Structural Equation Modeling can sometimes help researchers sort out these kinds of “circular causality” questions. Consider Figure 1. In this model, there are four possible reasons why therapeutic empathy would be correlated with clinical improvement:

1. Therapeutic empathy might cause a reduction in depression. In this case, B3 would be negative and statistically significant.
2. Depression might have direct causal effects on the patient’s perception of therapeutic empathy. In this case, B2 would be negative and statistically significant.
3. Depression and therapeutic empathy might not be causally related, but might both be influenced by some unknown third variable. In this case, B2 and B3 would not be statistically significant, but B4 and B5 would be positive and statistically significant.
4. Depression and therapeutic empathy might both have simultaneous direct causal effects on each other. In other words, high therapist empathy might trigger clinical improvement, which triggers an increase in the patient’s perceptions of therapeutic empathy. In this case, B2 and B3 would both be statistically significant.

Technically, the model in Figure 1 is called a “non-recursive model” because of the presence of the circular loop linking depression with empathy (B2 and B3). In other words, Therapeutic Empathy might cause a reduction in depression (B2), but depression might also cause a simultaneous reduction in the patient’s perception of therapist’s empathy (B3).

I tested these four competing models, along with my co-author, Dr. Susan Nolen-Hoeksema, in the 1990s and published the results in the top psychology journal for clinical research (Burns & Nolen-Hoeksema, 1991, 1992). We showed, for the first time, why therapeutic empathy is correlated with recovery from depression. It’s primarily because of a direct causal effect of therapist empathy on recovery from depression. If the therapist is warm and understanding, the patient will tend to recover more rapidly.

We were also able to demonstrate that depression will not have much, if any, effect on how the patient rates the therapist’s warmth and understanding. This means that severely depressed patients will not tend to perceive therapist empathy in a more negative manner than patients who feel happy and completely free of depression.

That study indicated that empathy is important, even in a highly technical form of therapy such as CBT (Burns & Nolen-Hoeksema, 1991, 1992; Burns & Spangler, 1999; Persons, Burns, & Perloff, 1988). Our finding was confirmed by a recent meta-analysis of 59 independent samples involving more than 3,000 clients treated with a variety of therapeutic orientations (Elliott, Bohart, Watson, & Greenberg, 2011). However, the size of the causal effect of empathy on depression was only modest, since empathy could only account for about a 30% reduction in depression, at most. Once that level of improvement has been achieved, nothing more can be gained from a warm and empathic relationship—other technical tools and skills will be necessary to facilitate additional improvement.

This research led to three immediate changes in the way my colleagues and I approached therapy. First, I changed clinic policies so that every patient would be required to rate his or her therapist’s empathy at the end of every session, using an Empathy Scale similar to the one I had used in the research studies. In addition, therapists were now required to review the ratings and process any feelings of dissatisfaction at the start of the subsequent session so that alliance problems could be dealt with immediately.

Second, I developed systematic empathy training techniques that all the clinic therapists practiced once a week so as to develop improved empathy skills, especially with patients who felt angry, mistrustful, or critical of their therapists. I also began including these exercises in workshops I was conducting for therapists throughout the United States and Canada.

Third, I encouraged therapists to check their egos “at the door,” both in training and in therapy sessions, since empathy failures were so common and since mastering the art of empathy is a lifelong process.

A = (Paradoxical) Agenda Setting

A therapist could measure symptoms at the start and end of every session and have superb empathy skills, but if the patient is not motivated to change, the depression, anxiety, marital conflict or addiction will persist. The Jesuit mystic, Anthony de Mello, said that we yearn for change, but cling to the familiar. Many of our patients have “one foot in the water and one foot on the shore.” On the one hand, they say they want help, but on the other hand, they dig in their heels and resist the therapist’s best efforts to help them. Treatment resistance is the cause of nearly all therapeutic failures. Unfortunately, very few therapists understand resistance and fewer yet know how to deal with resistance effectively.

In the 1970s and 1980s, there was a great deal of interest in coping skills. Research by Peter Lewinsohn at the University of Oregon indicated that simply encouraging depressed patients to engage in more productive and pleasurable activities could have significant mood-elevating effects.

