So You Want to Try CBT, DBT or ACT
Starting therapy can be a daunting decision for anyone. The relationship between therapist and client is a unique – or perhaps even strange – one. For forty-five to fifty minutes, once a week, all eyes are on you, and the floor is yours to talk about whatever comes to mind. Many find their minds going completely blank in moments like this. Others open up dutifully, though may notice later on how discomfiting it can be to be participating in a relationship that is more or less one-sided: Your therapist learns a lot about you, while revealing relatively little about themselves.
And yet – a trusting relationship built over time with a warm, affirming, well-trained therapist can be a valuable resource, especially in turbulent, chaotic, and frightening times such as these. Therapy isn’t supposed to be a cryptic experience, with all the power being consolidated in the hands of the therapist and the client being acted upon.
A good therapist will help de-mystify the process for you, but before you get through the door, there are a lot of therapies to choose from. A quick look at Psychology Today lists dozens of modalities, filled with acronyms and industry jargon. So, to help guide you even more – and to help you feel more secure in interviewing a therapist – here’s the first in a series of breakdowns to help you Choose Your Own (Therapy) Adventure.
The Alphabet Soup Therapies
Some of the most well-known and popular therapies are what I refer to as the alphabet soup therapies: CBT, and its offshoots, ACT, and DBT. CBT stands for cognitive behavioral therapy. It’s one of two older schools of thought with regard to therapy (the first being psychodynamic therapy, the most well-known “talk therapy” that emerged from Freud’s “talking cure” also known as psychoanalysis.)
CBT is popular because it is evidenced-based. This just means that it has been shown to be quantifiably effective when studied; this is important, because that means that insurances will cover it. CBT is often time-limited, with treatment plans that may span 8-12 weeks (length of time is also contingent on insurance), and has been found to be at least as effective as medication for conditions like anxiety and depression.
When I studied cognitive behavioral therapy as part of my Master’s program, I was struck by how structured the sessions were. Not every CBT therapist is going to practice the same way, of course, but those who practice by the book may offer a clear, directive approach to each session: The client and the therapist collaborate to identify a goal for the client, and then the therapist, through Socratic questioning, guides the client to better understand the relationship between thoughts, feelings, and behaviors. In cognitive behavioral therapy, you’ll be assisted in identifying irrational thoughts, the emotions the emerge alongside them, as well as automatic thoughts (often taking the form of unconscious “rules” to follow, for example), and deeper held poignant and often painful core beliefs – all of which function oftentimes as barriers to our stated goals to lead happier, more authentic, and more effective lives.
There are two offshoots of CBT that you might see listed on a clinician’s bio: DBT (dialectical behavioral therapy) and ACT (acceptance and commitment therapy). As a therapist, I’m fond of both (though officially trained in neither), for different reasons. To me, DBT is just cool – specifically when you consider its origin story. It’s one of the few modalities that I know of that was created by a clinician with lived experience – in this case, it was created for clients with diagnoses of borderline personality disorder by a clinician, Marsha Linehan, who herself had borderline personality disorder. Linehan and colleagues created DBT because they noticed that a standard CBT approach didn’t work as well with clients who had borderline personality disorder. DBT includes an understanding of dialectics (opposites) as central to its approach, something useful especially when considering that splitting and all-or-nothing thinking are common experiences for those who have borderline personality. DBT does the important work of validating (rather than refuting) current patterns of thinking while also coaching and supporting client to change their behaviors. When working at a formal DBT clinic, clients meet twice a week, once for individual therapy, and once in a group, where they are able to practice what they learn (interpersonal effectiveness, distress tolerance, reality acceptance, emotional regulation, and mindfulness) in relationship with others.
ACT, which stands for acceptance and commitment therapy, also utilizes mindfulness and non-judgment in its approach to therapy. ACT also has to do with the interplay between our thoughts and are identities – are you “just an anxious person” or are you a person who is feeling anxiety due to XYZ circumstances in your life? Similar to DBT, ACT encourages clients to accept their current state while simultaneously making a commitment to changing it, though the exercises and prompts that therapists may use in ACT differ from those in DBT by being more experiential than educational (and ACT also lacks the group or relational component of DBT).
Are the alphabet soup therapies right for you?
So, how would you know if CBT, ACT, or DBT are right for you?
One thing to consider is how they are different from more traditional talk therapies. The behavioral therapies are more firmly located in the here and now, the present, than, for example, a more psychodynamic, which can be more reflective and more focused on helping you understand your past as it relates to your present. Of course, this doesn’t mean that you’re not at all allowed to talk about the things you’ve been through, and upon intake, many therapists – as a means of building rapport – will likely want to get a sense of who you are and where you’ve been. Similarly, the core beliefs that are often revealed in cognitive behavioral therapy didn’t spring out of nowhere – but they also aren’t likely to be lingered upon and excavated.
