The patient looks around frantically. She is sobbing, panicking, overwhelmed by anxiety. She says she can't breathe; her lungs are about to collapse; her heart is about to stop. She feels like she is going to die.
Listening to this, Stanford psychiatrist David D. Burns calmly asks, "Do you think you could exercise strenuously right now?" Terri doesn't know; she just feels so bad. "Why don't we find out?" Burns suggests. "What's the most strenuous exercise you could do? Jumping jacks? Running in place?"
Uncomfortable, nervous laughter breaks out among the 100 psychologists, psychiatrists, social workers, and family and marriage counselors watching the scene unfold on a large video screen. It's part of Scared Stiff!—a two-day seminar on fast, drug-free treatment for anxiety and depression that Burns, MD '70, is giving in a nondescript hotel ballroom outside Chicago.
Some of the therapists have come because they want to hear what Burns has to say. The author of Feeling Good: The New Mood Therapy, one of the most successful psychotherapy books ever written, he's had 35,000 therapy sessions with depressed and anxious patients and as many as 50,000 therapists have attended his training programs over the past 35 years. Others need continuing education credits to maintain their licenses. To Burns, their reasons don't matter; he's determined to help them become better therapists. Why? Because he knows their deepest insecurity as professionals: that week in, week out, many are failing to help their patients in a profound and lasting way.
On the video, Terri says "I feel dumb" as she runs in place. "That's okay," Burns says. "If you have to feel dumb to get well, it would be worth it." Terri says she feels dizzy. "OK, well just keep going," Burns says, and then asks her to try some jumping jacks.
At this, the therapists laugh out loud, not because the scene is funny but because of Burns's quiet audacity.
"Could you do this if you were dying?" he asks Terri. "Can you see yourself in an emergency room doing jumping jacks?" Hesitantly, she begins to laugh. Soon she's belly laughing. The joy she feels surges off the screen. Turning from the video to the therapists, Burns says that's the kind of dramatic change he wants them to achieve. Terri had been experiencing five paralyzing panic attacks a week. She's had only one since Burns taped the session they've just viewed—and that was 20 years ago.
When Burns asks the therapists who would have backed off when Terri said she was going to die, almost all raise their hands—despite knowing that the best treatment for most people with anxiety is exposure to the very thing they fear most.
A woman stands up and takes the cordless mike circulating in the room. She says she had a client who was convinced she was going to "explode" right in her office. Terrified, she called 911. Burns says this is a perfect example of another situation where therapists are failing: They let patients hypnotize them into believing that their depression is unique, that they are the complete failures they believe themselves to be, or that their anxiety will kill them. When therapists buy into a patient's negative thoughts they validate them, Burns says, and eliminate any chance of successful therapy. When this patient got out of the hospital, she and the therapist found themselves back at step one, 10 years of therapy down the drain.
Burns delivers the hard news gently: If therapists want to get real, lasting results, they need to go hand-in-hand to "the gates of hell" with their patients, as he did with Terri. Burns knows why most therapists won't. They are afraid. Afraid the patient will have a heart attack, or get worse, or storm out and not come back, or sue.
Before showing the video, Burns warned that participants might find his approach "threatening or even disturbing." That he would challenge deeply held beliefs and the conventional wisdom they were taught. Particularly touchy is his long-held conviction that—except for those suffering from clear-cut mental illnesses such as schizophrenia, bipolar disease and severe depression—many pharmaceutical treatments have little or no effect.
Equally surprising: Burns tells the therapists he wants them to fail. Time and again. They can afford to do this because—unlike when he was a psychiatric resident in the 1970s and not one of his patients improved appreciably over an entire year—he now has 50 techniques they can try to cause "dramatic change" in patients. "Right away. Not in five or six years." Burns wants them to fail at technique after technique until they find the ones that work for each patient.
To some of the therapists, it sounds too good to be true. Burns reassures them that the techniques he's about to teach, once dismissed by the mainstream, are becoming the mainstream.
I know what he says is true. I've read his books and used his methods and have experienced the relief of having my own acute depression evaporate in an instant.
