Dr. Angela Krumm and Zane Pierce discuss cultivating delight in daily life, inspired by Ross Gay's book 'Book of Delight'. They explore the possibility of cultivating joy, reasons against it, experiment results on boosting happiness, and finding delight in simple accomplishments. They also discuss enhancing the human spirit through techniques for anxiety and depression, expressing gratitude to the listeners.

In this podcast, Dr. David Burns and Dr. Rhonda Baravsky discuss the progress made in a therapeutic intervention, rebuilding communication and understanding with children, and the impact of empathy. They also delve into moments of enlightenment and shifting perspectives, the importance of analyzing conflict in relationships, and overcoming defensiveness to build healthy relationships.

359: The Story of Indrani “Why can’t I get close to my daughter who I love so much?” Today, we present the awe-inspiring work that David and Jill did with Indrani in the Tuesday group at Stanford. Indrani was a mother with a heart-breaking but all-too-common story of a conflict with her daughter. Sometimes, we love someone tremendously, but every time we try to get close, they seem to push us away. The story should ring true and be helpful to so many people, as nearly everyone runs into conflicts at times with our family members, including our parents, siblings and children. And, as usual, the solution often involves attending to your “inner” dialogue, which is the conversation you’re having with yourself about the conflict, and the “outer” dialogue, which is what happens when you try to get close to the person you love. And today’s session illustrates not one, but two forms of enlightenment. The changes in the inner dialogue involves challenging and crushing the negative messages you’ve been giving yourself about h problem with the person you love so much. You can see Indrani’s Daily Mood Log if you click HERE. As you can see, she’s been telling herself that her daughter has shut her out of her life, and that she’ll die alone/ That’s incredibly sad! And she’s also telling herself that all of her friends have wonderful relationships with their daughters “and I don’t” and she’s blaming herself for the problem: “I deserve this treatment,” and “nothing I do pleases her.” You can also see the intensity of Indrani’s negative feelings, including sadness, anxiety, inadequacy, loneliness, embarrassment, discouragement, irritation, and more. You can also see a typical exchange with her daughter if you look at her Relationship Journal (RJ). As you may know, the whole theme of my interpersonal model in TEAM-CBT is that we create our own interpersonal reality at every moment of every day. In other words, we unknowingly create and cause the exact relationship problems that we complain about, but just don’t realize this, so we think there’s something wrong with the other person. But how can this be? If you look at Step 2 of Indrani’s RJ, her response to her daughter seems innocent enough! But stayed tuned, because Indrani makes a shocking and mind-blowing discovery during the session, and that discovery requires the exceedingly painful “death” of the “self.” But this “Great Death” is instantly followed by a “Great Rebirth.!” At the end of the session, a Tuesday group members named Keren, said this to Indrani: “You wowed me!” One of the men, Ed, could barely speak because he was sobbing. You may also be sobbing for joy when you listen to this heart-warming story. In part 1, today’s podcast, you’ll hear the initial T = Testing and E = Empathy. In part 2, in next week’s podcast, you’ll hear the M = Methods, including Jill and David’s incredible work with Indrani on her R and her rather sudden discovery, in Step 4, of exactly how and why she’d been driving her daughter away—and how to stop doing that and begin to communicate in a way with a far greater chance of enhancing closeness and love. The Jill and David turn to Imani’s Daily Mood Log so she can smash her distorted negative thoughts with the Externalization of Voices, and several role reversals illustrating the integration of Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique.) You can see Imani’s initial and final Brief Mood Surveys plus her Evaluation of Therapy Session, We are extremely grateful to Indrani for giving us this very intimate glimpse into her inner life in a way that will illuminate and inspire every person with the good fortune to listen to Indrani’s amazing Journey this evening! Thanks for listening! Rhonda, Jill, and David

Topics discussed in this podcast include the nature of physical symptoms of depression, treating schizophrenia with TEAM-CBT, therapists using self-help techniques, and understanding the difference between healthy and unhealthy emotions. The hosts also discuss translating the book 'Feeling Great' into Korean, gratitude, unity, and the launch of Feeling Good TV.

The podcast discusses the speaker's experiences in the 1960s, including the hippie generation, LSD, encounter groups, and transformative therapies like psychodrama. They also explore the spiritual dimension and the importance of therapy. The hosts share personal stories about living in a cool building, residency in Philadelphia, and their long-lasting relationship. Reflections on past experiences during the Vietnam War protests and resources for therapists and non-therapists are also discussed.

