Epistemic status: I listened to this, and I found these statements surprising in a “big if true” way. It didn’t seem obviously false, but I am very much relying on him here. If someone thinks his claims are completely made up, please let me know in the comments.
TLDR
David Burns claims in this podcast episode, with deliberate practice, he and a few of his students got to the point to learn to cure patients in a single or just a few sessions. David Burns is known for popularizing CBT through his book “Feeling Good”.
The quote in the next section is most important. The rest of the post contains other quotes I found interesting. Some of them are pretty long. Feel free to skip things. The transcript was generated with whisper, so there might be mistakes. You can find the whole transcript here.
David Burns on Teaching CBT
David Burns: I’ve realized that probably of the 50,000 people I’ve trained, you know, with, I mean, trained, I’d say someone who spent at least two days in one of my full day, you know, two full days with me and learning cognitive therapy, the new TEAM-CBT. There’s probably only been 10 or 15 who have been able to learn it. I’ve illustrated it on this program.
Spencer Greenberg: Wait only 10 or 15 of many thousands have been able to learn it?
David Burns: They have developed the same level of skill. It means, you know, a lot of people are doing it. There’s a feeling, there’s a feeling good institute in Mountain View, California. And they probably have 40 or 50 therapists associated with them. But there are wide ranges of skill levels and the ones like may or the ones when I work with people, I think you should be able to complete a course of treatment for depression in a single therapy session. It has to be two, it takes me two hours to do it, but it happens.
Spencer Greenberg: That’s a pretty amazing claim, right, that you could treat someone in two hours.
David Burns: I mean, yeah, yeah. And when I was young, I would have thought it was impossible. And I used to dream about it and say, would there be some way to get really good at psychotherapy? And I said, we’d have to measure things and nobody’s measuring anything because athletes, when they practice like for basketball, every time they throw the ball up, they can see whether or not it goes through the hoop. So they learn really fast, but we weren’t measuring anything. And I did a research study at Stanford inpatient unit to see how accurate therapists are and understanding how their patients feel. I gave you an example where my judgment of the patient was way off, but I had the scales that told me that immediately at the end of the session so I could correct the error. And that’s how my own skill has developed so rapidly because I’ve ever since 1980, I’ve never had a single patient that I didn’t measure their depression level and other things at every single therapy session and that information.
Example of the Mood Survey
I have all the the patients take this brief mood survey that I’ve developed. And they can fill it out in 30 seconds. And then I could look at their score and see exactly how depressed they are, how suicidal they are, how angry they are, how anxious they are. And you know, measures like that. So I can see right away, even I don’t know the patients, I can see exactly how upset everyone was. And so this woman had was very high on the depression and suicidal urges were high and the anxiety was high and the anger was extreme.
And she she said, could I help her work with her during this session. And I was so proud of how I was doing. And I used a powerful technique called externalization of voices and showed her how to blow her negative thoughts out of the water. And at the end of the at the end, I said, well, here’s boy, I’ve done such brilliant work today. This is someone I could talk about in a workshop or a podcast someday with Spencer Greenberg. I could talk about the magic I did even with the most severe in patients in a single hour really. And at the end, I have all the patients fill out their scores again and and hand them in to me as they’re walking out of the the room for the cognitive therapy group, the hour and a half group.
And when she handed it, her piece of paper to me and I looked at it, I was shocked because I thought all of her scores would be zero on the on the depression and anxiety. Instead, they had gone to the other extreme indicating the most severe depression a human being could have, the worst suicidal urges a human being can have, the worst anxiety, the worst anger she was enraged. And that I turned the piece of paper over to over to see my empathy ratings.
