Navigating Resistance in Therapy Sessions

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

1. Stan asks if any of my early methods have been abandoned by newer and more effective methods as CBT evolved into TEAM.
2. Stan asks if mild porn is harmful or helpful.
3. Rima ask how you can deal with compulsive liars.
4. Pretika asks what to do with patients who angrily resist positive reframing.
5. 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your Ask David podcasts which methods described in your earlier books you no longer recommend, because they have been superseded by more effective ones described in Feeling Great for example.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!