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

A Second Visit to David and Jill's Tuesday TEAM Training Group at Stanford Last week, you “sat in” on our Tuesday training group at Stanford and learned about two of the four most important techniques in the treatment of perfectionism, or any other Self-Defeating Belief. (For a list of 23 common Self-Defeating Beliefs, click here.) The Cost-Benefit Analysis (CBA): You weight the advantages against the disadvantages of trying to be perfect. The Semantic Technique, to find out how to word your new belief if you decide that your perfectionism belief isn’t working for you The purpose of those two techniques is to provide intellectual change. Tonight, you will join us again as we aim for emotional change at the gut level. This will be our agenda for the students in the class you will observe: 1. Please describe an example of a specific time when you felt upset due to perfectionism. What were your negative thoughts? How were you feeling? What was happening? 2. Downward Arrow Technique: Suppose you weren’t perfect, or you failed or screwed up in some way. Why would that be upsetting to you? What would that mean to you. 3. Externalization of Voices (Optional: possibly we will do this, maybe just mention it, depending on time.) 4. Experimental Technique / Examine the Evidence 5. Feared Fantasy 6. Wrap-up and Teaching Points As you can see, some exercises will be performed in the large group, with everyone present and contributing, and some exercises will be in the small, breakout groups. The small groups provide more time for participants to practice. We plan on recording both of the small groups so you can observe the training techniques we use for mental health professionals. Last week our focus was motivational, so we asked: is to your advantage to aim for perfection? How will this mind set help you and how will it hurt you? Tonight, one of the key techniques will focus on TRUTH: is it TRUE that you need to aim for perfection? We will be using the Experimental Technique and / or Examine the Evidence to see if we can answer this question. In addition, we will go into an Alice-in-Wonderland Nightmare World and meet an imaginary monster who claims superiority because she or he really is perfect and really has achieved incredibly more than anyone. This can sometimes help us answer two questions: Is it possible to be or become a “more worthwhile” or “superior” human being? Would it be desirable if you could? I hope you enjoyed this new format of “dropping in” on my Tuesday training group at Stanford. Let Rhonda and me know what you think. It was just an experiment, and we want to know what you might have liked or disliked about it. Thanks! Our free weekly Tuesday and Wednesday training groups are open to therapists of all persuasions from all around the world. For information including the requirements, you can contact: Tuesday night training group with David and Jill, Contact Ed Walton: EdWalton100@gmail.com Wednesday mid-day group with Dr. Rhonda Barovsky and Richard Lam, Contact Ana Teresa Silva:  ateresasilva6@gmail.com

Tuesday TEAM Training Group at Stanford In 1980 I published an article entitled "The Perfectionist's Script for Self-Defeat" in Psychology Today Magazine, in an attempt to get some publicity for my (then) new book, Feeling Good. At the time, it was the cover feature and became the most popular article in the history of that magazine. Perfectionism is definitely one of the most common themes I have confronted in my clinical work and teaching over the past many decades. If you would like to take a look, you can check it out at this link. They had fantastic colorful illustrations, including a bleeding dart board wtih a dart in the bullseye, and sadly you'll only get the text in black an white at the link. It seems that almost everyone succumbs to this mindset from time to time, and it can cause many negative moods. But at the same time, the attempt to be perfect brings many benefits at the same time. This can be a dilemma. The next several podcasts will be based on a two-week perfectionism class I developed for the weekly Stanford TEAM-CBT training group that I direct along with my esteemed colleague, Dr. Jill Levitt. This podcast class is suitable for therapists and non-therapists alike. These podcasts will give you the opportunity to “attend” the group and witness the procedures we use to train therapists. You will have the opportunity to practice the same techniques the students will practice when we break into small groups. I would encourage you to turn off your podcast temporarily so you can practice the exact same techniques on your own when we break into small groups for practice. For example, in the first class you are about to hear, we will spend 20 minutes doing a Cost-Benefit Analysis for perfectionism. You will find a blank CBA if you click HERE. I would encourage you to practice the same thing for 20 minutes during each practice group. During the first breakout group, you can spend 20 minutes listing the advantages and disadvantages or perfectionism. Ask yourself, “how might this mindset help me? And how might it hurt me?” You can use this blank CBA. After listing the advantages and disadvantages, weigh them against each other on a 100-point scale, and put two numbers adding up to 100 in the two circles at the bottom. For example, if the advantages are greater, you might put 75 and 25 in the two circles. If they are about equal, you can put 50 and 50. And if the disadvantages are somewhat stronger, you might put 40 and 60 in the circles. Remember, it’s not the number of items in the columns, but how you feel about them overall. Sometimes, one powerful advantage might feel much more important than the five disadvantages, and sometimes one powerful disadvantage might feel more important than numerous advantages. Part of the fun (hopefully) of this podcast is that you’ll get to hear the questions and suggestions of many of the 45 or so students in the class that night. As you will hear, we have a multi-cultural rainbow