184: What Comes First? Negative Thoughts or Feelings? Solving the Chicken vs. the Egg Problem, and More!

Today, Rhonda and David answer several challenging questions submitted by listeners like you.

1. What schools of therapy are embedded in TEAM?
2. Do negative feelings cause negative thoughts? Or do negative thoughts cause negative feelings? Or both? Or neither?
3. “Can TEAM-CBT help bipolar patients during the depressed phase?”
4. How do you make Externalization of Voices work? I get stuck! For example, my patient said, "It's unfair that I cannot get a job!"
5. Is there a cure for OCD?

1. What schools of therapy are embedded in TEAM?

Dear Dr. Burns,

I have some questions specifically about T.E.A.M. therapy. You mention in a blog post that T.E.A.M. therapy "integrates features and techniques from more than a dozen schools of therapy." I'm aware of many of the CBT techniques you use, but I don't think I've read yet of any technique belonging to any other schools of therapy. Would you be so kind as to mention such techniques?

Madelen

Hi Madelen,

This is important because I believe we need to get away from competing schools of therapy and need to create a new, data-driven structure for therapy based on research on how therapy works, which is what TEAM is. At the M = Methods part of the session, you can include methods from any school of therapy.

Here are some of the schools of therapy that I draw upon TEAM-CBT.

1. 1. 1. Individual / Interpersonal downward arrow: same (psychoanalytic / psychodynamic)
      2. Flooding / Experimental technique: behavior therapy (exposure)
      3. Externalization of Voices: Gestalt / Psychodrama / Buddhism
      4. Acceptance Paradox: Buddhism
      5. Self-Defense Paradigm: REBT
      6. CBA / Paradoxical CBA / Devil’s Advocate: Motivational techniques
      7. Identify the distortions / examine the evidence: cognitive therapy
      8. Empathy: Rogerian (humanistic) therapy
      9. Five Secrets / Forced Empathy: Interpersonal therapy
      10. Shame-Attacking Exercises: Humor-based therapy / Buddhism
      11. Be Specific / Let’s Define Terms: Semantic
      12. Feared Fantasy: Role-Playing / Psychodrama / Exposure
      13. One-Minute Drill / Relationship Probe: Couple’s Therapy
      14. Time Projection / Memory Rescripting: Hypnotherapy
      15. Anti-Procrastination Sheet: Behavioral activation therapy (Lewinsohn-type therapy)
      16. Brief Mood Survey / Evaluation of Therapy Session: data-driven therapy
      17. Talk Show Host / Smile and Hello Practice / Flirting Training: Modeling / teaching effective social behavior
      18. Storytelling: indirect hypnosis.
      19. Positive Reframing: Paradoxical psychotherapy.
      20. Hidden emotion technique: psychoanalytic / psychodynamic
2. Do you need more? Can provide if you want. Let me know why you have this particular interest!At any rate, I really enjoyed and appreciate your thoughtful questions, thanks!David

2. Do negative feelings cause negative thoughts? Or do negative thoughts cause negative feelings? Or both? Or neither?

Hello Dr Burns,

I would like to thank you for your podcasts. I greatly enjoy listening to them and find them very much helpful both in my personal life and my work as a psychologist.

I do have a question: you talk about how cognitive distortions cause anxiety and depression. Are cognitive distortions also a result of depression and anxiety? For instance, if a person was to become depressed after experiencing loss, would they then discount the positive in their lives to a larger extent, for example?

Thank you very much!

Audrey

Hi Audrey,

Yes, depression creates a negative bias in perceptions, so you pick out information and details that support your distorted thoughts, like "I'm a loser" or "my case is hopeless." My research, which I'll report in my new book, Feeling Great (sept 2020) indicates that negative thoughts trigger feelings of depression and anxiety, which, in turn trigger more negative thoughts. This is a negative vicious cycle. There is also a positive cycle, in that positive thoughts that you believe to be true trigger positive feelings, which, in turn trigger more positive thoughts! Thanks for the question, Audrey.

david 

3. “Can TEAM-CBT help bipolar patients during the depressed phase?”

Name: Sarah

Comment: Hi, Dr. Burns.

I am a big fan of your work and very much enjoy reading your blogs and listening to you and Fabrice on you weekly podcasts.

I am writing with a question that has to do with the depression side of bipolar disorder and the potential usefulness of CBT. I have not heard you speak about this topic before.

