Why Is Therapy Taking So Long? The causes and solutions for therapeutic drift
Curt and Katie chat about the tendency for therapists to drift clinically – meaning that they fail to use evidence-based practices that they have been trained to do. We explore the phenomenon of therapeutic drift, contributing factors, ways to mitigate risk, and what therapists can do to address this tendency that leads to poorer therapeutic outcomes. This is a continuing education podcourse.
Click here to scroll to the podcast transcript.Transcript
In this podcast episode we explore why therapists stray from using evidence-based practices
In order for therapy to be successful, both the therapist and client need to stay invested in the therapeutic process. We explore the reasons that therapy can stall, how to identify the causes, and how to get back on track toward achieving client goals.
What is therapist drift and why is it bad?
- Therapists will fail to use evidence-based treatment even when they have the tools and training
- May be seen as pushing back on manualized treatments that do not seem to focus on the relationship sufficiently
- Therapeutic drift can happen when the therapist and client are not in agreement or clear on the goals for treatment
- Not sticking to the plan for treatment and failing to make progress
- Mislabeling of treatment interventions
What factors contribute to therapeutic drift?
“When we look at common factors, yes – the relationship is very important. But having agreed upon goals and a model is [also a] part of common factors. It doesn’t excuse us from having a plan and specific interventions.” – Katie Vernoy, LMFT
- Client factors include avoiding talking about treatment goals
- Lack of adherent training and understanding of the models
- Therapist factors include not identifying optimal treatment methods or structures upon which to build creative intervention
- Therapists doing what feels good to them versus what is best for the client
- Systemic factors including teaching too many theories without sufficient depth
How can we mitigate the risks of therapeutic drift?
“It’s not necessarily the evidence-based treatment that’s the problem. It’s the way that you were forced into doing it [at an agency] that was the problem.” – Curt Widhalm, LMFT
- Practice-based evidence
- Setting treatment plans and single session agendas
- Outcome measures and client feedback
- Intentionality versus convenience
- Assessing bias and where our negative feelings about EBPs come from
- Collaborating with the client
- Deliberate practice
- Consultation, ongoing supervision
Receive Continuing Education for this Episode of the Modern Therapist’s Survival Guide
Hey modern therapists, we’re so excited to offer the opportunity for 1 unit of continuing education for this podcast episode – Therapy Reimagined is bringing you the Modern Therapist Learning Community!
Once you’ve listened to this episode, to get CE credit you just need to go to moderntherapistcommunity.com/podcourse, register for your free profile, purchase this course, pass the post-test, and complete the evaluation! Once that’s all completed – you’ll get a CE certificate in your profile or you can download it for your records. For our current list of CE approvals, check out moderntherapistcommunity.com.
You can find this full course (including handouts and resources) here: https://moderntherapistcommunity.com/courses/why-is-therapy-taking-forever-the-causes-and-solutions-for-therapeutic-drift
Continuing Education Approvals:
When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information
CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.
Resources for Modern Therapists mentioned in this Podcast Episode:
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
References mentioned in this continuing education podcast:
Hernandez, M. E., & Waller, G. (2021). Are we on the same page? A comparison of patients’ and clinicians’ opinions about the importance of CBT techniques. Cognitive Behaviour Therapy, 50(6), 439-451.
Hogue, A., Bobek, M., Porter, N., MacLean, A., Bruynesteyn, L., Jensen-Doss, A., & Henderson, C. E. (2022). Therapist Self-Report of Fidelity to Core Elements of Family Therapy for Adolescent Behavior Problems: Psychometrics of a Pragmatic Quality Indicator Tool. Administration and policy in mental health, 49(2), 298–311. https://doi.org/10.1007/s10488-021-01164-0
Reid, A. M., Bolshakova, M. I., Guzick, A. G., Fernandez, A. G., Striley, C. W., Geffken, G. R., & McNamara, J. P. (2017). Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders. Community mental health journal, 53(4), 432–437. https://doi.org/10.1007/s10597-017-0108-9
Speers, A. J., Bhullar, N., Cosh, S., & Wootton, B. M. (2022). Correlates of therapist drift in psychological practice: A systematic review of therapist characteristics. Clinical Psychology Review, 93, 102132.
Trivasse, H., Webb, T. L., & Waller, G. (2020). A meta-analysis of the effects of training clinicians in exposure therapy on knowledge, attitudes, intentions, and behavior. Clinical Psychology Review, 80, 101887.
Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour research and therapy, 47(2), 119-127.
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, 129-137.
Young, J. (2020). Putting single session thinking to work: conceptual, practical, training, and implementation ideas. Australian and New Zealand Journal of Family Therapy, 41(3), 231-248.
*The full reference list can be found in the course on our learning platform.
Relevant Episodes of MTSG Podcast:
Has Therapy Become the New Religion?
Stop Trying to Convince Clients to Change: An interview with Hillary Bolter, LCSW
What to do When Clients Get in Their Own Way
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
Consultation services with Curt Widhalm or Katie Vernoy:
Connect with the Modern Therapist Community:
Our Facebook Group – The Modern Therapists Group
Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 0:15
Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com, register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, or you can download it for your records. For a current list of our CE approvals, check out moderntherapistcommunity.com.
Katie Vernoy 0:47
Once again, hop over to moderntherapistcommunity.com for one CE once you’ve listened.
Curt Widhalm 0:48
Welcome back modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is another one of our continuing education eligible episodes. You want CEs for this episode post directions at the beginning and the end of the episode or go to our show notes over on mtsgpodcast.com. And we are talking today about ineffective therapy, about our hatred of manualized treatments and why that might not be the best of things. So in my own justifications of this episode, I actually realized that I do more evidence based treatments than I care to admit. I’m actually more of a model follower that I may have let on to the audience. And maybe I’m just doing some revisionist history here over a couple of 100 episodes. But I think we’re going to do some callbacks to some old episodes here that are maybe at first glance, kind of contradictory to what we’re talking about today. But I think that it fits in with everything. So when we prepare for these kinds of episodes, we tend to share some of what we’re talking about with each other. It’s I think it’s pretty obvious if you go back to some of the CE episodes, which ones are more me led and which ones are more Katie led, this one being a Curt lead episode. This is not a team, Curt team, Katie sort of thing. This is a who’s doing the heavy lifting of the research here. Just in preparation for some of these, we don’t end up both reading all of the articles here. So we do have a basis for what we’re talking about, we’re going to talk about some of our experiences, we’re gonna make some of you a little bit upset, and…
Katie Vernoy 2:41
Or a lot upset.
Curt Widhalm 2:42
Or a lot upset. So get your pitchforks and join our Facebook group, the Modern Therapists group or follow us on social media and let us know what you think. But we’re going to talk about therapeutic drift today and what that is, what it means for clients, what it means for us and ways that we can address this as individuals and systemically so that way, therapy can be as good as it could be.
Katie Vernoy 3:14
Okay.
Curt Widhalm 3:16
Just at first glance, Katie, what is therapeutic drift?
