Measuring therapist cognitions contributing to therapist drift: a qualitative study

Abstract

Therapist beliefs have been identified as a contributing factor to ‘therapist drift’ in cognitive behavioural therapy (CBT). Scales have been developed to measure therapist beliefs, but none explicitly measure ‘therapy-interfering cognitions’, and there is no research on their usage. The aim of this study was to explore how best to conceptualise such a scale’s content and usage, based on clinicians’ perceptions and experiences of current scales. Three focus groups were conducted, involving 12 participants who were either qualified or trainee CBT therapists. Transcripts were analysed using thematic analysis. Four main themes were generated: (1) The Awareness and Importance of Cognitions, (2) Factors Fuelling Therapist Cognitions, (3) Addressing Therapist Cognitions, and (4) Using the Scale. Participants thought it important to be aware of and address therapist cognitions (not underlying beliefs). Participants emphasised that therapist cognitions are not just products of the individual, but are influenced by external factors. A scale could enable therapists to do better work through reflective practice, as long as it was used not just to identify cognitions but also to support changes in therapist behaviour. A scale could also meet a perceived need for making this part of routine practice. However, participants discussed how therapists might have reservations about disclosing cognitions in this way. Recommendations for current practice, and future research developing such a scale, are made. Key learning aims (1) To describe the phenomenon of therapist drift, and the contributions of therapist beliefs to this. (2) To explore the usage of current scales for measuring therapist beliefs. (3) To understand, based on therapist experience, how to address therapist beliefs in current practice using scales.

Maladaptive therapist schemas in CBT practice, training and supervision: A scoping review

“…A summary of the key findings in each study is discussed below. Only four studies (Haarhoff, 2006;Phin, 2013;Martin & Khan, 2015;Rameswari et al, 2021) referred to therapist schemas as defined by Leahy (2001).…”

“…(3) Martin & Khan (2015) used an N=1 case study to reflect on working with a client presenting with complex Post-traumatic stress disorder. The therapist identified her own demanding standards schema (Leahy, 2001) (4) Rameswari et al, (2021) used focus groups to compile a list of common therapy interfering cognitions. The list used items from several existing scales including the TSQ.…”

“…Parker & Waller, 2019;Presley, et al, 2017). Rameswari et al, (2021) point out that these therapist cognitions do not arise solely from 'intrapsychic processes' (p10) but through an interaction between the organisation in which one is employed, training experience and the idiosyncrasies of clients If we think more broadly about schemas as being 'organized elements of past reactions and experience that form a relatively cohesive and persistent body of knowledge capable of guiding subsequent perception and appraisals (Segal, 1988, p.147) then we can hypothesize the existence of contextual schemas. Examples might include within specific workplaces-e.g.…”

Conceptualising and managing supervisory drift

“…Whilst there is no widely endorsed CBT-specific alliance measure for supervision, the Leeds Alliance in Supervision Scale (Wainwright, 2010) is an example of a measure that is brief enough to be administered at the end of a supervision session and can be reviewed as part of the next session agenda. Specific scales designed to elicit therapist cognitions which relate to drift have been proposed (Rameswari et al ., 2021) and referring supervisees to literature such as this and other related concepts (e.g. Leahy’s Therapist Schemas) may help to normalise discussion of therapy-interfering beliefs and behaviours within supervision (Leahy, 2001; Moorey and Byrne, 2019).…”

“…One of the potential consequences of inconsistent supervision practices is ‘supervisory drift’ (SD) (Grey et al ., 2014; Pugh and Margetts, 2020). Whilst the issue of ‘therapist drift’ has received some attention in the extant CBT literature (Rameswari et al ., 2021; Waller 2009), supervisory drift remains poorly understood in terms of its definition, prevalence, reasons for occurrence, identification in routine practice and potential solutions. This paper is an attempt to summarise what is known about this topic and to hypothesise potential causal mechanisms by drawing on existing supervision and interpersonal processes literature.…”