Living With The Devil We Know

We May be Anxious, but Not to Change

Magazine Issue
January/February 2013
Living with the Devil You Know

For the last 40 years or so, our profession has assumed that by copying the medical model, using science-based, pathology-focused, diagnosis-specific treatments, we’d have medical-style success (forget, for the moment, that medicine itself isn’t nearly as predictable and successful as advertised, nor even as scientific). By now, you’d think we’d have just about licked most ordinary mental disorders. Anxiety and depression—which get the lion’s share of therapists’ attention—should have gone the way of smallpox and polio, shouldn’t they? Well, not so much. If anything, given the sheer numbers of depressed, anxious, angry, violent, drug- and alcohol-addled people we see in our offices and around us, it would seem that rates of emotional and mental disorders in our society are just as high as ever, or possibly even on the rise.

Of course, psychotherapy “works”; we have plenty of evidence for that. It’s just that, even with all the fancy high-tech, evidence-supported, protocol-driven therapies, we aren’t doing nearly as well as we sometimes imagine, even with our own patients.

The findings from the British CoBalT trial that were recently published in the The Lancet underscore this fact. The investigators randomly assigned 469 chronically depressed, treatment-resistant patients either to the usual care (primarily antidepressant medications) or to the usual care plus cognitive-behavioral therapy (CBT). At the six-month evaluation, only 22 percent of the treatment-as-usual group had improved significantly, as compared with 46 percent of the patients in the meds-plus-CBT group.

These results indicate that neither treatment was terribly effective, since improvement was defined as a 50-percent reduction in patients’ scores on the Beck Depression Inventory (BDI). That’s not too impressive, since most patients with such a reduction in BDI scores will still be quite symptomatic: they definitely won’t be feeling much joy or self-esteem. The results also indicate that the antidepressants the patients in the treatment-as-usual group received appeared to have few, if any, beneficial effects above and beyond the positive effects caused by the passage of time. A 22-percent “improvement” rate is pathetic, to be blunt. Finally, although the psychotherapy helped, the effects left a lot to be desired, too, since more than half the patients didn’t even achieve a 50-percent reduction in depression severity.

Unfortunately, the findings from this study aren’t unusual. I’m not aware of any controlled-outcome studies in which any form of psychotherapy (or antidepressant drug therapy) has shown really dramatic or impressive results. In fact, in most cases, the outcomes for the treatment groups are barely greater than the outcomes for patients receiving placebos. I think all of us can agree that, despite the significant progress that’s been made in therapeutic treatment, there’s still enormous room for improvement in even those forms of psychotherapy that are heralded as state-of-the-art.

The Learning Curve

I began my career as a biological psychiatrist at the University of Pennsylvania during the early ’70s, the opening years of psychopharmacology’s appropriation of psychiatry. At the drug company presentations at the conferences I attended, I heard that 85 percent of depressed patients could be treated effectively with meds, but soon discovered otherwise. While some of my patients improved a bit, many others continued to suffer, no matter how many drugs I prescribed or how long I listened and supported them with traditional talk therapy. I could clearly see that my success rates were fairly similar to those in the treatment-as-usual arm of the CoBalT trial.

I began looking for a new and different treatment method to supplement the drugs, and my department chairman suggested I try the relatively new CBT approach, but I was highly skeptical. The idea of trying to change the negative thinking patterns of depressed and anxious people sounded too superficial, too “power of positive thinking,” and not nearly “deep” or “biological” enough to have any meaningful effects. To my amazement, however, CBT seemed to work a lot better than medications and talk therapy, and clients liked it. Sometimes, the results were fast and spectacular, even with discouraged clients who’d tried years of talk therapy and meds without much success.

However, despite many successes, my results were still far from perfect, especially in the treatment of anxiety. Many patients would begin to improve, achieving a 50- to 60-precent reduction in symptoms. Then they’d get stuck and continue to struggle with crippling shyness, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), or some other type of anxiety, no matter how many techniques I tried.

