Allen R. Miller, PhD, MBA
Director of CBT Programs, Beck Institute
Therapist drift can be defined as the failure of a clinician to effectively deliver a specific treatment, despite being adequately trained, and having the necessary resources and support to do so. Drift is something we commonly see among providers at all levels. In this blog, I will discuss how therapist drift often occurs and outline the steps Beck Institute is taking to reduce drift.
Why is this important? We are so often confronted with the paradox that effective treatments have been developed and tested for many common—and not-so-common—health and mental health disorders, and yet, most people who suffer from these conditions do not receive these life-changing evidence-based therapies. In addition, we see that many well-meaning therapists receive training in CBT and believe they provide CBT, but do not practice with fidelity to the model that has been studied and validated. And clients rarely know whether they are receiving evidence-based CBT, something more eclectic (which may contain elements of CBT but is not based on the cognitive model), or something completely different. Sadly, many clients who seek CBT receive treatment from a therapist who does not practice with fidelity. When clients do not make progress, they can become discouraged and assume CBT didn’t work for them.
Of course, some clinicians never learned to conduct CBT therapy, or conceptualize clients and apply the specific therapeutic techniques adequately in the first place. We developed and refined Beck Institute’s robust training programs to teach CBT to students, new practitioners, practitioners trained in other models, and CBT practitioners who want to improve their skills.
Drift may occur over time when clinicians have learned techniques but, for a variety of reasons, stray from the model or decide that certain aspects of the treatment are really not necessary. Some early career therapists may, for example, lack the confidence to gently interrupt clients to stay on track. Or they may feel uncomfortable questioning clients who don’t complete their Action Plans to identify and resolve obstacles that got in the way. Often, they fear upsetting the client. More experienced therapists sometimes value their clinical intuition more than what research has demonstrated to be effective. There are no absolute protections against this occurrence, but drift tends to occur among clinicians who practice in isolation without peer consultation or supervision. Having a like-minded peer group that meets regularly to discuss CBT clients and issues can provide some level of protection.
Drift also occurs in the process of treatment, including the development of a strong therapeutic alliance, maintaining a humanistic attitude toward clients and the purpose of treatment, setting agendas in sessions, and collaboratively creating effective Action Plans with steps clients want to take between sessions. We found in several large gatherings of well-trained, doctoral-level clinicians that there was very little agreement among them about what the process items should look like. In fact, when we asked a group of experienced clinicians to rate the same CBT therapy session using the most widely used assessment tool, the Cognitive Therapy Rating Scale (CTRS), we found that the scores varied broadly.
We made a study of this phenomenon that resulted in a revision to the CTRS, the Cognitive Therapy Rating Scale-Revised (CTRS-R) and to the development of a new on-demand course, CBT in Practice. One interesting aspect of these projects is that the items of importance did not change from what Dr. Aaron Beck established through research. What changed is how we evaluate therapists’ behavior and how we teach CBT to therapists.
The CTRS-R can be used in CBT supervision, but can also be used by individual therapists, to routinely “check in” with their practice and hold themselves accountable. The on-demand course CBT in Practice is appropriate for therapists who have trained in CBT, and perhaps have not recognized that they have drifted from the model. It’s designed for clinicians who would benefit from illustrative roleplays and full therapy sessions to really understand what happens minute-to-minute in a CBT session. Our supervision and certification programs also provide intensive training and opportunities for ongoing feedback, support and accountability. All these tools and programs are offered to individual clinicians and to staff at all levels of behavioral health organizations and agencies.
Please contact us at ewalsh@beckinstitute.org if you would like to learn more about how Beck Institute can help your organization prevent and ameliorate therapist drift and ensure that your clients are receiving evidence-based care that will help them get better and stay better.