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

Podcast 249 Update on the Amazing Feeling Great Book Clubs! July 5, 2021 Today we report on the first two Feeling Great Book Clubs, with Dr. Brandon Vance and Sunny Choi, LCSW. Brandon explained that more than 200 people signed up for the groups, and that he 100 people on the waiting list for a future book club. The first two clubs have been a tremendous success. Brandon explained why he started the Book Clubs: It’s because these are tools in the book that people who are struggling with depression and anxiety can use to get better. Roughly 10% of the people in the world have significant mental health problems causing functional problems in their lives. That’s eight hundred million people! I have asked myself how we can spread these tools to people around the world. Since I finished my psychiatric residency in 2003, I’ve been mostly working with individuals, but seeing factors influencing their mental health, like oppression, inequality, injustice, lack of safety, prejudice and othering, and environmental destruction with ensuing lack of resources. This has inspired my activism towards changing these things. I feel like we need to take action on those levels as a society. At the same time, we have powerful and empowering skills people can learn on an individual level, and these skills can be taught in group settings to relieve suffering. I think we actually need an “owner’s manual” for the mind, and could teach mental health to children, right along with the basics of reading, writing, and arithmetic, as well as adults. Some people have more access to these tools in psychotherapy, but many people in the world may not.  I would love to make these tools like those in Feeling Great more accessible to people worldwide.  The book, Feeling Great, does that, and I created the Feeling Great Book Clubs, as a way to reinforce those concepts, so people can come together in groups during this period of isolation, and learn these techniques, get support, and have their questions answered. Rhonda asked several questions, including Where do the book club members come from? Who helps them? What happens during the hour. The participants come from all over the world, including North and South America, Europe, Asia, Oceania, Africa, and the Middle East. Most are lay people, but 15% are therapists. A number of certified TEAM-CBT therapists help out voluntarily, including: Phillip Lolonis Katie Dashtban Sunny Choi Heather Clague Brandon described the breakout groups: The typical group starts with music, followed by meditation, and a general check-in on how people are feeling. This is followed by answers to questions members have submitted concerning the assigned reading for the week, and reviews of the chapters. Then everyone joins their breakout groups, which are the same each week. This facilitates the development of trust and bonding among the members in each group. There are specific instructions for the breakout groups that relate to the material in the chapters that were assigned for the week. They may discuss questions related to the chapters, or work on a skill presented in Feeling Great. For example, they may work on identifying the cognitive distortions in their thoughts. Then they may use the “Straightforward Technique” or other techniques to challenge their thoughts with “Positive Thoughts.” Last week while reading the chapters on Fortune Telling and Anxiety, we had a check-in circle, where one member describes a mildly embarrassing experience and shares some feelings she or he had. Then the other members practice responding with a couple of the Five Secrets of Communication. For example, they may use “Thought Empathy” to repeat a bit of what the person said along with an “I Feel” Statement and say, “I’m feeling sad to hear that.” In future weeks, we will use this same format but add more of the 5 secrets, including Feeling Empathy, the Disarming Technique, Stroking, and Inquiry. Sunny mentioned that it is neat to see people from the most remote corners of the globe connecting and developing friendships. He said that Brandon’s genius is in how he has created a safe environment to open up and has made the groups really fun, with singing and sharing that have made the groups a powerful and unique personal experience. Sunny explained that when he grew up in Hong Kong, he had anxiety and panic attacks, but you don’t always need a therapist to feel better. One of the most powerful groups was when Sunny shared his grief about a painful personal experience in the group, when his cousin’s restaurant was targeted and vandalized in an act of anti-Asian violence. Working with Sunny in front of the group as if he were a patient, Brandon demonstrated the Feared Fantasy Technique that they’d read about in Feeling Great that week. Brandon said Sunny’s vulnerability opened people up and made it easier for them to share their feelings and experiences. Sunny explained that many Asian people have an anti-therapist bias, but they are very receptive to learning how to use TEAM-CBT techniques in the context of a book club. The club has also stimulated the creativity of people in the group. For example, one member has started a weekly Daily Mood Log practice group and another made visual diagrams of the patient sessions discussed in the book. Sunny said that most of the group members began with the popular belief that therapy has to take a long time, but have discovered that this is not true, and that most people can improve and recover rapidly. At the end of the podcast Brandon played a beautiful audio with touching endorsements for the book club, and for Feeling Great, from people around the world. If you’d like to contact Brandon, you’ll find him at: www.brandonvancemd.com If you’d like to contact Sunny, you’ll find him at: www.bettermoodtherapy.com In the fall, Brandon will be leading two more book clubs starting in mid-August and running through mid-December. If you’d like to learn more about the book clubs or get on the waiting list for the next book club in the fall, please visit www.feelinggreattherapycenter.com/book-club. This would be a good to get on the waiting list for that group, since it is filling up rapidly! Rhonda and David

Podcast 248 Ask David and Rhonda! In today’s podcast, Rhonda and David answer some fascinating questions submitted by listeners like you! We both thank you for your interest in our show, and for your kind comments and terrific questions! The Questions Kati asks: I notice that in your therapy sessions, the negative feelings of most of your patients are reduced all the way to 0%, and many become euphoric. I was wondering whether this somewhat contradicts the idea that our negative feelings are useful to us in some way? Kati also asks: Do you believe that empathy can be ‘taught’? Yiftah asks: How could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise? Yiftah also asks: From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective? Esther asks: You say there is no convincing or consistent evidence to support most psychodynamic claims about the causes of things. What you said resonates, but aren’t you also just making claims? I have a psychodynamic supervisor, and am struggling to choose between empirically validated treatments and traditional psychodynamic approaches. Sean asks: Burns, what can you do when you are using the disarming technique and the person keeps interrupting you? Ben asks: Since exercise improves the mood of some people who are feeling down, doesn’t this prove that physiologic changes can improve mood, as opposed to changing negative thoughts? The Answers  Note: The answers below were based on David’s email exchanges with the people who asked the questions and were created before today’s podcast. Therefore, the podcast may contain new and different information from these show notes. Hopefully, both the show and the notes will be helpful to you. Rhonda and David   Kati asks I notice that in your live therapy sessions, the negative feelings of most of your patients are reduced all the way to 0%, and many become euphoric. I was wondering whether this somewhat contradicts the idea that our negative feelings are useful to us in some way. David responds Hi Kati, thank you for the kind comments! It is great to get negative feelings to zero and experience enlightenment and joy. However, no one can be happy all the time, so you will have plenty of opportunities to "learn" from negative feelings again. In addition, there is a difference between healthy and unhealthy negative feelings. Healthy sadness is not the same as clinical depression, healthy fear is not the same as a phobia or panic attack, healthy and unhealthy anger are quite different, and so forth. There will bumps in the road of life for all of us at times. * * * Kati also asks Do you believe empathy can be “taught?” As a mum (of a 15 and a 10 year old girls) and a (HS) teacher I notice some people seem to have it more ‘innately’ than others but would also love to think it is an aspect that can be intentionally developed in others in some way. If you think like me, I would love to hear your thoughts on how that could be done (i.e. what practices or strategies would be most helpful to use with young people in particular). I am still in awe that we can have a sort of conversation with such a brilliant and creative mind and I humbly hope you can address these two questions either in one of your podcasts or by responding to this message. In admiration, Kati David responds Thanks again, Kati, With regard to empathy, it is something that can be learned, but it takes commitment and practice. A good first step is the book I wrote on this topic called Feeling Good together. In addition, there is, as you say, an "aptitude" that people have for this or any skill, with a tremendous variability in the population. But regardless of your natural aptitude or lack of it, you can learn and grow tremendously. I started out with very poor listening skills. You can also search for Five Secrets of Effective Communication on the website, using the search function, and you'll find lots of podcasts teaching these skills. david * * * Yiftah asks How could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise? Dear Dr. Burns, I love your podcast and books. They have completely changed my practice and had helped my personally. In particular it was great to hear you working with Dr. Levitt with cognitive exposure, and your discussion about it. I have two questions regarding cognitive exposure with PTSD (for the podcast. First, how could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise? David responds Hi Yiftah, I try to deal with the Outcome and Process Resistance issues prior to agreeing to help any patient with anxiety. I might say something like this: “Jim, I’d really love to help you with your fears of X (whatever it is), and I’m pretty convinced that if we work together, you can make some great progress in overcoming your fears. I have more than 30 great tools to help you overcome anxiety, and you’re probably going