January 11, 2024
What was therapy like in the years leading up to the advent of CBT? Has CBT now been over-sold? How does CBT differ from "the power of positive thinking"? How can therapists who use CBT avoid invalidating clients' feelings? When, if ever, should people listen to their negative thoughts? To what extent can a person's good qualities contribute to their depression? Can empathy be learned? Is it possible to cure depression in a single psychotherapy session? What is TEAM-CBT? Is exposure therapy cruel? What are some strategies for silencing the voices in our heads that lead to depression, anxiety, and other negative mental states?
David Burns is Adjunct Clinical Professor Emeritus of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine, where he is involved in research and teaching. He has previously served as Acting Chief of Psychiatry at the Presbyterian / University of Pennsylvania Medical Center (1988) and Visiting Scholar at the Harvard Medical School (1998), and is certified by the National Board of Psychiatry and Neurology. He has received numerous awards, including the A. E. Bennett Award for his research on brain chemistry, the Distinguished Contribution to Psychology through the Media Award, and the Outstanding Contributions Award from the National Association of Cognitive-Behavioral Therapists. He has been named Teacher of the Year three times from the class of graduating residents at Stanford University School of Medicine, and feels especially proud of this award. In addition to his academic research, Dr. Burns has written a number of popular books on mood and relationship problems. His best-selling book, Feeling Good: The New Mood Therapy, has sold over 4 million copies in the United States, and many more worldwide. When he is not crunching statistics for his research, he can be found teaching his famous Tuesday evening psychotherapy training group for Stanford students and community clinicians, or giving workshops for mental health professionals throughout the United States and Canada. Learn more about him at feelinggood.com.
JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you joined us today. In this episode, Spencer speaks with David Burns about cognitive behavioral therapy and the TEAM technique.
SPENCER: David, welcome.
DAVID: Thank you. I'm excited to be on your show, and honored.
SPENCER: Well, I'm so excited to have you on. You probably don't realize this, but you were such a huge influence on me because I read your classic book, "Feeling Good," about cognitive behavioral therapy when I was a young man, and it just had a profound impact on my life. It really got me to think differently about my own thoughts and my own emotions. I found it incredibly useful. I ended up going to a CBT therapist after reading the book because I was like, "Wow, this is amazing." And it also started my journey really thinking about psychology and getting really excited about it. So yeah, it's just very exciting to be talking to you for the first time.
DAVID: Well, that's great. It was my pleasure. I'm just thrilled.
SPENCER: And for the audience members that have not heard your name, you are really one of the people that popularized cognitive behavioral therapy, also known as CBT. Before that, it was kind of a fringe thing. So why don't we start there? What was therapy like back in the day when you published "Feeling Good"?
DAVID: Well, I had been doing cognitive therapy for a few years. I had left my full-time position at the university after my residency, I was supposed to stay on at the medical school, and I got a grant from the federal government to develop a brain chemistry research laboratory because everyone was saying that depression is due to some chemical imbalance in the brain. And our research gave powerful evidence that that was absolutely not true. And clinically, I saw that what I was doing wasn't helping people. While I was giving out antidepressants by the bushelful, I would just say to people, "Tell me more." We were just supposed to encourage people to talk and give them pills, and I almost never saw anyone really recover from depression. And then I heard about Aaron Beck's cognitive therapy, and the department chairman says, "Why don't you check this out? He says that depression is due to negative thinking." And I said, that sounds really stupid. It sounds like Norman Vincent Peale's "Power of Positive Thinking." And he said, "Well, why don't you just go to his weekly seminar, and then you can try it with your patients and prove to yourself that it doesn't work?" And I said, "Yeah, that'd be kind of cool." So I started going to his weekly seminar, and there were only about seven of us, or five of us. Maybe in a big week, we'd have 12 people there. And I would take my most difficult patients and present them and say, "I have this woman just referred to me from the intensive care unit. She's an elderly woman who attempted suicide and she survived. They've sent her to me for follow-up care. What should I do?" And then I'd get input back, "Well, try this," and I'd go and try it, and usually it was very effective. I became amazed and I said, "Wow, this is for real." So I said, "I don't want to do that brain chemistry research and handout pills, pills, pills. I want to do something that will help people change their lives and go from despair to joy." And so that's what it was like in the early days, was helping people identify these distortions in their thoughts and make them aware that your thoughts create all of your emotions, and you can change the way you feel. It was just a very exciting, giddy time, and then after 'Feeling Good" came out, it began to spread. And as you know, it's now the most widespread — cognitive therapy — form of therapy in the world. And so we were successful in popularizing cognitive therapy. Now I'm trying to get people to think in new dimensions, because we've gone further ahead; that therapy has morphed quite dramatically. But I still use the early cognitive therapy techniques I learned and developed and continue to develop this very day.
SPENCER: And for those who don't know, Aaron Beck is considered one of the fathers of cognitive behavioral therapy so David was working directly with one of the originators of the method, which is so cool. One thing you mentioned, this idea of the power of positive thinking, I think people can confuse that with CBT. So maybe you could break down: how does what cognitive behavioral therapy tells you to do differ from just, say, thinking positively?
DAVID: Well, telling people to think positively is never helpful. It's not a technique I've used. I've learned or developed over 100 techniques to help people crush the distorted thoughts that cause the misery that we all have. But what you have to do is get someone to the point where they suddenly see that what they were telling themselves is actually not true, and in that very moment, the person's feelings will suddenly change. And the first idea of it is, you think the way you feel, and that goes back to Epictetus 2000 years ago. He's a stoic philosopher, a Greek guy, and he said people are not disturbed by things or events but by the views we have of them. In other words, your thoughts create all of your feelings. That's been controversial for 2000 years and we've just recently got some data that helped us test that scientifically, with data from an app I've been developing. To make it simple for the listeners, you can probably recognize these negative thinking patterns in yourself. Maybe you have had the thought, "I'm not good enough. I'm not smart enough. What's wrong with me?" Or maybe you're shy and anxious around other people. I had that problem for an awfully long time. A lot of times, people who are shy and anxious are also ashamed, saying, "What's wrong with me? I shouldn't be so anxious. Other people don't have this problem." Or you have public speaking anxiety and you're saying, "I'm just gonna blow it when I get in front of the audience. My mind will go blank." Or when you're feeling down, you tell yourself, "I'm a hopeless case. I'm an inferior human being. There's nothing special about me." And the first thing is to help people identify the thinking errors or cognitive distortions in those thoughts, and then help them smash the thoughts, prove to yourself that they're not valid. The original cognitive therapy worked like that. Maybe I can think of an example. I have my weekly teaching group at Stanford and it's free to clinicians from all over the world. If any of them want to join our group, they can. We meet for two hours every Tuesday night and teach clinicians these new techniques. But one of the first patients I presented to Beck was this woman, and it was sad. She had attempted suicide and she survived the suicide attempt. And so I said to Dr. Beck, "How can I help a suicidal patient? She's pretty serious. I present her case in the weekly training group that you've got here, and I tell her what you said." And Dr. Beck said, "Well, ask her how she was thinking the moment she tried to kill herself, because thoughts create all of our emotions, all our positive and negative emotions. So what was she telling herself?" So I said, "Ah, that makes perfect sense." So I was so eager to see her the next week, and she said, "What did you learn in the seminar?" And I said, "Oh, Dr. Beck said that I was supposed to ask you what you were telling yourself when you tried to kill yourself, because your thoughts create all of your feelings." And she said, "Oh, I was telling myself that I'm a worthless human being because I've never accomplished anything in my life. And all I've done is clean people's houses and scrub their floors. And there's just nothing special about me. And I just feel like a failure as a human being, and worthless, I feel worthless. And that's why I tried to kill myself. So what should I do about it?" And I said, "Oh, gosh, I don't know. You'll have to wait another week. I'll go back, I'll ask Dr. Beck and I'll tell you what he tells me." So I went back and Dr. Beck said, "Well, tell her to make a list of things she has accomplished in her life." And I said, "Ah, that makes perfect sense." So I went back to her. And she said, "What did Dr. Beck say?" And I said, "Well, he said to ask you about some of the things you have accomplished in your life." And she said, "Well, see, that's my problem. I haven't accomplished anything except scrubbing people's floors and cleaning their houses. That's all I've done, a cleaning lady." And she said, "So what should I do?" And I knew so little about this new cognitive therapy at the time, and so I said, "Well, maybe you can take it as a homework assignment," because that was another thing; we were assigning homework to our patients to do between sessions. I said, "Maybe you can think of something you've accomplished and then put it on a list and you can bring it to our next session." So she agreed to do that. The next session, I went back and I forgot to ask her about her list. And I asked her about her antidepressant because I was still prescribing antidepressants and foolishly hoping they do a lot for people (which they rarely did) and getting them to talk. And so we're halfway through the session, and I was listening, and she was talking. And then she said, "Well, did you want to ask me about my homework?" and I said, "Oh, I forgot all about it. Were you able to list anything?" And she handed me a piece of paper with about 10 things on it that she listed. And the first one, she said, "I forgot that almost all of our family died in the concentration camps in Germany, but I managed to escape with my children. And I got them to the United States and saved their lives. My husband died in the concentration camp. Everyone else died," and she said, "So I thought maybe that was an accomplishment of sorts. And then I thought, once we got to the United States, I started working cleaning people's houses and scrubbing floors, and I was able to get a roof over our heads and food for my boys and a place to sleep at night. And so I thought, well, maybe I could give myself credit for that." And then she said, "My son just graduated first in his class at Harvard Business School. And so that seems like a good thing, too." And then she wrote down, "I forgot that I speak five foreign languages fluently." And that she wrote down, "And I'm a gourmet chef," and there were just tears going down my cheeks. I said, "Well, how do you reconcile that with the idea that you're a worthless human being?" And she says, "Doctor, it doesn't make any sense what I was telling myself. It just doesn't compute at all." And I said, "Well, how are you feeling now?" She says, "I'm suddenly feeling a lot better. Do you have any more of these techniques?" I said, "Well, you'll have to wait another week. I'll ask Dr. Beck and I'll learn another one. I've been learning one technique each week, and that's the first one I've learned." So that was the story of how it all started. And suddenly, I saw people going from tears to joy, and I wanted to spend my life like that, not handing people pills and seeing few or no changes. It was very, very exciting. But over the years, like everything, there were strengths in the early cognitive therapy, there were weaknesses, and it's evolved. I've done a lot of research. I've had over 40,000 hours of treating people with severe depression and anxiety from all over the world. It's been a tremendous adventure to evolve psychotherapy to where now, it's even vastly more powerful and effective than the techniques we had in the early days of cognitive therapy. I might say, just to illustrate her point though, that you see, she was involved in thinking errors, and one would be called mental filtering. She's focusing on the negatives in her life and discounting the positives, overlooking what was beautiful about her and her life. She was also involved in a distortion called emotional reasoning, reasoning from her feelings. She felt worthless so she thought, "I must be worthless because I feel worthless." And she was also thinking, "I feel hopeless so I must be hopeless." And then she thought of suicide as the only escape from her pain. But there's ten or 12 of those thinking errors, and I just found it philosophically mind-blowing that depression results is a lie and anxiety is based on lies, too, that you're telling yourself things that are not true, but you don't realize you're fooling yourself because thinking errors are very subtle. And so people are as sure as the fact that there's skin on their hands that they're worthless and hopeless human beings, and when they discover that that's all a hoax, that that's not true, it's one of the greatest feelings in the world, being flooded from tears and worthlessness to joy. It's incredible, and it's incredible for the therapist, too, to give people that experience.
