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Tools, Not Schools, of Therapy, Part 2: Integrating 12 Treatment Models

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Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

By David Burns, M.D.

In the last edition of this newsletter, I listed 12 models I use every day in my clinical work and teaching. They are:

1. The Measurement Model
2. The Empathy (Rogerian) Model
3. The Motivational Model
4. The Cognitive Model
5. The Behavioral Model
6. The Exposure Model
7. The Hidden Emotion Model
8. The Interpersonal Model
9. The Acceptance (Spiritual) Model
10. The Role-Playing (Gestalt) Model
11. The Psychodynamic Model
12. The Relapse Prevention Model

If comprehended and applied skillfully, any one of these models can be incredibly illuminating and effective for certain patients. If you learn to integrate all 12 models, you can do some truly spectacular clinical work.

We get into trouble when we feel the need to identify with one or another school of therapy, and treat everyone with that method. This type of reductionism has been one of the biggest problems in our field. The different schools of therapy end up competing with each other, much like cults.

This is unfortunate because every approach generally contains substantial wisdom and a number of sound methods. Although many people think of me as a “Cognitive Therapist,” I do not see myself that way. I see myself as a therapist who uses cognitive techniques and many other methods as well, depending on the problems and needs of each specific patient. I’m convinced that we have a great deal to gain by learning to integrate these models, and to work together to develop a true science of human behavior.

In Part 1, I described the first three models. In Part 2, I’ll focus on the Cognitive and Behavioral Models.

The Cognitive Model
The Cognitive Model originated with the teachings of Epictetus and other Greek philosophers nearly 2,000 years ago. In his classic book, The Enchiridion, he stated that people are disturbed, not by things, but by the views we take of them. In other words our emotions do not result from what happens to us, but rather from our thoughts, perceptions, and interpretations of those events. This is true of all positive and negative feelings.

For example, right now you may be having some feelings. If you're feeling skeptical, you may be telling yourself, “This is too simplistic. Human emotions are far more complex. We all know that depression results from a chemical imbalance in the brain, and not from the way people think.” If you're feeling annoyed, you may be telling yourself, “Burns is a jerk. He's just promoting himself.” If you're feeling anxious, you could be telling yourself, “This is overwhelming. It's is going to be too hard for me to integrate all 12 treatment models in my practice.” And if you're feeling happy or curious, you may be thinking: “It will be really interesting to find out what he says about all these different treatment techniques.”

So different people may have different feelings when reading this. It's your thoughts, and not the words on the page, that are creating your emotions, even at this very moment. This concept is as basic as the law of gravity.

Are you familiar with Aaron Beck's concept of Cognitive Specificity? He advanced the theory of Epictetus in an important way. He suggested that specific kinds of negative feelings result from specific types of negative thoughts. For example, hopelessness results from the perception that things will never change; guilt results from the belief that you're bad because you've violated your own value system; shame results from the belief that others will look down on you; anger results from the belief that someone is taking advantage of you or treating you unfairly; anxiety results from the belief that you're in danger, and that something terrible is about to happen; inadequacy results from the belief that you should be better than you are; and depression results from the belief that you've lost something that's important to your sense of self-esteem, such as an important love relationship.

Cognitive therapists have made another discovery with significant philosophical and practical implications. When you're feeling depressed, anxious, or angry, the thoughts that trigger these feelings will nearly always be distorted and illogical. In other words, depression or anxiety do not result from reality – instead, these feelings are the result of a mental con.

You're probably familiar with my list of 10 cognitive distortions I first published in my book, Feeling Good. I have reproduced that list here, with permission. You can probably spot many of these distortions in your own thinking when you're feeling down or anxious, and I'm sure you have many patients who get trapped by these distorted thinking patterns as well.

