Checklist for Hiring a True Cognitive Behavioral Therapist (CBT)

As executive director of Kansas City Cognitive-Behavioral Therapy (KCCBT) and an expert 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. GOOD LUCK!

Timely Reply from Managing Editor, Air Force Times

From: Becky Iannotta
Sent: Tuesday, May 08, 2012 9:26 AM
To: combatcounselorchris@gmail.com
Subject: Letter to Air Force Times

Mr. Sorrentino,

Please allow me to introduce myself. I have been the editor at Air Force Times for about six months, yet I do not recall ever seeing a letter from you in my current role or in my previous position as news editor of Air Force Times. Your letter on accidents and redeploying troops makes it sound as if you have written on multiple occasions. I apologize if you have sent letters that went ignored.

I would like to publish your letter as it relates to the "thrill seeking behavior" and lack of qualified mental health providers, and your response to the suicide story. The letter will be edited for space and style, as is our policy.

Thank you for writing and for reading Air Force Times.

Sincerely,

Becky

Becky Iannotta

Managing Editor

Air Force Times

and my reply...

Ms. Ianotta,

Thank you for responding and for acknowledging the importance of these issues by publishing my letter. 

I have written on several occasions to Dr. Bret Moore (Kevlar for the Mind – psychotherapy related issues such as these), Ask the Lawyer (regarding being discriminated and retaliated against – as a male/disabled veteran – by the University of Missouri-Kansas City, a case that the US Department of Education is investigating and has found “cause” for mediation), as well as a few to airlet@airforcetimes.com where I sent these emails.

I would finally like to point out in Dr. Moore’s May 7^th follow-up piece on the “stigma” of mental health in the military.  I believe he missed a tremendous opportunity to fix some things that have been broken in the DoD and VA for a long time and even hurt the cause by “recommending” that military members go the “chaplains” if they want 100% confidentiality.  Of course, chaplains provide wonderful services and there is a time, a place, and a person best suited for that experience. But the problem is that these wonderful people are not (normally) qualified to properly treat our military with PTSD and other mental health issues.  These young men and women (military and veterans) are committing suicide in record numbers, or are not seeking the treatment they so desperately need, because THEY ARE AFRAID TO SEEK TREATMENT because it WILL ruin their career and/or they WILL lose their security clearance.  That stigma and paranoia carries over into the VA system where they see the same bureaucracy and lack of a sense of urgency in helping them as they saw in the military.  I have seen it first hand in my role as a licensed clinician on military installations and experienced it myself upon return from a year in the desert (Aug 01 – Aug 02).  Even as a mental health provider myself, I would not and did not seek treatment UNTIL I knew I was retiring and could not be hurt by “the system”.

In any event, it is nice to have you on board as editor and am glad that you took the time to read my concerns and publish them.

Best wishes,

Chris

Chris Sorrentino

Chris Sorrentino, LtCol, USAF (Ret)

LPC, NCC

Letter to the Editor - Air Force Times

I'm not sure why I bother sending these emails because I have never even been acknowledged, but I feel compelled to speak out anyway. Maybe it is time to retire dinosaurs such as Bret Moore and Robert Dorr, hiring writers who are more in-tune with the realities of current military issues.

Regarding the subject article from your May 7th issue, Ms. Jowers omitted a critical cause of accidents for Redeploying troops, "thrill seeking behavior". After 8-15 months in a combat zone going 100 mph, figuratively, not literally, coming back home is a huge adjustment. It is widely known among anybody familiar with human behavior and the military that thrill seeking, such as speeding or driving while impaired, increases dramatically upon return to home post/base. If you've been in combat, and I have, you are on an adrenaline rush for months on end and crave that rush upon returning home. It should come as no surprise and, if records were kept during previous periods of combat operations (WWII, Korea, Vietnam), you would see exactly the same trends. How could your writer miss such an obvious variable?