SPENCER: One thing that really impressed me about CBT when I first learned about it, was that I could start to notice it in my own mind. So yes, there were the studies, and those were very impressive. But additionally, I could start paying attention to what's going on in my mind. And I could start to notice, "Hey, you know, when I'm feeling emotional, I'll believe something. And then later, when I'm feeling better, I'm like, 'Of course, that's not true.'"
DAVID: Yeah. It's amazing, isn't it?
SPENCER: It really is. And if you start being mindful about your own thoughts, you start seeing these tricks your mind plays on you.
DAVID: Yeah. oh, yeah. It's really incredible. It's enlightening and a lot of people don't believe it. They don't grasp it. They fight against this idea, but I saw it in myself. My wife is a clinical psychologist — she's the brains in our family — and she saw it in herself, too. And we use these ideas in our own lives and the lives of our children. And I never would have committed my life in this direction if it hadn't been for that. I remember, once, I presented a patient to Dr. Beck in one of the seminars. The patient was coming to the clinic at the University of Pennsylvania Hospital. And I think he was behind in his bill or something like that, and I said something about it and the patient got upset. And so I told Dr. Beck and he said that you didn't handle that properly at all, and what you said probably hurt your patient's feelings, and he gave me some other idea how I should have handled it. And I panicked. Here's this great man telling me that I'm just out of my residency and I'm screwing up with a patient. And I went home on the train going to Bryn Mawr from Philadelphia, the 30th Street train station there, and I just started feeling worthless. And I was telling myself, "I'm a terrible human being. I'm a horrible therapist. They'll probably take away my medical license. I won't be able to practice in Pennsylvania. I have no future in psychiatry." And those thoughts seemed absolutely true. And then I told myself, there must be some distortions in those thoughts. And I say, "Oh, no, this is the truth. I'm seeing the truth about myself for the first time," and it was just horrible. And I got home. These were the days where they were talking about exercise helps and boosts your brain endorphins. That all turned out to be a lot of bullshit, by the way, but we were thinking that was true. So I went on this severe six-mile run with real steep hills, and I thought that'll get my brain endorphins up, and I'll feel better. But the farther I ran, the faster I ran, the more negative my thinking became. And it was like an absolute truth that I was a worthless human being. It was like I was seeing it for the first time and I was thinking, "How could I have spent my whole life not realizing how horrible I am?" And of course, I was involved in all-or-nothing thinking — that's another common thinking error: one mistake and the whole is ruined — but I didn't see it as a thinking error. That is how I was thinking. And hidden should statements: I should never screw up, I should be perfect, I should always do the right thing for patients. And then emotional reasoning again: I feel worthless so I must be worthless. And self-blame: beating up on myself instead of treating myself with compassion or understanding. And magnification and minimization is another one: magnifying how awful this error I made with the patient. So when I got home from the run, I was in even worse depression than when I started. And then I told myself, "Well, David, why don't you do what you tell your patients? Write your thoughts on a piece of damn paper and look at them and see if there's any thinking errors." Then I thought, "Oh, no, no, this is true. I really am a horrible human being. It's just a fact." And then I said, "No, David, write it down on a piece of paper and see if there's any thinking error." So I said, "Okay, I'll write it down. But this is bullshit." And so I wrote down my three or four thoughts: I'm a worthless human being. I screwed up. They're gonna take away my medical license. I have no future. And then I said, "Now are there any thinking errors here? I have no future. Well, that's kind of fortune telling, isn't it? Yeah. How do I know I have no future? And then I'm a horrible human being. Well, that's all-or-nothing thinking there. How horrible can you be? You were asking the guy to pay his bill and you didn't do it properly, but it's not like you killed him or something." And then I started asking...I found all these thinking errors in my thoughts. And then I said, "Is there any other way to think about it?" And I said, "Well, maybe I could just tell myself, I'm a beginner, I'm a young man. And I have the right to make mistakes and to correct those mistakes and learn from my mistakes. And I can be kind to myself, and I'm going to see the patient again tomorrow and I can tell them. "Hey, Mack, I feel you had a terrible week because I screwed up with you last week and I really hurt your feelings. I said the wrong thing and my supervisor scolded me. I am just so glad that you came back for another session and I can imagine how hurt and angry you feel, and disappointed. Let's talk about it." And he just started crying and he opened up and we had the best session ever. And then at the end of the session, he gave me a perfect score on the empathy scale and the helpfulness scale. He said it was a tremendous session. But it was the same thing that you said, Spencer, that when you experience these things yourself, you suddenly see something that you never saw before, and it's an amazing experience.
SPENCER: Now, that's a great example. I've found that one common thing that bothers people about CBT sometimes is, they think that they're being invalidated, like if some really bad thing happened to them, legitimately really a bad thing. Let's say they discover their spouse is cheating on them. They feel horrible, right? And then they say, "Well, what are you talking about? It's not just my thoughts. This really bad thing happened to me. Don't invalidate my emotion by telling me it's just my thinking."
DAVID: Yeah. And that's one of reasons I started evolving and changing cognitive therapy and morphing it into what we now call TEAM-CBT. But that's just one of many, many errors that therapists make, cognitive therapists and probably other therapists as well. But it's irritating when you see people make such stupid interpretations of a new development and use it in a corrosive way. But the first thing that you have to do when somebody is upset is to empathize and say, "That's a horrible thing that happened to you and I feel sad, too. I can imagine how angry and hurt you must be feeling. And tell me more about that," and getting on the same page with your patient in a kind and compassionate way. And kindness and compassion will never cure anyone of anything. But if you don't have it, you're gonna lose that patient and look like a stupid jerk right off the bat. But I've spent my life, I've trained over 50,000 therapists with my workshops in the United States and Canada. I've done two-day workshops for therapists and four- or five-day workshops for therapists and I've been teaching at Stanford, too, ever since we came back to California, and therapists make all kinds of horrible, horrible mistakes and it's sad. I still make mistakes myself. But I get scales for my patients that they rate me at the end of every session, how empathic I was. And the scales are very sensitive to the slightest therapeutic failures. And how helpful was the session and again, the scale is very sensitive to therapeutic errors. So when I'm making errors, I find out right away so I can correct them at the next session with the patient. I had a patient I saw at the Stanford inpatient unit. I developed a daily cognitive therapy program for the Stanford inpatient unit because all they were doing was electroconvulsive therapy and medications. And once I got the program, I did it for my volunteer work. I'm on the volunteer faculty at Stanford, I'm an unpaid faculty. I love teaching so I just do it for free. But I developed this program and once I got it going, I went in once a week to run the inpatient group (although it was daily), and teach. The nurses would come and see how to do it, how to work with cognitive therapy with these very severe patients. I remember one day, I was working with a woman who had had two horrible blows in the same week, and she was admitted for severe depression and suicidal urges. One, her husband told her that he was leaving her and, on the same day, she was fired from her job. And she had the thought, "I'm a worthless human being and I should end my life." And at the beginning of the groups, I have all the patients take this brief mood survey that I've developed; they can fill it out in 30 seconds. And then I can look at their score and see exactly how depressed they are, how suicidal they are, how angry they are, how anxious they are, measures like that so, even though I don't know the patients, I can see exactly how upset everyone was. This woman was very high on the depression, and suicidal urges were high, and the anxiety was high, and the anger was extreme. And she said, could I help her, work with her during the 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, I said, "Well, 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 can talk about the magic I did even with the most severe inpatients in a single hour really." And at the end, I have all the patients fill out their scores again and hand them in to me as they're walking out of the room for the cognitive therapy group, the hour-and-a-half group. And when she handed 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 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. I turned the piece of paper over to see my empathy ratings. The empathy scale goes from zero to 20. A score of 12 would be like what Hitler could get; that'd be a horrible score, unbelievably bad. Well, I think she gave me a zero on empathy, and a zero on helpfulness, 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 answers are on the left, the zeros. And on the empathy and helpfulness, the good ones are on the right, four. Could you correct it because we don't want to mess up the database?" Because I couldn't believe that those were valid scores. 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 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 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. 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 — but if you use these kinds of scales, the patients will be honest with you, and you'll find out right away. And if you have the courage to do it, your patients can become your greatest teachers of all.
SPENCER: For those who might have had a not very good introduction to CBT, or worked with a not excellent therapist who had this idea that CBT does invalidate your feelings, could you help them understand the distinction between when CBT is saying that your thoughts create your feelings, how is that different than invalidating the fact that that really was a bad thing that happened?