group with therapists from around the world. We started Part 1 of the Perfectionism Master Class with these important two questions: What is perfectionism? How would you define it? What is the difference between perfectionism and the healthy pursuit of excellence? Then we went on to the Cost-Benefit Analysis (CBA) in small groups. I forgot to record my small group, but you will hear a long list of advantages and disadvantages discussed when the large group reconvenes. As I mentioned about, I would encourage you to do your own CBA while we are in the small group. When we reconvened in the large group, we talked about the therapeutic strategies you would use once the patient has balanced the advantages against the disadvantages of perfectionism, including Sitting with Open Hands with patients who are reluctant to give up their perfectionism. I also discussed my strategy of aiming for “average” or even “below average,” as opposed to perfection. As I’ve aged, I’ve actually lowered my standards so low that everything looks pretty awesome to me! And my productivity, as well as the quality of my work, has actually improved greatly as a result. This paradoxical strategy may seem foolish to many devoted perfectionists at first, but it has proven exceedingly powerful and helpful in my life since I screw up so often! Seeing failures and mistakes as opportunities to learn and grow, rather than signs of failure or inadequacy, has been huge for me. Joy seems to spark my creativity and productivity way better than feelings of shame and anxiety. After the CBA exercise, we used the Semantic Technique to revise the perfectionistic belief, like, “I should always try to be perfect,” or “My worthwhileness as a human being depends on my performance (or achievements, etc.). The goal, as you will see, is to reword the belief with this goal in mind: Your new belief can reduce or eliminate most or all of the disadvantages or perfectionism while preserving most or all of the advantages. We DID record Jill’s small group, so you can hear her students working on the Semantic Revision of their perfectionistic belief, but I would strongly recommend that you turn off your podcast and see if you can revise your own perfectionistic belief while we are doing our small group work. Again, this was a 20-minute exercise. I am attaching some of the feedback from the first Tuesday group on perfectionism, Part 1. Next week, you’ll hear Part 2 of the Master Class on Perfectionism. If you are a therapist, you might want to join one of our weekly training groups. The group I conduct with Dr. Jill Levitt is the Tuesday group, and we meet from 5 to 7:30 (PST) on Tuesdays. In addition, Dr. Rhonda Barovsky and Richard Lam have a Wednesday training group that meets from blank to blank PST. Both groups involve an introductory 12-week curriculum for individuals who are not familiar with TEAM-CBT. After that, you may join the advanced group, learning with 40 to 50 colleagues every week. Both groups are free, but you will be required to: Sign the consent form for group membership and agree to the terms on it. Purchase the required course materials, including my psychotherapy eBook, Tools, Not Schools, of Therapy. Purchase the Therapist’s Toolkit and use the assessment instruments with every patient / client at every session. These tools are for sale in the shop at feelinggood.com, and discounts are available for therapists who want but cannot afford the tools. Practice during sessions using role-playing techniques and receive immediate specific feedback on what you did effectively and ineffectively so as to refine your skills. Do homework and use the techniques with your patients between sessions. Attend at least ¾ of the training groups. These are NOT drop-in groups. The free weekly training is available to licensed health / mental health professionals as well as graduate students in mental health who are studying to become psychiatrists, psychologists, counselors, clinical social workers, and so forth. TEAM-CBT is immensely powerful and looks easy, but it’s not. A great deal of commitment, time, and training is always needed to develop expertise. Many of our group members have continued with the group for many years, and we encourage that. Part of the training involves live personal work, which is recommended but not required. Jill and I believe that doing your own personal work is vitally important on the road to world class therapy skills. As you probably know, Rhonda and I publish many of those sessions as two-part podcasts, but only with the permission of the participants who are in the “patient” role on one of the evenings when we do personal work. Probably 15% or 20% of the sessions feature personal work with members who volunteer and ask for help. Social anxiety and feelings that “I’m not good enough” as well as relationship problems are popular themes for the individuals doing personal work on any given night. The personal work does not involve the development of an actual therapeutic relationship. It is simply a one-session, 3.5 hour experience in front of the group which is part of your personal development, so you can experience the TEAM-CBT in action in real time. If you have loose ends or unresolved issues at the end of your session, you can continue working on them with your own therapist. Dr. Levitt and I will not be involved in the development of an ongoing therapeutic relationship with you. The focus of the class is training, not treatment. After each class, members provide negative and positive feedback. The following are selected excerpts from tonight’s group, with light editing to improve readability. I think you will enjoy reviewing the feedback, especially if you are thinking of joining one of our training groups. The feedback is used to improve the teaching methods. Contact Information: If you want to join David and Jill's Tuesday group, that meets from 5:00-7:00 pm PST, please contact Ed Walton: edwalton100@gmail.com If you want to join Rhonda and Richard Lam's Wednesday group, that meets from 9:00-11:00 am PST, please contact Ana Teresa Sliva: ateresasilva6@gmail.com Thank you for listening, David, Jill and Rhonda

