Evolution of TEAM from CBT Porn Compulsive Liars Angry Patients Who Resist Where's the App? and More! Note: The answers below were written by David prior to the podcast, just to give some structure to the discussion. Keep in mind that the actual live discussion by Rhonda, Matt and David will often go in different directions with different information and opinions. So, please listen to the podcast for the more complete answers! Today's live discussion was especially fun and lively, so make sure you listen to the actual live podcast. Questions for this Ask David Podcast Stan asks if any of my early methods have been abandoned by newer and more effective methods as CBT evolved into TEAM. Stan asks if mild porn is harmful or helpful. Rima ask how you can deal with compulsive liars. Pretika asks what to do with patients who angrily resist positive reframing. Anonymous asks several questions about the Feeling Great App. 1. Stan asks about new approaches in TEAM for habits and addictions, as well the evolution of TEAM, as compared with the much earlier classical CBT. 2. Stan also asks if mild porno is helpful or harmful. Hi David. I read in the eBook (I think it was) that you have radically changed your approach and have many new methods for Habits and Addictions. I actually have many of your books such as: Feeling Good Feeling Good Handbook When Panic Attacks Intimate Connections Feeling Good together Feeling Great eBook I wonder if you could please tell us in one of your Ask David podcasts which methods described in your earlier books you no longer recommend, because they have been superseded by more effective ones described in Feeling Great for example. I am sure there must be a lot of material that is still valid in those earlier books and which is not mentioned in Feeling Great. It would be great to know which ones you no longer recommend for the general public. I also want to ask you about Porn Addiction. Do you think occasional mild porn use is harmful or beneficial? I read in a BBC article that porn probably isn’t harmful for most men, and can even be positive for couples. For example, some couples start to engage in oral sex after seeing it on the internet. Porn seems a bit like alcohol, if you abuse it it will be bad for your health but if you don’t go for the strong stuff and don’t over use it, it could be OK. I think some people might misinterpret your references to porn addiction as being any kind and intensity of porn use. Maybe these people feel anxious and shameful for using it as a result. I would welcome your clarification on this issue. Finally, even though I know you have heard it thousands, or hundreds of thousands of times, your work is having a really positive effect on my life. I am truly grateful for all that you do. Thank you, David. Warm regards Stan David’s Reply Hi Stan, I can turn this into a couple Ask David questions for the podcast if you like. There have been many upgrades of the therapy ideas and techniques over the years, as we develop greater understanding of how people change, and what works and what tends not to work. In addition, I would say that we develop new methods and ideas on a weekly basis. The TEAM models lends itself very nicely to evolution, perhaps one of the strong points. I can speak in more detail on the podcast, but here are two ideas. First, I have come to appreciate more and more that all change in emotions comes from a reduction in belief in the negative thoughts that trigger negative feelings with few, if any, exceptions. In addition, any reduction in belief in negative thoughts will case an immediate reduction in the negative feelings that thought causes. This insight angers many people who don’t really “get” it, so I don’t push it. I find that people sometimes do not take kindly to statements that challenge their sacred beliefs. A simple example would be jogging, or aerobic exercise. Some people believe on faith or personal experience that exercise has a mood elevating effect due to release of endogenous “endorphins” in the brain, and many even claim that exercise is the most effective antidepressant known. While some people do experience a mood lift after strenuous exercise, I believe this is due to the change in their thoughts, telling themselves and believing that this is going to be good for the health and outlook. So that thought can have potent effects on mood. I can describe some experiments on exercise and mood. Second, I have tilted much further in the direction of appreciating the existence and power of resistance in all emotional and behavioral problems, and the often magical power of the new resistance-melting techniques I’ve developed in opening the door to the possibility of rapid and dramatic change. I’m also very aware of the therapy wars, predicated on the belief that our group as THE answer and your group consists of fools! And typically, one or both of those who are arguing have never measured anything in their patients on a session by session basis to see if things are working or not. This is just the tip of the iceberg, however! You can find a free offer of two free chapters on Habits and Addictions on every page of my website in the right-hand panel. You will find a strong emphasis on powerful new techniques that focus on motivation, such as the Triple Paradox, the Decision-Making Tool, the Devil’s Advocate Technique, and more. Most of the techniques I developed in the early days of CBT still have a lot of power and I use almost all of them, sometimes with various modifications and upgrades. For example, I have added the CAT to the Acceptance Paradox and Self-Defense Paradigm in the Externalization of Voices (EOV), and now there are two versions of the CAT, one of them created just last week! On the porno question, I am not an expert in sociology research, so I don’t know, and I try to avoid giving expert answers on things I don’t have expertise in. My goal is not to proclaim what people should or shouldn’t do, but rather to help people who come to me asking for help. It is tempting to assume your own views are straight from God, but I find that my own narcissism just gets me into trouble most of the time! I do like your thinking, though, that much of the time there are no absolute answers, rather personal preferences, and the impact will often depend on how things are used. As you say, a glass of wine could add to your meal. A bottle of wine daily might get you into trouble with your health and habits! Warmly, david 3. Rima asks about compulsive liars How do you deal with people who are compulsive liars? I found that even when using the five secrets, they either get really angry and start on the offensive or completely deny no matter what you say. If you have a client or someone in your personal life that you have deal with that lies a lot even when faced with facts and proof, what is the best way to handle it? On another point, I know that we all tell lies to a certain extent but I’m wondering whether you can impart some wisdom on why some people are compulsive liars. David response: I have a policy of NEVER answering general questions. If you want help with a relationship problem, please fill out the first four steps of a Relationship Journal. That way, we can see what the other person said, and what you said next. Otherwise, you might frame it as wanting help figuring out how to “handle” this other person who is “to blame,” or behaving badly, and so forth, without pinpointing your own role in the problem, which is the whole key to interpersonal therapy. Then we will have some dynamite to play with, as opposed to bullshit which tends to be too gooey in my experience! Certainly, people who lie compulsively can be challenging and irritating for sure, but let’s take a look at the whole picture so we can also answer this question: Are you responding in a way that reduces the likelihood that they’ll be honest? I’d LOVE to answer this question again once you send an RJ partially filled out. Thanks! 4. Preetika Chandna asks about patients who angrily resist Positive Reframing My client was offended by the positive reframe questions (any benefits and values for anxiety). She was unable to 'see' any benefits to her anxiety despite 'priming the pump' and gathered evidence from friends to emphasize her point. She ultimately dropped out of therapy. I'm wondering if we can move forward without positive reframing and circle back later, or is an open hands with empathy the best option when a client refuses to reframe and is actually offended by the suggestion? David’s Take Sometimes you can do effective work without the A = Paradoxical Agenda Setting step in a highly motivated patient. However, I suspect a more fundamental problem is occurring here. Whenever you’re stuck with an angry patient, immediately go to E = Empathy, and don’t use any methods until you get an A, and have really re-established a warm, trusting relationship with the patient. I have emphasized the importance of using the BMS and EOTS with every patient at every session. Have you been doing this, and have you been getting a perfect score on the Empathy and Helpfulness Scales? This seems unlikely to me. Often anxious patients feel shame, especially if they have social anxiety, but this is also common with panic attacks and some other forms of anxiety. If she’s ashamed of her anxiety, it would make sense that he might get defensive when asked to positively reframe it. At this point, I can only speculate, since I don’t know the details of this case. Sometimes, it makes sense to pay a colleague for a couple consultation sessions to get “unstuck.” These are always extremely productive learning sessions. Positive Reframing, or Assessment of Resistance, is an art form, and sometimes you just can’t “see” the reasons for the resistance at first. You might recall, or want to listen to, our live session with Sunny, who developed a sudden relapse of intense anxiety when he decided to change his approach to work, or non-work. (see podcast # X). The traditional positive reframing was not effective, but then when we started on methods, I suddenly “saw” something none of us had seen before during the session. His “anxiety” was actually a sign that something wonderful was happening! You can always start with M = Methods, and then when you run into resistance, you can revisit resistance with a Paradoxical CBA, or Externalization of Resistance, or some other approach. But the crucial thing is to get on the same page, and stay on the same page, with your patient. David 5. From a therapist who wishes to be anonymous I have a question, I think that habits and addiction (including the online additional chapters) are very important. I wonder if they will ever get their own book and app? David’s take: Eventually we hope to include that dimension in our Feeling Great App. The Feeling Great book is designed for self-help. I wonder if you have suggestions regarding using the different role-playing techniques (such as externalization of voices) for patients or individuals that works on their own? David’s take: Yes, we use these role-playing techniques in the Feeling Great App. When are we expecting the app? David’s take: First quarter of 2024. Thank you ! Thanks for listening today!

Self-Acceptance, People who Resist, Secrets of Dynamic Job Interviews, Five Secrets with your Boss, Do Cognitive Distortions Cause Transgenderism? Note: The answers below were written by David prior to the podcast, just to give some structure to the discussion. Keep in mind that the actual live discussion by Rhonda and David will often go in different directions with different information and opinions. So, please listen to the podcast for the more complete answers! Questions for the this Ask David Podcast Rizwan suggests a new method for self-acceptance. Anonymous asks how to convince someone that depression is NOT due to a chemical imbalance in the brain. My father does not believe that you can change the way you FEEL by changing the way you THINK! Marc asks about tips for job interviews, as well as how to respond during periodic performance reviews at work. Brian asks if transgenderism could be the result of distorted thoughts. 1. Rizwan asks I have a question about the Acceptance Paradox that came to my mind during our Tuesday training group on 19 Dec, 23. As homework, will it be useful to ask clients to make a list of things which they have already accepted in life and made peace with? At the next stage, in the session, would it be useful if the therapist asks them, "why did you accept and make peace with those things? “Can you use the same criteria to accept other things in your lives which you are not accepting now?" Sincerely, Rizwan David’s take Yes, you can certainly try that and let us know how it works out? I do lots of spontaneous and “new” things in almost every therapy session. Some things work out, and others do not. That way, I learn from my clinical work. One thing to be aware of is that your proposed approach might overlap with “helping,” when a paradoxical approach might have more “punch” / impact, After all, the Acceptance Paradox is arguably more of a decision, than a skill. But try, even with yourself if you like, and let us know what you discover. TEAM constantly evolves, and you can be an important part of that process! Best, david 2. Anonymous asks how to convince someone that depression is not due to a chemical imbalance in the brain and that you can change the way you FEEL by changing the way you THINK? Hi David I love listening to your podcasts. And now I am seeing differences in my life but not my father who has been depressed for around 40 years. He is on medicines and has an extreme belief that it's on the basis of chemical imbalance. He is a pharmacist by profession, and loves to learn about how chemical changes mood swings. I am not able to convince him to read your books. He just take sleeping pills every single and sleeps all day. He is learning something about neuroplasticity which is actually the case that happens in cbt. But he think it's some kind of thought changing therapy which cannot change the chemical in our brain. Please help David. I would love you to answer this. Regards, Anonymous David’s Response Hi, I once gave the keynote address at a research conference at the Harvard Medical School. When the department chairman introduced me, he something like, “Dr. David Burns is going to show us how you can change brain chemistry with CBT, and without drugs!” It was pretty cool! That’s one dimension. And we could add more evidence and research findings to support our side of the argument. But on another level, we see the underlying issue of trying to convince someone who is taking an adversarial position and content with their own thinking and beliefs, and determined to argue no matter what evidence you present. In my experience, spending time trying to convince them is almost always a losing cause. All you do is engage in a frustrating philosophical debate, at least that’s my thinking! The podcasts on the theme of “How to Help and How NOT to Help” might be useful, in case you are looking for help with your relationship with your father. Your love and concern for him is huge and very touching! Okay to use in an Ask David? I will not use your first name! Best, david 3. Marc asks for tips on job interviewing. Hi David, I hope you are keeping well. I am wondering if you have any tips / strategies/resources that you recommend for an upcoming job interview? Also, you once told a story of someone who worked in the tech industry that you counselled, and you recommended some questions for him to ask in periodic performance reviews. Does this ring a bell at all? I've had trouble remembering/locating this Podcast. Stay well, Marc David replies Hi Marc, Yes, we can discuss the secrets of successful job interview on a podcast. I have LOTS of tips, actually, and we can perhaps do a podcast on this. We could also focus on how to respond to your supervisor during performance reviews, and I DO have an amazing story about that as well; it was the fellow who had been fired six times in two years. Thanks for reminding me. I might have given him the name of Rameesh, but not sure! Best, David 4. Brian asks: Could transgenderism result from distorted thoughts? Hi David, Happy New Year, and thank you for your amazing Monday podcasts. I just started listening to yours today about transgenderism. Could transgenderism be the result of distorted thoughts? I know it's a very sensitive subject like anti-depressants. Thanks, Brian David’s Reply Hi Brian, Thanks for the question. Copying Robin, as she’s the expert. But to my way of thinking, the answer is no. I believe, though I’m no expert, that gender identity as well as sexual preferences are primarily biological in origin, although there are obviously strong cultural influences and biases. For example, ice cream preferences are kind of inherent to people, and mysterious, and cannot be changed by changing our thinking! I love blueberry pie, and many others don’t care for it. Just a preference! Saying that gender results from distorted thoughts might also be hurtful, as if our identities might be somehow “wrong” or “defective.” Might use as an Ask David question if you and Robin have no objection. Best, david Thanks for listening today!

