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

This podcast was recorded eight weeks after the initial session with Marilyn. As you may recall, Marilyn became severely depressed when she discovered that she had Stage 4 Lung cancer. In spite of that horrific and real trauma, she completely overcame her negative feelings in the first session, which was broken down into a series of three consecutive podcasts, with commentaries as the session unfolded. Sadly, Marilyn experienced severe pain in her left rib cage from a metastasis from her lung cancer roughly two months later. This physical relapse triggered an understandable emotional relapse as well, with an understandable return of severe depression, anxiety and anger, so Marilyn agreed to record another podcast to illustrate how a tune-up works following the initial treatment. I would like to point out that the Relapse Prevention Training was critically important, so that Marilyn would know that relapses are a certainty, and that they can be dealt with effectively using the same techniques that worked the first time. This message is important so that the patient does not feel broadsided when the negative feelings return. Some patients have the false expectation that they'll be happy forever after they've recovered. But no one is entitled to be happy all the time! If the therapist and patient know how to deal with a relapse, and have practiced ahead of time, it will still be painful, but the patient and therapist will know what to do to make sure the patient can recover from the relapse quickly, instead of getting caught in another length episode of depression or anxiety. The entire session has been included in this single podcast. That’s why we’ve offered this as a bonus session between our weekly podcasts. You will need nearly two hours to listen to it, but I think you will find it’s a great investment of your time.

David and Fabrice begin by reading several incredibly touching reader comments on the live therapy with Marilyn. Marilyn experienced a severe depression relapse eight weeks after her initial session with Matt and David, because of a painful metastasis to her rib cage which frightened and demoralized her. She graciously agreed to come in for a tune-up with David and Matt which will be published as a special podcast within the next week or so. You will not want to miss this session! David addresses two questions posed by listeners. The first question has to do with so-called “third wave” CBT as well as Mindfulness-Based CBT and other innovations in CBT. David stresses the difference between specific and non-specific therapeutic techniques. He also discusses the distressing but exciting fact that few or no therapies have proven to be much more effective than placebos in the treatment of depression, and why this is the case. Another listener asked why David did not use Exposure initially in his treatment of the woman who was afraid that her baby would be switched at the hospital, and that she’d end up with the wrong baby. David concedes that if he’d thought of using Cognitive Flooding initially, it likely would have been effective. He also argues that Exposure and Response Prevention are not treatments for OCD, or for any anxiety disorder, but are simply tools one can use in treatment. David argues that for an optimal outcome, he combines four treatment models with every anxious patient: the Motivational Model, the Cognitive Model, the Exposure Model, and the Hidden Emotion Model. These models are discussed in detail on previous podcasts.

David emphasizes that the goal of the RJ is not simply to learn how to transform troubled, adversarial relationships into loving ones, but also how to achieve Interpersonal Enlightenment, which is the empowering but shocking realization that we are creating our own interpersonal reality—for better or worse—at every moment of every day! And although the reward of the RJ is greater love and joy in your daily living, the price is steep—it requires the death of the ego, which the Buddhists have called “the Great Death!” Together, David and Fabrice walk you through the five steps in the RJ, using real examples of individuals David has worked with in his workshops for the general public or for mental health professionals. One vignette involves a woman who complained bitterly that her husband had been relentlessly critical of her for 25 years. She said she came to the workshop because she wanted to know why men are like that. She found out why her husband was so critical, but the answer was not the one she expected! The other vignette involved a minister’s wife who complained that her husband was overly “nice” and unable to deal with negative feelings. As a result, she said their marriage was superficial and lacking in intimacy. She discovered precisely why their relationship was superficial—but it wasn’t exactly the answer she was looking for!

