I'd refer to Dr. Burns as a central figure in the development of Cognitive Therapy, but in his response to Question 3 he opposes joining schools of psychotherapy. Instead I'll just say this highly respected clinician and author has penned 11 books, most of which are found in the Cognitive Therapy section of your bookstore. His latest debuted only last week, with the following press release:

Based on 25 years of clinical experience and groundbreaking research involving more than 1,000 individuals, Feeling Good Together: The Secret to Making Troubled Relationships Work makes a case against the current popular theories about why we can't seem to get along (e.g. "Men are from Mars, Women are from Venus"), and offers a radically different approach for solving virtually any kind of relationship conflict. Dr. Burns provides numerous helpful examples and powerful, user-friendly tools for developing more loving and satisfying relationships with anyone.

I was thrilled and overwhelmed by Dr. Burns' elaborate and thoughtful answers. His illustrations, both clinical and personal, help me understand why he is such a popular writer and lecturer. Enjoy his generous response and feel free to comment if his words compel you.

Seven Questions for David D. Burns:

1. How would you respond to a new client who asks: "What should I talk about?"

Therapy is not to "talk about" things, but to change the person's life, and to relieve suffering, such as depression, anxiety, or relationship problems. Of course, empathy and skillful listening are important at the start of each session, but they are simply not sufficient to change the patient's life. You can talk until you're blue in the face, and therapists can nod and mutter, "tell me more," but you'll still be suffering from PTSD, or OCD, or depression, or lousy relationships with other people, or whatever the problem is.

After a period of empathy and listening, I will ask the question, "I would like to offer you something more than just support and listening, although that's obviously of great importance. I'm wonder if there's something you want help with in today's session? You've mentioned a lot of heartbreaking issues today-your brother's heroin addiction and suicide, they way your ex-wife has been abusing you, your problems with your son, and your social anxiety. I have many powerful tools to help you deal with these problems, and I'm wondering if this would be a good time for us to roll up our sleeves and get to work. Or, if you need more time to talk and vent, that's okay too. I don't want to jump in prematurely, before you're ready."

This gives the patient three messages: 1. I'm here to support you, although that's obviously of great importance; 2. I have much more to offer you than just listening, and more will be necessary if you really want to change your life; 3. Change is possible if we work together as a team.

Once the patient has described the problem, I conceptualize the nature of the problem and explore the likely reasons for resisting change in a kindly way, so as to reverse resistance, using paradoxical techniques. I also begin to think about the techniques that will be most likely to help the patient. I use approximately 50 techniques, such as the Interpersonal Downward Arrow, the Paradoxical Cost-Benefit Analysis, the Daily Mood Log, the Externalization of Voices, the Acceptance Paradox, and more. Some techniques are exceptionally powerful for depression; some work well for the anxiety disorders; some are helpful for relationship problems; and some are great for habits and addictions. There's no one panacea that works for everything.

2. What do clients find most difficult about the therapeutic process?

There is no standard "therapeutic process," since there are so many different schools of therapy. I tend to think in terms of "Outcome Resistance" and "Process Resistance." Here's how to think about Outcome Resistance. Imagine that there's were a magic button on this desk, and if you push it, all of your symptoms (such as depression, or panic attacks, a troubled marriage, or a bad habit or addiction) will instantly disappear, with no effort, and you'll go out of today's session in a state of euphoria. Will you push that button?

As it turns out, many people will NOT push the button, or would be highly ambivalent about it. For each person, the reasons will be different, but they are generally overpowering. Furthermore, Outcome Resistance is radically different for each of the four common targets: depression, anxiety, a relationship conflict, or habits and addictions). So there are four common, but distinct, types of Outcome Resistance.

Here's a brief example of Outcome Resistance for depression. A 37 year-old Catholic woman from San Francisco came to me for treatment after ten years of intractable, severe depression following an abortion. She'd had psychotherapy from numerous therapists and a multitude of antidepressants, but nothing had helped. The thought that was creating her intense pain and self-loathing was: "I deserve to suffer forever because I murdered my baby."

Will she press the Magic Button? Obviously not, and there are many possible reasons. First, she appears to see her suffering as a spiritual necessity, and her depression allows her to attain a kind of moral purity. She is playing many roles-judge, jury, and executioner, as well as the role of the convicted felon who is depressed and suffering. She thinks she MUST suffer in this way.

In addition, in her mind, her baby probably hasn't really died yet. She is keeping him alive with her depression, thinking about him every day. Her depression is her tribute to her baby. If she overcomes the depression, she may have to grieve, let go, and move forward with her life. And there are several other powerful issues that keep her stuck as well. If the therapist does not take these motivational factors into account, and deal with them with compassion and skill, she will simply resist-which is exactly what had been happening for the previous eight years.

Process Resistance is quite different from Outcome Resistance. Process Resistance means that you might WANT to change, but you don't want to pay the price of change. And unfortunately, there is no Magic Button. For example, let's assume that you're suffering from some type of anxiety, such as the fear of heights. I have described 40 powerful new treatment techniques for all the anxiety disorders in my latest book, When Panic Attacks, and you never know what method is going to work for which person, so some trial and error is always necessary. But we can say for certain that some type of exposure will be mandatory if you want to defeat the fear of heights, or any other type of anxiety disorder, for that matter.

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