Featured Photo is Dr. Amy Huberman The Amy Story, Part 2: The Joys of Doing the Laundry! Amy and her exuberant son, Sasha, and wife, Alena Last week you heard Part 1 of the Amy session, which included T = Testing, E = Empathy, and A = Assessment of Resistance. Today, you will hear Part 2 of Amy's exciting journey from perfectionism to JOY. M = Methods We used a variety of Methods to help Amy challenge her negative thoughts, starting with the first, “I’m failing my patients.” We started with Identify and Explain the Distortions, then went to the Double Standard Technique, and ended up with the Externalization of Voices. As a reminder, you can see Amy's Daily Mood Log at the start of her session here.. As an exercise, see how many distortions, or thinking errors, you can find in her first Negative Thought, “I’m failing my patients,“ using the list of cognitive distortions on the bottom of her Daily Mood Log. You’ll find the list of the ten cognitive distortions if you click here. After you’ve identified each distortion, see if you can explain two things about it: Why is this distortion in Amy’s thought unrealistic and misleading? Why might it be incredibly unfair and hurtful? You’ll find my list of the distortions in this thought at the end of the show notes. But don’t look until you’ve made your list! These techniques we used were effective , as you’ll hear on the podcast, especially the Externalization of Voices. You’ll hear us doing role-reversals with Amy, and the method that “won the day” was the CAT, or Counter-Attack Technique, combined with the Acceptance Paradox. The Acceptance Paradox involves finding truth in a negative thought with a sense of peace or even humor. The CAT involves confronting the hostile voice in your head and tell it to go fly a kite, or other gentle but firm message You’ll enjoy seeing some striking changes in Amy, as her tears and feelings of intense self-doubt are suddenly transformed into joy and laughter. Those changes created strong feelings of joy for Jill and me as well. We both have incredibly fondness and admiration for Amy, and feel great joy as well when she feels joy. Here are Amy’s final scores at the end of the session. Emotions % Now % Goal % After Sad, blue, depressed, down, unhappy 80 25 0 Anxious, worried, panicky, nervous, frightened 80 20 0 Guilty, remorseful, bad, ashamed 90 5 0 Worthless, inadequate, defective, incompetent 100 15 5 Lonely, unloved, unwanted, rejected, alone Embarrassed, foolish, humiliated, self-conscious Hopeless, discouraged, pessimistic, despairing 90 5 0 Frustrated, stuck, thwarted, defeated 80 5 5 Angry, mad, resentful, annoyed, irritated, upset, furious Other The Joyous Dr. Amy! Sudden and dramatic change is pretty trippy, but it isn’t much good if it doesn’t last. And it won’t! Negative thoughts and feelings will always return, because no one can be happy all the time. That’s why some relapse prevention training and ongoing practice and refinement of what you’ve learned can be vitally important. In our follow-up session with Amy one week later she said she’d felt way better during the week, but did, in fact, have some relapses and had to challenge her negative thoughts again. She’d been helped a lot by the idea that it was okay to fail, to seek consultation, and learn, and that failing with patients gave us endless opportunities to learn and grow as therapists. And it was also okay not to have to listen so intently to the attempts of the negative self to put her down. In fact, our misery almost never results from our failures, but from telling ourselves that we “shouldn’t” ever fail, and from punishing ourselves mercilessly when we do. One of her most exciting statements in our follow-up session was that she discovered that even something as humble as putting the dirty clothes into the washing machine could be a joyous experience without that negative voice in her brain constantly hollering at her that she wasn’t good enough! Teaching points It was hard, at first, for Amy to “see” how distorted and unfair her negative thoughts were. She is an extremely intelligent, accomplished, and beloved colleague, and yet most of us cannot “see” or really “grasp” that we can be pretty mean to when we’re feeling down and anxious. I have often said that feeling anxious and depressed is a lot like being in a deep hypnotic trance, telling yourself and believing things that just aren’t true. For example, Amy is doing beautiful work with the great majority of her patients, and is doing the exact same thing with the patients who are responding beautifully as she is with the two who are stuck. So, when she tells herself she’s a failure, she’s clearly involved in All-or-Nothing Thinking. In other words, she’s thinking that if she’s not perfect, she’s a complete failure and a fraud. She also seems to have many Hidden Shoulds (e.g. I SHOULD be able to help every single patient quickly) and Mental Filtering (focusing only on the negatives) and Discounting the Positive (ignoring the positives, as if they didn’t count.) The techniques that were the most helpful for Amy were Positive Reframing: that’s where we pointed out the positive aspects of Amy’s Negative Thoughts and feelings. The Externalization of Voices with Self-Defense, the Acceptance Paradox, and the CAT. Be Specific: Amy was Labeling herself as a “fraud” and a “failure,” and she was Overgeneralizing from two patients to her entire self and career. Jill emphasized Be Specific. In other words, focus on and accept what’s real. What’s real is that Amy has been valiantly struggling to help two patients who are stuck. She can just accept that, and get some consultation and guidance from a colleague, which would probably help her get unstuck. So, instead of labelling yourself as “a failure” and “a fraud,” which are just mean, vague words, you can tell yourself that you have a specific problem—in Amy’s case, getting stuck with two very anxious patients. Then you can focus on getting some help in solving that specific problem—for example, by seeking consultation from a colleague. Jill said that’s what she does when she gets stuck. I used to do that every week, especially when I was first learning cognitive therapy. Getting stuck, then, can simply be an opportunity for growth and learning cool new tools. If we never got stuck, we’d never learn anything new! The very moment Amy stopped believing her negative thoughts, her feelings instantly and dramatically changed. That change happened suddenly, over the course of about 30 seconds, and you can SEE it in her face and hear it in her voice. But it won’t last forever! Jill pointed out that the belief at the root of Amy’s problem was Perfectionism, and the idea that “I should know exactly what to do with all of my patients.” That may be a pleasant fantasy, and it might even motivate us to work hard and achieve, but it’s also a recipe for misery! Follow-up Rapid recovery is great, but will it stick? You will hear excerpts from our brief follow-up session one week later for Relapse Prevention Training. The idea is that none of us can feel happy forever, and negative thoughts will creep back into our minds sooner or later. However, you can anticipate this and prepare for it by challenging your negative thoughts with the same techniques that helped you the first time you improved. That’s because the details will usually be different every time you’re upset, but the pattern of self-critical negative thoughts will usually be the same. And this DID happen to Amy, just as it will happen to you. But this was an opportunity for her to deepen her understanding of perfectionism and to refine and enhance her ability to respond to her negative thoughts. During the weeks following the recording of this podcast, Amy found that she experienced some resistance to using the counterattack technique. She began to feel like she was relating to her perfectionism as an enemy and attacking it—and in doing so, was discounting all the good in it, including the values that came shining through during the Positive Reframing. She found that a better fit for her, instead of the counterattack, was to disarm her perfectionistic thoughts by seeing the truth in them. In fact, you could view this as yet another form of acceptance. When she did this, the perfectionistic voice in her head naturally backed down and gave her the space to do what matters to her unencumbered by self-criticism. I thought it was cool when she described experiencing waves of joy while doing the laundry—an activity that had always felt like a chore to her before, when it was accompanied by thoughts like “I should have finished this laundry days ago.” She discovered that without beating up on herself, something as humble as doing the laundry could be incredibly rewarding! After our follow-up meeting, I got a lovely email from Amy about the joys of giving up the need for perfection, and sent this follow-up reply to Amy: Thank you, Amy, you are the BEST! I did a four-day intensive in San Antonio years ago with a small group of about 25 therapists. As you know, I always BS and say “As the Buddha so often said . . . “ followed by something goofy or quasi-mystical or whatever, and most people seem to kind of like that and see it as fun or humorous or whatever. Well, I was doing that at the workshop, and at one of the breaks a woman approached me and said she was interested in my Buddhist remarks because she had been raised as a Buddhist in an Asian country where Buddhism is prominent. I panicked and thought I’d been found out and exposed as a fraud. She went on to say that their family gave up Buddhism, however, and she was sad. I asked why they gave up Buddhism, and she explained that her mother suffered from severe depression, and the Buddhists taught that’s because you think you “need” things, and if you’re a good Buddhist you won’t think that way and you won’t ever suffer. Since she suffered, she felt like a failure as a Buddhist, so the family gave up Buddhism. I told her that she might not be aware that there are actually two schools of Buddhism. There’s low-level Buddhism and high-level Buddhism. In low-level Buddhism, you’re not allowed to want or need anything, and you’re not allowed to suffer. That’s sounds like that was the school of Buddhism your family was raised in. But there’s another type of high-level Buddhism. In high level Buddhism you’re allowed to suffer and struggle, and screw up, and fail, and all sorts of stuff. She got animated and said, “I didn’t know that. Thank you so much. You’ve restored my faith in Buddhism, and I can’t wait to tell my mother!” Aside from my being elderly and half-demented, I hope that makes some sense in light of our work together with Jill! So, if you need any translation or explanation, Amy, I’m inviting you to join the high-level Buddhist therapist group where you’re allowed to screw up with some of your patients, or even many! Warmly, david Subsequent Follow-Up I forgot to tell you what happened to Amy’s two “stuck patients.” Well, she got some consultation about why these patients might be stuck, which is nearly always an Agenda Setting problem—the therapist is working harder than the patient due to the need to “help,” and this plays into the patient’s ambivalence. This struck a chord, and Amy was very excited to see her patients again, and both suddenly got “unstuck,” although in somewhat different ways. And that is why I call it the Acceptance Paradox. The moment YOU change, and accept yourself, your world will also change! Or, to put it differently. We often see the world as “different” or as “other,” thinking we are separated. The Buddhists see the world as “one,” and that is certainly true in therapy as well. Answers to the Quiz Question David’s list of Distortions in Amy’s Negative Thought: “I’m failing my patients.” 1. All-or-Nothing Thinking. This is not realistic because Amy is not stuck with all of her patients. And even though she's still far short of her hopes for these two patients, they may feel they are getting lots of TLC and support from Amy. 2. Overgeneralization. This is misleading because she’s overgeneralizing from her two failures to her “self,” and labeling herself as “a fraud and a failure.” She also overgeneralizing to the future, thinking things will never change or improve so she should get a new career. 3. Mental Filtering. She only focusing on the two patients who are stuck. 4. Discounting the Positive. She’s overlooking the fact that she’s going excellent work with a great many people, and has tremendous integrity, skill, and commitment to her patients. 5. Magnification and Minimization. She’s kind of blowing things out of proportion, although it’s always good to focus on patients who aren’t yes improving. 6. Emotional Reasoning, She FEELS like a failure so thinks she IS a failure. 7. Hidden Should Statement. She thinks she SHOULD be perfect! 8. Labeling. Same as Overgeneralization. See above. 9. Self-Blame. She’s blaming herself instead of loving herself and focusing on getting she help she needs and deserves! Thanks for listening today! Rhonda, Amy, and David

Featured Photo is Dr. Amy Huberman The Amy Story Part 1: True Confessions of a “Fraud” and a “Failure” Part 2: The Joys of Doing the Laundry Amy and her exuberant son, Sasha, and husband, Poppy Today’s podcast, and next week’s podcast, include a single, two-hour session with Amy Huberman, MD. Amy is a psychiatrist in private practice in Baltimore, MD. She also serves on the volunteer faculty at the Johns Hopkins University School of Medicine. Amy specializes in brief, intensive psychotherapy to help people overcome struggles with anxiety, OCD, and trauma, but today comes to us to get some help with her own anxiety. Often doing our own work can be a vitally important part of our training and growth as mental health professionals. Amy has been upset because she is stuck with two of her patients, and she’s telling herself that she’s a “fraud” and a “failure.” Although her life is undoubtedly very different from yours, the root cause of her problem might be very similar to the source of your unhappiness, especially if you sometimes get down in the dumps and tell yourself that you’re just not good enough. My co-therapist for this session is Jill Levitt, Ph.D. co-founder and Director of Clinical Training at the Feeling Good Institute in Mt. View California. Jill also serves on the Adjunct Faculty at the Stanford Medical School and is co-leader of my weekly TEAM Therapy training group at Stanford, Tuesdays from 5-7:00 pm pst. If you are interested in joining David and Jill's Tuesday group, please contact Ed Walton, edwalton100@gmail.com. That group is now virtual and therapists from the Bay Area and around the world are welcome to attend. It is free of charge. Rhonda Barovsky also runs a free weekly training group with Richard Lam, on Wednesdays, from 9-11:00 am pst, which is also free of charge. If you are interested in joining the Wednesday group, please contact Ana Teresa Silva, ateresasilva6@gmail.com. Because the groups are virtual, they are open to therapists from around the world. Amy has been a member of our Tuesday training group, and is a highly skilled, certified TEAM therapist. Like nearly all the mental health professionals who come for training every Tuesday, Amy has incredibly high standards and is sometimes harshly self-critical when she feels she is not living up to them. At the same time, those high standards can be strongly motivating, and this can create strong feelings of ambivalence when it’s time to change. Sound familiar? If you’re struggling with perfectionism, you might want to check out these two podcasts! Part 1. The True Confessions of a “Fraud” and a “Failure” Amy opened by saying she was anxious and telling herself: I’m about to reveal my weaknesses and my inner self—This is something I’ve never done before in such a public setting. . . I also have to confess that I’m struggling with social anxiety right now. I’m afraid that my patients might see this and think, “I don’t want to work with her! I want to work with a competent psychiatrist.” I Included that because I am hoping you will appreciate Amy’s incredible courage and gift of sharing her true inner self today! Amy described the problem that’s been bothering her for several weeks. Although she specializes in the short-term treatment of anxiety, she has been struggling with two patients with OCD symptoms who have been stuck and not making significant progress for a long time. This has triggered feelings of shame and intense anxiety which have invaded Amy’s every moment when she’s NOT seeing patients, and has even prevented her from getting restful sleep at night. She keeps ruminating and beating up on herself. You can see Amy's Daily Mood Log Amy here.. As you can see, she was feeling intensely sad, panicky and ashamed, and rated these three feelings as 80% on a scale from 0 (not at all) to 100 (the most severe). She was also feeling worthless and defective which she rated at 100%, as well as hopeless (90%) and stuck (80%). As you know, feelings do not result from the events in our lives (in Amy’s case, the fact that two of her patients were stuck), but rather from her thoughts, or interpretations, of those events. You can see on her Daily Mood Log that she was being intensely self-critical, telling herself that she was failing her patients, that she should refund their money, that she was not competent to practice psychotherapy and should find a new career, that she “should” know how to get them unstuck, and more, and finally that she was a fraud and a failure. Her belief in all of these thoughts was super high, ranging from 80% to 100%. And if you’ve ever felt down or inadequate, I’m sure you recognize the same types of thoughts in your own thinking, telling yourself that you’re a failure, or not good enough, and so forth. During the session, Jill and David went through the TEAM acronym: T = Testing We measured her negative feelings at the start of the session so we could measure them again at the end to see how we did. E = Empathy We listened and supported Amy without trying to “help” or “save” her. The goal was to understand her thoughts and feelings accurately, while providing a sense of compassion, warmth, and acceptance. This phase of the two-hour session lasted about 30 minutes, and Amy told us how she constantly ruminated about those two patients, asking herself “What am I doing wrong, what am I missing, what should I be doing differently?” She described these thoughts as a relentless “broken record in my brain.” She confessed that her deepest fear was, “What if they kill themselves and I was responsible for their deaths?” She said this fear was almost unbearable!” I pointed out that was also my deepest fear when I was in private practice—I was never upset by treating large numbers of severely depressed patients in back-to-back sessions, and it always made me happy, since I felt I had something to offer. But if I said something that hurt someone’s feelings, I found that pain almost unbearable until I saw the patient again the next week, and could talk things over and get back on a positive track. Jill pointed out that Amy’s ruminations showed that she was a highly responsible psychiatrist who cared deeply about her patients! And while that is certainly a positive thing, the intensity of her fears had invaded every minute of her life, making her life miserable, even when she was with her family. Amy said her fears have intensified since 2020, when she transitioned away from a traditional psychiatric practice involving long-term weekly psychotherapy and med-management, to focusing on short-term intensive psychotherapy using the TEAM model. Then we asked her to grade us at the end, thinking about three categories of Empathy: Did we understand how she was thinking? Did we understand how she was feeling? Did she feel cared about and accepted? She gave us an A, which triggered our move to the next phase of our work with Amy. A = Assessment of Resistance In this phase of the session, we pinpointed Amy’s goals for our session and melted away her potential resistance to her stated goal of learning to give up that self-critical voice in her brain. We asked her to imagine we had a Magic Button, and if she pushed it, all of her negative thoughts and feelings would instantly disappear, with no effort on her part, and she’d feel jubilant and happy. She said she wasn’t so sure she’d do that. Most patients say YES, but Amy is familiar with the TEAM approach and knows that negative thoughts and feelings often result from some of our positive qualities. Our strategy at this phase of the session was paradoxical: Instead of trying to help, save, or rescue Amy, and instead of trying to persuade her to change, we took the role of her subconscious resistance to change. With her help, we listed some of the many positives in her negative thoughts and feelings by asking these two questions. What does this negative thought or feeling show about you and your core values that’s positive and awesome? How might this this negative thought or feeling be helping you and your patients? Here are just a few of the positives we found in her negative thoughts and feelings: The Positives in Amy’s Negative Feelings Feeling What this Shows Inadequacy Keeps me from being overconfident Keeps me humble, so I’m open to what I may be missing Shows I care about constant growth and learning Shows I’m listening Shows I care about my patients Anxiety Motivates me to think about things from other perspectives Motivates me to work hard Keeps me honest Shows that I have high standards My high standards have motivated me to learn a lot. You can do the same kind of Positive Reframing with all Amy’s negative thoughts and feelings, as well as your own. The list of positives would be long and impressive! After listing these positives, we asked Amy these three questions: Are these positives real? Are they important? Are they powerful? How would YOU answer these questions if you were Amy? She gave a strong yes to all three questions. At the end we pointed out that it might not be such a great idea to push the Magic Button to eliminate the negative voice in her brain, because then all these positives would also disappear. Instead, she decided to use the Magic Dial to reduce her negative feelings to some lower level where she could keep all the positives but suffer much less. Here you can see her goals for how she wanted to feel at the end of her session. Emotions % Now % Goal % After Sad, blue, depressed, down, unhappy 80 25 Anxious, worried, panicky, nervous, frightened 80 20 Guilty, remorseful, bad, ashamed 90 5 Worthless, inadequate, defective, incompetent 100 15 Lonely, unloved, unwanted, rejected, alone Embarrassed, foolish, humiliated, self-conscious Hopeless, discouraged, pessimistic, despairing 90 5 Frustrated, stuck, thwarted, defeated 80 5 Angry, mad, resentful, annoyed, irritated, upset, furious Other As you can see, she decided to aim for fairly large reductions in all six of her negative feelings. These goals are not guarantees she will be able to reduce her feelings. In addition, the goals are not rigid, since she may be able to reduce them even further once she begins to challenge her negative thoughts. Our real aim at this phase of our work was to reduce her feelings of shame and failure so she could see that her “symptoms” were NOT the expression of what was WRONG with her, but the expression of what was RIGHT with her. Paradoxically, this often reduces the resistance to change and vastly enhances the possibility of rapid and dramatic change during the final, M = Methods portion of the session that you’ll hear next week, along with some follow-up information. The important thing we’ve hopefully accomplished is reducing Amy’s resistance so she can learn how to challenge and defeat the relentless and hostile voice in her brain that constantly puts her down whenever she fails to live up to her extremely high, and arguably perfectionistic, standards. End of Part 1 Thanks for listening today. Be sure to tune in to the exciting conclusion of the work with Amy next week! Rhonda, Amy, Jill, and David

