In This Chapter
^ Deciding to work with a professional CBT therapist Getting the most from your CBT therapist Identifying the characteristics of a good CBT therapist
M BT has gained popularity in recent years, due in part to research showing ^^that CBT is an effective treatment for many common psychological problems. These days, you can access CBT treatment by books, by the Internet, in groups, and in one-to-one sessions (Appendix A lists Web sites and organisations that you may want to contact). This chapter helps you determine how to seek further help, how to select a CBT therapist, and how to get the most out of your treatment.
The information in this book may be all you need to overcome your emotional problems. Or, you may consider checking out some of the other self-help books we recommend in Chapter 23, which can give more guidance on specific problems.
As well as self-help, you may decide that you want or need additional help from a qualified therapist. If you have problems that are severe or difficult to overcome, your doctor may also prescribe medication, or refer you to a psychiatrist for a more specialised assessment of your difficulties. Psychiatrists can usually refer you to a psychotherapist who is qualified to treat your specific problems. Your GP may also be able to suggest a therapist, whether or not you have also been referred to a psychiatrist.
Self-help approaches, such as books like this one, have the advantage of costing little, being easily available – even in the middle of the night and during holidays – and providing enduring advice for years to come. Perhaps most importantly, when you use a self-help book, you know that the person who’s making the changes in your life is You. A Good self-help book can be invaluable, even if you’re also seeking professional help. In fact, most CBT therapists recommend a book or two during treatment. Your therapist may collaborate with you, using a book of your choice – such as this one – as a resource. Alternatively, ask your therapist whether she has any suggestions for material you can read to help you get the most from your treatment.
Ask yourself the following questions to determine whether Now Is the right time for you to look for professional help:
How severe are your current problems? For example, if you have severe depression or if you feel like you can’t go on any more, seeking expert help is strongly recommended, as you may be too ill to benefit fully from self-help techniques. By ‘severe’ we mean that your problem is interfering significantly with your relationships, ability to work or carry on with normal daily activities. If you have experienced uninterrupted symptoms for more than two months, or if you notice that your symptoms are coming back more often, you must seek out professional help.
Have you tried self-help approaches in a consistent and systematic manner for at least two (and ideally six) weeks? If you feel you’re making some progress on your problems, you may not need to work with a professional at this time. However, if you are not satisfied with your rate of progress and still feel bad much of the time, then structured therapy sessions may help you.
Check out how long you need to wait for NHS (National Health Service) treatment in the UK. Putting your name on a waiting list sooner, rather than later, is a good plan if resources are overstretched in your area.
Do your problems interfere with your ability to concentrate and utilise self-help material? If so, a therapist may well be able to help you digest information and techniques at a pace you can manage.
Do you see the sense in self-help principles but struggle to apply them to your own life? Most therapists are much more experienced than you in applying psychological principles to specific types of problems. They can suggest more ways to help you move forward and guide you on how best to use the therapeutic techniques described in self-help books.
Have you reached a plateau or obstacle in your self-help programme that you can’t overcome on your own? By working with a trained and experienced therapist, you may develop the ability to overcome barriers and jump-start your treatment. A therapist can often have suggestions
That you may not have tried, which can serve as a motivator to get your treatment moving again.
Are you ready to share your problems with someone and team up with her on achieving shared goals for therapy? Therapy is a team effort. Therapists don’t ‘fix’ you. Your treatment still needs lots of input from you.
Thinking about the right therapy for you
Doctors and psychologists often recommend CBT because research evidence supports its effectiveness (refer to Chapter 1). Specifically:
CBT is an active problem-solving approach that helps you develop skills and enables you ultimately to become your own therapist.
CBT focuses on the present, whereas many other therapies focus on personal history. In CBT, you use your childhood experiences to help you and your therapist understand how you may have developed specific beliefs and ways of behaving. However, the focus is on your Current Problems and the ways in which your thinking and acting perpetuate your problems.
CBT emphasises a collaborative relationship in therapy. CBT therapists can help you build skills and they are likely to expect you to carry out assignments in between sessions.
