047: Tools… not Schools of Therapy

Tools… not Schools of Therapy

Fabrice asks David about the title of his TEAM-CBT eBook for therapists—Tools, Not Schools, of Therapy. David explains that the field of psychotherapy is dominated by numerous schools of therapy that compete like religions, or even cults, each claiming to have the answer to emotional suffering. So you’ve got the psychodynamic school, and the psychoanalytic school, the Adlerian school, the Beckian cognitive therapy school, the Jungian school, and tons more, including EMDR, behavior therapy, humanistic therapy, ACT, TMT, EMT, and so forth. Wikipedia lists more than 50 major schools of psychotherapy, but there are way more than that, as new schools emerge almost on a weekly basis.

David describes several conversations with the late Dr. Albert Ellis, who argued that most schools of therapy were started by narcissistic and emotionally disturbed individuals. Ellis claimed that most were self-promoting, dishonest individuals who claimed to know the true “causes” of emotional distress and insisted they had the “best” treatment methods. And yet, research almost never supports these claims.

David, who is a medical doctor, points out that we don’t have competing schools of medicine. Can you imagine what it would be like if we did? Let’s say you broke your leg, and went to a doctor who prescribes penicillin. You ask why he’s prescribing penicillin for a broken leg, and he explains that he’s a member of the penicillin school. He says he always prescribes penicillin—it’s good for whatever ails you!

That would be like an Alice in Wonderland world. And yet, that’s precisely how psychiatry and psychotherapy are currently set up. If you’re depressed and you go to a psychiatrist, you’ll be treated with pills. If you go to a psychoanalytic therapist, you’ll get psychoanalysis. Or if you go to a practitioner of EMDR, TFT, or Rational Emotive Therapy (RET), you’ll get EMDR, TFT, or RET. David argues that this just doesn’t make sense.

David argues that the fields needs to move from competing schools of therapy to a new, science-based, data-driven psychotherapy. He emphasizes that we’ve learned a lot from most of the schools of therapy, and that many have provided us with valuable insights about human nature as well as some useful treatment techniques. But now it’s time to move on, leaving all the schools of therapy behind. David acknowledges that this message may seem harsh or upsetting to some listeners, and apologizes for that ahead of time.

David and Fabrice also discuss the spiritual basis of effective psychotherapy, and David describes the reaction of his father, a Lutheran minister, on the day that David was born, as well as a tip his mother gave him when he was in third grade.

In the next Feeling Good Podcast, David and Fabrice will describe Relapse Prevention Training, since the likelihood of relapse after successful treatment is 100%. But if the patient knows what to do, the relapse doesn’t have to be a problem.


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

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

Hi Dr. Burns,

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

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

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


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

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

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

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

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




Hi Dear David Burns,

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

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

Sedef (from Turkey)

Hi Sedef,

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

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

All the best,

David Uncle

Is Love an Adult Human Need?

Is Love an Adult Human Need?

Hi Dr. Burns,

Hope you have time for another question. Maybe you can post this on your site.

In your Intimate Connections book you say that many people believe that they need a romantic partner to be happy (which you think is a false belief). Doesn’t this imply that people are either happy or unhappy, which is, or course, all or nothing thinking? Doesn’t happiness exist on a spectrum, from say 1 to 10?

Shouldn’t the question be, “Do people need a romantic relationship to achieve a certain level of happiness?”

To achieve a happiness level of 10, do people need a partner? If they could achieve a 10 without one, why would they bother attempting to then obtain one. Why bother trying to find a girlfriend if you’re not going to be any happier? How happy can one be without one?

Shouldn’t you change your statement to: people assume they can only achieve a happiness level of about a 2 without a partner when in actuality they can achieve a level of about a 7?

What are your thoughts?


Hi Richard,

Happiness, like all emotions, exists on a continuum, and you could measure it on a scale of 0 to 100, for example. So sometimes we are not happy at all, and other times we may be extraordinarily happy. The same is true of sadness, anxiety, anger, discouragement, shame, and so forth. Emotions do not exist in an All-or-Nothing way.

Our culture definitely teaches us that we need love to feel happy and fulfilled. In one of her famous songs, Barbara Streisand’s sings that “people who need people are the luckiest people in the world!” So most people naturally assume that we “need” love to feel a high level of happiness and fulfillment.

When I first heard Dr. Aaron Beck assert that love is not an adult human need in one of the weekly seminars I was attending during my research fellowship at the Penn Medical School, I had the thought, “My gosh, he must be a sociopath to say such a thing!”

