Self-Acceptance–Are We All Defective?

hike photo 9Hi everybody,

I’ve been getting lots of great emails with questions recently, and will try to get to as many as possible. Here is one from this morning.

Hi Dr. Burns,

I really hope you get to see this! I just wanted to say how I love your book and it has been helping me a lot I bought and read Feeling Good: The New Mood Therapy, and I’m currently reading your book on anxiety, When Panic Attacks.

But I did want to say one thing. On page 216, near the bottom, it says, ” … in fact, we’re all defective and you can view your ‘defectiveness’ as a reason for suicide or a cause for a celebration….”

I didn’t understand that. That we should view us being defective as a reason to kill ourselves?? It threw me off and I asked my friend to read it over. I just want to know what you meant!

It’s near the bottom second to last paragraph on page 216


Hi Nicole,

Sometimes I write things that may be hard to “get” at first, so I appreciate your question. First, let me emphasize that suicide is never appropriate or needed for someone who is feeling depressed and hopeless. However, was writing about something I call the Acceptance Paradox, where you achieve enlightenment by accepting your many shortcomings with a sense of inner peace, or even with a sense of humor. I call that “healthy acceptance.”

And when you “grasp” this notion that it is okay to be flawed and defective, or even wonderful, you can achieve liberation from feelings of depression, anxiety, shame and self-doubt. And it brings you a lot closer to other people, too, because, believe me, there are TONS of other defective people out there, so we can have a party and lots of folks will join us, and we can just hang out and not worry about having to impress each other.

But people who are depressed usually have what I call unhealthy acceptance. They wrongly believe that because they are defective, they should kill themselves.

If you CLICK HERE, you will find a chart that distinguishes healthy from unhealthy acceptance.  As you can see, healthy acceptance is characterized by joy, intimacy, laughter, and creativity. In contrast, unhealthy acceptance is characterized by cynicism, depression, hopelessness, and loneliness.

This is sometimes hard to “see” at first on an emotional level, especially if you are depressed, or prone to depression. But when you suddenly “get it,” it’s like seeing the grand canyon for the first time. It simply takes your breath away, and you discover that it’s only okay to be defective, it’s actually great–in fact, the very BEST way to be!

I am writing something more ambitious on this topic, and I’ll publish it here soon. This is just a beginning note intended to whet your appetite, hopefully at least! What I am writing about now are some of the more philosophical underpinnings of TEAM-CBT, although the notions are actually ancient, and go back at least 2500 years. I will try to address two questions:

  1. Is it possible to be worthwhile or to be worthless?
  2. Do we have a “self”?

Although these themes may seem abstract, they have powerful, practical, emotional consequences. Just one small example, let’s say you struggle with anxiety and shyness. You may have the fear that others will judge you because you are inferior, or not “good enough,” and this thought can cause tremendous suffering. But this thought is based on the notion that you have a “self” that can be evaluated or judged. When you see through this notion, you can experience liberation from your fears.

The Buddhists called this “The Great Death.” Of course, we all fear death, and struggle to keep our egos alive. But once you’ve “died,” so to speak, you can join the Grateful Dead, and then life suddenly opens up in unexpected ways. And for those who may misread me, or interpret my words literally, I am not referring to physical death, but death of the “self.”

So, stay tuned if this type of dialogue interests you! And thanks for reading this!

Doctor David

If you are reading this blog from Facebook or Twitter, I appreciate it! I would like to invite you to visit my, and register there as well. You will find a wealth of free goodies, including my Feeling Good blogs, plus all my Feeling Good Podcasts to date, and the Ask Dr. David blogs as well, along tons of resources, including videos for mental health professionals as well as patients and the general public!

An Anxiety Question and a Blessing from Turkey for “David Uncle!”

An Anxiety Question and a Blessing from Turkey for “David Uncle!”

Hi Dr. Burns,

whenpanicattacks-sm  Thank you for your life-saving books and blogs. They really help. I have given your book, When Panic Attacks, to others. It is so good! What I admire the most is your empathy and your desire to seek the truth.

I have a simple request. Can you clarify the use of cognitive flooding and thought-disputing? I find these two methods to be quite useful but confusing at times. For example, it doesn’t seem logical to flood my mind with panic thoughts and then turn around and dispute them. Perhaps morning flooding and evening disputing?

I don’t know that a general answer is possible but any thoughts you have are sincerely appreciated. I understand you do not give personal advice and that if you do answer, it will be for the help of many others who follow your blogs and appreciate your insights.


Hi Bill, Thanks for your kind comments and question. I am embarrassed that I can’t give you a good clear answer. But I’ll try to babble briefly. Remember that there are four treatment models for anxiety, and I use all four with every anxious patient I treat.

  • The Motivational Model—where you bring the anxious patient’s Outcome and Process Resistance to conscious awareness and melt them away.
  • The Cognitive Model—where you challenge the distorted negative thoughts that trigger the anxiety, using a wide variety of techniques such as Identify the Distortions, Externalization of Voices, the Experimental Technique, and so forth. You call this “thought disputing,” but there are more than 50 ways of disputing and crushing negative thoughts.
  • The Hidden Emotion Model—often the overly “nice” anxious individual is sweeping some feeling, conflict, or problem under the rug and not dealing with it. When the patient brings the problem to conscious awareness and deals with it, the anxiety often disappears completely.
  • The Exposure Model—where you flood yourself with anxiety by facing your fears. If you stick with it, in most case the anxiety will diminish over time and then disappear. You call this “cognitive flooding,” although that’s just one of many exposure techniques.

I describe these four models and methods in my recent series of Feeling Good Podcasts on the treatment of anxiety (Podcasts 22 to 28). You might enjoy listening to them, and can link to the first one if you CLICK HERE. All four treatment methods are helpful, but they work in different ways. You never know which method or methods will be the most helpful to any individual.

But I have to confess I don’t “schedule” them as you have suggested. However, that’s not a bad idea! In my experience, depressed and anxious individuals who work with these techniques, and actually try them, including the written exercises, as opposed to just reading about them, nearly always have the best outcomes. So stick with it!

And of course, if you need help or guidance, it never hurts to check with a mental health professional. However, I would personally tend to avoid a psychiatrist as my first choice, as you are likely to get drugs, drugs, drugs. Although I am a psychiatrist, and have prescribed medications on occasion, I find that most depressed and anxious individuals can now be treated quickly and effectively without medications. In addition, research studies indicate that many people recover from depression anxiety on their own after reading one of my books, but if you need a little guidance from an expert, there’s no shame in that at all! Sometimes, we all need a little help from our friends!




Hi Dear David Burns,

feelinggood  Firstly, I want to say thanks a lot for you book, “Feeling Good: the New Mood Therapy”! This book has changed my life! Now I love life and enjoy everything in life.

My story started after reading your book second time! Thanks very much! God bless you David uncle!

Sedef (from Turkey)

Hi Sedef,

Thank you so much for your kind and incredible comments, and for your blessing! I am thrilled that you are now loving life and enjoying life! That is like a miracle and the greatest gift a human being can receive.

It is many years since I wrote Feeling Good as a young man, editing it while we were on summer vacation in California, at Lake Tahoe. You might not have even been alive at that time! It seems like a miracle that my words have now touched you, so many miles away. God bless you, too, Sedef!

All the best,

David Uncle

Do We Have a “Self?” / Truth vs. Happiness

Do We Have a “Self?” / Truth vs. Happiness

IMG_1226Hi Dr. Burns,

Being as you love my questions here is another. It is a heavy philosophical one but don’t feel the need to give a long answer. The question is: Should we believe what is true or what makes us happy?

Albert Ellis, in his book “the Myth of Self Esteem,” actually mentions you. I know you’d want to kill the guy if he were still alive for destroying the basis of many of your books, but don’t you feel honored that grumpy old Al mentioned you? He writes a few hundred pages but all he seems to be saying is that you can’t prove whether you are worthwhile or not so you’d might as well believe that you are.

My new coach seems to think that truth is relative and all that kind of stuff. She thinks that you should believe what is best for you and don’t worry about whether it’s true. Even Dr. Ali Binazir says something like the usefulness of a belief is more important that its truth (can’t find exact quote).

What do you think? Should I believe what makes me happy and forget about logic or keep on thinking (and maybe be not as happy)?


Hi Richard,

Great questions, thanks!

First, with regard to Dr. Ellis, I was a huge fan of his, and we saw eye to eye on a great many topics. I admired his ruthless integrity and regard for the truth. He did not steal ideas from others, as so many in our field do, and call them his own, but always gave credit where credit was due. So I was a huge fan and always honored when he mentioned me!

of course, he was a wild man, no doubt about it, and all those who saw him in person during his workshops will know what I mean. Every third word that came out of his mouth was the F-word. But he had tremendous numbers of fans and followers. In fact, i think many people liked him because he was so delightfully outrageous and honest!

As you know, Dr. Ellis created Rational Emotion Therapy (RET), which later morphed into Cognitive Behavioral Therapy (CBT). He is considered the “grandfather of CBT.” Beck is often thought of as the “father of CBT.” I might be the son of CBT! Who knows? So many talented therapists and researchers have contributed to the new approaches in psychotherapy that began about four or five decades ago.

I agree with Ellis that you cannot measure your worthwhileness as a human being, so you might as well give up this fruitless and often painful endeavor. but I don’t even need to assume that I am worthwhile. I am too busy enjoying life to waste time on that idea!

I have a beautiful new kitty, Miss Misty. she doesn’t care whether or not I am worthwhile, either! But she loves to play and cuddle. That’s enough for me.

You can measure the worthwhileness of specific things, like this post. For example, you might give it an A, a B, a C, or below, depending on how much you like it and learn from it. But you cannot measure the “worthwhileness” of your “self.” In fact, there is no “self.” We can focus on improving in specific areas, however. For example, if you exercise regularly your conditioning will improve. But your “self” won’t improve!

One of the best students I ever had was Matt May, MD, who now teaches with me at Stanford and has a booming clinical practice. He is a totally fabulous clinician, dear friend and esteemed colleague. When he was a resident, I would supervise him three hours a week, going over clinical cases and personal issues as well, which is typical of what happens in psychiatric training.

One day we were driving back to my house from a pizza place where we’d been eating and discussing his cases, and going over some personal stuff. We stopped at a stop sign, and he looked at me in very meaningful way and said, “Dr. Burns, I want you to know that I’m working so hard every day to become a better person!”

I said, “Matt, I hope you get over that pretty soon!”

He immediately broke into laughter and “got it.” That was the moment of his enlightenment. Enlightenment often comes with laughter, as you realize your suffering has been the result of a kind of cosmic joke. This is a Buddhist notion going back 2500 years, but it is also embedded in most religions.

Thie idea that we have no “self” is mystical but practical and potentially liberating. Buddha got the ball rolling when he talked about the “Great Death,” or the death of the ego. I lost my “self,” along with my “self-esteem” years ago, when I was jogging home from the train station in Bryn Mawr Pennsylvania after work. And what a relief to get rid of them. They kind of fell off, and then I started jogging faster without having to carry them any longer.

Sadly, my “self” (and my pride) have a way of coming back to life from time to time, so then I have to get rid of them again! That sucks!

If you understand this, it is likely crystal clear and super obvious, perhaps. But if you don’t understand it, it is likely sounding like so much mumbo-jumbo!