Katie Vernoy 3:19
When I read the little snippets that you forwarded over to me that the idea of therapeutic drift or clinical drift or therapist drift seems to be that therapists move away from the models that they have been trained upon, and start just doing whatever they want. And…
Curt Widhalm 3:40
And shockingly, it leads to clients not getting the outcomes that they want.
Katie Vernoy 3:47
Well, according to these research articles, right? I think there’s, there’s a lot that we have to get into. I think more nuance than what you’re describing so far about what that actually means. Because when when I was looking through these articles and thinking about it myself, I think there is potentially a bias in the research if it’s the CBT folks that are doing the research. So I want to hear what’s going on before I go much further because it seems to me that you are learning a lot here and wanting to revise your statements around evidence based practices or manualized treatments.
Curt Widhalm 4:27
So I’m gonna start with the definition. This is from a 2016 article by Glenn Waller and Hannah Turner called ‘Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track.’ And they defined therapeutic drift as this occurs when clinicians fail to deliver the optimum evidence based treatment despite having the necessary tools and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. I know in some of our preparation for this episode, you know, and being able to kind of review and refine some of the messaging that we’ve put out there before is, Katie and I are big on common factors type things. We really do appreciate a lot of therapeutic alliance type stuff. We’ve gone in depth on how to build therapeutic alliance in some of our previous episodes, how to measure that, how to check back in with clients on if those things are still continuing to work out. And I think in our version of describing some manualized treatments before, that we lay out that sometimes that piece of manualized treatments gets kind of glossed over, it gets kind of rushed through things. And that’s why some manualized treatments don’t work. And maybe the impetus for the call for a lot of us to move out of community mental health agencies and into our own practices, allows for a little bit more freedom to be able to focus on building those relationships and using some of that therapeutic alliance in order to, I don’t know, help clients, but but it seems like in talking with a lot of therapists across our careers, that when we start to talk about therapeutic alliance in the ways of joining with the clients, helping to come to an agreement on what the goals of therapy are, and an agreement on how we’re going to address those goals, still leaves a lot of space to be able to do evidence based practices from the very beginning. This is just kind of in the first couple of sessions saying, hey, there’s some treatments out there that have really good evidence that allow for us to address this particular problem. And the one that seems to be the most robust in treating, for example, a particular phobia seems to come from something called exposure and response prevention. And here’s the evidence behind this. And here’s how it would look for us. Does this sound like something that you would move forward on? I think that little brief description is key to a lot of building therapeutic alliances in that, hey, I’m a clinician, I have a plan, and I’m getting your buy-in to this plan from the very beginning, that sets up manualized treatments or evidence based treatments to actually be effective. It’s how will we then adhere to those plans, that ends up being therapeutic drift or not. But I think in framing some of this conversation with our body of other podcast episodes, and everything else is we’re not anti manualized treatment, we’re anti not doing it well, or we’re not. We’re anti, you know, we’re anti bad therapy. And part of what makes good therapy is being able to use a good basis of some of the evidence that actually does work.
Katie Vernoy 8:03
We have an episode called ‘Is CBT Crap?’ and we’ll link to that in the show notes. But I think we, when I went back and listened to it, it really is what you’re describing. So this is not completely revisionist history. But it really is very cautious about these evidence based or manualized treatments. And I want to clarify that the evidence base that is around CBT, or those types of things, isn’t the only evidence base. There’s a lot of different…
Curt Widhalm 8:32
Sure.
Katie Vernoy 8:30
…types of treatment, different frameworks and models that have evidence and or are building evidence that could still be well used. I mean, you’re not saying that we all need to start using CBT or EMDR, or DBT, or ERP, or whatever it is, and all the alphabets. But there is that element of when we look at common factors, yes, the relationships very important. But having agreed upon goals, and a model is part of common factors. It doesn’t…
Curt Widhalm 8:39
Yes.
Katie Vernoy 8:41
…it doesn’t excuse us from having a plan and specific interventions. I think the thing when I was reading through some of the stuff that I get concerned about, that I don’t agree with, is this idea of being adherent to a model 100% of your therapy. I think, yes, ERP you need to be adherent to it. Like that is a particular type of treatment for a particular type of of issue that you need to be adherent for. But to me, I think there’s this other element of when we have a client that comes in with a lot of complexity, a single evidence based practice, done adherently may solve one problem…
Curt Widhalm 9:44
Sure.
Katie Vernoy 9:44
…and not all of them. And I think that’s where I want to get into the discussion around: What is it that we’re actually talking about? Because to me, the way if we go strictly to a kind of black and white, black and white model here we’re looking at somebody needs to do 10 sessions of CBT. And that’s going to be what it looks like versus using tools from evidence based practices, from promising models, from those things within an integrated model, right?
Curt Widhalm 10:15
Sure.
Katie Vernoy 10:15
To me, I think there’s, there’s an element of this where, in research, it is very nice to have a discrete problem with a discrete treatment, and it will get results. But when we’re looking at real clients in the real world, they’re very complex. And they don’t just most of them don’t just have a discrete problem. And so what is successful treatment? Now, you’ve already said, talk to the client, go back to the client, those types of things, like that’s part of the relationship. But I think, who is defining success in these meta analyses that you’re bringing up? Because to me, it’s like, if we’re going to start if the if the premise that we’re starting with is that people are getting worse outcomes, because they’re not using evidence based practices. Who is defining what successful outcomes are in these studies?
Curt Widhalm 11:03
So without directly answering that, and maybe getting to this and helping our audience on this is coming back to these conversations to the client is the common factors piece of it, that helps the client to be the one to determines whether or not things are successful. That is, our, our ultimate takeaway, as far as this piece of the argument goes. I’m sure that some of the studies that are out there, and I know that there’s well over 100 studies that look at therapist drift, and I didn’t read them all people, but…
Katie Vernoy 11:38
We don’t have that kind of time.
Curt Widhalm 11:39
But the articles that I look at, kind of look more at some of the clients feelings of not achieving success. This isn’t necessarily, you know, insurance companies or, you know, agency sort of descriptions of, you know, clients not reaching their treatment. There is some agency issues that we’ll talk about in in this episode here. But this is the ability to get clients to the place where they want to be, which is common factors. Okay?
Katie Vernoy 12:10
I mean, if we’re looking at it from a place of client defined successful outcomes, then I think this is something that I want to dig more deeply in. If it was like, ‘Hey, you have a CBT, your thought processes a little bit better, or you’re not afraid of thing A but now you’re afraid of thing B.’ Like, you know, that was the thing that I think I really struggled with in Community Mental Health was that it was: you get to a particular goal and funding runs out and off you go. And the complexity of the cases were not addressed by success.
Curt Widhalm 12:50
Right.
Katie Vernoy 12:50
And so so I want to dig in with this, because I think there’s, there’s a lot here that I think is really important to think about. And to me, it seems like the gold is going to be in the nuance, not in just use evidence based practices. And that’s not what we’re saying.
