The Final Five Therapist Errors (in no particular order)
This concludes our three-part series on Common Therapist Errors. I hope you’ve enjoyed it, and I apologize in advance if any of the ideas I’m proposing in today’s podcast seem “over the top” or simply off base.
I teach with great passion, but I’m not always right! Fortunately, my esteemed host, Dr. Fabrice Nye, challenges me quite a bit, and he is almost always right. Hopefully, you will enjoy our dialogue and the chance to think a bit more critically about psychotherapy.
And when you find I’ve made an error, or said something offensive to you, I hope you will put it in perspective. I’m kind of a mixed bag, to be honest. I believe I have a lot to offer, but I’ve got tons of flaws, too! I fight my flaws, but not always with success.
For better or worse, here are today’s therapist errors!
1. Confusing psychoeducation with psychotherapy. Pyschoeducation can be helpful, but it’s rarely curative. Effective psychotherapy requires much more.
Here are some examples of helpful psychoeducation:
- Teaching people about the list of ten common cognitive distortions from David’s book, Feeling Good: The New Mood Therapy
- Teaching people how to pinpoint their negative feelings at any moment in time using David’s Daily Mood Log
- Teaching people that your thoughts, and not external events, create all of your positive and negative feelings
- Explaining the Five Secrets of Effective Communication
- etc. etc. etc.
Psychotherapy means helping people CHANGE the way they think and feel, or helping people develop more loving and satisfying personal relationships. That requires a great deal of therapeutic skill and hard work on the part of the patient–during sessions and between sessions. it also requires a warm and trusting therapeutic alliance.
2. Belief in Gurus. Believing that the individuals who start schools of therapy are nice and well-balanced individuals! David describes conversations with the late Albert Ellis, PhD, who argued that many, and arguably most, are incredibly narcissistic and manipulative. Sometimes, individuals who appear incredibly charming and brilliant and inspiring have a dark underbellies they are keeping hidden!
David argues that it might be more desirable to have a science-based, data driven, systematic approach to psychotherapy, as opposed to a field dominated by therapeutic schools, which sometimes function almost like competing cults.
3. Reverse / “backward” statistical reasoning. Most therapists who work with patients with Borderline Personality Disorder as well as Multiple Personality Disorder, as well as patients who are prone to violence, believe that childhood trauma, deprivation, or abuse is the main cause of these problems. They believe this because patients with those diagnoses frequently describe traumatic experiences in their past, so they assume those experiences caused the patient’s disorder.
This is a statistical and conceptual error, because most individuals who experienced traumas when growing up never developed Borderline Personality Disorder or Multiple Personality Disorder. This is not to say that traumas are unimportant—traumatic experiences at any phase of life can be very damaging. What this DOES mean is that most psychiatric problems have other causes.
What are those other causes? They are not known, for the most part.
This information is not easy for many people to accept. For example, I just found this statement on WebMd:
“As many as 99% of individuals who develop dissociative disorders have recognized personal histories of recurring, overpowering, and often life-threatening disturbances at a sensitive developmental stage of childhood (usually before age 9).”
Here’s another web comment:
“Several studies have shown that a diagnosis of BPD is associated with child abuse and neglect more than any other personality disorders [7, 8], with a range between 30 and 90% in BPD patients [7, 9].” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472954/
The same source also stated that:
“. . . Widom and collaborators  followed 500 children who had suffered physical and sexual abuse and neglect and 396 matched controls, and they observed that . . . the presence of a risk factor, such as adverse childhood events, was not necessary or sufficient to explain the reason why some individuals developed BPD symptoms in adulthood, whereas others did not.”
If you are interested, you can find the references to these studies at the end of this blog.
Here is one way of understanding this error. Childhood sexual abuse is far more common in the population (typically estimated in the range of 15% of men and 25% of women), and if you add childhood trauma or neglect, these percentages in crease even more. AT the same time, the incidence of Borderline Personality Disorder or Dissociative Identity Disorder are typically estimated around 1%. That means that most individuals who have experienced childhood sexual abuse, neglect or trauma do not develop these disorders.
I do not in any way mean to minimize the importance of trauma, sexual abuse or neglect. The impact of these experiences can be profound and can include physical as well as psychological problems.
My only point, and perhaps it is an overly humble one, is that we simply do not know the causes of most (or any) of the problems listed in the DSM5 (Diagnostic and Statistical Manual of the American Psychiatric Association.) I think it is great that we have many treatments that can be helpful and effective for individuals, but it might not further our cause to jump to conclusions about the causes of things based on what we see before our eyes when we are doing clinical work.