In addition to CBT, you may come across dozens more therapeutic approaches when you investigate your treatment options. Some of the more common psy-chotherapies practiced today include the following:
Transactional analysis: Focuses on the internal relationship between the parent, adult, and childlike aspects of human personalities.
Person-centred therapy: Emphasises the therapist displaying warmth, empathy, and genuineness towards the client, but without directing the client.
Psychodynamic therapy: Focuses on the client expressing feelings derived from early experiences, as these feelings arise during the ongoing relationship between client and therapist.
Systemic therapy: Commonly used with families and couples, this emphasises the idea that emotional problems are the product of a dysfunctional system, for example a family or relationship.
Interpersonal therapy (JPT): Focuses on changes in life roles, grief, and disputes with significant others. IPT is another proven treatment for depression and some eating disorders.
Meeting the experts
Lots of mental health professionals are able to provide general counselling and support. If you specifically want CBT, don’t hesitate to say so. Many psychiatrists, psychologists, and nurses have had some training in CBT, but you’d be wise to find out the extent of her training and experience. Ideally, choose someone who’s had specialist training in CBT. Specialist training Means that the therapist has obtained a degree, diploma, or Master’s qualification in CBT from a university or recognised training institute.
Ask your therapist if she is accredited with either the UKCP (United Kingdom Council for Psychotherapy) or BABCP (British Association for Behavioural and Cognitive Psychotherapies), if you live in the UK (contact details for these organisations are listed in Appendix A). You can also ask your therapist to tell you where and when she studied, and if you’re sceptical, you can check this information out with the educational bodies they list. Some therapists have their certificates, which outline their qualifications, on display. If you are referred to a therapist by a psychiatrist, the psychiatrist may be able to give you more details about your therapist’s credentials, or to verify the information that a therapist gives you.
In the UK, anyone can call themselves a counsellor or psychotherapist, regardless of whether they have any professional training. A therapist with a recognised professional qualification will not be offended if you ask about their relevant training. You have every right to satisfy your desire to know about your therapist’s background and training, because this is Your Treatment. If you know that you want CBT as part of your treatment, you must ask about the CBT specifics of your therapist’s training and experience.
In case you’re a bit flummoxed by the range of different professionals offering help, here’s a little breakdown of them:
Psychiatrists Are medical doctors who specialise in psychological problems. They can prescribe medication and typically are more knowledgeable than family doctors about the drugs used to treat psychiatric illness. Not all psychiatrists are trained in CBT, although many can refer you to a CBT therapist who they’re familiar with.
Clinical psychologists Have usually studied a broad range of therapies and have basic training in how to apply therapeutic principles to specific problems. Many can offer CBT but may not have specialist training.
Counselling psychologists Have been trained in basic counselling and different types of psychotherapy. Like clinical psychologists, most counselling psychologists have no specialist training in CBT, but they may offer it as part of the techniques they use.
Nurse therapists Are originally trained in psychiatric nursing. They have a more in-depth understanding of psychological processes and disorders than general nurses. Psychiatric nurses in the UK may have undergone further training to specialise in CBT.
Counsellors Are usually trained in listening and helping skills. They may hold a certificate in basic counselling, or be more specialised in certain problem areas, such as addiction. They do not always have a psychology degree, or in-depth knowledge of psychological problems. Often, counsellors will not be specialised in a specific psychotherapeutic orientation like CBT.
Psychotherapists Have normally specialised in a specific school of therapy, for example CBT or person-centred therapy. The level of training and experience, however, can vary widely.
You have the right to ask your therapist or other mental health professional (such as community based nurses, social workers, and occupational therapists), how much experience they have of using CBT and to what level they have trained. You can also ask them how much experience they have of dealing with your specific problems, such as depression, panic disorder, or obsessive-compulsive disorder (OCD). If you’re not satisfied with the answers you receive, take the matter further. In most cases you can request a referral to another therapist either through your GP or psychiatrist.
Tracking Bou/n the Right CBT Therapist for \!ou
After you’ve decided to search specifically for a therapist with CBT training, you may have a bewildering number of questions to ask both yourself and potential therapists. This section poses, and helps you begin to answer, these questions.
