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.


What’s the Best School of Psychotherapy?

What’s the Best School of Psychotherapy?

Hi Dr. Burns,

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


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

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

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

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

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

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

The Schools of Therapy Have a Lot in Common with Cults

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

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

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

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

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

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

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

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

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

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

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

Most Schools of Therapy Promote Unproven Theories of Causality

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

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

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

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

Who’s right? Are they all right?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Claims of Therapeutic Superiority Usually Cannot be Documented

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

David Burns, M.D.

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


Antonuccio, DO, Burns, DD, & Danton, WG. (2002). Antidepressants: A Triumph of Marketing over SciencePrevention and Treatment, 5, Article 25. Web link: http://journals.apa.org/prevention/volume5/toc-jul15-02.htm

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

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

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

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

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

Burns, DD, & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive – behavioral therapy: a structural equation model. Journal of Consulting and Clinical Psychology, 60(3): 441 – 449.

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

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

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

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

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

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

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

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

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

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

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

020: The Truth About Antidepressants?

In this podcast, David and Fabrice discuss recent startling and disturbing research studies by Dr. Irving Kirsch and others that suggest that the chemicals called “antidepressants” may, in reality, have few or no true antidepressant effects above and beyond their placebo effects. Dr. Burns illustrates the placebo effect with a thought experiment, and explains why it is so confusing to researchers and the general public alike.

In addition, David and Fabrice discuss additional troubling research by Dr. David Healey and others that indicates that the chemicals called “antidepressants” appear to cause a doubling or tripling of the likelihood that a depressed individual will commit suicide or become actively suicidal, as compared with depressed individuals treated with placebos. David concludes with a discussion emphasizing that the needs of marketing are in conflict with the needs of sciences, and proposes some solutions to this serious problem.

Dr. Burns emphasizes that he is only providing his interpretation of some extremely controversial studies, based on his research training and clinical experience. He urges listeners to do their own research and critical thinking on this disturbing topic, and emphasizes that many may come to different conclusions.


Suggested Reading

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.

Garland, E. J. (2004). Facing the evidence: antidepressant treatment in children and adolescents. Canadian Medical Association Journal, 170, 489-491.

Healy, D. (2003). Lines of evidence on the risk of suicide with selective serotonin reuptake inhibitors. Psychotherapy and Psychosomatics. 72, 71-79.

Jureidini, N., Doecke, C.J., Mansfield, P.R., Haby, M.M., Menkes, D.B., & Tonkin, A.L. (2004) Efficacy and safety of antidepressants in children and adolescents, British Medical Journal, 328, 879-883.

Khan A, Khan SR, Leventhal RM, Brown WA (2001).  Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: a replication analysis of the Food and Drug Administration Database. International Journal of Neuropsychopharmacology, 4, 113-118.

Kirsch, Irving. (2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth. New York: Basic Books.

008: M = Methods (Part 2) — You Can CHANGE the Way You FEEL

In this Podcast, Dr. Burns describes his work with a severely depressed, suicidal, hospitalized woman with rapidly cycling bipolar illness, who’d had 15 years of failed treatment with drugs and psychotherapy. She was telling herself:

  1. This f___ing disease has ruined my life.

  2. I’m a burden to my family.

  3. My family and doctors would be better off if I were dead.

She was absolutely convinced that each of these negative thoughts was 100% true. Dr. Burns used several T.E.A.M. methods to help her challenge those thoughts, including Identify the Distortions, Examine the Evidence, the Experimental Technique, the Externalization of Voices, and the Acceptance Paradox. Listen to this podcast and find out about the shocking and rather unexpected impact of those techniques.


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.

Error #5: Failure to Set the Agenda

* ©2013 by David D. Burns, MD

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

In this blog I will focus on the biggest therapist error of all, by far—the failure to set the agenda. This may come as a surprise to therapists who think they do know how to develop a meaningful therapeutic agenda. Most therapists think this means making a list of the patient’s goals for therapy at the initial evaluation and then working together to achieve those goals in subsequent therapy sessions. There’s nothing wrong with that, but that’s not at all what I mean by Agenda Setting,  or more correctly, Paradoxical Agenda Setting, (PAS).

PAS is an amazing new approach that can lead to vastly faster recovery from depression, anxiety disorders, relationship problems, and habits and addictions. However, PAS can be very challenging to learn because it kind of goes against human nature to some extent. And, after all, therapists are human, and therapist narcissism and codependency can pose formidable barriers to learning these new treatment methods.

I’ll give you a feel for how PAS works, using a real case. If you find it intriguing, and want to learn how to do it, you’ll definitely need additional study, training, and practice. I’ll suggest some additional learning steps for you at the end of the blog.

At the start of each therapy session, it’s important to empathize, using the Five Secrets of Effective Communication. When you empathize, you don’t try to help the patient and you don’t give advice. Instead, you can paraphrase the patient’s words (Thought Empathy), acknowledge his or her feelings (Feeling Empathy), find the truth in what the patient is saying (Disarming Technique), and gently probe for more information (Inquiry). It is also helpful to express warmth and compassion (Stroking), and it can also be appropriate for the therapist to share his or her feelings with the patient as well (“I Feel” Statements),

Skillful empathy requires discipline and training. Most therapists believe they are reasonably empathic and have good listening skills. In many cases, this is not actually true. I have developed an Empathy Scale that my colleagues and I require all of our patients to complete in the waiting room at the end of every session. The score will show how your patient actually experiences you. Most therapists get failing grades initially from most of their patients. This can be upsetting, and a shock to the system. However, with practice, your scores can improve significantly, or even dramatically.

Carl Rogers believed that empathy was the necessary and sufficient condition for personality change, and his contributions were legendary. However, research and subsequent experience have shown that empathy is not enough. If a patient is struggling with severe depression, or OCD, or a troubled marriage, or a habit or addiction, you can be the greatest listener in the world, but nothing will change. The patient may think you’re wonderfully supportive and caring, but he or she will still be struggling with the symptoms that brought him or her to therapy in the first place.

That’s why we need methods. I have developed more than 50 powerful techniques that can help people overcome mood and relationship problems and addictions. But you can’t just jump from empathy to methods. This is where Paradoxical Agenda Setting (PAS) comes in. You might think of it as the bridge from empathy to methods. When you use PAS, you find out what, if anything, the patient wants help with in today’s session. Then you bring the patient’s subconscious resistance to conscious awareness, and melt the resistance away using a number of innovative techniques. If you do this skillfully, then when you come to the methods portion of the session, you will get much better and faster results. In fact, the impact of PAS on recovery can be dramatic.