Six Cool Ask David Questions from Carlos and Greg Carlos asks: 1. Are your tools available in Spanish? 2. Is there any evidence that TEAM can help patients with Borderline Personality Disorder (BPD)? 3. How do you get patients with BDP to stop jumping from problem to problem? 4. How do you get them to stop endless venting during therapy sessions? Greg asks: 5. What comes first, thoughts or feelings? 6. Can't a genuinely negative or tragic event directly cause negative feelings, without having to have negative thoughts?   Dear Dr. Burns: 1. I would like to use your BMS but I mostly work with patients in Mexico. Has there been any standardization of your tests in any Spanish speaking country? David and Rhonda address this.  You can email Victoria Chicural, who is one of the TEAM-CBT leaders in Mexico (along with Silvina Carla Bucci), at victoriachl@yahoo.com and ask her about access to TEAM-CBT forms that have been translated into Spanish. 2. I am wondering if TEAM has proven to be effective in the treatment of BPD (Borderline Personality Disorder). I use it a lot, but I have found quite a few challenging elements. David describes his published work, indicating an excellent response to TEAM-CBT in patients with BPD. 3. People suffering from BPD usually have trouble prioritizing tasks and activities. The same happens when it comes to setting objectives. Because of their emotion dysregulation, they usually decide to work on one objective, and later on, they sometimes say: "Well, this objective is not THAT important anymore. Let's do another." For them, doing the specificity part can be really challenging because their perspective changes very quickly and they usually go back to the former objective when they're being challenged by a similar situation!!! How do you get them to prioritize objectives and not to switch from one to another so quickly? Or, do you think I could be making a mistake when setting objectives? David describes the strategies he has developed for coping with this type of clinical problem, including the development of his Concept of Self-Help Memo that he required every new patient to fill out prior to their first therapy session. 4. BPD usually come up with a lot of material to the session. They may be facing complex PTSD but also dysfunctionality at work, at school, etc. They want to say everything in a single session even if we have agreed to follow one single objective. Many sessions turn into endless talking without getting anywhere - some of them argue they need to vent out what they feel - but as time goes by, they complain that therapy is not working! How do you deal with a patient who is overwhelmed with numerous factors in a session where you have a previously set objective? David describes the strategies he has developed for coping with this type of clinical problem, Carlos S Bouchanm, Clinical Psychologist David’s Response Hi Carlos, I think these would make for excellent Ask David podcast questions. If so, can we use your name and read your questions? I reported on the effectiveness of the forerunner of TEAM in the treatment of BPD is the Journal of Clinical and Consulting Psychology in the 1990s. TEAM was specifically developed for this population, since 28% of my patients in Philadelphia had BPD. In the live podcast, I will address the excellent questions you asked about treating individuals with BPD. Thanks! David From: Greg Hi David, Thanks for everything you do and for the great podcast! I have another couple questions possibly for the “Ask David” segment of the podcast. 5. Can you say some more about automatic thoughts? CBT is based on the idea that we’re thinking things that produce feelings, but with an automatic thought it just kind of pops up and is there. It’s not like actively, intentionally thinking it. Other schools of thought (for example Somatic Experiencing) posit that feelings from the nervous system occur first and that the thoughts are actually the product of that, which seems to run counter to the CBT view. This has been a little challenging and confusing. David and Rhonda discuss this, including new research on the causal links between emotions and thoughts. 6. How do you apply TEAM CBT to worries about real and true things, like a real diagnosis or a tragic event? It would seem that it’s not just one’s thoughts about it, but an actual threat or upsetting event causing feelings because that is simply how one would feel about. Maybe the thinking is accurate? This, too, has been particularly challenging and confusing, so I’d love to hear more on this. David and Rhonda discuss how thoughts trigger all of your feelings, even after a genuinely tragic event. Thank You, Greg L. David’s Response Thanks, Gary. These are great questions, and perhaps we can address them om an Ask David podcast! There are strong, clear answers that might be interesting or helpful, as nearly everyone has these questions! Best, david Thanks for joining us today! Rhonda, and David

A British Family Doctor on Burnout, Recovery and T.E.A.M in 10 Minute Consultations! Today, Rhonda and David interview Dr. Tom Gedman, a family doctor in England and one of the founders of TEAM-UK, along with Dr. Peter Spurrier who has also been a guest on a Feeling Good Podcast. Rhonda started the podcast with a kind email from an enthusiastic podcast fan who loved our podcasts with Dr. Mark Noble (#167 and #265) on the “Brainology” of TEAM-CBT. He said these podcasts were “pure gold” and appreciated a look behind the curtains to see how TEAM actually worked at the level of the brain. Tom described his burn out episodes, which started during his third year of medical school, resulting from a familiar theme—the belief that he was inferior and just not “good enough.” His inferiority complex was a severe, total body experience, with “horrible thoughts” for six months. After he recovered, he worried about going into that state again. And the stress returned again during his medical internship. He explained that as a General Practitioner (GP) in the British medical system, you only have ten minutes for each patient, and felt like all the pressure was on him to get it right, and stated that “the pressure broke me.” In Britain, you can get free therapy as a GP, and went to Dr. Peter Spurrier for help. Peter was using the TEAM-CBT he’d learned when he came to California the previous summer for one of David’s four-day intensives, and Tom described him as “a natural. We made a deep connection right away and the Positive Reframing really clicked!” Tom’s negative thoughts included: 1. I’m not good enough. 