BEDA 2017 Professional Roundtable Discussion: What is Therapist Drift?

I so enjoyed the 2017 BEDA conference, co-sponsored by NEDA. This conference represented the joining together of many wonderful and passionate professionals, dedicated to better understanding and treating Binge Eating Disorder.It was a pleasure to facilitate a roundtable discussion at the event to talk about the ways, we as clinicians, can veer off track from the treatments that we know work best. Below are some points covered during the roundtable:

What is Therapist Drift?

• When we, as clinicians, make an active choice to omit particular components of a therapy
• When we passively avoid key components of a therapy
• When we disregard our choice therapy’s limitations
• When we ignore a therapy’s strengths
• When we fail to adequately learn about therapies available
• When we stick to a particular therapy for personal reasons and comfort

In his paper, Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions, Glen Waller states, “It is important to recognize a protocol for what it is intended to be—a broad set of methods, designed to be applicable to the patient in a way that is reflective of their individual case, but guided by a set of principles. The clinical skill and artistry in the delivery of evidence-based therapy lie in how the clinician implements the protocol for the individual patient. However, despite this clear recognition that protocols and manuals need to be used flexibly, they are perceived negatively by many clinicians, who regard them as constraining their practice and artistry by limiting the individualization of formulation and intervention approaches. Therapists routinely deviate from those evidence-based approaches—a phenomenon termed therapist drift.”

The Research: Therapist Adherence to Evidence-Based Treatments

1) We, as therapists, rarely use manuals and we dislike them - even those manualized approaches that are proven to produce the best outcomes. Roughly 10% of clinicians routinely incorporate manuals into their practice. Most clinicians report using “mixtures” of empirically derived techniques with techniques that are unsupported by research.2) Even when we say we’re using an EBT, we are not really following the treatments. As an example, many clinicians will claim to be delivering CBT or FBT but will omit central strategies from the treatments.3) At times we, as therapist, back off certain treatments or treatment strategies that our patients find more challenging or aversive. Therapist anxiety leads us to…

• avoid interventions that challenge the patient “too much” (i.e. exposures, weighing, increasing food intake expectations)
• reduce expectations for weight gain in anorexia
• rely more on the therapeutic alliance to support change 

4) ‘Affiliation hypothesis’: we believe in a treatments’ effectiveness and therefore, assume it will be effective for our patients (i.e. insight-oriented dynamic psychotherapy to treat BN; longer treatment course and recovery rates pale in comparison to outcomes using CBT).5) We sometimes direct certain patients away from evidence-based treatments on various grounds such as chronicity, comorbidity, and complexity, even if there is no support for these factors being exclusionary.6) We, as therapist, believe that therapeutic alliance is central and will improve our outcomes. We often view manualized treatments as less supportive of the alliance with the client.Note: Glen Waller is a scholar, researcher, professor and clinical leader in the field of eating disorders. He’s written numerous papers on therapist drift. The excerpts referenced in this blog are pulled from his papers below. Waller G. Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions. Current Psychiatry Reports. 2016;18:36. doi:10.1007/s11920-016-0679-0.Waller G. Evidence-based treatment and therapist drift. Behav Res Ther. 2009 Feb; 47(2):119-27.Waller G, Stringer H, Meyer C. What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders?J Consult Clin Psychol. 2012 Feb; 80(1):171-5.Waller G, Turner H. Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track.Behav Res Ther. 2016 Feb; 77():129-37.

Other References for Further Study

Addis ME, Krasnow AD. A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals. J Consult Clin Psychol. 2000 Apr; 68(2):331-9.Cowdrey ND. Perspectives on eating disorders: Attitudes to sufferers, and patient experiences of what goes on in cognitive behavioural therapy. DClinPsy dissertation, University of Sheffield, Sheffield, UK; 2015.Cowdrey ND, Waller G. Are we really delivering evidence-based treatments for eating disorders? How eating-disordered patients describe their experience of cognitive behavioral therapy. Behav Res Ther. 2015 Dec; 75():72-7.Kosmerly S, Waller G, Lafrance Robinson A.   Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders. Int J Eat Disord. 2015 Mar; 48(2):223-9.Meehl PE. Why I do not attend case conferences. In: Meehl PE, editor. Psychodiagnosis: Selected papers (pp. 225–302)Minneapolis: University of Minnesota Press; 1973.Meehl PE.  Clinical versus statistical prediction: a theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press; 1954.Poulsen S, Lunn S, Daniel SI, Folke S, Mathiesen BB, Katznelson H, Fairburn CG. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosaAm J Psychiatry. 2014 Jan; 171(1):109-16.Simmons AM, Milnes SM, Anderson DA. Factors influencing the utilization of empirically supported treatments for eating disorders. Eat Disord. 2008 Jul-Sep; 16(4):342-54.Thompson-Brenner H, Westen D. Personality subtypes in eating disorders: validation of a classification in a naturalistic sample. Br J Psychiatry. 2005 Jun; 186():516-24.Tobin DL, Banker JD, Weisberg L, Bowers W. I know what you did last summer (and it was not CBT): a factor analytic model of international psychotherapeutic practice in the eating disorders. Int J Eat Disord. 2007 Dec; 40(8):754-7Von Ranson KM, Robinson KE. Who is providing what type of psychotherapy to eating disorder clients? A survey. Int J Eat Disord. 2006 Jan; 39(1):27-34.Von Ranson KM, Wallace LM, Stevenson A. Psychotherapies provided for eating disorders by community clinicians: infrequent use of evidence-based treatment. Psychother Res. 2013; 23(3):333-43 Waller G. Evidence-based treatment and therapist drift. Behav Res Ther. 2009 Feb; 47(2):119-27.Waller G, Stringer H, Meyer C. What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders?J Consult Clin Psychol. 2012 Feb; 80(1):171-5.Waller G, Turner H. Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track.Behav Res Ther. 2016 Feb; 77():129-37.Waller G. Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions. Current Psychiatry Reports. 2016;18:36. doi:10.1007/s11920-016-0679-0.Wilson GT. Review: Manual-based treatments: the clinical application of research findings. Behav Res Ther. 1996 Apr; 34(4):295-314.Wonderlich S, Mitchell JE, Crosby RD, Myers TC, Kadlec K, Lahaise K, Swan-Kremeier L, Dokken J, Lange M, Dinkel J, Jorgensen M, Schander L. Minimizing and treating chronicity in the eating disorders: a clinical overview. Int J Eat Disord. 2012 May; 45(4):467-7