Feeling Good Podcast | TEAM-CBT - The New Mood Therapy

Mariusz and his wife, Aleksandra, who is also a psychiatrist. Personal Work with Mariusz, Part 2 Mariusz and his wondaful family. Last week, you heard Part 1 of the personal work that Rhonda and I did with Dr. Mariusz Wirga, which included initial T = Testing and E = Empathy. Today, you'll hear the conclusion of our work, including the Assessment of Resistance, Methods, final Testing and follow-up. I am repeating this darling photo Mariusz's beloved cat, with his tail strait up, showing pride and love for Mariusz! Orangina at her favorite scratching post, with tail straight in the air to show pride and love for Mariusz!  A = Assessment of Resistance Once we empathized, we issued a Straightforward Invitation, asking Mariusz if he needed more time to talk and have us listen, or was ready to focus on the problem and see what we might do to help. Mariusz wanted to get to work, and said his goal for the session was to reduce his perfectionism, but when I asked the Magic Button question, he said he would not press it, even if the Magic Button would bring about a sudden and dramatic elimination of all of his negative thoughts and feelings. So, together, we listed the many positives and advantages of his negative thoughts and feelings, including: My anxiety keeps me on my toes. My feelings of inadequacy keep me humble. My hopelessness protects me from disappointment in the session with Rhonda and David isn’t effective. My hopelessness and loneliness show how much I care. My hopelessness shows how helpless I feel to free myself from the many pressures and heavy weights I have been carrying for many years. My negative thoughts and feelings show how much I care for others, including my wife and kids. My suffering with depression and anxiety increases my compassion and understanding of my patients who are suffering and frightened. My anxiety protects me from danger. My anxiety is motivating. My self-criticisms show that I have high standards. My loneliness shows that I welcome intimacy and close relationships. My sadness shows that I am realistic and willing to look at the dark side of life. As you likely know, this process is called Positive Reframing, which is looking at the positive side of things that appear to be negative. Effective Positive Reframing isn’t just listing positives from a list or book, like Feeling Great,  It’s suddenly “seeing” something that you hadn’t previously realized, and having an “ah-ha” moment. So, I asked Mariusz if he could see any additional positives in his fairly intense feelings of sadness and depression. To help him, I primed the pump a little bit by pointing out that sadness and depression are the feelings you have when you’ve lost something or someone your really cared about, or when you notice that something incredibly important is missing from you life. At this point, Mariusz became tearful and said he’d been very lonely as a child. Saying this gave him a “choking pain.” But he said he always turned away from his pain, and distracted himself, with work and activities. He said “I was an obedient child, and I was an only child. Both of my parents worked. “You say something is missing. I think what is missing is life I’m too busy. I’m always distracting myself. But I’m afraid that if I slow down, I won’t be able to pay my bills. I believe that 95%. Then I’ll be a burden. I’ll lose the respect of my family.” At the end of the Positive Reframing, he set his goals for the session, which you can see if you click on his Daily Mood Log again. As you can see, he did not seem to want to reduce his feelings to super low levels, which was surprising to me. M = Methods Rhonda suggested we could do a Feared Fantasy and asked what he thoughts others would think about him, but never dare to say, if he did slow down and they judged him. They’d think: You’re unreliable. We won’t include you anymore. We hate you. We reject you. We’ll tell the world about you. And his worst core fear was ending up in a homeless camp. We did role reversals using the Feared Fantasy Technique until he hit the ball out of the park, and did the same using the Externalization of Voices to defeat the negative thoughts on his Daily Mood Log. When you listen to the session, you’ll see that there was a lot of tenderness at this point, and we discussed our love for cats, and what we can learn from them—the joys of being average and loved and loving your life. We gave Mariusz several homework assignments: Finish your Daily Mood Log in writing, completing the Positive Thoughts and make sure you’ve crushed all of you negative thoughts. Experiment with being open and vulnerable with loved ones (wife and family) as well as colleagues. Practice saying no to colleagues who make requests on your time, and cut down on activities that are not cost-effective. T = End of Session Testing You can find Mariusz final Daily Mood Log if you click HERE, and his end of Session Brief Mood Survey if you click HERE, and his Patient’s Report of Therapy Session if you click HERE. David, add three links when you get documents. Rhonda and I wish to thank you, Mariusz, for a brave and touching session! You gave me the chance to process some of my own perfectionism, and to express my gratitude once again for the stray cats that my wife and I have adopted who have taught me so much about love, acceptance, and the simple things in life! Follow-Up I emailed Mariusz to find out what happened when he decided to become more open and vulnerable with wife, patients, and colleagues. He wrote back: Right before the Eureka moment, there is this state of dense confusion. So I was hesitant about where to go, but there was no visible path to choose yet. It feels like your brain is not getting it. It feels dense, also in an intellectual way. Like your brain stops working. It is quite dark and heavy. And then suddenly, the tears come and things become clear and light (in the sense of brightness and lifted weight). And that you all for listening today! Last month, January, was our biggest month so far, with more than 182 thousand downloads of Feeling Good Podcasts, and this is due, in large part, to your support of our efforts and sharing the show with friends and colleagues who might benefit from it! Thanks again, Mariusz! You are shooting into orbit! I'm SO proud of you and happy for you, and grateful to have had the chance to get to know you on a deeper and more human level, and to share a little of myself with you, too! Several days later, he sent me three addition al Negative Thoughts for his Daily Mood Log. They are touching, take a look at how he challenged and smashed them! Warmly, Rhonda, Mariusz, and David

Mariusz and his wife, Aleksandra, who is also a psychiatrist. Personal Work with Mariusz, Part 1 Mariusz and his wondaful family. In today’s episode, Rhonda and I do live TEAM-CBT with Psychiatrist Mariusz Wirga, MD, who has struggled with perfectionism his entire life. Our training philosophy for TEAM-CBT involves doing your own personal work for a variety of reasons, including: 1. When you sit in the patient’s seat, you develop a radically different perception of the value of the various components of TEAM, including T = Testing, E = Empathy, A = Assessment of Resistance, and M = Methods. 2. When you experience your own recovery, or “enlightenment,” you have a crystal clear vision of what’s actually involved in rapid, effective treatment. 3. You will be able to tell your patients, “I understand how you feel because I’ve been there myself, and it will be my pleasure to show you the path out of the woods.” This message makes a highly beneficial impact on most patients. Bio sketch, by Rhonda Among his many other accomplishments, Mariusz organized the highly successful first world congress for TEAM-CBT in Warsaw, Poland in 2022. He is planning a second four-day TEAM-CBT intensive in Warsaw from March 30 to April 2, 2023. If you are interested in attending, you can learn more at www.teamcbt.eu or www.teamcbt.pl. Mariusz says, " "For the first time ever we will teach a parallel track for business and corporate applications of TEAM CBT at the 4-Day Warsaw Intensive (www.teamcbt.eu & www.teamcbt.pl). It will be taught by our singular Dr. Leigh Harrington, with Polish psychologist and TEAM CBT therapist Patrycja Sawicka-Sikora. In 2023, there will also be major TEAM-CBT conferences in Bristol, UK (August 14-17, 2023, www.feelinggood.uk.com ) and Mexico City (November 6-9, 2023, www.teamcbt.mx )" In today's podcast we will listen to the Testing and Empathy portions of his session. Next week, you will hear the Assessment of Resistance and Methods and exciting conclusion of his session. T = Testing We began by reviewing Mariusz’s scores on the pre-session Brief Mood Survey, which you can review. We will, of course, ask him to take this test at the end of the session, so we can see how effective or ineffective we were in helping him change the way he’s thinking and feeling. Mariusz's beloved cat, Orangina, played a featured role in his session with Rhonda and David! E = Empathy We discussed his anxiety which had spiked in apprehension of today’s live session. He had several negative thoughts that we elicited with a brief Downward Arrow Technique. The percents indicate how strongly he believed each one. I will be talking about private issues, and people will think less of me. 70% Then people will be less likely to want to see me for therapy. 50% My patients might be disappointed in me. 50% This could affect me financially, and I won’t be able to pay the bills, and my daughter’s wedding is coming up. 50% (Mariusz, my estimate on % belief.) If that happens, my wife and kids will turn against me. (Need % belief that you had at the time, Mariusz.) My also reviewed the Daily Mood Log that Mariusz prepared prior to today’s session. Feel free to review it. As you can see, he woke up in the middle of the night and remembered that he’d forgotten to send a form he promised to send to a patient whom he’d seen two days earlier. You can also see that his negative feelings were very elevated, ranging from 60% to 85% for loneliness, embarrassment, sadness, inadequacy, frustration and anger,  to 100% for guilt, shame, and anxiety. If you review his DML, you will also see that he’d recorded 10 self-critical thoughts, and many of them were Should and Shouldn’t Statements. For example, “I should have sent her the homework. I shouldn’t have made such a basic therapy error.” He also identified the many distortions in each thought. All-or-Nothing Thinking, which is the mother of perfectionism, was present in most of them. Other common distortions included Should Statements, Overgeneralization, Magnification, and Self-Blame, to name just a few. Mariusz’s belief in all of his negative thoughts was high. You may recall the two requirements for feeling upset: 1. Your mind has to be filled with negative thoughts. 