The Dark Side of Clinical Practice–Protect Yourself and Your Clients

The Dark Side of Clinical Practice–Protect Yourself and Your Clients

Do you know how to predict and prevent suicide?

Treating people with depression and anxiety is, for me, and hopefully for you, an incredible privilege, and a source of tremendous personal satisfaction. I feel lucky to have  career that is so amazingly rewarding–but there’s a dark side to our work.

Experts tell us that 10% to 15% of chronically depressed patients will eventually commit suicide, even if they receive the best available treatment. Suicide is a horrible tragedy for patients, their families, and their therapists as well.

The impact can be devastating. Therapists typically struggle with feelings of intense loss, anxiety, failure and shame, and may also face the horrors of a humiliating and enraging malpractice suit which can drag on for years. Family members, friends, and therapists may struggle with this tragedy for years, or even decades, without resolution or relief.

Most therapists avoid talking about patient suicides due to feelings of anxiety, guilt and shame, and the fear of being judged. In case you missed it, you can still listen to David’s August 18, 2018 Feeling Good Podcast on suicide prevention and learn how to protect yourself, your patients, and their families from this horrific outcome.

You will learn what works–and what doesn’t–and you may save patient lives. You may also save yourself from a great deal of grief as well, so you can truly enjoy your clinical work without the fear of losing a patient in this terrible way.

If you want to take a deep dive into this subject, check out this May 15, 2017 blog on Suicide prevention as well. This may be anxiety provoking in the here-and-now, but may save you from far greater pain somewhere down the road!

This blog is part of a new approach I am using to send out blogs on topics of importance, with links to learn more, based on my previous podcasts and blogs. I hope you like it! let me know what you think. In addition, I have to thank a TEAM therapist and podcast fan, Angela Poch, for helping to make this a possibility!


* * *

Coming in May!

TEAM-CBT Methods for Anxiety Disorders–

Step-by-Step Training for Therapists

by David D. Burns, MD and Jill Levitt, PhD

WHEN: Sunday May 19th, 2019, 8:30 am – 4:30 pm PST
(11:30 am-7:30 pm EST)

WHERE: Join us live online or in person
at the Creekside Inn, Palo Alto, CA


7 CE hours available


This workshop counts towards Levels 1, 2 or 3 TEAM-CBT Certification.

WHO CAN ATTEND? Therapists of all levels are welcome

CAN I REGISTER IF I’M NOT A THERAPIST? Sadly, this workshop is geared for therapists. You might want to attend one of my two summer intensives, also listed below. They are geared for therapists, but anyone can benefit from them.

Absolutely! Heal yourself, heal your clients!




You will also:

  • Learn new skills to reduce resistance and boost the motivation to change. This is THE key to the treatment.
  • Learn how to treat all of the anxiety disorders quickly.
  • See actual live videos of the Six-Minute Cure for Severe and Incapacitating Panic Disorder and the Fifteen-Minute Cure for Severe OCD.
  • Practice and master the Externalization of Voices and Acceptance Paradox to overcome your own feelings of inadequacy and self-doubt.
  • Master Relapse Prevention Training for lasting results.

You will love this lively, amusing, and immensely useful day of training with Drs. Burns, Levitt and the Feeling Good Institute Staff. The trainers will use a combination of didactic teaching, live demonstrations, videos, and breakout group practice to enhance skill-building.

This wonderful workshop will stream live and is easily accessible from anywhere in the world on any device with WiFi. To join, just click on the link provided before the workshop.

More than twelve expert trainers will be available to assist
the online participants in the small group exercises!

You can attend in person or from home via Live Streaming

Act fast if you want to attend!

Don’t miss out learning from David Burns, MD,
one of the pioneers of Cognitive Therapy,

and Jill Levitt, PhD, Director of Training
at the Feeling Good Institute in Mt. View, CA!

* * *
Coming this Summer

There will be two awesome summer intensives for you this year!

July 15 – 18, 2019
Calgary four-day intensive
Sponsored by Jack Hirose & Assoc.

July 29 – August 1, 2019
South San Francisco four-day intensive
Sponsored by Praxis


If you can join us, they will be even better!

Solution to David’s Tuesday Tip #3*

Solution to David’s Tuesday Tip #3*

Here’s yesterday’s paradoxical tip #3

Therapists’ perceptions of how patients feel–the severity of symptoms–tend to be extremely inaccurate, at best, but most therapists are not aware of this.