to love all of them except for one, exposure. Confronting your fears is just one tool among many, but is a vitally important part of the process, and cure is usually impossible without exposure. “For example, I may ask you to do is (I explain the type of exposure we might use.) I know that will be terrifying, and it needs to be terrifying to be effective. I’ll be with you every step of the way, of course. But I need to know if you’d be willing to do that type of thing if I agree to work with you. “I know you’ve told me that you’ve had many therapists in the past who did not use exposure, and that might be why their treatments were not as effective as you’d hoped. And if you absolutely don’t want to use exposure, I would totally understand and support you, but sadly could not agree to treat your fear of X.” * * * Yiftah also asks From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective? You have a lot of experience with successful exposure treatments, but I had never worked with PTSD. And I hear some "PTSD experts" say that cognitive exposure is a dangerous process that can backfire. And according to papers I've read it doesn't always help. In other words, assuming that one had worked correctly with the Empathy and Assessment of resistance phases: how safe and how effective is prolonged cognitive exposure with severe PTSD? From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective? I mean are there some conditions or distorted thoughts that categorically need to be dealt with successfully before going for exposure? For example, would there be any special considerations when working with patients with thoughts connected to shame, self-blame and hopelessness, as well as habits and addictions, or relationship issues? Thank you Yiftah David responds Thanks again! Let’s assume that you are treating a veteran who is paranoid and living alone in the woods, who tells you that he is afraid of “losing it” and blowing people away with his automatic rifle. I would not want to have him fantasize blowing people away in order to overcome his fear, especially if he is prone to violence and has poor impulse control, and is psychotic. This could conceivably trigger him to do something violent, and I’d have a hard time explain my therapy methods to the police after he kills many people in the local mall. At the same time, the vast majority of anxious people who are afraid of doing something horrible or violent have OCD, and are totally safe. So, it takes judgment. Powerful techniques require therapists with exceptional skills, training, and thoughtfulness. It ALWAYS pays to be thoughtful and cautious! And this has nothing to do with cognitive exposure per se, but all of the > 100 techniques that I use. They can all hurt, including empathy, if not done skillfully, and with compassion. Backfiring occurs when therapists don’t do or know how to prepare the patient for the methods you plan to use. Anytime you “throw” techniques at patients, you are asking for trouble. Remember, TEAM is a systematic, step-by-step package that is done as a sequence. Your patient has to give you an “A” on empathy before you can even go on to the Assessment of Resistance. My experience has shown me that most therapists, including the so-called experts, do not know how to get an A grade on empathy, and may not have outstanding empathy skills. Trust is so important in the treatment of anxiety, and always has to come first. Before using any M = Methods, you will need to address the patient’s Outcome and Process Resistance, and get some agreement on what you plan to do and how you plan to do it. Should we not use a technique because it doesn’t always work? All techniques often fail. TEAM is based on “failing as fast as you can!” If you can’t use a technique that sometimes fails, then you can’t use ANY technique! Also, I never treat anxiety with one technique. I use a great many techniques drawn from four very different treatment models: the Cognitive Model the Motivational Model the Exposure Model the Hidden Emotion Model I sometimes get tired / annoyed with so-called experts who love to spout off, saying things that to my ear sound like half-truths. But then again, I do the exact same thing! At any rate, neither Jill nor I have ever had a bad outcome with any form of exposure, but we are both pretty careful, and try hard to be compassionate and to prepare the patient. You have to be thoughtful and careful. For example, Shame Attacking Exercises can be life changing, but they require half a brain on the part of the therapist. For example, I wouldn’t throw someone with poor interpersonal skills into a potentially awkward or hurtful Shame Attacking Exercise. All powerful techniques have the potential to heal or harm. The same scalpel that a surgeon uses to save a life can also be used by a murderer to slit someone’s throat. d * * * Esther asks You say there is no convincing or consistent evidence to support most psychodynamic claims about the causes of things. What you said resonates, but aren’t you also just making claims? I have a psychodynamic supervisor, and am struggling to choose between empirically validated treatments and traditional psychodynamic approaches. Hi David, I absolutely love your stuff! I’ve used some parts of feeling good in my practice as a therapist and in my personal life for some time, but I’ve recently gotten much more into your teachings and I’ve been thinking a lot about TEAM-CBT. And thank you for providing all these free resources for the public! In episode 230 (about 22 minutes in) Rhonda asked you about a common psychodynamic type of claim- “a child of alcoholics either become an alcoholic, marries an alcoholic or becomes a therapist of an alcoholic.” You responded by saying “people love those kinds of theories because people want to think they know the causes of things.” Then you went on to disagree, claiming that there isn’t much evidence to support these types of claims. At first what you said very much resonated with me, and yet I began to think about it and realized the irony in your response: you had explained people’s tendency to come up with such theories with your own cause (“people want to think they know the causes of things”), something which I doubt you’ve been able to test in a research study (though perhaps I’m wrong!) And yet what you said still resonates with me and highlights the crux of my question: isn’t there any value in intuition (without any evidence) in determining the causes of things? For instance, I think your causal explanation here is highly intuitive. (Even though an alternative explanation could have involved something not inherently psychological, like “people err because they think correlation implies causation” or something. This is not just a theoretical question for me. I currently work under a wonderful supervisor who takes a psychodynamic approach to many issues, and I am very suspicious of some his theories, but it seems that he is a great therapist. Further, I think that many people in school and in the early stages of practice (including myself) are conflicted about whether or not they wish to train further in evidence-based approaches or in a psychodynamic type of school. I think this important question is sometimes at the root of the issue. (Although psychodynamic theories are sometimes not at all intuitive.) For a practical example- something I always found intuitive is the role low self-esteem seems to play in people with inflated egos or the role it can play with those who have anger issues (In which the ego or anger serve to “compensate” for the low self-esteem). When I was working with a client who suffered in these two areas, I began by educating him about this notion (which resonated with him) and we began to address his low self-esteem. Later, however, I happened across an article claiming that this intuitive notion is not supported by research. It called into question many of my intuitions when conceptualizing cases and treating my clients. Finally, I just picked up a copy of “Feeling Great” (it’s awesome, by the way!) and I noticed you talked about the hidden emotion technique. Once we’re on the topic of evidence; do you have any evidence that this particular technique is helpful? Is there research backing such a technique? (I’m particularly suspicious of it given its psychodynamic flavor :) I apologize if you’ve addressed these questions somewhere already- I’ve only just begun to avidly read your stuff and listen to your podcast. Thank you so much! Esther David responds Hi Esther, This is an important email and if I can find the time, and may address it in an Ask David. You write: “This is not just a theoretical question for me. I currently work under a wonderful supervisor who takes a psychodynamic approach to many issues, and I am very suspicious of some his theories, but it seems that he is a great therapist.” It’s great that he is a great therapist, and it will be fun for you to learn from him. There are two caveats, perhaps. First, therapists’ views of changes in the negative feelings of their patients, like depression, are not especially accurate, so his self-report of his effectiveness may not have a lot of credibility. I have measured therapist accuracy in a study at the Stanford Hospital, and found an accuracy of only 3% in detecting changes in depression, even after exhaustive, systematic interviews with patients about how they feel. Second, most therapists have only a placebo effect, although they will strenuously insist it ain’t true! And their effectiveness is almost definitely not the result of the specific tools they are using, but other factors. Many outcome studies have been consistent with this type of conclusion. But still, learning from the wisdom of an older therapist can be awesome! With regard to the Hidden Emotion Technique, it IS a kind of modernized psychodynamic technique. I don’t think it has been studied, but I no longer keep up with research. I find it exceptionally helpful in myself (I am anxiety prone) and in about 50% or more of anxious patients. And I have found I can engage in really rewarding conversations with psychodynamic therapists when I describe this technique. I enjoy this type of dialogue, challenging our favorite ideas. Have you ever heard of the “confirmation paradox?” My memory is that if theory A predicts observation B, and you see observation B, you may wrongly conclude that theory A is confirmed. For example, the theory that the sun revolves around the earth predicts that the sun will come up in the east in the morning and set in the west in the evening. So, we do see that every day, and we wrongly conclude that we have confirmed our theory that the sun revolves around the earth. Same is true for psychological theories about the causes of depression or whatever. The problem is that your observations also confirm a large number of alternative theories that all would have predicted the same thing. You can disconfirm a causal theory with data based on an experiment or natural observation, but you cannot actually confirm any theory in science. You can only say that your data are consistent with this or that theory, and that you have failed to disprove your theory based on your observations. I tested many theories about the linkages between Self-Defeating Beliefs (SDBs), like Perfectionism, and changes in negative feelings over time in several hundred patients treated at my clinic in Philadelphia. The data was not consistent with causal linkages between SDBs and negative feelings, even though there were strong correlations between them at both time points, and even though changes in SDBs were strongly correlated with changes in SDBs. david PS You might enjoy this psychoanalysis poem by another Esther who is a member of our Tuesday TEAM training group at Stanford. GOODBYE TO ALL THAT: THE JOY OF PRACTICING PSYCHOANALYSIS No more forms, no need for technique No more brain strain week after week, Ditch those methods — fifty, a hundred, A thousand ways I might have blundered.   