Understanding and Supporting Severe Mental Health Disorders

Ask David: Getting Off Benzos How Does Music Stir Our Emotions? Combatting Negative Thoughts about the World Treating Schizophrenia with TEAM The Four Feared Fantasy Techniques and more!

Questions for today:

1. Mamunur asks: What’s the best way to withdraw from benzodiazepines?
2. Gray asks: How does music evoke such powerful emotional reactions?
3. Josh thanks David for techniques that have helped in his personal and professional life.
4. Harold asks: How do you respond to negative thoughts about the world, as opposed to self-criticisms? For example, “The world is filled with so little joy and so much suffering.”
5. Moritz asks: How do you help people with bipolar, schizophrenia, etc.?
6. John expresses gratitude for our answer to his question on Positive Reframing, which triggered an “ah ha moment.”
7. Rhonda asks: What are the four Feared Fantasy Techniques?

The answers below were written prior to the podcast. Listen to the podcast for the dialogue among Rhonda, Matt, and David, as much more emerges from the discussions!

1. Mamunur asks: What’s the best way to withdraw from benzodiazepines?

Ask David, Bangladesh question

Dear Sir,

I am writing to you from Bangladesh. Your book Feeling Good is a phenomenal work, and it has greatly helped in promoting the development of a healthy mind through logic and reason.

Sir, I have a question regarding benzodiazepine withdrawal, which is often prescribed for mental health disorders. Is there a specific CBT (Cognitive Behavioral Therapy) approach that can help in withdrawing from benzodiazepines? Your guidance on this would be invaluable, as many people have been taking it for years, either knowingly or unknowingly, without being fully aware of its severe withdrawal effects.

Thank you, sir, for your kind contributions to humanity.

Sincerely,

Mamunur Rahman Senior Lecturer

David’s reply

Dear Mamunur,

Thank you for your important question! I am so glad you like my book, Feeling Good, and appreciate your kind comments!

As a general rule, slow taper off of benzodiazepines is recommended. This might involve slowly decreasing the dose over a period of several weeks.

When I was younger I used to take 0.25 mg of Xanax for sleep, because it was initially promoted as being non-addictive, which was wrong. It is highly addictive. The dose I used was the smallest dose.

When I realized that I was “hooked,” I tapered off of it over about a week, and simply put up with the side effects of withdrawal, primarily an increase of anxiety and difficulty sleeping. These disappeared after several weeks.

Abrupt withdrawal from high doses of any benzodiazepine can trigger seizures, as I’m sure you know. That is the biggest danger, perhaps.

I do recall a published study from years ago conducted at Harvard, I believe at McClean Hospital. The divided two groups of people hooked on Xanax into two groups. Both groups were switched to Klonopin which has a longer “half-life” in the blood and is supposedly a bit easier to withdraw from than Xanax, which goes out of the blood rapidly, causing more sudden and intense withdrawal effects.

After this initial phase, both groups continued with slowly tapering off the Klonopin under the guidance of medical experts. However, one of the groups also attended weekly cognitive therapy groups, learning about how to combat the distorted thoughts that trigger negative feelings like anxiety and depression.

My memory of the study is that the group receiving cognitive therapy plus drug management did much better. As I recall, 80% of them were able to withdraw successfully. However, the group receiving drug management alone did poorly, with only about 20% achieving withdrawal.

My memory of the details may be somewhat faulty, but the main conclusion was clear that the support of the group cognitive therapy greatly enhanced the success of withdrawal from benzodiazepines.

I decided early in my career not to prescribe benzodiazepines like Ativan, Valium, Librium, Xanax, and Klonopin for depression or anxiety, because the drug-free methods I and others have developed are very powerful, and the use of benzos can actually make the outcomes worse.

Years back, a research colleague from Canada, Henny Westra, PhD, reviewed the world literature on treatment of anxiety with CBT plus benzos and concluded that the benzos did not enhance outcomes. Here is the link: https://pubmed.ncbi.nlm.nih.gov/12214810/.

I hope this information is useful and I will include this in a future Feeling Good Podcast.

 

2. Gray asks: How does music evoke such powerful emotional reactions?

Subject: Re: Podcast question: love songs

Hi David,

That's a really tough question. Music has a unique way of cutting straight to emotions for me, and it makes it especially hard to identify the thoughts behind them. My best way of explaining is with these two thoughts, which have to be viewed as a pair to get that emotional reaction:

1. My life would be perfect if I had that
2. I'm so far away from that

These thoughts don't resonate quite right for me, but it's something like that, going from imagining bliss to crashing to hopelessness within the space of a moment.

Thank you so much for your response.

Gray

David’s reply

You’re right. Music can be so beautiful, especially of course, the songs we love, that it is magical and emotional to listen to! It seems more like a sensory experience, than something mediated by thoughts, but we certainly have perceptions of beauty, etc.