As far as your editorial and reporting on the "lack of qualified mental health providers" in the DoD and VA, excuses both have been making for years, your writers have omitted another critical fact. The federal government has refused to acknowledge and hire master's-level licensed counselors for years! How can you, and they, whine about shortages of qualified clinicians when there are literally tens of thousands of licensed clinicians around the country, many looking for work, including me. I, for example, am a retired Air Force lieutenant colonel, combat veteran, disabled veteran, and licensed professional counselor (LPC) specializing in cognitive behavioral therapy (CBT) for post-traumatic stress disorder (PTSD). I have 30 years of education and experience working with anxiety and mood disorders, 21 of those licensed and nationally certified, yet the government readily hires social workers or psychologists fresh out of school over an "unqualified" clinician such as myself. Get a clue! Granted, not all LPCs have the experience I have, but if just 10% had the qualifications, the VA could easily fill those 1,900 vacant positions. Stop the whining and reporting half truths.

As far as Mr. Dorr is concerned, I'm sure I'm not the first person to mention this, I am sick and tired of his slanted, archaic, self-promoting chatter. Who the hell is he to tell the Air Force Chief of Staff which planes to keep and which ones to get rid of? I think it's time for some fresh blood and a current perspective in such a powerful role as is his. By the way, I'm not a volunteer for the position should you decide to join the 21st Century.

One more thing. In regard to the article on "Suicides" in the same issue, please read my blog http://www.combatcounselor.blogspot.com and the post on The Stigma Killing Young American Heroes.
Capt Julie Hanover is quite right when see says "they believe it will hurt their careers", but quite wrong when McCarthy says "we need to educate airmen" about the 97% "adverseless" action rate. Do you really think Airmen will seek treatment when they have a 3% chance of ending their career? Are you serious? Airmen, soldiers, sailors, and Marines WILL NOT SEEK MENTAL HEALTH TREATMENT until there is 100% protection and limited confidentiality as is the right if every non-military citizen!  Do you and DoD leadership really think that it is better or safer to have people avoid treatment and keep their clearance? If you do, I have some oceanfront property here in Missouri you might be interested in!

This information will be posted on my blog, http://www.combatcounselor.blogspot.com, so it won't go to waste when you ignore me once again. I have plenty of followers eager to hear what I have to say.

Thank you.

Chris Sorrentino, LtCol, USAF (Ret)
CombatCounselor

Follow me on Twitter @CombatCounselor
and on YouTube http://www.YouTube.com/combatcounselor

