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 related strategies.

Behavior Therapy 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 other factors.

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 conditions.

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 psychological problems.

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.

Acceptance and Commitment Therapy

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 Relational 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 enjoyable life.

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 state of the evidence in ACT research on the Association for Contextual Behavioral Science (ACBS) website.)

The Fourth ACT Summer Institute will be held May 28-30, 2008 at the Illinois Institute of Technology in Chicago. (Pre-conference workshops on May 26 & 27.) Click the logo for more information.

Contemplative Psychotherapy

What is Contemplative Psychotherapy?

Go to the Contemplative Psychotherapy Page

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).

Individuals
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.

Couples
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 gains 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 received much research support for its effectiveness in promoting sobriety, improving the couple's relationship, reducing violence and risk of violence, and improving overall family functioning.

Families
I am 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.

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. Cognitive-Behavioral 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 and substance abuse.

Acceptance and Commitment Therapy (ACT), is a newer therapy that has not yet accumulated sufficient evidence for inclusion on lists of empirically-supported treatments. 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 listed on future lists of empirically-supported therapies for specific disorders (this is my assessment of the existing research).

Contemplative 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 foreseeable future.

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.

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 agreeable.

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.

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.