It’s not something we like to talk about. In fact, it’s something I think many of us don’t really even know about. What I’m talking of is how therapists drift, stray, or deviate from what is evidence-based treatment into what is not.
Strangely enough, I’ve been thinking of this in relation to my post yesterday about ‘education’ and ‘information’ and ‘teaching’ in relation to the cognitive behavioural approach to pain management.
There are a lot of reasons for people failing to achieve expected outcomes from treatment: sometimes it’s the wrong formulation, sometimes the person doesn’t do what is expected/hoped for, and sometimes it’s not about either – it’s about ‘creative’ use of therapy…in other words, as therapists we don’t follow what the therapeutic process requires.
The paper I’ve referred to when discussing the ideas of ‘therapist drift’ is written by Glenn Waller. He identifies that there are two elements that are consistent across all the different types of CBT. One is that cognitions are challenged, and the other is the use of behavioural change. He notes that both of these can be stressful – for patient and clinician! And its as a result of inaccurate evaluation of the demands of the perceived stressors (ie, the ‘task’ the person needs to complete), and an inaccurate perception of the coping resources required that lead both clinician and participant off track.
The results of ‘drifting’ like this, whether because the patient hasn’t followed/adhered to the treatment, or because the therapist has ‘been creative’ about the therapeutic process, is that therapy may well be ineffective. We may attribute this treatment failure to the patient, saying things like ‘they didn’t stick to the treatment’, ‘they weren’t ready’, ‘they weren’t motivated’. We might even suggest that ‘this person isn’t suitable for CBT-based pain management’.
It’s less often that we consider our own actions and adherence to the CBT formulation. Waller identifies that good rapport, or an effective working relationship, and that this involves being nonjudgemental. What this means is that when things don’t work out, we can’t ‘blame’ either the patient or ourselves for failure to make progress – our job is to coach or facilitate so that patients can ‘become their own therapist’. This also means, according to Waller, that we need to agree with our patients that it’s important we don’t ‘protect’ patients from some of the more distressing or ‘hard’ aspects of therapy. This can happen when we, as therapists, are fearful of seeing someone in distress. Waller suggests that ‘the patient needs to be made aware from the assessment and formulation onwards that getting to a more adaptive mode of functioning is inevitably going to be stressful in the short-term.’ (Waller, 2009).
Waller also points out that effective therapy also depends on therapists working in a service that supports delivery of evidence-based and evidence-generating practice. This can be a real challenge in some settings – funding for treatment may not include sufficient time for comprehensive assessment, adequate numbers of sessions for treatment, or appropriate attention to ongoing learning, supervision or research.
Waller’s main argument, in this paper, is that ‘as clinicians, we are often active but unintentional agents in treatment going wrong, creating our own stumbling blocks’. He identifies three elements involved in creating treatment drift – clinician cognitions, emotions and behaviours. In his paper, he goes on to give examples of where therapists have drifted and both how they’ve gone wrong, and how to correct it.
I’ll discuss some more of his paper tomorrow – it makes for sobering reading, however, to know that most of us think of ourselves as ‘good’ practitioners. It has made me wonder whether I do, in fact, drift off from collaborating and facilitating and into ‘teaching’ and simply ‘informing’. What is the effect of ‘teaching’ rather than working with or collaborating with the person? Do I avoid pushing for behavioural change? It’s often the most stressful part of pain management because it elicits distress in the patient, and this in turn can elicit distress in me. What thoughts, emotions and behaviours do I have in response to my patients?
More tomorrow! Tune in and see what else I find out!
Glenn Waller (2009). Evidence-based treatment and therapist drift Behaviour Research and Therapy, 47 (2), 119-127 DOI: 10.1016/j.brat.2008.10.018