Saturday, July 7, 2012

Comparing and Understanding Behaviour Therapies

        In my last post, I discussed finding the right therapist. That process takes a little bit of work and research on the part of a client seeking out someone to treat them. The matter gets more complicated when you're investigating specific therapies and if they are relevant or not to you and if they fit with how you want to do the type of therapeutic work you're involved with. During my searches, I found that Cognitive Behavioural Therapy (CBT) is extremely popular amongst clients, they simply have heard of it. Now, I am not going to make an over-generalized sweeping like "CBT is crap." Although it has become quite posh for therapists to talk trash about CBT and other Behavioural interventions; I respect CBT for what is, a sometimes useful intervention that many people have found helpful. 

So, what is my opinion!? Well, it's complicated so just give me a few minutes to explain - then you can be the judge.

I think any therapist who has an interest in helping people will use some behavioural skills some of the time as the skills are easily accessible for clients, fun to teach and highly effective. There are numerous types of behaviour therapies and I have not covered all of them here but these are the ones I know best because I have been trained and supervised on all three of them.

Dr. Linehan's Cognitive Behavioural Treatment of Borderline Personality Disorder (aka, Dialectical Behaviour Therapy) Skills Manual is pictured above.

        My career as a therapist began in forensics at St. Joseph's Healthcare in Hamilton, ON. At this site Dialectical Behaviour Therapy (DBT) is the predominant system of therapy. Before arriving at the hospital, I had heard many of my Master of Social Work colleagues speak out against Behavioral Therapy - specifically CBT, calling it oppressive, judgemental, manipulative and superficial. They asked pointed questions and were generally unfriendly to a guest speaker who came from Toronto to speak with us about the use of CBT in their direct practice. One of my patients mistakenly referred to DBT as "Diabolical Behaviour Therapy" and I thought to myself "Man, people really do have a bad impression of this stuff."

I read the book, a handful of journal articles and did the online training and quickly came to realize that DBT is not manipulative at all. In fact, I found it extremely ethical. DBT is heavily based around skills and skill training, it puts the proverbial ball in the court of clients, telling them that if they want to see changes in the way people respond to them and what is happening in their life, they need to make changes themselves with how they interact with those people. At times in DBT, the therapist closes space and confronts clients about their decisions and actions, the therapist then asks how the skills clients learned could have helped and clients have the opportunity to constructively work through situations and problems using the skills. What is rather nice about this is that therapists can be validating here, telling clients "Yes, I agree that guy was being a jerk to you. How do you feel about how you reacted though?" This also places the therapist as an ally rather than an adversary. However, the therapists role as the expert still exists here in this position.

DBT requests clients to have a level of acceptance which is referred to in this model as "radical acceptance." This is a concept that can be empowering for some and infuriating for others. The core principal here is that clients accept the narrative of their lives, their history for what it is - accepting the situation just as it is. This is best illustrated during the online DBT training where a client remarks that they were abused as a child, that the abuse never should have happened. The therapist agrees with the client and tells them that acceptance is not the client conceding to the abuse and saying it's okay the abuse happened. No. Instead the client accepts that history as a part of their life "I am a person who experienced abuse." This is an essential concept to the next behavioural intervention I will discuss, Acceptance & Commitment Therapy (ACT) however, note that ACT goes deeper into this concept of acceptance and in my experience, puts acceptance in a more appropriate perspective.

This self-help book encourages introspection and treats therapy as a journey.

        Acceptance & Commitment Therapy (ACT) has the word acceptance right in the title, so you know some sort of submission to the way your life is, is just going to be a part of the program. Well, that is true but I would argue that this position in more comforting than what clients would experience in Dialectical Behaviour Therapy. ACT recognizes the pain and utter despair that living can be and really puts the acceptance of what your life is, into perspective. ACT's acceptance is similar to the radical acceptance of DBT by stating that accepting what is happening in your life and your past does not make it okay or say that you are in favour of it. ACT goes farther and states that it's

ACT really looks for what is important and meaningful for the client. This important distinction sets ACT apart from other behavioural interventions. There is a thorough assessment in ACT for therapists to work on with clients to discover clients values and make a commitment to taking action, being true to oneself to be the person you want to be.

