349: Ask David: Borderline Personality Disorder; Traumatic Events; and More!
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349: Ask David: Borderline Personality Disorder; Traumatic Events; and More!
So Stanford psychology students conducted research on David’s for-profit psychotherapy app, and the results were excellent.
Coincidentally David happens to teach psychology to those same students at Stanford, where he’s actively involved in research. That’s hardly “independent.”
Hi Noor,
Thanks, darn good point, not a perfect solution for sure. We have been doing the best we can with limited resources. We checked with a terrific researcher in Ohio but he wanted something like a million dollars a year or more to do some outcome studies, and we checked with a colleague familiar with antidepressant outcome studies for the FDA and he estimated a small initial study would cost $130 million dollars approximately. I am not involved in teaching students from the Stanford/Palo Alto University consortium, but still, you have a good point. I’ve worked full time for free for more than 3 years to make the app possible. Doin’ my best. What do you suggest? Please be part of the solution! You’re obviously very bright. Help us!
Also, I want to point out an arguably hostile tone to your email, not collaborative to my way of thinking. I conclude I must have done or said something that offended you or angered you quite a bit. Sometimes my comments can be offensive. Can you tell me what might have triggered you. I’m nearly 81, but still have a LOT of learning to do while I’m still kicking.
I have seen personally the conflicts of interest with drug company / university collaborative outcome studies, and felt quite shocked, so I understand your concerns I believe. The research students are supervised by a professor in the department of psychiatry and behavioral sciences, and hope to collaborate on a number of additional research studies on how the app works. I will be proud to be an author on those papers, hopefully, since they focus on basic science, and not clinical effectiveness, using sophisticated statistical modeling techniques. We already have isolated a number of variables with strong causal effects on changes in negative feelings. I see the app as a powerful research tool in addition to helping many people reduce negative feelings and boost their feelings of happiness and self-esteem.
Best, david
I care about you, David, and I care about scientific truth and its implications. It is the flatterers who should be shunned, and not we who would cast a little light on a conflict of interest. It is we who are your true friends, and not they who have every inducement to tell you what you want to hear and thereby so sweetly and so insidiously lead you astray. Iron sharpens iron, David, and opposition is true friendship.
“The duty of the man who investigates the writings of scientists, if learning the truth is his goal, is to make himself an enemy of all that he reads, and, applying his mind to the core and margins of its content, attack it from every side. He should also suspect himself as he performs his critical examination of it, so that he may avoid falling into either prejudice or leniency.” Alhazen.
Thanks, and you are so right! That’s why I love to do structural equation modeling using the AMOS program (Analysis of Moment Structures). This program allows me to test hypotheses quickly, suing data we’ve collected from app users. The neat thing is that the program shoots you down 90% of the time, and has no inhibitions about telling you the truth! And, as you’ve hinted, breakthroughs in science usually come when you’re willing and able to provide that your thinking, or some popular theory, is wrong. And when the program appears to confirm a causal link, or model of how the app works, or how psychotherapy works, I do work relentlessly to prove it wrong, to find some loophole. I really enjoy that path! Warmly, david
I begin from the assumption that cognitive psychotherapy is largely a placebo. Kirsch, Seligman and others have suggested as much. I see your fundamental contribution to the field not as TEAM-CBT but you yourself — David D. Burns, an unusually effective and honest therapist, achieving incredible outcomes through some particular X factor that remains unknown and isn’t replicable.
I see considerable refinement in TEAM-CBT, but I’m unable to discern any novel mechanism of action that wasn’t included in either REBT or CT. Testing, empathy techniques, assessment of resistance (referenting) and the various methods have all been around for some time, many of them invented by you decades ago.
I’m reminded of the brilliant Darrell Huff, author of How to Lie With Statistics, who so thoroughly understood the abuse of numbers that he was hired as a tobacco industry lobbyist. I’m not suggesting dishonesty in his case or yours, but rather pointing out the presence of bias, whether personal or institutional, and the technical expertise necessary to make biased arguments plausible to oneself and others.
I began as a True Believer. I’ve been unhappily rendered a skeptic quite against my will. I honestly don’t think we have anything substantial for patients. I would love to be proved wrong by you. When is publication?
