Introduction to Body-Mind-Behavior Therapy (BMBT)

Many of us have suffer from anxiety or depression, yet are still looking for a solution. Whatever you have been doing must not be working or you would not still be looking for answers.

Maybe you have been looking in the wrong places! Maybe you have been focusing on changing the "content" of your life (words, thoughts, emotions) instead of the "context", the part you actually have control over when it comes to internal problems (e.g. cognition...your thoughts).

In my upcoming book, "Get Off Your Buts And Live A Value-Driven Life ... That's A Freakin' Order!", I explain my proprietary approach to psychotherapy, integrating traditional cognitive behavioral therapy (CBT) with mindfulness-based CBT, called Body-Mind-Behavior Therapy (BMBT).

In BMBT, we focus first on what your BODY is telling us in terms of proper exercise, diet, and sleep as well as those internal sensations that "set-off" your anxiety or depression. Next, we focus on the MIND, teaching you how to be mindful in the present moment, accepting thoughts and emotions, and changing the "context" of how you relate to your thoughts rather than changing the thoughts themselves. Finally, BEHAVIOR becomes the target by clarifying your values, setting achievable goals, and making a commitment to taking action toward achieving those goals.

The result of BMBT is not another "quick fix", but a new way of life where you are mindful of the moment and ACT based on your values, rather than avoiding the things that you fear or make you sad.

Visit and SUBSCRIBE to my POPULAR YouTube channel, The CombatCounselor Channel, and  send me a message, telling me about your problem, what you have tried to do to fix it, and what result you would like to achieve:

http://www.youtube.com/user/CombatCounselor

Or SUBSCRIBE to the CombatCounselor Channel on Spreecast:

You may be one of the lucky viewers who has their issue addressed personally by CombatCounselor.

Good luck!

acceptance, ACT, anxiety, are, avoidance, cognitive behavioral therapy, CBT, acceptance and commitment therapy, combatcounselor, DBT, depression, journey, ACT, mental health, ptsd, mindfulness

Anger Management ... Can You control Your Anger?

It is difficult, if not impossible, to manage or control anger. Control is the problem, not the solution. You can control many things in the world, but when you try to control what is between your ears, you will fail miserably. 

Dealing with anger issues can be very simple, yet extremely difficult, because you have learned to react the way you do. You cannot "unlearn" it because the mind is a one-way street of sorts, once "it" is in there, "it" is there for good. However, you can learn new ways of responding to angry thoughts, changing the context rather than the content. Let me briefly explain. 

You could practice accepting angry thoughts, which cause angry emotions, just as they are, non-judementally, in the present moment. Those thoughts, which may be true or valid, or may not be true or valid, are most likely not productive. So, by accepting the thoughts for what they are, merely thoughts, you can let yourself experience any valid anger rather than pushing it away or you can simply observe the thoughts and not attach any judgment or importance to them. In either case, you now have control over the process (context) and how you react to the thoughts.

I said it is simple because it is. It is as simple as accepting thoughts, sensations, behaviors, memories, and emotions for what they are and without judgement. Becoming competent at doing that is the difficult part. It takes practice, mindfulness practice, every day of the week for the rest of your life. Would you trade a life complicated by anger, anxiety, depression, shame, guilt (etc, etc) for one of calmness and tranquility if I told you it would take only 5 to 30 minutes a day?

The mindfulness-based cognitive behavioral therapies (DBT, ACT, MBMT) are not just for "crazy" people, but for anybody who is tired of letting their thoughts and emotions run their lives. It is a positive psychology in the sense that we train ourselves to look at negativity as a transient state and is based on the traditions of Zen Buddhism while incorporating modern, effective cognitive behavioral techniques based on the latest scientific research.

There are 15 episodes of BODY-MIND-BEHAVIOR (BMB) BASIC TRAINING on my YouTube channel: CombatCounselor Channel can read more on our website, www.KCCBT.com and my blog, The CombatCounselor Chronicle. You can also follow me on Twitter @CombatCounselor or LIKE my Facebook page: Like CombatCounselor on Facebook . You can also search using the terms mindfulness-based cognitive behavioral therapy and Acceptance and Commitment Therapy (ACT).

Don't forget to follow @CombatCongressman on Twitter, subscribe to his blog CombatCongressman Connection, visit his website CombatCongressman.com AND VOTE FOR THOMAS C. SORRENTINO IN THE 2014 MIDTERM ELECTION - MISSOURI'S 6TH CONGRESSIONAL DISTRICT!

Client Beware: Protecting Yourself from Un(der)qualified “Therapists”

By Chris Sorrentino, MS, LPC, NCC

Chris Sorrentino is a combat and disabled veteran, retired military officer, and licensed professional counselor with over 30 years of experience and education in clinical psychology and cognitive-behavioral therapy.  Chris was an Assistant Professor of Behavioral Sciences and Leadership and Counselor at the United States Air Force Academy from 1988 to 1993.  He is the author of the future New York Times Best Seller Get Off Your Buts And Live A Value-Driven Life ... That's A Freakin' Order".

Many people seek the expertise and advice of “professionals”, paying top-dollar for, what they believe, is psychotherapy.  I have been a licensed psychotherapist (licensed professional counselor, or LPC, actually) for 20 years, having seen literally hundreds of clients, but very few ever asked me about my qualifications.  Of course, I am obligated, morally, legally, and ethically, to inform my clients about my education, experience, licenses, and approach to treatment (legally known as “informed consent”), and do so consistently.  However, there are multitudes of individuals and groups out there advertizing themselves as “therapists”, “life coaches”, “healers”, and other creative titles, hoping the public (you) will believe that they are qualified to help you with your psychological baggage.  Client beware!

