Ask Dr. David

Is Suicide Justified?

Dear Doctor David,

I read your book Feeling Good: The New Mood Therapy, with much interest. I think almost all what you say still applies today. But I have a question: in the book when you discuss suicide, you don’t mention physical pain as a reason.

I understand your belief that most, if not all, suicidal patients can be helped. But pain is not even listed in your index or table of contents. It seems like a strange omission to me.

So, do you think if one has enough incurable physical pain, it’s okay to commit suicide? I am not asking for personal help. This is just a general question.

Dave

Dr. Burns’ Response

I have fairly strong feelings on this subject, and all I can give you is my own personal take on it. I know it is complex and highly controversial. And in addition, each situation would have to be evaluated on its own merit. So my comments will be of a general nature only, and are not intended to be medical advice or recommendation.

When our beloved pets are in pain and dying, it is an act of love and mercy to let them go, rather than to make them suffer so horribly. I used to be a dog person, but my wife converted me to cats when our dog died of colon cancer a number of years ago. Now I am crazy about our cats, all of which are strays or rejected cats we adopted. I totally adore them, and you can read about one of them, Obie, on this website.

I have always told my cats that if they are old and suffering, I will not let them suffer. I have also told them that when they die, I will be there with them, giving them love and comfort to the very end.

Personally, I can’t see why we don’t treat our human loved ones with the same degree of mercy and compassion. Personally, I can’t see any merit at all in making a loved one suffer in agony. I don’t mean to inflict my views on anyone, and accept the fact that many people will have radically different and very strong views about this.

The situation of a loved one suffering in agony with a terminal illness is very different from individuals who are depressed or angry and wanting to commit suicide because of the distorted and unrealistic belief that they are hopeless, or in order to get revenge on others who they are angry with, perhaps because they feel rejected. I see suicide for emotional reasons as very violent and horrific act that is never justified or necessary. Once again, I realize and accept the fact that many others will have very different views on this topic.

That’s my take on it. Should I publish your excellent question and my answer on the website? Perhaps some others may be interested in this topic.

David Burns, MD

Dave’s Response to Dr. Burns

Dr. Burns,

I am delighted to get a response from you, particularly the response I was hoping for. Thank you so much for taking the time and making the effort to clarify your position for me.

Yes, after reading your book, I understood that for mental reasons, it’s seldom if ever rational to commit suicide. I was just wondering about the physical pain part.

Yes, by all means if you wish to post my question and your answer on your website, please do so. Good to know that you’re still actively involved in life. Good for you! Thanks again, Dr. Burns, for your answer!

Dave

Which Book Will Help Me the Most?

Dear Dr. Burns

I suffer from social anxiety and depression. I feel that I don’t need to see a therapist and believe that CBT will be enough to help me.

I have purchased three of your books: The Feeling Good Handbook, Ten Days to Self Esteem and Intimate Connections. This might be overkill but I really wanted to cover all the bases.

However now I am confused and don’t know where to start and how to manage the learning.  Which book should I work on first and how long do you think it should take to work through any given book? I believe somewhere you suggest that the Feeling Good Handbook this should be completed within 30 days. Any advice would be much appreciated.

Thanks

Beth

Dr. David’s Answer

Hi Beth,

Thank you for your question. There are no rules of the road. Ten Days to Self Esteem is the shortest and easiest book, with exercises you can complete at each of the 10 steps. Essentially, it is a 10-step program to teach you the basics of CBT and to show you how to boost your own self-esteem. The publisher has insisted on the name, Ten Days to Self Esteem, but I would prefer the name, Ten Steps to Self-Esteem, so you can complete it at your own pace.

Intimate Connections can be very helpful for loneliness and shyness–it is about the power dynamics of dating to some extent, and how to communicate, how to flirt, how to get people to chase you, how to deal with rejection, and so forth. It also shows you how to overcome the fear of being alone. It is somewhat autobiographical, too, since these are issues I struggled with when I was growing up.

