518: Why So Much Therapy Doesn't Work (And What Actually Does)

Episode 518: Why So Much Therapy Doesn't Work (And What Actually Does) Hosts: Kevin Cornelius, LMFT Dr. David Burns Guest: Jeremy Karmel What happens when therapy doesn't work? In this provocative episode of The Feeling Good Podcast, David Burns and Jeremy Karmel join Kevin Cornelius to examine some uncomfortable questions about the mental health field: Why do some people remain in therapy for years without getting better? Why do so few therapists measure their patients' progress? What happens when therapists become overly attached to one particular school of therapy? And how can we make psychotherapy more effective, accountable, and evidence-based? Jeremy brings a particularly personal perspective to the conversation. After experiencing severe depression in college and trying numerous forms of therapy without success, he worked with Matt May using TEAM-CBT and experienced a dramatic recovery in roughly two weeks. That experience ultimately led him to become deeply involved in TEAM-CBT and in the development of the Feeling Great app. David and Jeremy describe a list of more than 30 concerns about the way mental health care is commonly practiced today. They emphasize that the goal isn't simply to criticize therapists, but to encourage a radical improvement in the effectiveness of psychotherapy. In This Episode 1. Can financial incentives create a conflict of interest? David and Jeremy explore a difficult question: If therapists are paid by the session, is there an inherent incentive to keep therapy going longer than necessary? They contrast long-term therapy without measurable improvement with a model in which the therapist's goal is to help the client recover as quickly and completely as possible. David argues that therapists should be able to define what successful treatment looks like and determine whether their interventions are actually producing meaningful change. Kevin offers another perspective from his experience at Feeling Good Institute, where brief TEAM-CBT therapy can lead to rapid improvement while also generating referrals because clients recognize that the treatment is effective. 2. Are schools of therapy becoming like "cults"? David and Jeremy question the tendency within psychotherapy to become attached to particular theorists, schools, and treatment models. Instead of assuming that one approach explains every psychological problem, they argue for flexibility. Depression, anxiety, relationship problems, and other difficulties may have very different causes and may require very different interventions. David describes TEAM-CBT as a framework for effective psychotherapy rather than allegiance to one particular technique. He has developed more than 140 techniques and emphasizes selecting methods according to the individual's specific problem. Jeremy points out that therapists and patients can be tempted to treat the ideas of famous figures such as Freud or Carl Rogers as unquestionable truths rather than hypotheses that should be tested against evidence. 3. The refusal to measure Perhaps the strongest theme of the episode is the importance of measurement. David argues that therapists need to know whether their patients are actually improving—not simply assume that they are. His approach involves measuring symptoms at the beginning and end of sessions and tracking changes over time. If a person begins a session feeling 90% depressed and ends at 80%, that's useful information. If the numbers don't improve from week to week, the therapist has evidence that something needs to change. On the other hand, dramatic changes can provide tangible evidence that treatment is working. Jeremy shares the story of a friend who had apparently been depressed for 18 months or more while receiving therapy, yet neither the therapist nor the patient had been systematically measuring whether the depression was improving. 4. Therapists aren't always accurate judges of how their patients feel One of the most surprising parts of the discussion is David's argument that therapists' clinical intuition can be remarkably inaccurate. He describes research in which highly trained clinicians interviewed patients extensively and then estimated how depressed, anxious, angry, or suicidal the patients were. Their estimates were extremely inaccurate compared with the patients' own ratings. The lesson is humbling: We cannot reliably assume that we know how another person feels simply because we've spent a