2. You have to believe those thoughts. Mariusz also described his extremely busy and demanding schedule, including the groups he runs in the hospital for cancer patients, his clinical practice, research, teaching, organizing large international TEAM-CBT conferences, and more. His hectic schedule means he always has to be moving fast, so mistakes and slip ups are fairly common. That’s when he beats up o himself, gets anxious, and has trouble sleeping, which compounds everything. He also beats up on himself and feels guilty for falling behind in some of his commitments. Rhonda and I empathized, using the Five Secrets of Effective Communication, and then Rhonda asked him to grade our empathy. He gave us an A+. Orangina at her favorite scratching post, the one that Mariusz got for her, with her tail straight in the air to show pride and love for Mariusz! This ends Part 1 of the work with Mariusz. Next week, you'll hear the exciting conclusion of his session. Warmly, Rhonda, Mariusz, and David

What IS Hypnosis? Transcending Old Myths Today, Rhonda and I interview Dr. Michael Yapko, a clinical psychologist and expert in clinical applications of hypnosis. Michael D. Yapko, Ph.D. is a clinical psychologist residing near San Diego, California. He is internationally recognized for his groundbreaking work in applying clinical hypnosis, especially in the active treatment of depression. He has taught in more than 30 countries across six continents, and all over the United States. He has been a vocal critic of the medical model of depression and instead advocates for a social perspective, suggesting the problem is less in your biochemistry and more in your circumstances and perspectives. His YouTube lecture on “How to Recover from Depression” has now been viewed nearly 5 million times. Dr. Yapko is the author of 16 books, including his newest book for professionals called Process-Oriented Hypnosis, and his classic hypnosis text, Trancework (5th edition). His popular general audience books  include Depression is Contagious and Breaking the Patterns of Depression. His works have been translated into 10 languages. He is also the Chief Content Advisor for MindsetHealth, a digital hypnotherapy mental health app. More information about Dr. Yapko’s work is available on his website: www.yapko.com. On the personal side, Dr. Yapko is happily married to his wife, Diane, a pediatric speech-language pathologist. Together, they enjoy hiking in the Great Outdoors in their spare time. Michael’s first experience with hypnosis was as an undergraduate psychology student at the University of Michigan. He went to a clinical course on the topic of hypnosis which featured a live hypnosis demonstration. The demonstration subject was a woman who was suffering with intense chronic leg pain following a traumatic auto accident three years earlier. The relentless pain had disabled her and greatly impacted her life on many levels. Michael said he listened to her sad story in skeptical awe, unable to imagine what the hypnotist could possibly say to someone suffering so much that would be helpful to her. He was deeply absorbed in observing every nuance of the interaction wondering what help hypnosis might offer in such dramatic circumstances. The initial phase of the interaction was simply a series of suggestions for relaxing and focusing her attention. He gradually offered suggestions to visualize the pain as a dark, viscous liquid that could flow down her leg, out of her foot, into her shoe, and then spill out onto the floor as a “harmless puddle of pain.” And it was gooey! After re-alerting her from hypnosis, she became tearful and reported that she was pain-free for the first time in almost three years! The change in her appearance was both obvious and deeply impressive. Observing this dramatic demonstration of hypnosis for reducing chronic pain was a transformative experience for Dr. Yapko. He literally thought in that moment that hypnosis had remarkable potentials and that he would dedicate himself to learning all he could about the intricacies of hypnosis and its merits in a wide array of clinical interventions. The demonstration blew Dr. Yapko’s young mind and led to a 50-year career practicing, studying, writing about, and teaching clinical hypnosis to health care professionals worldwide. Although he has recently retired from active clinical practice, he continues to offer trainings and says his fascination with hypnosis is just as strong as ever today. There are a number of striking areas of overlap between Michael’s use of methods of clinical hypnosis and traditional Cognitive Therapy. For example, he routinely uses the Experimental Technique, and gives experiential homework assignments to help patients “see” or discover something that they have not previously seen or realized that would be helpful to them. This can be important when treating patients who hold rigid beliefs that can become the basis for emotional distress. However, the types of experiential experiments Michael suggests are sometimes more ambiguous in their purpose, and are sometimes more paradoxical, but all are designed to lead the patients to a shift in their mindset. In one example, Michael described a severely depressed woman who felt like a victim and constantly compared herself to others she actually knew very little, if anything, about. Then she felt terrible about herself because she was convinced that everyone else was happy and had beautiful, problem-free, ideal lives and she didn’t. She had developed unrealistic perceptions of other people on the basis of little or no actual data. These thoughts made her miserable and she was convinced she was the only one who had been singled out for misery. Of course, we can see many of the familiar cognitive distortions, including Mind-Reading, which is assuming, without evidence, that we know how other people are thinking and feeling or how their lives are going. For most people, this process is so reflexive and unconscious they don’t realize what they’re doing. As Michael said, “too often people think things and then make the mistake of believing themselves.” To her detriment, this woman had never tested her assumptions about others. Michael’s view was similar to that of cognitive therapists, that there would need to be a change in her way of reaching unfounded conclusions if she was going to feel better about herself and her life. But what kind of experiment, or exercise, could he assign to help her discover that her thinking WASN’T always correct ? Telling her to “stop doing that!” would not likely help her. Instead, Michael did a hypnosis session with her and oriented her to the idea that forming interpretations or conclusions without evidence is a reliable path to making mistakes that can be costly. Then Michael gave her an easy assignment that had the potential to make obvious how readily she formed conclusions without any evidence. He encouraged her to go on a hike in a state park near San Diego. The trail he wanted her to go on is called the Azalea Springs Trail, an easy three mile walk. The trail’s name suggests a beautiful trail with flowers and flowing springs and sounds like an awesome, inspiring experience. But in reality, the hiking trail goes through barren desert brush, eventually leading to a clearing. In the center of the clearing, there’s a rusty pipe sticking up out of the soil with a small amount of water dripping out. A sign attached to the pipe reads, “Azalea Springs.” All the expectations of an abundance of beautiful azaleas and a lovely flowing spring naturally exploded in only a moment! When she read the sign and realized how far off her expectations were from the reality, she suddenly “got it” and burst out laughing. She learned in a powerfully memorable way that our expectations are not always the way things are. Subsequently, having absorbed that powerful learning, she regularly caught herself making assumptions about others and using them to build them up and tear herself down. This hurtful pattern changed dramatically, giving rise to a much happier and more satisfying life. Michael also uses the Survey Technique, which is common in TEAM therapy. He described a shy man who desperately wanted to be married and fantasized living in domestic bliss in a house with a picket fence. But he was convinced that no woman would ever be interested in him because he’d been hospitalized for two weeks for depression 15 years earlier. Again, he was rigidly fixated on this unfortunate idea, which he believed to be absolutely true. Michael first conducted a hypnosis session that introduced the idea that “someone can be very sure…and very wrong.” Hypnosis often makes it possible to loosen the hold of unhelpful ideas and shift to a more useful perspective. This is because people in hypnosis process information differently than when in their usual frame of awareness. Having a rational conversation with someone is quite different than guiding someone through a hypnotic experience which can create possibilities that rational conversation alone simply can’t. Hypnosis is all about focus and Michael describes how people’s problems are often problems of focus: they focus on what’s wrong and miss what’s right, or they focus on the unchangeable past and miss positive future possibilities. Those of you who are familiar with CBT or TEAM may recognize these distortions as Mental Filtering and Discounting the Positive. It’s important to appreciate that hypnosis is NOT the therapy. Rather, it’s a vehicle for delivering therapeutic ideas and perspectives at a deeper level that can give rise to more adaptive automatic responses. Following hypnosis Michael gave his patient the assignment to generate a series of general questions that he’d be interested in hearing women answer. Michael included the following question as number 7 on his 10 question survey: “Would you consider dating, getting involved with, and even marrying a man if you knew he’d been hospitalized for two weeks for depression 15 years ago?”  