I began to notice some other limitations with the CBT model. Although the treatment techniques were powerful, the approach didn’t explain the when or why of anxiety or depression—something that many in the CBT community seemed to feel was irrelevant to successful treatment. It seemed obvious that negative thoughts triggered anxiety, but what caused the negative thoughts? What was it inside a person that made him or her so vulnerable to intense anxiety and insecurity?

Then one day, one of my patients got me to thinking about anxiety in an entirely new way. Margaret was a 25-year-old married woman who came to me because she was struggling with panic attacks at work. She was working as an administrative assistant for a man with a wholesale soda pop distributing company. She’d married and taken the job right after graduating from high school, foregoing her plans to attend college so she and her husband could afford to buy a house. Her father had helped get her the job through a family friend. Although she was doing good work and got along well with her boss, every time he walked past her desk, she developed feelings of intense nausea and had the urge to vomit. Then she’d have to go to the ladies room and lie down, waiting for the nausea to pass. Sometimes, she had to go home because she was so sick. Her doctor had run some tests and reassured her there was nothing wrong physically.

I used a battery of CBT techniques and Margaret faithfully did all her psychotherapy homework between sessions, but her symptoms only improved about 50 percent. Although she no longer had to seek refuge in the ladies room and was able to stay at work, she still struggled with strong feelings of anxiety and nausea. This wasn’t a satisfactory outcome by a long shot, but it was the same pattern I’d observed in so many of my anxious patients: they’d improve to a point, but then plateau, no matter how many techniques I tried.

I felt there must be something else going on, but had no idea what. I asked if she was angry or unhappy with her boss, but Margaret insisted, quite believably, that she admired him greatly. He treated her well, constantly sang her praises, and paid her well. She was happily married and had no conflicts with anybody.

Margaret had been working with the list of cognitive distortions from my book Feeling Good. One day, she asked whether All-or-Nothing Thinking, one of the distortions listed, could apply to family dynamics. When I asked what she was thinking about, she said that when she’d been growing up, her sister, Ann, had been labeled the “bad daughter” and she, Margaret, the “good daughter.” She explained that she’d always been expected to be a model citizen and perfect lady. She became studious, bookish, and hard working, getting straight A’s in school. She was responsible and ready to be helpful, did chores around the house, never tried smoking or drinking, and never disobeyed her parents. Likeable and popular, she was usually elected class president. As her parents said repeatedly, she was a “very good girl.”

Margaret went on to explain, however, that the “good girl/bad girl” labels weren’t really accurate, but a kind of caricature of a much more complex reality. In the first, place, she said that her sister, Ann, had always been a kind, conscientious person, who’d also gotten good grades and was now happily married with two children—not at all a wild, heedless party girl who never grew up. “And I,” Margaret told me cautiously, “am not as much a Goody Two Shoes as everyone seems to think.”

I asked what she meant, wondering whether I was about to hear revelations about a hidden life of secret vices. Nothing like that: what she meant was that she didn’t always want to be such a nice, compliant girl. Then she confessed that she secretly hated her job. Although working conditions were pleasant and her boss was terrific, she just didn’t want to spend her life selling soda pop. I asked what she’d be doing if she found her ideal job. She said that ever since she was a little girl, she’d always dreamed about being a dress designer, adding that she was good at art and had a talent for fabrics, color, and fashion. But how could she tell her boss, since he was so nice and she couldn’t stand seeming disloyal or hurting his feelings! It might show she didn’t appreciate what her father had done for her, and she was afraid she’d be letting down her husband as well.

A possible meaning of Margaret’s symptoms jumped to mind. Could her panic attacks be her way of saying, “This job makes me sick,” or “I can’t stand working here,” but instead of verbalizing her feelings, her symptoms allowed her to play the sick role and say, “I just can’t do this any more.” This idea resonated with Margaret, and she brightened up immediately. She left determined to talk things over with her boss and her husband.