Similar with some incredibly delicious food. Creates incredible delight and satisfaction, and no words are necessary other than “delicious!”

Sorry I can’t give you a better answer to your outstanding question!

Best, david

 

3. Josh thanks David for techniques that have helped in his personal and professional life.

Dear Dr. Burns,

I am sure you are swamped with substantive emails and fan mail, but I just wanted to express appreciation to you for all I have gained from your publicly available content. I have learned so much that I have applied in my personal life. I have also benefited tremendously in my work with clients.

So much of what you say about anxiety, and especially the hidden emotion technique, has allowed clients to have in almost every session an aha moment. I have not yet been able to see a complete removal of symptoms in one session yet, but as a therapist, I too have many skills yet to improve and much work to do.

So, in short, thank you so much for making your experience and wisdom available for free, and thank you for doing it in such an engaging manner.

Sincerely,

Josh Farkas

 

David’s Reply

Thanks, Josh. You are welcome to join our weekly virtual free training group I offer as part of my volunteer work for Stanford, if interested.

For more complete change within sessions, a double session (two hours) in my experience is vastly more effective. Is it okay to read your kind note on a podcast?

Warmly, david

 

4. Harold asks: How do you respond to negative thoughts about the world, as opposed to self-criticisms? For example, “The world is filled with so little joy and so much suffering.”

Dear Dr. Burns,

First of all, I would like to thank you for all your work and your outreach. Your books have profoundly influenced my thinking and value system. I really admire how you exemplify both scientific rigor and human warmth. Finally, I want to thank you for promoting the idea of “Rejection Practice! I haven't had a breakthrough yet, but some unexpected, very encouraging experiences.

I first came across Feeling Good 12 years ago when I developed moderate depression in the context of living with my ex-partner, who probably had borderline personality disorder. I tried the techniques in Feeling Good and also psychotherapy, but unfortunately without much success. I only started feeling a lot better when I began to rebuild my social life and leisure time activities (ballroom dancing, getting involved with a church, ...). Several months later, I also broke up with my ex-girlfriend. Since then, I've had ongoing mild depression.

I recently tried the techniques in Feeling Great but wanted to ask you for your opinion on a couple of negative thoughts I'm particularly stuck with. My issue is that I'm normally not attacking myself, but life in general. I keep on telling myself things like "Life is just one crisis after the other," "Life is for the lucky ones," "Really good things just don't want to happen," "Life is so much suffering and so little joy," and the depression itself makes these statements all the more convincing. (Triggering events can be rainy holidays, romantic rejections, grant interview rejections, etc.)

I think it could be helpful if in a podcast you could give more examples on resolving negative thoughts attacking life / the world rather than oneself. I also have many more questions for podcasts if you are interested.

Thank you for reading this, and thank you so much again for all your work!

With very best wishes,

Harold

 

David’s Reply

Happy to address this on an Ask David, and it would help if you could let me know what negative feelings you have, and how strong they are. I will be answer in a general way, and not engaging you in therapy, which cannot be done in this context. Is that okay?

I’m attaching a Daily Mood Log to help organize your thoughts and feelings. Send it back if you can with the Event, Negative Feelings and % Now columns filled out (0-100), and Negative thoughts and belief in each (0-100).

You can also fill in the distortion column using abbreviations, like AON for All-or-Nothing, SH for Should Statement or Hidden Should, MF for Mental filtering, DP for Discounting the Positives, and so forth.

Thanks!

If you were in a session with me, or if we were just friends talking, I would reply to your complaints with the Disarming Technique, Thought and Feeling Empathy, “I Feel” Statements, Stroking, and Inquiry, like this:

Harold: “Life is so much suffering and so little joy."

David: “I’m sad to hear you say that, but you’re right. There’s an enormous amount of suffering in the world, like the horrible wars in Ukraine and in the Mid-East. (I feel; Disarming Technique) It makes sense that you’d be upset, and have all kinds of feelings, even anger since there’s so much cruelty, too. (Feeling Empathy)

And even people who appear positive and joyful often have inner sadness and loneliness that they are hiding. (Disarming Technique) Your comment tells me a great deal about your core values on honesty and compassion for others. (Stroking) Can you tell me more about the suffering that you’ve seen that has saddened you the most, and how you feel inside? (Inquiry)

But I’m mainly interested in you right now. Can you tell me more about YOUR suffering, and especially if there’s some problem you might want some help with? (Inquiry; Changing the Focus)

I would continue this strategy until you gave me an A on Empathy, and then I would go on to the A of TEAM (Assessing Resistance), and ask what kind of help, if any, you’d be look for in today’s session. I might also use a paradox, like the Acid Test.

If you wanted to reduce some of your negative feelings, I might try a variety of techniques, such as “How Many Minutes?”