Michael then convinced him to go to the local mall and randomly stop women and ask them to respond to some survey questions he was researching. He could tell a number of women that he was conducting a brief survey and would appreciate getting their opinions. Although he got many varying opinions, he was shocked to discover that the vast majority of women said it would NOT be an issue. He had built his misery around a belief that had no bearing on how women actually felt. Once again, although Michael emphasizes the value of hypnosis, his  therapy techniques have some overlap with Cognitive Therapy. He promotes the idea that the shifts in both physiology and cognition that take place during hypnosis can provide a multi-dimensional foundation for amplifying the effects of virtually any type of psychotherapy. In fact, in his classic text on hypnosis, Trancework (5th edition), Michael cites numerous studies that show that hypnosis can enhance therapeutic outcomes for Cognitive Therapy. And why not? After all, every therapy utilizes suggestions in one form or another! Michael emphasizes the importance of psychotherapy homework between sessions which is also key in TEAM therapy as well as Cognitive Therapy. He will not give patients the room to “skip” or “forget” to do their homework assignments and uses hypnosis to build their curiosity and willingness to explore new possibilities by carrying out assignments. He described different factions in the world of hypnosis. Just as there are different approaches to psychotherapy, there are also differing views about the nature of hypnosis. For example, some experts promote the idea that hypnosis is an intrapersonal (within the person) phenomenon, a “fixed” or unchanging trait the person may have. They use “suggestibility tests” to assess whether and how responsive the patient might be to hypnosis. Michael and other experts view hypnosis differently, seeing it not as a fixed trait a person does or doesn’t have, but rather as a product of many different factors, including the patient’s expectations, the context in which it is being applied, the purpose for which it is being applied, and the quality of the therapeutic relationship that involves empathy and trust. He also believes that almost everyone has the capacity for hypnosis, but different people clearly have different aptitudes, or innate skills, for experiencing various aspects of hypnosis. For example, some people may have a greater capacity for pain reduction or elimination, while others may have a greater capacity for vivid visual imagination and fantasy, and so forth. Hypnosis provides an opportunity for people to discover their hidden strengths and talents. Can you imagine what it does for someone’s self-image, Michael asks, when they discover through hypnosis that they have untapped abilities they can use to handle a situation skillfully that previously had overwhelmed them? In fact, this is what draws Michael to hypnosis: the way it can empower people to discover and use more of their untapped innate resources. This is the exact opposite of the unfortunate myth perpetuated through hypnosis stage shows and Hollywood productions that somehow hypnosis diminishes people’s sense of control. That’s very important, so I’ll repeat it. The myth-based view is that hypnosis makes people obedient to the powerful hypnotist, who is often painted as a Svengali type of character. But in reality, hypnosis can be used to help make people more powerful, more autonomous, and more independent. Just the opposite! Michael has authored 16 books, including nine on the clinical applications of hypnosis. His latest book, entitled, Process-Oriented Hypnosis: Focusing on the Forest, Not the Trees, focuses on how, and not why, people generate their own problems and can be obtained at Amazon. Thanks so much for listening! And thanks so much, Michael, for sharing your wealth of experience and giving us the latest scoop on clinical hypnosis! Warmly, Rhonda, Michael, and David

Ask David: Featuring Matt May, MD What causes anxiety? Is recovery permanent? What if the cognitive distortions aren't helpful? Do hormones cause anxiety and depression? What's the role of vitamins and nutrition? How do Exposure and Response Prevention work? And many more answers to your questions! In today’s podcast, three shrinks discuss many intriguing questions about anxiety from individuals who attended one of Dr. Burns' free workshops on anxiety sponsored by PESI more than a year ago. Several of the questions were answered on the podcast, and a great many more are answered in the show notes below. But first, Rhonda opened the podcast by reading an endorsement from a listener named Rob, with a link. Here it is! Hi Dr. Burns: I'm a long-time listener/reader, first-time caller. I stumbled upon this endorsement for Feeling Good today, and I thought it was worth sharing with you. I can't think of a better endorsement for a book. I hope you enjoy it! "I’ve replaced my copy close to ten times, as I keep lending it to friends who never give it back." https://girlboss.com/blogs/read/feeling-good-david-burns-review Have a great day! Rob Thanks, Rob! And now, for the many excellent questions submitted by listeners like you! Many were answered in depth on the podcast, but you'll see that all questions have written answers as well. When you talk about someone recovering, is that free of panic attacks and anxiety forever, or a great decrease in symptoms but you will always be an anxious person to a certain extent? Especially for someone who has fundamentally been anxious since they were young so not episodic but continuous. David's Answer. Some people are anxiety-prone, and that is likely due to a genetic cause. I am like that, for example. Once you are 100% free of any form of anxiety, like my public speaking anxiety, you need to continue with exposure, or the old anxiety will try to come creeping back in. So, I do public speaking all the time! What if your client/patient understands the Cognitive Distortions but doesn’t believe them to be true? David's Answer. It is hard for me to comprehend what you mean. But I will say this. Anxiety and depression and other negative feelings result 100% from distorted negative thoughts. And the exact moment when you stop believing the thought that’s triggering your anxiety or depression, you will almost instantly feel relief. And here’s the precise answer to your question. When someone says, “I understand the distortions but it doesn’t help,” they still believe their negative thoughts. Resistance, too, is an issue. Nearly 100% of therapeutic failure results from jumping in and trying to help the patient without first comprehending the many reasons why the patient will fight against the therapist’s efforts to “help.” Has research been done on the possible relationship in hormone levels in women and anxiety or depression? Especially during pregnancy, post pregnancy, and those going through menopause? Also, can negative thoughts also depend on the person’s nutrition? Could it be that vitamins that are lacking? David's Answer.  First, I am not aware of any convincing evidence linking hormone levels with depression, anxiety, irritability, or any other negative feelings. However, we can say with certainty that whatever the cause, which is unknown, distorted thoughts will always be present and will be the trigger for the negative feelings. In or near the first chapter of my most recent book, Feeling Great, I describe case of post pregnancy depression, and you can take a look and see the mother’s negative thoughts clearly. And you will also see that the moment she crushed those thoughts, her depression disappeared! People want to “biologize” emotional problems, and I started out as a “biological psychiatrist” and researcher, but found the biological explanations to be erroneous and unhelpful. Could you please give a brief overview about Exposure with Response Prevention for OCD treatment.  Thank you! David's Answer. Sure, these are tools that can be helpful, along with many other kinds of tools, in the treatment of anxiety, including OCD. They are not, for the most part, treatments. I use four models in the treatment of every anxious patient: the Motivational, Cognitive, Exposure, and Hidden Emotion Models. Exposure is facing your fears and enduring the anxiety until the anxiety subsides and disappears. Response Prevention is refusing to give in to the superstitious rituals OCD users when anxious, like counting, arranging things in a certain way, and so forth. END OF QUESTIONS DISCUSSED LIVE ON THE PODCAST The answers to the questions below were written by Dr. Burns but not discussed on the Podcast. Questions can I ask to overcome the Cognitive Distortion “jumping to conclusions”? That is the toughest for me. David’s Answer. I would need a specific example. Jumping to Conclusions includes a vast array of topics and negative thoughts. Fortune Telling and Mind Reading are the most common forms of Jumping to Conclusions. Feelings of hopelessness always result from Fortune Telling. All forms of anxiety always result from Fortune Telling as well. Social Anxiety typically includes Mind-Reading, and Mind-Reading is almost universal in relationship conflicts. In addition, I never treat a distortion, an emotion, a diagnosis, or a problem. I treat human beings systematically, using the T E A M algorithm. Matt’s Answer. There are many methods in TEAM that can be applied in the form of a question. These methods and how they are carried out, depends on the circumstances and the specific thoughts a person is having. Below are some examples of negative thoughts (NT’s) and the types of questions that might help overcome them. (NT): ‘Something really bad is going to happen’  (Be Specific Technique): ‘Like what? What’s going to happen?’  