There are five steps in Paradoxical Agenda Setting:

  • The Invitation
  • Specificity
  • Conceptualization
  • Motivation
  • Methods

The Invitation Step

Let’s see how it works, using a real but heavily disguised case. A young man named Rameesh sought treatment from me in Philadelphia for severe anxiety and depression. He was working as a computer programmer, and those were the early days of programming.

Of course, I took his history first, and then spent most of the first treatment session empathizing with him. Then I issued the Invitation by saying something like this: “Rameesh, you’ve mentioned a number of problems, and you’ve told me how anxious and depressed you’ve been feeling. I can see that you’re in a lot of pain. I’d like to offer you more than just listening and support, and I’ve got some wonderful tools to share with you. I’m wondering if this would be a good time for us to roll up our sleeves and get to work on one of the problems that’s bugging you, or if you need more time to talk and have me listen, because listening is also important, and I don’t want to jump in before you feel ready.”

This is called a “Straightforward Invitation,” and it conveys several important messages to the patient:

  • “I care about you and I’m aware that you’re suffering a great deal.”
  • “Venting and getting support won’t be enough to get the job done if you really want to change your life.”
  • “I have powerful tools to help you.”
  • “You will have to ask me for help in order to make some magic happen.” This is based on the Biblical notion of “Ask and ye shall receive.”
  • “You will have to let me know when you’re ready to get to work and begin using these tools.”

Specificity Step

If the patient ignores your Invitation, or doesn’t feel ready to focus on something specific, you can empathize for a while longer, and then repeat the Invitation step.

Rameesh indicated that he did want help. Then you go on to the Specificity Step, and there are two levels of Specificity you can ask about. First, you can ask what problem she or he wants help with, with a simple question like this:

“Rameesh, I’m glad you feel ready to work on something together. You mentioned lots of problems that seem important, and any of them would work well, I think. What problem would you like to work on first?”

Rameesh indicated that he wanted help with his low self-esteem, but it could be anything that’s bugging the patient, such as procrastination, or panic attacks, or a marital conflict. It could be anything at all.”

Rameesh wants help with his “low self-esteem,” but we don’t really know what that means. To bring the problem to life, you go on to the second level of specificity—you can ask him to describe one specific moment when he was struggling with that problem. This is what I said to Rameesh:

“Rameesh, I’m glad you want help with low self-esteem because I would enjoy helping you with that. Although it’s incredibly painful to have low self-esteem, there are lots of tools we can use to help you boost your self-esteem and feel greater joy in life. But I need a bit of help from you. I’m wondering if you can describe a specific moment when you were struggling with low self-esteem. That way, I’ll have a better idea of how to help you. For example, you might be experiencing low self-esteem right now, sitting here in my office, or you might have been feeling bad about something that happened yesterday, or at any time in your life.”

Once Rameesh describes a specific moment when he was upset, you can ask him where he was, what time of day was it, and who he was interacting with. What did the other person say to him, and what did he say next? What was he thinking at that moment, and what was he feeling?

During the Specificity Step, it can also be helpful to ask questions along these lines:

“Rameesh, let’s assume that you and I successfully solved this problem. What would the solution look like? What would change? How would things be different?”

This question can be tremendously useful. Sometimes you will see why the patient is stuck, because the type of solution he or she is looking for may be unrealistic or self-defeating. For example, someone who is overly submissive may think that the solution to a relationship problem involves the opposite of submissiveness, such as becoming more aggressive, demanding, or argumentative. These strategies are almost certain to stir up hostility, rather than intimacy, collaboration, or respect.

Or, the person who is procrastinating may think the solution will involve developing great motivation before tackling the task he or she has been putting off. This strategy is doomed to failure, because the motivation will probably never come. If you want to overcome procrastination, you’ll have to make a commitment to get started in spite of the fact that you don’t feel like it. Once you’ve gotten started, you may realize that the task is not as bad as you imagined, and then you might experience some motivation.

When I asked Rameesh for a specific moment he was experiencing low self-esteem, he described a conflict with his boss the previous day. He’d met with her to review his performance evaluation. She said that she’d received numerous complaints about his work from his colleagues. They said that he was defensive and hard to get along with, and that he wasn’t a good team member.

Rameesh found the feedback from his boss very upsetting and got defensive. He insisted that his colleagues were jealous of him because he was from India, had dark skin, and was smarter than everyone else. He shouted that there was a conspiracy against him, and that he should be at the head of his computer team.

I asked Rameesh how his boss responded when he said that. He sadly explained that his boss put him on probation and threatened to fire him if he didn’t shape up. He said that he walked out of the meeting feeling like a total loser.

Now we know what Rameesh needs help with. If you ask 50 patients to describe a moment when they were struggling with “low self-esteem” you’ll get 50 completely different situations, all requiring individualized solutions. That’s why the specificity step is so important, and why formulaic, manualized therapy based on a diagnosis or problem is doomed to failure for many if not most patients.

Conceptualization Step

Now we come to the conceptualization of the problem. You can do this step on your own, in your head, or in collaboration with your patient. Ask yourself if the problem is an individual mood problem, such as anxiety or depression, or a relationship problem, or a habit or addiction, or a so-called non-problem, such as uncomplicated grief.

Rameesh asked for help with his “low self-esteem.” Now that we know what really happened, how would you conceptualize his problem? If you’ve printed this blog out, tick off any that apply. If you’re reading it on the website, make a mental decision before you continue reading.

1.    An individual mood problem, such as depression or anxiety

2.    A relationship problem

3.    A habit or addiction

4.    A non-problem, such as uncomplicated grief

The conceptualization step is vitally important for two reasons. First, each type of problem is associated with its own type of therapeutic resistance, so when you conceptualize the problem, you can begin to ask yourself about the kinds of resistance the patient will probably have when you try to help him or her. You can also think about what techniques you’ll use to melt away the resistance.

In addition, each type of problem responds to different types of techniques. I train my students and colleagues in how to use 50 basic psychotherapy methods, such as the Hidden Emotion Technique, the Acceptance Paradox, the Interpersonal Downward Arrow, the Externalization of Voices, and many others. Some methods are especially effective for depression, while others work well for anxiety disorders, or relationship problems, or habits and addictions. So when I do the Conceptualization Step, I’m also  thinking about the methods I’ll use once I’ve melted away the patient’s resistance.