But I decided to test what he was saying, spending more and more time alone, just to see what would happen. I did it as a series of experiments, using my Pleasure Predicting Sheet. It consists of several columns, and in the first column you schedule a variety of activities with the potential for pleasure, satisfaction, learning, personal growth, and so forth. In the second column, you record who you plan to do each activity with. Make sure you schedule some activities that you will do on your own, as well as activities you will do with others. In the third column, you predict how satisfying or enjoyable each activity will be, from 0 to 100.

Now you are ready for your experiment. Go ahead and do each activity, and after you’re done, write down how satisfying it turned out to be, between 0 and 100, in the fourth column.

When I did this, I was shocked to discover that I could be maximally happy when doing things by myself. This was a revelation to me, and at first it was hard to accept. These experiences definitely changed my thinking. But the conclusion was absolutely consistent with the basic premise of cognitive therapy, that our thoughts, and not external events, create all of our feelings, positive and negative. I have treated large numbers of people who were extremely depressed, even suicidal, who were very loved; but their minds were loaded with negative and distorted thoughts about themselves and their lives.

I am only touching on this topic in a superficial way here. You can read more about this notion in the first section of Intimate Connections, which is all about learning that you can be happy when you are alone. You can also read more about this in the chapter on “The Love Addiction” in my first book, Feeling Good: The New Mood Therapy. And you might want to watch the reality TV show, “Alone,” which just completed its third season. It’s all about being stranded in the wilderness alone for prolonged periods of time, to see how long you can survive. The winner receives $500,000.

The topic is extremely controversial, like so many topics in mental health / psychology. And everyone is pretty sure they are an expert who knows “the truth.” So the post might fire up some controversy.

At any rate, you asked why anyone would want to have a boyfriend or girlfriend, or friends at all, if you can be completely happy when you are alone. Well, there is a difference between “needing” something and “wanting” something. For example, I might want a fancy new sports car, but I don’t “need” one to be completely happy.

From a practical point of view, I have treated large numbers of single men and women who were having a terrible time in the dating world, and usually they were telling themselves that they “needed” love to feel happy. This made them come across as “needy,” and their neediness forced people to reject them. That’s because of the “Burns Rule,” which states that “people only want what they can’t get, and never want what they can get.” So if you need someone, you become what they can get, and they won’t want you.

So I always encouraged these single individuals to overcome their fears of being alone before I would teach them how to get people chasing after them. And this was nearly always effective. Once they no longer “needed” people, but had learned how to love themselves first, then they were far more successful in the dating world.

So that’s why all the chapters on flirting and such in Intimate Connections follow the initial section on learning to be happy when you’re lone.

Personally, I love to be alone! And many of the happiest moments in my life where moments when I was lone.

And I also love to hang out with others, and I love to give and receive love from those I’m close to as well. And that includes my family, students, friends, and even, or especially, our beloved cats!

Well, there my answer, Richard, but I’m sure we’ll get a ton of comments from folks who, like yourself, are hooked on the idea that we “need” love to feel maximally happy! I have created dozens of techniques to help folks overcome the fear of being alone, but that is perhaps for another day.

Oh, one last thing. If you have a firm belief that you cannot be happy when you are alone, it may function as a self-fulfilling prophecy. For example, I once treated a woman who’d been rejected by her husband, who was having an affair with his secretary. She told me she had proof she couldn’t be happy when she was alone, because she was alone and constantly miserable, for example when eating dinner.

I asked her what she had for dinner the night before. She said she sat in a chair facing the wall and ate a peanut butter sandwich.

I said, “Well, maybe that’s why you were feelings miserable. What would you have for dinner if you had invited your favorite person in the world for dinner? For example, some celebrity you intensely admire?”

She said she’s buy the best food at the grocery store and prepare a gourmet meal, with candles, music, etc. I suggested she might try doing that for herself, as an experiment, using the Pleasure Predicting Sheet. She predicted that shopping, cooking, eating would be 0% to 5%, a scale from 0% to 100%, because she’d be alone.

She also had a luncheon scheduled with her husband later in the week, and had predicted it would be 95%, since she wouldn’t be alone. She fantasized they’d talk about getting back together.

But she was shocked by the results of her experiments. Shopping and cooking a gourmet meal for herself were 95% satisfying. And then she sat down with herself, with music and candles, and ate the dinner, and it was 100%. She said she got so high—no drugs or alcohol, mind you—that she took herself out dancing (in the living room), and just loved being with herself. This blew her mind.

The luncheon with her husband was also mind-bending. He spent the entire lunch talking about what a wonderful lover his secretary was, and how they’d divide up their belongings for the divorce. And of course, he was an attorney, and his suggestions involved pretty much everything for him and nothing for her.

In the Outcome column of her Pleasure Predicting Sheet she recorded 0%. The data were simply not consistent with her belief that she “needed” her husband’s love to feel happy and fulfilled.

