CoChat
Sign Up
Cited by 256Psychotherapy Techniques and ApplicationsHealth Policy Implementation ScienceAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Waller, Glenn, Turner, Hannah·2016·Behaviour Research and Therapy
DOI 10.1016/j.brat.2015.12.005
Open this paper in CoChat — free account

Abstract

Therapist drift 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. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.

AI snapshot

Written from the paper’s full text.

TL;DR

Therapist drift is clinicians’ failure to deliver evidence-based therapy despite having the tools and resources, and it helps explain why such therapies are often less effective in routine practice. This review synthesizes evidence on why drift occurs—knowledge, beliefs, emotions, personality, safety behaviors, and social context—and proposes CBT-based strategies to reduce it.

Key findings

  • Drift is common: clinicians under-use evidence-based methods, especially behavioral/exposure techniques; even when therapy is labelled “CBT,” patients report substantial deviations. In PTSD, imaginal exposure is severely underutilised; eating-disorder clinicians show good awareness of evidence-based therapies but report using them relatively infrequently.
  • The therapeutic alliance is often overvalued: meta-analyses report correlations of 0.22 and 0.26 with outcome, equating to only 5–6% of variance, and longitudinal research suggests early symptom change drives improvement in the alliance rather than the reverse.
  • Drivers include inflated self-assessment (most therapists believe their skill is above average, with very few seeing themselves in the lower 50%), negative beliefs about manuals and exposure, anxiety and intolerance of uncertainty, therapist safety behaviors, and supervisory drift (supervisors consistently overrate supervisees’ abilities).
  • Proposed remedies include systemic dissemination, therapist selection/streaming, training focused on competence/adherence/outcomes, and a CBT approach for therapists (psychoeducation, cognitive restructuring, monitoring, behavioral experiments, exposure with response prevention). Uptake of clinical guidelines averages 17 years.

Methods

  • Narrative review, not a systematic review or meta-analysis, synthesizing recent evidence on therapist drift, with a focus largely on CBT.
  • Draws on surveys, experimental studies, meta-analyses, longitudinal studies, and clinical commentary; no new primary data are reported.
  • Concludes with a conceptual model and recommendations for reducing drift at systemic, training, supervisory, and individual-therapist levels.

Limitations

  • Stated: further research is needed into therapist drift and its reasons across a wider range of therapies, disorders, and techniques, and the impact of proposed interventions needs to be tested.
  • Stated/implicit: the evidence base is largely CBT, limiting generalizability to other therapies.
  • Evident: as a narrative review, it lacks a systematic search or formal quality appraisal, and several cited sources are in press or under consideration, making some findings provisional.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.brat.2015.12.005

Cites

111 of 111 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 85 cited sources checked · 0 supported · 0 flagged

  • Premisecitation
    § Accumulating evidence of therapist drift · p. 5

    There are substantial inter-therapist differences in how CBT is delivered across a range of disorders, even where the methods are widely available and well known.

    “there are substantial inter-therapist differences in how CBT is delivered across a range of disorders, even where the methods are widely available and well known”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites McAleavey, Castonguay & Goldfried, 2014 source

      Not checked in the free run.

    • cites Shafran, Clark, Fairburn, Arntz, Barlow, Ehlers Freeston, Garety, Hollon, Ost, Salkovskis, Williams & Wilson, 2009 source

      Not checked in the free run.

    • cites Szkodny, Newman & Goldfried, 2014 source

      Not checked in the free run.

  • Premisecitation
    § Our knowledge base · p. 7

    Many clinicians have negative attitudes to manuals.

    “Many clinicians have negative attitudes to manuals”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Addis & Krasnow, 2000 source

      Not checked in the free run.

    • cites Waller, Mountford, Tatham, Turner, Gabriel & Webber, 2013

      Not checked in the free run.

  • Premisecitation
    § Our beliefs and attitudes · p. 8

    There is some evidence that psychological therapists become less effective over the years following qualification.

