“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?” Harold
Dr. Burns’ Answer
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.
Do not copy, publish or reproduce without the written permission of Dr. Burns.
In this blog I will focus on the biggest therapist error of all, by far—the failure to set the agenda. This may come as a surprise to therapists who think they do know how to develop a meaningful therapeutic agenda. Most therapists think this means making a list of the patient’s goals for therapy at the initial evaluation and then working together to achieve those goals in subsequent therapy sessions. There’s nothing wrong with that, but that’s not at all what I mean by Agenda Setting, or more correctly, Paradoxical Agenda Setting, (PAS).
PAS is an amazing new approach that can lead to vastly faster recovery from depression, anxiety disorders, relationship problems, and habits and addictions. However, PAS can be very challenging to learn because it kind of goes against human nature to some extent. And, after all, therapists are human, and therapist narcissism and codependency can pose formidable barriers to learning these new treatment methods.
I’ll give you a feel for how PAS works, using a real case. If you find it intriguing, and want to learn how to do it, you’ll definitely need additional study, training, and practice. I’ll suggest some additional learning steps for you at the end of the blog.
At the start of each therapy session, it’s important to empathize, using the Five Secrets of Effective Communication. When you empathize, you don’t try to help the patient and you don’t give advice. Instead, you can paraphrase the patient’s words (Thought Empathy), acknowledge his or her feelings (Feeling Empathy), find the truth in what the patient is saying (Disarming Technique), and gently probe for more information (Inquiry). It is also helpful to express warmth and compassion (Stroking), and it can also be appropriate for the therapist to share his or her feelings with the patient as well (“I Feel” Statements),
Skillful empathy requires discipline and training. Most therapists believe they are reasonably empathic and have good listening skills. In many cases, this is not actually true. I have developed an Empathy Scale that my colleagues and I require all of our patients to complete in the waiting room at the end of every session. The score will show how your patient actually experiences you. Most therapists get failing grades initially from most of their patients. This can be upsetting, and a shock to the system. However, with practice, your scores can improve significantly, or even dramatically.
Carl Rogers believed that empathy was the necessary and sufficient condition for personality change, and his contributions were legendary. However, research and subsequent experience have shown that empathy is not enough. If a patient is struggling with severe depression, or OCD, or a troubled marriage, or a habit or addiction, you can be the greatest listener in the world, but nothing will change. The patient may think you’re wonderfully supportive and caring, but he or she will still be struggling with the symptoms that brought him or her to therapy in the first place.
That’s why we need methods. I have developed more than 50 powerful techniques that can help people overcome mood and relationship problems and addictions. But you can’t just jump from empathy to methods. This is where Paradoxical Agenda Setting (PAS) comes in. You might think of it as the bridge from empathy to methods. When you use PAS, you find out what, if anything, the patient wants help with in today’s session. Then you bring the patient’s subconscious resistance to conscious awareness, and melt the resistance away using a number of innovative techniques. If you do this skillfully, then when you come to the methods portion of the session, you will get much better and faster results. In fact, the impact of PAS on recovery can be dramatic.
There are five steps in Paradoxical Agenda Setting:
The Invitation Step
Let’s see how it works, using a real but heavily disguised case. A young man named Rameesh sought treatment from me in Philadelphia for severe anxiety and depression. He was working as a computer programmer, and those were the early days of programming.
Of course, I took his history first, and then spent most of the first treatment session empathizing with him. Then I issued the Invitation by saying something like this: “Rameesh, you’ve mentioned a number of problems, and you’ve told me how anxious and depressed you’ve been feeling. I can see that you’re in a lot of pain. I’d like to offer you more than just listening and support, and I’ve got some wonderful tools to share with you. I’m wondering if this would be a good time for us to roll up our sleeves and get to work on one of the problems that’s bugging you, or if you need more time to talk and have me listen, because listening is also important, and I don’t want to jump in before you feel ready.”
This is called a “Straightforward Invitation,” and it conveys several important messages to the patient:
“I care about you and I’m aware that you’re suffering a great deal.”
“Venting and getting support won’t be enough to get the job done if you really want to change your life.”
“I have powerful tools to help you.”
“You will have to ask me for help in order to make some magic happen.” This is based on the Biblical notion of “Ask and ye shall receive.”
“You will have to let me know when you’re ready to get to work and begin using these tools.”
If the patient ignores your Invitation, or doesn’t feel ready to focus on something specific, you can empathize for a while longer, and then repeat the Invitation step.
Rameesh indicated that he did want help. Then you go on to the Specificity Step, and there are two levels of Specificity you can ask about. First, you can ask what problem she or he wants help with, with a simple question like this:
“Rameesh, I’m glad you feel ready to work on something together. You mentioned lots of problems that seem important, and any of them would work well, I think. What problem would you like to work on first?”
Rameesh indicated that he wanted help with his low self-esteem, but it could be anything that’s bugging the patient, such as procrastination, or panic attacks, or a marital conflict. It could be anything at all.”
Rameesh wants help with his “low self-esteem,” but we don’t really know what that means. To bring the problem to life, you go on to the second level of specificity—you can ask him to describe one specific moment when he was struggling with that problem. This is what I said to Rameesh:
“Rameesh, I’m glad you want help with low self-esteem because I would enjoy helping you with that. Although it’s incredibly painful to have low self-esteem, there are lots of tools we can use to help you boost your self-esteem and feel greater joy in life. But I need a bit of help from you. I’m wondering if you can describe a specific moment when you were struggling with low self-esteem. That way, I’ll have a better idea of how to help you. For example, you might be experiencing low self-esteem right now, sitting here in my office, or you might have been feeling bad about something that happened yesterday, or at any time in your life.”
Once Rameesh describes a specific moment when he was upset, you can ask him where he was, what time of day was it, and who he was interacting with. What did the other person say to him, and what did he say next? What was he thinking at that moment, and what was he feeling?
During the Specificity Step, it can also be helpful to ask questions along these lines:
“Rameesh, let’s assume that you and I successfully solved this problem. What would the solution look like? What would change? How would things be different?”
