CBT versus ACT and minimum education qualifications for success
January 24, 2018 1:00 PM
I am 41 and setting up an appt for a therapist for the first time. Issues to focus us: handling aftermath of domestic violence, ADD strategies and coping mechanisms, divorce grief, step-parenting woes, anxiety, resolving problem behaviors such as passive aggressiveness that were established from family of origin trauma, impulse control. Need some guidance on selective between therapy options and minimum qualifications to screen for in practitioners.
I've narrowed down the selection to CBT practitioners (My BA is in psych and I feel I have a good understanding of many of the schools of therapy approaches and this one seems to have the best efficacy) but I'm being offered the choice of a traditional CBT therapist or a CBT/ACT therapist. Can anyone breakdown the differences based on personal experience and advise which one worked better for you? Efficacy studies I have reviewed online indicate no statistically significant difference between the two approaches so it looks to be more a matter of personal preference. Finally, back in the day when I planned to be a therapist, I planned to go all the way with a PhD in clinical psych. This makes me somewhat wary of a therapist who has only an MA or an MSW. In your experience oh great people of the green, do these masters' level practitioners know what they are doing or should I select a PhD holder to ensure better quality of care?
I've narrowed down the selection to CBT practitioners (My BA is in psych and I feel I have a good understanding of many of the schools of therapy approaches and this one seems to have the best efficacy) but I'm being offered the choice of a traditional CBT therapist or a CBT/ACT therapist. Can anyone breakdown the differences based on personal experience and advise which one worked better for you? Efficacy studies I have reviewed online indicate no statistically significant difference between the two approaches so it looks to be more a matter of personal preference. Finally, back in the day when I planned to be a therapist, I planned to go all the way with a PhD in clinical psych. This makes me somewhat wary of a therapist who has only an MA or an MSW. In your experience oh great people of the green, do these masters' level practitioners know what they are doing or should I select a PhD holder to ensure better quality of care?
Do you have the option of meeting with both therapists, even if it's just a quick 15-minute meet-and-greet with each? Your success in therapy depends so much more on how well you 'click' with your therapist, personality-wise, than the precise method they use.
Regarding the degree: in the US, requirements are determined by the state, and different state have different requirements for MA-level practitioners. But a PhD really isn't useful, if you want to work as a practitioner. Getting 'just' an MA/MSW isn't like working towards a PhD and then giving up when you get bored, or anything. It's not like the MA/MSW is a booby-prize for those who can't cut it in a PhD program. It's just the specific degree that allows one to do particular kinds of work with clients. The talent/abilities of a therapist can't be determined by whether they have a PhD or an MA/MSW.
posted by meese at 1:11 PM on January 24, 2018
Regarding the degree: in the US, requirements are determined by the state, and different state have different requirements for MA-level practitioners. But a PhD really isn't useful, if you want to work as a practitioner. Getting 'just' an MA/MSW isn't like working towards a PhD and then giving up when you get bored, or anything. It's not like the MA/MSW is a booby-prize for those who can't cut it in a PhD program. It's just the specific degree that allows one to do particular kinds of work with clients. The talent/abilities of a therapist can't be determined by whether they have a PhD or an MA/MSW.
posted by meese at 1:11 PM on January 24, 2018
You're right that the efficacy of both methods has been well-established, so I agree that the personal fit with the therapist is extremely important. I have had experience with a therapist who was specialized in traditional CBT and trained as an ACT therapist later, so the two approaches don't have to exclude one another. However, there are some differences, mainly in that ACT doesn't necessarily try to adjust thought processes, but encourages you to accept that they're there and to commit to action regardless of them (though I guess you know that already). I personally liked this approach, due to my sceptical attitude towards positive psychology, and found it effective. But I also liked and trusted the therapist, and that's key.
posted by Desertshore at 1:47 PM on January 24, 2018
posted by Desertshore at 1:47 PM on January 24, 2018
If you had gotten a PhD in clinical psych you would have been trained to work in clinical research, not counseling. Most programs do not offer doctorate-level counseling degrees anymore except oriented toward teaching (and academic research) anymore. You may find therapists with PsyDs, or PhDs in Social Work (they likely trained for research, program administration, and public health work rather than counseling). You'll find a smattering of therapists with doctorates in divinity, as well.