2. I’ll fail my patients. 3. I’ll do them harm. 4. I’m not smart enough. 5. I’ll never be normal. He explained that the last thought triggered feelings of hopelessness, which really was the worst emotion of all. He discovered the Feeling Good Podcasts and listened to about 200 of them in just two weeks! And after two or three hour-long sessions with Peter, he recovered and actually felt like he was on a “high” for about six months. He says, “I had almost limitless confidence!” Then he had an as-predicted relapse which disappeared after a 30-minute tune-up with Peter. Tom said that the he’d always admired Carl Rogers, who emphasized empathy, and began using the Five Secrets of Effective Communication in his medical practice. This helped him clinically, and he discovered that “you don’t always have to ‘help;’ skillful listening is often enough. For example, patients often have to wait for months to be seen medically, and they’re angry and frustrated at first. I acknowledge their frustration and let them know that I feel sad as well. This calms them down immediately.” He also gave an example of how trying to “help” a man with agoraphobia simply put the man into a state of rage. “I tried to convince him that exposure would be good for him, but we just got into an argument, and he threatened to report me to the authorities to have my medical license revoked! That experience taught me something really important about ‘helping.’ Many people have intense resistance and just want to be heard and understood.” For example, one of his patients was in tears because of her father’s Parkinson’s Disease. The patients was helped greatly by learning He that her emotional distress was actually her love for her father, and she suddenly felt proud of her “symptoms.” Another patient with a massive opiate addiction opened up about a severely disturbing childhood incident he’d never before talked about, and then was able to cut his opiate use “way down.” We also discussed Tom’s new plans for his medical practice, working with indigent individuals, and explored the possibility of testing my Feeling Good App with this population for free to see how they would take to it. He discovered that a group in England has “stolen” my names, and also have a “Feeling Good App” and a “Feeling Good Podcast,” which causes me considerable distress. We may have to rename our app the “Real Feeling Good App,” or some such name! Dr. Tom can be reached at BlueprintMedical.co.UK or at DrTomGedman.com. Tom, Rhonda, and I would also like to urge any listeners in or near England to attend the upcoming four day TEAM-CBT intensive in England from August 14 – 17th. This four day training conference will be awesome and only costs 440 pounds. Participants will receive 38 CPD points as well as credits in the TEAM-CBT certification program. For more information about the conference, go to www.TEAMCBT.UK. Thanks for listening! Rhonda, Tom, and David

Live Therapy with Veena: Part 3 of 3 Relapse Prevention Training In the last two weeks, you heard Parts 1 and 2 of our live work with Veena, a young woman who felt devastated for fear she would be unable to conceive. One week after the work with Veena, I received a request from colleagues to have a Tuesday evening session at Stanford on Relapse Prevention Training (RPT). Jill and I decided to demonstrate the RPT techniques with Veena so we could demonstrate this technique in real time with a real situation. Prior to the role play demonstrations that you will hear, I presented the highlights of RPT with four PowerPoint slides. Here are the guidelines when working with a patient who is depressed: 1. Do RPT immediately when the patient has recovered, and before you discharge the patient. This means that the patient’s scores on the Brief Mood Survey will be low and the patient is feeling terrific. If the patient’s scores are still elevated, they have still not recovered completely, and need more therapy work. 2, Inform the patient that the likelihood of relapse is 100%. Relapse is defined as one minute or more of feeling upset. By that definition, most of us relapse frequently, perhaps every day. However, these relapses do not have to be a problem if you anticipate them and know how to deal with them. 3. When they relapse, they will typically experience two kinds of negative thoughts. First, the negative thoughts that had previously will return. So, in Veena’s case, she will again be probably telling herself that “I cannot be happy without a kid,” “my in-laws will judge me and sideline me,” and so forth. Veena imagined having a relapse and prepared a Daily Mood Log prior to the training group. If you would like, you can review it here. 4. In addition, nearly everyone who relapses will have thoughts like these: This relapse proves that the therapy did not work. I’m a failure. I’m a hopeless case and I’ll be depressed forever. When I thought I’d recovered I was just fooling myself. I’ve been he same worthless person the whole time. My recovery was just a fluke. It’s crucial to challenge these thoughts with the Externalization of Voices technique ahead of time, BEFORE the patient relapses. That’s because they can easily see the many distortions in these thoughts when they’re in a good mood. But if you don’t do RPT, and wait until the patient relapses, the patient may be devastated, or even suicidal, and you, the therapist, will have lost much or all of your credibility. In contrast, when I prepare the patient for relapse, I