Then she asked me what she should do next. I told her that now that she no longer “needed” love, it would be pretty easy for her to do some flirting with attractive men she met, and I told her that as soon as she found someone she really liked, and she no longer even wanted her husband back, I promised her that her husband would then come crawling back to her.

And that’s exactly what happened. She met a handsome hunk of a guy who was also recently divorced, and they fell madly in love. That very day her Ex called and said he’d changed his mind, and begged for her to accept him back. But she didn’t. She told him she was far happier without him, and wanted the divorce to be accelerate.

Her husband called me in a rage. He’d referred his wife to me initially, because he was afraid she was suicidal, and he’d asked me take care of her. He shouted in the phone, “I told you to take care of her!”

I replied, “I did, I did!”

If you’re interested, you can read more about the story in Feeling Good. She was one of the first people I treated with cognitive therapy, way back in the early days! But I’ll never forget!



Hi Dr. Burns,

Thanks for your response. Here is mine.

You keep drawing a distinction between needing and wanting.

I don’t see the importance of that. You say you don’t need a sport car to be completely happy, but you may still want one. If you could be completely happy without one, why would you want one?

Also, in order to be completely happy (long-term, not just for a few seconds) what does one need? Do you agree with many psychologists that to live the happiest life you need four basic things:

1. enjoyable work

2. good friends

3. good hobbies

4. good romantic relationship


Thanks, Richard!

Excellent response! Can I post your response, and my email on my website, as part of the post, with or without your name? Beyond this exchange, that would be the end of the posting of exchanges, however, as it gets too long, perhaps.

Personally, my answer to your excellent question is no, but that’s just my take on it, and not some absolute truth. I don’t see these as “needs.” But you can set it up like that if you want, and think of these things like enjoyable work, hobbies, love, and friends as basic human “needs,” and this might not be a problem for you. As a “shrink,” I don’t try to teach people about some “right” or “wrong” way to believe or think about things. I simply try to help individuals with problems they are having.

Lots of people do not have enjoyable work, and yet they are quite happy. They see their work as a way to earn money, and they do things that are more interesting to them when they are not at work. There is no rule that says everyone “must” find enjoyable work.

When I was in college, I did construction labor in Phoenix for two summers. It was pretty demanding work, with pick and shovel, and also lots of sweeping with a big broom, and it was hot that summer, with little no shade on the construction sites. The temperature in the shade was usually 105 degrees, and the temperature in the sun where we were working was typically 135 degrees. One of the laborers I worked with was named Carmen, and he was constantly telling me I did not use the shovel or broom correctly, and he would show me better ways to dig or sweep.

I would not say that the work was “enjoyable,” but I was very grateful to have a job and the chance to earn some money. The hourly wage, due to the union, was $3.10 per hour (Local 383 of the AFL), which seemed like a fortune to me, since we did not have much money. Another summer I had a job filing checks in a bank, which was boring, but tolerable, but definitely not “enjoyable.” I did try to make it interesting, however. For example, I tried to learn about the lives of the other construction laborers I worked with, since in my upbringing I did not have the chance to meet lots of people who were doing construction labor for a living. I felt a bit intimidated, but they were all really kind to me, and I worked as hard as I could.

Many people, and perhaps most, do not have jobs that are especially enjoyable. Now, if they tell themselves, “Oh, an enjoyable job is a ‘need,’” then they might feel unhappy and pressure themselves a great deal, thinking they have somehow fallen short of some basic human need.” If they wanted help with their negative feelings, and only if they wanted help, we could use a great many of the TEAM-CBT skills to help them, and this would likely be a really easy problem to solve. But if they were not asking for help, then I would simply “Sit with Open Hands,” since I have no special expertise in what people in general “should” or “shouldn’t” think or believe. My task is to help individuals who are struggling with depression, anxiety disorders, relationship problems, or habit and addictions, assuming they want help.

The most fundamental error in psychotherapy, in my opinion, is trying to help someone who is not asking for help, as this nearly always triggers resistance and a kind of log jam between the patient and therapist may develop. Of course, if someone is ambivalent, and wants to dialogue about that, it can be very productive, and there are tons of TEAM-CBT tools we could use—Empathy, Paradoxical Agenda Setting, and Methods. For example, we could do a Cost-Benefit Analysis (CBA) and balance the Advantages against the Disadvantages of viewing an enjoyable job as a “need.” Then we could balance the advantages against the disadvantages on a hundred point scale. For example, is it 50-50? 60-40? 35-65?

Then we could do a second CBA, balancing the advantages against the disadvantages of thinking of an enjoyable job as a “want,” and balance the advantages against the disadvantages on a hundred point scale.