Did you make your choice(s)? Please don’t continue reading until you’ve decided. Does Rameesh have a mood problem? A relationship problem? A habit / addiction? Or a non-problem?

Most therapists say that Rameesh has a relationship problem, and that’s definitely true. I’m sure you recognized that as well. Clearly, Rameesh isn’t getting along with his boss or his colleagues. In fact, he sounds pretty paranoid, angry, and narcissistic.

But he’s also severely depressed and intensely anxious about losing his job, so he also has individual mood problems. Often, your conceptualization of the problem will involve more than one dimension. That means we may have to deal with several forms of resistance, and that we will have many kinds of techniques to help the patient as well.

Motivation Step

Rameesh has a fairly severe problem and we have some terrific tools to help him. This sounds like a marriage made in heaven. Should we jump in and help him now? That, of course, is the biggest therapeutic error at all. Before we try to help Rameesh, we need to think about why he might not want the very help he’s asking for. Then we need to figure out how to antidote that resistance. Here’s where the new PAS techniques can be invaluable.

When we’re suffering, most of us have one foot in the water and one foot on the shore. Part of us wants to change, but part of us resists change and clings to the status quo. Why might Rameesh forcefully resist our efforts to help him?

We’ll need to think about two different kinds of resistance. I’ve called them Outcome Resistance and Process Resistance. In its simplest form, Outcome Resistance means that the patient doesn’t want a positive outcome from the treatment. If the patient is depressed, Outcome Resistance means that the patient would strongly prefer depression, shame, hopelessness, and misery over joy, self-esteem, hope and productivity. That might seem odd to you. Why would a depressed patient want to remain depressed? In fact, there are many very good reasons for this, and as long as they remain unexamined, the patient is likely to remain stuck.

Process Resistance is a little different. Process Resistance means that the patient might want a positive outcome, but doesn’t want to do the thing he or she will have to do to produce a positive outcome. In other words, there is some process—such as psychotherapy homework, or exposure—that the patient will resist doing.

Let’s review some of the most common sources of Outcome Resistance:


Outcome Resistance

Process Resistance

Mood disorders

Depression, shame, guilt, self-criticism, inadequacy, worthlessness, and hopelessness.

The self-criticisms reveal the patient’s value system; the hopelessness protects against disappointment; and the relentless negative thoughts will seem to be true. Patients probably won’t want to do daily psychotherapy homework, such as recording negative thoughts on the Daily Mood Log or scheduling more satisfying and productive activities on the Pleasure Predicting Sheet.

Anxiety disorders

Phobias, OCD, Panic Attacks, Shyness and other forms of Social Anxiety, GAD, PTSD, Body Dysmorphic Disorder

Magical thinking—the patient thinks the anxiety or compulsive rituals will ward off danger. Patients probably won’t want to have to use exposure techniques because it will be so anxiety-provoking.

Relationship problems

Anger, marital conflict, disagreements with friends or colleagues/

Giving up the intense rewards of blaming the other person, feeling “right,” feeling morally superior, or fantasizing about revenge. The patient may not really want to get close to the person he or she is complaining about. Patients probably won’t want to pinpoint their own role in the problem because they’re so convinced it’s the other person’s fault. They may insist on endless blaming and complaining and fight hard against learning to change themselves.

Habits and addictions

Procrastination, overeating, drinking or drug addiction, having affairs, shopping, internet porn addiction, or dating someone who is abusive

Giving up the tremendous physical and psychological rewards of the habit or addiction. Patients probably won’t want to face the discipline, anxiety, deprivation, discomfort and hard work of giving up the instant gratification of their favorite “fix.” For example, the patient who wants to lose weight will not want to diet and exercise.

Once you’ve conceptualized some possible reasons why your patient may NOT want to change, in spite of the miserable status quo, you’ll need to learn how to share this information with him or her in a paradoxical but respectful manner. Here’s what I said to Rameesh:

“Rameesh, I have some powerful tools to help you with your low self-esteem and the problems you’re encountering at work, and I’d love to work with you. I believe you’re very smart, and I like you, and it would be a joy for me to show you how to turn your life around. I have no doubt that we could do exactly that. But I’m not sure it would be the right thing to do, and I’m really reluctant to share these tools with you.”

Notice that I’m not trying to “help” Rameesh and I’m not trying to persuade him to change or to work with me. Instead, I’m Dangling the Carrot—letting him know that I have some great tools, and that I want to work with him, but I’m also letting him know that he’s going to have to persuade me. I’m not going to try to persuade him.

Like most patients, Rameesh seemed taken aback. He insisted that he was tremendously interested in working with me and wanted to know what the problem was. Here’s what I said next:

“Rameesh, there’s a problem I’m struggling with. You’ve said that your colleagues treat you unfairly and that they’re jealous of you. That must feel extremely unfair, and I can imagine that you might be feeling incredibly angry and frustrated. You’ve said that they’re jealous and talking about you behind your back and treating you in a shabby way. Some people might think you’re being paranoid, but we know that’s not the case. We have proof that they’re bad-mouthing you, which is unfair. That’s what your boss told you in the evaluation.

“So I’m entirely on your side in this battle. But here’s the rub. They’re not here asking for my help. So if we work together, you’re the one who will have to do all the changing. You’ll have to learn to change the way you think and feel, as well as the way you communicate with them. And you’ll have to work your butt off during sessions, and you’ll have to do psychotherapy homework between sessions as well. But that seems rather unfair, since they’re the ones who are screwing up. Do you see what I mean? Why should you have to change when they’re to blame for the problem?

“What are your thoughts about this? Can you help me solve this dilemma?”

Here’s why I made this statement. First, I wanted to find the grain of truth in Rameesh’s complaints, so he’d feel accepted and so he’ll feel like we’re on the same team. Second, I wanted to convey some warmth, liking and respect, especially given his pretty strong narcissistic streak. I knew that if he felt judged, criticized, or belittled, he’d probably put up a wall and drop out of therapy before we even got started.

And I did like him, so my statement was genuine. But most important, I wanted to head off his resistance at the pass and let him know that he’d have to persuade me to work with him, and not vice versa.

Notice that I have become the voice of Rameesh’s subconscious mind. I am verbalizing all the reasons for him not to change. When you do this skillfully, the patient will nearly always suddenly let go of the resistance and buy into the treatment program. The effect is almost as basic as the law of gravity, and the results can be spectacular. We call this Paradoxical Agenda Setting because the therapist becomes the voice of resistance. If you do this skillfully, in nearly all cases the patient will suddenly become the voice of change.