This is the first in a series of articles I will write that will take some of the mystique away from psychotherapy.  Many people understand therapy based on what they have seen in movies, on HBO, in books, and on TV (e.g. Dr. Phil) and have no idea of what goes on behind closed doors.  My goal is to help you understand what psychotherapy is and is not, so you can make an informed decision about whom you can trust with your deepest, darkest secrets and pay hundreds, if not thousands, of dollars to in the process. The purpose of this first article is to inform you about who is qualified to provide psychotherapy and who (in my opinion) is not.

At the most basic level, there are specific requirements in each state for practicing psychotherapy and therapists are regulated by the state in which they practice.  There is a governing body for each specialty (e.g. LPCs, social workers, psychologists, psychiatrists) which specifies the requirements to practice in that state and we (therapists) are required to meet those requirements prior to seeing a single client.  For example, an LPC (like myself) in the State of Missouri is required to hold a master’s degree from an accredited institution with an emphasis in ten core areas (counseling theory, human development, diversity, testing, etc.) completing a supervised practicum and internship as well as 3,000 hours (over a two year period) of supervision under a qualified, licensed clinician (therapist).  Additionally, an LPC must take and pass the National Counselor Examination, an extremely difficult, comprehensive, nationwide exam in addition to passing a background check (to make sure we are not murderers, child molesters, or rapists).  Only then, if the board sees fit, do you receive a license to provide psychotherapy in the state.  Most states have similar requirements for each profession, but some variation exists from state to state.  You can check the requirements for each profession in your state by going to your state’s website.  In the case of Missouri, the Missouri Division of Professional Registration oversees licensure for all of the psychotherapy professions and you can find the requirements for yourself by visiting  http://pr.mo.gov/default.asp.  This brings me to my next topic, the professions.

Titles vary slightly from state to state, so I will focus on Missouri guidelines to simplify the discussion.  Again, you can check with your state’s regulatory body for the specifics of the state in which you reside.  In  Missouri, individuals qualified and licensed to provide psychotherapy are called licensed professional counselors (LPC), licensed clinical social workers (LCSW), psychologists, or psychiatrists.  Let me explain briefly the differences between them.  LPCs and LCSWs are master’s-level (normally, a two-year post-baccalaureate degree) clinicians having completed their graduate degree in the field of study in which they are getting licensed from an accredited institution (not a diploma mill), completed supervised practicum, internship, and clinical supervision (3,000 hours – 24 months), successfully passed the required national or state exam(s), not be a felon (remember the background check? – this will be important later), and be approved by the state board governing their specialty.  Finally, we are all professionally and ethically required, above all else, to “do no harm” and to protect your confidentiality.

So what is the difference between an LPC or LCSW and a psychologist?  I am glad you asked!  A psychologist goes through an almost identical, if not more rigorous, qualification process, with the difference being that they have completed a doctoral program instead of a master’s, normally consisting of three to four years of post-baccalaureate education in a School of Psychology (PhD), School of Education (EdD), or Professional School (PsyD).  Doctoral-level clinicians, beside the additional 1-2 years of school, have more course work and experience in research design and psychological testing than master’s level clinicians do.

Many people get psychologists and psychiatrists confused and I often get the question, what is the difference?  In a nutshell, psychiatrists are physicians (medical doctors – MD) who have completed a three to four year specialization in psychiatry whereas a psychologist calls him/herself “doctor” (because they have a “doctorate” degree), but cannot prescribe medicine.  Psychiatrists are an excellent choice if you believe you need medicine (anti-depressants, mood stabilizers, anti-psychotics, etc.), but, in many cases (and in my experience) have limited “clinical” expertise (think “talk therapy” like CBT) because they were trained using the “medical model” and believe drugs are the answer to most problems (more about that in a minute).

It really does not matter whom you choose (LPC, LCSW, psychologist, psychiatrist) as long as you can verify that they are licensed to practice in your state and you believe they can help you based on their individual training and expertise.  Fees obviously vary with LPCs, LCSWs being the least expensive in general, and psychiatrists being the most expensive.  All things being equal, the most important things to consider are: does the clinician’s approach make sense; is their approach compatible with your beliefs and values; and do you think you can get along with the person (can they be trusted)?

You might ask yourself, what is the difference between being licensed (e.g. licensed professional counselor) and being certified (e.g. NCC – National Certified Counselor)?  Licensure is a legal requirement mandated by the state.  Certification is a process in which a governing body (sometimes a state, county, or city and sometimes a private organization) develops requirements to give additional oversight and credibility to an individual or profession.  For example, I am required by the State of Missouri to be licensed (LPC) in order to provide psychotherapy to clients, but I have chosen to seek additional certification (NCC) through the National Board of Certified Counselors (aka NBCC - which, by the way, requires an additional 100 hours of continuing education every five years).  Each certifying body has their own requirements and processes, some very stringent (like NBCC) and others not so stringent, as I will highlight for you now.