THE STIGMA KILLING YOUNG AMERICAN HEROES

THE STIGMA KILLING YOUNG AMERICAN HEROES is based on ignorance and bureaucratic processes that have needed changing for decades, if not centuries. The brave men and women that make up our military are hesitant to seek mental health treatment from military practitioners because they are afraid, and rightly so, that their careers and/or security clearances could be at stake if they did. I served in the Air Force for over 20 years, retiring in 2005 as a lieutenant colonel, and experienced the stigma firsthand. I would not and did not seek help for post-deployment anxiety and depression UNTIL I pinned-on my silver oak leaf and knew I would be retiring (meaning "they" couldn't hurt me). I spent four years in four different combat zones, including "boots on the ground" in the Middle East one month before 9/11 and the first year of Operation ENDURING FREEDOM.
I recently returned from Fort Riley, Kansas, home of the 1st Infantry Division, better known as "The Big Red One", where I provided counseling to soldiers returning from Afghanistan and Iraq. Two of the battalions I worked with suffered high numbers of casualties, the 2nd Battalion, 34th Armor Regiment (2-34) and the 4th Squadron, 4th U.S. Cavalry Regiment (4-4 CAV), with several killed in action (KIA) and many more wounded in action (WIA). Dozens of brave young men and women received purple hearts, having lost limbs and suffering other wounds, many invisible to the naked eye.
"Not all wounds are visible", with traumatic brain injury (TBI) and Post-Traumatic Stress Disorder (PTSD) making up the majority of injuries of those returning home, many times caused or hastened by experiencing the effects of an improvised explosive devices (IEDs), the current weapon of choice of Taliban and Al Qaeda terrorists. When a young man loses his leg, he is considered a hero, and rightly so. But when a person "loses their mind", either through physical damage to the brain as is the case in TBI, or emotional damage as we see in those who have experienced severe trauma in combat, those coming home with PTSD, they are portrayed as weak or as malingerers by their comrades, or worse, the officers responsible for their health, safety, and well being.
Looking down on or thinking les of those who seek help for mental health issues has been a problem in the military for centuries, but is also a problem in our modern, technologically advanced, contemporary culture here in the US (and elsewhere). Post-Traumatic Stress Disorder (PTSD) has been around since the beginning of the human race and has been called many things over the centuries including exhaustion, railway spine, stress syndrome, shell shock, battle fatigue, combat  fatigue, and traumatic war neurosis. According to Wikipedia, "reports of battle-associated stress reactions appear as early as the 6th century BC. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BC he described, during the Battle of Marathon, an Athenian soldier who "suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier." Although this reaction would more accurately be diagnosed as conversion disorder rather than PTSD, it is an indication of the dramatic impact a traumatic event can have on a human being. Many people think of combat when they think of PTSD, but there are many causes, traumatic experiences, that can lead to symptoms, including accidents, physical and sexual assault/abuse, terrorism, as well as many others.
Ignorance in regard to psychotherapy and counseling is nothing new, and few people are enlightened enough to understand that it is a sign of strength, not weakness, to seek help or treatment from a qualified, licensed cliniician, be it a psychologist, psychiatrist, licensed professional counselor, or licensed social worker. There are many unqualified and unscrupulous individuals taking advantage of people weakened by emotional stress and the turmoil of modern life, and they have given psychotherapy a bad name. You can read more about these individuals elsewhere in this blog, so I will not elaborate here. However, it is no wonder that the many highly qualified, licensed, certified clinicians out there helping and saving lives every day are misunderstood, even feared by the uneducated and ignorant public so desperately in need of professional treatment.
Our young men and women in the military are returning from deployments having experienced horrifying events, either directly or as an observer. Estimates range from 20 to 50 percent of those returning from combat suffer from a mental health issue of one kind or another. The incidence of PTSD has been reported as high as 20 to 30 percent of military returning from recent combat. Yet many, if not most, do not seek treatment because they are afraid they will damage their career.
I have seen it firsthand in my own career, in my private practice and non-profit, and with soldiers recently returning from Afghanistan. Either their leaders, who can be squad and platoon leaders (enlisted) or company, battalion, brigade, and division commanders (officers), do not understand the devastation TBI and PTSD can cause in a person's life. Or they simply refuse to acknowledge the pain and suffering, maintaining the ridiculous macho bravado and reputation of a "real soldier" or "real man" who does not ask for help. These young men and women may even have a caring and compassionate chain-of-command now, but do not know whether the beliefs and attitudes of their "next" unit's leadership will be as flexible and understanding.  Because mental (behavioral) health treatment in the military IS NOT CONFIDENTIAL and becomes a permanent part of an individual's medical record, ANY TREATMENT becomes a matter of record for future leaders to hold against an individual or a reason to deny a coveted security clearance. It is no wonder young soldiers, airmen, sailors, and Marines are afraid to step forward for treatment, and no wonder that suicide rates among military members has skyrocketed.
Until military and civilian leaders understand the connection and impact the negative military mental health stigma has on our force's mental health and morale, these needless deaths will continue. When you are anxious, depressed, sleep-deprived, and suicidal with nowhere to turn, the options are limited, particularly when you are a skilled marksman with easy access to lethal weapons.
There is no reason military members cannot have the same rights and protections as the average citizen when it comes to confidentiality in psychotherapy. What does the military have to gain except complete, 100 percent control over their people, by allowing confidential communications between therapist and client in the military? The same restrictions that apply to confidentiality in the private sector would also apply in the military: danger to self or others; child, spouse, elder abuse; and criminal behavior would still need to be reported. But military members would know that anything else they say would remain confidential, allowing them to open-up, develop a trusting relationship with their therapist, and get the help the so richly and desperately deserve.
I challenge the Joint Chiefs of Staff (JCS), Service Secretaries, Secretary of Defense, and President of the United States to "do the right thing" and end the negative stigma associated with military mental health care by allowing the limited confidentiality described above to be instituted across the military. It will literally take years for our military to trust the system and routinely seek treatment for the problems caused by the rigors and stress of military service, but WE MUST START SOMEWHERE, WE MUST START TODAY! They deserve no less.