You asked if we should believe what is true, or what makes us happy? This is a vague question, so I don’t know what you are referring to. Usually I try to avoid general questions without specific examples. Perhaps you could make your question a bit more specific? For example, what belief in particular are you referring to?

If you go to Las Vegas you may want to believe that if you put your life savings on a number on the roulette wheel, you will earn a tremendous amount of money. But the likelihood is small, so even though the notion is enticing, you probably won’t want to do that.

In therapy, I use both truth and motivation in working with someone who is depressed, anxious or angry. Both are powerful and potentially healing technologies for folks. Obviously, we tend to believe things that appear to be true. But we also tend to believe what we WANT to believe. Motivation also plays a basic and powerful role in how we think and what we do.

Cult leaders motivate followers by telling them absurd things that could not possibly be true. For example, the Heaven’s Gate San Diego cult leader told his followers that if they committed suicide they would be reincarnated on the Hale–Bopp comet that was passing close to the earth. So they all killed themselves! The cult followers WANT to believe what they are being told, so they buy into it. Hitler used the same method to motivate people, telling them they were the superior race. People want to feel superior, and want to scapegoat and blame others for their problems.

From a philosophy of science perspective, some statements or theories can be proven to be false. For example, you can easily test the claim that if you drop your pen, it will float up to the ceiling. Drop it and you will see that this theory is false.

But sometimes we make value judgments, or stipulations, that cannot be proven one way or the others. For example, take the statement, “All men (or all humans) are created equal.” This is a value system we endorse, but it cannot be proven one way or the other. Our moral and legal laws are like this.

Take the belief, “I should always try to be perfect.” This cannot be proven to be true or false, it is just a value you might, or might not, endorse. There are many advantages to this belief, as well as many disadvantages. I deal with this belief all the time in therapy, as it seems to trigger feelings of depression, inferiority, anxiety, and defectiveness, to name just a few. But at the same time, the belief may motivate and make you feel like something wonderful is going to happen when you achieve your goal.

So, sometimes considerations about truth will dominate our thinking and our decisions, and sometimes considerations about advantages and disadvantages (motivational issues) will tend to dominate our thinking, and sometimes considerations of truth as well as motivation both play a role in how we think, feel, and behave.

This is all a bit too theoretical for me, although still interesting. I am a psychiatrist, but my main treatment tool is psychotherapy. The type of psychotherapy I do always focuses on something specific and real, for example, a specific moment when someone is upset and wants to feel better or behave more effectively. General discussions have been much less effective as treatment tools in my experience.

But still fun to talk about! So thanks, Richard!


Is Happiness a Distortion?

Is Happiness a Distortion?

Hi Dr. David Burns,

I am confused about the idea that depression and anxiety result from distorted thoughts. For example, you say that anxiety always results from the distortion called Fortune Telling—making unrealistic negative predictions that something terrible is about to happen.

If anxiety is results from telling yourself that something bad is about to happen, feeling alive and euphoric must result from predicting that you’ll have a good future—is that right? But isn’t that also a distortion?

Why should I believe that everything is going to be fine? Isn’t that equally ridiculous as believing something bad is going to happen?

Have a Nice Day!


Hi Jason,

Thank you for the thought-provoking question. I have edited your question to make it a bit more focused and understandable, and I hope that is okay. And here is the short answer if you don’t like to read too much of my babbling—it probably isn’t a good idea to tell yourself everything is going to fine, because it isn’t!

Bad things happen to all of us. For example, you’ll make mistakes, you’ll fail at some things, you’ll lose people and things you love, and you’ll experience illness and eventually, death. Good things will probably happen to us, too! For example, you seem to be interested in my work, and you ask good questions. That’s cool! I am honored by that, and consider myself fortunate.

But these events do not cause you to feel the way you do. Your thoughts create all of your feelings, positive and negative. That’s been known for at least 2,000 years, since the time of the Greek philosophers, like Epictetus, who said that humans are not disturbed by events, but rather by our views of them. In my opinion, the most important issue is whether your thoughts about these events are realistic or distorted.

In my two podcasts on my list of ten cognitive distortions, first published in Feeling Good: The New Mood Therapy, I emphasized that negative and positive distortions can both cause problems. Let’s focus on negative distortions first. The negative thoughts that trigger depression and anxiety will practically always have many of the distortions I’ve described, such as Jumping to Conclusions, All-or-Nothing Thinking, Overgeneralization, Should Statements, Self-Blame, Magnification and Minimization, Labeling, and more.

That’s why I’ve said that depression and anxiety are the world’s oldest cons—because you’re telling yourself things that simply aren’t true, but you don’t realize it. For example, depressed patients often feel worthless because they tell themselves that they are “losers” (All-or-Nothing Thinking). They may also feel hopeless because they tell themselves that they’ll be depressed forever and their problems will never be solved (Fortune-Telling).

As you so wisely pointed out, you see the exact same distortions in anxiety. For example, a woman with an intense fear of flying told herself, “Oh, I just know that the plane is going to run into turbulence and crash!” This is an example of Fortune-Telling–making an unrealistic prediction. It’s also an example of Magnification–blowing any real danger way out of proportion. And it’s an example of Emotional Reasoning as well–she’s reasoning from her feelings, telling herself that she feels frightened, so she must be in danger.

Cognitive therapists use many powerful techniques to help individuals struggling with depression and anxiety put the lie to the distorted thoughts that trigger their distress. In fact, I use more than 75 different techniques. And the very moment you stop believing the negative thoughts that trigger your depression and anxiety, you will immediately experience a profound improvement in your mood. However, this type of therapy is extremely sophisticated and requires a high degree of therapeutic skill and training. You can’t just tell someone to cheer, or feed them a line of positive baloney! People are not that stupid!

It would be wrong to conclude that all negative thoughts are distorted. In fact, many negative thoughts are valid, and not distorted. Realistic negative thoughts trigger healthy negative emotions, such as healthy sadness or healthy fear. For example, if you are walking in a dangerous part of town at night, you may be feeling frightened because you are telling yourself that you are in danger of being mugged or murdered. You don’t need to treat your fear with a pill or psychotherapy. You WANT the fear because it may keep you alive!

The same is true for the thoughts that trigger healthy sadness. For example, I recently lost my beloved cat, Obie, who was likely eaten by a predator in the middle of the night a couple months ago. I loved him tremendously, and he was the joy of my life. We were very close. In fact, I often described him as my best friend in the whole world, and one of my best teachers, too. Now I am grieving his loss, and will miss him for a long time! My grief is an expression of the intense love I felt for him, and does not need treatment. Nor do I need or want anyone to try to cheer me up. I’m fine with my sadness.

There are also ten positive distortions that are the mirror images of the ten negative distortions. For example, depressed patients are into the “nothing” of All-or-Nothing Thinking, but patients with mania are often into the “all” of All-or-Nothing Thinking when they tell themselves, “I am a winner! I’m the greatest!”

Politicians sometimes try to control people by combining negative and positive distortions. Hitler told the German people they were the superior race (the positive distortion) and that the Jews were inferior and to blame for Germany’s economic problems (the negative distortions). These positive distortions led, as we all know, to murder, sadism, and war. Some politicians today appear to be using similar strategies, and gaining a frightening amount of power.It is shocking and disturbing to me that so many people are gullible and cannot see through them!

Positive distortions not only trigger mania—which you can see in the crowds who were listening to Hitler’s speeches in a frenzy of manic excitement—but play a central role in narcissism, relationship conflicts, violence and addictions as well. Much of the world’s suffering results from negative distortions, but a great deal results from positive distortions as well.

Positive distortions are never the antidote to depression, in my opinion, and telling yourself nonsensical positive things that are not realistic will rarely or never be helpful to anyone, in my experience. But if you believe positive distortions, you will likely feel temporarily high, overly confident, and even euphoric.

Healthy joy results from positive thoughts that are realistic, just as healthy sadness results from negative thoughts that are realistic. I hope this helps to clarifies the difference between distorted and realistic thoughts.

For more information on how to overcome the thinking patterns that trigger depression and negative, I would guide you to any of my books, like The Feeling Good Handbook.



How to Find Your “True Calling” in Life!

How to Find Your “True Calling” in Life!

Dear David,

First of all, I would like to tell you that using the methods in your many wonderful books has changed my life!!

I have a question and it would be great to get your input. I work as a team leader/software engineer in a software company. I like my profession (I enjoy programming and managing) but I also care deeply about the environment and animals. (I also volunteer in an environmental non-profit organization). This situation leads to a recurring thought that causes me a lot of suffering: “I’m wasting my life when I’m working in this job (software).”

I feel that my life calling is working with animals/helping the environment and as long as I’m not working at that I’m wasting my life. Is this true? Am I wasting my life?

Is this the hidden emotion (elephant in the room) that causes this thought?

I really need your help!

Thanks, Sharon (name disguised)


Hi Sharon,

Thanks for your questions! It is spirit-uplifting that you have idealistic goals. My wife and I are also concerned about the environment and the welfare of animals.

I cannot give medical advice, or do therapy in this medium. I can only give some general ideas, but perhaps you will find them useful or interesting.

First, this might be the Hidden Emotion phenomenon, and it might not be. For example, let’s say there’s something else that’s bothering you that you are kind of pushing out of your mind. Perhaps there’s a conflict of some kind with a boyfriend, or a girlfriend, or a family member. Or perhaps someone is pushing you to loan them money, and you are tempted to give in because you’re so “nice,” but you don’t really want to. Or maybe there is a problem of some kind at work that you’re avoiding. It could be anything.

These are just examples of the kinds of conflicts that overly “nice” individuals sometimes tend to avoid.

If this is going on, then the obsessing about your career could, in fact, be a way of not dealing with the real issue. If this turns out to be the case, then you are a darn good detective! But you’re the only one who will be able to say one way or the other. If you open your mind to this possibility, some problem you’ve been avoiding might suddenly pop into your mind. Then if you deal with it more directly, the obsessions about your career might diminish or suddenly disappear. But this is just a possibility.

On the other hand, it might not be the Hidden Emotion phenomenon, but simply genuine ambivalence about your career. You do enjoy your career, which is great, but you are telling yourself that you “should” be doing something more meaningful with your career and with your life. Should Statements are one of the ten cognitive distortions, as you may know if you’ve read any of my books or listened to my two podcasts on negative and positive distortions.

We could view your career concerns as a genuine decision-making issue, but there are really two different decisions involved. The first decision is whether or not you want to change careers. The second decision is whether or not you want to beat yourself up by telling yourself, “I’m wasting my life because I’m working in software development.”

It might be useful for you to do a Cost-Benefit Analysis. Draw a line down the middle of a piece of paper and label the left-hand column Advantages and the right-hand column Disadvantages. You can put the negative thought that is bothering you at the top of the page. This is the thought: “I’m wasting my life working in software.”

Then list the Advantages and Disadvantages of believing that thought and beating up on yourself about your career, and balance them against each other on a 100-point scale. Is it 50-50? 60-40>? 35-65?

To make this easier for you, I’ve attached a CBA for that you can download if you CLICK HERE. You will see that your negative thought is already at the top of the page for you.

Notice that this is NOT a decision about your career. It is a decision about obsessing and making yourself unhappy about your career.