The way you use language is a personal decision. It is not so much the idea that one approach is inherently more “correct.”

Similarly, when you goof up at something, the way your think and use language will impact your feelings. For example, you can beat up on your “self,” telling yourself “I am a bad teacher,” or a “failure as a father,” or some such thing. These kinds of thoughts contain multiple cognitive distortions, such as All-or-Nothing Thinking, Overgeneralization, Labeling, Self-Blame, Emotional Reasoning, Mental Filtering, and Discounting the Positive, and they are hidden Should Statements as well. These distortions will probably trigger feelings of depression, shame, anxiety, inadequacy, loneliness, and hopelessness, because the negative thoughts sound so absolute and permanent.

Or instead, you can focus on the specific error you made as a teacher, or as a father, or whatever, and make a plan to correct it. These two approaches are a matter of personal choice, but they can have massive implications in terms of how we feel.

The idea that our thoughts create our feelings is also a spiritual notion, embedded in Buddhism and nearly all religious traditions. Buddha emphasized the importance of focusing on specifics, rather than thinking about our errors and shortcomings in global terms. He was one of the first to teach that our thoughts, and not our external circumstance or the events in our lives, cause all of our feelings, positive and negative. We are creating our own emotional reality at every moment of every day. This notion is some basic, obvious, and fundamental, that many people simply cannot “see” it, or grasp it. Understanding this notion is one form of enlightenment.

Many people with enjoyable work, good friends, wonderful hobbies, and great romantic relationships are depressed and suicidal—I have treated many of them in my career—and many people who lack these things are very happy. But again, it is a matter of choice how you want to think about your life. If you ruminate about things you don’t have, and you tell yourself that these are “needs,” how will you feel?

I go on Sunday hikes with members of my training groups at Stanford. The hikes are not a basic human “need.” I spent most of my life not going on Sunday hikes. So if the hikes are not a “need,” why do I go on them? That is the type of question you are asking. I go on the Sunday hikes because they are a lot of fun. It gives me the chance to do personal work with students and colleagues, and to get to know people on a deeper level. In addition, it is a nice way to get some exercise.

To me, wants and needs are very different. Why do we do anything? For me, I do things because I am alive, and grateful that life offers so many opportunities and experiences. We have a new kitten—sadly, my beloved Obie disappeared two months ago. He was my best friend and likely killed by a predator in the middle of the night, in the woods behind our house. I will grieve his loss for a long time. I still shout out his name when I am out jogging, thinking he might hear me and suddenly appear, even though I know he is gone. A neighbor kindly gifted my wife and me an adorable kitten they found abandoned by the side of Moody Road, near a trail I hike on. She was three weeks old and it was a rain storm. They took her home and gave her a loving home for several months. But they traveled a lot, and did not like to leave her alone, so they gave us this beloved kitten, Miss Misty, who is now 4 ½ months old. And what a joy she is! So cute and full of life, and love. But I do not think of Miss Misty as a “need,” but rather as a gift, or as a little miracle of sorts.

Dr. Beck once told an interesting story in our weekly training group when I was first learning cognitive therapy. He said he and his wife went to a night club to hear some jazz performance, and the man sitting alone at the table next to them seemed like he was having an extraordinarily good time, even though he was alone, Dr. Beck asked the man why he was so happy. The fellow said he was incredibly happy because he’d just gotten an extremely important promotion at work. Dr. Beck asked him what work he did, and what promotion he’d received. The man said he’d been working in a local bakery for 25 years, and he had the job of making the donuts in the kitchen in the back area of the bakery. But he said that earlier in the day, the manager said that he could actually arrange the donuts in the display area, and gave him a 10% raise, and thanked him for the excellent work he’d been doing for so many years. The man was beside himself with happiness! Dr. Beck talked to him a bit more and learned that the man was living alone and could not read or write, and had not graduated from fifth grade.

I guess the point Dr. Beck was making is that our thoughts, and not the facts of our lives, create our feelings. You can be miserable in the midst of abundance—like many of the depressed individuals I treated—or joyous in the midst of very little. It all depends on how you think about things.

Still, none of this is meant as persuasion, just examples to illustrate my own very different way of thinking about wants vs, needs. In my opinion, we “need” oxygen, food, and water to survive. The new reality TV show, “Alone,” illustrates this very well! But I do not believe that we “need” enjoyable work, love, hobbies, or friends, although all of these can be sources of pleasure and joy.

But that’s just my way of looking at things. Ultimately, we are all free to think about things in whatever way we want. And lots of therapists do like to emphasize the “needs” we have as human beings. And I would say this line of thinking is “politically correct,” too. Your point of view, Richard, is quite popular, and if it is working for you, then there is no real need to change!