Curt Widhalm 13:06
Right. Now, there are some client issues that lead to therapeutic drift. And this is largely going to be those clients that come in that have a poorly defined reasons for being in treatment, or it’s going to be reasons that they’re being assigned to therapy may be cases where it’s court ordered or something like that, or, you know, calling back to, you know, our men in therapy episode of people being sent by family members and just not really having good therapeutic goals. Newsflash, good common factors and good therapeutic alliance building helps to get those clients back on track. But we’ve likely all had those clients who show up and would rather talk about literally anything else other than the reason why they’re there.
Katie Vernoy 13:56
Sure.
Curt Widhalm 13:57
And so this is a client factor that comes in and I’ll point to Irvin Yalom, as far as being one of the best and most concise ways of addressing clients like these to get back on track is start talking about the therapy. You know, this is not like this is just out of those deliberate practice people who are like, you know, do all of these measurements as far as what therapy is. But even just being able to have conversations of like, ‘What are you doing here?’ like, ‘We’ve heard all the goals you came in with and now you’re talking about, you know, 90 day fiance rather than, you know, your own depression’ or something like that, that ends up being something where the clients end up contributing to therapeutic drift. Now…
Katie Vernoy 14:47
Well, I think it’s funny because when you were saying that I remember a meme or a GIF what, I don’t know which one it is. But anyway, it was this person that was just sitting there looking kind of confused and they’re like That feeling when you’re you start talking about ordering pizza on Thursday and by the end of the therapy session, you’re talking about your deepest darkest trauma or whatever. And it was funnier when it was out there. But I think the idea around therapist magic is that we can basically take anything and move to a therapeutic goal or a therapeutic conversation. I think when we were preparing on this, and we actually have our prep over on Patreon, everyone, so if you want to see what we look like when we’re behind the scenes go over there. But, but you were talking about, even if someone comes in without goals, and that was one of the problems we talked about on the therapy as a new religion episode. Our job is to get to a goal.
Curt Widhalm 15:41
Yeah.
Katie Vernoy 15:41
It’s to to figure out what that is, and and, you know, motivational interviewing, we have an episode on that. There’s a lot of different places where you can use some of this stuff to actually get to an agreed upon goal, even at from the beginning of treatment. And so I think…
Curt Widhalm 15:43
And those come from evidence based practices.
Katie Vernoy 16:04
Well, and I think when when I think about evidence based practices, I also think that there are still some very strong practices that don’t have an evidence base because their harvest study, right. And so I think some of the things I do, I think, work very well and don’t have an evidence base. And so maybe, maybe I’m a drifter.
Curt Widhalm 16:25
Well…
Katie Vernoy 16:25
But I’m not the only one.
Curt Widhalm 16:27
So, towards the end of the episode we’ll talk about practice based evidence.
Katie Vernoy 16:32
All right, all right.
Curt Widhalm 16:33
But you know, and I think that most of the research that we’re going to reference here, and is easily attainable does come from the CBT worlds. And part of it does speak to because it is easier to study. But CBT is by no means the only theory that talks about therapeutic drift. Francine Shapiro with EMDR was, you know, talking about people coming back to her and doing consultations and her being like, you’re not doing EMDR you’re doing EMDR flavored stuff. You know, we’ve heard feedback from guests, you know, like Jamie Marich as far as like, oh, you know, there’s people who do kind of EMDR-esque things. There’s a lot of clients that I have who’ve gotten what’s called EMDR, from other clients, or from other clinicians, and would they describe what happened? It’s not EMDR whatsoever. So part of this is a failure in building that therapeutic alliance of laying out what’s going to happen in treatment, and helping clients to understand what’s going to happen next. This is across a bunch of theories, there’s an article from the Australian and New Zealand Journal of family therapy that talks about therapeutic drift. So even in relational models, there is an adherence to treatment problem that we can have, despite whatever theory it is that we’ve got coming in. So while most of the research is on CBT, this can happen with any kind of theoretical approach.
Katie Vernoy 18:12
Well, I actually have two questions that I think the first one is, are we just talking about drifting away from commonly accepted practices and therapy and kind of allowing the client to talk about 90 Day fiance or whatever it is? Or are we talking about not using models that have or be adherent to models that are have this really strong evidence base? Because to me, I think there’s a difference there. And then the other element is do do we need to tell our clients this is CBT? Or this is EMDR? I mean, I think sometimes we do. But like, I know, I have a lot of maybe it’s CBT flavored interventions that I do. But then there’ll be times clients will be like, ‘Hey, I heard CBT is good for this.’ And then I go back and explain ‘Well, that’s what we’ve been doing for part of what the work that we’re doing. And we can do it more inherently, if you’d like. And this is what that would look like.’ And they’re like, ‘Oh, no, I don’t want to do it that way.’ So I think it’s that that element of do we need to tell our clients exactly what model we’re using so they can go do research on that model? And are we talking about using the model or, or just using good clinical practices that we’ve been trained? Like, what are we talking about here? I guess, let’s start with that.
Curt Widhalm 19:29
I think, I think for the most part, we have an ethical responsibility when appropriate to share the model that we’re working from with clients. But I don’t think that there’s…
Katie Vernoy 19:39
Why?
Curt Widhalm 19:39
Why not?
Katie Vernoy 19:40
Does it matter?
Curt Widhalm 19:41
Absolutely.
Katie Vernoy 19:42
I mean, I guess if you’re super adherent and you’re doing like, this is the model we’re doing. But I like I said, I’m probably a drifter, but I use a lot of different practices and so am I mid session saying okay, now I’m gonna go to a narrative narrative approach. Okay. Now I’m now I’m throwing in a CBT intervention, and now I’m doing like, I mean, all of those things are practices that are typically considered effective. They have an evidence base, but I’m not adhering to a single model.
Curt Widhalm 20:15
We have an ethical responsibility for clients to know what it’s like to have therapy with us.
Katie Vernoy 20:23
Sure. And I say that, but that’s not like, Hey, I’m doing this model.
Curt Widhalm 20:27
I think as long as you’re clear up front, you’re meeting that ethical need.
Katie Vernoy 20:30
Alright.
Curt Widhalm 20:31
So back back to what I
Katie Vernoy 20:33
Back to, like, what you actually want to talk about instead of me just riffing on the things that I’m interested in?
Curt Widhalm 20:39
Yes. Well, so part of this, and this is going back to that article by Waller and Turner is some of the therapist factors that go into therapeutic drift. And number one on their list is that we have to pick models of therapy that work.
Katie Vernoy 21:00
Okay.
Curt Widhalm 21:02
So, this is where, you know, our friends over at Very BadTherapy have a bunch of stories that get posted there, get shared there, as far as things where therapists are doing stuff, but I don’t know that it’s necessarily things that work. And this is where, you know, going back to your point a couple of minutes ago of how strict you are to the model, I think that you can do things that are different metaphors, or different ways of activating, for example, something from CBT, that is out of CBT, but doesn’t necessarily, you know, come off of the page. We’ve talked about, you know, working on anxiety, but doing it facing down the barrel of a Nerf gun of like, okay, I’m working on anxiety here. Being able to use calming techniques in that. Like, I don’t know that there’s a manualized treatment that says that this is what we’re going to do. But it’s very easy to put in our case notes have worked on clients anxiety in session with roleplay. Behavioral activation of clients target feelings and adaptive responses. You know, these are straight out of CBT. It’s the form that it takes CBT is, you know, if we’re building an animal CBT is the skeleton of it. The individual clinician factors of its are what adds out the muscles in the skin and everything else. There’s a core structure there that ends up working, but we have to pick something with a core structure that works in the first place.
