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

Podcast 257: What's an Intensive? Today's podcast features Dr. Lorraine Wong and Richard Lam who describe the intensive TEAM-CBT treatment program at the Feeling Good Institute in Mountain View, California. Dr. Wong is a board certified clinical psychologist and the Clinical Director of The Feeling Good Institute in Mountain View. Richard Lam is TEAM Certified Therapist, Trainer and Certification Program Manager at the Feeling Good Institute. An intensive is a departure from the conventional weekly 50-minute session and compresses an entire course of therapy into a brief period of time. David describes how he created this treatment approach accidentally at his hospital in Philadelphia when one of the world's most famous and beloved actors, a man who was a great fan of Dr. Burns first book, Feeling Good: The New Mood Therapy, contacted him and asked for treatment. However, there was a catch. He only had two days available, and asked if he could fly from Hollywood to Philadelphia and book all of my sessions for two days. I was delighted to do that, and scheduled 17 back-to-back 45-minute sessions on a Thursday and Friday. He came in a disguise, and explained that fans and the paparazzi were constantly hounding him, and that he felt like a hunted animal. I asked if the disguise was effective, and he said it wasn't working at all. People still hounded him and asked why he was wearing the disguise and asked for autographs. Because he was a powerful actor, the roleplaying techniques I have developed, like Externalization of Voices, were tremendously effective, and he actually made a complete recovery within a couple hours. Later on, I developed an intensive program for the patients in our inner-city neighborhood, with the help of the president of our hospital, and it was also incredibly effective for our patients who had few resources. However, they loved cognitive therapy! Richard and Lorraine explain how they are implementing the intensive concept at the FGI, working with people from around the United States and the world who come to Mountain View for several days for the treatment. They describe their work with a severely and chronically depressed man who came from Europe who seemed incredibly challenging at first. He was super skeptical and said that that he'd had tons of failed therapy but nothing and no one had ever helped him. He was telling himself things like this: Life isn't worth living. I'm a special case and no one will be able to help me. Life shouldn't be so hard. I should be able to enjoy life more. However, once they blew away his resistance using Paradoxical Agenda Setting, Richard explains that "it was a breeze to blow all of his negative thoughts out of the water." The treatment is costly in the short-term, but can be extremely cost-effective in reality because recovery often happens rapidly. It is my impression, too, that in the hands of a skillful therapist, extended sessions and intensive treatment with TEAM-CBT can often be amazingly effective. If you would like to contact them, you can go to the FGI website (www.feelinggoodinstitute.com) or email them: Richard@feelinggoodinstitute.com or Lorraine@feelinggoodinstitute.com. Thanks for listening, and thanks to Richard and Lorraine for being especially fun and gracious guests on today's podcast! Rhonda and David Dr. Rhonda Barovsky practices in Walnut Creek, California. She sees clients via Zoom, and in her office. She can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 4 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. Check out her new website: www.feelinggreattherapycenter.com. You can reach Dr. Burns at david@feelinggood.com.

Intense Performance / Public Speaking Anxiety, Part 2 of 2 Last week we presented the first half of the session with Michelle Wharton at the Live Therapy workshop on May 16, 2021. Michelle had been struggling with years of intense public speaking anxiety, especially in professional settings. So far, we've commented on the T = Testing and E = Empathy portions of the session. Today, we present the exciting and inspiring conclusion of that session. A = Assessment of Resistance At the end of the moving and tearful empathy phase, we asked Michelle about her goals for the session, which included Not to have to feel this terror at full volume. Not to be stopped from volunteering for things that require public speaking and teaching, and to be able to feel some excitement in my career! After Michelle said she would be willing to press the Magic Button to achieve all these goals instantly, with no effort, we suggested a round of Positive Reframing so we could see what might be lost of she suddenly achieved all these goals. You can click here to review the Positive Reframing that we did together, as well as Michelle's Emotions table at the end of the Positive Reframing. You can see her goals for each emotion when we used the Magic Dial. The idea is to dial each feeling down to a lower level that would reduce your suffering, while still allowing you to preserve all the awesome things about you! The Positive Reframing is one of the unique aspects of TEAM-CBT. Although we are encouraging the patient to keep the symptoms, the Positive Reframing typically eliminates or drastically reduces the patient's resistance to change, and opens the door to the possibility of rapid recovery. This will be true even if the patient has been struggling with a problem unsuccessfully for years or even decades, as was the case with Michelle. M = Methods We asked Michelle what Negative Thought she wanted to work on first, and she chose #5: "People will think you are selfish and self-preoccupied." She believed this thought 100%. First, we asked Michelle to identify and explain the cognitive distortions in this thought. As you can see on her Daily Mood Log (LINK), she found all ten distortions. Of course, the most prominent distortion in this