NT: ‘I’ll fail my biology test’  What-If Technique: ‘What if I failed my biology test, why would I be worried about that? (write down any new thoughts) What if those things happened, too, what then? (write down any new thoughts) What’s the absolute worst thing that could happen? (write this down).  Measurement: How certain am I, that these things will happen? On a scale from 0 – 100%, how likely are each of these predictions, in the form of negative thoughts, to occur?  Socratic Outcome Resistance: What do each of these negative thoughts say about my values that I can feel proud of? (write these down) What is appropriate about how I’m feeling and thinking? (write these down) What are the advantages of having these thoughts? (write these down). What would I be afraid of, if I didn’t have this thought? (write these down)  Pivot Question: Given the many positive values related to worrying, the advantages of doing so, the disadvantages of a carefree existence and the many reasons why my worry is appropriate, why would I change this?  Forgetful Clone (Double-Standard Amnestic Technique for Outcome Resistance): What would you say, to a dear friend, in an identical situation, when they asked these questions: ‘I’m really worried about failing my biology test, would you be willing to help me? (if ‘yes’, then continue) … Don’t I need to keep worrying? Won’t that protect me from failing? Don’t I need to worry, so that I’m highly motivated to succeed? Don’t I need to worry, so I avoid making mistakes? Don’t I need to worry, to maximize my rate of learning new material? Won’t I get lured into a false sense of security, if I stop worrying? Won’t I jinx it, if I get too confident? What would you recommend to me? How much do you think I should worry? I am prepared to do so … would it be helpful for me to go into a sustained panic, at this time?’  Cost-Benefit Analysis: Is worrying about failure worth the price? How would you weigh the advantages of worrying about failure against the disadvantages? What are the pro’s and con’s? How would you divide 100 points, to reflect the power of these two arguments?  Examine the Evidence, Motivational: What evidence is there that worrying improves academic performance, concentration and learning? What evidence is there that worrying worsens academic performance, concentration and learning? Magic Dial Question: ‘‘Should I remain maximally worried, at all times, forever? (If not, keep going) ’What amount of worry is best, for me, in this moment?’, ‘How about future moments? How frequently do I need to worry and for how long?’  Process Resistance for Activity Scheduling, Worry Breaks/Cognitive Flooding, Self-Monitoring/Response Prevention: ‘Would it be alright to ignore my worry most of the time and only focus on it during scheduled times? Let’s say I could learn how to be extremely calm and focused most of the day, without worry … would I be willing to worry as intensely as possible, for ten minutes, three times per day, to achieve this? When my worry comes up at other times, would I be willing to observe and record that event, then return to the task on my schedule?  Socratic Questioning: Am I absolutely certain that this thought is true, that I will fail? How do I know that I will fail? What specific questions will be on the Biology test that I will get wrong? What number grade will I get? A 60? 58? 39?’, ‘Would I bet money on my getting precisely that grade? Why not?’.  Examine the Evidence (cognitive): ‘What evidence is there that I will fail? What evidence is there that I will pass?  Reattribution: Let’s say that I fail. Would that be entirely my fault? Are there any other factors, outside my control, that might have contributed to this outcome? My genetics, for example? Or the nature of the world, into which I was born? Did I choose my genetics? Did I choose the world into which I was born, when I was born, my parents, teachers, etc.? Could any of these factors have played any role in the outcomes in my life?  Other examples of Inquiry-based methods, using different NT’s:  Negative Thought: ‘People will be angry and judge me, if I fail’  Interpersonal Downward Arrow: ‘What kind of people are they, if they judge me and look down on me, when I fail? How would I feel towards those types of people? Is it possible I feel angry? How do I express that feeling? What ‘rule’ am I following, in my relationships?’  Outcome Resistance: What’s good about me, for feeling anxious, rather than angry? What are the advantages of keeping my feelings inside? What would I be afraid of, if I expressed my feelings?  Process Resistance, 5-Secrets: Would I be willing to spend the time to learn the skills required to express my feelings, including anger, to people, in a way that made them feel good?  Negative Thought: ‘I’ll get sick and die’  Be Specific: ‘When? What time of day will that occur? What illness is going to kill me?’  Negative Thought: ‘I’ll lose my mind, crack up and go crazy’  Examine the Evidence: Has that ever happened to me? When was the last time? When you are working with clients, how do you handle it when they can challenge their thoughts very convincingly using a variety of techniques, state that they can see the logic in their restructured thought BUT they are still experiencing heightened anxiety and state that this hasn’t helped them? David’s Answer. They still have a strong belief in their negative thoughts. It is 100% untrue that they have “challenged them very convincingly.” Here’s an example. Let’s say you have an intense fear of glass elevators. You will say, “I can see that they are unsafe, but I am still terrified of going in one.” The moment you get on the elevator your belief that you are in danger will suddenly skyrocket to 100%. In other words, you still believe your negative thoughts. Of course, it is nearly always easy to overcome phobias, including an elevator phobia. As stated above, I use four models in treating every anxious patient. Simplistic formulas are just that—Simplistic! Treating humans is not like changing the oil in your car! Matt’s Answer: I am hard pressed to add anything of value to David’s awesome response, above. I might just reiterate that the Cognitive model, challenging the logic behind negative, anxiety-producing thoughts, is the least powerful of the approaches we have to anxiety. It is necessary, but almost always insufficient. Exposure, motivational methods and Hidden emotion are the real heavy-hitters. Until trying these, it is likely that the negative thoughts can be disproven ‘intellectually’ but not at the emotional level. How do you work with clients who state they are anxious all the time, experience strong somatic symptoms (body sensations) and cannot identify specific thoughts. They don’t catastrophize these somatic symptoms but really, really dislike them and want them gone! David’s Answer. I just ask them to make up some negative thoughts. That works well. For example, they may have the belief that the anxiety must be avoided because it may never disappear, or may believe that they are on the verge of going crazy, and so forth. Matt’s Answer, Anxiety can cause people’s brains to shut down, experiencing the ‘deer in the headlights’ phenomenon. Try to identify just one upsetting thought, then use the ‘what-if’ technique to expand on that. You’ll be off and running! How do you do techniques with a person who has active suicidal thoughts? David’s Answer. I don’t “do techniques.” I find out if they’re actively suicidal and in danger. If I know for certain that the person is safe, I treat them like human beings, with T E A M. I’m not a formula person. Each person will be different, and will respond to different methods. My books and podcasts are chock full of examples of actively suicidal people who responded. Matt’s Answer. I let them know that I don’t have the skill to help them unless I know they’re safe. If I’m worried for their safety, I’ll be afraid to use aggressive methods that may be required for them to recover. I’d need them to convince me of their safety before agreeing to work with them. If they can do so, I offer TEAM. If not, I ask if they’re willing to escalate the level of their care, e.g. to meet with me while hospitalized in a safe setting. I don’t work with patients who are at risk of harming themselves because I don’t believe in my ability to be helpful to them. Is it really okay to keep continuing the experimental technique when the patient does not want to continue? And, what if the therapist is not confident and something goes wrong in this situation? David’s Answer. I would need a specific example, but you are right that 75% or so of therapists are afraid of exposure and will not use it, fearing that something will “go wrong!” Matt’s Answer. It’s important to identify the resistance before initiating the method of exposure and to talk it through. Why would they not want to continue? What are they afraid of, if they get really anxious, during exposure? Write this down. Then, surrender, acknowledging that these are some excellent reasons to avoid exposure, in which case we can’t help them with their anxiety. Perhaps there’s something else they want help with? If they can convince you, and themselves, that exposure is precisely what they want to do, and they’re willing to keep doing it, even if it makes them very anxious, it’s appropriate to push a bit, in the moment of their doing exposure, to bolster them and help them through the rough patch. That said, I always give my patients a way out, if they don’t want to continue. That’s their choice, I just want them to be aware of the consequences, including a worsening of their anxiety. When doing experimental method, or the exposure method for example with who has sweating issue, how do you handle the hyper-vigilance he would have with people around, especially if someone actually laughed at him? David’s Answer. I would use the Feared Fantasy Technique, and Self-Disclosure. I would likely go with the patient into the real world to do these things, and have done so on hundreds of occasions. How would you work with someone who suffers from  Selective/Situational Mutism? David’s Answer. I have not run into that in my clinical practice. But 100% of the time, I would want to know what the patient’s agenda is. I would also want to know if there are powerful motivational factors that need to be addressed, looking at the whole person rather than the symptom. How different are Team CBT treatments for teens as compared to adults? David’s Answer. My experience is limited, but I would say no difference, really. I have loved working with teens, even though my main focus was on adults. When working with little kids, I think you need to incorporate play and games, although the basic concepts are the same. For example, you can do Externalization of Voices with puppets, the “Bad, Mean Self” and the “Positive, Loving Self,” or some such. We have featured shrinks who work with kids on many times on our podcasts. Thanks for joining us today! Matt, Rhonda, and David