Sometimes, seeing is believing, but sometimes, our “seeing” can be misleading.
I hope I have not offended anyone!
4. Believing in Mental Disorders. Do the so-called Mental Disorders” described in the DSM actually exist? Or are they simply the fabrics of our imagination?
Years ago, Thomas Szasz, a psychiatrist and psychoanalyst, wrote a popular and controversial book called The Myth of Mental Illness, in which he claimed that mental disorders do not exist. David argues that Szasz was only partially right. Most of what we see in the DSM are simply arbitrary constructs, and not real “disorders.” For example, most people worry about things from time to time. Worrying is unpleasant but normal, and there is a wide range of worrying in the population. Some people rarely worry, and some people almost constantly worry, and most of us are in-between.
The American Psychiatric Association will take the group who worry the most, and give them a label of “Generalized Anxiety Disorder.” But there is no such “thing.” It is not a real brain disorder. The same problem afflicts a great many of the so-called “disorders” listed in the DSM. These are problems, not brain disorders.
However, there are several real brain disorders, such as schizophrenia, Bipolar I Manic-Depressive Illness, and Alzheimer’s Disease. These are disorders of brain tissue or wiring, and are not simply variants of normal human behavior or experience.
When I work with individuals, I measure the severity of symptoms and say things like this, “Jim, I can see you tend to be very shy (or depressed or anxious, or whatever.)” I do not say, “Jim, I want you to know you have a brain disorder called “Social Anxiety Disorder,” because I feel that is potentially upsetting to the patient and not really “true.” In addition, shyness can be fairly easily treated in most cases without medication.
Most non-MD therapists do not make the mistake of confusing symptoms with “mental disorders.” It seems likely to me (David) that psychiatrist are more likely to make this mental error, since psychiatry, as I understand it, is emulating the medical model of diagnosis followed by medication treatment or some other kind of biological intervention.
5. Ignoring a Diagnostic Evaluation. Most therapists skip a formal diagnostic evaluation, because the DSM is so difficult to work with, and since a formal diagnostic interview can be frustrating and time-consuming. And, as I pointed out in my discussion of the previous error, it is somewhat misleading to tell patients they have mental disorders, like “Generalized Anxiety Disorder” or “Social Anxiety Disorder,” when, in reality, the patient is simply shy or has a tendency to worry a lot.
And yet, there can be significant negative consequences of NOT doing a thorough initial evaluation of the patient’s many symptoms, since you can easily overlook something important, like drug or alcohol abuse, or suicidal or violent urges in new patient.
The EASY Diagnostic Survey provides a fresh and helpful option. patients can complete it on their own, between sessions, and it automatically diagnoses more than 50 of the most common “disorders” in DSM5. Then the therapist can review it during a session and assign the diagnoses in less than ten minutes in most cases.
This provides the therapist with an accurate map of the patient’s problems. You do not have to think of them as a variety of “mental disorders,” but rather as areas of suffering and difficulty. I don’t tell myself I’m treating “Generalized Anxiety Disorder,” but rather treating a human being who is troubled by constant and excessive worrying–and fortunately, that is very treatable!
Therapists who are interest in purchasing a license to use the EASY in your clinical work can check this link.
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!
Good post David. I do think you are wrong about schizophrenia if I may say so. There has never been any conclusive evidence to say that it is a brain disorder. Over the years there has been numerous theories about schizophrenia, and all of them end up not showing a thing. It would be more honest to say we don’t know. Remember that the Nobel committee gave out a prize to Moniz for finding a cure to schizophrenia- lobotomy. His cure was based on the “known” cause of schizophrenia – reverberating brain circuits. This is no different than the ridiculous claim about brain disease and schizophrenia. I respect your work and your courage to say that depression is not a disease, but please take a look at these other sacred symbols of mental health. The sacred text for the mental health expert is the DSM and the sacred symbol is schizophrenia. Just as the Bible is the sacred text and the cross is a sacred symbol for the Christian. Schizophrenia is simply a label that people give to other people for (mid)behavior. Most people don’t like it when other people claim that they are Jesus or God, or Mohammed, or say that they have found some unusual meaning to life. But think about all the religious leaders from the past, they surely could be categorized as schizophrenic. Jesus, who said that he was the son of God, Buddha, who refused to eat for a period of time, all of these strange behaviors could be categorized as schizophrenia by mental health experts.