One advantage of telling yourself that you are wasting your life is that it might motivate you to change professions, so you will be more likely to pursue your goal. Another advantage might be that your self-criticism shows that you are a very caring and idealistic person, and not someone who ignores real problems in our society. A third advantage might be that your negative thought could be a kind of “moral punishment” for doing what you enjoy—software development! After all, many cultures and religions throughout history have felt that it is a sin to be happy and to enjoy yourself!

Another advantage of criticizing yourself is that it shows how humble you are, and how willing you are to examine your life in a serious and accountable way. And humility is a spiritual quality.

Yet another advantage is that your self-criticisms show that you have high standards, and those high standards have likely motivating you to accomplish a great deal in your career! And that’s definitely a good thing.

You can likely think of more advantages, and I’m just giving examples.

And you may conclude, after making this list, that you want to keep criticizing yourself. There is nothing wrong with that!

Then you could list any possible disadvantages of your negative thought in the right-hand column. For example, if you are not actually planning to change professions any time soon, then one disadvantage would be that you’re making yourself unhappy, and perhaps unnecessarily. And you might be able to list some more disadvantages as well.

After you complete you lists, put two numbers that add up to 100 in the circles at the bottom. The critical issue is not how many things you list in each column, but how they weigh out in your mind. What feels greater? The Advantages? Or the Disadvantages?

If the Advantages of the negative thought are greater, and you decide that that DO you want to continue criticizing yourself in this way, you could be to ask yourself how many minutes per day you want to devote to beating yourself up. Would five minutes be enough? Thirty minutes? Then you could schedule time each day to sit and make yourself miserable with a barrage of self-critical thoughts. At the end of your scheduled “Worry Break,” you could go back to joyous, happy living.

In addition, you could do two additional Cost-Benefit Analyses (CBAs). First, you could list the advantages and disadvantages of sticking with your current career. Then you could do a second CBA, listing the advantages and disadvantages of switching to some type of career involving your love of animals or your commitment to saving the environment.

Here’s something else to think about that might also be interesting to you. There is no rule that says that you have to have one supreme “calling” in life that you totally devote yourself to. It can be more than enough just to have a job to support yourself. And if you enjoy your work, so much the better! And that might be enough to ask from your work as a software engineer.

You can still do things in your spare time, if you want, to pursue more idealistic causes, or other interests, and it sounds like you are already doing this. On my Sunday hikes with individuals from my free weekly TEAM-CBT training groups at Stanford, we see volunteers in the Palo Alto Foothill Park removing invasive plants and weeds that do not belong in this area. They are doing something for the environment.

In my case, I devote a lot of volunteer time each year teaching and training therapists, and even helping them with personal issues in my training groups for community therapists at Stanford, and during our Sunday hikes as well. It is all totally free,, and it gives me a lot of pleasure!

My wife and I also devote enormous time to abandoned cats that we take in, and we absolutely love them! We have a small orchard and grow tons of apples that we feed to the many grateful deer in this area in the fall. The deer sometimes make a home in our front yard and sleep under our old plum tree! We love them! When they are hungry, the mother deer comes close to our house and stares into one of the windows. When I notice that, I go out and toss out about 75 or 100 apples for them, which they quickly devour!

You can also support political candidates who support your goals and causes.

In short, life does not have to have one calling, one purpose, or one meaning. You can have as many goals, purposes, and meanings as you want! The idea that your MUST have a career that involves some lofty goal is often just a trap, just another “should.”

Do you know that in the middle of my psychotherapy career, I suddenly got the urge to pursue a career in table tennis? That might sound goofy, but it’s true!

I had been really good in table tennis as a kid, and in college, too, but had never had any formal training. So I completely gave up my clinical practice and purchased a ball machine and video camera in the garage, and hired a professional table tennis coach who called himself Ernie the Black Pearl of the Caribbean. He had just moved to Philadelphia and was looking for people to coach, so I paid him to coach me 20 hours a week for about six months. He was the Caribbean champion and was phenomenally skillful. It was strenuous Olympic type training for four hours each morning, Monday through Friday.

I also purchased an Olympic table tennis table from Sweden, as well as costly Swedish rackets with special rubber on both sides that created increased spin and speed when you hit the ball.

Oh boy! I worked and worked on my table tennis. The game had changed completely from when I was a kid, so the training involved a lot of re-learning.

Then I saw a notice that there was going to be a four-day training camp at the Eastern Regional Table Tennis Training Center in Bethesda, Maryland. It appeared to be a training program for the US Olympic Team, and I called to ask if my son and I could attend. The woman who answered inquired about my national rank, and I explained that I did not yet have a rank, but that we were pretty good, etc etc. So agreed to register my son—who was about 15—and me in the program.

This was the chance of a lifetime! We were so excited that we got up at about 4 AM and drove from Philadelphia to Bethesda at 80 miles an hour the first morning of the program. We were the first to arrive, and the woman who greeted us at the door was the former US women’s table tennis champion. It was an amazing huge facility with Olympic tables and runways surrounded by fences so you’d have a large protected area to play at each table. She said my son and I could warm up while the other candidates were arriving.

We set each other up for slamming the ball, and I was thinking she’d be pretty impressed!

Then the other candidates starting arriving. They were these super athletic looking young men, and they brought their children with them. I thought, “Wow, that is so neat that these Olympic table tennis players are bring their children to watch!

About 25 people arrived, and then she announced, “Those who are registered for the four day training program please sit on this long bench.” My son and I jumped up eagerly and sat of the bench.

But to my dismay, as the other candidates arrived, we discovered it was a training program for children! This was NOT the Olympic team! My son and I were the oldest people there, except for one teenager who was 16!

Then she said she would match us up with other players to play a five game match, to see what our skill levels were. She matched me against an 11 year old named Jimmy who looked pretty nerdy. He had horn rimmed glasses and was barely tall enough for his head to be above the level of the table.

I thought, “Oh no, this is going to be pathetic. I’m going to crush this poor little boy, and it might demoralize him.

Before we started I asked him if he played a lot of table tennis, and if this was his main interest. He said, “I do play a little table tennis, doctor, but my main thing is squirrel hunting.”

To determine who serves first,  you hide the ball under the table in your right or left hand, and your opponent has to guess what hand it is in. If your opponent guesses correctly, he or she gets to serve first. But Jimmy generously said that wasn’t necessary and I could choose whether I wanted to serve or receive first.

I told him I wanted to serve, because I had learned these incredible, high-speed spinny serves that are virtually impossible to return in Sweden during a visit I made when I was in medical school. So I gave him a mind-boggling serve, just to let him know who was boss right away.

He was left-handed, so I served it in the direction of his forehand. The serve actually appears to go off the table, and then it curves back and hits the edge of table.

I served and it was a great one. But I suddenly heard a bang, like a firecracker, and the ball game back at over 100 miles an hour on the far edge of the table and bounced against the wall 35 feet behind the table. I did not miss it, because it came so fast I did not have time to swing at it! I could not believe what had just happened, and meekly announced the score, Love – 1! I tried another fantastic serve with the same result. And after three more “fantastic” serves, all returned by massive slams, it was Love – 5.

Then Jimmy said, “Doctor, maybe you should not use that type of serve. They were popular in Sweden about 20 years ago, but now everyone can smash them back. I asked what kinds of serves people were using now, and he said he’d show me.

Then he served an idiotic, slow serve that barely made it over the net, and I thought I could smash it back. But when I attempted to hit it, it went off at right angles, and I could not get it over the net! He had thrown it high in the air at the start of his serve, and then put some kind of fantastic spin on the ball, but blocked my site with his other arm, so I could not actually see what happened at the moment the ball hit his racked.

Then he did four more similar serves, all with the same result .Now it was my turn to serve again, and the score was Love – 10.

I lost five straight games to Jimmy, all by score of 21 to 0. Wow! It was stunning!

Then I asked Jimmy, “Do you have a rank or anything like?” He said, “Oh, I am second in the United States right now in my age division, but my main thing is shooting squirrels!” He winked as he said that, and then I saw what he meant!

Well, my excursion into the world of professional table tennis was quite the adventure, but I had to accept that I just could not get my body doing what my head wanted it to!

So I went back to something I was a little better at—psychotherapy and statistics (for research articles I was writing) and teaching. And I’ve enjoyed myself tremendously since then.

Still, I’ll never regret the time I decided to pursue my “true calling in life!”

Well, I’ll stop babbling now, but hope to hear from you!


What if the People Around Me are Not Real?

What if the People Around Me are Not Real?

Hi Dr. Burns,

I have read your book, Feeling Good, and now I’m reading your more recent book, When Panic Attacks. I done a Cost-Benefit analysis for one of my negative thoughts and that helped me greatly. I also found some cognitive distortions in my negative thoughts as well.

I have a question. Sometimes I think that the people around me might not be real or are all doing stuff just to keep me happy, almost as if my life is a some kind of a simulation. Iif you watched the movie, ‘Truman Show,’ you will know what I mean!

I especially feel this way when some coincidence in my daily life occurs, like running into a friend who I hadn’t seen for a long time, at some random place, or when I learn that someone else had thoughts that were similar to my thoughts at the same time.

If you have some tips or could share some of your experiences with patients who had similar problems, I would appreciate it!


Hi Sal,

Thanks for your question! I enjoy answering questions, and hopefully others will be interested as well. However, I cannot safely or ethically give medical advice or treatment in this medium, so my comments will be quite general, and might not apply to you. Remember to consult with a licensed mental health professional or physician in person for any questions concerning your health.

Now that my disclaimer is out of the way, I will try to answer your excellent question. During my psychiatric residency, I learned about two of the more unusual symptoms of anxiety called depersonalization and derealization. Depersonalization is when you get the feeling that you are unreal, and derealization is when you get the feeling that the world is unreal. So it sounds like the feelings you described could just be symptoms of anxiety. And if so, you’re on the right track reading my book, When Panic Attacks, which, as you know, is all about anxiety.

Sometimes anxiety results from the hidden emotion phenomenon I talk about in the book. I don’t know if you’ve read that section yet. That’s when you’re upset about something or someone in your life, but you’re not aware of this due to excessive “niceness,” so you sweep your feelings under the rug, so to speak, and you kind of “forget” about the problem that’s bugging you. Then the feelings come out indirectly, as anxiety. Then you use all your energy ruminating about the anxiety, and don’t take the time to figure out what’s really bothering you.

So I always include the Hidden Emotion Technique in my arsenal when treating someone with anxiety, because it can sometimes be tremendously helpful to pinpoint what the problem is, and then do something about it. Essentially, you think about your life, and the people you know, and the things you’re doing, and ask yourself questions like this:

  • Is there something bothering me that I pushing out of my mind?
  • Am I mad at someone?
  • Do I have some feelings or emotions that I feel like I’m not “supposed” to have?
  • Do I feel tense or uncomfortable about something, or someone, in my life?

Any questions along these lines can help. Usually, the hidden problem or feeling is something recent, not something buried in the past. I have no idea if this is the cause of your symptoms, but it is often a useful tool in understanding and treating anxiety.

I’ve had a Feeling Good Podcast on the Hidden Emotion topic, and you can probably find it easily if you review the podcasts on my website. I’ve got them all organized together there now. I think it was an Ask David podcast on how to deal with an “identity crisis.” In fact, I found it for you, so CLICK HERE if interested.

