Therapist drift redux: Why well-meaning clinicians fail
to deliver evidence-based therapy, and how to get
back on track
Reasons why evidence-based therapies might be delivered poorly:
Clinicians being inadequately trained in the therapy in question.
Working in a setting that doesn’t permit the implementation of the necessary
methods (not being able to provide the needed number of sessions).
Therapist drift.
Therapist drift = Therapists’ failure to deliver treatments, or failure to deliver them
adequately, despite having the necessary tools.
This can be a conscious or unconscious course of action.
Reduces the patients’ chances of improvement or recovery.
Three key elements of effective therapy:
1. The therapy has to work.
o Research supports evidence-based therapies, but their success depends on
proper implementation.
2. The patient has to engage in the therapy.
o Engagement differs from simply attending sessions.
o Patients should implement the lessons from therapy in their daily life.
3. The clinician has to deliver the therapy (appropriately).
o This is where therapist drift can undermine effectiveness.
Reasons for therapist drift
1. Knowledge base.
Relatively few therapists use the manuals and guidelines to enhance and maintain
knowledge and skills.
Some just don’t do this, others have negative attitudes towards manuals.
, 2. Beliefs and attitudes.
Negative attitudes about evidence-based methods can make us more cautious about
implementing them.
Philosophical stance Some people see psychotherapy as an art, others as a science.
This depends on their personal beliefs. Therapists base their practice on two contrary
philosophies:
o Romanticism = Prioritising intuition and clinical judgement in reaching clinical
decisions.
o Empiricism = Prioritising scientific evidence in reaching clinical decisions.
Self-assessment biases Therapists tend to overestimate their own skills.
o Problem presented by such beliefs: why try to improve as clinicians, if we
already believe to be operating at a very high level?
Clinician judgement Clinician judgement is substantially less effective than
protocol-driven approaches. It is essential for the flexible implementation of
protocols, but cannot substitute for them.
* see pros and cons of manualised treatments and protocols down below.
Overvaluing the therapeutic alliance can lead to therapist drift.
o A common assumption is that a strong alliance predicts better therapy
outcomes, but research only shows a weak correlation (without direction).
Some studies even suggest that the opposite is true: early symptom
improvement strengthens the alliance, rather than the alliance causing the
improvement.
o Spun-glass theory of the mind = Some therapists view their patients as
fragile, like spun-glass, leading to a reluctance to challenge them or encourage
necessary changes during therapy. This can result in therapist drift, out of fear
of causing emotional distress and to maintain a “good” therapeutic alliance.
o Good working alliance ≠ consistently good relationship. Balancing firmness
and empathy is very important.
* Pros manualised treatments and protocols:
They lower care costs.
They improve clinical outcomes, especially for less experienced therapists.
They provide structure, keeping therapists on track and ensuring consistency in
treatment.
* Cons manualised treatments and protocols:
They can limit creativity and flexibility.
Negative attitudes towards them can lead to poorer outcomes (especially in CBT).
to deliver evidence-based therapy, and how to get
back on track
Reasons why evidence-based therapies might be delivered poorly:
Clinicians being inadequately trained in the therapy in question.
Working in a setting that doesn’t permit the implementation of the necessary
methods (not being able to provide the needed number of sessions).
Therapist drift.
Therapist drift = Therapists’ failure to deliver treatments, or failure to deliver them
adequately, despite having the necessary tools.
This can be a conscious or unconscious course of action.
Reduces the patients’ chances of improvement or recovery.
Three key elements of effective therapy:
1. The therapy has to work.
o Research supports evidence-based therapies, but their success depends on
proper implementation.
2. The patient has to engage in the therapy.
o Engagement differs from simply attending sessions.
o Patients should implement the lessons from therapy in their daily life.
3. The clinician has to deliver the therapy (appropriately).
o This is where therapist drift can undermine effectiveness.
Reasons for therapist drift
1. Knowledge base.
Relatively few therapists use the manuals and guidelines to enhance and maintain
knowledge and skills.
Some just don’t do this, others have negative attitudes towards manuals.
, 2. Beliefs and attitudes.
Negative attitudes about evidence-based methods can make us more cautious about
implementing them.
Philosophical stance Some people see psychotherapy as an art, others as a science.
This depends on their personal beliefs. Therapists base their practice on two contrary
philosophies:
o Romanticism = Prioritising intuition and clinical judgement in reaching clinical
decisions.
o Empiricism = Prioritising scientific evidence in reaching clinical decisions.
Self-assessment biases Therapists tend to overestimate their own skills.
o Problem presented by such beliefs: why try to improve as clinicians, if we
already believe to be operating at a very high level?
Clinician judgement Clinician judgement is substantially less effective than
protocol-driven approaches. It is essential for the flexible implementation of
protocols, but cannot substitute for them.
* see pros and cons of manualised treatments and protocols down below.
Overvaluing the therapeutic alliance can lead to therapist drift.
o A common assumption is that a strong alliance predicts better therapy
outcomes, but research only shows a weak correlation (without direction).
Some studies even suggest that the opposite is true: early symptom
improvement strengthens the alliance, rather than the alliance causing the
improvement.
o Spun-glass theory of the mind = Some therapists view their patients as
fragile, like spun-glass, leading to a reluctance to challenge them or encourage
necessary changes during therapy. This can result in therapist drift, out of fear
of causing emotional distress and to maintain a “good” therapeutic alliance.
o Good working alliance ≠ consistently good relationship. Balancing firmness
and empathy is very important.
* Pros manualised treatments and protocols:
They lower care costs.
They improve clinical outcomes, especially for less experienced therapists.
They provide structure, keeping therapists on track and ensuring consistency in
treatment.
* Cons manualised treatments and protocols:
They can limit creativity and flexibility.
Negative attitudes towards them can lead to poorer outcomes (especially in CBT).
