Feeling Good Podcast | TEAM-CBT - The New Mood Therapy
Feeling Good Podcast | TEAM-CBT - The New Mood Therapy
About Feeling Good Podcast | TEAM-CBT - The New Mood Therapy
At Last! An Outcome Study! One of the wonderful things about TEAM-CBT is the dramatic and rapid changes we see in so many of our patients. But we've had a huge problem-no published outcome studies. And that has definitely limited the general acceptance and recognition of TEAM-CBT. Today, that era has come to an end, thanks to Dr. Elise Munoz, who joins our beloved Feeling Good Podcast to discuss a remarkable outcome study conducted at her Feeling Good Psychotherapy clinic in New York City. She wanted to evaluate the effectiveness of TEAM-CBT with teens and young adults. Dr. Munoz is the Founder and Lead Therapist at Feeling Good Psychotherapy and Adjunct Assistant Professor at New York University. She is also a Level 4 Certified TEAM-CBT Therapist & Trainer, and specializes in the treatment of anxiety, depression and life transitions. Elise conducted a “naturalistic” study of data from 116 teenagers and young adults aged 13 -24 years of age who were treated by 15 therapists between 2017 and 2022. In a “naturalistic” study, you simply analyze all the data from your patients to evaluate the effectiveness of the treatment. This is in contrast to a “controlled outcome study” where patients are randomly assigned to two treatments to see which treatment delivers the best results. Elise conducted the research study as part of her work for a Doctorate in Clinical Social Work at the University of Pennsylvania in Philadelphia. "The results," she says, "were encouraging." That's perhaps a humble description of her findings. David and Rhonda might say that the results were pretty awesome! Elise told us that although the average number of treatment sessions was 27, most of the patients made maximal gains after just 10 weeks (2.5 months) of treatment, and many achieved maximal improvement by the 5th session. Specifically, by the tenth session. 80% of the patients scored in the "subclinical" range on the depression scale of my Brief Mood Survey (with scores of 0 to 4) and 87% scored in the subclinical range on the anxiety scale (scores from 0 to 4) . These scales range from 0 (no symptoms) to 20 (extremely severe.) Prior to the study, only 30% were in the subclinical range. According to Elise, the rapid improvement suggested that most patients will not need long-term treatment, although some will need more time to incorporate their gains following their initial improvement, and many will want to remain in treatment to deal with other problems, such as relationship issues that are so important in this (or any) age range. Prior to the study, Elise trained the therapists in a weekend TEAM-CBT "boot camp," along with two hours per week of group training and 1 hour per week of individual consultation/supervision. My own view (David) is that learning TEAM-CBT is very challenging, requiring a minimum of one to two years of intensive training. However, the fact that therapists can get excellent results with a relatively small amount of training is encouraging. One of the key components of TEAM is T = Testing. We test every patient at the start and end of every therapy session, asking, "How are you feeling right now?" This provides the therapist with a kind of emotional X-ray machine that allows you to see the precise degree of improvement, or lack of improvement, at every session in multiple dimensions. Therapists can use the information to fine-tune the treatment on an ongoing basis. Many other research studies have demonstrated that session by session monitoring of symptoms, consisting of measurement and feedback, significantly improves outcomes in mental health treatment. (please contact Elise for a list of research studies you can look up online). Research indicates that roughly half of adolescents and young adults will suffer from some mental health problem. Therefore, it is essential to provide accessible, effective treatments to prevent the development of long-term mental health problems. We salute Elise for going the extra mile to evaluate the effectiveness of the treatment and to identify the therapists who get the best results. This requires courage and also allows our field to move forward based on real data rather than subjective impressions. Dr. Munoz’s fascinating work adds to the body of evidence supporting the effectiveness of TEAM-CBT. and also sets a commendable example of dedication to improving mental health outcomes through research and ongoing professional development in a private practice environment. The famous and idealistic “Boulder Model” of the “scientist / practitioner” is highly touted in graduate school graining programs for mental health practitioners, but is rarely practiced in real life. Dr. Munoz shows that the integration of science with clinical treatment in community settings is not only possible, but extremely important. Dr. Munoz’s research also indicates that the TEAM model offers an exciting path to improved mental health for teens and young adults!
Anger, Part 1 You suck! Screw you! Jay asks: Are you EVER going to do a podcast on anger? Dr. Burns, Also are you EVER going to do a podcast on Anger with Rhonda and Matt? You have done many podcasts on depression, anxiety, interpersonal relationships YET there is not one podcast addressing anger. Given the world we live in right now maybe it's time to address Anger from a TEAM-CBT perspective and give it the attention you have given anxiety and depression. All the Best, Jay In today’s podcast, Rhonda and David address this important but neglected topic that is perhaps more important than ever in today’s angry and violent world. David began by pointing out that in the feeling Good App, anger improved as much as six other negative feeling clusters, with fairly dramatic reductions in just a few days. This was completely unexpected and exciting, and has been replicated in numerous beta tests. Maybe there IS a small glimmer of hope in this troubled, angry world! David pointed out that anger is addictive Depression is not addictive because in depression you are thinking I am no good, and you have negative and painful distortions about yourself. Anger, in contrast, is addictive because you are directing the distortions at other people, telling yourself that they are no good, and they will never change, and so forth. These distortions directed at others trigger feelings of moral superiority and those feelings are intensely addictive. Any group that is at war tends to feel morally superior and sees the “other” as scum, the enemy, and these distortions give you justification for hurting and killing them and feeling good about what you are doing. What makes the treatment of anger fairly challenging is that most angry people are not looking for help. Distortions directed at others are key in conflicts with friends and loved ones as well as racial and religious hatred, and war and violence. How do you treat a patient who is angry? You always start with T = Testing. David’s research on therapist accuracy indicates that therapist accuracy is recognizing anger in their patients is incredibly poor. If you want to assess and deal with patient anger, the Brief Mood Survey at the start and end of every session can be invaluable, and the Evaluation of Therapy session at the end can also help. E = Empathy comes next. However, empathizing with someone who is angry can be challenging because they are often provocative, or want the therapist to align with them in their belief that the person they are angry with is to blame. We want the client to feel accepted, and have a warm relationship with their therapist so the therapist can easily get sucked into the patient’s blaming mind-set. David calls this “reverse hypnosis,” and this can sabotage the chance for effective treatment. Empathy can be challenging if the anger is directed at the therapist, or if the client is saying they are so angry they want to hurt someone. That can be ethically challenging because of the Tarasoff duties to warn the victim and notify the police. That is tough because the client can get upset with the therapist. A = Assessment of Resistance comes next, starting with the Straightforward or Paradoxical Invitation. With someone who is angry, we nearly always use the Paradoxical Invitation. Here’s an example: You have been talking about person X, and I can see you are pretty fed up with her. You said, you’ve tried everything and nothing works, and she won’t change. I have a lot of tools that could be very helpful if you want to do work on the relationship and turn it around. But I did not hear you saying that, and I am assuming that is NOT what you want. Don’t get me wrong, if you want to work on this relationship, I’d love to do that so you can develop a closer relationship, but at the same time, there’s no law that says you have to get along or like everyone. I’m assuming you DON’T want to work on your relationship with X, but want to make sure I’m understanding you. Am I reading your right? M = Methods Two invaluable tools are the Straightforward or Paradoxical Cost-Benefit Analysis for anger, blame, or for the relationship. Anger CBA What are the Advantages and Disadvantages of feeling intense anger at the other person. Blame CBA What are the Advantages and Disadvantages of blaming the other person for the problem. Relationship CBA What are the advantages and disadvantages of having a relationship with this person? David provided this example of a Paradoxical Anger CBA. A man was hospitalized involuntarily in Philadelphia who was brought in by the police. He was working at Savings and Loan company with disgruntled customers. A customer came in who was whining and complaining. The patient was a large and powerful man, and he got so angry at the whining customer that he picked him up and threw him against the wall. They called the police who arrested the man, but he seemed psychotic, or in a manic state, so they brought him, instead, to the hospital. He was sent to Dr. Burns’ cognitive therapy group shortly after he was admitted to the locked unit, and defiantly stated at the start of the group that he was sent here for “anger management!” Dr. Burns said he never tried to “manage” anger, and instead suggested that they could list some of the advantages and benefits of his anger with the help of the group, and also list what his outburst showed about him that was positive and awesome. Together, the man and the group listed more than a dozen positives on the white board, including: Truth was on his side People are too entitled, making demands on other people. The patient has a strong value system and was willing to put everything on the line for his beliefs He was willing to show his true feelings. And many more. At the end of the group, Dr. Burns reviewed all the really good reasons for his angry outburst, and said he did not see any reason for him to change or to give up his anger. The patient said he totally agreed. At the start of the group, the man’s anger had been 100 on a scale from 0 to 100. Dr. Burns asked him how angry he was now, and the patient said zero! The dramatic change came about because of the Paradoxical Cost-Benefit Analysis. That strategy can be tremendously helpful when you are working with an angry patient. You won’t get any buy-in by trying to convince the patient to manage their anger. David was actually siding with the patient’s resistance, and the patient could sense that David actually liked and admired him. This can form the basis of a trusting and productive therapeutic relationship. But many therapists are afraid of this type of paradoxical strategy and reluctant to let go of their addictions to “helping,” in spite of the high failure rate with that approach. You and your patient have to be on the same team if you want to use tools for effective change. If the patient is motivated and wants help, you can work on the inner dialogue or the outer dialogue, or both. The inner dialogue is the way you are thinking about the situation, and the outer dialogue is the way you are communicating with the other person. Anger always results from your inner dialogue—your thoughts about the other person, and those thoughts will nearly always be distorted. The Daily Mood Log can be very helpful at eliciting and challenging those distortions. The focus with the DML is on the inner dialogue, which will nearly always include a rich mix of positive and negative distortions including All-or-Nothing Thinking: Seeing the other person as a total loser. Overgeneralization: Generalizing from a negative moment or characteristic and seeing them in an entirely negative way based on this one negative habit, or feature they have. We all have features that are not likeable. WE generalize from the person’s actions to their SELF. You think the person is bad. Mental Filtering: Noticing and focusing and all the things about the other person that you find offensive. Discounting the Positive: Ignoring the person’s positive qualities, or telling yourself that they’re fake or don’t count. Mind-Reading You imagine the other person’s motives. When you feel angry you nearly always attribute malignant motives to them. Sometimes there are some truths and other times there are no truths. Fortune Telling: Telling yourself that the other person will never change. Magnification and Minimization: Exaggerating the other person’s “badness” and minimizing their good qualities. Emotional Reasoning: I feel angry at you, therefore, you are scum and I want to get back at you. You must be very bad. Labeling: We label someone as a terrorist as if the person’s entire person can be reduced to a label. There are terrorist actions but…a terrorist can be considered a freedom fighter by someone else. Shoulds He shouldn’t be like that. She shouldn’t have said that. Other Blame: Telling yourself the other person is to blame and that you are the innocent victim or their badness. Once you’ve identified the distortions in a thought, you can use any of the more than 100 M = Methods I’ve developed to challenge it, such as Explain the Distortions Externalization of Voices with Acceptance Paradox, Self-Defense, and Counter-Attack Technique Semantic Technique for Should Statements Forced Empathy Positive Reframing of the other persons feelings and behaviors Individual / Interpersonal Downward Arrow Examine the Evidence How Many Minutes Technique Paradoxical Double Standard Many more If our listeners (meaning you) want a Part 2 podcast on anger, we can describe helping the patient with the Outer dialogue, which is how you actually communicate with the person you’re feeling angry with. This was not discussed in great detail on today’s podcast, but we just touched on a couple points. The first topic is the difference between Attacking with your anger vs Sharing your anger. It’s not bad to be angry, but it is how you share and express your anger that’s most important. There’s a huge difference between healthy and unhealthy anger. If your goal is to hurt and demean the other person, it’s unhealthy, destructive anger. You may want to get back at the other person, hurt them, or put them down. Healthy anger is very different. Martin Buber, a 20th Century Jewish theologian, distinguished an “I-It” vis and “I-thou” relationship. Buddhist philosophy is similar. They say that the cause of all evil is the belief that you are separate from an external reality, so you see other person or group you’re angry with as the “enemy” or the “it,” that is separate from you, and “different,” as opposed to the “thou.” Then you can rationalizing using, hurting, or even killing them in order to advance your own interests, or so you think! Sharing your anger involves letting the person know directly and openly and respectfully that you are angry with them because of something they DID, and not because of something they ARE. The goal of healthy anger is to develop a deeper and more loving (or satisfying) relationship with the other person. Healthy anger is the decision you make to share your anger, rather than to attack with your anger out of vengeance, frustration or rage. Healthy anger is not the choice that most people seem to make, since unhealthy anger gives feelings of vengeance and moral superiority. A Part 2 podcast on anger might include Forced Empathy Relationship Journal (RJ What did the other person say? What did you say next? EAR Checklist / Bad Communication Checklist Consequences Five Secrets of Effective Communication List of 12 GOOD Reasons NOT to E = Empathize using Listening Skills A = Assertiveness—Sharing vs attacking with your anger R = Convey Respect The RJ Requires insight, communication skill, and the painful death of the “self” Examples: Why does my husband constantly criticize me? Why are men so critical? Why does my wife treat me like crap? Why can’t men express their feelings? Thanks for listening! Rhonda, and David
Ask David The fear of ghosts; the truth about nutritional supplements; the fear of fear; how does anxiety treatment work? And more. Today, David and Rhonda answer six cool questions submitted by podcast listeners like you! Joseph asks: How would you use exposure to confront your fear of ghosts? Salim asks: What herbs and supplements will help me become more zen and relaxed? Peter asks: How do you stop fearing the fear and discomfort of anxiety? Jillian asks: How does cognitive therapy work to help reduce anxiety? Sanjay asks: How do you give up wants, needs, and desires? Dana asks for help with the Disarming Technique. In the following, David’s reply was David’s email response to the person prior to the podcast, just suggesting some directions we might take on the podcast. The Rhonda comments were based on notes she took during the live podcast. For the full answers, make sure you listen to the podcast! Joseph asks: How would you use exposure to confront your fear of ghosts? Hi David and Rhonda, Thank you again for your wonderful replies and the amazing podcast. If you would humor me, I have another question -- I know David talked about exposure therapy in overcoming fears, but I wonder how this could apply to some fears like the fear of ghosts where it is caused by an over-active imagination (in which case, what should one be exposed to?) Regards Joseph David’s reply Cognitive flooding would be one approach. Will give details on podcast. Thanks! David Rhonda’s notes Find out what is happening in the person’s life, and treat that specific problem. Maybe someone developed a fear of ghosts after the death of a loved one, so the idea of being around death or dead things may also cause intense anxiety. Going to a cemetery may be part of their exposure. Other examples of exposure for overcoming the fear of ghosts could be: Approaching a scary, abandoned house Watching a scary movie about ghosts Fear of darkness may accompany fear of ghosts so staying in the dark may be part of your exposure. Fear of sleeping alone may also accompany fear of ghosts so sleeping alone in your home may be part of your exposure. Salim asks: What herbs and supplements will help me become more zen and relaxed? Hello Mr. David D Burns, I want to tell you that i loved "Feeling Good", your book helped me a lot in improving my life, I have a question, can you recommend herbs or supplements that help me be more Zen and more relaxed? I would be eternally grateful. 