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?”
Harold
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
References
Antonuccio, DO, Burns, DD, & Danton, WG. (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
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.
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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 Psychology, 58, 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 Psychology, 55, 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 Bulletin, 108, 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 Psychiatry, 41, 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 Psychotherapy, 13(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 Psychology, 47, 427-439.