Thanks, all excellent points. Irving Kirsch, in fact, helped us with the experimental design of the study. The students are finalizing the draft of the paper, which should be submitted soon, perhaps wtihin weeks. However, it typically takes time for publication, reviewer feedback and such. There’s a strong chapter on the placebo effect in my psychotherapy eBook, Tools, Not Schools, of Therapy. The chapter is entitled, “The Clinician’s Illusion.” I agree that there likely is an “X” factor, or many, and I have identified at least ten causal factors in hwo the app works. Those papers will be published, or at least written up for submission, some of them, after the outcome paper is completed. Keep up the good, critical thinking! That’s how I think! Best, david
Hi,
Jumping into the discussion between David and Noor. Here are my thoughts:
I’ve read all of David’s numerous books numerous times but I never quite understood the depth and genius of it until I began listening to the podcasts here.
Listening to David, I finally got it. When you mimic David’s words in your therapy session, you mimic his empathy and style, you learn how to transition like he does that works incredibly. The greatest way to transfer David’s genius to yourself and patients is to listen to him in real life.
When I discussed David’s approach with my child’s therapist, he said he is ‘familiar’ with David’s approach but does not ‘go for it’.
However, he is actually not familiar with much of David’s techniques.
My teenager was not cooperative in therapy and fought every initiative of his therapist, until I asked his therapist to listen to one of the podcasts where David shares the details of ‘melting the resistance’.
That blew away my son’s resistance. His therapist shared that he has begun using this on many of his patients with remarkable success.
If this technique proved to be so successful, and despite having read Dr. Burns books, the therapist did NOT pick up on this very basic technique, then that tells us why therapists believe that it’s Dr. Burn’s personality that does the trick, and not his techniques.
It’s true that David is incredibly gifted in many ways, but an intelligent person should be able to become a student of his style. We also must remember that David is older than most therapists, so he’s got the kind of experience that none of his students can possibly have.
Hi, Sandy.
I respectfully disagree. On page 262 of Beck’s 1979 Cognitive Therapy of Depression, the technique of listing the advantages of dysfunctional assumptions (“melting the resistance”) is described in detail. It’s noted there that this is “one of the most effective procedures” in cognitive therapy and that it “expands the boundaries” of one’s thinking and allows one to “experiment with new approaches.”
Warmth, empathy and humor — all of which David has in ample measure — aren’t innovations (and they aren’t even exclusive to psychotherapy.) These too were described by Beck, along with testing, as treatment fundamentals in this same textbook on the treatment of depression that was written decades ago.
So my question remains. If none of this is new to psychotherapy then what reason is there to believe as claimed that TEAM-CBT represents an advance that is effective for those who didn’t respond to standard CT? The only thing that will settle this is peer-reviewed research, and we don’t have that yet.
Since there are so many bad psychotherapists, I am not at all surprised that someone could benefit from listening to a session with an expert like David. But that’s a different issue, because improvements in therapist efficacy aren’t proof that TEAM-CBT does what it says it does. I am sure that patients will leave feeling good, but even a used card salesman can pull that off. The question isn’t can someone be sweet-talked and left holding the bag, but rather can they not only feel better but actually get better. That’s what remains unresolved, and the burden of proof is on the person making the claim. I’m just pointing out what seems to be a lack of evidence, as all of us are entitled to do and arguably have a responsibility to do for any novel treatment of conditions like clinical depression, the lethal complication of which is suicide.
Thanks, Noor. And that’s oe of the many reasons I’m now doing outcome studies with the app. Everyone gets the same, identical guidance, whereas you never really know what a group of human therapists are doing.
Studies with human therapists would also be of value, if anyone has the resources and motivation to do that. Hundreds of outcome studies have been done on cognitive therapy and many other forms of therapy as well, and the outcome literature in the treatment of depression seems to indicate that everything comes out about the same, and only slightly better than placebo treatments. That’s my reading of the literature, at any rate. I believe this is because of many factors, especially the fact that most clinicians, in my experience, don’t seem to grasp resistance, much less know how to melt it away.
Hundreds of clinicians have come to me for consultations (always free) on challenging patients they are stuck with. The cause of the therapeutic failuree, in practically every case, has been a failure to recognize or deal with intense resistance, which seems almost “invisible” to the eyes of most clinicians. In addition, even highly motivated clinicians sometimes (nearly always) find it very challenging to learn the new resistance-melting techniques that I’ve developed in TEAM.