🙏. Thank you so much. Salim David’s reply. Hi Salim, I don’t believe in the efficacy of herbs etc. except for their placebo effect. However, the written exercises in the book, like writing down your negative thoughts, can help a lot. You’ll find lots of free resources on my website. At the same time, the use of herbs and supplements is kind of a “cult” thing, and as you know, cult followers don’t like to have their views challenged! And our field of mental health is, to my way of thinking, a mine field of cults! Thanks! David Burns, MD Peter asks: How do you stop fearing the fear and discomfort of anxiety? David’s Reply Exposure! However, I don’t “throw” methods at symptoms, but rather work systematically with the TEAM approach, and always incorporate four models in my work with every anxious patient: The cognitive, motivational, exposure, and hidden emotion models. You can learn more about this in the free anxiety class on my website! You’ll find it right on the homepage for www.feelinggood.com. Thanks, David Rhonda added You don’t stop fearing the fear and discomfort of anxiety before doing an exposure. You do all of the work necessary using the three other models of treating anxiety (see the anxiety question directly below this one) and then you dive into the exposure, embracing the discomfort until it’s reduced or gone. Jillian asks: How does cognitive therapy work to help reduce anxiety? Hi David, I have questions about how using your methods helps people. I’m someone that uses an acceptance method for my anxiety with success and throughout this journey I’ve really been able to catch my mind trying to focus on the negative and trying to spiral into ruminating. With negative thoughts, how do your methods actually help, does it start to change the way you think or make you automatically think in more of a positive way (eventually without having to “challenge” each thought?) Do you have to believe the challenges to your negative thoughts in order for it to work? What if you believe the original negative thoughts more? Do you actually start viewing things in a more positive light? Kinds regards, Jillian David’s Reply Hi Jillian, I can make this an Ask David question for my weekly podcast if you like. You can find the answers, too, in the free anxiety class on my website and in my book, When Panic Attacks. Thanks1 Essentially, and I’ve covered this in detail in a podcast, cognitive techniques can be very helpful in reducing anxiety, but they are only one strategy among many. I actually use four models in treating anxiety: the Motivational Model, the Cognitive Model, the Behavioral (Exposure) Model, and the Hidden Emotion Model. You can learn more about them in Podcasts #22-28. You can find links here: https://feelinggood.com/list-of-feeling-good-podcasts/ I use all four models with every anxious individual I treat. The Acceptance Paradox is a small but important part of the Cognitive Model. Positive Thoughts have to be 100% true to be effective, but that does not mean they will be effective. They also have to radically reduce your belief in the negative thoughts triggering your anxiety. If you still believe your negative thoughts, you need to try a different method to challenge them. I have developed 125 or more methods for challenging negative thoughts, since each person is a bit different! Thanks! D Rhonda’s comments We do not treat a diagnosis with a formulaic process. We treat a human being, one specific event at a time. Empathy is absolutely necessary for the treatment. Here are David’s Four Models for treating anxiety: Motivational Model. You need to address the Outcome & Process Resistance with every anxious patient before trying any other methods. Outcome Resistance. Reasons clients may not want the change/outcome they are asking for. Or to put this in simple words, anxious patients may not want to let go of their anxiety, fearing something bad will happen. You can use the WHAT IF technique to get to their outcome resistance. What are they the most afraid of? What’s the worst that might happen? Process Resistance. What will I have to do that I don’t want to do? Exposure. No one wants to do exposure. You may also have to feel feelings that you do not want to feel. Feel intense emotions instead of binging, for example. Cognitive Model. Pick a specific moment you were anxious about a thought. Go through the DML, what is going on with your patient? The positive thought needs to be 100% true, and it must drastically lower the belief in the NT to be effective. Exposure and Response Prevention Model. Exposure is necessary and often helpful, both gradual exposure and flooding. Hidden Emotion Model. Nearly all anxious patients tend to be exceptionally nice people because people who are prone to anxiety tend to avoid conflicts and negative feelings. (Wanting something you are not supposed to want, or feeling anger). These feelings are swept under the rug, and they come out indirectly, as some type of anxiety. Sanjay asks: How do you give up wants, needs, and desires? Hello David, Rhonda, and Fabrice, It was really nice to meet Fabrice after a long gap. The topic Fabrice has started is very special of Should , Want and Need. I have heard about this topic in bits and pieces by you in many podcasts and also in your set of 4 podcast of self-deaths. I kept thinking a lot about this beautiful concept of Want versus Need. And if we are able to learn technique to balance between Want & Need ,our lives will become happier and more stress-free. Buddhist teachings say that Desire is the cause of suffering, so they want us to achieve a state with zero desires, which is Nirvana. Also, the Holy book of Hinduism Geeta says further that if the purpose of our desires are to fulfill a duty or to help someone, only in these two cases will desires be good and bring happiness to the person. So, desire to eat a Mango will not fall in any of the two😄 But the penultimate question is that if we don’t have desires, life will be very dull and boring. As you had mentioned in podcast number 348 with Dr. Tom Gedman that unless one is in a very very positive state (which is rare like Buddha himself was) then only you can remain in a state of zero feeling otherwise you are bound to fall down and will lead to a very fast relapse . I also agree that zero feelings or Zero desires state will ultimately lead people into depression therefore I feel the best way is to do positive-reframing of Need and dial it down to Want. So that we get the advantages of desires and leave the disadvantages of it . As you have mentioned a number of times that FEELING GOOD APP is a very high priority for you but you try to keep it as your “want” and try not to enter this desire in the NEED zone. Balancing desires on the border between Need and Want is quite challenging I request that please do a podcast for discussing as how to keep desires in check till want and if possible please develop a self-assessment questionnaire in a podcast with Matt May and Rhonda ,sounds i feel this is a valuable topic for exploration. It can provide listeners with tools and insights to strike a balance between fulfilling their desires for happiness and well-being without becoming enslaved by them. I hope my message is clear and I am eagerly looking forward to the discussions amongst yourself. Warm regards, Sanjay New Delhi , India David’s Reply. We can discuss this on a podcast, and I can tell you the story of a woman who attended a workshop I gave in San Antonio. She was raised as a Buddhist, but her family gave up Buddhism because her mother felt she’d “failed” at giving up wants and needs and desires. Rhonda added these definitions: Wants are personal preferences for things or experiences. Needs are essential requirements for survival and well-being. Desires are strong longings or aspirations that go beyond basic needs and contribute to a person's happiness and fulfillment. Shoulds are when we scold ourselves because we did or did not do something. Dana asks for help with the Disarming Technique. Dear David, I would like to request that you, Rhonda, and Matt show your listeners how disarming practice would sound with the following statements. Are you going to start that again? Or don’t start that again! Why are you back peddling again? You just want to rest on your laurels. Why are you doing this to me again? You’re going back on your word. I feel like when my flight response is in mode I cannot think of how to respond to targeted questions especially. I feel so inferior. Please think of any others you can and add to these to help. Thank you so much!!!! Dana David’s reply. Thanks, Dana, We might include these on an Ask David. It might help, too, if you could provide a brief context for these statements, and what, exactly, you typically say next. That way, we might be able to point out your errors as well, if you are interested in learning how you might trigger these statements. Of course, most folks don't want that, preferring to blame. But it can be empowering, at least for the brave! David Rhonda described one of the responses we modeled on the podcast. Are you going to start that again? Or don’t start that again! David’s A+++ reply (according to Rhonda) Ouch, I’m feeling zapped right now, and you’re right. I am starting up on something that’s been very annoying to you. I think it was aggressive on my part. I have to plead guilty as accused. I love you to death. When we go round and round it is painful for me, too. Clearly, I am to blame for that right now. I am ready to listen. Maybe you can tell me what it is like for you when I start preaching again and we go round and round. It is clearly disrespectful. I want to listen. You may be angry, frustrated, and pissed off. Can you tell me what this has been like for you and how you’re feeling right now? At the end of our answer on the podcast, David added: Dana, will you please take one of the examples you sent us, give us a context or a few details, and we will illustrate better disarming responses on a future podcast. Will you also please use the Relationship Journal, and make your own attempt at a 5-Secrets response that we could evaluate and make suggestions on a future podcast? Thanks for listening! Rhonda, and David
369 The Invisible Racism We All Deny, Featuring Drs. Manuel Sierra and Matthew May Today we’re joined by Drs. Manuel Sierra and Matthew May on the sensitive topic of racism. Manuel Sierra MD is a child and adolescent psychiatrist practicing in Idaho, one of the places where he grew up (he also spent time in Oregon). He was a classmate of Matt May during his residency training days at Stanford, and they remain close friends today. Rhonda begins today’s podcast with this mail we received from Guillermo, one of our favorite podcast fans: Guillermo asks: How do you respond to family or friends who make racist comments? Hello, Dr Burns Not sure if you have addressed this in any of the podcasts (I don’t recall it being a topic) but: I was recently in a group chat with some cousins, and I read some really disappointing racist comments about a particular group. Many people ignored it (as I did) and a couple AGREED with the comments. How can we balance not judging not just any people but our longtime friends and family about overtly racist actions/comments and the thinking that it is not the event but our thoughts that create our emotions? I don’t care about “judging them” (in the sense that I don’t think it is my place to “change” their views) but just hearing/reading comments like this bothers me when they come from people close to me. When I see it on tv or the internet, I don’t get affected because I feel it is beyond my control. I don’t believe they will change their views so do I just remove them from my life? I apologize, the topic is too wide, but I’ve been thinking about this. Sincerely grateful for all you do, Guillermo Manuel kicked off our answer to Guillermo by saying that he has been personally familiar with racism within families and communities, and says that he and Matt have talked about this topic “a lot.” He explained that: Although I am proud of my Mexican-American heritage, I was born and grew up in Oregon and Idaho, where I’m currently practicing. I encountered considerable racial bias when I was a kid, and later in life as well. I clearly cannot speak for all Mexican-American people, I can only speak for myself and what I’ve personally experienced, and I am extremely aware of how difficult the current times are. My grandparents didn’t teach my mom Spanish. She was a single mom, and we lived in a small town in Idaho. I also have family through marriage who live on Native American lands. In grade school I began hearing jokes about Mexican Americans, and this was very awkward, painful, for me. I also got ridiculed for not speaking Spanish. Even my grandfather asked me, “why aren’t you speaking Spanish?” There were also gangs where the racial bias got worse and frequently turned violent. After learning more about Manuel’s experiences, we modeled various ways of talking to a friend or family member who has made hurtful racist comments. Manuel cautioned that it might be best to do provide the feedback individually, and not in public, so as not to shame the person. In addition, this can reduce the chance for social posturing and responding in an adversarial way. Matt agreed and emphasized the importance of combining your “I Feel” Statement with Stroking. For example, you might say something like this, assuming the racial slur comment came from a relative or person you like, Jim, as you know, you’re one of my favorite people, but I want you to know that when you said X, Y and Z, it really upset me, because it sounded like a put down to people who are (Mexican, Jewish, Moslem, gay, or whatever). I (David) like this approach because it sounds respectful and direct, but not judgmental or condemning. Rhonda modeled an excellent alternative response which included this type of add-on: “And I’m going to request that you not say that again in my presence. “ I (David) would prefer not to add the directive statement at the end, which could, in theory, rankle some individuals with coercion sensitivity, because it might sound scolding. However, that’s just my take on it, and it’s not some kind of gospel truth. If you want to push your assertiveness and stick up for yourself, it might be effective, and was effective recently for Rhonda because the relative she said this to stopped making similar racial comments in her presence. I would suggest ending any kind of response to the person who made a racial slur with Inquiry, asking them about their racial feelings as well as the fact that you are criticizing them. Do they feel hurt, angry, anxious, or put down? You might also ask something along these lines--Have they always had negative feelings about this or that racial or religious group? Manuel described an experience in medical school when an attending doctor was supervising a group of medical students in how to do a particular medical procedure quickly, and said this to him, “You can be like a Mexican jumping bean!” Then Manuel asked himself, “Should I say something?” Which of course incurs the risk of retaliation from an authority figure in a position of power. Manuel mentioned that just because you’re working in a prestigious medical setting, this does not protect you from racial slurs. He described hearing people comment on how he and several Mexican-American classmates probably got into medical school because of their ethnicity, implying they weren’t sufficiently intelligent or on par with their classmates. He also mentioned an incident during his internship when he checked in on a patient wearing his white lab coat with stethoscope around his neck, and the patient asked him if he was there to pick up the trash and could he please get the doctor. Manuel humbly replied that he could pick up the trash, and he was the doctor. I asked Manuel how he felt when hearing these types of belittling and patronizing racist comments. He said that he felt annoyed, embarrassed, angry, put down, anxious, and alone. He described one of his best friends growing up who was white. However, this fellow grew up poor as well, so they easily formed bond because they’d had similar class-based experiences. His friend sometimes lived in all-black neighborhoods and had also felt out of place at times, not accepted, and targeted. I asked Manuel how he felt describing these intensely personal experiences on the podcast today, knowing so many people would be listening. He said, “It’s anxiety-provoking. My mouth is dry, my heart is racing, and I’m afraid I’ll sound like an idiot!” We discussed the differences between being unintentionally or intentionally offensive with racist comments, and also mentioned the related topic of bullying which, of course, is intentionally hurtful. Manuel said that an example might be calling me names or saying terrible things about my mother, or making threats to hurt your family, or your mom. Often the bully is trying to get you to fight, so you’d be beaten up. The bully’s goal is to humiliate you in front of others and make you feel bad about yourself. Manuel introduced us to some of the approaches he uses when working with kids who are bullied. I’d like to hear more on this topic but we were running out of time. We could address bullying on a future podcast with the same crew, since Manuel and Matt both have a lot to offer on that sensitive and exceptionally challenging topic. Let us know if you’re interested in hearing more. The response to bullying has to have two dimensions. First, your thoughts, and not the bully’s statements, create all of your moods. So, you can use the Daily Mood Log to record and modify your inner dialogue. The goal would be to support yourself and not buy into the notion that you are somehow “less than” or a loser or coward just because someone is trying to bully and exploit you in a sadistic fashion. The cognitive work is based on the idea that ultimately, only you can bully yourself. The words of the bully cannot affect you unless you buy into them. But then it’s your own beliefs that are the source of your emotional misery. Second, your verbal response to the bully can also be helpful to you, or it can serve to make the situation worse. But these techniques, based in part of the Five Secrets of Effective Communication, can be challenging to learn, especially during the heat of battle, so considerable practice is vitally important. The goal of changing your thoughts as well as the way you respond is not to blame you for the problem, but to give you some reasonably effective coping skills, perhaps similar to the verbal karate I mentioned in my first book, Feeling Good. At the end of the podcast, we did a survey among the four of us on whether meanness and aggression and exploitation is one of the inherent and genetically based drives in human nature, along with our more loving impulses and drives, or whether humans are basically good and all the hostility and killing is the result of adverse influences along the way. There was a sharp difference of opinion, and you can listen to the podcast to find out what everyone thought! We were, of course, just speculating, as this question is partly scientific and partly philosophical. I asked Manuel how he felt at the end of the podcast, and he said he was feeling a lot better. He was powerful and informative, and I was grateful he could appear with our team and teach us from the heart today! I hope you enjoyed today’s program as well. Thanks for listening! Manuel, Matt, Rhonda, and David
A Strange Paradox-- The Incredible Impact of Compassion + Accountability Featuring Adam Holman, LCSW We want to remind our listeners about the upcoming Mexico City TEAM intensive from November 6 – 9, 2023, organized by Level 5 TEAM therapist, Victoria Chicural, and Level 4 TEAM therapist Silvina Bucci. The Intensive will be held in a beautiful part of Mexico City (Sante Fe) at the Hotel Camino Real. There will be lots of opportunities to practice every aspect of TEAM-CBT along with many excellent, internationally renown TEAM-CBT trainers. I (David) will do a keynote address on Day 1, On Day 2 Rhonda and I will do a live TEAM demonstration with a volunteer attending the conference. On Day 3 everyone will have the opportunity to practice the TEAM model from start to finish. And on Day 4 Leigh Harrington and I will answer questions about the TEAM treatment model. This promises to be an Intensive not to be missed! To learn more and register, please visit their website: https://teamcbt.mx, Today we are joined by Adam Holman, LCSW, whose podcast 288 on April 22, 2022 was a big hit. He shared his strategies for working with kids with video game addictions, and his no-nonsense, patient-focused approach made good sense and resonated with many of our podcast fans. Today, he talks about what he calls a “Strange Paradox,” which is: If you treat people like they’re fragile, they act and behave like someone who’s fragile. If, in contrast, you hold them accountable, with compassion, they will discover their strengths. He began by commenting on hearing David talk about how therapists often get hypnotized by our clients without realizing it. When that happens, we buy into the clients’ beliefs that they’re helpless and hopeless. And, I (David) might add, worthless. When that happens, we start to treat them as if the beliefs are true, further proving to them that they’re helpless, hopeless, and worthless. This became incredibly evident after Adam had a unusual encounter with a child while on a hike with his partner near Prescott, Arizona. The child was shrieking in terror at the top of his lungs. As they got approached the child, they saw that he was paralyzed by fear of a swarm of flies near his head. They also realized that his family had already walked past, and were about 45-seconds down the trail, hoping that he would become brave and walk through the flies and catch up with them. But that clearly wasn’t happening. Adam walked past the flies and stood next to him before saying, “I know you’re scared, that’s okay. I just walked past the flies and it’s safe. You can walk through.” Then, the boy immediately stopped crying and walked past the flies on his own. The boy willingly chose to walk past them the moment that his suffering was acknowledged. He heard the message that there was nothing wrong with him or the fear that he was feeling. In other words, the acknowledgement of his fear send the message: “It IS scary, and you can do it. You’re capable of doing scary things.” And he immediately found his courage and became capable. Adam continued: My partner and I began thinking about the suffering that the boy had experienced in that moment, and how little he needed in order to become strong and courageous. We felt close to the boy, and talked about our own suffering, and our parents’ suffering that was passed on to us. We cried for three hours that day and began to think about all the suffering in the world. It felt incredibly relieving, I felt so connected to all of the people in my life, and naturally began thinking more about the suffering experienced by my clients. I realized that with many of them, I’ve just given in to listening without holding them accountable. I had been standing next to them, but I was treating them as if they could not walk past the flies. . . . I loved your podcast on stories from the 60’s, especially your experience when you were crying for hours when driving through the Nevada desert. All the same kinds of feelings bubbled up in me. I saw that his parents were just doing what they’d learned to do; to try to discourage the uncomfortable feelings by walking away from them. Unknowingly, this was sending the message that he isn’t strong enough and that he is weak for feeling so fearful. Like many of us, they had learned that it’s not okay to suffer, that experiencing feelings like fear is not acceptable. This, ironically triggers more suffering because you learn to avoid and fear your negative feelings, and you don’t gain the courage to sit with your painful feelings and the feelings of others You can say (to the little boy), it’s okay that you’re suffering and afraid, and that’s not a problem. I related to that boy. My dad was very critical, and would berate me for feeling anything other than happiness. Feelings like fear or sadness were signs of weakness, and eventually I stopped realizing that I was even feeling them. Then my feelings came out in the form of a lot of anxiety that I was avoiding, and the avoidance of that anxiety didn’t allow me the opportunity to see that I had strengths. Rhonda, Adam and David discussed the role of tears in healing. Rhonda mentioned the immense value of exposure in recovery from anxiety, as opposed to avoidance, and the importance of making her patients accountable. David mentioned that our field is based on the idea that your negative feelings, like depression, or fear, show that there’s something “wrong” with you, like a “mental disorder,” so you need to be fixed, by some pill, or some new school of psychotherapy. But if you’re trying to “fix” someone, you’re giving them the message that they’re “broken.” TEAM, in contrast, is based on the opposite idea, that our negative thoughts and feelings will always be the expression of what’s right with us, and not what’s wrong with us. “Getting this,” which may not be easy at first, can paradoxically open the door to rapid change, just as we saw with the frightened boy that Adam encountered on the hike. Finally, Adam discussed how he ended up applying what he realized to a client he had been working with. The client was diagnosed with “Treatment-Resistant OCD,” and had years of therapy and medication that had not brought him to much relief. Adam had been working with him for a few months and they were able to recognize some outcome resistance. Outcome resistance is when the client has one or many good reasons not to give up their symptoms. Specifically, this client had an intense fear of rejection, and was making sure that his appearance was absolutely perfect in order to prevent rejection. Adam discusses sadness and frustration over the term “Treatment Resistant”, noting that it often keeps people feeling more stuck. Once the client saw this, he decided that they wanted to go forward and let go of his compulsions and agreed to include exposure in his treatment. This would mean that he would have to let his appearance be imperfect, and allow himself to feel anxious. Thinking back on the treatment, Adam realized that he had been providing listening and support without making the patient accountable and insisting on exposure. The next session, Adam recognized that just like the boy, he needed to treat his client with compassion and accountability. Adam re-invited the client to address the OCD and offered the gentle ultimatum, reminding the client that in order to go forward, we’re going to have to do exposure. The client agreed, then started to hesitate as a result of his fear when he realized that the exposure would be taking place right at that moment. Adam messed up his own hair and invited the client to do it along with him. Adam reiterated that getting over it requires the use of exposure. The client then messed up his hair, and expressed feeling anxious for a few minutes before erupting into laughter. Then the client proceeded with his day without fixing his hair. He also decided to do more exposure on his own after session without giving into the anxiety. When he returned for the next session, he explained that his compulsions were gone for the first time in his life. The moment he was treated with compassion and accountability, he also found the strength to recover. So, what’s the bottom line? When working with your own fears, or the fears of your clients or friends, two things are required. First, respect and compassion can help you accept your fear without feeling broken, or ashamed, or less than. And second accountability can give you the courage to confront your fears for the first time, and make the magical discovery that the monster really had no teeth! This is one form of enlightenment, going back 2500 years to the teachings of the Buddha on the “Great Death” of the “Self.” Thanks for listening today! Adam, Rhonda, and David