Copyright 2012 - CombatCounselor and 3rd Wave Media Group - All Rights Reserved 

Lack of Integrity and Cutting Benefits Promised During Recruitment Hurts the All Volunteer Force

One huge barrier to voluntary service is making promises to enlistees, then not following through on your word. The Department of Defense (DoD) needs to stop attacking active duty, Guard, Reserve, and retired entitlements (e.g. Tricare fees, retirement benefits) and cut unnecessary programs and staff instead.

How many people cater to every whim of The JCS? 50? 100? 500? Maybe our top brass could cut back on some of the perks...huge staffs, private (government) planes, waste of resources (rock painting) during visits, among many others...and tighten their belts rather than taking aim on the benefits of those who have honorably served their country for 20+ years.

#Integrity means keeping ones' word, doing the right thing, even when nobody is watching...ACT WITH INTEGRITY Mr. Panetta and JCS...we are all watching! STOP CUTTING THE BENEFITS AND ENTITLEMENTS WE WERE PROMISED FOR RISKING OUR LIVES FOR OUR COUNTRY!

CombatCounselor Describes War-Induced Stress On Kansas City TV Station KMBC

An experienced combat veteran, retired Air Force lieutenant colonel, and expert in working with military and veterans with post-traumatic stress disorder (PTSD), Chris Sorrentino, a licensed professional counselor, Executive Director of Kansas City Cognitive-Behavioral Therapy, and President of Help4VetsPTSD, a non-profit dedicated to military and veterans with PTSD, discusses combat stress with ABC News affiliate:

Counselor Describes War-Induced Stress - Kansas City News Story - KMBC Kansas City

Sorrentino went on to describe his sorrow for the families of the 16 Afghanis allegedly killed by a US solider and for the soldier's family.  "My heart and prayers go out to the families of the victims, the soldier, and the Afghani people for their unimaginable losses" Sorrentino told Maria Antonia via Skype this afternoon.  LtCol Sorrentino happened to be out of the area at the time, working with re-deploying soldiers at an undisclosed location.

"The military is a microcosm of American society", Sorrentino added, stating: "and the extremely unfortunate events that occurred in Panjwai district, a rural suburb of Kandahar and a traditional Taliban stronghold, are not at all indicative of the behavior of our brave, dedicated, selfless military personnel and should be considered an isolated event". Our deployed military are heroes and this incident should not reflect negatively on them in any way.  It is understandable and warranted for the Afghan people to be horrified and upset about the attack, just as many American are, and justice will be served as the soldier's fate is determined in a court of law.

The facts have yet to be determined, but Sorrentino concluded "the negative stigma attached to mental health treatment in the military has existed for decades and will not, unfortunately, end anytime soon".  "If the attacks were related to combat-related stress or other psychological issues, an environment more conducive to military members seeking treatment, rather than fearing reprisal or loss of a security clearance, could have potentially mitigated this threat ".  LtCol Sorrentino asked President Obama to "end the negative stigma associated with military mental health care" in a question and answer session after January's State of the Union Address.  Unfortunately, Obama ignored Colonel Sorrentino's pleas and failed to respond to his question.