This question can be tremendously useful. Sometimes you will see why the patient is stuck, because the type of solution he or she is looking for may be unrealistic or self-defeating. For example, someone who is overly submissive may think that the solution to a relationship problem involves the opposite of submissiveness, such as becoming more aggressive, demanding, or argumentative. These strategies are almost certain to stir up hostility, rather than intimacy, collaboration, or respect.
Or, the person who is procrastinating may think the solution will involve developing great motivation before tackling the task he or she has been putting off. This strategy is doomed to failure, because the motivation will probably never come. If you want to overcome procrastination, you’ll have to make a commitment to get started in spite of the fact that you don’t feel like it. Once you’ve gotten started, you may realize that the task is not as bad as you imagined, and then you might experience some motivation.
When I asked Rameesh for a specific moment he was experiencing low self-esteem, he described a conflict with his boss the previous day. He’d met with her to review his performance evaluation. She said that she’d received numerous complaints about his work from his colleagues. They said that he was defensive and hard to get along with, and that he wasn’t a good team member.
Rameesh found the feedback from his boss very upsetting and got defensive. He insisted that his colleagues were jealous of him because he was from India, had dark skin, and was smarter than everyone else. He shouted that there was a conspiracy against him, and that he should be at the head of his computer team.
I asked Rameesh how his boss responded when he said that. He sadly explained that his boss put him on probation and threatened to fire him if he didn’t shape up. He said that he walked out of the meeting feeling like a total loser.
Now we know what Rameesh needs help with. If you ask 50 patients to describe a moment when they were struggling with “low self-esteem” you’ll get 50 completely different situations, all requiring individualized solutions. That’s why the specificity step is so important, and why formulaic, manualized therapy based on a diagnosis or problem is doomed to failure for many if not most patients.
Now we come to the conceptualization of the problem. You can do this step on your own, in your head, or in collaboration with your patient. Ask yourself if the problem is an individual mood problem, such as anxiety or depression, or a relationship problem, or a habit or addiction, or a so-called non-problem, such as uncomplicated grief.
Rameesh asked for help with his “low self-esteem.” Now that we know what really happened, how would you conceptualize his problem? If you’ve printed this blog out, tick off any that apply. If you’re reading it on the website, make a mental decision before you continue reading.
1. An individual mood problem, such as depression or anxiety
2. A relationship problem
3. A habit or addiction
4. A non-problem, such as uncomplicated grief
The conceptualization step is vitally important for two reasons. First, each type of problem is associated with its own type of therapeutic resistance, so when you conceptualize the problem, you can begin to ask yourself about the kinds of resistance the patient will probably have when you try to help him or her. You can also think about what techniques you’ll use to melt away the resistance.
In addition, each type of problem responds to different types of techniques. I train my students and colleagues in how to use 50 basic psychotherapy methods, such as the Hidden Emotion Technique, the Acceptance Paradox, the Interpersonal Downward Arrow, the Externalization of Voices, and many others. Some methods are especially effective for depression, while others work well for anxiety disorders, or relationship problems, or habits and addictions. So when I do the Conceptualization Step, I’m also thinking about the methods I’ll use once I’ve melted away the patient’s resistance.
Did you make your choice(s)? Please don’t continue reading until you’ve decided. Does Rameesh have a mood problem? A relationship problem? A habit / addiction? Or a non-problem?
Most therapists say that Rameesh has a relationship problem, and that’s definitely true. I’m sure you recognized that as well. Clearly, Rameesh isn’t getting along with his boss or his colleagues. In fact, he sounds pretty paranoid, angry, and narcissistic.
But he’s also severely depressed and intensely anxious about losing his job, so he also has individual mood problems. Often, your conceptualization of the problem will involve more than one dimension. That means we may have to deal with several forms of resistance, and that we will have many kinds of techniques to help the patient as well.
Rameesh has a fairly severe problem and we have some terrific tools to help him. This sounds like a marriage made in heaven. Should we jump in and help him now? That, of course, is the biggest therapeutic error at all. Before we try to help Rameesh, we need to think about why he might not want the very help he’s asking for. Then we need to figure out how to antidote that resistance. Here’s where the new PAS techniques can be invaluable.
When we’re suffering, most of us have one foot in the water and one foot on the shore. Part of us wants to change, but part of us resists change and clings to the status quo. Why might Rameesh forcefully resist our efforts to help him?
We’ll need to think about two different kinds of resistance. I’ve called them Outcome Resistance and Process Resistance. In its simplest form, Outcome Resistance means that the patient doesn’t want a positive outcome from the treatment. If the patient is depressed, Outcome Resistance means that the patient would strongly prefer depression, shame, hopelessness, and misery over joy, self-esteem, hope and productivity. That might seem odd to you. Why would a depressed patient want to remain depressed? In fact, there are many very good reasons for this, and as long as they remain unexamined, the patient is likely to remain stuck.
Process Resistance is a little different. Process Resistance means that the patient might want a positive outcome, but doesn’t want to do the thing he or she will have to do to produce a positive outcome. In other words, there is some process—such as psychotherapy homework, or exposure—that the patient will resist doing.
Let’s review some of the most common sources of Outcome Resistance:
Depression, shame, guilt, self-criticism, inadequacy, worthlessness, and hopelessness.
The self-criticisms reveal the patient’s value system; the hopelessness protects against disappointment; and the relentless negative thoughts will seem to be true.
Patients probably won’t want to do daily psychotherapy homework, such as recording negative thoughts on the Daily Mood Log or scheduling more satisfying and productive activities on the Pleasure Predicting Sheet.
Phobias, OCD, Panic Attacks, Shyness and other forms of Social Anxiety, GAD, PTSD, Body Dysmorphic Disorder
Magical thinking—the patient thinks the anxiety or compulsive rituals will ward off danger.
Patients probably won’t want to have to use exposure techniques because it will be so anxiety-provoking.
Anger, marital conflict, disagreements with friends or colleagues/
Giving up the intense rewards of blaming the other person, feeling “right,” feeling morally superior, or fantasizing about revenge. The patient may not really want to get close to the person he or she is complaining about.