Ask David: Burn Out; When Challenging Thoughts Doesn't Work; and more! Featuring Dr. Matthew May In today’s podcast, Matt, Rhonda and David discuss four challenging questions from podcast fans like you: 1. Joseph asks if it’s okay to take a break when you get “burned out.” Below, David expands on this and describes the difference between “healthy” and “unhealthy burnout.” 2. Joseph also asks why your feelings might not change when you challenge your negative thought with a positive thought that’s 100% true. 3. Dan asks about Step 4 of the Relationship Journal, which is the most difficult and important step in the TEAM interpersonal model—see exactly how you’re forcefully causing and reinforcing the very relationship problem you’re complaining about. For example, if the person doesn’t “listen,” you’ll see that you’re forcing them not to listen. If she or he doesn’t open up and express feelings, you’ll see that you prevent them from opening up. And if you think your partner doesn’t treat you in a loving and respectful way, you’ll suddenly see exactly why this is happening—if you have the courage to take look and see: But if fact, this is one of the “Great Deaths” of the “self” in TEAM-CBT, and very few folks are willing to “die” in this way. 4. Finally, Clay asks about EMDR. He’s been treated with it without success. David and Matt weigh in with their thoughts about EMDR. This question was not addressed on the podcast, since some practitioners of EMDR might be offended by David and Matt’s thinking, but they did describe their thoughts in the show notes below. If you are an EMDR enthusiast, you might prefer NOT to read our comments. Joseph writes: Thanks, David, for sharing so much on the podcasts! I have a couple questions. Personally, I find that when I'm burnt out, I get a lot more anxious automatic thoughts. While it's definitely good to combat these distorted thoughts by replacing them with realistic ones, my takeaway is that it's also sometimes wise to change our lives / circumstances (e.g. to take a break). By the way, I also wanted to ask if you've ever faced a situation where you are convinced that a thought is distorted and irrational (and you know what the realistic thought is), but you still can't shake it off? I sometimes get stuck when I already know the "right answer" (ie. what the realistic thoughts are based on the methods you've taught), but I just can't seem to get my brain to fully believe it. For example, I was recently on vacation and a small blip made me think "my vacation is ruined!". I immediately identified it as all-or-nothing thinking, and replaced it with "my vacation is still going very well even if it's not perfect" (and I'm convinced this thought is true), but somehow my mind kept going back to the automatic thought again and again. Curious if you've ever experienced this. Thanks again so much for your time and your teaching; just wanted to say I really appreciate it! :) Regards Joseph David’s Reply to Joseph. Thanks for the great questions. We address both of them on an upcoming podcast. Here’s the quick response. Yes, it is okay to take a break when you feel “burned out.” However, you can get “burned out” in a healthy or unhealthy way. For example, after I edit for two or three hours, which I love, my brain gets “burned out.” So I take a break and come back later, maybe even a day later, and I feel refreshed and filled with enthusiasm about writing and editing some more, because I love these activities. When I was in private practice in Philadelphia, I saw 17 patients back to back on Wednesdays. That way, I could have a three day weekend. Actually, I loved it and as the day went on, I got higher and higher. At the end I was exhausted, but exhilarated. I was never “burned out” because I loved what I was doing, and the clinical work was SO rewarding! However, sometimes I made a mistake and a patient would get very upset, sometimes angry with me, or felt hurt. THAT was when I got suddenly burned out and exhausted. But it wasn’t because of my work, or the conflict, but rather my thoughts about it, which generally involved a combination of self criticism and frustration with the patient, both the result of distorted thoughts, generally Self-Directed and Other-Directed Should Statements. And THAT kind of “burned out” won’t improve with a break. The answer is challenging and changing your own inner dialogue, as well as your dialogue with the other person, using the “failure” in the relationship as an opportunity to listen and support and create a deeper and more meaningful relationship. With regard to your second excellent question, we explored that in depth in the podcast, and also made it a problem for our listeners to think about. So tune in for the answers! This is a popular question I’ve been answering for more than 40 years, and the answers tell us a great deal about how cognitive therapy actually works. Thanks so much, Joseph!  Subject: Relationship Journal Gem I Found Dan (a former participant in David and Jill’s Tuesday training group at Stanford) writes: Hello to the Dynamic Duo (David and Jill), I came across this doc for Step 4 of the Relationship Journal, but I don’t really understand it and I don't remember the context. I know it was from the Tuesday Group years ago. It says it's about conceptualizing the problem, just not sure how to utilize this in step 4. Thanks. (You will find this document in the show notes below.) ~Dan (Daniel C. Linehan, MSW, LCSW) David’s Reply Hi Dan, Great question. In this document, I am trying to make it a bit easier for folks to see how they are triggering the very problem they are complaining about. So, I have listed three categories of common complaints. For example, an Empathy complaint would be that “My partner doesn’t listen,” or “always has to be right.” Then you ask, “If I wanted to force my partner to behave like this, how could I so?” Well, one good way would be to interrupt when your partner is trying to talk, or argue and insist your partner is wrong when they’re trying to make a point, and so forth. This would force your partner to argue and insist that they are right! It is pretty basic and obvious. But most human beings don’t “get it,” and in part that’s because a great many don’t want to. Blaming the other person seems way more popular than looking at your own role in the problem these days. Good to hear from you on this important topic! People can usually “see” how step 3 of the Relationship Journal works—you simply examine what you wrote down in Step 2, and you can almost always see no E (Empathy), no A (assertively sharing your feelings with “I Feel” Statements, and no R (conveying respect or liking to the other person, even when you’re angry.) But most people don’t seem to have the natural mental aptitude or the stomach for Step 4, where you go beyond Step 3 and explain EXACTLY how you FORCE the other person to behave in the exact way you’re complaining about. The document in the link is an attempt to help people with Step 4—IF you are willing to examine your own role in the problem. In Step 4, you ask yourself what category you see the other person in, and there are three choices to make it fairly simple. You might feel that they don’t listen or try to see your point of view. This would be an E = no Empathy complaint. Or you might feel like they can’t, or won’t, share their feelings. Instead, they might just keep arguing, or they might refuse to open up. This would be an A = no Assertiveness complaint. Or, you might complaint that they don’t treat you with warmth, love, or respect. That would be an R = no Respect complaint. This makes it much easier to “see” how your response to the other person in Step 2 actually causes and reinforces the exact behavior you’re complaining about. Lots of people get defensive or annoyed at this step of the RJ, and refuse to continue! That’s because Step 4 is all about the third “Great Death” of the “self,” or “ego,” in TEAM-CBT. Most of us don’t want to “die” in this way. It can feel humiliating, or shameful, to pinpoint your own role in the problem. But, there’s usually a big reward—you’re suddenly “reborn” into a far more loving and satisfying relationship. In the podcast, brave and wonderful Rhonda provided David and Matt with an example when she was visiting her son and daughter in law in Germany last month to help out with their twin baby girls. This example really brings this “Great Death” to life, and we are grateful to Rhonda for helping us in this very vulnerable and real way! Feel free to ask again if I have not made it clear. To me, this phenomenon