Ask David: Featuring Matt May, MD How can I help my son? Is rapid recovery just "First Aid?" Do early "attachment wounds" cause anxiety? What's the Hidden Emotion Model? Are anxious people overly "nice?" And more! In today’s podcast, three shrinks discuss many intriguing questions about anxiety from listeners like you, and begin with a question from a man who is worried about his relationship with his 11 year old son, who is just starting to get cranky and a bit rebellious. Then we field questions posed by thousands of individuals who attended one of Dr. Burns' free workshops on anxiety sponsored by PESI more than a year ago. Most of the answers included in the show notes below were written prior to the podcast, so the live podcast will contain more information than the answers presented below. Guillermo asks: How can I get close to my 11 year old son? Hi, Dr Burns Thank you for all the knowledge you share through your books and your podcasts. “the way you think creates the way you feel” has changed the way i view life. I wanted to share an exchange I had with my 11 yo son 2 days ago. I was asking him to move some stuff around to clean his room and he was not loving it so his attitude reflected that, then i asked him about a particular lovely drawing of his that i found (from kindergarten) and he was dismissive and said “just throw it away” and i raised my voice and said “I CAN ALSO HAVE A BAD ATTITUDE, WOULD YOU LIKE FOR ME TO TALK TO YOU LIKE THIS?” (I was rude and loud) To which, he got startled and teary eyed and said “no”. And i immediately felt bad, noting that i pushed him away when i wanted to get closer to him. I later came to his room and apologized for my behavior and gave him a hug. I said “im sorry i raised my voice, im sure that hurt you and that hurts me bc you're the most important person in the world to me” and i gave him a hug. That same night I heard podcast 278 or 279 and you said “the road to enlightenment is a lonely one, my friend” when responding to someone asking about the other person in a relationship. I thought, damn that’s true hahaha. I was going to say sorry but was thinking about what happened, this just reinforced it so much! After this I went over to his room to apologize. I seem to be struggling to stay close to him as he goes into his teenage years, any advice/thoughts that could help me improve my role in this? Thank you again for all you do, Guillermo David’s answer: I can't tell you what to do, but I loved your last sentence, " I seem to be struggling to stay close to him as he goes into his teenage years, any advice/thoughts that could help me improve my role in this?" In my book, Feeling Great, my dear colleague, Dr. Jill Levitt did this exact thing with her son with fantastic results. Said almost that exact thing! Warmly, david ANSWERS TO DAVID'S PESI ANXIETY LECTURE QUESTIONS Is this rapid response merely first-aid. Am I right in assuming the sustained work (psychodynamic, therapy, body work etc.) is still required? David's answer. Nope! But of course, all humans are unique, and some will require a longer course of treatment than others, but this is not due to any “first aid” problem! Matt’s Answer: I agree with a lot of this.  While we are frequently seeing rapid and complete elimination of negative feelings, like depression and anxiety, while using the TEAM model, we expect 100% of people to ‘relapse’, at some point in the future.  Educating people about this is important and part of ‘Relapse Prevention’.  Part of Relapse Prevention involves accepting the impermanence of things, including our euphoric, enlightened experiences.  As the Buddhists say, ‘we all drift in and out of enlightenment’.  Relapses, the ‘drifting in-and-out’ is a sign of a healthy brain.  Recovery is a bit like learning a new language, including how to talk-back to your negative thoughts.  While you can learn a new language, your healthy brain will not permanently forget your native tongue, so you’ll occasionally go back to old habits in thinking.  So, achieving optimal mental health requires an ongoing practice with the methodology.  Rather than some new methodology, however, the one that is effective will be the one that helped you recover, in the first place.  If it was Exposure, you’ll have to keep on doing that.  If it was talking back to your negative thoughts, then you’ll have to do that, occasionally, etc.  This can be a bit disappointing or disheartening to hear, if you were expecting permanence or perfection.  Paradoxically, accepting the imperfect and impermanent nature of our reality is what leads to relief and recovery.  That is to say, ‘Enlightenment’ is not a ‘perfect’ mental state but an acceptance of an imperfect one.  If this seems distasteful, Enlightenment may not be what you’re after!  For those of you willing to embrace and appreciate your average, imperfect and impermanent experiences in life, you are very likely to recovery.  You’ll still need Relapse Prevention, including a commitment to continue to practice on an ongoing basis.  This leads to a higher level of recovery, in which you become your own ‘best therapist’.  Another place where I agree with you is that one might achieve (imperfect) recovery from anxiety and depression, and even take on the responsibility of maintaining these results, and yet still not be satisfied with some other aspects of life.  It’s possible (in fact likely) for any given person to suffer, not only from mood problems, like anxiety and depression, but from other types of problems, like unwanted habits or addictions, or relationship problems.  TEAM contains methodologies that address these concerns as well.  ‘Recovery’ from these conditions is the same as for mood problems, in that recovery will be imperfect and impermanent and require practice to sustain.  What type of practice that might be depends on the individual and we can’t predict, in advance, what types of exercises will be effective, for a particular person.  In fact, there’s a danger in assuming we know what will be effective and closing our minds to alternative approaches.  It’s a common error, for therapists, to pick up one tool and use that, regardless of results, rather than trying new approaches.  This is kind of like having a hammer in your hand, and seeing all your patients as nails!  I like how David says it: ‘Treat people, not conditions’.  So, I think I agree with what you’re saying, in that it requires trial-and-error with multiple methodologies to achieve initial recoveries, as well as ongoing practice to achieve optimal results.  I also feel compelled to observe the tendency for certain dangerous and wrong ideas to persist in our culture, kind of like ‘Urban Legends’ or ‘Mythology’.  One example is the revolution that occurred in medicine when people realized that pathogens, like viruses and bacteria, cause disease.  It had previously been thought that disease states were caused by an imbalance of the ‘Four Humours’, blood, bile, phelgm and calor (heat).  The treatment, for pretty much anything that ailed you, back then, was leeches and blood-letting, in hopes of restoring the balance of these ‘humours’.  A revolution in our understanding of disease occurred with the invention of the microscope.  It was now possible to visualize microscopic organisms, like bacteria, that we now know, after many experiments, are responsible for disease states. This allowed us to develop medications, like Penicillin, that kill bacteria and lead to rapid recoveries from infections, like pneumonia and immunizations that prevent infection.  Despite undeniable scientific evidence, people are prone to believing the old mythology, keeping the wrong and outdated model alive.  For example, many people are afraid, on a cold day, because they think that exposure to cold temperatures will lead to having a disease, which is even called a ‘cold’.  Meanwhile, we know, scientifically, that it’s not cold temperatures or an imbalance of any ‘humour’, that is causing colds, flus, and pneumonia.  It is microorganisms, like viruses and bacteria.  If you don’t want to get a cold, it’s better to sanitize your hands and wear a mask, than to bundle up on a cold day.  Instead of bloodletting and leeches, try vaccines and antibiotics.  Of course, people also make up new mythologies, around these, much to their detriment and at great cost to society.  My advice would be to listen to develop a skeptical mind and read the scientific literature.  Or, try to understand Neil DeGrasse Tyson, when he says, ‘Science is True, whether you believe it, or not’.  A similar revolution in our understanding has occurred in the field of Mental Health.  Like seeing bacteria, for the first time, after the invention of the microscope, we are returning to the understanding (which ancient Greek and Buddhist philosophers noted, as well) that it is our negative thinking that causes our suffering, more than our circumstances.  We know, now, that psychoanalysis is not required, to optimize mental health, any more than bloodletting or leeches is required to treat Pneumonia.  Thanks to Dr. David Burns, there is now a rapid, highly effective and medication-free treatment for depression and anxiety, called TEAM. Is the Hidden Emotion Model suitable for anxiety caused by early attachment wounds? David's answer. These big words are out of my pay scale, although they certainly sound erudite! In fact, the cause of anxiety is totally unknown, so when you say “caused by” we are in different universes! But the simple answer is yes, in 75% of cases, anxiety is helped greatly by the Hidden Emotion Model. Thanks! Matt’s Answer:  The Hidden Emotion model would always be on my list of methods to try, for an individual who wanted help reducing their anxiety.  