So long agenda, don’t mention homework Just perfect that withering shmirk. Surveys, grades, throw them away You know it’s sex, whatever they say.   Gone for good are your twelve distortions, Out with charts and their crazy proportions. Is that a purse I see before me? Nope! It’s your mother’s vagina. You think that’s a joke?   Such progress we are making you must admit Only ten years and we are ready to dip Into that complex where troubles all lie The mom you must marry, the dad who must die.   Two hundred sessions a year and each one two hundred Over ten years $400,000! I sundered… WHAT? I was…er… giving thought to your dream (And the cabbage I missed doing TEAM.)   How can you say you’re worse off than before While standing in front of Enlightenment’s door? You say you’ve awakened to find I’m a nitwit, & at last you’re done with all of this horseshit!   Goodbye, my patient, there’s the door, A pity you are so very sore. But let me say just one thing more — You really are a frightful bore.   — Esther Wanning * * * Sean asks Dr. Burns, what can you do when you are using the disarming technique and the person keeps interrupting you? I’ve recently been practicing the 5 secrets and I am still learning how to apply the techniques. I listened to many podcasts and I’m reading your books/doing the exercises. I’m a complete believer in your method! Thank you! During the disarming, if the person continues to aggressively interrupt and ask pointed questions, how do I continue to stay engaged in the conversation? I repeat the steps. I agree/try and find the truth, paraphrase the comments, along with practicing feeling/thought empathy. The person continues to interrupt, argue, blame, and ask questions to prove their point. Do I just continue to try the secrets? In the moment it seems like it’s impossible, but I stay committed. Thanks Sean David responds Hi Sean, I have often said that these abstract questions have very little value. The devil is in the details, the specific example. If you give me an example of what the other person said, and what, exactly, you said next, I will probably, or almost certainly, be able to show you what your errors were, and how you are forcing the person to keep attacking you. However, this can be painful, to suddenly see how you are causing the exact problem you are complaining about. But also freeing. So, the answer, in short, is that you are probably not using the Five Secrets correctly, but you get lots of credit for your efforts, and some feedback may help you. d PS Sadly, I never got a specific example from Sean. That is too bad, because abstract questions and answers never have much, if any, practical value or impact. All the learning is in the specific example, which becomes a mind-blowing learning experience. But, sometimes people don’t seem to “get” this message! * * * Ben asks Since exercise improves the mood of some people who are feeling down, doesn’t this prove that? Hello David! I am a frequent listener of your podcast, and am currently going through your new book, "Feeling Great". The importance of treating depression at specific moments in time, addressing self-defeating beliefs, and the death of the "self" are all topics that are of particular interest to me. I have a question for you. You make the claim that depression & anxiety always result from distorted thoughts -- that our thoughts always cause our feelings. If that is the case, what do you make of the research that shows that aerobic exercise can be an effective treatment for them? Doesn't that indicate that there could be a physical basis for some cases of anxiety & depression? I have certainly found exercise to be tremendous help for me in keeping my anxiety at bay -- a vigorous session of exercise just seems to "slow down" my mind or reduce the volume of the voice that's always chattering away in the background for hours afterward. Could people be getting more depressed and anxious because they simply don't move as much or as vigorously as our bodies have evolved to? Thank you for your amazing work and the generosity with which you share it. I've recommended your podcast to many people, and will continue to do so! Take care, Ben David responds Hi Ben, Great question. I like your critical thinking! To test this idea, we would, of course, have to measure the positive and negative thoughts of individuals who are, and individuals who are not, helped by exercise. You cannot just assume something either way. I believe that all change in moods, regardless of the treatment intervention, is mediated by a reduction in the distorted thoughts that trigger the depression. This is a testable hypothesis. Many people tell themselves things like, “Oh, I’m exercising now, this will really help me, I’m keeping up with my commitments to my health,” and so forth. I, for one, have never had a mood elevation from exercise. My daughter finds exercise very helpful. I suspect you will find a sharp reduction in negative thinking in individuals who are helped by exercise. We have to be careful about jumping to conclusions about causality. I have a mild case of sciatica, and a medication like Tylenol makes the pain disappear. Does this mean that sciatica is due to a Tylenol deficiency? I did a study with an N of 1. I asked a severely depressed man to fill out a part of a Daily Mood Log every evening. He recorded the situation, then circled and rated his feelings, and then recorded his negative thoughts and how much he believed them. Then he flipped a coin and either jogged for 45 minutes or worked on challenging his distorted thoughts for 45 minutes. In both cases, after 45 minutes he recorded any reductions in his negative thoughts and feelings. The days when he worked with the DML he experienced pronounced reductions in his belief in his negative thoughts and in his negative feelings. The days he jogged, in contrast, there were no reductions in his negative thoughts or feelings. analysis of the data with structural equation modeling confirmed that the change in his negative feelings was caused by the reduction in his belief in his negative thoughts. Just a small pilot study, and could be done on a larger group. However, the researcher would have to have a sophisticated understanding of how the DML works, and how to elicit distorted thoughts from people who are depressed and anxious. david Ben’s reply Wow! I didn't expect such a quick and thorough reply! Thank you, David. Love the Tylenol example. Such a powerful way to demonstrate the hazards of assuming causality, and also show me how easy it is to assume causality without even realizing I am doing so. Your study of the severely depressed man was ingenious as well. It gave me some good food for thought about *why* exercise might be so helpful for me -- that I can't assume that it's because I've manipulated my physiology in some way. It could very well be that I end up feeling good because I have pursued a difficult activity that I value, and thus feel as though I have accomplished something. I can see why someone who *doesn't* rely on accomplishments to feel "worthwhile" or doesn't even think of exercise is an accomplishment might not get the same boost. Indeed, there have almost *certainly* been times that I've exercised and felt WORSE afterward, but I'm mentally filtering those instances out. Like when I've gone for a run even though I was supposed to be getting dinner ready, and then the family is frustrated w/ me and hungry! ;-) I don't really get to bask in the glow of Accomplishment(tm) then! Take care, and thanks again! -Ben David responds again Hi Ben, Thanks. I ‘ve always said the thing about exercise raising brain endorphins was just something someone made up, but people wouldn’t listen to me for the most part. I pointed that human brain endorphins cannot be measured, so there cannot be any evidence all for this theory. I recently said an article where they blocked brain endorphin receptors in people who got the runner’s high. They still got the runner’s high, proving brain endorphins could not possibly be involved! People tend to believe what they want to believe, regardless of the evidence. We see this in politics and in religion in a big way, but it is true in all walks of life. david Rhonda and David

The Night My Childhood Ended, Part 2 In today’s podcast, we present the second half of the therapy session with Todd, who did personal work focused on the impact of a traumatic event that ended his childhood when he was eight. Last week, we presented the T = Testing and E = Empathy phase of the session. Today we present the A = Assessment of Resistance, M = Methods, final testing, and teaching points. A = Assessment of Resistance Todd’s goal was to be able to feel more vulnerability by the end of the session. During the Positive Reframing, we listed the positives that were embedded in Todd’s negative thoughts and feelings. My sadness shows my humanity. My sadness shows my commitment to family. I put others before me and value the time people are taking by listening to this session. I challenge myself to work on myself. My negative thoughts and feelings make me a more loving husband and parent, and a more committed and effective therapist. I love my mom and want to protect her. I have high standards. Although I feel like I was and still am “a frickin’ coward,” sharing this shows tremendous courage. As you listen, you’ll see that it was incredibly difficult for Todd to see anything positive in the fact that he was that calling himself a coward. He kept thinking that he “should” have gone in earlier to try to help and save his mother, and that this might have changed the entire trajectory of his life. At the same time, he conceded that he was just a little guy, and that his father was an incredibly frightening and intimidating figure. You can see Todd’s Daily Mood Log at the end of A = Assessment of Resistance (link). As you can see, he wanted to reduce all of his negative feelings quite dramatically, but he wanted his sadness to remain at 100%, because he wanted to be able to feel this emotion and grieve. M = Methods Jill and I tried a variety of techniques during the