Today we answer six questions submitted by listeners like you: Harald: How can I find the Show Notes for the Feeling Good Podcasts? Kristin: How do you help patients who obsess about past traumatic events, with intrusive thoughts about a cruel ex-lover or bullying by classmates? These thoughts can feed into the idea that their life is miserable and  they can’t move forward because they feel blocked by these harmful memories. Valentina: How are cognitive distortions, self-defeating beliefs, and feelings of depression transmitted? What you describe in your books seems to describe my mother’s behaviors when I was growing up? Could it be that depression is transmitted by the family? Alicia: How would you treat someone with cyclothymic disorder who cycles between euphoria and suicidal depression? He’s happy now, so how do I get him to fill out the Daily Mood Log? Kathy: I’m a big fan, and I have a question about “bibliotherapy.” What’s the best way to use your books and other materials to help yourself? Matthew: Do you ever use drugs in the treatment of depression? Are medications sometimes necessary or helpful?  

Suicidal thoughts and urges are very common among depressed patients. The vast majority of depressed individuals have thoughts of suicide from time to time, and some struggle with serious suicidal urges. The experts tell us that 10% to 15% of chronically depressed individuals do eventually commit suicide, even if they are receiving treatment for depression. It is hard for me to believe that suicide is that common, but even if it is only 2% or 3%, that’s still very significant, especially if you have a large clinical practice and you treat lots of depressed individuals. Suicide attempts are shocking and devastating for the patient, for the family, and for the therapist as well. The loss of a patient through suicide is the dark side of our profession. The loss of life is a horrible and unnecessary tragedy, since the feelings of hopelessness that trigger suicidal urges are always the result of cognitive distortions; the belief that you are hopeless and cannot improve is never valid. Yet, the depressed patient does not realize this, and sometimes turns to suicide as the only way out of the suffering. Sadly, clinicians' capacity to assess suicidal urges in patients they are treating is very poor, and not significantly different from zero. In this podcast, I describe how you can solve this problem with the use of the EASY Diagnostic System and suicide interview at the initial evaluation, and the use of the Brief Mood Survey at all subsequent sessions, with no exceptions. In this podcast, I focus on two things. First, how can the clinician identify and evaluate a new (or old) patient who is struggling with suicidal thoughts and fantasies and determine if the patient is at risk for a suicide attempt? Second, how can the therapist make the patient accountable and guarantee that the patient will not now, or ever, make a suicide attempt? The “defensive psychotherapy” I recommend will sound unfamiliar to many therapists but can save lives and make your practice far more peaceful and rewarding! The approach to the suicidal patient involves Paradoxical Agenda Setting techniques, including the Gentle Ultimatum and Sitting with Open Hands.

The famed neuroscientist, Dr. Mark Noble, from the University of Rochester, has developed a strong interest in TEAM-CBT and has visited our Tuesday group and Sunday hikes on three occasions this year. I (David) feel very fortunate to have his collaboration and interest! Mark is a Stanford-trained geneticist and molecular biologist who is considered one of founders of the field of stem cell research. He has been developing a model of how TEAM-CBT affects the brain, and graciously agreed to present his model at our Tuesday evening Stanford TEAM-CBT seminar last week. Although his model is not yet fully polished and refined, and involves considerable speculation, it is an exciting first step, kind of like the time when astronomers broke away from the Catholic church and started trying to make sense of the universe. In this instance it is the “inner universe” Dr. Noble, all of us, are trying to understand. His model will evolve and get more and more refined over time. The participants in the seminar really liked his concept that we are doing micro-neurosurgery for depressed patients with TEAM-CBT! He is convinced that the rapid recovery we see with TEAM-CBT will probably never be equaled by medication, since the brain circuits that modulate happiness and unhappiness tend to use the same neurotransmitters. But with language, you can affect brain circuits far more selectively and effectively, almost like a micro-neuro-surgeon. Dr. Noble describes brain function in terms of the SNEFF model. This stands for Structures, Networks, Emotions, Frames and Filters, and links these concepts to the prefrontal cortex, amygdala and sympathetic nervous system. Then he describes the four steps of TEAM (T = Testing, E = Empathy, A = (Paradoxical) Agenda Setting, and M = Methods), and links each step to the SNEFF model, making interesting speculations on how TEAM works and what makes it so effective. Dr. Noble also discusses David’s “fractal” theory about psychotherapy and relates that to brain function as well as to the mathematics of complex structures. He describes how and why some people get stuck in the “homeostasis” of chronic, refractory depression and explains why TEAM-CBT is usually able to trigger sudden and dramatic changes in the brain, as well as in the way the depressed and anxious individual thinks, feels, and behaves. He also explains why conventional talk therapy is unlikely to be helpful for individuals struggling with depression and anxiety, and may, in some cases, make the depression worse. This is because neurons that “fire together wire together.” In other words, if you go to therapy and complain or emote about your life and your problems over and over, without taking action to change, the circuits in your brain that support complaining and feeling depressed will just get more and more intensely wired together. Dr. Noble also speculates on why Paradoxical Agenda Setting is such an important key in ultra-rapid-recovery and in the sudden transformation of brain function as well. Years ago, when I was kid on vacation in Minnesota, I saw an article in a small newspaper published in a rural area. A local scientist had speculated that one day we would have guided missiles and satellites and drew a simple diagram for the newspaper of how they would work. At the time it seemed a bit like science fiction, and I wondered if an unknown scientist from a small rural Minnesota town could actually predict a major scientific development. But now we see that he was right. Will we someday think about Dr. Noble in the same way? Listen to this exciting podcast, and you can decide for yourself!