Why Do We Resist Accepting Ourselves Other People, and the World? The Five Most Common Reasons! Rhonda and David are joined in today’s podcast by Dr. Matt May, a super popular and loved guest on our show, to discuss the resistance findings in David's recent survey on acceptance and resistance. The following is a summary of some of the statistical findings, but the actual podcast dialogue was wide ranging and tremendously engaging, and won't require a lot of statistical smarts! We also discussed the vitally important difference between healthy and unhealthy acceptance. Healthy acceptance is accompanied by feelings of joy, lightness, and liberation. Unhealth acceptance is accompanied by feelings of unhappiness and despair. Unhealthy acceptance is characterized by Should Statements and self-punishment for your failures and shortcomings. Healthy acceptance is an expression of self-love. The group brought the five most common reasons to life with engaging stories. Why should you accept yourself? We are not saying that you "should," and it's really a decision. However, the statistical models the I (David) developed indicated that healthy acceptance can trigger a 49% reduction in negative feelings and a 39% boost in positive feelings, which is tremendous. Matt told an inspiring story about two strategy for training the dolphins at SeaWorld. One strategy involved trying to shape the behavior of the dolphins with little shocks, in much the same way that some people train horses. Sadly, the dolphins went to the bottom of the pool and appeared depressed, not moving much. It was a complete failure. Then they tried a radically different strategy--they gave a new group of dolphins fish to reward them for doing the things the trainers wanted them to do. This strategy was tremendously successful. So, the question is whether you want to shape your own life with frequent shoulds and self-criticisms, which can have the effect of electric shocks every time you fail or screw up or fall short of your goals, or whether you want to shape your life with love and rewards. Some of us have discovered that acceptance is way more fun and vastly more effective! Quick Bottom Line The typical survey respondent endorsed 1/3 of the 12 Resistance Scale items, and seemed to believed that Acceptance would be foolish and lead to a life of misery and mediocrity. The actual causal impact of the Non-Acceptance and Resistance scales on positive and negative feelings was massive and appeared to be in the exact opposite direction. Findings The respondents in the Resistance survey endorsed an average of 33.8%. (+/- 0.1%) of the items, ranging from 0 to all 12. The most commonly endorsed was, “Acceptance is easy for rich and famous, but hard if you’re struggling just to pay the bills.” 47% (+/- 2%) endorsed this item. The least endorsed was, “If I beat up on myself, people will love me more,” although 25% (+/- 1%) of the people endorsed this item, so it was fairly popular. The high scores on the resistance scale items is also pretty consistent with my experiences over the years—the people in the study, and the people I’ve worked with, have expressed MANY reasons to beat up on themselves. You can see the list of the 12 Resistance Scale items below. I have bolded the five most often endorsed. As you can see, many people surveyed believed that acceptance is fine for people who are rich and famous, but terribly painful and foolish for people who struggle with real problems. Many respondents were convinced that acceptance leads to pain, robs you of motivation and does not make sense in a the world that’s falling apart. If I accept my flaws and shortcomings, I'll end up with a second-rate life. If I accept my flaws and shortcomings, I’ll lose all my motivation to learn If I beat up on myself and work my ass off, people will love and admire me. It would be tremendously painful to accept my flaws and shortcomings. That would be like giving up and having to live with a heavy load of inadequacies. Life has many real disappointments and losses. I don't want to feel happy and chipper by “accepting” all those negatives when the world is falling apart all around me. That just doesn’t make sense! I haven’t achieved many of my goals in life. I think it would be kind of pathetic to suddenly accept myself and feel enormous joy that I haven’t really earned or deserved. I’ve often fallen short, and I’ve made a lot of mistakes in my life. Are you saying that I should be happy about that? Hell NO! I am never going to accept myself as just another average or below-average person. That would be awful! If I accept my flaws, failures, and shortcomings, I’ll just be like everyone else. I won’t be special, and I won’t have the chance to become special. If I admit that I often fail and screw up, people will think less of me. If I’ve done things that have hurt others or if I’ve violated my moral values, then I deserve to suffer. Acceptance is fine and easy for people who’ve enjoyed tremendous success, but it’s really hard if you’re struggling to pay the bills, or if you feel like you haven’t succeeded at much. What did the analyses show about the impact of resistance and non-acceptance on how we feel? The Resistance scale had powerful direct causal effects on the Non-Acceptance scale and accounted for a whopping 46% of the variance is the Non-Acceptance scale. In other words, the more intense your resistance, the more you will fight against accepting your flaws. The causal effects of the Acceptance and Resistance scales on negative and positive feelings were massive. They can reduce positive feelings by as much as -48% and increase negative feelings by as much as +47%. Or, to put it differently, the statistical models predict that healthy self-acceptance will not lead to misery and isolation, but can dramatically reduce unhappiness and boost feelings of joy and self-esteem. The total effects of Singleness and Income on positive and negative feelings were relatively small, by comparison. In addition, about half of the causal effects of Singleness and Income are indirect and mediated by their causal effects on the Resistance and Non-Acceptance scales. The direct effects of Singleness on the positive and negative feelings scales were -4% (positive feelings) and +6% (negative feelings). The maximum direct effects of income on negative feelings were +4% (positive feelings) and -9% on negative feelings). To experience this boost if you’re in the lowest income bracket (<$25,000), you’d need a massive increase in income (>$200,,000.) Almost all of the 12 items were more strongly endorsed by younger individuals. Three items—Ri, R8 and R9—were more strongly endorsed by men at the p <.001 level or better. All three items had to do with the fear of not being “special” and ending up with a second-rate life if you accept yourself. White and Heterosexual were not associated with any Resistance items. However, individuals with more income and education were less likely to endorse many of the items. Higher educated respondents were less likely to endorse R1, 2, 4, 6, 7 and 12, and those with greater incomes were less likely to endorse R12. These were large effects. Thanks for listening today1 Rhonda, Matt, and David

Accept this Sh__? Hell No! Rhonda and David are joined in today’s podcast by two dear friends, Dr. Matt May, a popular regular on our show, and Matt Pierce, a co-founder of the soon-to-be-released Feeling Great App Brief bio sketch of Matt Pierce goes here, should you wish to include it in the show notes. Matt,. A pic would also be great, but not required. People get tired of the same pics each week, so a fresh face to illustrate this episode would be cool! You’ve probably heard about acceptance. It’s a popular buzzword in the mental health space these days. In fact, some experts claim that it’s THE key to happiness and enlightenment. It’s NOT, but it can be incredibly helpful. I wanted to learn more about Acceptance and put some numbers on it’s effectiveness, or lack of effectiveness, so I recently sent an invitation to the 45,000 people on my mailing lists to complete a new survey on acceptance and resistance. More than 1,000 quickly responded, which was great. I hoped the data could provide some answers questions like these: What is acceptance? How interested are we in accepting themselves, other people, and the world? Many people, and perhaps most of us, strenuously resist acceptance. Why? What are the things that we have the most trouble accepting about ourselves and others? Is all the hype about acceptance justified? Does it actually have meaningful effects on how we feel? Can money buy happiness? And if so, how much, exactly, does it cost? Why are single people more depressed and unhappy than people with partners? And if so, is it because of the lack of a loving partner? Or was there some other reason? Thanks for listening, David, Rhonda and Matt

Do we have a "Self"? Or "Personality"? What's the best way to combat Should Statements? Is TEAM effective without a therapist? What's the Difference between Positive Reframing and Positive Thoughts? Note: The answers below were written by David prior to the podcast, just to give some structure to the discussion. Keep in mind that the actual live discussion by Rhonda, Matt and David will often go in different directions with different information and opinions. So, please listen to the podcast for the more complete answers! Questions for today’s Ask David Podcast: Stefan asks if we have a “self” or a “personality.” Slash wants to know how to combat a “Should Statement.” Magellan asks about the effectiveness of TEAM without the guidance of a therapist. Werner asks about the differences between Positive Reframing and the Positive Thoughts you record on the Daily Mood Log. 1. Stefan asks if we have a “self” or a “personality.” What is the so-called “Great Death” of the “self,” referred to in Buddhism? Hi David, I really love your work, both the books and the podcast you’ve created. Lots of great tools there. I think your down-to-earth approach is effective and great in de-mythologizing mental health care. Still, one thing has been bugging me about your approach: the fact that you quite casually seem to discount the existence of the self. As a theologian I understand this position. In discounting the self as a construct, you’ll open the way to less resistance and more acceptance. I studied both Christianity and some Buddhism, and in that tradition the self is essentially something to let go of as an illusion. I think you called this the death of the ego, and it’s common in many mystical currents both within and without the major religious traditions. However, by embracing this tradition in a therapeutic setting, I think there’s a great risk to gloss over long-held implicit beliefs or patterns in the construction of a personality that might hold people back from reaching their full potential. More specifically, I’m talking about schemas or Lifetraps (in the terminology of Jeffrey E. Young and Janet S. Klosko). I know Aaron Beck supports their work to address these “chronic self-defeating personality patterns” that are usually considered the be part of the self. What’s your take on their work? Kind regards, Stefan David’s reply Hi Stefan, Personality, like "self" is not a "thing," but just the observations that different people have different behavioral patterns. So, some are more outgoing, for example, while others are more introverted and shy and insecure. The only meaning of "self" is the context in which the word appears. So, "behave yourself" simply means that you are misbehaving and need to stop! Can you come to the Sunday hike is a question. It does not need the add on, "and do you plan to bring you 'self.'" The only meaning of any word is the context, and many uses in the English language, or any language. Nouns do not always refer to "things." Words are just sounds that come out of our mouths. I don't go into this much because few people "get it." Thanks so much, Stefan. Warmly, david PS The above is my take on Wittgenstein's Philosophical investigations, published after he died in 1950. . Second PS I had a random and fairly weak thought, but here it is. When doing my daily “slogging” a while back, I was going through a pleasant and familiar path and noticing how beautiful everything was, and had the thought, “This land is so valuable and expensive, and I’m SO GLAD I don’t have to own it. It would involve a nightmare of paper work, taxes and all kinds of worries. But I can just enjoy it without any of those burdens of ownership. Then I thought of the “self,” and what a heavy burden it is to “have one,” and worry about whether or not it is “good enough,” or “inferior,” and so forth. Selves tend to be a bit overweight, and heavy to carry around. And how much more fun, beautiful, and rewarding life is without having to have a “self” to worry about. Rhonda found this helpful after a time feeling confused about the "self," and Matt added this: "Right, and if we own the 'land' one day, and it changes, the next moment, is it the same 'land'? Do we still own it?" Matt’s "Self" Thoughts Wittgenstein is one of my favorite philosophers due to the elegance of his solution to philosophical problems, which is to recognize that they are not, in fact, ‘problems’. Instead of trying to answer the question, ‘is there a self’, ‘do I have a self’, he would point out that these questions are meaningless and can’t be answered. One way to bring these questions into a form that could be useful and answerable, is to define the terms. What is the ‘self’, and what can it do? How would I know, if I had a ‘self’? If the definition was in the form of a testable hypothesis, we’d be a step closer to arriving at a meaningful answer. In some cases, this answer is incredibly meaningful, in terms of our mental state and relationships. Let’s try on a few possible definitions of ‘self’ and consider some experiments that could be done to test whether these hold water. ‘Self’: (from Meriam Webster): one’s essential being, which separates them from others. (I don’t find this definition useful, because now I just have to define what is an ‘essential being’? What are we talking about? ‘Self’: The subject of our experience; the thing that is thinking our thoughts, and feeling our feelings. (This is also problematic for many reasons. First, it’s based on an unproven assumption that experience requires an experiencer. Descartes believed this but Nietsche retorted that this logic was highly flawed as it smuggles the ‘self’ into the equation without any justification. Further, there are many ‘nondualistic’ philosophies that challenge the ‘separateness’ of ‘self’ and experience. Meaning, the presence of thought doesn’t mean anything other than the presence of thought. We ought to be skeptical of introducing additional complexity into the situation according to the principle of ‘Occam’s Razor’, that the simplest hypothesis that explains all the observations is more likely to be correct). ‘Self’: The ‘CEO’ of your mind, the aspec of yourself that is directing your body, attention and decision-making. (This is problematic in many of the same ways as the above definition. It’s also the most readily falsifiable definition. We can experiment with our ability to control our decision-making in a variety of ways, one of which is to see if you can ‘choose’, with your ‘self’ not to understand the words on this page. Or to sit quietly and not think. If our ‘self’ can’t use its ‘free will’ to control the brain’s activities in such simple ways, why would we imagine that we have a self, controlling our brain, at all? In fact, most of us believe in a ‘self’, which, if we attempt to define it carefully, it can be proven NOT to exist. However, this is an unacceptable conclusion for many people, even though it results in a form of enlightenment. This form of enlightenement is slightly different from ‘self acceptance’. It’s more like ‘waking up from a dream of a self’ than ‘acceping a flawed self’. All that said, yes, it’s often incredibly useful to inspect our assumptions about our ‘self’, in terms of our ‘roles’ and ‘rules’ in our relationships. David offers the ‘Interpersonal Downward Arrow’ to do this in a single session. There, we might discover we are stuck in a belief system that is counterproductive, like, ‘we must be perfect’, ‘we should never have conflict’, etc. There are countless ways people think about their ‘self’ which can be productive or a ‘trap’. Obviously, if we had no sense of our identity, purpose, role, etc., it would be hard to know what to do with our ‘selves' on a day-to-day basis! 2. Slash asks how she can combat her “Should Statement.” Hi David I did some exercises and found I a believe that I should play guitar effortlessly or else I should enjoy the process of learning. My disadvantages are greater in CBA. Now what thought should I replace with so that I could have the advantages too. Slash David’s reply Thanks, Slash! It is a should statement. Essentially, your “should” doesn’t make sense since there is no rule that says you should, must, or ought to enjoy something you don’t enjoy right now, so you are just putting pressure on yourself unnecessarily. I once had a patient who had previously been treated briefly by Dr. Albert Ellis when he was in New York. He was on vacation, and was feeling depressed and telling himself that he SHOULDN’T be unhappy since he was on vacation. He thought he SHOULD be enjoying himself. He said that the thing that helped the most was when Dr. Ellis said, “Where the F__K is it written that you are obligated to enjoy being on vacation?” (Ellis used that word a lot!) He said he immediately gave himself permission to feel miserable on vacation, and instantly felt better! This is an example of what I call the Acceptance Paradox. When he accepted his unhappiness, instead of struggling in shame to make it go away, it disappeared. I have a similar story. I used to have a keen interest in collecting coins from around the world, and when I was an intern at Highland Hospital in Oakland, I used to enjoy going to the local coin stores to see if I could find some interesting foreign coin to purchase for a few dollars. This was always exciting, but one day I was in the S & D Coin store just a few miles from our apartment, realized I was totally bored and had lost my interest in collecting foreign coins. I told the friendly dealer, and he said, “Oh, don’t worry about it. Just do something else in your free time for a few weeks and your interest in collecting will probably come back.” So, I did that, and that’s just what happened. Essentially, he was also giving me “permission” to feel the way I was feeling, and not the way I thought I “should” feel! And when I accepted my negative feelings, they ran their course and disappeared. That worked for me, but there are a lot of methods in TEAM, and you sometimes have to try quite a few before you find the one that works for you, since we’re all different. The “go to” method for Should Statements is called the Semantic Technique. Using this method, you could tell yourself, “Right now I seem to have lost interest in music. It would be great if it comes back again, and probably will. But it’s natural not to feel excited about music all the time.” Notice that I used “it would be great if” in place of the “Shoulds.” As an aside, we just completed a new class for the Feeling Great App entitled “Your PhD in Shoulds.” You might want to check it out. There’s also a lesson on perfectionism at the end of the class. Best, david Cost-Benefit Analysis If I make mistakes, then I am not talented enough to play guitar.(associating my self worth with talent of playing guitar.) Advantages of Believing This Disadvantages of Believing This 1.It will push me to work harder. 1.There is lot of internal pressure. 2.It will motivate me to try different things until I find any solution. 2.It makes me depressed. 3.It can help me to be perfect/achive skills like my idol guitarist. 3.It ruins my currently playing technique I want to master. 4.People will admire me. 4.It makes me stuck at particular point from where I am not able to move forward. 5.It shows that I am one cut above others. 5.It hinders my progress with respect to guitar playing skills. 6.People who think I am not enough I can prove it to them. 6.It makes me frustrated irritated. 7.It can help me to be confident. 7.Endless cycle which I feel I am stuck in the moment and cant get out of it. 8.The quest to achieve will take forever which will make me hopeless and which further decreases my tolerance to make mistakes/which will further make me vigilant to see my mistakes as fault which cannot be corrected. 9.My moral goes down. 3. Magellan asks: Can you do TEAM-CBT without a shrink? Dear David, Could you tell us about studies of the effectiveness of any written TEAM or other therapy materials offered without therapist guidance (for example when people are on a waitlist to see a therapist)? I think I heard of one done with Feeling Good. I wonder if one may be done with Feeling Great. Thanks, Magellan David’s response: We have impressive results with our app, which I can describe. It is completely automated without therapist guidance. It is kind of like my first book, Feeling Good, on steroids! I also have precise data on waiting list controls. The waiting list do not improve until they start the Feeling Great App and then they experience rapid and dramatic changes with a couple days. There's no doubt about the effectiveness of the app. Also, there's extensive research proving the effectiveness' o my first book, Feeling Good. There's no question about the effectiveness of these self-help tools. I have many questions about the effectiveness of human shrinks, however! 4. From Werner Spitzfaden: Positive Reframing vs Positive Thoughts I periodically come across clients who get confused by the concept of the Positive Reframing vs Positive Thoughts on the DML. The question they pose is if the Positive Reframe is similar to the Positive Thoughts on the DML? After some explanation I focus on Positive Reframing as a way of seeing that even the most difficult and painful thoughts and feelings reveal something powerful and awesome about us and then ask if that's true about them. This focuses on Outcome Resistance. The positive thoughts on the DML focus on defeating their negative thinking with 2 conditions needing to be present: their new positive thought needs to be believable and it has to drastically reduce the distress resulting from your negative thought. This focuses on the early stages of Methods coming after looking at Distortions followed by the Straight Forward Technique. I would love to hear David's take on this. David’s Response Yes, Werner, you are right! The goal of Positive Reframing is not to “Cheerlead” or to persuade the patient that their negative thoughts are not correct, but rather to help them see why they may fight to hang on to their negative thoughts and feelings, because they are beneficial and helpful in many ways. This is the latest list of questions you can ask when doing PR with a negative thought. Most will also apply to a negative feeling. What is the truth in this negative thought? (This is essentially the Disarming Technique applied to your own self-criticism) Why might this negative thought or feeling be healthy and appropriate, given my circumstances. Why might this negative thought or feeling be helpful to me? What does it show about me and my core values that’s positive and awesome? What might be some negative consequences of giving up this negative thought or feeling? You were spot on about Positive Thoughts. To be helpful, they must fulfill two conditions. They must be 100% true. Half-truths and rationalizations are rarely or never helpful/ They must drastically reduce your belief in the distorted negative thought. Hey, Werner, we miss you like crazy in the Tuesday group and in our (now small and humble) Sunday hikes. Hope you’re doing well.