Bob, a psychiatric resident named was treating a divorced woman who complained bitterly about her ex, and constantly argued with him whenever he came to visit with the children. Their relationship was clearly acrimonious, so Bob asked the woman if she wanted some help with the way she was communicating with her ex. She bristled and said that she was an attorney and that she could communicate just fine, thank you! Bob’s error was the same that many therapists make—of thinking that people with troubled relationships want help. Clearly, Bob’s patient was not asking for help. She just wanted Bob to agree that her ex was a bum! In many cases, and perhaps most, individuals who aren’t getting along with someone—such as their spouse, sibling, parent, colleague, or friend—aren’t really asking for help. They just want to vent and persuade you to buy into their negative view of the person they aren’t getting along with. They just want you to know what a loser the other person is! So how do we help people with troubled relationships? David emphasizes that empathy is always the first step. You try to see the world through the eyes of the patient without jumping in to try to “help.” Empathy, of course, is the "E" of TEAM therapy. Once the person feels understood and supported, the next step is called Agenda Setting. That’s the A of TEAM. One of the most important tools in Agenda Setting for individuals with troubled relationships is to first ask, “Is this relationship conflict something you want help with?” In many cases, the patient will say no, so you can ask if there’s something else he or she wants to work on. In the language of TEAM, this is called “Sitting with Open Hands.” The therapist has to let go of his or her attachment to “helping.” This is difficult for many therapists, due to the therapist’s compulsive urges to help. If the patient does want help, the next step is called Interpersonal Decision-Making. You ask what kind of help the patient wants, and make it clear that the patient has three choices. To leave the relationship. To improve the relationship. To stay in the relationship and behave in a way that will guarantee that the relationship will remain miserable. David emphasizes that the last choice is by far the most popular. The second most popular choice is the decision to leave the relationship. And occasionally, you’ll find a person who wants help improving the relationship. As you can see, Interpersonal Decision-Making is simply a more sophisticated way of asking the patient if she or he wants help! If the answer is still yes, the next Agenda Setting step is the Blame Cost-Benefit Analysis (CBA). You can ask the patient something along these lines: “Who, in your opinion, is more to blame for the problems in the relationship? You? Or the other person? And who, in your opinion, is the bigger jerk? You? Or the other person?” At least 80% of the time, the patient will say, “the other person!” You may feel the same way if you’re in a conflict with someone right now. However, blame is the most formidable barrier to intimacy, so before we can continue with the treatment, this issue must be skillfully addressed, or the treatment will probably fail. David and Fabrice guide the listener in doing a written Blame CBA, listing the advantages and disadvantages of blaming others for the problems in our relationships with them. They encourage you to pause the recording and to the written exercise during the podcast, but warn you not to do it if you are driving! Then they discuss how to process the results of the Blame CBA. If you would like to see a completed Cost-Benefit Analysis, click here. As you can see, the weightings at the bottom have not been filled out, so you can do that for yourself if you like. Make sure you put two numbers that add up to 100 in the two circles. Put the larger number in the circle under the column that feels more desirable. For example, if the advantages of blame greatly outweigh the disadvantages, you might put a 70 in the circle on the left and a 30 in the circle on the right. If the patient concludes that the disadvantages outweigh the advantages, you can proceed to the M = Methods phase of the TEAM therapy session, which involves the Relationship Journal (RF). This is a powerful tool that David has designed to create interpersonal enlightenment and the death of the ego. David and Fabrice will discuss and illustrate the RJ in the next podcast.

David describes the three assumptions of the Interpersonal TEAM Therapy: We cause the very relationship problems we are complaining about, but don’t realize this, so we blame the other person and feel like victims of his or her“badness.” David describes a man who endlessly complained about his wife during therapy sessions--she didn't like having sex with him, she spend money behind his back, and never bragged about him when they were out to dinner with friends. He had even taken notes for years on all the “bad” things his wife had been doing every day throughout their marriage, but overlooked the many hurtful and self-centered things he was doing to break her heart every single day. We do not want to have to look at our own role in any relationship conflict because it is too painful to have to confront our “shadow,” to use a Jungian concept, and because we want to do our dirty work in the dark. So we will deny our role and angrily punish anyone who tries to shed light on our role in the problem. David describes a severely depressed woman who complained that she was the victim of "loneliness in marriage," a concept she'd just read about in a popular women's magazine. She explained that her husband would not and could not express his feelings, and felt that he was to blame for their marital problems as well as the severe depression and loneliness she’d been struggling with for 25 years. And yet, in a therapy session when he tried to express his feelings, she exploded angrily and told him to shut the F__ up! When Doctor Burns asked her to reflect on what had happened in the session with her husband, she angrily threatened to fire him if he ever brought up the topic again! The first two principles paint a dark picture of human nature. The third principle is more optimistic—namely, that we have far more power to heal a troubled relationship than we realize, and this can often happen quickly, but there’s a stiff price to be paid.  First, we have to be willing to stop blaming the other person so we can examine and pinpoint our own role in the conflict. Second, we have to focus all of our energy on changing ourselves, rather than trying to change the other person. This can be extremely liberating and joyful, but it involves the exceedingly painful death of the ego. The Buddhists have called this type of enlightenment “the Great Death.’ In the next podcast, David and Fabrice will show you how to transform your own troubled relationships into loving ones--if that's what you want to do!