What Burns did in Feeling Good, the first mass-market, evidence-based, self-help book for the relief of depression, was explain the tenets of cognitive behavioral therapy (CBT) for the lay person: that depression is caused by self-defeating beliefs and negative thoughts—thoughts like "I'm not good enough," "I'll never amount to anything," or "I have no friends." Feeling Good included exercises readers could use to change how they reacted to such thoughts and to stop depression before it spiraled down into an endless abyss of despair and pain. Study after study has since demonstrated CBT's effectiveness.
Burns did not invent CBT; its philosophical underpinnings can be traced back to the Buddha or to Epictetus, the Stoic. Credit for laying the foundation of modern CBT generally goes to Philadelphia psychiatrist T. Aaron Beck and the late New York psychologist Albert Ellis. Burns remembers when he, like most psychiatrists, didn't believe that something as simple as how we think could cause depression.
Working at the University of Pennsylvania's Depression Research Unit in the 1970s, Burns researched the theory that low serotonin levels cause depression, an idea widely accepted as the "chemical imbalance theory" and conventional wisdom among popular media, many physicians and much of the public. Although Burns won the A. E. Bennett award from the Society of Biological Psychiatry in 1975 for his research on brain serotonin metabolism, he was not convinced that the chemical imbalance theory was valid. In one study, he and his colleagues gave massive daily doses of the amino acid l-Trytophan to depressed veterans in a double-blind study. L-Trytophan goes directly from the stomach to the blood to the brain, where it is transformed into serotonin. If depression results from a deficiency of brain serotonin, the massive increase should have triggered clinical improvement, but it didn't.
The study was published in a top research journal but did little to dim the growing excitement about the chemical imbalance theory. In 1988, Lilly launched the world's first blockbuster SSRI antidepressant, a drug with powerful effects on brain serotonin receptors. During its first 13 years, Prozac generated $21 billion in sales, or 30 percent of Lilly's revenues. Burns still wasn't convinced.
"I always wanted to see people's lives transformed from depression and anxiety to joy and peace," he says. In his clinical work, he didn't see that happening very often, no matter how many pills he prescribed. His department chair suggested that he sit in on one of Dr. Aaron Beck's weekly cognitive therapy seminars.
At first, Burns thought Beck's presentation sounded like "pure hucksterism"; still, he began using CBT methods if only to prove to himself that they didn't work. Soon, many patients he'd been treating with drugs and "you talk, I'll listen" therapy started to get better. A lot better.
Burns felt torn. He had just won a five-year grant to develop a brain serotonin lab at Penn. Yet he wasn't convinced serotonin played a role in depression or any other psychiatric disorder. After three agonizing months, Burns decided he'd "rather spend my life doing something that works." He left Penn and opened a private practice "in a storeroom with a window," two stories below Beck's Center for Cognitive Therapy.
Burns's doubts were vindicated by a landmark 2002 metastudy conducted by psychologist Irving Kirsch, now at Harvard, of all trials submitted to the FDA by the manufacturers of the six most widely prescribed antidepressants approved between 1987 and 1999. Not widely publicized until a 60 Minutes report in February 2012, it showed only a slight difference in patient response between the drugs and placebos.
Psychiatrist Matthew May was a fourth-year Stanford medical student when he stumbled upon an empathy-building seminar Burns was giving in the psychiatric in-patient unit. To create an empathic relationship, Burns often uses the "disarming technique," in which the therapist finds something true in whatever a patient is saying, no matter how far-fetched, unpalatable or critical of the therapist. At first, May was skeptical. Then he began to notice that Burns was connecting with patients in a way that was "far more sophisticated than anything I'd ever seen. I was immediately turned on."
Later, following a particularly tough morning, May, MD '02, went to see Burns, an adjunct clinical professor of psychiatry. Together, they did some depression-relieving exercises. "Within an hour," May says, "I felt completely different. It's one thing to read that our feelings are created by our thoughts. It's another thing to notice your feelings change completely when you defeat a negative thought. It's really miraculous. The minute that that happened I said, 'Wow, I want to learn more about this.' " Since then, May, who practices in Menlo Park and is also an adjunct clinical faculty member, has seen Burns "perform the same magic trick with people over and over again." With practice, May started to achieve similar results, thanks in part to the hundreds of hours of free supervision, coaching and feedback Burns has given him over the last decade.