As I mentioned in the opening paragraph, there are many people, some well-meaning, some not, who call themselves therapists or something similar, making you believe they are qualified to help you with your psychological problems.  Client beware!  These individuals go by titles such as “life coach”, “intuitive life coach”, “energy healer”, “psychic healer”, “hypnotist”, “spiritual counselor”...the list goes on and on.  There are individuals hosting radio shows and writing magazine columns, giving relationship and other advice to strangers with their only qualification being having been married for five years.  Another example are “certified” life coaches or spiritual counselors, who take as few as two or three courses (and pay a few thousand dollars) or complete as few as 16 hours of training, sometimes even less!  Some of these titles may sound impressive (what exactly is an “intuitive” life coach anyway?) and lead you to believe the individual has received the training to help you, but there is no state licensing body overseeing their “practice”, no stringent internship or supervision requirement (think 16 hours versus 3,000 hours), no continuing education requirement, and (remember what I said earlier?) NO BACKGROUND CHECK!  Many of these individuals may have good intentions, please do not get me wrong, but do you really want to pay someone with 16 hours of training hundreds or even thousands of dollars, confiding in them and sharing your deepest feelings and concerns?  I know that I do not.

There are some properly trained professionals (LPCs, LCSWs, psychologists, etc.) who may use titles such as those described above (e.g. hypnotist), the key difference being that these individuals have attained licensure in their state, completing the rigorous requirements defined by law (think LPCs, LCSWs, etc.).  So, when you decide you want help sorting out your problems, do not let titles and fancy names fool you and make sure you ask many questions, do a little research, and ensure you hire someone qualified to give you the help you so richly deserve.  Even among professionally licensed clinicians, there are good ones and bad ones, so make sure you understand the process, ask the right questions, and ensure you are getting what you are paying for, sound, professional assistance in helping you manage your life.  Notice I did not say anything about “advice”, because if they are giving you advice, even a licensed professional, turn and run as fast as you can.  More about that in a future article.

C.T. Sorrentino is currently writing a series of articles entitled You Think, You Are.  These articles take readers through ten steps toward better mental health, incorporating Kansas City Cognitive-Behavioral Therapy's proprietary, holistic, cognitive-behavioral approach to the treatment of anxiety and depression: Body-Mind-Behavior Therapy (BMBT).  These articles will also serve as the building blocks for his new book, also entitled Get Off Your Buts And Live A Value-Driven Life ... That's A Freakin' Order", a book that Chris hopes to publish in 2014.   He plans on writing a series of books focusing on the role of cognition, physiology (e.g. diet, exercise, and sleep), behavior (positive and negative), emotion, and values in maintaining a healthy mind and positive lifestyle.

COPYRIGHT 2013 – CombatCounselor and Kansas City Cognitive-Behavioral Therapy, LLC  ©

IS GETTING HELP A CAREER KILLER?...IT IS NOW!

LETTER TO THE EDITOR
AIR FORCE TIMES
OCTOBER 5TH, 2012

I have written to Air Force Times on numerous occasions and feel like I am wasting my time, so this will likely be my last contact. My primary concerns have related to military and Veteran mental health issues and the stigmas associated with seeking and receiving treatment as well as what a PTSD diagnosis can do to a military career.

I am a retired lieutenant colonel, veteran of four combat operations, disabled veteran, and licensed professional counselor (since 1991), specializing in the treatment of anxiety (e.g. PTSD) and depression with active duty and Vets. I am also executive director of the non-profit Help4VetsPTSD, Inc., a relatively young organization dedicated to helping active duty and Veterans with PTSD. I also consult with a DoD contractor providing short-term, solution-focused counseling to active duty military, Guard and Reserve personnel, and their families.

I have experienced the stigma firsthand, both while on active duty and as a clinician, before and after retirement. I thought your publication was on the right track in helping to eliminate the stigmas, until I read "IS GETTING HELP A CAREER KILLER?" (Kristin Davis) in your October 8, 2012 issue.

In a little more than one page, you managed to hinder any progress we have made in recent years and highlighted WHY AIRMEN (AND OTHERS) NEED TO BE AFRAID, VERY AFRAID, OF SEEKING MENTAL HEALTH TREATMENT, OR WORSE, TALKING ABOUT IT! I find it hard to believe that anybody with any common sense reviewed or edited that piece before publication. If there was not a negative stigma before...THERE IS SURE TO BE ONE NOW! What were you people thinking?

I am appaled by the lack of judgement in publishing such a piece and believe the reasons for NOT PUBLISHING THE ARTICLE in question are too numerous and obvious to mention.

For those who do not have the opportunity to read it, Ms. Davis reported on an Air Force NCO (non-commisioned officer) who sought help and educated other airmen, telling them about his battle with alcohol (which he is currently winning by the way) and other mental health issues. His supervisor, an obvious Neanderthal and ignorant moron, killed this gentleman's career by making statements about his alcoholism ON HIS ENLISTED PERFORMANCE REPORT (EPR) and marking him down, both career ending behaviors. The NCO in question, a master sergeant (E-7), appealed his "referral" EPR to his superiors and the Inspector General, and was turned away!

Everyone in the Air Force, Army, Navy, and Marines have heard plenty of horror stories like this one and now they have one more...a page and a half's worth in Air Force Times!

We do not need to hear more horror stories while 19 military and Veterans each day commit suicide...that is correct...19 each day! As long as these stigmas are perpetuated in the media, young heroes, our military and veteran men and women, will continue to die. For the first time in recorded history, MORE PEOPLE ARE DYING OF SUICIDE IN THE MILITARY THAN ARE DYING IN COMBAT!

The space taken up by that garbage could have been better utilized by providing accurate information about the stigma(s), what the implications of the stigma(s) are (e.g. suicides), and proposals on what we can do about it. We need a positive discussion started in this country, educating the public, our elected officials, and military leaders, about the problems in military and veteran mental health treatment and figure out a way to fix them...SOON!