Can You Treat ADHD with TEAM? Does Humor Play a Role in Therapy? What's the Difference between Rejection Practice and Shame-Attacking Exercises? Featuring Dr. Matthew May Note: Not all of the information covered here is in the podcast, and much of what we discuss in the podcast is not covered here. Questions for the next two Ask David Podcasts: Rich asks how you treat ADHD in TEAM. Hwa-Chi Qiu Alvarez asks about the use of humor in therapy. Rima asks about the differences between Rejection Practice and Shame-Attacking Exercises. Rich asks: How do you treat ADHD? From Richard: How about a podcast concerning ADHD? I feel that applying TEAM would work. No? I mean “disorders” arise from distortions…so what does a distraction “disorder” arise from? Thanks for all you do David, Rich David’s reply: Hi Rich, I don’t treat “disorders,” I treat individuals at specific moments when they’re struggling and wanting help! Hope that helps. As an aside, if you or a friend, colleague, or patient have ADHD and you can describe a specific moment when that person was struggling, I would love to hear about it! Then you’ll see how TEAM works it’s magic by focusing on individuals, and not “problems” or “disorders,” etc. TEAM is a “fractal psychotherapy.” I will explain! Warmly, david Matt’s Take: Thanks for the question, Rich! I love what David is saying, about treating the individual, not the diagnosis. There are a lot of things that can interfere with focus and attention, such as. medical problems, sleep difficulties, toxin exposure, substance misuse, and relationship problems. In addition, depression and anxiety can interfere with concentration and contribute to ADHD symptoms. Below, I’ve listed many of the distracting thoughts that my clients have had. Along with a list of some good things about being Distracted. Hope you enjoy! Matt’s A – Z List of Distracting Thoughts: I don’t feel like doing this This is boring and no fun I never get to do what I want It’s not fair I’ll do it later There’s plenty of time Best not to rush things I might be missing out on something interesting or important I’ll check my phone one more time, real quick, and then get right back to work This time will be different. Seriously. I mean it. Actually, I’m feeling too tired to concentrate I’ll just take a quick, 5-minute nap I’ll get to work when I feel more rested and motivated I’ve had a hard day and deserve a little break and some fun Tomorrow’s going to be really hard, so I need to rest up I just *can’t* concentrate, at all There’s something seriously wrong with me I lack willpower / I have no ambition I shouldn’t have to do this There’s no point doing this I’ll never be able to do this I need to be doing important, interesting things It would be really exciting and fun to … x, y, z, instead I need to tidy up a bit before starting this big project I don’t know where to get started / don’t want to mess up I’ll be too distracted if I don’t take care of this one thing, first Matt’s A – Z List of GOOD Reasons to be Distracted I can be spontaneous, have fun and be present, in-the-moment I won’t miss out on something interesting and important I won’t waste my life doing boring stuff that leads nowhere I’ll focus on what makes me happy I won’t let other people control me or make my decisions for me I like to feel powerful and in-charge; I call the shots This is my time, nobody controls me It’s calming to know that I’m in-control I want to treat myself with respect I want to be free, not shackled It’s important to take breaks I want to maintain a good work-life balance It’s fun and exciting to be a bit of a ‘rebel’ I’m my own unique person, doing things my way I just want to ‘go with the flow’, it’s easier I want to be safe, protected me from failure. I can’t really fail if I don’t give it my all I can get instant relief from the pressure anxiety when I outsource this task to ‘future me’ I deserve to do what I want, when I want to; I’m sticking up for me I can reject others’ advice and feel superior I don’t know where to start I can have more time to plan I’ll be less likely to mess up if I consider my approach carefully I don’t want to do an average job, this needs to be amazing I can prepare, talk, plan and complain; that’s more interesting and fun than doing I don’t have to face how dull and boring some parts of life can be I can daydream about a better life On the live podcast, Matt and Rhonda gave examples of individuals diagnosed with “ADHD” who all needed completely different and highly individualized treatment, which is what TEAM is all about. Matt described treating a boy with ADHD who would get anxious in class when he was called on to read out loud. He was afraid he’d get nervous and make mistakes, and the other students would judge him. The technique that helped him was the Feared Fantasy. Matt also described a fellow with ADHD who had trouble keeping appointments and getting places on time. He was helped by the technique I have called “Little Steps for Big Feats,” and the treatment was similar to the methods we used to treat procrastination. Rhonda described someone with ADHD who felt anxious in social situations, and he was helped with the same types of techniques we would used to help anyone with social anxiety. The bottom line: treat the person, not the so-called “disorder”! Hwa-Chi Qiu Alvarez suggests: An episode focused on humor and its uses/impacts could be interesting, I didn't find any. What are some strategies for when humor backfires? How did you learn to appropriately use humor with patients? David’s reply will include: First, time I “discovered” humor when teaching the psychiatric residents with Aaron Beck. How I think about my own use of humor: I just kind of blurt out things that are outrageous. Buddhists have concept of “Laughing Enlightenment,” which occurred during the Terri jumping jacks video. What laughing creates is the experience of not taking ourselves so The time I laughed with a patient during the entire session. When NOT to use humor, and what to do when it backfires. During the live podcast, Matt, Rhonda and David talked about why and how humor can be helpful—in therapy, in teaching, during podcasts, and in life in general. David talked about how he “discovered” humor when teaching a group of psychiatric residents at the University of Pennsylvania, and how he used a humorous Feared Fantasy to help a depressed FBI agent who was demoralized because he didn’t have a sense of humor. This was a problem because the men at work of joked around the water or coffee pot during breaks. When David modeled how to accept the fact that he had no sense of humor during the Feared Fantasy, it struck his funny bone, and he laughed so hard he fell out of his chair. This was a paradox, since the very moment he accepted the fact, without shame, that he had no sense of humor, he suddenly discovered his awesome sense of humor! I, David, call that the Acceptance Paradox. David also described how humor helped a woman who had struggled for ten years with terrifying panic attacks and extreme depression. David also warned about the pitfalls of using humor with angry or severely depressed individuals who feel intense grief or extreme worthlessness and hopelessness. Matt’s Take I’ve noticed that if you’re ‘supposed’ to laugh, you won’t. But, if you’re not supposed to laugh, you probably won’t be able to stop laughing. Maybe that’s why, when we tried to talk about it, on the podcast, it was really dry and unfunny? Normally I’m hilarious. Rima asks: I believe rejection practice is a fine art and I’m just trying to understand the specifics a little more, and how it differs from Shame Attacking Exercises. David talks about some of his male patients doing rejection practice by asking as many women out as possible and collecting no’s from them. The way David explains it, it seems standard practice for the patients to self disclose to the women that they are doing the rejection practice and are collecting no’s. My question is, if you disclose this information, would that be considered a safety behaviour and maybe less powerful exposure than not disclosing what you are doing? I’ll give you a personal example that hopefully will clarify more. I have been doing my own rejection practice to experience how it feels for myself. One of the things I set myself was to ask someone to sing a duet with me. I found that a little daunting so to make it easier for myself, I disclosed to a woman that I am doing shame attacking/rejection practice and thus would she help me and sing with me. I felt I was using a safety behaviour and protecting myself from certain judgements from her. Therefore, I’m wondering if the patient disclosing what they are doing would be as helpful exposure as not disclosing. David Comment You are confusing Rejection Practice with Shame Attacking Exercises. They are actually very different. You can do Rejection Practice with or without telling the person what you are doing. Shame Attacking is just done without giving away what or why you’re doing it. For example, if you want to sing in public, you can just do that. Or you can approach a person or couple and offer to sing for them, and then when done hold out your hand as if asking for a tip. There are certain general guidelines for Shame Attacking that we can mention, as they are very important. You can also do with as a duet with someone you know, so you are doing Shame Attacking together. But in this case, you are definitely not confusing it with Rejection Practice. During the live podcast, Matt discussed the pros and cons of two different styles of Rejection Practice, and David and Rhonda and Matt sharpened the contrast between Shame-Attacking Exercises and Rejection Practice, which are actually quite different, although there is clear some overlap. Rhonda described a Shame-Attacking Exercise that David persuaded her to do after a Sunday hike, in a Chinese restaurant when everyone was ordering dim sum. Rhonda went to a nearby table and asked the people who were seated if she could taste their food! This was almost impossibly anxiety provoking, but to Rhonda’s surprise, they let her tase one of their dim sum and she said it tasted great. They asked if she wanted more! It was a great exercise in overcoming social anxiety. Matt described one of his outrageous Shame-Attacking Exercises in a grocery store, lying on his back making angels in the snow in the produce section, talking loudly about what an awesome grocery store it was. He said that he was surprised and relieved to discover that no one seemed interested in what he was doing. He said that one of our illusions is that people are incredibly interested in us, whereas in reality, most people are mainly interested in themselves! Quite a useful discovery. Matt’s Take Hi Rima, thanks for this nuanced question, I can tell you’ve been paying close attention! As a little background, the fear of getting rejected can cause a lot of suffering and deprivation, both emotionally and in the form of loneliness, relationship problems and career development. Overcoming this fear can improve one’s social life, relationships and career. However, there’s a ‘necessary’ part of overcoming any fear, which people don’t want to do. It is to lower our defenses and face the fear directly. This is the only way to prove that we are, in fact, ‘safe’, for example, when we are rejected. Rejection Collection (getting rejected frequently and regularly, and counting these as ‘wins’) is a powerful social exposure method that has helped many people, including myself, overcome the fear of getting rejected. Huge thanks to David for helping me overcome my resistance to trying this (extremely challenging) exercise. Doing so has helped me overcome my fear and has radically improved many aspects of my life. Exposure may not work, however, for a variety of reasons. A common one is motivational. For example, we may not want to feel ok, if we’re getting rejected. We might prefer to feel upset, perhaps as a motivator to improve. Surprisingly, there are many good reasons to base some portion of our worth on the approval of others: Wanting to live up to their expectations, wanting to be open to feedback, wanting to avoid conflict, wanting to be maximally motivated to work hard, in our relationships, to be mature and responsible. TEAM therapy stresses the importance of raising these motivational elements to the surface for discussion, in an admiring way, before deciding whether to change anything about a person. If someone can still convince me that they want to overcome the fear of rejection and are willing to do the hard work, rejection collection is extremely effective and powerful. It’s good to know that one’s nerves won’t be the thing that gets in the way of developing a wonderful social life. Rejection collection can still fail, however, for other reasons. For example, it’s common to focus too narrowly on only one method. There are many, many methods that can help, and may be necessary, to overcome a fear of rejection. Just in the category of ‘Social Exposure’ there are quite a few: TEAM Therapy Social Exposure Methods: ‘Smile and Say Hello’ practice ‘Talk Show Host’ technique ‘Self-Disclosure’ ‘Flirting Training’ ‘Survey Technique’ ‘Shame attacking’ ‘Rejection Collection’ ‘Rejection Feared Fantasy’ You’re correct, too, Rima, about the problem of ‘safety behaviors’. Even if ‘rejection collection’ were the method that could lead to a cure, it still might fail if we are, in some way, ‘protecting’ ourselves, during the rejection collection exercise. The most common form of ‘safety behavior’ I’ve seen, when doing ‘rejection collection’, is to rush the process. Then, we can tell ourselves, ‘well, if I’d really tried and put in the time and all my effort, I wouldn’t have gotten rejected’. This defeats the most liberating experience of, ‘I got thoroughly rejected, despite my best effort, and it’s totally fine’. You asked, is it would be a ‘safety behavior’. if you said this to a stranger: “Please reject me, to help me get over my fear of rejection.’, I would not necessarily label it as a safety behavior, unless it was the only thing that was said. I would consider this to be ‘Self Disclosure’ (talking about oneself in a vulnerable way) combined with rejection collection. If this were the only thing you said to someone, then I’d agree that it’s a ‘safety behavior’, as there’s a rushed element to it, as opposed to a ‘best effort, still failed, it’s fine’ experience. The liberation of a ‘real’ rejection is a glorious thing and is, in my experience, most often achieved by combining multiple of the above techniques, starting with, ‘smile and say hello’, ‘talk show host technique’, ‘flirting’, self-disclosure, survey technique and only then asking for a rejection. Practicing this for a bit using the ‘Rejection Feared Fantasy’ (a role-play/practice exercise with one’s therapist) is often great preparation for the real-life experience. We thank Rhonda for recording for us today, when she is just starting to recover from COVID, and the day before a trip to visit her son, daughter in law, and two wonderful grandchildren. We love you Rhonda, and wish you the best for a wonderful month! Thanks for listening today, and thanks for submitting your excellent questions. Stay tuned for more answers to your questions next week, including these: Magellan asks about the effectiveness of TEAM without the guidance of a therapist. Werner asks about the differences between Positive Reframing and the Positive Thoughts you record on the Daily Mood Log. Anonymous asks several questions about the Feeling Great App. Matt, Rhonda, and David