of causing the very problems we are complaining about in our relationships with others is incredibly fascinating. However, change involves the “death of the self,” which is painful, because you have to see, usually for the first time, your own role in the problem you’re complaining about. It is based on the Buddhist idea that we create our own interpersonal reality at every moment of every day. In other words, we CREATE our enemies, and then whine and complaint about it! Most people don’t want to see this! They want the therapist (or friend they’re confiding to) to agree that the other person REALLY IS a jerk, or to blame, or whatever. They just want to complain and blame and feel superior! In my book, Feeling Good Together, I think I said something to the effect that we “want to do our dirty work in the dark.” In other words, we don’t want to turn the lights on so we can “see” how we’re actually causing the conflict. The person asking for help can nearly always be shown to be the 100% cause of the conflict. This technique is one I recommend when working with an individual, and not a couple. Other less confrontational techniques are probably more effective when you are working with both partners at the same time. Warmly, david (David D. Burns, MD) Here’s the document: Conceptualizing the Patient’s Complaint in Step 4 of the Relationship Journal (RJ) By David D. Burns, MD* Problem Area Specific Complaint—S/he Complaints about the other person’s lack of E = Empathy Won’t listen Does not understand me Always has to be right  Always criticizes me Constantly complains and ignores my advice Constantly brags and talks about himself / herself Doesn’t value my thinking or ideas. Is defensive and argumentative Doesn’t care about my feelings. Complaints about the other person’s lack of A = Assertiveness Cannot (or will not) express his or her feelings Cannot deal with negative feelings Expects me to read his or her mind Clams up and refuses to talk to me Won’t be honest with me pouts and slams doors, insisting s/he isn’t mad! won’t tell me how she / he is feeling. isn’t honest with me. suddenly explodes for no reason, out of the blue. Complaints about the other person’s lack of R = Respect Always has to get his or her way Is stubborn Is controlling Does all the taking, while I do all the giving Uses me Puts me down Is judgmental Does not care about me or respect me Only cares about is himself / herself Constantly complains and ignores my advice. Explanation. When you are using the Relationship Journal, you will usually have a complaint about the other person. For example, you may complain that she or he “never listens,” or “is always si critical,” or “constantly complains but never listen to my advice.” If you write down one thing the other person said in Step 1 of the RJ, and exactly what you said in Step 2, you can usually easily analyze your response with the EAR Checklist. That shows what you did wrong, and why your response was ineffective. You can also use the Bad Communication Checklist to pinpoint your communication errors, and some people prefer this format. In Step 4, you go spell out precisely why your response will FORCE the other person to keep doing the exact thing you’re complaining about. One easy way to conceptualize the nature of your complaint about the other person is with our convenient EAR algorithm. This document can help you “see” the problem you’re complaining about when you do Step 4 of the RJ. That makes it much easier to discover exactly how you are triggering and reinforces the exact problem you’re complaining about. LMK what you think! Clay writes: Hello David, I know you no longer practice, but could I please get an opinion from you on EMDR? So far I have done about six sessions of EMDR and I feel worse than when I began. Does one typically feel worse before one feels better with EMDR? I know you are for Team CBT, and I think it has a lot of merit and science behind it! It just seems a little magical to me that by alternately tapping that I am going to resolve traumas or anxiety issues that happened a long time ago and maybe even recently, but I am going into it with an open mind and the possibilities. Best to you and your family, David, and thank you for the revolution in cognitive therapy you started with Aaron Beck and Albert Ellis! Kind regards, Clay Wilson Hi Clay, I’ve never been an EMDR enthusiast. To me, it’s just cognitive exposure, which definitely can have value in anxiety, coupled with “eye jiggling.” Many of it’s proponents seem to think that they have found the holy grail, and I have no doubt that a few will slam me for me non-supportive response! And please remember that I’m a cynic, so take it with a grain of salt. In TEAM, we use more than a hundred M = Methods, and only after doing the T, E, A steps, which are absolutely crucial to success in most cases. Best, david PS I’m copying Rhonda and Matt. If we used your question on an Ask David, would you be open to that, with or without your correct first name? Happy to disguise your name. David D. Burns, MD Dear David, I greatly value your ideas and that you are a cynic. In 6 sessions of the EMDR, I have not felt any better. You are absolutely free to use my name and you don't need to disguise it at all. I live in Columbus, Montana and as far as I know, there is only one person in Bozeman who does Team CBT. I sent her an email but didn't hear back but it's 100 miles from us anyway. Thank you very, very much for your view on EMDR! I was thinking something similar myself. All the very best to you and your family! Most Sincerely, Clay David’s Response HI Clay, You’re welcome. My website is full of free resources, anxiety class, depression class, more than 300 TEAM podcasts, and more. My book, When Panic Attacks, is pretty cheap in paperback. Also, beta testing of thee Feeling Good App is still free. T = Testing, E = Empathy, A = Addressing Resistance, and M = Methods (more than 100.) A is likely the most important step! Thanks, best, david Matt’s Response Hi Dan and David, My guess is that EMDR showed some early results due to the tendency of most therapists to avoid exposure techniques and try to 'smooth over' anxious thinking and trauma, rather than just dive in and explore it, fearlessly. I suspect this created a large cohort of anxious and traumatized patients, waiting in the wings, for such treatment, so it showed immediate favorable data. However, this method is only one of dozens, and the setup is key. Why would you want to overcome something traumatic? Wouldn't it be more useful to remember it and avoid anything that resembles it? Meaning, there may be powerful methods, including exposure and (usually) less-effective methods, like 'eye-jiggling' and other distraction techniques out there for anyone, but why bother with these if the symptoms are helpful and appropriate? This is the main idea in TEAM . People recover when they want to recover, not when someone applies the correct methodology. -Matt Hi Dan, David, and Matt:  In addition to being a TEAM therapist, I also practice EMDR.  I find it to be very effective, especially when used within the TEAM structure.  It may not be for everyone, but it's great to have many options for our clients. -Rhonda  David’s comment. Yes, and here Matt’s is pointing out some of the paradoxical “Outcome Resistance” strategies we use with anxious patients when doing TEAM therapy. We become the voice of the patient’s resistance to change, and verbalize all the really positive things about the anxiety symptoms: how they protect us from danger and express our core values as human beings. Paradoxically, this often reduces resistance and opens the door to change. In TEAM, we treat the human being with systematic TEAM therapy. We do not treat symptoms with techniques. The meaning of this may be hard to “see” if you haven’t seen or experienced it. But there are a large number of actual therapy sessions your can listen to in the podcasts. Best, David Thanks for asking such terrific questions and for listening! We all greatly appreciate your support. Keep your questions and comments (negative as well as positive) coming! Rhonda, Matt, and David

Dr. Matthew May, a specialist in relationship problems, joins the podcast to discuss overcoming relationship issues. They delve into the concept of paradoxical invitations in therapy and the role of empathy in resolving conflicts. They also explore techniques for defending oneself and seeking common ground in disagreements. The speakers express gratitude for the podcast's impact and emphasize the importance of meaningful content.

