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Donna Sudak, MD speaking at the Beck Institute Excellence Summit 2017

Therapeutic Drift

How to Maintain Therapeutic Effectiveness

By Donna Sudak, MD

Many studies have demonstrated that work performance level for a variety of professions decreases in effectiveness over time. Specific activities are often mandated to help individual practitioners maintain skills at a high level. For example, practicing radiologists are required to review films and compare their readings to what was actually found to be wrong with a patient. Practicing psychotherapists have mandated educational requirements (for example, continuing education credits for maintaining licensure or board certification). However, such activities seldom, if ever, entail any focused practice or measurement of therapeutic skills. Even mandated peer review of patient records generally involves a review of documentation and treatment planning rather than an actual measurement of what occurs within a therapy session. Since we know that experienced professionals often stop improving and experience deterioration of their skills over time, this practice is short-sighted.

Recently, research has shown significant consequences of so-called “therapeutic drift” (Waller & Turner, 2016). The drop-off in skill levels of therapists, the variable use of empirically supported treatments, especially behavioral interventions in therapy, and the faulty implementation of such treatments potentially lead to further patient suffering and the public perception of ineffectiveness of our treatments. Compounding the problem of drift is biased thinking common to all therapists. Therapists’ misattributions about their own skill levels are significant. Walfish et al (2012) found in a multidisciplinary practitioner survey that not one therapist viewed him or herself as below average and that 25% of the respondents said they were in the top 10% of all therapists. Additionally, they rated the vast majority of their patients as improved, contrary to what we know about average rates of patient improvement.

So how do we overcome drift? Here are three steps every therapist can take to increase adherence and effectiveness.

First, measure patient outcomes. Lambert et al (2005) has demonstrated the value of regular outcome monitoring in a series of studies. Obtaining frequent ratings of patient symptoms using a validated instrument is critical to determine how therapy is progressing, since, as noted, clinicians are unable to accurately discern how patients are progressing. In addition, sharing the ratings with patients increases the value of such monitoring, as it creates a context to have a conversation about lack of progress and may potentially increase patient commitment.

Second, practice automatic sequences that you employ in therapy. This can involve observing carefully the micro-skills of therapy and systematically evaluating how effectively you perform. For example, agenda setting, homework assignments, automatic thought records, and obtaining and responding to feedback can be deployed and practiced in rotation with observation of patient responsiveness and evaluation of your efforts. This will increase the accuracy with which you employ the skill and decrease therapy “autopilot.” Without such deliberate practice you will fail to see how you can improve.

Third, listen to and rate therapy recordings with a validated instrument like the Cognitive Therapy Rating Scale. Even better, have an agreement with a like-minded therapist friend to share recordings and rate one another’s tapes. Chow and his colleagues (2015), in an interesting new article, linked deliberate practice activities to superior therapy outcomes. One observation they made was that therapists who spent time listening to recordings made an enormous difference in how well patients did. Cognitive-behavioral therapists can use the CTRS to evaluate the quality of their sessions, improve their performance, and consequently their patient outcomes.


Chow, D.L., Miller, S.C., Seidel, J.A., Kane, R.T., Thornton, J.A., Andrews, W.P. (2015) The Role of Deliberate Practice in the Development of Highly Effective Therapists. Psychotherapy, 52 (3), 337-345.

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of counseling psychology63(1), 1-11.

Lambert, M. J., Harmon, D., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology61, 165–174.

Walfish, S., McAlister, B., O’donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports110(2), 639-644.

Waller, G., & Turner, H. (2016). Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour research and therapy77, 129-137.

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