What does this mean? Is it true? And if so, what are the consequences?

Is there a solution to this problem? And what, if anything, does the solution have to do with the first of four “Great Deaths” of the therapists ego?

Here’s Dr. David’s solution

My research and clinical experience have indicated that therapists’ perceptions of how their patients feel, and their patients feel about them, can be (and usually are) extremely inaccurate. What this means, in practical terms, is that a patient may be feeling intensely depressed and even suicidal, and yet the therapist thinks the patient is doing well. Or, the patient may be doing reasonably well, but the therapist thinks he or she is still severely depressed.

This inaccuracy involves all the negative emotions–such as depression, anxiety, and anger–and all the positive emotions as well. But since most therapists do not routinely assess patients’ feelings with brief accurate tests at every session, therapist do no know how “off” their perceptions can sometimes be. And while I do not mean to be alarmist, this can sometimes result in a failure of the therapy, or even the death of a suicidal patient.

In addition, although most therapists feel they are experts at communication, my research and clinical experience have indicated that therapists perceptions of the therapeutic alliance are also typically way off. In addition, many therapists grossly overestimate their clinical and communication skills, but they do not realize this!

To solve this problem, I have developed the Brief Mood Survey (BMS), and require all my patients to complete it in the waiting room before each session begins, and once again after the session is over. The BMS asks patients how depressed, suicidal, anxious, and angry they are feeling “right now,” at the start and end of the session. The comparison of the scores gives therapists an extremely accurate assessment of how effective, or ineffective, the session was.

It is, in a sense, like having an emotional X-ray machine available for the first time. The data are extremely valuable, regardless of whether you are doing psychotherapy, psychopharmacology, or a combination of the two.

At the end of the session, patients also complete the Evaluation of Therapy Session in the waiting, and rate the therapist on empathy, helpfulness, and other important dimensions. This only takes about one or two minutes of the patient’s time and provides the therapist with more invaluable, but potentially shocking, information.

So what does all of this have to do with the first of the four “deaths” of the therapist’s ego? Therapists who use these scales will probably make a number of uncomfortable discoveries, including, but not limited, to these:

  1. Therapists will discover that their perceptions of how their patients feel, and how their patients feel about them, will often be wildly and alarmingly inaccurate.
  2. They will often discover that the session was not at all helpful to the patient–in other words, there was little or no improvement in how the patient felt during the session.
  3. The therapist will likely receive failing grades on the Empathy and Helpfulness Scales most patients at every single session, especially if they are using these scales for the first time.

And that’s what I mean by the “death” of the therapist’s ego. You may discover, to put it in street language, that you suck! It’s happened to me often, and I usually find it painful to discover that my perceptions were off and my efforts were not effective.

But here’s the cool thing. This information can empower you to grow and change your therapeutic approach, so you can begin to deliver true healing. If you review the information with your patients in a warm and open way, it can transform the quality of the therapeutic relationship and vastly boost your effectiveness. And that’s pretty darn cool! I’ve been doing this for forty years, and my patients have proven to be my best teachers–by far!

Well, that’s it for today. Thanks so much for reading this, and if you like my blogs and Feeling Good Podcasts and FB Broadcasts, and the many other free features on my website,, please use your sharing buttons to tell your friends. I am trying to build up my numbers as much as possible, and don’t know a great deal about social media, so anything you can do to spread the word will help.

AND you HAVE BEEN helping a lot already! Last month, (April 2018) my Feeling Good Podcasts with my esteemed host, Dr. Fabrice Nye, had more than 52,000 downloads. That’s a new record for us, so THANK YOU! I’d love to see those numbers soar even higher!


* Copyright © 2018 by David D. Burns, MD.

Coming in less than three weeks!

High-Speed TEAM-CBT for Depression and Anxiety Disorders 

I warmly invite you to attend this fabulous, one-day workshop by Drs. David Burns and Jill Levitt on Sunday, May 20th, 2018. Click on the link above for registration information.

  • 6 CE Credits
  • The cost is $135
  • You can join in person or online from wherever you live!

You will enjoy learning from David and Jill, working together to bring powerful, healing techniques to life in a clear, step-by-step way. Their teaching style is entertaining, funny, lucid, and inspiring. This is a day you will remember fondly!

In the afternoon, you will have the chance to do some personal healing so you can overcome your own feelings of insecurity and self-doubt. David and Jill promise to bring at least 60% of the audience into a state of spiritual and psychological enlightenment, WITHOUT years of meditation. That’s not a bad deal!