To learn more about the effects of various coping skills on recovery from depression, I developed a scale called the Self-Help Inventory (SHI). The SHI listed 45 things that people typically do to cope with feelings of depression, such as going to a movie, talking to a friend, confronting a fear, or getting caught up on something on which you’ve been procrastinating. Patients were asked to rate each coping activity on three separate scales:

1. How often do you do this type of thing when you’re feeling depressed?

2. How helpful do you think it would be if you tried it?

3. How willing would you be to give this a try if suggested by a therapist or trusted friend?

The first scale was a Behavior Scale. People with high scores were the “super-copers” who actively battled negative moods, and people with low scores were more passive when depressed. There was a widespread belief among mental health professionals that “super-copers” would be ideal candidates for an active form of therapy like CBT, whereas the more passive patients would do well with a psychodynamic approach or other therapies that rely more on insight.

The second scale was a Cognitive Scale. People with high scores were optimistic about the effects of their own efforts to fight depression, and people with low scores were more pessimistic. We thought that people with high scores on this scale would also be ideal candidates for CBT, since they anticipated improvement would result from self-help activities. In addition, their optimism might trigger improvement, since the belief that something will help often reduces feelings of hopelessness and tends to work as a self-fulfilling prophecy. This is often called the “placebo effect.”

The third scale was a Willingness Scale. People with high scores were very willing to try a variety of coping behaviors to battle depression, and people with low scores were much more resistant and less willing to try to help themselves. I anticipated that individuals with high scores would be more willing to do psychotherapy homework during the treatment and would recover more rapidly than individuals with low scores.

In a cross-sectional pilot study of a group of depressed women, my colleagues and I reported that all three scales were significantly correlated with depression severity (Burns, Shaw, & Crocker, 1987). As expected, women who were more depressed indicated that they used fewer coping strategies, had more pessimistic expectations that the coping strategies would be helpful, and were substantially less willing to give them a try, even if suggested by a therapist or trusted friend.

Of course, correlations tell us little about causal relationships, and only causal relationships hold the key to valid understanding and therapeutic innovation. Therefore, I initiated a longitudinal study of several hundred patients seeking treatment at my clinic in Philadelphia so I could find out if any of the three coping scales actually played a role in the therapeutic process. In these studies, I administered the Self-Help Inventory along with two measures of depression (the Beck Depression Inventory and the depression subscale of the Hopkins Symptom Checklist-90) at the initial evaluation and tested the patients 12 weeks later, using the same scales.

Once again, all three scales on the SHI were significantly correlated with initial depression. Which scale or scales, if any, actually predicted changes in depression? Put your best guess here before you continue reading.

Did you make your best guess? No? You’re just reading? I thought so! Please ask yourself which group recovered more rapidly? Were they the super-copers, the true believers, or the patients who were willing to try? Or, perhaps they all recovered at about the same rate. What’s your hunch?

Answer

Keep in mind that if a scale predicts changes in depression, then one can fairly persuasively argue that the scale, or something that’s correlated with the scale, has causal effects on depression. Since scientists still do not know the cause, or causes, of depression, we’re after some pretty big fish.

The Behavioral Scale did not predict changes in depression. Contrary to expectations, patients who were “super-copers” did not recover more rapidly than patients who were more passive at the initial evaluation. This finding was not consistent with the idea that super-copers were better candidates for CBT or that more passive individuals would be poor candidates for CBT. Both groups recovered at exactly the same rate. This finding also suggests that the passive behavior and “do-nothingism” that we see in depressed patients may simply be a symptom, rather than a cause, of the depression.

The Cognitive Scale did not predict changes in depression either. People who had a strong belief that coping behaviors would help did not recover more rapidly than people who were very pessimistic at the initial evaluation. This finding was not consistent with the widely held belief that highly optimistic patients are the ones who recovery more quickly when treated with CBT. This finding suggests that the negative expectations of depressed patients are also likely to be symptoms, and not causes, of depression.

One of the things I like about research is that our most cherished beliefs can usually be shown to be false. If you’re open to where the science guides you, this can be enormously exciting. But if you have fixed beliefs about how things work, negative results can be deeply disturbing. How about the Willingness Scale (WS)? This scale did have causal effects on recovery from depression, and the magnitude of the effect was large. Patients who indicated that they were more willing to try a variety of coping activities recovered much more rapidly than patients with low scores on the WS at the initial evaluation.