To listen to a podcast gives an overview of the four models I use in treating anxiety, CLICK HERE.

Also, the most recent Feeling Good Podcasts cover the topic of anxiety, and there is an entire podcast devoted to the Hidden Emotion Technique as well. It is scheduled for Monday, March 13, 2017. I think all the podcasts on the treatment of anxiety might be of interest to you.

Thanks again!


Is it Possible to be Happy All the Time?

Is it Possible to be Happy All the Time?

A frequent web visitor commented on a blogger who said that the propensity to feel depressed or anxious never really leaves a person. He asked if I agreed with this.

Here’s the answer. I am convinced that being flawed and having moments of irritability, depression, anxiety, and so forth is an inherent part of the human condition, at least for most of us, and probably everybody. It is not possible to be happy all the time, nor is this a realistic or useful goal–at least that’s my take on it.

We all fall into these black holes of self-doubt or anger from time to time. What I do is to create a ladder for each patient, so you can quickly climb out of the black hole whenever you fall in. That’s why the psychotherapy homework is so vital—so you can practice and learn these tools, so you can use them in the future whenever you need them. It is like riding a bicycle. The skill never really leaves you once you’ve learned how, but you won’t develop the right “brain muscles” without the written practice between sessions, using tools like the Daily Mood Log, the Relationship Journal, and so forth.

There are two goals in TEAM-CBT: Feeling better and getting better. Feeling better is the initial recovery, when the symptoms of depression and anxiety completely disappear, and you feel fantastic. This is a tremendous experience for the patient and for the therapist as well. The recovery usually happens suddenly during a session, and with the new TEAM-CBT techniques, if often happens very early in the treatment.In my experience, it often happens in the first session, assuming I can work with the patient for two hours or so if needed.

Getting better means that you have the tools to deal with the inevitable “relapses” that affect all human beings. To me, I define a “relapse” as one minute or more of feeling lousy. Given that definitions, we all “relapse” all the time! But it does not have to be a problem if you know exactly how to deal with it.

One minute of feeling upset is okay. Or an hour, a day, or a week. But I don’t want my patients to have to struggle with weeks, months, years or decades of misery.

I always tell my patients that we are all entitled to five happy days per week. If you aren’t having your five happy days, you need a little mental “tune-up!” But if you’re having more than five happy days per week, that could be a problem, and we may have to put you on lithium!

I will edit and post a partially completed blog on Relapse Prevention Training (RPT) before too long. RPT is fairly easy and only takes about 30 minutes in most cases. However, if the therapist fails to do RPT, the patient may be shocked, overwhelmed and devastated when the negative thoughts and feelings return. But if you have prepared the patient properly, he or she will know exactly what to do, and the “relapse” will be short-lived.

As an aside, my thinking is consistent with the thinking of the late Dr. Albert Ellis, the New York psychologist who founded a school of therapy call REBT (Rational Emotive Behavior Therapy). Dr. Ellis once wrote a paper on “The Impossibility of Maintaining Consistently Good Mental Healthy,” or some such title. He was making the same point, that we are flawed, and cannot achieve perfection.

Dr. Ellis pioneered much of the thinking that triggered the development  of CBT (Cognitive Behavior Therapy), and now TEAM-CBT, although he approached treatment in a radially different manner. Those who still remember him, and attended one or more of his wild workshops or talks, or his $5 admission fee Friday night live therapy demonstrations at his center in NY, will know what I mean!

Dr. Ellis was quite the character, very controversial, but his contributions were tremendous, and he had a great sense of integrity. He did not steal from others, as some in our profession have done, but always gave credit where credit was due. That was one of the main reasons I became a fan of his!


Where Can I Find Your books?

Where Can I Find Your books?

Hi Dr. Burns,

Hello I was wondering do you still have the feel mood therapy workbook they no longer sell them in store or online and I’m a person that retain information if I can write will I’m reading, because I have the book and I’m not retaining the information very well

Thank you in Advance,


Hi Shanta,

Thanks for the question. My books are all sold on Amazon, and other online book sellers, including:

  • Feeling Good: The New Mood Therapy
  • The Feeling Good Handbook
  • Intimate Connections
  • Feeling Good Together
  • When Panic Attacks

Hope that helps! You had the names wrong, so appreciate the chance to clarify! Let me know if you like any of my books.

All the best,


What’s the Best School of Psychotherapy?

What’s the Best School of Psychotherapy?

Hi Dr. Burns,

“I am a psychology graduate student and I need some advice. One of my professors urged all the students in our class to find the school of therapy that ‘fit us.’ How can I select the school of therapy that would provide the best fit for me? And what is considered to be the best school of psychotherapy?”


Thanks for your question, Harold. These are important issues! Right now there are hundreds of schools of psychotherapy in the United States, and more evolve almost on a weekly basis. We’ve got Adlerian Therapy, Psychodynamic Therapy, Psychoanalytic Therapy, Jungian Therapy, Humanistic Therapy, Existential Therapy, Interpersonal and Transpersonal Therapy, Supportive – Emotive Therapy, Rogerian therapy, Behavior Therapy, ACT, CBT, DBT, EMDR, REBT, TFT, Motivational Interviewing, and more.

It can be very appealing to join one of these schools of therapy, and there are some definite advantages. Once you’ve joined a school of therapy, it will provide you with a sense of security and confidence and give you a sense of belonging. You can tell your colleagues and patients that you are an “EMDR therapist” or a “psychodynamic therapist,” or whatever. We all want something to believe in, and we all like and benefit from the support of like-minded colleagues. But here’s my recommendation, Harold—don’t sign up for any of them.

Why would I take this position? After all, many of the schools of therapy have provided helpful perspectives on human nature along with a number of useful treatment techniques. I have personally been involved in the development and popularization of one of the most widely practiced and researched forms of therapy in the world—cognitive behavioral therapy (CBT). However, if you’ve attended any of my workshops, you know that I’m not a fan of any school of therapy for many reasons, such as:

  • The schools of therapy tend to compete like cults, or religions, fostering competitive feelings and unwarranted feelings of superiority. In addition, many have narcissistic founders who demand strong allegiance to their theories and treatment methods, rather than encouraging objective, systematic research.
  • Nearly all schools of therapy promote unproven theories about the causes of psychological problems like depression and anxiety.
  • Most make fairly bold and unjustified claims about their effectiveness. In fact, the effects of practically every school of therapy can be shown to be modest at best, and barely better than treatment with a placebo, if at all.
  • The practitioners of all the schools of therapy are usually convinced that their therapeutic techniques have highly specific treatment effects, whereas their effectiveness in most cases derives from non-specific effects that are common to all schools of therapy, such as the beneficial effects of the therapeutic relationship, or the patient’s belief that the therapy will help.
  • Most schools of therapy tend to treat all disorders with the same techniques, as if they had one cure-all or panacea all for all emotional problems.

I’m going to expand on some of these problems, so if you’re interested you can click here to read more. I want you to know that I share these concerns with apprehension. I don’t want to sound arrogant or overly critical of colleagues. My goal is not to insist that my own point of view is the “right” one, but simply to stir up some critical thinking and dialogue. I also want to emphasize the enormous contributions that most schools of therapy have made, and I want to encourage young practitioners to study them and learn from them. But when it comes time to sign on the dotted line, and become a follower, that’s where I draw the line.

I also want to emphasize that I sometimes hold views that turn out to be wrong. So feel free to criticize me, to comment on this article and to share you own point of view. I have no doubt that if we can all check our egos at the door, we can learn a lot from each other. But of course, that’s not always an easy thing to do.

The Schools of Therapy Have a Lot in Common with Cults

This first topic is perhaps the most sensitive, and I was sorely tempted to delete this section. But I’ll take a stab at it and hope for the best.

You might wonder what in the world schools of psychotherapy have in common with cults like Jim Jones and his Peoples Temple in Guyana, Marshall Applewhite and his Heavens’ Gate cult in San Diego, or David Koresh and his ‎Branch Davidians in Waco Texas. If you look up the definitions of a cult online, you’ll see they have a number of common features, including: 1. A grandiose leader who insists that his or her followers believe things that simply aren’t true. 2. A non-scientific treatment or ritual claimed by the followers to have exceptional healing powers. 3. Potentially harmful effects on the followers. 4. A belief that the cult has discovered some type of absolute “truth” and intense feelings of rivalry with competing cults.

Is it too much of a reach, and perhaps totally unfair, to view the schools of therapy through this rather unflattering lens?

I always admired the late Albert Ellis, Ph.D. Although I did not study with him or know him well, I thought he made enormous contributions to the field and probably did not get nearly enough credit for his innovative thinking, especially from academics. He was really one of the pioneers of the cognitive therapies that have grown so popular today. I liked him because he was ruthlessly honest—often to a shocking degree—and always gave credit where credit was due. He did not steal ideas or techniques from others and call them his own. Of course, he had plenty of shortcomings, like all of us. If you ever attended any of his workshops, you probably know what I mean. Every other word that came out of his mouth was the “F” word. But in spite of his wild and aggressive demeanor, he had a lot of wisdom to share.

On several occasions, I had the chance to sit next to Dr. Ellis and at dinners in conjunction with psychotherapy training events, so we had several long conversations. One of his favorite topics was how narcissistic and emotionally disturbed most of the important names in psychotherapy were. He knew a surprising number of the “greats” from 20th century psychology and psychiatry, including many individuals who are still quite popular today. He would point out how dishonest, exploitative, or paranoid this or that famous person was. It was fun to hear him talk!

At first I was shocked to hear his comments, but as I thought about it, I realized that what he was saying resonated with my own experiences and rang absolutely true. In fact, around the time of his own death, Dr. Ellis was the victim of horrific exploitation by several members of his own Board of Directors at his institute in New York. In fact, I believe that one of them was recently sent to prison.

We see great cartoons in the New Yorker and other media about how neurotic psychiatrists and psychologist are, but I think this stereotype is probably true in many cases. In fact, I believe that our field attracts people who feel wounded and who seek careers as therapists in their own personal search healing. Some become gurus, others become followers of gurus.

It is my belief, for better or worse, that narcissism, perhaps as much as skill or intelligence, is what propels people into prominence in our field, including those who start new schools of therapy. And the people who become their followers are sometimes those who are looking for membership in a cult led by a charismatic leader who appears to have the answers.

The situation in the hard sciences, like physics or chemistry, seems to be different. In college, I had friends and roommates with incredible brain power, and I realized they were way beyond me in intelligence. They tended to major in subjects like physics and math, and usually went on for PhDs in the hard sciences.  One of my roommates, Phil Allen, PhD, went on to become a world famous solid-state physicist at Stony Brook in New York. Another, Joe Stiglitz, PhD, went on to win the Nobel Prize in economics.  And while narcissism and egos undoubtedly also exist in those fields to some extent, you can’t get away with much if you don’t have the basic intelligence, skill and training.

I believe that our field—the behavioral sciences—is different, because the science is still quite soft, and so little is known. This provides fertile solid for schools of therapy that can thrive without much challenge. It is my hope that we will see a transition from the competing schools of therapy that currently dominate the landscape to a new science of psychotherapy based on research and empirical data.

