Answers to Questions from a Psychology Today Blogger

* ©2008 by David D. Burns, MD

Do not copy, publish or reproduce without the written permission of Dr. Burns.

Hi everyone. The following are some questions I answered for a Psychology Today blogger about psychotherapy. I had a lot of fun answering these questions, and I hope you enjoy reading my answers. Let me know what you think!

(Soon I will continue with my series on Secrets of Self-Esteem.)

How would you respond to a new client who asks: “What should I talk about?”

The goal of therapy is not to talk about things, but to change the person’s life, and to relieve suffering, such as depression, anxiety, relationship problems, or habits and addictions. Of course, empathy and skillful listening are important at the start of each session, but they are simply not sufficient to change the patient’s life. You can talk until you’re blue in the face, and therapist can nod and mutter, “Tell me more,” but you’ll still be suffering from PTSD, or OCD, or depression, or lousy relationships with other people, or whatever your problem is.

After a period of empathy and listening, I always ask a question along these lines: “I would like to offer you something more than just support and listening, although that’s obviously of great importance. I’m wonder if there’s something you want help with in today’s session? You’ve mentioned a lot of heartbreaking issues today—your brother’s heroin addiction and suicide, they way your ex-wife has been abusing you, your problems with your son, and your social anxiety. I have many powerful tools to help you deal with these problems, and I’m wondering if this would be a good time for us to roll up our sleeves and get to work. Or, if you need more time to talk and vent, that’s okay too. I don’t want to jump in prematurely, before you’re ready.”

This gives the patient three messages: 1. I’m aware that you’re suffering. I’m concerned, and I’m here to support you. 2. I have much more to offer you than just listening, and more will be necessary if you really want to change your life. 3. Change is possible if we work together as a team.

Once the patient has described the problem, I conceptualize the nature of the problem and explore the likely reasons for resisting change in a kindly way, so as to reverse resistance, using paradoxical techniques. I also begin to think about the techniques that will be most likely to help the patient. I use approximately 50 techniques, such as the Interpersonal Downward Arrow, the Paradoxical Cost-Benefit Analysis, the Daily Mood Log, the Externalization of Voices, the Acceptance Paradox, and more. Some techniques are exceptionally powerful for depression; some work well for the anxiety disorders; some are helpful for relationship problems; and some are great for habits and addictions. There’s no one panacea that works for everything.

What do clients find most difficult about the therapeutic process?

There is no standard “therapeutic process,” since there are so many different schools of therapy. I tend to think in terms of “Outcome Resistance” and “Process Resistance.” Here’s how to think about Outcome Resistance. Imagine that there’s were a magic button on this desk, and if you push it, all of your symptoms (such as depression, or panic attacks, a troubled marriage, or a bad habit or addiction) will instantly disappear, with no effort, and you’ll go out of today’s session in a state of euphoria. Will you push that button?

As it turns out, many people will NOT push the button, or would be highly ambivalent about it. For each person, the reasons will be different, but they are generally overpowering. Furthermore, Outcome Resistance is radically different for each of the four common targets: depression, anxiety, a relationship conflict, or habits and addictions). So there are four common, but distinct, types of Outcome Resistance.

Here’s a brief example of Outcome Resistance for depression. A 37 year-old Catholic woman from San Francisco came to me for treatment after ten years of intractable, severe depression following an abortion. She’d had psychotherapy from numerous therapists and a multitude of antidepressants, but nothing had helped. The thought that was creating her intense pain and self-loathing was: “I deserve to suffer forever because I murdered my baby.”

Will she press the Magic Button? Obviously not, and there are many possible reasons. First, she appears to see her suffering as a spiritual necessity, and her depression allows her to attain a kind of moral purity. She is playing many roles—judge, jury, and executioner, as well as the role of the convicted felon who is depressed and suffering. She thinks she MUST suffer in this way.

In addition, in her mind, her baby probably hasn’t really died yet. She is keeping him alive with her depression, thinking about him every day. Her depression is her tribute to her baby. If she overcomes the depression, she may have to grieve, let go, and move forward with her life. And there are several other powerful issues that keep her stuck as well. If the therapist does not take these motivational factors into account, and deal with them with compassion and skill, she will simply resist—which is exactly what had been happening for the previous eight years.

Process Resistance is quite different from Outcome Resistance. In Process Resistance, you might WANT to change, but you don’t want to do what you’ll need to in order to change. For example, let’s assume that you’re suffering from some type of anxiety, such as the fear of heights. We can say for certain that some form of exposure to heights will be mandatory if you want to defeat this fear. The same goes for every other type of anxiety: exposure will be necessary. Of course, most patients with anxiety will powerfully resist using exposure, since exposure can be terrifying. But there is no Magic Button. Exposure will be necessary if you want to defeat your fears. It’s not negotiable. So addressing the resistance up front is critical to success.

