Why should a therapist be concerned with Therapeutic Drift? As we drift away from therapy we also drift away from effective outcomes for clients.
What is therapeutic drift
Therapeutic drift is defined in many ways. Generally, it is when the therapist stops using therapeutic methods. It can also include when we stop focussing on outcomes.
How does it happen:
Basten (2019) outlined several factors that may be related to therapeutic drift:
· When a client does not initially respond to treatment
· When a clinician thinks their clinical judgment is superior to the research
· When a therapist does not feel comfortable with a manualized therapy
· The therapist’s emotional reactions
· When there is more than one clinical issue
· When the client wants to attend for supportive counselling
The examples in a PTSD context
When a client does not initially respond to treatment
“We are up to session four and nothing has happened. I have to do something to help them. It’s not working.”
Do you go back over your formulation? Do you review why you decided on the course of therapy? It was a collaborative process wasn’t it?
When a clinician thinks their clinical judgment is superior to the research
“We are barking up the wrong tree, I know they have PTSD and Depression. They really seem to be stuck in their childhood trauma. I need to do something different; they need more work on their childhood and what they missed out on. We need some primal therapy or some Vegetotherapy.”
“Academics don’t have clinical experience, the clients they see aren’t like the clients I have.”
This client is ‘complex’. Their problems aren’t in the research. There is no model of mental health that fits them. They are special.
How reliable is a clinician’s judgement? Grove and colleagues (2000) meta-analysis on clinical versus mechanical prediction found that “on average, mechanical-prediction techniques were about 10% more accurate than clinical predictions.” pg 19
When a therapist does not feel comfortable with a manualized therapy
“This is a cookbook; It is too formulaic. I won’t be responding to the client’s needs. It will take away the art of therapy.”
Have you talked to a therapist who has used a manualized therapy? Have you tried it out?
When the client wants to attend for supportive counselling
Sessions where you talk about lots of different things the client could try and settle on none. These are likely to be supportive counselling sessions.
“Hi how was your week?” “Well let me tell you about it!” This week I was so busy, I didn’t have time to think. I had to go to my brother’s wedding, and you know how difficult he can be. I get triggered by him. Then I had to take my kids to school camp, and you know that is a worry! I never know how they will feel, will they cope? I wonder if I am doing the right thing by them, am I putting them at risk, will something happen to them like happened to me? Then my husband needed me to attend two work functions this week. I don’t feel safe in crowds. I get so anxious when I attend these events, I hyperventilate before them.
You provide a listening ear and suggestions. “Have you tried that idea of watching your thoughts when you think about your brother.” “Have you thought about those breathing techniques when you start to feel panicky.”
There is no outcome, no agreement on what to do outside of the therapy room. A formulation of the client’s problem and a focus using a theoretical model has become lost.
The therapist’s emotional reactions
Strong emotions in our clients, particularly if they have experienced trauma are inherent in the experience. If you find yourself thinking things like: “If I push the client, I will cause harm, they will leave therapy.” “If the client is upset, I am a bad therapist.” It may be worth thinking about who’s emotional reaction you are worried about. Are you using Paul Meehl’s (1973) “spun-glass theory of the mind.”
“Spun-glass theory of the mind” – being fearful that they (the therapist) will somehow ‘break’ their ‘fragile’ patient if they ask them to undertake any change, despite the fact that the rest of the patient’s week might be spent in extremely distressing circumstances. Pg 7 Meehl (1973)
When there is more than one issue to be worked upon
“Oh, there are so many traumas I couldn’t possibly choose one to focus on.” “I am having relationship difficulties as well as my PTSD; I need to work on my relationship.”
What can we do about it
If you are delivering Cognitive Processing Therapy (CPT) for PTSD LoSavio, (2019) has developed a questionnaire that assesses therapist stuck points for delivering CPT. Of course, regular supervision and peer consultation are also things that can assist.
Summary
Guarding against therapist drift is important if we want good outcomes for our traumatised clients. Considering that some clients suffering from PTSD can avoid to treatment for 35-40 years effective treatment is important. Therapists considering their own process is important for good outcomes. As Glenn Waller and Hannah Turner (2016) stated.
“Our concerns about challenging or distressing our patients through the use of behavioural or cognitive change can result in our engaging in clinician safety behaviours – not pushing patients to change, so that our self-identity as positive characters in their lives is not threatened.” Pg 10
References
Basten, C., (2019). The Art of CBT : Individualised Strategies to Respond to Common Obstacles in Therapy. Sydney: Australian Academic Press
Corvalan, J. C., & Klein, D. (2011). PTSD: diagnosis, evolution, and treatment of combat-related psychological/psychiatric injury. Missouri medicine, 108(4), 296–303.
Grove, W. M., Zald, D. H., Lebow, B. S., Snitz, B. E., & Nelson, C. (2000). Clinical versus mechanical prediction: a meta-analysis. Psychological assessment, 12(1), 19–30.
Meehl, P. E. (1973). Why I do not attend case conferences. In P. E. Meehl: Psychodiagnosis: Selected papers (pp. 225–302). Minneapolis: University of Minnesota Press.
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 Therapy, 77, 129. doi:http://dx.doi.org/10.1016/j.brat.2015.12.005
LoSavio, S.T., Dillon, K.H., Murphy, R. A. & Resick, P. A. (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes. Professional Psychology: Research and Practice. Advance online publication. PTSDpubs ID: 52080