TEAM for Troubled Couples A New Twist! Today we are joined by a favorite guest, the brilliant Thai-An Truong. Thai-An is a Licensed Professional Counselor (LPC) and Alcohol and Drug Counselor (LADC). She is the first Certified TEAM-CBT Therapist and Trainer in Oklahoma. She has found TEAM-CBT to be life-changing professionally and personally and is passionate about training other therapists in this “awesome approach.” In her private practice, Thai-An specializes in the treatment of trauma and OCD. To learn more about her TEAM-CBT Trainings, visit www.teamcbttraining.com Thai-An has been featured on many Feeling Good Podcasts focusing on Depression and social anxiety (Live demonstration, 187) Postpartum Depression and Anxiety ( 218) How to Get Laid (Ep. 264) OCD ( 283) Grief (Ep 344) Now Thai-An adds an important dimension to the TEAM Interpersonal Model—working with trouble couples, as opposed to working with individuals with troubled relationships. She also describes a new way to use Positive Reframing to reduce patient resistance to giving up David’s famous list of “Common Communication Errors,” and she adds five new errors to the list. At the start of the podcast, Thai-An described a woman who complained that her husband often “shuts down” when they are communicating about a sensitive topic, and she wondered why. Thai-An decided to invite him to join the session so his wife could find out why. This really opened things up, and the wife discovered that her husband shut down because he was feeling inadequate when she pointed out all the things that were wrong with the house, and he was taking her comments as criticism. However, the more he shut down, the more she complained, and this pushed him away even further since her criticisms intensified his feelings of inadequacy. Thai-An then used Positive Reframing to help her see why he shut down. One of Thai-An’s new ideas was to use Positive Reframing to cast our list of “errors” on the “Bad Communication Checklist” in a positive light, just as we do with the negative thoughts and feelings of people who are using the Daily Mood Log. By siding with the patient’s resistance and listing all the good reasons NOT to change, nearly all patients paradoxically let down their guard and powerful urges to oppose change. Instead, they open up and become receptive to the many methods for challenging distorted thoughts. Thai-An has observed the same phenomena with troubled couples. When they see the GOOD reasons to why they or their partners use dysfunctional ways of communicating, they paradoxically let down their guard and become more willing to use the Five Secrets of Effective Communication. She says: Positive reframing started to open them up to each other, and helped them see each other in a more positive light. At the same time, they discovered that they shared the same values. Voicing the good reasons to maintain the communication errors as well as the cost of change (e.g., it’ll be hard work, I’ll have to focus on changing myself, it’ll be vulnerable) allowed each partner to melt away their resistance to change. David comment: This is an excellent example of a “double paradox.” Once again, instead of trying to “help,” which often triggers intense resistance, the therapist sides with the resistance, and this paradoxically triggers strong motivation to change! Thai-An reminded us that it’s important to go through the TEAM structure before moving forward with tools to help the couple change. For testing, she asks both partners to complete the version of David’s Brief Mood Survey that includes the Relationship Satisfaction Scale, and asks both to complete the Evaluation of Therapy Session at the end. She makes sure both partners rate her empathy toward them at 20/20 (perfect scores) before proceeding to the next steps. During the Assessment of Resistance, she begins to work with David’s Relationship Journal to get a specific moment in time of conflict. Then when they do Steps 3 and 4, where they identify their own communication errors and their impact on their partners, she does positive reframing of the bad communication errors, which you can see here, along with five new errors that Thai-An has listed below. The Bad Communication Checklist* Instructions. Review what you wrote down in Step 2 of the Relationship Journal. How many of the following communication errors can you spot? Communication Error (ü) Communication Error (ü) 1. Truth – You insist you're "right" and the other person is "wrong." 10. Diversion – You change the subject or list past grievances. 2. Blame – You imply the problem is the other person's fault. 11. Self-Blame – You act as if you're awful and terrible. 3. Defensiveness – You argue and refuse to admit any imperfection. 12. Hopelessness – You claim you've tried everything and nothing works. 4. Martyrdom – You imply that you're an innocent victim. 13. Demandingness – You complain when people aren’t as you expect. 5. Put-Down – You imply that the other person is a loser. 14. Denial – You imply that you don't feel angry, sad or upset when you do. 6. Labeling – You call the other person "a jerk," "a loser," or worse. 15. Helping – Instead of listening, you give advice or "help." 7. Sarcasm – Your tone of voice is belittling or patronizing. 16. Problem Solving – You try to solve the problem and ignore feelings. 8. Counterattack – You respond to criticism with criticism. 17. Mind-Reading – You expect others to know how you feel without telling them. 9. Scapegoating – You imply the other person is defective or has a problem. 18. Passive-Aggression – You say nothing, pout or slam doors. * Copyright ã 1991 by David D. Burns, MD. Revised 2001. Thai-An Truong’s 5 Additional Communication Errors: Shut down—You shut down and ignore the other person or give them the silent treatment. Avoidance—You hide your feelings and avoid talking about hard topics, or disconnect through some form of escape. Rejection—You make threats to leave – “I’m done with you,” or “I can’t deal with this anymore,” or “I want a divorce.” Control—You insist that the other person “needs” to behave or communicate differently, or “should” or “shouldn’t” behave the way they do. Invalidation—You tell the other person they shouldn’t feel the way they feel. Here’s how Thai-An did the Positive Reframing with this couple. First she asked the wife, “Why might your partner suddenly want to “shut down” and stop communicating during a conflicted exchange?” She also asked, “What does this do for the person who is shutting down?” This is the list of positives they came up with. Shutting down . . . Keeps me safe and protects me from more criticism Protects my partner from hurtful comments I might make. Shows that I value our marriage and my partner’s feelings. Shows my love for my partner, and for myself. It shows that I’m feeling hurt and want to be appreciated. Guarantees that I won’t make things worse. Shows that I want to protect myself from becoming overly vulnerable and getting invalidated again. Shutting down feels less risky than sharing my feelings. Once she saw why he shut down, she realized the negative impact of her complaints, and began to provide more genuine words of appreciation to him. He said that this meant so much to him and made all the hard work worth it. Her common communication errors included “truth” and “making complaints.” He realized, again through positive reframing, that she also wanted validation, that raising children can be hard, and that she ALSO wanted appreciation for how well she was keeping up with the home and the care of their children. So, when she wasn’t getting validation and appreciation from him, she was even more likely to complain to try to voice her perspective. Once he was able to stop shutting down, and instead began to make more disarming statements, use feeling empathy, and stroking, she was much less likely to complain. They also realized they had the same values of wanting healthier communication and to provide a safe and happy home for their children. Was this effective? Both went from 10/30 and 11/30 on the relationship satisfaction scale (shockingly poor scores) to 26/30 by the end of the relationship work together (extremely high scores indicating outstanding scores on my Relationship Satisfaction Scale.) Thai-An provided us with a cool Positive Reframing document for all of the communication errors. You can check it out if you CLICK HERE. I (David) pointed out that Positive Reframing can also be used in conjunction with the Relationship Journal in another way. In step one of the RJ, you write down one thing the other person said, and you circle all the many feelings they were probably having, like hurt, alone, anxious, angry, sad, unloved, and many more. In step two you write down exactly what you said next, and circle all the feelings you were having. This would be an ideal time to do Positive Reframing of your partner’s negative feelings, so as to shift you perception that the other person is “bad” or “to blame” or some negative interpretations that you may be making. This reframing might be helpful in the same sense that my technique, Forced Empathy, can sometimes cause a radical shift in how you see the person you’re at odds with. Announcements On January 4, 2024, Thai-An Truong will be offering a 14-week training program in TEAM couples therapy for mental health professionals. The class will meet weekly from 11:30 to 1:30 East Coast time. To learn more, please go to Courses.teamcbttraining.com/relationships There will be a 4-day TEAM-CBT Intensive November 6-9, 2023, in Mexico City, at the Hotel Camino Real. To learn more, please go to: https://teamcbt.mx/welcome Thanks for listening today! Let us know what you thought about our show! Thai-An, Rhonda, and David
AI and Psychotherapy— Doomsday or Revolution? Featuring Drs. Jason Pyle and Matthew May Today we feature Jason Pyle, MD, PhD and our beloved Matthew May, MD on a controversial, exciting and possibly anxiety-provoking podcast on the future of AI in psychotherapy and mental health. Will AI shrinks replace humans in a doomsday scenario for shrinks? Or will AI serve shrinks and patients in a revolutionary way that sees the dawning of a new age of psychotherapy? You are all familiar with Matt, due to his frequent and highly praised appearances on our Ask David segments, but Jason Pyle, MD, PhD, will probably be new to you. Jason joined the Evolve Foundation as Managing Director in 2022 to focus his work on the mass mental health crisis and the rampant diseases of despair, which afflict tens of millions of Americans. The Evolve Foundation is a private foundation dedicated to the advancement of human consciousness. Evolve is active in philanthropy and venture investments in the mental health fields. Jason is an accomplished biotechnology executive with over twenty years of executive management and technology development experience. He is committed to developing healthcare technologies and bringing science-backed healing to the most important problems of our generation. Jason is a veteran who served as a US Ranger, and earned an Engineering degree from the University of Arizona. He received both his MD and PhD in Neurosciences from the Stanford University School of Medicine, where he met Matt May and they became close friends. At the start of today’s podcast, Matt and Jason reflected on their long friendship, starting as classmates at the Stanford Medical School 20 years ago. The following questions were submitted by Jason, Matt, and David prior to the start of today’s podcast. Jason’s Questions: How important is the role of therapist rapport with patients? If it is important, how might AI accomplish or fail to accomplish this? Given the limitations of AI, what parts or pieces of the therapeutic process might it best serve? One of AI's potentially best features is that it can interact with a person anytime/anyplace, how could this be useful to augment the current therapeutic paradigm? We talk a lot about patients using AI, but how could therapists use it to better serve their needs? Matt’s Questions about AI: What is AI? How does it work? If therapists strengths tend to be their weaknesses and vice-versa, what might we expect to be the strengths and weaknesses of an AI therapist? How do these expectations match up with what David is seeing in the data? Is AI safe? Can it be made to be safe? What would be the best case scenario for AI, in therapy? David’s question about AI: Will AI replace human therapists? Jason kicked off the discussion with a brief description of AI and machine learning, and outlined four potential roles for AI in psychiatry and psychology: An AI therapist full replaces the human therapist An AI helper augments human therapist, acting as a 24 / 7 therapist helper in a myriad of ways involving ongoing support for patients between therapy sessions and support for patients during crises. AI helps the therapist with rudimentary tasks like record-keeping, recording, and summarizing sessions. AI can study transcripts of therapy sessions for research purposes, rating what procedures were done as well as degree of adherence to the therapeutic methods, and the skill of the therapist. The ensuing dialogue was illuminating and exciting. In fact, I got so engrossed that I stopped taking notes, so you’ll have to give it a listen to find out. However, one thing that was interesting and unexpected was highlighting the strengths and weaknesses of AI. For example, a patient with social anxiety might benefit greatly from armchair work, focusing on ways to combat distorted negative thoughts, but will still have to interact strangers in social situations to conquer this type of fear. David and Matt nearly always go with the patient out into the world for interpersonal exposure exercises, and find that the presence and trust and “push” from the human therapist can be invaluable and necessary. It is not at all clear that an AI therapist working via a smart phone could have the same effect, but that might require an experiment to find out. Jumping to conclusions without data is rarely safe or accurate! Maybe an AI “helper” could be very helpful to individuals with social anxiety! Jason raised the question of whether AI could replicate the trust and warmth and rapport of a human therapist, and whether the warmth and rapport of the therapeutic relationship was necessary to a good therapeutic outcome. I (David) summarized some of the findings with our Feeling Good App showing that app users actually rated the “Digital David” in the app substantially higher on warmth and understanding that the people in their lives. And now that we are incorporating AI into the Feeling Good App, the quality of the empathy / rapport from our app may be even higher than in our prior beta tests. We have not done a direct comparison between the rapport of human therapists and the rapport experienced by our Feeling Good App users. Many people might jump to the conclusion that human shrinks have better rapport than would be possible from a cell phone app, but this might be the opposite of the truth! In my research (David), I’ve seen that most human shrinks believe their empathy and rapport skills are high, when in fact their patients do not agree! In my research on the causal effects of empathy on recovery from depression in hundreds of patients at my clinical in Philadelphia, and also in more than 1300 patients treated at the Feeling Good Institute in Mountain View, California, it did not appear that therapist empathy had substantial causal effects on changes in depression. The late and famous Karl Rogers believed that therapist empathy is the “necessary and sufficient” condition for personality change, but most subsequent research has failed to support this popular belief. I (David) believe that AI therapists are likely to outperform human shrinks in rapport, warmth, trust, and understanding, but it remains to be seen whether this will be sufficient to make much of a dent in the patient’s symptoms of depression, anxiety, marital conflict, or habits and addictions. Other techniques are likely to be required. However, we may have new data on this question shortly, as we will be directly studying the effectiveness of AI empathy on the reduction in negative feelings. We might be surprised, as our research nearly always gives us some unexpected results! Rhonda gave a strong and appreciated pitch for the idea that there is something about a person to person interaction, like a hug, that will never be duplicated by an app. If this is true, or even believed to be true, then there will likely never be a complete replacement of human shrinks by AI apps. But once again, you can believe this on a religious, or a priori, basis, or you can take it as a hypothesis that can easily be tested in an experiment. We do have very sensitive and accurate tests of therapists’ warmth and empathy, so “rapport” can now be measured with short, reliable scales, making head to head comparisons of apps and humans possible for the first time. At one time, it was thought that AI would never be able to beat human chess champions, but that belief turned out to be false. The podcast group also discussed some of the potential shortcomings of an AI shrink. For example, the AI does not yet have the insight of how to “see through” what patients are saying, and takes the patient’s words at face value. But a human therapist might often be thinking on multiple levels, asking what’s “really” going on with the patient, including things that the patient might be intentionally or unintentionally hiding, like feelings of anger, or antisocial behaviors. At the end, all four participants gave their vision, or dream, for what a positive impact of AI might have on the world of mental illness / mental health. Rhonda had tears in her eyes, I think, over the suggestion that an effective and totally automated AI therapist would be scalable and might have the potential to bring ultra low-cost relief of suffering to millions or even hundreds of millions of people around the world who do not currently have access to effective mental health care. And I would add the individuals who now have access to mental health care, often cannot find effective treatment due to severe limitations in therapists as well as all current schools of therapy. Jason described his vision for an AI shrink as the helper of human therapists, extending their impact and enhancing their effectiveness. Jason is super-smart and wise, and I found his vision very inspiring! I have trained over 50,000 therapists who have attended my training programs over the past 35 years, and one thing I have learned is that most shrinks, including David, have tons of room for improvement. And if a brilliant and compassionate AI helper can enhance our impact? Hey, I’m all for that! Thanks for listening today! Let us know what you thought about our show! Jason, Matt, Rhonda, and David