And on the empathy scale goes from zero to 20. And a score of 12 would be like what Hitler could get. Like that’s a bet, that would be a horrible score. Unbelievably bad. Well, I think she gave me a zero on empathy and a zero on healthfulness. And I couldn’t believe it. I took her aside and I said, Margaret, this is part of a research study and it’s easy to get confused when you take these scales on the mood scores. The good ones are good answers are on the left, the zeros and on the empathy and healthfulness, the good ones are on the right, the four, four, make could you correct it because we don’t want to mess up the database. And she looked at her, because I couldn’t believe that those were valid scores. And because she’d, I thought she’d done so great. And she said, no, there’s no mistake here, doctor. And I said, what are you talking about? I thought it was a fantastic session that we had. And she said, well, good for you, maybe. And I said, what are you talking about? What, what happened?
And she said, well, when you said that I’d had a double whammy, that really hurt my feelings and I thought you were making fun of me. Well, I had, I had used that expression. You’ve lost your husband and your work, the two sources of self-esteem. I said, that’s like a double whammy, but she thought I was making fun of her. And I had no idea. And I said, let’s sit down and talk about this. I’m, this is just devastating. And I can imagine how hurt and angry you feel. And took maybe five minutes to work that through and develop that warmth and trust. But therapeutic failures, therapists don’t even know when they’re acting lame. And that, but if you, if you use these kinds of scales, the patients will be honest with you and you’ll find out right, right away. And if you have the courage to do it, your patients can become your greatest teachers of all.
Relapse Prevention Training
And then I do relapse prevention training, which takes about 20 minutes. It could be at the next session or at the end of the first, you know, session. I just sometimes I wait a day or two and then do the brief relapse prevention training. And then they’re done. And that’s how it works.
And what do you teach during the relapse prevention? Well, there’s three things. First, I say it’s a hundred percent certainty that you’re going to relapse. No one is entitled to be happy all the time. All you’re entitled to is five happy days per week and two miserable days. And if you don’t have your five happy days, you need a tune up. So you better call me and come back for a little mental tune up. But if you don’t have your two miserable days, you’re getting too happy. So that’s a concern also. But they went I say when you relapse, it could be tomorrow. It could be three weeks from now. It could be anytime. But everyone has the same exact thoughts. You’ll tell yourself my improvement was just a fluke. The treatment wasn’t real. Burns is a fraud. I’m a hopeless case after all. I’m worthless after all. This proves that the therapy didn’t work. And I have them write those thoughts down on a piece of paper, then identify the distortions in them because right now they’re feeling happy. So it’s easy for them to crush those thoughts.
For example, instead of telling yourself, this proves that the therapy didn’t work. You can they might come up with a thought like, “No, the therapy was amazingly helpful. But last night I had a fight with my partner, went to bed angry. And I woke up today feeling worthless and miserable and hurt and alone. And maybe it’s time for me to pick up the tools again and use them.” And then I say, “How is that?” Well, they say, “Oh, that’s tremendous. You know, and they can easily crush these thoughts when they’re in a good mood before it comes.” And I roleplay the thoughts with them and say, “No, I’m your negative self. And I want you to know that you know, that the treatment didn’t work because you’re so depressed today. The treatment was superficial. It wasn’t deep enough.” And then see if they can crush it. Maybe they can say, “No, the treatment was fantastic. My only mistake is listening to your bullshit right now. It’s I’m upset. I have a right to be upset. And I’m going to see what I can do to deal with this situation. And I have plenty of tools to deal with that.”
I have one thing I can tell my partner that I love them and that I felt badly about our argument. And let’s talk it over. And I can also talk back to these ridiculous distorted thoughts I’m having right now. So that’s how it goes. And it’s there. It’s easy for them to do that. And I have them record that on their cell phone as the easiest way and say now when you relapse, make sure you have this recording available so you can listen to it. And if you have any trouble, just call me and you can come in for a tune up. I give lifetime guarantees on my work. I’ll give you three unlimited tune ups for the rest of your life if you ever need me again. And I hope you will because if you don’t relapse and need me, I’ll never see you again. And I’ve really come to like you and feel very proud of you and affection towards you. And I’m sad to lose you now, but I wouldn’t have it any other way because you’re feeling joy now. And that’s the greatest thing for me to have you recover really rapidly. And the 40,000 hours of patients I had, I don’t think more than eight or ten ever contacted me for tune ups.