However, I think it will probably take decades to make this transition, just as it took physics and astronomy nearly 100 years to break away from the Catholic Church around the time of the Copernican Revolution. One reason is that none of us like to be challenged, especially when we have strong beliefs. I’ll return to this thread at the end.

Most Schools of Therapy Promote Unproven Theories of Causality

Most schools of therapy strongly promote theories about the causes of emotional problems such as depression, anxiety disorders, relationship problems, and habits and addictions. This can be reassuring to therapists and gives them feelings of expertise. But are these theories valid?

After a recent workshop in the mid-west one of the participants offered to drive me to the airport, and we had great conversation along the way. He was a neat guy, and I really liked him. He mentioned, however, that he was a Jungian therapist, and wondered why the techniques I was teaching in the workshop emphasized rapid symptom relief without exploring the childhood causes of the patients’ problems.

This was a great question. At first, I felt puzzled and anxious, and started to think that I was missing the boat in my therapy and teaching. But then I reminded myself that the causes of all psychiatric disorders are still unknown, and that most current theories can easily be proven to be false if put to the test.

Each school of therapy seems to have a different idea about the causes of various psychiatric disorders, such as depression or anxiety. If you go to a psychodynamic or psychoanalytic therapist, he or she may tell you that your feelings of insecurity stem from painful childhood experiences or from your relationship with your father or mother when you were growing up. But if you happen to go to a cognitive therapist instead, he or she will probably tell you that your problems result from distorted thinking patterns and self-defeating beliefs, such as perfectionism, or the belief that you need love, approval or great success to feel happy and to be worthwhile. Psychotherapists from other schools of therapy will have yet different theories about the causes of your problems. You may be told, for example, that your low self-esteem results from a lack of close, loving relationships, from a lack of belief in God, from prejudice and social injustice, from poverty, from your genes, from dietary problems, from a lack of exercise, or from a myriad of other factors. And if you go to a psychiatrist, he or she will probably tell you that your depression results from a chemical imbalance in your brain.

Who’s right? Are they all right?

I’m not aware of any convincing, consistent evidence that confirms any of these theories. In fact, scientists don’t yet know why some people are more prone to depression, panic attacks, anger, addictions, schizophrenia, or anything. We have lots of theories, and some day we’ll have the answers, but we don’t have the answers yet. In fact, all we can say with certainty is that none of the current theories have been validated.

Although most of my career has been mainly devoted to clinical work and to the development of new psychotherapy methods, I’ve done a fair amount of research to learn more about how psychotherapy actually works. In the process, I’ve had the chance to test a number of popular theories about the causes of various psychiatric problems. In practically every case, the research simply did not support the theory I was testing.

For example, there is a popular school of therapy called Interpersonal Therapy, and it’s touted as an effective treatment for depression. It was developed by Gerald Klerman and Myrna Weissman (Klerman GL, Weissman MM. 1984). They hypothesized that depression results from a lack of close, loving relationships, so they help depressed individuals develop better relationships with others as well as greater feelings of independence and self-reliance. That approach seems to make pretty good sense, and it’s a fact that many depressed individuals have problems in intimate relationships. But is it true that depression actually results from relationship conflicts or from difficulties forming close, loving relationships?

Some clinicians have speculated that the causal connection between relationship problems and depression is in the opposite direction. They argue that depression and low self-esteem lead to troubled relationships, rather than vice versa. The idea is that you can’t learn to love others until you learn to love yourself, and that if you’re feeling depressed and worthless, you’ll have distorted thoughts about your relationships with the people you love. Some clinicians have even argued that depression triggers relationship problems because depressed individuals can be annoying to interact with.

So which theory is right? Do relationship problems cause depression? Or does depression lead to relationship problems? Of course, it is possible that both of these theories are correct—depression and relationship problems could trigger each other in a system of circular causality. This is a bit like the chicken and the egg problem. Which came first? Is it possible to sort this out using empirical data?

I had the chance to test these theories in a study of several hundred patients treated at my clinic in Philadelphia. We tested all patients at the initial evaluation and again 12 weeks later using highly sensitive scales that assess the presence and severity of depression along with the quality of intimate, loving relationships. Some patients were severely depressed while others were not depressed at all. Some patients had wonderful, fulfilling, loving relationships while others were lonely or struggling with profoundly unsatisfying relationships with other people. This gave me and my colleagues an opportunity to find out if these variables were linked, and if so, why.

As expected, we discovered a modest negative correlation between depression and relationship satisfaction (r = -.42) at both time points (Burns, DD, Sayers, SS, & Moras, K, 1994). As you might expect, patients who were more depressed reported significantly lower levels of satisfaction in their intimate relationships, and patients who reported greater relationship satisfaction appeared to have significantly lower levels of depression. This confirmed the findings of previous researchers who had reported almost identical results. In addition, changes in depression were correlated with changes in relationship satisfaction during the first twelve weeks of treatment. In other words, as patients’ feelings of depression improved, their feelings of relationship satisfaction improved. So far so good. But correlations tell us little or nothing about causal effects. The estimation of causal effects requires a more sophisticated type of statistical analysis called non-recursive structural equation modeling (SEM).

When we looked at the causal connections between depression and problems in intimate relationships using SEM, the results fell into a very different perspective. Although there was a small causal effect of relationship problems on depression, as well as a simultaneous reciprocal causal effect of relationship problems on depression, the sizes of these effects were so tiny as to be theoretically and clinically insignificant. In other words, problems in intimate relationships did not appear to be important causes of depression, and depression did not appear to be an important cause of relationship problems.

The mathematical models also predicted that the successful treatment of the relationship problems of depressed individuals will have almost no specific effects on their depression, and that successful treatment of depression in individuals with troubled relationships would do little, if anything, to improve their relationships have (Burns, DD, Sayers, SS, & Moras, K, 1994). These results were not consistent with the basic premise of IPT, which states that relationship problems are a major cause, and perhaps the most important cause, of depression.

Of course, the proponents of IPT could point to published studies indicating that IPT can be helpful to depressed individuals. That’s true enough, but as you’ll see below, the effects of practically all forms of therapy can be shown to be non-specific, and mediated by common factors such as the quality of the therapeutic alliance. And as you’ll also see below, few, if any, forms of psychotherapy for depression, including IPT, can be shown to have therapeutic effects that are much greater than the effects of treatment with a placebo.

One of the predictions from our research study on relationship problems and depression was confirmed when my book, Ten Days to Self-Esteem (Burns, 1993) was released. This is a ten-step group training program to help people overcome depression, and it can be administered by lay people or by mental health professionals. Before the book was released, I tested the program in dozens of informal studies around the United States and Canada. In every group we saw a similar result. Most of the individuals who started the program reported depression plus troubled relationships at the initial group session. Ten weeks later, most of the participants had improved substantially and many were completely undepressed.

But what effect did this have on the quality of intimate relationships? There were few or no effects whatsoever, exactly as the study of depression and relationship problems had predicted. At the beginning of the Ten Days to Self-Esteem  program, most patients were depressed with miserable marriages. At the end, they were happy with miserable marriages. The treatment program for depression was very successful but did little or nothing to help their relationships.

There were two potentially important implications from these studies. First, the causes of relationship problems appear to be radically different from the causes of depression. And second, the techniques for treating troubled relationships will have to be radically different from the techniques for treating depression.

Along with colleagues, I have also tested one of the key ideas of cognitive behavior therapy (CBT)—namely, that CBT works by changing patients’ self-defeating beliefs (SDBs), such as perfectionism and dependency. Once again, my colleagues and I studied several hundred patients at the initial evaluation and at the 12-week evaluation at my clinical in Philadelphia (Burns, DD, & Spangler, D, 2001). At the initial evaluation and at the 12-week evaluation, patients who were more depressed reported higher levels of SDBs, such as perfectionism and dependency, as predicted. In addition, during the first twelve weeks of treatment, changes in perfectionism and dependency were significantly correlated with changes in depression. So far so good. However, more sophisticated statistical analyses indicated that changes in SDBs did not seem to cause changes in depression. Instead, depression and SDBs appeared to change simultaneously because of some unknown third variable with causal effects on both of them. This result was clearly inconsistent with one the basic premises of cognitive therapy, and showed that although cognitive therapy can often be amazingly helpful for depressed individuals, it may not work in the way we think.

I have also tested a number of other popular psychological theories, like the idea that women are from Venus and men are from Mars, which has been popularized by Deborah Tannen, John Gray, and others. According to this theory, men and women have problems in intimate relationships because they use language differently. Men use language to solve problems, whereas women use language to communicate feelings. So when a woman is upset, she tries to tell her husband how she feels. He responds with suggestions about how she might solve the problem that’s bothering her. She feels hurt, frustrated, and angry because she wants support, not problem-solving. He feels hurt, frustrated and angry because he’s doing his very best to help, and his wife is rejecting his efforts. According to this theory, we can save troubled marriages by training men and women to communicate differently, and to develop a better understanding of the important differences in how men and women use language.

That sounds great, and there have been lots of best-selling books that have promoted this concept. But when I tested this theory, along with my colleague, Dr. Diane Spangler, using data from men and women with happy or troubled marriages, the statistical analyses indicated that the hypothesized differences between men and women did not appear to exist, and did not appear to have any of they theorized causal effects on relationship satisfaction levels (Spangler, D., & Burns, DD, 1999). It simply wasn’t true that women were from Venus and men were from Mars. Men and women seemed to have the same kinds of problems expressing feelings, and listening to the feelings of others. Dr. Spangler and I concluded that men and women are both from the Earth, and that we all struggle in much the same ways when we’re in conflict with our spouse or partner, or with family members, colleagues, or friends.

I also recently had the chance to test a popular theory about the causes of habits and addictions, such as overeating, binge eating, and alcohol abuse. Some experts promote the idea that people turn to addictions because of emotional problems—they’re lonely, angry, depressed, or anxious. This theory is often promoted in the media as well. We are told that we comfort ourselves with food, alcohol, or drugs when we’re upset. This is called “emotional eating” or “emotional drinking.” And based on this theory, many weight loss or addiction specialists treat people with eating disorders or addictions with techniques designed to boost self-esteem and reduce negative feelings like depression, loneliness, anxiety, or anger. The idea is that once you’re feeling better about yourself, the urges to binge, or to drink or use drugs, will naturally diminish.

That’s a very appealing theory. Is it valid?

To check this out, I studied approximately 165 consecutively admitted patients at the psychiatric inpatient unit of the Stanford Hospital several years ago. Some of the patients were greatly overweight and reported overeating and binge eating while others of normal weight reported little or no overeating or binge eating. In addition, some of the patients were struggling with habits and addictions such as alcohol or drug abuse or addiction, while others rarely or never used drugs or alcohol. My colleagues and I also surveyed all the patients for more than 50 common psychiatric disorders, such as depression, anxiety disorders, personality disorders, and relationship problems. This gave me the chance to test the theory that habits and addictions result from emotional problems like depression.

The results were surprising. Depression and low self-esteem did not appear to be important causes of overeating. In fact, patients who were more depressed were actually somewhat less likely to binge and overeat, a result which is the exact opposite of what many experts teach.