Patients probably won’t want to pinpoint their own role in the problem because they’re so convinced it’s the other person’s fault. They may insist on endless blaming and complaining and fight hard against learning to change themselves.
Habits and addictions
Procrastination, overeating, drinking or drug addiction, having affairs, shopping, internet porn addiction, or dating someone who is abusive
Giving up the tremendous physical and psychological rewards of the habit or addiction.
Patients probably won’t want to face the discipline, anxiety, deprivation, discomfort and hard work of giving up the instant gratification of their favorite “fix.” For example, the patient who wants to lose weight will not want to diet and exercise.
Once you’ve conceptualized some possible reasons why your patient may NOT want to change, in spite of the miserable status quo, you’ll need to learn how to share this information with him or her in a paradoxical but respectful manner. Here’s what I said to Rameesh:
“Rameesh, I have some powerful tools to help you with your low self-esteem and the problems you’re encountering at work, and I’d love to work with you. I believe you’re very smart, and I like you, and it would be a joy for me to show you how to turn your life around. I have no doubt that we could do exactly that. But I’m not sure it would be the right thing to do, and I’m really reluctant to share these tools with you.”
Notice that I’m not trying to “help” Rameesh and I’m not trying to persuade him to change or to work with me. Instead, I’m Dangling the Carrot—letting him know that I have some great tools, and that I want to work with him, but I’m also letting him know that he’s going to have to persuade me. I’m not going to try to persuade him.
Like most patients, Rameesh seemed taken aback. He insisted that he was tremendously interested in working with me and wanted to know what the problem was. Here’s what I said next:
“Rameesh, there’s a problem I’m struggling with. You’ve said that your colleagues treat you unfairly and that they’re jealous of you. That must feel extremely unfair, and I can imagine that you might be feeling incredibly angry and frustrated. You’ve said that they’re jealous and talking about you behind your back and treating you in a shabby way. Some people might think you’re being paranoid, but we know that’s not the case. We have proof that they’re bad-mouthing you, which is unfair. That’s what your boss told you in the evaluation.
“So I’m entirely on your side in this battle. But here’s the rub. They’re not here asking for my help. So if we work together, you’re the one who will have to do all the changing. You’ll have to learn to change the way you think and feel, as well as the way you communicate with them. And you’ll have to work your butt off during sessions, and you’ll have to do psychotherapy homework between sessions as well. But that seems rather unfair, since they’re the ones who are screwing up. Do you see what I mean? Why should you have to change when they’re to blame for the problem?
“What are your thoughts about this? Can you help me solve this dilemma?”
Here’s why I made this statement. First, I wanted to find the grain of truth in Rameesh’s complaints, so he’d feel accepted and so he’ll feel like we’re on the same team. Second, I wanted to convey some warmth, liking and respect, especially given his pretty strong narcissistic streak. I knew that if he felt judged, criticized, or belittled, he’d probably put up a wall and drop out of therapy before we even got started.
And I did like him, so my statement was genuine. But most important, I wanted to head off his resistance at the pass and let him know that he’d have to persuade me to work with him, and not vice versa.
Notice that I have become the voice of Rameesh’s subconscious mind. I am verbalizing all the reasons for him not to change. When you do this skillfully, the patient will nearly always suddenly let go of the resistance and buy into the treatment program. The effect is almost as basic as the law of gravity, and the results can be spectacular. We call this Paradoxical Agenda Setting because the therapist becomes the voice of resistance. If you do this skillfully, in nearly all cases the patient will suddenly become the voice of change.
Rameesh told me that he definitely wanted to work with me, and would do practically anything if I would agree to work with him. I told him, once again, that he would have to do all the changing, and that he’d have to do at least one full hour of psychotherapy homework every day, 7 days a week. Once again, I emphasized how unfair that seemed.
He said he didn’t care how unfair it was, and that if I’d work with him, he’d do more psychotherapy homework than any patient I’d ever had.
I told him that was the message I was hoping for, and that I’d love to work with him.
Then he suddenly broke down and started crying. When he pulled himself together, he told me that he had a confession to make, and that he’d been lying to me. I asked what he’d been lying about. He explained that his boss didn’t really put him on probation—she’d fired him. And he confessed that he’d been fired six times, from six different jobs, in the past two years. He said that everywhere he went it was the same thing over and over. And if I could show him how to change his life, he’d do anything I asked him to do.
Rameesh was a joy to work with. He did more psychotherapy homework than anyone I’d ever worked with. I used basic tools, such as the Daily Mood Log, to help him with his depression and anxiety, and the Relationship Journal to help him with his conflicts with others. He worked relentlessly, and within a few weeks his depression had vanished. He also became a master at using the Five Secrets of Effective communication to deal with criticism and conflicts with others.
He was unable to find work in Philadelphia, since he’d pretty much burned his bridges at the only companies using his type of programming. But then he got an offer from a software engineering company in Georgia. He asked for my advice about whether to make the move.
I suggested he could tell them that he could only accept their offer if his new boss would agree to meet with him 15 minutes once a week to criticize his performance. They were taken aback, and said they’d never had a request like that, but agree since they were desperate to hire a programmer with his skill set.
Rameesh called for a phone tune-up about six weeks after he moved. He said things were going swimmingly, and he’d actually won the “Employee of the Month” award, and his picture was posted in the lobby of the company. He said the Five Secrets of Effective Communication worked like magic when he was receiving feedback from his boss.
The next time I heard from him was a second phone tune-up six months later. He was still on a high and explained that he’d gotten several promotions, and his salary had doubled. That was our last therapy session we ever had.
I didn’t hear from Rameesh again for many years. Then, one December, I received a Christmas card from Rameesh, with a note inside that was written on his company’s official stationery. He said he hoped I hadn’t forgotten who he was, and explained that things were still going great—he’d gotten married and had a baby, and was still working at the same company. But he wrote that he wanted me to take a look at the letterhead on the stationery and that he hoped I’d be proud of him. I checked it out and noticed that it said Rameesh XYZ, President and CEO, XYZ Software Company!
