Is That Bad if Your Practice Deteriorates?

A Country Doctor, Part 1 of 2: "Nothing I do makes a difference!"

This is the first of two podcasts on one of the live therapy demonstrations that Dr. Jill Levitt and I did at our psychotherapy workshop on Sunday, May 16th, 2021. I think you will find the session interesting and incredibly inspiring!

Our patient is a physician in a small town in the mid-west. I want to thank Dr. Scherer for her tremendous courage in sharing this very personal experience with all of us. Dr. Levitt practices at the Feeling Good Institute in Mountain View, California, where she also serves as Director of Clinical Training. She also teaches at our weekly TEAM-CBT training group as Stanford.

I am thrilled to share the audio of Jillian’s live session as a two-part podcast, since only mental health professionals are allowed to attend the workshops sponsored by the Feeling Good Institute. Many non-therapists were eager to attend, and disappointed when they learned that only shrinks could attend. But this gives all of you the chance to hear what you missed, and I think you will NOT be disappointed!

When Jill and I asked for volunteers for the live demonstrations in the workshop, Jillian was the first to respond with an offer to volunteer. This was her email, describing her situation..

Hi Dr. Burns,

I am writing to you offering to be a volunteer for the live demonstrations in the workshop on 5/16, if you need one.

I am learning TEAM CBT, and have been enjoying it personally as well as trying to do more of it professionally. I am a family medicine physician, but I have my own direct primary care clinic. This means that I can spend 1-2 hours with a patient if needed. I have been slowly offering this to patients who want to do the work to improve their mood or anxiety.

As for why I am writing, my anxiety and need to please people is huge and disruptive to my enjoyment of life. I keep striving and achieving things likely to get the attention of others. I fear not knowing the answer and making a mistake with my patients.

This had caused me to develop anxiety and insomnia at my last job. I sought counseling and physician coaching, but ultimately I wound up leaving that job, moving to another state [due to intense stress and demands of that job], and starting my own practice. My current practice is going well, but I am annoyed when patients come in or call with questions I don't know the answer to.

I constantly worry that I will not be able to figure something out by myself and that the patients will leave me. In addition, I continually strive for [yet another] training certificate.

As you know, I did medical school, residency, and fellowship, but I also have a lactation consultant certificate, training in lifestyle medicine, and now a Level 1 TEAM-CBT certificate with enough hours for Level 2, and most recently I started a 3-year program to become a pastor for our church. And I realize that I will not have the time to sustain all of these. It is as if I love the journey of getting the certificates, but I am not great at implementing them, so I move on to something else.

As for the rest of life, I have a great life, but I am melancholy most of the time. My husband is terrific, sensitive, understanding, loving, and yet, I am constantly reading marriage books because I think it could be better. My 2 children, aged 8 and 4, are smart and funny, but I live constantly thinking I am going to screw them up and so I read even more parenting books.

My family medicine practice is thriving and offers me part-time work at great pay with autonomy, yet I dread Monday mornings. Overall, my life should be an A+ and enjoyable, but somehow I make it seem like everything is going wrong all the time.

I have sought counseling and even TEAM-CBT earlier this year via teletherapy from FGI. I continue to do a Daily Mood Log about 3-4 times a week. I feel like we got so far, but not to complete recovery.

My FGI therapist was the eighth therapist I have been to, but the others were mainly talk therapists. I just thought I would reach out in the hope that maybe you need a volunteer, and maybe I would have the opportunity to work with you live. It would be nice if my anxiety and faulty core beliefs didn't steal my joy.

Sincerely,

Jillian

As you can see, Jillian is an incredibly dedicated physician, but feels like she is never doing enough for her patients. At the start of her session, she described her incredibly stressful previous job, when she was often on call for 72 hours at a time, often going long hours without sleep. She said, “I used to walk to work, hoping I’d get hit by a car.”

Although, as you saw in her email, she finally quit, and set up her own practice in another state, she continued to struggle with depression and the belief that she wasn’t doing enough. Her constant self-criticisms robbed her of happiness, in spite of the fact that she had a fabulous practice, superb medical and human skills, and a wonderful husband and children.

Her unhappiness confirms what Epictetus taught us nearly 2,000 years ago: we are upset, not by things, or events, but by our views of them. In this case, the facts of Jillian’s life are all stellar. In fact, she rates her life and practice as A+. And yet, she was still lacking in the most important dimension: happiness and self-esteem.