I had the fear of heights when I was young, along with many other fears and phobias, including the fear of dogs, bees, horses, and blood. When I was in high school, I wanted to be on the stage crew for the play Brigadoon, but the drama teacher, Mr. Bishop, told me that he couldn’t accept any students with the fear of heights, since the stage crew had to work up near the ceiling, with the lights and curtains and such. I told him I had the fear of heights. He said I couldn’t be on the stage crew, unless. . . I was willing to get over my fear.

I said I was very willing, but didn’t know how. He said it was easy, and he’d show me right then and there if I wanted. I said, “Great, let’s do it.”

He brought me into the theatre, and set up a 12 foot ladder in the middle of the stage, so it wasn’t close to anything. He said, “All you have to do is get up on the top rung of that ladder and stand there.” I asked, “Is that all you have to do?” He said “Yes, that’s how you do it.”

I was young and naïve, so I bravely started climbing up that ladder. By the time I reached the top, my fear was 100 on a scale of 0 to 100. In fact, I was terrified, and there wasn’t anything to hold onto. He was way below, standing next to the ladder. I said, “What should I do now, Mr. Bishop?” He said, “Nothing, just stand there until you’re cured.” I said, “But isn’t there something I’m supposed to do?” He said, “No, just stand there.”

Fifteen minutes went by and my fear level was still 100. I said, “I’m still anxious.” He said, “That’s okay, just wait it out.’

Another five minutes went by, and my fear suddenly started to disappear. It took about five seconds, and suddenly it had vanished entirely. I wasn’t afraid. I said, “I think I’m cured now, Mr. Bishop.”

“That’s great,” he said. “You can come down now and you can be on the stage crew of Brigadoon.” After that, I LOVED heights. I always wanted to be the one to go way up to the ceiling and work the highest lights. I couldn’t even remember what it was like to have the fear of heights. In fact, sometimes, when you defeat a fear, the thing you feared so intensely becomes a source of great pleasure. But there was a price to pay. You can’t defeat any type of anxiety simply by lying on the couch and talking about the past while the therapist mumbles, “Tell me more.”

Process Resistance also differs radically for each of the four common targets: depression, anxiety, a relationship conflict, or habits and addictions. This means that there are eight common types of resistance—there are four types of Outcome Resistance, and four types of Process Resistance. Clients will sometimes have several forms of resistance operating all at once. That’s because they may be depressed and anxious at the same time, and may also be struggling with loneliness or troubled personal relationships.

My colleagues and I have developed powerful new techniques that allow therapists to pinpoint and reverse each patient’s resistance before using any techniques to solve the specific problem. The integration of these motivational techniques into the therapy has led to tremendous breakthroughs in our treatment, and we are now seeing extremely rapid recovery in a high percentage of the patients who come to us for treatment.

What mistakes do therapists make that hinder the therapeutic process?

Nearly all therapeutic failures result from what I call “Agenda Setting errors,” or the complete failure of the therapist to set the agenda. Most therapists do not appear to know how to pinpoint and reverse therapeutic resistance—to head it off at the pass. Instead, they try to persuade the patient to change, or to do the psychotherapy homework, while the patient resists and yes-buts the therapist. The therapist ends up doing all the work and feeling frustrated and resentful.

Most therapists believe they understand Agenda Setting, but they don’t. It appears easy, but it is the most sophisticated and difficult therapeutic skill of all. The paradoxical Agenda Setting techniques my colleagues and I have developed represent, we believe, a major advance in therapy.

A second mistake is to join a school of therapy, such as psychodynamic therapy, cognitive therapy, EMDR, ACT, or TFT, or whatever happens to be in vogue. I’m all for TOOLS, not SCHOOLS, of therapy. To me, the schools of therapy compete much like religions, or even cults, all claiming to know the cause and to have the best method for treating people. And new schools of therapy seem to get created almost every week, always with a guru and always with enthusiastic followers who are sure they’ve found “the answer.”

The third big error is the failure to measure the patient’s symptoms and the therapeutic alliance at every session. My formal and informal research at Stanford has revealed that therapists’ perceptions of how patients feel—how depressed or suicidal they are, how anxious they are, or how angry they are—are poorly correlated, and often entirely uncorrelated, with how patients actually feel. But therapists, including psychiatrists and psychologists alike, don’t realize this, and wrongly believe that they ARE reasonably sensitive, when they really aren’t. In fact, that’s one of the most common causes of suicide—the therapist didn’t realize just how depressed and despondent the patient was.

To solve this problem, I’ve created brief, highly accurate scales that measure depression, suicidal urges, anxiety, anger, and relationship satisfaction, along with positive feelings such as joy, creativity, and intimacy. Patients complete the scales in the waiting room just prior to, and after, every single therapy session, recording how they’re feeling right now, at this exact moment. After each session, they also rate the therapist on warmth, understanding, and helpfulness, and describe what they liked the least and most about the session. These forms only take a minute to complete, yet allow therapists to see, for the first time, how their patients actually feel, how much they’ve improved (or failed to improve), and how the patient really experienced the therapist, at every single therapy session. Because patients complete these scales before and after the session, leaving them in the office before they go home, it actually doesn’t take any time from the therapy

This practice, perhaps more than anything else, has led to a revolution in how we do therapy, by making both therapists and patients far more accountable. Our patients become our greatest teachers, because they tell us what’s working and what’s not working for them. I can’t imagine doing effective therapy without these assessments. But it requires courage to do, because you often discover that your patients’ feelings about you are very different from the way you thought. And for some reason, patients feel far more open and candid when completing these therapy evaluations on paper. In fact, they can be surprisingly honest and critical of therapists—far more so than in actual sessions.

