David Burns Thinks Psychotherapy Is a Learnable Skill. Git Gud.

post by Morpheus · 2024-01-27T13:21:05.068Z · LW · GW · 20 comments

This is a link post for https://podcast.clearerthinking.org/episode/192/david-burns-cognitive-behavioral-therapy-and-beyond/

Contents

  TLDR
  David Burns on Teaching CBT
  Example of the Mood Survey
  Relapse Prevention Training
  Empathy Training in Tuesday Session
  Performance of His Colleagues and the Feeling Good App
  Conclusion
None
20 comments

Epistemic status: I listened to this, and I found these statements surprising in a “big if true” way. It didn't seem obviously false, but I am very much relying on him here. If someone thinks his claims are completely made up, please let me know in the comments.

TLDR

David Burns claims in this podcast episode, with deliberate practice, he and a few of his students got to the point to learn to cure patients in a single or just a few sessions. David Burns is known for popularizing CBT through his book “Feeling Good”. 

The quote in the next section is most important. The rest of the post contains other quotes I found interesting. Some of them are pretty long. Feel free to skip things. The transcript was generated with whisper, so there might be mistakes. You can find the whole transcript here.

David Burns on Teaching CBT

David Burns: I've realized that probably of the 50,000 people I've trained, you know, with, I mean, trained, I'd say someone who spent at least two days in one of my full day, you know, two full days with me and learning cognitive therapy, the new TEAM-CBT. There's probably only been 10 or 15 who have been able to learn it. I've illustrated it on this program.

Spencer Greenberg: Wait only 10 or 15 of many thousands have been able to learn it?

David Burns: They have developed the same level of skill. It means, you know, a lot of people are doing it. There's a feeling, there's a feeling good institute in Mountain View, California. And they probably have 40 or 50 therapists associated with them. But there are wide ranges of skill levels and the ones like may or the ones when I work with people, I think you should be able to complete a course of treatment for depression in a single therapy session. It has to be two, it takes me two hours to do it, but it happens.

Spencer Greenberg: That's a pretty amazing claim, right, that you could treat someone in two hours.

David Burns: I mean, yeah, yeah. And when I was young, I would have thought it was impossible. And I used to dream about it and say, would there be some way to get really good at psychotherapy? And I said, we'd have to measure things and nobody's measuring anything because athletes, when they practice like for basketball, every time they throw the ball up, they can see whether or not it goes through the hoop. So they learn really fast, but we weren't measuring anything. And I did a research study at Stanford inpatient unit to see how accurate therapists are and understanding how their patients feel. I gave you an example where my judgment of the patient was way off, but I had the scales that told me that immediately at the end of the session so I could correct the error. And that's how my own skill has developed so rapidly because I've ever since 1980, I've never had a single patient that I didn't measure their depression level and other things at every single therapy session and that information.

Example of the Mood Survey

I have all the the patients take this brief mood survey that I've developed. And they can fill it out in 30 seconds. And then I could look at their score and see exactly how depressed they are, how suicidal they are, how angry they are, how anxious they are. And you know, measures like that. So I can see right away, even I don't know the patients, I can see exactly how upset everyone was. And so this woman had was very high on the depression and suicidal urges were high and the anxiety was high and the anger was extreme. 

And she she said, could I help her work with her during this session. And I was so proud of how I was doing. And I used a powerful technique called externalization of voices and showed her how to blow her negative thoughts out of the water. And at the end of the at the end, I said, well, here's boy, I've done such brilliant work today. This is someone I could talk about in a workshop or a podcast someday with Spencer Greenberg. I could talk about the magic I did even with the most severe in patients in a single hour really. And at the end, I have all the patients fill out their scores again and and hand them in to me as they're walking out of the the room for the cognitive therapy group, the hour and a half group. 

And when she handed it, her piece of paper to me and I looked at it, I was shocked because I thought all of her scores would be zero on the on the depression and anxiety. Instead, they had gone to the other extreme indicating the most severe depression a human being could have, the worst suicidal urges a human being can have, the worst anxiety, the worst anger she was enraged. And that I turned the piece of paper over to over to see my empathy ratings. 

And on the empathy scale goes from zero to 20. And a score of 12 would be like what Hitler could get. Like that's a bet, that would be a horrible score. Unbelievably bad. Well, I think she gave me a zero on empathy and a zero on healthfulness. And I couldn't believe it. I took her aside and I said, Margaret, this is part of a research study and it's easy to get confused when you take these scales on the mood scores. The good ones are good answers are on the left, the zeros and on the empathy and healthfulness, the good ones are on the right, the four, four, make could you correct it because we don't want to mess up the database. And she looked at her, because I couldn't believe that those were valid scores. And because she'd, I thought she'd done so great. And she said, no, there's no mistake here, doctor. And I said, what are you talking about? I thought it was a fantastic session that we had. And she said, well, good for you, maybe. And I said, what are you talking about? What, what happened? 

