CBT in Denmark
Historical development of behavioural and cognitive therapy in Denmark:
In Denmark interest in behavioural approaches began late and developed only slowly.
This failure to thrive may to a large extent have been due to the continuing absence of
an academic base for research, theoretical development and training. In the
department of psychology at the University of Copenhagen experimental
phenomenology was, until the late 1960s-early '70s, the predominant school of
thought. Though fine and original contributions to general psychology were made
from this centre, only limited time was given to the development of other fields or
approaches. Though a more pluralistic climate developed from around 1970, student
interests centred mainly on, among others, Freudian and Marxist schools of thought.
Fields such as the experimental psychology of learning were not prominent and little
applied research was completed. During this period the field of clinical psychology,
as applied in e.g. adult and child psychiatry, remained almost exclusively
psychoanalytic in orientation.
Thus, behavioural psychology had only a few, though very committed, advocates in
academic positions - among these were Melvin Lyon at the University of
Copenhagen, Mogens Brun at the Royal Highschool of Educational studies and
Thomas Nielsen at the University of Århus – and their teaching positions were in
general psychology, rather than clinical. In addition to these, a small number of
individual clinicians and students were inspired by the literature on behaviour therapy
and in 1975 the Danish Association for Behaviour Therapy was founded (with
psychologist Preben Wagner as its first president).
In the absence of a major centre of research or clinical excellence, members were
encouraged to form local groups for study of basic literature and for mutual
supervision of clinical work.
During the following years the DABT organized a number of workshops with
prominent foreign practitioners and theoreticians in behaviour therapy – from the
U.K. Victor Meyer was a regular visitor and his emphasis on individual case analysis
became a major influence on many clinicians in the DABT. During the same period
several visits by Fred Kanfer provided further theoretical and clinical inspiration at an
advanced level. A number of workshops by other outstanding foreign clinicians and
researchers followed, all crucially important in providing models of excellence in
CBT; these included Ron Ramsay, Peter McLean, Charles Ferster, David Lane,
Robert Sharpe, Sheldon Rose, Richard Stuart, Joseph LoPiccolo, Fanny Duckert, Ivar
Hand, Lawrence Burns, Ivar Løvaas, Martin Seligman, and several others.
During the 1980s individual clinicians in psychiatry, school psychology and special
education were increasingly applying behaviour therapy in their work with clients.
However, behavioural psychology was still controversial and the widespread
misunderstandings of the approach provided an ongoing challenge for practitioners.
Little clinical research was conducted on issues directly related to theory or practice
in behaviour therapy; an exception was a study on effects of controlled drinking as a
treatment goal with alcoholics; the study was done in the early eighties at the St Hans
Hospital by Per Vendsborg and Karin Sønderbo. In general, however, the lack of an
applied research tradition was still evident and progress was can be attributed to the
work and teaching of individual clinicians.
The increasing emphasis on cognitive concepts in the field during the '80s appeared
to stimulate new interest and perhaps facilitated the already slowly increasing interest
and acceptance among a slightly larger number of practitioners. Like several
organisations abroad, the DABT updated its name and became the Danish
Association for Behavioural and Cognitive Therapies ( S.A.K.T.). As in other
countries this development was the cause of theoretical controversy within the field,
but this was limited and fairly short-lived - perhaps due in equal measure to the small
number of people involved and the pragmatic, rather than philosophically committed,
position of many clinicians. (Some observers might attribute the smoothness of this
transition to the easy-going attitude said to be typical of the Danish national
Denmark joined the European Association in 1979. During an international meeting
a decade later, the president of DABCT Irene Oestrich offered Copenhagen as the
host of the world Congress scheduled for 1995. Irene has been a founding member of
the Danish association, was well known in DK as an author and workshop leader in
CBT. She was determined that the congress should accommodate both behavioural
and cognitive approaches at a time where separate events were increasingly being
planned. Working closely with the behavioural and cognitive scientific committees
(chaired by L-G. Öst and David M.Clark, respectively) Irene and the organising
committee secured a memorable World Congress in Copenhagen in July 1995. Over
a thousand 1000 delegates from 39 countries attended the event. As intended, the
programme included both behavioural and cognitive contributions - prominent
among these were presentations by founding fathers of the field such as Joseph
Wolpe and A.T.Beck.
The congress was considered highly successful by delegates and participating
organisations. Interestingly, the number of Danish delegates was very modest -
indeed, twice as many colleagues attended from e.g. Sweden or the U.K. and even
Australians vastly outnumbered the locals! However, in the following year’s interest
in CBT among Danish mental health professionals has increased considerably and the
DABCT has more than tripled its membership in the last 8 years. Reasons for this
may include the success of the World Congress as well as the zeitgeist of increased
focus on evidence-based treatments. A crucial role has been played by a more local
phenomenon, namely the great organisational, educational and diplomatic talents of
the next DABCT president, psychologist Lennart Holm. During those years a model
of basic and advanced training courses were developed, combining workshops and
group supervision. In these activities we have been fortunate in having the help of
prominent foreign colleagues.