Where Do Feelings Come From? Getting Unstuck from Apathy Ancient Stoic Philosophers--and More! Ask David Questions for Today Bystad: Why is it so helpful to write down your negative thoughts when you’re upset? Anyinio: Do we have to have a thought every time we have an emotion? What if I see a car coming fast and about to hit me? Would I have to have a fast automatic thought? Raghav: How can I get unstuck from apathy? Anita: What are the necessary and sufficient conditions for emotional distress as well as escape from emotional distress? Louisa: Can you tell us some more about the ancient and modern Stoic philosophers who influenced the development of CBT and TEM-CBT? Answers to today’s questions. The following answers were written before the podcast. The information on the podcast may be quite different in some cases, and will typically provide much more information than the brief answers below. David Bystad asks: Why is it so helpful to write down your negative thoughts when you’re upset? Dear David! I have practiced the paradoxical approach where I just write down my thougts / worries without challenging them. I think I learned that approach from your great book «When Panic Attacks». This is something that really works for me, especially for worries. It is almost like I «get the worries out of my head». Can you talk about this approach in your lovely podcast, why is it so effective for some people?? Best regards from Martin David’s reply Great question. Will address it the next time we record an Ask David podcast! Anyinio asks: Do you ALWAYS have a thought before you can experience an emotion / feeling? David’s response The word “thought” is just a form of shorthand for perception. Perception can take many forms. When you see a car about to hit you, you already HAVE a negative and alarming thought! If you like, you can check out the railroad track story in my Feeling Good Handbook. It is a story about a man who became euphoric after his car was hit by a train going 60 MPH because of his thoughts about it! When a deer spots a pack of howling wolves, it runs in terror. It does not have a “thought” in English, but it DOES have the perception of being in imminent danger, and it DOES experience intense, sudden fear. However, the deer did NOT feel fear / anxiety until s/he SAW and correctly interpreted the pack of wolves. Thanks, best, david Raghav asks: How can I get unstuck from apathy? Hi Dr. Burns, I hope you’re doing well and thank you so much for all of your incredible work! It has really helped me pull myself out of some of the deepest depressions and anxieties I’ve had. I wanted to ask for your help with a problem I’ve been facing recently: I seem to get stuck in depressive cycles at times where I don’t want to do a DML even though I know it will make me feel better. When I start doing the positive reframing, it helps melt away this resistance, but I still mope around for a while before I start the positive reframing. My thoughts during this time are generally “There’s no point to getting better,” “Doing a DML is like forcing myself to cheer up,” “I should care about getting better more than I do right now,” and “There’s no meaning to life.” How would you recommend I go about dealing with this apathetic state? I would greatly appreciate any help in this matter! Thanks, Raghav David’s reply: You could perhaps list: All the really GOOD reasons NOT to do a DML. What the procrastination / avoidance shows about you and your core values that positive and awesome. How the avoidance helps you. Something along those lines. I might make this an Ask David question if that’s okay with you. Could use your first name only, or a fake name if you prefer. Thanks! Good question, as so many can relate to it! Best, david Raghav’s response to David Here’s the answers I came up with: Good Reasons NOT to do a DML Doing a DML might be difficult and take a long time. I might not be able to answer some of my thoughts. Even if I do a DML, I might not be able to change my mood. Even if I change my mood, there’s no point in being happy. There’s no sense of meaning in doing a DML. It feels inauthentic to try to change my mood. Even if I do a DML now, I will return to this state again. Doing a DML is like forcing myself to cheer up and I don’t want to be forced to do anything. I want to be able to get better without doing a DML. I might have to confront really negative and distressing thoughts. Core Values it shows about me I care about doing things successfully — I don’t want to half-ass it. I want to put my best foot forward when doing tasks — i.e. not do them when I’m tired. I want to be self-reliant and be able to solve all my problems myself. I care about being able to change my mood. I care about having meaning in life. I care about being authentic to my emotional states — I can honor my apathetic/bored side. I can sit with my sadness and apathy rather than trying to escape it. I care about having lasting solutions rather than short-term fixes. I’m my own man — I’m not going to be forced to do something I don’t want to do. I care about being able to deal with my emotional problems without “crutches.” How the Avoidance Helps Me It means that I don’t have to do the hard work of doing a DML. I don’t have to engage in the ups and downs of life if I’m apathetic/avoidant. I can keep engaging in avoidance and distracting myself. It feels like there are no consequences to my actions so I feel more free. I don’t have to do the hard work required to build meaning into my life. I can fully engage and honor my apathy and boredom. I’ll push myself to search for lasting solutions to my problems. It pushes me to improve my mental capabilities of solving my problems. It helps me avoid the pain and anguish of actually addressing really negative thoughts. It pushes me to find more interesting things to fill my life with. Raghav David’s reply Great work, thanks! So now my question is this: Given all these positives, it is not clear to me why you’d want to do a DML. What’s your thinking about this? Best, david Anita asks about the necessary and sufficient conditions for emotional distress as well as escape from emotional distress? Dear David While revisiting Feeling Great I was thinking further about the interplay of necessary and sufficient conditions that are correlated to emotional distress. Necessary condition: You must have a negative thought Sufficient condition: You must believe in the negative thought I was thinking of another sufficient condition that may account for the behavioural component of emotional distress: Sufficient condition: You must act in way that reinforces your negative thought. For me this additional sufficient condition unlocks another philosophical underpinning why exposure is a key to overcoming anxiety. For example, if I have a negative thought I’m going to screw up in a presentation and then I believe it 100%. I can still summon up the courage to go ahead and do the presentation. Thus, I’m behaving in a way that doesn’t fulfil the second sufficient condition, and therefore another way to reduce emotional distress. More often than not, the presentation is not as calamitous as I anticipated anyways. Thanks for reading. Warm Regards Anita David’s reply Hi Anita, Great question, thanks. I greatly appreciate folks who think more deeply about these things. Exposure is a desirable tool in the treatment of anxiety, for sure, but if you point is “necessary and sufficient” for emotional distress, then the action thing is an unnecessary and erroneous, to my way of thinking, add-on. For example, many people who are severely depressed and believe themselves to be worthless do very little, and others do a great deal, but both feel the same severity of distress. Could we use this for an Ask David, with or without your first name? If so, we could also discuss the “necessary and sufficient” for emotional change. Here the sufficient condition is that you no longer believe the negative thought, or your belief has gone down significantly. You can respond, too, if you like to my comments. Warmly, david Anita’s Response to David Thanks David, sure I’d be pleased if you find any of what I wrote useful for your listeners. Feel free to use my first name. I’m also curious to know more about the depth of belief in a negative thought as a sufficient condition for emotional distress. Is there a particular intensity or tipping point that might lead to the emotional distress? David’s Response: The greater you belief in a negative thought, the greater the emotional impact. There’s no “tipping point.” I loved the premise of your book: “When you change the way you think, you can change the way you feel” It got me pondering about the possibility other things such as some behaviours in addition to thoughts that could be associated with emotional distress. David’s Response: Your own or someone else’s behaviour won’t have any effect on you until you have a thought, or interpretation, of what’s happening. This is the basic premise of CBT, going back 3500 years or more. An example I’m thinking of is workplace procrastination. Let’s say I have been given two weeks to tackle a laborious project. I might initially have thoughts there is plenty of time and I can procrastinate for the first week doing things I find more satisfying at work. Towards the end of the second week, panic sets in as I rush through the project so I can still meet the deadline. After the event, I start ruminating and believing self-critical thoughts such as “I shouldn’t have been so lazy” and “I’m never able to handle projects well.” Is it to say, the behaviours before the event has little to no bearing on the negative thoughts or belief after the event? And if so why is it really the case that the negative thinking comes into play after the event happens? David’s Response: Negative thinking can happen before, during, or after an event. I really have gained much from many of your books. I’m inquiring to deepen and refine my own thought processes. Thankyou Warm Regards Anita David’s Response Thanks so much for you kind and thoughtful comments. Louisa asks: I’d like learn more about the ancient and modern Stoic philosophers who influenced the development of CBT and TEM-CBT. Hello Rhonda and David, I am a Belgium based listener thoroughly enjoying the podcast and sharing it far and wide! I love the TEAM CBT structured approach. I find in particular that many of the methods are (relatively) easy to remember and administering self-help feels much easier than I ever imagined. Well-done, David! I wonder if David could talk one time about the different influences various figures in the development of CBT right from its inception with (it seems to me) the Roman Stoics until this century. Some names that come to mind are Seneca, Epictetus, Marcus Aurelius, to Albert Ellis, Aaron Beck & William Glasser (these last three all since passed away.) Are they any particular names that stick out as having been particularly useful in the development of TEAM CBT and why or how? Do the Roman Stoics still have anything to offer us? Thanks for the great show! Louisa David’s Response Hi Louisa, Thanks, will include in the list of questions for the next Ask David, depending on time constraints. Best, david PS Albert Ellis documents much of the history in his book, Reason and Emotion in Psychotherapy. I believe that Karen Horney, the feminist psychiatrist of the first part of the 20 th century, discuss lots of the current ideas as well, especial the “need” for love, success, etc. and the idea that we have an “ideal” self and a “real” self. We get upset when we realize that the two don’t match! David and Rhonda are grateful that Matt can join us often on the podcast.
Self-Esteem, Self-Confidence, and Self-Acceptance What's the Difference? What's More Important? Questions for today’s Ask David podcast David asks: What’s the difference between self-confidence, self-esteem, and self-acceptance? Guillermo asks: How do you help people who are not asking for help or don’t even know they need help with depression? The answers to today’s questions in these show notes were written before the podcast. The information on the podcast may be quite different and will typically provide much more information than the brief answers below. David David asks: What’s the difference between self-confidence, self-esteem, and self-acceptance? Hello David, The mental health world seems to like or argue about the meaning of terms like self-confidence, self-esteem, and self-acceptance? What’s the difference between them, and which one is the best thing to have? David’s response: Great question, David. I think of self-confidence as the conviction that you’re probably going to win because you’re very good at something. Self-esteem, in contrast, is the decision to love yourself whether you win or lose. Between those two, I’d say that self-confidence is more fun, but self-esteem is more important. But where does self-acceptance fit in? That’s the big buzz word these days, although the concept has been around for ages. We’ll have to ask the experts today to find out where it fits in! I’m a bit confused at the moment! Guillermo asks: How do you help people who don’t know that they need help with depression? Hello, Dr Burns I was curious as to how you would help someone who isn’t aware (or capable to know--but not in a medical sense) that they need help. You've said before that the worst thing you can do is try to help (especially when no one asked for help), but how have you handled in the past cases when someone isn’t aware that they need help for depression? Seems like it would be very tough without the person being motivated. As always, thank you for all you do, Guillermo Campos Rhonda, Matt, and David will reply on the podcast. David and Rhonda are grateful that Matt can join us often on the podcast.
Shoulds and More with our Beloved Fabrice! Three little words that will make your life miserable are “shoulds,” “wants,” and “needs,” says Dr. Fabrice Nye, the father / creator of the Feeling Good Podcast several years ago. But for the purpose of this episode, we’ll add a fourth word, “Musts,” which was popularized by Dr. Albert Ellis, who referred to it as “Musterbation.” Fabrice says that, “Shoulds are a trap. . . . There’s no such thing as a should, except for the laws of nature. For example, if I drop my pen, it “should” fall to the floor because of the effects of gravity. And sure enough, it does! “But when I say, ‘I should get an A on my upcoming exam,’ i may just be setting myself up for frustration. That’s because there’s no laws of the universe saying that people will always get As on their exams. "Similarly, if I say it SHOULDN’T be raining today, I'm involved in fiction, not reality. The clouds don’t obey our whims, they are just obeying the laws that govern the weather.” Fabrice explained that when you apply shoulds to some past event, telling yourself that your shouldn’t have made some mistake, you just make yourself guilty because it sounds like you’re scolding yourself. Again, you’re living in some fictitious reality where things are always the way you want them to be, because it’s impossible to change the past Fabrice reminded us that the Anglo-Saxon origin of the word, “should,” is “scolde.” So when you “should” on yourself, you’re actually scolding yourself. Fabrice also explained that the concept of “needs” can also get us into emotional hot water, since we sometimes tell us that we “need” things that we may want but don’t really “need.” So, if you tell yourself that someone “needs” to do something for you, you are simply applying pressure to the situation. For example, you might want or prefer for the person to be on time for appointments or planned activities, but you don’t “need” them to be on time. Similarly, you might want to find someone to love, or someone to love you, but you don’t “need” love, according to Fabrice. . . . and David agrees! It has been shown in research studies that infants and young children need love to grow and develop in a healthy way, but love is not an adult human need. According to the Buddhists, “needs” are not real. They’re just cravings, or intense desires that we’ve elevated to some godly state. Of course, there ARE things that we really do “need.” For example, we “need” to breathe to stay alive, and we “need” to have gas in the car if we want to drive to San Francisco. Those things are needed to fulfill a particular goal. So the key to an actual need is adding the phrase, “...in order to...” Fabrice also described some “want” traps. For example, you may sit at your computer cruising the internet or playing digital games, all the while telling yourself “I really want to get to work on my paper,” or taxes, or whatever. But in point of fact, you DON’T want to get to work on the thing you’re putting off. You WANT to be doing exactly what you are doing. Fabrice explains that we “trick ourselves into thinking we want something (like doing our taxes) when we really want to be doing something else (watching TV, playing computer games.) So, once again, we are telling ourselves stories that don’t map onto reality." Our real “wants” are the result of an unconscious cost-benefit analysis we make in our head, where the choice that comes out on top is our real want. It’s only when I really start doing my taxes that I’ll know this is what I want to be doing (probably because the urgency of the matter made the cost-benefit analysis tip in that direction). David was trying to see if this concept of “wants” can be helpful in therapy but had trouble seeing how this might help someone who’s procrastinating. Fabrice explained it like this: First, we need to realize that we are doing what we want in the moment; so, it’s a choice. Next, we can make our cost-benefit analysis conscious and see that we’re only considering short-term factors (e.g., it’s a lot more comfortable right now to be watching TV than doing taxes). Finally, we can develop some empathy for our future self (the one who will be pulling an all-nighter three weeks from now, or who will have to pay late fees) to reevaluate our cost-benefit analysis with more complete data. Fabrice also explained that procrastination can sometimes be difficult to treat because it’s an addiction. Rhonda also commented on the use of these concepts in therapy. Fabrice concluded the podcast by saying that he watches out for those three little words in his own thinking: “should, need, or want.” Thanks for listening today. Fabrice, Rhonda, and David
Menopause-- The End? . . . or the Beginning? Rhonda starts today’s podcast, as usual, with a warm endorsement from Sally, a podcast fan who really liked Podcast 355 on the topic of “Relationship Problems: Be Gone!” She said the role-play demonstrations were “incredible” and especially helpful. We’ll keep that in mind and see if we can do some more role-playing demonstrations in future podcasts, along with instructions so you can practice at home, as well. This can be extremely helpful if you want to master the techniques we describe. They may sound simple, but they’re not! In our recent podcast on free practice groups (put LINK), you can find many virtual practice groups you can join from home to practice many of the techniques in TEAM-CBT with like-minded colleagues and become part of the growing TEAM-CBT community. We now have many excellent and free practice groups for the general public as well as and training groups for shrinks. Today, Mina returns to the show with a new problem—pre-menopausal symptoms that are scaring her and casting a shadow on her future as well as her marriage with her husband, Maurice. Menopause is a topic that freaks many people out, due to feelings of anxiety and shame which can sometimes be intense. Today, menopause will be out in the open and front and center. However, Meina is confused because so many problems and feelings are swirling around in her head, and she doesn’t quite know where to start. At the start of the session, Mina's Brief Mood Survey indicated mild depression, severe anxiety, moderate to severe anger, and greatly diminished feelings of happiness and relationship satisfaction, thinking of her husband, Maurice.f If you review Mina’s Daily Mood Log. you can see that the Upsetting Event is irregular periods due to menopause. You can also see that Mina is struggling with fairly feelings of depression, anxiety, shame, inadequacy, loneliness, embarrassment, hopelessness, frustration and anger, and she’s giving herself some intensely negative messages, like “My body is falling apart,” and “My husband will leave me,” and “I’ll get osteoporosis and die in pain like my grandmother,” and more. During the initial Empathy phase of the session, Mina described quite a lot of personal and professional concerns, as well as somatic complaints of various kinds. Sometimes, in the past, Mina has developed numerous somatic complaints that terrify her, because she has interpreted them as possible serious diseases, like multiple sclerosis. However, excellent physical evaluations rarely or never provide any medical evidence or explanation for her symptoms. This pattern of obsessing about somatic symptoms is actually quite common. Many general practice doctors report that as many as a third of their patients complaining of pain, dizziness, and so forth do not have any medical disease that could possibly explain the symptoms. In fact, in his classic book, Caring for Patients, the late Dr. Allen Barbour from Stanford reported that about half of these types of patients experience a disappearance of their somatic symptoms when they identify some conflict or problem that they've been avoiding, and then take steps to express their feelings or solve the repressed problem. Pretty much every time, this has been true of Mina, too. It often turns out that she is upset about something she is sweeping under the rug, and the Hidden Emotion Technique has proved extremely helpful in pinpointing the hidden feeling or conflict. Then, as soon as she acts on this information, and expresses her feelings, the somatic problems immediately disappear. So, our first task in today's session was to see if the same thing was happening. It turned out that she was quite upset with her husband, Maurice, so we did a Relationship Journal to see if we could get a better understanding of what was going on. Her complaint was that Maurice did not want to talk about “difficult feelings.” Instead, he suggests they go for a nature walk or watch a movie. So, she felt sad, anxious, rejected, hurt, frustrated, and alone. But, as is the case nearly 100% of the time, when we examined a brief interaction between them—what did he say and what did she say next—it became clear that she was actually pushing him away and putting him down. This was understandably painful for Mina to see, and a bit embarrassing, but she was super brave, and saw how she could use the Five Secrets to respond to Maurice in a radically different and more inviting manner. As an aside, the person who seeks treatment for a relationship problem will nearly always discover that they have actually be causing the very problem they’re complaining about. If Mina’s husband had come to us for help, he would have made the exact same shocking discovery—that HE was causing the problem he was complaining about. I call this strange but fascinating phenomenon the “theory of interpersonal relativity.” Mina feared abandonment, but discovered that her real problem was that she was rejecting her husband, and forcing him to reject her! Although this type of sudden insight can be tremendously painful, it is also liberating at the same time. That's because people discover that they have far more power than they thought. Mina felt helpless, but was actually pulling the strings. Once you “see” this, you have the option of moving in a radically new and more rewarding direction. Mina promised to send a follow up once she’s had the chance to try a new approach during her interactions with Maurice. We have our fingers crossed! In addition, we worked with Mina's negative thoughts and feelings on her Daily Mood Log, starting with Positive Reframing, which she found helpful. What did her negative thoughts and feelings show about her that was positive and awesome, and how were they helping her? Then we did several rounds of Externalization of Voices and she was quickly able to knock her negative thoughts out of the park, with incredible results that you can see if you examine the emotions goal and outcome columns on her emotions table HERE. As you can see, there was an immediate and dramatic reduction in all of her negative feelings. We publish these TEAM-CBT sessions because we believe that the vast majority of mental health professionals do not know how to trigger rapid and extreme changes in how people think, feel, and interact with others. It is our hope that these podcast live therapy sessions, in conjunction with our weekly training groups, will make mental health professionals aware of what’s now possible, and how TEAM-CBT actually works. We try to make it look simple, but it requires tremendous training, practice, and commitment. Rhonda and I have strong, tender feelings toward our dear colleague, Mina, and we are deeply indebted to her for making herself vulnerable in a public forum so that we can all learn and feel much closer to one another. Personal work is one of our finest teaching tools. In addition, feelings of respect, love, and connection are so often missing in our embattled and hostile political and world environment these days. We cannot change the world, but we can definitely make our own small ripples in the pond, and work on changing ourselves. If you'd like, you can take a look at Mina's Brief Mood Survey and Evaluation of Therapy Session at the end of the session. Thanks so much for listening today! Rhonda, Mina, and David