    “Indeed, there is some evidence that psychological therapists become less effective over the years following qualification”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Shapiro & Shapiro, 1982 source

      Not checked in the free run.

  • Interpretationreasoning
    § Our beliefs and attitudes · p. 8

    We appear to have an over-inflated view of our own ability level.

    “In short, we appear to have an over-inflated view of our own ability level, just as is found in other areas of human activity.”
    Quote in the paperSubstantial claim
  • Premisecitation
    § Our beliefs and attitudes · p. 10

    How likely we are to implement evidence-based therapies is driven at least in part by the information that we have about them and the attitudes that we hold towards them.

    “In general, how likely we are to implement these evidence-based therapies is driven at least in part by the information that we have about them and the attitudes that we hold towards them”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Cahill, Foa, Hembree, Marshall & Nacash, 2006

      Not checked in the free run.

    • cites Deacon, Farrell et al., 2013

      Not checked in the free run.

    • cites Harned, Dimeff, Woodcock & Contreras, 2013 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. 9
  • May combine two claims. 13

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given
    § Abstract · p. 3

    Research into therapist drift has increased substantially over the past five years.

    “The research into this phenomenon has increased substantially over the past five years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § Accumulating evidence of therapist drift · p. 6

    Simply labelling what one does as CBT is no guarantee of what will be delivered or the ability of the therapist to deliver it.

    “Taken as a whole, these findings remind us that s imply labelling what one does as 'CBT' is no guarantee of what will be delivered or the ability of the therapist to deliver it.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Accumulating evidence of therapist drift · p. 6

    In eating disorders, clinicians show good levels of awareness of evidence-based therapies, but report using them relatively infrequently.

    “In the field of eating disorders, clinicians show good levels of awareness of evidencebased therapies, but report using them relatively infrequently”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Simmons, Milnes & Anderson, 2008 source

      Not checked in the free run.

    • cites von Ranson, Wallace & Stevenson, 2013a

      Not checked in the free run.

    • cites Waller, Stringer & Meyer, 2012 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Our beliefs and attitudes · p. 8

    The use of evidence-based manuals results in lower costs of care and superior clinical outcomes than the use of unstructured approaches.

    “The use of evidence-based manuals results in lower costs of care and superior clinical outcomes than the use of unstructured approaches”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Addis & Waltz, 2002

      Not checked in the free run.

    • cites Cukrowicz et al., 2011 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Our emotions · p. 12

    Therapists with low self-esteem who do not implement evidence-based approaches have lower self-esteem than those who do.

    “Simpson-Southward et al. (under consideration) found that therapists with low selfesteem who do not implement evidence-based approaches have lower self-esteem than those who do.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Simpson-Southward et al. (under consideration)

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Systemic change · p. 16

    Age and experience are not enough to ensure that we improve, and might be more closely related to drift from evidence-based methods and weaker patient outcomes.

    “Age and experience are not enough to ensure that we improve, and might be more closely related to drift from evidence-based methods and weaker patient outcomes”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Grove et al., 2000 source

      Not checked in the free run.

    • cites Shapiro & Shapiro, 1982 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning
    § Summary of reasons for therapist drift · p. 15

    We are likely to need multi-faceted approaches to changing our own practice.

    “That range of reasons for drifting means that we are likely to need multi-faceted approaches to changing our own practice.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Our safety behaviors · p. 13

    Such clinicians tend to focus on the role of the therapeutic alliance as an agent of change, and to prioritise its role over that of the therapeutic techniques that are supported by the evidence, even when doing so is associated with poorer outcomes.

    “Such clinicians tend to focus on the role of the therapeutic alliance as an agent of change, and to prioritise its role over that of the therapeutic techniques that are supported by the evidence, even when doing so is associated with poorer outcomes”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Brown et al., 2014 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § Our safety behaviors · p. 13

    We engage in safety behaviors to reduce our own level of anxiety in the short term, but run the risk of becoming less effective clinicians in the long term.

