Checklist for Hiring a Clinician Specializing In Cognitive Behavioral Therapy (CBT)

I receive many calls from people looking specifically for a therapist specializing in CBT. Because I rarely have any openings, I make a lot of referrals. Unfortunately, there ARE FEW TRUE COGNITIVE BEHAVIORAL THERAPISTS, at least in my area.

When I say "TRUE COGNITIVE BEHAVIORAL THERAPIST", I mean somebody who is an expert in CBT (which requires advanced knowledge of learning theory; e.g. classical and operant conditioning, relational frame theory, etc.) and practices using "primarily" cognitive and/or behavioral techniques. Easier said than done!

Many therapists call themselves "COGNITIVE BEHAVIORAL" even though they may know little, if anything, about CBT. Why? Because most therapists (licensed professional counselors, clinical social workers, psychologists, and psychiatrists) depend on health insurance as reimbursement for their services AND insurance companies ONLY reimburse for empirically supported treatments (EST), with CBT being the primary (sometimes only) EST for the vast majority of anxiety and mood disorders (which make up the vast majority of disorders being treated).

Many of my clinical colleagues will probably not be happy with what I'm telling you and to them, as the character Gilly on Saturday Night Live would say: "uh huh"..."sorry!". We ALL owe it to our clients to be honest and provide the MOST EFFECTIVE TREATMENT available for our client's particular condition, which in many cases means CBT (the most researched and scientifically proven treatments available for many, not all, conditions).

When looking for a cognitive behavioral therapist, I suggest doing an advanced search on Psychology Today's Therapist Finder, screening for therapists in your zip code specializing in CBT for YOUR CONDITION. Once you have narrowed the list, start calling them and ask the following questions:

1. Are you a cognitive behavioral therapist and, if so, what technique(s) do you use for people with my kind of problem?

Answer: Yes. Answers could include exposure, exposure and response prevention (OCD), prolonged exposure (PTSD), activity scheduling (depression), cognitive restructuring, behavioral activation or rehearsal, and contingency management among others. Exposure, in vivo, imaginal, and prolonged, just to name a few is the treatment of choice for most anxiety-based disorders (e.g. generalized anxiety disorder, OCD, PTSD, agoraphobia, panic disorder, social anxiety disorder, simple phobias) 

2. Which CBT therapy do you adhere to and who is the person (theorist) influencing your practice the most? 

Answers: Cognitive Therapy (Primary Theorists: Beck, Ellis); Cognitive Behavioral Therapy or Stress Inoculation Training (Primary Theorists: Meichenbaum); Acceptance and Commitment Therapy - ACT (Primary Theorists: Hayes, Strosahl, Blackledge); Dialectical Behavior Therapy - DBT (Primary Theorists: Linehan); Mindfulness-Based Cognitive Therapy - MBCT (Primary Theorists: Williams, Teasdale, and Segal); Mindfulness-Based Stress Reduction - MBSR (Kabat-Zinn)

3. Estimate the percentage of techniques you use in therapy that are STRICTLY cognitive behavioral. 

Answer: AT LEAST 60 - 70% is acceptable, preferably more. 

4. Can you tell me the difference between positive reinforcement, negative reinforcement and punishment?

Answer: Positive reinforcement involves increasing the likelihood of a behavior occurring in the future by rewarding the organism immediately following the desired behavior. Negative reinforcement involves increasing the likelihood of a behavior occurring in the future by removing an aversive stimulus immediately following the desired behavior. Punishment involves introducing an aversive stimulus immediately following a behavior you are trying to eliminate and may work for a short time, but research indicates that it is ineffective in the long-term for changing behavior. 

If they cannot answer this question, they know little if anything about the most important aspects of CBT and should probably be eliminated).

5. Do you offer FREE initial consultations (preferably in person, over the phone by exception)?

Answer: Yes. In-office consultations are preferred. If a therapist wants to charge you, keep looking unless they are obviously VERY SKILLED in CBT and you have no alternatives.

6. Are you licensed in your state (LPC, LCSW, licensed psychologist/psychiatrist, etc) AND certified (by whom)? What is your license/certification number?

Answer: Yes. Not all licensed therapists are also certified by a recognized national certifying body (requires passing a national exam and paying annual dues), but those who are indicates additional credibility and professionalism. Ask for the certifying body and certification number, then look up the licensing and certifying organizations on the internet and check to see if they actually exist, are current, and free of complaints or violations.

Unfortunately, there are many unqualified, unlicensed people out there calling themselves therapists, life/executive coaches, spiritual healers, etc. and probably do not have the necessary education, experience, licensing, and certification required to help you solve problems of the mind. Read my post "Client Beware" for more details about therapist credentials and picking a therapist.

Read my "Client Beware" Blog Post

In conclusion, CBT is one of the most researched, proven, effective, time-limited and cost effective (many problems can be treated effectively in 3 months or less - one one-hour session per week)  therapies available today and the treatment of choice for many psychological problems. So if you are looking specifically for a therapist specializing in CBT, as many educated consumers are, the preceding information should be helpful.

With that said, there are many reasons why CBT may not be appropriate for you or your particular problems. There are many good therapies and therapists available, so I recommend you do some research and know what you are looking for when selecting a therapist. In any event, to reinforce the importance of my earlier point, MAKE SURE THEY ARE LICENSED (PSYCHOTHERAPIST) IN YOUR STATE if nothing else.

Feel free to contact me if you have any questions or need additional assistance finding the right therapist for you.  You can also watch my video series on YouTube: BMBT Basic Training with CombatCounselor 

GOOD LUCK!

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 21^st 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 21^st Century.

References

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.