In addition, the effect of the Willingness Scale on changes in depression appeared to be mediated by patients’ compliance with psychotherapy homework assignments. Patients with higher WS scores at the initial evaluation did more psychotherapy homework, which in turn led to changes in depression (Burns & Nolen-Hoeksema, 1991, 1992). This result is exciting because of the rather profound theoretical and practical implications about the etiology and treatment of depression.

Several years later, I replicated these findings in a second study with an entirely new group of patients, and published the findings in the same journal (Burns & Spangler, 2000). Subsequently, other investigators reported that scores on the Willingness Scale also predicted improvement in an outpatient self-help group for depression modeled after my book, Ten Days to Self-Esteem (Kazantzis, Deane, & Ronan, 2000).

The research with the WS echoed what I was observing clinically. Patients who were willing to work hard during sessions and between sessions usually recovered quickly. In contrast, patients who refused or forgot to do their homework between sessions recovered much more slowly, if at all, and many of them dropped out of therapy prematurely.

One of the shortcomings of the SHI was its extreme length—patients had to complete 135 ratings of coping behaviors. This limited the use of the SHI in real-world settings. Therefore, I modified the scale in several ways. First, I eliminated the Behavioral and Cognitive Scales since they did not predict improvement. I also reduced the length of the WS from 45 coping activities to just 10 and improved the response options. Now I had a scale that patients could easily complete and score in less than one minute—but would the new scale be reliable and valid?

To find out, I administered the brief Willingness Scale to two groups of consecutively admitted patients at the Stanford Hospital psychiatric inpatient unit (total N = 160) at the time of admission along with several scales to assess depression severity. The reliability of the brief scale was excellent: 90% or more in both cohorts of patients. We tested the patients again roughly one week later, prior to discharge from the hospital. Once again, patients with high scores on the WS at the time of admission improved substantially, but the patients with low scores on the WS improved very little, if at all.

This was surprising, since the treatment on the inpatient unit is heavily biological, with a primary focus on medications and electroconvulsive therapy. The findings indicate that the association between motivation and recovery from depression is not related to the treatment methodology. The findings also indicate that even in an inpatient setting, one of the major mechanisms of recovery may result from psychosocial, rather than biological, variables.

The WS is the first variable I am aware of that has been shown to have robust, consistent effects on recovery from depression in inpatient and outpatient samples, regardless of the treatment method that is employed. We are now using an even shorter, 5-item version of the WS clinically, since the scores can help clinicians quickly identify new patients who are likely to recover rapidly and those who are likely to resist and recover more slowly. We believe that the latter group will benefit from new interventions we have developed which are designed to boost patient motivation and reduce resistance.

Based on these studies, I radically changed the approach to treatment that I’d been using for years, and developed the Paradoxical Agenda Setting (PAS) techniques that are now at the heart of T.E.A.M. Therapy. The PAS methods are beyond the scope of this document, (see Burns, 2005, for more information), but the basic idea is to melt away the patient’s resistance prior to using any techniques to help patients with their depression, anxiety, relationship conflicts, or habits and addictions.

To facilitate this process, I developed the list of the eight most common patterns of therapeutic resistance, as along with many techniques to reverse each pattern. Certainly more research is needed, but from a clinical perspective, these PAS techniques appear to have revolutionized treatment and have produced high-speed recovery for many patients who had failed to make significant progress after years of more conventional therapy, including “Beckian” CBT.

My colleagues and I are convinced that failures of Agenda Setting represent the most common cause of therapeutic failure. We also believe that the vast majority of therapeutic failures can be quickly and dramatically reversed with the skillful and compassionate use of the PAS techniques I’ve developed.

M = Methods

Over the years, I’ve developed many techniques to help patients challenge and defeat the negative thoughts that trigger depression, hopelessness, and low self-esteem, as well as fears, phobias, anxiety, and feelings of panic. My treatment philosophy has always been to “fail as fast as you can,” since you can never predict what technique will work for what patient or problem.

