This was yesterday’s paradoxical tip of the day!
Some people think that therapy consists of codependent schmoozing behind
closed doors, with the occasional bit of “advice” or “tell me more” thrown in.
Are they right?
Hi everybody,
I am trying, perhaps without complete success, to say this politely, without enraging anybody too much . . . . but
I am sad to say that I think this Tuesday comment is somewhat correct. Many therapists just talk with patients for months or years without much change, often without specific goals, and without measuring anything from session to session to document change, or the lack of change. When I was a psychiatric resident, this type of treatment actually had a name. It was called “supportive emotive therapy.” The patient talks, the therapist listens and provides support, and encourages the outpouring of emotion at times.
Some experts claim that this type of therapy provides a “corrective emotional experience.” The idea is that the relationship with the therapist will correct some shortcoming or void in the patient because of his or her childhood and lack of support and nurture while growing up.
I’m not convinced this non-directive approach corrects much, if anything. In addition, while I know I have lots of helpful techniques to offer, and some reasonably good empathy, I’m not convinced that a relationship with me will ever correct much of anything, to be honest! I’m quite surprised, actually, that so many individuals–colleagues, clients, and students–are even willing to put up with me.
I can be, to be honest, kind of annoying and difficult at times. I don’t see myself as a “corrective emotional experience” much of the time!
I favor therapy that works rapidly, with specific goals and changes that can be documented by assessments of the patient’s feelings at the start and end of every session. This includes testing feelings of depression, suicidal urges, anxiety, and anger,as well as the patient’s feelings of satisfaction with his or her spouse or partner. The assessment of the therapist’s empathy and helpfulness by the patient after every session is also invaluable and, to my way of thinking, mandatory.
While skillful listening will always be an important part of therapy, it will rarely or never be sufficient to help a patient recover from severe depression, or any anxiety disorder, or a troubled marriage, or a habit or addiction. Much more is required, including specific techniques to help the patient change his or her life, as well as resistance-melting techniques to boost the patient’s motivation and collaboration.
Patient homework between sessions will also be a must, in my opinion. You cannot, for the most part, change your life or learn new skills without practice, any more than you could learn tennis or how to play the piano without practice between lessons with your coach or teacher.
All human beings are corruptible, and we all have a kind of inherently lazy streak. So if a therapist has a full-fee private patient, and the patient just wants to schmooze and vent every week for months or years, without being accountable and without doing psychotherapy homework, the therapist will have a guaranteed income and an easy job, since there isn’t a whole lot the therapist has to learn in order to provide this type of non-specific talk therapy, or if you prefer, “non-treatment.”
I apologize deeply if my skeptical / cynical streak is showing, but I sincerely believe our field is in need of reform, and I am saddened and sometimes frustrated, even angered, by the overall poor skill level among mental health professionals.
On the positive side, last week’s intensive in Whistler, Canada was just awesome. Oops, Lisa Kelley has urged me not to go over the top with language, so let me say it was a bit above average. In fact, the ratings for all four days were the highest I’ve received–by a big margin, actually–in the last 25 years or more of doing workshops. I was thrilled and grateful to have such a warm and responsive group.
My dear colleague, Jack Hirose, who organized the conference, said the ratings were also the highest he has seen in the many hundreds of workshops he has sponsored in Canada. I was helped by my dear colleague, Mike Christensen, who attended and assisted with the teaching. Mike was also my co-therapist in the live demonstration with an audience volunteer who had experienced severe trauma and abuse.
Working with her was an inspiring and riveting experience. We were fortunate to due a high definition video of the session, and I hope it will be available for some type of teaching program for you.
If you would like to attend a similar conference, consider my upcoming San Francisco intensive in a few weeks. I will try my hardest to make it a little above average, too! See the details below.
Thanks!
David
* Copyright © 2018 by David D. Burns, MD.
* * *
Hey, folks, my San Francisco summer intensive will start in a few weeks. it is always one of my BEST training programs of the year. The group will be quite small, giving you lots of chances for Q and A and personal connection with me, plus networking with your colleagues. In addition, many individuals from my Tuesday group at Stanford will join me to provide feedback for you during the small group exercises.
Here are the specifics:
Coming in San Francisco in August
High Speed, Drug Free Treatment of Depression and Anxiety Disorders–
A Four-Day TEAM-CBT Advanced Intensive
August 6 – 9, 2018, South San Francisco Conference Center, California
For more information, click here
or contact http://www.iahb.org/
phone: 800-258-8411
If you can only attend one of my workshops, consider this intensive! it is simplly
THE BEST!
Seating is limited. Register now if you want to get in on the action!
Hope to see you in San Francisco in August! David
* * *
Also coming up soon on David’s Sunday FB Live Broadcasts
Sunday, July 15th, 2018, at 3 PM: The Disarming Technique–Taking a Deeper Dive, with special guest, Mike Christensen
Sunday, July 22nd, 2018, at 3 PM: The Shouldy Approach to Life–How to Crush Should Statements, with special guest, Jill Levitt, PhD
If you attend live, you can ask questions and be a part of the show. However, they are all recorded so you can tune in anytime on my Public FB page!