Transgender Issues Featuring Dr. Robin Mathy Emily Dickinson, from Amherst, Massachusetts, was one of the greatest American 19th century poets, and after hearing one of our Amherst professors explain her life and work, I fell in love with her incredible poetry. When she attended Mt. Holyoke College as a freshman, she was obligated to sign up as a “Christian,” a “Non-Christian with hope,” or a “Non-Christian without hope.” She was the only student who had ever signed up as a “Non-Christian without hope,” and she was given one semester to change her registration category. When she refused, she was asked to leave, and spent the rest of her life living in Amherst, baking cookies for children and writing her fabulous poems, which were sometimes included in her cookie packages. Her poetry was all about loss, which was much the story of her life. However, she was not self-pitying, which is part of what makes her poetry so sad and magical. Emily Dickinson always dreamed of visiting the west, but never got the chance to travel much beyond the outskirts of Amherst. She once wrote, To make a prairie, It takes one clover, and a bee. One clover and a bee. And reverie. The reverie alone will do, if bees are few. Tears come to my eyes every time I think about that poem! When I was a student at Amherst, we used to visit her grave, and I once actually knocked on the door of the house where she once lived. I explained I was a huge fan and actually got the chance to look around. I actually found a poem scribbled on a scrap of paper on a window ledge. Today we interview Dr. Robin Mathy, who describes herself as “A human who hopes.” Robin is a well-published expert on LGBTQ issues, with a specialization in transgender research and political activism based on science to debunk hateful myths about sexuality. She is also a new member of our Tuesday training group at Stanford! In addition to studying to become a TEAM therapist, Robin is a Doctor of Social Work student at Tulane University. She is a researcher and activist who has published four books and more than 50 peer-reviewed articles or book chapters. She is a beloved member of David and Jill’s Tuesday TEAM CBT group. Rhonda kicked off today’s podcast by reading two very moving endorsements from people who heard part 1 of the live work with Jessica, “Living with Regrets,” which we had published just prior to our interview with Robin. Then Rhonda kicked off our dialogue with Robin by asking if there are any special treatment considerations when you are working with trans individuals. Robin said that there really aren’t—TEAM-CBT is already highly personalized and individualized, so we let the patient set the agenda. Robin emphasized the importance, of course, of being warm, affirming, and supportive. In addition, do not assume that the patient is there because of gender identity issues, or automatically refer them to a support group on that topic, because the patient’s issue may be radically different, and that would amount to stereotyping your patient. I asked Robin for a simplified introduction to LGBTQ, including what these terms actually mean. That’s because I have to admit I never had any good sexual diversity training during my medical school or psychiatry residency, and I suspect that some of our podcast fans, perhaps many, would also appreciate a little enlightenment based on science. Robin pointed out that transgender has to do with identity issues: what is your sense of self? Do you see yourself more as a woman or a man? And sometimes, this will be quite different from the gender you were assigned at birth. So, for example, you may be assigned as a boy at birth, but your sense of who you are may be a girl, when you are young, and a woman as you develop during puberty. In this case, you would be a trans-gender woman. To be respectful, you should refer to a transgender woman as she or her. And, of course, if you were assigned as a girl at birth, but your sense of who you are is a boy/man, you would be a transgender man, referred to as he / him. Some transgender people are nonbinary, meaning they do not want to be referred to as either a man or a woman, and they do not want to be referred to with either binary pronoun. To be respectful and sensitive, you should always ask someone what pronouns they prefer. In contrast, the terms, LGBQ, do not refer to gender identity, but rather to sexual attraction. So, a lesbian is a woman who is sexually or romantically attracted to women, and a gay man is attracted to men, and so forth. The term, “cis,” refers to your gender that was assigned at birth. According to the National Center for Transgender Equality, When a person begins to live according to their gender identity, rather than the gender they were thought to be when they were born, this time period is called gender transition. Deciding to transition can take a lot of reflection. . . . Possible steps in a gender transition may or may not include changing your clothing, appearance, name, or the pronoun people use to refer to you (like “she,” “he,” or “they”). But it can be a bit more complex. Robin says: A lot of people like me do not actually identify as transgender. I was assigned as a male at birth, but I have always felt like a girl / woman. I think of myself as gender-diverse, not as transgender. . . I remember taking a bath with my sister when we were young, and I realized that I had something that didn’t belong on me. . . . My parents raised me as a boy, but I was always effeminate. As I developed as a teenager, my transition was from being “me” to being “fully me” and completely embracing my identity as a woman. This was freeing to me. We are taught to believe that there are two types of chromosomes that determine our gender: XX for female and XY for male. But this is misleading because there is actually a broad range of chromosomal makeups (sex), sexual attractions as well as gender identities, and gender identity and sexual attraction can be completely independent. For example, someone can be a transgender woman, and be attracted to either men or women or both. Robin pointed out that some transgender women can look like glamorous women, and two transgender women have actually won national beauty contests. "It is cruel," Robin suggests," to insist that transgender women must use men’s bathrooms, just because they have the XY chromosome set." She pointed out that gender identity usually develops by age 7, but in trans individuals the incongruity between their gender identity and sex assigned at birth crystallizes at around age 10 or 11, during puberty. Although many transgender people recall being gender nonconforming and/or identifying as another gender in early childhood, we now know this is not always the case. We discussed the pain of discrimination trans individuals face, and Robin described her own suicide attempt in her early twenties, in part because her male sexual organs and secondary sex characteristics like facial hair “disgusted me.” Fortunately, she was assigned a very understanding gay psychiatrist in the hospital, and he said that she could start transitional hormone therapy right away if she was interested, and this was a great help. She said that she was a candidate for the Olympic wrestling team, and it was clear that she did not appear feminine to others because of her muscles, and she experienced a great deal of ridicule and rejection when began to transition. This negative bias included some medical professionals she consulted for help. Eventually she was able to obtain gender-affirming surgery. She said she came out as gender-diverse in March 2023 to be an advocate because 24 states in just the past three years have banned gender-affirming medical care for minors. Robin also clarified the meaning of the term, queer, which used to be a pejorative term. Now it is embraced by the LGBTQ community as a term referring to all sexual and gender minorities. Toward the end of our interview, Robin emphasized the importance of hope, and said she had a “glimmer” of hope, even in her darkest hours. To learn more about Robin’s pioneering work, or if you are interested in the science and research regarding transgender issues, Robin warmly invites you to visit her YouTube channel, (27) Robin Mathy - YouTube. She says, “Please feel free to disseminate the information” and wants you to know that “I love comments (positive and negative).” So give her some feedback if you’re so inclined! Thanks for listening today! Robin, Rhonda and David

Overcoming Loneliness Part 2-- A Master Class on the Feared Fantasy Technique Featuring Dr. Orly Marmur This is the second of a two-part series on loneliness, featuring the courageous personal work of Dr. Orly Marmur with Drs. David Burns and Jill Levitt as co-therapists. After Orly shared her story, we worked on helping her learn to use the Five Secrets, especially the Disarming Technique and Inquiry, to develop closer relationships with others. Jill described the philosophy of this approach as learning to be ”interested” in others—encouraging them to talk about themselves—rather than trying to be “interesting" or "impressive," which is usually a losing battle. We also worked with the Feared Fantasy technique to help Orly deal with her fear of rejection. Essentially, we explained that we would enter an Alice-in-Wonderland Nightmare World where there were two weird rules:. If you think people are judging you or looking down on you, they really are! In this Nightmare World, people are not polite but get right in your face and tell you all the negative thoughts they’re having about you. We asked Orly to describe the worst criticisms she thought her friends might have about her. Here’s the list: We’re not really interested in you. You don’t really say or create anything interesting. You are by yourself. We have families. You’re not funny enough. You’re not fun enough. You’re too intellectual. You’re too political. You’re a liability. Orly bravely took the role of herself to kick things off, and Jill and David played the role of the “friends from hell,” and verbalized these criticisms to Orly. At first Orly struggled to respond effectively to the critical statements. She got stuck defending herself at times, and forgot to express interest in the critic and the specific criticisms. David and Jill modeled more effective responses, using the Five Secrets of Effective Communication, including The Disarming Technique (finding truth in the criticisms), Inquiry (ask for more information with a spirit of curiosity) Thought and Feeling Empathy (acknowledging how the critic was thinking and feeling) “I Feel” Statements (sharing feelings like sadness, shame, and loneliness in an open, respectful way) and Stroking (expressing positive regard for the critic, even in the heat of battle). Orly did a fantastic job, as you’ll hear on the podcast, and we did some role reversals to refine certain responses. The goal of the Feared Fantasy is not so much to prepare for rejection in the real world, since very few people would ever say these things in such a harsh and open way. The Feared Fantasy “Monster” actually exists primarily in your own mind. But since most of us never think about the thing we fear, we don’t realize or discover that the monster has no teeth. That is to say that by engaging with your greatest interpersonal fears, you discover that if someone were to attack you with over the top vague criticisms, you would survive, and it would reveal something terrible about the other person, not about you! The Feared Fantasy Technique brings this to life in a dramatic, emotional, and vivid way. At the end of the session there was a dramatic reduction in all of Orly's scores on the Emotions Table of her Dailly Mood log. Her Unhappiness dropped from 40 to 0 Anxiety dropped from 100 to 5 Shame went from 85 to 0 Worthlessness dropped from 95 to 0 Loneliness fell from 100 to 10 Self-consciousness fell from 8 to 5 Hopelessness fell from 100 to 5 Stuck and defeated fell from 100 to 0 Resentment fell from 90 to 0 Disappointed in myself fell from 100 to 0 As you can see, there was a dramatic reduction in all of her scores. We asked Orly what the most important healing elements during the session were. What techniques were that were most helpful. Orly said that the empathy from Jill and David was really important as she felt heard and accepted. The Feared Fantasy Technique also made a huge difference, as it taught her what she wanted, which was to feel intense feelings without doing anything about them. Orly felt that this is the continuation of earlier work that made her realize that she struggles with Emotophobia (which means “the fear of feeling your emotions), and she wanted to increase her capacity to simply feel. Rhonda, Jill, and David want to give a shout out and virtual hug to Orly for a most fantastic session and learning opportunity for all of us. Teaching Points Here are a few teaching points for therapists as well as the general public. The secret of meaningful relationships is to be interested in others instead of trying to be “interesting” or impressive. You do not need to add more accomplishments to the list in order to feel close and loved by others. The Disarming and Inquiry Techniques (which are parts of the Five Secrets of Effective Communication) are extremely important in calming troubled relationships, if used skillfully, because they open the door for the other person to be heard and validated, and hopefully interested in healing and repairing the relationship. When you use the Feared Fantasy Technique, you discover that the rejecting “monster” you feared has no teeth, and you may also discover that you are the one who created it. In other words, the “monster” you’ve feared was always just the projection of your own self-criticisms! The Feared Fantasy is an intense method that can be helpful when the patient feels “trapped” or intensely afraid of rejection. However, it requires a strong foundation of trust between the therapist and the patient, especially when you respond to the “monster’s” criticisms with acceptance and vulnerability. The more “over the top” the criticism is in the feared fantasy, usually, the more successful the method is, because you discover two things: 1) that the extremely harsh criticisms reveal something negative about the critic, rather than about you, and 2) specific criticisms (e.g., “you haven’t read enough books”) are very easy to agree with and disarm and do not have to hurt your ego! Rhonda pointed out that during the early empathy phase of the session, Jill and David did “very basic, simple empathy” without any attempt to cheerlead or “help.” Very few therapists can do this, and most therapists don’t even realize that their empathy / listening skills are poor. The use of David’s empathy scale at the end of every session with every patient can be extremely eye-opening for therapists who are brave, because you will see how your patient really sees you and rates your empathy skills. Effective therapy is highly individualized and rarely or never formulaic. Orly started out by asked for help with symptoms of PTSD that started the day of the horrendous slaughter of many Israeli citizens by the invading Hamas fighters. But the session evolved into something entirely personal involving Orly’s relationships with herself and with other people. In the end, Orly worked on accepting herself, connecting with others, and reducing her own perfectionism and perceived perfectionism, a therapeutic agenda that emerged as David and Jill empathized and collaborated with Orly. This led to Orly feeling less lonely, isolated, and numb, and more able to feel her feelings! Follow-up (many weeks later) Orly reported that she has felt “calm and quiet” since her session. She has definitely attempted to use the Disarming and Inquiry Techniques in several relationship situations, but said that the most important change has been her feelings of “inner calm and peace of mind.” She said that she is no longer so invested in doing for others or attempting to show people that she is there for them. She simply lets things unfold naturally and is now able to let go and accept it when things she hoped for don’t happen. This may be related to reducing her underlying beliefs around perfectionism and perceived perfectionism that were targeted in the feared fantasy work that she did during the session. Instead of thinking that she has to be impressive in order to be loved, she has learned to accept herself, which is arguably the greatest change a human can make! For those who might be looking for a bottom line, I (David) might summarize Orly’s subtle but remarkable change as a boost in acceptance of self and the world—a result that is easy to explain, but difficult for most people to comprehend, and even harder implement in our own lives. A big thanks to you, Orly, for teaching all of us through your own courageous personal work as the New Year unfolds and hopefully offers more world peace and increased love and connection. Thanks for listening! Warmly, Rhonda, Jill, Orly, and David

Overcoming Loneliness Part 1-- How to Develop Loving Relationships Featuring Dr. Orly Marmur This is the first of a two-part series on loneliness, featuring the courageous personal work of Dr. Orly Marmur with Drs. David Burns and Jill Levitt as co-therapists. Orly is a clinical psychologist from Southern California and member of our Tuesday TEAM-CBT training group at Stanford. She loves to hike, and recently went on a 25 mile solo hike from the North to the South Rim of the Grand Canyon, an arduous hike that she planned for a long time She happened to be hiking on October 7, 2023, the day of the Hamas invasion of Israel. The hike was a huge victory for Orly, but when she arrived at the top of the South Rim, her cell phone was instantly bombarded with news and emails about the Hamas invasion and brutal murder, beheading, and rape of many innocent Israeli citizens. For the next several days, Orly’s mind was flooded with flashbacks of her life, growing up in Israel when the country was still young, and living through four wars. Her father and brothers were in one war together, and her brother was wounded, but survived and recovered. Orly felt guilt and shame because she was not there to help. She said that she wanted to go to Israel to help her brother with his farm, but was conflicted because she did not want to abandon her clinical practice in Southern California. She explained: I grew up with the people who started the State of Israel. Those were idealistic, heroic times. My grandmother left Europe when she was 17 and settled in Israel. The focus was on building. We learned to be heroic. A few days later, in the Tuesday group, David noticed that I was feeling down and lonely unable to focus and “checked out.” I had a hard time feeling my feelings. I had shut down. I began being flooded with memories of sexual molestation at my grandparents’ house when I was a girl in Israel. I remember standing next to a tree, and feeling like I was “different” from the other kids, I started feeling sad and guilty about losing so many relationships over the years. I’ve alienated so many people, and now I want to accept responsibility for that. When my daughter was 1 year old, I became friends with other parents at the day care center. We became like an extended family as our kids grew up, getting together on Fridays for dinner, celebrating holidays together and being there for each other. However, during the pandemic, I began to feel rejected by them. And sometimes there were individual rejections. We had often camped out together over the years, but all of a sudden, I was not invited. I was the only single person. The rest of the group are couples. Over the years, I was told a few times that, at times, my presence makes things difficult. Since then, I’ve been invited to some but not other functions of our group. I haven’t felt like people are interested in me, or like me. I also want to feel my feelings and develop a sense of empathy for others and greater pride in myself—after all, I DID survive. I became very politically active with others interested in supporting Israel after the October 7th invasion. I was hoping to feel close to people, but it didn’t work because I still felt alone. I had hoped they’d be impressed with my political activism, but it didn’t help. My problem was not the war, but me. I’m hoping today you can help me to feel my feelings again! I realize that I tend to jump to action rather than feel my feelings. I think that it has to do with my upbringing and the circumstances and culture that I came from. Next week you will hear the exciting conclusion to the work with Orly, and a follow-up several weeks later. Orly's Daily Mood Log. End of Part 1 Thanks for listening today! Rhonda, Jill, Orly, and David

The Anxious Child— Three Common Errors Parents Make, and How to Avoid Them! Featuring Dr. Taylor Chesney Today we interview Dr. Taylor Chesney who is the Director of the New York office of the Feeling Good Institute. She specializes in the treatment of children and teens, and today will tell us about the three biggest errors parents make in dealing with anxious kids. Dr. Chesney has been a guest on several of our podcasts in the past (episodes 107 and 263, and Corona Casts 4 and 6) and is a terrific teacher and therapist. She recently taught a 12 week course for therapists working with teens and children (ages 6 to 18) and their parents and brings us some of the highlights today. She always begins treatment by interviewing the child and the parents and pinpoints what they want help with. Then she assesses how hard they are willing to work to bring about that change. The goals may be quite different for the child and the parents. It’s crucial to develop a meaningful therapeutic contract with the children, as well as the parents, as opposed to thinking your role is to “fix” the child for the parents. If the child is less than 11 years old, she meets with the parents first. If the child is 12 and up, she meets with the child first. Either way, she empathizes with the child and encourage them to tell their side of the problem. During or after empathizing, she does Positive Reframing, to show the child what their negative feelings, like depression and anxiety, show about them that’s positive and awesome. For example, if you’re sad about not being invited to a birthday party, it shows that you value friendships, and that you care a lot about other people. If the child is anxious, she will teach them how their anxiety can be helpful. For example, if the child is a good athlete or student, anxiety can be an important motivating force in their success. But sometimes we might get too anxious and feel intensely anxious about something that is not actually dangerous. Then you might experience your anxiety as trouble eating, a belly ache, trouble sleeping, or some other symptom that gets in the way of your optimal functioning. The most important question with parents and children is usually: “Do you want to learn some tools and skills to help you change the way you feel?” She also teaches children and teens what different kinds of emotions are, and the kinds of thoughts that trigger them. For example, if you feel anxious, you’re probably telling yourself that you’re in danger and that something bad is about to happen. If you feel guilty, you’re probably telling yourself that you’ve done something bad, or that you hurt someone you love; and if you’re feeling angry you may be telling yourself that someone is trying to hurt you or take advantage of you. Taylor brings the core cognitive therapy ideas to life with examples that children can understand. Here’s how she explains the idea, taught by Epictetus nearly 2,000 years ago, that our feelings do not result from what happens to us, but from our thoughts about what’s happening. Let’s say that you got a 90 on a test. How would you feel? You might feel overjoyed if you studied hard and felt like you did a good job and got a wonderful grade. However, if you felt like you had to get a 95 to raise your semester grade in the class to an A, and you even skipped going to the prom to study extra hard, you might feel sad, ashamed, frustrated, angry, and disappointed, telling yourself that you “failed.” Same grade, but two radically different emotional reactions, depending on how you think about your grade. Conclusion: it’s not what happens, but what you tell yourself, that triggers all of your positive and negative feelings. Taylor said that anxiety is incredibly common in her clinic population and that surveys indicate that a whopping 25% of children have an anxiety disorder. She teaches her patients that anxiety in children, teens, and adults results from giving in to the urge to escape from a frightening or uncomfortable situation instead of facing your fears and discovering that the monster has no teeth. For example, Taylor was in the ocean with her 9 year old son, and there were jellyfish in the ocean. Her son was terrified and wanted to get out of the water and back to the shore. Taylor asked him what he was telling himself, and he said he was thinking that the jellyfish were bad. She also told him, “It’s okay to be afraid and to be careful and avoid the jelly fish, but you can also choose to stay in the ocean. Then we can have some fun together playing in the water.” He decided to stay and have fun and felt proud of himself! She described Three Common Mistakes parents make in dealing with an anxious child. Error #1: The Quiet Out Trap She explained that we love our children, and don’t want them to suffer, so we may give them an easy way out. For example, if your child is afraid to go to the party when you are dropping them off, you might say, “If you don’t want to go to the party, we can go home.” This seems like a kind and loving thing to do, protecting your child. However, you’re teaching the child that he or she can escape from anxiety through avoidance, so the child’s fear of social interactions actually increases. It also teaches the child that you don’t think they can handle the situation. An alternate response would be to say, “Let’s go in and sit down together!” She advised against cheerleading or trying to convince your child that they have nothing to be afraid of (e.g. “it’s not that scary” “there’s nothing to be afraid of.”) Instead, you can tell them that it’s okay to feel the fear but do it anyway, and you can often model that together with them. Error #2: The Escalation Trap In this trap, you let your fearful and avoidant child become more and more anxious and demanding, until they freak out and throw a temper tantrum, and then you give in to them. This, again, provides immediate relief, but in the long run you are training them to escalate and throw a tantrum to escape from having to face their fears, and on a broader scale, any time they want to get what they want. Error #3: The Mental Filtering Trap Mental Filtering is one of the ten original cognitive distortions, and it means focusing on the negatives in any situation and ignoring, or discounting the positives. It’s a common cause of depression, but can also be a communication error if you focus excessively on what your child is doing wrong. Instead of pointing out your child’s errors, you might say, “Johnny, I love how you stayed calm when X happened. You’re really getting good at that.” In other words, you can comment on what they are doing right. She said that showing kids how to be successful is more effective than berating them for what they’re doing wrong. This is an effective and low-stress way of reshaping their self-defeating behaviors. David mentioned that this positive style of communicating can also be highly effective in a work environment, and that he uses it a great deal in his interactions with colleagues on the app team. If done in a genuine way, it can quickly reduce conflict and enhance morale and mutual respect. How to Teach Parents David asked Taylor if many parents resist implementing these kinds of changes. Taylor said that if she calmly and clearly teaches the parents what they’re doing that isn’t working, using the Five Secrets of Effective Communication, most parents quickly become motivated to grasp their mistakes and change their strategies in dealing with their children. Taylor also “Sits with Open Hands” when making suggestions to parents. She explains it like this: This means that if what the parents are doing works for them, and they aren’t willing to work hard to make changes, I accept this. But if they’re willing to work hard and change, we can work together to help them implement more effective parenting strategies. Getting parents to work together as a team can be very important, but some parents may fight over the best way to discipline and raise their kids. These conflicts between mom and dad are one of the major causes of the unhappiness in the kids and get in the way of change. Taylor emphasizes “Little Steps for Big Feets,” and might set small attainable goals for the parents who are at odds. For example, can they just sit next to each other and perhaps even “fake” a unified front for one conversation? Parents do not have to commit to making these changes “for the rest of their lives,” but make experimental small changes instead, for a small discrete period of time, and then check in and see if the change makes a difference. If it does, they may be motivated to continue to try to implement more changes. Taylor typically works with children and their parents for 12 to 16 sessions and gives them a tool set to change some specific problem they came to therapy to solve. She has worked virtually for the most part since the start of the pandemic, but is now starting to see some people in person again. She offers classes for mental health professionals and also runs a monthly case consultation group on the last Wednesday of every month from 12:30 – 2 pm EST. For more information, you can reach Dr. Chesney at Taylor@FeelingGoodInstitute.com. Every fall, Taylor teaches a 12-week training course for therapists on TEAM-CBT for children and adolescents. You can also check the www.FeelingGoodInstitute.com website for more information on TEAM-CBT training for children and adults. Thanks for listening today! Rhonda, Taylor, and David