Because of her constant and intense feelings of insecurity, Jillian heroically pursued more and more specialty trainings and certifications, thinking that eventually she would develop feelings of competence, confidence, and happiness. She even enrolled in a three-year training program to become a minister, in addition to enrolling in the certification and training program for TEAM-CBT, and more.

But nothing was ever enough. That’s because, as the sages have taught through the ages, the answer is within. No amount of expertise or accomplishments will ever solve Jillian’s problem.

Jillian’s life was perhaps like trying to get the elusive brass ring on the Merry Go Round, except her ride was far from merry. She told us that she sometimes had fantasies of escaping to a remote tropical island.

Perhaps you, too, have sometimes felt like you’re not good enough, or that you or your accomplishments are just not good enough. Let us know what you think about the answer that Jillian found in front of a live audience that day, and whether it might apply to you as well.

In today’s podcast, you will hear the first portion of her session (T = Testing and E = Empathy), and next week you will hear the fantastic conclusion (A = Assessment of Resistance) and M = Methods.)

T = Testing

To get started, take a look at the Daily Mood Log that Jillian shared with us at the start of her session.

As you can see, Jillian’s negative feelings were all intense. You would not have known how powerful her suffering was if you had met her in her daily life. In person, she comes across as you might expect from her email: exceptionally warm, thoughtful, human, conscientious and likeable.

That’s one of the really important reasons for Testing. You can see exactly what you’re dealing with, in terms of the type and severity of negative feelings. In addition, we’ll ask Jillian to rate her feelings again at the end of the session. That way, we’ll know how effective—or ineffective—the session was. This information can sometimes be humbling, but it is always illuminating.

Neither Jill nor I could conceive of doing therapy without the Testing! At the end, we’ll also ask her to rate us on Empathy, Helpfulness and other dimensions using exceptionally sensitive scales that can highlight even the smallest therapeutic errors that the therapist would not otherwise be aware of.

E = Empathy

During the empathy phase of the session, Jill and I empathized while Jillian described her struggles with negative feelings and a lack of happiness and self-confidence.

During the empathy portion, I did the downward arrow technique to learn more about Jillian’s fears and Self-Defeating Beliefs. The goal was not to change Jillian, but simply to understand the root of her suffering at a deeper level.

We started with the thought, “I should know how to fix people who come to me with a problem like depression, anxiety, headaches, or headaches, or even the lack of money to pay for the medications I prescribe.”

Here’s how the Downward Arrow dialogue evolved:

David: And if you sometimes do not have the solution for your patients, what does that mean to you? Why is that upsetting to you?

Jillian: Then people will be disappointed and leave me.

David: And then what? What are you the most afraid of?

Jillian: My practice will deteriorate.

David: And then?

Jillian: My patients will think I’m a failure.

David: What would happen then? What are you the most afraid of?

Jillian: Then the whole town will think I’m a failure.

David: Of course, no one would want something like that to happen, but we might all experience it differently? What would that mean to you if the whole town thought you were a failure? Why would that be upsetting to you?

Jillian: That would mean I’m a loser.

David: And if that were true, what would that mean to you?

Jillian: That would mean that I don’t mean anything to anybody.

David: And then? What would happen if you didn’t mean anything to anybody?

Jillian: Then there’d be no point in life.

That was pretty much the bottom of the barrel. The purpose of the Downward Arrow Technique is to uncover the Self-Defeating Beliefs at the root of your suffering. Once you’ve generated your Downward Arrow list, all you have to do is review it, and then look at my list of 23 Common Self-Defeating Beliefs and circle all the ones that seem to fit.

As an exercise, you might want to take a look at the list and see how many you can find before you see the ones that Jillian found!

Here’s Jillian’s list:

1. Perfectionism
2. Perceived Perfectionism
3. Achievement Addiction
4. Approval Addiction
5. Fear of Rejection
6. Pleasing Others (Submissiveness)
7. Worthlessness
8. Spotlight Fallacy
9. Brushfire Fallacy
10. Superwoman

A Country Doctor, Part 2 of 2

A = Assessment of Resistance

At the end of the moving and tearful empathy phase, we asked Jillian about her goals for the session, which included the ability to

• enjoy my work
• to give away all of my certificates
• set limits with my patients
• feel happy with what I do
• not have to fear my work anymore!

After Jillian said she would be willing to press the Magic Button to achieve all these goals instantly if we had one, we suggested Positive Reframing first. to see what might be lost of she suddenly achieved all these goals. You can creview the Positive Reframing that we did together.