At the start of the next session, much to my shock, a beaming Margaret announced that she’d talked things over with her husband and boss, who both supported her desire to change careers. She assuaged her feelings of disloyalty to her boss by giving him eight weeks’ notice and promising not to leave until she’d trained a suitable replacement. “And,” she said triumphantly, “I haven’t felt panicky or sick to my stomach even once since telling my boss.” Her symptoms had disappeared and her scores on the depression and anxiety tests were zero, indicating she was ready to terminate treatment. It was our last session. Six months later, Margaret sent me a thank-you note explaining that she’d found a job as an apprentice to a woman who manufactured women’s clothing, had never had another panic attack, and was still doing great.

Exploring the Hidden Cause

At first, I thought that Margaret’s case was just an isolated example, but over time, I began to notice the same pattern with more and more anxious patients who seemed stuck. I started asking them if there was something going on in their lives that they hadn’t told me about—something that was bothering them. At first, they’d all deny it, but after a few sessions, a hidden emotion or problem would emerge. When the patient expressed the hidden feeling or took steps to solve the problem he or she had been avoiding, the anxiety improved significantly or, more often, disappeared completely, just as in Margaret’s case. It seemed that these patients were trying to teach me something important about the deeper causes of anxiety, something that wasn’t a part of my CBT training. They were giving me a new tool I decided to call the Hidden Emotion Technique.

The vast majority of these patients were exceptionally nice individuals who felt a strong urge to please others. In fact, most of them seemed to exhibit—beneath their panic attacks, anxieties, and fears—phobias about conflict, anger, or negative emotions of any kind. They seemed to experience a kind of emotional perfectionism, the belief that they should always be happy, pleasant, calm, and totally in control of their feelings, even at the expense of their own desires and emotional needs.

In other words, when anxiety-prone individuals get feelings or urges that don’t seem “proper” or “acceptable,” they sweep them under the rug without realizing they’re doing this. Then they suddenly develop a phobia, a panic attack, or OCD symptoms and completely lose sight of the hidden problem or feeling that triggered the anxiety in the first place. This dynamic isn’t always happening—sometimes a phobia is just a phobia—but through the years, I’ve observed it in roughly 75 percent of my anxious patients, and when I help them uncover the hidden emotion, the anxiety disappears with astonishing regularity.

As I thought back to my own childhood and life, I noticed this pattern as well. When I was growing up, I struggled with all kinds of fears and phobias. I feared bees, dogs, horses, blood, heights, vomiting, cameras, public speaking, social occasions, and more. Why had I been so afraid of so many things?

Like so many of my anxious patients, I’ve felt a strong urge to be nice. I’m not entirely sure where it came from, but I was what’s known as a PK, or “preacher’s kid.” My father was a Lutheran minister and a basically kind man, but strict, demanding that his children adhere to a fairly rigid formula of “goodness.” We were expected not just to follow rules, but to follow them in a humble spirit, always to be polite and considerate, to please others, and to be models of good behavior. To this day, when I’m beginning to feel a sense of dread or generalized anxiety about my life, it’s usually because I’m feeling annoyed with someone, or upset about something, that I’m sweeping under the carpet—because I think I’m not “allowed” to have those kinds of negative feelings. When I bring the problem to conscious awareness and deal with it, in most cases, the anxiety immediately disappears.

You might call this the Excessive Niceness Syndrome, and it’s made me think about anxiety and phobias in ways much different from those I was taught during my psychiatric training. We commonly refer to phobias, panic attacks, and obsessive worrying as symptoms of anxiety disorders, as if they were mysterious pathological conditions without any meaningful connection to the emotional life of the person who’s experiencing them. In fact, we’re sometimes taught that depression and anxiety result from some type of chemical imbalance in the brain, although that theory has never been validated. Now I’m inclined to view anxiety as part and parcel of the human condition. Specifically, I wonder whether anxiety might ultimately result from a kind of existential fear of the self—fear of who we are and how we really feel as human beings. Perhaps these phobias and fears serve the purpose of safely isolating us from uncontrollable urges, feelings, desires, and impulses that we dislike and that contradict our idealized notions of who we think we are or should be.

