Why Isn't TEAM More Popular? Why Do So Many Therapists Resist TEAM CBT? Featuring Matt May, MD

Why has the therapeutic community been so resistant to TEAM? This topic has been a concern to me or many years. To be honest, it isn't new. From the very start of cognitive therapy, when I was first learning it, I began modifying it to make it more dynamic, powerful, and effective. But to be honest, I ran into a small (at the time) of Beck loyalists who branded me as an "outsider," something Beck also did when my book, Feeling Good, began to sell and gain popularity. This saddened and frustrated me, and still does, but it had some great spin-off. On my own, my ideas and approaches grew rapidly, and there was no scarcity of young therapists who wanted to work with me.

Below, you will ready Matt's take on why TEAM CBT has not caught on better, followed by my own thoughts. So read, and enjoy, and feel free to share your own thinking on this topic!

On the live podcast, you will hear our lively discussion with our beloved and brilliant host, Rhonda! Thanks for listening today!

Matt, Rhonda, and David

Matt's take:

Hi David,

I'm excited to discuss this topic! Also, I agree we would be hard-pressed to cover it in an hour, which I believe is the goal for the podcast.

So, why isn't TEAM isn't more popular? My short answer is that TEAM isn't more popular because many therapists don't want to learn it. Those reasons will vary from one person to another and relate to concepts in the model, itself, like 'process resistance' and 'outcome resistance'.

While biological factors, like deficits in cognitive flexibility and neuroplasticity, the 'primacy effect' and age-related changes in the brain, combined with the complexity of the TEAM model, will make it near-impossible for some folks to learn it, these barriers are hard to address with our current technology

For the purpose of this conversation, it probably makes more sense to consider the psychological barriers therapists have to adopting a model that is scientifically proven to be superior to other approaches.

As a proponent of TEAM and an instructor, I'd love to know what I'm doing wrong, in presenting the model and how to get more people excited about learning it. While more research would help us see the problem more clearly, here are some factors that likely play a role:

1. It seems humans have a hard time adopting new truths, regardless of the field being considered. I believe it was Schopenhauer who said all new truths go through three phases on the way to acceptance: People will ridicule it, violently oppose it, then say they knew it all along as self-evident!
2. One cause of this is something called the 'primacy effect'. People preferentially retain the first version of a story they hear. If that information is corrected, later, they will continue to believe the first version they heard.
3. Biological Factors play a role in learning, including genetics, aging, illness and toxic exposure. 'Switching gears', mentally, is more challenging in people with Schizophrenia and their first-degree relatives, for example. We know that neuroplasticity is greatest in our youth and declines over our lifespan. Hence the importance of early education and attending to our overall health, habits, nutrition and medical care.
4. Socioeconomic and Cultural factors certainly play a role. This is well documented in the book, 'The Emperor's New Drugs', showing how marketing prevailed over science in promoting "antidepressants". Many therapists in training tell me, 'oh, they wouldn't let me use a measurement tool where I work'.
5. Lack of 'Critical Thinking'. What people believe often has nothing to do with what is evidence-based or logical. Many people reject global warming despite the evidence and prefer to believe in conspiracy theories.
6. We tend to preferentially believe what someone says if we feel a kinship or loyalty to that person or view them as an 'expert'. People might believe RFK Jr. when he says immunizations are dangerous, for example, because he is in their political party and in a position of power, rather than review the science for themselves.
7. Sunk-Cost Fallacy: People who have gone through training may have a sense that they have invested too much time and money in their education to discard that model and start afresh.

Even if we covered this in just a few minutes, we'd still be up against the hardest part of TEAM to learn, Agenda Setting. Lots of 'Good Reasons' NOT to have open hands, explore topics paradoxically, and reasons this is challenging, technically.

So, yeah, we'll have a lot to discuss and I'm looking forward to that!

Sincerely,

Matt

Here is David's list

1. Taking a page out of your book, Matt, our field is filled with so-called "schools" of therapy that function much like cults, most with a narcissistic "leader" at the helm. In a cult, members are required to be absolutely loyal, and to believe in claims the guru makes that have little or no evidence to back them up. For example, most "schools" of therapy claim to know "the" cause of emotional distress, when the causes of depression and other forms of emotional disturbance are still not known.

What I have been suggesting is that we get rid of all the schools of therapy and usher in a new era of science-based, data-driven therapy, which would amount to a revolution in our field. This idea, which I feel passionate about, always meets with stiff and hostel opposition / push back. People just don't want to hear it.