    “In short, we engage in safety behaviors to reduce our own level of anxiety in the short term, but run the risk of becoming less effective clinicians in the long term.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Systemic change · p. 17

    The scenario of therapists delivering therapies that they have not had training in exists and has long been tolerated.

    “While it would be hard to argue therapists should be delivering therapies that they have not had training in, exactly that scenario exists and has long been tolerated”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Royal College of Psychiatrists, 2013

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given
    § Our safety behaviors · p. 14

    The greater our characterological level of intolerance of uncertainty, the faster we will learn to avoid ever suggesting to patients that they should change.

    “The likelihood is that the greater our characterological level of intolerance of uncertainty, the faster we will learn to avoid ever suggesting to patients that they should change.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § Our safety behaviors · p. 13

    The patient's anxiety can trigger anxiety in the therapist, and our own anxiety-reduction behaviors can encourage those of the patient.

    “The patient's anxiety can trigger anxiety in the therapist , and our own anxietyreduction behaviors can encourage those of the patient.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationreasoning
    § Summary of reasons for therapist drift · p. 15

    These factors mean that we engage in safety behaviors in order to reduce our own anxiety about pushing for behavioral change.

    “These factors mean that we engage in safety behaviors in order to reduce our own anxiety about pushing for behavioral change.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given
    § Summary of reasons for therapist drift · p. 15

    Our tendency to drift away from evidence-based practice is the product of a range of very human experiences and characteristics.

    “It is clear from the evidence of recent years that our tendency to drift away from evidence-based practice is the product of a range of very human experiences and characteristics.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Our safety behaviors · p. 13

    More anxious clinicians implement behavioral change less and are wary of implementing other central therapeutic techniques.

    “there has been more evidence to support the proposal that more anxious clinicians implement behavioral change less and are wary of implementing other central therapeutic techniques”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Meyer et al., 2014 source

      Not checked in the free run.

    • cites Turner et al., 2014 source

      Not checked in the free run.

    • cites Waller et al., 2012 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning
    § Our emotions · p. 12

    If we are unable to tolerate anxiety, we are likely to edge into safety behaviors that mesh with those of the patient.

    “However, if we are unable to tolerate anxiety, we are likely to edge into safety behaviors that mesh with those of the patient”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Systemic change · p. 16

    Uptake of clinical guidelines is slow and patchy, with an average of 17 years between the development of new knowledge via rigorous testing and its widespread clinical uptake.

    “Uptake of clinical guidelines is notoriously slow and patchy, with an average of 17 years between the development of new knowledge via rigorous testing and its widespread clinical uptake”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Institute of Medicine, 2001

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given
    § Conclusion · p. 22

    Therapist drift is caused by multiple interrelated factors-personality, knowledge, beliefs and attitudes, emotions, interpersonal milieu, and safety behaviors-that can interact.

    “We fail to deliver treatments effectively for a variety of interrelated reasons -our personalities, knowledge, beliefs and attitudes, emotions, interpersonal milieu and safety behaviors can all interact to ensure that we drift.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning
    § Conclusion · p. 22

    Without further research into therapist drift and proposed interventions, it is highly likely that clinicians will continue to fail to deliver evidence-based treatments effectively and many patients who could benefit will not do so.

    “Without this work, it is highly likely that we will continue to fail to deliver evidence-based treatments effectively as we could, and that many patients who could benefit from our work will not do so.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Systemic change · p. 18

    Preventing therapist drift requires intra-clinician comparison of outcomes.

    “Outcomes can be compared across services, in which case the concerns raised by Fairburn & Cooper (2011) are worthy of consideration, but the prevention of therapist drift requires intra-clinician comparison of outcomes -are we getting better or worse at getting our patients well?”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given
    § Conclusion · p. 22

    Supervision is no guarantee of effective therapy, because supervisory drift is just as possible as therapist drift.