DAVID: I had a colleague come to me for emergency treatment, and she allowed me to record it and actually published the session as a podcast. Marilyn Coffee was her name, clinical psychologist and someone who'd had a pretty hard life, but she had just beautiful empathy skills and worked with the most severe people and was very kind and giving. She said, "David, I went to my doctor yesterday, and he said I have stage four lung cancer. I'm devastated because I've never smoked and I feel in perfect health." And so I did a live session with her and part of it was, first, empathize and how horrible this is and how much we all love her and care for her. And she feels devastated and 100% angry and 100% anxious and 100% lonely and abandoned, and just awful. And I don't move on in this session until the patient gives me an A or an A plus on empathy. And I say after 20 minutes or so, maybe 30 minutes, "What grade would you give me on empathy in terms of understanding how you're thinking, understanding how you're feeling, and accepting you, giving you a sense of acceptance?" And if you can get an A or an A plus, then you can go on, but if you don't get an A — if you get an A minus or a B plus — then you still haven't understood the patient, you say, "Well, tell me the part that I missed." But at any rate, I had a co-therapist, Matt May, one of my former students at Stanford and now a superb local clinician, I think probably one of the finest psychiatrists in the world. I'm certain he is. We did co-therapy and recorded it and then we say, "Now what would you like help with today? Is there something you want help with?" And she said, "Well, gee, all these negative feelings. I'm feeling ashamed. I'm feeling devastated. I'm feeling hopeless." All of her negative feelings were at 100. She had nine different categories of negative feelings at 100, and said, "Well, now, what would you like if we could work a miracle here today? What miracle would you be hoping for?" And she said, "It's impossible because something real happened. The cancer is not a cognitive distortion, and I'm gonna die." "Then what would you want in the session?" She said, "Well, if there's some way that I could at least be not feeling so down and horrible." And then before we try to bring about that, I said, "Suppose we have a magic button and if you pressed it, all of your negative thoughts and feelings would instantly disappear with no effort and you'd go into a state of euphoria, would you press that magic button?" And just like every patient, she said, "Oh, I'd press it in a heartbeat." I said, "Well, we don't have a magic button. But I do have some pretty magical techniques and probably could give you tremendous, tremendous relief today, maybe make all of your negative feelings disappear. But I don't think that would be such a good idea." And she said, "Why not? Because that's what I need, David." And I said, "But you see, maybe these negative feelings are actually showing something beautiful and awesome about you and your core values as a human being and maybe they're helpful to you in some way. And why don't we take a look at that before we try to make them disappear? What does your sadness show, Marilyn, about you that's beautiful and awesome?" And she said, "Well, maybe it shows my love of life," never married or found a loving partner in her life, but she had a very close contact with her dog, with people who were struggling, whom she would help. She was a devout Catholic, used to go to masses every day, always giving, and she'd go to meditation retreats. She says, "It shows my love for life." And I said, "Is that true?" She said, "Absolutely!" I said, "Is that important?" She said, "Absolutely!" "And then you're very angry. What does your anger show about you that's positive and awesome?" And one of her negative thoughts was, "I think I've been duped by some of my spiritual mentors. I think they were frauds, some of these Catholic priests," and I said, "Well, you're 100% angry. What does that show about you?" And she said, "Well, maybe it shows my sense of integrity, my sense of fairness and the fact that I'm willing to stick up for myself," and on and on. "And what's great about your anxiety. You're 100% anxious. If you press the magic button, it'll disappear." She said, "Well, maybe my anxiety is going to keep me on my toes, so I'll go to doctors, I'll get the best treatment I can, I'll stay alive as long as I can." And I said, "Absolutely! What a beautiful thing that is. And what is your guilt and shame showing about you?" "Well, it shows I have a moral compass." "What does your loneliness show?" She said, "My loneliness shows my love for people." And suddenly we had a list of 20 beautiful things that her negative feelings showed about her, and they were real, powerful big things, you see, so we weren't telling her her negative feelings were rubbish, but quite the opposite, that her depression, her anxiety, her anger, her guilt, her shame, her loneliness and hopelessness were showing beautiful things about her. And then I said, "Well, gosh, Marilyn, why would you want to press that magic button? Because you'll go into a state of euphoria, and all your negative feelings will go down the toilet, but then all these beautiful qualities will go down the toilet. Is that what you want?" She said, "Oh, no, no, that wouldn't be right. And I should feel sad. This is appropriate to feel so sad. It would be ridiculous if I didn't feel sad. I just found out I'm going to die of cancer." And so I said, "Suppose we had a magic dial and we could dial these feelings down instead of making them disappear? How sad would you want to feel?" She said, "Well, maybe 15 out of 100 instead of 100 out of 100 would be enough?" I said, "Great, let's put that down. That's your goal for sadness and depression? 15%. How anxious do you want to feel?" She said, "Well, maybe 10% would be enough." She re-rated her goal for all of these negative feelings. And most of them, she wants a little bit of that feeling, but not 100%. And that's a technique I've developed called positive reframing. And it honors the patient's negative feelings rather than telling the patient you shouldn't feel that way or this shows what's wrong with you. See, shrinks have been trained to tell therapists your depression is because of what's wrong with you. But with the new approach that I've developed in the last 10, 15, 20 years, we're going in the opposite direction. And before we take the negative feelings away, we actually argue for the patient to maintain those negative feelings. They're beautiful. It's not because of what's wrong with you; it's because of what's right with you. And paradoxically, that opens up the door for rapid change. And that was a long way of saying it but agreeing with you that you never want to be interacting with the patient to make them feel like they're foolish or that there's something wrong with them, but go in the opposite direction. And then we ask, "Now what are you telling yourself? What are the thoughts? You see, it's not this event; even cancer is not the cause of your depression. It's what you're telling yourself. What are you telling yourself, Marilyn?" And she said, "Well, I'm telling myself that I'm a failure as a human being because I never found a life partner. And there must be something wrong with me because I wasted a lot of my time being an alcoholic and drinking. And also, I'm a failure, because I'm beginning to doubt the existence of God." And she had all these negative thoughts, and they were the same damn distortions that I had when I was upset or that you had when you were upset, and then we were able to work on them. I said, "Now you're calling yourself a failure because you never found a loving partner. And would you say that to someone else, Marilyn, who you were counseling? Would you say, 'Oh, you're a failure, because you never found a loving partner?'" She said, "No, I'd never say that to somebody. That would be cruel." I say, "But you're saying that to yourself. What would you say to someone else who was just like you?" She said, "I would tell them that it's sad that you never found a life partner. That doesn't make you a failure. You were gay, you were abused when you were little, you've had a hard life, and you've given a lot of love to people. You have a lot to be proud of. You've got a master's degree in theology. You've gotten five master's degrees. And you've also gotten a PhD in Clinical Psychology. You've been involved in environmental movements. You've gone to South America to help indigenous people who were struggling. You have a lot to be proud of." And I say, "Yeah, and are those things true of you, Marilyn?" She says, "Yeah, I'm talking about myself," and then tears came to her eyes because she was being kind to herself. And she suddenly saw that it was her thoughts. "The cancer is bad enough, but your suffering is because you're beating up on yourself. You're being mean to yourself." And she said, "Wow, I'm feeling better." And she said, "Well, how can I talk back to this thought, Dr. Burns, that I'm a failure religiously because I'm losing my belief in the afterlife. I don't know if there's going to be an afterlife. And I'm supposed to believe that. What could I talk to myself?" And I said, "Well, Marilyn, I'll tell you, I've never told you this before. But once when I was jogging home from the train station in Philadelphia, God came to me in a vision. And God said, 'David, if you believe in me, I'm gonna be goddamn disappointed in you.' I said, 'Don't worry, big guy. I've got your back.'" And Marilyn caught the joke and started laughing. And it was just a great moment to share with her again, that she was just being so ridiculous. I said Mother Teresa lost her belief in God throughout much of her career, and any religious person who believes in God all the time is a fraud or a fool. God would never want us to be doing that, and she saw it. At the end of this session, all of her scores went to zero. And this happened, this really happened. I'm just not bullshitting. And it's recorded on one of my Feeling Good podcasts, one of the earliest ones we had. And it was a beautiful thing. And she outlived her prognosis by quite a few years. She used to come down to Stanford from Oakland, California for chemotherapy, because they had the best at Stanford, and then we'd go out to lunch and stuff like that. And we finally lost her about a year ago. She never died of the cancer. She died of a stroke. She was a beautiful person. It's a gift to be able to give her the gift of self-love and joy. And every day when I go out on my jog or my walk for my exercise, I talk to her, tell her I still love her and think about her. I talk to my cat Obi who died, whom I love, too. He changed my life also. He was one of the best friends I ever had, Obi. But anyway, that's how it works. You have to honor people. And you have to be a technician with clever techniques, and we've developed many techniques to help people crush these thoughts that make our lives miserable. But you have to have kindness and compassion, too, and so that's this kind of new TEAM-CBT that I've developed and I wrote about that in my last book, "Feeling Great." If anyone wants, they could look it up on Amazon that has all of this new positive reframing and stuff that has made the treatment even way more powerful than the early versions of cognitive therapy. Now I've got the job of trying to convince the world, well, cognitive therapy was good in its day, but there's something way better now. And so that's my latest campaign. It's not an easy campaign, by the way. It's hard to get people to change their minds about an approach but the problem, for the reasons you mentioned, were limitations with cognitive therapy that were very real.
SPENCER: You're a victim of your own success. [laughs] You helped spread CBT so successfully. But one thing that really comes across talking to you is just that you are a person of tremendous empathy and compassion. And I wonder if, yes, you have all these technical things you bring to the table, all these techniques you've learned that help people, but also you just bring this incredible compassion. I wonder if that just gives you a competitive advantage when you're treating patients.
DAVID: Yeah, it does. And I had to learn it because that didn't come naturally to me. And I've learned a lot from some of my students who now work with me. Yeah, I teach. I have a co-teacher with our free Stanford training. If any of you are therapists and you want training, you just contact me and you'd be welcome to join our weekly training group. Jill Levitt, she's a clinical psychologist, she's the one I told you I hiked with this morning, because we had been working virtually and so it was fun to see her in person. She's a brilliant clinical psychologist. Her dad was one of my classmates at Amherst, so she's a generation behind me, but really, really brilliant and also compassionate. I do a lot of co-therapy with her and I model the kindness in the words that she uses that can convey that. If you convey compassion and warmth to a patient, that's 90% of the battle, but you have to have more than just that. You could be the kindest person in the world and your patients could give you perfect empathy scores, but if you didn't have the techniques to help them identify the distorted thoughts and techniques to change those thoughts, and also to give them the motivation to crush those thoughts, you won't get very far. You have to bring many, many skills to the table. And that's why I've been working on this Feeling Good app, because I've realized I probably, of the 50,000 people I've trained — train, I mean someone who's spent at least two full days with me in learning cognitive therapy, or the new TEAM-CBT — there's probably only been ten or 15 who have been able to to learn it. I've illustrated it on this program.
SPENCER: Only 10 or 15 out of many thousands, have been able to learn it?
DAVID: That have developed the same level of skill, yeah. That means a lot of people are doing it; there's a Feeling Good Institute in Mountain View, California, and they probably have 40 or 50 therapists associated with them. But there are a wide range of skill levels, and the ones like Matt May... 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 takes me two hours to do it, but it happens.
SPENCER: That's a pretty amazing claim, that you could treat someone in two hours.
DAVID: 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. 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. I did a research study at Stanford inpatient unit to see how accurate therapists are in 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, 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 I wanted to get better and better and so I've changed the methods and changed the methods and changed my approach until now, my skill level has become massively beyond what it was when I was a young man doing a psychiatric residency training at one of the top training centers in the world, but we weren't taught anything that had value that I was aware of. And I learned it along the road working with people and the measurements. I measure things at the start and end of every single therapy session so I can see: how are you feeling right now at the start of the session? How are you feeling right now? How depressed and anxious, how angry at the end of the session? And that's how I first began to see that it was possible with some patients to get almost a complete elimination of their negative feelings in a single session. Then you've got to do relapse prevention training because the negative feelings will certainly come back. So you teach the patient how to deal with them when they come back. That's pretty easy. But then once I saw that I could get this occasionally, then I learned how to get it most of the time. It's not 100% of the time, but I would say it's 90% of the time, and that's why I'm so excited about this new innovation in the therapy that we've been developing with my group at Stanford.
SPENCER: Could you break down how it works? You already talked about the positive reframing aspect where you think about your emotions as reflecting your values and you think about what level you really want that emotion. And you also talked about the feedback loop, making sure to collect the data at every session of how they're doing. What are the other aspects to TEAM that you think are innovations on top?