Alcohol and drug abuse also did not seem to result to any great extent from depression and low self-esteem, either. Instead, most alcohol and drug use could be accounted for by a new scale I have developed called the “Urges to Use Scale.” This scale assesses fantasies, temptations, and urges to get high. The scores on this scale were massively correlated with alcohol and drug use. Once this relationship was taken into account, no other variables appeared to have any significant causal effects on alcohol or drug use.

These findings suggested that binge eating, alcohol and drug abuse may not be emotional disorders in most cases, but might instead be disorders of desire. In other words, people binge and overeat because food tastes darn good, and we all love to eat. The epidemic of obesity in our culture during the last 100 years is probably not because of any increase in stress or depression in society, but because of the availability or so much delicious, high-calorie food and the means to obtain it, along with all the temptations on TV and in malls for high calorie fast food. Most people probably abuse drugs and alcohol for much the same reason–because most human beings love to get high, and because drugs and alcohol are so tempting and so easily available in our culture.

I don’t want to promote my findings as the gospel truth. All studies, including my own, have significant flaws, and need independent validation. My point is simply that I have not been able to validate most of the theories about the causes of emotional problems proposed by the various schools of therapy.

There’s no doubt that most of our cherished theories about the causes and cures for psychological problems can sometimes be way off-base. But how about the biological theories, like the idea that depression and anxiety result from a chemical imbalance in the brain? We’ve been told that depressed and anxious individuals don’t have enough of a brain chemical called serotonin. Serotonin is one of the chemical messengers that transmit signals from one nerve cell to the next. The idea is that you get depressed because there isn’t enough serotonin to transmit signals properly in those portions of the brain that regulate emotions like depression, fear, anger, hope, and happiness.

The chemical imbalance theory is promoted all the time in television ads for antidepressants and other psychiatric medications. It is promoted in many textbooks and medical schools as well. Is this theory valid? What’s the evidence that depression or any other psychiatric disorder results from a chemical imbalance in the brain?

To the best of my knowledge, the chemical imbalance theory has never been validated in any convincing way and, in my opinion, it’s probably not true. I actually started out as a biological psychiatrist at the University of Pennsylvania School of Medicine in Philadelphia, and did full-time research on the chemical imbalance theory for several years. I received one of the top awards in the world, the A. E. Bennett Award, in 1975 from the Society for Biological Psychiatry for my research on brain serotonin metabolism (Burns, DD, London, J, Brunswick, D, & Pring, M, et al., 1976). In addition, I have personally prescribed antidepressant medications on more than 15,000 occasions, so you can see that I am not an “outsider” with a negative bias towards biological theories or treatments, and I have written chapters on the chemical imbalance theory for psychopharmacology textbooks. But in my own research, and in my reading of the world literature, I have never seen any convincing evidence that depression results from a deficiency of brain serotonin, or any other kind of chemical imbalance in the brain.

My colleagues and I tested the chemical imbalance theory with a simple research study at our depression research unit at the Philadelphia VA Hospital during the 1970s. We randomly assigned hospitalized depressed veterans to two treatments in a double-blind fashion. Double-blind means that the patients and the staff as well did not know which group each patient was assigned to. One group received milkshakes laced with massive doses of L-tryptophan, an essential amino acid that goes straight from the stomach to the blood, and then it diffuses directly into the brain. Then the L-tryptophan is converted into serotonin, the chemical that is supposedly lacking in depression.

The other group of veterans also got daily milkshakes, but their milkshakes did not contain any L-tryptophan. One would predict that if depression results from a lack of serotonin in the brain, the group of veterans who got the milkshakes laced with L-tryptophan would improve more, due to the massive increases in their brain serotonin levels. The depression levels of both groups were measured daily for several weeks by researches who were also blind to the treatment—in other words, they also did not know which veterans received the milkshakes laced with L-tryptophan.

How did the results turn out? Did the veterans who got the massive daily doses of L-tryptophan improve more? In fact, there were no statistically significant differences in the depression levels in the two groups at the end of the treatment. This result clearly contradicted the theory that depression results from a deficiency of brain serotonin. We published that study in the top psychiatry journal (Mendels, J, Stinnett, JL, Burns, DD & Frazer, A, 1975), but it largely went unnoticed until recent years, when people have finally begun to quote and reference our paper.

There are almost certainly biological and genetic factors that contribute to emotional problems, such as depression and anxiety, but we just don’t yet know what those factors are. We don’t really even know to what extent depression and anxiety result from software problems in the brain (e.g. problems in learning and neuronal circuitry) as opposed to hardware problems such as enzyme deficiencies or abnormalities in the structure or functioning of the neurons. But the “chemical imbalance” theory has not stood the test of time and no longer gains much attention from young neuroscientists, who view that the brain is an amazing, high-powered super-computer and not a hydraulic system of chemical balances and imbalances.

As a physician, I have been trained to document what I tell my patients. I can’t just make things up. So if I tell a patient that he or she has iron deficiency anemia, I have to back this up with lab tests and data. It’s actually pretty easy to diagnose and treat iron deficiency anemia. The blood smear shows microcytic, hypochromic red blood cells, the serum iron levels are low, and there’s a clear cause of chronic blood loss, such as hemorrhoids or excess menstrual bleeding.

But we have no tests for any so-called “chemical imbalances” in the brain. So when a psychiatrist tells a depressed patient he or she has a chemical imbalance in the brain, this seems unfair, or even unethical, since there’s no way that claim could be documented. It’s just a theory, not a fact, and it’s a theory without a great deal of merit. But the patient doesn’t know this, and assumes the doctor is an expert. So if a doctor tells you that you have a chemical imbalance in your brain, you will probably conclude that you need treatment with an antidepressant which will, presumably, correct the imbalance. Of course, sometimes drugs can be helpful, or even life-saving for individuals with severe problems, but the majority of depressed and anxious individuals can now be rapidly and successfully treated without drugs.

Why do the members of various schools of psychotherapy so strongly believe theories that have not been validated, and that probably never will be validated? A lack of critical thinking is a big problem. For example, treatments and causes aren’t necessarily connected in the ways that therapists and patients think. Aspirin may cure headaches, but it doesn’t follow that headaches are caused by an aspirin deficiency. But the same token, correcting distorted think can improve depression; but it does not follow that depression is caused by distorted thinking. Or, to take another example, a patient may feel better after weekly sessions with a warm and supportive therapist who encourages the patient to vent about painful childhood experiences. But it does not follow that the patient’s feelings of depression and anxiety were caused by childhood experiences. Or, to take a third example, a depressed patient may improve substantially and quickly when a behavior therapist encourages him to schedule more rewarding and satisfying activities, rather than sitting around feeling miserable and doing nothing. But it does not follow that his depression was caused by a lack of rewarding activities. And finally, a depressed patient may improve three weeks after her doctor prescribed an antidepressant. But it does not follow that her depression resulted from a chemical imbalance in her brain, and it does not even follow that the pill had a true antidepressant effect, as you will see below.

So when patients ask us why they are struggling with depression, anxiety, or any other problem, what should we tell them? You’ll have to make up your own mind, and you may have your own favorite theories about causality. I simply tell my patients that the causes aren’t yet known, but the good news is that we have powerful new tools to help them. This is a message that most patients want to hear.

The Schools of Therapy Encourage Therapists to Treat All Problems with One Therapeutic Approach or Technique

Another strange and to me unfathomable problem is that each school of therapy typically treats practically everyone with the same therapeutic approach, no matter what the patient’s problem happens to be. If you go to a psychoanalyst, you’ll get years of free association on the couch. If you go to a psychodynamic therapist, you’ll get psychodynamic therapy. If you go to a behavior therapist, you’ll get behavioral therapy. If you go to a cognitive therapist, you’ll get cognitive therapy. If you go to a therapist who uses Thought Field Therapy (TFT), you may be asked to tap on your eyebrow, and if you go to a therapist who uses EMDR (Eye Movement Desensitization and Reprocessing), you may be asked to jiggling your eyes while imagining something frightening, like a traumatic event. If your therapist does not belong to any particular school of therapy, you may simply be encouraged to vent (possibly for years) while the therapist listens and throws in some occasional advice. And if, instead, you go to a psychiatrist, you’ll probably get a prescription for pills.

Can you imagine what it would be like if we had schools of medicine? You might have the penicillin school, for example, so if you went to a “penicillin doctor,” he would treat you with penicillin. You have a cold? You get penicillin. You have a broken leg? You get penicillin. It sounds absurd, but to my way of thinking, that’s how most schools of therapy operate—they nearly always have one standard approach for just about every problem that walks through the door. This is called “therapeutic reductionism.” It’s the idea that you can treat everyone with the same approach, and it’s one of the biggest problems with having schools of therapy.

Think about all the treatments that are available for lung disorders. There are hundreds and hundreds of lung problems, including TB, emphysema, dozens of different types of pneumonias, a multitude of lung cancers, and more; and there are hundreds and hundreds of treatments for lung problems. But the brain is thousands of times more complex than the lung. So the idea that we’d have one type of treatment for all the emotional and behavioral problems that humans have seems to me to be extraordinarily unrealistic, and almost delusional. And yet, that’s what many “experts” and therapists alike seem to believe and promote.

Of course, it doesn’t start out that way. Take CBT (cognitive behavior therapy), for example. CBT was initially developed for individuals struggling with depression, and it works fairly well for depression, although we now have a newer and far more powerful version of CBT called T.E.A.M. therapy. I was proud to contribute to the development and popularization of CBT in the 1970s and 1980s. But when I began to treat anxiety, I found that CBT was helpful but incomplete; other methods were also needed for most of my patients. And when I began treating troubled couples or individuals struggling with relationship problems, I found that CBT didn’t work at all. In fact, CBT often seemed to make relationship problems worse.

For example, if you have a troubled marriage or you’re not getting along with someone you’re annoyed with, you may have thoughts like these about the person you’re not getting along with:

  • He’s self-centered jerk.
  • All he cares about is himself.
  • He never listens.
  • He shouldn’t be like that.
  • He’s to blame for the problems in our relationship. It’s all his fault.

Perhaps you’ve had thoughts like these from time to time, too! It’s easy to show that these thoughts are distorted in much the same way that the thoughts of depressed individuals are distorted—they’re chock full of distortions such as All-or-Nothing Thinking, Overgeneralization (“He never listens,”) Mental Filtering, Discounting the Positive, Mind-Reading (“All he cares about is himself”), Fortune Telling, Emotional Reasoning, Labeling (“He’s a self-centered jerk”), Should Statements (“He shouldn’t be like that,”) and Blame (“It’s all his fault.”)

But in my clinical experience, people with relationship problems didn’t seem particularly interested in learning that their negative thoughts about the other person are distorted and illogical. In fact, pointing this out usually just makes things worse and triggers more anger, defensiveness, and arguing. After a number of failures using CBT to help individuals and couples with relationship problems, I finally accepted the fact that CBT was simply not a useful tool, at least in my hands, for interpersonal problems. Over the years, I developed completely different and far more effective approach which I’ve described in my book, Feeling Good Together (Burns, 2009).

Other therapists who were strongly committed to CBT took a different path; they promoted CBT for just about everything from marital problems to bed-wetting to addictions to schizophrenia. But later research simply doesn’t support the idea that we can have one panacea for all psychiatric problems. For example, research has clearly shown that CBT for schizophrenia just isn’t effective. Click this link in your browser if you’d like to link to a recent and sobering review of these studies.