Lisa Nicole Bell is the host of the highly regarded podcast, Behind the Brilliance. In this lively interview, Nicole and David talk about David’s path into the mental health field the difficulties and rejections David faced getting his first book, Feeling Good, published David’s advice to listeners interested in therapy how he approaches perfectionism, depression, and anxiety with patients the joys of a life free from the need to be special— and much more! Lisa's show delivers a smart and funny take on pursuing ambitions, designing a life, and living joyfully. Lisa’s most recent media work includes producing an Australian documentary on identity and gender politics within sports and a digital docu-series produced by Academy Award-winning actress Viola Davis.

David and Jill do M = Methods, and show Lee how to respond to his wife more skillfully, using the Five Secrets of Effective Communication (link). Like everyone who is trying to learn the Five Secrets, Lee struggles with several blind spots: “I Feel” Statements. Lee has tremendous difficulties sharing his feelings openly, in a respectful manner. He seems indoctrinated with the cultural idea that men should not be vulnerable and express feelings. Lee makes the common error of “problem solving” instead of asking his wife to share more of her feelings. Lee makes another common error of apologizing and using the trite phrase “I’m sorry” instead of encouraging his wife to open up. David discusses the different between dysfunctional and effective apologies. David and Jill do lots of role-play practice with Lee and give him a homework assignment. T = Testing. After the session is over, Lee completes the Brief Mood Survey again. His scores indicated that his feelings of  anxiety and anger have completely disappeared, and he also has a perfect score  Positive Feelings Survey and the Relationship Satisfaction Scale. He also gave David and Jill perfect scores on the Empathy and Helpfulness scales and wrote what he liked the best about the session: “My epiphany came at the moment I realized I had been afraid of emasculating myself and realizing that my vision of what a “man” should be was completely inaccurate.” At the end, Jill reads an emotional email from Lee describing how he relapsed and started arguing with his wife, and then remember to empathize use the Five Secrets instead, with an amazing result!

