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Feb 22, 2021

  1. Ask David: Questions on self-esteem, recovery from PTSD, dating people with Borderline Personality Disorder, recovery on your own, and more!

Jay asks:

  1. Is psychotherapy homework still required if you’ve recovered completely from depression in a single, extended therapy session?
  2. Is Ten Days to Self-Esteem better than the single chapter on this topic in Feeling Good?
  3. Are people who were abused emotionally when growing up more likely to get involved with narcissistic or borderline individuals later in life because the relationship is “familiar?”
  4. Many patients can read your books and do the exercises and recover on their own. Is a teacher or coach sometimes needed to speed things up?
  5. Is it possible for a person to become happy WITHOUT needing anyone else if they have had depression in past and/or PTSD?
  6. Also, how would Team-CBT address treating PTSD? PTSD can involve a person having multiple traumas.

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  1. Is psychotherapy homework still required if you’ve recovered completely from depression in a single, extended therapy session?

Thanks, Jay, I will make this an Ask david, if that is okay, but here is my quick response.

Although many folks now show dramatic changes in a single, two-hour therapy session, they will still have to do homework to cement those gains, including:

  1. Listening to or watching the recording of the session
  2. Finish on paper any Daily Mood Log that was done primarily in role-playing during the session. In other words, write the Positive thoughts, rate the belief, and re-rate the belief in the corresponding negative thought.
  3. Use the Daily Mood Log in the future whenever you get upset and start to have negative thoughts again.
  4. I also do Relapse Prevention Training following the initial dramatic recovery, and this takes about 30 minutes. I advise the patient that relapse, which I define as one minute or more of feeling crappy, is 100% certain, and that no human being can be happy all the time. We all hit bumps in the road from time to time.

When they do relapse, their original negative thoughts will return, and they will need to use the same technique again that worked for them the first time they recovered. In addition, they will have certain predictable thoughts when they relapse, like “this proves that the therapy didn’t rally work,” or “this shows that I really am a hopeless case,” or worthless, etc.

I have them record a role-play challenging these thoughts with the Externalization of Voices, and do not discharge them until they can knock all these thoughts out of the park. I tell them to save the recording, and play it if they need it when they relapse.

I also tell them that if they can’t handle the relapse, I’ll be glad to give them a tune up any time they need it. I rarely hear from them again, which is sad, actually, since I have developed a fondness for nearly all the patients I’ve ever treated.

But I’d rather lose them quickly to recovery, than work with them endlessly because they’re not making progress!

People with Relationship Problems recover more slowly than individuals with depression or anxiety for at least three reasons, and can rarely or never be treated effectively in a single two-hour session:

  1. The outcome and process resistance to change in people with troubled relationships is typically way more intense.
  2. It takes tremendous commitment and practice to get good at the five secrets of effective communication, in the same way that learning to play piano beautifully takes much commitment and practice.
  3. Resolving relationship conflicts usually requires the death of the “self” or “ego,” and that can be painful. That’s why the Disarming Technique can be so hard for most people to learn, and many don’t even want to learn it, thinking that self-defense and arguing and fighting back is the best road to travel!

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  1. Is Ten Days to Self-Esteem better than the single chapter on this topic in Feeling Good?

Yes, Ten Days to Self-Esteem would likely be a deeper dive into the topic of Self-Esteem. It is a ten-step program that can be used in groups or individually in therapy, or as a self-help tool. There is a Leader’s Manual, too, for those who want to develop groups based on it.

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  1. Are people who were abused emotionally when growing up more likely to get involved with narcissistic or borderline individuals later in life because the relationship is “familiar?” I was involved with a woman with Borderline Personality Disorder, and it was exhausting! Why was I attracted to her?

Thank you for the question, Jay.

Most claims about parents and childhood experiences, in my opinion, are just something somebody claimed and highly unlikely to be true if one had a really great data base to test the theory. We don’t really know why people are attracted to each other. Many men do seem attracted to women with Borderline Personality Disorder. Perhaps it’s exciting and dramatic dynamic that they’re attracted to, and perhaps it’s appealing to try to “help” someone who seems wounded.