Title: CombatCounselor Describes War-Induced Stress On Kansas City TV Station KMBC

Key Words:  KMBC, TV, Kansas City, MO, MIsouri, combatcounselor, combat, counselor, war, induced, stress, PTSD. PTS, trauma, disorder, television, 

Submission to President Obama: State of the Union Q&A (January 24th, 2012)

As a retired Air Force officer, combat veteran, disabled veteran, and licensed professional counselor (since 1991) I am not surprised many of the hundreds of thousands of young men and women who have served in Iraq/Afghanistan came home with PTSD, TBI, and other disorders, but are EXTREMELY hesitant to seek help and treatment. 
Until the Commander-in-Chief, JCS, Service Secretaries, and chain of command (in all services) STOP THE RETALIATION and END THE NEGATIVE STIGMA associated with mental health treatment in the military, our young men and women ARE GOING TO CONTINUE TO AVOID TREATMENT, SUFFER, AND COMMIT SUICIDE!
TAKE OFF YOUR BLINDERS and give our airmen, soldiers, seamen, and Marines 100% confidentiality in mental health treatment and EDUCATE THE BROWNSHOES who keep this ridiculous schema alive. Follow CombatCounselor and @CombatCounselor on Twitter for more information and updates.
Mr. President, Will you work to put an end the negative stigma attached to military mental health care and the associated unprecedented SUICIDE rate among military members/veterans because they are afraid to ask for the help the so richly deserve?
combatcounselor - , Kansas City, MO.
Watch the video on The CombatCounselor Channel...SUBSCRIBE!

White House Facebook Page

You Think, You Are: Anxious...A Journey from Avoidance to Acceptance

You only THINK you are anxious. If the thought did not enter your mind, you could not feel anxiety. What I am saying is that YOU can control anxiety (or depression, etc.) by altering the way you react to and experience anxious thoughts, sensations, or even other emotions you may be interpreting to be anxiety (e.g. anger).
That is why I say "You Think, You Are" anxious. If you Think anxious thoughts, you will experience anxiety unless...
you decide to experience anxious thoughts, feelings, and memories simply for what they are: thoughts, feelings, and memories!
Anxiety is the fear of fear. When we were roaming the plains, prairies, and mountains as hunter-gatherers, it was adaptive to be anxious about things that could kill us (bears, lions, falls, lightening, etc.), otherwise our species would have died off long ago. Anxiety is still adaptive when it involves fear of things that can honestly harm us. The problem is that many of us are anxious about many arbitrary things in life that are not necessarily dangerous, we only PERCEIVE them to be dangerous.
For example, public speaking is the #1 fear around the world, yet nobody has ever died from public speaking (excluding Julius Ceasar and a few others who happened to be speaking when killed). Other common fears include fear of heights (acrophobia) and of spiders (arachnophobia) as well as some less common such as germs (OCD) and open spaces (agoraphobia). Some people even fear intense anxiety or panic (panic disorder).
So, when we fear things that are not necessarily inherently dangerous, we are limiting our ability to experience and enjoy the present moment because we are so enveloped in thoughts and sensations caused by the fear inducing event or thing.
In Body-Mimd-Behavior Therapy (BMBT), I teach my clients first to learn mindful meditation or the ability to focus on the present moment (StayPresent ©). Next, I teach them to expect and accept the  unexpected nonjudgmentally and with curiosity (BeResilient ©). Finally, we explore and identify the clients's core values (e.g. integrity, honor) and help them develop goals and commit to actions that are in accordance with those values, even though those actions may make them uncomfortable or even anxious (StayTheCourse ©). Because they are acting based on things that are important to them, they are more likely to act in the face of fear or other painful emotions.
Avoidance is the cause of anxiety, depression and many other inorganic disorders because it is very rewarding in the short-term. When you avoid something that frightens you, anxiety goes away for a while and that is very rewarding. The problem being that if you are avoiding life, it is rarely joyful and leads to more and more problems. The key is to accept and experience intense, uncomfortable emotions like anxiety, learning by approaching rather than avoiding, that anxiety goes away on its own given that you can withstand the situation long enough to prove it. That is the biggest problem, that most people avoid or escape the anxious situation BEFORE they get a chance to learn that 1) anxiety will not kill you; and 2) anxiety will NATURALLY diminish (disappear) on its own (that's called habituation). It is impossible to stay in a highly aroused state of fear or anxiety for long.
So, the next time you experience fear in a situation the is not inherently dangerous, take a deep breath, experience and accept the thoughts and sensations for what they are, and face whatever your particular demon happens to be, knowing that you are acting based on what is important to you...YOUR VALUES!

