I was concerned that our recent “Ten Most Common Therapist Errors” show might antagonize people, but we got quite a lot of positive and encouraging feedback from listeners, which was surprising to me. As a result, Fabrice and I decided to take a chance and publish two more shows on common therapist errors this week and next week. We hope you like these shows!
Make sure you let us know what you think, and let me apologize in advance if I come across as annoying or overly cynical. All of the errors I describe are correctable; the goal is to improve the treatment of individuals struggling with depression, anxiety, troubled relationships, or habits and addictions. Thanks!
Here are the five errors discussed in today’s show.
1. Failure to hold patients accountable. Example, the therapist may let the depressed patient slip by without doing psychotherapy homework, since the patient insists he or she doesn’t have enough time or motivation to do the homework; or the therapist may agree to treatment an anxious patient without using exposure, since the patient may resist exposure; or a patient may treat someone with a relationship conflict without exploring the patient’s role in the problem, and so forth.
David argues that this rarely or never leads to significant change, much less recovery. However, many therapists, and perhaps most, get seduced into this error for a variety of reasons.
2, The “corrective emotional experience.” This is the belief that the patient’s long-term relationship with the therapist will be sufficient for growth and recovery, without having to do any psychotherapy homework or be accountable. Therapist may imagine himself or herself as the loving and nurturing parent the patient never had.
David argues that this caters to the therapist’s ego and feeds into what the patient wants as well—a long-term relationship built on schmoozing.
But does it lead to recovery?
Here’s David’s short answer: Nope! Warmth, empathy, and trust are necessary ingredients for good therapy, but they are simply not sufficient. Your patient may think you’re the most wonderful and supportive listener in the world, but that will rarely or never lead to recovery from depression, an anxiety disorder, or an addiction, and it will not lead to the skills to heal troubled relationships, either.
3. Responding defensively to patient criticisms. David argues that therapists almost always react defensively to criticisms by patients, such “you don’t’ get me,” or “you aren’t helping,” or “you don’t really care about me.” He describes an interesting five-year study of psychoanalysts in Atlanta, Georgia, sponsored by the National Institute of Mental Health (NIMH), to find out how the analysts responded to patient criticisms. You may find the results surprising!
He gives an example of defensive responding during a workshop he conducted at a hospital in Pennsylvania. Therapists can learn to correct this error with lots of practice with the Five Secrets of Effective Communication, but this requires several things:
- Using the Patient’s Evaluation of Therapy Session after each session so can quickly pinpoint empathy / relationship failures.
- Lots of practice with the Five Secrets.
- Humility, and the willingness to see the world through the eyes of the patient. This requires the “Great Death” of the therapist’s ego!
4. Joining a school of therapy and treating everything with the same method or approach. Can you imagine what it would be like if medicine was organized like this, with “schools of therapy,” like the “penicillin school”? David apologetically argues that the abolition of all schools of therapy would be a good thing. Fabrice disagrees, and argues that the treatment of psychological problems is inherently different from the treatment of medical disorders.
Let us know what YOU think!
5. Confirmation paradox. I (David) majored in the philosophy of science in college, and this was one of the first topics, and it definitely applies to our thinking about the causes of emotional problems. I’ll try to make it really simple and understandable.
Here’s the essence of this error. If I have a theory that predicts the patient’s behavior you may conclude that your theory is correct. But this logic can be very misleading. Here’s a general science example
- Your theory: the sun circles around the earth.
- Your prediction: if my theory is true, the sun will come up in the east each morning and set in the west each evening.
- Your observation: the sun DOES come up in the east and set in the west, exactly as predicted.
- Your erroneous conclusion: the sun circles around the earth.
Now let’s consider a psychotherapy example. Many therapists believe that perfectionism and insecurity result from growing up with parents who emphasized hard work and high standards as a precondition for being loved. Now let’s assume that you have a perfectionistic and insecure patient who remembers feeling like s/he wasn’t good enough when growing up. So, you conclude that the patient’s interaction with demanding parents caused the perfectionism and insecurity.
But the perfectionism and insecurity may not have resulted from any childhood experiences or interactions with parents. It may have been strongly influenced by genetic factors, or social / environmental pressures.
We can put this in the same framework as the example about the sun:
- Your theory: Perfectionism and insecurity result from growing up in unloving families that emphasized high standards and achievement rather than unconditional love and nurture.
- Your prediction: Insecure, perfectionistic patients will report childhood experiences with unloving parents who pushed them to work harder, etc.