The Feeling Good Handbook is a strong book with a focus on depression as well as anxiety, including shyness, and relationship conflicts as well.

I would start with any one of them and focus on it. There is considerable overlap, so once you learn the techniques they will all flow very easily for you. The key is doing the exercises while you read. The people who do the exercises are almost always the ones who benefit the most from any of my books.

It is kind of like riding a bicycle. You can’t learn to ride by reading about bicycles or watching people ride bicycles. You’ve got to get on a bicycle and give it a try. It might feel a bit shaky, or new and unfamiliar at first, but you can quickly learn to ride.

Research studies have shown that many people can use these books without a therapist and benefit tremendously. Some people with more severe or long-standing will also need the help of a skillful and compassionate therapist, of course.

I am now working on something new and extremely exciting, and will announce it as soon as possible on this website.

Thanks so much!

David Burns, M.D.

Does Tapping Work?

Dear Doctor David,

I am interested in your Scared Stiff anxiety workshop, as 95% of my primary care patients deal with this in some way, and I would argue that it is more common and in some ways more harmful than depression. I am a fan of CBT.

Question: is TFT (“tapping”) a lot of hooey or is there something to it? I have had some good personal experience, and would like to use it with primary care patients because I like simplicity and something that I can teach the patient to use at home (like deep breathing technique or affirmations). I like tools that the stressed patient can do RIGHT NOW, without an appointment or prescription, without spending money, without regard to insurance status, without needing more than 2 or 3 minutes, and without depending on an external source like the bottle of Jack, the pill (legal or otherwise), the partner, the “provider”, etc.

I respect your work, and you are an MD.  I would appreciate your thoughts on the TFT technique.

Kindest regards,

Lisa

Dr. David’s Answer

Hi Lisa,

Thank you for your question. TFT and EMDR combine something new (like tapping on your eye brow or jiggling your eyes back and forth) with exposure techniques that have been around for decades. I am skeptical that these types of distraction add much, if anything, to good, old-fashioned exposure. You can read about “Tapping” TFT if you click this link and you can read about EMDR at if you click this link

When I treat anxiety disorders, I combine a wide variety of exposure techniques with cognitive techniques, motivational techniques, and the Hidden Emotion Technique. You can read about these four treatment models in my book, When Panic Attacks, or in my psychotherapy eBook. I do not use eye jiggling or tapping on body parts during exposure, and have not found them to be necessary for outstanding or even dazzling results.

In my psychotherapy eBook I have a chapter entitled “The Clinician’s Illusion.” This refers to various ways that therapists and researchers fool themselves into believing things that may not be true. One problem I describe is called “coupling.” That’s where you combine an old, established technique, such as exposure, with some new technique, like eye jiggling or tapping on the eyebrow or whatever. Of course, exposure can be remarkably helpful, but you may mistakenly attribute the clinical improvement to the new technique that you are “coupling” with the older and more established technique.

In some cases, therapeutic enthusiasm may be due to the illusion of “seeing is believing.” If you use one of these newer techniques and your patient improves, it is natural to conclude that the treatment worked and that they theory is valid. But the special component you are using (such as eye jiggling, rhythmic knee tapping, or eyebrow or clavicle tapping) may, in fact, just be hooey, to use your language. The patient probably improved because of the exposure, and not because of the new component. Unfortunately, it is really easy for us to become “true believers,” especially if some new treatment is skillfully and aggressively marketed. Then we get invested and don’t like to be challenged, but challenging our thinking is the basis of science.

Another potential problem that confuses therapists and researchers alike is the placebo effect, which can be powerful. What’s the placebo effect? If people strongly believe something will help, it has a good chance of helping, even if it is nonsensical. When patients take an antidepressant and recover, or try some new treatment and recover, we think the pill or the therapy was the effective ingredient—but in most cases, the improvement is just due to the placebo effect.