Empathy Training in Tuesday Session
Deliberate practice sessions, in which they meet every Tuesday and role-play an interaction with their most challenging patients:
I mean, therapists, we have very rigorous empathy training techniques so that therapists can learn to get to perfect empathy with almost any patient within 30 minutes of the first time you meet with the patient. So what that means is the patient gives you an A, not that you give yourself an A. Because the way you grade yourself will rarely be similar to the way the patient grades you. So it’s about how the patient feels, how you’re doing.
How do you teach people the empathy? That might surprise the listener. How do you actually learn that? Well, the way I do it, it’s pretty challenging. I would say for the therapist and they don’t all have the courage to do this type of thing. But in the Tuesday group, I might say, what is the most critical, challenging, threatening patient imaginable? What would that person say to you or what have patients said to you? And they list things like, oh, patients tell them things like, “You don’t really care about me. You’re not really helping me. You don’t really understand how I feel inside,” things of that nature. [...]
I train them on the worst things that someone might say to them because if you can handle that, you can handle anything. And the techniques are, it’s EAR, empathy, assertiveness, and respect. There are three empathy techniques. That’s the disarming technique, which means finding truth in what the patient says, even if it seems unfair or exaggerated. And it’s based on what I call the law of opposites. The law of opposites is, if you agree with a hostile criticism and you genuinely agree that it’s totally correct, the person will instantly stop believing that. And that’s a paradox. So let me repeat it. If someone gives you a horrible criticism, like let’s say it’s someone on the inpatient unit who’s been involuntarily hospitalized, and say a teenager who’s trying to get out of the hospital to kill someone or to kill themselves. And they might shout at you, “You’re a jerk. You don’t care about me. You’re like a probation officer,” something like that. And you know, what could the inpatient doctors say? How could you agree with that? You see, because if you agree with it, the person will stop believing it. So you might say something, you know, “I feel the same way you do. I absolutely haven’t been helpful to you. I haven’t been understanding how you’re feeling inside. And I really am kind of like in the role of a probation officer. And I hated as much as you do. It’s not the way I want to relate to you. And I can imagine you’re mad at me and pissed at me and pissed at the inpatient unit. You’re here involuntarily. And you want me to let you out. And yet, I understand you told the nurses this morning you want to get out so you can kill yourself. Get out of the hospital. And I can tell you that I care about you. And if I let you out and you killed yourself, I don’t think I could live with myself. But at the same time, I’m feeling pretty stupid like I really haven’t done a good job with you. And you have every right to be pissed off at me.” That would be like the disarming technique. And when you say something like that, the patient melts in your hands. Here is somebody’s finally listening, finally hearing me. But that’s the disarming technique. And it’s like a magical technique. But it’s hard to learn because it requires the death of the therapist’s ego or a normal person can do it. You don’t have to be a therapist, but it requires the death of the self. That’s one of the four great self, great deaths that the Buddha talked about. Well, he just talked about the great death, but there’s actually four great deaths. And this is the death of your ego to hear the anger that’s being directed at you.
Another thought in feeling epithetia paraphrasing the patient’s words, acknowledging how the patient is probably feeling based on the words you’re saying “I don’t understand you.” And you’re right, I’ve done a shitty job of that. And I can imagine how angry you might be feeling and hurt and kind of disillusioned. “Tell me more about that. Am I on the right page? Am I reading you right right now?” And that would be like thought empathy, repeating their words, feeling empathy, acknowledging their feelings and inquiry. “Am I getting it right?” Those would be the three empathy techniques disarming, thought and feeling empathy and inquiry.