Grass Roots TEAM-CBT Completely FREE Practice / Training Groups Today we interview four courageous pioneers of free and low-cost TEAM-CBT for the masses, featuring Brandon Vance, MD, Patricia O’Neil, Ana Teresa Silva, DVM and Nicholas Santascoy, PhD. Many of you are already familiar with Brandon Vance and Heather Clague’s awesome online Feeling Great Book Clubs which will start again, running from September 13, 2023, through December 6, 2023. The book clubs are popular and have gotten wonderful reviews.  They are a fun and engaging way to structure your reading, discuss the book, see demonstrations, practice tools, ask experts questions and connect with others around the world who are working on Feeling Great – and no one is turned away for lack of funds. Sound interesting? You can learn more and join here. But you may not be aware of a growing number of fantastic totally free self-help groups springing up for people around the world. These groups offer training in different aspects of TEAM-CBT. For example, Patricia offers DAILY (!) practice sessions that focus on the use of the Daily Mood Journal. You can also join free 5-secrets practice groups groups that focus on changing habits groups that practice a variety of TEAM tools a book club focused on When Panic Attacks and more! All these groups are free and open to anyone worldwide. To see the growing list, go to https://www.feelinggreattherapycenter.com/free. This list is invaluable, and check the link from time to time because the offerings will likely continue to expand. Keep in mind that these are NOT therapy groups, but layperson-led self-improvement groups. Brandon and Rhonda remarked that these free groups are part of a heart-warming movement which continues the culture of generosity that David has created, starting with David’s decades-long free weekly training groups for mental health professionals. The new self-help groups also carry the spirit of relating to others with deep empathy. The goal is to create an atmosphere of giving and support in mutual healing. A second goals is to learn to appreciate each other despite our differences. And so, the ripples that David has created continue to spread, and you can become a part of this process! Nicholas Santascoy is a research psychologist, academic coach and learning specialist who discovered Feeling Good in 2005.  He found it tremendously helpful and years later, began working with a TEAM therapist who suggested Brandon’s Book Club. When the book club reached the Daily Mood Journal section, he asked if he could start a free DMJ practice group, which he did, and it’s still going on each week, more than two years later. He was thoughtful about the group’s structure, making it clear to the participants from the beginning that he is NOT a therapist and that this is not therapy. It is simply a place to practice TEAM with support – an important disclaimer for any non-therapist running a practice group. In his groups, each person spends 10 minutes at the start working on some common task, like describing an upsetting event for a Daily Mood Log, or suggesting positive reframing for a negative thought or feelings, and so forth. Or they might go through a sequence starting with one negative emotion, one negative thought, one cognitive distortion, one positive reframe, and one positive thought. His group has also worked with the exercises described in the two free chapters on habits and addictions offered at the bottom of Dr. Burns’ website. Nicholas described working with a man with intense performance anxiety who had an upcoming job interview with a panel of eight individuals who were evaluating him. He was intimidated and anxious, but reluctant to give up his anxiety for a number of reasons. First, he was convinced that if he didn’t worry, he wouldn’t prepare effectively. In addition, he was convinced that he needed anxiety to do his best during the interview. Nicholas encouraged him to test these beliefs with experiments. He discovered, much to his surprise, that he was still strongly motivated to prepare for the interview when he was feeling relaxed and confident. He also recorded his interview and reviewed it afterwards. He was surprised to discover  that his best performance during the interview was when his anxiety had dropped to zero. Ana Teresa Silva is a Portuguese veterinary doctor who decided she wanted to work with people and became a coach in 2020. Ana Teresa developed a free Portuguese Five Secrets practice group in May of 2021. This quickly became an international group in English, free and open to anyone, and ran for two years and got rave reviews from participants. After that, she handed over the leadership to Linda Roth, M.Ed. This kind of group, in my (David’s) opinion is incredibly important because learning the Five Secrets is a lot like learning to play the piano. It’s possible to make beautiful music, but the Five Secrets are challenging to learn. Practice, combined with humility and the intense desire to learn, are the keys to learning and personal change. Patricia O’Neil, a former schoolteacher, loves David’s books like Feeling Great, When Panic Attacks, Feeling Good Together and more. Patricia experienced a very severe, prolonged and immobilizing depression, and tried ALL of the standard medical treatments, even including electroconvulsive therapy, but her depression continued. She then started reading Feeling Great and joined Brandon and Heather’s Feeling Great Book Club in 2022, and began to pull herself out of depression.  After several weeks she asked if there was a group for people who want to work their way through the book together in-between Book Club meetings, perhaps even daily, to “apply the strategies the best we can.” Brandon encouraged Patricia to start her own study group. She did! And not only that, she started many other groups as well – all completely free - including a When Panic Attacks Book Club, her daily Daily Mood Journal group, an eating healthy accountability chart, a coaches in training group and her own free advanced Five Secrets Practice group for people who have completed a Five Secrets Deep Dive series. Several of the participants in today’s podcast had anxiety about being on the podcast. Patricia generously volunteered some of her negative thoughts, including: I might not do well. I’m gonna mess up! Brandon might regret asking me to join the group today. My flaws and imperfections will be on display. She said that these thoughts contained many of the familiar cognitive distortions, such as Fortune Telling, Magnification, and Should Statements, to name just a few. She also described some of the strategies she used to challenge these thoughts, including these positive thoughts: The whole future of the world doesn’t depend on how well I do today! I probably WILL mess up, and that’s okay! Then she bravely and tearfully described her own battles with depression since her