I used to joke in workshops that we could create a new “ear tugging” school or psychotherapy, based on tugging on the ear lobes to let the evil spirits and pressures out of the brain, so the brain can get back into a proper balance again. I used to say that if you could get your depressed patients to believe in this notion, 35% to 50% would recover in three weeks as a “result” of their ear-tugging, especially if they work hard and do their five minutes of “ear tugging” homework every night. But in reality, it would just be the placebo effect.

Therapists in my workshops seemed to get a kick out of this example and laughed when I illustrated “ear tugging.” However, several years later a physician approached me during one of the breaks at my workshop, and asked if I’d heard about a fantastic new treatment for depression and anxiety. He had literature promoting the new treatment and wanted permission to distribute it. He swore that the new treatment had a 90% success rate and worked almost immediately.

I was intrigued and asked what the treatment was. He said it was called “Ear Tugging.” This is the honest truth. And he had paid quite a lot of money to attend a training program in this new “treatment!”

We all want to believe in something. People who challenge our beliefs are sometimes punished. In part, that’s probably why Socrates was put to death and forced to drink the poison hemlock–the people of ancient Greece did not want their cherished beliefs challenged.

Well, I’m no Socrates, and my thinking about TFT and EMDR may not be fair or accurate. It’s just my take on things, and I want to apologize ahead of time if I am way off-base. I’m just sharing my own thinking, for what it’s worth, but remember that I don’t know all the answers, and often my point of view is wrong.

Please let me know if I can post your interesting question, and my reply, on my website.

All the best,

David D. Burns, M.D.

Lisa’s Reply

Dr. Burns —

I’m happy to be part of your online discussion, and thank you for this thoughtful perspective – I appreciate it very much!

Didn’t Galileo face a similar problem as Socrates when he proposed that the Sun and not the Earth was the center of the world?  There is so much we don’t fully perceive and thus can’t understand, and so much associated fear.

I think it is important and interesting to collaborate broad-mindedly in figuring out what works, and in differentiating the genuinely effective intervention from its lucky-underwear surroundings.

These effectiveness questions are interesting and important, because isn’t the use of science-based exploration how CBT evolved into TEAM and how things improve generally?  I think so, and I am glad I asked you.

I come from a long line of people with depression and some bipolar as well, as well as apparently menopause-induced psychosis. That’s why I have always been interested in exploring what helps and what doesn’t and why.

Revolutionary to me was the idea that you are more than your thoughts, and that it is possible to change your frame of mind by working with the content of your thoughts. The shift from a negative to a positive orientation through thoughts and behaviors over which one has some control has been enormously helpful to me and makes so much sense.

So thank you!

And thank you for this response, and I will hope to attend one of your workshops in the future.

Kindest regards,

Lisa

Dr. David’s Second Response

You are so right. There were decades of suffering due to the Copernican revolution. And you are right that therapy methods can evolve rapidly, just as computer chips keep getting faster and better. Every week we develop new treatment and training techniques at my weekly training groups at Stanford and other locations around the SF Bay region.

Getting quantitative feedback from every patient at every session is tremendously helpful, both from a clinical and from a research perspective, because you can see what really works, and what does not.

I hope to meet you at an upcoming workshop!

All the best,

David Burns, MD

Why Do We Act in Such an Illogical Way?

Dear Dr. Burns,

My name is Sonja and I am a student of psychology in Mainz, Germany. Ironically, I got my first depressive episode in the middle of my studies. After reading “Feeling Good,” I just had the strong wish to let you know how awesome and amazing your book is!

It seems to me that it is not written only for people with depression or other mental illnesses, but it has a huge potential to enrich all kinds of human interactions. The methods you describe for fighting against the symptoms of depression seem so totally logical and comprehensible that I wonder why most people act in such an illogical way, even if they are more or less healthy.