When he discovered that one of his patients had made a nearly successful suicide attempt and was clinging to life in the ICU of a local hospital, a psychologist felt depressed, anxious, guilty, ashamed, inadequate, worthless, discouraged, and angry. He was telling himself:

1. I should have known he was suicidal. 100% (Should Statement; Mind Reading)
2. It's all my fault. 90% (All-or-Nothing Thinking; Self-Blame; Emotional Reasoning; Discounting the Positive)
3. I'm a failure. 100% (Overgeneralization; Discounting the Positive; labeling; Emotional Reasoning; Hidden Should Statement; Self-Blame)
4. If he dies, I'll probably get sued. 50% (Mind-Reading; Fortune Telling)
5. It's unfair. He should have told me he was feeling suicidal. 100% (Blame; Should Statement; Labeling)
6. My colleagues will look down on me if they find out what happened. 90% (Mind Reading; Discounting the Positive)

As you can see, I've listed some of the distortions in each thought in parentheses. I've also indicated how strongly this psychologist believed each negative thought, on a scale from 0% (not at all) to 100% (completely). When we're upset, we strongly believe that our negative thought are absolutely valid, as in this example. In fact, if we didn't believe the negative thoughts, we wouldn't feel depressed or anxious. In addition, the moment we stop believing the negative thoughts, our emotions will suddenly change.

However, that's easier said than done. That's because most of our patients have been giving themselves negative messages—"I'm such a loser. What's wrong with me? I'll NEVER get better."—for years, if not decades. Friends, family members, and previous therapists have probably tried to talk patients out of these thoughts, without success. So if we're to help our patients, as well as ourselves, we'll need new, powerful, and creative methods.

Those of you who have attended my workshops are familiar with my list of "50 Ways to Untwist Your Thinking," which describes 50 cognitive, behavioral, motivational, and interpersonal techniques such as the Individual and Interpersonal Downward Arrows, the Paradoxical Double Standard Technique, Examine the Evidence, the Experimental Technique, the Straightforward and Paradoxical Cost-Benefit Analyses, the Externalization of Voices, the Acceptance Paradox, the Hidden Emotional Technique, and many more. Many techniques are needed because you can never predict which technique will be help for a particular patient. So you will usually have to try as many as 10 or 15 techniques, or even more, before you find the one that will work for a patient.

I call this concept "Failing as Fast as You Can." Here's the idea. Let's assume that a patient has the belief, "I'm a worthless, defective human being. I'm defective at the core." and he believes this thought 100%. I've had hundreds of patients over the years who had this exact thought, and I suspect you've seen many as well. As long as he believes it, he'll feel inadequate, ashamed, inferior, depressed, and hopeless, to name just a few of his negative feelings. Now, let's assume that you try technique after technique that doesn’t work, and he still believes that he's defective. You try Identify the Distortions, Examine the Evidence, the Semantic Method, Let's Define Terms, Thinking in Shades of Grey, and Memory Rescripting, but they don't help, and he still feels desperately depressed. But then, after trying 15 techniques, you try a Paradoxical Cost-Benefit Analysis, and it does work. He stops believing he's "defective at the core," and his symptoms suddenly disappear. He tells you he feels happy and has a sense of self-esteem for the first time in many years.

Here's my question. If you try five new techniques each session, approximately how many sessions will it take before this chronically depressed man recovers? Think about it for a moment before you continue reading.

The answer is simple – three or four sessions. And this is not just some mathematical concept, but what my colleagues and I observe every day over and over in our clinical work.

Here's another question. Suppose you try your favored method with this patient over and over? This could be a method you learned during graduate school, perhaps a method your supervisor was enthusiastic about, such as psychodynamic therapy, EMDR, behavior modification, hugging the inner child, or simply empathic ventilation. How many sessions will be required before your depressed patient recovers?

The answer is maybe never. That's because the method or methods you usually use probably will not include the method that works for him. That's not just mathematical concept, either. Most of the patients I've seen in my career have been in therapy for years or even decades with no success before we began working together. Most had seen many therapists, often more than 5 or 10, without any improvement.

Once patients have experienced their first dramatic recovery, they often feel fantastic. Many have told me that it's the best they've ever felt in their entire lives, almost like being born again.

Of course, these euphoric feelings can't last indefinitely. All human beings get upset from time to time. The question is not, "Will this patient relapse," but rather, "Will he be prepared for relapse, so he can nip it in the bud?" That's why Relapse Prevention Training is so crucial. It only takes one session, and I'll describe how it works in a future edition of this newsletter.