From my work with large numbers of clients with every conceivable type of anxiety, I’ve learned more about the nature of the hidden problems that trigger the symptoms. First, the problem is almost never buried in the past. It’s something that’s bothering the client in the here and now. Second, it’s something obvious and simple, like hating law school, but feeling you have to stay in law school because your father always wanted you to be a lawyer. Third, it’s usually a symbolic expression of the hidden conflict. For example, the law student with panic attacks doesn’t have to say, “Dad, I’ve decided to drop out of law school because I don’t want to be a lawyer. I want to become a journalist.” Instead, by assuming the sick role, the student can say, in essence, “I just can’t continue with law school because I’m going crazy: I’m on the verge of a nervous breakdown.” This symbolism isn’t created at the conscious level, of course. Anxiety is a kind of creative poetry that the brain automatically generates, much like dreaming. As a therapist, you have to “listen” to the poem to detect the symbolic meaning.

Although the Hidden Emotion Technique appears to me to be a significant advance in the treatment of anxiety, I don’t mean to minimize the enormous contributions of the many brilliant therapists who’ve developed CBT and other new forms of psychotherapy. I’m proud of my own contributions to CBT and still enthusiastically use its techniques with every depressed and anxious individual I treat. But I now have a new model, which seems to illuminate some of the whys and whens of anxiety, along with a powerful new treatment tool to help dislodge anxious clients who’ve gotten stuck with only partial improvement when I’ve used more traditional forms of CBT.

Resistance Meets Motivation

Even armed with the Hidden Emotion Technique and a wide variety of powerful CBT approaches, I still couldn’t reach some depressed and anxious patients. That began to make me wonder whether we might be missing something fundamental about our clients, even about human nature. Was it possible that our single-minded desire to help our patients might be blinding us to some incredibly important paradox of human nature? For example, in today’s problem-oriented, solution-focused atmosphere, we assume that clients come to us for relief of their suffering. At least, that’s what they tell us: “I want to stop having panic attacks every time I go out in public. Please help me!” “I want to stop obsessing and having nightmares about the bad thing that happened to me years ago. Please help me!” “I want to stop feeling hopeless and worthless all the time. Please help me!”

So that’s what we earnestly set out to do: we try to give them what they say they want, and while some of our patients play ball and appreciate our efforts, others respond quite differently. They begin to “yes-but” us, or put up a wall, or simply “forget” to do their psychotherapy homework week after week. Pretty soon, we end up doing all the pushing, while the patient does all the resisting, and everyone becomes frustrated or even angry at each other about the situation.

I sometimes think that, for all our supposed expertise in human psychology, we can sometimes be a little naïve about a hidden antipathy to change that exists as an undercurrent beneath our clients’ stated and genuine desire for change. Anthony de Mello, a Jesuit mystic, once said that we yearn for change, but cling to the familiar. What if our clients have mixed feelings about receiving the help they want and seem to need? What if their reasons to resist change actually reflect something positive, or even flattering, about their values and goals in life? Could it be that humans are sometimes far more complicated than even our newer, presumably smarter, models of therapy have taken into account?

As therapists, we’re influenced by the medical model. We assume that, just as any rational person with a broken arm, inflamed appendix, or bacterial infection would be a willing and eager customer for medical care, surely a person suffering from severe anxiety or depression would be equally motivated to receive the healing that we offer. But what if this isn’t the case? Over and over again, I’ve treated patients in genuine pain, sincerely hoping I can provide relief, who turn on a dime, so to speak, when I assure them that they can recover, usually much sooner than they think. Sometimes, they suddenly react, not with feelings of gratitude and relief, but rather with muted enthusiasm or even open opposition and hostility.

