A growing phenomenon termed ‘therapist drift’ references a clinician’s tendency to deviate from evidence-based treatment approaches as protocols are often viewed negatively. Some clinician’s regard them as constraining to their practice and artistry by limiting the individualization of formulation and intervention approaches. Despite the overwhelming support that individualized approaches to eating disorder treatment result in poorer outcomes than evidence-based intervention strategies, apprehension persists. A recent article published to Current Psychiatry Report aimed to understand why.
It has been known for some time that evidence-based interventions are considered the gold standard in the treatment of eating disorders. Study author Glenn Waller writes “A number of therapies had been identified that reduced the severity and presence of bulimia nervosa and binge-eating disorder, including cognitive-behavioral therapies (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT).” Despite well-documented support for evidence-based practices, a number of misconceptions about the treatments contribute toward therapist drift. One such belief is that research results cannot be replicated in a typical clinical setting. Some clinicians fear that an unachievable level of supervision or in-service training will be required to achieve similar results, placing undue stress on a practice and its practitioners. Secondly, clinicians fear that proper adherence to strict protocols will inhibit their ability to practice in their own unique style, hindering their artistry and clinical judgment. This will be an important misconception to reverse, as evidence-based practices were not intended to strip a clinician of unique skill but rather to succeed as a result of specialized delivery. Effective delivery of evidence-based treatment lies in how each unique clinician implements a specific protocol.
A third variable that contributes to therapist drift is patient reluctance to commit to stricter protocols. Waller reports that this reluctance may be a result of experiences with therapists who omit aspects of evidence-based treatments, resulting in a learned expectation that treatment is not, or should not be challenging. This learned avoidance of challenge is not confined to the patient. A fourth variable is the subsequent anxiety experienced by the clinician when faced with patient reluctance. Clinicians may report anxiety surrounding the more demanding elements of therapy (e.g. weighing patients; changing their food intake) and feel “bad” for distressing the patient and experience a desire to individualize treatment. This pattern of behavior is most clearly observed in cases where therapist and patient fall into an unproductive pattern of discussing the causes of the eating disorder without engaging in behavioral change. An attempt to avoid anxiety and distress on the part of the clinician may result in looser protocol adherence and contribute to therapist drift.
As studies continue to demonstrate the reliability and validity of evidence-based practices in eating disorder treatment it is important that as eating disorder specialists, we continue to make honest appraisals of our practice methods and motives. With quality training and supervision, our patients will benefit from the implementation of gold standard protocols.