Cognitive therapists focus not only on challenging the upsetting negative thoughts in the here-and-now, but also on modifying the underlying attitudes and beliefs that trigger these problems in the first place. Cognitive therapists believe that maladaptive beliefs explain the timing of episodes of depression, anxiety or anger. Some of the more familiar ones include Perfectionism, Perceived Perfectionism, the Achievement Addiction, the Approval Addiction, the Love Addiction, Entitlement, Submissiveness, and Conflict Phobia, to name just a few. Let's assume that you have the Achievement Addiction. That means that you base your self-esteem on your accomplishments and productivity. This is common in our culture. In fact, this mindset traces back to the Calvinist work ethic—you ARE what you DO—and is at the basis of Western civilization.

If you have this mindset, a cognitive therapist would predict that as long as you feel pleased with your productivity and achievements, you'll feel reasonably happy and contented. But when you fail or fall short of your goals, you may be vulnerable to episodes of anxiety or depression.
Albert Ellis called these attitudes "Irrational Beliefs." Aaron Beck called them "Dysfunctional Attitudes." Jeffrey Young called them "Schemas." I call them "Self-Defeating Beliefs." These beliefs are not purely good or bad, but contain a mixture of positive and negative components. There are many rewards from basing your self-esteem on your productivity, or on being loved, or on trying to be perfect. There are also many negative consequences. Helping the patient sort out the positive and negative consequences with a Cost-Benefit Analysis is usually the first of many steps in changing a Self-Defeating Belief. Other useful tools include the Semantic Method, the Experimental Technique, the Feared Fantasy, and the Acceptance Paradox, to name just a few. Modifying the patient's value system is an important aspect of personal growth as well as relapse prevention.

The Cognitive Model really shines in the treatment of depression and anxiety disorders, although it's not the only model I would use. The Behavioral Model is also very useful in treating depression, and the Exposure and Hidden Emotion Models are vital in the treatment of anxiety disorders. I rarely use the Cognitive Model in treating relationship problems, as it tends to be ineffective and may even make the patient or troubled couple worse. I've developed motivational and interpersonal techniques which seem to be far more effective for relationship problems. In the treatment of habits and addictions, the Cognitive Model can be useful, but motivational techniques take center stage, since habits and addictions are inherently motivational problems.

When I wrote, Feeling Good, first published in 1980, Cognitive Therapy was a relatively unknown approach, and my publishers were convinced that the book would have extremely limited market appeal. Since that time, Cognitive Therapy has become the most widely used form of therapy in the world, and the most researched treatment in history. In addition, Feeling Good has sold more than 5 million copies worldwide. One of the reasons for this success is that I have a secret sales force: surveys of American and Canadian mental health professionals indicate that Feeling Good is the book most often recommend, or “prescribe” for patients struggling with depression. I have been very grateful for this support and thrilled that the book has proven to be so helpful for so many people.

One reason that therapists prescribe Feeling Good (as well as The Feeling Good Handbook) is because these books may have actual antidepressant effects for some patients. This was not my goal when I wrote these books. I simply wanted to share some new treatment developments I was excited about and hoped to make the therapist’s work a bit easier. I imagined that patients could read the book between sessions as a way of speeding up their learning about CBT. That way, therapists can focus on individualizing the treatment for each patient, rather than having to teach the basics over and over.

Work by Dr. Forrest Scogin, a research psychologist at the University of Alabama, suggests that Feeling Good may do more than psycho-education, and may substantially lift the moods of some patients suffering from depression. He and his colleagues have reported that two-thirds of individuals seeking treatment for moderate to severe depression who were given a copy of Feeling Good recovered within four weeks, even though they received no other treatment during this time. In contrast, a control group of patients who were not given the book failed to improve.

Then they told the waiting list group that they would have to wait for four more weeks before seeing a therapist or receiving an antidepressant, but gave them a copy of Feeling Good and encouraged them to read it. In the next four weeks, two-thirds of this group recovered or improved sufficiently that they no longer needed treatment.
Was the improvement simply a placebo effect that would result from reading any book? To find out, Dr. Forrest Scogin and his colleagues conducted a third study.