Air Force/Military Times has at least one "supposed" expert on staff, Bret Moore (Kevlar for the Mind), who should have, at least, reviewed the article before publication. Hopefully, he would have recommended squashing the story before it went to print, but based on some of his work, I am not confident that would have happened either.

On a similar note, Robert Dorr's (a long time writer for Air Force Times who gets about one-third of a page EVERY week - Why? I don't know) comments last week on the American-Indian gentleman being "wrong" in his perception, that some nose art depicting Native-Americans in the Air Force is offensive, is ludicrous and insensitive. A perception cannot be wrong and the young man has a right to stand up for his heritage and beliefs! What is wrong is printing garbage like that Mr. Dorr regularly spews onto the page, like black and white vomit, and the Davis article in question this week on career killing...WRONG Air Force Times...shame on you Ms. Ianotta! Becky Ianotta is Managing Editor, Air Force Times.

CombatCounselor...OUT!

Introduction to Body-Mind-Behavior Therapy (BMBT)

Many of us have suffer from anxiety or depression, yet are still looking for a solution. Whatever you have been doing must not be working or you would not still be looking for answers.

Maybe you have been looking in the wrong places! Maybe you have been focusing on changing the "content" of your life (words, thoughts, emotions) instead of the "context", the part you actually have control over when it comes to internal problems (e.g. cognition...your thoughts).

My upcoming book, "You Think, You Are...Anxious: A Journey from Avoidance to Acceptance", explains my proprietary approach to psychotherapy, integrating traditional cognitive behavioral therapy (CBT) with mindfulness-based CBT, called Body-Mind-Behavior Therapy (BMBT)

In BMBT, we focus first on what your BODY is telling us in terms of proper exercise, diet, and sleep as well as those internal sensations that "set-off" your anxiety or depression. Next, we focus on the MIND, teaching you how to be mindful in the present moment, accepting thoughts and emotions, and changing the "context" of how you relate to your thoughts rather than changing the thoughts themselves. Finally, BEHAVIOR becomes the target by clarifying your values, setting achievable goals, and making a commitment to taking action toward achieving those goals.

The result of BMBT is not another "quick fix", but a new way of life where you are mindful of the moment and ACT based on your values, rather than avoiding the things that you fear or make you sad.

Visit my YouTube channel and  send me a message, telling me about your problem, what you have tried to do to fix it, and what result you would like to achieve:

http://www.youtube.com/user/CombatCounselor

You may be one of the lucky viewers who has their issue addressed personally by CombatCounselor.

Good luck!

Finally, A Therapy That Makes Sense...and Works – Acceptance and Commitment Therapy

 by

Chris Sorrentino, LPC, NCC

             Coming from a primarily cognitive-behavioral background, I am quite happy to see “the third wave of behavior therapy” (Hayes, 2004, p.16), as Hayes and others have called it, emerge to address some of the missing links, so to speak, of a somewhat strict and inflexible cognitive-behavioral approach to treatment.  This third wave of therapies, including Acceptance and Commitment Therapy (ACT – pronounced as a word, not an acronym) and Dialectical Behavior Therapy (DBT – Linehan, 1993), focus on mindfulness and acceptance, both of which are influenced by the traditions and practice of Zen Buddhism.  I have used meditation in my own life for quite some time and, while integrating this practice with what I know about cognitive-behavioral theory and methods, have found it quite effective in dealing with the day-to-day stresses of life in general.  I will now focus on ACT in general and the readings specifically to elaborate on my reactions to the philosophy of Functional Contextualism, Relational Frame Theory (RFT), and ACT as a treatment modality. 

            Having read Walser and Westrup’s text (2007) on ACT for Post-Traumatic Stress Disorder on a couple of occasions, I still did not have a good grasp of ACT and how it functioned as a therapy.  It was a bit too fuzzy for me until I read Hayes (1999) book and the assigned reading by Blackledge (2007).  Blackledge was able to state the concept of cognitive defusion in such a way that it really made sense to me for the first time.  He used relevant and creative examples, explaining the concept in simpler terms than Hayes had done previously.  He also expanded on defusion techniques (e.g. the I-Here-Now concept and violation of speech parameters) in a way that really made me understand the role of context in language and how defusion (and context) play a role in the, very behavioral, application of exposure in ACT.  It was kind of an “ah hah” moment for me that really made me understand what Hayes and others have been trying to say for so long, that you can use some very behavioral techniques in a context of total acceptance to reduce anxiety and other problematic emotions.  Blackledge (2007) also helped me understand RFT much better than Walser and Westrup (2007) or even Hayes (1999 & 2004) have tried to do.  Maybe Hayes has become so enmeshed with his theory and understands it on such a complex level that it is difficult for him to explain in easily understandable terms.  In any case, the Blackledge article was an excellent choice and really helped me understand ACT in general and cognitive defusion in particular much better than I have in the past.

            The Blackledge and Hayes (2001) article is quite informative, helping clarify the connection between language, experiential avoidance, cognitive defusion, and exposure in ACT.  It also helps clarify the difference between ACT and CBT, where thoughts emotions, and memories are simply accepted as such rather than trying to modify them as is done in the cognitive model.  The fact that language and rule-governed behavior are additive in the sense that what we have experienced (behavior, thoughts, emotions, memories, etc.) can never be eliminated, makes me think that a contextual, acceptance-based approach may be a way to get the mind to create positive, novel, experience-based memories founded on acting in accordance with personal values.  The vignette, although rather brief and somewhat simplistic, was a good illustration of ACT at work and helped clarify some of the concepts and techniques of the therapy.  After reading the two Blackledge articles (2001 & 2007) specifically, I have a much greater understanding of and appreciation for ACT and am quite excited about the possibilities this type of approach offers to clinicians and clients alike.  ACT is a treatment approach that can be applied to a diverse number of people and disorders, and is blind to cultural influences in the sense that the therapist accepts the client as they are and helps them establish values that are consistent with their culture of origin, personal experience, and unique view of the world.