Although the concept of “failing as fast as you can” might sound negative, it’s actually quite positive, because it rests on the assumption that there is a method that will help each patient. Therefore, the more methods you try, the sooner you will find the one that works. A trained T.E.A.M. therapist can easily try and fail with four, five, or even more techniques each session. Let’s assume that a patient with chronic and severe depression has the thought, “I’m defective at the core.” As long as he continues to believe that thought, he will feel worthless, hopeless, ashamed, inadequate and angry, to name just a few of the negative feelings that are typically triggered by that type of thought. The moment he stops believing that thought, he will immediately feel better. But that’s far easier said than done, because this thought is rooted in deeply-held beliefs about himself. And there’s no doubt that family members, friends, and therapists, have tried hard to convince him that he really is worthwhile—but these efforts have not been effective.

If we want to succeed where others have failed, we’ll have to use many powerful and innovative techniques that no one has used before. For example, we might try Identify the Distortions, the Individual Downward Arrow, the Pleasure Predicting Sheet, Examine the Evidence, the Paradoxical Double Standard, Externalization of Voices, Feared Fantasy, Acceptance Paradox, Paradoxical Cost-Benefit Analysis, and Semantic Method, to name just a few. Most of these techniques will not be effective, and he’ll still believe he’s “defective at the core.”

Let’s assume that the sixteenth technique works, and the patient suddenly stops believing that she or he is defective, and begins to feel a lot better. If you can fail four or five times each session, how long will it take before he recovers? The math is simple: dramatic improvement will probably occur within three or four sessions. But if you only have a small number of techniques in your therapeutic arsenal, and you resolutely continue to use them over and over, then the treatment may drag on for months or years without any tangible improvement.

What is the evidence, if any, that the therapy methods my colleagues and I have been developing are actually effective? This is not a trivial question. Some investigators have suggested that most forms of psychotherapy may only be effective because of non-specific factors, such as the therapeutic alliance, or placebo effects, as opposed to specific techniques that are unique to each school of therapy (Messer & Wamopld, 2002).

In 1985, I collaborated in a study with one of my former students, Dr. Jackie Persons, to see if we could find out how CBT actually works (Persons & Burns, 1985). We examined changes in mood during individual psychotherapy sessions in a group of patients from our clinical practices, and examined two variables of interest: 1) the patient’s rating of therapeutic empathy during the session; and 2) the reductions in the patient’s beliefs in his or her distorted negative thoughts during the session. Did either variable account for the improvement in mood, or the failure of the patient’s mood to improve, during sessions?

Together, empathy and the reduction in negative thoughts accounted for an almost unbelievable 85% of the variance in depression scores at the end of the session, when controlling for depression severity at the start of the session. In addition, the relationship variable (empathy) and the technical variable (reductions in the belief in the distorted negative thoughts) made additive and independent contributions to the improvements in depression severity. I believe this was the first demonstration that cognitive techniques actually work by changing negative thinking patterns with specific techniques, such as Externalization of Voices, but the study also highlighted the importance of trust, warmth, and understanding.

This is one of the main reasons that we measure symptoms at the start and end of every therapy session. We’re looking for large, obvious effects—dramatic reductions in symptoms within a single session—and not just placebo effects. So are we really able to achieve this, or are we fooling ourselves?

A complicating factor is that T.E.A.M. therapists emphasize the importance of psychotherapy homework as well as hard work in sessions, so during the week, patients practice and master the techniques that their therapists have introduced during therapy sessions. Although a number of studies have reported significant correlations between psychotherapy homework and recovery from depression, we are again left with the chicken vs. the egg problem. What comes first, willingness to do psychotherapy homework, or clinical improvement?

This problem is similar to the conceptual and statistical problem we encountered when evaluating the effects of therapeutic empathy on recovery. Here’s why. A loss of motivation is one of the classic symptoms of depression, so we might anticipate that more severely depressed individuals would be less likely to complete psychotherapy homework (HW) assignments between sessions. As patients improve, we would anticipate a boost in motivation should lead to an increase in HW compliance. If this were the case, the correlation between HW compliance and clinical improvement might result from a causal effect of depression on HW, and not vice versa. Then there would be no reason to assign psychotherapy HW, since it would not actually speed up the recovery process.

This, of course, is another problem of circular causality, since there are several possible causal pathways linking depression with HW compliance:

1. HW compliance might reduce depression severity and facilitate recovery, just as cognitive and behavioral therapists suggest.
2. Clinical improvement might lead to increases in HW compliance.
3. HW and clinical improvement might have no causal linkages, and might both result from some known or unknown third variable, such as motivation, with simultaneous causal effects on depression as well as HW compliance.
4. HW compliance and clinical improvement might be linked in a system of simultaneous circular causality.