Rameesh told me that he definitely wanted to work with me, and would do practically anything if I would agree to work with him. I told him, once again, that he would have to do all the changing, and that he’d have to do at least one full hour of psychotherapy homework every day, 7 days a week. Once again, I emphasized how unfair that seemed.

He said he didn’t care how unfair it was, and that if I’d work with him, he’d do more psychotherapy homework than any patient I’d ever had.

I told him that was the message I was hoping for, and that I’d love to work with him.

Then he suddenly broke down and started crying. When he pulled himself together, he told me that he had a confession to make, and that he’d been lying to me. I asked what he’d been lying about. He explained that his boss didn’t really put him on probation—she’d fired him. And he confessed that he’d been fired six times, from six different jobs, in the past two years. He said that everywhere he went it was the same thing over and over. And if I could show him how to change his life, he’d do anything I asked him to do.

Methods Step

Rameesh was a joy to work with. He did more psychotherapy homework than anyone I’d ever worked with. I used basic tools, such as the Daily Mood Log, to help him with his depression and anxiety, and the Relationship Journal to help him with his conflicts with others. He worked relentlessly, and within a few weeks his depression had vanished. He also became a master at using the Five Secrets of Effective communication to deal with criticism and conflicts with others.

He was unable to find work in Philadelphia, since he’d pretty much burned his bridges at the only companies using his type of programming. But then he got an offer from a software engineering company in Georgia. He asked for my advice about whether to make the move.

I suggested he could tell them that he could only accept their offer if his new boss would agree to meet with him 15 minutes once a week to criticize his performance. They were taken aback, and said they’d never had a request like that, but agree since they were desperate to hire a programmer with his skill set.

Rameesh called for a phone tune-up about six weeks after he moved. He said things were going swimmingly, and he’d actually won the “Employee of the Month” award, and his picture was posted in the lobby of the company. He said the Five Secrets of Effective Communication worked like magic when he was receiving feedback from his boss.

The next time I heard from him was a second phone tune-up six months later. He was still on a high and explained that he’d gotten several promotions, and his salary had doubled. That was our last therapy session we ever had.

I didn’t hear from Rameesh again for many years. Then, one December, I received a Christmas card from Rameesh, with a note inside that was written on his company’s official stationery. He said he hoped I hadn’t forgotten who he was, and explained that things were still going great—he’d gotten married and had a baby, and was still working at the same company. But he wrote that he wanted me to take a look at the letterhead on the stationery and that he hoped I’d be proud of him. I checked it out and noticed that it said Rameesh XYZ, President and CEO, XYZ Software Company!

I was bursting with pride in Rameesh and what he’d done. Now he had more than 600 employees working for him. If I hadn’t used PAS, he’d probably still be my patient, insisting that he was a victim of other peoples’ insensitivity.

That’s just a brief overview of how PAS worked for one patient. If you think you might want to learn more about PAS, there are several tools that could help you, including:

  • Read my psychotherapy eBook, Tools, Not Schools, of Therapy, and do the written exercises in it.
  • Get mentoring / individual training from a certified T.E.A.M. Therapist at the new Feeling Good Institute.
  • Attend one of my two-day workshops, or even better, a four-day intensive.
  • Attend one of our free (or paid) weekly psychotherapy training groups in Northern California.
  • Purchase and study one of the interactive training videos at TeamTherapyTraining.com
  • Watch my free video on the Motivation Revolution on my Hot Links page.

[*]   Copyright ã 2009 by David D. Burns, M.D.

Error #4: Reverse Relationship Hypnosis

* ©2012 by David D. Burns, MD

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

When a patient complains of relationship problems—such as a troubled marriage or a conflicted relationship with a family member, colleague, neighbor, or friend—the patient usually depicts himself or herself as the victim and implies that the other person is to blame for the problem. For example, the patient may emphasize the other person’s insensitive or self-centered behavior, and insist that the other person is a jerk who really shouldn’t be that way. Therapists frequently buy into this way of thinking about the conflict. We do this because of our desire to support and help our patients, and also because this is politically correct. And, after all, there is an enormous amount of violence and bad behavior in the world. So when the patient points out all the annoying things the other person said or did, on some level, he or she is right

However, in most cases, you have succumbed to the patient’s hypnotic spell. And once you’ve bought into the idea that the patient really is the innocent victim, the therapy will have little chance of being effective. I’m not aware of any tools powerful enough to help individuals who blame others for their problems.

It is not easy for therapists to escape from this type of trap. In fact, most therapists don’t even realize they’ve fallen into a trap. And it’s somewhat addictive, too. It can feel good to collude with the patient and scapegoat the other person. I see therapists falling into this trap over and over again.

In my psychotherapy eBook[2] (Tools, Not Schools of Therapy) and in my relationship book for the general public (Feeling Good Together), I describe the three basic principles of what I call Cognitive Interpersonal Therapy (CIT). CIT is based on three principles:

  1. We forcefully create the relationship problems that we complain about so intensely, but we’re not aware of this, so we feel convinced that we’re innocent victims.
  2. We’re not interested in discovering our role in the problem. We want to maintain the façade of innocence so we can continue to do our dirty work in the dark.
  3. We have far more power than we think to transform troubled relationships into loving and joyous ones. Furthermore, this can often be done amazingly quickly. However, there will be a price to pay. You’ll have to be willing to pinpoint your own role in the problem and focus all of your efforts on changing yourself, rather than blaming the other person or trying to change him or her. This can be painful, because it requires the death of the ego, or what the Buddhists call “the Great Death.”

I once gave a half-day workshop in Seattle on relationship problems for the general public. It was sponsored by a local hospital as a part of their public outreach program. At the start of the workshop, I asked the participants to think of one person they didn’t like or get along with, and to write down one thing the other person had said to them during an argument or disagreement, and exactly what they said next. I explained that this brief exchange was all we would need to pinpoint the exact cause of the problem and illustrate how to transform hostility and defensiveness into trust and love.

Then I asked if anyone would like to describe the difficult person in his or her life. A woman who was sitting in the first row was waving her hand in the air excitedly, so I called on her first. She said that her name was Martha, and that her husband was the difficult person in her life. She explained that he’d been relentlessly critical of her all day every day for the past 35 years. She said she’d come to the workshop to find out why men were like that.