If any of them are doing direct therapy work, almost all of them will have to additionally complete the exact same hardcore requirements most states have for licensed therapists. There is no "just". You are in qualified hands with any state certified therapist, at least as far as the state regulations stand right now.
A lot of people find ACT to be "warmer" than really classic CBT, though in practice most CBT practitioners are not going to be overly distant either. Most therapists know more than one style and this is something you can discuss with them when you talk about their plan and approach. I would worry first about finding any therapist that is taking new patients, fits your schedule, then fits your personality, before worrying that their exact therapeutic methodology is slightly different than you are anticipating.
posted by Lyn Never at 1:49 PM on January 24, 2018
If any of them are doing direct therapy work, almost all of them will have to additionally complete the exact same hardcore requirements most states have for licensed therapists. There is no "just". You are in qualified hands with any state certified therapist, at least as far as the state regulations stand right now.
A lot of people find ACT to be "warmer" than really classic CBT, though in practice most CBT practitioners are not going to be overly distant either. Most therapists know more than one style and this is something you can discuss with them when you talk about their plan and approach. I would worry first about finding any therapist that is taking new patients, fits your schedule, then fits your personality, before worrying that their exact therapeutic methodology is slightly different than you are anticipating.
posted by Lyn Never at 1:49 PM on January 24, 2018
Just a bit of a correction on the Ph.D. statement by Lyn Never: people who get PhDs in clinical psych do train in and do practice counseling. In fact, the vast majority of people who get Ph.D.s in clinical psych go into some kind of practice rather than research. There simply are not enough research positions and funds in the world to support everyone going into research, and many choose the degree as "scientist practitioners" meaning, they have an understanding of research and thus can be excellent consumers of academic research in guiding their clinical practice. I am a holder of a Ph.D. in clinical psychology, and do nothing but work with patients, as is the case for every member of my graduating class.
As to the OP's question; CBT is based on the principal that our emotional responses are guided by our own interpretations of situations, and learning different ways to interpret our experience can impact our emotional well being. So, for example, if a child fails a test, they could have the thought "Oh, I didn't study quite enough. I'll do better next time." or they could think "I failed this test because I am truly stupid. Because I'm stupid, no one likes me. Not my teacher, not my parents. I will be humiliated and I can't deal with this." You can see where one would prompt a more neutral mood than the other. In CBT you learn to evaluate your thoughts to weigh how likely or realistic they are, and if they seem to be not likely, how to substitute a different thought that is more realistic. You also focus on developing strategies to manage strong emotions, like scheduling activities for depression or learning relaxation techniques for anxiety.
ACT takes some of those same principals, but adds a component of mindfulness, and the idea that some painful thoughts are real and cannot be changed, but we can find ways to accept them and change our lives or reaction to them. So for someone with a past that includes trauma, that is real. Learning to honor and accept that is important. Equally important is recognizing that you and your life matter and working together to find ways to live with that truth while also making changes.
Both are very efficacious, and like others have said a lot depends on your relationship with your therapist. That being said, given the breadth of the different concerns you are bringing to therapy, someone who is versed in both approaches might be a good fit.
posted by goggie at 2:14 PM on January 24, 2018
As to the OP's question; CBT is based on the principal that our emotional responses are guided by our own interpretations of situations, and learning different ways to interpret our experience can impact our emotional well being. So, for example, if a child fails a test, they could have the thought "Oh, I didn't study quite enough. I'll do better next time." or they could think "I failed this test because I am truly stupid. Because I'm stupid, no one likes me. Not my teacher, not my parents. I will be humiliated and I can't deal with this." You can see where one would prompt a more neutral mood than the other. In CBT you learn to evaluate your thoughts to weigh how likely or realistic they are, and if they seem to be not likely, how to substitute a different thought that is more realistic. You also focus on developing strategies to manage strong emotions, like scheduling activities for depression or learning relaxation techniques for anxiety.