Katie Vernoy 22:46
Okay, but do we have to have one core structure. I mean, there’s, there are arguments that a lot of the models are just different language for the same thing. So for me, I feel like I can move freely between those. But it is something where there are very different models that have very different opposing things that you have to sort through.
Curt Widhalm 23:05
And that’s one of the great things in this in these meta analyses that I’m reading is that it’s picking the right model that works for the right problem. This is not like, alright, if you’re a really good brain spotting therapists and you have a family come in, you’re not just going to have everybody sit around and do brain spotting and for 45 minutes.It’s that’s the wrong application of a theory to the wrong environment.
Katie Vernoy 23:34
Sure.
Curt Widhalm 23:35
So you have to, you have the freedom to pick and choose which evidence works with which presentation is coming in. This is not a one size fits all argument. It’s which of the evidence supports the treatment that you’re facing right in front of you.
Katie Vernoy 23:55
And so you can switch models with an individual client when a different presenting issue shows up?
Curt Widhalm 24:01
Absolutely.
Katie Vernoy 24:02
Okay.
Curt Widhalm 24:04
So…
Katie Vernoy 24:04
That’s not how I read what you said. It was adherent evidence based practice.
Curt Widhalm 24:09
Well, it’s inherent to the practices that work for the particular problem that’s there. And it’s clarifying the priority of which ones of those you work on first, or how you’re going to approach them simultaneously.
Katie Vernoy 24:22
Okay.
Curt Widhalm 24:24
Number two…
Katie Vernoy 24:24
That’s not how I read it. So I’m hopeful that I like what you’re saying.
Curt Widhalm 24:28
Okay.
Katie Vernoy 24:28
I like what you’re saying, that wasn’t what I read.
… 24:30
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Curt Widhalm 24:33
The next thing is, even when we talk about picking the right evidence, we then have to do it.
Katie Vernoy 24:41
Sure.
Curt Widhalm 24:42
It’s, it’s, you know, all right. I can call this CBT. But if it’s not CBT, then I’m just saying, you know, something is a different name for what it is.
Katie Vernoy 24:53
Sure. To that point, I think there’s an element of what I do that does what you’re talking about. And so I have a client, I’m very relational, we’re developing goals. Potentially, there’s a little bit of motivational interviewing or there might be, you know, some sort of CBT structure in place, there might be other pieces. And then when we actually get to a particular discrete thing, I can see myself doing a CBT thought record, I use that a lot. That’s, that’s something where I train on the thought record, we do the thought record. I provide them with resources, so they can do it at home. And there are times within that, that something comes up. And especially if it’s more of a client with either complex trauma or very big old trauma, we can we can identify one of the core beliefs or one of the automatic thoughts is based in a trauma. And at times, I may shift in that, depending on the client, I may shift in that moment, depending on where we are in treatment to then a narrative approach to talking about the trauma that’s brought up. Because I find narrative much more helpful when talking about past trauma. That’s just my personal, that’s what it works, that’s what that’s what works for me. I’m shifting in the same session, from one model to the next based on what’s being presented in front of me. And I’m doing it without saying, Okay, we’re going to shift to narrative right now. And so to me having that dynamic approach and being able to tap into a different tool because of what came up during the first one. And I’m sure there’s probably times when you’re doing EMDR, and something comes up and there needs to be some other adjuncts that comes in to help with with the treatment. I’m assuming, I don’t know, I don’t know EMDR. So maybe I shouldn’t make that point. But, but I don’t see that as adherent. I see that as responsive. And using stuff that works in the moment, but not necessarily like here is my CBT treatment. I mean, is that what you’re saying?
Curt Widhalm 26:54
What I’m saying is that, and this is maybe talking about practice based evidence a little bit earlier than I had originally planned here, but I’m gonna make a case for what you’re talking about first.
Katie Vernoy 27:09
Okay.
Curt Widhalm 27:09
And then I’m going to talk about what’s in the research and where you fall into one of those two things. Maybe in both.
Katie Vernoy 27:19
Okay.
Curt Widhalm 27:21
At one of the previous CAMFT annual conferences, one of the keynote speakers was Tony Rousmaniere. And he’s been on our podcast here in the last couple of months. And he was talking about basically deliberate practice type things and getting client feedback. And he was showing a video of one of the sessions that he was doing with a client where he admitted, like, he’s like, I probably use six or seven different theories in this one session. And he’d have various moments where he’d posit there was a bunch of people in the audience who grumbled, you’re confusing the clients and blah, blah, blah, and this kind of stuff. And I’m assuming he had done this presentation several times and was expecting that’s as being some of the response. But he showed at the end of the session, the session rating scale that the client had completed, and how the client ended up finding the switch between the different theories and different approaches was helpful. So this is not to say that you have to be so hyper focused on just remaining adherent to a particular model. But you have to have the evidence that when you’re switching, it works.
Katie Vernoy 28:37
Sure.
Curt Widhalm 28:37
And I think that that’s the part that getting back into this Waller and Turner article is they point out that a lot of clinicians do things because it feels good for the clinician, or it’s based on the clinicians biases that these things work. But there’s no follow up that this is practice based evidence that it actually works.
Katie Vernoy 28:59
Sure.
Curt Widhalm 28:59
And so we get into kind of this freedom space of I do things because it feels good for me, or because I see that things are working based on my training across a couple of different theories. But it doesn’t really matter if what our feelings are of why things work. If the clients aren’t also saying that this works for them.
Katie Vernoy 29:20
I think that’s fair. And to be honest, I think the the way that I often approach that is I say there is this tool, it’s called the thought record. This is what it’s like, Would you like to learn it? And I try to identify the folks that I think would that it would be effective with. As we’re going along, if something comes up and there’s an activation or there’s something that I feel like requires a switch. I’ll say, Hey, did you want to continue with this thought record, or do you want to address this piece that just came up right now? And this is how we might address it. So, I, like you, I probably am a little bit more adherent than I would…
Curt Widhalm 29:55
Yeah.
Katie Vernoy 29:56
You know, and I’m definitely very client based but I think I think that’s the distinction, right. I think I’ve also heard clients say that they’ve had therapists kind of go off on something that they didn’t want to really talk about, but felt like they needed to, because that’s what the therapist was really driving at. And they weren’t feeling heard and seen. And so I think that the distinction you’re describing is, we need to make sure we’re checking in with the clients, whether it’s a formal, you know, outcome, at the end of session, or if it’s a in the moment, here’s what here’s what the options are, what are you feeling in this moment that would be most effective for you.