tell them that their first relapse will actually be a GOOD thing, because when they pull out of the relapse, then they’ll know for sure that they have the tools they need to defeat their negative thoughts whenever they’re upset for the rest of their life. And that is the crucial difference between FEELING better, which is what happens the first time they recover, and GETTTING better, which is what happens when they recover from their first relapse. I had them record their role-playing with me defeating their relapse thoughts with Externalization of Voices, and tell them to listen to that recording whenever they relapse. And that if they can’t pull out of the relapse on their own, they can always come back for a session or two for a tune-up. I also tell my patients I hope they will relapse often, because if they don’t ever relapse, I won’t ever see them again, and this is a sad thought since I’ve just gotten to know them and really like them. When I was in clinical practice, relapses were rare. Only a handful of patients ever returned for a tune-up, and it was almost always one or two sessions and then they were on their way again. Of course, this was not a controlled outcome study, since I was in private practice, but  it was definitely encouraging. In summary, RPT can save you from a lot of grief when your patients relapse, and it may even save the lives of some of them. It doesn’t take long, 30 minutes or so at most, but the payoffs can be tremendous. Thank you for listening today! Veena, Rhonda, Jill, and David

Live Therapy with Veena: Part 2 of 3 Last week you heard the first half of the session with Veena, a young woman who was devastated by a medical problem that may make it difficult or impossible to conceive the child she is dreaming of. Today, you will hear the inspiring and dramatic conclusion of her story, along with the feedback comments from the individuals in David and Jill's Tuesday training group who witnessed the live work. A = Assessment of Resistance Jill asked if she felt ready to roll up her sleeves and get to work on some aspect of what she’d been telling us, and she was. Jill then asked what she was hoping to get from tonight’s session. If we could offer a “Miracle Cure,” what would that look like? She said, “I’d feel a lot less guilty and responsible, so I would no longer feel like the problem was my fault. I’d know that I did my best and that I can be okay even if people don’t like me or judge me. Jill asked the Magic Button question, and she said that she love to see her guilt go all the way to zero, but not her many other negative feelings, like depression, anxiety, inadequacy, self-consciousness, hopelessness, upset, insecurity and self-doubt. With Positive Reframing in mind, we listed many of the positives in these negative feelings, including: Sadness. This feeling shows that I care for people and want to give them the best. It shows that I also care for my own dreams of having a baby. And it shows how much I love my mother. Anxiety, worry. This is a warning signal, reminding me to be alert and do my best, and do what the doctors require. Guilt. Shows that I’m humble and willing to be accountable and examine what I’ve done and look at my own mistakes. Self-Consciousness. Protects me by making me cautious so I don’t just blurt out everything. Defectiveness. I see my flaws, and allows me to get closer to others, and to feel happy for the success of others. Hopelessness. When I told my husband I felt hopeless, he became SO supportive. Also, I gave myself some space so I could create an action plan. You can see the goals Veena set for each emotion on her Daily Mood Log if you click HERE. Veena with her in-laws M = Methods During the methods phase of the session, we used a variety of techniques, especially Externalization of Voices with the Acceptance Paradox, Self-Defense, and the CAT (Counterattack Technique.) We did quite a few role-reversals, which is typical, before Veena got to wins that were “huge.” There were lots of tears and laughter, and eventually Veena blew all of her negative thoughts out of the water. It was inspiring to observe this process, and to be a part of it. You can see her final Daily Mood Log if you click HERE. I think it is fair to say the Veena experienced a kind of enlightenment which was profound. Final T = Testing You can see Veena’s end-of-session Brief Mood Survey and Evaluation of Therapy Session if you click HERE. You can also see her final Daily Mood LOG if you click here. Our work with Veena was some of the most inspiring work that I can recall. It was tremendously mood-uplifting, and took on a spiritual quality. You will have to listen to the session to get a feel for how majestic it was. But in my opinion, Veena did not just recover, but she achieved enlightenment, which including discovering how to love herself and her extended family as well! The following is an email I sent Veena the next morning: Hi Veena, Thanks. You were totally awesome last night, thanks so much for your contribution. I am sure the podcast will reach huge numbers of people and make a big impact on peoples’ lives. I cannot remember a more exciting and loving session. We will see what the groups thinks in the feedback. I did not copy or read the chats during the session, but perhaps you or Jill did. . . We will invite you to join us on a podcast recording to get some follow-up information from you, as folks will be very interested, for the two-part podcast. Yes, I think we really were walking on holy ground last night! Thanks so much for making that happen! I am trying to recall (and will do more of this) the teaching points from last night, and a few seem important to me. They seem awfully basic and simple, but still of towering importance and have to be “seen” to be understood at a deep level. 1. In TEAM, even when a problem is “real,” it is still our thoughts that create our emotions. Our thoughts really DO create all of our feelings. 2. Those thoughts can be subtly distorted in all kinds of ways and seem determined to trick us into believing things that are not true. And even super smart people, like Veena, can be fooled. 