retirement several years ago, and her gratitude at having found so many skills to deal with negative mood swings more effectively. Her comments were touching and inspiring, and actually embodied the goal of the practice groups that are rapidly emerging. The goals including: provide a structure for free ongoing practice and learning give individuals around the world the chance to join the emerging community of TEAM enthusiasts provide opportunities to connect with others in the spirit of openness, acceptance, and compassion. Most humans are hungry, even desperate, for love, learning, and relief of suffering, along with a connection with others who also care. Brandon and his many fans and colleagues are transforming this idealistic vision into a practical reality. At the end of this moving interview, Brandon mentioned a number of additional groups that are rapidly forming including two Signal text groups created by Derek Gurney. “Mission Accomplished or Refused,” is a place to “report on plans to tackle aversive tasks” and take accountability – which is an effective tool for changing habits. He has also created an  “Exposure Celebration” class, which sounds like a terrific chance to do exposure with the support and reinforcement from others. This is something tremendously helpful for people struggle with all types of anxiety. Again, please click here to see more information about these wonderful and completely free Grassroots TEAM CBT groups! And if YOU have a free TEAM practice group you’d like to start or have started and want to add to the list, please email Brandon Vance, MD (brandonvance@gmail.com). In fact, I’ve always dreamed of free self-help groups for mood problems, with much the same spirit of lay healing you find in Alcoholics Anonymous. And now, in my old age, it is tremendously encouraging to see this happening. I have to pinch myself, in fact! Thanks, Brandon, Nicholas, Ana Teresa, and Patricia! Warmly, David and Rhonda

353: The Inner Scoop on “No" Practice! The “Inner” and “Outer” Dialogues— The “Inner” and “Outer” Solutions As you know, I have created many powerful communication techniques, including the Five Secrets of Effective Communication and more. One of the additional techniques is called “No” Practice, and it’s designed for people who have trouble saying “no,” or setting limits with other people. Essentially, you do a role-play with a colleague or therapist who keeps pestering you with pushy demands, and you have to practice saying “No” in a polite but firm and assertive way. Sounds simple, right? But it’s not! People have many reasons for not wanting to say “No.” For example, you may be afraid of hurting the other person’s feelings, or letting them down, or running the risk that they may get mad at you if you don’t say, “Yes.” In addition, you may feel like you’ll miss out on some special activity if you say no, so you end up way over-committed. In this session, you will meet an exceptionally compassionate and highly trained young psychiatrist named Lee, who asked for help with a problem relating to some of his patients. My co-therapist is Dr. Jill Levitt, who is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California. Lee explained how he struggles with saying “no” when patients make inappropriate requests, like pushing for a medication they’re addicted to, and wanting premature discharge from the inpatient unit when they have unrecognized safety issues. Instead, he seems to get drawn into long explanations of his thinking and why he’s declining the other person’s requests, sometimes for half an hour, and ends up frustrated when the other person still doesn’t “get it” and with himself for spending the time. People often think that therapy is easy, and that people just need encouragement, advice, or behavioral practice to change the way we interact with others. But as you will vividly see in this session, that is often not the case, and things that may seem simple or obvious can seem almost impossibly difficult to learn. Why does this happen? Why is it so difficult for people to learn new and seemingly simple verbal skills? Well, to find the answer, we have to go back to the teachings of the Buddha and Epictetus, who taught us that our negative feelings do NOT result from what’s happening, but from our thoughts. What does this mean? Well, Lee is an incredibly intelligent and compassionate young psychiatrist, and he’s clearly highly motivated, and yet he seems very slow in learning how to say “no.” Can his thoughts illuminate his apparent resistance to learning a new approach? During the session, Dr. Levitt reminded us of the fact that whenever you are involved in a conflict with someone, or any interaction for that matter, there are always two dialogues going on: the Inner and Outer Dialogues, and if you ignore either one of them, you may have difficulties triggering change. The Outer Dialogue involves what you say to the other person, and what they say next, and how you respond. For example, Patient says: “Doctor, I want to get discharged from the hospital.” Lee says: “No, I can’t do that because you’d be in danger and without a place to live. You’d be living on the streets, and it wouldn’t be safe for you.” Patient (who is in a state of psychosis) responds: “No doctor, I’ll be okay, because I’m living with Michael Jackson.” Then Lee tries to explain his thinking again, and then the patient asks to be discharged from the hospital again. And this cycle repeats itself many times, over and over, for as much as an hour. And they both end up frustrated and a bit miffed. Why is it so hard for Lee to say no in a kindly way and then move on to some other activity? That’s where the Inner Dialogue can be so important. It appears that Lee has two types of distortions that interfere with his ability / willingness to say “no.” Self-Directed Should Statements. Lee appears to believe that he “should” be able to explain his thinking to any patient. He wants to convey respect, responsiveness, and care when denying a request. This is, of course, an expression of his high standards, his compassion, and his desire to communicate clearly to his patients. But, as is so often the case, Lee takes this goal a little to far, think he should “always” be able to do this, regardless of how psychotic or confused or demanding a patient might be. Essentially, the healthy pursuit of excellence as a psychiatrist has gone a little too far and has arguably morphed into a self-defeating kind of medical perfectionism. Self-Directed Shoulds typically trigger feelings of guilt, shame, anxiety, and inadequacy. They are often accompanied by several other distortions, including All-or-Nothing Thinking, Mind-Reading, and Self-Blame, to name just a few. Other-Directed Should Statements. Lee appears to think that his patients “should” understand and acknowledge his thinking if he’s being reasonable and realistic. He may also believe that