I do offer unlimited free weekly virtual psychotherapy training every Tuesday evening at Stanford for clinicians from around the world, regardless of therapeutic orientation and background.
I also agree that feeling better is not the same as getting better. Gutting better means understanding and mastering the tools your responded to the first time you recovered, so you can use those tools in the future, whenever the negative thoughts and feelings return–and they nearly always will! In my clinical practice, the big challenge was feeling better. The getting better part was reasonably easy–Relpase Prevention Training 9RPT) WITH externalization OF VOICES PRIOR TO DISCHARGING PATIENTS. iT ONLY TOOK ABOUT 30 MINUTES, and seemed very helpful.
But as you say, we clinicians can fool ourselves so easily, and that’s one reason why T = Testing is so vitally important, using state of the art assessment instruments.
One big problem in the field, among MANY huge problems in the so-called behavioral sciences, is that many community therapists will call themselves what is currently in vogue, but without any genuine mastery of the technique(s) they advertise on the their websites. Many patients have told me they went to “cognitive” therapists who never once asked them about their negative thoughts, for example.
TEAM therapy can be pretty awesome, but it is extremely challenging to master, and many therapists are looking for simpler formulas for this or that so-called “disorder.”
I’m rambling, so will stop. Thanks again!
Best, david
Oh, by the way, your idea about enthusiasm was the first idea that popped into my mind in the early days of cognitive therapy. I dismissed CBT because It thought it was something like my enthusiasm that caused the improvement, as opposed to belief in negative distorted thoughts. I was surprised to learn that my enthusiasm had the opposite effect of annoying many patients, so I had to tone it down a lot.
Learned the same with the app. IN the early tests, we got shot down fairly brutally for many enthusiastic / optimistic statements! Getting tons of feedback from users has been a class in humiliated has been very eye opining. If you show your patients / app users that you are genuinely interested in and open to their feedback, negative and positive, they will be pretty darn open with you! The question is rarely, ‘Are patients honest?” But rather, “Can therapists tolerate honesty from patients.” The answer to the first question is “almost always yes,” and the answer to the second questions is “sadly, no, in a great many cases.”
I loved the talk about BPD and the nuances you pointed out. However, I was kind of frustrated that you finished off the topic by mentioning that you developed powerful techniques for BPD but didn’t go on to talk about what they are. You kind of dangled the carrot…Please, Dr Burns, can you create a podcast where you talk about your most effective techniques for BPD. Will be very helpful! Sandy
Hi Sandy, and thanks so much for your kind and thoughtful comments. You are right. There’s an intense resistance to my work among many therapists. If anyone DOES want to learn, I try to remind people that for more then 20 years, I’ve offered free weekly psychotherapy triaging in my weekly Stanford class. Since it’s now virtual, therapists from around the world can attend and see for themselves. My co-leader, Jill Levitt PhD, and I put a lot of effort into our teaching, and absolutely love the process, which includes live therapy demos about once a month or so.
However, because many human therapists can be strangely stuck in their ways, I have turned my attention in the past several years to creating the Feeling Good App, since the computer does what I tell it to do! And our beta testing indicates surprisingly strong and rapid improvements in the way beta testers feel. And now, as we add AI to our package, the sky’s the limit.
At the same time, I do respect people’s skepticism, trying to explain away positive outcomes, attributing dramatic improvement to other causes. When I first learned cognitive therapee, I also thought there was some other “ingredient” that caused the improvement, like therapist enthusiasm, or something like that, or a mega-placebo effect. Using app data, I’ve been able to create sophisticated statistical models that reveal how the app really works, and how people actually change. What are the factors that cause rapid reductions in negative feelings? I’ve identified at least ten or 15 variables with strong causal effects in changes in negative feelings, and hope to publish some of the most interesting in scientific journals.
All the best, David
Hi, David.
You make a number of important points on which we are in total agreement. Specifically, I believe that apps such as yours have the potential to be arguably the single most effective psychotherapeutic intervention since the introduction of cognitive therapy for all the reasons you just gave, including standardization and immediate feedback. One might also add scalability, if designed to be intuitive and affordable. And following the insights of Kahneman’s latest book titled Noise, lessening the possibility of human error and bias will arguably be another big advantage of the app.