    “Even supervision is no guarantee of effective therapy, as supervisory drift is just as possible as therapist drift.”
    Quote in the paperNot a substantial claim
21 of 21

  • The paper relies on this without support.

    Knowledge of the disorders that we work with is a prerequisite for successful treatment.

    “It might seem obvious that knowledge of the disorders that we work with is a prerequisite for successful treatment.”

  • The paper relies on this without support.

    CBT is where most of the evidence on therapist drift has been generated.

    “The focus will be largely on cognitive-behavioral therapy (CBT), simply because that is where most of the evidence has been generated.”

  • The paper relies on this without support.

    Therapist drift reduces patients' chances of improvement or recovery.

    “the patient receives treatment that deviates significantly from the evidence-base, reducing their chances of improvement or recovery.”

  • The paper relies on this without support.

    Assessing adherence routinely is a highly intensive exercise and demands very high levels of resource.

    “Second, assessing adherence routinely is a highly intensive exercise, demand very high levels of resource.”

  • The paper relies on this without support.

    Policy is a weak tool for influencing what happens in the therapy room.

    “Policy is a weak tool for influencing what happens in the therapy room.”

  • The paper relies on this without support.

    Fully monitoring competence and adherence is resource intensive.

    “Competence and adherence are important to ensure, but to monitor them fully is resource intensive.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Widespread reports of difficulties in implementing exposure therapy for PTSD in clinical settings stress the importance of considering therapist views in efforts to disseminate new treatments.

    “Widespread reports of difficulties in implementing exposure therapy for PTSD in clinical settings (Waller and Turner 2016), for example, stress the importance of considering therapist views in efforts to disseminate new treatments.”

    From Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy (2021) · cites this paper as Waller and Turner 2016

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Stobie citation omits a listed author

    Minor

    The in-text citation names four authors, whereas the corresponding 2007 reference lists Taylor as a second author.

  • Wallace and von Ranson citation year differs from reference

    Minor

    The text cites this author pair as a 2011 study, but the corresponding reference lists it as published in 2012.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 5

  1. Addis, 1999, Barriers to evidence based practice: addressing practitioners' concerns about manual based psychotherapies, Clinical Psychology: Science and Practice, 6, 430
  2. Hansen, 2002, The psychology dose-response effect and its implications for treatment delivery services, Clinical Psychology: Science and Practice, 9, 308
  3. Horvath, 1991, The relationship between working alliance and outcome in psychotherapy, Journal of Consulting and Clinical Psychology, 38, 139
  4. McHugh, 1994, Psychotherapy awry, American Scholar, 63, 17
  5. Simpson-Southward, 2015, The impact of case presentation and intra-individual factors on how supervisors guide clinicians in treatment of depressed cases, The Cognitive Behaviour Therapist

Cited by

Sorted by citations

Related

Authors
Waller, G., & Turner, H.
Affiliations
  • University of Sheffield (GB)
  • Southern Health NHS Foundation Trust (GB)
Corresponding author
Waller, Glenn
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2016-02
Volume
77
Pages
129-137
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2015.12.005
OpenAlex
W2198446845
Cited by
256
References
107
Citations by year
2026: 26 · 2025: 23 · 2024: 30 · 2023: 29 · 2022: 35 · 2021: 34 · 2020: 33 · 2019: 16 · 2018: 13 · 2017: 13 · 2016: 3
FWCI
12.00
Type
journal article
Language
en
Open access
closed
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Behaviour Research and Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
evidence-based psychotherapy, intervention fidelity, evidence-based practice implementation, therapist personality, therapist emotions, social environment
MeSH terms
Attitude of Health Personnel, Clinical Competence, Female, Health Personnel, Humans, Male, Psychotherapy, Cognitive Behavioral Therapy, Guideline Adherence, Evidence-Based Practice

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review