You will also leave this workshop with renewed confidence as well as specific, powerful tools that you can use right away to improve your clinical outcomes!

You will LOVE this workshop. Seating for those who attend live in Palo Alto will be strictly limited, and seats are filling up fast, so move rapidly if you are interested. Online slots are also limited.

Jill and I hope you can join us!



Can We Prevent Suicide Attempts?

Can We Prevent Suicide Attempts?

tHi friends and colleagues,

I just received the following email from a therapist who was shocked to discover that her patient was suicidal after reviewing his scores on the Brief Mood Survey. Her intervention likely saved his life.

Patient suicides are not uncommon, sadly, and represent the dark side of our profession. The death of any patient is an enormous tragedy for the patient, obviously, and is devastating for the family and friends as well. Patient suicides can be incredibly demoralizing and anxiety-provoking for the therapist, too. It is imperative, in my opinion, that therapists have the best, state-of-the-art tools for detecting the emergence of suicidal urges so that we can intervene and have the greatest chance of preventing these horrible events.

In two upcoming Feeling Good Podcasts, Fabrice and I will discuss what happened to a psychologist named Harold who thought he did not need to use the Brief Mood Survey to track his patients’ symptoms at the start and end of every therapy session. Like so many therapists, Harold  was convinced that he was sensitive and empathic and really understood how his patients felt with reasonable accuracy. When his favorite patient unexpectedly committed suicide following a particularly “good” therapy session, Harold was understandable devastated. He felt intensely depressed, anxious, ashamed, inadequate, alone, hopeless, and angry. You may find these two podcasts interesting and sobering.

My research and training experience indicate that therapists’ perceptions of how their patients feel (in terms of suicidal urges as well as severity of depression , anxiety and anger) are often way off-base, but therapists don’t realize this because most of them are not assessing assessment scales to track progress at every session. In addition, therapists’ perceptions of how empathic and helpful they are also way off-base much of the time for the same reason. They don’t measure empathy, and most don’t even ask patients to rate how warm and understanding they are.

That’s why I developed tools like the Brief Mood Survey, so therapists can track patient progress in multiple dimensions before and after every therapy session. I believe it’s use represents a major breakthrough in psychotherapy, because it’s like having an emotional X-ray machine to inform the therapist about what’s really going on, and to guide the treatment. Of course, I’m more than a little biased on this point! And the use of the BMS requires lots of courage, because the vast majority of patients are shockingly honest in the way they rate their therapists on these scales, and while the information can be invaluable, and even life-saving, it can also be quite disturbing and threatening to the therapist’s ego.


Hi David,

I just wanted to let you know that I recently started using the THERAPIST’S TOOLKIT and found myself in a similar situation you described. I recently had a patient whose scores were virtually ZERO on the Brief Mood Survey one week (meaning no symptoms at all), so I was convinced he was doing well. However, the following week I was alerted to high scores on your two-question “suicidal impulses” scale, which, to my chagrin, I nearly missed. That’s because I am in a new office with low lighting and I am visually impaired. But when I looked more closely, I discovered there my patient not only had suicidal thoughts and urges, but an actual plan for suicide!!!

Boy was I grateful having on hand the full blown Suicidal Urges Survey and Suicide Assessment Interview, which I proceeded to do in a two-hour session the following day. Just as surprising, his scores following THAT session were all ZERO again (except for Empathy and Self Help:-)

(David’s explanation. Scores of zero on the Depression, Suicide, Anxiety and Anger Scales are the best possible scores, indicating no symptoms at all. In contrast, scores of 20 out of 20 on the end-of-session Empathy and Helpfulness Scales are the best possible scores, indicating that the therapist was tremendous empathic and helpful during the session.)

Although I was/am at least temporarily relieved by the rapid reversal, I can’t say I know how to account for it, since most of the interview was assessment based, unless I just ooze TEAM-CBT without realizing it!

All that came to mind was “Hawthorne Effect.” As an aside, I know the “Suicidal Urges” survey is one of the “experimental” ones, but I saw no scoring sheet; I imagine they generally correspond with the BMS, the higher the worse.

Also, in answer to your query, I for one would LOVE to learn more about the Self-Defeating Beliefs survey and/or any info you impart in this regard. I was focused on that with the patient when I almost missed his staggering scores on the two questions on suicidal impulses. But I would like to return to it, and I will plan to give it for homework on a weekly basis to check his “emotional temperature” which is vitally important for this patient as you can imagine, I will consult some colleagues as well who have expertise in ethics and legal issues.

