101: Therapy Wars–REBT vs TEAM: Mirror, mirror, on the wall . . .

A fan who wishes to remain anonymous (we’ll call him Jim) wrote a thoughtful question based on an internet video he’d just watched on The REBT Advocate’s YouTube channel, featuring Tommy Bateman and Dr. Michael Edelstein. One of their listeners had asked what they thought about the new TEAM-CBT developed by Dr. David Burns. They said they were not terribly familiar with TEAM, but looked it up on Wikipedia, and had three criticisms:

  1. The T = Testing is not important or desirable since you can just ask patients how they’re doing, and if they keep coming, it must mean you’re doing a good job. Testing, they think, is an artificial attempt to “dress up” the therapy and makes the treatment too clinical and impersonal!
  2. E = Empathy is not important, either, because patients pay good money to get help, and not to feel validated. Self-help books, they say, wouldn’t help if empathy was important.
  3. A = (Paradoxical) Agenda Setting is also unimportant. Resistance does not need to be addressed in treatment, since patients can go elsewhere if they aren’t getting the help they want.

This is what “Jim” concluded after listening to the REBT podcast:

“I don’t think they know as much about TEAM as they claimed. It made me angry that they were dismissing it so flippantly. Maybe you can invite yourself to talk on their podcast!

“I appreciate your approach to therapy a lot, even if I don’t always agree with you. I have watched every episode of your Feeling Good Podcasts and find the live therapy sessions especially intriguing!”

Sincerely, “Jim”

Thanks for the great question, Jim, and I appreciate your comments! Fabrice and I took a quick look at the video you saw on line and I strongly resonated with your assessment. Although there was value in all of their criticisms–there is ALWAYS truth in any criticism– I agree that they perhaps didn’t really grasp TEAM. And, like you, I found the comments flippant and disrespectful, kind of like a series of hurtful put-downs, rather than an attempt to grasp the potential value of something new or an invitation to meaningful and respectful dialogue.

I felt a bit angry, to be honest!

And I might add that in my interactions with Dr. Albert Ellis, the creator of REBT, I always found him to be incredibly respectful, warm, and supportive of my work. He was THE BEST, in my opinion! Toward the end of his career, he actually changed his mind about the importance of empathy, based on my research, and decided that empathy could, in fact, be helpful. I have many fond memories of times we talked and will always be grateful for his work and career; and also for his wonderfully wild, wacky and incredibly genuine and real personality!

Dr. Ellis was famous for his outrageous–and usually brutally honest and accurate–comments about other schools of therapy. And  I have to confess that sometimes I’ve also been guilty of dismissing competing schools of therapy in a flippant way, and I’ve gotten rightfully battered for that at times. People don’t like that type of adversarial dialogue for the most part. When I slip up and try to promote myself in a narcissistic way, it’s mostly thumbs down! But it sure can be tempting!

The perceived lack of empathy in some REBT therapists was actually one of Dr. Aaron Beck’s motivations for creating Cognitive Behavioral Therapy (CBT), which evolved about ten years after Dr. Ellis created REBT. CBT shares much in common with REBT, but with a greater emphasis on research to find out what really works, and empathy and the therapeutic alliance. CBT was also the first school of therapy to emphasize testing at every session to assess therapeutic progress, or the lack of progress.

The adversarial attitude of putting down the competition is at the heart of the “therapy wars,” with everyone claiming to have the “best” approach and dismissing other approaches. But if you look at all of the outcome studies of psychotherapy for depression or anxiety, for the most part, nothing comes out much better than treatment with placebos. So perhaps an attitude of humility, curiosity, and openness to new approaches would be more productive and appropriate.

The comments of Dr. Edelstein and Mr. Bateman were especially hard for me to hear, since I’ve always been a huge fan of Dr. Albert Ellis and I have so many respected friends and colleagues who are REBT therapists. I’ve always felt the contributions of Dr. Ellis to the field were legendary, and I’ve always supported and admired him.

My goal in TEAM has never been to create yet another competing school of therapy, but rather to create a systematic, data-driven approach to therapy based on process research on what works and what doesn’t work. I am convinced that therapists from any school of therapy who use T = Testing and work hard to improve their E = empathy skills will experience improved outcomes.

A = (Paradoxical) Agenda Setting is also important. Learning to melt away patient resistance and boost patient motivation can dramatically speed recovery, and is one of the most important components of TEAM! And I think that virtually all therapists, and especially REBT therapists, will have to admit that they have many patients who DO “yes-but” them and resist their efforts to help or persuade their patients to change.

But what does the research show? Is there any solid evidence for the various components of TEAM? At the end of these show notes, I have compiled a list of just a few of the published, peer-refereed studies that have led to the development of TEAM, and you can hear a summary of some of these studies on today’s podcast.