thought is Mind-Reading. That's because Michelle thinks she knows how other people will be thinking and feeling about her when they find out about her intense public speaking anxiety. This distortion is nearly always present in any form of social anxiety. I know this from my clinical work and personal experience, since I have personally suffered from at least five forms of social anxiety, including extremely public speaking anxiety, when I was young. You feel absolutely certain that you're flawed and that people will judge you! Then we challenged the Negative Thought, and Michele she was able, with a little help and a couple of role reversal, to crush it. Take a look. (LINK) Here were Michelle's reflections on that portion of the session. First we used the Double Standard and I think that's when I said this to the imaginary friend with the exact same problem: "I think you're being kind of brave." Then it evolved into Externalization of Voices. Both David and Jill played the negative Michelle and I had a little difficulty talking back to my Negative Self. I connected on a logical level, but didn't yet have the ammunition or determination I need to blow my Negative Thoughts out of the water. David spotted my ambivalence immediately, and suggested that maybe it wasn't something we should work on. Before he made that comment, I didn't even realize that I had mixed feelings about giving up my intensely self-critical thoughts. At that point, I found myself making the decision to fight back and felt myself getting stronger. The next time David (as the Negative Michelle) asked if he could talk to me for a minute I told him he had only 30 seconds to make his point because it was time to back off. I had some hesitation about only using the Counter Attack to defeat the thought but David said he liked the feisty response. Then David and Jill both told me of all the positive feedback that was coming through the chat, and I was given the opportunity to use the Survey Method with a couple of audience members. I think I asked two or three people if they thought I was using up valuable time, since that was one of my painful Negative Thoughts. The both commented that they found the session incredibly helpful and that they could relate to these feelings of anxiety and shame, and that they weren't judging me harshly at all! Here you can see how Michelle challenged thought #9. As you can see, her belief in this thought fell from 100 to 50, and then to 0. Negative Thoughts % Now % After Distortions Positive Thoughts % Belief 5. people will think that you're selfish and self-preoccupied. 100 50 0 AON OG MF DP MAG/MIN ER LABE SS SB In fact, I'm being kind of brave!! 100 My anxiety is very real, and it's good to ask for help. 100 My fear of public speaking is a common and exceptionally worthy problem! 100 You can see Michelle's Emotions table at the end of the session, after she had crushed all of her Negative Thoughts. Emotions % Now % Goal % After Emotions % Now % Goal % After Down 40 5-10 5 Embarrassed, foolish, self-conscious 100 5 0 Anxious, panicky 100 20-30 0 Discouraged 70 0 0 Inferior, inadequate, incompetent 90 25 5 Frustrated, stuck 80 10 0 Lonely 80 0 0 Angry, mad, resentful, annoyed, irritated, upset, furious 60 0 0 After the workshop, Michelle sent us this email. HI David and Jill, I was going to write to you and tell that I would probably be happy to go ahead with the podcast but that I wanted to do a DML on some concerns about judgements as well as concerns about crossing of professional boundaries (worrying that I'm 'oversharing' with clients). Then, I just so happened to have supervision scheduled with Robyn Blake-Mortimer (another Level 4 therapist in Adelaide - I think she was Robyn Fowler when working in New York) this morning and she suggested we do some TEAM personal work on it. It was incredibly helpful and I've decided that I'd be happy for you to share the podcast, if Jill and Maor give permission. Robyn helped me to see that there was probably (intentional distortion!) a large impact on my life from the fact that my family survived Cycle Tracy (Christmas 1974) despite our house being 99% destroyed. Our lives were hugely affected and I (now) see a strong connection between this and the bed wetting. Which is not to say it changes the 'ok-ness' of the issue, rather that it helped me to see the amount of cognitive distortions that were in my worries about broadcasting the podcast (that 'my problems should all be fixed by now'). Another liberating moment for me, thanks again to TEAM. Here's what was left of our house after the Cyclone - just the bathroom where we were. Thank you again. M. This was my response to Michelle: Wow, Michelle, that's fantastic, kudos, I really like the way you've caught the pass and you're running for a touchdown, like a speedy wide receiver (if you follow football.) I really like all of your thinking and plans! Also, something both of you might want to consider is if we might consider turning each session into two consecutive podcasts. People love and are helped the most by live work podcasts. This is not required, and is just a thought. So proud of both of you! Warmly, david Michelle's scores on all the scales on the Brief Mood Survey at the end of the session were zero, and her scores on the Happiness Test soared to 100%. Her ratings of Jill and David on the Empathy and Helpfulness tests were perfect as you can see at this link. Here's what she wrote on the question on "what did you like the least about your session?" "Absolutely nothing!! This was such a gift and I feel so fortunate and incredibly grateful." Here's what she wrote on the question on "what did you like the best about your session?" "Addressing the ambivalence, the Positive Reframing, the warmth from you both, and how it helped me to soften into and accept these feelings." On the audio, you will also hear the amazing follow-up interview we had with Michelle many weeks after this session. Thanks for listening. I hope you learned a ton and were moved emotionally and inspired. Write and let us know what you think! And thanks, too, to Michelle for giving all of us a gift that's worth far more than gold! Rhonda, Jill, Michelle, and David