First in a series of podcasts on how to transform troubled relationships into loving ones—if that's what you want to do! David begins with the story of how he got into working with troubled couples as well as individuals with troubled relationships shortly after his first book, Feeling Good, was published. Because cognitive therapy was beginning to generate excitement worldwide as the first drug-free treatment for depression, everyone thought it might also be effective for other kinds of problems, including troubled relationships. And there were fairly good reasons to suspect that cognitive therapy might be helpful. When you’re in conflict with a loved one, friend, colleague or stranger who you can't get along with, you’ve probably noticed that you will usually have negative thoughts like these running through your brain: It’s all his fault. (Blame, All-or-Nothing Thinking) She’s a jerk. (Labeling, Should Statement, Mental Filter, Hidden Should Statement) He’ll never change! (Fortune Telling, All-or-Nothing thinking, Discounting the Positive, Emotional Reasoning) All she cares about his herself. (Mind-Reading, Discounting the Positive, Mental Filter, Over generalization) I’m right and he’s wrong about this! (Blame, All-or-Nothing Thinking) She shouldn’t be like that. (Should Statement, Blame) Sound familiar? And as you can see, these thoughts contain all the same kinds of cognitive distortions that depressed individuals have, as I've indicated in parentheses. If you're familiar with the cognitive distortions, you may be able to pinpoint even more than the ones I've listed. The only difference is that when you're in conflict with someone, the distortions will usually be directed at the person you’re not getting along with, rather than yourself. Although these thoughts will usually be distorted, you may not realize this (or even care) when you're upset. You'll probably be convinced that the person you're mad at really is a jerk, or really is to blame, or really is wrong. In addition, these thoughts will tend to function as self-fulfilling prophecies. For example, if you think someone is a self-centered jerk, you will usually treat him or her in a hostile or unfriendly way, and then he or she will get defensive and hostile, and will look like a jerk. Then you'll tell yourself, "See, I was right about him (or her)!" David got excited about these insights and wrote a draft of a book called Couple in Conflicts, Couples in Love, and sent it to his editor in New York to see what she thought. The new book was about how to modify the distorted thoughts and self-defeating beliefs that trigger and magnify relationship problems. David's editor called the next day with an offer of a large advance, exclaiming excitedly that the book was sure to be a #1 best seller. David was ecstatic, and set out to edit the book for publication. In the meantime, he was using the new approach with troubled couples as well as individuals with relationship conflicts. But after six months of repeated treatment failures, he concluded that cognitive therapy was not at all effective in the treatment of relationship problems. The approach sounded great on paper, but it didn't work in the real world. David sadly returned the advance to his publisher and cancelled the contract. He promised that if he could figure out why cognitive therapy didn't work for troubled relationships, and if he could find a better treatment method, he’d write another book. Figuring it out took 25 years or research and clinical experience, and the name of the book he eventually did publish is called Feeling Good Together, now available on Amazon.com. David and Fabrice then discuss some of the most popular theories about the causes of relationship problems: The skill deficit theory: We want loving relationships, but don’t have the communication and negotiation skills to get close to the people we’re not getting along with. The barrier theory: We want loving relationships, but something gets in the way, such as unrealistic expectations or distorted thoughts about the person we’re not getting along with. Other barrier theories include the idea that women are from Venus and men are from Mars popularized by John Gray, Deborah Tannen, and others. According to this theory, women use language to express feelings, and men use language to solve problems, so they both end up frustrated and not understanding one another. Another popular theory is the idea that we project childhood conflicts with our parents onto others, and thus recreate the same dysfunctional patterns repeatedly in every new relationship. The self-esteem theory: You can’t develop loving relationships with others if you don’t know how to love yourself. The motivational theory: We have troubled relationships because we WANT them! David emphasizes that the first three theories are all very optimistic--they all are based on the idea that human beings are basically good and want loving, peaceful, joyous relationships. But something gets in the way, such as a barrier of some type, or the lack of communication skills, or the lack of self-esteem. And they are all very hopeful, since we can teach people better skills, or remove the barriers to intimacy, or help people develop better self-esteem. David also emphasizes that these theories have only two problems. First, the theories that they're based on are false. Second, the treatments that have evolved from these theories are not effective. David and Fabrice describe research on the validity (or total lack of validity) for these theories as well as the effectiveness (or lack of effectiveness) of the treatment techniques and schools of therapy that have evolved from these theories. David then discusses the motivational theory which is much less optimistic about human nature, and emphasizes that humans have competing positive and negative motives. In the next podcast, they will discuss the basics assumptions of the new treatment approach David has created for relationship problems, based on the motivational theory.