I’ve been saying that you can’t treat schizophrenia with CBT for more than three decades. In fact, it was abundantly clear the first time I tried to treat a sad and severely disturbed schizophrenic young man named Karl with CBT. Karl was angry and agitated because he was convinced his most private and intimate thoughts were being broadcast so that others knew what he was thinking. Since he was a college student, this delusion was understandably frustrating and embarrassing to him. He was also convinced the receptionist in the next room was eavesdropping on our sessions and could hear everything we were discussing.

To show him how unreasonable this was, I decided to use a CBT technique called the Experimental Technique. I told Karl that the receptionist wasn’t making much money, and I put a $20 bill on the desk. I said we could both concentrate on the money, and that if she could “hear” our thoughts, she could knock on the door and I would gladly give her the money, which she probably needed.

Karl and I concentrated on the $20 bill for a full minute, and of course, nothing happened. Then I asked Karl what he concluded. He said this proved that the receptionist could read our minds, since she heard our thoughts and our conversation and decided to trick us by not knocking on the door. That way, she could continue to “listen in” during his sessions.

One of the things I’ve learned over my career is to treat people with what they want help with, and not to treat their “disorder” or diagnosis. And although I’ve treated hundreds of individuals with schizophrenia, I cannot recall even once when a schizophrenic man or woman was asking for help with the delusions and hallucinations. Instead, the asked for help with the same kinds of things that any patient might ask for help with—depression, loneliness, and problems in relationships. And I was able to help most of them using CBT as well as tools drawn from other schools of psychotherapy. But this didn’t affect their schizophrenia—it simply helped their moods, relationships, and outlook on life. That was useful, but certainly not a cure or treatment for the terrible disorder of schizophrenia.

I don’t mean to be overly critical of my CBT colleagues or to single them out—just about every school of therapy has suffered the same fate. The practitioners start out with a therapeutic method that can be at least partially helpful for one specific type of problem, such as depression or anxiety, but soon branch out and promote their new school of therapy for just about everything. To my way of thinking, this is misguided.

Claims of Therapeutic Superiority Usually Cannot be Documented

Most practitioners are completely convinced that their school of therapy has the best treatment techniques, and many are evangelistic in their crusades to get other colleagues and students to jump on board. But how convincing are the data behind the claims that this or that school of therapy is the most effective treatment for some condition such as depression, panic attacks, PTSD, marital problems, addictions or anything else?

Before I address these questions, I have to define the placebo effect. Most people don’t understand the placebo effect, so it fools clinicians and therapists alike. Suppose I call a press conference and announce some new breakthrough treatment for depression. It could be a new school of psychotherapy or a new drug. Let’s imagine it’s a new antidepressant that my pharmaceutical company has just begun to market.

At the press conference, I announce that this new drug has fantastic antidepressant effects and absolutely no side effects whatsoever. And there are no withdrawal effects if you stop taking it. We are so convinced that it’s the safest and best antidepressant ever developed that we are going to give it to one million depressed Americans for absolutely free in the largest depression outcome study ever undertaken.

And oh, by the way, the name of our new drug is Placebin. Of course, Placebin is simply a placebo,–a pill containing some inert powder with no active chemical ingredients whatsoever. But I don’t let anyone know that.

How many of the people who receive Placebin will recover within three to five weeks? The answer is 35% to 50%. So one month later, there will be between 350,000 and a 500,000 Americans who will swear that Placebin changed their lives. They’ll appear on all the latest TV talk shows, singing the praises of Placebin. But it wasn’t the Placebin that got them better—it was the placebo effect.

What is the placebo effect and how does it work? Scientists aren’t completely certain, but here’s one possible explanation. The feeling of hopelessness is one of the worst symptoms of depression. When you’re depressed you’ll probably believe that your problems will never be solved and that your suffering will go on forever. Almost all depressed patients feel like this to some extent. As a result, you may begin to give up on life and abandon many of the activities that used to give you feelings of pleasure and satisfaction, like playing tennis, exercising, hanging out with friends, or simply getting caught up on things you’re behind on. You succumb to “do-nothingism.” This nearly always makes the depression worse, so you conclude that you really are hopeless.

As you can see, hopelessness functions as a self-fulfilling prophecy, and you get caught in a vicious cycle. Hopelessness leads to do-nothingism which leads to greater feelings of hopelessness.

Now let’s say that you learn about some new treatment, like a new pill or some new type of psychotherapy, and you believe that it could help. As a result, your hopelessness goes down and you begin to think and act in a more positive and productive way. You start playing tennis again, and you get together with friends, and you get to work on the things you’ve been putting off. These activities can have potent antidepressant effects, so your depression improves. Now you’re involved in a positive self-fulfilling prophecy, because the positive actions and positive feelings reinforce each other and prove that things weren’t really hopeless after all. As a result, your depression improves and may disappear completely.

The only problem is that you may attribute the improvement to the pill, when in fact, the pill did nothing to help you. You actually cured yourself.

In fact, you could create any kind of weird or bizarre treatment for depression, and if you could sell it to your patients with some type of convincing explanation, 35% to 50% of them will recover fairly quickly. Now you and your patients will both conclude that the therapy is powerful and effective, even if it does not have any specific antidepressant effects at all above and beyond the placebo effects.

The gold standard in research on any psychological or medical treatment is that it must outperform placebo to a clinically and statistically meaningful degree. In addition, the benefits of the treatment must outweigh any potential hazards or side effects. If the treatment cannot meet this standard, it cannot be certified as valid. It’s really no better than what the early snake oil salesmen used to hawk.

How do the current schools of psychotherapy hold up when judged by this standard? If you look at the empirical data, including controlled outcome studies on psychotherapeutic treatments for depression or just about any psychiatric disorder, you will discover that, with very few exceptions, there really aren’t any forms of psychotherapy that can outperform placebo treatments in an impressive way.

How can this be? After all, both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been show to be about as effective as antidepressants in the short-term. In addition, CBT appears to be somewhat more effective than antidepressants in the long-run. As a result, CBT has been widely accepted to be the most effective form of psychotherapy for depression. That sounds great, especially if you’re a cognitive therapist.

But if you look at the outcome studies on antidepressants, you will discover that antidepressants rarely outperform placebos to a clinically significant degree. For a good review of the literature, you can read Irving Kirsch’s outstanding little book entitled The Emperor’s New Drugs: Exploding the Antidepressant Myth (Kirsch, I. 2010 ) as well as a critical review of research on antidepressant medications (Antonuccio, DO, Burns, DD & Danton, W. 2002). So saying that your favorite brand of psychotherapy is as good as antidepressants is, to my way of thinking, damnation through the faintest of praise. And I don’t mean to single out CBT—you’ll see the same result with all of the psychotherapies that have been promoted for the treatment of depression.

Most Schools of Therapy Probably Don’t Work in the Way their Practitioners Think

Most therapists believe that they have highly specific and effective treatment methods that account for the effectiveness of the treatment. For example, most cognitive therapists believe that CBT works by changing negative thinking patterns, so they use a large number of cognitive restructuring techniques. In contrast, most behavioral therapists believe that behavior therapy works by encouraging depressed patients to participate in more rewarding and satisfying activities. And most interpersonal therapists believe that IPT works by teaching patients how to develop more rewarding relationships with others. But if you look at research on how therapy actually works, you will discover that few or none of the schools of therapy seem to work in the way their practitioners claim they work. The specific methods usually contribute little or nothing to the patient’s improvement, once you factor in the non-specific treatment effects.

Much of the empirical research on psychotherapy has indicated a surprising lack of specificity in the mechanisms by which these different treatments work. For example, several investigators (Imber et al. 1991; Rehm et al. 1987; Zeiss, Lewinsohn, & Munoz, 1979) have reported that cognitive therapy, behavioral therapy, and interpersonal therapy had similar effects on depression as well as on cognitive, behavioral and interpersonal target variables, even though the treatments were designed to focus only on cognitions, behaviors, or interpersonal skills, respectively. Similarly, Simons, Garfield, and Murphy (1984) reported that the reductions in negative thinking patterns in depressed patients who were successfully treated with cognitive therapy and no medications were comparable to the reductions in negative thinking in patients who were successfully treated with antidepressant drugs without cognitive therapy.

Thus, treatments which postulate very dissimilar factors in the causation and maintenance of depression and which utilize dissimilar therapeutic interventions typically appear to have surprisingly similar effects in nearly all measured target symptoms. This non-specific pattern of therapeutic effects is consistent with the idea that all these treatments might actually relieve depression through some non-specific factors that are common to all forms of therapy. For example, depressed patients who are exposed to any form of therapy will improve to some degree due to the placebo effect as well as the beneficial effects of a warm, caring relationship with the therapist.

In addition, a number of researchers have pointed out that much of the research on psychotherapy as well as psychiatric medications is just a form of marketing, rather than pure science. For example, in a classic paper published in the journal, Psychological Bulletin, researchers reviewed the world outcome literature on the treatment of depression with a wide variety of therapies, including no therapy, cognitive therapy, behavior therapy, psychodynamic therapy and even antidepressant drug therapy (Robinson, LA, Berman, JS, & Neimeyer, RA, 1990). Most of these studies compared two or three forms of therapy in an attempt to discover which type of therapy was the most effective. Which brand of therapy won the race?

All of the therapies appeared to be more effective than no therapy at all, and nearly all of the studies reported fairly significant gains for depressed patients, with one or another brand of therapy being identified as “the best.” But what was confusing was that each study seemed to identify a different brand of psychotherapy as the winner. Some researchers reported that cognitive therapy was the most effective treatment, while other researchers that psychodynamic therapy, behavior therapy worked the best, and so forth.

Then the researchers identified the school of therapy that the researchers felt allegiance to, and controlled for this potential source of bias in the statistical analyses. Now the results looked radically different—there were no differences at all between the different types of psychotherapy. They all performed about the same, and none performed in a really stellar way.

The researchers concluded that the outcome literature is heavily biased by the researchers who conduct the research, and proposed that we might be better off studying how psychotherapy works rather than trying to investigate which brand is the most effective, so that a new science of psychotherapy can evolve and replace the schools of therapy that currently compete with each other.

I strongly resonate with that conclusion. I look forward to the day when we no longer have schools of psychotherapy, and we have, instead, a data-driven science of psychotherapy that’s based on research on how psychotherapy actually works—what are the ingredients of therapeutic success or failure, regardless of what school of therapy you’re using? How can we use that information to develop the powerful psychotherapies of the future today? How can therapist discover how effective or ineffective they’ve been at every therapy session, and how can they use this information to improve the therapy and accelerate recovery? How can we develop powerful and specific training techniques so as to develop world-class therapists who can obtain and document superior treatment outcomes?

The really good news is that I believe that day has already arrived. That’s what my colleagues and I have been developing over the past ten years in my weekly training groups at Stanford—a new form of psychotherapy that’s based on research on how psychotherapy works. It’s called T.E.A.M. Therapy. T.E.A.M. stands for four crucial ingredients of effective therapy:

T = Testing. We test patients in multiple dimensions at the start and end of every therapy session using the Brief Mood Survey (BMS), so therapists can see, for the first time, exactly how effective, or ineffective, every session is, from the patient’s perspective. Patients complete the BMS in the waiting room just before the start of the session, and once again immediately following the session, so the procedure does not take away from any of the precious minutes of therapy time.

