David Burns received his medical degree from Stanford University School of Medicine and completed his psychiatry residency at the University of Pennsylvania School of Medicine. Currently, he 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 was named Teacher of the Year three times by the class of graduating residents at Stanford University School of Medicine, and feels especially proud of this award. His best-selling book, Feeling Good: The New Mood Therapy, has sold more than 4 million copies in the U.S., and been popular worldwide.
This interview with David Burns and Michael Yapko is excellent, but too long to fit in the Newsletter, so readers are encouraged to view the entire video interview on the Erickson Foundation website. (www.erickson-foundation.org)
Michael Yapko: Can you provide some biographical background and talk about the developmental forces that shaped your interest in becoming a psychiatrist? Also, not a lot of people know that early in your career you were a drug researcher, but eventually abandoned pharmaceuticals in favor of psychotherapy. Could you please talk about that transition as well?
David Burns: Maybe we could start with why I left — although not entirely, but for the most part –psychopharmacology. After my residency in psychiatry at University of Pennsylvania medical school, I completed three years of research as a post-doctoral fellow. I did both clinical and basic research. During that time, I addressed the theory that depression and anxiety are the result of a chemical imbalance in the brain, specifically that patients with depression have a serotonin deficiency, and patients with mania have an excess. Yet, I couldn’t find evidence that any psychiatric disorder resulted from a chemical imbalance in the brain.
I was given the prestigious A. E. Bennett Award for my research on brain serotonin metabolism. The award was based on a worldwide competition and I only mention it to say that I wasn’t an outsider; I actually was an insider in the psychopharmacology world.
At our depression research unit at the VA hospital, we did a direct double-blind research study on this theory. We split a group of depressed veterans into two groups. Both were given supplementary milkshakes every day, but half got milkshakes laced with 20 grams of L-tryptophan. Now, that’s a massive dose of an amino acid that goes directly from the stomach into the blood and into the brain and is synthesized into serotonin. Subsequently, half of the depressed veterans showed a massive increase in brain serotonin.
Every day we measured the depression levels of both groups with the Hamilton Depression Test. After a few weeks, we broke the code to look at the changes in depression levels in the two groups. There were absolutely no differences. The results were inconsistent with the theory that depression results from a deficiency in brain serotonin.
In 1975, that study was published in a leading psychiatric journal — Archives of General Psychiatry — but it largely went unnoticed until recent years. I went on to write chapters for psychopharmacology textbooks on brain serotonin and depression and other psychiatric disorders. I reviewed the entire world literature, and again came to the conclusion that it’s not clear why people are proposing this theory.
Finally, I asked my advisor, who at the time was one of the world’s top three psychopharmacologists, why we were putting all this energy into a theory about brain serotonin when I could not find any evidence for it. He said, “Well David, to tell you the truth, a number of years ago several of us got together to try to start the field of biological psychiatry. We know there are thousands of substances in the human brain, but the first one we learned how to measure with an assay, was serotonin. So, kind of tongue and cheek, we made up this theory that depression is due to too little serotonin and mania is due to too much. We just wanted to get the field of biological psychiatry going so we could submit grants to NIMH and get funding and start brain research.” I said, “That’s ridiculous as a basis for a dominant theory in our field. I’m not sure I want to spend my life doing research on something like this.” He replied, “Listen David, don’t rock the boat. I could get you started testing antidepressants for drug companies. You’ll make millions every year. You’re already becoming world famous. Don’t challenge the system.” I told him I don’t care about that stuff. I went into psychiatry because I wanted to see people get better, not because I wanted to have millions in grants.
At the American Psychiatric Association meetings I attended, they would say antidepressants cure 85% of patients with depression. I told them, “That is baloney! I treat hundreds of patients — where are all the cured ones?” Most of my patients were not getting better. A few got better; a few got a little better, but many were unchanged and a lot were deteriorating. I decided I had to find some form of psychotherapy to supplement the drug therapy.
MY: I assume that’s how you came to cognitive therapy?