Hi Dr. Burns,

Yes you can use my first name if you publish our emails. We could go on forever so i will respond briefly.

As far as four things people need for happiness, maybe we could add a fifth which would be good health (depression being bad health).

Also, there are people who are happy who have bad jobs but are they really a 10 on the happiness scale or more like an 8?

Thanks for your thorough response.


Hi Richard,

You are most welcome! And thanks for the good dialogue which will likely interest a few people. However, this blog may make some people mad (at me, not you), since my thinking is somewhat politically incorrect.

But once again, my answer is no. Good health is wonderful, but not a requirement for happiness, and certainly not a guarantee for happiness, either.

In addition, my hunch is that there is no “cap” on happiness one way or the other. I have had many patients test this theory with the Pleasure Predicting Sheet that I described earlier in the blog. An experiment can be a nice way to check these beliefs out, sometimes.

I’ve treated or known many people with severe illnesses who were tremendously happy and content with their lives. And I’ve treated many, of course, who were in great health, but miserably unhappy.

I had a pretty severe problem with my right hand years ago (reflex sympathetic dystrophy), and had to do hand exercises 18 hours a day for 6 months to get my hand back to normal, or close to normal. I also had to go for hand therapy several times a week in a gym designed for people with serious hand injuries.

I was always amazed at the cheerfulness and friendliness of many patients in that gym who had the most grotesque and horrible hand injuries you can imagine. One was a woman with extremely advanced arthritis in both hands, and her profession was restoring rare paintings. She could barely move her fingers! And I can remember a professional skier whose hand had been crushed by a truck, and it was as flat as a pancake, making it nearly impossible to hold onto those things that skiers hold while skiing. But they weren’t complaining, and had the most positive outlook on life.

And I can remember an African America high school student who was doing some kind of exercise on one of the hand machines next to me, so I struck up a conversation and asked him what he planned to do with his life when he finished his schooling. He said he was hoping to become a professional basketball player. Then I asked him about his hand injury—what had happened?

He explained that he was injured when using a saw in his shop class at his high school, and that both of his hands had been cut off. He explained that they tossed his hands into a bucket of ice water and rushed him to the University of Pennsylvania Hospital Emergency room, and that Dr. Osterman (who was also my doctor) had sewn his hands back on. And he told me he wasn’t giving up on his dream!

But there were usually one or two patients in the hand gym who were miserable complainers, nasty, demanding, and hard to be around—and usually their hand injuries were mild. So once again, it is our thoughts, and not the external circumstances, that create our emotions, positive and negative. But that’s just my mind-set, and others will have different ideas for sure!

I remember diagnosing terminal lung cancer in a woman I treated in our hospital in Philadelphia before I moved back to California years ago. I had been making rounds with the residents to prepare for my medical board examination when we moved to California, since I had let me medical license in that state run out and was pretty rusty on my memory of medicine.

The woman was very cheerful, and the residents who I made rounds with kept telling me that she “should” be more upset, as if her reaction to her diagnosis was somehow wrong, or involved denial, or some such thinking. But she told me that she was a deeply religious woman, and that she was extremely grateful that she’d had a good life, with two daughters who she loved and who loved her a great deal. She told me that she had nothing to worry about, and nothing to be upset about, because if it was God’s time to take her home to heaven, then she was ready to make the trip!


David’s Ted Talk

Hi Web visitors,

I was thrilled to get this unexpected and wonderful email today:

Hi Dr. Burns,

I just published this post on The Huffington Post entitled The Best Ted Talk I’ve Ever Seen, on your Tedx Talk in Reno. It was amazing. To view my post, CLICK HERE.

James E Porter

I am very appreciative, James! Thanks so much!


Answers to Questions from a Psychology Today Blogger

* ©2008 by David D. Burns, MD

Do not copy, publish or reproduce without the written permission of Dr. Burns.

Hi everyone. The following are some questions I answered for a Psychology Today blogger about psychotherapy. I had a lot of fun answering these questions, and I hope you enjoy reading my answers. Let me know what you think!

(Soon I will continue with my series on Secrets of Self-Esteem.)

How would you respond to a new client who asks: “What should I talk about?”

The goal of therapy is not to talk about things, but to change the person’s life, and to relieve suffering, such as depression, anxiety, relationship problems, or habits and addictions. Of course, empathy and skillful listening are important at the start of each session, but they are simply not sufficient to change the patient’s life. You can talk until you’re blue in the face, and therapist can nod and mutter, “Tell me more,” but you’ll still be suffering from PTSD, or OCD, or depression, or lousy relationships with other people, or whatever your problem is.