This time, they again assigned depressed patients seeking treatment at the medical center to one of two waiting list groups for a period of four weeks. The patients in one group received a copy of Feeling Good, and the patients in the second group received a copy of Victor Frankl’s book, Man’s Search for Meaning. The evaluated the patients’ moods weekly for the next four weeks with the Hamilton Rating Scale for Depression as well as the Beck Depression Inventory. Once again, two-thirds of the patients who received a copy of Feeling Good improved substantially and did not need any further treatment. In contrast, the patients who received Man’s Search for Meaning did not improve. The researchers concluded that the improvement in the Feeling Good was not simply a placebo effect, and that bibliotherapy can have meaningful and significant antidepressant effects if the book contains information specifically helpful for patients who are suffering.

Finally, one might wonder whether those effects will last or were simply a flash in the pan. Follow-up studies have revealed that these patients have maintained their gains without relapses for up to three years so far. These results are almost as good, if not better, than the results generally obtained with antidepressant medications and / or psychotherapy in controlled outcome studies. I’ve included references to a number of the bibliotherapy research studies at the end of this edition of the newsletter. However, it’s important to emphasize that no treatment, including bibliotherapy, is a panacea – some patients will respond, and others will not. Once again, that’s a good reason not to fall in love with any one method of treatment, but rather to get training in a wide variety of approaches and techniques.

The Behavioral Model
People often equate Behavior Therapy with Exposure Therapy, but I use these terms differently. As you know, Exposure Therapy involves confronting your fears in reality – so-called “Classical Exposure” – or in your mind, so-called “Cognitive Exposure.” Exposure techniques are invaluable in the treatment of the anxiety disorders, and I'll describe them next. In contrast, I use the term “Behavior Therapy” to refer to a variety of behavioral activation and anti-procrastination techniques.

Dr. Peter Lewinsohn, from the University of Oregon, is one of the best-known proponents of behavioral therapy for depression. It is well known that a loss of motivation is one of the key symptoms of depression. Most depressed patients experience a loss of motivation to do things that used to give them a sense of pleasure or satisfaction – such as playing tennis, going to a movie with a friend, or getting caught up on your filing. Severely depressed patients may lie around in bed, doing little or nothing. This do-nothingism saps the patient's morale and intensifies the depression, leading to even more motivational paralysis. So the patient gets trapped in a vicious cycle.

Dr. Lewinsohn has reported that simply encouraging depressed individuals to do more pleasurable and rewarding activities can lead to significant improvement. That's one reason why Cognitive Therapy quickly morphed with Behavior Therapy and became Cognitive Behavior Therapy, or CBT. But behavioral activation techniques, like the Daily Activity Schedule, were an inherent part of the treatment from the very inception of Cognitive Therapy. In fact, some of the earliest methods I developed, such as the Pleasure-Predicting Sheet and the Anti-Procrastination Sheet, were behavioral techniques.

One of the neat things about CBT is that behavioral activation techniques can be used to test dysfunctional attitudes and beliefs. That way, you can kill two birds with one stone. For example, an accountant named Roberto sought treatment after his wife, a surgery resident, announced that she no longer loved him and was gong to move out of their apartment. He was devastated, and even more so when he discovered that she'd been having an affair with a doctor in the hospital where she worked. One of the beliefs that contributed to his depression was his overwhelming conviction that he could never be happy without Alice's love. Roberto thought of her as one of the "beautiful people." She was attractive, brilliant, and popular, and she was pursing a glamorous career in plastic surgery. By comparison, he saw himself as an inferior, dull, and unexciting person, with little to offer.

This thinking pattern is extremely common among people who have been rejected. You idealize the person who rejected you and tell yourself you could never be truly happy and fulfilled without his or her love. In some cases, this line of thinking seems so real that the person who has been rejected commits suicide.

