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  #1  
Unread August 27th, 2005, 08:08 PM
josh Adams josh Adams is offline
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Default Inexperienced Therapists

Mr. Pretzer,

I was wondering if you would be willing to comment on an issue that has bothered me for a while. I have noticed a trend that many inexperienced therapists use the interventions from CBT in a reckless way, stringing together intervention after intervention without ever talking the time to build rapport with the client. In my opinion, this often leads the therapist to do something "to" a client rather than "with" a client. I also believe that the linguistical nature of CBT can lead to some abuses by inexperienced therapists. As an example, words like disputation and illogical thoughts etc. are part of the lexicon of your therapy. Again, in my experience, I have found that these words have led some therapists to attack a client rather than work with a client by saying "you are having an illogical thought right now" as though the therapist is superior to the client.

Now, I am sure that you could simply chalk this up to bad supervision or say "of course this happens to new therapists because they are still learning." However, I have seen this much more with therapists who practice CBT vs. other theoretical orientations. I will admit that other orientations have their own problems. I have noticed that many psycho dynamic people want clients to keep feeling their feelings beyond the time where it is probably helpful. I was wondering what the leaders in CBT are doing to make sure that this misuse of your therapy is limited? I am fully aware that a well trained CBT therapist does take the time to build rapport and is very effective with clients. unfortunately, the vast majority of therapists never train under someone such as yourself so they can learn the style properly.
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  #2  
Unread August 27th, 2005, 09:58 PM
James Pretzer James Pretzer is offline
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Default Inexperienced or Incompetent?

You are right that there are many therapists who say they are doing CBT but who do it badly in a variety of ways. Since CBT is an approach that has many specific techniques, one of the most common errors is to simply barrage the client with techniques without taking time to form a collaborative relationship and develop a conceptualization. When therapists do this it greatly decreases the effectiveness of CBT and sometimes can be quite harmful.

My experience is that sometimes the problem is simply that the therapist is inexperienced and a little supervised experience solves the problem. Sometimes the problem is that the therapist learned CBT 20 or 30 years ago and hasn't kept up on recent developments. However, often the problem is that a therapist without training in CBT decides that reading a book or attending a one-day workshop equips them to do CBT. Stop and think about it. Would anyone read a volume of Freud and declare themselves a Psychoanalyst or attend a one-day workshop and declare that they know Gestalt Therapy? For some reason, people get the impression that CBT is so simple that there is no need to actually learn how to do it right.

After more than 20 years training therapists in CBT, my experience has been that some therapists get adequate CBT training in grad school if they get extensive supervised experience through practicum and internships. However, most therapists finish grad school with quite limited training in CBT. Reading, workshops, and conferences can help a lot but it takes much more than a single book or workshop to provide a solid grounding in CBT.

How much does it take? Our intensive training program involves ten day-long sessions, reading two or more texts, demos, videos, role-plays etc. (see post #6 in the thread re finding training in CT at http://www.behavior.net/bolforums/showthread.php?t=161). It provides participants with a solid foundation in CT and they get enough practice and feedback so that when we rate tapes of real-life therapy sessions using the Cognitive Therapy rating scale, most participants do well. I certainly wouldn't mind having a little more class time and having individual or small group supervision but the feedback we get is that this type of training works quite well.

It would be great if there was some way to make sure that everyone who claims to be doing CBT was doing it well. However, there isn't much that leaders in CBT can do to stop therapists from doing CBT without adequate training, knowledge, and skill. Anyone can claim to do CBT whether or not they know what they are doing. The main things that leaders in CBT have done is to publish many high-quality texts and journals, to establish a number of professional organizations, to offer a variety of training opportunities, and to offer several certification programs. Those who want to learn how to do CBT well have a variety of opportunities. Unfortunately, there is no practical way to stop people from claiming that they are doing CBT when they are just using a random assortment of techniques they picked up somewhere. It's not as though we could send the therapy police after them even if we wanted to.

One thing that I would recommend is that all authors of texts on CBT and all workshop leaders make a point of explicitly mentioning the importance of establishing a therapeutic relationship, the importance of basing interventions on a clear understanding of the client and his or her problems, and the importance of adequate training (which can include educating oneself by reading widely, attending workshops, and taking advantage of any supervision opportunities that are available). Maybe we can get the word out.
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  #3  
Unread August 27th, 2005, 11:26 PM
josh Adams josh Adams is offline
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Default Re: Inexperienced Therapists

Thanks for your response. I think that your last point is one major facet to resolve the problem. However, I have to wonder if some statement by leaders in your field have contributed to the problem. I heard one well known CBT therapist tell a story about how he trained nurses to do CBT work with their clients and they were as effective as therapists. I know that the operative words is "He Trained," but I am afraid that many do not hear that phrase. They hear "hey anyone can do this stuff." The other point I wanted to make is related to the language that CBT uses. I also think that this has contributed to the problem. I have heard therapists say that they often dispute what the client says (disputation). If you think about the general meaning of the word, when people get into a dispute, it generally is not very pretty. I believe that it would help greatly if authors were to address this issue directly in the strongest of terms. Finally, regarding supervision, it has been my experience that the supervisors are often just as bad.

I agree that we can not send out the therapy police. I also agree that it is silly to believe that one can learn CBT in a one day workshop. I think this is my point. CBT is deceptively simple to an untrained practioner and that is its danger. I know a bunch of executive coaches that say they do CBT. I doubt that they really do. Thanks for being so open minded about this issue. I really do have respect for you all.
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  #4  
Unread August 29th, 2005, 09:32 AM
JustBen JustBen is offline
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Default Re: Inexperienced Therapists

Quote:
Originally Posted by josh Adams
The other point I wanted to make is related to the language that CBT uses. I also think that this has contributed to the problem.
I know where you're coming from on this, Josh, and I can tell you that it's not just a problem for clients. Novice therapists, too, can be initially mislead by words like "disputation", "rational", and "dogmatic" -- all of which have different meanings in the world of CT than they have in other contexts. (Some schools of therapy use words like "cathexis" and "reaction formation" which have virtually no meaning at all outside the psychological world. It simplifies things, but it doesn't, if you know what I mean.)

I've noticed this as a bigger problem in REBT (i.e. the "Ellis" brand of CBT) than it is in CT (i.e. the "Beck" brand). I suspect that CT's greater emphasis on collaborative empiricism helps the client understand that what is being "disputed" (actually "addressed" might be a better term here) is the faulty belief, not the person of the client. In REBT, on the other hand, there is often much more direct disputation where the therapist confronts the client with the "irrationality" of his or her thoughts. (REBT doesn't require this kind of approach, necessarily, but it seems like a lot of REBTer's are big fans of Ellis and try to emulate his direct style.)

I don't think the solution lies in changing the words. The only two choices are using a word that already exists or making up a completely new word. If we used a word that already exists, then we're back on the same pony ride -- confused meanings, etc. If we simply make up a word, then we run the risk of alienating people with what will almost certainly be perceived as "psychobabble". Like your other critique, I think the answer is in better training. I don't think any improvement in standards is going to come from the top down -- there are already many training programs and organizations in place and leaders of the field don't really have any leverage to pressure inexperienced therapists into doing the right thing. I think those leaders would do well to educate clients about good therapy. Clients are usually customers, after all, and they have the ultimate form of leverage: the pocketbook (or HMO card, as the case may be). When clients ask therapists tough questions about training, supervision, etc., I think you'll see therapists scrambling to be able to provide the right answers.
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