DAVID: Well, it's a real simple thing. T is testing, E is empathy, A is called either agenda setting or assessment of resistance (whatever you want to call it), and M is methods. And that's the linear order that we do things so we start at the beginning of the session. Before the session begins, the patient takes my brief mood survey, which is how are you feeling at this moment? And it takes them about 30 seconds to fill it out. And then I see their scores at the beginning of the session, and I can see how depressed they are on a zero to 100 scale, how suicidal they are, how anxious they are, how angry they are. And these scales are like 95 to 98% accurate; they're amazingly precise and correct. And if it's a voluntary patient, they give you the true information. I empathize. And I gave you an example of how I did that with Marilyn Coffy. And I train patients in the Tuesday group... 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. And that means 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 how the patient feels you're doing.
SPENCER: Well, how do you teach people to empathize? That might surprise the listener. How do you actually learn that?
DAVID: Well, the way I do it is pretty challenging, I would say, for the therapists 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 patients tell them, things like, "Oh, 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. And then we teach the therapists what sounds easy, but isn't. It's something called the five secrets of effective communication, and these are five communication techniques you can use in response to anything a patient says, or a spouse says, a family member, anybody. I train them on the worst thing that someone might say to them, because if you can handle that, you can handle anything. And the technique is EAR: empathy, assertiveness and respect. There's three empathy techniques: 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. And 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 — 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 what could the inpatient doctors say? How could you agree with that? Because if you agree with that, the person will stop believing it. So you might say, "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 hate it 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 of the hospital so you can kill yourself. 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. I really haven't done a good job with you, and you have every right to be pissed off at me." That would be the disarming technique. When you say something like that, the patient melts in your hands. Here, somebody's finally listening, finally hearing me. 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. 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 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. And then there's thought and feeling empathy, 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 disillusioned. Tell me more about that. Am I on the right page? Am I reading you right, right now?" That would be 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 'I feel' statements would be assertiveness, sharing your own feelings. "I feel really sad and a bit ashamed to realize that I've failed you so badly, but you're right. At the same time, I'm thinking that this could be a chance for us to develop the kind of relationship you want and the kind of relationship I want. And so with that in mind, tell me how you're feeling and tell me all the things I've been saying and doing that have been turning you off and not working for you, problems I haven't been helping you with." That's the way we train the therapist, so they pair off in groups of two or three, and one plays the angry patient and attacks the therapist, and the therapist has to respond with the five secrets, and then we give them a grade right away. Was it an A, a B, a C, a D? And they always do terrible. And then we say, "Well, your grade was (maybe) a B-minus, and that's out of kindness that we'll give you that grade. But you did some things right. Here's what you did right. But when you said, 'blah, blah, blah,' that's not going to work at all. Let's try a role reversal. Try it again." And we go. It's called deliberate practice. And we do role reversals until the therapist gets an A. That's how I teach empathy. It's hard because they have to be willing to fail in front of other therapists. They're all thinking that they're the only one who's inept. They're all pretty darn inept, to be honest. If you have humility, then you can grow and learn so we use the philosophy of joyous failure. When I'm teaching in the Tuesday group, you have to check your ego at the door, and do these very challenging exercises that are going to point out your weaknesses instantly. And if you're willing to fail, you can learn tremendously.
SPENCER: That's so interesting. It's such a cool way of teaching empathy. Because when you think about this, this seems like such a difficult thing to teach. But it seems like you've broken it down systematically, and you have a training program where they can actually practice it. It actually reminds me of an experience I've had online, where sometimes when people will write really harsh criticisms of things I've written in a really obnoxious way, what I've actually found the most effective is just acknowledging any part of what they said that's true.
DAVID: Yeah, that's right.
SPENCER: And then very calmly just explaining why I think that they may be mistaken in other points, but in a very polite, gentle way. And I find that their belligerence usually goes way down. They'll start out really belligerent but they're almost taken off guard by the gentleness of my reply, and then they tend to lower the temperature down to the level I'm at. It's worked really well for me. It just reminds me of some of the things you're teaching.
DAVID: Yeah, you're so right in what you're saying. It's an amazing phenomenon. I had a podcast with a woman that I treated for what Howard Hughes had, a contamination phobia kind of obsessive compulsive disorder. And she'd had 25 years of washing her hands and spending two hours in the shower. It was just dominating her life. She was afraid of doorknobs because people would touch them and she thought she'd get germs. I treated her live in one of the Tuesday groups, my Stanford Tuesday group. We do live treatment, so people can watch and ask questions and it was an amazing experience and the woman, at the end of the session... Well, first, we went into the women's bathroom and touched all the toilets and this totally freaked her out.
SPENCER: You may have to explain that a little more for the listener who's not familiar. [laughs]
DAVID: She's afraid of contamination, and I used a lot of techniques with her, but one of the keys is to confront your fear so she'd have to touch germs where germs are instead of avoiding, the way she's been doing. And then after we got out of the bathroom, I had 30 Stanford students there in the women's bathroom, watching us touch the inside of the toilet. That was freaking her out. I said, "How anxious are you?" She said, "120 on a zero to 100." I said, "Well, that's not high enough. So let's walk out to the front of the building and touch all the doorknobs on the way." And all that was freaking her out. But I said, "You have to do this." She was forcing herself to confront her fear. And we got out that the worst thing for her was the glass door at the behavioral sciences building at Stanford because we'd have all these people's hands on there, and so I made her open the door. And then we went out and there was a trash barrel that was empty, but it had maybe an eighth of an inch of grime all over on the inside of it, black, gooey stuff. And I said, "Here's the last thing. I want you to put your hands in here and get them all gooey and dirty, and then rub them on your face." And she said, "No, I can't do that." And I said, "Oh, you can do that. You are going to do that now." And this is where the empathy comes in because I knew this woman loved me; she really trusted me, because you can't do this stuff if the patient doesn't trust you. But she says, "No, I'll vomit if I do that." And I said, "All the better. You can just put your hands in there and get them all grimy, and vomit all over yourself." And then she says, "No, no, you do it first." And I said, "No problem." So I stuck my hands in and then pulled them out and rubbed them all over my face. So there's all this black stuff all over my face. And then I said, "Okay, your turn." So she says, "I guess I have to do this." So she stuck her hands in there, pulled them out and rubbed them on her face and all the students started cheering. It was so cool. And one of them got out his iPhone and photographed that and made a 30-second video of it. We went back into the behavioral sciences building and back to the seminar room and we all sat down. And I said, "How are you feeling?" She started sobbing and I said, "Why are you crying?' She says, "Because I'm cured. I'm not afraid of it. It was like a miracle that happened here tonight." It was so moving. But at any rate, I had her on a podcast to say rapid recovery is possible for most people, even when you think you're a hopeless case, which she had thought. And then I got an email from somebody, a two-word email — and coming back to your point about when people are hostile to you — it said, "Fuck you." That was all it said, and it pissed me off, to be honest. Apparently, this guy didn't like the idea that people could recover rapidly and thought I was some kind of a fraud, a con artist, a liar. It was probably someone who had struggled. So I wrote back to him. and I said, "Sometimes my critics are my best teachers. Obviously, I must have done or said something that really angered you. And I know you have important information to share with me and I would appreciate it if you'd be my teacher and teach me." And then I just got the kindest imaginable email back from this fellow and he became a huge fan; it was just what you were saying. But it's hard to do that sometimes because we want to lash out at other people. We want to defend ourselves and get back at people who say things that hurt our feelings. And it's hard for me sometimes, too, to tell you the truth. I'm human. Sometimes I blow it. I'm not always acting saintly. But if you even can act saintly part of the time, it's pretty damn awesome.
SPENCER: Well, yeah, a therapist goes through such intense pressure in the heat of the moment where they're being challenged by a patient and to do that in real time, I imagine, is very, very challenging.
DAVID: Yeah. But once you get at it, it's so much fun because it's such a joy to be able to respond by finding the truth in what someone is critical of you, to find the truth in what they're saying and to honor them. It just blows their mind as you pointed out a few moments ago.
SPENCER: Going back to the story of the exposure therapy of the woman who would obsessively clean herself, some people I've heard who, talking about exposure therapy, think of it as almost cruel. I remember reading an article called "The Cruelest Cure" or something. Some people listening to this might think, "Wow, that sounds like torture you were putting this woman through. You were making her do this." So how do you think about that? When is it pushing someone too hard?
DAVID: Well, that's why I've developed an app because therapists, I don't think, are gonna get it. And we've incorporated AI into our app now. The cool thing is that AI is the student I always dreamed about because it learns fast and does exactly what I tell it to do. But the school of psychotherapy or the field of psychotherapy is made up of cults with cult leaders. They're called your Aaron Becks or your Carl Jungs or the Fritz Perls, these various famous people, and they're often just narcissistically trying to promote themselves. And I guess you don't mind controversy on your program. Albert Ellis was someone I really admired, and he was the first one to point that out, that nearly all of the great people in psychiatry and psychology are kind of sick puppies, sociopathic or narcissistic, exploitative people. So people get these ideas that they know the answer. But exposure therapy, 80% of therapists in the United States refused to use exposure therapy for the reason that you mentioned; they think it's some form of insensitivity and cruelty. And of course, any powerful technique has the potential to hurt as much as the potential to heal. And so you've got to have courage as a therapist and you have to combine compassion with powerful techniques. Take the woman that I just described to you. The few minutes of intense anxiety ended 25 years of daily, all-day-long misery. What a good deal is that, and she's been great ever since that session. She's followed me to workshops; she came all the way from California just to attend a workshop I did in Atlanta. And so she could get up on the stage and have people watch her rubbing her hands on the floor and rubbing them on her face and telling people how great it was to be liberated. Exposure therapy is just one technique of maybe 100, 125 techniques I use but it has its place. I myself had probably 17 anxiety disorders myself, starting from childhood. I know I had a phobia of blood when I was young. I was afraid of bees, horses, dogs, heights. I've had crippling public speaking anxiety, all kinds of social anxiety. Anything that an anxious patient has, I can say, "Oh, I've had that, too. I know how much that sucks. And what a joy it's going to be to show you how to overcome that anxiety because I've been there myself and I know how to solve that." Patients love hearing that. There's a lot of ways to treat anxiety, a lot of techniques, but exposure has to be a part of the solution. For example, let's say you're trying to treat someone with social anxiety without having them talk to strangers because they're afraid of doing that. Well, how could you say they're cured if they won't talk to strangers? I go out with them and say, "Let's go talk to strangers together. I'll do it with you. Let's get over this fear today. Let's make it happen now." But it takes courage and compassion. But it kind of frosts me when therapists take these highly opinionated positions on things. "Oh, that's awful. That's a cruel cure." Well, you don't know what the hell you're talking about, buddy. And now I sound opinionated, but it's kind of funny opinionated. [laughs]
SPENCER: When I was younger, I went to a CBT therapist or guy who said he's a cognitive behavioral therapist who had me go to bars at night completely alone and he would give me homework like, "Okay, you're gonna introduce yourself to five strangers." This was terrifying for me. My heart would pound in my chest. I felt like I was gonna die, but I believed him. Pushing through the fear was... I believed deep down that that was going to get me to the other side. So I would force myself to do it. And it was incredibly powerful for me. After doing this a bunch, I now feel like I'm at the point where I'm less afraid than the average person
DAVID: Well, lookit, you've got a fantastic podcast with thousands of people listening to you every week.