if he’s doing his best, then his patients “should” argue fairly and acknowledge when they understand what he tells them and “shouldn’t” be manipulative, unreasonable or argumentative. Other-Directed Shoulds often trigger feelings of frustration and anger, and are often associated with All-or-Nothing Thinking, Mind-Reading, Emotional Reasoning, and Other-Blame, to name just a few. Another teaching point is that we nearly always create our own interpersonal reality, but we don’t realize that because we feel like victims and see the problem as coming from outside of ourselves. Lee’s urge to continue to try to “win” the arguments with patients actually forces them to keep arguing their case and trying over and over again to get their way. That’s just human nature. We’ve all seen that people can be pretty obstinate and determined to get their way, no matter what. That’s why a focus on what you can do to change will often lead to a change in other people; in contrast, repeated efforts to persuade them to change is almost never effective. By way of analogy, my wife and I have recently had a bit of a problem with our cat, SweetiePie. She was a rescue cat, and we love her to death, and do everything we can to make her happy. She loves us intensely and shows her gratitude with loud purring almost all day long when she’s not asleep or out in the back yard exploring. BUT, she has been pestering us for cat candy, and has gained too much weight. Here’s what happens. She jumps up on my desk, and puts her paw on my keyboard, and stands if front of the computer terminal so I can’t see. So, I give her two or three pieces of cat candy on her perch next to me. She jumps up and greedily devours it. Next, she jumps back on the desk and puts her paw on the keyboard. I “explain” to her that she’s eating too much candy, and try to put her back on her perch, so she swats me with her claws and draws blood if I’m not quick to pull my hand away. So, I give her a few more pieces of candy, which she devours and then goes to sleep. Similar routine with my wife. She follows her, crying like she’s on the verge of death, and swatting at her ankles until she gets cat candy and / or a 30 minute lap snuggle. So, in short, we have been “forcing” her, inadvertently,  out of love, to manipulate us for cat candy. In other words, we “reward” her manipulations by giving her cat candy and love. As a result, our pour girl is gaining too much weight. Of course, the solution is simple. Melanie has agreed to give her only four pieces of cat candy per day, and I am limiting her to two pieces, just so she’ll know she’s still loved. And when she tries to swat me with her claws, I just explain in a kindly way that I don’t like that and put her on the floor. She caught on right away and seems to have accepted the new routine. Of course, we continue to give her abundant helpings of love every day, many times a day, as the love has zero calories! So, what’s the bottom line? If you’re trying to learn the Five Secrets of Effective Communication, and you want to change the way you communicate with others, remember to attend to your Inner Dialogue, as well as what you are actually saying to the other person during the conflict, especially if you’re getting anxious, defensive, angry, frustrated or upset. If you write down your negative thoughts, I think you’ll find many similar distortions to the ones described above, and this can give you another handle on change the way you think, feel, and connect with the people you care about, as well as the ones you don’t! Incidentally, the belief that we are separate from others and from our environment is the essence of evil, according to some Buddhists, and perhaps nearly all of the world’s religions have had similar beliefs, though couched in different language. But what this means to me is that when we struggle with friends of loved ones, and we are locked into frustrating conflicts, we typically feel like we are “separate” from the other person who is “doing something” to us. And this perception can not only trigger anger and frustration, but sometimes even violence. As humans, we seem to have great difficulty “seeing” our own role in the conflict. And sometimes, we don’t even WANT to, because the so-called “Great Death” of the self can be very painful. This is especially true when we see ourselves as morally superior to the other person who is “bad” or “to blame.” We are indebted to Lee for giving us this superb example of a problem that nearly all human beings struggle with, and also sharing his vulnerability and humanness with all of us in such an open and generous way! And we salute and thank Lee for courageously showing us the way with an intensely personal and real example. Contact info Dr. Rhonda Barovsky practices in Walnut Creek and Berkeley, California. She can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 5 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. You can reach Dr. Burns at david@feelinggood.com. You can reach Jill Levitt, Ph.D. at jilllevitt@feelinggoodinstitute.com. She is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California (www.feelinggoodinstitute.com) You can reach Lee at bananaquitting@gmail.com Group Feedback The following are a few of the comments in the feedback at the end of the Tuesday class. These are comments from the mental health professionals who observed the session with Lee. Please describe what you specifically disliked about the training? What could have been improved? Were there some things you disagreed with or did not understand? LOVED it! NOTHING Can't think of anything I only wish that we could have more time for this work with Lee. I kept feeling like I wanted to jump in and try some of these skills myself.   Please describe what you specifically liked about the training? What was the most helpful? Were there some things you learned? I liked the externalization of resistance and would've like to see more with that or maybe even a “rules & roles” regarding patient/doctor relationships. I really liked Lee’s work. I also struggle with saying no, and I liked all of the role reversals and honest feedback from everyone involved. I found Jill's insight at the end of the session regarding the conceptualization of the problem, particularly the internal versus external solution (during the “no” practice), to be quite valuable. It was clear that Lee was facing conflicting desires - the need to act in the best interests of his clients while also seeking acceptance and approval. Taking the time to delve deeper into those internal factors may have further strengthened the effectiveness of the external solution (the “no” practice). Was helpful to see the miracle cure/goal clarified, as well as the 'acid test'. Good to see the model in action! I just enjoyed Lee's honesty , caring and professionalism. He brought up an issue that has been close to my heart as I worked with schizophrenic