1. TEAM integrates high-level empathy and compassion with firm accountability. Give Stanford story with Sunny Choi, and the statement that "Stanford graduate students and faculty cannot be held accountable for doing psychotherapy homework. The need insight-oriented therapy!" This angrily issued statement conveyed, actually, two cult-like (to my thinking) components: First, we KNOW that patients should not be asked to do psychotherapy homework between sessions. Second, we KNOW that "insight-oriented therapy" is the treatment, without ever evaluating them.
2. TEAM focuses on the here and now, and emphasize a "fractal" approach to treatment, where the same distortions and self-defeating beliefs will be embedded in the patient's negative thoughts and feelings every time she or he is upset. So, when you change the present, you have already changed the past.
3. Whereas most therapies have traditionally (and still) focus on the past, thinking they will find the cause of the patient's distress in some pattern or traumatic event.
4. TEAM focuses on rapid change in the here and now, where as many (most?) therapies focus on talk therapy that unfolds slowly, over a period of months, years, or even more. This DOES provide a powerful financial incentive to do "talk therapy," since this drastically provides financial security and reduces the incredible pressure of constantly have to find new patients.
5. TEAM is very challenging to learn. I have taught over 50,000 therapists in the past 35 years or more, through my supervision of graduate students and psychiatric residents, my weekly training group at Stanford, and my workshops, including intensive, around the US and Canada.

And one lesson that has emerged is just how difficult it is to learn TEAM. It requires a high level of intelligence and aptitude, and an unusual dedication and commitment. A great many of the most important tools, like Assessment of Resistance, and Externalization of Voices with the CAT, Self-Defense, and the Acceptance Paradox, are extremely difficult to learn and master. And most give up, and drop out, in favor of some simpler and more formulaic therapy that is easy to learn.

1. TEAM training requires constant role-playing with specific and immediate feedback on your performance, which includes bot a letter grade (A, B, C, etc.) as well as what you did that was effective, and where you fell short and might need to fine-tune your technique with frequent role reversals, always with feedback. This means lots of criticism along the way, which many (most?) therapists do not like. And although we repeatedly emphasize the philosophy of "joyous failure," and "learning through failure," most people do not buy it emotionally. We all want success and compliments! And NOT the "great death" of the self."
2. The "great death" permeates every phase of the T E A M process. At the T = Testing, you will nearly always learn that your perceptions of your patients feel, and how they feel about you, are way off base. This is critically important, but painful for most, as it is a direct body blow to our "need" to be in the role of "expert."

Unlike most other forms of therapy, we require therapists to measure patients' feelings, "in the here and now," at the start and end of every therapy session, using brief, highly reliable scales that assess feelings of depression, suicidal urges, anxiety, anger, and also happiness, as well as relationship satisfaction or discord. These scales function like an "emotional X-ray machine," allowing therapists for the first time to see exactly how effective or ineffective you were in every therapy session.

Can you take it?

On the positive side, this information will allow you to fine tune the therapy and learn from all of your patients every day. On the negative side, you may not want to have to "see" your failures before your eyes at every session with every patient. David: Tell the story of Tuesday group patient who proudly showed me her depression (and other scores) over the previous year with one of her patients. . . But there was absolutely no improvement in any scale.

This was shocking and it made me very sad. My goal is to get dramatic changes within a single session.

1. This "great death" continues during the E phase. TEAM therapists are required to ask "What's my grade on empathy" during the session, and also patients fill out the Empathy Scale and other scales on the "Patient's Evaluation of Therapy Session" right after the session. These scales are set up to make therapist failure common, almost universal at first. A warm and curious dialogue about where the therapist went wrong can revolutionize the therapy and deepen the relationship—quickly. But at what cost to the fragile ego of the insecure shrink?
2. The "great death" continues with A = Paradoxical Agenda Setting. You give up your role as the "expert:" or "helper" or "rescuer," which many therapist refuse to do, and instead "become" the patient's subconscious resistance, arguing, with compassion and logic, that there are many GOOD reasons NOT to change.

This freaks therapists out!

1. The "great death" continues with the M = Methods phase of the session. I have developed roughly 140 methods to help people challenge distorted negative thoughts and self-defeating beliefs, and have always taught that no one method will work for everyone who's depressed and anxious. So you will have to try many methods, using the Recovery Circle, to find the one that works for each patient.

But these methods are challenging to learn, and most therapists don't seem to have the intelligence, aptitude, or commitment to learning how to use them.

1. Many of the methods and insights of TEAM or subtle nuances that many therapists do not "get" or perhaps do not want to "get." Example, the ACT training group, where someone held up the Feeling Good book and said, "We do not want THIS!" They falsely believed that "leaning into" your feelings is always the answer, and wrong believed that TEAM tried to make people happy all the time—called Toxic Positivity—whereas nothing could be further from the truth. In fact, I mentioned healthy negative feelings as early as, I think, Chapter 3 in Feeling Good, "Sadness is Not Depression," where I told the story of an elderly man who died on the Stanford inpatient medical service one evening when I was a medical student.
2. Much of what I teach is shocking and at odds with what people are taught in graduate school. For example, the idea that most people with depression and anxiety—NOT everybody!—can be effectively treated in a single, extended therapy session.