Hi Exi, thanks for your comment! Sincerely, david
Dr. Burns the link you posted about easy doesn’t work (on the end of the notes, on this line “Therapists who are interest in purchasing a license to use the EASY in your clinical work can check this link. “). The link sends you to this direction “https://wordpress.com/page/feelinggood.com/75” where doesn’t show anything
Just fixed the link, thanks! Let me know if you have any additional problems. All the best, david
Another terrific podcast from you and Fab Man. I love the fact that you treat a person and their symptoms rather than a label, i.e. GAD, Depression, OCD,etc. The medical model clearly advocates using ‘medicines’ to treat these so called disorders rather than exploring the specific problems that need to be worked on. I believe that this approach makes so much sense and it boggles my mind why psychiatrists aren’t trained in this way rather than pushing pills which is not effective.
Also, the DSM labeling of some of these ‘disorders’ seems absolutely ridiculous. Conduct Disorder. Oppositional Defiant Disorder. Are you kidding me?!!
Lastly, do you believe that labels can convey discouragement rather than hope? For example, if you said, “Joe, your scores indicate that you have Severe Anxiety and it is gonna be a long road out with tons of anti-anxiety medicine and relaxation techniques.. Wouldn’t Joe feel more anxious just hearing this diagnosis? To me this is where empathy would be key in helping out.
Sorry for the little rant. It must be the coffee!
Keep up the great work!
Thanks, Phil, we’re on the same page entirely! Absolutely! So please keep on ranting. I like having a partner in rant! I would add that there are two sources of astonishment. First, the diagnostic system, with its emphasis on transforming normal human suffering into a system of “brain disorders” or “mental disorders” is so bizarre and against all the principles of common sense and statistical reasoning as well (eg turning a continuous variable into a dichotomous one). Second, it is equally bizarre that so few mental health professionals, including the experts in the American Psychiatric Association, cannot seem to “see” or understand this! But I believe motivation plays a huge role in what we believe or do not believe. And there is a strong motivation among psychiatrists to be more like “real doctors” who make diagnoses and then prescribe drugs. In my opinion, it’s an attempt to create a more respectable self-image, or identity, for psychiatrists. But yes, the patient does not have the sophistication to see through the system, and might, in fact, feel dispirited thinking they have a “mental disorder” such as “Social Anxiety Disorder,” when in point of fact they are simply shy, a feeling that nearly all of us have in varying degrees. It also creates the expectation that the problem can, or should, or must be treated with a pill of some kind, hence a huge psychiatric medication industry that supports this way of thinking, too! david
When I think of all the tireless work that you do it makes sense that your approach (T.E.A.M.) is way above anything that any other mental health professional is doing. Here’s a guy (you) who has spent countless hours working with unhappy, anxious, etc. individuals through 30,000 to 40,000 sessions. Decades of listening to humans who are suffering and offering hope. It’s clear that all this time and effort has led you to identify WHY folks are suffering (resistance among other things) and HOW to resolve the problems of everyday life. Is it perfect, no! But it’s a much better approach than to listen to someone whine and complain and offer a ‘magic pill’ that will somehow get them a job, learn effective communication skills and be motivated to change for the better.
I agree that psychiatrists might think they are on the lower end of the totem pole because they aren’t doing ‘real’ medicine, per se. But from a financial prospective they can make a load of dough. Just nod your head, listen, refill the prescription and on to the next patient. Sounds good to me! Big Pharm loves it!
It’s clear you are unselfish in your quest to help people achieve their potential and for this I am forever grateful.
I always enjoy hearing from you and look forward to future podcasts.
Thanks, Phil, I really resonate with your comments, and feel the financial motive is strong, as you can make a lot more income by seeing lots of patients for brief med follow up sessions. All of us humans are so motivated by money, and often, too, by political considerations. I am hopeful that eventually our field will evolve to a far more effective approaches! Thanks so much for your interest. I apologize for my bland / lame comment, but just got up and about to hike with my students for our Sunday morning hike! d
Thanks David! Have a great hike
and I look forward to you and Fab Man’s podcast tomo. Best, Phil
Thanks, Phil. Hope you enjoy today’s Ask David. We had a big hike, with about 13 folks or so, and went to a vegan Chinese place for brunch afterwards, and kind of pigged out, I think! Our dim sum restaurant had to go out of business due to increased rent, which is very sad since it was fabulous (The Joy Luck Palace), so we are trying to find a substitute. david