patients in clinic and day hospitalization settings and have experienced EXACTELY what Lee described. You feel between the devil and the deep blue sea when the medical staff conveniently toss responsibility to the less professional staff and when those in the trenches need to be there for the patients by saying NO. I LOVED David's comment about being disrespectful to patients with schizophrenia by going on and on with lofty brainy arguments while the loving thing to do is to be empathic stroking and firm. From my experience when I am real with my patients, they feel the best. Thank you, Lee, David and Jill. This was beautiful , heartwarming, and I am so touched to belong in this group. David and Jill's exquisite empathy, the Positive Reframe, and the NO practice. EVERYTHING!!! This was truly incredible! David and Jill are an unbeatable tag "TEAM!" Jill's warmth and empathy and teasing out the variables of Lee's story that were not always apparently obvious. Lee's vulnerability and seeing his depth and caring as a Psychiatrist was heartening and impressive. It helped me understand the flow of TEAM CBT and how things fit together better by seeing a live session from the beginning. I LOVED that Dr. Burns and Jill had to go down several different avenues to see what would work best. This closely reflects my own experience of therapy with my patients. Seeing them struggle a little made me feel even more sure that TEAM is the only approach that makes sense and cures people. This was a really wonderful session. I appreciate Lee volunteering, sharing with us his work challenges, and allowing us to see his kind and caring personality. I loved the masterful work of Jill and David. It seems to me that practicing responding to his patients with the use of the 5 secrets was imperative and I was amazed to see how that helped dropping down the feelings on the DML before we got to work on the Negative Thoughts. Once again, TEAM works like a charm! That this was a powerful real life issue that Lee shared. I enjoyed the empathy and how that led to sorting out conceptualization and miracle cure. David and Jill's combined efforts to go in many directions to help Lee see where he is stuck. I struggle in exactly the way Lee does in these sorts of situations, and it was so helpful and inspiring to me to see him do this work. Thank you, Lee! I was deeply moved by your deep caring for your patients and values around wanting your patients to have agency and understanding when there's so little in their world that they can control. I wish every psychiatrist had more Lee in him/her/them! I appreciate that Lee opened up himself in the group and I could observe the personal work of David and Jill, the amazing masters of TEAM-CBT. I admire Lee's compassion and warm heart toward his patients and I owed a lot to Lee who has very high standards to make things clear, just as he has done in his teaching in our Newbie group. And I think his sadness and anger might be an expression of his passion toward justice and dignity of his hospitalized patients. Appreciated Lee sharing with the group and doing personal work on a challenging problem. Liked when Jill brought up the internal versus external solution and then the session switched gears to work on the negative thoughts that made it so difficult for Lee to say no. Really enjoy the personal work, and getting to see the TEAM process unfold in skillful hands. I appreciate that you gave Lee time to explain his points, and that he was able to be truthful and disagree at times, and then you asked why and he explained further. This led to a more nuanced exploration and conceptualization of his issues and goals. I liked the focusing of a major part of the problem of "saying no" to a relationship / Five Secrets issue...resulting from internal and external shoulds. I appreciated the comparison with parent/child discipline, and not getting sucked into arguments. I also appreciate that you were able to pinpoint the problems around trying to get desperate, even schizophrenic patients, to understand one's point of view. It was great seeing the modeling of how to respond to some of these difficult patient situations. And how to clearly define the agenda when a patient is unclear about their goals. Also, so admiring of Lee. I liked how Jill and David navigated figuring out what Lee wanted to work on (when they came up with the three options). Issues that have "internal" and "external" components to them are difficult for me, and I often get confused. Seeing Jill and David work that out helps me wrap my head around how to go about it, thanks. Please describe what you learned in today’s group. I appreciate Lee's vulnerability and I have so much respect for how he cares for his patients. I appreciated seeing the multiple role-playing attempts and was bummed when we ran out of time. I have so much admiration for Lee and feel for how much he's struggling. Personal work, externalization of voices, magic dial, Daily Mood Log (DML), 5 secrets, etc. How Five Secrets and No practice fit within the DML work That they could have started on the internal work of negative thoughts or the external work of "NO practice" TEAM at it's best! I observed NO practice and would like to learn more specifically about it ... Seeing the TEAM model unfold step by step in real time is always an incredibly valuable learning experience. Hearing Jill entertain potential directions to go in (i.e. crushing negative thoughts vs. No practice.) Learning challenging scenarios in context of "NO" practice was really awesome! Just magnificent overall! THANK YOU!!! Always feel so privileged to be part of this uniquely wonderful community of like-minded professionals! We are so lucky! I don't have to be smooth and have all the right answers immediately. This process is highly collaborative. How to employ the team model especially conceptualization and role play with NO practice and Five Secrets practice. How dealing with severely mentally ill pts can be so difficult. There's a sixth secret in effective communication: the willingness to use one's power in a kindly way to give the shot and get it over with. It's so helpful to me to add this secret to my armamentarium! Positive reframing and No practice, along with Externalization of Voices and Externalization of Resistance. I learned something about Lee, and about the difficulties of psychiatric hospital work for doctors! Also, seeing the process unfold skillfully, teasing out the problem to work on, Externalization of Resistance, Positive Reframing, Externalization of Voices, No/5 Secrets Practice, etc. How to be clear on agenda setting when patients are unclear on their goals. I was reminded about how to ask about a client's goal in order to guide agenda-setting. It was nice seeing the five secrets role-play / no practice. I've been inspired to start practicing daily like David said he did. Can never get enough of that!