And she said, well, when you said that I'd had a double whammy, that really hurt my feelings and I thought you were making fun of me. Well, I had, I had used that expression. You've lost your husband and your work, the two sources of self-esteem. I said, that's like a double whammy, but she thought I was making fun of her. And I had no idea. And I said, let's sit down and talk about this. I'm, this is just devastating. And I can imagine how hurt and angry you feel. And took maybe five minutes to work that through and develop that warmth and trust. But therapeutic failures, therapists don't even know when they're acting lame. And that, but if you, if you use these kinds of scales, the patients will be honest with you and you'll find out right, right away. And if you have the courage to do it, your patients can become your greatest teachers of all.

Relapse Prevention Training

And then I do relapse prevention training, which takes about 20 minutes. It could be at the next session or at the end of the first, you know, session. I just sometimes I wait a day or two and then do the brief relapse prevention training. And then they're done. And that's how it works.

And what do you teach during the relapse prevention? Well, there's three things. First, I say it's a hundred percent certainty that you're going to relapse. No one is entitled to be happy all the time. All you're entitled to is five happy days per week and two miserable days. And if you don't have your five happy days, you need a tune up. So you better call me and come back for a little mental tune up. But if you don't have your two miserable days, you're getting too happy. So that's a concern also. But they went I say when you relapse, it could be tomorrow. It could be three weeks from now. It could be anytime. But everyone has the same exact thoughts. You'll tell yourself my improvement was just a fluke. The treatment wasn't real. Burns is a fraud. I'm a hopeless case after all. I'm worthless after all. This proves that the therapy didn't work. And I have them write those thoughts down on a piece of paper, then identify the distortions in them because right now they're feeling happy. So it's easy for them to crush those thoughts.

For example, instead of telling yourself, this proves that the therapy didn't work. You can they might come up with a thought like, "No, the therapy was amazingly helpful. But last night I had a fight with my partner, went to bed angry. And I woke up today feeling worthless and miserable and hurt and alone. And maybe it's time for me to pick up the tools again and use them." And then I say, "How is that?" Well, they say, "Oh, that's tremendous. You know, and they can easily crush these thoughts when they're in a good mood before it comes." And I roleplay the thoughts with them and say, "No, I'm your negative self. And I want you to know that you know, that the treatment didn't work because you're so depressed today. The treatment was superficial. It wasn't deep enough." And then see if they can crush it. Maybe they can say, "No, the treatment was fantastic. My only mistake is listening to your bullshit right now. It's I'm upset. I have a right to be upset. And I'm going to see what I can do to deal with this situation. And I have plenty of tools to deal with that."

I have one thing I can tell my partner that I love them and that I felt badly about our argument. And let's talk it over. And I can also talk back to these ridiculous distorted thoughts I'm having right now. So that's how it goes. And it's there. It's easy for them to do that. And I have them record that on their cell phone as the easiest way and say now when you relapse, make sure you have this recording available so you can listen to it. And if you have any trouble, just call me and you can come in for a tune up. I give lifetime guarantees on my work. I'll give you three unlimited tune ups for the rest of your life if you ever need me again. And I hope you will because if you don't relapse and need me, I'll never see you again. And I've really come to like you and feel very proud of you and affection towards you. And I'm sad to lose you now, but I wouldn't have it any other way because you're feeling joy now. And that's the greatest thing for me to have you recover really rapidly. And the 40,000 hours of patients I had, I don't think more than eight or ten ever contacted me for tune ups.

 

Empathy Training in Tuesday Session

Deliberate practice sessions, in which they meet every Tuesday and role-play an interaction with their most challenging patients:

I mean, therapists, we have very rigorous empathy training techniques so that therapists can learn to get to perfect empathy with almost any patient within 30 minutes of the first time you meet with the patient. So what that means is the patient gives you an A, not that you give yourself an A. Because the way you grade yourself will rarely be similar to the way the patient grades you. So it's about how the patient feels, how you're doing.

How do you teach people the empathy? That might surprise the listener. How do you actually learn that? Well, the way I do it, it's pretty challenging. I would say for the therapist and they don't all have the courage to do this type of thing. But in the Tuesday group, I might say, what is the most critical, challenging, threatening patient imaginable? What would that person say to you or what have patients said to you? And they list things like, oh, patients tell them things like, "You don't really care about me. You're not really helping me. You don't really understand how I feel inside," things of that nature. [...]