I’d also think about the Hidden Emotion Technique. Is there some problem in your life right now that you’re not dealing with, so you instead obsess about the problems in the world to distract yourself?

I would continue this strategy until you gave me an A on Empathy, and then I would go on to the A of TEAM (Assessing Resistance), and ask what kind of help, if any, you’d be look for in today’s session. I might also use a paradox, like the Acid Test.

If you wanted to reduce some of your negative feelings, I might try a variety of techniques, such as “How Many Minutes?”

I’d also think about the Hidden Emotion Technique. Is there some problem in your life right now that you’re not dealing with, so you instead obsess about the problems in the world to distract yourself? I ask this because your negative thoughts are very general, but I always focus only on specifics, specific problems and moments. What’s has been going on with your parents or in the past or present that you are distressed about? I’ve found that when I (or my patients) solve one specific problem that’s bugging me, everything seems to suddenly brighten up.

For example, you wrote : “I asked someone out I like; she surprisingly said yes. After 10 days of not hearing from her, I messaged her, . . . “ I wrote a book about dating, Intimate Connections, because I was a nurd and had a lot to learn about dating. One idea is that waiting 10 days might not be a good idea to arrange the specifics of the date, as that might make her feel uneasy. There’s a lot to learn about dating, for example.

A tool like the Pleasure Predicting Sheet can sometimes help, too. And finally, a good therapist can also often speed things up. Sometimes two heads are better than one. You seem extremely smart and willing to work hard, so there’s all kinds of room for growth, learning, and greater joy.

The Feeling Great App is NOT therapy, but the tools there might also be helpful, especially since you are willing to work hard a do a lot. That’s super important.

Can I use this email in my reply in the show notes if we discuss your excellent questions? And should I change your name to Harold?

Warmly, david

Best, david

 

 

5. Moritz asks: How do you help people with bipolar, schizophrenia, etc.?

Hi David,

You have mentioned a few times that there are only a handful of "real" psychological disorders with known causes, as opposed to just a collection of symptoms.

Could you please tell a bit about how you would go about helping somebody with one of the "real" disorders (like Schizophrenia or Bipolar) using TEAM therapy?

Most of the episodes with personal work seem to fall into the other category (anxiety, depression, compulsive behavior), so I'd be really curious about some examples.

Best regards,

Moritz Lenz

 

David’s Reply

Hi Moritz, Thanks! Good question, and happy to address this on an Ask David. Here's the answer in a nutshell. When working with someone with schizophrenia, the goal is to help them develop greater happiness and interpersonal functioning, exactly the same as with anyone else, using TEAM. The goal is not to cure schizophrenia, because we still do not know the cause and there is no cure. But we can help individuals with schizophrenia with problems that they are having.

Bipolar: in the manic phase, usually strong meds are indicated, and often at least one hospitalization. For the rest of their lives, including depression, TEAM works great.

Can add more in the podcast.

Best, david

 

6. John expresses gratitude for answer his question on Positive Reframing, which triggered an “ah ha moment.”

Hi David and Rhonda!

I have listened to Episode 415 and your response to my positive reframing question!

I had a bit of a aha moment! I think I had been approaching it in the cheerleading sense and trying to encourage myself with these positive qualities rather than attaching the positives to the negative thoughts and feelings themselves!

This has created a much stronger emotional response during the positive reframing section! The building up of the negative thoughts and feelings is a gamechanger! Thanks so much for the time and attention given to it during the podcast.

Thanks so much again, I appreciate you folks way more than you could know!

John

David’s Reply

Thanks, Rhonda and John. Yes, you’ve pointed out a huge error many people make when trying to grasp positive reframing. If it is okay, we can include your comment in a future podcast.

Warmly, david

 

7. Rhonda asks about the four Feared Fantasy Techniques:

David’s Reply

Here are the four Feared Fantasy Techniques

• • Approval Addiction / Perceived Perfectionism: “I judge you.”
  • Achievement Addiction: “High School Reunion.”
  • Love Addiction: Rejection Feared Fantasy
  • Submissiveness: No Practice

There are quite a number of additional role plays, too, as you know. Maybe a question about all the role plays, bc we all have:

Self-Critical Thoughts:

• • Paradoxical and Straightforward Double Standard
  • Externalization of Voices

Uncovering Techniques

• • Man from Mars

Tempting Thoughts

• • Devil’s Advocate Technique
  • Tic-Tok Technique

Resistance

• • Externalization of Resistance
  • How Many Minutes?

Five Secrets / Relationship Conflict

• • Intimacy Exercise
  • One Minute-Drill

I’ll bet you can think of more, too! This is one of the unique features of TEAM, but for whatever reason it seems like few therapists use them. As you know, on average they tend to be way more potent and emotional, and of course fast impact.

Warmly, david