When considering what approach is right for you, it’s also important to consider what it is you’re struggling with in terms of your mental health, and what you want to change. As mentioned above, CBT is shown to be reliably effective in treating anxiety and depression – but trauma therapist Peter Levine noted in Trauma and Memory that cognitive approaches might now be the best suited for deeper trauma work. Levine specifically cautions clinicians in using yet another offshoot of cognitive behavioral therapy – prolonged exposure therapy – in working with clients with PTSD, because the continuous hashing and rehashing of traumatic events can (unsurprisingly) be extremely stressful for clients – even to the point of increasing anxiety and worsening symptoms of post-traumatic stress disorder.
DBT, of course, was designed for clients with borderline personality disorder, though is not only for clients who have borderline personality disorder. Many of the aspects of DBT were created to help support clients through deeply intense feelings, specifically those around suicidal ideation and self-harm. Also, given the group component to DBT, I would certainly recommend it as something to consider looking into more for folks who experience a lot of intensity, highs and lows, ups and downs, and all or nothing thinking in relationships. One way to practice relationships, of course, will come out within the therapeutic alliance (a fancy way of saying, how you get along with and experience the relationship with your therapist). But your groupmates, located more as peers, also provide invaluable practice and information in terms of relating.
Finally, ACT might be for you if you’re unsure of, or feel conflicted about, your values. ACT, like DBT, uses mindfulness – but also underscores the importance of acting in integrity with our values as a means of reducing distress and anxiety. This is easier said than done, of course. For example: it’s one of my goals to read more and doomscroll less, something I haven’t quite gotten the hang of yet, because it brings two of my values into direct competition: Prioritize self-care and lifelong learning (read more), and stay well-informed of current political events (doomscroll). With an ACT therapist, I would be in a supported environment to mindfully and non-judgmentally observe what arises during this conflict, identify more specifically what my core values are, and explore what it might look like to act in integrity with those values – and then commit to that.
TL;DR: Is DBT Right For Me?
DBT might be right for you if you notice that you’re prone to intense or unstable relationships, high intensity mood swings with very high highs and very low lows, and a pattern of impulsivity in your decision-making that often leaves you feeling regretful of your actions. DBT helps provide clients with tools to better understand and regulate their emotions in order to have happier, healthier relationships with themselves and others.
TL;DR: Is ACT Right For Me?
ACT might be right for you if you seek a more action-oriented approach to therapy. ACT is helpful in getting clients to overcome avoidance and denial by encouraging non-judgmental, mindful observance of existing behaviors, and supporting clients in identifying whether those behaviors are aligned with their values. Often, when the actions we take are out of alignment with our values, we feed stress, anxiety, and other painful emotions. ACT helps you accept and contextualize these negative feelings, rather than trying to avoid or minimize them, in order to get you moving forward with your commitment to change what you want to change in your life.
How to vet your therapists
If you’ve ever perused Psychology Today or any other listing site for clinicians, you might notice that many therapists include a laundry list of modalities in which they are competent. And certainly, we get a lot of exposure to different types of therapy in school, in continuing ed courses, and in supervision. But if you’re really, really interested in one of the above therapies, make sure you’re ask your therapist about their training. You’ll have a different experience, for example, with a clinician who has spent a couple of years receiving training and building expertise at the Beck Institute for Cognitive Therapy Training (like my amazing professor – thanks Prof Q!) than you will with someone like me, who took one dope semester of it as an elective in my Master’s program, but otherwise doesn’t have any further training or certification.
Remember, it’s okay to ask questions! You can ask specifically about their training – “What types of therapies are you certified in, and how do you typically make use of these training in sessions?” You can also describe what you hope to get out of therapy by saying something like, “I’m hoping for a structured, directive approach to understanding my social anxiety/my relationship patterns/why I say and do things more impulsively than I’m comfortable with. How would you address that in session?” Also remember – the cognitive behavioral therapies often come with homework – things to experiment with in-between sessions that you and your therapist then discuss together. DBT, in particular, has a whole workbook of skills. If this is something that you want to be part of your therapeutic experience, you can mention that, too.
Most importantly – take note of how your prospective therapist responds to being questioned. This is something to be aware of even beyond vetting for modalities and training, but just in general. Does your therapist have a vested interest in being perceived as the “expert” in the room? What would it mean for you if so? In my opinion, there’s nothing wrong with a more eclectic approach – I draw from elements of the alphabet soup therapies as they apply, and as my ongoing reading, training and participation in continuing education courses, and supervision, broadens what I’m able to offer in terms of my approach. But just know that, just as you’d research a medical doctor or specialist, you are certainly welcome – and encouraged – to do some digging about your therapist. After all, if they do their job right, you’ll be sharing some your most vulnerable self with them – and they need to be up to that responsibility and honor.
Tune back in next week for the next episode of Choose Your Own (Therapy) Adventure: The Trauma Therapies.