Their unwillingness to continue doesn’t look to me like covert or unconscious resistance, but something else. Faced with the real possibility of cure, some patients seem to back off in a kind of horror, almost as if the disappearance of the symptoms would result in the loss of something vitally important to them, or might even force them to confront something even worse than their symptoms. My work with a young man named Sam is a good example.

He came to me for treatment after struggling with severe PTSD. Six months earlier, he’d been working in a Burger King near Temple University in Philadelphia. One night, just before he closed up, two gunmen robbed the place. Before they left, they threw him into a walk-in freezer and left him there to die, laughing on the way out about the clever thing they’d done.

The next morning, the manager came in early and was alarmed to see the doors open and the lights still on. When he opened the freezer, he found Sam huddled in a corner and shivering, but still alive. Although he’d survived, he was badly traumatized. The gunmen never were captured.

Sam soon developed panic and rage attacks, and spent most of his waking hours haunted by vivid memories of the incident. He constantly worried that it would happen again, and woke up at night from terrible nightmares. When he wasn’t struggling with flashbacks or worrying about getting mugged again, he imagined finding the men and taking revenge on them. He said the anger and panic had totally consumed his life. All he wanted, he told me, was to get his life back, if that was possible, though he doubted it was.

In our first session, I told Sam that the prognosis was actually quite positive. I said his symptoms didn’t actually result from the traumatic event, but from the constant stream of negative thoughts and vivid, frightening images that crossed his mind. I explained that we had many new techniques to help him modify those thoughts and images, and briefly described some of them. I then added that, although I couldn’t make any promises or guarantees, there was a good chance we could reduce his anxiety and rage significantly, and perhaps eliminate his symptoms entirely.

He asked how long the treatment would take, given how severe his symptoms were—probably a long time, he supposed, years even. I said that these things were difficult to predict and that the treatment might take not years, but several months or more. However, if we worked hard together, I told him, there was a good chance we might be able to eliminate his symptoms more quickly, maybe in just a few sessions.

Sam looked at me for a moment without expression and then, to my astonishment, flushed and began barking angry questions and “yes-butting” me, as if I’d suggested we try a course of voodoo or animal sacrifice. How was it possible that the techniques I’d described could make the least difference to what he was going through? Didn’t I realize just how horrible what he’d experienced had been? Sure, such simpleminded stuff might work for somebody with really dumb, little problems, but did I not understand that he felt like absolute shit 24 hours a day? I was supposed to be a doctor, who was trained to recognize and treat serious problems, wasn’t I? What kind of crap was I peddling, anyway, with my talk about all this CBT baloney?

I was taken aback. Here I was offering a message of hope and glad tidings, which I thought would relieve Sam immensely, and he was responding with anger, clearly on the verge of getting up and walking out. I realized I was failing with an anxious patient once again. In fact, this time, I was failing before we’d even gotten started. Why was Sam so forcefully resisting my efforts? Could it be that he that, in some way, he really didn’t want to get better?

In near desperation, I decided to try another tack. One of the first CBT techniques I developed wasn’t even a cognitive technique at all, but a Cost-Benefit Analysis (CBA), to deal with motivational problems, particularly with patients with borderline personality disorder. The analysis assesses motivation—whether the patient really wants to change.

You draw a line down the middle of a piece of paper from top to bottom and label the two columns Advantages and Disadvantages. At the top of the sheet, you define the problem; it can be any negative thought, feeling, habit, or belief that the patient is struggling with. Then you and the patient list the advantages and disadvantages of that problem and, afterward, you ask the patient to balance the advantages against the disadvantages on a 100-point scale. That’s called a Straightforward CBA. Alternatively, if the patient is oppositional, you can simply list the advantages of the dysfunctional thought, feeling, or belief, and then agree that the patient would probably be better off not changing. That’s called a Paradoxical CBA, and it’s the approach I decided to try with Sam.