I was bursting with pride in Rameesh and what he’d done. Now he had more than 600 employees working for him. If I hadn’t used PAS, he’d probably still be my patient, insisting that he was a victim of other peoples’ insensitivity.
That’s just a brief overview of how PAS worked for one patient. If you think you might want to learn more about PAS, there are several tools that could help you, including:
Read my psychotherapy eBook, Tools, Not Schools, of Therapy, and do the written exercises in it.
Get mentoring / individual training from a certified T.E.A.M. Therapist at the new Feeling Good Institute.
Attend one of my two-day workshops, or even better, a four-day intensive.
Attend one of our free (or paid) weekly psychotherapy training groups in Northern California.
Purchase and study one of the interactive training videos at TeamTherapyTraining.com
Do not copy, publish or reproduce without the written permission of Dr. Burns.
When a patient complains of relationship problems—such as a troubled marriage or a conflicted relationship with a family member, colleague, neighbor, or friend—the patient usually depicts himself or herself as the victim and implies that the other person is to blame for the problem. For example, the patient may emphasize the other person’s insensitive or self-centered behavior, and insist that the other person is a jerk who really shouldn’t be that way. Therapists frequently buy into this way of thinking about the conflict. We do this because of our desire to support and help our patients, and also because this is politically correct. And, after all, there is an enormous amount of violence and bad behavior in the world. So when the patient points out all the annoying things the other person said or did, on some level, he or she is right
However, in most cases, you have succumbed to the patient’s hypnotic spell. And once you’ve bought into the idea that the patient really is the innocent victim, the therapy will have little chance of being effective. I’m not aware of any tools powerful enough to help individuals who blame others for their problems.
It is not easy for therapists to escape from this type of trap. In fact, most therapists don’t even realize they’ve fallen into a trap. And it’s somewhat addictive, too. It can feel good to collude with the patient and scapegoat the other person. I see therapists falling into this trap over and over again.
In my psychotherapy eBook (Tools, Not Schools of Therapy) and in my relationship book for the general public (Feeling Good Together), I describe the three basic principles of what I call Cognitive Interpersonal Therapy (CIT). CIT is based on three principles:
We forcefully create the relationship problems that we complain about so intensely, but we’re not aware of this, so we feel convinced that we’re innocent victims.
We’re not interested in discovering our role in the problem. We want to maintain the façade of innocence so we can continue to do our dirty work in the dark.
We have far more power than we think to transform troubled relationships into loving and joyous ones. Furthermore, this can often be done amazingly quickly. However, there will be a price to pay. You’ll have to be willing to pinpoint your own role in the problem and focus all of your efforts on changing yourself, rather than blaming the other person or trying to change him or her. This can be painful, because it requires the death of the ego, or what the Buddhists call “the Great Death.”
I once gave a half-day workshop in Seattle on relationship problems for the general public. It was sponsored by a local hospital as a part of their public outreach program. At the start of the workshop, I asked the participants to think of one person they didn’t like or get along with, and to write down one thing the other person had said to them during an argument or disagreement, and exactly what they said next. I explained that this brief exchange was all we would need to pinpoint the exact cause of the problem and illustrate how to transform hostility and defensiveness into trust and love.
Then I asked if anyone would like to describe the difficult person in his or her life. A woman who was sitting in the first row was waving her hand in the air excitedly, so I called on her first. She said that her name was Martha, and that her husband was the difficult person in her life. She explained that he’d been relentlessly critical of her all day every day for the past 35 years. She said she’d come to the workshop to find out why men were like that.
I explained that scientists don’t yet know why men are the way they are, or why women are they way they are, but if she’d read what she wrote down, perhaps we could get some insight into the cause of her marital problem. What, exactly, had her husband said to her, and what, exactly, did she say next?
She said, “Well, just this morning, he said ‘You never listen!'”
I asked what she said next. What had she written down?
She replied, “Oh, I just said nothing and ignored him!”
The audience erupted in laughter. They could immediately see something pretty obvious that she did not seem to be aware of.
When you use CIT, you examine your own response to the other person instead of blaming him or her, and you ask yourself three questions based on the EAR acronym:
E = Empathy—Did I use good listening skills? Did I find some truth in what the other person said? Did I acknowledge how she or he was thinking and feeling?
A = Assertiveness—Did I share my own feelings openly and directly?
R = Respect—Did I convey warmth and caring to the other person, even in the heat of battle?
Well, it isn’t hard to see that Martha was 0 for 3. First, there was no empathy. She didn’t acknowledge her husband’s feelings or acknowledge any truth in what he’d said. In addition, she didn’t share her own feelings openly and directly—instead she ignored him and froze him out in a passive-aggressive manner. And finally, she clearly didn’t convey any warmth or respect.
This analysis will be threatening to most patients. Martha came to the workshop to find out why her husband was so screwed up. She was blaming him. Suddenly, the finger of blame is pointing at her. This may not be what she had in mind! Because the method is very powerful, it requires lots of trust and warmth, because the patient ends up in a very vulnerable position.
When you use CIT, you also ask the question—what will the impact of my response be on the other person? How will my husband think and feel if I respond this way? What will he conclude? How will he behave?
Once again, the answer is pretty obvious. Martha’s husband will conclude that he was absolutely right—once again, Martha didn’t listen. Since she hasn’t yet gotten it, he’ll have to try again, and again, and again.
So now, Martha knows the answer to her question—why are men like that? Why are they so critical? Sadly, it’s because Martha forces him to be like that. And she’s done that all day, every day, for the past 35 years.
This insight can be extremely painful. I have done this type of analysis myself on many occasions when I was in conflict with a family member, patient, or colleague. And it is always painful for me, too. I HATE having to do this. But it can be very liberating. That’s because of the third principle of CIT—we have far more power than we think to change a troubled relationship. Since we are triggering the problem, we also have the power to change things.
I’ve used this approach with more than 1,000 individuals with troubled relationships, including many mental health professionals who have attended workshop for training and personal growth. In virtually every case, the person who is complaining has failed to empathize, express his or her feelings, or convey respect. So he or she is always 0 for 3 on the EAR analysis. In addition, when you examine the consequences of the patient’s response to the person she or he isn’t getting along with, you discover that the patient is forcing the other person to behave in exactly the way the patient is complaining about.