DB: At first, I tried several other things. Then, I heard about Aaron Beck and cognitive therapy and the department chairman said, “David, why don’t you try this out as a part of your research fellowship?” It wasn’t love at first sight, though. Negative thinking causes depression? Change the way people think and you can change the way they feel? I said, “That’s like Norman Vincent Peale or Dale Carnegie or some kind of positive thinking stuff. I just know that doesn’t work.” He said, “Why don’t you go to Beck’s seminar and try it with a few of your worst patients and just prove to yourself that it doesn’t work.” So I began going to a weekly seminar and every couple of days I would present my worst, most suicidal patients. I would get input from the department chairman and I would go back and try it on my patients and they started saying, “Hey, this stuff really helps. This is great. Do you have more techniques?” It was the patients who really sold me on it.
MY: The influence of cognitive therapy is now worldwide. You have been a huge proponent for cognitive therapy for a very long time. In recent years your repertoire has expanded considerably. Has cognitive therapy changed? Have your ideas about treatment changed, and if so, how so?
DB: I don’t know if cognitive therapy and cognitive therapists have changed, but my own thinking and that of my colleagues has changed dramatically. First, I want to say I’m deeply indebted to Albert Ellis and Aaron Beck, pioneers who changed the history of psychotherapy. They were brilliant clinicians and they gave us incredible gifts. But, they didn’t have all the answers. Cognitive therapy, although it’s given us a tremendous amount, hasn’t been the entire answer. Not everyone is helped. There are some people who respond quickly, but others seem to just say to therapists, “Yes, but…” So I began gathering data and doing research to try to find out more about the patients who don’t respond rapidly. If we could discover what the problem is, then put one, two, or three new dimensions into the treatment to address that, maybe we could develop the psychotherapies of the future.
So along with my colleagues at Stanford and elsewhere, we developed a new approach. We call it “T.E.A.M. therapy,” and it’s not a school of psychotherapy. Rather, it’s an understanding of how psychotherapy works, based on research and clinical experience. What are the ingredients of psychotherapeutic success or failure?
One of the biggest things we’ve discovered is that motivation and resistance play a great role in our cognitions and perceptions — in how we think, feel, and behave. I’ve developed 15-20 powerful techniques to bring resistance to conscious awareness. I use these before I use any therapy techniques to melt a patient’s resistance. In this way, the patient becomes a powerful collaborator with the therapist. It appears – and we have to get outcome studies to validate this – that we’ve made an amazing breakthrough in the speed of therapy. This may sound like malarkey, but patients with severe depression and anxiety, many of whom have been depressed for years or decades, are recovering in just one or two therapy sessions, with a complete elimination of their symptoms. We can’t do it all the time, but I would say more often than not. It’s astonishing and exciting. For us, this motivation revolution is as big and as important as the cognitive revolution was 40 or 50 years ago.
MY: A focus on motivation has been there throughout the history of therapy. People talk about unconscious fears of failure, unconscious fears of success, and secondary gains. People even blame depressed patients for wanting to be depressed because, presumably, they are rewarded. But, you’re talking about something different, aren’t you?
DB: Yes. Going all the way back to Freud, I want to honor clinicians who have wrestled with issues of resistance and motivation, and tried to develop techniques to deal with it. I think our approach is probably a lot different from what most therapists have previously done. First, we delineated eight different kinds of resistance. We call them “process resistance” and “outcome resistance.” And, they’re completely different for these four problems: depression, anxiety, relationship issues, and habits or addictions. There is an outcome and process resistance for each of these four targets. Thus, there are eight completely different types of resistance.
Looking at depression, for example, the outcome resistance generally has to do with having to accept something about yourself that you don’t want to accept. It might be something as simple as being a perfectionist. You may beat up on yourself every time you make a mistake or fall short of your goals, and you develop relentless self-criticizing and self-blaming behaviors. This creates horrible depression, but often reflects someone’s values — the most beautiful and awesome part of that person.
So when we deal with resistance we try to make patients proud of their depression, and show them why they possibly should not give it up. This is not a paradoxical trick or an attempt to manipulate the patient. A therapist actually tries to get inside the patient’s mind, become that patient’s subconscious and discover that perhaps this person should not change — that this is really a beautiful thing about them. If you can do that in a skillful way, the paradox is that the moment that you sell the patient on the fact that they shouldn’t change, suddenly their resistance disappears and they’re quite hungry to change. Then, when you swoop in with the techniques…bang! You often hit the ball out of the park right away, rather than struggling and fighting with the patient for months or even years.