I told him that since what I’d been saying about our chances for rapid recovery seemed to be upsetting him, maybe I’d been overlooking some important advantages of the rage and panic. Perhaps, we should list the advantages of feeling that way in the left-hand column of a CBA. I always say this with genuine respect, sincerity, and curiosity, which I truly feel. If patients think it’s one more clever CBT intervention or manipulation, it won’t work. My fundamental stance is that, at this point, I don’t really know what’s important to my patient, and there might be some really good reasons for him or her to resist getting symptom relief.

Sam perked up and immediately pointed out one rather obvious advantage of his PTSD: the anxiety and constant vigilance protected him from danger and kept him safe. If he let his guard down, he might get robbed again, or even killed. I agreed that the area where he lived and worked—near Temple University in Philadelphia—was extremely dangerous, and said that he had a darn good point, and he should list that in the Advantages column of his CBA. I asked if there might be some additional advantages to the anxiety and anger he was constantly feeling.

He went on to point out that the anger showed that he wasn’t going to just passively accept having thugs abuse and nearly kill him, as though he were some weak doormat, whom anybody could push around. He said that if he suddenly began to feel happy again, it would make him look like a wimp. Driving the point home, Sam added, “Hell, no, Dr. Burns, I have every right to be angry. I’m not going to let those guys walk all over me and then feel happy about it!”

I told him that was a great point, and that his anger showed that he intended to stick up for himself and not put up with any abuse from anybody. His anger, in fact, was an expression of his self-esteem, so he should add that to the Advantages column as well.

Then he came up with a third advantage of keeping his symptoms. He said that if he could be cured in just a few sessions, as I’d suggested, and all his feelings of anger and panic suddenly vanished, it would imply that what had happened to him was trivial. But it wasn’t trivial. It was a horrible, traumatic event that almost killed him and practically ruined his life. So I asked him to add that to the plus side, too.

Now I could see my initial error. I’d jumped in to help Sam without taking time to empathize with his suffering, and without taking into account all the reasons he might have not to change. I still make this mistake at times, and in my opinion, it’s the most common cause of therapeutic failure. Let me repeat that. The compulsive need to help, which usually results from therapist codependency or narcissism, is the cause of nearly all therapeutic failure. We jump in and try to help because that’s our role, and we can’t bear the bad feelings we might experience if we were unable to help, or if our patients didn’t want our help. Although most therapists will say they understand this intellectually, few can avoid this error.

Once I realized what I’d been doing wrong, I said something like this:

“Sam, I can see that I’ve been barking up the wrong tree, and I owe you an apology. What you’re saying makes a lot of sense. It would be foolish to let down your guard, because it is dangerous where you live and you have every right to be enraged. What those guys did was sadistic and awful. You’ve been through a living hell. If you could recover in just a few sessions, which might actually be possible, it would be like saying the trauma was insignificant and didn’t count for much. It would be insulting to you.

“To be honest,” I went on, “I’ve changed my thinking. You’ve convinced me that we probably shouldn’t try to eliminate the rage and panic attacks. Your feelings make perfect sense: they show that you have a sense of dignity and self-respect, and don’t want to put yourself in harm’s way again. Now I can see where you’re coming from.”

How Helpful Is Helpful?

When I made this statement, I became the voice of Sam’s resistance. I call this technique the Externalization of Resistance, because you externalize the patient’s inner voice committed to maintaining the status quo. I also call this Sitting with Open Hands, because you aren’t trying to grab or persuade the patient to work with you. Instead, you verbalize all the reasons not to change, and you’re willing to let the patient go. If you do this skillfully, with warmth, logic, and compassion, patients won’t have to argue for the resistance anymore, because you’ve made the case for them, Instead, most will usually jump to the other side of the argument and suddenly become the voice that argues for change.