One could use an experimental strategy to attack this problem, but since I’m a clinician in private practice, I can’t randomly assign my patients to HW vs. no HW groups. Instead, I used the same non-recursive structural equation modeling techniques I described earlier to examine the causal linkages between homework compliance and recovery from depression in several hundred patients treated at my clinic in Philadelphia during the first 12 weeks of therapy. Here’s what we found (Burns & Nolen-Hoeksema, 1991, 1992):

1. HW compliance and recovery from depression were significantly correlated, but the magnitude of the correlation was small. As expected, patients who did the most HW also reported the greatest reductions in depression.
2. The correlation between HW and changes in depression resulted from a direct causal effect of HW compliance on changes in depression.
3. The magnitude of this effect was large. In fact, nearly all the patients who consistently did HW recovered and nearly all the patients who refused to do HW failed to improve. Many of these patients deteriorated or dropped out of therapy prematurely.
4. Depression had a reciprocal causal effect on HW compliance, but the magnitude of this effect was so small as to be trivial. For the most part, severely depressed patients did as much HW as patients who were minimally depressed, or not at all depressed.
5. Psychotherapy HW compliance was associated with motivation, as measured by the Willingness Scale (WS) at the initial evaluation. In fact, much, if not all of the effect of the WS on recovery from depression was mediated by psychotherapy HW compliance.

Once the vital importance of psychotherapy HW became clear to me, I changed clinic policies in several respects. First, I developed a “Concept of Self-Help Memo” that we mailed to every prospective patient prior to the first therapy session. The memo describes the importance of HW and lists ten of the most common types of HW patients are asked to do, such as recording negative thoughts on the Daily Mood Log, scheduling more pleasurable and rewarding activities on the Pleasure Predicting Sheet, or recording a problematic interaction with a friend or family member on the Relationship Journal.

The memo also includes a “Self-Help Contract” patients must complete and sign, indicating whether they agree to do the HW, and if so, how many minutes per day, and how many days per week they are willing to do psychotherapy HW. The memo also includes a list of “25 GOOD Reasons NOT to do the Psychotherapy Homework.” This list includes all of the most compelling excuses patients have given over the years for not doing the HW—such as feeling hopeless, overwhelmed, angry, unmotivated, and so forth. Patients are asked to indicate which reasons most reflect their own feelings.

I trained the staff to negotiate HW compliance with each new patient, after reviewing the memo together, in a paradoxical manner. Essentially, we told individuals with mixed feelings about HW that they could not be accepted as patients at the clinic because our methods were not effective in the absence of the HW. However, we would be happy to provide a referral list to local clinicians who do not require psychotherapy HW if they would prefer a different type of treatment. We also told the patients that we did not want to get rid of them, and hoped they would decide to work with us, but if they did, they should know that the issue of psychotherapy HW was not negotiable.

We were initially concerned that we might lose many patients because of this method, but surprisingly, it seemed to have the opposite effect of boosting patients’ determination to work with us. Out of a group of 700 consecutive patients, fewer than ten declined treatment or requested referral outside of the clinic because of the HW requirement.

Bibliotherapy Research

“Bibliotherapy” (reading from a self-help book like Feeling Good between sessions) has always been an essential part of the therapy I’ve done, and is a formal component of the T.E.A.M. Treatment Model. However, the book the patient reads depends on the type of problem she or he is struggling with. Feeling Good focuses primarily on depression. The Feeling Good Handbook has a much broader range of topics, including depression, anxiety, and relationship problems. When Panic Attacks covers anxiety disorders, and Feeling Good Together brings the interpersonal model and methods to life. And, of course, there are many additional self-help books on the market that therapists routinely “prescribe” for patients. In the late 1980s, Dr. Forrest Scogin, a research psychologist at the University of Alabama, conducted a remarkable series of studies designed to answer two questions: 1. What’s the least expensive way to treat patients suffering from clinical depression? 2. Do self-help books actually help?