ACT takes some of those same principals, but adds a component of mindfulness, and the idea that some painful thoughts are real and cannot be changed, but we can find ways to accept them and change our lives or reaction to them. So for someone with a past that includes trauma, that is real. Learning to honor and accept that is important. Equally important is recognizing that you and your life matter and working together to find ways to live with that truth while also making changes.
Both are very efficacious, and like others have said a lot depends on your relationship with your therapist. That being said, given the breadth of the different concerns you are bringing to therapy, someone who is versed in both approaches might be a good fit.
posted by goggie at 2:14 PM on January 24, 2018
Not all therapists (in my jurisdiction, anyhow) are well versed in working with ADD. If that is a big part of your issues, you might want to select specifically for a therapist with that kind of experience.
posted by Cheese Monster at 2:22 PM on January 24, 2018
posted by Cheese Monster at 2:22 PM on January 24, 2018
CBT and ACT can both be very effective - I've tried and benefitted from them both. If, after a while of trying these modalities, you find that some of what you're experiencing isn't shifting, please consider trying trauma-focused therapies such as EMDR, IFS or somatic modalities.
I'm pretty sure the benefit I got out of CBT happened in the first six months to a year - after that it was a lot of internally arguing myself into knots and feeling bad about the fact that I couldn't seem to "out-think" the issues that were causing me to suffer the most. ACT was also helpful, but while engaging in the mindfulness aspect of it I occasionally found myself coming across overwhelming feelings that were beyond my capacity to just 'mindfully observe', so what was supposed to be a calming experience became kind of anxiety-provoking in itself.
I will be forever be grateful to the CBT therapist who finally said to me, look, I think this is trauma talking, and I really want you to see someone who specialises in trauma so that you can resolve it, rather than just finding more ways of working around it. I hadn't previously thought of myself as a trauma survivor, but six months of trauma therapy shifted things that CBT never could have. Read up on top-down/bottom-up processing to understand why sometimes trauma-focused modalities help when CBT/ACT do not. (Bessel Van Der Kolk is a good place to start).
posted by embrangled at 5:21 PM on January 24, 2018
I'm pretty sure the benefit I got out of CBT happened in the first six months to a year - after that it was a lot of internally arguing myself into knots and feeling bad about the fact that I couldn't seem to "out-think" the issues that were causing me to suffer the most. ACT was also helpful, but while engaging in the mindfulness aspect of it I occasionally found myself coming across overwhelming feelings that were beyond my capacity to just 'mindfully observe', so what was supposed to be a calming experience became kind of anxiety-provoking in itself.
I will be forever be grateful to the CBT therapist who finally said to me, look, I think this is trauma talking, and I really want you to see someone who specialises in trauma so that you can resolve it, rather than just finding more ways of working around it. I hadn't previously thought of myself as a trauma survivor, but six months of trauma therapy shifted things that CBT never could have. Read up on top-down/bottom-up processing to understand why sometimes trauma-focused modalities help when CBT/ACT do not. (Bessel Van Der Kolk is a good place to start).
posted by embrangled at 5:21 PM on January 24, 2018
Based on personal experience, CBT/ACT was more effective for me.
There were times when CBT felt like the therapist was trying to get me to doubt or diminish my own experience. I'm sure that wasn't the intent. Much of the time, CBT was trying to get me to (and I was willing to) step back and acknowledge my biases, see my tendency to focus on worst-case scenarios, and so on. And when it worked, it was like "oh hey, look at that, maybe things aren't so bad." But at times, CBT felt like a heavyhanded sowing of doubt: "do you think you might be exaggerating?" and "are you sure it's really that bad?" and my response was to defend what I really do know to be true: I'm not exaggerating, and yes, it's that bad.
ACT was more helpful in those situations. Because ACT was like, sometimes bad things happen. Acknowledging that this bad thing happened, how do you choose to move forward from it? I felt like ACT was more respectful of my ability to know my own experience and state it accurately. And I still rely on what ACT taught me to ask myself: "knowing what happened / is happening, and knowing what my values are, how do I move forward?"