That said, it’s better to select methods based on an individual’s specific negative thoughts rather than the presence or absence of trauma in childhood.  In fact, the assumption that we know the cause of anxiety is problematic because it may lead to a kind of therapeutic ‘tunnel-vision’ and delayed recovery, as time is wasted, trying the same approach, repeatedly, expecting different results. For example, assuming that ‘early attachment wounds’ are the ‘cause’ of anxiety may trigger the false belief that the most effective treatment would be many years, even decades, of Psychoanalysis.  This has been disproven, scientifically, yet it lingers in our minds, as a kind of mythology, passed down from our past.  Rather than subjecting our patients to decades on the couch, talking about their childhoods, it’s far more effective to ‘fail our way to success’, using multiple methods and measuring outcomes after each one, to discover what is actually effective for them.  Once you find the method(s) that are helpful, these will continue to be helpful, for that individual, throughout their lifespan, and it’s just a matter of practice. Another question about the Hidden Emotion model: when do you consider it “niceness” in anxious people and when is it the fear/anxiety to upset others due to the anxiety? David's answer. That can happen, but not usually in my experience. The “niceness” typically results from automatic suppression of uncomfortable feelings and problems. When they hidden problem or feeling is brought to conscious awareness, in most cases the anxious individual deals with it or expresses the feelings, and that’s when the anxiety typically disappears completely. As a part of my anxiety disorder, at times, I feel flat, emotionless and disconnected from everything around me. How do you treat that? David's answer. I use T E A M, not formulas! I do not treat symptoms, I teat humans. Matt’s Answer:  You could start with a Daily Mood Log, writing down the details of what was happening, in one specific moment in time, when you felt this way.  Include what you were thinking and feeling, including ‘flat’, ‘emotionless’ and ‘disconnected’.  For example, let’s imagine you had thoughts like, ‘nothing will ever change’, ‘this is pointless’, ‘I’ll never feel better’ and/or, ‘I shouldn’t be feeling so disconnected and flat’ or ‘I should be more in-touch with my emotions’ and/or ‘I need to be more up-beat’ or ‘people will reject me if I’m not more enthusiastic’.  You’d have to identify your particular thoughts, these are just guesses. After this, you could decide what, if anything you wanted to change.  If some change is desired, you might imagine a ‘magic button’ that would achieve that change, without any effort on your part.  For example, the button might eliminate all the upsetting feelings on your Daily Mood Log.  However, everything else in your life would remain the same.  Can you identify any reasons NOT to press that button?  Are there any positive values you have, related to these thoughts?  Would there be any down-side to pressing that button?  This represents your ‘Outcome Resistance’.  Typically, there will be many pieces of resistance that would need to be acknowledged or addressed before methods will be effective in helping you.  You can read in one of David’s many excellent books, like ‘Feeling Great’ and ‘When Panic Attacks’ how to make the most of this approach and what the next steps are. Thanks for listening today. MANY more cool questions on the best treatment techniques for anxiety next week. Matt, Rhonda, and David

What's the Antidepressant Myth? Have We Been Scammed?     Today, Rhonda and I interview one of our heroes, Dr. Irving Kirsch, who is a giant in depression research and a fun, down-to-earth human being at the same time! Dr. Kirsch is Associate Director of the Program in Placebo Studies and the Therapeutic Relationship, and a lecturer on medicine at the Harvard Medical School (Beth Israel Deaconess Medical Center). He is also Emeritus Professor of Psychology at the University of Hull (UK) and the University of Connecticut (USA). Dr. Kirsch has published 10 books, more than 250 scientific journal articles and 40 book chapters on placebo effects, antidepressant medication, hypnosis, and suggestion. He originated the concept of response expectancy. This is the expectation that people have that a given treatment or intervention will be helpful. Kirsch’s 2002 meta-analysis on the efficacy of antidepressants influenced official guidelines for the treatment of depression in the United Kingdom. His 2008 meta-analysis was covered extensively in the international media and listed by the British Psychological Society as one of the “10 most controversial psychology studies ever published.” His book, The Emperor’s New Drugs: Exploding the Antidepressant Myth, has been published in English, French, Italian, Japanese, Turkish, and Polish, and was shortlisted for the prestigious “Mind Book of the Year” award. It was also the topic of a 60 Minutes segment on CBS and a 5-page cover story in Newsweek. In 2015, the University of Basel (Switzerland) awarded Irving Kirsch an Honorary Doctorate in Psychology. In 2019, the Society for Clinical and Experimental Hypnosis honored him with their “Living Human Treasure Award.” In today’s podcast, we cover a wide range of topics, including a patient-level reanalysis of all of the data on the effects of antidepressant medications versus placebos submitted to the FDA. This analysis included more than 70,000 depressed individuals and indicated something troubling and surprising. The difference in improvement between individuals treated with antidepressants and individuals receiving antidepressant medications was only 1.8 points on the Hamilton Rating Scale for Depression. This test can range from 0 to 50, and a difference of 1.8 points is not clinically significant. In addition, the beneficial antidepressant effects observed in both the placebo and “antidepressant” groups are large, with reductions of around 10 points or so on the Hamilton Scale. These were the shocking discoveries that led to his popular book, The Emperor’s New Drugs (LINK), and to his appearance on the Sunday evening 60 Minutes TV show. In addition, Dr. Kirsch agreed that tiny difference between the “effects” of antidepressants vs placebos could be the result of problems in the experimental design used by drug companies. Because they give patients in the placebo groups pills with inactive ingredients, there are no side effects in the placebo groups. This makes it fairly easy for individuals to guess what group they were assigned to—the “real” antidepressant group or the placebo group. This might account for the differences in the groups, since many individuals in the medication groups may think, “Hey, I’m getting some side effects. I must be in the antidepressant group. That’s terrific!” This thought would be expected to trigger some mood elevation, but it’s the thought, and not the pill, that causes this. In contrast, some individual in the placebo groups may have the thought, “Hey, I’m not getting any of the side effects they described. I must be in the placebo group!” And this thought may trigger disappointment, and a worsening of depression. This would contribute to differences between the drug and placebo groups in drug company outcome studies with new chemicals that they hope to get approved as “antidepressants.” This problem could easily be corrected by the use of active placebos, like atropine, which produces dry mouth, a side effect of many antidepressants and has been used as an active placebo in a small number of trials. Most of the studies using active placebos have failed to show any significant effect of the antidepressant over the active placebo. Drug companies have been reluctant to implement this change in their research designs, perhaps due to the fear that it will “erase” the tiny differences that they have been reporting. This would be of potential concern since billions of dollars are at stake if the FDA gives you permission to call your new chemical an “antidepressant.” We also discussed Dr. Kirsch’s unlikely journey to Harvard. When he was in England, planning to return to the United States, he asked a colleague at Harvard if it would be possible for him to get a library card so he’d have access to articles in research journals. His colleague told him that it was difficult to obtain a library card for people not affiliated with Harvard. However, they were willing to offer him a position as Instructor on Medicine, given that he was the Associate Director of the  Program in Placebo Studies and the Therapeutic Relationship, which was hosted at one of the Harvard teaching hospitals. That’s a wow! But certainly deserved, and a most fortunate affiliation with unanticipated and highly positive consequences that have led to many important discoveries on how the placebo effect actually works. The placebo effect is not a bad thing, and has been one of the doctor’s best “medicines” for hundreds if not thousands of years. On the podcast, we also discussed the confusion—for patients, doctors, and researchers alike—caused by the placebo effect. For example, many people who receive antidepressants do improve, and some recover completely. They will SWEAR by antidepressants, and may feel hurt or disappointed by the results of Dr. Kirsch’s research. But in fact, there is no discernable difference between the effects of placebos and so-called “real” effects. And one of the downsides of the confusion about placebos is that people who take antidepressants and improve have improved because of changes in their thinking, and not from the antidepressant. But they wrongly give credit to the pills they took, whereas they deserve the real credit for overcoming their feelings of depression. We discussed many other topics, including pushback he has received from the psychiatric community and some in the general public as well who have not taken kindly to his findings. I, too, have experienced that when I have summarized the data in the Food and Drug Administration, and have had to be very careful in how I present this information, because none of us want to discourage anyone who is depressed. We have also invited Dr. Kirsch to consult with us on the research design we use in our beta testing of the Feeling Good App, and have developed tests of “expectations” (the so-called placebo effect) that we will use in our latest beta test as well. We want to “walk the walk” and not just “talk the talk” and find out how much the improvement we see in beta testers might be due to a placebo, or “mega-placebo” effect. Rhonda and I were honored and thrilled to have this chance to interview Dr. Irving Kirsch, a friend and research giant for sure! Thanks so much for listening to today’s podcast! Irving, Rhonda, and David