I was never before so exited by a book and just wanted you to know that your work is appreciated🙂. I just wanted to tell someone, but didn’t expect that all of the people around me would understand my excitement.

With kind regards,

Sonja

Dr. David’s Response

Thank you Sonja! Your kind words are greatly appreciated. I agree with you that it is kind of a mystery why we human beings do this to ourselves—why do we beat up on ourselves so relentlessly with negative messages that are so distorted and unfair? Even though we don’t yet know the causes of depression and anxiety, it is great to have powerful, practical tools to help people break out of bad moods. And when a patient or reader has been helped, I feel the joy, too! Best of luck in your ongoing studies and career.

Please keep in touch! And if you ever visit the San Francisco Bay Area, please visit my training group that meets at Stanford Tuesday evenings. And thank you for giving permission to publish your wonderful note on my new website!

David Burns, MD

Can You Treat Habits and Addictions Without a Support Group?

Dear Dr. Burns,

Do you believe that addictions can be healed without a support group? And if so, why is there no book by Dr. Burns specifically on addiction recovery?

Ploni

Dr. David’s Response

Hi Ploni,

Thanks for your question. I have a new workshop on addictions and habits for next year, so I have been thinking about this topic. Also, some of my students and colleagues in my weekly training group at Stanford treat habits and addictions, including eating disorders, drug and alcohol abuse, and so forth. So we spend quite a bit of time developing new treatment techniques.

I think that support groups, like AA or Smart Recovery, can be helpful for many people with addictions, and support groups like Recovery International (formerly Recovery, Inc) can be helpful to people with mood or relationship problems. However, some people can conquer habits and addictions without a support group. Partly, it depends on the severity of the problem and the motivation of the individual.

Many people believe that people overeat or use drugs or alcohol to self-medicate their own depression, loneliness, or low self-esteem. While this may be partially true in some cases, I believe that habits and addictions are primarily motivational problems, and not emotional problems. My recent research on approximately 160 patients admitted to the Stanford Hospital’s psychiatric inpatient unit did not seem to support the notion that depression and anxiety trigger addictions. In fact, individuals who were depressed actually tended to binge less, on average, than individuals who were not depressed. I have not published this finding, as the main focus of the research was different–but the negative correlation between overeating and depression was consistent with conventional psychiatric thinking that a loss of appetite can be a symptom of depression and low self-esteem.

In addition, I could not validate the idea that depression and low self-esteem have a causal effect on alcohol or drug abuse, either. But a brief assessment test I developed called the “Urges to Use Scale” was massively correlated with drug and alcohol use. This seems to indicate that positive, seductive temptations are the driving force behind most, if not all, addictions.

In other words, my findings suggested that people drink or overeat or use drugs primarily because it feels darn good to overeat or get high.  So why do we overeat? I believe that we overeat because of the abundance of good food in our society, and because eating is immediately reinforcing. Of course, alcohol and drugs are also widely available in our culture, and TV ads provide powerful temptations to drink.

While distortions are involved in addictions, they are mainly positive distortions, such as “Oh, that beer would taste SO GOOD!” Or “I deserve some dark chocolate right now. I’ve had such a hard day.” I have created a list of ten positive distortions that correspond to the ten negative distortions in my books, such as Feeling Good. They positive distortions are mirror images of the negative distortions, and I will post them soon on my website.

Of course, negative distortions also play a role in addictions, along with positive distortions. After giving in to the temptation to drink or overeat, we may scold ourselves with negative distortions: “I SHOULDN’T have eaten that chocolate. I’m just a fat pig. I’ll NEVER lose weight!” These thoughts can trigger feelings of shame and hopelessness, which can trigger more addictive behavior, such as overeating or compulsive drinking.