- Your observation: Your insecure, perfectionistic patients DO describe their parents as demanding and lacking in love and support.
- Your erroneous conclusions: The patient’s childhood experiences caused the perfectionism. 2. The patient will have to “work through” these childhood experiences if s/he wants to overcome the feelings of perfectionism and insecurity.
Dr. Fabrice Nye currently practices in Redwood City, California and treats individuals throughout the world (but not across U.S. state lines) via teletherapy. You can reach him at firstname.lastname@example.org. You can reach Dr. Burns at email@example.com. If you like our jingle music and would like to support the composer Brett Van Donsel, you may download it here.
TWO COOL UPCOMING WORKSHOPS FOR YOU
Dr. Jill Levitt and I are offering what I think will be an outstanding workshop on the treatment of unwanted habits and addictions on Sunday, February 10. Our Sunday workshops are tremendously fun, so consider attending if you are interested. We quickly sold out in-person but you can still join online.
THERE WILL BE MANY EXPERTS TRAINERS TO GUIDE THE ONLINE GROUP IN THE SMALL GROUP EXERCISES
During the program, you will have the chance to work on one of your own habits / addictions so you will get the double benefit of learning cool new treatment techniques and doing some personal healing at the same time!
You will develop a deeper understanding of Outcome and Process Resistance, and you will learn how to deal with this twin-horned Devil. As you know, TEAM-CBT features many innovative techniques to reduce Outcome and Process Resistance.
Here’s the BAD news. Very few therapists have the skills, insights, or mind-set to deal with resistance, and this is the main cause of therapeutic failure in the treatment of depression, anxiety disorders, relationship problems, and habits and addictions.
Here’s the GOOD news. Once you acquire these skills, your clinical effectiveness will soar!
Here are the specifics–
Act fast if you want to attend!
Don’t miss out learning from David Burns, MD, one of the great pioneers of Cognitive Therapy, and from the fabulous, Jill Levitt, PhD, Director of Training at the Feeling Good Institute in Mt. View, CA!
TEAM-CBT Methods for Unwanted Habits and Addictions: Step-by-Step Training for Therapists
WHEN: February 10th, 2019, 8:30 am – 4:30 pm PST
(11:30 am-7:30 pm EST)
WHERE: Join us live online or in person at the Creekside Inn, Palo Alto, CA.
HOW MUCH DOES IT COST? $135,
WILL I GET CE CREDITS? YES!
7 CE hours available
WILL I GET CREDIT IN THE TEAM LICENSURE PROGRAM? YES!
Completion of this workshop also counts towards TEAM-CBT Level 1, 2 or 3 Certification
WHO CAN ATTEND? Therapists of all levels are welcome
CAN I REGISTER IF I’M NOT A THERAPIST? In my opinion (Dr. Burns), although the workshop is geared for therapists, it will be taught in a clear and basic way that anyone can benefit from. Please check with the Feeling Good Institute if you want to attend.
CAN I WORK ON MY OWN HABIT / ADDICTION? Absolutely!
Heal yourself, heal your clients!
WILL I HAVE FUN? Yes!
You will also:
- Learn new skills to reduce resistance and boost the motivation to change. This is THE key to the treatment of any habit or addiction.
- Learn how to use Dr. Burns’ powerful Decision-Making Tool and Triple Paradox Technique.
- Practice and master the Devil’s Advocate Technique to help you and your patients overcome difficult-to-stop habits and addictions to drugs, alcohol, overeating, procrastination, and more.
You will love this lively, amusing, and immensely useful day of training with Drs. Burns, Levitt and the Feeling Good Institute Staff. The trainers will use a combination of didactic teaching, live demonstrations, and breakout group practice to enhance skill-building.
This wonderful workshop will stream live and is easily accessible from anywhere in the world on any device with WiFi. To join, just click on the link provided before the workshop.
* * *
If you can’t join us for the addictions workshop, consider this cool program on the treatment of anxiety disorders in the spring. But register soon if you want to attend in person, as the in person slots are limited.
TEAM-CBT Methods for Anxiety Disorders–
Step-by-Step Training for Therapists
by David D. Burns, MD and Jill Levitt, PhD
May 19, 2019
You can attend in person or from home via Live Streaming
Stay tuned for more details or check it out now!
I’m excited that you may have online courses for the general public. That is a great idea, and I can’t wait to sign up.