SPENCER: It really is transformative sometimes, but also terrifying. And I think on a broader level, I feel like one of the most powerful heuristics in my whole life that I've ever developed, was that I'm going to always try not to let fear hold me back from doing something valuable. Of course, there are times when you should be afraid of things, something dangerous or whatever. But it's really about understanding when, okay, I'm afraid, but this thing is worthwhile and I'm not going to let the fear stop the worthwhile thing. So I'm totally sold on the power of it but I also get why people are scared to do it. And also, if done badly, how it could have bad consequences. I suspect if halfway through with that patient, she'd run out of the building screaming and then never call you again, that would be very bad, right?
DAVID: Yeah, I didn't tell you the first part of the story. But yes, you've got to have an agenda with the patient, and you've got to have the trust of the patient. You've got to do it collaboratively. But before I took her out to confront her fear, I told her a little summary of my favorite Rod Serling "Twilight Zone" in the group. Did you ever watch that TV show?
SPENCER: I've seen a few episodes.
DAVID: There was this one about — it's my favorite episode — and it had an elderly woman in an apartment building, and this supervisor comes in and says, "Listen, lady, we're tearing this building down. All the other people here have left, and you're the only one left, and we've got to tear it down today. And so you've got to get out of here." And she says, "No, no, I'm not going to leave this apartment building," and she explains to him why. She says, "Ever since I've been a little girl, I've been able to see Mr. Death. Other people can't see him. I don't know why. But I saw him once as a little girl, and when he touches you, you die. I saw him on a bus once and no one else could see him, and he went up and he touched a fellow who immediately died. And ever since, I've been determined, I'm not going to let Mr. Death touch me because I can recognize him. And if I go outside of this building — I haven't left this building for years and years — if I go outside, I know he's going to come and touch me and I'm going to die. And that's why I'm not going to leave the building." And this construction superintendent gets disgusted and says, "Listen, lady, I'll be coming back. We're coming back this afternoon, and we're gonna tear down this building. You've got to get out of here." And he storms off angrily. And then she hears this wailing sound outside her door, "Help! Help!" And she opens the door — there's a chain on it — to look out. And it's this police officer fallen in the snow and he says, "Help! I've been shot. Help!" And she says, "Oh no. You're not going to trick me. I think you're probably Mr. Death." And he says, "No, no, please help me, please. I'm in pain. I'm cold. Please help me." It's Robert Redford; that was the actor. Maybe none of your fans will remember him but he's one of these ultra-handsome guys. So she says, "Okay, I'll let you in if you're not Mr. Death." And he says, "Oh, no, I've been hurt." And she has him lie down on her bed in this little tiny apartment and she makes some tea for him. She's comforted and she's helping this police officer. And then the superintendent comes back in and she doesn't want to open the door. She gets to thinking maybe he's Mr. Death. But finally, he rips the door open and comes in and says, "Lady, we're tearing it down now and you've got to go." And then she says, "No, I can't because this police officer on my bed is injured and I can't leave him here." And the superintendent says, "What police officer? I don't see any police officers. You get out of here." He storms off angrily and then she looks in the mirror and she sees her bed reflected in the mirror and there's no one on it. She realizes that the police officer's actually Mr. Death, and then she says, "You tricked me! You tricked me!" She says, "Am I going to die now?" And he reaches out his hand to her and he says. "There's no loud sounds, there's no pain involved. In fact, it's already happened." He takes her hand and she looks on the bed, and she sees her dead body on the bed. He says, "Our adventure has just begun," and he takes her hand and they walk out kind of in a romantic way, this elderly woman and this young Robert Redford-type of guy. And the meaning of the story is that she confronts this fear she's had — the fear of death — and she discovers there's nothing there even to fear and she's going to have this beautiful, beautiful experience. And I told her this story before we went out and I said, "Now, are you ready to die? Because you have to die to be cured of your OCD and your contamination phobia." Then I reached out my hand to her and said, "Are you ready now?" She took my hand and then I knew that she trusted me and it was the time to do it. But you have to have that love and connection with your patient. And if you just go and start throwing exposure techniques at patients, sure, they'll freak out. But it's not because the exposure is dangerous. It's just because you're a crappy therapist and you didn't know how to develop a warm, trusting relationship. I've never run into any resistance with exposure, or a bad outcome. But I've never done exposure without a clear agenda with the patient and the trust that this is what we're going to do and this is how we're going to change your life.
SPENCER: I'm not sure we finished going through all the letters of TEAM. I think we talked about empathy.
DAVID: Testing, empathy, and the agenda setting, in other words, the elimination of the patient's resistance, where we see that what you thought was your symptoms — symptoms of a mental disorder — is actually what's beautiful and awesome about you, your core values. And then once the patient sees that and dials down their goal for their negative feelings, then we go into methods and I take a negative thought like 'I'm not as good as I should be,' or 'I'm a loser' or whatever it happens to be, 'I'm a hopeless case,' and then I just use techniques, one after another, to crush that thought. We start out identifying the distortions in the thought, explaining the distortions, maybe use a technique called the experimental technique or externalization of voices or the double standard technique, just techniques like 'would you say this to someone else,' that's the one I used with Marilyn Coffy and it just worked really beautifully for her. And in the early days of cognitive therapy, before we had these techniques to eliminate resistance or reduce resistance, I used to have to try 10, 15, 20 techniques before I could find the one that worked for a patient. Now with the new elimination of resistance techniques, generally, three or four or five or six techniques at most, that, when we get to that method's phase, the patient can smash their first negative thought, just blow it out of the water or reduce the belief in it to zero. And once they've crushed one negative thought — they might have written down on their daily mood log eight or ten negative thoughts — then I go into something called externalization of voices where I become their negative self and attack them (with their permission) with their negative thoughts. And they can generally just then blow them all out of the water. If they get stuck on one, we do a role reversal. And that part of the session usually only takes 15, 20 minutes and then their symptoms are gone. I say, "Now how do you feel? How depressed are you? You wanted to go from 100 to 20. How are you? How depressed are you at this moment?" And they say, "Oh, zero. It's completely gone." "And how anxious are you?" "Oh, zero." "How guilty and ashamed are you?" "Five out of 100." "How inadequate and worthless do you feel?" "Oh, zero." Their feelings just fall pretty much down into the basement at that point. They go beyond what goals they had and bring most of them down to zero or very small levels. And that's it, 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 session. 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.
SPENCER: And what do you teach during the relapse prevention?
DAVID: Well, there's three things. First, I say, "It's 100% certain 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 I say, "When you relapse — it could be tomorrow, it could be three weeks from now, it could be anytime — 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 therapy didn't work,' they might come up with the thought, "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. Maybe it's time for me to pick up the tools again and use them." And then I say, "How was that?" They say, "Oh, that's tremendous." 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, "I'm your negative self and I want you to 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. I'm upset; I have a right to be upset. And I'm gonna see what I can do to deal with this situation. And I have plenty of tools to deal with it. For 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 right now." So that's how it goes and it's easy for them to do that. And I have them record that — on the cell phone is the easiest way — and say that, "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 free 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, 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, so it seemed very effective. And when they did, I remembered them. I had a guy call me not long ago whom I hadn't seen for 35 years. He had severe OCD. But he called me not for a tune-up but because he wanted to use my anxiety scale in his research. He'd become this very famous researcher from the National Institute of Health. But I miss my patients, and the ones that were the toughest to treat, that were the most critical of me and who then turn their lives around, I miss them. Sometimes I wish I could call them and say, "Hello. Do you remember me?" especially if I treated them when they were a suicidal teenager or something like that. Really tough, because I grew so fond of all the patients that I ever had. But you have to let them go. You can't be calling them on the telephone; it would be unethical or something.
SPENCER: What is the average number of sessions that you find you need with a patient to help with depression or anxiety?
DAVID: Well, for me, it's just one, one two-hour session. My colleagues, some of my students who have developed tremendous expertise, say that they'll typically see patients for three or four, maybe five sessions, and it's a problem for them economically, because their patients get better so fast, 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 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 skills. So they start building a tremendous following after a year or two and the word gets around. With our Feeling Good app, which we hope to be releasing probably in October or November in through there — and we're doing beta tests, if any listeners want to beta test, it's free, and it'll always be free if people can't afford it — we see pretty tremendous improvements in people with the Feeling Good app. In roughly two days, we see like a 50 to 60% reduction in seven negative feelings, feelings of depression, anxiety, guilt, shame, loneliness, hopelessness, anger. But that was in our pre-artificial intelligence phase with the app. We're now creating artificial intelligence David in the app. And it is hard 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. We haven't beta tested it yet. We'll be beta testing it within the next few weeks. But that, I think, could be a real game changer for psychotherapy for people all over the world because the app is going to be very inexpensive and scalable. Now we're not allowed to say that it's a treatment for depression, and it's not; it's just a self-help tool at the current time. It seems to have tremendous promise in helping people with negative feelings. We're just trying to help people. We're not trying to treat mental disorders with the app. We're just trying to help people reduce and eliminate negative feelings and boost positive feelings. But we'll see because it's hard to get therapists up to the level that I've gotten to over 40 or 50 years of constant feedback from patients. It's been a long road for me to learn how to do this and it's hard for human therapists to learn how to do it. Some have learned it somewhat and some have learned it very, very well. But the app, I think, is going to be able to do it extraordinarily well, and opens up a new road, a new highway for the future of mankind, if the human race survives. And my dream is always to be able to bring this kind of rapid, dramatic change to people all over the world who can't afford therapy, and even if you could afford it, you can't find anyone who can help you. That's what my life's goal has been.
SPENCER: David, before we finish up, how would you feel about doing a rapid fire round where I ask you a bunch of quick questions and just get your quick thoughts on them.
DAVID: Oh, yeah, I can do that. I love doing that.
SPENCER: Awesome. All right. Let's do it to wrap up because there's just so many things I didn't get to ask you. I at least want to get your quick take.
SPENCER: What do you think the role is for SSRIs in treating depression?
DAVID: I think they have no effect other than the placebo effect. That's based on Irving Kirsch's analysis of all the data in the Food and Drug Administration where patients were randomly assigned to SSRIs or to placebo. Irving Kirsch is the Associate Director of the placebo research institute at Harvard. He has a wonderful book on that topic called "The Emperor's New Drugs." It's an easy read, popular science, you can get it on Amazon. It's highly recommended. People hate it when I say this, but I've been a researcher in my life. I review articles for scientific journals, and one of the peer people that they get to point out problems in articles. Kirsch's research is stone solid. The SSRIs, I haven't prescribed them. For 25 years, I haven't used an antidepressant. Before that, I gave them out 16,000 times to patients just because patients demanded them. They had heard that they're so good and I didn't want to get sued. So if they wanted them, I prescribed them. But I never saw much from them. And I've never used them in the last 25 years.