Personal Work with Dr. Tom Gedman-- Overcoming Performance Anxiety The Triumphant Conclusion Last week you heard Part 2 of our personal work with Dr. Tom Gedman, which included T = Testing and E = Empathy. This week you will hear the dramatic and inspiring conclusion of the session, including A = Assessment of Resistance and M = Methods. Dr. Tom's beloved pal Start of Part 2 A = Assessment of Resistance We began with the Invitation Step, asking Dr. Gedman what he hoped to accomplish in today’s session. His list included: Develop some clarity on the direction of my business. Become more authentic in my video recordings promoting my clinical work. Increase in self-confidence. Feel accepted by David and Rhonda. My ability to push ahead during recordings instead of stopping and backing down because it isn’t “good enough.” Dr. Gedman said that he’d gladly push the Magic Button to make his negative thoughts and feelings instantly disappear, but agreed to look at some of the positives in them first by asking these types of questions of each negative thought or feeling. Is there some truth in this negative thought? Could this negative thought or feeling be appropriate or even healthy, given my circumstances? How might this negative thought or feeling be helping me? What does this negative thought or feeling show about me and my core values that’s positive and awesome? Could there be some negative consequences of giving up this negative thought or feeling? The Positives in My Negatives Negative thought: “I can’t be authentic on videos. I look like such s smug phony.” I want to be other-centered, and focused on how I might be able to relieve the emotional struggles and health problems of my patients. I value being authentic and genuine. I want to help people who resonate with my message. I don’t want to hide. I want to be open with my flaws. I value honesty and integrity. I value humility. I value compassion. Negative feeling: sadness I care a great deal about my dream. I don’t want to fail and let my family down. Negative feeling: shame Motivates me to work harder Shows my love for my family. I’m aware that I’m letting down the very people I want to help. Negative feeling: inferior, inadequate Show that I respect and admire the many people who have superior skills at talking live in front of a camera. Shows that I’m aware of what others have accomplished. Shows I don’t feel superior to others. The idea behind the Positive Reframing is to help the patients see that their negative thoughts and feelings are not the expression of what’s “wrong” with them, but what’s right with them. This paradoxically reduces the resistance to change and opens the door to the possibility of rapid recovery. You can see Dr. Gedman’s goals for each of the negative feelings on his Daily Mood Log if you click here. As you can see, instead of trying to eliminate his negative thoughts and feelings by pushing the Magic Button, he has decided to dial them down to lower levels with the Magic Dial. Of course, these are only goals. We will need methods to challenge and smash his negative thoughts so we can reduce his negative feelings. M = Methods Rhonda, Tom, and David used a variety of methods to work on several negative thoughts Tom wanted to work on first, including numbers 1, 2, and 4 from Tom’s Daily Mood Log.. I can’t be authentic. I look like a smug phony. 100% I waste so much time on my videos. I should be quicker. This should be easier. 100% David and Rhonda will judge me for what I’m doing. 80% We used several methods including Explain the Distortions, Survey Technique, Externalization of Voices (with Self-Defense, Acceptance Paradox, Counter-Attack Technique,) and more You can see Dr. Gedman’s end-of-session scores on his nine negative feelings on his Daily Mood Log if you click here. As you can see, eight of the feelings fell all the way to zero, and his feelings of inadequacy fell from 100 all the way to 5. Toward the end of the session, we discussed Tom’s medical and psychological philosophy, which might appeal to some of our podcast fans, especially if you live in England. First, he uses TEAM-CBT in individual two-hour sessions to help help people who are struggling with feelings of depression and anxiety. He finds this work thrilling because you can often see amazing changes within a single session, just like we saw in Tom’s work today. Dr. Gedman also hopes to develop TEAM-CBT groups as well. This can be difficult because you need many referrals, but in my experience, TEAM groups can be incredibly effective, and cost-effective as well. In addition, Tom also has a Functional Medical Practice which focuses on developing healthy nutritional and eating habits, consistent exercise, limiting the intake of toxins, developing loving relationships via the Five Secrets of Effective Communication, and enhancing spirituality. If you would like to contact Dr. Gedman and learn more about his clinical practice, he can be reached at www.DrTomGedman.com. Toward the beginning of these show notes, I reminded everyone of how anxious and insecure our beloved Rhonda felt at the start of our work together, when she took over for Fabrice. And now, she seems to be the poster child for charm, warmth, humor, and charisma. That doesn’t usually happen automatically. Rhonda, like Tom, did her hard personal work, using the Daily Mood Log and several TEAM-CBT methods. But one thing that has been especially helpful to her, after initially “beating” her insecurity, has been the constant exposure work, with hours of weekly podcast recordings. I, too, have had the chance to do constant, ongoing exposure for my own extreme feelings of inadequacy in front of live audiences or cameras, since I teach every week at my Stanford psychotherapy training class, as well as frequent workshops, In addition, I have recorded almost daily for the Feeling Great App, which should be released in the first quarter of 2024. This exposure work has helped me cement and extend my gains in overcoming my own performance anxiety. I plan to contact Tom to recommend the same. Perhaps in England they have program similar to Toastmasters, where you can have the chance to speak in public frequently and get valuable feedback from peers and colleagues. I want to give a big hug and thanks to you, Tom, for sharing your intensely personal and real personal work with all of us today, and thanks, too, for reminding us of our own humanity and the magic of humility and the “Great Death” of the “Self.” Thanks for listening today! Tom, Rhonda, and David

Personal Work with Dr. Tom Gedman-- Overcoming Performance Anxiety Have you ever struggled with Performance Anxiety? That can include public speaking anxiety, as well as anxiety when having to perform in an athletic or musical event, or speak on the radio, TV, or internet , etc. This is one of the most common forms of anxiety that we see in mental health professionals, as well, of course, in general citizens, including children, teens and adults. Today you will hear Part 1 of the live work with Dr. Tom Gedman, a British physician struggling with intense performance anxiety, including the initial T = Testing and E = Empathy. Next week, you’ll hear Part 2 of the session as David and Rhonda do the A = Assessment of Resistance and M = Methods portions of the work with Dr. Gedman. You may recall Dr. Gedman from our previous podcast (# 348). Recently, Dr. Gedman has wanted to promote his new programs on health and mental health in brief videos he plans to publish on social media sites, but finds himself crippled by negative thoughts that make him freeze up in front of the camera, like these: I’m not good at this. 100% I can’t be authentic. 100$ I’ll look like a robot! 100% Tom practices in England as a family practice doctor, but has decided to work part time for the national health service while he establishes his clinical practice because he is only permitted to spend 10 minutes with each patient. He has developed a love affair and expertise with TEAM-CBT, and wants the freedom to practices in the way he wants, offering two-hour individual and group sessions, where he emphasizes the integration of physical with mental health. But this means having to advertise his clinical practice to solicit patients, and this is a bit of a treadmill because of the rapid changes he sees in so many of his patients. Hence, his urgent need to overcome his public speaking / performance anxiety. I have a soft spot in my heart for anyone who’s struggle with these types of anxious thoughts and feelings, because I have encountered them on many occasions in my professional career when I had to present my work in conferences, or even when attending receptions that included other mental health professionals. In fact, I am the “voice” on the Feeling Great App that I’ve been developing over the past several years, and it took me some time to get comfortable with the recordings, since I told myself that I “had to sound natural, spontaneous, and inspiring.” Of course those internal and external demands caused the exact opposite—feelings of tension, insecurity, pressure, and intense self-doubt, resulting in “robotness” as opposed to spontaneity! Yikes! It was a dreadful battle for a while! So, I KNOW how Tom has been feeling. And our beloved Rhonda has been there, too, especially when she took over from Dr. Fabrice Nye as host of the Feeling Good Podcast that you’re listening to right now. If you recall, she was feeling pretty darn insecure! (See Podcasts # 142 and 143.) Perhaps you’ve also struggled with social or public speaking anxiety, and felt insecure, panicky, frustrated, or ashamed? Have you? Even in our weekly training group at Stanford for mental health professionals, these feelings are rampant and nearly universal. Part 1 of the work with Tom T = Testing Tom brought a partially completed Daily Mood Log to today’s session. You can review it if you CLICK HERE. As you can see, he was feeling nine different categories of negative feelings, all intensely, with estimates ranging from 70 to 100. This is why T = Testing is necessary for all mental health professionals, regardless of your so-called “school” of therapy. People, like Tom, may look attractive and filled with enthusiasm and joy on the outside, and still be experiencing EXTREME levels of distress inside. The T = Testing vasty improves your accuracy in understanding how your patients are feeling. It also makes you accountable, which can be sobering, because we will again ask Tom how he’s feeling at the end of the session. The improvement, or lack of improvement, will tell us EXACTLY how effective, or ineffective, we were today in our work with Tom. This is a great bonus for therapists who are courageous enough to use my Brief Mood Survey at the stat and end of every session, with every patient, because your patients become your best teachers, by far. But it’s also a threat, because the numbers don’t lie, and you’ll also be confronted by your ineffectiveness with many of your patients / clients. Sadly, a great many therapists would prefer not knowing the truth! E = Empathy Although Tom had previously defeated these anxiety-provoking thoughts and reached a state of relative enlightenment and joy, the thoughts have come creeping back into his psyche. That’s one of the things about anxiety. Once you’ve beaten it, you have to keep up the assault with frequent, ongoing exposure, or the anxiety will once again invade your brain and body. But the good news is that the methods that helped you initially are very likely to help you again, and if you continue using exposure after your first recovery, you can greatly reduce the probability of relapse. These are the methods that helped Tom in the past: Positive Reframing of his negative thoughts and feelings following the initial E = Empathy phase of his session. Externalization of Voices Survey Technique Self-Disclosure (vs hiding) of his negative feelings of insecurity Tom said, Those techniques worked like magic when David and Mike Christensen did a live demonstration with me several months ago at a TEAM-CBT conference in England. I opened up about how I was feeling inside, and sobbed for several minutes during the session. Then I developed amazing relationships with colleagues at that conference. I was on a high for several months. The TEAM-CBT session was life-changing. It gave me my life back. But now I’ve lost my way again. Can those methods help Tom again today? You will get the chance to look behind closed doors as Rhonda and David do some personal TEAM-CBT work with Tom. Tom continued to explain his situation as Rhonda and David empathized. I’m very passionate about the work I want to do, but when I try to convey my message, I tighten up. . . I did 18 takes on a brief message to promote my new practice, but I just wasn’t authentic. I felt enormous pressure to entertain. If I don’t get over this, people will think I’m a quack. I’ll get criticized. The work I do with patients behind closed doors has been amazing. personal The last couple patients I saw got their mood scores down all the way to zero. Those sessions were intensely exciting! But how can I get the word out to the many people who need help with feelings of depression and anxiety, as well as poor habits of exercise and eating? I’m just not earning much money now. My wife is working long hours to support our family while I’m trying to guild up my clinical practice. I feel so guilty. I take care of our three-year old son. On Monday, I felt so frustrated and discouraged that I felt like I was on the verge of a breakdown. I feel sad and worried that things won’t pan out. It’s high stakes. . . I’ve always been a perfectionist. It’s helped me, but it’s also held me back. I’m just angry at myself for not getting myself out of this desperate situation. Rhonda and David paraphrased Tom’s words and acknowledged his intensely negative feelings as he spoke, without trying to be helpful, and without making interpretations or trying to cheer him up. Then we asked Tom to give us a grade on empathy, thinking of these three aspects of effective: How well did we understand how Tom was thinking? How well did we understand how he was feeling inside? Did we create a sense of warmth, connection and acceptance? Tom gave us an A. Next week, you’ll hear the dramatic conclusion of our session with Tom, including the A = Assessment of Resistance and the M = Methods, and, of course, the final T = Testing to find out if the session was helpful! End of Part 1 Thanks for listening today! Tom, Rhonda, and David

Rhonda Describes the GRIP Program and Interviews GRIP Graduate, Shakur Ross The Guiding Rage Into Power (GRIP) Training Institute serves incarcerated men and women in California. Their mission is to create personal and systemic change to turn violence and suffering into opportunities for learning and healing. I (Rhonda) was introduced to the GRIP program when two of my dearest friends, Steve Zimmerman and Vicki Peet, invited me to a yearly celebration of the GRIP Training institute. I was blown away by who I met and what I learned that I wanted to share it with the Feeling Good Podcast listeners. Thank you, David, for letting me deviate from our typical subjects. The GRIP program is a different subject for the Feeling Good Podcast, because it is not about TEAM-CBT. What the GRIP Program and TEAM-CBT have in common is that they are both evidence-based programs that incorporate CBT theory and methods into their treatment methodology. But the main thing they have in common is that people who engage in these two therapies experience profound, enlightening changes in their lives. From their program: “The GRIP program is an evidence-based methodology developed over 25 years of work with 1000’s of incarcerated people and many victim/survivors. Rooted in Restorative Justice principles, the program’s trauma informed model integrates cutting-edge neuroscience research. Students engage in a yearlong, in-depth journey to comprehend the origins of their violence and develop skills to track and manage strong impulses rather than acting out in harmful ways. They transform destructive beliefs and behaviors into an attitude of emotional intelligence that prevents revictimization.” The GRIP Training Institute was started in 2011. As of October 2020, nine years after running its first group, 915 students have graduated. Of the 915 graduates, 369 were released from prison. Only 1 graduate in nine years returned to prison, which is a recidivism rate of 0.3%, which is very impressive considering the recidivism rate for California is between 44-46%. Many, if not all of the graduates, say that GRIP saved their lives. Something many people who have benefitted from TEAM-CBT echo. At the GRIP celebration, I was standing in line waiting for the buffet. A man got in line behind me. It was confusing where the line ended, which was not directly behind me. In another circumstance I might have mentioned to him that the line ended somewhere else, but he was kind of scary looking, big, buff with obvious prison tattoos on his neck so I didn’t say anything. But the line moved slowly and I was curious so I asked him what his connection to GRIP was. He told me he was a graduate of the program and then politely asked me the same question. It has been my experience that often people love to talk about themselves more than they are interested in other people so I was immediately impressed that he was as interested in me as I was in him. When I told him I was a therapist, he asked me what kind of therapy I practiced. I explained TEAM-CBT, and he was super interested! He told me he loved CBT, and had learned a lot about himself through that kind of therapy because GRIP incorporated it in their program. I asked him about his experience in GRIP and his tough exterior transformed right in front of me as he talked about how GRIP saved his life. I talked to several other men (so far only men have graduated from the GRIP program because the services have only recently been brought to a women’s prison), and had the same experience. I met our guest on this podcast, Shakur Ross, who kindly agreed to share his journey of transformation with us. GRIP graduates continue to do the work and live as Peacemakers. Shakur works for GRIP and returns to San Quentin and other prisons to provide the same lessons that he received. The podcast starts with an interview with Kim Moore, the Executive Director of the GRIP Training Institute, who explains some of the key concepts of the program. Thanks for listening today! Rhonda