A listener named Benjamin asks about procrastination. He wrote: “The live therapy with Marilyn was very interesting - like other listeners, I was impressed by her character and strength. “Towards the end of this most recent podcast, you were musing on what topics to cover in future podcasts. I would love to hear about how you treat people suffering from chronic laziness ("Do Nothingism"). In particular, there seems to be a strong potential of a Catch-22 with Process Resistance: The patient cannot find the motivation to do anything, yet they have to carry out the process (do the homework) to improve. “Even worse, in "Feeling Good", you categorize "Do Nothingism" into around 10 different categories, and suggest a different approach for each one. What should a lazy person do, who identifies with multiple categories, but is already starting to feel overwhelmed at the prospect of doing one of those activities, let alone five of them? “I would love to hear David's thoughts on this!” David and Fabrice begin by thanking Benjamin, and David emphasizes how helpful and inspiring it is to receive specific questions like this, which makes it easy to create a (hopefully) informative and interesting podcast. David says that his thinking about the treatment of procrastination has changed greatly since he wrote Feeling Good. One big change is that he no longer tries to “help” individuals who procrastinate, since this will cause them to continue to procrastinate, and the failure will now be the failure of the therapist, who’s “helping” wasn’t good enough. Instead, David outlines a multi-step approach, based on someone who has ten years of unfiled papers that have piled up in his office, so that by now 15 feet of desk space is completely covered by piles of papers roughly one foot high. Fabrice plays the role of the resistant patient, and David plays the role of the therapist. The steps include: Paradoxical Agenda Setting: David asks, “The procrastination seems to be working for you. Why would you want to change? Let’s make a list of all the benefits of procrastination, and all the reasons NOT to change.” David emphasizes that the patient has to convince the therapist that this is something he really does want to change. It’s NOT the therapist’s role to help or to convince the patient to change! Miracle Cure Question: What kind of help would you like in today’s session? Most patients say they need help with motivation. David declines to offer this, explaining that it isn’t on the therapeutic menu today—only the “Blue Plate Special!” The patient must agree to begin working on the filing in spite of having no motivation. David also explains the underlying concept behind this strategy: most procrastinators are waiting for motivation, but that never works. You’ll be waiting forever, because you’re NEVER going to feel like doing all that filing! You aren’t entitled to motivation! Productive individuals know that action comes first, and motivation comes second. Specificity: What time would you like my help in overcoming your procrastination? The patient’s requests for help yesterday or tomorrow are declined by the therapist, so they settle on 6 PM today. Little Steps for Big Feats: Let’s list the first five things you would need to do tonight at 6 PM, making sure that every step can be completed in 15 to 30 seconds. They list these steps: Walk into my office Choose one pile to start working on Pick up the top piece of paper on the pile Put it into a blank manila file folder Label the file folder Let’s Be Specific: David asks if Fabrice needs help with Step 1? Step 2? Etc. Fabrice finally admits he can do these five steps. Five Minute Rule: David asks if Fabrice will agree to do these five steps between 6 PM and 6:05 PM, and if he will agree to work on his filing for ONLY those five minutes. At the end of the five minutes he has completed 100% of the assignment. The rationale is that if Fabrice tries to do it all, he’ll get so overwhelmed that he won’t do anything. But if he agrees to ONLY five minutes, that will be do-able. And if he surprises himself, and gets motivated to do more, he can, be he only gets credit for the first five minutes. Problem – Solution