You Can Also Follow CombatCounselor on:

Welcome to CombatCounselor Chronicle, an E-zine dedicated to giving you the most current, pertinent information on cognitive behavioral therapy (CBT) and mindfulness-based CBT available.

Chris Sorrentino, a.k.a CombatCounselor, is a leader and expert in cognitive behavioral therapy. He combines 30 years of experience in psychology with the discipline from having served as a U.S. Air Force officer for 20 years, 4 of those in combat zones, retiring as a lieutenant colonel in 2005.

The Leader in Military and Veteran Psychology ... Follow Me to Mental Health!

Monday, December 19, 2011

Grief: Feel the Pain to Heal

Grief, be it the loss of a friend, family member, OR pet, is difficult. Don't avoid those feelings, embrace & accept them.

The pain can seem unbearable, but it is not. Many times we avoid the emotions associated with loss and tell ourselves "I'm strong", "I can take it", or "I'll deal with this later". Not a good idea. Although difficult and painful, if you do not let yourself experience the emotions (anger, depression, guilt, etc.) now, they will catch up with you later, when you least expect it. That is called avoidance. I am not saying that you should wallow in your grief or pity, and there definitely are limits on how long you should grieve, but experience the emotions naturally in order to heal.

The opposite of avoiding grief is lingering in it. You should experience the emotions as long as they last. Do not avoid them, but do not hold on to them any longer than necessary. You will never totally get over the loss of someone you love, and you should not, but the pain will ease with time IF you allow yourself to experience the pain naturally and in the present.

StayPresent, BeResilient

Sunday, December 18, 2011

Thought of the Day

We cannot change evolution's work, but we can alter what we pay attention to (mindful experience ) and how we REACT to "perceived" threat (acceptance).

Evolution has predisposed humans to be on the lookout for danger, even when there may be none (e.g. worry about flying). If we can be mindful and fully experience the present moment, understanding that the anxious thoughts we are having are merely thoughts, then we are able to experience what is happening in a nonjudgmental way.

Practice being mindful throughout the day in different contexts, enjoying each moment rather than ruminating about the past or worrying about the future because THIS MOMENT WILL QUICKLY VANISH AND BECOME A MEMORY. Do you want that memory to be of the past, future, or of what is happening RIGHT NOW?



Monday, December 5, 2011

Trouble Sleeping? ... Join the Club!

Do you have trouble sleeping? Well, a great many Americans do, so you are not alone! Want to do something about it? Read more...
A recent study in published in the journal Sleep indicated that the average American loses 11 working days each year due to insomnia...11 DAYS! 
BOTTOM LINE: Use common sense and reduce exposure to blue light after dark to sleep better. You can also:
1. Sleep in a cool, dark room.
2. Avoid caffeine and nicotine (stimulants) at night.
3. Develop a regular sleep routine, waking & going to bed at the same time EVERY DAY OF THE WEEK.
4. Use your bed for sleeping (sex is OK...whew!) ONLY.
5. Exercise regularly - more than 2-3 hours prior to bedtime
6. If you are having trouble sleeping, get out of bed until you are tired enough to sleep.
7. Download a "White Noise" app for your smartphone (turn ringer off or use "airplane mode")
The April 2012 issue of Money Magazine stated that "If Nothing's Working...Try cognitive behavioral therapy: CBT, a form of therapy that seeks to train your mental habits is one of the most effective methods of treating sleep ills. Most people see improvement after four to six's usually about $200 a session...a good night's sleep is always a sound investment."  You can find a cognitive behavioral therapist on Psychology Today's Therapist Finder  by entering your zip code and using the advanced search to narrow your options down to "cognitive behavioral" therapists in your area, specializing in your unique situation...there are many, many filters to find the therapist you need. REMEMBER: MANY THERAPISTS CALL THEMSELVES "COGNITIVE BEHAVIORAL" in order to receive payments from insurance companies, so understand what a cognitive behavioral therapist does and ask pertinent questions to see if they are who the say they are:
  • Which theorists do you base your work on? 
    • B.F. Skinner, Aaron/Judith Beck, Albert Ellis, Donald Meichenbaum, Marsha Linehan, Steven Hayes are all acceptable
  • Which cognitive behavioral techniques do you use (have them explain their answers)?
    • Cognitive restructuring, exposure, response prevention, prolonged exposure, interoceptive exposure, mastery and pleasure activity scheduling, mindfulness, dialectics, cognitive defusion, values-clarification are valid answers
  • How long should therapy take?
    • CBT is time-limited by nature and should take no more than 3-4 months MAXIMUM to complete
    • Most treatments take from 4-14 sessions (50-90 minutes each), but some of the more complex cases, like DBT for Borderline Personality Disorder, take as much or more than one year
There has also been recent research that proves that "blue" light, the kind we get from sunshine, TV and computer screens, light bulbs, even alarm clock numbers, stimulates seratonin (which helps keep you awake and alert among other things) and suppresses melatonin (a hormone which tells you it's time to sleep). Orange light, which comes from the opposite end of the light spectrum, has the opposite effect, helping to produce melatonin and inducing sleepiness.
So, what does that mean for you insomniacs? Reduce eye exposure to blue light after dark by staying away from the sources listed above or use orange light at night to read and do other things. Candle light produces orange light, so act like Abe and go "au naturale" after dark (I mean read by candlelight, not get naked).
You can buy orange lightbulbs online and there are other things you can do:
2. Download a free app that will automatically adjust your monitors visible spectrum based on time of day:

                                              CLICK HERE - LINK TO FREE APP

3. Buy orange safety goggles or glasses, also available online, and wear them at night before bed.Sleep tight!

Thank for information on the ligjt spectrum and effects on sleep.

© 2012 CombatCounselor - All Rights Reserved

Sunday, December 4, 2011

Do you want pity, unoriginal content, obscure quotes, or updates on my life?

If you want pity, unoriginal content, obscure quotes, or updates about my life, you came to the wrong place...stop whining, complaining, and feeling sorry for poor little you! Take responsibility for your life and do something about what's bothering you . THAT'S AN ORDER!

I offer 100% FREE INFORMATION based on 30 years of education and clinical experience. Listen to what I have to say or don't. It doesn't really matter to me, I'm going to keep it up whether you listen or not. Why? Because I'm passionate about what I do and want to help people who have the spine to ask for help and put in the hard work it takes to change.

If you can find one place on ANY of my sites where I ask you to buy something, as Cal Washington used to say, "I'll eat my hat"!


Have a great life...StayPresent, BeResilient, StayTheCourse!

Published with Blogger-droid v1.7.1

Friday, December 2, 2011

The Therapeutic Alliance

This article focuses on therapeutic (working) alliance in counseling, a critical component related to successful outcome in counseling.  I examine a small number of studies, providing background related to the general effects of counseling and the Working Alliance Inventory (WAI) and discussing the impact of the alliance in counseling.  I conclude with a discussion of the implications of the information presented, specifically focusing on the contextual model and the importance of general effects in counseling, the importance of developing a collaborative relationship with clients early on, understanding how clients early formative and current relationships affect their ability to form a working alliance, achieving a balance between process related techniques and alliance strengthening skills, and, finally, evaluating client attachment style and how it may affect the working alliance.  
                        Keywords: Alliance, therapeutic, counseling, client, attachment, contextual.