After a period of empathy and listening, I always ask a question along these lines: “I would like to offer you something more than just support and listening, although that’s obviously of great importance. I’m wonder if there’s something you want help with in today’s session? You’ve mentioned a lot of heartbreaking issues today—your brother’s heroin addiction and suicide, they way your ex-wife has been abusing you, your problems with your son, and your social anxiety. I have many powerful tools to help you deal with these problems, and I’m wondering if this would be a good time for us to roll up our sleeves and get to work. Or, if you need more time to talk and vent, that’s okay too. I don’t want to jump in prematurely, before you’re ready.”

This gives the patient three messages: 1. I’m aware that you’re suffering. I’m concerned, and I’m here to support you. 2. I have much more to offer you than just listening, and more will be necessary if you really want to change your life. 3. Change is possible if we work together as a team.

Once the patient has described the problem, I conceptualize the nature of the problem and explore the likely reasons for resisting change in a kindly way, so as to reverse resistance, using paradoxical techniques. I also begin to think about the techniques that will be most likely to help the patient. I use approximately 50 techniques, such as the Interpersonal Downward Arrow, the Paradoxical Cost-Benefit Analysis, the Daily Mood Log, the Externalization of Voices, the Acceptance Paradox, and more. Some techniques are exceptionally powerful for depression; some work well for the anxiety disorders; some are helpful for relationship problems; and some are great for habits and addictions. There’s no one panacea that works for everything.

What do clients find most difficult about the therapeutic process?

There is no standard “therapeutic process,” since there are so many different schools of therapy. I tend to think in terms of “Outcome Resistance” and “Process Resistance.” Here’s how to think about Outcome Resistance. Imagine that there’s were a magic button on this desk, and if you push it, all of your symptoms (such as depression, or panic attacks, a troubled marriage, or a bad habit or addiction) will instantly disappear, with no effort, and you’ll go out of today’s session in a state of euphoria. Will you push that button?

As it turns out, many people will NOT push the button, or would be highly ambivalent about it. For each person, the reasons will be different, but they are generally overpowering. Furthermore, Outcome Resistance is radically different for each of the four common targets: depression, anxiety, a relationship conflict, or habits and addictions). So there are four common, but distinct, types of Outcome Resistance.

Here’s a brief example of Outcome Resistance for depression. A 37 year-old Catholic woman from San Francisco came to me for treatment after ten years of intractable, severe depression following an abortion. She’d had psychotherapy from numerous therapists and a multitude of antidepressants, but nothing had helped. The thought that was creating her intense pain and self-loathing was: “I deserve to suffer forever because I murdered my baby.”

Will she press the Magic Button? Obviously not, and there are many possible reasons. First, she appears to see her suffering as a spiritual necessity, and her depression allows her to attain a kind of moral purity. She is playing many roles—judge, jury, and executioner, as well as the role of the convicted felon who is depressed and suffering. She thinks she MUST suffer in this way.

In addition, in her mind, her baby probably hasn’t really died yet. She is keeping him alive with her depression, thinking about him every day. Her depression is her tribute to her baby. If she overcomes the depression, she may have to grieve, let go, and move forward with her life. And there are several other powerful issues that keep her stuck as well. If the therapist does not take these motivational factors into account, and deal with them with compassion and skill, she will simply resist—which is exactly what had been happening for the previous eight years.

Process Resistance is quite different from Outcome Resistance. In Process Resistance, you might WANT to change, but you don’t want to do what you’ll need to in order to change. For example, let’s assume that you’re suffering from some type of anxiety, such as the fear of heights. We can say for certain that some form of exposure to heights will be mandatory if you want to defeat this fear. The same goes for every other type of anxiety: exposure will be necessary. Of course, most patients with anxiety will powerfully resist using exposure, since exposure can be terrifying. But there is no Magic Button. Exposure will be necessary if you want to defeat your fears. It’s not negotiable. So addressing the resistance up front is critical to success.

I had the fear of heights when I was young, along with many other fears and phobias, including the fear of dogs, bees, horses, and blood. When I was in high school, I wanted to be on the stage crew for the play Brigadoon, but the drama teacher, Mr. Bishop, told me that he couldn’t accept any students with the fear of heights, since the stage crew had to work up near the ceiling, with the lights and curtains and such. I told him I had the fear of heights. He said I couldn’t be on the stage crew, unless. . . I was willing to get over my fear.

I said I was very willing, but didn’t know how. He said it was easy, and he’d show me right then and there if I wanted. I said, “Great, let’s do it.”

He brought me into the theatre, and set up a 12 foot ladder in the middle of the stage, so it wasn’t close to anything. He said, “All you have to do is get up on the top rung of that ladder and stand there.” I asked, “Is that all you have to do?” He said “Yes, that’s how you do it.”