Featuring Dr. Matthew May In today’s podcast, Matt, Rhonda and David discuss four challenging questions from podcast fans like you: 1. what do you do with patients who use marijuana excessively but have no interest in changing or reducing their use? 2. How do you help clients control their anger? 3. How can you use TEAM if you are only allowed to see clients for 15 to 20 minutes? 4. If David never went into the medical / mental health field, what career path do you think you would have chosen? The answers on the show are live and will differ considerably from the information below, which is primarily to document the full questions that the fans submitted.   1. When a client expresses concerns in multiple areas of their life, such as mood, relationships, and habits, is there a particular hierarchy that you follow? In particular, what do you do with patients who use marijuana excessively but have no interest in changing or reducing their use? I'm particularly interested in your perspective on the hesitancy within the therapeutic community to treat individuals with co-occurring depression and anxiety, alongside marijuana habits or addictions that they do not wish to address. How do you approach and navigate this complex situation, and what are your thoughts on effectively addressing the client's mental health concerns while considering the impact of their substance use on the therapeutic process? With the increasing acceptance and use of medical and recreational marijuana, do you believe it is still morally or ethically justifiable to turn away clients who use marijuana and express no desire to quit? It appears to be a prevalent practice, and I would appreciate your insights on this matter. Casey Zeigler Matt: Great Question, Casey! For me it depends on the pattern of usage and reasons for using Marijuana. For example, if someone gets anxious and then uses marijuana to reduce their anxiety, then I'd be unable to help them treat their anxiety if they weren't willing to set marijuana aside, for a while, to practice some new methods. I might ask, 'imagine you could feel calm and relaxed, but didn't need marijuana to accomplish this. What would it be worth to you, to have that ability? For example, would you be willing to go through an uncomfortable period of deprivation and awkwardly failing at methods to reduce your anxiety, in order to get there?" David: in a Harvard study years ago, individuals with benzo addictions were randomly assigned to two withdrawal groups: Klonopin-only slow withdrawal, and Klonopin slow withdrawal plus group (I think) CBT. The success in terms of numbers of patients who successfully withdrew was far greater in the CBT group. Or, if they used Marijuana to avoid feeling depressed, I'd wonder if they would be willing to set that aside temporarily, in order to prove that they could feel great without Marijuana. My approach is to identify what the patient wants and to be realistic about the approach to achieve those results. There's also long-term data showing that daily use of marijuana is associated with worse mental health, in the long-term. David: I think these decisions have to be individualized, and consultation with a colleague when in doubt can be very helpful.2. I have a question about anger. How do you help clients control their anger? 2. How do you help clients control their anger? I was going to mention it to you as a good topic to cover anyway in a podcast, because it is the one emotion that has not particularly been dealt with in the podcast. This is ironic, since anger is apparently the one emotion we don't acknowledge!). I did a search and there were only two that touched on it and neither covered how someone can learn to control their anger. I have had several clients who talk of how they snap at their children or partners and want to learn to deal with it. Does it work to use a daily mood log in these cases, as the emotions are more like explosive reactions, and maybe less easy to defeat with distortion-free positive thoughts? Thanks Andy Perrson Matt: Thanks, Andy! I can help people overcome anger, but they probably don't want the type of help I can offer! David: individuals beta testing the Feeling Good app have shown dramatic and rapid anger reductions. In a group or individual therapy context, I would use TEAM systematically. I do not typically “throw methods” at feelings, problems, diagnoses, etc. I treat humans, finding out what’s going on in their lives, conceptualizing the problem, melting away resistance, and choosing methods based on all of that. All that being said, the CBA or Paradoxical CBA are almost always the first techniques with anyone who is angry: vignette about the angry doctor and the angry banker. 3. Do you have any tips to use TEAM skills for very short time session(about 15 to 20 minutes). I am not yet running my private practice. I am employed in other person's private clinic as a psychiatrist and usually prescribe pills and the time per patient is at most 20 minutes. Luci Eunkyoung Yang Matt and Rhonda; This would require a focus on 'homework' outside of session. Happy to discuss. David: Can empathize and refer to groups, app, books for those who want more help. 4. If David never went into the medical / mental health field, what career path do you think you would have chosen? A few guesses, a magician (I believe he referenced in a podcast an affinity for magicians), theatre (Brigadoon story - fear of heights), politician (David sometimes has an opinion on a variety of topics), lawyer (David knows all about black/white thinking, as well as being able to see things in shades of grey), scientist (creator of TEAM-CBT), writer (best selling author) or entrepreneur (what couldn't he create/sell?) Whatever the path, he would have been a leader in that field too for sure and I'm so grateful that he chose ours. Best, Todd