‘That’s what I always wanted – to have a way to help people quickly’

In a nutshell, what is TEAM-CBT?

TEAM-CBT is an evolution out of and beyond cognitive therapy. It's not a school of therapy, it's a structure for all of psychotherapy.

'T' stands for Testing and we test clients at the start and end of every single therapy session. We ask 'How are you feeling right now? to find out if we've been effective. And the ideas could be effective within a single therapy session, rather than over months or years.

The 'E' stands for Therapeutic Empathy – it's forming a warm relationship with the client in the client's opinion, not in the therapist's. The therapist's perception of empathy will be largely uncorrelated with the client's perception of the therapist's empathy – research studies have shown that their perceptions, unlike the client's, rarely have anything to do with outcome.

The 'A' stands for Assessment of Resistance which has to do with making subconscious resistance conscious, then melting it away with a variety of paradoxical techniques.

Finally, we go to 'M' which is Methods – helping the client challenge distorted thinking with a wide variety of techniques drawn from over a dozen schools of therapy. TEAM-CBT is not a new school of therapy, it's an attempt to get away from all schools of therapy and develop a new era of data-driven and science-based psychotherapy.

You're the founder of TEAM-CBT. How did that come about?

In the 70's when I first started going to Dr Aaron Beck's weekly seminars at the U. Penn Medical School, there were only a handful of cognitive therapists in the world and most people thought we were quacks. I've always loved cognitive therapy because many clients recovered pretty quickly and that's all I cared about. In 1980 my book Feeling Good was published, just as cognitive therapy was beginning to take off.

Prior to that, I was a full-time psychopharmacologist doing brain research – handing out pills and encouraging patients to vent, but seeing very little success in doing so. Once I started using cognitive therapy techniques, I noticed that about half of my clients were showing incredible recoveries in five or ten sessions. It was mind blowing.

That was great but I often thought, what's wrong with those clients who fight and don't recover rapidly? If you look at psychotherapy outcome studies, none have ever exceeded a 50 per cent improvement rate for depressed clients, even after months or years of treatment. And to me that's horrible, so I wanted to see what is it about the people who aren't responding? How are they different? What's blocking them?

My research indicated that most therapeutic failure resulted from therapeutic resistance. So that moved me into many innovations to help solve that problem – to melt away therapeutic resistance at the very start of treatment. Although it has a lot of cognitive ingredients, TEAM-CBT is quite different from Beckian cognitive therapy, in part because it also involves a new kind of teamwork between the client and the therapist.

How does TEAM-CBT work with motivation?

Well, I'd rather talk about how TEAM-CBT works with resistance. Many people who are depressed will cling to depression, and people who are anxious cling to anxiety, precisely because there are tremendous benefits to these feelings. What we think about as resistance in TEAM-CBT is that our suffering is not a reflection of what's wrong with us, but of what's right with us. Depression and anxiety nearly always emerge, in part, out of high standards, accountability, humility and other qualities. If you can help the client see that it's like a fantastic, unexpected discovery – suddenly the resistance disappears and the client wants to change.

From there recovery is just a stone's throw away. And that's what I always wanted in my clinical work – to have a way to help people quickly. Yet what I learned as a medical resident didn't do it most of the time. What I learned in cognitive therapy didn't do it half the time. And now with TEAM therapy I'm seeing it at least 90 per cent of the time. There's a powerful tendency toward relapse in all of us, so Relapse Prevention Training is also an important dimension in TEAM-CBT.

In your experience, do these changes always happen quickly?

The vast majority of my patients experience fairly rapid recoveries. In fact, I nearly always treat patients in a single therapy session lasting two hours, and that's the end of the treatment, more or less. However, patients with relationship problems or habits and addictions are typically more refractory and require more time. That's because the resistance is more intense. People have asked me 'how long does it take clients to get better?' and I would jokingly say, 'generally 30 seconds – but sometimes as long as a minute'. It might take a long time for clients to get to that moment when the whoosh of recovery occurs. But what we've tried to do in TEAM-CBT is get to a place where we can get there maybe within two hours, rather than over months of sessions.