361: Cultivating Delight Today we feature Dr. Angela Krumm, Clinical Director at the Feeling Good Institute (FGI) in Mountain View, Ca, and Zane Pierce, LMFT, a Level 3 TEAM therapist at FGI, on a novel and arguably controversial tool which is not aimed at reducing negative feelings, but rather boosting positive feelings. Zane Pierce Rhonda, as usual, starts the podcast with a wonderful email from Andrew who really enjoyed Podcast 357, on what David learned on the streets of Palo Alto in the wild and wonderful latter half of the 1960s. Then Angela described her Journey to Delight, which may be silly and goofy, or wonderful, or perhaps a little of each. She was inspired by a podcast interview she heard with Ross Gay, who wrote the popular Book of Delight, a book of ultra short essays he wrote every day for a year, starting on his 42nd birthday, describing “common place” things he noticed that were amazing, inspiring, or delightful. An example was noticing a weed with a beautiful flower growing out of a crack in an ugly piece of concrete. Then Angela noticed that she felt “neutral” during and after a pleasant family hike on a pleasant and beautiful day, with the people she loved. She asked herself, “Why did I only feel neutral? And can something be done to cultivate greater delight and joy in our daily lives? She asked herself, “I want to be more open to delight in my life—is it possible to cultivate delight? And if so, how?” She reasoned that since we have more than 100 TEAM-CBT to reduce and eliminate negative feelings, like depression, anxiety, shame, inadequacy, and even anger, couldn’t we create some methods for boosting positive feelings? Could we focus, for example, not just on how to challenge and crush our negative internal dialogues, but also on how to cultivate more positive self-talk? Can we “elevate” our more neutral moments. In order to set the agenda, she did a Cost-Benefit Analysis during one of her Thursday morning training groups with the therapist at FGI. She asked David, Rhonda and Zane to list some really GOOD reasons NOT to try to cultivate greater delight in our lives, including: People who are hurting and struggling need compassion. It’s important to see the truth and reality of the negative realities we confront every day in our personal lives as well as on the news. Negative feelings can motivate us to work hard. Negative feelings and self-criticisms often show that we have high standards and humility. And many more. She encouraged us to list the reasons to focus on the beautiful and awesome things we sometimes ignore or overlook going on all around us all the time, including: the possibility of feeling more joy, slowing down in life, and being more present in the moment. Angela described an informal experiment she set-up to i see if adding positive self-talk to otherwise neutral activities could increase delight. Forty two therapists participated in small groups of four to do some shared activities, while some completed the activities solo. Participants completed my 5-item Happiness Scale as well as a sixth item measuring feelings of “delight” prior to and after the experiment. The experiment was simple—engage in a neutral or common place activity. The key variable was to actively add positive self-talk to the activity. And of course there was a requirement that the positive self-talk has to be 100% true (e.g., can’t lie to yourself or say fake positive things). In the small group, Zane and Angela walked through a park and several participants decided to swing on the park's swing set. Their positive self-talk motivated them to try out the swings, which was quite “delightful.” Then they walked separately, adding positive talk to their activities and observations. Zane described his “journey to delight,” noticing a sickly Giant Redwood that was struggling and nearly dead. But, he found green sprouts coming out of it, as the tree was still struggling to grow and survive. Zane also spotted a hummingbird on his walk. Adding positive self-talk to otherwise neutral activities increased his happiness score by 50% (swinging at the park and 20% (observing nature). This was especially poignant since Zane tragically lost his beloved younger brother to suicide just two months ago. This was devastating, and one of the most difficult periods of his life. He said, “It turned my world upside down.” Our hearts go out to Zane, and we are grateful that you, Zane, could share this special time with us today, given the tragic and horrible circumstances you’ve had to face. I have many happy memories with Zane, who used to be a faithful and beloved member of my Sunday morning hiking group. We had to abandon the Sunday hikes during the Covid pandemic, and now I’m limited in my walking due to low back pain. I hope to get the hikes going again one day. Zane and his wonderful wife, Daisy have appeared on some of the most popular podcast episodes in the past, including # 79: “What’s the Secret of a ‘Meaningful’ Life? Live Therapy with Daisy.” Angela shared that folks who participated alone did things like vacuuming up pet hair, commuting in the car, drinking coffee, going for a walk. Angela reported on the results of her experiment. She saw a 39% boost in happiness scores in the group of 42 individuals, and a boost of 75% in feelings of delight, resulting from the efforts to cultivate positive self-talk during the exercises. Examples of positive self-talk might include: “I have a strong pair of legs that allow me to walk.” “What a treat to take a break in my day.” “This tea smells so sweet.” For example, one of the participants generated self-talk while vacuuming dog hair for five minutes, a frequent and fairly unwelcome chore. Here are examples of her positive self-talk: “I'm contributing to canine diversity by putting up with this shedding…. If there weren't people like me, the world would be all poodles and doodles.” “It's true that the work never gets done…And yet, even a little vacuuming is an improvement.” “It's fun to see the fur get sucked into the vacuum and to find places, such as under the couch, where it hides.” We talked about some potential uses of “Delight Training,” as well as a few potholes to avoid. For example, when individuals are struggling with strong feelings of depression, anxiety, or anger, encouraging positive self-talk may make the patient feel worse, since it could be experienced as superficial or insensitive to the suffering. In addition, it might seem insensitive as well when working with individuals with genuinely negative or horrific life circumstances, such as homelessness, terminal illness, war, and so forth. On the other hand, it may play a useful role in heightening positive feelings in individuals who have moved their negative feelings scores to zero, so they can do more than just overcome negative feelings like depression, but have some tools for exploring and enhancing the world of positive emotions. David described a patient vignette of a young woman who sought treatment because she wanted to have “more fun in life.” David asked her to make her therapeutic goals specific and real by asking, What time of day would you like to have more fun? Where will you be then? What would having more fun look like?” This led to a meaningful and challenging homework assignment with an unexpected and funny outcome. Zane ended the podcast with some tips about positive self-talk. First, the positive thoughts have to be 100% true to be effective. This is also true, by the way, when countering distorted negative thoughts. He said he is trying to turn this into more of a habit, noticing every day delightful and wonderful seemingly “commonplace” things, like something one of his two children say or do, riding his bicycle, or just taking a bite of a fresh, tasty apple. He also explained that he is still grieving the loss of his brother, but the excursions into the more positive side of his life has provided a welcome balance. Thank you for listening today! Angela, Zane, Rhonda, and David
360: The Story of Indrani “Why can’t I get close to my daughter who I love so much?” Today, we present Part 2 of the awe-inspiring work that David and Jill did with Indrani in the Tuesday group at Stanford. Indrani was a mother with a heart-breaking but all-too-common story of a conflict with her daughter. Sometimes, we love someone tremendously, but every time we try to get close, they seem to push us away. The story should ring true and be helpful to so many people, as nearly everyone runs into conflicts at times with our family members, including our parents, siblings and children. And, as usual, the solution often involves attending to your “inner” dialogue, which is the conversation you’re having with yourself about the conflict, and the “outer” dialogue, which is what happens when you try to get close to the person you love. And today’s session illustrates not one, but two forms of enlightenment. The changes in the inner dialogue involves challenging and crushing the negative messages you’ve been giving yourself about h problem with the person you love so much. You can see Indrani’s Daily Mood Log if you click HERE. As you can see, she’s been telling herself that her daughter has shut her out of her life, and that she’ll die alone/ That’s incredibly sad! And she’s also telling herself that all of her friends have wonderful relationships with their daughters “and I don’t” and she’s blaming herself for the problem: “I deserve this treatment,” and “nothing I do pleases her.” You can also see the intensity of Indrani’s negative feelings, including sadness, anxiety, inadequacy, loneliness, embarrassment, discouragement, irritation, and more. You can also see a typical exchange with her daughter if you look at her Relationship Journal (RJ). As you may know, the whole theme of my interpersonal model in TEAM-CBT is that we create our own interpersonal reality at every moment of every day. In other words, we unknowingly create and cause the exact relationship problems that we complain about, but just don’t realize this, so we think there’s something wrong with the other person. But how can this be? If you look at Step 2 of Indrani’s RJ, her response to her daughter seems innocent enough! But stayed tuned, because Indrani makes a shocking and mind-blowing discovery during the session, and that discovery requires the exceedingly painful “death” of the “self.” But this “Great Death” is instantly followed by a “Great Rebirth.!” At the end of the session, a Tuesday group members named Keren, said this to Indrani: “You wowed me!” One of the men, Ed, could barely speak because he was sobbing. You may also be sobbing for joy when you listen to this heart-warming story. In part 1, today’s podcast, you’ll hear the initial T = Testing and E = Empathy. In part 2, in next week’s podcast, you’ll hear the M = Methods, including Jill and David’s incredible work with Indrani on her R and her rather sudden discovery, in Step 4, of exactly how and why she’d been driving her daughter away—and how to stop doing that and begin to communicate in a way with a far greater chance of enhancing closeness and love. The Jill and David turn to Imani’s Daily Mood Log so she can smash her distorted negative thoughts with the Externalization of Voices, and several role reversals illustrating the integration of Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique.) You can see Imani’s initial and final Brief Mood Surveys plus her Evaluation of Therapy Session, We are extremely grateful to Indrani for giving us this very intimate glimpse into her inner life in a way that will illuminate and inspire every person with the good fortune to listen to Indrani’s amazing Journey this evening! PS I emailed Indrani this morning to see how she's doing, and recevied this wonderful reply: I’m still feeling great…very light and hopeful. I’ve listened to the audio. I sound goofy at times but loved re-living the moment when the truth dawned on me and how I felt immediately afterwards. My daughter Soni ( like the Japanese electronic company :) is coming on Thursday. I would’ve been filled with intense anticipatory anxiety but now I can’t wait to give her a big hug and use what I’ve learnt to connect with her. I’m looking forward to watching the video with Soni. Thank you so much Dr. Burns and Jill! Thanks for listening! Rhonda, Jill, and David
359: The Story of Indrani “Why can’t I get close to my daughter who I love so much?” Today, we present the awe-inspiring work that David and Jill did with Indrani in the Tuesday group at Stanford. Indrani was a mother with a heart-breaking but all-too-common story of a conflict with her daughter. Sometimes, we love someone tremendously, but every time we try to get close, they seem to push us away. The story should ring true and be helpful to so many people, as nearly everyone runs into conflicts at times with our family members, including our parents, siblings and children. And, as usual, the solution often involves attending to your “inner” dialogue, which is the conversation you’re having with yourself about the conflict, and the “outer” dialogue, which is what happens when you try to get close to the person you love. And today’s session illustrates not one, but two forms of enlightenment. The changes in the inner dialogue involves challenging and crushing the negative messages you’ve been giving yourself about h problem with the person you love so much. You can see Indrani’s Daily Mood Log if you click HERE. As you can see, she’s been telling herself that her daughter has shut her out of her life, and that she’ll die alone/ That’s incredibly sad! And she’s also telling herself that all of her friends have wonderful relationships with their daughters “and I don’t” and she’s blaming herself for the problem: “I deserve this treatment,” and “nothing I do pleases her.” You can also see the intensity of Indrani’s negative feelings, including sadness, anxiety, inadequacy, loneliness, embarrassment, discouragement, irritation, and more. You can also see a typical exchange with her daughter if you look at her Relationship Journal (RJ). As you may know, the whole theme of my interpersonal model in TEAM-CBT is that we create our own interpersonal reality at every moment of every day. In other words, we unknowingly create and cause the exact relationship problems that we complain about, but just don’t realize this, so we think there’s something wrong with the other person. But how can this be? If you look at Step 2 of Indrani’s RJ, her response to her daughter seems innocent enough! But stayed tuned, because Indrani makes a shocking and mind-blowing discovery during the session, and that discovery requires the exceedingly painful “death” of the “self.” But this “Great Death” is instantly followed by a “Great Rebirth.!” At the end of the session, a Tuesday group members named Keren, said this to Indrani: “You wowed me!” One of the men, Ed, could barely speak because he was sobbing. You may also be sobbing for joy when you listen to this heart-warming story. In part 1, today’s podcast, you’ll hear the initial T = Testing and E = Empathy. In part 2, in next week’s podcast, you’ll hear the M = Methods, including Jill and David’s incredible work with Indrani on her R and her rather sudden discovery, in Step 4, of exactly how and why she’d been driving her daughter away—and how to stop doing that and begin to communicate in a way with a far greater chance of enhancing closeness and love. The Jill and David turn to Imani’s Daily Mood Log so she can smash her distorted negative thoughts with the Externalization of Voices, and several role reversals illustrating the integration of Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique.) You can see Imani’s initial and final Brief Mood Surveys plus her Evaluation of Therapy Session, We are extremely grateful to Indrani for giving us this very intimate glimpse into her inner life in a way that will illuminate and inspire every person with the good fortune to listen to Indrani’s amazing Journey this evening! Thanks for listening! Rhonda, Jill, and David
Are the "physical" symptoms of depression specific or non-specific? How do you treat schizophrenia with TEAM? Why don’t more shrinks help themselves? Healthy vs unhealthy negative feelings-- what's the difference? Questions answered in this podcast: 1. Laura asks: Why don’t you include the physical symptoms of depression in your assessment tests? 2. Fred asks: How would you use TEAM-CBT to treat individuals with schizophrenia? 3. Author not known: Why don’t the therapists you treat with TEAM treat themselves using self-help techniques? 4. Zach: How does David understand the difference between healthy and unhealthy emotions? Is there any overlap between EFT (Emotionally Focused Therapy) and David’s TEAM-CBT? The following are David’s written responses to these questions. However, in the podcast, Rhonda and David discuss them, and their answers together may differ or enlarge on the material below. Also, in some cases, the written answers contain additional information not included in the live podcast. 