Methods phase of the session, including a new version of the Double Standard Technique. I played the role of the 8-year old Todd, and he played the role of himself. I verbalized all of his Negative Thoughts, “But isn’t it true that I rally was a frickin’ coward?” and challenged him to crush them. This helped Todd get in touch with his compassionate and realistic self. You can see his final Daily Mood Log. As you can see, there was a dramatic reduction in all of his negative thoughts except sadness, which fell to 80%. You will recall that his goal for sadness was 100%. There were lots of positive messages for Todd throughout the session in the chat box. There were many outpourings of love and admiration for Todd's courage and vulnerability. We sent those messages to him after the end of the session, and that was when the tears finally came. Here’s an email we received from him after the session. What an evening! I just saw the video again and I was so blown away from the amazing love and support I felt from all of you last night. I also was able to tear up a bit when I was reading all of the heart felt chats that Alex had shared with me. I would give all of you an A+ on empathy for sure. Finally, I'm so grateful to JIll and David for their compassion, and for helping me reconnect with little Todd and feel much closer to all of you. What an awesome night and group! Brandon Vance MD sent a link to a song one of his students created, and Todd responded to it: Last night, it was so awesome to listen to the musical recording that your student so beautifully shared with us. I'm not one to cry very easily, but I was so moved by the lyrics and the emotions in that song. I've been so amazed at how you continuously evolve TEAM in so many wonderful and creative ways. Kudos! Here's the link to the song if you'd like to listen! I also found it moving and beautiful. Cassie Kellogg is the performer and songwriter, and her song is called Double Standard, which is the method that proved so helpful for Todd. Some interesting information about Brandon and Cassie, as well as the words to her song, appear at the bottom of the show notes. There were also tons of positive comments about the session in the teaching evaluation at the end of the session, with overwhelming outpourings of love and appreciation for Todd. Time after time, the personal work we sometimes do while teaching seems to make the most positive emotional impact on our students. And, of course, the teaching value can be tremendous. Teaching Points 1. T = Testing is crucial. If you met Todd, you would have no idea how he feels inside, and if you were his therapist, and you did not use the Brief Mood Survey at the start and end of every session, and the Evaluation of Therapy Session at the end of every session, you would also be partially “blind” to how Todd was feeling, and how dramatically his feelings changed at the end of the session. Most therapists still are not using session by session assessment, and they are at a severe disadvantage that they are not even aware of. I am convinced that it is impossible to do great, or even excellent therapy with these, or similar, instruments. 2. Sometimes you have to slow down to speed up. During the empathy portion I made and corrected an error, with Jill's help, of jumping in prematurely with a method that fell flat. It is easy to give in to hunches and try methods prematurely, prior to doing careful and skillful E = Empathy and A = Assessment of Resistance. One good thing about TEAM is you can easily "right the boat" when it tips, and get back on track. TEAM works way better as a systematic package. Some therapists who learn about TEAM may try to "borrow" this or that M = Method, and incorporate it into their current approach, but that is generally far less effective. 3. A = Assessment of Resistance can be challenging. Positive Reframing can be quite difficult because you have to "see" something obvious that is almost invisible to the naked eye. Initially, Todd had tremendous trouble seeing any value in his self-critical thought that he was "an effing coward” when he and his older brother hid out during his parents’ brutal and terrifying fight. TEAM is not a cookbook, formulaic, treatment manual type of therapy. It requires “insight” on the part of the therapist, and the skills to lead the patient into seeing what you. therapit, (hopefully) have seen. 4. Childhood traumas can often be reversed--quickly. Another important teaching point might be that even traumatic childhood events that have totally rocked someone's world and self-esteem for decades can often be "undone" quickly using TEAM. Joy and self-esteem are possible for every human being. 5. Hopelessness is a cruel illusion. If you’re depressed, you have a deep (and misguided) incredibly painful belief that things are hopeless when they aren't. These feelings of hopelessness are common, but demoralizing at best and dangerous at worst. More about Brandon and Cassie: Dr. Brandon Vance writes: Cassie was an outstanding student of mine when I was teaching CBT last fall at CIIS in San Francisco (California Institute of Integral Studies). My final project was on sharing CBT with the public and suggested that the students could do a creative project or a paper. Cassie was inspired by the Double Standard technique personally and professionally, as she's studying to be a Marriage and Family Therapist. She wrote this song for her final project. Although she has had some experience singing, this was the first song she ever wrote (and she taught herself piano recently). I played the song just before the Feeling Great Book Club one week. and then read the words out loud in the book club. My voice cracked as I was tearing up reading them. As a musician, I am blown away at the power of the words, how well-crafted the song is, and Cassie’s singing and performance. Even the old record-like quality of the recording, with the slightly out-of-tune piano, and faint sounds of kids in the background, adds to the atmosphere! Here are the beautiful words to Cassie's song, Double Standard: You get so down on yourself Convinced you don’t need help What would you say If the reflection in the mirror Was someone you loved Would you say, babe, you’re worth it It’s okay not to be okay Would you help her up and remind her Of her strength And don’t you deserve the same grace So when you’re down on yourself Convinced you don’t need help Remember what you’d say if the reflection in the mirror was someone you love tell yourself that you’re worth it it’s okay not to be okay hold yourself up and remember all your strength you deserve all the grace so when you’re down on yourself convinced you don’t need help remember what you’d say if the reflection in the mirror was someone you love because the reflection in the mirror is someone who deserves love Thanks Todd! Thanks Cassie! Thanks Brandon! You have touched all of us! If you would like to contact Todd, you can reach him at: todd.daly@gmail.com Warmly, david and rhonda

The Night My Childhood Ended, Part 1 In today’s podcast, we present the first half of a therapy session with Todd, who describes a traumatic event that ended his childhood when he was eight. Next week, you will hear the exciting and inspiring last half of Todd’s session. My co-therapist is Dr. Jill Levitt, the Director of Training at the Feeling Good Institute in Mountain View, CA, and one of the co-leaders of my weekly training group at Stanford. We are deeply indebted to Jill and Todd for making this incredible and extremely personal podcast possible. Todd hopes, and we all hope, that it will be helpful to many people around the world who are suffering, and perhaps hiding the scars from your own traumatic experiences. As we always do in TEAM, Jill and I went through T, E, A, M in consecutive order, and I will give an overview of each phase of the session. T = Testing and E = Empathy Todd started by saying: I’m uncomfortable with all the attention I’m getting right now, and I’m worried about derailing the group, since our plan was to have teaching on exposure tonight. I’m going to describe one of the worst nights of my life, when I was 8 years old. It was the last night our family lived together, and my childhood essentially ended. But I’m not looking for a pity party. When I think about that night, I feel 100% sad and shitty. My life isn’t shitty. but when I think about that night, it’s incredibly discouraging. Here’s what I’m telling myself right now: I’m more screwed up than anyone else in this group. 100% I worse than all of the others. 100% My parents got married very young, when they were 18. I was raised in the 1970’s, which wasn’t the child-centered world like it is today. My parents drank all the time. and they’ve both had lifelong challenge with addictions and mental health. In fact, my mom got arrested for a DUI just last week. I have one older brother, and we were on our own most of the time. My parents had a horrible fight one night. It was the last night our family was together. They were both drunk and screaming at each other. They began physically fighting in their bedroom, and I thought my dad was going to kill my mom. My brother and I were scared, and we hid in the bedroom and created a fort with our bunk beds. Then things got quiet, so we decided to see what had happened, and went into their bedroom. Mom was badly beaten up, her face was all bruised, and dad seem horribly embarrassed and ashamed. It was devastating, because I told myself that I should have done something to help her, to save her, and I felt, and still feel, like a frickin’ coward. I believe that 100%, and have felt ashamed every time I think about it. I feel all alone. I’m here, but I’m not here. That was the end of my childhood. I don’t like to think about it. My father moved out, and my brother lived with him. I lived with our mom. The idea at home was always, “don’t speak unless you’re spoken to.” Dad was very angry and controlling. He was angry at my mom for not taking better care of my brother and me. He was angry at life, and I’m also angry and disappointed in her for not taking better care of us. I want to be able to get in touch with my vulnerability and my emotions. Then I stop myself and say, “I’m not allowed to have these feelings.” I want to be consoled, comforted, and not be so hard on myself. Maybe I want people to feel closer to me. You can see Todd’s Daily Mood Lot at the start of the session (link). As you can see, he was incredibly upset, and had eight Negative Thoughts, and his belief in all of them was strong, with most at 100%. Next week, you will hear the dramatic conclusion of Todd’s personal work, including the A and M of TEAM! If you would like to contact Todd, you can reach him at:  todd.daly@gmail.com david and rhonda