To use a (probably bad) analogy, I think schools of therapy are like schools of martial arts (Karate, Jui Jitsu, Boxing, Kung Fu). Every school honored a master and thought their school was the best. It wasn’t until ultimate fighting tournaments occurred that people realized the best martial artists were MIXED martial artists who combined the best techniques from all the schools.
Team CBT is the Mixed Martial Arts of therapy in my opinion.
Hi Rob, awesome analogy, thanks! d
This was a very interesting podcast. I like how Fabrice makes counter points to David’s point of view from time to time. I think David’s analogy about the medical model is totally off base as Favrice pointed out. This is not medicine in the literal sense. It is medicine in the metaphorical sense. When we someone has no guts it would be absurd to do an intestinal transplant to give him more guts. By the same token when someone’s life is messed up, or thinking is messed up, it is absurd to insist on a medical intervention. Psychotherapy is a form of religion, and what is wrong with that? Religion can be a beautiful thing. The only reason psychotherapy wants to be exalted to the medical realm is because anything that is not seen as science is disparaged in our day. When a kidney malfunctions, we can use the medical model because we know the purpose of a kidney is to secrete urine. When a person “malfunctions”, we cannot use the medical model because medicine cannot tell us what the purpose of a person is. That is the realm of philosophy and religion. Psychotherapy has assumed the role of religion in a secular society. It would be more helpful and honest if we acknowledged this fact.
Thanks for your thoughtful comment, Exi! When physics tried to break away from the Catholic Church, there was a hundred year period of resistance. But the result of substituting science for religious beliefs is obvious. I think you’re right that psychotherapy has become like competing schools of religion, although I do not favor that. My goal is not to make psychotherapy like medicine, that was only an analogy, but to make it data-driven and science based, so we can develop the powerful psychotherapies of the future. And, to my way of thinking, that’s what TEAM-CBT is. I believe that there is a spiritual component to psychotherapy, but without measurement what happens is often pretty kooky and ineffective. Just my thinking, as remember that I’m often way off base! david
David, thank you for you kind reply. I respect your point of view. In my opinion, trying to make psychotherapy more like science is doomed to fail, because psychotherapy deals with peoples lives, and life is not a scientific experiment! I think what you are doing is good, but is a type of secular religion and I think more therapist would be better off if they acknowledged it. You have one kind of therapy and I have another. You cannot use science to measure many things in a persons life. Just as you cannot use science to tell you which religion is best to follow. For example, a person is depressed because they hate their marriage, a therapist helps them change themselves and now they are divorced. Is the person better or worse off? Science cannot answers this question, only persons can. Persons can only answer based on values that make sense only for their life.
Thanks so much. You say my efforts, and those of others, to introduce testing and accountability into psychotherapy are doomed to failure. Lots of folks feel that way, that’s for sure, thinking that things must be, perhaps a bit mysterious to be useful. My personal experience is not really consistent with this. I get extremely rapid and lasting recovery, for example, when treating depression or anxiety disorders. We measure symptoms with brief, accurate tests right before and after each session (testing severity of depression, anxiety, anger, suicidal urges, and so forth). This has revolutionized our clinical work and lead to numerous improvements in treatment. But good therapy is never, to my way of thinking, inconsistent with anyone’s religious beliefs. To the contrary, the individuals religious beliefs are often deeply affirmed at the moment of recovery, and they suddenly “see” things at a much deeper level. My father was a minister, and he was deeply suspicious of psychiatry, arguably hostile. I say, “Phooey to that!” But please keep your thoughtful comments coming. I appreciate your interest greatly! You’re a thinker, and a challenger, a lot like me! All the best, david
Thanks for allowing me to make contrary comments on your blog, I recognize that we see things very differently from each other even though I am a fan of your work. Perhaps we are like two ships in the night – never the twain shall meet. My only point that I will try to clarify further is that “recovery” can only be defined by the user. Would taking a suicidal urge away from someone who wants to die be a good thing or a bad thing? In my view it can only be up to the person to decide whether such an urge is good or bad, science cannot tell us, but philosophy and religion can, which is why I view psychotherapy as religion – because it sneaks in values in the back door, under the guise of science. If you ask me, suicide is sometimes morally justified, sometimes not; sometimes blameworthy and sometimes praiseworthy; sometimes neither; it totally depends on the person and his circumstances. In a further radical example, ask yourself if the Church of Euthanasia is good or bad. They advocate sodomy, suicide and abortion as holy values, can science tell us if these values are good?