1. Laura asks: Why don’t you include the physical symptoms of depression in your assessment tests? Author: Laura asks a question about post #248: “David and Rhonda Answer Your Questions about Exercise, Empathy, Euphoria, Exposure, Psychodynamic Therapy, and more!” Comment: Fabulous, David. Bless you. Have you done a show on assessments? I'll be honest about my confusion. Some of the measures that you have developed almost seem too simple to be accurate. For example, the depression test isn't sensitive to any of the physical manifestations of the illness. Anyway, I was just curious about that. David's Reply Thanks, Laura! Good questions! First, the so-called physical symptoms of depression are non-specific and not uniquely associated with depression. Only the core emotional symptoms are good indicators of depression: feeling down, hopeless, worthless, unmotivated, and not enjoying life. If you want to measure physical symptoms, they won’t give you much information about depression, but at least they need to be worded correctly, which they aren’t in most assessment tols. For example, you can measure weight gain, OR weight loss, in single and separate items, but not in the same item. But if you go to a mall and ask how many people have had weight gain, you’ll probably find that more than 50% report weight gain, but this is rarely due to depression, rather it is due to overeating! Similarly, a significant fraction will say yes to a question about weight loss, and in the vast majority of cases this will be due to dieting, not depression. Similarly with the other poorly thought out physical symptoms, like trouble sleeping. The reliability of my depression measures has typically been .95 or better, as compared with measures like the Beck or PHQ9 that have only .78 to .80 reliability coefficients (called “coefficient alpha.”) I have observed a phenomenal lack of critical thinking behind most current psychological tests for depression, anxiety, and other variables of interest to clinicians and researchers. You also asked about apps for anxiety, like OCD, as opposed to depression. The Feeling Good App causes rapid and significant reductions in, not one, but seven categories of negative feelings, including feelings of depression, anxiety, guilty/shame, inadequacy, loneliness, hopelessness and anger. Thanks so much! Finally, I have to confess my bias toward trying hard to make things simple, so we can all understand what we’re talking about! When things are overly complicated or hard to “get,” I usually feel fairly suspicious about the person who is trying to “teach.” In college I always had the policy that if I can’t understand what the teacher is trying to say, the teacher has a problem! My thinking today is pretty similar! I’ve always appreciated teachers who keep things simple for us mere mortals who appreciate having things explained clearly and in everyday words. Best, david 2. Fred asks: How would you use TEAM-CBT to treat individuals with schizophrenia? Hi David, Do you have any schizophrenia thought experiments? Most of my clients struggle with voices. I tell them there is always a good voice, which I believe is the Holy Spirit woven into every person at birth. I also tell them to welcome the voices and listen for what they need, because the voices need to be welcomed back into the body - the "family" - of the person, according to Internal Family Systems. I welcome your thoughts. I am not a therapist so anything I say or do needs to fit my role as a recovery coach. Fred South Bend, Indiana David’s Reply. Thanks, Fred, great question. I have treated many individuals with schizophrenia, but they have rarely or never asked for help with the voices they hear. I like to set the agenda for each patient, finding out what they specifically want help with. And individuals with schizophrenia respond very well to TEM-CBT, both the individual treatment model for depression and anxiety, as well as the interpersonal model for relationship problems. An experience early in my career highlighted the folly of trying to challenge the delusions of individuals with schizophrenia. A young man, a new patient, seemed uncomfortable and when I inquired, he explained that the receptionist, Lucretia, was listening in because she could “hear” our thoughts and our conversation. I explained that Lucretia did not have much money, and that if he wanted we could do an experiment to test his belief. I put a $20 bill on the desk and said that if Lucretia knocked and came into the office, she could have the money. So I did that and Lucretia did not knock on the door or appear in the office. I asked the young man what he concluded from our “experiment.” He said that she “knew” it was an experiment since she could “hear” our thoughts, and didn’t come in because she didn’t want us to know she was “listening in” on our dialogue! That’s an excellent example of what happens when the shrink tries to set the agenda, as opposed to helping patients with what THEY want help with! In my experience, you can help individuals with schizophrenia with self-esteem, anxiety, and relationship problems with psychotherapy, and they do feel and function somewhat better, but they still, sadly, have schizophrenia. This is my thinking only, and others may differ. I know that Aaron Beck and many of his followers have done research studies claiming they can help schizophrenia with traditional CBT. I am skeptical, but have not read those studies or evaluated the data with a critical eye! So who knows? Maybe they have some decent results. Best, david 3. Author not known asks: Why don’t the therapists you treat with TEAM treat themselves using self-help techniques? Why can't the TEAM-CBT therapists who have done personal work with you on the podcasts do that work themselves in self-help mode?" They know all the techniques and have all the tools. With no qualifications, I have my own theory on that, which is actually based on TEAM. I don't know how to give myself the level of E=empathy required to move on to the next stage. So I guess my question could be reworded as "Is it possible to give yourself sufficient empathy in self-help mode?" or "Are there techniques or tools you can use to give yourself empathy in self-help mode?" David’s Response Thanks, cool question! Blind spot, especially in relationship problems To get experience in the “patient” role Sometimes, we all need a little help from a friend, and that can sometimes be vastly faster than trying to do everything on your own. But in terms of empathy, I believe you CAN treat yourself with empathy, warmth, and compassion, and that is actually one of the keys to recovery, whether or not you’re in treatment with a shrink! 4. How does David understand the difference between healthy and unhealthy emotions? Is there any overlap between EFT (Emotionally Focused Therapy) and David’s TEAM-CBT? Hi Dr. David and Dr. Rhonda, I have a question if you have a chance, and maybe this is better for an Ask David. David talks about healthy emotions sometimes, and this feels like a faint through-line to EFT model. Does David have a framework for understanding healthy emotions or emotional needs? When a client is grieving, David encourages the tears to flow and notes it’s an expression of how much the client valued something. David also demonstrates what EFT would call protective anger, when using the counterattack method, “I’m tired of listening to your BS.” And lastly David demonstrates what EFT labels self-compassion while using the acceptance paradox and 5 secrets responses to critical thoughts. Thanks, Zach David’s Response Thanks for the excellent question. I have to confess that I don’t know much about EFT, but I think there’s a lot of overlap in different “therapies” since many people “borrow” ideas from other experts, and get so excited about them that they call them their own, and simply give them a new name, claiming to have something entirely new. And it sounds like there are some definitely similarities between my TEAM-CBT and what is called “EFT.” If this is true, I’m certain I didn’t do the “borrowing” since I don’t attend to the work of others in the field, for better or worse. At any rate, I have always taught my students that each negative feeling has a healthy and an unhealthy version, as you can see in the following table. The main difference is that the healthy version results from valid negative thoughts, and the unhealthy version results from distorted negative thoughts. However, in the past 25 years or so, I’ve taken a new look at so-called “unhealthy negative feelings” in my TEAM-CBT. There, we reframe the negative feelings, showing what’s beautiful and awesome about each one. IN other words, we genuinely try to sell the patient on NOT changing. Paradoxically, this approach, which I call Positive Reframing, seems to melt the patient’s resistance to change, and that nearly always opens the door to the possibility of rapid change. Healthy vs Unhealthy Negative Feelings Healthy Version Unhealthy Version Sadness, grief when you’ve lost someone or something you loved Depression, worthlessness, hopelessness Healthy fear when you’re in danger Anxiety, nervousness, worry, and panic, and phobias Healthy remorse when you’ve hurt someone you love Neurotic guilt, blaming yourself for something you’re not entirely, or at all, responsible for Healthy inadequacy and awareness of your very real shortcomings and limitations Worthlessness, inferiority Missing someone you love Desperate loneliness, abandonment, feeling unlovable Discouragement when you fail or when things don’t work you Hopelessness Sharing your anger in the spirit of love and respect Unhealthy anger, aggression, acting out your anger with the goal of hurting or upsetting the other person, or getting back at them Thanks so much for listening today! Warmly, Rhonda and David
Podcast 357: Stories from the 60s, Part 1 Today’s podcast will be a little different. I had the good fortune to be alive in Palo Alto, California during the late 1960s. For me, it was a magical era of happenings, the Haight-Ashbury District in San Francisco, psychedelics, war protests, civil rights activity, cool music, learning about life, and cutting an awful lot of medical school classes! But what I learned on the streets was far more valuable in my later career as a psychiatrist, working with real people with real problems, than anything I learned in medical school. It was an era of magic, to be honest. In fact, to me, California has always had the feel of magic. And that magic is still alive and well, happening every day, at least in my life. Let me know if you like these stories. I shared them at my weekly Stanford training group, and publish the recording of that evening’s training session here, with trepidation. Some of the stories are pretty far out. If you like them, and want more, I have a lot more, which I’ve listed below. Just let me know, and I’ll gladly start babbling again. . . IF I haven’t been arrested! If you’d like to see one of the R-rated but gorgeous Larry Keenan photos taken at my “Uptightness” happening, you can see it at this link: Look for the photo called “The Kiss.” https://www.larrykeenan.com/prints Larry Keenan, a brilliant young commercial photographer at the time, attended my “uptightness” happening and took many fantastic photos that day. Larry became a famed photographer of many of the greats of the “Hippy Era,” like Bob Dylan, Neil Cassady, Lawrence Ferlinghetti, and a host of others. Sadly, Larry passed away several years ago, but I will always be grateful to him for the gorgeous and now-famous photos he created that day in the infamous but glorious 60’s! Warmly, david Part 1 (in this podcast) Psychodrama / encounter David gets put down: Rob Krist’s encounter group The return of tears: My first psychodrama marathon The pompous professor: False front / tragic surprise Spiritual Desert experience: Sadness as celebration Dating / Relationships / R-Rated Having fun and making a movie: "Uptightness” Part 2 (not yet recorded: let me know if you'd like a Part 2!) More Stanford stories not yet covered: let me know if interested! Husain Chung and the crazy teen from LA: When a stallion wants to run A frightening encounter with Vic Lovell: And a mentor’s advice Threats from unwanted guests: Fighting back with paradox Bar next to the Free University Coffee House: Outrageous works, even with Hell’s Angels Inside the Free University Coffee House: How I met my wife The day we bombed Cambodia: Triggering a riot at Stanford, beaten by police, motorcycle smashed to bits, handcuffed, arrest announced on the campus radio station, escaped The bearded man on the quad near the Stanford student union—Telling me to “sit with open hands” Ken Kesey and his merry pranksters in the Stanford student union—they were dressed in pajamas or clown outfits and Neil Cassady was juggling hammers) The tape recorder experiment: Bizarre week, unexpected conclusion Medical School Stanford medical school interview: Unexpected outcome The day that Gene Altman and I attended class: Totally weird Broken jaw: Anger, fear, and intense pain that suddenly vanished Getting kicked out of neuropathology class Encounter at the Medical School: Psychiatry and Psychotherapy—Are they Relevant or Obsolete? Featuring Hussain Chung Missing graduation ceremony: Didn’t pick up my diploma until years later Homeless in Carmel Valley: Saved by Ramadan, Subud Re-entry: The Highland Hospital Emergency Room Dr. Allen Barbour’s Medical Outpatient Clinic Hidden emotion 1: One of Stanford’s first coronary artery bypass patients Hidden emotion 2: Doc, what happened? I’m not dizzy anymore! Hidden emotion 3: Help! I need emergency surgery NOW! Here’s the Stanford group feedback from group after telling stories 1 – 5 Positive Feelings about the Training Not at all true Somewhat true Moderately true Very true Completely true N/A 1. I felt I could trust my trainer. 0 0 0 0 17 1 My trainer paid careful attention to what I said 0 0 0 0 7 11 My trainer critiqued my work in a sensitive manner. 0 0 0 0 7 11 I felt good about the training I received. 0 0 0 0 17 1 Overall, I was satisfied with my most recent training session. 0 0 0 0 17 1 Negative Feelings during Training Not at all true Somewhat true Moderately true Very true Completely true Sometimes I felt uncomfortable during the training. 18 0 0 0 0 Sometimes I felt defensive during the training. 18 0 0 0 0 Sometimes I felt frustrated during the training. 18 0 0 0 0 Sometimes I felt anxious during the training. 18 0 0 0 0 Sometimes I felt insecure during the training. 16 2 0 0 0 Helpfulness of the Training Not at all true Somewhat true Moderately true Very true Completely true N/A I expect to use these ideas with patients I am now treating 0 0 2 1 11 4 What I am learning seems useful in my clinical training. 0 0 1 2 13 2 My trainer and I are working together effectively. 0 0 0 2 10 6 The training was helpful to me. 0 0 0 1 16 1 I felt I was learning and growing during the training session. 0 0 0 1 16 1 Respectfulness and Safety of the Training Not at all True Somewhat true Moderately true Very true Completely true N/A My trainer was sensitive to potentially relevant cultural, racial, religious, age, gender, or sexual identity issues that might impact the therapy. 1 0 2 0 13 2 My trainer created a safe and warm space for all identities. 1 0 1 0 14 2 Difficulties with the Questionnaire Not at all true Somewhat true Moderately true Very true Completely true It was hard to be completely honest answering some questions. 16 1 0 0 1 My answers weren’t always completely honest. 16 1 0 0 1 Sometimes I did not answer the way I really felt inside. 16 1 0 0 1 Please describe what you specifically disliked about the training? What could have been improved? Were there some things you disagreed with or did not understand? Nothing N/A Was too short na I'm starting to catch on to the fact that David has read more than 3 books... Nerd. :) It is funny coming from David and I believe he used it affectionally... most of use won't get away with the term "Chainaman" perhaps Asian American Loved the group tonight n/a Nothing I disliked. My answer of "somewhat insecure" from above was about my comments and whether they were helpful or "good enough." Please describe what you specifically liked about the training? What was the most helpful? Were there some things you learned? I really enjoyed learning from David's stories. Thank you for sharing these personal stories with us. I had been looking forward to the evening's stories but I didn't know emotional and impactful they would be. I was especially touched by David's & Cai's tears and appreciate how much they both shared. It had to be especially difficult to share over Zoom because sometimes it can sound flat. With most people muted it can be hard to hear the feedback from the audience but the connection still felt very powerful. I truly appreciate your openness and willingness to show your vulnerable side. Just like many others, I was deeply moved by your heartfelt tears as you shared stories about the woman you believed would succumb to cancer, your beautiful encounter with your wife Sara, and the journey of creating "Uptightness." You didn't have to let us into those deeply intimate and personal experiences, and for that, I am genuinely grateful. This was absolutely amazing! It couldn’t have been more special. Thank you Dr Burns! You are a national treasure and gift to us all. Can’t wait for the podcast so that I can re-live it exposure and being uncomfortable with adult stuff so silly but real for me I was touched by the depth of emotion David manifested in telling some of the stories, his deep compassion and humility, and the reality of celebration of sadness. I liked feeling closer to David both from his sharing deep feelings and by his telling about life events like how he met Melanie. It was cool to have stories illustrating powerful lessons and even some that illustrate the mundane (e.g. mostly not a lot happened when David spent a week disclosing every feeling). What a wonderful night. These stories brought that time period alive for me, and having not lived through that era, that was a real treat. The only thing I was surprised about, and a bit sad, was seeing that David appeared to be a little self-conscious or something. David, I hope I can reassure you that even though I was silent and didn't have any questions, you had my full attention. It was like watching a profound and entertaining movie. - Ed W I really loved hearing about the spiritual connections with others that you had, David. I also loved seeing the photos afterward and you showing us who you were talking about in your stories. What a beautiful, magical time! Some very interesting and very touching stories. Made me feel closer to the group and gave some insights into the 60s and the development of TEAM CBT That was beautiful. More and more I'm convinced therapy is art verified by science. This very human tradition of telling stories is so important to our work as therapists/people. I enjoyed this greatly. A two hour work of art I was fortunate enough to have experienced. Thank you, much love. It was mesmerizing and holy God listening to the stories now I understand how he could have come up with such an amazing Tool It was lovely to travel back in time and get snap shots of David's live in the 60s. I appreciated the tender moments of sadness and also the spiritual mystical moments. I like David even more knowing that his calling was to council people, and the journey he has taken to become a conventional healer. It is an honor to be part of this training, almost feels like a type of lineage. I mostly found it just very enjoyable and fun and salacious. But I also liked the tears and the parts about people hiding their suffering and how we all really suffer but often have a hard time showing it. That was beautiful. Fabulous! How wonderful to learn more about David, learn about his "weird" past and shadow side, and share in his authentic expression of intense feelings. He really opened up and it did make me feel closer to him! The desert story was inspirational to me, and Cai's story as well...I, too, love the book Siddartha. Interesting to learn of the origins of techniques such as Externalization of Voices and Downward Arrow. Really contextualizes it for me. Not to mention bringing the "magic" of California in the 60s back to life. Thank you! Left me yearning for more! It was a spellbinding evening, and it felt to me like we were right there with you, David, in the desert seeing the multicolored clouds with our tears flowing, or at the psychodrama marathon crying for the woman who was dying, or on in a field with you and lots of naked ladies at the "Uptightness" event. And now it makes so much sense to me how your methods like EoV and the Downward Arrow all grew out of these experiences you shared with us tonight of tapping deeply into that River of Emotions that you talk about. Thank you, David, for sharing this with us! Seeing David’s tears. Love him even more. Learned so much from the stories I liked this evening very much. I felt very close to you, David, and to the others who shared, and I felt honored to be a part of it. There were so many good stories. I think your story of being in the desert and the woman suddenly giving up drinking might be an example of a powerful prayer-- I know it sounds pretty goofy and I would have thought so too when I was an atheist not long ago, but I've had some experiences that have really led me to believe some seemingly goofy things. Please describe what you learned in today’s group12 responses It was such a moving & emotional evening filled with incredible stories, some of which seem too wild to be true but you certainly had the pictures to back it up! Even though I'd been working with the pictures they really came to life after hearing the context and learning more about the people in them. Thank you! It was terrific to hear the origin story of the greatest psychotherapy approach ever developed the founding go team cbt I learned it is unnecessary to be uptight except for cinematic purposes. We are all connected and affect each other on an energetic level <3. Thank you, David! I need to think about all these things for a bit to say exactly. In simple words enlightening It's important to be more raw, more open to others' suffering. But also to have fun, be wild, take chances! David's amazing stories of his experiences in the 60s. How David discovered the River of Emotions and how to tap into it. How being open minded leads to great things including connection to others in kind and loving ways Too much to say Thanks for listening today!, David and Rhonda
