Cognitive-Behavioral Therapy (CBT)?
The Short Answer
Compared to some traditional psychotherapies,
when following a CBT approach I focus less on childhood experiences and
unconscious memories and more on patterns in present thinking and behavior. I
also address aspects of clients’ histories that continue to "show up" as they
try to move forward with their lives.
The Long Answer
Cognitive-Behavioral Therapy (CBT) is a treatment approach incorporating
techniques from both Cognitive Therapy and Behavior Therapy.
Cognitive Therapy focuses on the
influence of one’s thinking on feelings and behaviors, including distressing
feelings (e.g., anxiety or depression) and problematic behaviors. Cognitive
therapists help clients identify automatic thoughts, characteristic distortions
in their thinking, unhelpful or unworkable attitudes or beliefs, and how all of
these cognitive phenomena contribute to their difficulties. Cognitive
therapists challenge clients’ thoughts, assumptions, and beliefs—directly
through disputation in session, or by assisting clients to consider alternative
perspectives, identify and weigh out evidence for or against their ideas, and
is the application of behavioral and learning principles in understanding
clients’ behaviors and then altering the context to encourage the learning of
new, more adaptive, and less problematic behaviors. Behavior therapists use a
variety of in-session and out-of-session exercises and experiments to facilitate
the learning of behaviors that work better (result in more favorable outcomes)
for their clients.
Cognitive-behavioral therapists use both
cognitive and behavioral strategies to varying degrees. In truth, there is no
single, unitary approach we could identify as “CBT.” Some CBT treatments
emphasize cognitive strategies while others emphasize behavioral strategies.
Individual CBT therapists may tend to emphasize cognitive or behavioral
strategies depending on their own style, the client’s presenting problem, or
A value that underlies CBT is that therapy
should be based on research and the best available science rather than vague
models or untestable hypotheses. As a result of this value, CBT approaches have
been subjected to far greater scientific scrutiny than other therapy
approaches. In response to this pressure, the techniques used by CBT therapists
have evolved, retaining and improving effective techniques while discarding
techniques that are found to be less effective.
CBT has become the most
well-known, mainstream approach to therapy, partly because it has, by far, the
strongest research support for its effectiveness in treating a wide range of
emotional and behavioral problems. CBT has been found effective in treating
depression, anxiety disorders, the effects of trauma, substance abuse and
addiction, complications related to medical conditions, and many other
What is the history of CBT? How did
Cognitive Therapy and Behavior Therapy come together?
The history of CBT dates back to the seminal work of B.F. Skinner, the father of
modern behavior therapy. At that time, behavior therapy was a reaction to
the traditional Freudian forms of psychotherapy that were only loosely based on
scientific principles and were difficult to subject to rigorous scientific
study. Skinner held psychology accountable as a science of human behavior.
Techniques drawn from Skinner's basic behavioral science continue to be employed
with good effect in modern psychotherapy. Skinner's account, however, had its
limitations. The most notable limitation was that his account of human language
and cognition failed to generate a vigorous line of basic research, limiting its
evolution to forms that could be employed with patients with complicated
Instead, the field opened to the work of Albert Ellis
and Aaron T. Beck, the founders of modern cognitive therapy. Ellis and Beck,
and their many successors, transformed the practice of psychotherapy by
emphasizing therapy techniques that aimed to change the content and manner of
clients' thinking, not just their overt behavior. Cognitive therapy and
behavior therapy continued to cross-fertilize each other over the intervening
decades up to the present day. The combination of behavioral and cognitive
therapies has proven to be effective in treating a wide range of life problems,
driving these therapies into the mainstream of psychological treatment.
For more information on CBT
and upcoming conferences,
visit the website for the
Behavioral and Cognitive Therapies (ABCT).
What is Acceptance
and Commitment Therapy (ACT)?
The Short Answer
ACT is a scientifically-based
therapy that uses mind/body and mindfulness techniques and
creative exercises to promote a fundamental shift in how you
experience troublesome thoughts, feelings, and memories. Using
ACT, we can empower you to change by ending your struggle with
uncontrollable private reactions and helping you take action in
valued areas of life.
The Long Answer
Acceptance and Commitment Therapy, more commonly known as ACT (said as
the word "act"), is an innovative form of psychotherapy that has grown
from the same roots and traditions as cognitive-behavioral therapy (CBT). ACT
has built upon both the strengths and the weaknesses of modern CBT. As
described above, the original cognitive theorists parted ways with traditional
behaviorists partly due to difficulties in developing an adequate behavioral
account of human language and cognition. While this departure produced many
effective therapies, it also marked a shift away from the basic behavioral
science on which behavior therapy was grounded.