Good research on topics like this would be enormously challenging, and people would just ignore the results if not in line with their own thinking. Our field is not yet very scientific, but is dominated by “cults” and people who believe, and who desperately want to believe, things that are highly unlikely, in my opinion, to be true.

I do quite a lot of data analysis using a sophisticated statistical modeling program called AMOS (the Analysis of Moment Structures) created by Dr. James Arbuckle from Temple University in Philadelphia, someone I admire tremendously. This program does something called structural equation modeling. In the typical analysis, the program tells you that your theory cannot possibly be true, based on your data. If you are brave, this can lead to radical changes in how you think and see things, especially if you are not “stuck” in your favored theories. But this type of analysis is not for the faint of heart.

All the best,


Here is Jay’s follow-up email:

HI Dr. Burns,

As you know A LOT of people attribute their present problems (depression / anxiety / relationship conflicts / addictions) to their "abusive" or "toxic" relationship with their parents. It is interesting that it seems some people internalize negative beliefs about themselves based on what their parents said to them on a consistent basis.

But it seems you are saying the data does not support that theory.


Thanks, Jay, I’m glad you responded again. There may be some truth to those kinds of theories. We know, for example, that abused or feral cats often have trouble with trust. So, we don’t want to trivialize the pain and the horrors that many humans and animals alike endure.

At the same time, people are eager to jump onto theories that “sound right” to them and serve their purposes, and most of these theories are not based on sound research. Here are two examples from my own research.

I tested, in part, the theory that depression comes from bad relationships, and also that addictions result from emotional problems.

I examined the causal relationships between depression on the one hand and troubled vs happy relationships with loved ones on the other hand in several hundred patients during the first 12 weeks of treatment at my clinical in Philadelphia, and published it in top psychology journal for clinical research. (will include link) That was because there were at the time two warring camps—those who said that a lack of loving and satisfying relationships causes depression, and those who said it was the other way around, that depression leads to troubled relationships. And the third group said it worked both ways. My study indicated that although troubled relationships were correlated with depression, there were NO causal links in either direction. Instead, the statistical models strongly hinted that an unobserved, third variable had causal effects on both simultaneously.

This is the only paper in the world literature that I am aware of that has tested the causal links between intimacy and depression, but because the results did not satisfy anyone, the paper is rarely or never quoted, and did not seem to influence those who were advocates of one or the other theories. As they say, wrong theories die hard.

Here’s the reference:

Burns, D. D., Sayers, S. S., & Moras, K. (1994). Intimate Relationships and Depression: Is There a Causal Connection? Journal of Consulting and Clinical Psychology, 62(5): 1033 - 1042.

I also looked at the causal links between all kinds of emotional problems and all kinds of addictions in 178 or so patients admitted to the psychiatric inpatient unit of the Stanford Hospital. I was unable to confirm any significant causal links between depression, anxiety, loneliness, anger, and so forth and any kind of addiction (overeating, drugs, alcohol, etc.) The only possible causal link I could find was a small causal link of depression on reducing the tendency to binge or overeat. This was a secondary and unpublished analysis of data I collected in validating my EASY diagnostic system.

I don’t mean to encourage insensitivity to suffering or and I don’t want to stop or stifle creative thinking about the causes of depression and anxiety and addictions. I simply want to emphasize that the causes of depression, and most other emotional problems, are still totally unknown. That is a very simple statement, but it seems to me that most folks don’t “get it,” or don’t want to hear it.

Maybe we all want to explain things, or blame others, or think of ourselves as “experts,” or perhaps we feel uneasy with thinking that we don’t yet know the causes of most psychiatric problems, like depression and anxiety or troubled relationships. It may be comforting to think we do know the causes of negative feelings or human conflict.

This is my thinking only, and I’m often off base!

Tell me what you think.