My sister in law lives in Switzerland and has been diagnosed with a fairly severe case of bipolar disorder. She does not cycle rapidly, but her manic and depressive states are quite severe. In fact, she has been hospitalized several times during her manic episodes.

For the first time in her life, I believe my sister in law has finally accepted the fact that she is bipolar, and she is actively pursuing treatment and trying to get better. After hearing me talk about all the great information I have learned from you, my husband has hunted down several CBT practitioners in Switzerland, in the hopes that changing my sister in law’s thoughts will help her navigate the overwhelming depression she is currently experiencing. Unfortunately, most of the practitioners she has contacted have said that they cannot help her, because she has bipolar disorder. Of course, this is only adding to her sense of hopelessness.

In your opinion, could CBT and challenging negative thought distortions be helpful to someone who is bipolar and currently experiencing the depressive side of the disease?

In my mind (a layperson who has used CBT to help with panic disorder) it seems so obvious that it could help, but several Swiss psychotherapists seem to disagree with me! Are these therapists afraid to take on a complicated case or is there really nothing they can do?

I would love to hear your take on it. Thank you so much for your endless work helping people to feel good!

Sarah

David will describe his experience running the lithium clinic in Philadelphia at the VA hospital, and will discuss the very important role of good psychotherapy for bipolar patients, although medications will also play an important role in the treatment.

4. Externalization of Voices: How do you make it work? I get stuck! "It's unfair that I cannot get a job!"

Dear Dr Burns and Rhonda,

I've just finished listening to all of the Feeling Good Podcasts. What a gift! My immense gratitude to you and Fabrice for the time and effort that has gone into these podcasts, as well as the wonderful show-notes.

I am a family physician and I work with impoverished patients, many of them refugees. Depression and anxiety are common. We can't find CBT therapists for our patients within their means, so I end up trying to provide some counselling despite not having much background or training (a dangerous proposition, I know, but we have little choice.) Medications tend not to be too helpful, as David points out. I am starting to try to integrate TEAM concepts.

I have a question about Externalization of Voices. In all of the examples you've shared in the podcast, whenever David does a role reversal and models the positive voice, he always seems to "win huge". I'm less experienced and find I'm not batting 1000. What do you do when neither you nor the patient have been able to win huge?

Many thanks again for all you do,

Calvin

PS The episode on How to Help and How Not to Help was one of the best yet!

Hi Calvin,

Thanks for the kind comments! Can you tell me what the thought is that you’ve failed with?

All the best,

David D. Burns, M.D.

Hi David,

There have been a couple of examples where we could only get a small win.

With the first patient, the thought he was tackling was: "It's not fair that I've worked so hard in life, but I can't get a job."

I tried modelling self-defense, along the lines of "I've accomplished a lot given how many challenges I've faced." I also tried suggesting the Acceptance Paradox with something like: "It's true that life's not fair. Who said it should be fair?" This was only a 'small win.' I felt stuck.

Another patient felt her chronic insomnia was driven by anxiety. She feared she would never sleep well again. The though was "I'm going to be chronically tired and no longer able to enjoy life the way I used to." We tried: "Sure, I may be more tired than I used to be, but I'll still be able to enjoy life to some extent." Again, this was a small win, not enough to crush it.

Thanks again for your willingness to help!

Calvin

David’s response

Hi Calvin,

All therapeutic failure, pretty much, results from a failure of agenda setting. I’m not sure you’ve been trained in A = Paradoxical Agenda Setting. The A of TEAM is now also called Assessment of Resistance. When people can’t easily crush a Negative Thought, it is nearly always because they are holding on to it. This is called “resistance.”

Let’s focus on the first thought, "It's not fair that I've worked so hard in life, but I can't get a job."

This thought triggers anger, and anger is the hardest emotion to change because it makes us feel morally superior and often protects us from feelings of inadequacy, failure, or inferiority. If you do not deal with the underlying resistance to change, the patient will defeat your efforts.

When you do Positive Reframing, you start with a Daily Mood Log with one specific moment when the patient was upset and wants help. The anger will be only one of a large number of negative emotions the patient circles and rates, and there will always be numerous negative thoughts as well.

The negative feelings might also include sad and down, anxious, ashamed, inadequate, abandoned, embarrassed, discouraged / hopeless, frustrated, and a number of anger words like annoyed, resentful, mad, and so forth.

This is super abbreviated, but you would then do A = Paradoxical Agenda Setting (also now called Assessment of Resistance.)