List: David asks Fabrice to put a line down the middle of a piece of paper, from top to bottom, and list all the problems that will get in the way at 6 PM, and then to list convincing solutions to each problem in the right-hand column. Fabrice lists two problems: 1. I won’t feel like it. And 2. Traffic might be heavy, so I might not get home by 6 PM. “I Stubbornly Refused” Technique: David asks Fabrice to agree to an unusual phone call at 6:05 PM! TIC – TOC Technique: David plays the role of Fabrice’s “Task-Interfering Cognitions” (TICS) that will tempt him to procrastinate, and asks Fabrice to play the role of the “Task-Oriented Cognitions” (TOCS) he can use to combat the TOCs. The TICS include the familiar ones such as: Five minutes won’t help, the job is overwhelming. Even if I get started, I’ll just relapse, so there will never be a permanent solution. It’s not such a big problem, I don’t need to do my filing now. I can watch Game of Thrones on TV instead. That will be more fun. It will be too anxiety provoking to get started. It’s too late to get started anyway. Tomorrow will be a better day. David confesses the problem is one that he actually had, and describes how he solved it, using this exact approach!

The responses to the Marilyn session were extremely positive. At the start of the podcast, Fabrice reads a response from a listener who was moved and inspired by the work Marilyn did. David and Fabrice discuss two questions commonly raised by people who have seen David's live demonstrations with individuals experiencing severe depression and anxiety. Since the change in Marilyn’s scores were so fantastic, some skeptical listeners have asked, “Was this real, or was it staged?” Others have asked if patients are simply giving favorable answers on the Brief Mood Survey and Evaluation of Therapy Session forms as a way of being “nice” to the therapist. David points out that the opposite is true. If patients are in treatment voluntarily, without some kind of hidden agenda such as applying for disability, they tend to be exceptionally honest in the way they fill out the forms. In fact, most therapists find that they get failing grades from nearly every patient on every scale at every session at first. This can be very upsetting, especially to therapists who are narcissistic and defensive about criticism. But if the therapist is humble and open to the feedback, the patient’s feedback on the Brief Mood Survey as well as the Evaluation of Therapy Session forms can provide a fabulous opportunity for growth and learning. So in short, it is not true that patients fill out the forms just to be “nice” and to please the therapists. The scores are brutally real! If you are a therapist and a doubters, you can give the assessment instruments a try, and I think you’ll be surprised, and perhaps even shocked when you review the data! Still, David acknowledges that the rapid and phenomenal changes he now sees most of the time when using TEAM-CBT are hard to believe, especially when you've been trained to think that recovery is a long, slow process. David discusses a model of brain function proposed by a molecular biologist / geneticist, Dr. Mark Noble, that allows for extremely rapid change. David and Fabrice also address the question—can these kinds of miraculous results last, or are they only a flash in the pan? David emphasizes the importance of ongoing practice whenever the negative thoughts return. The “one and done” philosophy is not realistic. Part of being human is getting upset during moments of vulnerability, and that’s when you have to pick up the tools and use them again! David describes experiencing three hours of panic just a few days ago, and Fabrice asks what techniques he used to deal with his own negative feelings, including Identify the Distortions, Examine the Evidence, Reattribution, and the Acceptance Paradox. David agrees with the Dalai Lama that happiness is one of the goals of life, but emphasizes that it is not realistic to think one can be happy all the time. Fortunately, you can be happy most of the time--but you have to be willing to pick up the tools and use them from time to time when you fall into a black hole!