Although he is often identified as a cognitive behavioral therapist, Burns, like Groucho Marx, doesn't particularly want to belong to a club that would have him as a member. "If you look at medicine, we don't have just one technique for treating all problems," Burns tells his Chicago audience. "Can you imagine going to a doctor with a broken leg and he prescribes penicillin? You'd say, 'Why are you giving me penicillin for a broken leg?' And the doctor says, 'Well I'm in the penicillin movement. Brain tumor, broken leg, you get penicillin.' It would seem ridiculous." Burns feels the same way about therapists who rigidly subscribe to a single therapeutic approach. He currently draws from at least 15 schools of therapy, calling his methodology TEAM—for testing, empathy, agenda setting and methods. It's an approach he hopes will someday be as big a breakthrough as CBT was decades ago.
Testing means requiring that patients complete a short mood survey before and after each therapy session. In Chicago, Burns asks how many of the therapists do this. Only three raise their hands. Then how can they know if their patients are making progress? Burns asks. How would they feel if their own doctors didn't take their blood pressure during each check-up?
Burns says that in the 1970s at Penn, "They didn't measure because there was no expectation that there would be a significant change in a single session or even over a course of months." Forty years later, it's shocking that so little attention is paid to measuring whether therapy makes a difference, particularly given the estimated $147.4 billion spent annually (2009) in the United States on mental health, most of it by the government and insurance companies.
"Therapists falsely believe that their impression or gut instinct about what the patient is feeling is accurate," says May, when in fact their accuracy is very low. "I haven't met anyone yet who can read minds." In Chicago, most attendees believe they are aware of how their patients are feeling at least half the time. Burns quickly disabuses them, citing his own and other research showing only a 10 percent overlap between how a patient says he is feeling and how the therapist thinks the patient is feeling. This huge margin of error is the same for patients contemplating suicide. A therapist who has collaborated with Burns for three years says it was only their brief mood surveys that alerted her to two patients' intentions to commit suicide. Nothing in their sessions had clued her in to how serious their situations were.
An error many therapists make, says Burns, is skipping empathy and agenda setting and jumping straight into methods. It's the desire to fix patients instantly that drives this ultimately unproductive shortcut. Without perfect empathy, he says, a therapist cannot help patients bring their resistance to change to a conscious level where it can be addressed. Burns urges therapists to have patients rate them for empathy on an evaluation form at the end of every session. Very few do. Why? "Sometimes people don't want to get negative feedback," says May, "and are a little bit afraid of the patient's anger."
For Burns, agenda setting is the key to therapeutic success. And the key to agenda setting is specificity: focusing on an upsetting incident or moment around which different methods can be tried. Saying "I just haven't made anything of my life" is unlikely to lead anywhere. Recognizing that a month-long severe depression came on just after a best friend made millions when her company went public makes it possible to apply methods to that event and restore a sense of balance and well-being.
At 4:30 on a winter afternoon it's already dark outside the Behavioral Sciences Building on Quarry Road. Inside, Burns is meeting with Theo (not his real name), a member of the Tuesday Night Group, an informal weekly gathering of medical students, residents and local therapists that Burns has held for more than 10 years. Burns asks to see Theo's daily mood log, a two-page form on which patients record the negative thoughts and emotions they experienced after an upsetting event. In addition to rating the intensity of their emotions on a numerical scale, they must also write down what therapists call cognitive distortions—such as "catastrophizing" (expecting only the worst to happen), "emotional reasoning" (believing, for example, that if we feel stupid, then we must be stupid) or "mind reading" (assuming that what we imagine other people are thinking is what they actually think)—that give credibility to negative thoughts.
Theo's upsetting event was a patient saying he could not afford any more 50-minute sessions at $150 a crack—a bargain in the Bay Area, where 40-minute sessions sometimes run $300. Theo, whose practice is relatively new, feels he didn't help the patient quickly enough. "I'm trying to be David," he says, referring to Burns, "and I'm making a fool of myself." He just can't get enough done in 50 minutes. This, and the empty slots that stick out like missing teeth on his appointments calendar, caused him to write "I'm not going to have a successful practice," a thought he believes at the "80 percent level." At home, his spouse has been out of work and is deeply depressed. He has ranked his feelings of anxiety and inferiority at 75 percent. (Anything close to 100 percent would be unbearable, the verge of a breakdown or the inability to perform what physicians call the "activities of daily life.")