You're Out OF YOUR MIND

If you haven't tried mindfulness meditation, you ARE literally OUT OF YOUR MIND! I don't mean you ARE crazy or somehow will never get it back. What I mean is that when you practice mindfulness, your mind and the present moment ARE 100% CONNECTED, so it is impossible to be anywhere else.

When you are in what Echart Tolle calls "being" mode or "consciousness", you, your mind, and experience in the present moment are one in the same. You ARE not rumimating about the past or worrying about the future, what Tolle calls "doing" mode or "unconsciousness". And when you are BEING, you ARE able to experience things as they are without judgment, in a totally willing and accepting way. Nothing is good or bad, it just "IS" and you move onto the next moment prepared to accept whatever may come your way.

That is what mindful meditation is about. So when I say "YOU ARE OUT  OF YOUR MIND", I mean that to experience truth is to experience the present moment just as it is...then do it again...and again.

Obviously, nobody can or should spend 100% of their time being mindful in the present moment. But if you can practice and learn the skill, you will be able to call on the ability when you need it, making life much more interesting and joyful.

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

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?

StayPresent
BeResilient
StayTheCourse

CombatCounselor

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 sessions...it'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:

1. Orange screen covers are available for computer monitors. Use them at night.

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 you.to: marksdailyapple.com for information on the ligjt spectrum and effects on sleep.

© 2012 CombatCounselor - All Rights Reserved

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"!

DO YOU WANT TO CHANGE YOUR LIFE FOR THE BETTER? THEN SUBSCRIBE!

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

CombatCounselor

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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.

Conclusions

            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.

References

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

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.

Anxiety: Change the Context, Not the Content

Tweet from @CombatCounselor:

"You cannot make #anxiety go away. You can change your relationship to it and #embrace, rather than #avoid it.#StayPresent, #BeResilient"

http://twitter.com/CombatCounselor/status/141986877350752257

What I mean is that if you TRY to eliminate anxiety by avoiding it, it only makes things worse. By avoiding, it may be very rewarding in the short-term, but you don't learn that anxiety naturally goes away on its own. This process is called HABITUATION.

If you fear anxiety, you'll avoid it and make it your enemy. If you change the way you relate to it, embracing anxiety instead, you can experience it on your terms, making it less threatening.

Changing the CONTEXT, the way you perceive anxious thoughts, sensations, and memories, rather then trying to change the CONTENT (e.g. positive thinking), allows you to control the situation. Because you can't control anxiety, control.the way you react to it.

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Resilience: Armor for Your Mind

Listen carefully to what I say, but don't believe a word of it. Language and rule-governed behavior have severe limitations, experience does not.

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

Resilience is key to mental health and is something you can enhance through acceptance of and willingness toward aversive events. Are you focusing on the content of your life (thoughts, sensations, emotions) or on the context (what's happening right now)? You do have a choice.

NOW, GET OFF YOUR BUT! Yes, it's spelled right. Replace the word "but" with "and" and accept responsibility for your behavior and your life. Try it, see how it feels.

StayTheCourse ... BeResilient!

Title: Resilience: Armor for Your Mind

Key Words: anxiety, combatcounselor, depressed, depression, health, kccbt, mental, resilience, resilient, therapy, fear, armor, mind, PTSD, BeResilient, chronicle

"End of the War" by Brittany Holmes

Brittany Holmes, an upcoming new artist, sent me this link. Thanks for this inspiring and beautiful song Brittany...you will be a star!