David and Jill do A = (Paradoxical) Agenda Setting with Lee, starting with the Invitation: Jill asks Lee if he wants help with the relationship conflict, and if this would be a good time to roll up our sleeves and get to work. Lee indicates that he does want help. They review the first two steps of his Relationship Journal, where Lee had recorded one specific thing his wife said to him, and exactly what he said next. Here’s what he wrote down: Step 1 – She said: Write down exactly what the other person said. Be brief: I was trying to convince my 18-month-old daughter to put her pajamas on. I was calm. Eventually, I raised my voice an octave or two and in a stern voice I told my daughter to put her pajamas on. Afterwards, Liza said, “I don’t think you need to use that tone with a small child.” Step 2 – I said: Write down exactly what you said next. Be brief: I said, “I don’t think there was anything wrong with what I did. You can be stern without losing your shit*. There are times when she needs to know I am serious and not messing about anymore.” It then devolved into a debate over a clash of values on how to raise our daughter. * Transcribed as-is from Lee’s Relationship Journal. Lee also circled all the emotions he thought she was having, along with all of the emotions he was having. He thought she was feeling: Sad and unhappy Anxious and worried Rejected and alone Discouraged, pessimistic, and despairing Frustrated and stuck Angry, annoyed, irritated and upset Other feelings: troubled, defensive, dismayed, downhearted, and disconnected Here’s how he was feeling: Unhappy Anxious and worried Guilty, remorseful, bad and ashamed Inferior, inadequate, defective and incompetent Embarrassed, foolish and self-conscious Hopeless, discouraged and despairing Frustrated Angry, mad, resentful, annoyed, irritated, upset and furious Other feelings: hostile, loud, critical, agitated, defensive, stubborn, exasperated, sarcastic, powerless, diminished, low, resistant, confused, judgmental, vulnerable, inept Step 3. Good vs. Bad Communication. When David and Jill ask Lee to examine his response to his wife, he had to admit that his response in Step 2 had all the characteristics of bad communication—he did not acknowledge any of her feelings, he did not share his own, and he did not convey love and respect. This was disturbing and surprising to Lee. Step 4. Consequences. When David and Jill asked Lee to examine the impact of what he said to his wife, they suddenly ran into a wall of resistance, which is almost universal in relationship work. The Relationship Journal is an incredibly powerful tool, and it can be extremely painful because you have to stop blaming the other person and examine your own role in the relationship. Lee suddenly and painfully discovered the answer to his question of why his wife was so controlling and critical of him—it was NOT because of the influence of her mother, but rather because he was forcing her to treat him like that almost every time he interacted with her. This insight cannot be denied when you do the Relationship Journal, and it’s potentially incredibly empowering, but it can be incredibly painful at the same time. You will also hear a masterful and paradoxical response by Dr. Levitt when Lee resists—and as a result, his resistance suddenly disappears, and he jumps on board!

For the past couple months, Fabrice has asked me to set up a live therapy session to illustrate how to treat troubled relationships using TEAM-CBT. I was fortunate to get an email request from a colleague named Lee who wanted help with his marriage. He explained that his wife was very controlling and critical of him and attributed this to the fact that she had a controlling mother. This is very typical in troubled relationships, most of us are convinced that the problem is the other person’s fault. Of course, Lee told us that his wife, in turn, blames back and feels that Lee is the one who needs to change. Lee initially thought we’d do couples therapy, but in TEAM-CBT we actually prefer to treat just one person in a troubled relationship. Two weeks ago, Jill and I sat down with Lee on a Saturday morning, linking to each other on the internet since he lives abroad, for a three-hour treatment session. The session has been broken down into three separate podcasts plus commentary from Fabrice, Jill and David on each of the three segments. By way of disclaimers, Lee is a colleague who does coaching for individuals with alcohol addiction problems. We are not entering into a formal treatment relationship with Lee. Instead, he has offered to help us illustrate a therapy technique, using a real person problem, as part of his training and personal growth. We are deeply grateful to Lee for letting us share his intensely personal “session” with you! Today, you will hear the first segment on T = Testing and E = Empathy. Lee will tell his story. Jill and I will listen without trying to “help” or “rescue” Lee. On the Brief Mood Survey, he indicated no depression or suicidal urges. He was mildly anxious and slightly angry. His Positive Feelings Survey indicated that he was quite happy except in two areas: He felt only moderately close to people and only slightly connected to others. You will also hear him say that he felt like one of the loneliest people we would ever meet toward the end of the empathy phase of the session.

How to select the techniques that will be most helpful for various kinds of problems, and how to individualize the treatment for each patient.

For a long time, Fabrice has wanted to do a show on my list of "Fifty Ways to Untwist Your Thinking" called "Fifty Ways in Fifty Minutes." So we finally did it, and it was fun! If I'm helping you overcome depression or anxiety, I'll ask you to fill out a Daily Mood Log, so you can list your negative thoughts and feelings at some specific moment when you were upset. You may be thinking, "I'm a failure," or "I should not have made that mistake," or "I'm unlovable." Your negative thoughts will nearly always be distorted, but you'll still believe them, and that's why you're feeling depressed and anxious. And the moment you discover that your negative thoughts aren't true, you'll immediately feel better. But that's not going to be easy, because you've probably been giving yourself the same negative messages for years, or even decades.  And friends and family members, and even your therapist, may have been trying, unsuccessfully, to talk you out of them. That's why I've developed more than fifty methods to help you crush the negative thoughts at the heart of your suffering. So today, you'll take a look at the landscape!