You would start with a Straightforward or (better in this case) Paradoxical Invitation—does the patient want help with how he’s feeling? You might tell him he has every right to feel angry and upset and might not want help with his negative feelings as long as he has no job.

If he insists he DOES want help, you can ask the Miracle Cure Question, and steer him toward saying he’d like all of his negative thoughts and feelings to disappear, so he’d feel happy.

Then you can ask the Magic Button question. If like most patients, he says he WOULD push the button, you can tell him there is no Magic Button, but you DO have lots of powerful techniques that could be tremendously helpful. But you’re not sure it would be a good idea to use these techniques.

When he asks why not, you could say it would be important to look at the positive aspects of his negative thoughts and feelings first. Then you do Positive Reframing, and together you can list up to 20 or more positives that are based on each negative emotion and each negative feeling. To generate the list of positives, you can ask: 1. What are some benefits, or advantages, of this negative thought or feeling? 2. What does this negative thought or feeling show about me, and my core values, that’s positive and awesome?

For example,

1. 1. 1. My sadness is appropriate, given that I don’t have a job. If I was feeling happy about this, it wouldn’t make sense.
      2. The sadness shows my passion for life, for work, and for being productive.
      3. My anger shows that I have a moral compass and value fairness.
      4. My anxiety motivates me to be vigilant and to look for a job, so I don’t get complacent and starve.
      5. My anxiety, in other words, is a form of self-love.
      6. My anger shows self-respect, since I have a lot to offer and contribute.
      7. My hopelessness or discouragement shows that I’m honest and realistic, since I have tried so often and failed.

This is just an example, and with a real patient, it can be very powerful as I have the facts and know the patient, whereas in this example I am just making things up.

Then once you have a long and incredibly compelling list, you can ask, “Well, given all of those positives, why would you want to press that Magic Button? If you push it, all these positives will go down the drain at the same time that your negative thoughts and feelings disappear.

Then you resolve the patient’s dilemma with the Magic Dial.

All this is done AFTER E = Empathy (you have to get an A from your patient) and BEFORE using any M = Methods, like externalization of voices.

If you do this skillfully, the Externalization of Voices technique will go way better, because the person will be determined to reduce the anger and other negative feelings. But if the patient says he or she does not want to change, and wants to be intensely angry, that’s fine, too!

If this is not clear enough, you could also get some paid case consultations from someone at the Feeling Good Institute, which could be invaluable. This is the most challenging and valuable tool of all!

Not sure how much training you’ve had in TEAM.  There are online classes that are excellent. Also, on my workshop page you can check out my upcoming workshop with Dr. Jill Levitt on resistance.

There are podcasts, too, on resistance / paradoxical agenda setting as well as fractal psychotherapy.

Thanks!

David

5. Is there a cure for Obsessive Compulsive Disorder (OCD)?

Hi Dr. Burns,

I have been suffering from OCD and depression post the delivery of my daughter and have been on antidepressants for the last 7 years. I have recently start going for counseling too with a psychologist. In fact, she is the one who recommended your book which I am finding very useful. Your website is very helpful too.

I had just one general question: Are OCD and Depression 100% curable or are they only controllable and one has to be on medicines for the rest of their lives?

Reason why I am asking this is the last time we tried to taper down the medicines I ended up having a worse relapse. I want to know if I can plan for a second pregnancy.

I know you do not reply to personal messages but would really be grateful if you could reply to this mail

Looking forward to hearing from you

Regards

"Betsy"

In my dialogue with Rhonda, I emphasize that I rarely use medications in the treatment of anxiety and depression, including OCD, and I would urge this listener to use the search function on my website to search for podcasts and blogs on antidepressants, anxiety, OCD, and Relapse Prevention Training, and you will find lots of specific resources. For example, if you type in OCD, you will find the Sara story (episode 162) plus lots of additional great resources on OCD, including podcasts 43 - 45 (this page provides links to all the podcasts), and more.

Also, my books, When Panic Attacks, and the Feeling Good Handbook, could be very helpful, and you can link to them from my books page. I use four models in the treatment of OCD, and you can find them if you listen to the basic podcasts on anxiety and its treatment. They are the Hidden Emotion Model, the Motivational Model, the Exposure Model, and the Cognitive Model. All are crucial important for recovery, and clearly explained in the podcasts on anxiety.

Thanks for listening today, and thanks for all the kind comments and totally awesome questions!

David and Rhonda