           The therapeutic alliance, or “working” alliance as Bordin (1979) defined it, is widely accepted as a crucial component of successful outcome in counseling and has been studied extensively.  I examine a relatively small number of studies here and with a somewhat limited focus due to time and other constraints related to this assignment.  I will start by providing some background related to the general effects of counseling as well as a widely used instrument in measuring the alliance, the Working Alliance Inventory (WAI).  I will then discuss the impact of the alliance in counseling, focusing on a few key studies, finishing with a discussion of the implications of the information presented.
General Effects and the Therapeutic Alliance
            In Wampold’s book, The Great Psychotherapy Debate, he identified therapist effects as a “critical factor in the success of therapy” (2001, p. 202).  More specifically, in their article on therapist and patient variability in the therapeutic alliance, Baldwin, Imel, and Wampold (2007) pointed out that it is the therapist’s contribution to the alliance that is foremost in determining a successful outcome for the client.  Wampold (2001) supported the contextual model (versus the medical model), contending that is the general effects (common factors – therapeutic alliance, therapist competence, a belief, by the therapist and client, in the effectiveness of the therapy, etc.) of psychotherapy that are key to a successful outcome, not the specific effects (techniques) of any particular therapeutic approach.   That being said, it is widely contended that it is the therapeutic alliance that will account for a great deal of the variability, both positive and negative, in the client’s outcome.
The Working Alliance Inventory (WAI)
            The Working Alliance Inventory (WAI), developed by Horvath and Greenberg in 1968, is a widely used instrument for measuring the therapeutic alliance and was the instrument of choice in the majority of the studies discussed here. The WAI is a 36-item self report survey consisting of three subscales that mirror Bordin’s three components of the working alliance, goals, tasks, and bonds, and uses a 7-point Likert-type scale.  Parallel forms are available for both clients and counselors (Satterfield and Lyddon, 1995).
The Therapeutic (Working) Alliance
            One of the most important tasks that we as counselors have is to form a positive, healthy, nurturing working alliance with our clients.  As we discussed briefly above, Bordin (1979) defined the working alliance as a collaborative process in which client and counselor  (a) mutually endorse goals or counseling outcomes; (b) join in tasks related to the attainment of successful outcomes; and (c) establish positive personal attachments, or bonds, which are characterized by trust, acceptance, and confidence.  A good working alliance is based on two important factors.  The first factor is the relationship that the counselor develops and fosters from the very beginning of counseling.  Kokotovic and Tracey (1990) found that clients who were viewed by their counselors as having poor social relationships in general had greater difficulty in forming working relationships (alliances) with their counselors.  A second factor is the relationship the client has or had with his or her parents, because that relationship will give us insight into how the client relates to their social network and, ultimately, most likely predict how they will relate to their counselor.  In support of that assertion, Mallinckrodt (1991) also reported evidence of a correlation between clients’ recollections of the quality of their childhood bonds with their parents and the strength of the working alliance.
            In Kivlighan’s (1990) study, the relationship between counselor technical activity (use of intentions – set limits, educate, assess, explore, change, restructure, and support) and working alliance (as rated by the client) was analyzed during the course of four counseling sessions.  Two groups of undergraduate students were asked to participate in a study in which sessions were analyzed to see if the use of intentions by the counselor affected the quality of the therapeutic alliance.  The study found that during the four sessions, three of the intentions mentioned above, assess, explore, and support, were negatively correlated with the working alliance as measured by the WAI.  The authors were somewhat surprised by the negative correlation of the support intention (offering support or encouragement) with the alliance, but concluded that this may have occurred because it put the client in a more passive role.  They also proposed the following questions: 1) “Can counselors be trained to decrease their use of the assessment, explore, and support intentions?” and 2) “Would this training affect client-rated alliance?” We are not sure that such training would be either indicated or useful based on a study with such obvious limitations, considering the importance of assessment, exploration, and support in counseling.  At best, the study points to the need to balance such strategies, with the counselor paying particular attention to the use of intentions that may put the client in a more passive role versus those that will enhance the working alliance.
            According to Satterfield (1995), a client whose attachment style is characterized by a lack of trust in the availability and dependability of others (low level of “depend”) may be more likely to evaluate the counseling relationship in negative terms, particularly during the early phase of counseling. The authors recruited ninety-six first-time clients seeking counseling through the university to participate in a study in which they completed the Adult Attachment Scale (AAS) prior to counseling and the WAI (client version) after the third session.  Sixty participants completed the study and the authors concluded that client attachment, particularly the “depend” measure, is in-fact negatively correlated with the working alliance and may lead to unfavorable counseling outcomes. They also recommended further research on the impact of counselor knowledge of client attachment dimensions and the affect they may have on the working alliance.
            What should counselors focus on if we are to accept the hypothesis of the contextual model and the importance of general effects in counseling as proposed by Wampold?  Based on the research, one of the most important things we can do is learn how to better foster a therapeutic, empathic, nurturing alliance with our clients.  As Bordin (1979) recommended, we should focus on developing a collaborative relationship with our clients early on, setting mutually agreeable goals, working together toward successful outcomes, and establishing positive bonds.  Kokotovic and Tracey (1990) and Mallinckrodt (1991), taught us that we should understand how our clients early formative relationships and their ability to form and maintain current relationships affect their ability to form a strong working alliance.  Kivlighan  (1990) emphasized the importance of focusing on a balance between process related techniques (intentions) and alliance strengthening skills, such as those endorsed by Carl Rogers (genuineness, empathy, and warmth).  Finally, Satterfield (1995) points us to the need to assess our client’s attachment style, looking particularly for those clients who may be characterized by a lack of trust in the availability and dependability of others, and how their attachment style may contribute to the alliance.   In conclusion, because alliance effects are so intertwined with outcome, whether positive or negative, we owe it to our clients to “do no harm” and do everything in our power to foster a positive working alliance.
Baldwin, S.A., Imel, Z.E., & Wampold, B.E. (2007).  Untangling the alliance-outcome correlation: Exploring the importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75 (6), 842-852.

Bordin, E. S. (1979).  The generalization of psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.

Kivlighan, D. M. (1990). Relation between counselors' use of intentions and clients' perception of working alliance. Journal of Counseling Psychology, 37(1), 27-32.

Kokotovic, A. M. and T. J. Tracey (1990). Working alliance in the early phase of counselor. Journal of Counseling Psychology, 37, 16-21.

Mallinckrodt, B. (1991). Clients' representations of childhood emotional bonds with parents, social support, and formation of the work alliance. Journal of Counseling Psychology, 38, 401-409.

Satterfield, W. A. and W. J. Lyddon (1995). "Client attachment and perceptions of the working alliance with counselor trainees. Journal of Counseling Psychology, 42 (2), 187-189.

Wampold, B. (2001).  The Great Psychotherapy Debate. Mahwah, NJ: Lawrence Erbaum Associates.

© CombatCounselor 2011 – All Rights Reserved

Thursday, December 1, 2011

Freud and Psychoanalysis versus Hayes and ACT: Time for a Change?