Thanks for your thoughts. Keep up the good work.
You make good points that values are involved as well as science–this is true in all of science actually, the exact same structure. Some things are stipulated, and somethings can be proven / disproven. One reason I do testing is for the reason you mention–suicidal urges. I have done research to determine the accuracy of clinicians in knowing when their patients are suicidal. It is good to know, because if you know someone is suicidal, you can nearly always intervene to save that person’s life. Then the person often goes on to full recovery, but at that moment of hopeless, she or he may be ready to pull the trigger. So I test for suicidal fantasies and urges at the start and end of every therapy session, with no no exceptions. My research has show that the accuracy of clinicians in judging when and if and how severely suicidal their patients feel at any point in time is 0% accuracy. As a therapist, one of my stipulations is that I’m there to help the patient recover and get back to joy and self-esteem, if that’s what the patient wants. I cannot do this effectively without the testing at each session. Can other therapists do this effectively without testing? Research shows a clear an unambiguous answer, and the answer is no. Again, my thinking only! d
David – Point taken on science. Although I would tend to dispute that things like the speed of light are value laden.
You mentioned joy and self-esteem. I values theses things as well, but many things give people joy and self-esteem, smoking gave Freud much joy, he said that without smoking, life would not be worth living! Does this mean that smoking 🚬 counts as therapy? There are many things in life that give self-esteem – doing well at your job for one may do this. Does this make having a job and doing well at it is Therapy? My point is only that under the guise of science, the whole of life gets subsumed by Therapy and psychiatry. From my point of view, we should try to be honest and use clear non-therapeutic, non-technical jargon when talking about life. When we obfuscate, we can further confuse ourselves and the people we work with.
Interesting first sentence. I majored in philosophy of science, and one of the first we learned was the part of the theory of relativity that is empirical, and the part that is stipulated. The idea that light goes the same speed in opposite directions is a stipulation known as the alpha constant. It cannot be tested or proven. There is a stipulation and an empirical aspect to all of science. For example, the idea that we would treat depression is a stipulation. Hundreds of years ago. some people thought of epilepsy, not as an illness, but as a special religious gift some people had.
You asked if smoking counts as therapy. I don’t think there’s a smoking school of therapy, but who knows? Certainly, if someone is depressed and comes to me for treatment, then I want to measure the depression and changes in depression at each session, so I can monitor the treatment and find out if the work I’m doing is effective. I have done experiments at Stanford to find out if clinicians / experts can detect changes in depression in individuals they are working with. The accuracy turned out to be only 3%. That’s why I used sensitive and accurate, brief assessment tests with every patient at every session, without exception. Now, if someone is depressed, or has OCD, and does not want treatment, that would be his or her decision. But if someone comes to me and asks for help, then I want to make sure I am delivering the help they want and need. I definitely agree with you about jargon. Sometimes I think that people use big words to disguise the fact that they do not know much!
It also dawned on me that you are not looking for information, but rather wanting a forum to promote your own thinking. This is a pretty good one, I think, but I’ll stop explaining what I do, and why, as I realized that is not something you are asking for. Big mistake on my part, please accept my apologies! I think your goal, perhaps, was more to let me know how wrong I am about certain things that are near and dear to you! Totally understandable! 🙂 david
David. Thanks for the reply. I am not looking to promote my own thinking, I am looking to have a thoughtful dialogue with another person who finds these ideas interesting. It is at the intersection of ideas that we find truth. If I have offended you, mea culpa.
Oh, thanks, no offense. It just occurred to me that it had become more of a debate than dialogue. I feel, rightly or wrongly, that I have some pretty amazing information to share, but realized I was “selling” and you seemed to be “resisting,” which is also a common therapeutic error. I get sad though, and a bit frustrated, when I have something really mind-boggling that I want to share! But then I hit a wall–a wall of my own creation, by the way! And that, to my way of thinking, is both a practical reality plus a spiritual principle. We create our own interpersonal reality at every moment of every day! But don’t seem to notice or realize that we are doing that! So we get into the role of victim and complain! A topic for another day, perhaps! I am very grateful for your interest, and I too have spent much time on these fascinating topics! d
Does Fabrice ever join in on the comments? I’d love to hear his take on this.