I explained that scientists don’t yet know why men are the way they are, or why women are they way they are, but if she’d read what she wrote down, perhaps we could get some insight into the cause of her marital problem. What, exactly, had her husband said to her, and what, exactly, did she say next?

She said, “Well, just this morning, he said ‘You never listen!'”

I asked what she said next. What had she written down?

She replied, “Oh, I just said nothing and ignored him!”

The audience erupted in laughter. They could immediately see something pretty obvious that she did not seem to be aware of.

When you use CIT, you examine your own response to the other person instead of blaming him or her, and you ask yourself three questions based on the EAR acronym:

E = Empathy—Did I use good listening skills? Did I find some truth in what the other person said? Did I acknowledge how she or he was thinking and feeling?

A = Assertiveness—Did I share my own feelings openly and directly?

R = Respect—Did I convey warmth and caring to the other person, even in the heat of battle?

Well, it isn’t hard to see that Martha was 0 for 3. First, there was no empathy. She didn’t acknowledge her husband’s feelings or acknowledge any truth in what he’d said. In addition, she didn’t share her own feelings openly and directly—instead she ignored him and froze him out in a passive-aggressive manner. And finally, she clearly didn’t convey any warmth or respect.

This analysis will be threatening to most patients. Martha came to the workshop to find out why her husband was so screwed up. She was blaming him. Suddenly, the finger of blame is pointing at her. This may not be what she had in mind! Because the method is very powerful, it requires lots of trust and warmth, because the patient ends up in a very vulnerable position.

When you use CIT, you also ask the question—what will the impact of my response be on the other person? How will my husband think and feel if I respond this way? What will he conclude? How will he behave?

Once again, the answer is pretty obvious. Martha’s husband will conclude that he was absolutely right—once again, Martha didn’t listen. Since she hasn’t yet gotten it, he’ll have to try again, and again, and again.

So now, Martha knows the answer to her question—why are men like that? Why are they so critical? Sadly, it’s because Martha forces him to be like that. And she’s done that all day, every day, for the past 35 years.

This insight can be extremely painful. I have done this type of analysis myself on many occasions when I was in conflict with a family member, patient, or colleague. And it is always painful for me, too. I HATE having to do this. But it can be very liberating. That’s because of the third principle of CIT—we have far more power than we think to change a troubled relationship. Since we are triggering the problem, we also have the power to change things.

I’ve used this approach with more than 1,000 individuals with troubled relationships, including many mental health professionals who have attended workshop for training and personal growth. In virtually every case, the person who is complaining has failed to empathize, express his or her feelings, or convey respect. So he or she is always 0 for 3 on the EAR analysis. In addition, when you examine the consequences of the patient’s response to the person she or he isn’t getting along with, you discover that the patient is forcing the other person to behave in exactly the way the patient is complaining about.

And we can see that clearly in the example Martha provided. However, this doesn’t mean that Martha’s husband is innocent. If he’d come to the workshop, and Martha had stayed at home, I would have helped him pinpoint his role in the conflict, and he would have made the same painful discovery—that he actually forces Martha not to listen.

I call this the theory of interpersonal relativity. Probably that’s too fancy of a term, but it means that the person who is asking for help will always turn out to be the entire cause the problem.

This approach requires enormous therapist empathy, gentleness and compassion, because the discovery will nearly always be shocking for the patient. Some patients will resist or even decide that they don’t want this type of therapy. But if patients have the strength and good will to endure the discovery that they are triggering the problems they complain about, there will be two huge rewards. First, they will suddenly understand the cause of all of the problems in all of their relationships, because they are almost certainly doing the same thing to other people they don’t get along with. This represents a kind of enlightenment—they discover that they are not, in fact, victims, but are instead creating their own interpersonal reality at every moment of every day. This is a Buddhist principle, but it’s also embedded in practically every religion, including Christianity, the Jewish religion, and many others.

And finally, and perhaps of greatest importance, I can show them how to solve the problem using the Five Secrets of Effective Communication. But that’s a topic for another day.

In a nutshell, most of our patients, and most of us as well, have one or more troubled relationships. Even if patients are seeking treatment for depression, or anxiety, or a habit or addiction, there’s a good chance that at some point in the therapy, they’ll begin to talk about some person who they’re at odds with. They’ll usually try to convince you that the problem is the other person’s fault. If you find yourself agreeing with the patient, ask yourself if you’ve been hypnotized. Once you recognize this, you can break out of the trance and help your patient pinpoint what’s really going on—if she or he is willing. Those of you who want to learn more about the nuts and bolts of doing this may want to read my eBook or Feeling Good Together.

I do not mean to imply that other people are always innocent, and that the patient is the only one who is to blame. In fact, other people often DO act like jerks. We all know that. The patient’s description of how the other person’s annoying behavior is likely to be true. But the patient is nearly always leaving something of vital importance out of the description—and that’s his or her role in the problem.

Thanks for listening! I suspect this blog might stir up a little controversy. Let me know if you have any feedback.

The next blog will cover Error #5, which is by far the greatest therapeutic error of all. So stay tuned!

All the best,

David Burns, MD


[1]     Copyright © 2012 by David D. Burns, MD. Do not quote or copy without written permission from Dr. Burns.

[2]        For an order form, send an email to david@feelinggood.com.

Error #3: Reverse Anxiety Hypnosis

* ©2012 by David D. Burns, MD

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

In my last blog, I discussed something I call “Reverse Depressive Hypnosis.” That’s where the patient inadvertently “hypnotizes” the therapist into believing that she or he REALLY IS hopeless, worthless, and so forth. It is sometimes hard to resist falling into this potentially destructive trance, or even noticing that it has happened. Today, I will describe “Reverse Anxiety Hypnosis.” In a nutshell, that means that the anxious patient persuades you that she or he is too fragile (or not yet ready) to confront his or her fears using powerful exposure techniques.

In my book, When Panic Attacks, I describe several models I use in treating anxiety disorders, such as chronic worrying, phobias, PTSD, Panic Disorder, Agoraphobia, OCD, shyness, public speaking anxiety, and others, including:

  • The Motivational Model—Although anxiety can be exceedingly painful, you may secretly believe that your anxiety is helping you, or protecting you, so you are reluctant to give it up. A simply example would be the fear of flying. You may think that your fear protects you from getting on a plane and crashing.
  • The Cognitive Model—You learn how to challenge the distorted negative thoughts that trigger the anxiety.
  • The Exposure Model—You confront your worst fears, rather than running away from them.
  • The Hidden Emotion Model—You bring hidden feelings and conflicts to conscious awareness. When they express these feelings and solve the problems you’ve been avoiding, the feelings of anxiety often improve dramatically or totally disappear.