Asking yourself the right questions
Sifting through directories of CBT therapists can be quite a daunting prospect. You may feel like there’s a lot you want to find out about but aren’t sure exactly how to ask for the information.
To help locate and select the best CBT therapist for you, consider the following questions:
Where can I find a CBT-trained therapist? Begin by asking for recommendations from your doctor, psychiatrist, or friends. Many practitioners are listed in the telephone directory, although you may need to call them to find out more about their backgrounds. Additionally, you can look on Web sites (see Appendix A) for accredited CBT therapists. Accredited therapists Have usually reached a recognised level of training and experience. In the United Kingdom, therapists are accredited by the BABCP or the UKCP (or both). In the United States, therapists are licensed by the State in which they practise.
How much can I afford to pay? In the UK, CBT is sometimes available on the NHS, but you may probably be placed on a waiting list first. Your GP is your best first port of call. Unfortunately, relatively few GP surgeries offer CBT treatment on site. You do have a right to appropriate treatment through the NHS. If your doctor recommends you for CBT, then technically the NHS needs to provide it for you. If you have done some background research on your specific problems and have articles outlining CBT as the recommended treatment, you can show these to your doctor and request a referral.
Fees for private CBT vary from practitioner to practitioner, depending on location, training, and experience. In general, the more experienced and highly trained the therapist, the higher the fees. But, shopping around can save you money. Some practitioners have a limited number of lower-fee sessions for people on low incomes. Sometimes, trainee CBT therapists may not charge, or they may offer a reduced rate. Many trainees are very competent and provide good-quality service. However, before beginning therapy with a trainee, find out who she reports to, her arrangements for consulting, and who monitors her professional supervision. Then, you know who to talk to if you have any concerns or complaints about the treatment your trainee therapist provides.
Would I prefer a male or female practitioner? When you’re selecting a therapist, try to be open-minded about their sex. However, some people, perhaps because they have issues with sexual abuse or relationships, may prefer either a male or a female therapist. If you feel the sex of your therapist impairs your ability to discuss your problems openly, raise your concerns with them or your doctor, who should then refer you to another therapist.
You may also wish to have therapy with someone who is from the same cultural background as you are. Ask your doctor if they can recommend a local service that may be able to get you some culturally specific counselling.
Does the therapist have the appropriate experience or training? If you
Have a specific problem, such as panic attacks, addiction, or OCD, you’re best looking for a therapist with experience in treating your specific disorder. If you find a practitioner who you like but who doesn’t have experience in your disorder, ask whether they’re prepared to find out more about your problem. If not, find another therapist.
How many sessions do I need? Estimating the number of therapy sessions you may need is difficult. In general, CBT is briefer than psychoanalysis or psychodynamic therapy, which typically involves regular sessions for a year or a number of years. In general, unless your problem is very specific, such as snake phobia, we suggest initially trying six sessions and then reviewing the treatment progress with your therapist.
A common estimate for CBT is between 8 and 20 sessions. You will normally start off with weekly sessions and build in bigger gaps as you progress. However, for complex and longstanding problems, CBT can last two years or more, with multiple sessions per week. Ask your therapist to give you a rough idea of how many sessions she believes you need after her initial assessment of your problems.
Your therapist can also regularly review your treatment with you, which may help give you a clearer sense of how many more sessions you need.
Ultimately, you – not your therapist – must determine how long you choose to stick with CBT treatment.
Can I take along my copy of CBT For Dummies Or another self-help book? As we mention earlier, CBT therapists often suggest self-help material and can usually help you work through a self-help book. If you’ve been using a book that you find useful, take it along to your first sessions. Your therapist may already be familiar with the resource; if not, she may be prepared to read through it.
Speaking to the specialists
Make the most out of your initial phone contact with possible therapists by asking about whatever questions are on your mind. Once you make an assessment appointment with a therapist, you may want to list a few things that you want to discuss during your first meeting. Here are some ideas of what questions to ask your therapist:
Although CBT therapists vary as to how much they’re prepared to discuss over the phone before your first meeting, the following questions are reasonable after you identify a potential therapist:
How much do you charge [if the therapist is a private practitioner]?
How long are your sessions?
Do you charge a cancellation fee?
