How do I choose a therapist and a therapy approach?

Choosing a therapist can be an overwhelming task. One look in the yellow pages shows lists of names, and not everyone lists in the yellow pages. The many possible credentials of therapists is one factor to consider. Some people identify themselves as therapists but do not have credentials that require licensure within their state. In general, a licensed practitioner has been through a screening process that usually involves testing within their field. The level of training is another consideration. There are master's levels (social workers), doctorate levels (psychologists), as well as medical doctorate levels (psychiatrists) who conduct psychotherapy. Clinicians of various credentials may then have further training within a specific area of psychotherapy, such as psychoanalysis.

If you believe you will need medication, it may be more fruitful to see a psychiatrist who also performs psychotherapy. Because of cost considerations, however, this option is not always feasible. Many insurance plans provide reimbursement for a master's level therapist only, and fees are usually less than that for psychologists or psychiatrists. If there is a specific

treatment modality in mind, one method of finding a therapist is to obtain referrals from professional societies for that specific modality. If modality is not the issue of concern, referrals can be obtained from a primary care physician. Questions may be asked of the therapist over the phone and a consultation arranged. If you are uncomfortable with the therapist after the consultation, it is important to consider the reasons for your discomfort. For example, discomfort may be due to individual psychological issues at the heart of the problem that are projected[1] onto the therapist immediately and thus quitting the therapist may not solve the problem. However, a fit with the therapist's style needs to be achieved to develop a working relationship.

What is cognitive—behavioral therapy?

Cognitive-behavioral therapy is based on two separate theoretical models, both cognitive and behavioral. Cognitive models are based on the premise that cognitions, or thoughts, determine emotions and behavior. Automatic thoughts[2] are one type of cognition that may be distorted by errors of thinking such as over-generalization[3], catastrophic thinking[4], jumping to conclusions, or personalization. Errors in thinking tend to be more frequent and intense in depression as well as in other psychiatric disorders. Behavioral models are based on theories of learning such as by modeling or by reinforcement to certain responses.

Cognitive-behavioral therapy is an approach that uses techniques based on the models described previously here. A greater emphasis on cognitive approaches or on behavioral approaches may be taken depending on the disorder and the stage of treatment. Cognitive techniques include

• Psychoeducation

• Modifying automatic thoughts

• Modifying schemas[5]

Behavioral techniques include

• Activity scheduling

• Breathing control

Contingency contracting[6]

• Desensitization/relaxation training

• Exposure and flooding[7]

• Social skills training

Thought stopping[8] /distraction

Through many of these techniques patients learn to manage their anxiety and reactions to stress appropriately. Exposure training is a technique that uses graded exposure[9] to a high-anxiety situation by breaking the task into small steps that are focused on one by one.

Cognitive-behavioral therapy has been the best studied form of psychotherapy and has been shown to treat depression effectively. It is probably more appropriate in cases of mild to moderate depression that is acute. Treatment typically lasts 3 to 6 months with 10 to 20 weekly sessions. The patient is expected to be an active participant in trying new strategies and will be expected to do homework.

  • [1] the attribution of one's own unconscious thoughts and feelings to others.
  • [2] thoughts that occur spontaneously whenever a specific, common event occurs in one's life and that are often associated with depression.
  • [3] the act of taking a specific event, usually psychologically traumatic, and applying one's reactions to that event to an ever increasing array of events that are not really in the same class but are perceived as such.
  • [4] a type of automatic thought during which the individual quickly assumes the worst outcome for a given situation.
  • [5] representations of the world in the mind that affect perception of and response to the environment.
  • [6] a behavioral therapy technique that uses reinforcers or rewards to modify behaviors.
  • [7] a behavioral therapy technique that involves exposure to the maximal level of anxiety as quickly as possible.
  • [8] a technique used to suppress repetitive thoughts.
  • [9] a psychotherapeutic technique that uses gradual exposure through a hierarchy of anxiety-provoking situations. This may begin with imagery techniques first and then progress with limited exposure in time and intensity before full exposure occurs.
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