I train them on the worst things that someone might say to them because if you can handle that, you can handle anything. And the techniques are, it's EAR, empathy, assertiveness, and respect. There are three empathy techniques. That's the disarming technique, which means finding truth in what the patient says, even if it seems unfair or exaggerated. And it's based on what I call the law of opposites. The law of opposites is, if you agree with a hostile criticism and you genuinely agree that it's totally correct, the person will instantly stop believing that. And that's a paradox. So let me repeat it. If someone gives you a horrible criticism, like let's say it's someone on the inpatient unit who's been involuntarily hospitalized, and say a teenager who's trying to get out of the hospital to kill someone or to kill themselves. And they might shout at you, "You're a jerk. You don't care about me. You're like a probation officer," something like that. And you know, what could the inpatient doctors say? How could you agree with that? You see, because if you agree with it, the person will stop believing it. So you might say something, you know, "I feel the same way you do. I absolutely haven't been helpful to you. I haven't been understanding how you're feeling inside. And I really am kind of like in the role of a probation officer. And I hated as much as you do. It's not the way I want to relate to you. And I can imagine you're mad at me and pissed at me and pissed at the inpatient unit. You're here involuntarily. And you want me to let you out. And yet, I understand you told the nurses this morning you want to get out so you can kill yourself. Get out of the hospital. And I can tell you that I care about you. And if I let you out and you killed yourself, I don't think I could live with myself. But at the same time, I'm feeling pretty stupid like I really haven't done a good job with you. And you have every right to be pissed off at me." That would be like the disarming technique. And when you say something like that, the patient melts in your hands. Here is somebody's finally listening, finally hearing me. But that's the disarming technique. And it's like a magical technique. But it's hard to learn because it requires the death of the therapist's ego or a normal person can do it. You don't have to be a therapist, but it requires the death of the self. That's one of the four great self, great deaths that the Buddha talked about. Well, he just talked about the great death, but there's actually four great deaths. And this is the death of your ego to hear the anger that's being directed at you.

Another thought in feeling epithetia paraphrasing the patient's words, acknowledging how the patient is probably feeling based on the words you're saying "I don't understand you." And you're right, I've done a shitty job of that. And I can imagine how angry you might be feeling and hurt and kind of disillusioned. "Tell me more about that. Am I on the right page? Am I reading you right right now?" And that would be like thought empathy, repeating their words, feeling empathy, acknowledging their feelings and inquiry. "Am I getting it right?" Those would be the three empathy techniques disarming, thought and feeling empathy and inquiry.

And then there's, "I feel" statements would be assertiveness, sharing your own feelings. Like "I feel really sad and a bit ashamed to realize that I've failed you so badly, but you're right. And at the same time, I'm thinking that this could be a chance
 

Performance of His Colleagues and the Feeling Good App

My colleagues, my some of my students who are the real, have developed tremendous expertise, say that they'll typically see patients for three or four or maybe five sessions. And it's a problem for them economically because their patients get better so fast. So it's hard to keep their practice full. If you have the old-fashioned thing where people just come and talk to you for hours and months and years or even a decade or more, you don't need to get new patients. But the, you have to get a lot of new patients with these new techniques because they work so rapidly. But it generally works out because the word gets around that so and so has these phenomenal, phenomenal skills. So they get it start building, you know, a tremendous following after, you know, a year or two and the word get gets around. 

With our feeling good app, which we hope to be releasing probably in October or November and through there. And we're doing beta tests. If any listeners want a beta test, you know, it's free and it'll always be free if people can't afford it. We see pretty tremendous improvements in people with the, with the feeling good app and roughly two days. We see like a 50 to 60 percent reduction in seven negative feelings, feelings of depression, anxiety, guilt, shame, loneliness, hopelessness, anger. But that was, it are pre-artificial intelligence phase with the app. We're now creating artificial intelligence David in the app. And it's hard to say, to tell the difference between being treated by me live and being treated by the app that we're training because it's learned to do kind of exactly what I do. It just works faster than I do. And so we're, we haven't beta tested it yet. We'll be beta testing it within the next few weeks.

I applied for beta-testing, but it is currently only available on iOS. 

Conclusion

It seems pretty clear that David Burns is probably exaggerating a bit. But even if just a weak version of his claims is true, it seems like getting a really skilled psychologist would be worth it, even for a high price premium. Anyone knows a psychologist like that? Thank you in advance for your comments!

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