Do you have any experience of treating my particular kinds of problems? Are sessions booked in a fixed time slot each week, or can they vary? Where do you practise? Do you have a waiting room? Can I tape-record our sessions?
Fighting your fears about seeking specialist help
We often comment to each other about how strange our jobs are. We like what we do very much, butthe reality is that for most people therapy is an unfamiliar experience. Most people don’t sit in front of a stranger and tell him about personal problems. Being apprehensive about starting therapy is entirely natural, and you may have some common worries about seeking help, such as the following:
What if working with a professional doesn’t help me? Treatment may not have an immediate effect. However, if you’re committed to getting better, the treatment will probably have at least some benefit. Proceeding down the professional path may seem like a big risk, but you’re very likely to be glad you took it.
What if talking about my problems makes them worse? Goodtherapy, and/orthe right medication, very rarely worsens problems. Sometimes, you may feel a temporary increase in discomfort while on the road to long-term recovery. We discuss this more in Chapters 7 and 9.
What if I’m too embarrassed to tell my therapist what’s really bothering me? Tell your therapist if you’re feeling embarrassed or ashamed. She may well be able to put your mind at rest by explaining that many of your feelings are normal. You don’t have to divulge all to yourtherapist straightaway (although doing so may be the most efficient route), and you can take some time to build trust between the two of you.
What if my therapist thinks I’m mad and wants to keep me in hospital? Yourtherapist or psychiatrist is not going to think that you’re
Mad, or judge you negatively for being disturbed. She will frequently see patients with yourtypes of problems. People are assessed to stay in hospital against their will only in extreme circumstances… If you’re a danger to yourself or to others, if you’re actively suicidal, or are neglecting yourself badly, you maybe detained in hospital-but this would be to keep you safe, notto punish you. Most areas in the UK now have home treatment teams so that regular visiting is available to support people in their own homes, so they don’t need to go to hospital.
What if my therapist passes on my private information to social services or my employer? The information that you share with any mental health professional is confidential and will not be given to family members, or employers without your explicit (usually written) consent. An exception to this is when very clear risks to yourself, or others – including children – are identified.
Only in very extreme and relatively rare circumstances do therapists ask social services to assess the impact of a mental health problem on a patient’s family or children. In all but the most extreme circumstances, yourtherapist can tell you of his intention to involve any outside agencies.
If you have any of the above worries, voice them with your doctor or therapist. Worrying is normal, and any mental health professional with even the smallest amount of therapy experience can be sensitive to your concerns and discomfort. If they’re not sensitive to your needs, consider seeking help from somebody else.
If you’re comfortable with the answers you receive from phoning your therapist, seek out answers to the following more detailed questions during your first meeting:
Can you explain your theory about what’s maintaining my problems? What sort of things do you think I need to do to overcome my problems? How many sessions do you estimate that I need?
What do you expect of me in therapy – and what I can expect from you? Can you recommend any reading or self-help materials to me?
Making the Mast of CBT
So what can you expect from your CBT therapist? As a general rule, a lot! Most likely, you’ll end up feeling that you’re working hard both during and between sessions.
Discussing issues during sessions
When you meet with your CBT therapist, expect extensive two-way discussion, as well as some challenging questions from your therapist. Topics for collaboration may include the following:
Treatment goals: CBT is goal-focused. Your therapist is likely to ask you about your therapeutic goals early in treatment. If your goals are not realistic, your therapist will discuss this with you.
Specific problems, causes, and solutions: A skilled CBT therapist can share her ideas about what’s perpetuating your problems, and invite you to work with her on what can help you in the long run. You can also expect your therapist to agree With you To a treatment strategy, which is likely to include homework assignments.
Although you may, on occasion, feel awkward with your therapist, she’s speaking from a place of sound, clinical experience, and knows that some behavioural exercises, although they can be uncomfortable for you in the short term, can get you better in the long term.
Expect your sessions to be focused. Your therapist may interrupt and refocus you if you stray off the point, and do not address the actual issues that brought you to treatment. Additionally, a good CBT therapist may pull you up if you avoid working on your problem areas.