Eifert et al (2009) described their protocol for working with anxiety disorders, which they call the Act for Anxiety program.  In their program, they introduce value and goal related work much earlier in the process than Hayes (1999 & 2004) has described.  Hayes has noted that the therapeutic steps in ACT are fluid and can be shuffled or adapted based on the experience of the therapist and the needs of the client, but I think it may be a little early in treatment (no later than session 3 according to the authors) to focus on values and goals.  Since they are proposing a 12-session treatment protocol, I would think that focusing on the skills involved in addressing creative hopelessness, cognitive defusion, and self as context would provide a better foundation for value and goal work than vice versa.  Additionally, in session four and five, they propose an “acceptance of anxiety exercise” where clients are “encouraged to make full contact with the experience of anxiety” (Eifert et al, 2009, p. 373).  I doubt that the client will have a solid enough grasp of mindfulness and acceptance at this point in therapy to allow them to experience the kind of therapeutic exposure required for a successful outcome.  It seems far too early for such an intervention and could possibly do more harm than good at this point in treatment.  I also found it confusing when they later referenced “getting ready to face anxiety with mindfulness acceptance” in relation to the goals of sessions six and seven (Eifert et al, 2009, p. 374).  If clients are expected to make full contact with the experience of anxiety in sessions four and five, what is the difference in how it addressed in sessions six and seven?  

            Which brings me to the article by Forman et al (2007) and the randomized controlled trial (RCT) involving ACT and Cognitive Therapy (CT).  The subjects may have been randomly assigned to treatment, but to call this a “controlled” trial is, to put it mildly, a bit of a stretch of the imagination.  First, if you want to compare your treatment (in this case ACT) to the “gold standard” (CT), you probably should not start out by bashing cognitive therapy.  On one hand, they site all of the outcome studies pointing to the efficacy of CT, but, on the other hand, consequently site the research that points to a “lack of consistent support for postulated cognitive mechanisms of CT” (Forman et al, 2007, p. 774).  When they cited the research supposedly showing the effectiveness of ACT, the authors quickly pointed out that all of the studies lacked an active comparison group and were conducted by researchers with an allegiance to ACT, not a very convincing argument.  The therapists used in the trial who were trained in ACT also received six hours of additional training (50 percent more) when compared to the therapists trained in CT, so they would probably be more competent than those providing CT.  Therapist allegiance was also (supposedly) controlled by “asking” the therapists (before they entered the study and knew little about either ACT or CT) which treatment they thought would have better outcomes, so that control goes out the window.  So, in the end, the authors determined that ACT was as effective as CT, which they stated in the beginning of the article was not very effective to begin with.  If you want to compare your treatment option to another model, you should probably say nice things about the comparison if you want to sway readers into accepting your proposal.

            Finally, Hayes et al (2006) did an excellent job of laying out the framework for ACT, explaining the basic philosophy, principles, and processes in a succinct and easily understandable manner.  I really don’t have much else to say other than the fact that they point out an inconsistency I have noticed in Hayes’ other works (1999 & 2004).  Hayes developed ACT as a therapy and began research back in the 1980s, but did not develop the philosophy (Functional Contextualism) and theory (Relational Frame Theory) until the late 1990s and early 2000s.  Even though I think ACT in general is quite thought provoking and even a possible breakthrough in how we approach human suffering, it concerns me that the philosophy and theory were developed to explain the treatment approach.  It’s the old chicken or egg (or cart before the horse) analogy all over again.  I am not saying that ACT is not a valid treatment modality because of this switch, I am only saying that I believe ACT would have more credibility (to me anyway) if the philosophy and theory had been developed or hypothesized first.

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.

Eifert, G.H., Forsyth, J.P., Arch, J., Espejo, J., Keller, M., and Langer, D. (2009).  Acceptance and Commitment Therapy for anxiety disorders: Three case studies exemplifying a united treatment protocol. Cognitive and Behavioral Practice, 16, 368-385.

Forman, E.M., Herbert, J.D., Moitra, E., Yeomans, P.D., and Geller, P.A. (2007). A randomized controlled trial of Acceptance and Commitment Therapy and Cognitive Therapy for   anxiety and depression. Behavior Modification, 31 (6), 772-799.

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.

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.