Curses! That sounds horrible!

And even worse-sounding is the idea that change typically happens suddenly, at the very moment patients stop believing their distorted thoughts.

Of course, since most therapists have not seen these phenomena, due perhaps to not having the skill, they insist instead that David is some type of fool, liar, or con artis.

Okee Dokee!

1. People—therapists and patients alike—do not "get" a great many of the key ideas in TEAM. For example, let's say the socially anxious patient totally believes the thought, "I shouldn't be so screwed up!" the necessary and sufficient conditions for emotional change.

• The necessary condition: The Positive Thought (PT) must be 100% true. Rationalizations and half-truths have never helped anybody.
• The sufficient condition: The PT must drastically reduce your belief in the negative thought. And that's when your negative thoughts will suddenly change.

1. There is even more of what I teach is shocking and at odds with what people believe. For example, 2,000 years ago Epictetus stated they key premise of all the cognitive therapies: "People are disturbed, not by things, or events, but by the views they have of them". And recently, our research team has provided proof of this for the first time, in a study of nearly 7,000 users of our Feeling Great app, using sophisticated statistical modeling techniques.

So, the three tenants of cognitive therapies, including TEAM, are:

• First, you FEEL the way you THINK. In other words, all of your positive and negative feelings result from your thoughts in the here-and-now.
• Second, depression and anxiety are the world's oldest cons. In other words, your negative thoughts, like "I'm not as good as I should be," or "I'm a hopeless case,"—will be loaded with many of the ten cognitive distortions and are extremely misleading—but you don't realize this when you're upset. You will believe these thoughts with all your heart and feel CERTAIN that they are 100% true.
• Third, you can CHANGE the way you FEEL.

But lots of people will won't have it. They keep insisting on theories that simply aren't true—that emotions cause thoughts, for example—and on methods that may have little or no "punch" above and beyond the placebo effect. Story of Tuesday group student who was scolded in her graduate school counseling program for using the words "thought" or cognition during a therapy session. She was told ONLY to focus on feelings.

1. Many people—therapists and patients alike—strongly believe that therapist empathy is THE key to healing. I have developed many powerful empathy tracking and training methods, but our clinical experience and research has shown, over and over, that therapist empathy is NOT the key to healing. They keys involve using TEAM systematically, and the rapid healing happens during the A and M for the most part. But those are the hard parts!
2. Other problems include the idea that we can convert normal human emotional distress into a series of "mental disorders" that are listed in the DSM, the "bible" of the American Psychiatric Association. In TEAM, we consider each patient's patterns of suffering at the start of therapy, quickly and easily screened by the EASY Diagnostic System, but monitor therapy and patient progress with simple tools that measure feelings, like depression, anxiety, anger, and more. But this is an argument for another day.

There's a lot more issues, too. Have I, David, contributed to the resistance to TEAM? Absolutely I have. I plead guilty as accused, and I'm proud of it. I'm totally aware that people—maybe even you— get turned off by criticism, and naturally recoil to protect your "in group," as Matt so clearly pointed out, and maintain loyalty to your "leader," whether it's Freud, Jung, Beck, Hayes, Rogers, or whoever.

People are more emotional than rational, and people can be intentionally cruel and deceptive, too, all in the name of what they believe. We see that in our politics these days too. People believe things that are totally false, and wildly implausible, because the group or leader says it's true, it's the way things are.

I'm a strong believer that science and truth will win out in the long run. Is this inevitable? I'm not totally confident, and have my doubts, but I am also filled with hope, and look to a future with more therapists like our beloved Matt May, MD and others who have dared to venture in a radically new direction, much like the early astronomers like Galileo and Copernicus who dared to challenge the superstitious teachings of the Catholic church.

Those brave and brilliant early souls said, "things are NOT the way you think!" And they used data and mathematical modeling to prove their points. But there were a hundreds years of intimidation and suffering until people finally began to catch on to the then-ridiculous and outrageous ideas that the sun does NOT actually revolve around the earth, and that the earth is NOT the center of the universe.

Those NOTS changed history. Can it happen again in the fields of psychiatry and psychotherapy? I hope so, and I've been giving my all, in my teaching, research, clinical work and writing, to make this happen. Sadly, I've fallen far short of my dream, but I'm thankful every day for what I've got, and the wonderful colleagues I'm privileged to know and love.

Warmly,

David, Matt and Rhonda