Hallmarks of a good CBT therapist
CBT practitioners exhibit some fairly predictable behaviours in session. You can use the following list of attitudes, actions, and interactions to help you determine whetheryou’re actually receiving CBT treatment, and to assess the standard of yourtherapy. In general, good CBT therapists:
Help you define problems and ask about your goals and expectations for therapy.
Explain a bit about CBT atyourfirst meeting and invite you to ask questions.
Use scales and measures, such as a Depression inventory {refer To Chapter 10), to help monitor your progress.
Evaluate your problems based on the CBT model and explain this process to you so you can do it yourself in the future.
Ask questions to elicit your thoughts and help you evaluate them.
Are active in sessions, educating you about CBT and its perspective on your problems, asking questions, writing things down, and making suggestions of ways to try to improve your problems.
Develop therapy homework exercises with you, to be carried out between sessions.
Reviewyour homework. If you haven’t done it, a thorough therapist can discuss the obstacles that stopped you doing so.
Regularly reviewyour progress and reassess your goals with you.
Invite feedback about therapy generally, and openly listen to any constructive criticism you give.
Invite you to voice any doubts, reservations, and fears you have about aspects of your CBT.
Challenge your unhelpful beliefs and behaviours and help you to do the same on your own.
Encourage you to be independent and to take personal responsibilityforyour mental health.
Answer most of your questions, and tell you why if they don’t or can’t answer others.
Refer you to another professional if you require additional or alternative help.
Receive regular clinical supervision (in which they have their work listened to or have discussion with other therapists) to improve their practise. Don’t be afraid to ask about this: It’s important!
Okay, so this list is rather long, but we recommend consulting it if you have any doubts about your CBT therapist. Don’t hesitate to take this list to your therapist and ask her to clarify her position on any or all of these points. Even though you may be seeing an experienced or qualified CBT practitioner, attitudes and styles of therapeutic delivery can vary dramatically. Like many therapists, we’re always pleased when clients suggest ways in which we can make sessions more helpful.
Overall, your CBT therapist is likely to be pretty human. Your CBT therapist shouldn’t give the impression that she considers herself above you, or fundamentally different from you, simply because you’re the patient and she’s the professional. Most skilled CBT therapists acknowledge that they’re the experts on CBT, and possibly on particular psychological problems, but that You Know Yourself Best. Therefore, they may ask you a lot of questions about your experiences, thoughts, and feelings, rather than telling you what you experience, think, and feel.
Just as you can expect your CBT therapist to be open and honest during sessions, you can get even more from your sessions by being open about your own doubts and reservations. Although doubt is wholly natural, be prepared to reconsider your reluctant feelings about change.
Even if you know intellectually that a new way of thinking or acting is better, you may still have a gut reservation. For example, we often see clients who realise that their perfectionism is highly toxic but still fear that they may perform badly if they give it up. In these cases, we often have to help people see that being more flexible doesn’t mean dropping their ideal standards. You can strive for excellence without demanding perfection.
Being active between sessions
CBT is in part educational, so your therapist may use a whiteboard, pen and paper, and various printed forms in your treatment. At some stage, your therapist may give you an ABC form or a thought record sheet (which we explain in Chapter 3).
Some of your homework will be written and some will be behavioural – whatever form it takes, however, you can expect your therapist to give you a solid rationale for any intervention they use, or homework they suggest. Your therapist is also likely to give you handouts and reading matter.
Being ready to engage actively in therapy is a major key to your success, so if you are asked to do an exposure assignment or behavioural experiment that you don’t feel ready to take on, say so, and suggest an alternative. You may want to address any ambivalence about therapy using a cost-benefit analysis: Weigh up the costs and benefits of carrying on as you are, versus trying out new ways of thinking and behaving.
In order to make your CBT experience successful, do your homework! We find that whether a client completes therapy assignments or not is the single best predictor of success. CBT involves retraining your attention,
Changing your behavioural patterns, and adopting new ways of thinking. It takes practice and repetition to break old patterns and to replace them with new ones.
Consider therapy as a temporary experiment. Give your therapist’s advice a shot and see what happens. You can always return to your old ways or try out a new strategy if you think therapy isn’t working well.