Although Theo is obviously upset, this is a training session, not a therapy session, and so Burns asks what the two of them should do next. Theo suggests the "externalization of voices" technique, in which the therapist (or friend or spouse) hurls the patient's negative thoughts right back at him. It's the patient's job to defeat those thoughts.
"People will think I'm a loser," Burns says, as Theo's inner voice.
"And they'd be right," Theo answers, disheartened. "I am a loser." (Theo has an advanced degree from Stanford.)
Burns reminds Theo that in this exercise he needs to find positive thoughts he "believes in 100 percent" that will crush his negative thoughts completely.
"You have to accept that you're not going to have a successful practice," Burns jabs.
"It's silly to jump to conclusions," Theo answers.
"Well, you failed the patient who dropped out," Burns says.
"We don't know that," Theo answers. "That's black or white. That's not how the world works."
"Still, you don't know what you are doing."
"I'm learning every week. I'm having some remarkable success," Theo says more assertively. "Openings just mean that people's schedules change. The reality is that therapists have openings."
"The reality is that you are a loser."
"That's just not true!" Theo retorts with a conviction that was entirely missing moments before.
Burns asks who won the exchange.
"I did," Theo says.
When Theo quantifies his "after" feelings, anxiety has dropped from 75 to 40 percent, inferiority from 75 to 30. He reminds himself that therapy is a science and an art. That is why seasoned therapists with decades of experience come to the Tuesday Night Group, which is about to start down the hall and where I—rather than observe the process as an objective wallflower—will be the patient, the subject, the guinea pig.
I had known about Feeling Good for at least a decade. Between 2002 and 2007, I served as the Peace Corps director in Cameroon, where a nurse, an OB/GYN and a pediatrician met the physical and mental healthcare needs of up to 200 volunteers dotted across a country the size of California. Unsurprisingly, the poverty, entrenched fatalism and endemic corruption of Cameroon caused some previously bright-eyed optimists to sink into despair and depression. I handed out dozens of copies of Feeling Good to volunteers. In my own low moments, I would pick it up and often find relief after reading just a few pages or completing an exercise or two.
For the 20 therapists seated around the conference table, Burns summarizes my daily mood log. Coming back to the Stanford campus, lovely as it is, and the Bay Area, where I lived for 20 years, invariably brings up deep-rooted feelings of insecurity. Am I good enough? Have I come close to fulfilling my potential? Do my achievements match up with the outsized accomplishments of my Business School cohort—three of whom are regulars in the Forbes 400 and dozens of others who have created or headed large enterprises, or made millions upon millions?
Apparently not, because even though my financial health is good, I feel as though my successes are meaningless and that at any moment I could be penniless and on the street—a fear my mother, who grew up in the Depression and died at 92, took with her to the grave. Over the previous several weeks, I'd been barely able to resist the gravitational pull drawing me into a black hole of psychic misery. My answers on the Burns Depression Scale (a long-form survey) totaled 69, deep in the range of severe depression. It may not have helped that more than a year earlier, after an extended period of feeling good, I stopped taking the antidepressants I'd been on for at least 15 years.
For more than two hours, the group tries multiple TEAM methods to help me crush the negative thoughts that cause me to see my life as one of missing out, rather than the one I've lived, which has been incredibly fortunate, privileged and rich. Visualization, the double-standard technique, externalization of voices, role reversal—none of the techniques get through to the inner me, the person frequently trapped inside a hardened cyst of self-criticism. Like the novice underdog in a Kung Fu movie, I parry every one of the masters' attempts to weaken my resistance, even as I don't understand it myself.
"I'm wasting everybody's time," I say, frustrated with myself as much as with our collective lack of progress. My existential angst is insignificant compared to the therapists' regular patients—gang members, people with disintegrating marriages, suicidal tendencies, bipolar disease, addictions and more—who have real problems. "What an ass I am," I add quietly.
"What are the distortions in that thought?" Burns asks.
"I don't know what an ass is," I say sarcastically.
"Well, it's someone who comes in here and wastes our time," Burns ripostes, breaking the group up into welcomed laughter.
"Is it true that you are wasting people's time?" Burns asks.
"I don't know," I say, before adding "mind reading" to my list of cognitive distortions, because in reality I don't know if I'm wasting people's time. I only think that it's true.
"Would that be something we could get some data on?" Burns asks, leading me into the "evidence-based technique."