Of course, with certain kinds of problems, progress will be much slower. But most clients are eager for rapid results and relief and incredibly grateful when it happens. They're not usually looking for a long and costly therapeutic relationship. The concept of rapid recovery infuriates some therapists and even some patients who have been trained to think that recovery from depression and anxiety is a long, drawn-out process requiring many months or years. If you're really invested in your own approach to treatment, it's hard to be challenged at such a fundamental level.

If you were to whittle down the elements of TEAM-CBT into one key principle, what comes to mind? What is it that leads to this rapid transformation?

Well, there are two key principles. The first stems all the way back to the Greek stoic philosophers like Epictetus – the notion that when you change the way you think, you can change the way you feel. The second is that our weaknesses are often our greatest strengths. Our suffering is often the expression of what's most beautiful and awesome about us, and not the result of this or that so-called 'mental disorder' or defect.

How can TEAM-CBT help people in today's world?

The way I see it, TEAM-CBT gives people a way to change their way of seeing the world and gain the skills to feel better about their life. It can be amazingly effective, but it's hard to teach and learn, and most people around the world don't have access to effective treatment, even if they could afford it.

My dream has always been to create the psychotherapy of the future that will be fast and effective for nearly all those struggling with depression and anxiety. Over the past several years I've been developing a Feeling Good app which is entirely automated. Beta tests have been very encouraging and we hope to launch the app in the fall of 2023. I'm hopeful that it will make an impact on the lives of large numbers of people around the world.

What do the sceptics say about TEAM-CBT?

Many psychoanalysts will also say that measurement is sinful – that it's going to hurt the therapeutic process to measure empathy, or to measure helpfulness. We've found that measurement of patient's feelings at the start and end of every session is perhaps the most important key to effective treatment. In research I've done at the Stanford inpatient unit, for instance, we found that the therapist's assessment of how their patients are feeling will have almost zero relationship with how their patients actually feel.

That's a sobering thought.

Yes, it's painful. I'll probably get some sharp criticism here. But a part of our philosophy is that therapeutic breakthroughs often come through 'failure'. If you have the courage to face and process it with your clients, you can have great breakthroughs. I think the use of brief, accurate assessments at the start and end of every session can be helpful to all therapists and my hope is that we can move into a realm of data driven therapy.

What other aspects of TEAM-CBT do you encounter resistance to?

In my work with clients I try to make it clear that language doesn't explain external reality. This concept is consistent with the work of Ludwig Wittgenstein, the famed 20th century philosopher, who focused on how we can sometimes fool ourselves with language. For example, a depressed client who thinks they're not worthwhile believes that a worthwhile or worthless human could exist – as if that meant something in a literal sense – but it doesn't. And the goal of therapy is not to go from worthless to worthwhile, but to reject the notion entirely.

For example, I enjoy talking with you. I don't know you, maybe you're working for the National Enquirer and I'll be smeared… that wouldn't be bad, at least I'll get some recognition!… but it's just fun hanging out with you. That doesn't make you worthwhile, it doesn't make me worthwhile, it's just a fun thing to hang out, and that's all there is. Once you see this it can be enlightening, but it's hard to get at first.

What is the most important lesson life has taught you recently?

One lesson life has taught me over and over again is that people will love and accept me for being flawed and humble, for being real and not trying to impress them. I've learned that I don't need to be proving things to people to have them like me or love me. It's a lesson I've been learning all my life in one way or another.

What is something that people don't know about you, that if they found out they'd be surprised?

I've had a fear of bees, horses, vomiting, dogs, heights and blood, to name just a few. I've had crippling public speaking anxiety. I had a panic attack once. And that's why I love treating people, because I know how awful it can be and what a joy it's going to be to show who I'm working with the way out of the woods.

What advice would you give to aspiring psychologists?

To read all of my books and admire me tremendously! Just joking – I'm not sure. I would say don't join a school of psychotherapy, but do data-based psychotherapy. Track symptoms with accurate assessment tests at the start and end of each session – your clients will teach you much more than your graduate school ever did.

What is your definition of success?

Learning from failure.

• David Burns, MD is an Adjunct Clinical Professor Emeritus of Psychiatry at Stanford Medical School, and has served as visiting scholar at the Harvard Medical School. He is author of Feeling Good: The New Mood Therapy and host of the popular Feeling Good Podcast.
• Dr Kal Kseib is a Chartered Psychologist. Read more of his interviews.