Here’s Jillian’s Emotions table at the end of Positive Reframing, showing her goals for each emotion when we used the Magic Dial. The idea is to dial each feeling down to a lower level that would reduce your suffering while still allowing you to preserve all the awesome things about you!

 

Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, blue, down, unhappy 80 15   Embarrassed, foolish, humiliated, self-conscious 50 10   Anxious, nervous 90 20   Hopeless, discouraged, pessimistic, despairing 100 0   Bad 70 0   Frustrated, stuck, thwarted, defeated 90 5   Inferior, inadequate, incompetent 95 5   Angry, mad, resentful, annoyed, irritated, upset, furious 100 10  

 

Jillian said that the Positive Reframing really opened her up, especially when we read the list of positives out loud. It kind of shocked her in a good way so see that her negative feelings were not really problems, defects, or symptoms of one or more “mental disorders,” but the expression of what was most beautiful and awesome about her as a human being, and as a physician.

This Positive Reframing is one of the unique aspects of TEAM-CBT. Although we are encouraging the patient to keep the symptoms, rather than pressing the Magic Button that makes them disappear, it paradoxically eliminates or drastically reduces the resistance to change, and opens the door to the possibility of ultra-rapid recovery.

M = Methods

We asked Jillian what Negative Thought she wanted to work on first, and she chose #9: “I’m not having a big enough impact.” She believed this thought 100%.

First, we asked Jillian to identify and explain the cognitive distortions in this thought, and she focused on these: Should Statement; Self-Blame, All-or-Nothing Thinking, Mental Filtering, and Discounting the Positive.

In retrospect, I think I spotted two additional distortions: Emotional Reading (I feel I’m not having a positive impact, so I must not be having a positive impact) and Mind-Reading (my patients expect me to have the answers to all their problems and judge me when I don’t have all the answers.)

Then we challenged the Negative Thought, and Jillian she was able, with a little help and a role reversal, to crush it, as you can see here.

Usually, crushing one Negative Thought is about all you really have to do, because once the patient blows one Negative Thought out of the water, there is usually a kind of “cognitive click,” and the brain suddenly changes, and all the positive circuits suddenly get fired up. It’s amazing to behold, and you will hear it for yourself!

The dam did suddenly break, and Jillian could clobber the rest of her Negative Thoughts fairly easily, using a combination of Self-Defense, Self-Acceptance, and a lot of the CAT technique. She suddenly appeared to be a radically and delightfully different person during the Externalization of Voices.

You can see her feelings on the Emotions table at the end of the session.

Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, blue, down, unhappy 80 15 0 Embarrassed, foolish, humiliated, self-conscious 50 10 0 Anxious, nervous 90 20 0 Hopeless, discouraged, pessimistic, despairing 100 0 0 Bad 70 0 0 Frustrated, stuck, thwarted, defeated 90 5 0 Inferior, inadequate, incompetent 95 5 0 Angry, mad, resentful, annoyed, irritated, upset, furious 100 10 0

Jillian’s scores on my Happiness Test on the Brief Mood Survey also soared to 100% and her ratings of Jill and David on Empathy and Helpfulness tests were also perfect.

After the workshop, Jillian sent this email.

Hi Jill and David,

As I drove home tonight from my office, I actually felt like my heart had been opened. My chest didn't feel as tight and locked-up like it normally does. It felt so relaxed. I put my baseball cap on, rolled the windows down, and listened to 90's country music (my favorite) on my drive and sang loudly. I have spent the last hour checking my new superpowers. There have been negative thoughts, but telling them to "shut the heck up. I am not listening to you" has been quite liberating. I even was greeted by my 4 year old when I got out of the car. I knelt down and hugged her without the worry of being a rotten mom, but rather one of feeling like I am the perfect mom for her, flaws and all.

Thank you for this opportunity. I took a chance to email you in the first place after listening to a podcast weeks ago. I thought there would be no chance in heck that I would be selected. I am glad I had this remarkable opportunity and grateful to have worked with both of you.

Much love and admiration,

Jillian

I hope you enjoy it as much as we did. Again, a big hug and thanks to the star or our podcast, Dr. Jillian Scherer who gave us all an incredible gift today!

Thanks for listening. I hope you learned a ton and were moved emotionally. Write and let us know what you think!

Rhonda, Jill, Jillian, and David