No, not sure he’d want to, but I can sure check with him! Currently, all gets funneled through me. Good thinking! d PS I do send him stuff if it relates to the podcast or positive comments about him. So he could certainly reply if he wants and has the time. d
Dr Burns I don’t know if you read this but I read the dialog that you have with existential stoic and he says “My only point that I will try to clarify further is that “recovery” can only be defined by the user.” and that’s exactly what you have said on past podcast (i think 3 podcast ago). You don’t say to the patient what values to have or what believes are good or bad, the patient do a reflection and decide what is good for her. And its until the patient decide when he feel ok or good or great when therapy ends, and the TEAM therapist helps untils his/hers skills and tools can (sitting with open hands its part of that, i think). Anyways I think he or her (stoic) would agree more with you if he/she listen to all your podcast. Anyways. I’m going to listen to your podcast, I went straight to the comments.
yes, that’s exactly right, Frances! The patient must ask for help, and (for the most part) it is up to him or her to decide what he or she wants help with. The patient may have OCD, for example, but not want help with that, but may want help with some other problem. That is the stipulation component of psychotherapy. Once the patient has decided that he or she wants help with depression, for example, or social anxiety, then the science comes in, so I will measure severity of symptoms and progress at each session, and use techniques (from the 100 or so in my “Toolkit,”) that have been show to have effectiveness for that specific problem. And you are also absolutely right that the existential stoic does not appear to have much, if any, knowledge about my work. TEAM treatment methods and concepts are actually difficult to grasp, and you can attribute your own meanings to my words (or anyone’s words) and begin to criticize–but your criticism may be based on your own mental “picture” of what the other person is trying to say. In addition, your mind can be temporarily closed, so you are not interested in “hearing” or “listening,” but rather in promoting your own gospel. If the existential stoic is a therapist, I would be alarmed to send a depressed loved one to him, knowing he just “does his own thing,” based on what appeals to him and his religious beliefs, rather than methods that have been shown in research studies to be effective. I hope he is NOT a therapist, and likely he is a lay person, but who knows! Anyway, these are just my thoughts, but I really appreciated your commentary and kind comments! All the best, david
Thank you for all the helpful and interesting information and resources you share in your podcasts, videos and website regarding TEAM therapy. I particularly appreciate how you and Fabrice have clarified so many topics through your detailed discussions.
Notwithstanding your efforts, I remain confused about some items. In this podcast, Fabrice @ 24:00 discusses a patient with whom Fabrice has “sat with open hands” and issued the “gentle ultimatum”. Fabrice reports @ 24:48 that the patient does not want to work on his depression on the terms Fabrice requires. In other podcasts, David has indicated that, at this point, the therapist should say, “Is there anything else you would like help with?” However, Fabrice @ 24:58 suggests that the patient may wish to create a list of reasons for why the patient would (or wouldn’t–the audio is unclear) want to keep his depression.
Is this type of list at the outset of agenda setting designed to re-evaluate the patient’s decision? Or, is the list being used to “make a decision” as in the case of a problemed relationship, where the patient is indecisive and uses lists to determine whether the status quo, abandoning the relationship or working on the relationship is most desireable? (Though Fabrice didn’t indicate his patient was indecisive.)
When would it be appropriate to respond to an “unwilling” patient with Fabrice’s suggestion for a list or with David’s indication to move on to another issue?
Thank you for considering my questions.
Thanks, Taylor, it is hard to approach these questions on the general level, as a specific case works way better. But in general terms, we try to reduce or eliminate outcome resistance as well as process resistance in TEAM-CBT, but the issues and techniques are radically different from each other. The Outcome Resistance issue in depression is almost always that the patient’s has to accept something he or she does not want to accept in order to recover. For example, the patient may (wrongly) believe that she or he could not possibly feel happy and fulfilled without being loved, highly successful, or “special.” For example, I recently treated a case of postpartum depression. The woman was depressed and beating up on herself because she felt she was not as happy as a newborn mother “should” be. To recover, she will have to accept the fact that she is sometimes ambivalent about motherhood and the loss of her previous activities, including her work, which she loves. I have developed lots of powerful and, I believe, highly innovative techniques to melt away the Outcome Resistance of the depressed patient. She recovered in a single session, which was great!
The Process Resistance in depression always has to do with the patient’s willingness (or unwillingness) to do psychotherapy homework. This is a must, hence the “Gentle Ultimatum.” I personally (and cannot speak for others, including Fabrice), never try to help or convince a patient who refuses to do homework, as this effort is doomed, in my experience to failure. But Sitting with Open Hands is usually very effective! David