A Cognitive Behavioral Critique of Time-Limited Dynamic Psychotherapy

 by

Chris T. Sorrentino, LPC, NCC

             Some of the younger readers haven’t had this experience, but 20 to 30 years ago, theories of personality in general and treatment methods specifically were stovepiped or, as Rudyard Kipling would say “never the twain shall meet” (Kipling, 1889).  According to one of my old textbooks, Personality,  by Jerry M. Burger (Burger, 1990), there was the psychoanalytic camp including the likes of Erikson, Horney, and Fromm, the trait theorists such as Allport, Cattell, and Eysenck, the humanists with Maslow and Rogers taking the lead, the behavioral/social learning group which included Skinner, Bandura, and Rotter, and, finally, the new kids on the block, the cognitive bunch led by Kelly, Mischel, and Ellis (although Beck and Meichenbaum were also quite well known by this time).  The various theories and their clinical applications were extremely diverse and scientists, as well as clinicians, were passionately dedicated to their particular favorite.  Over the past 30 years, I have seen an extraordinary evolution of these theories and their applications.  Today, there is so much overlap and similarity between theories and methods that it’s getting harder and harder to see the difference between them, on paper at least.
            Levenson (2003) discusses, on several occasions, the similarities between Time-Limited Dynamic Psychotherapy (TLDP) and the cognitive-behavioral model.  Levenson states “Not only psychoanalysis but other theories as well are increasingly incorporating interpersonal perspectives, for example, cognitive therapy, behavior therapy, and gestalt therapy (p. 303).  She went on to say that “Modern cognitive theorists voice analogous perspectives when they talk about interpersonal processes that lead to experiential disconfirmation” (p. 307) and “The second goal of providing a new understanding focuses more specifically on cognitive changes than the first goal just discussed, which emphasizes more the affective–behavioral arena” (p. 308).  Originating in the psychodynamic camp, TLDP today looks very little like the psychoanalysis of old, having embraced an eclectic treatment approach that focuses on interpersonal factors and a directive, here and now approach while moving away from insight, interpretation, and a very non-directive approach to uncovering the repressed psychosexual conflicts of long ago.  Hip-hip-hooray!  Unfortunately, once again, there wasn’t a lot of information in the readings related to treatment methods and techniques, so I hope we will be discussing this more in class.

           Aaron Beck’s concept of the “schema” (Beck and Clark, 2010) is not much different then Greenberg’s concept of the “scheme” (Greenberg et al, 2004).  Levenson (2003) also discusses the “interpersonal schema” and “schemata” on several occasions, but never really defines the concept in depth.  In fact, she quotes Goldfried and Newman (1986), who said:

A number of contemporary writers have independently suggested the possibility that a common [integrative] language may ultimately come from the field of experimental cognitive psychology and social cognition....Concepts such as “schema,” “scripts,” and “metacognition” have the potential for covering therapeutic phenomena observed by clinicians of varying orientations (pp. 46–47). (Levenson, 2003, p. 310). 

Based on what I can infer from the context in which the terms were used in Levenson’s article, it sounds like a concept very similar to both Beck’s and Greenberg’s, the only difference being that Beck focused on cognitions, Greenberg on emotions, and Levenson on interpersonal relationships.  I don’t want to spend too much more time on this because I discussed the issue at length in my last paper, but want to add one more point.  The concept of transference is more commonly being utilized by members of the different camps (psychodynamic, cognitive, etc) and the application of transference (and countertransference) in treatment is becoming more and more similar.  As Levenson stated, “transference is not considered a distortion but rather the patient’s plausible perceptions of the therapists behavior and intent” (Levenson, 2003, p. 303) while Beck (1979) made several references to transference and its usefulness in therapy from a cognitive perspective.   Even Linehan (1993) mentioned the similarities between the psychodynamic emphasis on transference and her concept of therapy interfering behaviors as opposed to any aspect of cognitive-behavioral therapy.

               I found it interesting that training effects (Henry, Schacht, Strupp, Butler, and Binder, 1993) could have such a profound impact on outcomes, an assertion supported by Wampold (2001) in his defense of a contextual model and the corresponding limitations of the medical model.   Henry (Henry et al, 1993) found significant effect size differences between the two groups (trained by Trainer A and B) and that Trainer A was more effective than Trainer B for several reasons.  We know that there are “thearpist effects” which influence treatment effectiveness and that some therpists are more competent than others, whether we’re talking about their influence on specific or general factors.  For example, if specific factors are repsonsible for outcome as the medical model proposes, then therapist comptency in that particular treatment modality should have an effect on outcome.  As a result, more seasoned, better trained clinicians will see better results with their clients than less experienced, novice therapists.  At the same time, if general factors are responsible for outcome as the contextual model proposes, therapist competency (in terms of empathy, belief in the modality, ability to convince the client of its effectiveness, etc), in general, should also have an effect on outcome.  Some clinicians, usually (but not necessarily) the more experienced variety, should also have better outcomes with their clients than less experienced (competent) therapists. 

                  Henry (Henry et al, 1993) found exactly that when comparing therapists providing training on how to provide Time-Limited Dynamic Psychotherapy (TLDP) in the study in question using a treatment manual.  It appears that, from the discussion and conclusions in the article, it was the general effects of the individual trainers that were responsible for the differences between groups as the contextual model would predict.  This finding has serious implications on the validity of any study which uses a treatment manual and trains clinicians to treat clients in accordance with the manual.  Not only is there going to be variability in abilities within groups being trained, but there will also be variability between groups depending on the skills and approach of the facilitator.  Wampold (2001) has shown that allegiance has a siginifcant effect on outcome in randomized control trials (RCT) and that, even when utilizing a treatment manual, the allegaince effects are large.  Add to that the impact of trainer attributes, as described by Henry et al (1993), and we have some very serious confounding variables related to RCTs in general and the utilization of treatment manuals (and any associated training) in particular when measuring efficacy.