My TEAM CBT group (with Lynne Spevack) meets tomorrow, and we will focus on Testing, yay! And on Monday I will be starting Taylor Chesney’s TEAM CBT group! Both groups meet 2x/month. If only there were a group that met every day:-)

Meanwhile, I hope you’ve received my check by now for the EASY Diagnostic System which I cannot wait to get my hands on and need it desperately!!! When might I expect to receive the email with this valuable info?

I am enjoying your Feeling Good Podcasts, as well as your Feeling Good Blog and newsletter. I am more than fairly certain, were it not for your inventory (the Brief Mood Survey), I would have missed this potentially life-saving intervention. I’d even done a brand new Intake the week before. Although we do not have the power 100% to prevent a person from committing suicide, if we do not detect it we don’t have a fighting chance. I at least have the peace of mind now that with this knowledge, I can do everything in my power to insure this patient gets all the help he needs and hopefully the right help.

Thank you for being you and your contributions for making such a meaningful difference in the world for our patients and us therapists!


PS I also really appreciated your podcast on anti-depressants, which I LOVED and wasn’t surprised. I’m sure that took tremendous courage, along with your well-intact integrity to speak your truth. I wish more Psychiatrists were like minded. Until there is such a paradigm shift, which I think is coming, such decisions will have to be decided between the patient and their doc largely comprised of big Pharma mentality. who’ve drunk the cool aid, sadly.

Hi Kathy,

Thank you for your enlightening email. I greatly enjoyed reading it, and kudos to you for saving your patient’s life.

You asked about the scoring of the two-item Suicidal Urges scale. I intentionally don’t have a strict numerical scoring key, as I want the therapist to attend to it thoughtfully. There are some guidelines in the massive update to the Therapist’s Toolkit. You probably have it already, but email me if you need it.

The first of the two screening items asks about suicidal thoughts and fantasies. Most depressed individuals will have these thoughts, such as the idea that they might be better off dead, but this is not generally alarming if there are no suicidal urges. Of course, you will always want to back up the survey with some questions to make sure.

The second of the two screening items asks about suicidal urges or plans. Any endorsement of this item is more worrisome, and usually merits a suicide assessment interview, just as you did. In general, you will only have to do this once with any particular patient, and it should ideally be done at the beginning of therapy, at the initial evaluation.

A third thing is to note changes in how the patient answers these two items, since any increase in the scores can indicate the development of increased suicidal urges. And as you say, we cannot 100% prevent suicide attempts in our patients, but the Brief Mood Survey will give you vastly improved information, since you will have the patient’s scores at the start and end of every therapy session.

One additional point, most versions of the Brief Mood Survey ask how the patient is feeling right now, just prior to the start of the session, and once again right after the end of the session. This is so the therapist can find out how effective, or ineffective, the session was. Such information is incredibly valuable! However, you can also ask if the scores reflect how the patient was feeling during the week, between the sessions. This is important, because the patient may have had times when he or she was feeling more suicidal, and this might merit a more intensive interview to assess the risk.

When you receive you EASY Diagnostic System from me (I assume you’ve already don this), you’ll find a structured screening interview for suicidal patients at the end of the diagnostic manual. This can be very helpful. There’s also a chapter in my psychotherapy eBook (Tools, Not Schools, of Therapy) on “The Prediction and Prevention of Suicide and Violence” that can be helpful as well. I have also included that chapter in the upgrade to the Therapist’s Toolkit.

Finally, please give Lynne Spevack my regards. She is a terrific teacher and therapist! I enjoyed catching up with her at the Newark workshop and encouraged her to meet more frequently with her training group. I agree that twice a month is not really enough. Keep in mind we now have three TEAM-CBT training centers in New York (for links, check out my referral page), plus numerous weekly online training groups that therapists around the world can join.

All the best,



If you are reading this blog on social media, I appreciate it! I would like to invite you to visit my website,, as well. There you will find a wealth of free goodies, including my Feeling Good blogs, my Feeling Good Podcasts with host, Dr. Fabrice Nye, and the Ask Dr. David blogs as well, along with announcements of upcoming workshops, and resources for mental health professionals as well as patients!

Once you link to my blog, you can sign up using the widget at the top of the column to the right of each page. Please firward my blogs to friends as well, especially anyone with an interest in mood problems, psychotherapy, or relationship conflicts.

Thanks! David