Ask David: Burn Out; When Challenging Thoughts Doesn't Work; and more! Featuring Dr. Matthew May In today’s podcast, Matt, Rhonda and David discuss four challenging questions from podcast fans like you: 1. Joseph asks if it’s okay to take a break when you get “burned out.” Below, David expands on this and describes the difference between “healthy” and “unhealthy burnout.” 2. Joseph also asks why your feelings might not change when you challenge your negative thought with a positive thought that’s 100% true. 3. Dan asks about Step 4 of the Relationship Journal, which is the most difficult and important step in the TEAM interpersonal model—see exactly how you’re forcefully causing and reinforcing the very relationship problem you’re complaining about. For example, if the person doesn’t “listen,” you’ll see that you’re forcing them not to listen. If she or he doesn’t open up and express feelings, you’ll see that you prevent them from opening up. And if you think your partner doesn’t treat you in a loving and respectful way, you’ll suddenly see exactly why this is happening—if you have the courage to take look and see: But if fact, this is one of the “Great Deaths” of the “self” in TEAM-CBT, and very few folks are willing to “die” in this way. 4. Finally, Clay asks about EMDR. He’s been treated with it without success. David and Matt weigh in with their thoughts about EMDR. This question was not addressed on the podcast, since some practitioners of EMDR might be offended by David and Matt’s thinking, but they did describe their thoughts in the show notes below. If you are an EMDR enthusiast, you might prefer NOT to read our comments. Joseph writes: Thanks, David, for sharing so much on the podcasts! I have a couple questions. Personally, I find that when I'm burnt out, I get a lot more anxious automatic thoughts. While it's definitely good to combat these distorted thoughts by replacing them with realistic ones, my takeaway is that it's also sometimes wise to change our lives / circumstances (e.g. to take a break). By the way, I also wanted to ask if you've ever faced a situation where you are convinced that a thought is distorted and irrational (and you know what the realistic thought is), but you still can't shake it off? I sometimes get stuck when I already know the "right answer" (ie. what the realistic thoughts are based on the methods you've taught), but I just can't seem to get my brain to fully believe it. For example, I was recently on vacation and a small blip made me think "my vacation is ruined!". I immediately identified it as all-or-nothing thinking, and replaced it with "my vacation is still going very well even if it's not perfect" (and I'm convinced this thought is true), but somehow my mind kept going back to the automatic thought again and again. Curious if you've ever experienced this. Thanks again so much for your time and your teaching; just wanted to say I really appreciate it! :) Regards Joseph David’s Reply to Joseph. Thanks for the great questions. We address both of them on an upcoming podcast. Here’s the quick response. Yes, it is okay to take a break when you feel “burned out.” However, you can get “burned out” in a healthy or unhealthy way. For example, after I edit for two or three hours, which I love, my brain gets “burned out.” So I take a break and come back later, maybe even a day later, and I feel refreshed and filled with enthusiasm about writing and editing some more, because I love these activities. When I was in private practice in Philadelphia, I saw 17 patients back to back on Wednesdays. That way, I could have a three day weekend. Actually, I loved it and as the day went on, I got higher and higher. At the end I was exhausted, but exhilarated. I was never “burned out” because I loved what I was doing, and the clinical work was SO rewarding! However, sometimes I made a mistake and a patient would get very upset, sometimes angry with me, or felt hurt. THAT was when I got suddenly burned out and exhausted. But it wasn’t because of my work, or the conflict, but rather my thoughts about it, which generally involved a combination of self criticism and frustration with the patient, both the result of distorted thoughts, generally Self-Directed and Other-Directed Should Statements. And THAT kind of “burned out” won’t improve with a break. The answer is challenging and changing your own inner dialogue, as well as your dialogue with the other person, using the “failure” in the relationship as an opportunity to listen and support and create a deeper and more meaningful relationship. With regard to your second excellent question, we explored that in depth in the podcast, and also made it a problem for our listeners to think about. So tune in for the answers! This is a popular question I’ve been answering for more than 40 years, and the answers tell us a great deal about how cognitive therapy actually works. Thanks so much, Joseph! Subject: Relationship Journal Gem I Found Dan (a former participant in David and Jill’s Tuesday training group at Stanford) writes: Hello to the Dynamic Duo (David and Jill), I came across this doc for Step 4 of the Relationship Journal, but I don’t really understand it and I don't remember the context. I know it was from the Tuesday Group years ago. It says it's about conceptualizing the problem, just not sure how to utilize this in step 4. Thanks. (You will find this document in the show notes below.) ~Dan (Daniel C. Linehan, MSW, LCSW) David’s Reply Hi Dan, Great question. In this document, I am trying to make it a bit easier for folks to see how they are triggering the very problem they are complaining about. So, I have listed three categories of common complaints. For example, an Empathy complaint would be that “My partner doesn’t listen,” or “always has to be right.” Then you ask, “If I wanted to force my partner to behave like this, how could I so?” Well, one good way would be to interrupt when your partner is trying to talk, or argue and insist your partner is wrong when they’re trying to make a point, and so forth. This would force your partner to argue and insist that they are right! It is pretty basic and obvious. But most human beings don’t “get it,” and in part that’s because a great many don’t want to. Blaming the other person seems way more popular than looking at your own role in the problem these days. Good to hear from you on this important topic! People can usually “see” how step 3 of the Relationship Journal works—you simply examine what you wrote down in Step 2, and you can almost always see no E (Empathy), no A (assertively sharing your feelings with “I Feel” Statements, and no R (conveying respect or liking to the other person, even when you’re angry.) But most people don’t seem to have the natural mental aptitude or the stomach for Step 4, where you go beyond Step 3 and explain EXACTLY how you FORCE the other person to behave in the exact way you’re complaining about. The document in the link is an attempt to help people with Step 4—IF you are willing to examine your own role in the problem. In Step 4, you ask yourself what category you see the other person in, and there are three choices to make it fairly simple. You might feel that they don’t listen or try to see your point of view. This would be an E = no Empathy complaint. Or you might feel like they can’t, or won’t, share their feelings. Instead, they might just keep arguing, or they might refuse to open up. This would be an A = no Assertiveness complaint. Or, you might complaint that they don’t treat you with warmth, love, or respect. That would be an R = no Respect complaint. This makes it much easier to “see” how your response to the other person in Step 2 actually causes and reinforces the exact behavior you’re complaining about. Lots of people get defensive or annoyed at this step of the RJ, and refuse to continue! That’s because Step 4 is all about the third “Great Death” of the “self,” or “ego,” in TEAM-CBT. Most of us don’t want to “die” in this way. It can feel humiliating, or shameful, to pinpoint your own role in the problem. But, there’s usually a big reward—you’re suddenly “reborn” into a far more loving and satisfying relationship. In the podcast, brave and wonderful Rhonda provided David and Matt with an example when she was visiting her son and daughter in law in Germany last month to help out with their twin baby girls. This example really brings this “Great Death” to life, and we are grateful to Rhonda for helping us in this very vulnerable and real way! Feel free to ask again if I have not made it clear. To me, this phenomenon of causing the very problems we are complaining about in our relationships with others is incredibly fascinating. However, change involves the “death of the self,” which is painful, because you have to see, usually for the first time, your own role in the problem you’re complaining about. It is based on the Buddhist idea that we create our own interpersonal reality at every moment of every day. In other words, we CREATE our enemies, and then whine and complaint about it! Most people don’t want to see this! They want the therapist (or friend they’re confiding to) to agree that the other person REALLY IS a jerk, or to blame, or whatever. They just want to complain and blame and feel superior! In my book, Feeling Good Together, I think I said something to the effect that we “want to do our dirty work in the dark.” In other words, we don’t want to turn the lights on so we can “see” how we’re actually causing the conflict. The person asking for help can nearly always be shown to be the 100% cause of the conflict. This technique is one I recommend when working with an individual, and not a couple. Other less confrontational techniques are probably more effective when you are working with both partners at the same time. Warmly, david (David D. Burns, MD) Here’s the document: Conceptualizing the Patient’s Complaint in Step 4 of the Relationship Journal (RJ) By David D. Burns, MD* Problem Area Specific Complaint—S/he Complaints about the other person’s lack of E = Empathy Won’t listen Does not understand me Always has to be right Always criticizes me Constantly complains and ignores my advice Constantly brags and talks about himself / herself Doesn’t value my thinking or ideas. Is defensive and argumentative Doesn’t care about my feelings. Complaints about the other person’s lack of A = Assertiveness Cannot (or will not) express his or her feelings Cannot deal with negative feelings Expects me to read his or her mind Clams up and refuses to talk to me Won’t be honest with me pouts and slams doors, insisting s/he isn’t mad! won’t tell me how she / he is feeling. isn’t honest with me. suddenly explodes for no reason, out of the blue. Complaints about the other person’s lack of R = Respect Always has to get his or her way Is stubborn Is controlling Does all the taking, while I do all the giving Uses me Puts me down Is judgmental Does not care about me or respect me Only cares about is himself / herself Constantly complains and ignores my advice. Explanation. When you are using the Relationship Journal, you will usually have a complaint about the other person. For example, you may complain that she or he “never listens,” or “is always si critical,” or “constantly complains but never listen to my advice.” If you write down one thing the other person said in Step 1 of the RJ, and exactly what you said in Step 2, you can usually easily analyze your response with the EAR Checklist. That shows what you did wrong, and why your response was ineffective. You can also use the Bad Communication Checklist to pinpoint your communication errors, and some people prefer this format. In Step 4, you go spell out precisely why your response will FORCE the other person to keep doing the exact thing you’re complaining about. One easy way to conceptualize the nature of your complaint about the other person is with our convenient EAR algorithm. This document can help you “see” the problem you’re complaining about when you do Step 4 of the RJ. That makes it much easier to discover exactly how you are triggering and reinforces the exact problem you’re complaining about. LMK what you think! Clay writes: Hello David, I know you no longer practice, but could I please get an opinion from you on EMDR? So far I have done about six sessions of EMDR and I feel worse than when I began. Does one typically feel worse before one feels better with EMDR? I know you are for Team CBT, and I think it has a lot of merit and science behind it! It just seems a little magical to me that by alternately tapping that I am going to resolve traumas or anxiety issues that happened a long time ago and maybe even recently, but I am going into it with an open mind and the possibilities. Best to you and your family, David, and thank you for the revolution in cognitive therapy you started with Aaron Beck and Albert Ellis! Kind regards, Clay Wilson Hi Clay, I’ve never been an EMDR enthusiast. To me, it’s just cognitive exposure, which definitely can have value in anxiety, coupled with “eye jiggling.” Many of it’s proponents seem to think that they have found the holy grail, and I have no doubt that a few will slam me for me non-supportive response! And please remember that I’m a cynic, so take it with a grain of salt. In TEAM, we use more than a hundred M = Methods, and only after doing the T, E, A steps, which are absolutely crucial to success in most cases. Best, david PS I’m copying Rhonda and Matt. If we used your question on an Ask David, would you be open to that, with or without your correct first name? Happy to disguise your name. David D. Burns, MD Dear David, I greatly value your ideas and that you are a cynic. In 6 sessions of the EMDR, I have not felt any better. You are absolutely free to use my name and you don't need to disguise it at all. I live in Columbus, Montana and as far as I know, there is only one person in Bozeman who does Team CBT. I sent her an email but didn't hear back but it's 100 miles from us anyway. Thank you very, very much for your view on EMDR! I was thinking something similar myself. All the very best to you and your family! Most Sincerely, Clay David’s Response HI Clay, You’re welcome. My website is full of free resources, anxiety class, depression class, more than 300 TEAM podcasts, and more. My book, When Panic Attacks, is pretty cheap in paperback. Also, beta testing of thee Feeling Good App is still free. T = Testing, E = Empathy, A = Addressing Resistance, and M = Methods (more than 100.) A is likely the most important step! Thanks, best, david Matt’s Response Hi Dan and David, My guess is that EMDR showed some early results due to the tendency of most therapists to avoid exposure techniques and try to 'smooth over' anxious thinking and trauma, rather than just dive in and explore it, fearlessly. I suspect this created a large cohort of anxious and traumatized patients, waiting in the wings, for such treatment, so it showed immediate favorable data. However, this method is only one of dozens, and the setup is key. Why would you want to overcome something traumatic? Wouldn't it be more useful to remember it and avoid anything that resembles it? Meaning, there may be powerful methods, including exposure and (usually) less-effective methods, like 'eye-jiggling' and other distraction techniques out there for anyone, but why bother with these if the symptoms are helpful and appropriate? This is the main idea in TEAM . People recover when they want to recover, not when someone applies the correct methodology. -Matt Hi Dan, David, and Matt: In addition to being a TEAM therapist, I also practice EMDR. I find it to be very effective, especially when used within the TEAM structure. It may not be for everyone, but it's great to have many options for our clients. -Rhonda David’s comment. Yes, and here Matt’s is pointing out some of the paradoxical “Outcome Resistance” strategies we use with anxious patients when doing TEAM therapy. We become the voice of the patient’s resistance to change, and verbalize all the really positive things about the anxiety symptoms: how they protect us from danger and express our core values as human beings. Paradoxically, this often reduces resistance and opens the door to change. In TEAM, we treat the human being with systematic TEAM therapy. We do not treat symptoms with techniques. The meaning of this may be hard to “see” if you haven’t seen or experienced it. But there are a large number of actual therapy sessions your can listen to in the podcasts. Best, David Thanks for asking such terrific questions and for listening! We all greatly appreciate your support. Keep your questions and comments (negative as well as positive) coming! Rhonda, Matt, and David
355: Relationship Problems: Be Gone! Featuring Dr. Matthew May In today’s podcast, Matt, Rhonda and David discuss relationship problems, and how to overcome them. We also give instructions on the Paradoxical Invitation, one of the most important and difficult techniques for TEAM-CBT therapists to learn. We started today’s podcast interviewing Tania Ahern and Andy Persson who give a plug for the upcoming TEAM-CBT intensive from August 14 to 17, 2023 in Bristol, and incredible British city with an outstanding TEAM-CBT training program in store for you. Many notable TEAM experts will be presenting, including Drs. Leigh Harrington, Heather Clague, Marius Wirga, Stirling Moorey, Mike Christensen and many other notable teachers. Special thanks to Peter Spurrier for being a fantastic TEAM therapist and organizer! I will also be there virtually doing a keynote address, a Q and A session, and a live TEAM-CBT demo with a workshop volunteer. The amazing Mike Christensen will be my co-therapist. Hope to see you there! Go to TEAMCBT.UK for registration and more information. Today we focus on relationship problems, starting with a real example, which often makes for the best teaching. Rhonda recently spent time with her son and daughter-in-law to help with their new twin babies. Rhonda’s daughter-in-law had a very difficult delivery, and was in the hospital for several weeks following the birth of the babies. Rhonda worked relentlessly cooking and cleaning for them, feeding the babies, changing their diapers, and comforting them, and providing help for the new mom, who was overwhelmed and fearful of bathing the babies, thinking she might hurt them when attempting to bathe them. As so often happens in real life, Rhonda ran into a severe conflict with her daughter-in-law and responded with anger, and we all so often do. She reveals how terrible she and her daughter-in-law felt, and how she saved the day after deciding to have a “redo” of the interaction, using the Five Secrets of Effective Communication. Rhonda, Matt and David described one of the most difficult therapy tools in TEAM-CBT, the Paradoxical Invitation Step, and contrasted it with the Straightforward Invitation. Rhonda also mentioned some podcasts for further information on the Relationship Journal and the Interpersonal Model in TEAM-CBT. There are even more, but here are some that might interest you. My book, Feeling Good Together, is also a must-read for anyone wanting to make profound changes in the way you connect with the people you love, as well as your patients if you’re a shrink! # Podcast Title Min 054 Interpersonal Model (Part 1) — “And It’s All Your Fault!” Healing Troubled Relationships 54 055 Interpersonal Model (Part 2) — “And It’s All Your Fault!” Three Basic Assumptions 27 056 Interpersonal Model (Part 3) — “And It’s All Your Fault!” Interpersonal Decision-Making and Blame Cost-Benefit Analysis 46 057 Interpersonal Model (Part 4) — “And It’s All Your Fault!” The Relationship Journal 44 226 The “Great Death” in a Corporate / Institutional Setting 56 227 Echoes of Enlightenment 43 We finished today’s podcast with some entertaining role-playing exercises, using the Five Secrets of Effective Communication in interactions with extremely difficult individuals. This gave me the chance to role-play some incredibly obnoxious and practically impossible to please. My favorite role! Enjoy! Warmly, Rhonda, Matt, and David
Grass Roots TEAM-CBT Completely FREE Practice / Training Groups Today we interview four courageous pioneers of free and low-cost TEAM-CBT for the masses, featuring Brandon Vance, MD, Patricia O’Neil, Ana Teresa Silva, DVM and Nicholas Santascoy, PhD. Many of you are already familiar with Brandon Vance and Heather Clague’s awesome online Feeling Great Book Clubs which will start again, running from September 13, 2023, through December 6, 2023. The book clubs are popular and have gotten wonderful reviews. They are a fun and engaging way to structure your reading, discuss the book, see demonstrations, practice tools, ask experts questions and connect with others around the world who are working on Feeling Great – and no one is turned away for lack of funds. Sound interesting? You can learn more and join here. But you may not be aware of a growing number of fantastic totally free self-help groups springing up for people around the world. These groups offer training in different aspects of TEAM-CBT. For example, Patricia offers DAILY (!) practice sessions that focus on the use of the Daily Mood Journal. You can also join free 5-secrets practice groups groups that focus on changing habits groups that practice a variety of TEAM tools a book club focused on When Panic Attacks and more! All these groups are free and open to anyone worldwide. To see the growing list, go to https://www.feelinggreattherapycenter.com/free. This list is invaluable, and check the link from time to time because the offerings will likely continue to expand. Keep in mind that these are NOT therapy groups, but layperson-led self-improvement groups. Brandon and Rhonda remarked that these free groups are part of a heart-warming movement which continues the culture of generosity that David has created, starting with David’s decades-long free weekly training groups for mental health professionals. The new self-help groups also carry the spirit of relating to others with deep empathy. The goal is to create an atmosphere of giving and support in mutual healing. A second goals is to learn to appreciate each other despite our differences. And so, the ripples that David has created continue to spread, and you can become a part of this process! Nicholas Santascoy is a research psychologist, academic coach and learning specialist who discovered Feeling Good in 2005. He found it tremendously helpful and years later, began working with a TEAM therapist who suggested Brandon’s Book Club. When the book club reached the Daily Mood Journal section, he asked if he could start a free DMJ practice group, which he did, and it’s still going on each week, more than two years later. He was thoughtful about the group’s structure, making it clear to the participants from the beginning that he is NOT a therapist and that this is not therapy. It is simply a place to practice TEAM with support – an important disclaimer for any non-therapist running a practice group. In his groups, each person spends 10 minutes at the start working on some common task, like describing an upsetting event for a Daily Mood Log, or suggesting positive reframing for a negative thought or feelings, and so forth. Or they might go through a sequence starting with one negative emotion, one negative thought, one cognitive distortion, one positive reframe, and one positive thought. His group has also worked with the exercises described in the two free chapters on habits and addictions offered at the bottom of Dr. Burns’ website. Nicholas described working with a man with intense performance anxiety who had an upcoming job interview with a panel of eight individuals who were evaluating him. He was intimidated and anxious, but reluctant to give up his anxiety for a number of reasons. First, he was convinced that if he didn’t worry, he wouldn’t prepare effectively. In addition, he was convinced that he needed anxiety to do his best during the interview. Nicholas encouraged him to test these beliefs with experiments. He discovered, much to his surprise, that he was still strongly motivated to prepare for the interview when he was feeling relaxed and confident. He also recorded his interview and reviewed it afterwards. He was surprised to discover that his best performance during the interview was when his anxiety had dropped to zero. Ana Teresa Silva is a Portuguese veterinary doctor who decided she wanted to work with people and became a coach in 2020. Ana Teresa developed a free Portuguese Five Secrets practice group in May of 2021. This quickly became an international group in English, free and open to anyone, and ran for two years and got rave reviews from participants. After that, she handed over the leadership to Linda Roth, M.Ed. This kind of group, in my (David’s) opinion is incredibly important because learning the Five Secrets is a lot like learning to play the piano. It’s possible to make beautiful music, but the Five Secrets are challenging to learn. Practice, combined with humility and the intense desire to learn, are the keys to learning and personal change. Patricia O’Neil, a former schoolteacher, loves David’s books like Feeling Great, When Panic Attacks, Feeling Good