Jessica Malvicino Live Work With Jessica-- Living with Regrets Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our “patient” was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you’ve also looked back on your life and thought, “If only I would have . . . “ done something I didn’t do,” as well as, “I wish I hadn’t done X, when I was young.” Last week you heard the initial Testing and Empathy portions of the session with Jessica. Today you'll hear the Assessment of Resistance, Methods, and final Testing.. Part 2 of the Jessica Session A = Assessment of Resistance Jessica said her goal for the session was learning to accept life and move on, and not have such constant feelings of emptiness, with so many “I should have” thoughts running through her brain. Although Jessica, like most people, said she’d press the Magic Button to make all of her negative thoughts and feelings disappear, we decided to do some Positive Reframing first, to see if there were some positives hiding in her negative feelings. We asked the following questions about a number of her negative feelings and thoughts: Why might this thought or feeling be appropriate and healthy? Why might this thought or feeling be helpful to you? Why does this thought or feeling show about you and your core values that’s positive and awesome. ? As you probably know, the goal of there are two goals for this paradoxical exercise: First, we want to bring the patient’s subconscious resistance to conscious awareness. Second, we want her to see that her struggling and suffering is NOT the result of what’s WRONG with her, but rather, what’s RIGHT with her. The moment that people really “see” and “get” this, there’s often a sharp and sudden reduction in feelings of shame, and a strong burst of motivation to crush the negative thoughts at the heart of her misery. Here are some of the Positives we listed: SADNESS My sadness shows my passion and love of dancing. It shows my dedication to the idea of having a fulfilling career. It shows that I’m a very loving person. ANXIETY, WORRY, NERVOUSNESS These feelings show that I’m responsible motivate me to complete tasks help me avoid procrastination make me vigilant and protect me from danger SHAME These feeling show that I’m concerned about others I’m human I want to please others with my career I admire my mom and want to make her proud I want her to admire me I’m humble I want to feel close to others ANGER These feelings show that I’m a caring and passionate person I have character I have a moral compass I’m feisty and strong I’m accountable My anger also empowers me After listing these and other positives, Jessica decided to use the Magic Dial to reduce her negative feelings to lower levels, but not necessarily all the way to zero, as you can see in the goal column on her emotions table: Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90 20 Foolish 100 0 Anxious, worried, nervous 90 10 Discouraged 97 5 Bad, ashamed 95 0 Frustrated, stuck, defeated 100 5 Inadequate 90 0 Angry, mad, resentful, annoyed 95 10 Lonely 92 5 Other Then we went on to M = Methods These were some of the negative thoughts that Jessica wanted to challenge, along with the percent she initially believed each of them: I’m a failure. 90% My mom is to blame for not understanding the career path that I wanted. 90% I was an idiot for not following my dreams. 100% Nothing will truly fulfill my professional career. 100% I have to “settle” for my professional career now.100% She had many others ad well. We used a variety of techniques to challenge and crush these thoughts, including the Externalization of Voices with Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique), and used frequent role reversals to help Jessica get to “huge” wins when she was in the role of her positive thoughts. Here you can see Jessica’s scores in the “% After” column. As you can see, her scores were extraordinarily low, which is terrific. Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90 20 0 Foolish 100 0 3 Anxious, worried, nervous 90 10 0 Discouraged 97 5 0 Bad, ashamed 95 0 0 Frustrated, stuck, defeated 100 5 10 Inadequate 90 0 0 Angry, mad, resentful, annoyed 95 10 5 Lonely 92 5 0 Other Typically, such drastic and sudden reductions in negative feelings not only indicate “recovery,” but the experience of feelings of joy and enlightenment. At the end we asked Jessica two questions: Are the scores valid, or is she just trying to please us? If they are valid, what were the most healing and helpful aspects of the session? As you listen to the end of the live session, you’ll find out what she said! Rhonda and I hope you enjoyed the session with Jessica. We believe that live work with real people, and not role players who are pretending to be in therapy, is invaluable, and one of the best—and only—ways to learn many of the subtleties of rapid and effective treatment. And if you are a general citizen, and not a therapist, I hope your found our work with the brave and wonderful Jessica to be inspirational and educational, especially if you have also sometimes felt depressed, anxious, or ashamed, and if you have found that regrets about the past can put a real damper on your capacity to live and enjoy your precious present moments! Our best teaching is usually through live work, and so we give you, Jessica, a warm thanks and salute for the great teaching YOU have done today! Thanks for listening, everybody! Jessica, Rhonda and David

Live Work With Jessica-- Living with Regrets Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our “patient” was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you’ve also looked back on your life and thought, “If only I would have . . . “ done something I didn’t do,” as well as, “I wish I hadn’t done X, when I was young.” Today you'll hear the initial Testing and Empathy portions of the session, and next week you'll hear the Assessment of Resistance, Methods, and final Testing.. Part 1 T = Initial Testing DAVID WILL SUMMARIZE SCORES ON BMS AND DML You can also see her scores on the emotions table of her Daily Mood Log here. Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90 Foolish 100 Anxious, worried, nervous 90 Discouraged 97 Bad, ashamed 95 Frustrated, stuck, defeated 100 Inadequate 90 Angry, mad, resentful, annoyed 95 Lonely 92 Other As you can see, these negative feelings were all incredibly intense. E = Empathy Jessica, who grew up in Florida, explained that she started ballet dancing at the age of 3, and when she was 17, she won a prestigious full scholarship to study and have the chance to join a world renowned ballet company. Jessica was incredibly excited, but her mom did not see ballet as a “true career.” In addition, her mother was quite protective, which was not uncommon in the Cuban community, and told Jessica she could only accept the scholarship if she agreed to live with her grandparents in New York. Jessica angrily rebelled and turned down the offer. Although she continued to dance professionally until her first daughter was born 14 years ago, she battled with feelings of anger and regret the entire time, while also blaming her mother for her. unhappiness. She eventually got a bachelor’s degree in journalism, and worked in television for a period of time. Then she got a master’s degree in counseling, and found that she loves clinical work and helping people. However, she continued to live with feelings of regret and anger directed at her mom from age 17 to her current age of 40, for a total of 23 years, and explained that she frequently “takes it out” on her mom during periods of irritability. She also has feelings of grief about what she’s lost when she see her young niece dancing ballet beautifully now. This statement brought tears to her eyes. Jessica described all the sacrifices she’d made when growing up in order to become a top dancer, including periods of bulimia to maintain the thinness that her teachers always stressed. She explained that “everyone did it—they weighted us frequently and would grill us if we were even a little bit overweight. . .” and this was all in order to fulfill her ultimate dream of becoming a world class ballerina, a dream that vanished. Jessica gave Rhonda and David an A on Empathy, and said that the self-disclosure felt uncomfortable, but helpful. Next week, you'll hear the inspiring conclusion of the work with Jessica!

Today's special guest, Brittany. Podcast 375. I'm Struggling! Ask David Live: a New Podcast Twist We start today’s podcast with a visit from Dr. Jacob Towery. You might recall that one year ago he offered an amazing and (almost) totally free two-day workshop for shrinks and the general public on overcoming social anxiety. Roughly 90 people attended, and it was a huge success. The only “cost” was a $20 contribution to a charity of your choice, including Doctors Without Borders and several others. Dr. Jacob Towery This year, Dr. Towery will be repeating this incredible program on March 16 and 17, 2024, which will be on a Saturday and Sunday, in Palo Alto. Once again, the title will be “Finding Humans Less Scary.” Jacob and Michael Luo will lead the program and will be assisted by 10 - 20 expert therapists who will lead the break-out groups. Last year, people described the program as “transformative” and “life-changing.” Social anxiety can have a significant impact on your life, so you owe it to yourself to attend if you or a loved one has struggled with any of the five common forms of social anxiety:Shy Bladder Syndrome Shyness in social situations Public Speaking Anxiety Performance Anxiety Test Anxiety You’ll learn and practice tons of awesome anxiety-busting techniques, including Smile and Hello Practice, Flirting Training, Rejection Practice, Talk Show Host, Shame-Attacking Exercises, and much more. Social anxiety rarely exists alone, but is nearly always associated with other mood problems, such as loneliness, shame, depression, and substance misuse with alcohol and benzodiazepine pills to try to combat the symptoms, to name just a few. How do you sign up? It’s easy! Just go to FindingHumansLessScary.com If you attend, let us know how it worked out for you, what you learned, and how you grew. Thanks so much, Jacob, for making this kind of world-class experience available to everyone who’s looking for some help, and some wild, life-changing and zany fun in March! Brittany, an enthusiastic podcast fan, asked for help with a conflict with her husband. She wrote: Hi Dr. Burns, I’m struggling a bit. My husband reads a ton of articles and feels that the media has been portraying a lot of the current events incorrectly, especially the horrifying Israel/Palestine conflict. He is extremely frustrated by this and has become depressed because none of his friends or family seems to want to talk about it. He says he feels alone & isolated. I have never been much into politics, abd I don’t know enough to have a real opinion on things to say who is right. I try to be a good listener to whatever he says. For example, I may say “yeah, that sounds really frustrating,” and then I agree with what he says. But I’m obviously doing a bad job at the empathy because he says the support he gets from me is not satisfactory at all. Sometimes I feel like a parrot, just repeating back what he says. I think you had an example before on an Ask David where you showed how to empathize with someone who says how awful everyone is and how awful all the liberals are. Something like that. But I can’t find it. When I empathize my husband says I just don’t get it and nobody is doing anything to help these innocent people who are being attacked, and he says that I am not doing anything either. I’m at a loss on how to reply? Maybe you could do an example on an Ask David. Sorry for the long message. - Brittany Hi Brittany, Sorry you’re struggling, this is a common but important problem. Yes, we can and will do that. Can you give me an example of something he says to you, and exactly what you say next? You can use the attached Relationship Journal I you like. Try to complete steps 1 and 2 at least, and mail back to me ASAP. Lots of people with this problem these days, so could be great ASK D question. Weren't you on the show live once a few years back? I know you’ve sent us some great questions. I'm thinking MAYBE you could join and practice with us, using your example. Do you have / have you read my book, Feeling Good Together? Best, david It turned out that Brittany was eager and willing to join us live on today’s podcast . This is kind of an experimental podcast where we not only respond to a great question by one of our fans, but actually invite that person to get our “expert” help in real time and live on a podcast. You can let us know if you like this format. To get us started, Brittany sent us an example of a Relationship Journal she had prepared. I thought this was really well done, and gave her revised version a grade of A-, which is way better than most people can do. I sent her an email saying that she could probably add more acknowledgement of his feelings and her feelings, like feeling alone and hurt and a bit lonely, and also a bit more Stroking, like "I want you to know how much I love you, and how special you are to me. And that's why it's so had for me to realize that I've really been letting you down." We practiced with Brittany using my Intimacy Drill, which you'll hear on the podcast. Essentially, one of us would play the role of Brittany's husband, and we would say something she wanted help responding to, and she used the Five Secrets to respond. Then Rhonda, Matt and David gave her an overall grade (from A to F), along with fine tuning suggestions, emphasizing what she did that was especially effective and if there were any changes that might make her excellent responses even better. Then we did role reversals so we could demonstrate ow we might respond, followed by additional role plays until she was satisfied with her response. Five Secrets of Effective Communication This approach is called "Deliberate Practice" and it is by FAR the best way to master the Five Secrets so you can use them successfully in real time. We also discussed her concern that at home she'd been feeling like "a parrot" when she tried the Five Secrets. That is always caused by the absence of "I Feel" Statements in your statements, and we modelled how to correct this error. One of the biggest problems in the way people communicate during a conflict or argument is defensiveness, and given in the urge to argue and defend your territory, so to speak. Matt explained that this nearly always results from thinking you have a "self" that you have to defend. Another common Five Secrets error is the failure to acknowledge the other person's anger. Therapists and the general public nearly always make this error, because of a mindset I call "anger phobia" or "conflict phobia." However, Brittany did really beautiful work during the podcast exercises, as you'll see when you listen. We (the so-called "experts") also practiced what we preached and took turns responding to criticisms, which is always fun and challenging, and often humbling when we goof up! Let us know what you think about this new format of having someone who asks a question actually appear live on the podcast so you can actually learn through practice while we answer your question. Thanks for listening today, and thank you Brittany for blazing new trails on our podcasting adventure! Brittany, Rhonda, Matt, and David