Intense Performance / Public Speaking Anxiety, Part 1 of 2 This Is podcast features the first of the two live therapy demonstrations that Dr. Jill Levitt and I did at our psychotherapy workshop on Sunday, May 16th, 2021. I hope you enjoy this dramatic and inspiring session! Jill and I believe that doing your own personal work is vitally important to the growth and credibility of a mental health professional for many reasons. First, when you're in the patient role, you can see things from a radically different perspective, including a far greater, first-hand appreciation of the errors that shrinks make as well as what is especially helpful. Second, if you are successful in your own work, you can tell your patients, "I know what you're going through, and how intensely painful it is, because I've been there myself, and I can show you how the way out of the woods as well!" This is a message that most patients welcome. And finally, the personal work you do with TEAM-CBT is a fantastic way of comprehending how this new approach really works. Our "patient" today is Michelle Wharton, a forensic and clinical psychologist from Australia. I want to thank Michelle for her tremendous courage in sharing a very personal experience with all of us. I also want to thank Dr. Levitt, who practices at the Feeling Good Institute in Mountain View, California, where she serves as Director of Clinical Training. Jill is also a co-leader at my TEAM-CBT training group at Stanford. I am especially thrilled to share Michelle's live session with you, since only mental health professionals are allowed to attend the workshops sponsored by the Feeling Good Institute. Many non-therapists were eager to attend, and disappointed when they learned that only shrinks could attend. By way of compensation, this podcast will give all of you the chance to hear what you missed, and I think you will NOT be disappointed! When Jill and I asked for volunteers for the live demonstrations in the workshop, Michelle sent us this email, describing her situation. Hi Jil and David, I've just seen your email on the listserv asking for volunteers for the live therapy training on 16 May and thought I'd put up my hand. I'm an Australian clinical and forensic psychologist with Level 2 TEAM-CBT certification based in Adelaide, South Australia. I had been thinking about volunteering to do some work on social anxiety and feelings of inadequacy. I know this has impacted me at different points in my life like holding back my career contributing to perfectionism, and causing high anxiety in social settings. My anxiety is probably more work-related but does impact personal relationships where I just assume I'm not particularly important. After reading your post, it just kept playing thru my mind that I wouldn't be a very good volunteer. This thought was keeping me awake, which paradoxically also made me think I might actually be a good volunteer. Also, from the fractal perspective, the anxiety triggered by just thinking about volunteering is probably reflective of all of my inadequacy concerns. So, I've attached a Daily Mood Log (DML)/ If you think it might be useful let me know. Since I'm in Australia, the workshop will be from 1am-8am in my part of the world. We scheduled Michelle at the start of the workshop, due to the tremendous time difference, but it still required enormous commitment on her part to work with us in the middle of the night! That kind of motivation is extremely helpful and often predicts rapid changes, but it's no guarantee and we'll have to see what happens in the session. This will be a two-part podcast. In today's podcast, you will hear the first portion of Michelle's session (T = Testing and E = Empathy). Next week you will hear the fantastic conclusion (A = Assessment of Resistance) and M = Methods.) I hope you enjoy the session as much as we did. Again, a big hug and thanks to Michelle, the superstar of the podcast! T = Testing To get started, take a look at the Daily Mood Log (LINK) that Michelle shared with us at the start of her session. As you can see, most of Michelle's negative feelings were intense, especially the anxiety and embarrassment, which she rated at 100%. You would not have known how overwhelming her suffering was if you had met her in daily life because she comes across as warm, bright, personable, and likeable. But inside, a part of her is dying, and that's the part she's been hiding and fighting desperately to change. Her actions today—opening up and become completely vulnerable in front of a large live audience of mental health professionals—required incredible courage and was a fantastic gift to all of us. That's one of the really important reasons for Testing. You can see exactly what you're dealing with, in terms of the type and severity of negative feelings. Of course, we'll ask Michelle to rate her feelings again at the end of the session. That way, we'll know how effective—or ineffective—the session was. This information can sometimes be humbling to therapists, especially when you see that things didn't improve during your session, but it is always illuminating. Neither Jill nor I could conceive of doing therapy without the Testing! At the end of today's session, we'll also ask Michelle to rate us on Empathy, Helpfulness and other dimensions, using brief but sensitive scales that will highlight even the smallest therapeutic errors that most therapists would not otherwise be aware of. Using these scales also requires therapist courage, because the information is often disturbing and unexpected, but it is always illuminating and potentially super helpful. That's because you can discuss any low ratings you