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.

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 lot of time talking with them.

Measurement provides information that intuition cannot.

5. Measurement can transform the therapist, too

David explains that measurement isn't simply a way of judging the patient—or judging the therapist. It can become one of the most powerful tools for improving clinical skill.

If a therapist believes a session went wonderfully but the patient's ratings show otherwise, the therapist has an opportunity to learn. Likewise, if a particular intervention consistently produces dramatic improvements, measurement can reveal what works and help the therapist do more of it.

Kevin shares his own experience of how using testing transformed his work with clients and helped him learn how to become a more effective therapist.

6. What can therapists and patients do differently?

The episode ultimately isn't about giving up on therapy. It's about demanding better therapy.

David argues that the problems discussed—including conflicts of interest, allegiance to particular schools of therapy, and the failure to measure outcomes—are solvable. Therapists can begin using data to evaluate their effectiveness and become more willing to change their methods when patients aren't improving.

Kevin also encourages people seeking therapy to ask prospective therapists whether they use measurement and whether they track progress from session to session.

• Therapy should be evaluated by its results. Good intentions, empathy, and a strong therapeutic relationship are important, but they aren't substitutes for meaningful improvement.
• Therapists need to measure. Without measurement, it can be difficult to know whether a client is improving, staying the same, or getting worse.
• Don't assume one therapy fits every problem. Different emotional and relationship problems may require different techniques.
• Question therapeutic dogma. Famous therapists and established schools of therapy can offer valuable ideas, but their claims should be evaluated rather than accepted simply because they come from an authority.
• Clinical intuition has limits. Even experienced therapists may be surprisingly inaccurate when judging how patients are actually feeling.
• Measurement is a learning tool. Tracking outcomes doesn't just hold therapists accountable—it helps them discover what works and improve their skills.
• Patients can become informed consumers of therapy. Asking a prospective therapist how they measure progress can provide valuable information about their approach.
• Therapy can be brief and effective. The goal shouldn't necessarily be years of treatment; the goal should be meaningful improvement and relapse prevention.
• The field can change. David, Jeremy, and Kevin emphasize that the problems they identify aren't inevitable. Therapists can adopt more flexible, measurable, evidence-based approaches.

How do you know if your therapy is working?

If you're a therapist, do you routinely measure your clients' symptoms and satisfaction? If you're a therapy client, has anyone ever shown you objective evidence that you're getting better?

And perhaps most importantly: Would you have the courage to discover that your current approach isn't working—and then change it?

Jeremy Karmel works with David Burns on the Feeling Great app and became passionate about TEAM-CBT after experiencing a dramatic recovery from severe depression during college. After trying numerous forms of therapy without success, he worked with Matt May and experienced a complete clearing of his depression in approximately two weeks.

This conversation is the beginning of a larger discussion about the problems—and possibilities—of modern psychotherapy. As Kevin notes at the end of the episode, there are solutions to many of the problems discussed, and future episodes will explore more of them.

If this conversation resonated with you, please subscribe to The Feeling Good Podcast, leave a rating or review, and share this episode with someone who struggles with anxiety or avoidance. Your support helps more people discover practical, evidence-based tools for overcoming fear and building happier lives.

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Thank you for listening to The Feeling Good Podcast!

Kevin Cornelius, LMFT is a Level 5 Certified Master TEAM-CBT Therapist and Trainer and the Clinical Director of Feeling Good Institute--Silicon Valley. He specializes in the treatment of trauma, anxiety, depression, relationship problems and insomnia. You can reach Kevin at kevin@feelinggoodinstitute.com and visit his website at www.tools4change.me.

You can reach Dr. Burns at david@feelinggood.com.

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