Ask Rhonda, Matt, and David! Tips for Joy and more! In today’s Ask David, we are honored to feature Matthew May, MD, a former student of David’s during his psychiatric residency training, and now esteemed colleague. Rhonda and David are thrilled that Matt can join us, not only because he is a dear and loved colleague, but also because he is one of the greatest therapists on planet earth! Plus, he’s an incredibly gentle and compassionate man. Rhonda Asks: What is the most effective way to help a suicidal patient? Rhonda Asks: How would you teach, the technique, Thinking in Shades of Grey to therapists or patients? Brian Asks: Any tips for joy? ThisLife asks: "Could you possibly explain why Albert Elis thinks the three valid uses of shoulds are valid, and provide the source where he explain this point, if convenient?” Mark Asks: Why is trying to change a person or help fix a person's emotional problems insulting? And how can I stop this habit? Along the same lines, EJG asks, “What’s the best way to help people who don’t want any help?” Rhonda and David

The Paradoxical Nature of TEAM In today’s podcast, we are honored to feature Matthew May, MD, a brilliant and beloved colleague of Rhonda and David. Rhonda suggested the topic for today’s podcast on the Paradoxical Nature of TEAM, and Matt and I were more than excited to dive into this cool topic! We reviewed the paradoxical nature of the four components of TEAM. As you will see, each paradox requires one of the four "great deaths" of the therapist's "self," or "ego." The Paradoxes in T = Testing TEAM therapists assess how the patient is feeling “right now” in at least six dimensions just before the start and just after the end of every therapy session using brief, extremely accurate scales for negative feelings like depression, suicidal urges, anxiety, and anger, as well as happiness and marital / relationship satisfaction. These scales are like an emotional X-ray machine so therapists can see, for the first time, exactly how effective or ineffective they are in every single therapy session. You can also see exactly what happens to the patient’s feelings between therapy sessions. Therapists may make several potentially disturbing discoveries during Testing. His or her perception of how the patient feels are frequently wildly inaccurate. The therapist’s perceptions of the degree of improvement in his patients may be shocking, since the therapist will often discover that patients have not improved, and may even feel worse. These “disturbing” discoveries can be celebrated, because the therapist, if humble and open, can accept the fact that his or her therapeutic strategies are not sufficient, and that meaningful change has not yet happened. The therapist can search for and try different treatment methods that may be more helpful for each patient. Paradoxically, the therapist’s failures become golden opportunities for learning and growth every day, and your patients will become the greatest teachers you’ve ever had. This involves the first of four “great deaths” for the TEAM therapist—the death of the “self” that has expert understanding of how patients actually feel. You will discover that your perceptions are very inaccurate in many or even most situations. This discovery can transform the way you practice if you have the courage and humility to try something new! The Paradoxes in E = Empathy At the start of the session, the therapist attempts to listen and provide an empathic, compassionate connection with the patient, reflecting back how the patient is thinking and feeling and convey acceptance and warmth. But here’s what happens in TEAM. When assessing empathy with the “What’s My Grade Technique” during the session, the therapist will often / nearly always discover that you didn’t really “get” the patient. When you review your scores on the Empathy and Helpfulness Scales that patients complete at the end of every session, most therapists are shocked to see that they get failing grades from most or nearly all patients after most or nearly all therapy sessions. Paradoxically, this is a big plus because it allows the therapist to explore his / her failures with the patient in a spirit of humility and curiosity at the start of the next session. If done skillfully, this can lead to therapeutic breakthroughs as well as a significant deepening of the therapeutic alliance. But this also requires a second “great death” of the therapist’s ego, because patients’ criticisms on the feedback forms will nearly always be accurate, and often biting. If you have the courage and skill to acknowledge that truth, the therapeutic relationship can be instantly transformed. Learning skillful empathy skills, using the Five Secrets of Effective Communication, requires tremendous commitment and practice, and the “beginner’s mindset.” The Paradoxes in A = Assessment of Resistance (formerly called Paradoxical Agenda Setting) During this phase, the therapist brings the patient’s subconscious resistance to conscious awareness, and melts the resistance away using approximately 20 “resistance melting” techniques, such as Positive Reframing, the Paradoxical Invitation, the Acid Test, the Gentle Ultimatum, the Externalization of Resistance, Sitting with Open Hands, and more. During this phase, the therapist, paradoxically, does NOT try to “help” the patient, but instead assumes the voice of the patient’s subconscious resistance, helping the patient suddenly “see” why she or he actually should NOT change. Paradoxically, the moment the patient “gets it,” there will be an illumination, and the patient will suddenly lose his or her resistance and become way more open and collaborative. This what makes the rapid recovery in TEAM-CBT possible. The patient also discovers, paradoxically, that his or her symptoms, like depression, hopelessness, and feelings of worthlessness, anxiety, or rage, are NOT the expression of what is wrong with him or her, like a “mental disorder” or “chemical imbalance in the brain--but the manifestation of what is right with him or her. In other words, there are tremendous benefits hidden in every negative thought and feeling. In addition, every negative thought and feeling reveals something positive and awesome about the patient and his or her core values. These discoveries can be mind-blowing for the patient and therapist. Matt and Rhonda do an entertaining role play of a woman who is enraged with her husband, and blames him for all of the problems in her marriage. Matt beautifully illustrates (as he always does!) exactly how to “Sit with Open Hands” and transform her angry resistance into enthusiastic collaboration and a willingness to examine her own role in the problem. Matt and David also discuss an amazing concept called “therapeutic entanglement,” borrowed from quantum physics. They explain how the minds of the therapist are often connected, constantly mirroring each other during the session. So, the more the therapist becomes the resistant and oppositional part of the patient’s subconscious mind, the more the patient assumes the helpful mind an role of the therapist. This phase of the therapy involves the third “great death,” because the therapist’s “helping” or “rescuing” ego has to die. That’s because your job is to see exactly why the patient should not change, and to help the patient discover this as well. The moment the patient “sees” this, and “gets it” at the gut level, recovery will be just a stone’s throw away. The Paradox in M = Methods. At this stage, the therapist focuses on one of the patient’s negative thoughts, like “I’m a loser,” or “I’m unloveable,” or “I’m a hopeless case,” and selects ten or fifteen M = Methods to challenge and crush the thought. Methods might include Explain the Distortions, Examine the Evidence, the Paradoxical Double Standard, the Externalization of Voices, the Acceptance Paradox, and more. TEAM-CBT includes more than 100 methods drawn from more than a dozen schools of therapy. The goal is not therapeutic success, but therapeutic failure. That’s because the faster you fail, the faster you’ll get to the technique that works. And the very moment the patient stops believing the Negative Thought that’s causing his or her negative feelings, the feelings will change. This phenomenon can sometimes be dramatic, even mind blowing. But even in this process, the therapist is almost always playing the role of the patient’s negative thoughts, and the patient is the one who is arguing for change. The M = Methods involves the death of the therapist’s “expert self,” thinking that you’re going to help, rescue or save the patient with your favorite brand or school of therapy, or the exciting new method you learned in some workshop and taught by some charismatic guru. TEAM involves giving up all the schools of therapy, and the spirit of “failing joyously” using a wide variety of methods drawn from more than a dozen schools of therapy. TEAM is not a new school of therapy, but a science-based, data-driven framework for how all therapy works. And so, that’s a little peek into the extensively paradoxical nature of TEAM-CBT! What’s the point in having such a paradoxical approach to therapy? I (David) can only speak from personal experience, I love having tools that can work dramatically and quickly for the vast majority of my patients. That’s because the moment they “recover,” I “recover,” too, and we both become euphoric. So I’m highly motivated to push for rapid and dramatic changes, and this is usually (but not always) possible. I love having a form of therapy that makes patient resistance virtually impossible. I no longer have to deal with resistance. It is impossible for a patient to resist, due in large part to the Buddhist concept of “sitting with open hands.” I love empowering my patients so that they don’t have to hang around with me for months or years waiting for change that never happens. It’s exciting to put the tools for change in their hands, so they’ll know how to deal with the inevitable relapses of negative thoughts and feelings that all human beings will experience, from time to time, for the rest of their lives. Rhonda and I are convinced that Dr. May is one of the greatest therapists on the planet earth. If you have a question or would like to contact Dr. May, please check out his website at: (www.matthewmaymd.com) Rhonda and David