That’s what happened here. Sam replied, “Yes, but aren’t we supposed to fill out the Disadvantages column? Isn’t there a downside to the constant panic and rage attacks?”

I asked Sam if he could list some disadvantages in the right-hand column of the CBA. What price was he paying to maintain these symptoms? What was the downside?

Sam came up with one disadvantage right away. He said that he wasn’t convinced that the anxiety really kept him safe. He said that maybe the bad guys can smell it when you’re scared and are even more likely to mug you. By contrast, if you’re confident and alert, you may actually be safer.

I told him to write that down in the Disadvantages column, but continued to play the voice of his resistance. I reminded him that even if the panic attacks didn’t protect him, he still had every right to be angry: his anger showed he was a man and not a mouse.

“Yeah, but I’ve got the right to be happy, too,” he answered immediately. “And those guys don’t even know I’m angry. They’re probably in Florida robbing 7-Elevens by now. I’ll probably never see them again. So I’m the only one who’s suffering. I’m actually punishing myself.”

I asked him to record that in the Disadvantages column as well, but continued in the role of his resistant self, and said, “Yes, that may be true, but if we could make the symptoms go away quickly, wouldn’t that trivialize what happened? After all, it was dreadful, and your feelings of rage and panic are absolutely justified.”

Sam argued, “Yeah, but if I could quickly overcome those feelings, I could get my life back and stop feeling miserable 24 hours a day.” He added this to the Disadvantages column.

Notice that the more I verbalized all the reasons not to change, the more Sam became convinced that he really did want to change. This was the opposite of the “helping” or “rescuing” role that had gotten me into hot water at first. But the helping role was the one I’d been trained for and felt most comfortable inhabiting. The helping or rescuing role may be a role that you occasionally get trapped in as well. When therapists ask me for help with cases they’re stuck with, it’s nearly always a circumstance in which the patient is complaining, but not really asking for help, or the patient is asking for help, but the therapist hasn’t brought the patient’s resistance to conscious awareness and pointed out all the reasons not to change.

Finally, I asked Sam to assess the advantages of feeling constantly angry and panicky against the disadvantages on a hundred-point scale. Were they 50/50? 60/40? 30/70? Sam decided that the disadvantages outweighed the advantages by a significant margin, so he put 35 in the circle under the Advantages column and 65 in the circle under the Disadvantages column at the bottom of the CBA.

At this point, the antagonism disappeared and Sam asked about the tools I’d referred to earlier. Then I just used simple cognitive techniques, such as the Daily Mood Log, Identify the Distortions, Examine the Evidence, Externalization of Voices, and Acceptance Paradox, along with exposure techniques such as Cognitive Flooding and Memory Rescripting, and his symptoms completely disappeared within a few sessions. However, if I hadn’t dealt with Sam’s resistance, I’m pretty sure that all the techniques in the world would have been ineffective, and he probably would have dropped out of treatment.

With time, I began to notice the same phenomenon, in varying degrees, with nearly all of the patients I was treating, so I called this phenomenon Outcome Resistance. In the simple terms, Outcome Resistance means that clients will resist or fight against the therapist’s efforts to help because, on some level, they’re afraid of or don’t even want a good treatment outcome. In most, if not all, cases of anxiety, the Outcome Resistance results from Magical Thinking, the irrational belief that the anxiety, while painful, is protecting clients from something even worse.

You can see Magical Thinking in every type of anxiety disorder, including generalized anxiety disorder (GAD), panic attacks, agoraphobia, crippling shyness, performance anxiety, OCD, PTSD, or even a simple phobia. For example, let’s say you’re treating a woman with GAD. She makes herself miserable with constant worrying about her children or husband. She worries that her children may get into an auto accident and be killed after a party with friends, or she may worry about her husband’s health or job security. Why does she resist treatment that can keep her from tying herself in knots from irrational worry? Here’s one possibility that I’ve seen numerous times: she may secretly believe that her worrying protects her family and keeps them safe, and that if she suddenly stopped worrying, they would get killed. She may also believe that the worrying is what a good wife and mother is supposed to do. It’s an expression of her love.