Sigmund Freud
It goes without saying, Sigmund Freud is an icon, having had a tremendous influence on psychology in general and psychotherapy in particular.  However, exposure to Freud and psychoanalysis in undergraduate, graduate, and post-graduate programs, I believe, has outlasted his contributions and become rather tedious.  Studying Freud and psychoanalysis in an undergraduate introductory psychology course or even an undergraduate or graduate theories course is understandable and warranted.  I have been exposed to Freud countless times in numerous courses and, to be totally honest, I think it is a waste of time to continue to study a theory that has never been proven and been the laughing stock of serious behavioral scientists for decades.  It is hard to believe that clinicians still practice psychoanalysis in the 21st Century and that a current text applying developmental theories to counseling (Kraus, 2008) or one on theories of human development (Newman and Newman, 2007) would spend as many as 67 pages discussing it.  Surely, there are more deserving, practical, and recent theories that could have been printed on those pages, Relational Frame Theory for instance.
“The third wave of behavior therapy” (Hayes, 2004, p.16), as Steven Hayes and others have called it, has emerged to provide an experiential option for those who practice and are treated with cognitive behavioral therapy (CBT).  This third wave of therapies includes Acceptance and Commitment Therapy (ACT – pronounced as a word, not an acronym) and Dialectical Behavior Therapy (DBT – Linehan, 1993), both of which focus on mindfulness and acceptance, and influenced by the tradition of Zen Buddhism.  ACT is based on the philosophy of Functional Contextualism and a developmental learning theory known as Relational Frame Theory (RFT), a fairly recent theory developed by Hayes over the past 15 to 20 years. 
Relational Frame Theory is a rather difficult theory to grasp, but both Blackledge (2007) and Blackledge and Hayes (2001) helped clarify the theory and the connection between language, experiential avoidance, cognitive defusion, and exposure.  Blackledge and Hayes (2001) also clarified the difference between ACT and CBT, where thoughts emotions, and memories are simply accepted as such (in ACT) rather than trying to modify them as is done in CBT.  According to RFT (Blackledge and Hayes, 2001), language and rule-governed behavior are additive in the sense that what we have experienced (behavior, thoughts, emotions, memories, etc.) can never be eliminated and, therefore, we must create positive, novel, experience-based memories founded on acting in accordance with personal values rather than “replacing” negative experiences.  This concept is quite contrary to CBT, where thoughts are analyzed and manipulated, even though ACT is considered a cognitive behavioral therapy.
            Relational Frame Theory has been studied extensively and Hayes et al (2006) has done an excellent job of describing the framework of ACT, explaining the basic philosophy, theory, principles, and processes in a succinct and easily understandable manner.  There is a large and ever-accumulating body of research and literature, both on RFT and on ACT, empirically supported and validated research as opposed to the unproven psychoanalytic or psychosexual theories of Freud and his cohorts.  In my opinion, the 67 pages spent on Freud in our two texts would have been much better spent focusing on a more recent and exciting theory such as RFT. I have personally seen RFT and ACT in action in my own practice, and the results are quite amazing, results taking days or weeks rather than years, as is the case in psychoanalysis. In conclusion, my reaction to Freud and psychoanalysis are, obviously, quite strong.  Again, my goal is not to diminish Freud’s impact or contributions, only to recommend that our time might be better spent on something more current and relevant to clinical practice in the 21st Century.

Blackledge, J.T. (2007). Disrupting verbal processes: Cognitive defusion in Acceptance and          Commitment Therapy and other mindfulness-based psychotherapies. The Psychological Record, 57, 555-576.

Hayes, S.C. and Blackledge, J.T. (2001). Emotion regulation in Acceptance and Commitment Therapy. Psychotherapy in Practice, 57 (2), 243-255.

Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A., and Lillis, J. (2006). Acceptance and             Commitment Therapy: Model, process and outcomes. Behaviour Research and Therapy,             44, 1-25.

Hayes, S.C., Strosahl, K.D., and Wilson, K.G. (1999). Acceptance and Commitment Therapy:      An Experiential Approach to Behavior Change. New York, NY: The Guilford Press.

Hayes, S.C. and Strosahl, K.D. (Eds.). (2004). A Practical Guide to: Acceptance and Commitment Therapy.  New York, NY: Springer Science+Business Media, LLC.

Linehan, M.M., (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder
New York, N.Y: Guilford Press.

Newman, B.M. and Newman, P.R. (2007). Theories of human development. Mahwah, NJ:            
Lawrence Erlbaum Associates, Publishers.

Walser, R.D. and Westrup, D. (2007). Acceptance and Commitment Therapy for the Treatment     of Post-Traumatic Stress Disorder and Trauma Related Problems: A Practitioners Guide         to Using Mindfulness and Acceptance Strategies. Oakland, CA:  New Harbinger     Publications, Inc.