Integrating TEAM-CBT with Martial Arts Training! Podcast Episode 330, Featuring Dor Star Our guest today is Dor Star. Dor is an educational counselor (MA) and a level 2 TEAM practitioner who works with children in Israel who have emotional and interpersonal problem. He works with children as young as four years old, but most of his work is with children ages seven to twelve years old. The children he works with experience various challenges and difficulties such as: Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), learning disabilities, tantrums, outbursts of anger, all kinds of anxieties, social difficulty, bullying and much more. His work is unique because he works mainly in small groups (4-6 participants) using martial arts and sports as therapeutic tools. In his work Dor uses the TEAM model with some adaptation, because of the children’s ages and sports methods, with great success! In fact, one can say that he discovered for himself, and for his patients, a new way to use the TEAM model. He also teaches sports and martial arts trainers who are interested in entering the field of child therapy. Dor describes his first encounter with TEAM-CBT, which blew him away, but he was initially frustrated because he was thinking of his conventional ways of dealing with kids VS TEAM. But after a few weeks he discovered that he could use the TEAM structure to improve his approach, and wow, did he ever start to shine, as did his results with TEAM. Today’s podcast was really a breath of fresh air! Dor began with T = Testing, and describes how he developed simple assessment tools to rate how his children (aged 4 to 11) were feeling at the start and end of his classes, but also how they felt about him. He uses simple questions like “Did I understand you today? How well did I listen?” He also asks them, “How much fun was the session,” and “How did you grade yourself?” Then they grade him on a scale from 0 (the worst) to 10 (the best.) So, it’s quick, easy, and . . . shocking. Dor says: “I found out that I wasn’t nearly as effective as I thought. Sometimes the kids thought the class was fun, but I got really low grades on Empathy, as well as how depressed, anxious and angry they were feeling at the start and end of each group session. Essentially, I discovered that I wasn’t achieving almost any of my goals for my kids. This was disturbing at first, and I had to let my ego die. But I decided to try to view it as valuable information that I might be able to use to learn and grow.” For example, I had one of the most amazing sessions with an 11 year who was smiling the entire time. I was absolutely certain it was one of my best sessions ever. But when I asked him for my grade, he gave me a 3 out of 10! When I asked why, he explained that at the start I didn’t introduce myself or ask him about himself! So, in this simple but compelling way, Dor has used the T = Testing to transform the entire way he works with kids! I believe he’s had the same experiences I’ve had with the T = Testing component of TEAM. Dor has made his patients his teachers, and this has led to some amazing and revolutionary developments in his approach. Dor emphasizes the importance of E = Empathy, and says that “the Five Secrets of Effective Communication” are incredible! For example, if they’re having a rage attack, or a temper tantrum, you can tell them they are absolutely right in the way they’re thinking and feeling.” He also uses what he calls the Five Ways of Love. Verbally expressing respect and liking Giving service: tying a child’s shoes, giving them some water during the training. These small acts can create feelings of trust and connection. Spending time with them, paying attention to them. This is especially important because so many are angry and try to push others away. They are good at getting other people to reject them and not want to spend time with them. Giving gifts, something they can take home and show to their parents. Making physical contact with them during the martial arts training, playing with them, having fun. I (David) would note that physical contact might be something to be careful with. Of course, when you are teaching martial arts, it may be perfectly justified and desirable. I came from the psychotherapy perspective, and I have been trained that ANY touching of a patient other than shaking hands at the initial and final sessions is grounds for a malpractice suit as well as an ethics charge. Dor also made some really illuminating comments on the A = Assessment of Resistance (formerly called Paradoxical Agenda Setting.) At the initial evaluation, he talks to the teachers, parents, and students. The agendas from teachers and parents are things like “he has an anger problem” or a problem paying attention in class, or whatever. However, 90% of the time, the children frequently are unaware of those agendas, or have no interest in the goals of the teachers and parents. Instead, he finds out what the children want to work on, and finds this to be the most and only effective way to approach the treatment. He says that it is fairly easy to set goals with children of any age, even as young as 4 years old, but those in the 8 to 11 years of age are the most difficult. He said that the children’s goals may be to learn how to hit back when they are being bullied in school, or to have fun and make friends with other kids. I was delighted to hear about Dor’s methods of setting goals with his kids and have felt strongly along these lines for many years! I say, Kudos, Dor! He also described doing a Cost-Benefit Analysis of crying when being bullied, and also helps his children see the positives in their symptoms using Positive Reframing. Dor explains: For example, I worked with a child who was bullied at school. In order for the work to be effective, I asked that the boy who bullied him be included in the group as well. After seeing the bullying happening in real time, I had two private five minute sessions with each child while the other kids played. In these sessions I used empathy techniques and received a score of 10 I started fooling around with the TEAM-CBT Agenda-Setting techniques. The goal was for the child who suffers from bullying to choose to behave in a different way. The child said he was willing to do it to prove to me that he is strong and to get back at the kids who beat him. I then talked to the bully boy and asked him if he was willing to help me work with that boy. He was happy to do it because he wanted him to stop crying all the time and get punished for it. After that the M = Methods part was really easy and fun. I hade the bully train the kid =whom he’d bulled. Two meetings after that they were best friends. In my experience (and I have done this process several times) the bully is the best therapist for a child who suffers from bullying! After Dor described his approach to helping kids who are being bullied, he said that if the parents or authorities step in to help it can make things worse because they child is placed in the role of being a baby, which may intensify the bullying. David asks: Dor, is a safety plan for the child important? Can the child always learn to deal with the bullying on their own? Any details or examples would be great! This was Dor’s answer: I didn't address it enough, but you can't provide good therapy without providing good education. That's why I like working in schools because I can easily talk to the teachers. It is clear that we as adults need to talk about values and set boundaries, and in severe cases we may need to intervene and provide a safety net for the therapeutic process. But I feel that it is my job as a therapist to give my patient the tools to deal with their problems on their own. And bullying, like any problem in a relationship, is about guilt. And as soon as I stop blaming the other and start trying to improve myself and treat the other and his wishes with respect the change begins to happen. David: I agree strongly with what you just said! My research when I was in Philadelphia years back strongly supported the notion that blame is one of the main causes of relationship conflicts. Dor continues: In another case of mine, I worked with a child who complained that whoever was sitting on him was yelling at him and throwing things at him. I wasn't sure what could be done and gave him all kinds of bad suggestions At this point a 10-year-old boy with autism stopped me () and asked him what he asked the boy who was bothering him. He said that the he was criticized for the exact same thing--he was making noises that disturbed the boy next to him. From there we continued with homework to find out what is bothering that child, to tell him that he is right, and to ask him if he is ready to stop hitting and yelling at the second patient and his behavior will change. It was a huge success. Dor continues to talk about the idea of specificity which is so central to TEAM-CBT: I discovered that the techniques we teach children should be direct and simple. In the past we believed in all kinds of indirect techniques that were supposed to somehow help the child. The idea is to stop using general definitions like "self-confidence" "concentration abilities" and "social problems." Instead, we can start being specific in our goals and techniques. Rhonda and I were thrilled to learn about Dor’s terrific work adapting TEAM to working with very young people. I encouraged Dor to consider a book on TEAM for TOTS (or some other title) so other therapists can learn how to adapt TEAM to work with children with specific problems such as intense shyness, autism spectrum problem, ADHD, anger issues, and more. Several days after the recording session, Dor was already working on his book. Awesome! Thanks so much for listening today! Rhonda, Dor, and David If you wish to contact Dor, you can email him at: dorstra@gmail.com