Curt Widhalm 30:35
And this goes back to that article that I was mentioning earlier in the Australian and New Zealand Journal of family therapy. This is by Jeff young, it’s called ‘Putting single session thinking to work: conceptual, practical, training, and implementation ideas.’ And what is described here is that we need to set not only the agendas at the beginning of the overall treatment, but even within each single session. And this is asking things even as simple to whether it’s an individual client or a family client is are we on track? Is this what you wanted from today’s meeting, and especially if you set the agenda at the beginning of the session of, hey, at the beginning of the session, you said that you wanted to talk about this, and now we’re seven miles or this being Australia 13 kilometers away from where, you know, you said that you wanted to come things, have things come up in session that ends up making it to where you’re better able to stay on track. This is goal setting and goal adherence, as opposed to just rigidly following some sort of treatment plan.
Katie Vernoy 31:49
Okay. I mean, I agree with that. And I do that, I think. You know, anyone that’s done supervision for any length of time, you have to set set agendas, and I got very comfortable with setting agendas, you know, what would you like to talk about today? Oh, I got three things. Okay. Which one is most resonant? Which one’s most on your mind? Where do we want to start? And try to manage the time of the session to get to the things? And oh, hey, we expected you want to shift shift gears, you want to keep talking about this? You know, those types of things? So I think it, I think that all makes sense. I still don’t see how we’re promoting evidence based practices, though. I mean, are we are we fully into practice based evidence at this point?
Curt Widhalm 32:33
Well, so I think that even just in hearing your kind of tonal shift from like, you know, these articles pissed me off to how this all fits together. And the more that you’re kind of being like, okay, maybe I actually do do this. It’s doing that piece of it, that part where you’re do-doing. That…ah, sophomore humor. It’s the part where you’re doing it, that you do that part of it with more intention. That’s where this stuff actually does all kind of come together. It’s not just doing you know, whatever it is, you know, across my career, it’s, you know, I’ve gotten from hearing people talk about things of, you know, I am an eclectic therapist, or, you know, stuff like that, too. You know, the terminology these days is more, I’m an integrative therapist, that it’s, but it’s doing it with intention, not just with what’s most convenient.
Katie Vernoy 33:34
Well, and and I think the thing when I was thinking about this and reading the snippets that I was able to get to. What frustrated me and maybe this is just in the the way these particular articles were written is that it it sounded like the goal was fit widget A into widget B, right? Or do it this way, and really be adherent to a manualized treatment, which we’re not agreeing with that part. We’re saying do the relationship to that common factors, all that stuff? So I’m, I’m not making you defend these articles. But I think the thing that kept coming up for me is that there is an element of this where a lot of the research, at least historically have been on on single groups of folks. There’s there’s oftentimes small groups of folks. It’s discreet issues, discrete models. And so the evidence base to me has been hard to hold above all else. I think that having some of these promising practices, evidence based practices, best practices, whatever it is, I think is very helpful. And when I go to trainings, I’m pulling out the things that helped me, but the, the desire to be, I’ll be dramatic, shackled to evidence based practices doesn’t fit for me. It doesn’t fit for folks who are coming from lived experience. It doesn’t fit for being able to look at cultural differences, neurodevelopmental differences. Like there’s so many different ways that we work and operate that yes, not all models are gonna work for all clients. And we need to do that assessment. That’s part of being a good therapist. But I think there’s also any rigidity around and adherence to a model, I think, doesn’t necessarily match with the types of folks who are coming into treatment in the real world. I think middle class, white college students who are going to a clinic and having a study done and have a particular discrete issue. I think it does work. But I go back to I think that we have to figure out what success is and what is needed for healing. And what that actually looks like. Because I think getting to a goal even sometimes may not be what some folks are looking for in treatment. I’ll call back to the ‘Is therapy the new religion?’ episode, some people are wanting to have an ongoing dynamic process of personal growth. Is that not therapy? I mean, like…
Curt Widhalm 36:10
Well, no, to that point, though, is what we’re already talking about as far as therapeutic alliance, if that’s what the client says that they want, and there is a best way to meet that need. You match, the best way to meet that need with what the client wants.
Katie Vernoy 36:25
Evidence based practice that is relational, it’s just have a good relationship with your client. I mean, I know that there was some studies being done to try to to codify and make common factors and evidence based practice. But as far as I know, there’s not like, oh, well, the evidence suggests that just having a good relationship with your client is sufficient.
Curt Widhalm 36:49
You still have those kinds of theories, whether it’s analysis, whether it’s Rosarian approaches, there is an evidence there. You still have to follow the principles of those treatments. It’s not just like, Alright, you’re bi weekly 1pm, that pays me my full rate, and it’s just here forever. Like, that’s something where there’s still the need to check in with like, Hey, how are you feeling about how treatments going? Here’s, you know, kind of where, where we can go with this kind of information. What is it that you’re wanting to work on, not just in this session, but over the next couple of months? That is coming back to talking about the treatment itself.
… 37:33
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Katie Vernoy 37:35
I think maybe what I’m getting into is that there is this nuance around what is treatment. And I think some of the work I do with my longer standing clients is really attachment based. And it is experiential attachment. And it’s someone that’s in their corner, helping them to process things week to week or month to month, however frequently they’re coming in. And I think to me, I have goals, and I think the client does too. But it’s it’s not a it’s not like I want to have a better life. It’s I want to continue to work on relationships, and I’m doing that through the therapeutic relationship.
Curt Widhalm 38:13
So what you’re working on is an attachment based theory…
Katie Vernoy 38:18
Sure.
Curt Widhalm 38:18
…without necessarily calling it that.
Katie Vernoy 38:21
Yes, yeah. Well, I mean, I think I may even call it that, actually, as I think about it. But I think it’s it doesn’t feel super goal driven. It’s it’s a it’s a longer time horizon. And so I think when I’m when I’m looking at that, when I’m saying I’m going to be present with you, I’m going to be I’m going to continue to root for you and what you want for your life. And I’m going to help you to sort those things out. And I’m going to experientially have relationship where we can have ruptures and repairs, we can have moments of deep connection, we can, you can feel very known. It’s almost like the safe space therapy versus goal driven therapy in my mind. By the nature of it, it’s it doesn’t feel goal driven in the traditional way that I think like CBT is or even EMDR is. It’s very much process. It’s a it’s a process goal.
Curt Widhalm 39:17
And if that’s what the goal is, and the client agrees to it, then I think that that’s fine.
Katie Vernoy 39:27
Okay.
Curt Widhalm 39:28
But you’re also talking about, you know, a number of the therapist factors that are talked about in this Waller and Turner article of even our philosophical stances about what evidence based treatment is our self belief on how well we can deliver those. And so what they recommend is doing some self assessments bias work. And I think that you took this to be as like, well, the CBT researchers are saying that in order to do CBT, better, we need to do CBT on ourselves about CBT. And it’s just all CBT all the way down.
Katie Vernoy 40:06
Yes, yes, I did. I did take that a little bit literally.
Curt Widhalm 40:13
But it’s, you know, even really being able to do a CBT intervention on ourselves of what are the pros and cons of some of these treatment models? You know, the where and where did those cons really come from? If a lot of our experiences of having to deliver some of these treatments, in a agency type setting that really forces us to practice in ways when we’ve been exposed to a bunch of other theories in our graduate training or other trainings that we do that ends up becoming a point of frustration. It’s not necessarily the evidence based treatment, that’s the problem. It’s the way that you were forced into doing it, that was the problem.