If you combine all four models, you can often achieve a complete elimination of the anxiety rather quickly. Patients love the Motivational, Cognitive and Hidden Emotion Models because they can be enormously helpful and fun to learn, but they typically hate Exposure Model. That’s understandable—we all avoid the things that terrify us. I can vouch for that, as I have personally experienced and overcome more than a dozen kinds of anxiety.

Patients will often hypnotize their therapists into believing that they are too fragile to use exposure techniques. If the therapist falls into this trance, and buys into that notion, the treatment will be doomed. It is practically impossible to overcome any form of anxiety without using exposure techniques. Exposure alone will rarely be enough—the Motivational, Cognitive and Hidden Emotion Models will also play vital roles in the treatment—but exposure will be mandatory.

When I give workshops on the treatment of anxiety, I ask the therapists in the audience to raise their hands if they routinely use exposure techniques when treating anxious patients. Usually, only about 25% of the hands go up, at most. This means that most therapists are NOT using exposure techniques in the treatment of anxiety disorders.

This might seem surprising, or even disturbing, since exposure is one of the most researched and validated psychotherapy techniques in history. So why aren’t all therapists using and requiring exposure? There are many reasons. Some therapists do not believe in using powerful techniques like exposure, thinking that empathy and talk therapy alone will be sufficient. But the most common reason patients and therapists avoid exposure is fear. The therapist thinks the patient is too fragile for powerful exposure techniques. In other words, the therapist has been hypnotized by the patient. So the therapist and patient talk and talk and talk in a general way, exploring the past, but the symptoms do not improve much, if at all.

Dr. Matt May is a former student of mine at Stanford, and we now teach together on the voluntary faculty. He is terrific hypnotist. He is also very suggestible and easy to hypnotize. He has told me that he often falls into trance when treating patients and then has to snap himself out of it.

Matt recently treated a young woman whom I’ll call Susan. Susan came all the way from Cleveland for intensive treatment with Matt because she’d been struggling for years with severe social anxiety. (The details are always disguised to protect patient identities.)

Susan showed up at Matt’s office dressed quite formally, in a business suit. She described how she’d been treated for more than 15 years with conventional talk therapy plus a wide variety of medications with no improvement. Although she was an attractive and talented young professional, her crippling shyness in social situations, coupled with severe public speaking anxiety had severely hampered her social life and her career. She felt ashamed, lonely, hopeless, and defective.

Matt asked what she was the most afraid of. What was her greatest fear? She explained that she was intensely afraid of making a fool of herself in public, or saying or doing the wrong thing, and having people look down on her and see how crazy and defective she was. This fantasy was so terrifying to her that she avoided interacting with people in practically all social situations and refused to give talks at work.

Ten minutes into their first session, which was devoted to clinical history-taking and assessment, Susan asked if there was any hope for her, given the severity of her problems, and how long the treatment might take. On impulse, Matt said that if she wanted, they could just take a ten minute break from taking the clinical history and cure her, and then he could complete the history. She seemed shocked and asked how he could possibly cure her in ten minutes, especially given so many years of unsuccessful treatment from numerous psychologists and psychiatrists.

Matt explained that she simply had to confront her fears, rather than running away from them. He said he wanted her to do a Shame Attacking Exercise. When you do a Shame Attacking Exercise, you make a fool of yourself in public on purpose by doing something foolish or bizarre, so can discover that the world doesn’t come to an end after all. I believe this fantastic technique was developed by the late Dr. Albert Ellis.

He told her he wanted her to go to the Starbuck’s which was just a half a block away from his office. Once inside, she was to lead the customers in singing and cheering, much like a cheerleader at a football game.

She was shocked and indignant, and insisted that this assignment sounded like malpractice, and that someone proper should NEVER do something as socially inappropriate as that!

Matt suddenly became ashamed and profoundly apologetic. He said he couldn’t believe he had asked her to do that, and went back to taking the history, all the while feeling intensely anxious. Do you know what happened? Susan had instantly hypnotized him into believing that she COULDN’T and SHOULDN’T have to confront her worst fears.

After ten minutes, Matt realized what had happened and snapped himself out of the trance. He told her that what she said was a lot of BS, and that she COULD and MUST do the Shame Attacking Exercise. In fact, they were going to go and do some Shame Attacking Exercises together—RIGHT NOW. So he led her out of the office and suggested they could start by doing something even more extreme outside the grocery store across the street.

So they both lay down on the sidewalk right in front of the front door of the grocery store, so that people would have to step over them to get inside. Matt asked her how intense her anxiety was, between 0% and 100%, and she replied “95%.” Matt said that wasn’t high enough, and he wanted her to push it to 100%.

Next, they pretended to be making snow angels, and then they pretended to be riding invisible bicycles while lying on their backs. It started to rain slightly, but they stuck with it.

A customer stepping over them to get inside asked what they were doing on the ground. She announced, “Oh, this is my shrink. We’re having a psychotherapy session. He often has his sessions on the sidewalk rather than in his office.”

Then Matt said, “You can join us if you like. It’s really nice lying here, kind of like being on the beach in Miami!”

Susan noticed that the people inside the grocery store were pointing at them, which made her anxiety even worse. This was her worst fear coming true—that people would think she was some kind of weirdo.

Then the store clerk came out and asked, “Are you guys okay?” She explained that they were fine and just enjoying themselves on the sidewalk. The clerk explained that the manager wanted them to leave. So they got up and left. Matt asked how she felt, and she said, “That was awesome!” She said that her anxiety had suddenly dropped to zero!

Why did that happen? It was because she confronted her worst fear, but nothing really terrible happened. She started laughing and said she felt triumphant.

Matt said, “Great! You’re cured now, and it only took ten minutes. Now we can go back to my office and I can finish your history.”

Susan said, “No! We’re not done yet. We still have to go into Starbuck’s and do our thing!” So they went into Starbuck, where a long line of people were waiting to buy coffee. Her anxiety suddenly spiked when Matt said, “Okay, time to do your thing.”