SPENCER: Do you see any role for physical exercise in mental health? You mentioned earlier that maybe it's not effective from your point of view.
DAVID: It's not effective from my point of view, but it also has a placebo effect. So if you exercise and you're telling yourself, "I'm really doing something for my health," then you're going to be feeling good, and it's the thoughts, not the physical exercise. The research on endorphins has shown that the whole endorphin thing was a scam. They administered... A study I saw recently really did the proof of this fact that I've been claiming for years. People get antagonistic when I say this because a lot of people like exercise. If you like exercise, God bless you, do it and enjoy it. But they gave a drug, randomly assigned people to two groups and gave half of them a drug that blocked endorphins in the brain and then had both groups exercise and tracked changes in their mood. There was absolutely no difference in the two groups which proved that the endorphins had no role in any improvement in exercise. I once had a man whom I worked with in the early days when people were touting exercise. He had also escaped from Nazi Germany and he went to New York, started shining shoes on the streets of New York City, and he was alone as a teenager. He eventually became a multimillionaire and he owned several city blocks in downtown New York. He had a manufacturing company. He came to me as an elderly man. He said he'd never had one minute of happiness in his life, that he felt like a worthless human being. So I said, "Well, your problem was, you've got to boost your brain endorphins through exercise." So I got him into running and I got him running 12 miles a day. He was in his late 70s. And I said, "Ezekiel, how did you feel at the start of your 12-mile run?" He said, "I felt like a worthless human being." And I said, "How did you feel at the end of your 12-mile run?" He said, "I felt like a totally exhausted worthless human being." It didn't do a thing. He could have run from New York to Los Angeles, and he would have felt as bad. Finally, I asked him, because he had been to psychiatrists his whole life and he could afford the best, and no one, he said, had been able to help him. I said, "Well, Ezekiel, why do you feel like a worthless human being?" and then tears came to his eyes, and he says, "Well, I've been hiding this from everybody. I feel worthless because, ever since I've been a little boy, I've had a fear of the dark and claustrophobia." And I said, "Ah, no wonder. This guy could run for the rest of his life, and he would still feel worthless. The exercise isn't going to cure that." But I told him, too, that the cure would be to set his alarm for 2am when it's dark, wake up, and go into his basement in the middle of the night, and roll himself up in a carpet. It's pitch black — don't have the lights on — but have a recording device, and then just stay there until you're cured. He fired me. He said, "That's stupid. That's horrible. I could never do that," and stormed out of the office. And then he called me several weeks later, and he said, "Dr. Burns, I went to another psychiatrist in New York to find out if you were crazy. The psychiatrist says, 'No, Burns is not crazy and you should do what he told you to do.' So could I come back and you can tell me exactly what you want me to do, and I'll do it." So I told him to do it and then he came back the next week. He had gone into his basement in New York City and, in the middle of the night, rolled himself up in the blanket. And I said, "Then speak out loud, so we can hear what you're so afraid of in the dark and with claustrophobia." He said he thought that a ghost would come out of the darkness and sit on his chest and suffocate him. He was 100% out of zero to 100 with that thought, and he kept thinking that for 20 minutes, and he was still 100% panicky. And then he said, "I suddenly said out loud, 'Ghost, if you're going to come and sit on my chest, do it now and get it over with. I'm sick of waiting for you.'" He says no ghost appeared and he suddenly started laughing. And he said he had no fear of claustrophobia, no fear of the dark, and no longer felt like a worthless human being. Everyone is different and you have to target the treatment to the exact problem and the thoughts that the person has. Exercise is great. I try to exercise every day, but I hate every minute of it. It's never given me a runner's high, or even a tiny mood boost. But I do it for my health. I like to individualize the therapy to each person's specific problem, and everyone is different. And everyone has something unique and challenging and requires unique, creative techniques to show a person how to get out of the trap they're in.
SPENCER: Okay, next question for you. What do you think of the so-called dodo bird hypothesis? This is a claim that if you do randomized control trials, pitting different therapeutic techniques against each other, that they all kind of perform similarly.
DAVID: That's absolutely true. That's why I've developed TEAM therapy because in all of the outcome studies for different forms of psychotherapy — how much do they reduce the Beck's Depression Inventory score — and all these studies are unimpressive. The most that they show is maybe 50% of the patients that are treated for months, maybe half of them get a 50% reduction in the Beck's Depression Inventory score. That's pathetic; that's terrible. That means the other half didn't even get a 50% reduction in the depression score. Now, I'm not allowed to talk about our app as having antidepressant properties, and we're not treating depression. But I can tell you that in two days, people with the app get 60% reduction in seven different negative emotions. So you can conclude what you like. You'll get a 30-40% with a placebo effect and that's in most schools of therapy; they don't get any more than a placebo effect and they don't like to admit it. All these schools of therapy want to think they're the cat's pajamas for the treatment of depression, or for the treatment of anxiety disorders, but the data does not support that. And that's why I've been trying to develop powerful, fast-acting treatments that have effects massively beyond placebo effects.
SPENCER: Does that mean you don't think that cognitive behavioral therapy which you taught in your original classic book, Feeling Good, is better than, let's say, psychodynamic therapy in terms of outcomes?
DAVID: When administered by humans now, when people read my book, "Feeling Good," there's been ten outcome studies on that book that are fairly encouraging. Forrest Scogin, research scientist in the University of Alabama, clinical psychology researcher, did many outcome studies just handing my book, "Feeling Good," to people. They had said, "Before you see your doctor for your appointment for your depression, just read this book. And in four weeks, then you can see your psychiatrist for medications or psychotherapy or whatever." And then at the end of the four weeks, 50 to 65% of them had improved so much that they no longer wanted or needed any professional treatment or any medications. And that's one of the reasons I've created the app because I thought, "Wow, if the book can do that, the app could certainly do better," and that's what our beta testing has shown. But you've got to be directing your interventions at the level of motivation as well as cognition if you want to get really fast results to melt away the person's resistance and help the person see that their negative symptoms are not the result of what's wrong with them, but what's right with them. And that's the technique that seems to open the door to improvement that seems to be vastly beyond the effects of placebo. A placebo confuses people, because if I told patients I've got this new ear-tugging therapy, and all you have to do is tug your ears three times a day, and it'll get those imbalanced gasses out of your ear, and your depression will go away, and a patient believed that and did that, 35% of them would be cured of their depression in three or four or five weeks. But it's not ear-tugging; it's just their belief that something good is going to happen. That's how most schools of therapy operate. They have maybe a little punch above and beyond the placebo effect, but not much. And that's why I've been trying to develop something much more powerful than that. That's been my goal with my work on the Feeling Good app to see if we can make that happen. Maybe a device can deliver to people what all these schools of therapy have tried hard to, but the human therapists are pretty limited even when supposedly highly trained and don't, to my way of thinking, outperform placebos by much, just as the so-called antidepressants don't outperform placebos by much either.
SPENCER: Just to clarify, make sure I understand what you're saying, it sounds like you think that cognitive therapy as taught in your book does significantly beat placebo and does beat, let's say, psychodynamic therapy. But cognitive therapy as practiced by an average practitioner doesn't? Is that what you're saying?
DAVID: No, I think that the cognitive therapy practiced by the average clinician has placebo effect and a bit more, and is probably on par with reading the book, "Feeling Good," and doing some of the exercises in there. But even the people that have read "Feeling Good," well, what happened to the 50% who didn't improve by reading "Feeling Good"? Why didn't they improve? You see, that's the question I've been trying to answer in my research and in my clinical work. And the answer seems to be that... See, in "Feeling Good," I didn't deal with resistance and most therapists do not know how to deal with resistance. They keep trying to throw help at patients and that paradoxically makes quite a high percentage of patients resist because people don't like it when people throw help at them or try to cheerlead them, just as you gave some dramatic examples of that earlier.
SPENCER: So then something like psychodynamic therapy, or ACT or Mindfulness-Based Stress Reduction, etc, do you think those also would outperform placebo?
DAVID: No, no, they won't. Maybe a little bit. But all of these, the best that they can do is just outperform placebo by a little bit. And so I guess it's good if you've got some improvement in some patients. But to me, people who are depressed, they want to wake up in the morning and say, "It's great to be alive." They don't want to be feeling 30% less depressed.
SPENCER: One question that I've wondered about just for myself, is that I found some of my beliefs have been very affected by reframing and things like that. But I find other beliefs of mine, when I've tried to use techniques like that, the same thought will keep coming back. So I'll feel better in the moment. I'll feel I've done a reframing around that thought. But then maybe a day later or a week later, it comes back again. How do you think about that? Do you think that the reframing just wasn't effective enough or what do you say to that?
DAVID: Well, I think that happens to everybody. I think that's what it means to be a human being and that's why you've got to be prepared to pop out of those relapses, but it's not in the cards to not have that happen. I think if you get really good at crushing the negative thought that causes your relapse, whatever it is, the thing that's bugging you, if you can reduce it all the way to zero and get really good at it, then you can get pretty good at popping out of those negative moods. I think the Buddha or somebody said, "You can't stop the birds from landing on your head, but you can prevent them from building a nest in your hair." I don't think the Buddha said that [laughs] but somebody said that. You have to work at it. If you tell me what your thought is, we can work on it at this moment, make it a little bit more specific.
SPENCER: Oh, sure. I think for me, one of the most common recurring kinds of thoughts I'll have is that I might have said something that upset someone or bothered someone. It especially gets triggered if a friend starts acting unusually, like usually they reply right away, but then they, let's say, don't reply for three days. I'll start thinking, "Did I say something wrong? Did I upset them in some way?" And so I tend to have a lot of recurring thoughts like that.
DAVID: Oh, yeah. So kind of an obsession thing type of deal.
SPENCER: I don't know. I'm not sure how you would define an obsession exactly. But I think I'm very worried that I will hurt someone or upset someone.
DAVID: Yeah. I can identify with that, for sure, because people used to tell me, "How can you stand to see depressed people all day long?" When I was in private practice, I used to see 17 depressed patients in a row for full sessions. And to me, the longer the day went on, the higher I got. I love being with depressed people because I had something to give them. But if I hurt or upset somebody during a session, it was like being shot in the stomach with a bowling ball. It's very painful and then I'd get very exhausted and down on myself. And if you said something that upset or hurt someone, what would that mean to you? Why would that be upsetting to you? And I'm doing something now called a downward arrow technique and I'm doing it on paper. I wrote, "I upset or hurt them," and I drew a downward arrow under. Suppose that had happened? What would that mean? Why is that upsetting to me?