received at the start of the next session. If you do this skillfully and non-defensively, with warmth, respect and curiosity, the dialogue can greatly deepen the therapeutic relationship. So, in an odd way, we often "hope" for failing grades on the Empathy and Helpfulness Scales! But processing poor scores often involves the "great death" of the therapist's ego. This information can be shocking, especially if you thought, as most therapists do, that your empathy skills were good or even excellent. In fact, you will witness such a failure in today's session! Yikes! But you can also ask yourself the question—did Jill and David have to be afraid of their "failure?" Or was it actually a gift in disguise? And if you're a therapist, and you start using "What's My Grade," will you have to be afraid of grades lower than an A, which is the lowest passing grade? E = Empathy During the empathy phase of the session, Jill and I empathized while Michelle described her struggles with intense and incapacitating public speaking anxiety, which is particularly intense in professional situations. Michelle was visibly shaking and tearful as she said she was grateful and horrified to have overwhelming anxiety that has had a horrible impact on her career and has held her back. She's avoided promotions to more senior positions that might require a good bit of public speaking. She said, "I can feel myself sweating, with a dry mouth, and wondering, 'what are they thinking?' They're probably wondering how I got my qualifications, and thinking I'm stupid! "I feel distant, and the audience feels distant, and I find myself thinking that the people in the audience are critical and judgmental. I have the image of feeling isolate, alone, and crying while people are watching. "My fears have even stopped me from doing clinical supervision, which is something I would totally love doing. "There's a lot I'm holding back. . . but I'm not sure what." During the Empathy phase, Michelle poured her heart out, and both Jill and I did really careful empathy, summarizing her words, acknowledge her feelings, and using "I Feel" Statements to convey warmth and support. I'm not always the best at empathy, but Jill is a true master, and that is one of many reasons I love teaching and doing co-therapy with her. At the end of the Empathy phase, when we were reasonably certain we've done a good job, we asked Michelle to rate us on Empathy. This technique is called "What's My Grade," and it is frightening but can be extraordinarily helpful. And we spell it out, by asking, "Would you give as an A, a B, A C, a D?" This is a thousand times better than asking, "How are we doing," because the patient will just say "fine." But if you ask for a grade, you'll get the truth. And sure enough, Michelle gave us a B! That means we'd vastly missed the mark. Was this a good or bad result? From a Buddhist perspective, it's a great result, because "failure" does not actually "exist." Michelle actually just gave us some information that was fantastically important. So, we simply asked, "Can you tell us about the part we missed?" And then patients will tell you something really important. Here's what she said: "The sensation in my body right now is huge. . . I can feel it in my stomach . . . And I'm asking myself what the hell am I doing? "I'm holding my hands tightly. . . I feel pressure on my throat . . . a knot in my stomach, shaky hands, and tears are streaming down my face. . . . The volume is turned way up right now. "You're over there on one side, and I'm on the other side. . . . I feel alone. . . I feel distance. . . . This is just like standing at a podium, with a gaping divide between me and the audience. . . . I'm in a spotlight. . . . but I want to feel emotionally held. "A part of me pushes support away, because I don't want any cheerleading. . . and I want to be able to do this for myself, and I think that I should be able to do this for myself. "I want to share something that I've been hiding. I've been holding back. Do I dare to do this?" Then Michelle tearfully described a problem she'd had with bedwetting up until she was thirteen years of age. Her parents took her to a GP and a hypnotherapist, and thought she'd grow out of it. The message she heard was, "You should get over this." She described waking up every morning with shame, washing the sheets each morning and taking them outside to dry. And, she said, "That's where this all started! The language I used at this time in my life was so hurtful, telling myself I couldn't even get this right. I know that the internal bully really came to life in this moment but I had never seen it until this moment." David made a joke at this point and asked if the bedwetting ever stopped – it took a second for that to sink in then we all laughed and discussed the value of humor within therapy. David advises that humor, like any powerful healing tool, must be used with thoughtfulness, and never to hurt a patient or put him or her down. In addition, humor is usually not a good idea with a patient who is feeling angry, as it may seem like the therapist is belittling the patient. After a bit more empathy and Jill offered an "I Feel" statement about her own nervousness prior to the start of the group and I then Jill then asked for our grade on empathy. Michelle says, "I gave you both an A and at that point and you asked if I felt ready to get to work and I said yes!" Next week, you will hear the exciting and dramatic conclusion to this session, include A = Assessment of Resistance, M = Methods, and T = Testing at the end of the session to assess changes in negative feelings, if any, as well as how Michelle graded us on Empath and Helpfulness during the session. We will also give you a live multi-week follow-up, to see if the effects stuck, or were just a flash in the pan, and what the most important keys to relapse prevention might have been! Rhonda, Jill, Michelle, and David End of Part 1