The article by Shefler, Time Limited Psychotherapy with Adolescents (2000), was quite interesting from a cultural diversity perspective.  I found it interesting that the Israeli adolescent seemed to be struggling with many of the same types of issues as American youth and Shefler’s description of the intervention was probably not much different than an intervention that would be used by a clinician using TLDP here in the United States.  One thing that really turned me off was Shefler’s references to “masochistic tendencies” and “incestuous fantasies” (Shefler, 2000, p. 92):

            Heightened sensitivity to frustration and to a lack of love and support characterizes the narcissistic awakening that typically occurs in adolescence. This awakening can either set the adolescent on track toward healthy development or on the road toward personality disturbance or toward a narcissistic character first manifested in adolescence. Masochistic tendencies toward painful pleasure and passivity characterize adolescent fantasies among both males and females. In addition, preoccupation with issues of bisexuality, anxiety surrounding bodily change, and remnants of incestuous fantasies frequently become intensified.  I understand the relevance of a narcissistic awakening and a preoccupation with sexuality or body image in the budding adolescent, but masochistic tendencies and incestuous fantasies sounds more like the psychoanalysts of old and not the here and now, interpersonal TLDP therapist of today.

            Finally, I didn’t see much relevance in the Strupp article (Strupp, 1990) and don’t think it added much to the readings.  In my opinion, it highlighted his own narcissistic tendencies in that he was clearly off the mark with Helen, but refused to admit it.  Having so much anger toward men in general, he should have referred her to a female therapist in the very beginning and finally admits to it in the discussion section (Strupp, 1990, p. 655):

            Thus, after a few sessions, when the patient's relative unsuitability had become apparent, one might have referred the patient elsewhere, openly admitting one's difficulty in working with her. In so doing, one would not commit the error of blaming the patient for the difficulty but simply indicate that in the therapist' judgment there was no match. He was way off the mark, alienating an already hostile client (and most modern women in general) by insisting that she really wanted to be a man (penis envy).  If TLDP is focused on the here and now, interpersonal aspects of personality and not on the interpretation of and insight into latent psychosexual process characteristic of the old psychoanalytic model, what was Strupp trying to do?  In the end, he refused to admit to his mistakes when working with Helen and even concluded that the therapy was beneficial to the client, clearly displaying his lack of insight and objectivity into his own therapeutic skills as well as his personality.

References

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York, NY: The Guilford Press.

Beck, A.T. and Clark, D.A. (2010). Cognitive Therapy of Anxiety Disorders – Science and Practice.  New York, NY: The Guilford Press.

Burger, J.M. (1990). Personality (Second Edition). Belmont, CA: Wadsworth Publishing, Inc.

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington, DC: American Psychological Association.

Goldfried, M. R., & Newman, C. (1986). Psychotherapy integration: An historical perspective. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 25–61). New York, NY: Brunner/Mazel.

 Henry, W. P., Schacht, T. E., Strupp,H. H., Butler, S. F., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Mediators of therapists' responses to training. Journal of Consulting and Clinical Psychology, 61(3), 441-447.

Kipling, R. (1889).  The Ballad of East and West.  In Wikpedia online.  Retrieved from 

http://en.wikipedia.org/wiki/The_Ballad_of_East_and_West

Levenson, H. (2003). Time-limited dynamic psychotherapy: An integrationist perspective. Journal of Psychotherapy Integration , 300-333.

Shefler, G. (2000). Time-limited psychotherapy with adolescents. The Journal of Psychotherapy Practice and Research , 88-99.

Strupp, H. H. (1990). The case of Helen R: A therapeutic failure? Psychotherapy , 644-656.

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

Emotion-Focused Therapy Versus Cognitive Behavioral Therapy...What Next?

Emotion-Focused Therapy Versus Cognitive Behavioral Therapy...What Next?

              Emotions are obviously a key focus when working with clients in a psychotherapeutic alliance no matter which theoretical orientation you might favor.  Emotion-Focused Therapy (EFT) may very well be a useful approach to resolving emotional disturbances, but the readings really did not give me enough information to make an informed decision in that regard.  I will refer to the readings to elaborate on this point, make some general comments regarding “humanistic” psychology, and provide some thoughts on the similarities of different theories as well as the need to develop one overarching meta-theory.

            You will have to excuse me, because I come from a primarily cognitive-behavioral framework and, therefore, have some difficulty grasping some of the “grayness” of humanistic and some of the experiential theories.  Do not get me wrong; even though I am somewhat of a dichotomous thinker, I still believe there are some very valuable concepts to be taken out of the readings and humanistic theories in general.  However, in Elliott, Watson, Goldman, and Greenberg’s text entitled Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change (2004), there is very little mention of therapeutic methods or techniques.  The text explains Process-Experiential Theory in appropriate detail, although I would not necessarily say it was “made simple” as the title of chapter two suggests.  Because I come from a “primarily” cognitive-behavioral perspective, that doesn’t mean that I don’t utilize an eclectic approach and find value in other treatment modalities formulated by such notable and intelligent theorists such as Rogers, Perls, Moreno, or Freud.  On that note, I would have hoped to read more about the contributions of EFT regarding therapeutic techniques, that is all I’m saying.

            In fact, none of the readings, with the exception of Repairing Discordant Student-Teacher Relationships: A Case Study Using Emotion-Focused Therapy (Lander, 2009), focused on therapeutic methods or techniques, which I found quite disappointing.  I hope that these missing components will be elaborated on more in other works.  Lander (2009) did provide an excellent case study that I found quite interesting and possibly useful in working with children.  Since I have very little experience working with small children, the techniques utilized piqued my interest and will inspire me to seek additional information regarding their specific applications. 

            As Wampold (2001) stated so elaborately in his text, I saw the “general effects” in Lander’s (2009) case study as being equally, if not more, responsible for the positive changes (outcome) in the relationship between Guy and Ms. Greenberg.  I believe the individual techniques were an excellent vehicle for building an alliance between teacher and student, and that the collaborative nature of the exercises did more to repair the relationship than any of the exercise’s products.  For the first time, the two individuals were able to see each other as human beings with struggles and emotions not so different from each other.