Katie Vernoy 40:57
So let’s, let’s I want to clarify. I know that there are potentially some, some self assessment that might be happening just as people are listening. So, so what are the therapist factors in this? Let’s list them out. And in summarize them, because I’m getting lost because I keep…
Curt Widhalm 41:14
Okay.
Katie Vernoy 41:15
…distracting us.
Curt Widhalm 41:16
So, our knowledge base, whether or not we’re actually trained in the treatment models that work.
Katie Vernoy 41:23
Okay.
Curt Widhalm 41:24
Our beliefs…
Katie Vernoy 41:25
We need to keep getting trained?
Curt Widhalm 41:26
Yes. Our beliefs and attitudes, it can be, you know, our attitudes about exposure based methods might make us more cautious in implementing hierarchies when working with things like OCD, panic disorder, eating disorders, those kinds of things.
Katie Vernoy 41:42
So for example, if we don’t like exposure therapy, because we personally believe it’s torture, or awful, and we don’t use it, we may be shortchanging our clients because there is evidence that exposure therapy works,
Curt Widhalm 41:55
Correct.
Katie Vernoy 41:57
Okay.
Curt Widhalm 41:58
We can contribute to therapeutic drift by our philosophical stance, whether we view ourselves as clinicians and what works as intuition versus empiricism. So if we believe…
Katie Vernoy 42:18
I’ll need you to explain that one to me.
Curt Widhalm 42:19
If we believe that what makes therapy works is what the clinicians idea of what works in particular moments, kind of very intuitive, self driven therapist factors, overly strong self ego factors about the therapist themselves, rather than the body of evidence that seems to work. If we more strongly identify in the first category, we’re going to be more prone to drifting off of what ends up working as an example of this. Right? You know, my students these days are always amazed at the amount that is written about why therapists should not sleep with their clients. And it’s like, you know, the big debate on this back in the 70s and 80s. Do you remember what some of the clinicians results or what some of their justifications were?
Katie Vernoy 43:10
No.
Curt Widhalm 43:11
Some clinicians believed that it probably helps the clients if I sleep with the clients. You know, this is…
Katie Vernoy 43:19
Ok, it makes them, they feel loved.
Curt Widhalm 43:22
They feel loved. Yeah. That is the kind of example where maybe not to those extremes of like, I am this agent of change that can evoke this feeling in a client because of this thing. There’s a reason that sleeping with your clients is not only not part of the evidence base, but is unethical and illegal on top of it.
Katie Vernoy 43:45
Yeah, well, I want to talk about this particular one a little bit more, because intuition. I mean, I think it is important for clinicians to have some trust in their own intuition. I think they need to also have empiricism. But is this something where it’s more trust, but verify? Like is it seek out your own intuition and verify that this is the path to go? Because, yes, sleeping with your clients, if that was an intuitive leap, that’s a crappy intuitive leap. But I think there are times when something is happening in the session, and I intuitively jump into a question or, you know, kind of put forward an intervention that at times is off base and we move on, or at times, they’re like, Oh, my God, I didn’t say this thing, because I didn’t want to but how did you know that? You know, and so I think there’s that element of, I don’t want to say clinicians shouldn’t be intuitive and shouldn’t trust their intuition. I mean, one argument is that our intuition comes from being very grounded in our training. And that we these are the things that common, commonly will come up and we can sort through them. But I don’t want to get to a place where I don’t hear you saying that it’s all or nothing. But…
Curt Widhalm 45:09
It’s when we place…
Katie Vernoy 45:10
I think tuition is valid for therapists, don’t you think?
Curt Widhalm 45:13
Well, and intuitions valid in the way of like, we have a whole episode one, you can’t trust your gut, like, intuition comes from some place and you’re bringing up if that someplace is training, then you’re probably doing something that’s adherent to an evidence based thing.
Katie Vernoy 45:33
But you’re talking about intuition versus empiricism? I think our intuition comes from what we know. And so I’m saying intuition and empiricism versus intuition versus empiricism. Right? I mean, is that okay.
Curt Widhalm 45:47
I think it’s, I think you’re making a tomato tomahto argument.
Katie Vernoy 45:51
All right. All right.
Curt Widhalm 45:52
But there’s, and this is not to, again, this is not to be, you have to rigidly follow these things. That they’re even within a lot of the models is building on some of that clinical intuition into clinical judgment that allows for the flexible implementation of some of the protocols. But it’s not a substitute for the protocols. And I think that that’s maybe where your argument is, where I’m hearing it is, you’re kind of saying the same thing.
Katie Vernoy 46:24
Okay. Okay, that’s fine. I got it now. I understand.
Curt Widhalm 46:32
One of the other things that is pointed out is the way that our emotions impact the way that we go about our sessions. And what Waller and Turner talk about is therapist anxiety. And there’s a whole host of research on, especially in the delivery of CBT. But I think that in one way or another this is going to be across any number of treatments, is therapists with higher levels of anxiety are less likely to push clients to do things that are behaviorally activating. And they’re less likely to do things like assign clients homework and follow up on the homework and make clients apply the principles learned in therapy to the other 167 hours out of the week.
Katie Vernoy 47:24
I think that make sense. I certainly know at times when my anxiety is higher, I’m less likely to push things. For sure. And I think there’s there’s definitely times when I identify the anxious thought and have to act anyway.
Curt Widhalm 47:41
Now…
Katie Vernoy 47:43
But I know some sometimes the anxiety can be personal, but it can also be based on I don’t want this client to end treatment prematurely. So I don’t want to ask them how it’s going, or I don’t want to do the things. And so I think there’s that element of our anxiety, we need to address it because it can hurt our clients regardless of whether it’s clinical or more administrative.
Curt Widhalm 48:03
And you know, especially for those in private practice, where it’s if I ask it, they’re like, ‘You know what, I’m actually good.’ Then that’s part of your income that’s leaving as well. And that is based in anxiety. And Waller has another 2013 article, Waller et all, that shows that therapists who report higher levels of depression are likely to hold more negative attitudes to manualized approaches to therapy. And those therapists with low self esteem, this is Simpson-Southward et all, do not implement evidence based approaches. They have lower self esteem than those therapists who have higher levels of self esteem. And I can already hear some of the audience members being like, well, of course, the CBT people are full of themselves and more likely to just follow through on things.
Katie Vernoy 48:56
But I actually think that there’s there’s an argument for the reverse. I mean, to me, it seems like being strongly inherent to a model would be very safe, you would know exactly what to do. And you would, you would be propping your own self up behind an evidence based practice versus so. So I would see people with lower self esteem using models more consistently, adherent models more consistently, because they don’t trust their own judgment or they don’t they don’t feel like they can go outside of the model. So this is interesting to me that that’s the reverse.
Curt Widhalm 49:27
Well, here’s where I think anecdotally what’s going to happen in this is when there’s a protocol to follow, it can be measured how close you are to the protocol. So if you don’t use it, you can’t get measured. So I think it’s an avoidance behavior.