3. We are not aiming for improvement, although that is obviously desirable, but a dramatic transformation of the human spirit and outlook. 4. Warmth, tenderness, and compassion—for others and for yourself--are important and powerful. 5. There is a strong mind-body connection, and healing your soul can often help to heal your body. 6. Good therapy can sometimes be much more than just “therapy.” Something almost magical can sometimes happen, and the change can sometimes happen rapidly. However, many people do not like hearing this, and some are even angered by this idea! This is especially true of people who have suffered and struggled for many years without success in changing the way they think and feel. 7. Recovery sometimes requires courage and trust. Just more babbling from the old guy! Apologies if it sounds ridiculous or “off.” If other teaching points come to mind, please let us know so I can add them to the list! I am betting that Jill and Veena can maybe add to this list! (and edit it as well) Warmly, david Below, you will find some excepts from the feedback that the participants provided after the session. 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?  Nothing. It was beautiful. I wouldn't want to change anything about tonight's experience. It was so moving! Please describe what you specifically liked about the training? What was the most helpful? Were there some things you learned? I loved Veena's personal work and besides my admiration and pride of her and the gratefulness to David and Jill for sharing this wonderful work . . . I enjoy the empathy and validation as well as the trust in the process that was so beautifully demonstrated. Beautiful job by all concerned. Very impressed with Veena and how clearly she "got it" when she used the CAT (Counterattack Technique). I was very moved by Veena's story and her courage in sharing it with us. I felt as if we were witnessing a kind of history because, in the past, wives who couldn't bear children were often devalued and even rejected. Veena pushed back against that kind of thinking and instead chose to love herself. By working toward dispelling the distorted thoughts, she affirmed not only herself, but women with similar experiences now and throughout history. When she affirmed that her mother, mother-in-law, and husband would be empathetic and wouldn't actually reject her, I felt elated, thinking that the world is making progress and becoming a more compassionate place. I was also touched by the following ideas: feeling genuine sadness without distortions; locating the source of pain in distorted self-critical thoughts; painful experiences bringing loved ones closer together. The safe space that was created, the sensitivity with which the topic was handled and the respect accorded to the client. It’s incredible how the trainers (Dr. Burns & Jill), set aside their ailments, and were with Veena through her journey of anticipatory loss, and her fears and apprehensions, along with her inner battle of dealing with deeply entrenched social conditionings, that are hard to face and ward off. I loved the session. Enjoyed watching the whole team model unfold. I’m so grateful to Veena for sharing this previous part of her life with all of us. It was a huge honor. I am constantly surprised by Dr Burns’ and Jill’s mastery of TEAM and their deep empathy skills. This was moving and exhilarating…all at once. Observing two great therapists in action. I liked how Jill and David would make notes to the class about what step they were going on to next. Veena was so amazing and brave to share her experience. As a 23 year old woman with fears of fertility issues myself due to genetics, I found the experience extremely profound and impactful on a personal level. It was awesome to go from the NEWBIE group to this session whereby a lot of the skills we were learning individually were incorporated sequentially into the session. Thank you to everyone!! I liked seeing david and jill go through the entire team model. I liked the pointing out of the Emotional Reasoning distortion and even using the straight forward technique. Excellent! I really liked seeing an entire session completed in one sitting. A very beautiful night. I really felt for Veena and what she is going through, and it was great to see her recovery. David and Jill were empathic and so knowledgeable. The humor in dark moments. the tears from time to time It was exciting to see how as Veena shed the self-blame, simultaneously she was able to see the people in her life as the caring, kind people she knows them to be--and no longer to feel afraid that they would reject her. Accepting herself allowed her to see others as accepting, and not critical. What training could be better than watching David and Jill tag TEAM thru the model! Thanks to Veena's willingness to be vulnerable and her bravery doing this personal work and inviting us all into her world and her pain. It felt like we were all a web of love and support surrounding her and a privilege to get to know her. It was extraordinarily rich and illuminating. I loved everything: the incredible empathy Jill and David demonstrated and how things were turned around for Veena. I was amazed that this was accomplished in such a short period of time; I always am when it comes to live work! I also loved knowing Veena more and seeing how wonderful of a person she is; I have so much admiration for her!!! Incredible empathy and 5 secrets from both Jill & David! So much warmth and love from the group. Seamless incorporation of the steps & methods. Please describe what you learned in today’s group15 responses DML at it's best!!!! TEAM-CBT, done by skillful therapists, with open and vulnerable client, can be such a gift! I learned again how to go through the entire team-CBT process of crushing negative thoughts and helping clients to feel better. There were so many moments of subtle shifts by Jill. Each one of them were penny drop moments for me. . . Thank you both. That people have a