Featured photo is Mina as a child (more pics below!) 374 Anger, Part 2 You Have Always Hated Me! In the Anger Part 1 podcast (371 on November 20), Rhonda, Matt and David discussed the fact that when you’re feeling angry, there’s always an inner dialogue—this is what you’re saying to yourself, the way you’re thinking about the situation—and an outer dialogue—this is what you’re saying to the other person. In Part 1, we focused on the inner dialogue and described the cognitive distortions that nearly always fill your mind with anger-provoking inner chatter about the ‘awfulness” of the person you’re mad at. Those distortions include All-or-Nothing Thinking, Overgeneralization, Labeling, Mental Filtering, Discounting the Positive, Mind-Reading, Fortune Telling, Emotional Reasoning, Other-Directed Should Statements, and Other-Blame. That’s a lot—in fact, all but Self-Blame. And sometimes, when you’re ticked off, you might also be blaming yourself, and feel mad at yourself at the same time. Matt suggested I add these comments on Self-Blame or it's absence:: Another possible addition would be when you identify the absence of Self Blame when we’re angry. For me, it’s been easier to think of that as a positive distortion, because you are blind to, or ignoring, your own role in the problem. In other words, when I’m blaming someone else, it’s me thinking my poop smells great and tit's all the other person's fault.. I’ve wondered if we fool ourselves like this because of the desire to have a special and perfect “self,” which we then defend. Because nobody’s perfect, our "ideal self," as opposed to our "real self," is just a pleasant, but potentially destructive, fantasy. Still, we try to preserve and project the fantasy that we are free of blame and the innocent victim of the other person's "badness," , and we imagine there we have a perfect “self” to defend. Or, as you’ve said, at times, David, “anger is often just a protective shell to hide and protect our more tender and genuine feelings.” We also discussed the addictive aspect of anger, since you probably feel morally superior to the “bad” person you’re ticked off at when you’re mad, and this makes it fairly unappealing to change the way you’re thinking and feeling. Your anger also protects you from the risk of being vulnerable and open and genuine. Today we discuss the Outer Dialogue, and how to express angry feelings to another person, as well as how to respond to their expressions of anger. The main concept is that you can express anger in a healthy way, by sharing your anger respectfully, or you can act out your anger aggressively, by attacking the other person. That’s a critically important decision! Toward the start of today’s podcast, Rhonda, Matt and David listed some of the distinctions between healthy and unhealthy anger. The following is just a partial list of some of the differences: Healthy Anger Unhealthy Anger You treat the other person with respect, even if you’re angry. You want to put the other person down. Your goal is to get closer to the other person. You want to get revenge or hurt or humiliate the other person. You hope to improve the relationship. You want to reject or distance yourself from the other person. You want to understand the other person’s mindset and find the truth in what they’re saying, even if it sounds ‘off’ or ‘disturbing’ or offensive. You want to prove that the other person is ‘wrong’ and persuade them that you are ‘right’. You want to understand and accept the other person. You insist on trying to change the other person. You express yourself thoughtfully. You express yourself impulsively. You come from a mindset of humility, curiosity, and flexibility. You come from a position of moral superiority, judgement, and rigidity. You are patient. You are pushy and demanding. Optimism that things can improve and that there’s a great potential for a more meaningful and loving connection. Hopelessness and feelings of certainty that things cannot improve. Open to what I’ve done wrong and how I’ve hurt you. Focus on what you’ve done wrong and how you’ve hurt me. I-Thou mindset. I-It mindset. You’re vulnerable and open to your hurt feelings. You put up a wall of toughness and try to hide your vulnerable true feelings.. You look for positive motives, if possible, and don’t assume that you actually understand how the other person is thinking and feeling.. You attribute malignant motives to the other person and imagine that you can read their mind and know exactly why they feel the way they do. You accept and comprehend the idea that you can feel intensely angry with someone and love them at the same time.. You may believe that anger and love are dichotomies, and that conflict and anger, in some way, are the ‘opposite’ of love or respect.. To bring some dynamics and personality to today’s podcast, Mina, who’s made a number of noteworthy appearances on the podcast, agreed to describe what she learned on a recent Sunday hike. (I’ve started up my Sunday hikes again, but in a small way now that the pandemic has subsided, at least for the time being. I’m struggling with low back pain when walking and that severely limits how far I can go.) Mina began by explaining that when she was talking to her mom on the phone. Her mom described a conflict with woman friend who seemed angry with Mina’s mom. Mina said, “I can see why that woman got angry with you.“ Mina explained that her mother, who is “conflict phobic,” paradoxically ends up with conflicts with a lot of people. However, Mina’s mother sounded hurt by Mina’s comment, and said, “You’ve always hated me since you were a little girl! You always looked at me hatefully!” Here are some of Mina’s "angry" childhood photos: Mina explained how she felt when her mom said, "You’ve always hated me.” My jaw dropped when she said that! It was such a shock. I’ve always felt like she was my best friend! . . . I hate feeling angry. It makes me every bit as uncomfortable as anxiety. If I express my anger, it goes away, and I feel better. But I don’t usually express it, and then it comes back disguised as weird neurologic symptoms. And that, of course, is the Hidden Emotion phenomenon that is so common in people who struggle with anxiety. When you try to squash or hide negative feelings your think you’re not “supposed’ to have, they often resurface in disguised form, as phobias, panic, OCD symptoms, chronic worrying, or any type of anxiety, including, as in Mina’s case Health Anxiety—that’s where you become convinced you have some serious neurologic or medical problem, like Multiple Sclerosis. Matt suggested that I might remind folks of my concept that “anger allays get expressed, one way or the other.” He’s found this idea to be both true and incredibly helpful for “us nice folks who think we can get away without expressing our anger, thinking we can avoid conflicts, entirely. This always backfires, in my experience!” On the recent Sunday hike, Mina practiced how to talk with her mom, using the Five Secrets of Effective Communication. After that, she used what she’d practiced on the hike to talk to her mom about their relationship, and then got an “I love you” message from her mom the next morning. This made Mina very happy, but because she had a full day of back to back appointments, Mina decided to spend time crafting a thoughtful reply at the end of the day, when she had a little free time. But when she went back to her computer at the end of the day to send a message to her mom, she discovered that her mother had deleted the loving message she sent early in the day, and Mina felt hurt. When Mina asked her mom about it, her mom said that deleting the message was just an error due to ‘old age.” However, Mina did not really buy this, and thought her mom probably felt hurt and angry because Mina had not responded sooner. In the podcast, we practiced responding to mom using the role-play exercise I developed years ago. Essentially, one person plays the role of Mina’s mom, and says something challenging or critical. Mina plays herself and responds as skillfully as possible with the Five Secrets, acknowledging the other person’s anger and expressing her own feelings as well. We practiced responding to mom’s statement, “You’ve always hated me.” Matt played the role of mom and Mina gave a beautiful Five Secrets response. You’ll enjoy hearing her response, and Matt’s and Rhonda’s helpful feedback, when you listen to the podcast. Then Mina asked for help responding to another statement from her mom, who had also said: All of the kids your age are angry, because you were neglected a lot of the time because of the war in Iran, and your dad and I were busy doing what we had to do to survive and avoid being arrested. All of my Iranian friends with children your age are experiencing the same thing. Matt and Rhonda did more role plays with Mina, followed by excellent feedback on Mina’s Five Secrets response. Again, I think you’ll enjoy the role-playing and fine tuning when you listen to the podcast. One of the obvious take-home messages from today’s podcast is to use the Five Secrets of Effective Communication when you’re feeling angry and talking to someone who’s angry with you as week, As a reminder, these are the Five Secrets. LINK TO 5 SECRETS And to make it simple, you can think of talking with your EAR: E = Empathy (listening with the Disarming Technique, Thought and Feeling Empathy, and Inquiry) A = Assertiveness (sharing your feelings openly with “I Feel” Statements) R = Respect (showing warmth and caring with Stroking) However, here’s the rub: People who are angry will usually NOT want to do this! When you’re ticked of, you will almost always have a huge preference for expressing yourself with the Unhealthy Anger described above. Matt urged me to publish my list of 36 reasons why this intense resistance to healthy communication. LINK HERE for the LIST 12 GOOD Reasons NOT to Empathize 12 GOOD Reasons NOT to Share your Feelings 12 GOOD Reasons NOT to Treat the Other Person with Respect. So, as you can see, there’s a lot more to skillful communication of anger than just learning the Five Secrets of Effective Communication, although that definitely requires tremendous dedication and practice. But motivation is the most important key to success or failure. When you’re upset with someone, you can ask yourself, “Do I want to communicate in a loving, or in a hostile way?” The reward of love are enormous, but the seduction of hostility and lashing out is at least as powerful! This battle between the light and the dark is not new, but has been blazing for tens of thousands of years. And, of course, the decision will be yours. Thanks for listening today, Mina, Rhonda, Matt, and David

Why Therapy Fails One of the most common reasons patients contact me is to find out why the therapy isn't working. They may be TEAM-CBT patients or patients of therapists using other approaches. Therapists also ask for consultations on the same problem--why am I stuck with this or that patient who isn't making progress? In the Feeling Good App, my colleagues and I have been looking into this as well. Most app users report excellent and often rapid results, but some get stuck, in just the same way they might get stuck in treatment with a therapist. I have tried to organize my thinking on this topic, because if you can diagnose the cause of therapeutic failure, you can nearly always find a solution. Of course, the app is not a treatment device, but a wellness device, but the same principles apply. So today, Rhonda, Matt and I discuss a couple reasons why therapists and patients alike sometimes get stuck. Matt described a patient who was misdiagnosed with a psychotic disorder who turned out to have sleep apnea. When the proposer diagnosis was made and treated, the patent suddenly recovered. Rhonda described a patient who jumped from topic to topic and always brought up a new problem before completing work on the previous problem. This problem was solved when Rhonda explained the importance of sticking to one problem for several sessions, until the problem was resolved. The patient then began to make progress. David described a depressed woman from Florida who was stuck in treatment, and not making progress, and then the therapist said "I just can't help you," This hurt and confused the patient who wrote to me. There were essentially two problems--the patients depression what brought her to therapy in the first place, and her unresolved hurt feelings when the therapist "gave up" on her. This problem reflected many failed relationships is the patient's life. This was resolved when the patient took the initiative to schedule a session to talk about the conflict more openly with excellent results. In addition, the patient had heard that she "should" accept herself, but didn't know how to accept her constant self-critical troughs and intensely negative feelings. I suggested she make a list of the benefits of her negative thoughts and feelings, as well as the many positive things they showed about her and her core values as a human being. She came up with an extremely impressive and long list! For example, her criticisms showed her high standards, her humility, her dedication to her work, her accountability, and much more. In addition, she'd achieved a great deal because of her relentless self-criticisms. I asked her why in the world she'd want to accept herself, given all those positive characteristics She decided NOT to accept herself, and was delighted with her decision. She said she felt profound relief! An unusual, but awesome, path to acceptance! In other words, she ACCEPTED her "non-acceptance." I hope you find today's podcast interesting and helpful. Of course, ultimately therapy is part science and part human relationship art. That's why Rhonda and I offer free weekly training groups for therapists who wish to develop their therapeutic skills. The groups are on zoom so therapists from around the world are welcome. Matt offers a consultation group (free to Stanford psychiatric residents) every other Tuesday for therapists who want help with difficult, challenging cases. To learn more, you'll find details and contact information at the end of the show notes. When Therapy Doesn’t Work-- And How to Get Unstuck (for Therapists and Patients) By David Burns, MD Here’s are some of the most common reasons why therapy might fail or appear to be stuck / without progress. Some of them will be of interest primarily to clinicians, while others will be of interest to clinicians and patients alike. And many of these reasons will also apply to individuals using the Feeling Good App who are stuck in their attempts to change the way they think and feel. But what does “stuck” actually mean? The definition, of course, is subjective. I believe that a substantial or complete elimination of depression and anxiety can typically be achieved in five sessions with a skilled TEAM therapist. I use two-hour sessions, and can usually see dramatic change in a single session, although follow-ups may be needed for Relapse Prevention Training or other problems the patients might want help with. In my experience, the treatment of relationship problems and habits and addictions usually takes much longer than the treatment of anxiety or depression. The techniques to treat relationship problems and habits and addictions actually work just as fast as the techniques to treat depression and anxiety, but the resistance can be far more intense. For example, someone may be ambivalent about leaving a troubled relationship or giving up a favored habit for many months or years before making a decision to move in a new direction. And, of course, the treatment of biological problems like schizophrenia and bipolar I disorder will nearly always require a long term therapeutic relationship, often requiring medications in addition to therapy. The problems and errors I’ve listed below are mostly correctable. And although there are many traps that therapists and patients fall into, the vast majority of therapeutic failure the patient's hidden 'resistance' to change and the therapist's lack of skill addressing it. This is true in clinical practice and in psychotherapy outcome studies, as well. On the one hand, a great many patients will feel ambivalent about change. For example, a patient with low self-esteem may not want to stop being self-critical and accept themselves, as-is, but to have a better version of themselves, first. Or they may want to overcome their fears without facing them. Or they might want a better relationship but would want the other person to do the changing. Unfortunately, most therapists lack the skills to address resistance and, in fact, often make it worse by trying to motivate the patient to change, rather than understand their hesitation to change and discuss it with them. This is one area where TEAM training has a great deal to offer, including over 30 skills therapists can learn to address motivation and resistance. The following list of 37 reasons why therapy fails follows the structure of T, E, A, M. Errors at or before the initial evaluation Patient is just window shopping Patient does not buy into the cognitive model Incorrect conceptualization of type of problem, so you end up using the wrong techniques. To simplify things, I think of four conceptualizations: Individual mood problem (depression or anxiety) Relationship Problem Habit / Addictions “Non-problem”: healthy negative feelings such as the grief you might feel when a love one dies Patient is not in treatment out of choice. For example, a teenager might be brought in by parents to be “fixed,” like bringing in your car to the local garage for a tune up, and you don’t have an agenda with your patient. Or a parent might be court-ordered to go to therapy if he wants to have custody of his children. Failure to ask patients to complete the Concept of Self-Help Memo, the How to Make Therapy Rewarding and Successful memo, and the Administrative Memo prior to the start of therapy. These memos fix a great many therapeutic problems that are likely to emerge later on, like homework non-compliance, premature termination, and policies about confidentiality, last minute cancelling of sessions, conflicts of interest (eg patient is seeking disability) and more. Most therapists ignore the use of these memos, only to pay a steep price later on. Failure to mention the requirement for homework and similar issues the at initial contact with the patient. Failure to explore the patient’s motivation for treatment. T = Testing Diagnostic errors: not recognizing additional problems which patient may have in addition to the initial complaint, such as drug or substance abuse, psychosis, intense social anxiety, past trauma or abuse, or hidden problems the patient is ashamed to disclose. This is easily solvable by the use of my EASY Diagnostic System prior to your initial evaluation. It screens for 50 of the most common DSM “diagnoses” and only takes ten minutes or so out of a therapy session to review and assign the “Symptom Cluster Diagnoses.” Failure to use Brief Mood Survey before and after each session. This error makes the therapist blind to the severity or nature and severity of the patient’s feelings, which cannot be accurately identified by a patient interview or therapy session. As a result, the therapist’s understanding will not be accurate, and the therapist will not be to pinpoint the degree of change (or failure to change) during and between therapy sessions. E = Empathy Failure to ask patients to complete the Evaluation of Therapy Session after each session. As a result, it will not be possible for therapists to understand their level of empathy, helpfulness, and several other relationship dimensions critical to good therapy. Failure to use the “What’s My Grade” technique while empathizing with the patient. Failure to receive training in the Five Secrets of Effective Communication and the three advanced communication techniques. These techniques are difficult to learn, requiring lots of practice and commitment, but can be invaluable in therapy and in the therapist’s personal life. A = Assessment of Resistance (also called Paradoxical Agenda Setting) Failure to recognize and deal with Outcome Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions. Failure to recognize and with Process Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions. The “because” factor: I won’t let go of my depression until “I’ve lost weight,” or “I’ve found a loving partner,” or “I’ve achieved something special,” or “I’ve found a better job / career,” or “I’ve achieved my goals at X.” This is another type of Outcome Resistance. M = Methods--errors using the Daily Mood Log Patient “cannot” identify any Negative Thoughts The way you worded your Negative Thought. The common errors include thoughts describing events or feelings, rhetorical questions, long rambling thoughts, or thoughts consisting of a few words or phrases, like “worthless.” No Recovery Circle / many need many techniques combined with the philosophy of “failing as fast as you can.” This allows you to individualize the treatment for each patient. It is simply not true that there is one school of therapy or method (like meditation, mindfulness or daily exercise, etc.) that will be helpful, much less “the answer,” for all patients! The way you did the technique / incorrect use of technique. Many of the most powerful techniques, like Interpersonal Exposure, Externalization of Voices, Paradoxical Double Standard, Feared Fantasy, and many more require considerable sophistication and training. They can be fantastic when used skillfully, but they aren’t easy to learn! Trying to challenge your negative thoughts in your head / vs on paper or computer. This is associated with Process Resistance for depression—refusing to do the written homework, and it is exceptionally common. Trying to challenge the negative thoughts of someone else or encouraging them to think more positively: won’t work! In my first book, Feeling Good, I spelled out the warning that cognitive techniques are for you, and NOT for you to use on other people, including friends, family, and so forth. It is my impression that many people ignore this warning. When they discover that the person they are trying to “help” does take kindly to identify the cognitive distortions in their thoughts, both end up frustrated. Failure to “get” the Acceptance Paradox / using too much self-defense in your positive thoughts, especially Technique when doing Externalization of Voices Using the Acceptance Paradox in a defeatist, self-effacing way Failure to include the Counter-Attack Technique when doing Externalization of Voices. This techniques is not always necessary, but can sometimes be the knock out blow for the patient’s endless inner criticisms. Not understanding the necessary and sufficient conditions for emotional change when challenging distorted thoughts. Too much focus on cognitive / rational techniques when far more dynamic techniques are needed, such as the Experimental Technique (e.g. exposure) in treating anxiety or the Externalization of Voices or Hidden Emotion Techniques Not recognizing that the patient’s negative thoughts might be valid (I think that my partner is cheating on me) and trying to get your patient to challenge the “distortions” in the thoughts Other therapist errors Codependency: addiction to trying to “help” / cheer up the patient / solve some problem the patient has Need to be “nice” and refusal to hold patients accountable Narcissism: unwilling to be criticized, unwilling to fail, needing to stay in the expert role Difficulties “getting” the patient’s inner feelings, due to lack of skill with Five Secrets and the failure to use Empathy Scale Difficulties forming a warm and vibrant therapeutic relationship, which can sometimes result from strong (and nearly always unexpressed) dislike of the patient Commitment to a favored “school” of therapy / thinking you are superior to colleagues and have the one “correct” approach Failure to use assessment tools with every patient at every session Failure to make patients accountable for homework Four types of reverse hypnosis: this is where the patient hypnotizes the therapist into believing things that simply aren’t true. Depression: the patient may really be hopeless or worthless Anxiety: the patient is too fragile for exposure Relationship problems: the patient is too fragile for / not yet ready for exposure Habits / addictions: not making the patient accountable or assuming patient isn’t yet “ready” to give up the addiction, or the patient needs to have emotional / relationship problems fixed first Unrecognize, unaddressed conflicts with therapist that need to be addressed with Changing the Focus. This error often results from the therapist’s fear of conflict or patient anger, and is usually accompanied by a failure to use the Evaluation of Therapy Session, which would send a loud signal to the therapist that something is wrong. Failure to do Relapse Prevention Training prior to discharge. Conceptualization errors. Failure to use or select the most effective therapeutic approach and techniques for the patient’s problem. For example, the Daily Mood Log and Recovery Circle are great for depression and anxiety, although there will be some important differences in the choice of methods for depression vs. anxiety. For example, Exposure and the Hidden Emotion Technique are great for anxiety, but rarely useful for depression. The DML has only a secondary role in the treatment of relationship problems (the Relationship Journal is more direct and useful) or habits and addictions (the Triple Paradox and Habit and Addiction Log (HAL) are far more useful. The therapist may be committed to a school of therapy, like Rogerian listening, without addressing resistance or using methods. Or therapist may believe that psychodynamic or psychoanalytic therapy, or ACT, or traditional Beckian cognitive therapy, will be the “answer” for everybody. The schools of therapy function much like cults, causing feelings of competitiveness (our guru is better than your guru) and sharply limiting the critical thinking and narrowing the consciousness of the faithful “followers.” Conflicts of interest. The therapist may subconsciously want to keep the patient in a long-term “talking” relationship due to emotional or financial needs. The therapist may have been taught that therapeutic change is inherently slow, requiring many years or more. This belief will always function as a self-fulfilling prophecy. Thanks for listening! Matt, Rhonda, and David