In his first study, Dr. Scogin and his colleagues randomly assigned 80 senior citizens seeking treatment for major depressive episodes at the University of Alabama to one of two groups. Patients in the both groups were told they would be placed on a four-week waiting list before beginning treatment. Patients in one group were given a self-help book (either my Feeling Good or Peter Lewinsohn’s Control Your Depression) and asked to read it while waiting for treatment. Patients in the second group were not given any book to read while waiting for treatment.

Every week a research assistant contacted the patients in both groups and administered a depression test to assess the severity of symptoms. At the end of the four weeks, the two groups were compared. Surprisingly, two-thirds of the patients who received a self-help book had improved substantially or recovered. In fact, these patients did not need any further treatment at the medical center. In contrast, there was little or no significant improvement in the patients who did not receive a book. To the best of my knowledge, this was the first scientific study to show that at least some self-help books can have antidepressant effects (Scogin, Hamblin, & Beutler, 1987).

In the next phase of the study, Dr. Scogin and his colleagues told the patients who had not received a book that they would have to wait four more weeks before beginning treatment, but he now gave them one of the two self-help books and asked them to read it while waiting. Once again, two-thirds of these patients also recovered, just like the patients in the first group who had received a self-help book at the beginning of the study. This study provided strong evidence that the rather strong beneficial effects of the “bibliotherapy” were probably not due to chance (Scogin, Hamblin, & Beutler, 1987).

The results suggested that self-help books actually had antidepressant effects comparable to the effects of individual psychotherapy or treatment with antidepressant medications, but the effects appeared more rapid, since most outcome studies of drugs or psychotherapy last 12 to 16 weeks, and not just four weeks. Given the tremendous pressure to cut health-care costs, these findings are of considerable interest, since a mass-market paperback book costs less than one day of antidepressant drug treatment,and is presumably free of troublesome side effects as well.

The researchers still could not be certain that either book had any specific antidepressant effects, since reading any book might have a comparable “placebo effect.” To evaluate this possibility, Dr. Scogin and his colleagues conducted a new study with a slightly different experimental design. Once again, they randomly assigned a group of depressed patients to one of two groups, and both groups were told they would have to wait four weeks before beginning treatment. However, the patients in one group were given my book, Feeling Good, and the patients in the other group were given a “placebo book” that was not expected to have any antidepressant effects. The book they received was Victor Frankl’s classic book entitled Man’s Search for Meaning. If the patients in both groups improved to a comparable degree, it would show that reading could be helpful if you are depressed, but it might not make any difference what you read.

The researchers reported that the patients who received Victor Frankl’s book did not improve significantly, but the patients who read Feeling Good did. This indicated that the improvement from Feeling Good was real and not just a “placebo effect” (Scogin, Jamison, & Gochneaut, 1989).

Finally, the researchers addressed another important concern: would the antidepressant effects last? Motivational speakers can get a crowd of people fired up and feeling optimistic for brief periods of time, but these brief mood-elevating effects may not last. The same problem holds for the treatment of depression with psychotherapy or medications. After a period of time, many patients who initially improved relapse back into depression. These relapses can be devastating and sometimes even more difficult to treat than the initial episodes because patients feel so demoralized and hopeless.

To find out if the effects of Feeling Good would last, Dr. Scogin and his colleagues conducted several follow-up studies. The initial follow-up study was for a two-year period (Floyd, Rohen, Shackelford, et al., 2006; Scogin, Jamison, & Davis, 1990), and the next follow-up study was for a three-year period (Smith, Floyd, Jamison, & Scogin, 1997). These studies revealed that the patients who initially improved after reading Feeling Good did not relapse, but continued to improve. Many indicated that when they were upset, they simply opened up Feeling Good and re-read the section that had been the most helpful initially. The researchers concluded that these self-administered “booster sessions” were important in maintaining a positive outlook following recovery. The public health implications are considerable, since these follow-up bibliotherapy booster sessions were free.

Since his pioneering studies, there have been additional studies of bibliotherapy in a variety of settings and for a variety of patient populations of all ages. Taken as a whole, the results indicate that bibliotherapy can be almost as good, if not better, than the results obtained with antidepressant medications or psychotherapy in controlled outcome studies (Ackerson, Scogin, Lyman, & Smith, 1998; Floyd, Scogin, McKendree-Smith, et al., 2004; Jamison & Scogin, 1995; Mains & Scogin, 2003; McKendree-Smith, Floyd, Scogin, 2003). These studies are somewhat surprising and very encouraging.