Ask David: Featuring Matt May, MD 329: How can you deal with a “narcissist?” In today’s Ask David, we respond to a listener who requested a podcast on the topic of narcissism, including how to deal with them, so we will focus on these topics. The following show notes were prepared prior to the actual podcast to provide a structure. For more great information, listen to the podcast, as much more was covered! David What is the definition of “narcissistic personality disorder”? Narcissism involves: Grandiose fantasies and feelings, thinking that you are superior to others Lack of empathy for others Extreme self-centeredness Intolerance to criticism or disapproval Urges for revenge on anyone who crosses you. We do not know whether these are just extremes of personality characteristics that everyone has in varying degrees, or whether it actually consists of a “disorder” that is qualitatively different and distinct. But it is definitely true that all of the characteristics I have bulleted above do exist to some degree in most, if not all, human beings. How do you treat narcissistic patient? I do not treat diagnoses, just human beings. This is a radical departure from the way many mental health professionals approach their work. No matter who I’m treating, I always start with the T and E of TEAM (Test and Empathy) and then move on to A = Assessment of Resistance (formerly called Paradoxical Agenda Setting.) The main idea is to find out what, if anything, the patient wants help with. It would be rare for someone with narcissistic qualities to want help with their narcissism. Generally, they want help with a troubled relationship or with feelings of depression, anxiety, or anger. Then I would ask them to zero in on one specific moment when they were upset and wanting help, and deal with Outcome and Process Resistance. If the patient can convince me that she or he does want help, then I move on to M = Methods, and the methods would have to do with the nature of the problem they want help with. I once presented a case illustrating rather dramatic and rapid recovery in a patient I was treating for depression and anxiety. To my way of thinking, it was a great outcome. However, during the Q and A I got an angry rebuke from a therapist in the audience who pointed out that I hadn’t treated the patient’s “obvious narcissism.” This is the “great divide.” I don’t feel like it’s my calling to evangelize for any model of “ideal mental health.” For the most part, and there are always exceptions to every rule, I do not impose my agenda on the patients, but try to work with what they want to change. I might suggest possible ways we could work together, but in the final analysis it is up to the patient. I liken my role to that of a plumber. If you’ve got a broken toilet, give me a call and I’ll fix it. But I don’t go from door to door promoting copper pipes! How can you deal with narcissistic individuals in the real world? Once again, it depends on the specific moment that you want help with. However, I always like to emphasize the value of the Disarming Technique and Stroking when interacting with someone with strong narcissistic tendencies. The goal, in my opinion, might be on “dealing with them skillfully” as opposed to “changing” them or “winning.” For example, (David can give example of Erik’s friend when growing up.) What are the causes of narcissism?  Scientists do not know, for the most part, what causes most of the so-called “mental disorders” listed in the Diagnostic and Statistical Manual of the American Psychiatric Association, but it seems possible, even likely, that there could be genetic and environmental causes, and the environmental causes could have to do with the past (childhood influences) and present. For example, when people begin to experience significant success, in academics, sports, or some other field, others begin to admire them and want to be with them. This can fire up our egos, and can feel good. And as they level of fame and status increases, the attraction of others intensifies, and eventually people fear saying no or contradicting the narcissistic person who has such power. So, the narcissistic person is constantly reinforced, even for bad behavior or irrational beliefs, with little or no negative feedback to correct his or her course of actions and thinking. Some experts also point to profound feelings of shame and insecurity under the surface, which might also be genetic, at least in part, or triggered by adverse childhood experiences. What you have to let go of to relate to someone who is narcissistic? To my way of thinking, you have to give up the idea that the narcissistic person is going to take you seriously or care about you, You may also have to give up the notion that you are going to “change” or “help” them. You may have to use a more manipulative approach, using lots of Disarming and Stroking, instead of being so sincere and serious. This involves “letting go,” and moving forward with your life. What is “Malignant Narcissism?” This is a severe form of narcissism where the person will resort to extreme tactics to get their way, including murder. You see this in politics and cults. Names like Jim Jones, Adolph Hitler, and even some politicians today around the world, and many despots throughout human history. What does it mean when someone is “manipulative?” David explain that he’s heard that term for years, decades really, but did not understand what it meant until a few weeks ago, based on a personal experience. The group contrasts a relationship based on using people, and seeing them as objects, vs a relationship based on warmth, vulnerability, trust, respect, and openness. Thanks for listening today! Matt, Rhonda, and David

"Overcoming Toxic Shame" Join Dr. Jill Levitt and me  at our fabulous new workshop Sunday, February 5th, 2023 8:30am - 4:30pm PST - 7 CE units Click here for information and registration In today's podcast, David and Jill describe their new workshop on Overcoming Toxic Shame. This workshop will feature video snippets from a fantastic session with a beloved colleague named Melanie who struggled with intense feelings of anxiety and shame for more than 8 years. You will see her transformation from utter despair to joy in a single therapy session lasting roughly two hours, and you will get the chance to learn and practice the techniques that were so transformative for her. Most mental health professionals also struggle with feelings of shame because of their belief that they aren't "good enough" and from fears of being found out. You will have the chance to heal yourself while you master cool new techniques to transform the lives of your patients! In today's podcast, David and Jill do a live demonstration of a couple of the many techniques they will illustrate on February, which will include the Paradoxical Double Standardl Technique, Externalization of Voices, and the Feared Fantasy. You will not only witness a remarkable change in Melanie, as well as a sudden, severe and unexpected relapse half way through the session. David ang Jill will ask, "If you were the therapist, what would you do right now?" What follows is AMAZING! Jill practices and serves as the Director of Training at the Feeling Good Institute in Mountain View California. She is also co-leader of my Tuesday evening weekly training group at Stanford (now entirely virtual). This group is totally free and is available to mental health professional in the Bay Area and around the world. You can reach Dr. Burns at david@feelinggood.com.

Live Therapy with Cody, Part 2 of 2 Last week we presented the first of our session with Cody, a young man wanting help with his fairly severe social anxiety since childhood. My co-therapist for this session was Dr. Rhonda Barovsky, the Feeling Good Podcast co-host, and Director, Feeling Great Therapy Center. Today, you will hear the exciting conclusion of his session, and the follow-up as well! Part 2 M = Methods We focused on cognitive work and interpersonal exposure techniques as well. I will leave it to you to listen to the podcast, as I became so engrossed in what we were doing that I stopped taking notes. However, we used a number of tools within the group, including: Identify the Distortions in his thoughts Examine the Evidence Externalization of Voices Self-Disclosure Rejection Practice The Experimental Technique The Feared Fantasy And more. Cody received an abundant outpouring of love, respect, and encouragement from those in attendance (LINK). We also gave Cody two “homework” assignments to complete following the group. Do at least three Rejection Practices in the mall and notify the training group members via email within 24 hours that he had completed this assignment. Complete the Positive Thoughts column of your Daily Mood Log. If you'd like to see Cody's complet4ed Daily Mood Log, you can check this LINK. If you'd like to see Cody's intimal and final Brief Mood Survey plus Evaluation of Therapy session, check this LINK. As you can see, there were dramatic changes in all of his negative feelings. However, he wanted to retain some anger toward his childhood friends who made fun of him. Here’s the email we received from Cody about his homework assignment. Hello groupers, I can proudly say mission accomplished! Although it took me around 7 hours to do it, I did it. A lot of emotions came up as I kept trying and chickening out. I really feel like something has changed in me, by the last person I felt almost no anxiety and now I keep asking myself why I was ever afraid of this (I hope it sticks. I know I'll need to keep up this momentum I'm sure). Having to do this email and being held accountable to you all was what drove me to the finish line. Thanks again, see you all next week! Thanks to you, Cody. You were incredibly inspiring in group and after and the work you did will touch the hearts of many people, just as you have already touched the hearts of all the people in our group! And thank you all for listening! Cody, Rhonda, and David