In spite of the intense anxiety she once again felt, she locked the fingers of her right and left hands together, and inverted her hands in the air above her head, and waved them like a victory fist, and then ran around in circles, saying, “It’s such a wonderful day. I’m so happy to be here. I’m so glad to be alive. Life is wonderful! I love the coffee here in Starbucks.”

Then she led the customers in cheerleading and got many people dancing and running around the store with her. Matt said he felt so proud it brought tears to his eyes.

During her several-day intensive with Matt, Susan did other Shame Attacking Exercises as well, including wearing an extremely sexy outfit in public, and confronting her fears of how people would think about her.

Coincidentally, I spoke with Matt on the phone this morning and asked him about Susan, since the treatment was more than a year ago. He had just received an email from her with a progress report on how she’s been doing since she finished her intensive. She said she was still on a high and that her life had opened up in incredible ways. One of the most significant changes was that even though she’d been very successful in her professional career, she had decided to switch careers and go back to graduate school so she could become a therapist. I have included some excerpts from her email below, printed with her permission, so you can read her personal account of the Shame Attacking.

The exposure techniques are not always that dramatic or extreme, but they nearly always require tremendous courage and commitment, both on the part of the therapist as well as the patient. This means that therapists will have to avoid falling into the anxious patient’s trance. If you combine Exposure Techniques with the Motivational, Cognitive and Hidden Emotion treatment models, the rewards can be tremendous.

In my next blog, I will discuss a third type of reverse hypnosis—relationship hypnosis. That’s where the angry patient, or the patient who simply isn’t getting along with his or her spouse, or a family member, or a friend or colleague, convinces you that he or she is an innocent victim and that the other person is to blame for the problems in the relationship. It is very difficult not to succumb to this trance, but if you get hypnotized in this way, the prognosis for effective treatment becomes very low.

Error #2: Reverse Depression Hypnosis

* ©2012 by David D. Burns, MD

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

Last time we discussed the consequences of therapists’ failure to measure changes in symptoms as well as the quality of the alliance at every session. Today, I’m focusing on another common therapist error you may have never heard of—hypnosis of the therapist by the patient!

We all know that some therapists hypnotize their patients, but I’ll bet you’ve never heard of the reverse type of hypnosis—that’s when the patient hypnotizes the therapist, and the therapist doesn’t even realize that he or she has fallen into a trance. It’s important to know about reverse hypnosis, because it can sabotage the therapy.

Of course, the patient doesn’t dangle a pendulum in front of the therapist while saying “You are getting very sleepy, very sleepy”—but we can sometimes fall into trances without realizing it. And when you are in a trance, you will tend to believe things that are not valid.

There are three common forms of reverse hypnosis:

  • Depression Hypnosis—depressed patients convince you that they really are hopeless and worthless.
  • Anxiety Hypnosis—anxious patients convince you that they really are too fragile to confront their fears using exposure techniques.
  • Relationship Hypnosis—Patients with troubled relationships convince you that their relationship problems really are the other person’s fault and that they really are the victims of the other person’s bad behavior.

Depression Hypnosis

Nearly all depressed patients are totally convinced that they are worthless, inferior, or defective. They are usually equally convinced that they are hopeless, that their problems are insoluble, and that they will be miserable forever. If you’ve ever felt depressed, you know how powerful and painful these feelings can be.

The thoughts that generate these demoralizing feelings are nearly always distorted—you may be familiar with the list of ten Cognitive Distortions that I first published in my book Feeling Good. When you fall into the black hole of depression, your thoughts typically involve distortions such as:

  1. All-or-Nothing Thinking—You look at things in black or white categories. If you’re not a complete success, you tell yourself that you’re a total failure.
  2. Overgeneralization—You see a negative event—such as rejection by someone you love, or failure to achieve your goal—as a never-ending pattern of defeat.
  3. Mental Filtering—You focus on some flaw, failure, problem or shortcoming, as if this reflects your entire self. This is like the drop of ink that discolors the beaker of water.
  4. Discounting the Positive—This mental error is even more spectacular. You tell yourself that your good qualities don’t count. In this way, you can maintain the belief that you’re defective, or that you’re a total loser.
  5. Jumping to Conclusions—There are two common forms of this distortion: Fortune Telling involves making dire negative predictions that aren’t warranted by the facts. For example, when you’re depressed you tell yourself that you’re problems are hopeless and that you’ll be miserable forever. Mind-Reading involves telling yourself that others are looking down on you without any good evidence. Shy people do this in social situations, imaging that everyone else feels confident and that everyone can see how anxious and inept they feel.
  6. Magnification and Minimization—Blowing things out of proportion, or shrinking their importance. For example, when you procrastinate you dwell on ALL you have to do (Magnification) and tell yourself that getting started and doing a little bit would just be a drop in the bucket (Minimization).
  7. Emotional Reasoning—This is reasoning from how you feel: “I FEEL worthless (or hopeless), so I must BE worthless (or hopeless).”
  8. Labeling–You label yourself as “lazy” or “a loser,” or you label someone else as “a jerk.”
  9. Overt and Hidden Should Statements—As in, “I SHOULDN’T have made that mistake,” or “I SHOULD be better than I am.” Should Statements directed against yourself trigger feelings of depression, guilt, shame, and inferiority. Should Statements directed against others, or against the world, trigger anger and frustration.
  10. Blame—There are two common varieties. Self-Blame leads to depression, and Other-Blame leads to anger and conflict.

But when you’re feeling depressed, anxious, or angry, you don’t realize that your thoughts are distorted and misleading because they feel and seem overwhelmingly realistic. The goal of Cognitive Therapy is to help the patient put the lie to these distorted thoughts. And the moment you stop believing them, you’ll feel much better.

But here’s the funny thing. Toward the beginning of therapy, I usually buy into the patient’s negative thinking. Patients are extremely good and convincing themselves and others that they really ARE worthless losers who are doomed to lives of mediocrity and misery. So I get panicky for a little while in the first or second session because I start telling myself, “This person really DOES sound like a bit of a worthless loser. Maybe there aren’t any distortions this time!”

I don’t mean to mean to sound cruel or insensitive—it is just that I have fallen into a kind of depressive trance, and most therapists do the same thing. I have bought into the patient’s extremely negative and distorted thinking. You could even think of this hypnotic trance as a form of super-empathy, because the therapist can really SEE the world through the patient’s eyes. The patient’s intensely negative view of himself or herself and the world suddenly seems almost impossible to dispute.