Katie Vernoy 49:44
Sure, sure. I can see that.
Curt Widhalm 49:47
So…
Katie Vernoy 49:47
It was probably a bell curve of…
Curt Widhalm 49:50
Sure.
Katie Vernoy 49:51
…who’s adherent and the people right in the middle.
Curt Widhalm 49:53
And so some of the stuff back to Waller and Turner. They get into our personalities might be something that contributes to therapists drift. And they show that people who are more likely to adhere to protocols, if they have the trait of being open to experience. And if clinicians have higher levels of resilience, organization and competence, they have better outcomes when delivering brief evidence based interventions.
Katie Vernoy 50:21
Okay, I think I have to say that one again,
Curt Widhalm 50:24
People who are open to experience and have higher levels of resilience, organization and confidence have better outcomes when delivering brief evidence based interventions. This basically boils down to you if you’re really timid in being like, Excuse me, like, to address your anxiety? Like, could you? Possibly, maybe? I mean, some people, it’s okay, if it’s not you, but some people might, you know, work on their anxiety a little bit better, if they have to face being around the thing that triggers their anxiety every so often. But if that’s not you, it’s okay. Like that is not selling exposure and response prevention at all.
Katie Vernoy 51:15
Sure, but you, you the impression is, is pretty, pretty bad. But I think that the element that I come back to is there are clients that are not going to be open to it. And so maybe you don’t present it to the clients if you have to present it that cautiously. But I think there are some clients who would appreciate you don’t have to do this, but this is this is something that can work. Now being so timid about it, okay, maybe that’s a problem. But, but I don’t see having caution and saying you are in charge of your treatment and you don’t have to do this, but this is something that works for folks. What do you think about it? To me, I think that’s okay. I don’t I believe that oftentimes, and especially with the CBT, like the adherence, you know, like hardcore CBT, folks, it’s like, this is a treatment that will work. This is what we’re going to do. And people saying, oh, okay, I’ll try it. Versus when you have a lot of different models that you’re you’re thinking about, that might work.
Curt Widhalm 52:30
And so this is getting into the next point here, which is our own safety behaviors as therapists when we run into these kinds of resistances. Is it something where it’s like at the first sign of a client’s anxiety towards a treatment, that we just jump to the next theoretical model that doesn’t have to have our clients face those issues? That this is being able to say, oh, right, I’m accommodating you. But am I also enabling you while doing that accommodation?
Katie Vernoy 53:04
And I think that’s a really hard question. Because we’ve we’ve had other conversations, and I’ll see if I can find them and put them in the show notes. But, but like, is it resistance? Or are you pushing your own agenda? To me, it seems like, we need to be present for the client. But we also need to be able to encourage them, empower them to do hard things. And so I think that’s where these are, this is where nuance comes in. And I think each person’s personality is going to show this show up with this differently. But yeah, if somebody is not willing to push forward with something in any way, or whatever, I think there’s the option, Do you terminate treatment, if they’re just not, they’re not doing anything? They’re not, they’re actually not actually working on anything, because they don’t want to do this treatment that you think is the evidence based practice that would work best.
Curt Widhalm 53:54
So, this is where, again, you do the check in with the clients as far as saying, Hey, we agreed that this was a pathway that we were gonna go. You’re, you know, running into, you know, some some growth edges here, or, you know, what comes next in this approach doesn’t seem to be working for you. Here’s what our options are. Here’s ways that we can address this in being able to do our work here. It’s coming back to that therapeutic alliance. It’s not just making that accommodating jump without coming back to How is treatment working? What’s working for this out of you? All right, or what’s working out of this for you and what’s not working out of this? So that way we can be able to address the problem together, rather than just making a jump into whatever’s the next convenient thing.
Katie Vernoy 54:48
So it’s just it’s continuing to come back to we need to be checking in with the client.
Curt Widhalm 54:52
Yes.
Katie Vernoy 54:53
But I think when when we talk about resistance, and all of that I prefer to work with resistance with the client is that what you’re saying is saying, identifying the resistance saying, Hey, you, you’re showing resistance to this idea. Let’s talk about what that’s about and determine if this is not the right treatment for you, or it just as scary for you. I mean…
Curt Widhalm 55:15
Correct.
Katie Vernoy 55:15
…is that kind of what you’re talking about? Okay.
Curt Widhalm 55:17
Yeah, that’s, that’s addressing it with the client. It’s not just being like, Well, that didn’t work, it’s time to throw out CBT to narrative to essential oils, and just being like Here smell this.
Katie Vernoy 55:34
Oh, that smells.
Curt Widhalm 55:37
So the last several points here is about the therapist factors that goes into things deal with how therapists what kind of work environment, they are, particularly in their social contexts. The more that we hang out with other people who work like us, the more that we engage in peer supervision, the more that we engage in clinical supervision, or mentorship type things, the more likely we are to remain on track with what we’re doing. And this is a lot of, again, things that are supported out of deliberate practice of like, we get mentors, and we get good ongoing clinical supervision or good consultation about things. So that way, we’re getting just a different perspective, we’re not just mired in our own biases of, hey, this seems to be working, you’ve got to be able to explain this to other people as far as why this works as well.
Katie Vernoy 56:36
So a lot of what you’re talking about with the therapist factors, and please add on because that we went all over the place. And so I don’t have them all, kind of in my memory. But it seems like there’s this element of rigidity, lack of thought, lack of kind of checking in with the client or being able to explain to the client what it is being done. Like, to me, it seems like the therapist factors really come back to philosophy, thinking we know better and, and not feeling confident enough to either do the evidence based practices or to make our clients do them. Okay, because to me, it just keeps, we keep saying, work with the client, check with the client and do things that work. And I feel like that is self evident. But I think this other piece, and this is something that I think some folks may struggle with, and this is really important to consider is getting a community or a supervisor or consultant that can help make sure that you’re on track, because I think I can have in my head, this is what I’m working on. And this is how I’m working on it. But if I don’t actually have to tell anybody that I can just be sitting in a room with a person and drifting off into hanging out with a client and not doing a whole lot that’s really effective. And so it’s it’s it’s actually trying to be very strategic with that and getting some consultation that kind of holds an accountability there.
Curt Widhalm 58:08
Yeah.
Katie Vernoy 58:09
So what else might be causing this drift young man?
Curt Widhalm 58:12
So we also need to look at some of the systemic contributions to this. And I’m going to kind of is we’re nearing the end of our episode here. I’m going to point it to kind of institutional places to keep the focus on this. This isn’t necessarily the only places of them. But I’m going to start with earlier in our career, one of the places that contributes to therapeutic drift is the very way that our educational system for therapists is set up. That as the licensing test tackle that every therapist needs to know every theory that’s being in practice, that the graduate institutions in response to that then have a responsibility to teach the theories that are on the test. And even in the time since you and I have been in graduate school 20 ish years ago for you, 15 ish years ago for me. But even since I was in grad school, and knowing the curriculum of what’s being taught in the programs that I’m in, talking with graduate students, talking with post graduate, pre licensed people is the number of theories that students are expected to be taught, ar and expected to learn and that they’re tested on as part of their graduate program does not allow for them to reach any sort of depth of actually being trained very well on most of these, if at all.