In a nutshell, here are a few of the highlights from research:

  • Session-by-session testing has been shown to improve therapeutic outcomes.
  • Research indicates that therapists’ perceptions of how their patients feel, and how their patients feel about them, are not accurate, and are frequently wildly inaccurate. This can have life and death implications, for example, in treating depressed patients with episodic suicidal impulses.
  • Therapeutic empathy has a direct causal impact on reducing depression. However, the magnitude of the effect is small. However, therapeutic empathy and trust can enhance, and even make possible, the therapeutic effects of other more powerful techniques.
  • Patient motivation is the only variable in the world literature that has been shown to have large causal effects on recovery from depression.

Finally, I’ll share an email I just received from another Feeling Good Podcast fan. It kind of cheered me up from the funk I was in after watching the REBT folks rip into TEAM!

Hi Dr. Burns,

I really enjoyed the recent Feeling Good Podcast on how you overcame many challenges to get your book published (podcast #99, the interview with Nicole Bell). I love the fact that you require measurement before and after every session as well as homework. Hope you and your great work will continue to take your field out of the Dark Ages. I suspect you won’t have much difficulty publishing your new book, Feeling Great!



T = Testing, E = Empathy, A = (Paradoxical) Agenda Setting–
What can we learn from research?

Research on Testing

Boswell, JF, Kraus, DR, Miller, SD & Lambert, MJ (2013). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, DOI: 10.1080/10503307.2013.817696 (2013)

Hatcher, R. L., Barends, A., Hansell, J. & Gutfreund, M.J. (1995). Patients’ and therapists’ shared and unique views of the therapeutic alliance: An investigation using confirmatory factory analysis in a nested design. Journal of Consulting and Clinical Psychology, 63(4), 636 – 643.

Research on Therapeutic Empathy

Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive – behavioral therapy: a structural equation model. Journal of Consulting and Clinical Psychology, 60(3): 441 – 449.

Burns, D. D., & Auerbach, A. (1996). Therapeutic Empathy in Cognitive – Behavioral Therapy: Does it Really Make a Difference? Chapter 7 in Frontiers of Cognitive Therapy (P. Salkovskis, ed. ) New York: Guilford Press, pp. 135 – 164.

Eisen, K. P., & Burns, D. D. (2007). Getting specific about “non-specific” factors: The role of therapeutic alliance in cognitive therapy. Psicologia Brasil (Psychology Brazil).

Krupnick, J. L. et al. (1993). The role of the therapeutic alliance in psychotherapy and psychotherapy outcome: Findings in the NIMH treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64(3), 636 – 643.

Orlinsky, D. E., Grawe, K., & Parks, B. K. (1995). Process and outcome in psychotherapy–Noch einmal. Chapter 8 in A. E. Bergin & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavioral Change (pp. 270 – 376). New York: John Wiley & Sons, Inc.

Persons, J., & Burns, D. D. (1985). Mechanisms of action of cognitive therapy: Relative contributions of technical and interpersonal intervention. Cognitive Therapy and Research, 9(5): 539 – 551.

Research on Therapeutic Resistance / Motivation

Burns, D. D., Adams, R., & Anastopolous, A. (1985). The role of self – help in the treatment of depression. Chapter 19 in Handbook for the Diagnosis, Treatment and Research of Depression, (Beckham, E. E. and Leber, W. R., eds. ), Homewood, II: Dorsey Press, pp. 634 – 669.

Burns, D. D., Shaw, B. F., & Crocker, W. (1987). Thinking styles and coping strategies of depressed women: An empirical investigation. Behavior Research and Therapy, 25(3): 223 – 225.

Burns, D. D., & Nolen-Hoeksema, S. (1991). Coping styles, homework compliance and the effectiveness of cognitive – behavioral therapy. Journal of Consulting and Clinical Psychology, 59(2): 305 – 311.

Burns, D. D., & Spangler, D. (2000). Does psychotherapy homework lead to changes in depression in cognitive behavioral therapy? Or does clinical improvement lead to homework compliance? Journal of Consulting and Clinical Psychology, 68(1): 46 – 59.

Burns, D. D., & Spangler, D. (2001). Can We Confirm Our Theories? Can We Measure Causal Effects? A Reply to Kazantzis et al. (2001). Journal of Consulting and Clinical Psychology, 69(6), 1084-1086.

Burns, D. D., & Auerbach, Arthur H. (1992). Do self – help assignments enhance recovery from depression? Psychiatric Annals, 22(9): 464 – 469.

Burns, D., Westra, H., Trockel, M., & Fisher, A. (2012) Motivation and Changes in Depression. Cognitive Therapy and Research DOI 10.1007/s10608-012-9458-3 Published online 22 April 2012

Burns, D. D. (March / April, 2017). When helping doesn’t help. Psychotherapy Networker, 41(2), 18 – 27, 60.

Persons, J.B., Burns, D.D., & Perloff, J.M. (1988). Predictors of dropout and outcome in cognitive therapy for depression in a private practice setting. Cognitive Therapy and Research, 12, 557 – 575.