Unlike negative distortions, positive distortions create immediate positive consequences if you give in to them. That’s why habits and addictions can be challenging to treat, and why motivational techniques are of tremendous importance. Traditional cognitive therapy techniques can be helpful for the negative distortions, but new and different kinds of techniques are needed to combat the positive distortions, such as Paradoxical Agenda Setting, the Decision-Making Form, and the Devil’s Advocate Technique, to name just a few. Of course, Empathy and respect for the patient are also extremely important.

All the best,

David D. Burns, M.D.

How Can I Find a Good Therapist?

Dear Dr. Burns —

You seem to be a very involved, structured and positive therapist. It has been difficult to find a therapist that fits this description. I’ve seen a couple of “cognitive therapists” but it only ended up being traditional talk therapy. No one has been able to be consistent with the three-column technique or other strategies.

I am very knowledgeable about your strategies but I easily lose focus and get confused. I need guidance and consistency. What do you recommend therapy wise? How or where do I find a competent therapist?

Dear friend,

This is one of the most common questions I get at this site. Many people want to know how and where to find a good cognitive therapist, or a good therapist in general.

First, you can look on my website referral page. This will show you how to find cognitive therapists in various regions. This is a good place to start. You can also search for “cognitive therapy referral” on Google.

My colleagues and I in California have developed a new form of therapy, called T.E.A.M. Therapy, that can be surprisingly effective and fast-acting for many individuals who are struggling with depression and anxiety. T.E.A.M. addresses some of the limitations of cognitive therapy, especially in the areas of therapeutic resistance and motivation.

You can go to the website, FeelingGoodInstitute.com, to find therapists trained in the latest T.E.A.M. therapy techniques. We hope to be able to list more therapists trained in the new techniques in more locations in the United States, Canada and Europe over the next year or two. Unfortunately, at the moment most of our therapists are here in the San Francisco Bay Area. To overcome this problem, in the past some people have arranged to come here for several days of intensive, back-to-back sessions. The goal is to make a therapeutic breakthrough, and then follow up on that with a local therapist if needed after returning home. This option can be somewhat costly, and is not a good choice for everyone, but for some people it could be very helpful, or even life-changing.

What are your other options? You can call the local psychological, psychiatric or clinical social work associations in your region to ask for help. You can also call the corresponding departments at any local universities to ask. Finally, you will find several centers for cognitive therapy listed on my referral page. You can email or phone them and ask for help. They may know of someone in your region they can recommend.

My books can help you learn these methods as well, although they are not intended as a substitute for therapy with a mental health professional. There have been many published outcome studies on my book Feeling Good: The New Mood Therapy. Researchers have reported that two-thirds of the depressed people who were given the book improved or recovered within four weeks with no other treatment. That’s very exciting, but of course, the book is not a panacea, and many people will also need the help of a compassionate therapist.

Here’s a reference to one of their many research studies supporting the use of my books.

Smith, N. M., Floyd, M. R., Jamison, C., and Scogin, F. (1997). Three-year follow-up of bibliotherapy for depression. Journal of Consulting and Clinical Psychology, 65(2), 324-327.

Of course, you can view a list of all my books, with brief descriptions, on the Books page.

The Ten Days to Self-Esteem is a systematic, ten-step program for learning cognitive therapy individually or in groups. This book presents a brief and a somewhat simplified version of cognitive therapy. A group leader’s manual is also available as an eBook.

I wish I could do more. I have been frustrated by how hard it can be to find a therapist who adheres to these methods in the way they are intended to be administered.

Finally, if you are struggling with depression or anxiety, I would like to emphasize the importance of the written Daily Mood Log, which is a five-step process you do on paper, not in your head. When you write down your negative thoughts you can more easily attack them, one by one. You can learn about the Daily Mood Log in any of my books, such as The Feeling Good Handbook. And if you are struggling with a relationship problem, such as a conflict with a family member, friend, or colleague, I w3ould encourage you to try the written exercises, such as the  Relationship Journal, which are described in a step-by-step manner in my latest book, Feeling Good Together.

All the best,
David Burns, MD

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