#254, Ask Matt, Rhonda, and David (with the famed Dr. Rutherford Knows) Today we are again joined by the fantastic Dr. Matthew May for an Ask David. Rhonda and I are thrilled that Matt will be joining us every month. His input will give you a broader range of insights and answers to your many excellent questions! Here are the questions we will address on today's podcast. Karine asks: How can I help my daughter with anorexia? Shirley asks: How can you deal with people who are emotionally abusive, using the Five Secrets of Effective Communication? Guy asks: Are there any Five Secrets practice groups I could join? * * * Karine asks: How do I help my daughter with anorexia? Hello Dr. Burns, I am trying to help my daughter who is starting to have anorexia with your book as the consultations are not working and we are waiting on a list for a specialist which can take months or even year here in Quebec. I have read both of your last books and i am getting good to use it for social anxiety. However. i can't see exactly how to apply it for eating disorder. I asked her to list the benefits she gained from not eating and i am trying to help her see the cognitive disorder in it but it is much harder (ex: i loose weight quickly...which will do ... ) i may help her see the cognitive disorder in the « which will do ... » but not in the « i will lose weight » statement ). Could you help me see the pattern i should follow please as i really think your technique can help her faster and better than the traditional psychologist conversation. Regards Karine * * * Shirley asks: How can you deal with people who are emotionally abusive, using the Five Secrets of Effective Communication. Hello David and others, I have been convinced how important using the Five Secrets of Effective Communication are. I do have a question about living with a person who is emotionally abusive. He uses his criticisms of others to manipulate and control them. How do you accept the criticism of such a person who is taking advantage of you accepting the criticism. My soul wants to rebel against these criticisms and against the person who is trying to manipulate me. How do you navigate such a relationship when the abuser will never acknowledge that they are abusing others. He lives in a fantasy world of excuse making and blaming others. Also, how do I acknowledge my weakness and allow the "death" of my ego to happen? Thanks for your consideration and help. Shirley We reviewed this problem and describe how we treat relationship conflicts using TEAM-CBT. This involves giving up blame and examining your own role in the problem. You will discover--and this might be disturbing, or enlightening, or both--that you are contributing in a BIG way to the very problem you're complaining about. You can review Shirley's partially completed Relationship Journal if you link here. * * * Guy asks: Are there any Five Secrets practice groups I could join? David, Please consider asking one of your skilled therapists to create a Five Secrets of Effective Communication "Practice Group." Possibly the group could be run weekly (virtually) and it would be an opportunity to repeatedly practice each of the secrets. I practice on my own, but I know that learning is often strongest when working with others. Guy Marshall David's Response Hi Guy, Ana Teresa Silva has a five secrets zoom practice group. Check with her! They are just getting started. ateresasilva6@gmail.com We have an exciting podcast scheduled the next time Matt visits. We will address the many controversies around exposure therapy, and will be joined by a patient Matt recently treated with the fear of leaches! We will also address some of the hundreds of questions submitted by the more than 6,000 fans who registered for my free 90-minute presentation on rapid Recovery from Anxiety which was sponsored by PESI. All the best, Rhonda, Matt, and David (plus Rutherford) If you would like to contact Dr. May, you can reach him at: www.MatthewMayMD.com. Matt added that people interested in treatment can schedule a free 15-minute phone call there, my schedule permitting. Dr. Rhonda Barovsky practices in Walnut Creek, California, but due to Covid-19 restrictions is working mostly via Zoom, and can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 4 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. Check out her new website: www.feelinggreattherapycenter.com.

#253: Sadness as Celebration, Part 2 In today's podcast, Rhonda and David present Part 2 of their work with a young woman named Rose who has been struggling with profound feelings of grief since learning of a discouraging update on her father's struggles with multiple forms of cancer. A = Assessment of Resistance At the end of the moving and tearful empathy phase, Rhonda asked Rose if she felt ready to do some work, or needed more time to talk and share her thoughts and feelings. She said she was ready to do some work, and described her goals for the session: I know I cannot change the facts, and I would not want to eliminate the grieving, but I would like to dial down the intensity of some of my emotions, particularly when I'm triggered. Next, we did some Positive Reframing to highlight what was positive about Rose's feelings. You can click here review the list of positives that we generated. Rose's Positive Reframing Table* Thought or Feeling List your negative thoughts or feelings, one by one, in this column. Advantages and Core Values--Ask yourself What are some advantages of this thought or feeling? How might it help, protect, or benefit me? What does this negative thought or feeling show about me that is positive and awesome? How does it reflect my core values? Sadness, depression Shows my deep love for my dad and honors the contribution and impact he's made in my life Shows the strength of our relationship Anxiety The anxiety is warranted in this situation, shows that I'm being realistic with the situation