And we can see that clearly in the example Martha provided. However, this doesn’t mean that Martha’s husband is innocent. If he’d come to the workshop, and Martha had stayed at home, I would have helped him pinpoint his role in the conflict, and he would have made the same painful discovery—that he actually forces Martha not to listen.
I call this the theory of interpersonal relativity. Probably that’s too fancy of a term, but it means that the person who is asking for help will always turn out to be the entire cause the problem.
This approach requires enormous therapist empathy, gentleness and compassion, because the discovery will nearly always be shocking for the patient. Some patients will resist or even decide that they don’t want this type of therapy. But if patients have the strength and good will to endure the discovery that they are triggering the problems they complain about, there will be two huge rewards. First, they will suddenly understand the cause of all of the problems in all of their relationships, because they are almost certainly doing the same thing to other people they don’t get along with. This represents a kind of enlightenment—they discover that they are not, in fact, victims, but are instead creating their own interpersonal reality at every moment of every day. This is a Buddhist principle, but it’s also embedded in practically every religion, including Christianity, the Jewish religion, and many others.
And finally, and perhaps of greatest importance, I can show them how to solve the problem using the Five Secrets of Effective Communication. But that’s a topic for another day.
In a nutshell, most of our patients, and most of us as well, have one or more troubled relationships. Even if patients are seeking treatment for depression, or anxiety, or a habit or addiction, there’s a good chance that at some point in the therapy, they’ll begin to talk about some person who they’re at odds with. They’ll usually try to convince you that the problem is the other person’s fault. If you find yourself agreeing with the patient, ask yourself if you’ve been hypnotized. Once you recognize this, you can break out of the trance and help your patient pinpoint what’s really going on—if she or he is willing. Those of you who want to learn more about the nuts and bolts of doing this may want to read my eBook or Feeling Good Together.
I do not mean to imply that other people are always innocent, and that the patient is the only one who is to blame. In fact, other people often DO act like jerks. We all know that. The patient’s description of how the other person’s annoying behavior is likely to be true. But the patient is nearly always leaving something of vital importance out of the description—and that’s his or her role in the problem.
Thanks for listening! I suspect this blog might stir up a little controversy. Let me know if you have any feedback.
The next blog will cover Error #5, which is by far the greatest therapeutic error of all. So stay tuned!
Do not copy, publish or reproduce without the written permission of Dr. Burns.
In my last blog, I discussed something I call “Reverse Depressive Hypnosis.” That’s where the patient inadvertently “hypnotizes” the therapist into believing that she or he REALLY IS hopeless, worthless, and so forth. It is sometimes hard to resist falling into this potentially destructive trance, or even noticing that it has happened. Today, I will describe “Reverse Anxiety Hypnosis.” In a nutshell, that means that the anxious patient persuades you that she or he is too fragile (or not yet ready) to confront his or her fears using powerful exposure techniques.
In my book, When Panic Attacks, I describe several models I use in treating anxiety disorders, such as chronic worrying, phobias, PTSD, Panic Disorder, Agoraphobia, OCD, shyness, public speaking anxiety, and others, including:
The Motivational Model—Although anxiety can be exceedingly painful, you may secretly believe that your anxiety is helping you, or protecting you, so you are reluctant to give it up. A simply example would be the fear of flying. You may think that your fear protects you from getting on a plane and crashing.
The Cognitive Model—You learn how to challenge the distorted negative thoughts that trigger the anxiety.
The Exposure Model—You confront your worst fears, rather than running away from them.
The Hidden Emotion Model—You bring hidden feelings and conflicts to conscious awareness. When they express these feelings and solve the problems you’ve been avoiding, the feelings of anxiety often improve dramatically or totally disappear.
If you combine all four models, you can often achieve a complete elimination of the anxiety rather quickly. Patients love the Motivational, Cognitive and Hidden Emotion Models because they can be enormously helpful and fun to learn, but they typically hate Exposure Model. That’s understandable—we all avoid the things that terrify us. I can vouch for that, as I have personally experienced and overcome more than a dozen kinds of anxiety.
Patients will often hypnotize their therapists into believing that they are too fragile to use exposure techniques. If the therapist falls into this trance, and buys into that notion, the treatment will be doomed. It is practically impossible to overcome any form of anxiety without using exposure techniques. Exposure alone will rarely be enough—the Motivational, Cognitive and Hidden Emotion Models will also play vital roles in the treatment—but exposure will be mandatory.
When I give workshops on the treatment of anxiety, I ask the therapists in the audience to raise their hands if they routinely use exposure techniques when treating anxious patients. Usually, only about 25% of the hands go up, at most. This means that most therapists are NOT using exposure techniques in the treatment of anxiety disorders.
This might seem surprising, or even disturbing, since exposure is one of the most researched and validated psychotherapy techniques in history. So why aren’t all therapists using and requiring exposure? There are many reasons. Some therapists do not believe in using powerful techniques like exposure, thinking that empathy and talk therapy alone will be sufficient. But the most common reason patients and therapists avoid exposure is fear. The therapist thinks the patient is too fragile for powerful exposure techniques. In other words, the therapist has been hypnotized by the patient. So the therapist and patient talk and talk and talk in a general way, exploring the past, but the symptoms do not improve much, if at all.
Dr. Matt May is a former student of mine at Stanford, and we now teach together on the voluntary faculty. He is terrific hypnotist. He is also very suggestible and easy to hypnotize. He has told me that he often falls into trance when treating patients and then has to snap himself out of it.
Matt recently treated a young woman whom I’ll call Susan. Susan came all the way from Cleveland for intensive treatment with Matt because she’d been struggling for years with severe social anxiety. (The details are always disguised to protect patient identities.)
Susan showed up at Matt’s office dressed quite formally, in a business suit. She described how she’d been treated for more than 15 years with conventional talk therapy plus a wide variety of medications with no improvement. Although she was an attractive and talented young professional, her crippling shyness in social situations, coupled with severe public speaking anxiety had severely hampered her social life and her career. She felt ashamed, lonely, hopeless, and defective.
