302: Why am I like this? Live Work with Nazli! Part 2 of 2

Today, you will hear the the second half of the live therapy session that Dr. Jill Levitt and I did with Nazli, a young woman from Turkey, at our recent “David Burns Live” workshop on May 22, 2022. Nazli has been struggling with intense performance anxiety and generalized anxiety, and generously who volunteered to be a “patient.” Jill and I are very grateful for Nazli’s courage in sharing herself so courageously with all of you, and hope you enjoy the session and learn from it. Last week, we played the first half of the therapy session, including the initial T =Testing and E = Empathy. Today, you will hear the exciting conclusion, including A = Assessment of Resistance and M = Methods, and final T = Testing. As a reminder, you can review the Daily Mood Log and Brief Mood Survey (BMS) that Nazli filled out at the start of the session. Part 2 of the Nazli Session: A = Assessment of Resistance and M =  Methods After a period of empathizing, Nazli gave Jill and David an A in Empathy, so we moved on to the Assessment of Resistance portion of the session. This often involves the following steps:

• Invitation Step
• Miracle Cure Question
• Magic Button
• Positive Reframing
• Pivot Question
• Magic Dial

Jill issued a Straightforward Invitation, asking Nazli if she was ready to get down to work, or if she needed more time to vent. She said she was ready to go to work, so Jill asked what changes she was hoping for during the session. This is the so-called “Miracle Cure Question.” This helps to focus the session on something specific. Nazli said that her hope was to reduce or eliminate the negative thoughts and feelings that were making her clinical work so stressful. And like nearly everyone, she said she’d eagerly press the Magic Button. Then Jill and David pointed out that although we didn’t have a Magic Button, we did have some powerful techniques that could help, but it might not be the best idea to use them. That’s because there might be some positives hidden in her negative thoughts and feelings, and perhaps we should first take a look. David and Jill asked Nazli these three questions: 1. Given your circumstances, why might this negative thought or feeling be totally appropriate and understandable? 2. What are some benefits, or advantages of this negative thought or feeling? 3. What does this negative thought or feeling show about you and your core values that’s positive, beautiful, or even awesome? This technique is called Positive Reframing. The goal of Positive Reframing is to reduce the patient’s subconscious resistance to change, along with their feelings of shame about their symptoms.. Paradoxically, the moment patients see the beautiful and awesome things about their negative thoughts and feelings, their resistance to change typically disappears. Positive Reframing is one of the unique features of TEAM-CBT and it opens the door to the possibility of rapid change. As an exercise, see if you can find some positives in five of Nazli’s feelings,

• Anxiety
• Ashamed, bad
• Inadequate
• Hopeless
• Angry

Please do this on paper, and NOT in your head, using the blank Positive Reframing Tool you’ll find at the end of the Daily Mood Log. Getting it “right” isn’t important. What is important is trying. This will get your brain circuits firing in a new way. Then, when you see the work that we did with Nazli, you might have your own “ah-ha” moment, as well as a powerful new skill that may be helpful to you as well. Okay. Did you do that yet, or do you plan to look at the answer without doing the exercise? Oh! I see! You’re planning to look at the answer. If you want to learn at a deep level, whether you’re a therapist or lay person, do the exercise first! It may be challenging at first, but it will fire up your brain circuits, so when you look at the answer, you’ll suddenly have a new and deeper understanding of Positive Reframing. When you’re done, you can check this link to see the work that Jill and I did with Nazli. But either way, I’m grateful that you’re listening to these podcasts and reading the show notes! If you click on this link, you can find the Emotions table from Nazli's Daily Mood Log showing her goals for each negative feeling after we use the Magic Dial. After we finished the Magic Dial, we went on to the M = Methods portion of the TEAM-CBT session, and helped Nazli challenge some of her negative thoughts using a variety of techniques including Explain the Distortions, the Externalization of Voices, Examine the Evidence, the Acceptance Paradox, and more. One of the thoughts she wanted to work on first was this one: “If I don’t fix this patient or make him/her satisfied, then she/he will judge me and think poorly about me.” Together with Nazli, we identified a number of distortions in this thought, including a couple more that popped into my mind while doing the show notes:

• Fortune-Telling: Making a negative prediction without good evidence.
• Mind-Reading: Assuming that I know how my patients are thinking.
• Hidden Should Statement: Telling myself I should be doing better.
• Mental Filtering: Selectively noticing the times sessions have not gone well.
• Discounting the Positive: Overlooking the positive feedback I typically get from patients and supervisors.
• Magnification and Minimization: Magnifying the importance or “awfulness” of negative feedback from patients, and overlooking the potential value of processing their negative and positive feedback with them at the next session.
• Emotional Reasoning: Thinking that my feelings of inadequacy and anxiety mean that I really am screwing up with patients
• Self-Blame: Beating up on myself constantly when I’m seeing patients.

Nazli’s belief in this thought went down from 80% to the range of 10% - 20%, since there was some truth in the thought. Sometimes you’ll want to smash a negative thought, so your belief in it goes all the way to zero. Sometimes, it’s okay just to reduce your belief in a thought substantially, but not all the way to zero. We also encouraged Nazli to begin using the Brief Mood Survey (BMS) and Patient’s Evaluation of Therapy Session (EOTS) with every patient at every session so she can get immediate and accurate feedback of how she’s doing, and so she can fine-tune her therapeutic strategies based on this information. This practice is vastly more effective than Mind-Reading, since therapists’ perceptions of how patients feel tend to be wildly inaccurate most of the time. If you are a therapist, T = Testing at start and end of every  is a vitally important key to personal and professional growth, although it takes courage because sometimes—or even often—you will have to confront some information that may threaten your feelings of pride! You can see Nazli’s final ratings of her feelings on the Emotions table her Daily Mood Log at the end of the session. Since the changes in all of her negative feelings were dramatic, we asked Nazli two questions: 1. Are these ratings valid, or are you just trying to please David and Jill? 2. If so, what were the effective ingredients of your session. What, more than anything else, accounted for the significant and rapid changes you experienced? You will hear how she answered these vitally important questions on the podcast, and you can see Nazli’s BMS and EOTS after her session if you click the link. Thanks for tuning in last week and today! Once again, Rhonda, Jill and I want to thank our wonderful and courageous Nazli from the bottom of our hearts! We hope you enjoyed this session, and the chance to look behind closed doors to see how psychotherapy actually works in a real session with a real human being who, like nearly all of us, struggles at times with that ancient belief that “I’m just not good enough!” In fact, we’re all, in many ways, “not good enough,” and will probably never be “good enough.” But that is never the cause of our problems, especially our lack of self-esteem. Do you know what the actual cause is? Do you know what the solution is? Take your best shot, make a guess, and then you can click on this link. Thanks! Rhonda, Jill, Nazli, and David