Because of this great potential, I’m playing the role of the gadfly when it comes to need for research. Unless I’m overlooking something, I am not hearing that there’s any data beyond clinical anecdotes that assessment of resistance is conducive to superior outcomes, nor that this technique has been tested against other methods presented as novelties and therefore plausible sources of hope for the patient.
If you believe in a particular technique, like melting resistance, and you present that technique with energy and enthusiasm, and the patient has never tried that technique before and is therefore inspired by its possibilities and gets excellent results, then you will have largely created that good outcome regardless of the technique used. That is, it’s self-fulfilling. To be a fair test, two versions of the app would have to involve you (David) enthusiastically recommending in the video portions of the app another completely different technique, and yet I doubt you would be able to do that precisely because you don’t believe in its efficacy. Now, if you ran these A/B tests on that, and it always came out that one technique always effected big improvements, then there would be some reason to believe. But not until then.
Is this an unfair criticism, David?
(By the way, we are quite in agreement on that there is an absurd profusion of therapies that have no evidence base, and that most therapists labeling themselves as “cognitive” have no idea what is meant by the term.)
Dear fellow gadfly,
There are no unfair criticisms. Only thoughtful and intelligent criticisms.
One of the nice things about app research is that we measure changes every few minutes, after every class, and this is just one of many ways to isolate and measure the precise causal effects of all aspects of the TEAM model. And the SEM software I use is totally unbiased and unforgiving, and relentless is proving you and your model and your thinking to be incorrect. When I was in practice, I idd considerable process research on how psychotherapy for depression operates, published in journals like JCCP, and resistance / motivation emerged as huge. Happy to send some references if you’re interested. But now, with massive amounts of app data constantly flowing in, I’m able to identify all kinds of variables contributing to outcomes. It’s excting to discovery what really does work, and what is actually not so important, at least ina causal sense. All the models in all the many beta tests have confirmed the massive impact of resistance / motivation, measured precisely, on changes in all negative feelings. That’s just one dimension but an important one. Once the Stanford colleagues publish the outcome patient, using a research design similar to Forrest Scogin’s first outcome study using my book, Feeling Good. I hope to publish some of these process papers.
I also have some exciting (to me at least) data testing, finally, Epictetus’ claim that negative thoughts, and not events, actually cause negative feelings, using non-recursive SEM techniques. I have also been able to test, in a rigorous and precise way, Irving Kirsch’s hypothesis that expectations play a significant role in degree of improvements. The new data ssets we are generating seem to be loaded with secrets about how psychotherapy actually works. I find the concept of projection endogenous variables into linear space to be a useful tool, since so many variables are potentially involved in circular causality.
This is probably too general of an answer, as it the studies are all precise and specific, but I just wanted to judge you on so you will keep criticizing in your extremely thoughtful and awesome way!
Warmly, david
Thanks, David. If you could cite those papers, I would appreciate. Thanks.
By the way, have you also studied resistance in the therapist and its impact on the patient?
And also, doesn’t the fact that expectations play a key role in therapy suggest to you that you’re dealing with the placebo effect? (Mind you, Beck claims the opposite in CT of Depression — that the treatment will work whether you believe in it or not, as surely as a cast will heal a broken bone regardless of your belief in it. This would be a better argument, to my mind, for the effectiveness of a treatment.)
As for Epictetus and other Stoics who say happiness comes wholly from within I might suggest that they be compelled to spend several days in rags in a blizzard without food and then they would see the folly of their ways. If you have evidence to the contrary, kindly speak and edify us.
Thanks again, noor. I have to be brief because I have a data conference with an Israeli data scientist shortly. I hope to learn some new stuff! Always fun.
1. I have long believed we should study the feelings of shrinks just prior to and at the end of sessions, to see how the beliefs and feelings of therapists, including resistance, might have significant causal effects on changes in negative feelings. Such studies would be very difficult for many reasons. We don’t so much have to worry about this when the computer is the one who delivers the interventions.
2. I am not familiar with the various ways people think about or define the “placebo effect.” Would love to learn more. But I do think that expectations can play a significant role in therapy, in life, in relationships, and so forth. My research on mechanisms of change in app users indicates many effects are occurring simultaneously, and the challenge is to measure them precisely and figure out the linkages. My research so far suggests that all, or nearly all, change is ultimately mediated by change in belief in distorted negative thoughts. I’ve seen this result in several independent data sets, and it is definitely high on the priority list of hopefuly publications.