SPENCER: Well, two things come to mind. One is that I've had a bunch of occurrences in my life, where I've accidentally hurt someone or upset someone in my life and I didn't realize at the time, but then it suddenly blew up where they suddenly got very angry at me. I think on some level, I feel a little traumatized by some of those experiences where I feel like maybe this person is going to abandon me or maybe they're going to be suddenly angry at me. I think I'm a little over-sensitized to that. And I think the other piece for me there is that I really care about being ethical and it feels to me like harming someone is unethical, and that feels like it's cutting against one of my core values.
DAVID: That's beautiful, actually. So if I hurt them, then they'll abandon me. And that would mean that I'm unethical. Is that right?
SPENCER: I guess I would think of it as two different pieces. One, that they might abandon me, and two, I might have done something unethical. Both of those, I think, weigh on me.
DAVID: Yeah. Well, there's a couple of ways we can go with this. Yes, I said something and a colleague whom I really love and admire so much just got really pissed off and said, "I'm really angry with you." And it was actually a relief because he's often unassertive and it was actually good that he was saying he was angry with me. And we had a meeting today. Several of us were kind of all upset and talked it through and it turned out to be very productive. But I know how painful those kinds of thoughts and feelings can be. Is this something that you want help with?
SPENCER: Yeah, absolutely.
SPENCER: Because 95% of the time, it's just in my imagination. It's just that they were busy or it was not a big deal. It's just that my brain, I think, is ready for that small percentage of time where I actually really did upset someone.
DAVID: Sure. So if you had a magic button and you could press it and be cured of this, would you press the button?
SPENCER: Well, what you said earlier, it really resonates with me. I wouldn't put it down to zero because I don't think that's the right amount. I think that one should be conscious of their effects on others and should strive to notice if they've upset someone. But I think I do it maybe 90% too much. Maybe I'd push it down to 10% of what I'm doing it at.
DAVID: Sure. Let's just make a little quick list of positives and then we can do some little externalization of voices. I don't know if it'll have any value or go anywhere, but it might be kind of fun. Let's make just a little list of positives. By the way, what are your negative feelings when you're having these thoughts? Do you feel anxious?
SPENCER: Yeah, I feel anxious. I will replay the thing in my mind and I think that drives me in an anxiety loop where I'm feeling tense and my stomach might hurt.
DAVID: Oh, yeah. And how anxious and tense would you feel, between zero and 100?
SPENCER: I'm probably 50.
DAVID: Okay, what else?
SPENCER: I think that's the main thing. I'll replay the conversation sometimes. I'll replay the last conversation we had and go through it bit by bit looking for a mistake I might have made, like, oh, wait, maybe it was that thing I did. Maybe they're not texting me back because of that thing I said. It's an unpleasant kind of fixated state to be in.
DAVID: That's what I mean by obsessing. Do you feel guilty or ashamed when you're thinking about these things?
SPENCER: I think I feel a little guilty. Sometimes I just feel like I can't figure it out and I can't find anything I did that could cause their change of behavior. And then I'll feel more anxious. But if I think I hit on something, I'm like, "Oh, maybe that thing I said was insensitive," or something like that, then I will start feeling bad. I'll feel guilty.
DAVID: How guilty between zero and 100?
SPENCER: I think it depends on how much I feel like I might have hurt them, but maybe 30 or 40.
DAVID: Okay, well, I'll put 40 for the upper level on that. Do you feel inadequate or inferior?
SPENCER: I don't. I tend to have a lot of confidence so I don't tend to feel those kinds of feelings.
DAVID: Do you feel sad or unhappy or down when you're thinking like this?
SPENCER: I feel sad if I start thinking, well, maybe this relationship is damaged.
DAVID: Yeah, sure. Oh, this relationship might be damaged. Right.
SPENCER: Right. And then I'll feel sad, like there's something that could have been lost.
DAVID: And how sad between zero and 100?
SPENCER: Maybe 30.
DAVID: 30, okay. Any other feelings? Frustrated, hopeless, alone, lonely, angry, upset, embarrassed?
SPENCER: I don't think I really feel those but I do feel something that I don't know if there's a word for it, but it's the feeling like I should have done better. I should have known better. Yeah, I should have been able to take charge.
DAVID: Okay, well, I'm writing this down. I call that another negative thought, a should statement. I should have done better. So now, what do these negative thoughts and feelings show about you that's positive and awesome. How are they helpful to you as well? What comes to mind?
SPENCER: I think that, hopefully, they show that I really care about not hurting people, that I care about acting ethically, that I care about these relationships being good, and that I want to avoid any kind of rupture in a relationship.
DAVID: Yeah. So I'm writing down three things. You could be writing them down, too. These thoughts and feelings show that I care, show that I'm ethical, and show that I want positive or loving relationships.
SPENCER: Well, I think in terms of benefits, sometimes it does lead to me realizing I did do something wrong and making amends. Or noticing, "Hey, you know what, I could have done that better," and then that helps me do better in the future. So I definitely don't think it's useless. I just think I'm just doing it too much. I'm overly sensitive.
DAVID: Exactly. A lot of times, our problems are just too much of a good thing. [writes] I can make amends and it keeps me on my toes, keeps me from getting complacent.
SPENCER: Yeah, and helps me be a better friend.
DAVID: Yeah, helps me be a better friend. So I've written down five positives. There's probably more but this is kind of a quick version of things. It shows that I care. It shows that I'm ethical. It shows that I want loving, caring relationships. It sometimes gives me the chance to make amends when I have screwed up. And it helps me be a better friend. Does that seem accurate?
SPENCER: Yeah, that's exactly right.
DAVID: And so are these things important?
DAVID: Are they real?
SPENCER: Yes, I think so.
DAVID: Are they powerful?
SPENCER: I would say so.
DAVID: Yeah. So good reason not to press that magic button. But if we could dial them down, how anxious would you want to feel? That was 50%. What would be a healthy amount?
SPENCER: I think about 10% seems reasonable.
DAVID: Is that enough anxiety for you?
SPENCER: I think so because I feel that I just want enough anxiety that I'm aware, that it's on my radar, but not enough that it's pulling me in, sucking me into the...
DAVID: That sounds like a good amount. How guilty do you want to feel? That was 40.
SPENCER: Maybe with guilt, I think I want to feel zero until I actually am confident I've done something wrong. I don't want to preemptively feel guilt when in fact, most of the time, I didn't do anything wrong.
DAVID: Okay, so zero. How sad do you want to feel? The sadness really shows your love for other people, right?
SPENCER: Yeah, and I think it's sort of like guilt. If it turns out I did damage the relationship, then I do want to feel sad and maybe 40% is reasonable. But I don't want to jump the gun. I don't want to pre-feel sad when maybe I didn't actually damage the relationship. I'm just kind of ruminating about the possibility of having damaged it.
DAVID: Okay. So you'd want to bring the guilt and sadness from 40 down to zero and maybe keep the anxiety from 50 down to ten? Something like that?
SPENCER: That sounds reasonable, yeah.
DAVID: Yeah, okay. Now do you want to try a really strong technique?
SPENCER: Let's do it.
DAVID: Okay. Now in this technique, we'll take turns. We'll both be named Spencer and one of us will be the negative Spencer and one will be the positive Spencer. I'll be the negative Spencer and I'm going to attack you with your negative thoughts. I'll sound like another person but I'm not; I'm just you talking to you. I want you to be the positive Spencer and see if you can defeat me. There are several strategies you can use. You can use self-defense, you can use self-acceptance, and you can also use something called the counter-attack. And that'll become obvious as we work together here. The idea is to see if we can blow these negative thoughts out of the water. There's five of them. And you tell me which one you want to start out on: I upset or hurt them. They'll abandon me. I'm unethical. This relationship might be damaged. I should have done better.
SPENCER: Maybe they'll abandon me.
DAVID: Okay. Could I talk to you for a minute, Spencer?
DAVID: You know who I am.
SPENCER: You're negative me, I assume?
DAVID: Yeah, that's right. And I just wanted to remind you, in case you'd forgotten, that they're probably going to abandon you, Spencer.
SPENCER: Well, the vast majority of my friends have never abandoned me.
DAVID: Okay, who won?
SPENCER: I don't know who won. [laughs] I guess I did?
DAVID: You won, okay. Did you win big or small?
DAVID: Small, let's try a role reversal. By the way, what does that show, that you won small?
SPENCER: That I have room for improvement, I guess.
DAVID: Right, but how does that relate to this relapse thing that you're talking about?
SPENCER: Well, I imagine that, with bigger wins, it would be more persuasive to myself and probably more persistent.
DAVID: Yeah, that might be what we'd be hoping for. We don't know that for a fact. But that's the reason we're doing this, of course. Do a role reversal.
SPENCER: Okay, so I'm negative Spencer? Well, the reason they didn't text you back is probably because they're not interested in hanging out with you anymore.
DAVID: Well, I have several things to mention to you. First, I get tired of your bullshit. There's really no evidence for that. I haven't had friends that don't want to hang out with me. Certainly, I've screwed up at times and will screw up in the future and I won't always be saying the correct thing. And I think in a good relationship, there's room for screwing up and hurting each other's feelings and sometimes talking those things over can make relationships closer and better. But there is one person who definitely has abandoned me.
SPENCER: Who is that?
DAVID: That's your bullshit. You're always talking in my ear, trying to put me down. Cut it out. I'm tired of you.
DAVID: Okay, who won?
SPENCER: Well, definitely positive Spencer won that one.
DAVID: Was that big or small?
DAVID: Big or huge?
SPENCER: Somewhere between big and huge, I'd say.
DAVID: Okay, let's do a role reversal back and see if we can keep pushing it up higher.
SPENCER: One thing I noticed is that you address it at multiple levels. And I think that's something I didn't do. I just addressed it at one narrow level.
DAVID: Yeah, that's right. You can come at these things from a number of angles. Spencer, your friend hasn't called you back and you may have hurt his feelings and he's probably going to abandon you.
SPENCER: Well, first of all, it's really common that people don't call back for a few days. This happens all the time. It doesn't really mean anything at all. Second of all, you have a strong relationship with this person. Even if they were annoyed at you, it could be an opportunity to make the relationship even stronger by working through it with them. And it's very unlikely to end your relationship. And even if it did end your relationship, you have so many other people that care about you that you have strong relationships with, that you'd be completely fine. But the reality is that you spend so much time worrying about this, and it almost never is actually the case that anything's wrong.
DAVID: Okay, who won?
SPENCER: Positive Spencer.
DAVID: Big or small?
DAVID: Big or huge?
SPENCER: Meh, big. [laughs]
DAVID: Well, now, let me ask you a question here. Maybe you don't want to get to huge on this one, huh?
SPENCER: Yeah, well, I want to have that opening that I do make mistakes, that I will sometimes screw things up. I will sometimes have offended someone and I want to leave that open. I don't want to fully close that possibility.
DAVID: Okay, now what rating do you give yourself adding that piece in? That's called the acceptance paradox.