"Yes, we could ask people around the room," I say.
"Would they be honest?"
"I don't know."
"We could check it out."
"Yes, we could check it out—but I don't know that I would believe them."
A marriage and family therapist is so anxious to say something that she's coming out of her seat like a first grader who has to pee. "I'm incredibly appreciative," she says of my being there.
Because the TNG is a training group, the person typically in the patient's seat is a therapist who knows the procedure, knows the expected responses and outcomes, and is, perhaps, a bit in awe of Burns's mastery of the Socratic method. My intransigence reminds her that it isn't always as easy as Burns can make it seem. When I ask if she's being truthful, she says, "I haven't been so truthful in a long time."
"The reason people are here is to learn how do to therapy," says Jill Levitt, who is co-developing the TEAM approach with Burns, May and a dozen other Bay Area therapists. "Therapy isn't easy. As human beings, we all struggle. The answers aren't so clear." To see Burns struggle with me, Levitt says, makes the therapists in the group feel less insecure.
After the session, Burns repeatedly apologizes, telling me that he made "every mistake in the book." Because we had communicated many times in preparation for this article, and because I'd found great relief and improvement from using Feeling Good in the past, the group skipped the empathy and agenda-setting components of the TEAM methodology. As Burns put it, they "jumped in too soon to try and fix" me.
Unlike the doctors we know from life, television and the movies, Burns couldn't be further from the silent, note-taking, classical therapist who reveals little or nothing about his personal life. He freely divulges the 15 different types of anxiety he suffered in the past, including morbid fears of blood, horses, heights, bees, public speaking, shyness, failure, dogs, rejection and vomiting. In his private practice, he could tell patients, "Oh yes, I've had that too," and let them know there's a way out of the suffering. Burns doubts that therapy can succeed when the therapist breasts all his personal cards. "To me, the difference between therapist and patient is a slim and somewhat artificial distinction."
Burns had planned on graduate studies in psychology until his undergraduate adviser at Amherst suggested medical school and psychiatry instead. The adviser saw little difference between the two fields except that psychologists could not write prescriptions, and drugs "were going to become so important in the future." Just months before graduation, Burns began applying to medical schools.
There was one problem. Because of his morbid fear of blood, Burns had not taken any biology. But his adviser assured him his "gift of gab" would get him in somewhere.
His interview at Stanford was scheduled for 15 minutes. Burns met with the head of the anatomy department in a dark, dreary lab in the basement of the Stanford Museum and asked question after question. Two and a half hours later, the chairman told him he was "the kind of young man we need here at Stanford Medical School." When Burns said it was unlikely that he could attend because of the cost—his father, a Lutheran minister, didn't believe in borrowing money—the professor told him, "I'm chairman of the admissions committee. You're going to come to the Stanford Medical School and you're not going to pay one penny. Now what was your name again?" Remembering the interview, Burns says lightheartedly, "I just bamboozled the guy."
The chairman might have done well to listen more and talk less, because Burns says he was the worst student who ever enrolled. In anatomy, "I was just slashing, slashing, slashing. I couldn't find anything. It looked like hamburger in there." He didn't do any better in histology, where cells under the microscope "looked like modern art." (Burns says he didn't return to Stanford as an MD until everyone who had known him as a student was no longer on the faculty.)
When second-year medical students had to draw each other's blood, Burns walked out of class, went to the dean and said, "This isn't for me. I never wanted to be a doctor." The dean gave him a year off to think it over.
In the mid-1960s, California, like Burns, was changing. The Be-In and the Summer of Love weren't far away. Burns hung out in Palo Alto. He bought a motorcycle, a Triumph Scrambler 500, Fonzie's bike on Happy Days. "Here I was, this rigid kid with a religious upbringing—to have my own motorcycle and begin to know and love people and not be so judgmental, to see that life could be fun."
Burns was living in a garage with an 18-year-old hippie named Melanie, whom he'd met by asking if she needed a ride. They later married and raised two children, including son Erik, '99; Melanie completed a PhD at the University of Pennsylvania and started her own clinical psychology practice. Says Burns, "We've been on that motorcycle ever since."
Because he "didn't have anything better to do," Burns returned to finish medical school. He spent the year after graduation on the Monterey Peninsula counseling people in coffee houses and on the beach. He loved what he was doing, but he and Melanie were hitchhiking from place to place and sleeping on friends' floors. While living on food stamps, Melanie became pregnant.