Together and more. Patricia experienced a very severe, prolonged and immobilizing depression, and tried ALL of the standard medical treatments, even including electroconvulsive therapy, but her depression continued. She then started reading Feeling Great and joined Brandon and Heather’s Feeling Great Book Club in 2022, and began to pull herself out of depression. After several weeks she asked if there was a group for people who want to work their way through the book together in-between Book Club meetings, perhaps even daily, to “apply the strategies the best we can.” Brandon encouraged Patricia to start her own study group. She did! And not only that, she started many other groups as well – all completely free - including a When Panic Attacks Book Club, her daily Daily Mood Journal group, an eating healthy accountability chart, a coaches in training group and her own free advanced Five Secrets Practice group for people who have completed a Five Secrets Deep Dive series. Several of the participants in today’s podcast had anxiety about being on the podcast. Patricia generously volunteered some of her negative thoughts, including: I might not do well. I’m gonna mess up! Brandon might regret asking me to join the group today. My flaws and imperfections will be on display. She said that these thoughts contained many of the familiar cognitive distortions, such as Fortune Telling, Magnification, and Should Statements, to name just a few. She also described some of the strategies she used to challenge these thoughts, including these positive thoughts: The whole future of the world doesn’t depend on how well I do today! I probably WILL mess up, and that’s okay! Then she bravely and tearfully described her own battles with depression since her retirement several years ago, and her gratitude at having found so many skills to deal with negative mood swings more effectively. Her comments were touching and inspiring, and actually embodied the goal of the practice groups that are rapidly emerging. The goals including: provide a structure for free ongoing practice and learning give individuals around the world the chance to join the emerging community of TEAM enthusiasts provide opportunities to connect with others in the spirit of openness, acceptance, and compassion. Most humans are hungry, even desperate, for love, learning, and relief of suffering, along with a connection with others who also care. Brandon and his many fans and colleagues are transforming this idealistic vision into a practical reality. At the end of this moving interview, Brandon mentioned a number of additional groups that are rapidly forming including two Signal text groups created by Derek Gurney. “Mission Accomplished or Refused,” is a place to “report on plans to tackle aversive tasks” and take accountability – which is an effective tool for changing habits. He has also created an “Exposure Celebration” class, which sounds like a terrific chance to do exposure with the support and reinforcement from others. This is something tremendously helpful for people struggle with all types of anxiety. Again, please click here to see more information about these wonderful and completely free Grassroots TEAM CBT groups! And if YOU have a free TEAM practice group you’d like to start or have started and want to add to the list, please email Brandon Vance, MD (email@example.com). In fact, I’ve always dreamed of free self-help groups for mood problems, with much the same spirit of lay healing you find in Alcoholics Anonymous. And now, in my old age, it is tremendously encouraging to see this happening. I have to pinch myself, in fact! Thanks, Brandon, Nicholas, Ana Teresa, and Patricia! Warmly, David and Rhonda
353: The Inner Scoop on “No" Practice! The “Inner” and “Outer” Dialogues— The “Inner” and “Outer” Solutions As you know, I have created many powerful communication techniques, including the Five Secrets of Effective Communication and more. One of the additional techniques is called “No” Practice, and it’s designed for people who have trouble saying “no,” or setting limits with other people. Essentially, you do a role-play with a colleague or therapist who keeps pestering you with pushy demands, and you have to practice saying “No” in a polite but firm and assertive way. Sounds simple, right? But it’s not! People have many reasons for not wanting to say “No.” For example, you may be afraid of hurting the other person’s feelings, or letting them down, or running the risk that they may get mad at you if you don’t say, “Yes.” In addition, you may feel like you’ll miss out on some special activity if you say no, so you end up way over-committed. In this session, you will meet an exceptionally compassionate and highly trained young psychiatrist named Lee, who asked for help with a problem relating to some of his patients. My co-therapist is Dr. Jill Levitt, who is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California. Lee explained how he struggles with saying “no” when patients make inappropriate requests, like pushing for a medication they’re addicted to, and wanting premature discharge from the inpatient unit when they have unrecognized safety issues. Instead, he seems to get drawn into long explanations of his thinking and why he’s declining the other person’s requests, sometimes for half an hour, and ends up frustrated when the other person still doesn’t “get it” and with himself for spending the time. People often think that therapy is easy, and that people just need encouragement, advice, or behavioral practice to change the way we interact with others. But as you will vividly see in this session, that is often not the case, and things that may seem simple or obvious can seem almost impossibly difficult to learn. Why does this happen? Why is it so difficult for people to learn new and seemingly simple verbal skills? Well, to find the answer, we have to go back to the teachings of the Buddha and Epictetus, who taught us that our negative feelings do NOT result from what’s happening, but from our thoughts. What does this mean? Well, Lee is an incredibly intelligent and compassionate young psychiatrist, and he’s clearly highly motivated, and yet he seems very slow in learning how to say “no.” Can his thoughts illuminate his apparent resistance to learning a new approach? During the session, Dr. Levitt reminded us of the fact that whenever you are involved in a conflict with someone, or any interaction for that matter, there are always two dialogues going on: the Inner and Outer Dialogues, and if you ignore either one of them, you may have difficulties triggering change. The Outer Dialogue involves what you say to the other person, and what they say next, and how you respond. For example, Patient says: “Doctor, I want to get discharged from the hospital.” Lee says: “No, I can’t do that because you’d be in danger and without a place to live. You’d be living on the streets, and it wouldn’t be safe for you.” Patient (who is in a state of psychosis) responds: “No doctor, I’ll be okay, because I’m living with Michael Jackson.” Then Lee tries to explain his thinking again, and then the patient asks to be discharged from the hospital again. And this cycle repeats itself many times, over and over, for as much as an hour. And they both end up frustrated and a bit miffed. Why is it so hard for Lee to say no in a kindly way and then move on to some other activity? That’s where the Inner Dialogue can be so important. It appears that Lee has two types of distortions that interfere with his ability / willingness to say “no.” Self-Directed Should Statements. Lee appears to believe that he “should” be able to explain his thinking to any patient. He wants to convey respect, responsiveness, and care when denying a request. This is, of course, an expression of his high standards, his compassion, and his desire to communicate clearly to his patients. But, as is so often the case, Lee takes this goal a little to far, think he should “always” be able to do this, regardless of how psychotic or confused or demanding a patient might be. Essentially, the healthy pursuit of excellence as a psychiatrist has gone a little too far and has arguably morphed into a self-defeating kind of medical perfectionism. Self-Directed Shoulds typically trigger feelings of guilt, shame, anxiety, and inadequacy. They are often accompanied by several other distortions, including All-or-Nothing Thinking, Mind-Reading, and Self-Blame, to name just a few. Other-Directed Should Statements. Lee appears to think that his patients “should” understand and acknowledge his thinking if he’s being reasonable and realistic. He may also believe that if he’s doing his best, then his patients “should” argue fairly and acknowledge when they understand what he tells them and “shouldn’t” be manipulative, unreasonable or argumentative. Other-Directed Shoulds often trigger feelings of frustration and anger, and are often associated with All-or-Nothing Thinking, Mind-Reading, Emotional Reasoning, and Other-Blame, to name just a few. Another teaching point is that we nearly always create our own interpersonal reality, but we don’t realize that because we feel like victims and see the problem as coming from outside of ourselves. Lee’s urge to continue to try to “win” the arguments with patients actually forces them to keep arguing their case and trying over and over again to get their way. That’s just human nature. We’ve all seen that people can be pretty obstinate and determined to get their way, no matter what. That’s why a focus on what you can do to change will often lead to a change in other people; in contrast, repeated efforts to persuade them to change is almost never effective. By way of analogy, my wife and I have recently had a bit of a problem with our cat, SweetiePie. She was a rescue cat, and we love her to death, and do everything we can to make her happy. She loves us intensely and shows her gratitude with loud purring almost all day long when she’s not asleep or out in the back yard exploring. BUT, she has been pestering us for cat candy, and has gained too much weight. Here’s what happens. She jumps up on my desk, and puts her paw on my keyboard, and stands if front of the computer terminal so I can’t see. So, I give her two or three pieces of cat candy on her perch next to me. She jumps up and greedily devours it. Next, she jumps back on the desk and puts her paw on the keyboard. I “explain” to her that she’s eating too much candy, and try to put her back on her perch, so she swats me with her claws and draws blood if I’m not quick to pull my hand away. So, I give her a few more pieces of candy, which she devours and then goes to sleep. Similar routine with my wife. She follows her, crying like she’s on the verge of death, and swatting at her ankles until she gets cat candy and / or a 30 minute lap snuggle. So, in short, we have been “forcing” her, inadvertently, out of love, to manipulate us for cat candy. In other words, we “reward” her manipulations by giving her cat candy and love. As a result, our pour girl is gaining too much weight. Of course, the solution is simple. Melanie has agreed to give her only four pieces of cat candy per day, and I am limiting her to two pieces, just so she’ll know she’s still loved. And when she tries to swat me with her claws, I just explain in a kindly way that I don’t like that and put her on the floor. She caught on right away and seems to have accepted the new routine. Of course, we continue to give her abundant helpings of love every day, many times a day, as the love has zero calories! So, what’s the bottom line? If you’re trying to learn the Five Secrets of Effective Communication, and you want to change the way you communicate with others, remember to attend to your Inner Dialogue, as well as what you are actually saying to the other person during the conflict, especially if you’re getting anxious, defensive, angry, frustrated or upset. If you write down your negative thoughts, I think you’ll find many similar distortions to the ones described above, and this can give you another handle on change the way you think, feel, and connect with the people you care about, as well as the ones you don’t! Incidentally, the belief that we are separate from others and from our environment is the essence of evil, according to some Buddhists, and perhaps nearly all of the world’s religions have had similar beliefs, though couched in different language. But what this means to me is that when we struggle with friends of loved ones, and we are locked into frustrating conflicts, we typically feel like we are “separate” from the other person who is “doing something” to us. And this perception can not only trigger anger and frustration, but sometimes even violence. As humans, we seem to have great difficulty “seeing” our own role in the conflict. And sometimes, we don’t even WANT to, because the so-called “Great Death” of the self can be very painful. This is especially true when we see ourselves as morally superior to the other person who is “bad” or “to blame.” We are indebted to Lee for giving us this superb example of a problem that nearly all human beings struggle with, and also sharing his vulnerability and humanness with all of us in such an open and generous way! And we salute and thank Lee for courageously showing us the way with an intensely personal and real example. Contact info Dr. Rhonda Barovsky practices in Walnut Creek and Berkeley, California. She can be reached at firstname.lastname@example.org. She is a Level 5 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. You can reach Dr. Burns at email@example.com. You can reach Jill Levitt, Ph.D. at firstname.lastname@example.org. She is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California (www.feelinggoodinstitute.com) You can reach Lee at email@example.com Group Feedback The following are a few of the comments in the feedback at the end of the Tuesday class. These are comments from the mental health professionals who observed the session with Lee. Please describe what you specifically disliked about the training? What could have been improved? Were there some things you disagreed with or did not understand? LOVED it! NOTHING Can't think of anything I only wish that we could have more time for this work with Lee. I kept feeling like I wanted to jump in and try some of these skills myself. Please describe what you specifically liked about the training? What was the most helpful? Were there some things you learned? I liked the externalization of resistance and would've like to see more with that or maybe even a “rules & roles” regarding patient/doctor relationships. I really liked Lee’s work. I also struggle with saying no, and I liked all of the role reversals and honest feedback from everyone involved. I found Jill's insight at the end of the session regarding the conceptualization of the problem, particularly the internal versus external solution (during the “no” practice), to be quite valuable. It was clear that Lee was facing conflicting desires - the need to act in the best interests of his clients while also seeking acceptance and approval. Taking the time to delve deeper into those internal factors may have further strengthened the effectiveness of the external solution (the “no” practice). Was helpful to see the miracle cure/goal clarified, as well as the 'acid test'. Good to see the model in action! I just enjoyed Lee's honesty , caring and professionalism. He brought up an issue that has been close to my heart as I worked with schizophrenic patients in clinic and day hospitalization settings and have experienced EXACTELY what Lee described. You feel between the devil and the deep blue sea when the medical staff conveniently toss responsibility to the less professional staff and when those in the trenches need to be there for the patients by saying NO. I LOVED David's comment about being disrespectful to patients with schizophrenia by going on and on with lofty brainy arguments while the loving thing to do is to be empathic stroking and firm. From my experience when I am real with my patients, they feel the best. Thank you, Lee, David and Jill. This was beautiful , heartwarming, and I am so touched to belong in this group. David and Jill's exquisite empathy, the Positive Reframe, and the NO practice. EVERYTHING!!! This was truly incredible! David and Jill are an unbeatable tag "TEAM!" Jill's warmth and empathy and teasing out the variables of Lee's story that were not always apparently obvious. Lee's vulnerability and seeing his depth and caring as a Psychiatrist was heartening and impressive. It helped me understand the flow of TEAM CBT and how things fit together better by seeing a live session from the beginning. I LOVED that Dr. Burns and Jill had to go down several different avenues to see what would work best. This closely reflects my own experience of therapy with my patients. Seeing them struggle a little made me feel even more sure that TEAM is the only approach that makes sense and cures people. This was a really wonderful session. I appreciate Lee volunteering, sharing with us his work challenges, and allowing us to see his kind and caring personality. I loved the masterful work of Jill and David. It seems to me that practicing responding to his patients with the use of the 5 secrets was imperative and I was amazed to see how that helped dropping down the feelings on the DML before we got to work on the Negative Thoughts. Once again, TEAM works like a charm! That this was a powerful real life issue that Lee shared. I enjoyed the empathy and how that led to sorting out conceptualization and miracle cure. David and Jill's combined efforts to go in many directions to help Lee see where he is stuck. I struggle in exactly the way Lee does in these sorts of situations, and it was so helpful and inspiring to me to see him do this work. Thank you, Lee! I was deeply moved by your deep caring for your patients and values around wanting your patients to have agency and understanding when there's so little in their world that they can control. I wish every psychiatrist had more Lee in him/her/them! I appreciate that Lee opened up himself in the group and I could observe the personal work of David and Jill, the amazing masters of TEAM-CBT. I admire Lee's compassion and warm heart toward his patients and I owed a lot to Lee who has very high standards to make things clear, just as he has done in his teaching in our Newbie group. And I think his sadness and anger might be an expression of his passion toward justice and dignity of his hospitalized patients. Appreciated Lee sharing with the group and doing personal work on a challenging problem. Liked when Jill brought up the internal versus external solution and then the session switched gears to work on the negative thoughts that made it so difficult for Lee to say no. Really enjoy the personal work, and getting to see the TEAM process unfold in skillful hands. I appreciate that you gave Lee time to explain his points, and that he was able to be truthful and disagree at times, and then you asked why and he explained further. This led to a more nuanced exploration and conceptualization of his issues and goals. I liked the focusing of a major part of the problem of "saying no" to a relationship / Five Secrets issue...resulting from internal and external shoulds. I appreciated the comparison with parent/child discipline, and not getting sucked into arguments. I also appreciate that you were able to pinpoint the problems around trying to get desperate, even schizophrenic patients, to understand one's point of view. It was great seeing the modeling of how to respond to some of these difficult patient situations. And how to clearly define the agenda when a patient is unclear about their goals. Also, so admiring of Lee. I liked how Jill and David navigated figuring out what Lee wanted to work on (when they came up with the three options). Issues that have "internal" and "external" components to them are difficult for me, and I often get confused. Seeing Jill and David work that out helps me wrap my head around how to go about it, thanks. Please describe what you learned in today’s group. I appreciate Lee's vulnerability and I have so much respect for how he cares for his patients. I appreciated seeing the multiple role-playing attempts and was bummed when we ran out of time. I have so much admiration for Lee and feel for how much he's struggling. Personal work, externalization of voices, magic dial, Daily Mood Log (DML), 5 secrets, etc. How Five Secrets and No practice fit within the DML work That they could have started on the internal work of negative thoughts or the external work of "NO practice" TEAM at it's best! I observed NO practice and would like to learn more specifically about it ... Seeing the TEAM model unfold step by step in real time is always an incredibly valuable learning experience. Hearing Jill entertain potential directions to go in (i.e. crushing negative thoughts vs. No practice.) Learning challenging scenarios in context of "NO" practice was really awesome! Just magnificent overall! THANK YOU!!! Always feel so privileged to be part of this uniquely wonderful community of like-minded professionals! We are so lucky! I don't have to be smooth and have all the right answers immediately. This process is highly collaborative. How to employ the team model especially conceptualization and role play with NO practice and Five Secrets practice. How dealing with severely mentally ill pts can be so difficult. There's a sixth secret in effective communication: the willingness to use one's power in a kindly way to give the shot and get it over with. It's so helpful to me to add this secret to my armamentarium! Positive reframing and No practice, along with Externalization of Voices and Externalization of Resistance. I learned something about Lee, and about the difficulties of psychiatric hospital work for doctors! Also, seeing the process unfold skillfully, teasing out the problem to work on, Externalization of Resistance, Positive Reframing, Externalization of Voices, No/5 Secrets Practice, etc. How to be clear on agenda setting when patients are unclear on their goals. I was reminded about how to ask about a client's goal in order to guide agenda-setting. It was nice seeing the five secrets role-play / no practice. I've been inspired to start practicing daily like David said he did. Can never get enough of that!
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