3. Will send list of several key publications when I get a minute. Have to run in a couple minutes.
4. Even in the face of physical adversity and pain, thoughts and feelings have a massive effect on how we feel emotionally and physically.
Thanks again for cool questions and highly appreciate (and rare) solid dialogue on these topics!
Warmly, david
Back again. Here are a few keuy references on aspects of TEAM, especially the role empathy and motivation / resistance in recovery from depression.
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., & 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., 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. (2020). Feeling Great. Eau Claire, WI: PESI.
Remarkable! So here’s the thing, Davis. You take the position that emotional change is mediated by cognitive change, which is mediated by homework completion which is depends upon willingness. This then suggests a number of questions.
First, the willingness scale is a measure of process resistance. Is there any evidence that the assessment of resistance technique decreases either process resistance, outcome resistance or both? I don’t see that addressed in these papers, nor do I see answer to the following two questions.
Second, is there any evidence that interventions which improve willingness are then able to improve treatment outcomes?
Third, if there is evidence for the improvement of outcomes with these interventions (e.g., TEAM-CBT), what kind of results are we talking about? Are they much superior to the outcomes figures for other therapies that you recently alluded to, which you pointed out are little better than placebo? Are they merely exceeding the current rate of effectiveness for CBT, which Johnsen and Friborg claimed in 2015 is half as effective today as it was several decades ago? What’s the story?
You’ll excuse me for question you in this way. I saw Stanton Peele speaking with a doctor claiming a 70% recovery rate for those seeking treatment with him for substance abuse, and Peel said, “Seventy percent? That’s incredible. Where was this published?,” to which the doctor replied, “Oh, well, we haven’t published on that.” These days a lot of people are singing the praises of CBT, and I’ve heard some report an 80% efficacy rate, but I think the latest meta-analysis I saw put it around 40% or thereabouts, which is probably about the response rate you’d get from given people Tics Tacs.
But, taking your side for a moment, I suppose it could be that you’ve hit upon the therapeutic relevance of Festinger’s work from the Fifties about how “believing is seeing,” and that one dissonant idea will suppress the other, and along with it will thoroughly distort reality, and until that changes then recovery is impossible.
When people claim a percent improvement rate without measuring change accurately, I totally dismiss what they are saying. Again, I have a great chapter on this topic in my book, Tools, Not Schools, of Theapy, entitled “The Clinician’s Illusion.”
We have clear evidence that Willingness has causal effects on changes in mood that are mediated by changes in belief in negative thoughts, but do not measure changes in Willingness We culd do that in a future beta test.
Thanks again, Noor! Best, david
PS It is my clinical observation that boosting willingness in my clinical work using a variety of techniques opens the door to extremely rapid change. However, I’m not measuring sequential changes in willingness during clinical work, only “observing” it clinically. And, as you say, this might be more of the “Clinician’s Illusion!”
Thank you, David. It has been both an honor and a pleasure to discuss these matters with you, and doubly so given the rare opportunity of hearing from a man of your stature and immense contribution to the welfare of all humankind. May peace be upon you. Noor.
You are very kind, and it i a really fun thing for me, and an honor, to engage in scientific dialogue with a superb critical and creative thinker! Warmly, david
Dear David, I read this thread and it is interesting.Noor makes good points but fails to recognize that everything in therapy doesnt have research to back it up. It borders on the irrational to think that you need research for everything.It simply cant be so. This is a problem with people who adhere to science.Doctors dont go by science all the time. The problem lies within Noors black and white thinking which is rather fanatical. Cognitive therapy isnt everything and it isnt used for all disorders. However David let me talk and we never used cognitive therapy and I recovered from a myriad of problems. The key was that he listened to me and heard me and I felt accepted and understood. David has alot to offer with years of being in the field and the truth is there are not many good therapies out there.Most of them cause harm or are ineffective and have been proven to be so or you can rule it out on a common sense level. Not everything is science. Sounds like alot of smart talk polished up byNoorjust to say that.
Thanks Debby for your wisdom! A warm and trusting relationship with someone who listens can be deeply meaningful and welcomed by all of us! And science, like everything, has its limits! And some people ARE quite impressed with themselves! Best, david