I tried a number of techniques with Roberto that were not effective. He continued to feel severely depressed and constantly ruminated about how miserable he was destined to be without Alice. Around the fifth session, I encouraged him to test his belief with the Pleasure-Predicting Sheet. This is a multi-column sheet that allows patients to schedule a variety of activities with the potential for pleasure, learning, or personal growth. Then they predict how satisfying or rewarding each activity will be on a scale from 0% (not at all0 to 100% (completely). Depressed individuals often make low predictions, since they anticipate misery and a lack of pleasure. After they complete each activity, they record how satisfying it turned out to be, on the same scale from 0% (not at all0 to 100% (completely). The activities often have antidepressant effects, and the data patients collect can be revealing.

You can see Roberto's Pleasure-Predicting Sheet. At the top, I told him to record the belief that was plaguing him: "I could never be happy without Alice's love. If I'm alone, I'm destined to feel miserable." In the first two columns, he scheduled a variety activities and indicated who he'd do each activity with. I emphasized the importance of doing some activities by himself, and some with other people. In the third and fourth columns, he predicted how satisfying each activity would be and recorded how satisfying it actually turned out to be after he completed it.

Roberto was surprised that many activities he did by himself, such as jogging, or going back to work and organizing his desk, turned out to be far more rewarding than he predicted. In addition, he agreed to go on a blind date arranged by a friend, but only predicted 5%, since he was convinced he could never be happy without Alice's love. But he had a terrific time, and recorded 95% in the "Actual Satisfaction" column.

In contrast, he predicted 100% satisfaction on eating lunch with Alice – something she'd suggested. He had fantasies of wooing her back. Instead, she talked about how happy she was and how great her new lover was, and wanted to go over the details of the property settlement for their impending divorce. He recorded a satisfaction level of 0% after the luncheon.

The data on Roberto's Pleasure-Predicting Sheet was not at consistent with his belief that Alice was the only possible source of joy and satisfaction in his life. In reality, she seemed to be more of a source of misery and unhappiness. His depression began to lift, and with a few sessions had disappeared completely. Roberto terminated therapy after a total of 10 sessions.

I never saw him again, but he sent me a letter two months later. He explained he was still doing well and wanted to thank me for the work we did together. He wanted me to know that he'd been entirely alone on Christmas Eve and New Year's Eve as well. But he said that, he was completely happy both evenings because he'd discovered that he could be happy alone, and that he actually liked himself. He said he never would have believed this was possible prior to the time we worked together.

That was the last time I heard from Roberto, but I treated a relative of his several years later. She told me that was still doing well. He'd remarried and had two wonderful children. His business seemed to be booming as well.

But Alice had not done so well. Her glamorous affair had eventually disintegrated, and when she learned that Roberto had a new girlfriend he was serious about, she decided that she wanted him back. But he discovered that he was no longer interested. Sadly, she eventually committed suicide.

References
Ackerson, J., Scogin, F., Lyman, R.D., & Smith, N. (1998). Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. Journal of Consulting and Clinical Psychology, 66, 685-690.
Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith, T. P., Sommer, R., & Zuckerman, E. L. (2003). Authoritative guide to self-help resources in mental health (2nd ed.). New York: Guilford.
Santrock, J.W., Minnett, A.M., & Campbell, B.D. (1994). The Authoritative Guide to Self-Help Books. New York: Guilford Press.
Scogin, F., Hamblin, D., & Beutler, L. (1987). Bibliotherapy for depressed older adults: A self-help alternative. The Gerontologist, 27, 383-387.
Scogin, F., Jamison, C., & Davis, N. (1990). A two-year follow-up of the effects of bibliotherapy for depressed older adults. Journal of Consulting and Clinical Psychology, 58, 665-667.
Scogin, F., Jamison, C., Floyd, M., & Chaplin, W. (1998). Measuring learning in depression treatment: A cognitive bibliotherapy test. Cognitive Therapy and Research, 22, 475-482.
Scogin, F., Jamison, C., & Gochneaut, K. (1989). The comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting and Clinical Psychology, 57, 403-407.
Smith, N.M., Floyd, M.R., Jamison, C., & Scogin, F. (1997). Three-year follow-up of bibliotherapy for depression. Journal of Consulting and Clinical Psychology, 65(2), 324-327.

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