"We didn't have any way to survive," Burns says. "I thought at least if I went back and did an internship and residency, I still wouldn't know anything, but the people would think I knew something so they would pay me." He began an internship at Highland Hospital, the primary trauma center for Oakland and Alameda County, claiming he "didn't know how to listen to the heart, look into the ears, read X-rays or any of those things." To learn the basics, he reported to Highland one month early, as a volunteer in the emergency room.
Not long after, a man who "looked like a slab of meat from a butcher shop" was brought in. These were the days when the Bay Area, particularly the East Bay, teemed with revolutionary fervor. The victim had blown himself up constructing a bomb. There was blood everywhere.
A nurse dragged Burns over to where a team was frantically working to save the bomber's life. "You see those black specs?" she said. "That's gunpowder. You have to remove it. Get busy with this."
She gave him a toothbrush.
"It was horrible," Burns remembers. "For 20 minutes, I was at 100 percent on the panic scale." Then he realized he was helping save a life. "It was like lightning. All of a sudden I had no fear." Finding a sense of inner calm, he told himself, "By the end of this month, I'm going to be a real doctor," something he never thought actually possible. Unwittingly and unwillingly, he had just experienced the exposure model, in which patients with anxiety or phobias confront their greatest fears and realize that they can survive and thrive. Recalling his years at Highland, Burns says, "The things I had been so afraid of became a source of joy and satisfaction." His blood phobia of 30 years had disappeared.
Early in his career, Burns says, he couldn't stand making mistakes, adding perfectionism to his self-confessed list of character flaws. "Now I'm happy to make errors, because I can correct them to form a deeper bridge with the person. It's very rare to have a patient who isn't absolutely delighted when you say, 'I read your feedback. The session didn't go well. You actually got more upset and I made about three really horrible errors.' If you do that from the heart and not as a gimmick, boy, it's a wonderful thing." Of therapists who don't insist on measurement or can't accept patients' feedback, Burns is categorical: "I think it's a sin."
Since Burns first contemplated a career in psychiatry, the field has changed dramatically. Depression is now regarded as an illness rather than a personality quirk. CBT, as a member of the Tuesday Night Group put it, "has become the language of counseling." And study after study has confirmed that it works, by itself or in conjunction with medication, and almost always more quickly and effectively than treatment with medication alone.
Burns, however, is not sanguine about a field his books helped transform. For him, too much of what passes for psychotherapy today is just an "awful lot of schmoozing behind closed doors, with the occasional advice thrown in." He considers the relief provided by therapy and medication to be a "very meager measure of improvement" when compared with the levels of anguish and despair patients continue to experience. And although he has never been opposed to the use of medication, he's concerned about normal behaviors becoming medicalized and medicated, and about the inevitable professional conflicts that arise when psychiatrists must choose between scheduling four 15-minute medication consultations an hour or one traditional therapy session—a choice that can triple the fees generated during the same time period. Irving Kirsch is more outspoken. "One hundred years from now, people will look back at the age of giving SSRIs and they will have a reputation that's akin to bloodletting."
What David Burns wants is for patients with depression to rediscover confidence and dignity and joy and delight. To get there, he says, psychiatry must begin using the type of rigorous, data-driven analysis common in the natural sciences. Therapists need to forget that they are supposed to be disciples of this or that school and apply what has been proven and known to work. He wants to give people suffering from depression the tools to right their boats long before capsize becomes imminent. And for medications to be used only when they are truly called for, not to correct what were once considered normal fluctuations in the ebb and flow of human emotions.
Since my evening playing the guinea pig at the Tuesday Night Group, my scores indicating severe depression have subsided to what is for me the tolerable range of mild depression. Through combinations of CBT and medication, many patients experience similar reductions of 20 to 50 percent. For Burns, that is not nearly good enough. Despite all the progress made since the first patient lay down on Freud's couch, the road ahead is long. "To treat anybody," says Burns, "is still very challenging."
Robert L. Strauss, MBA, MA '84, is a recipient of the U.S. Department of State's Meritorious Honor Award and a three-time winner of the Lowell Thomas Award for excellence in travel writing. He lives in Barcelona, Spain, with his wife and daughter.