I was young and naïve, so I bravely started climbing up that ladder. By the time I reached the top, my fear was 100 on a scale of 0 to 100. In fact, I was terrified, and there wasn’t anything to hold onto. He was way below, standing next to the ladder. I said, “What should I do now, Mr. Bishop?” He said, “Nothing, just stand there until you’re cured.” I said, “But isn’t there something I’m supposed to do?” He said, “No, just stand there.”

Fifteen minutes went by and my fear level was still 100. I said, “I’m still anxious.” He said, “That’s okay, just wait it out.’

Another five minutes went by, and my fear suddenly started to disappear. It took about five seconds, and suddenly it had vanished entirely. I wasn’t afraid. I said, “I think I’m cured now, Mr. Bishop.”

“That’s great,” he said. “You can come down now and you can be on the stage crew of Brigadoon.” After that, I LOVED heights. I always wanted to be the one to go way up to the ceiling and work the highest lights. I couldn’t even remember what it was like to have the fear of heights. In fact, sometimes, when you defeat a fear, the thing you feared so intensely becomes a source of great pleasure. But there was a price to pay. You can’t defeat any type of anxiety simply by lying on the couch and talking about the past while the therapist mumbles, “Tell me more.”

Process Resistance also differs radically for each of the four common targets: depression, anxiety, a relationship conflict, or habits and addictions. This means that there are eight common types of resistance—there are four types of Outcome Resistance, and four types of Process Resistance. Clients will sometimes have several forms of resistance operating all at once. That’s because they may be depressed and anxious at the same time, and may also be struggling with loneliness or troubled personal relationships.

My colleagues and I have developed powerful new techniques that allow therapists to pinpoint and reverse each patient’s resistance before using any techniques to solve the specific problem. The integration of these motivational techniques into the therapy has led to tremendous breakthroughs in our treatment, and we are now seeing extremely rapid recovery in a high percentage of the patients who come to us for treatment.

What mistakes do therapists make that hinder the therapeutic process?

Nearly all therapeutic failures result from what I call “Agenda Setting errors,” or the complete failure of the therapist to set the agenda. Most therapists do not appear to know how to pinpoint and reverse therapeutic resistance—to head it off at the pass. Instead, they try to persuade the patient to change, or to do the psychotherapy homework, while the patient resists and yes-buts the therapist. The therapist ends up doing all the work and feeling frustrated and resentful.

Most therapists believe they understand Agenda Setting, but they don’t. It appears easy, but it is the most sophisticated and difficult therapeutic skill of all. The paradoxical Agenda Setting techniques my colleagues and I have developed represent, we believe, a major advance in therapy.

A second mistake is to join a school of therapy, such as psychodynamic therapy, cognitive therapy, EMDR, ACT, or TFT, or whatever happens to be in vogue. I’m all for TOOLS, not SCHOOLS, of therapy. To me, the schools of therapy compete much like religions, or even cults, all claiming to know the cause and to have the best method for treating people. And new schools of therapy seem to get created almost every week, always with a guru and always with enthusiastic followers who are sure they’ve found “the answer.”

The third big error is the failure to measure the patient’s symptoms and the therapeutic alliance at every session. My formal and informal research at Stanford has revealed that therapists’ perceptions of how patients feel—how depressed or suicidal they are, how anxious they are, or how angry they are—are poorly correlated, and often entirely uncorrelated, with how patients actually feel. But therapists, including psychiatrists and psychologists alike, don’t realize this, and wrongly believe that they ARE reasonably sensitive, when they really aren’t. In fact, that’s one of the most common causes of suicide—the therapist didn’t realize just how depressed and despondent the patient was.

To solve this problem, I’ve created brief, highly accurate scales that measure depression, suicidal urges, anxiety, anger, and relationship satisfaction, along with positive feelings such as joy, creativity, and intimacy. Patients complete the scales in the waiting room just prior to, and after, every single therapy session, recording how they’re feeling right now, at this exact moment. After each session, they also rate the therapist on warmth, understanding, and helpfulness, and describe what they liked the least and most about the session. These forms only take a minute to complete, yet allow therapists to see, for the first time, how their patients actually feel, how much they’ve improved (or failed to improve), and how the patient really experienced the therapist, at every single therapy session. Because patients complete these scales before and after the session, leaving them in the office before they go home, it actually doesn’t take any time from the therapy

This practice, perhaps more than anything else, has led to a revolution in how we do therapy, by making both therapists and patients far more accountable. Our patients become our greatest teachers, because they tell us what’s working and what’s not working for them. I can’t imagine doing effective therapy without these assessments. But it requires courage to do, because you often discover that your patients’ feelings about you are very different from the way you thought. And for some reason, patients feel far more open and candid when completing these therapy evaluations on paper. In fact, they can be surprisingly honest and critical of therapists—far more so than in actual sessions.