lot of beautiful qualities. I felt I learnt anew the power of empathy and the importance of asking our clients specifically what caused the change. Thank you so much Veena. I got some therapy by proxy tonight. I felt myself take a kind of journey with you from fearful for you, and judgmental (of your aunties!) to warm and open and loving - by witnessing your transformation. A better understanding and appreciation of the entire team model and using that for a real life situation. More of the artfulness and symphony of the steps being followed with empathy being woven again and again throughout and bringing out the birth of what is really true about the self, mother, mother-in-law, and husband rather than the assumptions and self-deprecation. On how to get from T to M with E and A in the middle! I loved David's insight that this is what it means to be in a loving relationship--to hurt at times. So wonderful to get to watch Jill move through TEAM in her warm, empathic, brilliantly thoughtful way, with David interweaving his work of genius!!! So grateful to be part of this incredible community! Thanks so much! The importance of Thought Empathy and flexibility with using different techniques, as I tend to be quite rigid. For example, I love how David went right into EOV which I believe would work wonderfully with someone who knows TEAM well. It definitely did work for Veena. So very helpful to see TEAM in action in its entirety by the masters of TEAM CBT! Thank you for listening today! Veena, Rhonda, Jill, and David

Live Therapy with Veena “It's all my fault!” The star of today’s 2-part podcast is Veena Mulchandani, a 28-year old certified Indian TEAM therapist who has just learned that her difficulties becoming pregnant result from an infection in one of her fallopian tubes. Veen feels devastated and fears that she might never be able to have a child. She also fears that her husband and extended family will judge and reject her, since there is so much pressure in Indian culture for women to have babies. And although she has many medical options, including IVF, she is intensely fearful that they might not be successful. My beloved colleague, Dr. Jill Levitt, will be my co-therapist for today’s session. Jill is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California (www.feelinggoodinstittute.com). Today you will hear part 1 (T = Testing and E = Empathy), and next week you will hear the exciting conclusion (A = Assessment of Resistance and M = Methods), along with some follow-up. Part 3 will be the Relapse Prevention Training we did one week after treating Veena. Jill and I treated Veena in our Tuesday evening training group at Stanford. We feel that personal work is an essential part of the training of any therapist. Veena with her two very beloved nephews who she considers being a mother to T = Testing and E = Empathy At the start of the session, we reviewed Veena's Brief Mood Survey just prior to the start of the session. You can review it if you click on it here. Veena was tearful and said that to make matters worse, her mother has been recently diagnosed with brain cancer, and although she is doing “okay,” she is not doing “great.” Veena explained that she has always dreamed of being a mother, and feels like she is lettinhttps://feelinggood.com/wp-content/uploads/2023/04/01-BMS-wt-ETS_veena-1.pdfg down the many people who love her and want to see her have a baby. She and her husband first talked about having children when Veena was 24, but they decided to defer that for a few years because of the intense demands of her graduate schooling. Now Veena is blaming herself, thinking she “should” have gotten pregnant when she was 24. I mentioned to Veena that my parents tried but were unable to create a pregnancy, so they finally adopted 3 children. Then I came along unexpectedly, after they had given up. I also said that I’ve treated many women who felt like they couldn’t become pregnant, who then became pregnant. You can listen to the dramatic podcasts featuring my session with Daisy and her husband, Zane (#79 and #80) as well as podcasts 268 and 269 featuring a session with Carly (Click here for list of podcasts with links). Both women became pregnant shortly after those sessions, and I hope we can do the same for Veena! However, the key is overcoming the tremendous despair, shame, anxiety, and disappointment that the woman feels, so that the body can heal and prepare for the pregnancy. You can see Veenas partially completed Daily Mood Log if you click here. As you can see, her negative feelings are extreme, and she is telling herself that I may never be a mother. I will ruin Sumit’s (her husband’s) life with her. My marriage may go “down the line” because of the absence of a kid. It’s all my fault for postponing the pregnancy when I was 24. My in-laws, who love me so much, may start ignoring me because I cannot give them an heir. I will always be looked down on and sidelined by my own people. My mother is ill, and I will not be a good daughter if I cannot give her a grandchild. There is no meaning to life without children. My own body cannot suffice for my baby. Her belief in these thoughts ranged from 60 to 80 or more, and she rated most at 100%. Veena with parents I asked Veena how she was feeling after opening up in front of so many colleagues in the Tuesday group. She said she felt sensitive and exposed, and was afraid they don’t understand and will also judge her for not starting earlier with attempts to become pregnant. Although we were still in the Empathy phase of the session, I suggested she might want to do an experiment to find out how they were feeling. Although this idea made her anxious, she asked quite a number of the Tuesday group members how they felt, and received an outpour of warmth, love, tenderness, and support. We asked Veena how we were doing in terms of Empathy. Did we understand how she was thinking? How she was feeling inside? And did she feel accepted. She gave us an A+, and so we were ready to move on to the A = Assessment of Resistance, which you will hear at the start of next week’s podcast. Thank you for listening today! Veena, Rhonda, Jill, and David