Because of this research, the use of self-help books to supplement therapy has become commonplace. Surveys indicate that most therapists now “prescribe” bibliotherapy for patients they are treating. I am very proud that surveys of North American mental health professionals indicate that Feeling Good is the most highly rated and commonly recommended book for patients struggling with depression (Santrock, Minnett & Campbell, 1994).

However, it is important to emphasize that no treatment, including bibliotherapy, is a panacea—some patients will respond and others will not. Once again, that’s a good reason not to fall in love with any one method of treatment, but rather to use a variety of approaches and techniques. In addition, my colleagues and I are not using bibliotherapy as a stand-alone treatment, but simply as one component of our T.E.A.M. Therapy model. Presumably, seeing a skillful and compassionate therapist while reading the book should be significantly more effective than simply reading the book on one’s own, but I am not aware of any research that has addressed this important question as of yet.

Final Comments

In the late-1980s, Dr. Jackie Persons and I published the first uncontrolled outcome study of CBT in private practice outpatient settings working with depressed patients with extensive Axis I and Axis II comorbidity, and compared the efficacy with controlled outcome studies of CBT with highly rarified, homogenous populations of patients with major depressive disorder and little or no comorbidity (Persons, Burns, & Perloff, 1988). This work shed a favorable light on the efficacy of CBT in private practice settings. Of course, the T.E.A.M. treatment model goes far beyond CBT. Those early studies also highlighted the importance of psychotherapy HW compliance as one crucial component of effective treatment.

In the early 1990s, Dr. Susan Nolen-Hoeksema and I published much more extensive psychotherapy outcome and process studies based on several hundred patients treated at my clinic in Philadelphia, and I’ve alluded to some of our findings on Empathy and psychotherapy HW earlier in this manuscript. But there were other interesting findings, including the fact that depressed patients with severe Borderline Personality Disorder (BPD) recovered almost as quickly as depressed patients without BPD (Burns & Nolen-Hoeksema, 1991; 1992).

Approximately 20% to 30% of our patients were diagnosed with BPD at the initial evaluation, usually in conjunction with many other diagnoses (Burns & Nolen-Hoeksema, 1991). In fact, the patients with BPD played a crucial role in the development of all four aspects of the T.E.A.M. model, including testing at each session, empathy, paradoxical agenda setting, and the use of many methods, rather than just a few, to help the more difficult and challenging patient.

References

Ackerson, J., Scogin, F., Lyman, R.D., & Smith, N. (1998). Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. Journal of Consulting and Clinical Psychology, 66, 685-690.

Antonuccio, D.O., Danton, W.G., & DeNelsky, G.Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26, 574 – 585.

Antonuccio, D.O., Burns, D., & Danton, W.G. (2002). Antidepressants: A triumph of marketing over science? Prevention and Treatment, 5, Article 25. Web link: http://journals.apa.org/prevention/volume5/toc-jul15-02.htm

Antonuccio, D.O., Danton, W.G., DeNelsky, G.Y., Greenberg, R., & Gordon, J.S. (1999). Raising questions about antidepressants. Psychotherapy and Psychosomatics, 68, 3-14.

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Burns, D. D., & Auerbach, A. (1996). Therapeutic Empathy in Cognitive-Behavioral Therapy: Does it Really Make a Difference? Chapter 7 in Frontiers of Cognitive Therapy (P. Salkovskis, ed.) New York: Guilford Press, pp. 135 – 164.

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Burns, D.D., & Spangler, D. (2000). Does psychotherapy homework lead to improvements in depression in cognitive behavioral therapy? Or does improvement lead to increased homework compliance? Journal of Consulting and Clinical Psychology, 68(1), 46 – 59.

Burns, D.D., Westra, H., & Trockel, M. (2011). Motivation and Changes in Depression in Two Inpatient Cohorts. Manuscript under review.

DeRubeis, R. J., Hollon, S. D. Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., O’Reardon, J. P., Lovett, M. L., Gladis, M. M., Brown, L. L., & Gallop, R. (2005). Cognitive Therapy vs. Medications in the Treatment of Moderate to Severe Depression. Archives of General Psychiatry, 62: 409-416. Web abstract:

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