Katie Vernoy 59:44
Yeah, we had a good conversation with Diane Gehart about this on one of an episode i’ll stick that in the show notes too.
Curt Widhalm 59:51
And so if we’re not training people very well on things and there’s kind of you know, this, I guess field-wide approach of like, yeah, I guess whatever theory you’re gonna get, you know, trained on Well, that’s going to happen at your agency. That it’s, you know, there’s just kind of this, nobody’s stepping up and being like, you know, what we really should get people to focus on core competencies of a handful of theories, rather than an ever growing amount of expensive books that you know, dive deeply into things, but only get one or two chapters assigned out of them. So not being taught early enough in our career, and in depth enough model to work from is one of the contributing factors of if we enter into our education with like, alright, every week’s a new flavor of therapy, we’re going to be more prone to behaviorally doing that when we’re actually delivering therapy out in the real world.
Katie Vernoy 1:00:52
No, yeah, the sheer number of models is ridiculous. And I think for me, yeah, getting trained 20 ish years ago, I, I really felt like I was trained pretty well. And it was kind of grounding in psychodynamic and CBT at the same time. It’s really interesting how similar they actually are. That was one of the arguments was that they actually just were the same thing with different names. But…
Curt Widhalm 1:01:19
The other systemic thing that I’m going to point to here as well, and we’ve kind of broached this a little bit, even in this episode here, but it’s agencies that are delivering treatments to get people, you know, through a rapid number of sessions to, you know, reduce the symptomology and funding runs out. That does not allow for the actual adherence to even the evidence based treatments that they’re potentially selling. Or that they’re potentially advertising out to consumers or funding sources or these kinds of things. So if you’re in an agency where, you know, crap on CMH, here for a moment, but if you’re in an agency, where it’s like, Alright, you’ve got 12 sessions to deliver CBT to this client, as an agency policy, you know, bean counter, you are going to be able to do CBT in 12 sessions, because this one, you know, research article justifies what my funding sources are. If that doesn’t allow for you to actually do the appropriate approach for what the client’s problem is, of course, you’re going to drift off of what you’re being assigned. And this leads to a lot of poor practice and a lot of poor feelings about evidence based treatments that could potentially work if given the appropriate structure and setup to make them work.
Katie Vernoy 1:02:42
Completely agree, I think that the challenge that I saw in Community Mental Health was that there just wasn’t enough time to truly dig in sufficiently. And I think there was also the models chosen were based on very short term models. And so you have a client that comes in with very complex presentation, and you’re doing 12 sessions of trauma focused CBT, like you can’t address it all and it becomes especially for newer clinicians, it becomes really hard to like, how do you sort through what it is I do? Okay, well, I guess I just follow this model, and all will be well. I have another systemic thing that I was thinking about, because I think it’s something that I’ve faced at different points in my career. Later on, when when it’s up to us, as clinicians, to continue to get continuing education potentially, to dig deeper into a model, it is hugely expensive and or really hard to get the right training. And I’m thinking is it EFT or IFS, one of them has like a lottery to get into. Like, people can’t even get the official training unless they win the lottery. And so I think there’s this element of super expensive training and protocols that isn’t approachable for everyone. And so, you know, the, we have too many models to choose from, that we don’t know much about in grad school. We go into some sort of an agency or even into a private practice, honestly, where somebody has, this is how I work. And you either have the time to do it, or you don’t. You learn about it or you don’t. And that’s kind of where you’re stuck. Unless you then can spend 1000s of dollars to get one of these more robust trainings and get certified in it and feed the the therapy trading complex. And and it just it doesn’t feel approachable. It doesn’t. I mean, it like I even just because I think I would like to get trained in EMDR but it’s takes so much friggin time and it’s expensive. So I’m like, Okay, I need to be able to be present. I need to be able to do this thing. And it’s also expensive. And so it’s really hard to then as a clinician, invest in your self or even to figure out which one you want to do, because you’re like signing away, half, half a month’s salary or something in order to try to get something. And it just it feels, it feels really daunting. And so I think that it makes sense that people are not especially in an inherent way, sticking to some of these evidence based practices if they just don’t have the time or money, or previous training to be able to do that.
Curt Widhalm 1:05:29
So in order to reduce this stuff, you know, some take away things. As much as we like to talk about, here’s policy changes that can happen, I don’t think that this is something that gets done with policy sorts of stuff. I mean, maybe the reduction of the number of theories that have to be taught within graduate programs.
Katie Vernoy 1:05:51
Or even insurance and kind of Medicaid limits on on treatment and…
Curt Widhalm 1:05:57
Sure.
Katie Vernoy 1:05:57
…and how they are run. Because in an agency’s evidence based practices are about 10%, doing whatever the manualized treatment is, and like 90%, all of the paperwork.
Curt Widhalm 1:06:10
So in the absence of a strong policy suggestion here, this is one of those things where all right, this is the system that we’re in. And some of these responsibilities do fall to us as individuals in order to address these things. And so if it’s start doing more evidence gathering, about your practice, so that way that you can talk with clients of like, here’s why I’m veering off of this model at this point, based on what is effective with me and the interventions that I use in my practice, I’m going to introduce maybe a new option here. How does that work with you? So part of this is keeping track of your own success rates.
Katie Vernoy 1:06:54
Yeah.
Curt Widhalm 1:06:55
Part of this is joining peer consultation groups. Get a, you know, consultation, get feedback from somebody who does these kinds of treatments better than you so that way, you can continue to learn and continue to be able to stick to the parts of your treatments that do have an evidence base, so that way you’re practicing legally and ethically. But this really does come down to like check in on your own biases towards this stuff. I had originally thought in conceiving of this episode that all right, therapeutic drift, you know, we do hear the stories of like people walking out of sessions being like, I didn’t talk about what I wanted to talk about at all. And then I kind of went through this growth phase of looking at all of this background stuff of like, this is just CBT people talking about CBT stuff. But the more that I dug into this, and hopefully, you’re feeling kind of the same way as this isn’t a push just towards being very judicious towards using the models or anything that doesn’t look like it isn’t good therapy. This is more of be very intentional with what you’re doing. Have reasons for doing it. Don’t just be reactive to things. Have a plan and make sure that with your clients therapy is working.
Katie Vernoy 1:08:17
That makes sense.
Curt Widhalm 1:08:19
You can find our show notes over at mtsgpodcast.com. You can follow the directions on the intro and outro to get CE credits for this over in our moderntherapist community. Join our Facebook group, the Modern Therapists group. Follow us on our social media. And if you liked this longer form content, it definitely helps us out if you consider becoming a patron or supporting us through Buy Me a Coffee and until next time, I’m Curt Widhalm with drifting less than she thought Katie Vernoy.
… 1:08:49
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Katie Vernoy 1:08:52
Just a quick reminder, if you’d like one unit of continuing education for listening to this episode, go to moderntherapistcommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps.
Curt Widhalm 1:09:07
Once again, that’s modern therapistcommunity.com.
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