ACT is based on a behavioral account of
human language and cognition called
Frame Theory (RFT). The work on RFT began approximately 25 years ago and
marks a return to the crossroads where cognitive therapy altered course. RFT
has “filled in the gaps” left by Skinner's theories and has, in contrast to
Skinner's model, generated a vigorous body of basic research into human language
and cognition. This return to the basic science has also provided fuel for the
development of new treatment approaches. The “fruit” of this progress can be
found in the philosophy and basic concepts underlying ACT.
ACT therapists, like their CBT counterparts,
agree that what and how we think has a significant impact on our day to day
functioning, our distress, and our coping. However, ACT has moved away from the
traditional cognitive therapy emphasis on changing or correcting the content
or form of thoughts in order to alleviate suffering. Instead, ACT aims
to alter the functions of our private experiences (thoughts, feelings,
memories, bodily reactions), so they no longer entangle us. Said another way,
ACT aims to change our relationship with our thoughts, feelings, memories, and
bodily reactions so we can become free from their grip, and free from the
patterns that bind us and prevent us from living a flexible, meaningful, and
In the service of these aims, ACT
incorporates acceptance strategies, experiential exercises, mindfulness
techniques, and a wide range of behavioral approaches already known to be
effective from CBT. While ACT conceptualizes human suffering through a
behavioral lens, the application of ACT often looks much different than
traditional behavior therapy. In essence, ACT has retained much of “what works”
from a behavioral perspective—including a coherent and testable model—while
permitting a more creative and flexible set of approaches for the therapist to
use to help alleviate the suffering of clients.
While the empirical work around ACT is
younger than that of CBT, initial results are quite promising. Preliminary
studies have found favorable results in using ACT in treating depression,
anxiety disorders, substance abuse and dual diagnoses, chronic pain, and some
medical conditions. (Therapists or researchers may want to review the
the evidence in ACT research on the Association for Contextual Behavioral
Science (ACBS) website.)
Additional resources on ACT.
Information about ACT
Trainings in Maine & New England.
Workshops on ACT
offered through the White Pine Institute
For more on ACT,
visit the ACBS
website. For a list of popular media articles on ACT, you can link to
this page. Please talk with me if you have any questions.
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Behavioral Couples Therapy
Behavioral Couples Therapy?
I am experienced using Behavioral Couples Therapy (BCT), a form of therapy
effective in helping couples change difficult patterns, improve communication
and family functioning, and reduce violence in relationships. BCT is
particularly effective as a primary treatment for substance abuse and dependence
(see Couples below).
for Substance Abuse and Addiction
Breaking free from addictive patterns can be particularly difficult and
requires specialized approaches. When working with addicted individuals, I add
motivational enhancement and relapse prevention therapies to my therapy. A
particular strength of mine is treating alcoholic or addicted individuals with
respect and without the moral judgment that often accompanies addictions
treatment. I support individuals’ use of AA/NA and 12 step programs and
have found ACT and motivational
strategies readily adaptable to 12 step concepts. However, I have worked
effectively with many clients who are not open to 12 step philosophies.
During the time in which I worked as a staff psychologist at
the VA Boston Healthcare System, I gained experience using Behavioral Couples
Therapy (BCT) as a form of family-involved substance abuse
treatment that focuses on the couple and family, not just the individual who is
addicted. While the addicted person remains responsible for his or her
change, the couple and family are included in the recovery plan. The
spouse or partner
an active role in the treatment, minimizing the sense of helplessness that
often comes with being with an alcoholic or addicted person. While the
mainstream recovery culture often discourages family members from becoming more
involved, the science clearly points in another direction. BCT has
research support for its effectiveness in promoting sobriety, improving the
couple's relationship, reducing violence and risk of violence, and improving
overall family functioning.
willing to provide consultations to family members who are concerned about a
loved one’s use of substances. I engage families with strategies that can help
move the addicted person toward change while disentangling family members from
patterns that can keep the entire family system stuck.
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Evidence-based psychotherapies (EBPs) are forms
of psychological treatment that have been tested in research
programs and found to have scientific support for their
effectiveness. Most EBPs with a legitimate claim to being
"evidence-based" have multiple studies that have found the
treatment to be superior (at minimum) to (a) no treatment, (b) a
placebo, and (c) treatment-as-usual or nonspecific support or
counseling. These studies are usually expected to be of
sufficient quality to be published in peer-reviewed journals and
withstand the scrutiny of the scientific community.
