The Ten Worst Errors Therapists Make–and How to Avoid Them*
©2012 by David D. Burns, MD
Do not copy, publish or reproduce without the written permission of Dr. Burns.
Really good therapy may tend to go against human nature to a certain extent. Unfortunately, therapists keep gravitating toward familiar approaches that are comfortable but ineffective. I have created a list of the ten most common errors therapists make, with the solutions I have proposed for each error. In today’s blog, I will focus on the first of these errors.
Error #1. The Failure to Measure
The great majority of therapists want to work “intuitively,” without quantitative assessment of changes in symptoms each session, and without a quantitative assessment of the quality of the therapeutic alliance. This failure to measure results from the belief that we “know” fairly accurately how our patients are thinking and feeling, based on our training as well as our own feelings and perceptions during the session.
My research and clinical experience have indicated that this belief may be misguided and, in some cases, even dangerous. Therapists’ perceptions of how their patients feel tend to be inaccurate. In other words, your patient could be enraged, and yet you may believe that she or he is not at all angry. Or your patient could have significant negative feelings about you as well as the treatment you are offering, but you may be convinced that you have developed warmth and understanding with that patient. Or, your patient could be planning a suicide attempt within the next couple days, but you may think that he or she is making good progress and feeling a lot better.
Here’s my solution to this problem: My colleagues and I require all patients to complete the Brief Mood Survey (BMS) in the waiting room immediately before each sessions begins, indicating how they feel right now. The BMS includes brief, highly accurate scales that measure depression severity, suicidal urges, anxiety, anger, relationship problems, and positive feelings such as joy, self-esteem, and productivity. It only takes about one minute to complete the BMS.
The patient hands the BMS to the therapist at the start of the session, and the therapist will instantly know exactly how the patient is feeling. The therapist records the scores on a flow sheet in the chart—this takes less than 15 seconds, and a glance will show the therapist exactly how much, or how little, the patient has been progressing since the first session. The therapist also knows exactly how disturbed the patient is feeling right now, at the start of the session, so any serious problems can be addressed.
After the session is over, the patient completes the BMS once again in the waiting room, indicating how she or he feels right now. The patient also rates the therapist on warmth, empathy, helpfulness, and other therapy process dimensions, using extremely sensitive scales, and writes down what he or she liked the least, and the most, about the session. It takes the patient about two minutes to complete the end-of-session assessments. The patient leaves these end-of-session assessments in the therapist’s box before going home.
You can review this information right away, when the session is still fresh in mind. It is like having the world’s greatest supervisor providing specific and accurate feedback at the end of every single therapy session. You will discover exactly how effective you were (or weren’t), and how much your patient improved (or failed to improve) during the session. If you are courageous, this information has the potential to transform your clinical work. However, humility will be required, because the information will often be disturbing to you.
In the Bible, there is mention of the “unforgiveable sin.” Theologians have debated about what this sin might be. I have to confess that I don’t know the answer, but I do believe there is an “unforgiveable sin” that therapists make—and that is the failure to measure. I am convinced that it is impossible to do world-class therapy without measuring at each session. I also believe that the failure to measure reflects a kind of therapist arrogance, or narcissism—the belief that we are “experts” and that our own perceptions of how patient feel (or feel about us) are somehow more accurate than the patient’s perceptions of how they actually do feel. In most cases, nothing could be further from the truth.
Some therapists resist the use of the assessment scales, arguing that patients won’t be honest in the way they fill them out, and will simply tell therapists what they think the therapist wants to hear. Once again, nothing could be further from the truth. When my students (psychiatric and psychology graduate students) use the assessment scales initially in the clinical work, most get failing grades from nearly every patient at nearly every session. So their patients are NOT telling them what they want to hear—they are telling them what they DON’T want to hear!
How about seasoned clinicians like yourself? Unfortunately, your experience will probably be similar. Initially, most seasoned clinicians receive failing grades on the therapeutic empathy and therapy helpfulness scales from almost every patient as well. This can be a huge blow to the ego, and it is one of the reasons that many clinicians refuse to use the scales. They can’t stand the heat.
But there is a silver halo around this cloud. Most students and community clinicians who use the scales with every patient at every session, and who do some Empathy Training using methods I’ve developed, report that within a few weeks, they receive perfect scores 80% of the time, rather than failing scores nearly 100% of the time. So there is hope for a remarkable transformation in your clinical skills—if you have the courage to take this huge step!
Thanks for listening. David Burns, MD
Remarkable post Dr. Burns, especially how in therapy school and subsequent training I was taught to get better at working intuitively as you mentioned in the opening paragraph! It looks like the therapist reads the post-session assessment after the patient has left. What do you do if the assessment shows the mood is worse or that the patient has suicidal urges (and by now the patient is gone)?
Thanks, Mike. If the post-session assessments show that the patient has gotten worse, it usually means that your approach was poor, and you can think about how to change between sessions, and process the patient’s feelings at the next session. This is how you grow and evolve as a therapist, although it can be painful to discover that your approach is not only ineffective, but the patient is feeling worse. It can also mean that you said something that hurt the patient’s feelings, or upset the patient. It is vitally important to process this with the patient and let it help guide the session. A third possibility might be that the patient touched on something upsetting that needs further work, such as a traumatic event the patient mentioned during the session, something perhaps that he or she has not dealt with.
If you discover that the patient has become suicidal, you can get on the phone and find out if the suicidal urges are serious, and urge the patient to come back immediately for further evaluation, or go to an emergency room immediately. If the patient refuses, you can call 911 and ask the police to intervene.
Hope this is helpful!
Very helpful – thank you! I appreciate how generous you are with your time and expertise.
You’re welcome! david
Thank you Dr. Burns, this actually incouraged me to use more assessments in class aswell (being a French and English teacher). Thank you so much for your honest and always encouraging words. You never disappoint!