Ask Rhonda, Matt and David! Ask David #243 May 24, 2021 David and Ronda answer your questions about the role of hope, treating court-ordered patients, suicide threats, being a virgin, and moral scrupulosity. Guest expert, Dr. Matthew May, joins us for this fascinating podcast featuring questions from fans like you!  V3A asks: What is the role of hope? EdG asks: How would you deal with a patient who doesn’t like you or doesn’t want to come for treatment, but has been required by either an employer or the courts? Preetika asks: Recently, a client said she felt suicidal and that made me feel suicidal about anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas. Dale asks: How would you do Positive Reframing with someone who is suicidal? Miho writes: From church and from my parents, I have been told repeatedly I need to save myself for marriage thus this has been my core belief when I am dating. Although it had never bothered me before, now that I am in my last 20s it seems I have heightened anxiety and misaligned expectations when dating as literally no one around me thinks in this way, and I have been told I do not "look" like I am inexperienced. May I know which would be the best tool for combatting other people's opinions when it really does seem that their opinion is the "truth" of the world? Robyn writes: I would very much like to hear about how you treat patients suffering OCD with moral/religious scrupulosity. * * * V3A asks: What is the role of hope? Hi David, how do you fit the cultivation of hope into TEAM-CBT? Being such an important aspect of recovery, it seems to be most needed in those that most need help, creating a seemingly unwinnable situation for those people. If someone has enough hope to seek treatment, is that enough to make a recovery? * * * EdG asks: Just listened to Podcast 025 on how to relate to a patient you dislike, Very useful! What about the opposite situation? How do you deal with a patient who may have a hidden agenda, like coming to you in order to avoid a legal problem or because s/he was ordered by an employer or the courts? Thanks, EdG. That's sometimes fairly easy, and might make this an Ask David. I once told such a patient that if he wanted to work with me he'd have to have an agenda of something he really wanted to change, and he would also have to do tremendous amounts of psychotherapy homework, and that this was non-negotiable, and that he or she might prefer going to another therapist who would be more of a pushover! In my limited experience, this was very effective, and seemed to motivate the man who came to me. He did, in fact, work tremendously hard! david PS We can get Rhonda's take on it, as she does forensic work. * * * Preetika asks: Recently, a client said she felt suicidal and that made me feel suicidal about how anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas. Dear Dr Burns, Thanks for sharing your wonderful podcasts, they are of immense value. I have been using your brief mood surveys and though I found it tiresome initially, I realized its value when I I uncovered suicidal thoughts in a patient that came forth only because of repeating the mood survey each session. Further, do you think a brief behavior survey at the start of a session is beneficial to record sleep, eating, and self harm patterns is needed to assess how clients are doing in between sessions? Does it have value? Recently, a client said she felt suicidal and that made me feel suicidal about how anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas. Thanks for so many continuing insights and for making therapy feel real, Preetika Hi Preetika, Perhaps you can search on website using search function and find the podcast on suicide prevention. Then let know what you think. When you use the Brief Mood Survey and Evaluation of Therapy Session, you said it was tiresome at first. What were your scores on the Empathy Scale? Scores below 20 are failing grades. Most of my colleagues, and myself, find this anything but "tiresome," but rather dynamic and fantastically challenging. Also, what percent reduction do you see in patient's depression scores within sessions? This shows your level of skill and effectiveness. 25% to 35% reduction within a session is a fairly good benchmark of sorts. This is called the Recovery Coefficient. Have you looked at that? I find it pretty exciting, and also challenging, especially when the scores don't change, and also when they do1 Thanks for the great question. David * * * Dale asks: How would you do Positive Reframing with someone who is suicidal? Would you suggest that it says that they have a strong self-awareness of the severity of their hopelessness that protects them from more disappointments? Or perhaps a wake-up call message from there awareness of some kind? All the best Dale Hi Dale, Suicide is handled differently, in part due to the legal stipulations that make therapists guilty, and you can use the search function to find and listen to my podcasts on this topic. Thanks! David * * * Miho writes: From church and from my parents, I have been told repeatedly I need to save myself for marriage thus this has been my core belief when I am dating. Although it had never bothered me before, now that I am in my last 20s it seems I have heightened anxiety and misaligned expectations when dating as literally no one around me thinks in this way, and I have been told I do not "look" like I am inexperienced. May I know which would be the best tool for combatting other people's opinions when it really does seem that their opinion is the "truth" of the world? Hello Dr. Burns, First of all, thank you (and Rhonda!) so much for providing us with a great podcast. It has helped me tremendously and it is great to hear both of your voices. Your book "Feeling Great" is amazing as well and I just can't find enough words to express my gratitude for all that you do. I have 2 questions regarding romantic relationships and your opinion would be much appreciated if you have time. (I am a female in my late 20s) 1) I feel that I tend to associate past events to the present, for example when a guy tells me that he is busy with work, even if he is genuinely busy and there is proof, I remember the time my ex-boyfriend made that excuse to actually hide the fact that he was going out clubbing and doing drugs. It is not that I don't trust the person in front of me, but rather the feelings of anxiety from past creeps up on me due to those thoughts and makes me insecure (if that makes sense). I am not sure which tool I should use to get over this kind of thinking, as in the moment when I reframe my thoughts it works, but soon after another example would set me off again. 2) From church and from my parents, I have been told repeatedly I need to save myself for marriage thus this has been my core belief when I am dating. Although it had never bothered me before, now that I am in my last 20s it seems I have heightened anxiety and misaligned expectations when dating as literally no one around me thinks in this way, and I have been told I do not "look" like I am inexperienced. May I know which would be the best tool for combatting other people's opinions when it really does seem that their opinion is the "truth" of the world? Warmest regards, Miho Hi Miho, Thanks. I will add this to the Ask David list. It will take some time, as we have lots of great questions listed at the moment. I resonate, though, as I was raised in a religious family and told not to kiss girls, etc. which was, I think, damaging.. Sex is natural and inevitable, and perhaps best left “undemonized.” At any rate, you would need to decide on your own moral values, and then we could deal with any fears of disapproval from one side or the other. Really love and appreciate your openness. d * * * Robyn writes: I would very much like to hear about how you treat patients suffering from OCD with moral/religious scrupulosity. Dear David and Rhonda: Thank you so much for your calming, effective and often laugh-out-loud funny podcasts, filled with a generosity of wisdom. I deeply appreciate them and recommend them to others also. They have helped shape my view of CBT into something far more empathetic and human. I would very much like to hear about how you prefer to treat patients suffering OCD with moral/religious scrupulosity. I understand that exposure with response prevention is considered the standard treatment, but I don't understand how this works directly with fears about things that are unethical or immoral. For example, a deeply law-abiding person who is afraid of accidentally breaking the law ("was I speeding? I need to check if that was a police camera! what if I was doing something illegal and I didn't realise it?") or a very kind person who goes out of their way not to kill anything due to fear of consequences in the afterlife ("did I just step on an ant? I'd better check the soles of my shoes in case! I don't want to wash my hands in case it kills skin mites!") And would it change anything in your approach if the patient was someone who had had negative experiences with the law through no fault of their own (ie validating their fear)? Or who had a sincere belief that they should pray to be forgiven or purified for their perceived "sins" (a coping behavior which isn't negative in itself)? How do you even go about creating willingness in the patient to see these behaviors as problematic? It seems like it is much easier to treat for a fear of cats - it's easy to make an exposure ladder to the actual fear, it's ethical and safe to expose the patient, and the experience can ultimately be very positive - which is quite reinforcing. But what do you do when the patient is suffering from a good quality taken too far (obeying the law, refraining from killing etc.)? Obviously you can't invite them to break the law or kill things because that's not moral or ethical, so I'm assuming you can only ask them to sit with the discomfort of uncertainty? Is that just as good as working with the direct object of fear itself? Or have I missed something? I'd love it if you could talk about scrupulosity sometime! Thank you very much again. Kind regards Robyn Hi Robyn, If you like, I will include in an ask david. The short answer is one that I give every week on the podcasts—I don’t throw techniques at folks based on a diagnosis or problem. As often as I say it, people don’t seem to get it, and this is the biggest problem in our field—trying to figure out how to “help” or rescue our patients. Of course, cognitive flooding might be one of 15 or 20 methods I might use, and there are tons of others, but first one has to find out what, if anything, the patient wants, and then deal skillfully with Outcome and Process Resistance. This MUST come before trying any methods. More on this when Rhonda and I discuss your excellent question. d Matthew May MD practices in Menlo Park, California. He is on the adjunct faculty in the department of psychiatry at Stanford and practices in Menlo Park, California. Although most psychiatrists rely primarily on medications, Matt tells me that the majority of his depressed and anxious patients recover rapidly without medications as a result of his proficiency with TEAM-CBT. He is also a superb teacher and has a weekly online supervision group for mental health professionals interested in learning and refining TEAM therapy skills. You can contact him via his website. Next week, Matt will join us again in a fascinating podcast on the paradoxical Nature of TEAM-CBT! Don’t miss it! Rhonda and David