Let's take a moment here and acknowledge how scary this can be for some. Just discovering your values alone and committing to taking action to fulfill them in your life and make them a part of living your life is a task, an obligation. Some might see this as a burden. ACT attempts to make this experience empowering and offering some freedom for clients to acknowledge the way they want to live their life.

CBT is popular, it's like the Michael Jackson of therapy, you may not like him, you might even think he's unethical but you've definitely heard some of his tunes and he has a number of gold records because of them.

        I don't know about you, but I think that is a catchy line "Change how you feel by changing the way you think." It's simple and sounds incredibly accessible. It's like an epiphany or lightbulb moment: "DUH! The problem with how I feel is the way I think!!!!" Well, as it turns out it's not necessarily that easy all the time and sometimes your thoughts are completely accurate. The intervention offered here, Cognitive Behavioural Therapy (CBT) is about getting the right story in your head about who you are. This is a good way of challenging and disputing thoughts. However, how easy is it to really identify distortions in thinking. It isn't. Anyone who argues any differently is once again playing that role we social workers love to hate, the expert.

The work that is done in Cognitive Behaviour Therapy is rigid, what I mean by this is that the therapy is a process which is manualized or structured. This results in specifications over how the therapy sessions are conducted, what skills are taught when, how they are taught and what they address. A critique here is that the CBT process is "cookie cutter" or simply not unique to each client. Some argue that this is not a bad thing, insurance companies in Canada and mental health hospitals seem to have it at the top of their lists or some times even the only treatment on their list approved. This does not come as a surprise to me, the research shows that CBT is effective and it is short-term, you don't need many sessions or hours with a therapist to work through the material.

I have as of yet to see a sophisticated clinician who is a Cognitive Behavioural Therapist in Hamilton or even in the greater academic community but that does not mean they are not out there.

At the end of the day, it's about what works best for clients. I ask myself, how can I use what I know to be useful with the person sitting across from me in the therapy session?

        After having been trained in all of the above therapies, practicing and being supervised on each individually I have come to find that Acceptance & Commitment Therapy (ACT) fits best with my practice. I do not wish to devalue any of the other therapies, I still use DBT skills and found the training extremely helpful. Likewise, with CBT, I was able to put the intervention into practice which has been foundational to my understanding of behavioural interventions in general and has been greatly beneficial to the work that I do in ACT because at the end of the day, ACT is still a behaviour therapy!

Just working towards being a better clinician,
Tim Gordon.
Hamilton, ON


  1. my prof just talked about this the other day in psych class.."Change how you feel by changing the way you think" funny you should mention it. good read!

  2. Great article. I recently read an article by a social worker in the Journal of Humanistic Psychology titled "A Person-Centered Approach to the Treatment of Borderline Personality Disorder," by Adam Quinn. He touches on a number of similar points, emphasizing acceptance in the relationship a great deal. Something he wrote in the section on DBT was interesting: Linehan has mentioned that DBT has been called "blackmail" therapy because of the emphasis on behavior change. It seems like ACT may be closer in philosophy to person-centered therapy, than it is to DBT's philosophy.

    Great blog - keep it up!

    1. Hi Bert, thanks for your comment and words of encouragement! I'm glad you enjoyed the post.

      I would be interested to read that Person-Centered article, I am a BIG fan of Carl Rogers. As a student I am still trying to discover how I can continually integrate my love of Rogers work into more behavioural work.

      Talk soon,

  3. Interesting and useful article. Thank you for sharing your thoughts!

  4. If people practice Mind over Mood then a lot of outburst could be prevented. But it will be challenging for those people with sudden out busts.
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