E = Empathy. Therapist learn sophisticated and compassionate empathy skills through systematic and rigorous training techniques. Patients also rate therapists on Empathy and Helpfulness at every session, using the Patient’s Evaluation of Therapy Session. This is a brief but highly sensitive and accurate assessment instrument that allows therapists to spot and deal with any problems in the therapeutic relationship immediately, so these feelings do not undermine the treatment.

A = (Paradoxical) Agenda Setting. This is one of the most unique aspects of T.E.A.M. therapy, and it’s missing from nearly every school of therapy currently practiced in the United States. Although nearly all patients are hurting and desperately want relief, most have at least some mixed feelings about changing, and in many cases the resistance to change is intense. T.E.A.M. therapists recognize two common patterns of resistance for each of these four targets: depression, anxiety disorders, relationship problems, and habits and addictions. This makes for a total of eight types of resistance, and the failure to address them effectively is the cause of nearly all therapeutic failure.

Therapists trained in T.E.A.M. use sophisticated and powerful techniques to bring subconscious resistance to conscious awareness quickly, right at the beginning of the therapy, before trying to help the patient using specific techniques. Once the patient is aware of the resistance, the therapist melts it away using a variety of paradoxical techniques.

This procedure can have amazing antidepressant effects, and puts the therapist and patient on the same team, working together collaboratively. As a result, any methods the therapist uses will be vastly more effective.

M = Methods. T.E.A.M. therapists use more than 50 powerful treatment techniques, and the selection of techniques will depend on the type of problem the patient wants help with. These methods are drawn from many different schools of therapy and are individualized to the specific problem the patient wants help with.

For example, depressed patients will be treated with the Daily Mood Log and Pleasure-Predicting Sheet, along with specific techniques such as Identify the Distortions, the Paradoxical Cost-Benefit Analysis, the Individual Downward Arrow, The paradoxical Double Standard Technique, the Externalization of Voices, and more. If the patient is struggling with an anxiety disorder, the therapist may use some of the techniques just described along with a wide variety of motivational and exposure techniques, plus the powerful Hidden Emotion Technique. If, in contrast, the patient wants help with a relationship problem, the therapist may use the Interpersonal Decision-Making Form, the Blame Cost-Benefit Analysis, the Relationship Journal, the EAR Checklist, the Five Secrets of Effective Communication, the One-Minute Drill, and the Intimacy Exercise. And if the target symptom is a habit or addiction, the therapist will probably use the Decision-Making Form, the Habit / Addiction Log, and the Devil’s Advocate Technique, along with specific Relapse Prevention Techniques.

At this point you might be feeling skeptical and thinking, “Burns is just another narcissist who is starting yet another school of therapy and thinking that he has the one true answer. Well, I’d have to agree with you on that, at least in part. I’ve certainly struggled with my own narcissistic tendencies, and they’ve gotten me into trouble on numerous occasions. I have to struggle against that all the time, and I’m not always successful. And perhaps that’s one reason I’m so aware of the negative impact of narcissism on our field.

However, I want to emphasize that T.E.A.M. is not yet another school of therapy, but just the opposite. It is a flexible, systematic, data-driven approach to psychotherapy that evolves almost on a weekly basis, and integrates features and techniques from more than a dozen schools of therapy. My colleagues and I are constantly doing research to learn more about what works, and what doesn’t work, and why. In addition, in my free psychotherapy training groups at Stanford, we develop new and more refined training methods every week as well. And finally, when we’re doing clinical work, every single therapy session with every single patient becomes a mini-research study, since we’re getting immediate and accurate feedback on what is working and what is not.

To learn more about T.E.A.M., please visit my website,, where there are lots of resources for therapist and the general public as well, including my psychotherapy eBook entitled, Tools, Not Schools, of Therapy.

Well, Harold, that’s my take on the schools of therapy. Now let me know what you think. Thanks!

David Burns, M.D.

Adjunct Clinical Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine


Antonuccio, DO, Burns, DD, & Danton, WG. (2002). Antidepressants: A Triumph of Marketing over SciencePrevention and Treatment, 5, Article 25. Web link:

Burns, D. D. (1993; 1999). Ten Days to Self – Esteem. New York: Quill.

Burns, D. D. (2006 [(hardbound); 2007 (paperback)]. When Panic Attacks. New York: Broadway Books.

Burns, D. D. (2009). Feeling Good Together. The Secret of Making Troubled Relationships Work.  New York: Broadway Books.

Burns, D. D., & Burns, S. (2005). Tools, Not Schools, of Therapy. . Los Altos Hills, Ca: Author.

Burns, DD, London, J, Brunswick, D, Pring, M, et al. (1976). A kinetic analysis of 5 – hydroxyindoleacetic acid excretion from rat brain and CSF. Biological Psychiatry, 11(2): 125 – 147.

Burns, DD, & 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, DD, Sayers, SS, & Moras, K. (1994). Intimate Relationships and Depression: Is There a Causal Connection? Journal of Consulting and Clinical Psychology, 62(5): 1033 – 1042.

Burns, DD & Spangler, D. (2001). Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy? Behavior Therapy, 32: 337-369.

Imber, S. D., Pilkonis, P. A., Sotsky, S. M., Elkin, I., Watkins, J. T., Collings, J. F., Shea, M. T., Leber, W. R., & Glass , D. R. (1991). Mode-specific effects among three treatment programs. Journal of Consulting and Clinical Psychology58, 352-359.

Kirsch, I. (2009). The Emperor’s New Drugs: Exploding the Antidepressant Myth. London, Random House Group.

Klerman GL, Weissman MM, Rounsaville BJ & Chevron ES.(1984) Interpersonal psychotherapy of depression. New York: Basic Books.

Mendels, J., Stinnett, JL, Burns, DD & Frazer, A. (1975). Amine precursors and depression. Archives of General Psychiatry, 32: 22 – 30.

Rehm, L. P., Kaslow, N. J., & Rabin, A. S. (1987). Cognitive and behavioral targets in a self-control therapy program for depression. Journal of Consulting and Clinical Psychology55, 60-67.

Robinson, L. A., Berman, J. S., & Neimeyer, R. A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin108, 30-49.

Simons, A. D., Garfield, S. L., & Murphy, G. E. (1984). The process of change in cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry41, 45-51.

Spangler, D., & Burns, DD. (1999). Is it true that women are from Venus and men are from Mars? A test of gender differences in dependency and perfectionism. Journal of Cognitive Psychotherapy13(4): 339-357.

Zeiss, A., Lewinsohn, P., & Munoz, R. (1979). Nonspecific improvement effects in depression using interpersonal skills training, pleasant activities schedules or cognitive training. Journal of Consulting and Clinical Psychology47, 427-439.

Can You Treat an Addiction to Romantic Fantasies?

Can You Treat an Addiction to Romantic Fantasies?

Hi Dr. Burns,

I have really enjoyed your podcasts – they make Mondays the best day of the week!

I am just a lay person but I’m very fascinated with how differently all of our minds operate. One thing you have talked about is treating addiction, and the resistance to treatment. I’m curious if you have ever seen a case where the addict is fixated on a fantasy, an idea in their mind that they perceive to be special somehow, but would be ordinary to any other onlooker. Specifically the example I had in mind was a romantic fantasy.

This type of addiction becomes devastating when the addict becomes aware of the reality and how different it is from their fantasy. Is there any way to cure a person who is addicted to a romantic fantasy? I think there are some who refer to this as “limerence” but I don’t think this is a widely accepted terminology.


Hi Susan,

Thank you. I’m so glad you enjoy the Feeling Good Podcasts, and I hope more and more people will sign up for them. Your support really encourages Fabrice and me!

Yes, I’ve treated many individuals who were addicted to some romantic fantasy, or some other thought or fantasy they were hooked on. You are right to call this an addiction, because the fantasy can provide a kind of mental high.

I cannot do therapy in this medium, but I can give you a general example of how I might proceed to work with someone with this problem. Keep in mind that your specific details will be different, so much of this will not apply to you.

The first thing I’d do, after empathizing for a period of time, so my patient felt completely understood and accepted, would be to help him or her list all the really great things about the fantasy. It is exciting, it provides distraction from other problems that may be causing anxiety, and it lets you hang on to the person you are fantasizing about, without having to let him or her go. It also shows that you have high ideals for your romantic life, care a great deal about others, and value loving relationships. Your fantasies are also a kind of fabulous compliment to the person you are fantasizing about. And, the fantasy may protect you from the problems of dating real people, who can seem pretty darn flawed and annoying in comparison with our fantasies about our ideal partner, who looks fantastic and fulfills our every dream. In addition, you can avoid the whole reality of dating, which can be massively time-consuming, energy draining, anxiety-provoking, and frustrating.

Then I would say, given all these benefits, why in the world would you want to give that up?

Now the ball would be in your court to try to persuade me to work with you, and to try to convince me that you really do want to change. If you cannot convince me, then I would “Sit with Open Hands,” letting you know that it is totally okay with me if you keep fantasizing. As long as you enjoy it, and it doesn’t cause problems, there is really no good reason to change.

But if you did want to change, there are a host of powerful methods we could use, such as Self-Monitoring (tracking each time you have the fantasy, using a wrist counter, like golfers wear on their wrists to keep track of their score), the Devil’s Advocate Technique, scheduled Fantasy Breaks, and more. We could also work on improving your dating skills and relationships with people you are interested in, with Smile and Hello Practice, Flirting Training, Rejection Training, the Dave Letterman Technique, Shame Attacking Exercises, Self-Disclosure, and more.

A business graduate student came to me for help because he’d broken up with his girlfriend, who was now dating another fellow in his class. And he kept having fantasies of the two of them having sex together. This disturbed him greatly, and made it hard to pay attention in class, but he couldn’t shake the fantasies from his mind. He also started driving past her apartment over and over, to see if the other fellow’s car was parked outside.

After trying several techniques that did not help, I suggested he wear a golf score counter, and count how many times each day he had these distracting sexual fantasies of his ex-girlfriend making love to her new boyfriend. I told him that all he had to do was just click his wrist clicker, and then just let the fantasy go and carry on with what he was doing.

At the end of the day, I told him to record the total on his calendar and reset the counter to zero for the next day. I told him to keep it up for four weeks, since the fantasies often diminish in the third week.

For the first three weeks, he averaged more than 90 fantasies per day. Then the numbers started falling, and by half way through the fourth week, they disappeared entirely, along with his depression.

Any one technique like that might, or might not, help. That’s why I developed dozens and dozens of techniques to help individuals who are feeling unhappy, or who are addicted to people or substances that are making their lives miserable.

One woman kept having romantic fantasies after her boyfriend broke up with her. She kept thinking about how wonderful he was and remembering some incredibly loving moment. After spending some time deciding whether she was really motivated to let go of the memories—since that would mean having to grieve his loss and admit he was gone—we tried a number of techniques. The one that helped was Image Substitution. Each time she had some wonderful memory of him, she would switch to some disturbing memory of him—and there were many! That did the trick nicely!

Thanks, Susan for your excellent question. I think many people can identify with thinking we “need” some person or something to feel happy and fulfilled. I could write much more on this topic, but this is already long.

You might also want to read my recent post on “Is Love an Adult Human Need?”