What, exactly, constitutes
sufficient evidence of effectiveness is a much-debated topic
within the mental health fields these days. The criteria
listed above are minimal and some EBPs have far surpassed this
low bar. Various mental health organizations have begun to
list treatments that are "empirically-supported," often
assigning various levels of approval for listing as
empirically-supported based on the quantity and quality of data
in support of the treatment.
Therapy (CBT), for example, is accepted as
empirically-supported for a wide range of problems.
Behavioral Couples Therapy
(BCT) is accepted as empirically-supported as a primary
treatment for alcoholism.
Commitment Therapy (ACT), is a newer therapy that has begun to accumulate sufficient evidence for inclusion on lists of
empirically-supported treatments. For example, ACT is now listed as having strong research support for chronic pain and modest research support for depression. However, the strength of
findings in support of ACT thus far and the ACT community's
commitment to basic science have led some experts to include ACT
in the broader category of "evidence-based" (read about the
state of the evidence in ACT research). Considering the
preliminary evidence and the sheer volume of research being
conducted on ACT right now, it is likely that ACT will be on additional future lists of empirically-supported therapies for specific disorders.
Psychotherapies are relatively newer and less well-defined
as a group. They tend to have different therapy aims, less focus on the alleviation of
symptoms, and less value given to controlled research
methodologies. Contemplative Psychotherapies have not been
subjected to rigorous scientific study and are not considered
evidence-based. Given the nature of these therapies, it is
unlikely that they will be listed as "evidence-based" in the
Why is the empirically-supported therapy movement controversial?
This question is quite large
and somewhat beyond the scope of this site. In summary,
though, I will say that there are many important and valid
concerns and criticisms about the move to form lists of
effective treatments. Critics often cite the potential for
various organizations, including managed care companies, to
start restricting access to or reimbursement for therapy based
on that therapy being on such lists. This runs the risk of
excluding many forms of therapy, including therapies that have
different ideas about the purpose of therapy or about what,
exactly, is a successful outcome in therapy. Other critics argue
that the types of studies done to determine efficacy are too
controlled or not valid for other reasons.
What is your stance on evidence-based psychotherapies?
While sympathetic to the
concerns raised by many of my colleagues, I support the movement
to identify evidence-based treatments. I greatly value
science as a community effort and believe that, to the best of
our abilities, our treatments should be based on sound science.
In my practice, I use evidence-based methods whenever possible,
when the context supports their use, and when a client is
I agree with critics of this
movement that many of the most important therapy outcomes--such
as quality of life, living according to one's values, happiness,
intimacy, and living with a sense of vitality and
authenticity--are incredibly difficult to measure. And I
agree that some of these outcomes may never be understood
adequately to be measured well. However, the history of
science shows that we would have encountered innumerable dead
ends had we stopped pushing the limits when our ability to study
a phenomenon seemed insufficient.
I also agree that the results
of this effort may be misused by some, such as managed care
companies. However, I believe that curtailing the
scientific effort to prevent the misuse of its products leaves
all of us poorer. I believe that what is called for is a
deliberate, values-driven scientific effort, in conjunction with
advocacy efforts, to move mental health treatments forward.
I agree with critics of the
evidence-based treatment movement on at least one other
important issue: Treatment outcome studies and the data they
produce are insufficient as an end point. These studies,
sometimes called "horse races" due to their pitting of
treatments head-to-head against one another, provide an
important and informative but very particular form of data. What we need
is to go beyond treatment outcome studies to dismantling studies
(What about the treatments worked?) and back to a basic science
of behavior (When those components worked, through what
processes did they work?). In other words, we do not need
to lower the bar to prevent the misuse of the research, we need
to raise the bar to improve the products of the research and
make them more meaningful and valuable as a truly scientific
study of human behavior. Such research would be relevant
to academic researchers and clinicians alike.
Understanding the underlying processes will allow therapists on
the "front line" to use therapy procedures and methods with
scientific support and to do so NOT merely by following a manualized protocol, but with all of the creativity and vitality
present in the best therapy encounters.
evidence-based mean manualized therapy?
I do not use manualized
treatment protocols and believe that manuals are not the
inevitable end point of this movement. I believe that
therapy, at its best, is a fluid and intimate encounter between
individuals. While manuals can be effective, especially
for treating circumscribed problems or as a training tool, I
believe that manualized therapies are too restrictive and
inflexible for most therapy encounters.
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