And then there’s, “I feel” statements would be assertiveness, sharing your own feelings. Like “I feel really sad and a bit ashamed to realize that I’ve failed you so badly, but you’re right. And at the same time, I’m thinking that this could be a chance
Performance of His Colleagues and the Feeling Good App
My colleagues, my some of my students who are the real, have developed tremendous expertise, say that they’ll typically see patients for three or four or maybe five sessions. And it’s a problem for them economically because their patients get better so fast. So it’s hard to keep their practice full. If you have the old-fashioned thing where people just come and talk to you for hours and months and years or even a decade or more, you don’t need to get new patients. But the, you have to get a lot of new patients with these new techniques because they work so rapidly. But it generally works out because the word gets around that so and so has these phenomenal, phenomenal skills. So they get it start building, you know, a tremendous following after, you know, a year or two and the word get gets around.
With our feeling good app, which we hope to be releasing probably in October or November and through there. And we’re doing beta tests. If any listeners want a beta test, you know, it’s free and it’ll always be free if people can’t afford it. We see pretty tremendous improvements in people with the, with the feeling good app and roughly two days. We see like a 50 to 60 percent reduction in seven negative feelings, feelings of depression, anxiety, guilt, shame, loneliness, hopelessness, anger. But that was, it are pre-artificial intelligence phase with the app. We’re now creating artificial intelligence David in the app. And it’s hard to say, to tell the difference between being treated by me live and being treated by the app that we’re training because it’s learned to do kind of exactly what I do. It just works faster than I do. And so we’re, we haven’t beta tested it yet. We’ll be beta testing it within the next few weeks.
I applied for beta-testing, but it is currently only available on iOS.
Conclusion
It seems pretty clear that David Burns is probably exaggerating a bit. But even if just a weak version of his claims is true, it seems like getting a really skilled psychologist would be worth it, even for a high price premium. Anyone knows a psychologist like that? Thank you in advance for your comments!
I don’t know a ton about Burns or his work, but for things in the class of stuff like psychotherapy, meditation, and other ways to work with your problems and (hopefully) improve your life so you more live the life you want to live, two claims can be simultaneously true:
Psychotherapy-like-stuff can and should be able to fix acute problems in short order, and if it’s not you’re using an ineffective technique for the problem at hand
Psychotherapy-like-stuff has to be done ~forever because there are always subtle ways you’re getting in your own way that you could work on to get marginal gains
The trouble is we don’t do a great job of making these two competing claims clear, nor do we often make clear for any particular intervention, technique, practice, etc. whether it is intended for acute or chronic use.
My guess is that some versions of psychotherapy are a scam if you have to pay for more than 5 sessions, and some versions are doing exactly what they should be if you are paying to go every week, and that’s because they are serving different purposes. Alas, we don’t make this clear, and I think sadly there are enough unscrupulous providers who profit from the ambiguity that there’s not a strong push to clear this point up with the general public.
Exactly right. However, I am extremely doubtful about anyone who claims that all their patients are cured within a few sessions. That sounds very unlikely unless they screen out people with anything more than minor hang-ups. Sure, in many cases, the root cause of the psychological problem can be identified and the patient can learn a few techniques and then they no longer need further therapy. However, lots of people in therapy are dealing with negative mental processes that were baked into them by a difficult childhood or a traumatic experience. Those sorts of issues can require on-going therapy to keep the patient on track and in a positive mindspace. One quick tricks don’t work on someone with severe codependency or agoraphobia or anorexia. Maybe, with time, they can work through these issues and no longer need therapy, but this could take years.
I think anorexia is in a different category because the patient often doesn’t want to get better. David Burns talks about it a little on https://feelinggood.com/2019/11/25/168-ask-david-the-blushing-cure-how-to-heal-a-broken-heart-treating-anorexia-and-more/, where he mentions that some sort of therapy with a 50% success rate is good.