Hi David. Thank you very much for an another awesome post. I appreciate your comments around schmoozing and agree wholeheartedly around the need for specific goals and we certainly need to be attempting to assist clients in the shortest time possible. On the other side of the coin I think there are issues and clients who do not respond to a very brief approach and that may be due the fact that the practioner is not skilled or trained enough (I will admit that this is a real possibility) in your model or another model of brief therapy. What do you recommend that therapists do when they encounter a client who cant formulate specific goals, wont work with the daily mood log and who refuse to do homework but they still want to come to therapy to vent and gain support? Some therapists who do long term therapy believe that they develop a relationship with the client that is corrective and that it is this experience of this different kind of relationship in therapy that is healing for the cl (we could say the client has some kind of in-vivo exposure through having a different kind of relationship to which they are accustomed too via the therapuetic relationship.). Some argue that this produces change in the client without them needing to do specific task or homework, but due to this, it tends to lengthen the treatment process. I would love to hear your opinion on this matter David, as you have opened up such an important issue for all of us.
Thank you again for your wonderful work
Thanks Kevin for your thoughtful comment. I negotiate homework compliance at the initial evaluation, and send something called “The Concept of Self-Help Memo” to all new patients prior to the initial evaluation. It states that homework will be mandatory if they wish to be seen in my clinic. If patients are looking for talk-only therapy, without learning and practicing specific tools to help them overcome their problems, I simply tell them that I don’t know how to do that type of therapy, and that they might want to get that type of therapist, who also does not believe in the value of homework. I also tell them I’d love to work with them and likely have the tools to help them change their life, and possibly even quickly, and that I’m not trying to get rid of them, but if they want to work with me, the issue of homework would be non-negotiable. Surprisingly, in a group of 700 consecutive patients evaluated at my clinic in Philadelphia, all but seven elected to stay with my clinic and do the homework! The paradoxical approach seemed to intensify their determination to work with us. I published an outcome study one of the top psychology research journals showing that nearly every patient who did at least some reasonably consistent homework improved or recovered completely, and nearly every patient who refused to do homework failed to improve. Many of them simply dropped out of therapy, and some even got worse. That study was why I developed the policy I described above.
You mentioned that many therapists do long-term therapy, thinking the therapeutic relationship will heal the patient. In all honesty, I am sad to say I am quite skeptical! I do believe therapeutic empathy is important, and should be measured at every session, but it is not powerful enough to cure depression, resolve an anxiety disorder, heal a troubled marriage, or lead a patient out of a habit or addiction. And if these “relationship therapists” were to use my empathy scale with their patients, nearly all would discover that their patients would give them failing grades at every session. But sadly, the relationship therapists will usually, if not always, refuse to use this scale!
Anyone, more words from the skeptical david! And I apologize, too! But that’s how I see it, for better or worse, and remember that I am sometimes right and often wrong. So take it with a grain or two of salt! Respectfully, David
Wow! What a great solution David; and good back-and-forth with Kevin.
I hope you don’t receive strong backlash from therapists favoring a longer-term approach to healing.
Mike in San Antonio
Well, I think I probably live in a wave of backlash, plus many who might support my thinking to some extent! Thanks for your comment! But you are right. We humans DO like to defend our territory! david
What is going on with Lisa Kelley’s recommendation that you use less over-the-top language, such as “awesome”? Is this just some friendly teasing between the two of you?! 🙂
She has rightly pointed out that when I get too enthusiastic–in my teaching or in my treatment, it sometimes has a tendency to turn some people off, thinking I am over the top and loony, so I can lose credibility. This is quite true! At the same time, I get confused, because you have to project some enthusiasm to inspire folks. I guess a balance is called for, so I try to tone down my language at times. But I have other flaws far worse than this one, so I don’t get overly guilty about being too enthusiastic sometimes! Thanks, Mike! david
I like what you write at the end, Dr. Burns. To me, your words (“I am sometime right and often wrong….”) remind of some 12 Steps Recovery language: “Take what you like and leave the rest”, referring to what is shared in a meeting by members of the group.
Speaking of 12 Steps do you have any thoughts, that you can share, on recovery groups like AA or Al-Anon?
Mike in San Antonio
They say the best things in life are free, so I support AA and Al-Anon strongly. Not totally on board with everything, of course, but so what. They are there providing endless support to people who are struggling who really need that support and benefit from it. So what’s not to like? Sadly, AA is not the answer for everyone, but it is an answer for many! Thanks for the great question. d
Do you have any examples of people for whom AA cannot help (and, where can they turn for help)?
Sorry, Mike, I do not understand your question. david
You wrote, “Sadly AA is not the answer for everyone….”. My question is what recovery do you recommend for those not in AA? For example, do you recommend CBT-TEAM?
If someone has a severe alcohol or drug problem, I would require AA or Smart Recovery or the support group of their choice, possibly daily at first, in addition to see me. I can give them things that AA (or any support group) cannot possibly give them, and AA can give them things (like a sponsor and free unlimited meetings and support) I cannot possibly give them. david
Hi Dave, this type of therapy would be the “E” only of TEAM as far as I’m concerned. It has it’s place, but limited. The patient may feel better, but not get better.
Right, thanks! And we could also, perhaps, call it “pseudo E” since it is the assumption of empathy by the therapist, without testing of empathy to see what’s really going on. Most therapists in private practice who use my Empathy Scale with their patients for the first time are a bit surprised to discover that they receive failing grades on empathy from their patients 50% to 100% of the time. So it would not be particularly correct to call it “Empathy.” Perhaps we could think of it more along the lines of “failed Empathy.” But the therapist is twice condemned because: 1. his or her empathy skills are actually poor; 2. he or she is not aware of this and (quite wrongly) believes he or she is rather good at empathy! But narcissistic (in my opinion) therapists do not WANT to measure empathy or symptoms, as this makes them accountable for producing real, measurable change.
Just my rather skeptical thinking again, but backed up by quite a bit of research that points to these (perhaps annoying) conclusions.
David