It shows my love for my dad, being worried is a way of showing care and concern It shows that I don't want him to suffer It motivates me to connect with him and to make every moment count It makes me vigilant so I explore every possible treatment option It motivates us to think about moving to be closer to him It has motivated us to schedule another visit again in July Guilt Shows my connection to our family Drives us to visit as much as possible Shows that I don't want to live with regret Feeling defective Shows that I'm honest about my flaws Shows I feel that I'm not doing a good job supporting others, so it means I have high standards in my relationships Shows that I'm vulnerable Lonely Shows my love for my dad and the important role he plays in my children's life Shows how strongly that I value relationships Motivates me Hopelessness Shows I am being realistic Prevents me from getting my hopes up too high Prepares me for the inevitable Makes me value and make each moment count Might decide to discontinue the chemo if it causes problems and isn't helpful Makes me more vigilant Frustration Shows I haven't given up or thrown in the towel Anger I will fight and contest this! Now you can review Rose's Emotions table at the end of Positive Reframing, showing her goals for each emotion when we used the Magic Dial. The idea is to dial each feeling down to a lower level that would reduce your suffering, while still allowing you to preserve all the awesome things about you! Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, down, unhappy 100 50-60 Lonely, alone 80 10 Anxious, worried, frightened 100 30 Hopeless, discouraged, pessimistic, despairing 90 10 Guilty 80 15 Defeated 70 20 Defective 70 10 Angry 80 25 As you can see, she wanted to dial all of her feelings down to low levels, with the exception of her sadness, which was an expression of her love for her dad. M = Methods We used Explain the Distortions, the Double Standard Technique, and the Externalization of Voices, including the CAT (Counter-Attack Technique). Here's how Rose challenged Negative Thought #1. 1. He's going to die; we're running out of time. 100 50 No distortions We're all going to die, but I can be present on those moments when we are together. 100 David discussed healthy vs unhealthy grief, and shared some stories of love and loss. He also talked about the concept of sadness as celebration. In this case, a celebration of Rose's love for her Dad. The impending loss, of course, is tragic, but the wonderful father daughter relationship is beautiful and perhaps somewhat scarce, as so many people have not had such a beautiful relationship with their parents. At the end, Rose said the session was "incredible and special" You can take a look at her end of session scores on the Daily Mood Log (link). After the session, Rose sent the following email: Hello David and Rhonda, Thank you so much for that amazing session today. I am feeling so much more contentment and gratitude after talking with you both. I even feel lighter and more hopeful. The key insight for me was realizing how special and precious this relationship is that I have, and rather than focusing on what I won't have. It sounds like a cliché, but it is true for me and seems to have freed up a weight. I will definitely do my homework, and will can send you the completed DML after listening to the session as that may help. And as for sharing with my dad, I'm going to be calling him to tell him what a wonderful session I had and that when it is published he can listen to it so as to have and share this beautiful experience. Thank you so much once again! Rose Markotic Thank you for listening today! Rhonda, Rose, and David

#252: Sadness as Celebration, Part 1 In today's podcast, Rhonda and David present Part 1 of their work with a young woman named Rose. Rose is a 38-year-old mother of two boys aged 2 and 5. She works as a Therapist at an outpatient clinic, the East Bay Center for Anxiety Relief, and is a member of our Tuesday training group at Stanford. Rose sought help because of her profound grief after talking to her mother about her father's recent visit to his oncologist. Her father has had many severe health problems in the past several years. He's been a survivor, but suddenly the outlook seems bleak, and Rose feels tremendous sadness and fear, because of her deep love for her father. In most cases, grief does not need treatment. Clearly, grieving is healthy and even necessary when you lose someone you love. However, it can be helpful to distinguish healthy from unhealthy grief. From a cognitive therapy perspective, all feelings, including grief over the loss or impending loss of someone you love, result from your thoughts. Healthy grief results from negative thoughts that are not distorted. For example, if a loved one dies, you may think of all the things you loved about that person and the experiences you will no longer be able to share. Your sadness is actually an expression of your love. Healthy grief, in contrast, results from distorted thoughts. For example, in my book, Feeling Good, I described a young physician who became suicidal when her brother committed suicide because she told herself; "I should have known he was suicidal that day. His death was my fault, and so I, too, deserve to die." This thought triggered intense guilt, and it contains many of the familiar cognitive distortions, including Self-Blame, Emotional Reasoning, Should Statements, and Discounting the Positive, and Fortune-Telling, to name just a few. With my help, she was able to challenge and crush her distorted thoughts, and her depression disappeared. Then she was then able to grieve his tragic death. Paradoxically, the distorted thoughts that triggered the unhealthy grief had actually prevented her from grieving in a healthy way. Today's podcast is illuminating because Rose is experiencing a combination of healthy and unhealthy grief resulting from a