Often narcissistic therapists—and there are many—cannot tolerate the assessments, because the patient feedback is too devastating to their sense of self-esteem. And for the rest of us, it can be painful to recognize we’re not as helpful, warm, and understanding as we thought we were. The reward, however, is a far more authentic, trusting, and ultimately effective therapeutic alliance.

In your opinion, what is the ultimate goal of therapy?

There is no “ultimate goal of therapy.” Thinking there is some ultimate or universal goal of therapy is one of the most fundamental errors of our field. To me, that concept is rather arrogant, as if therapists were some kind of spiritual experts who knew what human beings are supposed to be like.

Instead, I ask patients to describe a specific moment when they felt upset, a moment they want help with. It can be any moment, and any type of problem, but it has to be real and specific as to person, place, and time. A vague complaint, like the young woman who said, “Life stinks,” isn’t very useful. I might have to ask, “Where were you when you noticed the smell? What was going on?”

The problem the patient wants help with could be a moment of depression, or a recent panic attack, or an argument with his or her spouse, for example. Then I explore motivational issues, taking into account Outcome Resistance and Process Resistance. Once the resistance has been overcome, I use a wide variety of techniques to help the patient solve the problem. The techniques that are the most effective will differ for different types of problems. In other words, the techniques that are the most helpful for depression, anxiety, anger / relationship problems, or addictions are quite different from each other.

I see my role as a hired helper, and my patient is my boss. The patient describes the problem she or he wants help with. But when the patient really comprehends what was going on at that moment in his or her life, and suddenly learns how to turn that problem around, they often experience a kind of enlightenment, and all their problems will fall apart at that moment, much like a house of cards. The depression suddenly gets transformed into joy and laughter, for example. This is a tremendous event to observe and participate in, and it is part of what makes therapy such a joyous and amazing experience for me.

What is the toughest part of being a therapist?

Skillful, state-of-the-art therapy requires constant practice and training. For the past eight years, I have been running a weekly psychotherapy training and development group at Stanford as part of my volunteer teaching for the Department of Psychiatry. The group now meets at my home, and is open to therapists in the community, as well as Stanford students. The group is a very rewarding experience. In fact, it’s the highlight of my week. But it’s not always easy. The therapists who attend have to practice, using role-playing techniques in a variety of challenging scenarios. They get graded immediately, and have to face their failures in order to grow. If you can check your ego at the door, this is tremendous fun and a terrific learning experience. But if your ego gets involved, it can be rather intimidating to have to fail in front of colleagues you respect and admire.

The same thing happens in therapy. As I mentioned above, I’ve developed extremely sensitive scales that patients fill out in the waiting room after every single therapy session. They rate their therapists (including me) in a variety of dimensions, such as Empathy, Helpfulness, Satisfaction with the session, Negative Feelings during the session, and other variables. Although most therapists believe that they are warm, caring, and effective, most are shocked to discover that they get failing grades from practically every patient at every session when they first begin using these scales. This is extremely shocking to novice as well as advanced therapists. However, with training, therapists can learn to transform those therapeutic failures into tremendous breakthroughs, and over time, their ratings begin to soar.

Learning to accept failure on multiple levels is, to my way of thinking, the key to become a world-class therapist. But that means humility, and setting your ego aside, while you develop superb new technical skills.

What is the most enjoyable or rewarding part of being a therapist?

Seeing people change—the sudden transformation of depression, hopelessness, and worthlessness into joy and self-esteem. Or suddenly defeating a fear. Or suddenly learning to let go of anger, blame, and resentment. Those experiences of sudden and profound change always blow my mind. I love that experience, and it happens often. This is the true gift of a career as a therapist.

What is one pearl of wisdom you would offer clients about therapy?

We are seeing high speed changes in patients now, true rapid recovery. Many patients are now showing dramatic gains, or complete recovery, in just a handful of sessions, using the powerful new methods we have been developing.

What saddens me is seeing patients who have been going to therapy for years and years with no change, but they keep going to the same therapist. To me, that’s not right. And what also saddens me is that so many people don’t have access to good therapy, either because they can’t afford it, or because they’ve had trouble finding someone they can work with effectively.

I think our field has a lot of room for growth, and for catching up with the other more basic sciences, such as biology, chemistry, or physics. That’s the goal that my colleagues and I have been aiming for in our work developing a new a more powerful model of therapy.


[1] Copyright © 2008 by David D. Burns, M.D.