Matt asked what she was the most afraid of. What was her greatest fear? She explained that she was intensely afraid of making a fool of herself in public, or saying or doing the wrong thing, and having people look down on her and see how crazy and defective she was. This fantasy was so terrifying to her that she avoided interacting with people in practically all social situations and refused to give talks at work.
Ten minutes into their first session, which was devoted to clinical history-taking and assessment, Susan asked if there was any hope for her, given the severity of her problems, and how long the treatment might take. On impulse, Matt said that if she wanted, they could just take a ten minute break from taking the clinical history and cure her, and then he could complete the history. She seemed shocked and asked how he could possibly cure her in ten minutes, especially given so many years of unsuccessful treatment from numerous psychologists and psychiatrists.
Matt explained that she simply had to confront her fears, rather than running away from them. He said he wanted her to do a Shame Attacking Exercise. When you do a Shame Attacking Exercise, you make a fool of yourself in public on purpose by doing something foolish or bizarre, so can discover that the world doesn’t come to an end after all. I believe this fantastic technique was developed by the late Dr. Albert Ellis.
He told her he wanted her to go to the Starbuck’s which was just a half a block away from his office. Once inside, she was to lead the customers in singing and cheering, much like a cheerleader at a football game.
She was shocked and indignant, and insisted that this assignment sounded like malpractice, and that someone proper should NEVER do something as socially inappropriate as that!
Matt suddenly became ashamed and profoundly apologetic. He said he couldn’t believe he had asked her to do that, and went back to taking the history, all the while feeling intensely anxious. Do you know what happened? Susan had instantly hypnotized him into believing that she COULDN’T and SHOULDN’T have to confront her worst fears.
After ten minutes, Matt realized what had happened and snapped himself out of the trance. He told her that what she said was a lot of BS, and that she COULD and MUST do the Shame Attacking Exercise. In fact, they were going to go and do some Shame Attacking Exercises together—RIGHT NOW. So he led her out of the office and suggested they could start by doing something even more extreme outside the grocery store across the street.
So they both lay down on the sidewalk right in front of the front door of the grocery store, so that people would have to step over them to get inside. Matt asked her how intense her anxiety was, between 0% and 100%, and she replied “95%.” Matt said that wasn’t high enough, and he wanted her to push it to 100%.
Next, they pretended to be making snow angels, and then they pretended to be riding invisible bicycles while lying on their backs. It started to rain slightly, but they stuck with it.
A customer stepping over them to get inside asked what they were doing on the ground. She announced, “Oh, this is my shrink. We’re having a psychotherapy session. He often has his sessions on the sidewalk rather than in his office.”
Then Matt said, “You can join us if you like. It’s really nice lying here, kind of like being on the beach in Miami!”
Susan noticed that the people inside the grocery store were pointing at them, which made her anxiety even worse. This was her worst fear coming true—that people would think she was some kind of weirdo.
Then the store clerk came out and asked, “Are you guys okay?” She explained that they were fine and just enjoying themselves on the sidewalk. The clerk explained that the manager wanted them to leave. So they got up and left. Matt asked how she felt, and she said, “That was awesome!” She said that her anxiety had suddenly dropped to zero!
Why did that happen? It was because she confronted her worst fear, but nothing really terrible happened. She started laughing and said she felt triumphant.
Matt said, “Great! You’re cured now, and it only took ten minutes. Now we can go back to my office and I can finish your history.”
Susan said, “No! We’re not done yet. We still have to go into Starbuck’s and do our thing!” So they went into Starbuck, where a long line of people were waiting to buy coffee. Her anxiety suddenly spiked when Matt said, “Okay, time to do your thing.”
In spite of the intense anxiety she once again felt, she locked the fingers of her right and left hands together, and inverted her hands in the air above her head, and waved them like a victory fist, and then ran around in circles, saying, “It’s such a wonderful day. I’m so happy to be here. I’m so glad to be alive. Life is wonderful! I love the coffee here in Starbucks.”
Then she led the customers in cheerleading and got many people dancing and running around the store with her. Matt said he felt so proud it brought tears to his eyes.
During her several-day intensive with Matt, Susan did other Shame Attacking Exercises as well, including wearing an extremely sexy outfit in public, and confronting her fears of how people would think about her.
Coincidentally, I spoke with Matt on the phone this morning and asked him about Susan, since the treatment was more than a year ago. He had just received an email from her with a progress report on how she’s been doing since she finished her intensive. She said she was still on a high and that her life had opened up in incredible ways. One of the most significant changes was that even though she’d been very successful in her professional career, she had decided to switch careers and go back to graduate school so she could become a therapist. I have included some excerpts from her email below, printed with her permission, so you can read her personal account of the Shame Attacking.
The exposure techniques are not always that dramatic or extreme, but they nearly always require tremendous courage and commitment, both on the part of the therapist as well as the patient. This means that therapists will have to avoid falling into the anxious patient’s trance. If you combine Exposure Techniques with the Motivational, Cognitive and Hidden Emotion treatment models, the rewards can be tremendous.
In my next blog, I will discuss a third type of reverse hypnosis—relationship hypnosis. That’s where the angry patient, or the patient who simply isn’t getting along with his or her spouse, or a family member, or a friend or colleague, convinces you that he or she is an innocent victim and that the other person is to blame for the problems in the relationship. It is very difficult not to succumb to this trance, but if you get hypnotized in this way, the prognosis for effective treatment becomes very low.
Do not copy, publish or reproduce without the written permission of Dr. Burns.
Last time we discussed the consequences of therapists’ failure to measure changes in symptoms as well as the quality of the alliance at every session. Today, I’m focusing on another common therapist error you may have never heard of—hypnosis of the therapist by the patient!
We all know that some therapists hypnotize their patients, but I’ll bet you’ve never heard of the reverse type of hypnosis—that’s when the patient hypnotizes the therapist, and the therapist doesn’t even realize that he or she has fallen into a trance. It’s important to know about reverse hypnosis, because it can sabotage the therapy.