Professor Yehuda’s TEAM-CBT Israeli Initiative! Today’s podcast is the latest in a series Rhonda has created featuring people who are doing interesting and creative things with TEAM-CBT. In today’s episode, we feature Yehuda Bar-Shalom, D.H.L, TEAM CBT level 4 trainer and therapist, who will teach us all about the use of TEAM in the school system. Yehuda, who is an associate professor appointed by the Council of higher education in Israel, is the first person we know to teach TEAM to school counselors in a practical way. (We also refer you to our podcast episode 152 where we interviewed Amy Spector, MFT, who is a TEAM therapist providing TEAM therapy to “at-risk” teen-agers at a high school in the San Francisco Bay Area.) Yehuda is an educator, psychotherapist and researcher. He has served as president of Hebraica University in Mexico City, the only Jewish University in Latin America which is open to students of all religious faiths. When he became the president of Hebraica University, he adapted the psychology and wellbeing department so that it became a training program for TEAM therapists. When he returned to Israel in 2020, Yehuda’s former student Victoria Chicurel, and several others, continued the Mexico TEAM training program. Yehuda has authored seven books and almost 70 academic articles on education and society, with a focus on Jewish education, social entrepreneurship and consulting in psycho-educational settings, mostly from a CBT perspective. He has been the Vice President of the David Yellin College in Jerusalem, and the Dean of Education at the Ono Academic College. His book, Educating Israel: Educational Entrepreneurship in Israel’s Multicultural Society was published in 2006. Yehuda is married to Amira Bar Shalom, and has three children. Yehuda, who in his professional life is both a therapist, educator, and researcher, earned his doctorate in education in 1997, conducting research on applying Bion’s theory in group work with adolescents.  When he was teaching school counselors, he realized he wanted to become a counselor, so, 20 years after earning his research doctorate, he went back to school and earned a Master’s degree in school counseling, and later another Master degree in the treatment of addictions. He also studied for a two-year certificate in cognitive behavioral therapy at the Psagot Institute, where he met Maor Katz, MD, Director of the Feeling Good Institute, and one of the Psagot instructors who taught TEAM therapy. Yehuda also learned about TEAM therapy by listening to the Feeling Good Podcasts. When he started listening, he thought TEAM therapy was “like a miracle.” Yehuda then attended several of David’s TEAM training workshops, as well as on-line trainings sponsored by the Feeling Good Institute (FGI). He has also studied one-on-one with Level 5 TEAM therapist, Daniel Minte. Yehuda currently teaches at a master’s level training program for school counselors at the Ramat Gan College in Israel. He is committed to teaching TEAM to school counselors for many reasons. One is that using TEAM provides school counselors with an immediate way to create a fast connection to students. In addition, TEAM can more quickly help students who are struggling with their moods, behaviors, relationships, or habits and addictions. Yehuda emphasizes the importance of T = Testing for the school counselors, and teaches them how it helps create empathy. For example, the school counselor might say this to a new student, “Oh, I see your score on anger is such and such. Tell me about that.” Yehuda explained that school counselors are like primary care physicians. They have the immediate pulse on the student’s needs and feelings. He is training the school counselors to speak with their students using the Five Secrets of Effective Communication. He also shows the counselors how to teach the Five Secrets, so their students can use this tool in their lives. He gave an example of how a school counselor might use the Disarming Technique when interacting with a child who feels angry and wants to escape. The counselor might say, “Wow, I can see that you’re feeling really angry about being sent to me for counseling and that you want to escape! I want to escape, too!” Then the child feels understood and opens up. Yehuda is also teaching the school counselors how to identify their own distorted negative thoughts, and how to positively reframe and challenge them. Once the counselors learn these skills for themselves, they can teach them to their students so that the students can learn to challenge their own distorted thoughts. The school counselors are also learning the use of paradox, so prominent in TEAM therapy, in order to help them understand their students’ motivations about why they feel and act the way they do, and how their understanding of their students’ motivations can lead to the change. The school counselors Yehuda trains are often quite skeptical and don’t believe him or David, which is understandable. He encourages them to maintain their skepticism but do an experiment and try these tools so they can see what happens. They are often pleasantly surprised by the results. Yehuda describes the counselors he trains as humble, down-to-earth, and hungry to master new techniques that can boost their effectiveness when working with troubled students. If you want to learn more about Yehuda’s work, visit his website at: https://sites.google.com/view/yehudabarshalom Rhonda and David

Live Work with Elizabeth, Part 2 (of 2) “I’m tired of being terrified. I want to be at peace!” Last week, we brought you Part 1 of a session with a women who's been struggling with anxiety and the fear of poverty every since she was 13 years old. that included T = Testing and E = Empathy, including an empathy error that David and Jill corrected. Today, we bring you the conclusion of that amazing session! After the empathy correction, Elizabeth suddenly said: “I don’t talk about this stuff very much as an adult. I’m feeling overwhelmed in a good way right now. A sense of peace is opening up.” You can review the partially completed Daily Mood Log Elizabeth gave us at the start of the sess if you click here. Her goal for the session was to get some relief from the constant pressure she put herself under to function and to keep her practice full. A = Assessment of Resistance Together, we did Positive Reframing with her negative thoughts and feelings, asking: What does this thought or feeling show about you and your core values that’s positive and awesome? What are some benefits, or advantages, of this thought or feeling? Together, we came up with this list of the positives. They keep me moving. They are very familiar. They show I’ve got a good work ethic. They show I’m a responsible human being. They show I care deeply about my family and my business. They show I’m determined to change the family history of failure and deprivation. The anxiety protects me from failure. It has kept me alive. It has paid the bills. Keeps me independent and self-supportive. Shows I’m strong and confident. Shows my love for my daughter. You can see Elizabeth’s Daily Mood Log with her goals for each negative feeling cluster if you click here. M = Methods Next we helped Elizabeth challenge her negative thoughts using Identify the Distortions, Explain the Distortions, and Externalization of Voices, starting with her seventh Negative Thought, “I need the pressure to function,” which she initially believed 100%. She identified the following cognitive distortions in this thought: All-or-Nothing Thinking, Jumping to Conclusions (Fortune Telling), Emotional Reasoning, and Magnification / Minimization. She decided to challenge the Negative Thought with this Positive Thought: I do not need pressure to function. I have functioned many times without pressure just fine. She believed this thought 100%, and this reduced her belief in the Negative Thought to 10%. Then we did Externalization of Voices with this thought and many others. Then David suggested Cognitive Flooding. The idea is to flood yourself with anxiety by imagining whatever it is that terrifies you the most. Every minute or two you record the time, your anxiety (0 to 100), and any fantasies you are having. The goal is to make yourself as anxious as possible for as long as possible. Over time, your anxiety falls, and eventually disappears. This can be frightening, and requires some courage on the part of the therapist and patient, but it can be extremely helpful and often works rapidly. Cognitive Flooding Flow Sheet   Time Anxiety Fantasy Comment 6:34 100 I am looking at my appointment schedule, which is only half full, and the phone is not ringing with new patients   6:35 100 Only two patients are scheduled, no one is calling to inquire about therapy   6:36 110 My throat is getting tight, and I’m telling myself that other clinicians in our practice rely on me, and I’m letting them down.   6:37 Eliz can fill in anxiety ratings, perhaps I’m asking myself, “What will we do? What’s going to happen?”   6:38 Eliz can fill in anxiety ratings, perhaps My schedule is drying up. My associates don’t have any patients. Jill begins with the What-If Technique. What’s the worst that could happen? 6:39 Eliz can fill in anxiety ratings, perhaps The economy is crashing. I have to let go of my associates. This is devastating. And then what? What’s the worst that could happen? 6:40 Eliz can fill in anxiety ratings, perhaps I’m standing in my office by myself. Everyone is gone. I’m alone. No one is calling for training or treatment. And then what? What’s the worst that could happen? 6:42 50 I have to keep working alone in a dark office until I’m 80 years old. And then what? What’s the worst that could happen? 6:43 30 Now I’m 85 years old, still trying to make things worse. My husband has a heart attack and Parkinson’s Disease. Now I have to treat people for free.   At this point something unexpected happened. Elizabeth burst into tears, and said: “I’m angry because this is what I’ve always wanted to do. . . I don’t want to have to charge people for therapy. I just want to treat people for free. She said the flooding was powerful, and melted the conflict she’d been experiencing: “I want to embrace therapy, and do something for free. I love doing therapy. And my biggest fear is that I cannot do that!” David suggested doing the cognitive flooding whenever she felt a pang of anxiety about her practice. You can see Elizabeth's end-of-session Daily Mood Log if you click here. Jill suggested a homework assignment for Elizabeth after the session: You can develop a cognitive flooding script with the What-If Technique. Record it on your phone, and listen to it daily until you get bored and your anxiety no longer flares up. Here is Elizabeth’s follow-up report: I did two rewrites on the script and listen to it daily for about two weeks. The in vivo exposure was to take my schedule offline for at least two weeks and stop trying to keep it full.  I took my schedule offline until Saturday, March 13th thru Tuesday, April 6th.  I have not scheduled anyone new or additional clients during this time.  