The rapid cure stuff is mainly about depression and anxiety disorders, I guess agoraphobia should count (with the caveat that the patient has to be well enough to reach the therapist’s office). Certainly whether it “could take years” is the crux of the matter; David Burns very much denies it should ever take nearly that long.
His verbal patterns have my scammer hackles up.
I am extremely skeptical for reasons described in Book Review: All Therapy Books.
The general idea here is that the “form of therapy” isn’t what’s important but rather the skill of the therapist.
David Burns claims that out of 50,000 people trained in his form of therapy around 0.2% have skills to achieve these kinds of results.
If Scott ten colleges were randomly picked out of those 50,000 people it would not be surprising if none of them would be at that high end of the skill level.
Then there’s the other argument about deliberate practice. On main feature of David Burns form of therapy is that it sees therapists engaging in deliberate practice as an important aspect of becoming a good therapist. Most schools of therapy don’t really go for deliberate practice. I think it’s plausible that the rate of people with high skill in a school of therapy that engages in deliberate practice is higher than elsewhere.
I see, that all makes a lot of sense. I take back my objection then. It seems at least plausible that Burns is correct here.
In my experience, academically trained clinicians tend to think of everything they are trying to do as an intervention. Like, thinking of teaching as an intervention, where you want to get the participants to certain behavioral standards, and you are ultimately responsible for the efficacy of this intervention (especially if you can also define the expected outcomes). Imagine if you teach a class. After the final exam, you notice that there are a bunch of questions that no one got right. This is nothing to be proud of because either your measurement instrument (i.e., exam) is very off, or your intervention protocol (i.e., lesson plan) is very off. Similarly, clinical scientists would not be very proud of saying, “Yeah, I taught a course to 50,000 people and only 10 or 15 of them got an A, and this shows how much of a genius I am.” They would go back and revise their lesson plan. What if the students are just not very motivated, you say? Well, then we need to figure out a way to improve motivation, or adjust the measurement for the fact that most students are not very motivated, or adjust the intervention protocol so motivation matters less, or maybe all of the above.
Based on the excerpt, what David Burns is suggesting is not very new stuff. I’d be very surprised if the episode was recorded recently because the claim that “nobody’s measuring anything” is simply not true—it’s called routine outcome monitoring. For me, that was one of the first things to learn in a graduate-level clinical psychology class. Of course, there is a lot of research about it, so there is nothing mysterious about pre- and post-session measurements. Sounds almost like pointing at a large language model and saying, “Look at this massive linguistic network! It is really good!”
This claim really bothers me: “And the 40,000 hours of patients I had, I don’t think more than eight or ten ever contacted me for tune-ups.” My friend recently went to visit a physical therapist for a muscle pain issue. Over the course of the treatment, her pain got worse, but the therapist kept telling her that it was totally normal. But… the pain was really bad, and she felt like the therapist didn’t really understand how bad it was. She finished all 10 sessions as planned and never reached out to the therapist again. Plus, the sessions were expensive.
Believe it or not, humans can overfit too. Focusing on “challenging patients” (how do you operationally define challenging anyway?), especially with the examples provided, sounds like a pretty bad idea. Responding to direct confrontation or insult with open acceptance is not even something I had to take a class to find out. These archetypical challenges are so saturated in the professional literature and dialogues, you kind of just pick them up at some point far earlier than receiving any practical training. I’ve seen quite a few first or second-year psychology undergrads quickly overfit to an elaborate but empty “you are right and your feelings are valid, so tell me more” response to a lot of minor confrontation or when someone expresses their feelings about anything. This kind of practice is not very informative if you want to have an empathetic yet helpful conversation about someone’s drinking problem when they have just recovered from a heart surgery. And, patients can get stuck or even deteriorate without verbally challenging the clinician.
As for the app: “Change over time is not ‘treatment response’,” but feel free to prove me wrong with RCT.