Then, several weeks later, when the patient and I have been working together effectively, and the patient develops the ability to crush the negative thoughts, the patient and I can suddenly see how distorted they were all along. We have both snapped out of the trance, and the patient feels a sudden flood of relief, or even euphoria. At that point, it dawns on me that I had succumbed, once again, to the patient’s depressive hypnosis.

This is not a trivial or rare problem. In fact, therapists are sometimes even trained to buy into the patient’s negative thoughts. At continuing education conferences, for example, therapists might be advised to “educate” patients and their families into believing that the prognosis for depression is guarded, and that while they can be helped somewhat, they may always have to struggle with depression and may need to take antidepressants and other medications indefinitely to correct the “chemical imbalance” in their brains, much as diabetics need to take insulin forever. Or, they may need psychotherapy indefinitely. And, of course, once you give your patients that message, many of them will believe it, and it becomes a self-fulfilling prophecy.

Early in my career, I asked Dr. Aaron Beck, a brilliant pioneer who helped to create and develop cognitive therapy, if some patients REALLY WERE hopeless. He said that he had never once bought into the notion that any depressed patient was hopeless. He said that this optimistic philosophy had worked out well in clinical practice, and that I might have to make a policy decision of my own on whether or not I would buy into that type of thinking.

I settled on the same policy, and it has always paid off for me. I remind myself that no matter how severe or overwhelming the depression might seem, the patient can, in fact, recover and feel joy and self-esteem again. That policy has been invaluable in my clinical work, and it has never let me down.

Of course, the belief alone won’t cure patients. You have to have many good treatment tools to back up your vision.

I could write a chapter or book with examples of rapid recovery in patients who initially seemed hopeless or worthless, but I’ll just give you an extreme and brief one example here. When I was in Philadelphia, we had an intensive program for patients from out of town. The idea was to try to complete an entire course of therapy in a week or even less by seeing patients several hours every day. It was a pretty successful program.

I can recall an incredibly challenging woman named Eve who travelled all the way from Germany for treatment. (I always disguise or change the facts to protect patient identities.) Eve had struggled with intractable depression and OCD for more than 40 years, with no success at all. She’d been treated with every known antidepressant and tons of other drugs, and had been hospitalized on numerous occasions. In addition, she’d received more than 100 ECT (electroconvulsive) treatments. Psychotherapy didn’t work either. Eventually, she was given a frontal lobotomy, but that did not help, either. Two years later, she had a second lobotomy, again with no beneficial effects.

Eve wanted to know if there was any hopeThe situation did not look very promising, to say the least, but I tried to hide my pessimistic feelings. I told Eve that while I couldn’t make any promises, we’d sometimes had surprisingly positive results with even the most severe cases, and that the new treatment techniques that my colleagues and I had developed were definitely worth a try.

I wasn’t able to take her on myself, since my practice was temporarily full, so I referred her to a colleague who was working with me at our clinic. I must confess that I had a sense of relief that I didn’t have to treat. Her situation seemed impossible.

Two days later I asked my colleague how things were going with Eve. He seemed in a surprisingly chipper mood and said that the symptoms of depression and OCD had vanished and that she was feeling happy for the first time in decades. I asked him what in the world he’d done. He said that she was easy to treat and that he just used the same techniques we use all the time, such as the Daily Mood Log, Identify the Distortions, the Paradoxical Double Standard Technique, the Externalization of Voices, the Acceptance Paradox, and several others.

It dawned on me that once again, I had succumbed to a “depressive trance” without realizing it.

Now my colleagues at the Feeling Good Institute in Northern California have created a similar intensive program for people from around the country who want to commute it for short-term treatment. For more information, go to the FeelingGoodInstitute.com website.

Or, to learn more about how to defeat the negative thoughts that trigger depression and anxiety on your own using self-help techniques, check out one of my books, such as Feeling Good.

Thanks for reading this.  In my next blog I’ll discuss Reverse Anxiety Hypnosis.

David Burns, MD

News Release: When Panic Attacks

The New, Drug-Free Anxiety Therapy That Can Change Your Life
By David D. Burns, M.D.

 “Another masterpiece from the author who helped millions help themselves with Feeling Good: The New Mood Therapy. Dr. Burns’ elegant writing style, compassion and humor translate powerful psychotherapy methods into accessible, practical, and helpful tools for the vast number of individuals who struggle with anxiety.”

—Henny Westra, Ph.D., Associate Professor and Director of the York University Anxiety Research Clinic

Anxiety is the most common mental health problem of all. Whether it’s as mild as shyness and chronic worrying or as severe as Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder, most of us suffer from some type of anxiety. Your doctor will probably tell you that these conditions result from a chemical imbalance in the brain, and therefore drugs represent the best—and only—effective treatment.

Not so, says highly regarded psychiatrist and bestselling author David Burns, M.D. in his new book WHEN PANIC ATTACKS (Broadway Books; June 12, 2007; 464 pages; 978-0-7679-2083-4; $14.95). According to Dr. Burns, there’s no convincing evidence that anxiety results from a chemical imbalance in the brain. Furthermore, every type of anxiety—including chronic worrying, phobias, test anxiety, social anxiety, public speaking anxiety, Panic Disorder, hypochondriasis, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, and Body Dysmorphic Disorder—can be treated effectively and quickly without medications.

Dr. Burns explains that anxiety, like depression, is never caused by reality, but rather from the negative way we think about things. When we’re feeling anxious or insecure, we’re involved in a gigantic mental con but we don’t realize it. Do any of these thoughts sound familiar?

  • “I just know this plane is going to run into turbulence and crash.”
  • “What if my mind goes blank when I give my presentation at work? Everyone will see how nervous I am and think that I’m a complete idiot.”
  • “Why am I so shy and insecure? Other people don’t feel this way. I’m such a loser.”
  • “I feel like I’m about to crack up and have a nervous breakdown.”

In WHEN PANIC ATTACKS, Dr. Burns shows readers how to defeat their fears without having to take pills or delve into the past. He describes 40 powerful anti-anxiety techniques and shows readers how to select the methods that will work best for them. He brings these techniques to life with stories of real people who quickly overcame every conceivable type of anxiety, emphasizing that the goal is not just feeling somewhat better, but complete and lasting recovery.

If you’re worried sick and sick of worrying, if you’ve spent sleepless nights obsessing about your work, family, relationships, or health, and you want to enjoy greater creativity, productivity, and self-confidence, WHEN PANIC ATTACKS is the book for you.