MY: Let’s use your example of someone who’s a perfectionist. You’re not labeling the perfectionism as pathology. Rather, you’re telling this person that their perfectionism actually has merit.
DB: And it does. And maybe that’s something they should be proud of, which accounts for the way they are today. Maybe that’s something they would not want to give up.
MY: I assume you’re also helping them to develop –selectivity — that perfectionism in this context is okay; it actually makes sense and serves them. But perfectionism in the other context is debilitating.
DB: Absolutely. What we think and the opposite are simultaneously true. There’s a healthy and an unhealthy edge to everything. That’s why therapists have so much trouble learning to be great therapists, and why patients fall into traps. There’s healthy sadness, and neurotic depression. There’s healthy anger, and unhealthy anger. There’s a healthy pursuit of excellence, and neurotic perfectionism. People get confused about this. Here’s an example that might clarify it.
(Note: The case example David provides is wonderful but lengthy. It can be viewed on the video of this interview, available on the Erickson Foundation website – www.erickson-foundation.org.)
MY: I want to switch topics and ask you about your book, Feeling Good. You’ve contributed something huge and lasting. And, the book is practical. It is brilliantly written, easy to use, and expansive in its ideas. I have to know what your process was in writing it, and how you view the enormous success of this work.
DB: Well, thank you for those kind words. When I went into private practice, at first I had just a few patients and lots of time on my hands. But, I was going to Beck’s seminars, and at the start of the seminar I would always present my worst patient. I was getting great input, and I was watching these miracles happen in my practice. I thought, ‘Wow, it would be great to share this information with patients.’ So, to use my free time, I started writing it up, but also because there’s a lot in cognitive therapy that you have to explain to patients, including the basics and the 10 cognitive distortions or self-defeating beliefs like perfectionism. I thought if I could write the material for handouts to give to my patients, I could then individualize therapy for them. They could do the “grunt work” on their own, reading the handouts, and I could individualize the therapy.
A patient once said to me, “We have all-or-nothing thinking, and should statements, and overgeneralizations, and mental filters. Why don’t you give us a one-page list of the 10 distortions?”
So I went home that night and wrote for about 15 minutes and the next day, handed it to patients. They really loved it. Eventually, one of them said, “You know, you could publish this as a book.” That’s how Feeling Good came into existence.
I think there are a few things about it that made it catch on. The first is that it actually helps who read it, but I didn’t intend it as a self-help book. The other thing is the tone of the book. I have so many depressed patients that I know how they think, so I could speak right to the mind of the reader. That’s been a blessing.
MY: I want to reiterate a couple of key points before we close. It was a really powerful statement on your part to talk about how early on you were challenging the serotonin hypothesis and how much that’s made a difference in your view of things. The fact that here we are all these years later and people are still buying into that hypothesis, despite having no evidence for it, speaks volumes about how glacially slowly this field changes. I also want to highlight what you’ve done to change your direction, and encourage others to also change direction. With your more recent work in motivation, you’ve been able to demonstrate what you’ve added to the cognitive therapy by enhancing its value. Is it fair to say that so much of what depresses people, so much of what makes people anxious, is perspective?
DB: Yes, it’s the way we view things. But, also our motivations are just as important because sometimes we want to see things in a particular way. If you want to see things in a certain way, you will see them that way. And, when you take that into account and develop motivational technology along with powerful techniques to change these distorted thinking patterns, then it’s as if one plus one equals 100. There’s a kind of a synergistic explosion that we’ve seen happening, and it’s an exciting practical breakthrough for the field.
MY: David, I want to thank you for your time and being so generous in doing this interview.
David Burns will be presenting at the 2018 Brief Therapy Conference in Burlingame, California. He will be providing a number of sessions, including his Keynote presentation “Feeling Great: High-Speed Cognitive Therapy.” See what other speakers will be at our conference here.