After thinking about the podcast some more one interesting aspect was:
David Burns seems to count this as evidence that his treatments are long-term effective. If only so few people contacted him again, to me that doesn’t seem to be evidence of long-term effectiveness but evidence that the people did not feel like contacting him again was a straightforward thing to do.
Given how much of a deal David Burns makes about the importance of measurement, this seems strange. He could easily send all his patients after a year a follow-up email to let them fill out a form of his depression scale but seems not to.
It’s completely unclear to me why telephoning a past patient to check up on whether they are doing well would be unethical.
Yes, I also found that fishy. I tried finding negative reviews from patients online, but had a hard time with queries, because I didn’t know how to exclude reviews of his book properly.
Does anyone know more about this scale and the question it uses?
Might be this one: https://feelinggood.com/wp-content/uploads/2013/10/evaluation-of-therapy-session-v-1-for-article.pdf
David Burns also has his own podcast, many episodes of which are example live sessions of this rapid cure (see https://feelinggood.com/list-of-feeling-good-podcasts/ and search for “live therapy”, or https://feelinggood.com/podcast-database/ which has a fancy Javascript interface allowing filtering on tags).
He does often make the explicit claim on his podcast, that 90% of patients can be cured in one or two sessions (plus one more for “relapse prevention”). It’s a bit hard to know how much of this is from a selection effect on the patients though. I’m pretty sure I recall him also mentioning that he only treats (people studying to be) therapists for liability reasons now that he doesn’t have an active clinical practice with insurance. And I think when he had on one of the app developers, they mentioned in passing that they had discussed some social anxiety issues, but it sounded like there wasn’t any dramatic breakthrough on that.
I don’t personally, but you could check out https://www.feelinggoodinstitute.com/, they say “Expect meaningful change within five therapy sessions”; I assume that means five 1 hour sessions and probably one 2 hour session is more effective than two 1 hour sessions (due to time wasted on recalling previous context, breaking flow, etc).
I want to be in the community where we’re all expected to become swole in both bayesian epistemology and CBT skills. If I had to choose one or the other communal competencies I think being able to CBT each other is probably a better starting point.
I wonder if I should go out and look for psychotherapist cultures that see a convergence between mental health and rationalist epistemology, or whether they’ll have already found us via ssc/tlp.
If you listen to David Burns, then learning these skills needs deliberate practice with explicit feedback on skills like empathy. Most psychotherapist cultures just don’t have that. Copying psychologist culture doesn’t get you the those kind of skills.
If we would want to follow what Burns says, it would make more sense to have a culture where after you meet with another rationalists both of you fill out feedback forms where they rate each other empathy in the conversation and maybe a few other metrics.
I don’t see what’s difficult about having a norm of just telling people when they’re not understanding you/not seemingly trying, and caring about that?
Rather than this Feeling Good app for patients, I’d be more interested in an app that let people practice applying CBT techniques to patient case studies(or maybe even LLMs with specified traits), in order to improve their empathy and help them better understand people. If this could actually develop good therapists with great track records, then that would prove the claims made in this article and help produce better people.
Interacting with a case study and interacting with a real person are quite different as far as empathy goes. If you train on making LLM feel understood that might not make a person feel understood if you do the same thing.
These ideas and techniques don’t sound particularly original, from what I have experienced with CBT. Maybe I am missing something important, but this just sounds too good to be true. I find it more likely that the patients that didn’t return because the magic bullet turned out to just be a chunk of lead, and they didn’t want to throw good money after bad.
Aliefs can’t be changed by just believing harder. They take time and practice to be ease and change. Those changes can be scary too. I expect that most people would need support as they go through that process.
Now, that doesn’t mean that the tools that he’s talking about aren’t effective over time. CBT, as I understand, has a good track record, so if you find parts that are helpful to you, stick with it! Just don’t expect such quick success.
Nothing that David Burns advocates is about just trying to believe harder.
His basic thesis is that someone who has a lot of deliberate practice can facilitate techniques in a way that’s a lot more effective.