            Elliott, Watson, Goldman, & Greenberg (2004) mentioned that neo-humanism evolved because the humanistic movement “fell out of favor” (p. 6) in the 1970s and 1980s, but did not elaborate on why that occurred.  I have to assume it is because that is when the behavioral and cognitive revolutions in psychology began to take hold and the humanists really did not fit very well with the medical model.   It would have been nice to hear why the humanists believed this happened, why they felt compelled to create a neo-humanistic model, and what the differences are between the two. 

            I have noticed a lot of discussion of “dialectical” frameworks in the literature over the past several years and it seems to be a concept catching on in many theoretical camps including Linehan’s Dialectical Behavior Therapy (DBT) and EFT.  Is that the big difference between humanistic and neo-humanistic models?  Dialectical constructivism, as described by Elliott, Watson, Goldman, & Greenberg (2004), is not much different from dialectics as described by Linehan (1993).  Both Greenberg and Linehan are talking about the polarity of emotions as well as the dialectical relationship between therapist and client, yet they are coming from humanistic and cognitive-behavioral perspectives respectively.  Is it the dialectical opposition of emotions that separates the humanists of old from the neo-humanists or is there something more radical that I may have missed in the readings?

            I have to say that I take exception to the term “humanistic” psychology in general.  It is not that I do not believe in the principles behind the humanistic perspective, because I see many positive and useful ideas coming out of the writings of “humanists”.  My concern is that if a theory or therapy does not fall within the confines of the humanistic model, does that mean that all other models are inhumane?  What makes the humanistic theories more relevant to humanism than others theories, therefore making it necessary to make this very specific distinction?  Aren’t all theories concerned with helping people solve their problems and lead happier, healthier lives humanistic?  Don’t psychodynamic, behavioral, cognitive, developmental, and humanistic models all treat people with dignity and respect, nurture their clients, and show compassion for fellow human beings?  Of course they do! 

            In reality, the different theories or models of psychopathology and treatment are starting to look more and more similar as time goes on.  I can see many similarities between EFT and CBT for example.  EFT refers to the concept of the “scheme” while CBT uses the term “schema” to capture pretty much the same concept (I believe “schema” came first by the way).  Elliott, Watson, Goldman, and Greenberg (2004, p. 7-8) say they “use the word ‘scheme’ instead of ‘schema’ because ‘schema’ implies a static, linguistically based mental representation, whereas ‘scheme’ refers to a plan of action”.  They go on to say that a scheme is a process, not a thing, including linguistic components but consisting mostly of preverbal elements such as bodily sensations (physiological), images (also cognitions), and smells that are “not directly available to awareness”.  In Beck’s latest book (Beck and Clark, 2010, pp. 44-46), his concept of schemas is not much different from that of Greenberg et al.  Beck describes not only a cognitive-conceptual schema, but behavioral, physiological, motivational, and affective (emotional) schemas as being integral in primary threat mode activation, all of which are “automatic” processes (not directly available to awareness).  Humanists apparently use the “empty chair” technique (referred to, but not elaborated on, on p. 32 of the Greenberg reading), a technique developed by Fritz Perls, but also utilized in cognitive-behavioral therapy as a technique in role playing or behavioral rehearsal.  The readings state that the focus in EFT is on emotions rather than cognitions, but when describing emotions, the authors, Elliott, Watson, Goldman, & Greenberg (2004) and Pascual-Leone & Greenberg (2007), all describe them in terms of thoughts, statements, and cognitions and it is those statements that Pascual-Leone & Greenberg (2007) used to measure “emotion” in the research they describe.  So are emotions and cognitions that different or are they integrated in such a way that they become almost indistinguishable?

            In conclusion, with few exceptions, most science is based on theories that are more or less accepted as facts.  The theory of relativity, for example, doesn’t have four other competing theories explaining how celestial bodies relate to each other in the universe and there aren’t six different theories of evolution (although creationists have an alternative theory of their own), so why does psychology have so many theories of the mind, personality, behavior, emotion, and the treatment of psychopathology?  If we want to be taken seriously as scientists and validate our research on human psychology with credibility, we will eventually need one overarching meta-theory of psychology.  As I stated above, many of the remaining theoretical camps are all starting to sound more and more alike, only using different jargon and semantics to make their approaches sound novel and intelligent.  Rather than fighting each other over who is right, why don’t they all put their heads together and come up with one overarching theory of psychology that we can all accept?  Could that theory change over time?  Possibly.  Nevertheless, who has to say that the theories of relativity and evolution might not change with some unforeseen dramatic discovery in the future?  At least we could be taken seriously as a science and focus our funding and efforts in one direction rather than eight or ten.  If the general effects of therapy are as critical as Wampold (2001) suggested, what would the credibility of one psychological theory add to client expectation, the therapeutic alliance, and positive outcome?  One thing is for sure, allegiance factors, which according to Wampold (2001, p. 206), account for up to ten percent of the variability of outcomes, would be a thing of the past.

References

Beck, A.T and Clark, D.A. (2010). Cognitive Therapy of Anxiety Disorders – Science and Practice.  New York, NY: The Guilford Press.

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington, DC: American Psychological Association. 

Lander, I. (2009). Repairing Discordant Student-Teacher Relationships: A Case Study Using
Emotion-Focused Therapy. Children & Schools, 31, 229-238.

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

Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional Processing in Experiential Therapy: Why “The Only Way Out Is Through”. Journal of Consulting and Clinical Psychology, 75, 875-887.

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