And clients have not had access to my online schedule during this time. I have gone through varying degrees of anxiety and woke up once in the wee hours of the morning to worry, but overall, there has been a significant decline in my anxiety, worry and checking to see if my schedule is full. This exposure has been very powerful! Jill added this teaching point about Cognitive Flooding: You have the patient imagine the worst thing that could possibly happen and tell it in the narrative form, so it sounds like the What-If Technique playing out...For example, someone with OCD and fears of contamination can tell the story of the worst thing that could happen... "and then I would be dirty, and then I would contaminate my child, and she would get sick, and end up in the hospital, and . . . " etc. At the same time, you also focus on the patient's negative thoughts and feelings and take anxiety ratings every minute or so. The M = Methods illustrated in the podcast include: What’s my grade? What-If Technique Downward Arrow Technique. Daily Mood Log Positive Reframing Identify the Distortions Examine the Evidence Externalization of Voices Cognitive Flooding (combined with What-If Technique) In vivo exposure and response prevention (Jill’s homework assignment for Elizabeth) After each Tuesday group, we get quantitative and qualitative feedback from the members about the quality of the teaching. You can see some of the teaching feedback for the session if you click here. Rhonda and I, and all the members of our Stanford Tuesday training group, and all of our thousands of podcast fans, want to thank you, Elizabeth and give you a great virtual hug! Rhonda and David Follow-Up I just received this lovely note from Elizabeth to report on what has happened since her session in the Tuesday group. Hello Group, Last week April 7th, my schedule went back online after being offline for three weeks.  The process was seamless, my practice did not fall apart.  The other clinician's schedule did not become empty and we did not get a bad reputation.   I no longer fear I will be 80 years old, desperate with a handful of clients and supporting my husband who has a terminal illness.  Or my daughter having to financially support us both.  Even as I write this I am smiling and laughing a bit.  I do not feel driven by the fear of financial ruin nor have I compulsively checked my schedule making sure it is full.  I have more brain space for other things. I believe I have the peace I requested in my miracle cure.  Of course, I will relapse, I already have a couple of times and I have quickly recentered. A deep heartfelt Thanks to David, Jill, and all of you who participated with feedback or witnessed my personal work. My Warmest Regards, Elizabeth

“I’m tired of being terrified. I want to be at peace!” Live Work with Elizabeth, Part 1 (of 2) This podcast features Elizabeth Dandenell, LMFT, who runs a successful treatment clinic in Alameda, California for anxiety disorders, The East Bay Center for Anxiety Relief (www.eastbayanxiety.com.). She is a certified Level 4 TEAM therapist and trainer, and also helps teach mental health professionals at our Tuesday psychotherapy training group at Stanford. We are deeply indebted to Elizabeth for allowing us to publish the very personal, dramatic and inspiring work she did that evening. I also want to thank Jill Levitt, PhD, who was my co-therapist in the work with Elizabeth. Jill practices at the Feeling Good Institute in Mt. View, California (link)  where she is Director of Clinical Training, and teaches with me at Stanford. Like most mental health professionals, Elizabeth occasionally struggles with feelings of anxiety, stress, and self-doubt, and wanted to do some personal work in a recent Stanford Tuesday group. The personal work takes courage, but is crucial to the training and personal growth of all therapists. She was hoping for help with fears that have haunted her since her father died when she was just 13 years old. She explains: I started working when I was 13 years old and that is when the pressure to make money began because my father was an unsuccessful businessman. We were all just scraping by. I started working because my father was unable to pay basic bills at times like phone and electric.  Or our car didn't always run. He was not good at running his own business and money flow was very inconsistent. I discovered when I started working that I could have some control with financial stability if I had my own money and would help out paying the phone bill occasionally. This is when the anxiety of not having enough to survive kicked in and developed the" pressure" I discussed in the podcast and in my daily mood log.. This pressure to survive has has fueled my anxiety for years. My father died from Parkinson’s Disease in a nursing home when he was 77. He wa on Medicaid because he had lost everything. I was 50 when he died. You will hear many techniques that Jill and I used during the session, including Cognitive Flooding. This is, to the best of my knowledge, one of the first times that we have captured this type of Exposure live on a Feeling Good Podcast. Combining Cognitive Flooding with the What-If Technique (pioneered by Dr. Albert Ellis) makes the confrontation with your deepest fears especially powerful.  Listening to that portion of the session will be illuminating for many therapists and patients alike, especially if you are not familiar with, or confident in, the use of exposure  in the treatment of anxiety. Elizabeth’s anxiety was triggered by an exercise we did called “No Practice” in one of the David and Jill workshops for mental health professionals. Essentially, you practice saying “no” to someone who is pressuring you and making unreasonable demands on you. But in Elizabeth’s case, and perhaps for you, too, those demands are internally generated. If you click here, you can see the partially completed Daily Mood Log that Elizabeth brought to the session. T = Testing We began our session by reviewing Elizabeth’s scores pre-session scores on the Brief Mood Survey. The scores indicated only mild anxiety and minimal anger, but these scores probably do not reflect the intensity of the anxiety and terror she often feels. We then went on to: E = Empathy Elizabeth said, “That workshop exercise (“No Practice”) got me thinking about an unresolved issue I’ve been struggling with my entire life.” She explained that I’m doing too much in my life. I complain and then I take too much on and get overwhelmed. I fill my plate too much, and I tell myself that my patients need me, so I’m always taking on new patients to keep my schedule full . . . At times I get really anxious and don’t feel competent or confident. Who I am today is due to constant pushing, pushing, pushing, and never letting up. She explained that the problem started when she was 13: We didn’t have much money, and my father died penniless, in poverty in a skilled nursing facility. I’m always pushing for fear of meeting the same fate, telling myself that if I slow down I might not have enough money for my daughter’s college education, or for our retirement. I work so hard I was once even treated for adrenal fatigue. But my husband and I are not in any financial danger now, and things are fine, and I’d love to have time for more walks, for more meditation. But I’m terrified of slowing down. We did the What-If Technique to explore Elizabeth’s fear of slowing down. What was at the root of her fears? David: What would happen if you slowed down? What are you the most afraid of? Elizabeth: We might not have enough for my daughter’s college and for our retirement. David: And then what? Elizabeth: Our daughter would have to take out student loans. David: And if you did not have enough for your retirement, and your daughter had to take out student loans, what then? What are you the most afraid of? Elizabeth: My father’s life collapsed at the end, and he ended up in a skilled nursing facility with nothing. (tears) Jill pointed out a belief at the root of Elizabeth’s fears. “If I slow down, we won’t have enough money for survival. This fear has been haunting and driving me since I was 13.” Elizabeth said it felt unjust, and that she was angry that she could not take a break without feeling a sense of panic. She said, “it’s all about family values. I wish the work ethic hadn’t been driven into me so hard.” She said she’s struggled with constant worries about money, and wondering whether she can pay her bills ever since she was 13. She said, “It’s not about having fancy things—that doesn’t interest me. It’s all about survival.” Although Elizabeth and her husband are doing really well, and her treatment center is doing really well, she constantly worries, keeps her schedule more than full, and cannot say no to a new patient. She gives herself the message that she should be working longer hours, and that she can work overtime to make room for every new patient. She said, “For years I’ve wanted not to be so overwhelmed, and I’m still stuck with so much on my plate. . . ‘I’m tired of being terrified and want to be at peace. I want to learn to let go of this constant fear, but I don’t know if I can let it go. I want to feel differently, and not just do differently. “I want to be at peace with my business. I want the freedom to say yes or no. I want the freedom of choice. “If I have a day off, I don’t know what to do. It feels weird. My greatest fear is ending up in a nursing home on Medicaid, like my father.” I decided to explore this fear once again, using the Downward Arrow Technique. David: And then what would happen? What would that mean to you? Elizabeth: My daughter would see me and realize she would have to support herself. David: And then what? What would that mean to you? Elizabeth: That would mean I was worthless. (tears) That would mean I was not enough. And then I’d be rejected. Now I’m feeling so ashamed! (more tears) At this point, we summarized what Elizabeth and been saying and feeling, and asked her to grade us on our empathy so far. Would she give us an A, a B, a C, a D, or what? This “What’s My Grade” technique is powerful and helpful, but a bit intimidating for the clinician. Elizabeth said she’d give us an A- or B+. That’s not bad, but it is really a failing grade, because we’re aiming for an A. When this happens you can ask, “What am I missing?” Elizabeth explained that we’d done a great job on the thought and feeling empathy, but she did not feel as much warmth and acceptance as she was hoping for because she was feeling very ashamed about her story Jill reminded us of the need to include “I Feel” Statements to our empathy (my bad), and then we shared our feelings of sadness and admiration for Elizabeth, and quickly got an A. As a teaching point, your perceptions of how empathic you are, if you are a therapist, will not be accurate. That’s why the “What’s My Grade” technique can be so valuable. When you fall short, the patient will tell you why, and can easily make a correction and greatly enhance the therapeutic relationship. Superb empathy is desirable, and necessary if you want to do top-notch clinical work, but it won’t cure much of anything. So we’ll need something more! Next week you will hear the amazing last half of the session, starting with A = Assessment of Resistance and then going on to M = Methods, and end of session T = Testing. In next week's podcast, you'll hear the final half of Elizabeth's session and, if you like, you can also listen to some of the Q and A from the participant's in the Tuesday group who watched the session live. Rhonda and David