Making Space for Grief Featuring Thai-An Truong, LPC, LADC Today, we feature a popular podcast guest, Thai-An Truong who joins us from Oklahoma. Thai-An is a level 5 Certified TEAM therapist and trainer who specializes in post-partum problems as well as anxiety disorders, with a special focus on OCD. Today Thai-An describes a TEAM-CBT technique to help with grief. She believes that empathy is always crucial, and emphasizes that people who have lost a loved one need to be encouraged to express and accept their feelings and to make space for their grief. However, because empathy alone may not be enough, it is often helpful to go beyond empathy and offer specialized techniques to help the patient deal with feelings of grief and loss. In her work specializing in women struggling with post-partum depression, she has seen many women grieving over a loss—such as the loss of a pregnancy, or the loss of a parent when their child is young, or the loss of an infant at birth, or during the first couple months after delivery. She said that the entire TEAM model can be invaluable, including the initial Testing and Empathy, the Daily Mood Log to detect the grieving patient’s (often distorted) negative thoughts, as well as the Assessment of Resistance (the positive reframing step, and the Methods. Healthy grief is often complicated by feelings such as depression, guilt, anger, and more. These feelings can complicate and get in the way of healthy grieving. For example, Rhonda treated a woman who was struggling with guilt over the death of her son, who was in great pain because of advanced, metastatic cancer. At one point, she told him that it was okay to “let go,” and her son died shortly after that. But then, she felt guilty and blamed herself for his death, thinking he might have lived several more days if she had not said that. Thai-An said that losing a son or daughter is one of the greatest pains a parent can have. You may beat up on yourself with “I should have done X” or “I shouldn’t have said or done Y.” But these negative, self-critical thoughts and feelings will nearly always be expressions of your core values as a human being, and your love for the child you lost. This can sometimes be eye-opening, and a relief for the person who is grieving. Thai-An has struggled with grief. She told us about the loss of one of her best friends 16 years ago. He was like a brother, a young man with bipolar manic-depressive illness. At times during manic episodes, he would get high and go out “teaching” on the streets. During one of these episodes something tragic happened—Thai-An was unable to find out what—but her friend was found dead in an alley. Thai-An felt a profound sadness and regret, and to compound the problem, her friend’s mother cut ties with Thai-An, who didn’t even know if a funeral was held or was able to ask any questions about what happened to him.. Thai-An felt understandably hurt and angry,. She recently found out he was buried near a Buddhist Temple in Houston, Texas. She emphasized the value of maintaining a ritual with the person who has died so as to continue the relationship. For example, a woman had a beautiful baby boy who died of an overwhelming infection shortly after he was born. This woman loves nature, and thinks of her son whenever she gardens. For example, when she sees a little bird, she thinks, “that little bird looks just like him!” Thai-An feels that a wide variety of rituals can nurture the bond with the person who died. You might light a candle, or even bake a cake for the baby or person you have lost. The goal is not to achieve some kind of “closure” that is so often emphasized in the media, but rather to continue a positive and meaningful relationship with the person you have lost. Thai-An illustrated a therapeutic technique she calls the Grief Method that involves doing a role-play with the person who has died. The therapist first gathers messages that the grieving patient would like to share with their deceased loved one. The therapist then takes on the role of the patient as the patient takes on the role of the person who has diedThis gives the patient the chance to have a conversation with the love one they have lost. In the following role play, Rhonda played the role of Sam, the young man who died of overwhelming cancer, and Thai-An played the role of his mother, who was grieving and feeling guilty about her son’s tragic death. Thai-An (as Mother): Hi Sam, I really miss you every single day. Rhonda (as Sam): Hi Mom, you’re the person I miss the most. Thai-An (as Mother): I’m sorry we had an argument shortly before you died. Rhonda (as Sam): It’s no big deal. . . We got into little fights pretty often. . . but we always got over it. Thai-An (as Mother): I regret that I left when the doctor told me to leave the room. I should have stayed, so I could be with you when you died. Rhonda (as Sam): I understood that they pushed you to leave the room, and I know that you would have stayed if they’d let you. . . I was in a lot of pain, and I was ready to leave. You gave me a lot of reassurance. Now I’m with grandma. Thai-An (as Mother): I would have done everything for you. Rhonda and Thai-An processed the experience together, and they both cried, even though it was only a role play. Thai-An emphasized the importance of letting your negative feelings flow, and continuing your bond with the person or beloved pet you have lost. For parents who have suffered the loss of a child, Thai-An recommends the book Shattered: Surviving the Loss of a Child by Gary Roe. To access her free grief training for therapists, you can visit courses.teamcbttraining.com/grief. This summer, Thai-An will be offering a special 14-week training course (2 hours / week) which will focus on treating individuals and couples with relationship problems using TEAM. For more information on this and other TEAM training courses, go to courses.teamcbttraining.com. . Thank you for tuning in today! Rhonda, Thai-An, and David