Of course, the patient doesn’t dangle a pendulum in front of the therapist while saying “You are getting very sleepy, very sleepy”—but we can sometimes fall into trances without realizing it. And when you are in a trance, you will tend to believe things that are not valid.
There are three common forms of reverse hypnosis:
Depression Hypnosis—depressed patients convince you that they really are hopeless and worthless.
Anxiety Hypnosis—anxious patients convince you that they really are too fragile to confront their fears using exposure techniques.
Relationship Hypnosis—Patients with troubled relationships convince you that their relationship problems really are the other person’s fault and that they really are the victims of the other person’s bad behavior.
Nearly all depressed patients are totally convinced that they are worthless, inferior, or defective. They are usually equally convinced that they are hopeless, that their problems are insoluble, and that they will be miserable forever. If you’ve ever felt depressed, you know how powerful and painful these feelings can be.
The thoughts that generate these demoralizing feelings are nearly always distorted—you may be familiar with the list of ten Cognitive Distortions that I first published in my book Feeling Good. When you fall into the black hole of depression, your thoughts typically involve distortions such as:
All-or-Nothing Thinking—You look at things in black or white categories. If you’re not a complete success, you tell yourself that you’re a total failure.
Overgeneralization—You see a negative event—such as rejection by someone you love, or failure to achieve your goal—as a never-ending pattern of defeat.
Mental Filtering—You focus on some flaw, failure, problem or shortcoming, as if this reflects your entire self. This is like the drop of ink that discolors the beaker of water.
Discounting the Positive—This mental error is even more spectacular. You tell yourself that your good qualities don’t count. In this way, you can maintain the belief that you’re defective, or that you’re a total loser.
Jumping to Conclusions—There are two common forms of this distortion: Fortune Telling involves making dire negative predictions that aren’t warranted by the facts. For example, when you’re depressed you tell yourself that you’re problems are hopeless and that you’ll be miserable forever. Mind-Reading involves telling yourself that others are looking down on you without any good evidence. Shy people do this in social situations, imaging that everyone else feels confident and that everyone can see how anxious and inept they feel.
Magnification and Minimization—Blowing things out of proportion, or shrinking their importance. For example, when you procrastinate you dwell on ALL you have to do (Magnification) and tell yourself that getting started and doing a little bit would just be a drop in the bucket (Minimization).
Emotional Reasoning—This is reasoning from how you feel: “I FEEL worthless (or hopeless), so I must BE worthless (or hopeless).”
Labeling–You label yourself as “lazy” or “a loser,” or you label someone else as “a jerk.”
Overt and Hidden Should Statements—As in, “I SHOULDN’T have made that mistake,” or “I SHOULD be better than I am.” Should Statements directed against yourself trigger feelings of depression, guilt, shame, and inferiority. Should Statements directed against others, or against the world, trigger anger and frustration.
Blame—There are two common varieties. Self-Blame leads to depression, and Other-Blame leads to anger and conflict.
But when you’re feeling depressed, anxious, or angry, you don’t realize that your thoughts are distorted and misleading because they feel and seem overwhelmingly realistic. The goal of Cognitive Therapy is to help the patient put the lie to these distorted thoughts. And the moment you stop believing them, you’ll feel much better.
But here’s the funny thing. Toward the beginning of therapy, I usually buy into the patient’s negative thinking. Patients are extremely good and convincing themselves and others that they really ARE worthless losers who are doomed to lives of mediocrity and misery. So I get panicky for a little while in the first or second session because I start telling myself, “This person really DOES sound like a bit of a worthless loser. Maybe there aren’t any distortions this time!”
I don’t mean to mean to sound cruel or insensitive—it is just that I have fallen into a kind of depressive trance, and most therapists do the same thing. I have bought into the patient’s extremely negative and distorted thinking. You could even think of this hypnotic trance as a form of super-empathy, because the therapist can really SEE the world through the patient’s eyes. The patient’s intensely negative view of himself or herself and the world suddenly seems almost impossible to dispute.
Then, several weeks later, when the patient and I have been working together effectively, and the patient develops the ability to crush the negative thoughts, the patient and I can suddenly see how distorted they were all along. We have both snapped out of the trance, and the patient feels a sudden flood of relief, or even euphoria. At that point, it dawns on me that I had succumbed, once again, to the patient’s depressive hypnosis.
This is not a trivial or rare problem. In fact, therapists are sometimes even trained to buy into the patient’s negative thoughts. At continuing education conferences, for example, therapists might be advised to “educate” patients and their families into believing that the prognosis for depression is guarded, and that while they can be helped somewhat, they may always have to struggle with depression and may need to take antidepressants and other medications indefinitely to correct the “chemical imbalance” in their brains, much as diabetics need to take insulin forever. Or, they may need psychotherapy indefinitely. And, of course, once you give your patients that message, many of them will believe it, and it becomes a self-fulfilling prophecy.
Early in my career, I asked Dr. Aaron Beck, a brilliant pioneer who helped to create and develop cognitive therapy, if some patients REALLY WERE hopeless. He said that he had never once bought into the notion that any depressed patient was hopeless. He said that this optimistic philosophy had worked out well in clinical practice, and that I might have to make a policy decision of my own on whether or not I would buy into that type of thinking.
I settled on the same policy, and it has always paid off for me. I remind myself that no matter how severe or overwhelming the depression might seem, the patient can, in fact, recover and feel joy and self-esteem again. That policy has been invaluable in my clinical work, and it has never let me down.
Of course, the belief alone won’t cure patients. You have to have many good treatment tools to back up your vision.
I could write a chapter or book with examples of rapid recovery in patients who initially seemed hopeless or worthless, but I’ll just give you an extreme and brief one example here. When I was in Philadelphia, we had an intensive program for patients from out of town. The idea was to try to complete an entire course of therapy in a week or even less by seeing patients several hours every day. It was a pretty successful program.