Crushing Negative Thoughts In this third and final podcast featuring live therapy with Marilyn, David and Matt move on to the M = Methods phase of the session along, and encourage Marilyn to challenge the Automatic Negative thoughts on her Daily Mood Log using techniques such as Identify the Distortions, the Paradoxical Double Standard Technique, the Externalization of Voices, and Acceptance Paradox. Marilyn emerges as a powerful partner and begins to crush the negative thoughts that had seemed so real and overwhelming at the start of the session. David emphasizes that the perceptions of therapists can often be way off base, so even though Marilyn appeared to change—fairly dramatically—during the session, David, Fabrice, and Matt will not know for sure until they review Marilyn’s end of session ratings on the Daily Mood Log, Brief Mood Survey, and Evaluation of Therapy Session. David defines a relapse as one minute or more of feeling lousy. Given this definition, all human beings will “relapse” frequently, including Marilyn. But relapses following recovery do not have to be a problem if the patient is prepared for them ahead of time. You will hear David and Matt doing relapse prevention using a number of techniques, including the Externalization of Voices. Fabrice, Marilyn, Matt and David discuss the session, and what it meant to Marilyn from a personal and spiritual perspective. You can view this session as a powerful psychological experience—a “mind-blowing” single session “cure,” if you will—or as a profoundly healing spiritual experience: the emergence, resurrection, or rebirth from the “Dark Night of the Soul.” And you can ask yourself—did a genuine miracle happen here today? Marilyn DML, end of session, mood only Marilyn BMS before and after, v 1 I, David, am very indebted to Marilyn for making this phenomenal and intensely personal experience available to all of us. What a gift! Thank you, Marilyn. We love you! I also want to thank my co-host, Fabrice, for making these podcasts happen! What a joy it is to work with you every week, Fabrice. And I want to thank my fantastic co-therapist, former student, and colleague, Matthew May, MD, for support and friendship over these many years! Matt, as you know, I often sing your praises in my workshops around the country, telling people how amazing you are. Now they will see what I mean first-hand! I hope that through these three podcasts, Marilyn will touch large numbers of people for years, even decades, to come. If you were touched by these recordings, please let your friends and colleagues know, so that they might have the chance to “tune in” as well. In the first session with Marilyn, I mentioned the highly controversial theory that our pain usually results from our thoughts, and not from the circumstances of our lives. What do you think now?

The Hidden Side of Depression, Anxiety, Defectiveness, Hopelessness and Rage We nearly always think about negative feelings, such as moderate or severe depression, as problems that an expert must try to fix, using drugs and / or psychotherapy. There are a multitude of theories about why humans become depressed, including, but not limited to: We get depressed because reality sucks. We believe our mood slumps result from the circumstances in our lives, such as being alone following a rejection, experiencing the loss of a loved one, not having enough money, education or resources, social prejudice, or (as in Marilyn’s case) facing some catastrophic circumstance, such as severe illness. We get depressed because of insufficient love and nurturing in childhood, or because of traumatic childhood experiences. Biological factors. We get depressed because of our genes, or diet, or because of a chemical imbalance in our brains. Certainly, there can be some truth in all of these theories. Reality does kick us all in the stomach from time to time, and the pain we feel is understandable. My wife and I lost her father to Parkinson’s Disease a few years ago. We loved him tremendously, and his loss was extremely painful for everyone in our family. And most of us have experienced less than ideal circumstances when growing up, and many have even been victimized by horrific and tragic circumstances, such as child abuse. And clearly, some severe psychiatric illnesses, such as schizophrenia, do result from some kind of brain abnormality. But the problem with all of these theories is that they put us at the mercy of forces that are largely beyond our control—since we often cannot do much to change reality, rewrite our childhoods, or modify our brains short of taking this or that medication. In this podcast, Matt and David take a radically different approach, and argue that Marilyn’s intense feelings of depression and anxiety are not “mental disorders” that reflect some defect in Marilyn, but rather the expression of what is most beautiful and awesome about her. They also argue that there are large numbers of advantages, or benefits, of feeling the way she does, using several Paradoxical Agenda Setting techniques such as the Miracle Cure Question, Magic Button, Positive Reframing, and Magic Dial. The results are stunning and unexpected. Or, as Marilyn put it, this portion of the session was “mind-blowing.” The third and final podcast next week will include the M = Methods phase of the session along with the end-of-session T = Testing and wrap-up, including Relapse Prevention Training. Marilyn DML with goal column