During the same period a group at the University of Århus and Risskov University
Hospital (including Merethe Mørch, Nicole Rosenberg, Esben Hougaard and others)
had launched training programmes and authored several books on CBT, providing
much-needed literature in Danish.
The training courses are now available in several parts of the country have been
completed mainly by psychologists and psychiatrists, but also by nurses, social
workers and physicians in general practice. In several psychiatric hospitals staff have
been trained in CBT and an recent multi-authored book on Cognitive Behavioural
Milieu Therapy has been published recently. At the large psychiatric Sankt Hans
Hospital a Centre of Cognitive Therapy has been established with Irene Oestrich as
director. An ongoing research project on the treatment of low self-esteem in
psychiatric patients is been undertaken in collaboration with Nick Tarrier and
colleagues at the University of Manchester.
Another piece of applied research undertaken on the treatment of hypochondriasis,
comparing cognitive-behavioural treatment (based on Paul Salkovskis' work) with
standard psychiatric care. This project is done jointly by a large private CBT-clinic
and a department of liaison psychiatry at a Copenhagen hospital.
In April 2003 Denmark once more hosted of an international event, this time the
Nordic Congress in CBT, with a program covering a wide range of topics and
presenters including Art and Christine Nezu, Ed. Craighead, Lars Göran Ôst, Erikur
Arnasson, Terro Timonen and many others.
In the light of the many other positive developments already mentioned it seems that
cognitive-behavioural therapy has, at long last, gained a permanent recognition and a
growing position in this country.
The current activities reflect the growing impact CBT is having on adult psychiatry
(and in the private practice sector). A correspond in child psychiatri is yet to take
place. However, the DABCT has recently successfully held its first training course on
CBT with children, again combining workshops by foreign and national authorities
(incl. Phil Kendall, Tom Ollendick, Will Yule, Tammie Ronen, Tony Attwood and
others) with group supervision by experienced local clinicians.
In the year of 2002 we completed the first training program on supervision. The
course was established in collaboration between Irene Oestrich and Lennart Holm
from the eastern part of Denmark and Nicole Rosenberg from the western part of the
country. Training supervisors as well as therapist are of crucial importance for the
future development in the field and DACBT has training as one of our main task. We
will continue to expand our training opportunities for clinicians and other mental
health professionals, in line with the requirement for further professional
development as deemed by the Psychological Association and the Psychiatric
Psychologists and psychiatrists qualified to carry out psychotherapy.
In order to become approved as specialist in psychotherapy one needs 600 hours of
practical works (including therapy hours, evaluation etc.), 200 hours of supervision
100 hours of personal training or therapy and 300 hours of theory and method within
different themes (incl. psychopathology, theory on psychotherapy etc.). The
supervision has to include minimum 125 hours from the tradition one wishes to
specialise in and 50 hours from a different school of thought. The training can begin
after one has acquired the status of authorised psychologist, which takes a minimum
2 years of working as a psychologist, while receiving supervision and participating in
ongoing professional development.
Qualification of supervisors: The training can begin when one has specialised in
psychotherapy and worked minimum 5 years after authorisation. The training
includes minimum 120 hours of providing supervision to other psychologists or
psychiatrists within a 2 years period. The training also includes 40 hours of
supervision on ones own supervision and 30 hours of teaching on theory and methods
Psychiatrists receive a basic psychotherapy training which includes 60 sessions of
therapy and 60 sessions of supervision. This training can be followed by a
specialisation in psychotherapy, which includes 60 hours of theory, and between 60
and 90 hours of supervision depending on whether it is individual or group therapy.
The program also includes personal therapy and some theory and supervision from
another psychotherapy tradition than the one one’s specialised in.
DACBTs basic training program is approved by the Danish Psychological
Association to accredit for 66 hours of theory and 30 hours of supervision or personal
training. And our advanced course is also accridited. In the beginning there were
some discussion regarding the idea of “personal therapy” per se in order to be
approved as a therapist. The tradition of therapist receiving personal therapy has
never been prominent within our field. One could argue, as we did, that in order to
secure the integrity and the ethical position of the therapist, video supervision would
be a more suitable method, rather than requiring therapist working out personal
issues. The Psychiatric Association has been less flexible on this issue and they still
require feedback on personal style and supervision to be separated.
We are now in the process having the supervisor training approved by the
Psychological Association and the Psychiatric Association.
DACBT currently has 350 members and we run a one year basic introductory course
in CBT, a series of advanced courses and a supervisor training course well as we also
run a number of open workshops with internationally recognised workshop leaders.
Antonia Sumbundu has chaired the association since spring 2002, when the office
moved to St. Hans Hospital in Roskilde.