mix of undistorted and distorted thoughts. The work that Rose did is incredibly inspiring, and sad. Today we will publish the first half of the session, including T = Testing and E = Empathy. Next week, we will publish the second half of the session, starting with the question, "What do we have to offer our patients once we've empathized?" Then you will hear the A = Assessment of Resistance and M = Methods portion of our work with Rose. T = Testing Take a look at the Daily Mood Log (LINK) that Rose shared with us at the start of her session. You will see that she had very elevated scores in 8 different categories of negative feelings, suggesting she was in pretty intense distress. We will ask her to rate these feelings again at the end of the session so we can see if she experienced any changes during the session. I'm a firm believer that all therapists should use testing at every session, and many are now doing this, but lots of therapists still refuse for a variety of reasons. I was going to say "bogus reasons," but didn't want to sound harsh or dogmatic! To me, the refusal of psychotherapists or psychiatrists to measure symptoms at every session is the "unforgiveable sin!" I don't believe it is possible to do good therapy, much less world class therapy, without Testing, for a wide variety of reasons: Therapists perceptions of how patients feel, and patients feel about them, are not accurate. Measuring suicidal urges at the start and end of every session can save lives. Seeing how effective. or ineffective, you were at every session allows you to fine tune the therapy and abandon strategies and methods that aren't working in favor of better techniques. This turns your patients into the greatest teachers you've ever had—IF you can take the heat! You will see, for the first time, how your patients rate your Empathy and Helpfulness at every session. At first, this information can be incredibly shocking, but if you process it with your patient at the next session in the spirit of humility, warmth, and curiosity, the experience can be transformative. E = Empathy Rose explained that she was feeling acute grief because of her father's health problems. He had extensive surgery to remove a cancerous kidney in 2014, but the surgeons found additional unusual growths around his spleen. Her dad has also had open heart surgery, surgery to remove a bone tumor, and many other serious medical problems. She said, "he's like a cat with nine lives, but we're concerned that now he's near the end." He experienced GI distress and vomiting in September of 2020, and was hospitalized again in February of 2021, but they found nothing. In March, he was again hospitalized, and the doctor found an aggressive cancerous liposarcoma in his abdomen. Then they found more tumors in his back, and determined that it was Stage 3. The usual treatment would include radiation and more surgery, but he simply cannot stand any more surgeries, so we began to lose hope. Rhonda commented that he's suffered greatly, and the family has suffered as well, since 2014. Rose and her family finally got to visit him in San Diego on Memorial Day, and this was helpful. She said he's still really active with the activities he loves, including golf and gardening, and treasures every moment, and loves spending time with his two grandsons. Rose painfully described the impact of the pandemic, which meant they were only able to visit him twice in the past year. That made it especially nice to connect and see his grandsons during their Memorial Day visit. She said he was especially "present" and cherished those moments. She said: He was doing pretty well, and was telling his friends that he's happy with what he's accomplished in his life. He grew up in Bosnia, and was poor, with many challenges, so family is really important to him. Catholicism was the center of his culture. The whole family feels more connected now. The grief has brought us closer together. He's started chemotherapy, but I'm pessimistic. The doctor said it was only 20% effective, and it's expensive: $3,000 a month. I do not really know what the timeline is, but it was helpful to visit in person and to see that he can feel joy. My negative feelings typically run in the range of 50 to 60, but they can be suddenly triggered and spike much higher; for example, when I tell myself that he won't get to see his grandchildren and share so many important moments with them when they're growing up. He tries to comfort us when we ask how he's doing, and he says, "I'm okay; I'm just a little tired." My anxiety fluctuates because so much is not known. I'm not sure how this will affect him. What will the impact be? I'm afraid he'll get depressed because he may not be able to do the activities he loves, like golf. I also struggle with feelings of guilt. Should we have visited more? Should we move from the Bay Area to San Diego? We've been having some zoom calls, but they're hard. The boys compete for his attention on the calls. Rhonda asked: "You seem to have so much love for him. What has it been like to have him for a dad?" Rose answered: I have two brothers, and I'm the only daughter, so there's always been a special connection between my dad and me, and his values of hard work and family. Soccer has been really important, and he was so proud when Croatia won the world cup. Connection has always been so important. I wanted to go to South America when I was in my 20's, because I wanted to learn more Spanish and seek adventure. Everyone said it could be dangerous, so don't go alone. So my dad went with me, and we had our own wonderful adventures. When I think about that, it makes the feelings of loss all the more painful, because we're losing that connection. Rhonda and I asked for a grade on empathy. She said: "The session feels warm and I feel connected with both of you. A+" End of Part 1 Next week, you can hear the inspiring and moving conclusion of today's session.