We typically think of resistance as something pathological. We’re taught that some patients are committed to their symptoms because of a neurotic addiction to misery and self-pity, or because they like being in the victim role, or because of “secondary gain,” such as getting attention from others. Such assumptions are formulaic, applicable to anybody, and not related in any specific or compelling way to the individual patient you’re treating. Worse, they’re condescending, even insulting, suggesting that the patients are shallow, selfish, manipulative, and whiny.

Now I understand resistance as displaying something positive about the patient and his or her values, representing a kind of personal integrity, and consciously try to make my patients proud of their resistance. Paradoxically, this seems to make it easier for them to change and far more motivated to work with me.

In retrospect, this seems obvious to me, but therapists find it extremely hard to assume this perspective, as I did myself at first. We’re trained to think of symptoms as bad, pathological artifacts that need to be eradicated. Because we have such a strong desire to jump in and help—get rid of that bad thing!—we have a hard time imagining that symptoms often serve a real, even honorable, purpose in a patient’s life.

Obviously, most of what we call resistance to therapeutic change, for want of a better word, is to a greater or lesser degree unconscious. Patients aren’t usually slyly manipulating us or engaging in conscious strategies of refusal for some unspecified gain, although occasionally that can happen. For example, many drug addicts are skillful at manipulating doctors so they can get prescriptions for opiates. But most of the time, patients’ initial reluctance to get with our program isn’t from some primordial stubbornness or neurotic desire to suffer, but rather a manifestation of the patient’s core values.

For example, a depressed man may beat up on himself because of his failures in his career and his failures to be the kind of husband and father he wants to be. But in his misery, he’s really saying, “I have high standards, and I don’t want to settle for second best. I intend to hold myself accountable for the failures in my life. I won’t let myself off the hook so easily” So the shame, worthlessness, and relentless self-abuse may actually reveal something admirable and positive about him—a sense of integrity and humility, a desire to do better with his life.

If this is true, then, when we try to override the patient’s resistance, we may undermine therapy. For one thing, many patients will just be pissed off and leave, as Sam almost did, because we haven’t “gotten” them on some deep level: we haven’t comprehended the real reason for their suffering. We’ve failed to recognize that resistance to change may reflect something positive or beautiful about the patient and his or her personal values. By respecting and honoring their refusal, we give breathing room to the resistance, and in doing so, shift their energy from fighting us to fighting for themselves in a far more genuinely therapeutic way.

As therapists, we need to improve our models, techniques, and methods and rethink our compulsive need—in the interests of being kind and helpful—to doing something, anything, to make things all better as soon as possible, before we fully comprehend what our patients want. We need to become a little more savvy about the contradictions and paradoxes of human nature.

Once again, none of these new techniques negates the tremendous accomplishments of those who developed CBT and other new forms of psychotherapy. However, if we learn to deal skillfully with the patient’s resistance before trying any techniques drawn from any school of therapy, our efforts to help will become far more effective. We may finally find ways to connect with the remaining 50 percent or more of patients who aren’t making satisfactory or meaningful progress, even when treated with the best medications and, presumably, the best psychotherapy treatments.


Illustration © Sis / Dante Terzigni

David Burns

David D. Burns, MD, is an emeritus adjunct clinical professor of psychiatry and behavioral sciences at the Stanford University School of Medicine. His best-selling books, Feeling Good and the Feeling Good Handbook, have sold over five million copies worldwide. Although he was a pioneer in the development of cognitive behavior therapy (CBT), he also created a more powerful approach called TEAM-CBT.

More than 50,000 therapists have attended his training programs over the past 35 years. His website,, offers many free resources for therapists and clients alike, including his tremendously popular Feeling Good Podcasts which draw more than 50,000 downloads per month.