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:
- 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!
- 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.
- 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!”
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. https://www.psychotherapynetworker.org/blog/details/1160/when-helping-doesnt-help
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.
I certainly appreciate the detail with which you responded, David. I especially like the research references we can pursue on our own.
Another excellent overview of what TEAM-CBT is all about. I have forwarded this to my daughter, a newly qualified MSW, in the hope she will overcome her resistance to listening to me by reading this and listening to the podcast! Whatever the outcome, your podcasts have been of great personal benefit.
Thanks, Richard, much appreciate your kind words! david
Dr. Burns, out of topic, but did you show to Albert Ellis you findings on T.E.A.M. especially what you describe about the death of the ego (disarming technique)? If yes, how did he respond? I read a little of his book “the myth of self esteem” and I remember he gave you an A on what he tougth was unconditional self acceptance.
From his book: “So David Burns gets an A for his consistent acceptance of acceptance! Unlike Aaron Beck, he goes out of his way to teach the philosophy of USA, UOA, and ULA-as, of course, does REBT. ”
Anyways thanks for you podcast
PS: Can you give a second read to what “Rajesh” commented on “Solution to David’s Tuesday Tip #11*”? He talk about “the philosophy of self acceptance in the context of anxious feelings and behaviour. ” (the tip was “Self-acceptance is the greatest change a person can make.”).
Here’s the link to your post: https://feelinggood.com/2018/06/27/solution-to-davids-tuesday-tip-11/
Hi Joshua, Thanks for the quotes. That is so cool, and was not familiar with them. Will take another look at the post you mentioned. David
More. I forgot to comment. I had some interactions with Dr. Ellis, and always deeply appreciated him. Our relationship was purely positive, and very kind I would say. When he was alive, TEAM was barely beginning to evolve from CBT, as you have pointed out, but he was always very open to new ideas. We were on the same page in many many regards, such as the non-existence of the “self” and the non-existence of “self-esteem.” He was a very wild, creative, honest, and memorable character. I miss him a lot! Another “great” but not in our field was the philosopher, Ludwig Wittgenstein, who I also admired tremendously. His philosophy toward the later part of his life was very similar to the philosophy behind CBT and now, of course, TEAM. I think the Buddha stumbled across the same ideas way ahead of the rest of us! david
I have experience as a patient and a student of psychology from both REBT and CBT. I think that these therapists are coming from a very superficial understanding of TEAM. From my perspective TEAM is not another school of therapy but the natural evolution of CBT starting with Dr. Abraham Low in the 1930’s, then RBT , CBT and finally TEAM.
On the other hand, there are probably some people that want an approach that is less empathetic, more to the point, as it were. REBT is an amazing form of therapy.
As for me, I love the double column technique. I carry my paper and pen and if needed, I am prepared.
I appreciate your efforts.
Thank you Renee, I agree with all of your comments! Good to hear from you! Warmly, david
That was a great discussion on REBT VS TEAM CBT. I think both have their own place & importance how & when they help people alleviate emotional suffering. Personally, I am flexible to use both depending on what helps me.
In the context of Empathy that was discussed in the prodcast I do like to agree with both Ellis (‘Empathy is neither necessary nor sufficient) & David Empathy as a part of TEAM CBT.
I think Ellis’s comment was in line with unconditional self acceptance that he wanted his patients to buy in the philosophy of unconditional self acceptance (USA) instead of conditional acceptance ie. you accept yourself just because your therapist accepts you & shows empathy towards you. Probably, empathy could prepare some patients for USA.
In relation to what David says about Empathy, I agree its very important to win patients confidence in the therapist & also break the resistance. Empathy can do the trick to prepare the patient but, to what degree? I think David can answer that :)..
Thanks, and well stated. Empathy alone is not going to cure anyone of much of anything, but it sure helps, especially if you are going to be using powerful techniques that require trust. Karl Rogers felt that empathy was the necessary and sufficient condition for change, but later research and clinical experience did not support that claim. He was undoubtedly a tremendously effective and helpful therapist, but sadly others were probably not able to mimic his therapeutic style as well as he had hoped. Still, his contributions are legendary, even though his basic assumption was not quite correct! david
Thanks David. To add, in my opinion the strength of REBT is that it forces you to see things as it is and to certain extent prepares you to face the worst. Some of its techniques can be done mentally.
But, what makes TEAM CBT and your books on it unique is the Empathy in your writing style. Its detailed and captures very closely the negative emotions one experiences in the face of adversity , techniques to overcome fearful physical manifestation of irrational fears, a systematic approach to deal with negative thoughts that are difficult to catch, relationships skills that probably REBT maynot have to my knowledge and the confidence you build by giving loads of techniques that work most of the times and you know that you can fall back to those techniques if you slideback. That’s really encouraging.
I thank you for all the good work 🙏
Thanks, Rajesh! Always a pleasure hearing from you! david
Thank you for answering so gracefully, David, but to me those questions were so ridiculously ignorant, they didn’t deserve your time or air time or listeners’ time.
After reading your fantastic “Feeling Good” and “Feeling Good Handbook” I just finished reading your brilliant brand new “Feeling Great” and I’m impressed beyond words with your expertise and effectiveness.
Thanks so much!
Thank you for the kind words, Sanja! Deeply appreciated! Warmly, david
Excellent discussion! As a research scientist I am very familiar with the conflict that exists between subjective and objective test results (hence the SOAP notes). My question would be – how can the therapist be sure the client is being truthful when s/he responds to the pre and post session mood surveys? Are they exaggerating or telling the therapist what they think s/he wants to hear?
Thanks, it’s quite the opposite, in fact. Unless the patient has an ulterior motive, like looking bad to get on disability, the responses are incredibly accurate and often what the therapist does NOT want to hear. The problem is not patient dishonesty, but patient honesty. Therapists who use my empathy scale for the first time, for example, get between 50% and 100% failing grades from their patients. And often, the pre and post session ratings will show no improvement in mood, or even a worsening. If you have courage, the use of the Brief Mood Survey and Evaluation of Therapy Session can transform your practice. But be prepared for some surprises! david