological) are related to junior clinicians' reported use of cognitive-behavioral therapy techniques. Thirty-two clinicians (mean age 1⁄4 28.9 years; mean length of CBT experience 1⁄4 1.5 years; 23 female, nine male) who offered CBT were assessed for their cognitive, behavioral and physiological characteristics (Intolerance of Uncertainty scale; risk taking; skin conduc- tance response and heart rate variability). While the three different facets of anxiety were relatively poorly associated with each other, as is usual in this literature, each facet was linked differently to the reported delivery of CBT techniques (P < .05). Overall, higher anxiety levels were associated with a poorer use of exposure methods or with a greater use of other behavioral or cognitive methods. Of the three facets of anxiety, only physiological reactivity showed an association with the clinicians' temporal characteristics, with more experienced therapists being more likely to have greater skin conductance responses to positive and negative outcomes. These findings suggest that clinicians who are more anxious are less likely to deliver the full evidence-based form of CBT and to focus instead on less chal- lenging elements of the therapy. Potential ways of overcoming this limitation are discussed.
    Full-text · Article · Dec 2015 · Behaviour Research and Therapy
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    • "Three accredited and nationally registered psychologists provided treatment and all had either Masters Degrees or Doctoral Degrees in clinical psychology. Based on the findings of previous studies (Craske et al., 2009; Johnston et al., 2011) and to minimise therapist drift (Waller, 2009), the nature of the contact was protocolised and key aims included (1) reinforcing the main messages of each lesson, (2) answering questions, (3) reinforcing progress and skills practice, (4) problem solving the use of skills, (5) normalising the challenges of recovery, and (6) obtaining feedback about the participant's perception and engagement with the course. Each contact was designed to take ≤10 min, but more time was provided when clinically indicated. "
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    ABSTRACT: Disorder-specific cognitive behavior therapy (DS-CBT) is effective at treating major depressive disorder (MDD) while transdiagnostic CBT (TD-CBT) addresses both principal and comorbid disorders by targeting underlying and common symptoms. The relative benefits of these two models of therapy have not been determined. Participants with MDD (n=290) were randomly allocated to receive an internet delivered TD-CBT or DS-CBT intervention delivered in either clinician-guided (CG-CBT) or self-guided (SG-CBT) formats. Large reductions in symptoms of MDD (Cohen's d≥1.44; avg. reduction≥45%) and moderate-to-large reductions in symptoms of comorbid generalised anxiety disorder (Cohen's d≥1.08; avg. reduction≥43%), social anxiety disorder (Cohen's d≥0.65; avg. reduction≥29%) and panic disorder (Cohen's d≥0.45; avg. reduction≥31%) were found. No marked or consistent differences were observed across the four conditions, highlighting the efficacy of different forms of CBT at treating MDD and comorbid disorders.
    Full-text · Article · Aug 2015 · Journal of anxiety disorders
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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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