Also agreeing that the degree doesn't matter as much as whether you click with the therapist.
posted by Former Congressional Representative Lenny Lemming at 5:40 PM on January 24, 2018
There were times when CBT felt like the therapist was trying to get me to doubt or diminish my own experience. I'm sure that wasn't the intent. Much of the time, CBT was trying to get me to (and I was willing to) step back and acknowledge my biases, see my tendency to focus on worst-case scenarios, and so on. And when it worked, it was like "oh hey, look at that, maybe things aren't so bad." But at times, CBT felt like a heavyhanded sowing of doubt: "do you think you might be exaggerating?" and "are you sure it's really that bad?" and my response was to defend what I really do know to be true: I'm not exaggerating, and yes, it's that bad.
ACT was more helpful in those situations. Because ACT was like, sometimes bad things happen. Acknowledging that this bad thing happened, how do you choose to move forward from it? I felt like ACT was more respectful of my ability to know my own experience and state it accurately. And I still rely on what ACT taught me to ask myself: "knowing what happened / is happening, and knowing what my values are, how do I move forward?"
Also agreeing that the degree doesn't matter as much as whether you click with the therapist.
posted by Former Congressional Representative Lenny Lemming at 5:40 PM on January 24, 2018
This is slightly orthogonal to your question, but I wrote a research based comment on how to get the most out of therapy that might be useful to you. : https://ask.metafilter.com/41831/Nuts-and-bolts-of-effective-psychological-therapy-from-a-patients-point-of-view#643460
posted by OmieWise at 7:34 PM on January 24, 2018
posted by OmieWise at 7:34 PM on January 24, 2018
My experience is specific to the state of IL, but I think it is similar in other states. Here, you have to have a license to have your own private practice. The only place you will see MSWs/MAs practicing is generally in a community mental health type setting or a place that bills Medicaid. To bill insurance, a practitioner has to be licensed; to bill Medicaid, they do not.
I recommend looking for someone who is an LCSW or LCPC. I am about to sit for my LCSW, and in IL it meant having a Masters degree in Social Work plus 3000 hours of supervised social work experience. For an LCPC, I believe it's a Masters degree, sitting for LPC, two years of supervision, and then sitting for LCPC. Both are highly qualified do to therapy and you will probably have an easier time finding someone with those qualifications. In my geographic area, PhD psychologists in private practice are much less common than LCSW/LCPC.
Finally, I would recommend against focusing too much on research or on a strict methodology. Most therapists draw from multiple different theoretical orientations, and the most important quality in a therapeutic relationship is a good fit, IMO. Someone can be great at CBT, but if their personality doesn't click with yours, then it's not going to be as effective.
Likewise, if you are doing CBT because the research says it's the best, you might be selling yourself short. The theoretical orientation that works best for YOU will be the one that you respond to best. You may start out with a strict CBT therapist and find that it just doesn't work for you. You may have to switch therapists a few times. Finding a therapist and a treatment that works for you isn't as simple as research makes it seem.
posted by catwoman429 at 12:15 PM on January 25, 2018
I recommend looking for someone who is an LCSW or LCPC. I am about to sit for my LCSW, and in IL it meant having a Masters degree in Social Work plus 3000 hours of supervised social work experience. For an LCPC, I believe it's a Masters degree, sitting for LPC, two years of supervision, and then sitting for LCPC. Both are highly qualified do to therapy and you will probably have an easier time finding someone with those qualifications. In my geographic area, PhD psychologists in private practice are much less common than LCSW/LCPC.
Finally, I would recommend against focusing too much on research or on a strict methodology. Most therapists draw from multiple different theoretical orientations, and the most important quality in a therapeutic relationship is a good fit, IMO. Someone can be great at CBT, but if their personality doesn't click with yours, then it's not going to be as effective.
Likewise, if you are doing CBT because the research says it's the best, you might be selling yourself short. The theoretical orientation that works best for YOU will be the one that you respond to best. You may start out with a strict CBT therapist and find that it just doesn't work for you. You may have to switch therapists a few times. Finding a therapist and a treatment that works for you isn't as simple as research makes it seem.
posted by catwoman429 at 12:15 PM on January 25, 2018
This thread is closed to new comments.
posted by jeoc at 1:08 PM on January 24, 2018