SPENCER: It feels like that helps close the gap.
DAVID: Oh, yeah?
SPENCER: Yeah, you want to leave that opening or I want to leave the opening that I could be in the wrong and so I don't want to go to 100% and just blow it completely out of the water. Because every once in a while, that nagging voice will be right.
DAVID: Yeah. I love that. That's great. And you're just saying, "I'll always be screwing up in my life. And my screw-ups are something that can be opportunities to grow and to get closer to people."
DAVID: My problem isn't my screw ups. My problem is listening to your bullshit. Okay, are you ready for another attack?
SPENCER: I'm ready, yeah.
DAVID: You know, Spencer, Burns is trying to get you into some kind of ridiculous bullshit, but the fact is, don't listen to him, because you might have hurt or upset your friend.
SPENCER: First of all, I'm tired of your bullshit, you're telling me this way too often. Second of all, I'm really good at taking criticism and building relationships with friends where they can bring things up if they do feel hurt. And so if they actually are feeling bad about our interaction, very likely, I'll find out about it. Third, even if they were hurt, and I didn't find out about it, there's a very high likelihood that our relationship would still be great in the end. They'd get over it after a little while, and we'd still be able to get along well together, and they'd forgive me. And even in the worst case scenario where this person did abandon me, I would still have so many other wonderful people in my life, that I'd be totally fine. But I will leave open the possibility of being wrong. I'll keep that ten percent in mind so you don't have to keep bugging me with it because I am already aware of it.
DAVID: Okay, who won?
SPENCER: Positive Spencer.
DAVID: Big or small?
SPENCER: Big. I'd say big.
DAVID: Big or huge?
SPENCER: I'd say between big and huge. I think that was stronger.
DAVID: Yeah, what did you do that made it stronger?
SPENCER: It felt more confident and felt more self-assured.
DAVID: I thought of one dimension. I don't know if it'll help it but try another role reversal.
SPENCER: Are you negative Spencer again, or positive?
DAVID: I'll be the positive, because I thought it was pretty darn close to huge, but there's one little gap that we might be able to fill out.
SPENCER: So you know, Spencer, your friends are eventually going to ultimately abandon you, and if someone doesn't text you back for a few days, that's a sign that they might be about to never respond to you again. You should spend all your time trying to figure out what went wrong and how you fucked up.
DAVID: [laughs] Well, I'm fucking up right now by listening to you, let's start out with that one. And in the second place, I'd like to say that that's very unlikely. I'm really great at taking criticism and if I did say something that hurt someone's feelings, we'd undoubtedly talk about it and end up loving each other more. I don't need to be afraid of raw spots in relationships. That's a part of life. But you've often told me this ridiculous thing that someone's gonna abandon me because I said something to hurt their feelings. If that happened, that would show that there was something very sensitive in that person that I was not aware of. That would be very unusual for a friend to take that behavior. And so I might let the dust settle for a bit and then get back to them and just say, "I've been missing you and clearly I said something that hurt you a lot. I'm doubly cursed because I don't even realize what I did that hurt you so much. But if you'd be open to it, I'd love to get together and talk to you and tell you how much I love you and care about you and find out what way I screwed up and see the truth in your criticism. Would you be open to doing something like that?" That's the way I would handle it so, although that's unlikely to occur, that could conceivably occur. And it would just let me know that I had among my many pretty robust friends, someone who's awfully (maybe) fragile and vulnerable, and I could still offer support to that person.
SPENCER: Yeah, I think that's a really good element to bring in because there's this issue of responsibility that, if someone's upset, it doesn't necessarily mean that I'm in the wrong. And I think my brain jumps to blaming myself for it.
DAVID: Sure. Let me show you another way. Say, "if someone's upset, it shows you're in the wrong," say that to me.
SPENCER: If someone's upset at you, it means that you fucked up and it's your fault.
DAVID: I think there's a lot of truth in that; I may have done it because I was mad at somebody and lashed out at them or I might have said something that inadvertently hurt their feelings. But I can tell them that I want to hear what they have to say and learn from them and find out the way I screwed up. I'll be screwing up for the rest of my life. But I do have one big screw-up though, that I'm going to try to get over today.
SPENCER: Oh, yeah? What's that?
DAVID: Listening to your horseshit constantly chattering in my ear. Get the fuck out of here.
SPENCER: [laughs] It's so funny to me because it's so different than the... I don't know if you're familiar with video of internal family systems where you treat every kind of voice in your head with kindness and compassion as though all the concerns are valid. Your approach is so different from that, it makes me laugh.
DAVID: Yeah. Who won that one? How did that work for you?
SPENCER: Yeah, well, I liked that. Certainly, positive Spencer won that one.
DAVID: Yeah, big or small?
DAVID: Big or huge?
SPENCER: I'd say huge, yeah.
DAVID: Huge. How did I get to huge?
SPENCER: Well, I feel like you accepted the droplet of truth and droplet of wisdom but also dismissed the voice at the same time.
DAVID: Yeah, and I think that's the difference with getting into huge, the acceptance paradox. And then that might be the thing for you to work on in terms of getting to your next level of enlightenment, because you said that earlier in our recording, too, a little bit that if someone criticizes you, you don't have to let that upset you or maybe that's a reflection on them. And I go in the opposite direction, say that's always a reflection on me to some degree, but without that issue of blame, to use the disarming technique and see the truth in their criticism. And that will generally dissolve the conflict and, whether or not it does, it gives you a lot more power when you can incorporate the acceptance paradox into your response. But at any rate, I know it's getting late. And I just want to tell you one more thing: you should have done better.
SPENCER: [laughs] Well, I think I do a really good job building friendships that are deep and lasting the vast majority of time. Of course, I make mistakes. Of course, I sometimes screw things up. But I think I do a good job of learning from those mistakes from listening to the critiques that people have, trying to get better from them. But most importantly, shut the hell up.
DAVID: Yeah, great. Who won?
SPENCER: Positive Spencer.
DAVID: Big or small?
DAVID: Big or huge?
SPENCER: I think pretty huge.
DAVID: Yeah, getting closer. Well, that's my assessment, is that going a little further into acceptance could bring you to the level of greater happiness. You'll always have times of slipping back but the greatest thing that holds people back is working too much on self-defense and not enough on acceptance. Let's do just a little final exercise here and then I'll demonstrate some acceptance. Just start ripping into David, just saying anything you want, just horrible things, true or false.
SPENCER: You know, David, you're overhyping your therapy. There's no way you can really cure people in two hours. You're self-deluded.
DAVID: Okay, just one at a time.
SPENCER: All right, sorry. [laughs]
DAVID: Well, first of all, let's take the thought that I'm overhyping my therapy. That's absolutely true and that irritates a lot of people, too. I have a lot of flaws. That's just one of many flaws. If you knew me better, you'd see I have a lot of things. I screw up in all kinds of ways so I have to plead guilty as accused.
SPENCER: Do you actually believe that? Do you feel that when you're saying that?
DAVID: Yeah, it's true. I do see almost everyone get elimination of symptoms in a two-hour therapy session, so that part isn't overly hyped, but I really promote my therapy, and a lot of people like that and a lot of people hate that. But it's generally better to be humble than to be overly hyping things. I genuinely believe that that's an error that I made all the time. I probably made it a lot on your show. Try again.
SPENCER: You know, you accuse the psychologists as being cult leaders. Who's to say you're any different? Are you just pushing your own paradigm saying it's better than everyone else's? Isn't that what every big psychologist has done?
DAVID: Absolutely. I plead guilty as accused there, too. I've been trying to move the field to a science of psychotherapy, data-driven, measuring things at the start and end of every session, and getting ratings from patients on empathy and helpfulness. I think that'll make a lot of people honest and I think that's an important contribution to the field. And I don't have much respect for people who don't use measurement and testing. But at the same time, I do have kind of a cult following, that's for sure. And I tell myself, "God, you're no better than the rest," and I think that's true. I'm very narcissistic and I have a big ego. It's actually helped me because I'm not that bright. So I work so hard because of my narcissism and I have made a lot of discoveries. But yes, I am also kind of a cult leader. I do research; I spend 10, 15 hours a week analyzing data from our app and seeing what's good about it, what's not, where it's falling short. So I give myself a lot of credit for integrity, too. But yes, and I kind of love being a cult leader. In fact, if we do another episode, I want to do it in video so I can wear robes and sit with flowers around me. [laughs] So how did I do?
SPENCER: [laughs] I think you did great. Well, you did a great job of accepting the criticism and not trying to deny it and not turn...
DAVID: Yeah. Why should we have to deny anything? You know what I mean? Give me a harsher one. Give me a harsh criticism. You're giving me easy, easy.
SPENCER: Really? Oh, man. All right. Well, throughout your career, you must have let down 100s or even thousands of people who came to you, thinking you were their last hope. And yet, you didn't help them.
DAVID: Yeah, especially early in my career. There were a lot of people I helped and a lot of people who fired me. They were turned off by me. I was too enthusiastic. And even to this day, even recently, a couple of colleagues got pissed off at me and it was very upsetting. I hardly slept last night, to tell you the truth. And we had a great conference just before the call and worked things out, which was a great relief to me. But ever since I've been little, even my parents used to tell me, "David, you're really hard to get along with," and they were right. [laughs] And so I'm just grateful that there have been so many that I've been able to help and I'm grateful that my skills have evolved and I've been able to develop levels of compassion that I never had when I was younger and cockier. But I fail all the time. Not only the patients I work with, but the family that I love: my son, my daughter, my wife. I love them a lot, but I've failed all of them in many ways. And I think it's kind of a miracle that so many people seem to still like me in spite of all of my failures. It seems kind of like a miracle. I have so many people in the Tuesday group. I think the fact that I treat everyone for free, and I teach for free, I figure that gives me a little slack there. So they can't say, "Well, you're not worth the money," type of thing. But yeah, I'm a very, very flawed person on all kinds of levels.
SPENCER: Well, David, I just wanted to thank you so much for coming on. This has been a really amazing conversation. Thank you, thank you so much. I really appreciate it.
DAVID: Thanks so much, Spencer. You're really awesome. I had high expectations for being on your show and it was even better than that. So thank you so much. I really appreciate you.
SPENCER: Thank you, David.
JOSH: A listener asks: "What is the meaning of life?"
SPENCER: From my point of view, life doesn't have an objective meaning; so there's not "a" meaning of life. Meaning is an emotion that humans have, or an experience that humans have. We can have a sense of something being meaningful. And when you think of it that way — as an experience that humans have — then lots of things can be meaningful, and it's gonna differ for different people. But for many people, things that are meaningful [include]: love and building relationships; having children is meaningful for a lot of people; having projects that have ends that they really care about or that push them to their limits or challenge them; those are things that people tend to find meaningful. And if you think that meaning is not an objective property of things but rather an experience, a human experience, or experience of conscious beings, then I think there's lots of things that are meaningful.
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