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!

Online Therapy: Boon or Bust?

In a modern world with technology making it easier and easier to communicate across the street or around the planet, we as psychotherapists face uncharted ground and ethically borderline situations when communicating with clients. I see people who call themselves "therapists" on Twitter and other social networking sites offering therapy via email and Skype (to name just two potential platforms) ... AND THAT CONCERNS ME!

Based on my experience, education, and knowledge of clinical ethical standards for our profession, email is "dodgy" to say the least, offering little protection for confidential communications. Skype therapy has been challenged by licensing boards and professional ethical standards (National Board of Certified Counselors, American Counseling Association, American Mental Health Counselors Association) based on state of licensure, with restrictions on whom licensed clinicians can see, particularly concerning domicile of both parties.

In Missouri and Colorado, two states in which I am licensed, licensed professional counselors (LPC) like myself ARE NOT ALLOWED to see clients outside of our state, even if it happens to be over the internet. The reasons for this are numerous, but, most importantly, the well being of our clients should be utmost in our minds. We cannot travel across state lines to see clients and, therefore, cannot travel virtually cross state lines via the internet either.

There are situations where it may be advantageous to see clients remotely, especially when a client is housebound or in geographically remote areas where face-to-face visits would be cost or time prohibitive. Otherwise, it is ALMOST ALWAYS IN THE CLIENTS BEST INTEREST to meet in person. 

Research on language has indicated that a majority of human communication is "non-verbal" with estimates ranging from 70 to 90 percent. Body language is one non-verbal mode of commuication where context is critical in understanding what is being communicated. Electronic commuications do not allow us to experience body language when discussing sensitive and often complex personal experience as is necessary when performing psychotherapy. Intonation is another non-verbal cue we use to determine what exactly is being communicated, a phenomena that is severely restricted, particularly in written communication.

Confidentiality is of utmost concern when working with clients and electronic commuications are not secure, allowing for potential exposure of extremely sensitive experiences, thoughts, and emotions. Would you want the NSA listening in on your therapy season?  I know I do not!

The individuals performing "Skype Therapy" are many times unlicensed, a fact that can easily be manipulated on websites, blogs, and social networking sites. Few understand that WE MUST BE LICSENED in the state in which we practice in order to offer psychotherapy to the public. Licensure involves AT LEAST a masters degree in psychology or counsleng, and in some cases a doctorate (PhD or PsyD) degree from an accredited institution of higher learning. On top of the degree, practicums, supervision, and post-graduate experience totaling in the thousands of hours (3,000 and up in most states) are required in addition to passing a national exam in order to become licensed. People have been "hanging shingles" for many years without proper training, education, and licensure, so why would things be any different today? 

I have preached about unlicensed and other unqualified individuals (can you say "life coach?) elsewhere in this blog, so I will not elaborate here. It will suffice to say that being "certified" is not enough. I, for example, am a National Certfied Counselor (NBCC - since 1991), but I am AND MUST BE licensed in the state in which I practice in order to LEGALLY PERFORM PSYCHOTHERAY. 

As I have also mentioned in other articles, YOU MUST CHECK AN INDIVIDUALS LICENSE BEFORE INITIATNG THERAPY WITH THE STATE REGULATORY AGENCY COVERING PSYCHOTHERAPISTS IN YOUR AREA. Then, and only then, should you consider undergoing treatment, whether it is face-to-face or over the internet. I would recommend face-to-face treatment in all but the most austere or complex situations.