#251, Ask Matt, Rhonda, and David (with the famed Dr. Rutherford Knows) Today we are again joined by the fantastic Dr. Matthew May for an Ask David. Rhonda and I are thrilled that Matt will be joining us every month. His input will give you a broader range of insights and answers to your many excellent questions! Today's questions were submitted by the more than 6,000 people who registered for my free talk on July 8, 2021 on the Rapid Treatment of Anxiety Disorders which was sponsored by PESI. I was very grateful to PESI for organizing this event, since it was open to shrinks as well as the general public, and that is the same audience that Rhonda and I are trying to reach with our Feeling Good Podcast. By the way, thank you for your ongoing support of the Feeling Good podcasts. Our four millionth download should happen in August! Please keep telling friends about the podcast if you think they might be interested. The very shy but erudite Dr. Knows may again join us and make an occasional comment. Let us know if you like his input and want to hear more from him in future podcasts. If you don't like him, we can quietly sweep him to the sidelines. Here are the questions we'll answer today: Hello Dr Burns, excited to be here at your talk today. Could you tell us more about dependency on anti-anxiety medications (benzodiazepines like Valium, Librium Ativan, Xanax, and so forth) and how to inform the client about the dangers of addiction? If this treatment you describe for anxiety disorders is 'rapid' does it linger? Is this rapid response you describe in your treatment of anxiety disorders merely first-aid? Am I right in assuming that the sustained work of psychodynamic therapy, body work, and so forth will still be required? Can you discuss any published or ongoing empirical research on the efficacy of TEAM-CBT compared to other therapy techniques? How does Rational Emotive Behavior Therapy (REBT), developed in New York by the late Dr. Albert Ellis in the 1950s, fit into the picture? How does the cognitive distortion, Fortune Telling, apply to specific phobias? Rhonda, Matt, Rutherford, and I thank you for joining us today, and hope you enjoyed the dialogue! Rhonda, Matt, and David (plus Rutherford)

#250: How to Tell Someone, "You Suck!" Featuring special guests, Dr. Matthew May and the always exciting but pedantic Dr. Rutherford Knows, plus our podcast regulars, Rhonda and David Rhonda begins the podcast with a wonderful email from a woman who asked how you might use the Five Secrets of Effective Communication when you have to deliver give negative feedback to someone. Hi David and Rhonda, I'm an avid listener of the podcast and reader of Dr. Burns' material. I've been working my way backwards listening to all the podcasts, and I now own all of Dr. Burns' books and am working my way through those, too! I've especially found the live therapy on the podcast and role-play using the Five Secrets incredibly useful. The Five Secrets of Effective Communication are like a cheat code for life. As I've been applying it in my own life, every conflict has had a phenomenal outcome and I end up closer with the other person. It's incredible. You've given many useful examples of using the Five Secrets on the podcast to respond to someone, for example, who is attacking you and you use the disarming technique and inquiry to hear more about how it's been for them. My question is, how would you use the Five Secrets to initiate a conversation where you have to be the one to bring up something that the other person doesn't want to hear, or that it may be painful for them to hear? I started to think about this when consulting for a CEO who needed to fire someone, but needed to keep the relationship amicable, as well as consulting with another business owner whose employee had been deceitful and she needed to have a "come-to-Jesus" talk with him. Similarly, I've always struggled to bring up something that's bothering me to a spouse or loved one, because I didn't know how to initiate the conversation, and keep it from devolving into an argument (my greatest fear!). Could you perhaps do a role play on the podcast to demonstrate using the Five Secrets of Effective Communication to initiate a difficult conversation, such as: Firing or correcting an employee? Telling a spouse (or loved one) when you've felt hurt or angry because of something they did? Obviously you would still use all the same techniques (Stroking, I Feel statements, Inquiry, etc.), but I would love to hear an example. I find the role plays especially useful and would love to hear your expert wording for how you would approach this. Thank you to both of you for all your tremendous work! Rosemary We loved this request, and model how to deliver the bad news to someone using the Five Secrets. David mentioned that when he was in clinical practice, several women he treated were reluctant to give clear negative signals to men who were chasing them, for fear of hurting their feelings. So, out of excessive "niceness," they ended up leading the man on, sometimes for months, and hurting him even more. It is probably far more merciful and caring to be honest with someone in a kindly way, so he or she can let go and move forward with his or her life. Rhonda, Matt, and David illustrate David's "Intimacy Drill." In this exercise, the person delivering the bad news is Person A, and the person receiving the bad news is Person B. The drill involves four steps. First, Person A delivers the bad news to Person B, trying to use the Five Secrets of Effective Communication (link). The bad news might be telling Person B that she or he has been fired, or that you're angry with Person B, for example. Then Person A gives himself or herself a letter grade on how well she or he did. Was it an A, B, C, D, or an F? Then Person B and the observers give a letter grades to Person A as well.. Next, everyone points out what Person A did that was effective, and what was ineffective, using Five Secrets terms. For example, you might say that the Feeling Empathy and Stroking were great, but there was no "I Feel" Statement or Inquiry at the end. Then you can do a role-reversal, and try to model an improved response. This is, by far, the best way to learn the Five Secrets of Effective Communication. However, it requires non-defensiveness on the part of all who participate, and the philosophy of "joyous failure." This means that you view your errors as opportunities for learning and growth instead of shame and defensiveness! If you want to master the Five Secrets for use in ANY situation, the "Intimacy Exercise" is a fantastic way to practice. However, remember to check your ego at the door, because you'll probably gets some low grades and make plenty of errors, especially if you're a beginner. But if you work at it, and keep practicing—which very few people do—you can develop some fantastic communication skills that can help you in personal and professional relationships. Today, we also introduced, in a small way, the very shy and erudite, and somewhat pompous, Dr. Rutherford Knows, who makes an occasional comment. He may agree to participate in future podcasts as well. Dr. Knows could be a really great podcast enhancement, since he (hopefully) makes the rest of us look really good! Let us know what you think! Rhonda and I are really pleased to work with Dr. May again. He is a dear friend and colleague, and, according to David and Rhonda, Matt is one of the finest therapists and teachers on planet earth! I strongly agree with this assessment of Dr. May. If you wish to contact him, you can reach him at: www.MatthewMayMD.com. Matt added that people interested in treatment can schedule a free 15-minute phone call there, my schedule permitting. Thanks! Rhonda and David Rhonda, Matt, and David (with Dr. Rutherford Knows)

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