I can recall an incredibly challenging woman named Eve who travelled all the way from Germany for treatment. (I always disguise or change the facts to protect patient identities.) Eve had struggled with intractable depression and OCD for more than 40 years, with no success at all. She’d been treated with every known antidepressant and tons of other drugs, and had been hospitalized on numerous occasions. In addition, she’d received more than 100 ECT (electroconvulsive) treatments. Psychotherapy didn’t work either. Eventually, she was given a frontal lobotomy, but that did not help, either. Two years later, she had a second lobotomy, again with no beneficial effects.
Eve wanted to know if there was any hopeThe situation did not look very promising, to say the least, but I tried to hide my pessimistic feelings. I told Eve that while I couldn’t make any promises, we’d sometimes had surprisingly positive results with even the most severe cases, and that the new treatment techniques that my colleagues and I had developed were definitely worth a try.
I wasn’t able to take her on myself, since my practice was temporarily full, so I referred her to a colleague who was working with me at our clinic. I must confess that I had a sense of relief that I didn’t have to treat. Her situation seemed impossible.
Two days later I asked my colleague how things were going with Eve. He seemed in a surprisingly chipper mood and said that the symptoms of depression and OCD had vanished and that she was feeling happy for the first time in decades. I asked him what in the world he’d done. He said that she was easy to treat and that he just used the same techniques we use all the time, such as the Daily Mood Log, Identify the Distortions, the Paradoxical Double Standard Technique, the Externalization of Voices, the Acceptance Paradox, and several others.
It dawned on me that once again, I had succumbed to a “depressive trance” without realizing it.
Now my colleagues at the Feeling Good Institute in Northern California have created a similar intensive program for people from around the country who want to commute it for short-term treatment. For more information, go to the FeelingGoodInstitute.com website.
Or, to learn more about how to defeat the negative thoughts that trigger depression and anxiety on your own using self-help techniques, check out one of my books, such as Feeling Good.
Thanks for reading this. In my next blog I’ll discuss Reverse Anxiety Hypnosis.
Do not copy, publish or reproduce without the written permission of Dr. Burns.
Really good therapy may tend to go against human nature to a certain extent. Unfortunately, therapists keep gravitating toward familiar approaches that are comfortable but ineffective. I have created a list of the ten most common errors therapists make, with the solutions I have proposed for each error. In today’s blog, I will focus on the first of these errors.
Error #1. The Failure to Measure
The great majority of therapists want to work “intuitively,” without quantitative assessment of changes in symptoms each session, and without a quantitative assessment of the quality of the therapeutic alliance. This failure to measure results from the belief that we “know” fairly accurately how our patients are thinking and feeling, based on our training as well as our own feelings and perceptions during the session.
My research and clinical experience have indicated that this belief may be misguided and, in some cases, even dangerous. Therapists’ perceptions of how their patients feel tend to be inaccurate. In other words, your patient could be enraged, and yet you may believe that she or he is not at all angry. Or your patient could have significant negative feelings about you as well as the treatment you are offering, but you may be convinced that you have developed warmth and understanding with that patient. Or, your patient could be planning a suicide attempt within the next couple days, but you may think that he or she is making good progress and feeling a lot better.
Here’s my solution to this problem: My colleagues and I require all patients to complete the Brief Mood Survey (BMS) in the waiting room immediately before each sessions begins, indicating how they feel right now. The BMS includes brief, highly accurate scales that measure depression severity, suicidal urges, anxiety, anger, relationship problems, and positive feelings such as joy, self-esteem, and productivity. It only takes about one minute to complete the BMS.
The patient hands the BMS to the therapist at the start of the session, and the therapist will instantly know exactly how the patient is feeling. The therapist records the scores on a flow sheet in the chart—this takes less than 15 seconds, and a glance will show the therapist exactly how much, or how little, the patient has been progressing since the first session. The therapist also knows exactly how disturbed the patient is feeling right now, at the start of the session, so any serious problems can be addressed.
After the session is over, the patient completes the BMS once again in the waiting room, indicating how she or he feels right now. The patient also rates the therapist on warmth, empathy, helpfulness, and other therapy process dimensions, using extremely sensitive scales, and writes down what he or she liked the least, and the most, about the session. It takes the patient about two minutes to complete the end-of-session assessments. The patient leaves these end-of-session assessments in the therapist’s box before going home.
You can review this information right away, when the session is still fresh in mind. It is like having the world’s greatest supervisor providing specific and accurate feedback at the end of every single therapy session. You will discover exactly how effective you were (or weren’t), and how much your patient improved (or failed to improve) during the session. If you are courageous, this information has the potential to transform your clinical work. However, humility will be required, because the information will often be disturbing to you.
In the Bible, there is mention of the “unforgiveable sin.” Theologians have debated about what this sin might be. I have to confess that I don’t know the answer, but I do believe there is an “unforgiveable sin” that therapists make—and that is the failure to measure. I am convinced that it is impossible to do world-class therapy without measuring at each session. I also believe that the failure to measure reflects a kind of therapist arrogance, or narcissism—the belief that we are “experts” and that our own perceptions of how patient feel (or feel about us) are somehow more accurate than the patient’s perceptions of how they actually do feel. In most cases, nothing could be further from the truth.
Some therapists resist the use of the assessment scales, arguing that patients won’t be honest in the way they fill them out, and will simply tell therapists what they think the therapist wants to hear. Once again, nothing could be further from the truth. When my students (psychiatric and psychology graduate students) use the assessment scales initially in the clinical work, most get failing grades from nearly every patient at nearly every session. So their patients are NOT telling them what they want to hear—they are telling them what they DON’T want to hear!
How about seasoned clinicians like yourself? Unfortunately, your experience will probably be similar. Initially, most seasoned clinicians receive failing grades on the therapeutic empathy and therapy helpfulness scales from almost every patient as well. This can be a huge blow to the ego, and it is one of the reasons that many clinicians refuse to use the scales. They can’t stand the heat.
But there is a silver halo around this cloud. Most students and community clinicians who use the scales with every patient at every session, and who do some Empathy Training using methods I’ve developed, report that within a few weeks, they receive perfect scores 80% of the time, rather than failing scores nearly 100% of the time. So there is hope for a remarkable transformation in your clinical skills—if you have the courage to take this huge step!