Often narcissistic therapists—and there are many—cannot tolerate the assessments, because the patient feedback is too devastating to their sense of self-esteem. And for the rest of us, it can be painful to recognize we’re not as helpful, warm, and understanding as we thought we were. The reward, however, is a far more authentic, trusting, and ultimately effective therapeutic alliance.

In your opinion, what is the ultimate goal of therapy?

There is no “ultimate goal of therapy.” Thinking there is some ultimate or universal goal of therapy is one of the most fundamental errors of our field. To me, that concept is rather arrogant, as if therapists were some kind of spiritual experts who knew what human beings are supposed to be like.

Instead, I ask patients to describe a specific moment when they felt upset, a moment they want help with. It can be any moment, and any type of problem, but it has to be real and specific as to person, place, and time. A vague complaint, like the young woman who said, “Life stinks,” isn’t very useful. I might have to ask, “Where were you when you noticed the smell? What was going on?”

The problem the patient wants help with could be a moment of depression, or a recent panic attack, or an argument with his or her spouse, for example. Then I explore motivational issues, taking into account Outcome Resistance and Process Resistance. Once the resistance has been overcome, I use a wide variety of techniques to help the patient solve the problem. The techniques that are the most effective will differ for different types of problems. In other words, the techniques that are the most helpful for depression, anxiety, anger / relationship problems, or addictions are quite different from each other.

I see my role as a hired helper, and my patient is my boss. The patient describes the problem she or he wants help with. But when the patient really comprehends what was going on at that moment in his or her life, and suddenly learns how to turn that problem around, they often experience a kind of enlightenment, and all their problems will fall apart at that moment, much like a house of cards. The depression suddenly gets transformed into joy and laughter, for example. This is a tremendous event to observe and participate in, and it is part of what makes therapy such a joyous and amazing experience for me.

What is the toughest part of being a therapist?

Skillful, state-of-the-art therapy requires constant practice and training. For the past eight years, I have been running a weekly psychotherapy training and development group at Stanford as part of my volunteer teaching for the Department of Psychiatry. The group now meets at my home, and is open to therapists in the community, as well as Stanford students. The group is a very rewarding experience. In fact, it’s the highlight of my week. But it’s not always easy. The therapists who attend have to practice, using role-playing techniques in a variety of challenging scenarios. They get graded immediately, and have to face their failures in order to grow. If you can check your ego at the door, this is tremendous fun and a terrific learning experience. But if your ego gets involved, it can be rather intimidating to have to fail in front of colleagues you respect and admire.

The same thing happens in therapy. As I mentioned above, I’ve developed extremely sensitive scales that patients fill out in the waiting room after every single therapy session. They rate their therapists (including me) in a variety of dimensions, such as Empathy, Helpfulness, Satisfaction with the session, Negative Feelings during the session, and other variables. Although most therapists believe that they are warm, caring, and effective, most are shocked to discover that they get failing grades from practically every patient at every session when they first begin using these scales. This is extremely shocking to novice as well as advanced therapists. However, with training, therapists can learn to transform those therapeutic failures into tremendous breakthroughs, and over time, their ratings begin to soar.

Learning to accept failure on multiple levels is, to my way of thinking, the key to become a world-class therapist. But that means humility, and setting your ego aside, while you develop superb new technical skills.

What is the most enjoyable or rewarding part of being a therapist?

Seeing people change—the sudden transformation of depression, hopelessness, and worthlessness into joy and self-esteem. Or suddenly defeating a fear. Or suddenly learning to let go of anger, blame, and resentment. Those experiences of sudden and profound change always blow my mind. I love that experience, and it happens often. This is the true gift of a career as a therapist.

What is one pearl of wisdom you would offer clients about therapy?

We are seeing high speed changes in patients now, true rapid recovery. Many patients are now showing dramatic gains, or complete recovery, in just a handful of sessions, using the powerful new methods we have been developing.

What saddens me is seeing patients who have been going to therapy for years and years with no change, but they keep going to the same therapist. To me, that’s not right. And what also saddens me is that so many people don’t have access to good therapy, either because they can’t afford it, or because they’ve had trouble finding someone they can work with effectively.

I think our field has a lot of room for growth, and for catching up with the other more basic sciences, such as biology, chemistry, or physics. That’s the goal that my colleagues and I have been aiming for in our work developing a new a more powerful model of therapy.

[1] Copyright © 2008 by David D. Burns, M.D.