031: Live Session (Mark) — Agenda Setting Phase (Part 3)

Part 3—A = Paradoxical Agenda Setting (PAS), Initial Segment

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In the early days of my career, I (Dr. Burns) would have assumed that Mark definitely wanted to change–after all, he’d been in a lot of pain for a long time, and he came to the session because he wanted help. So, following the empathy phase of the session, I would have jumped in with a variety of cognitive therapy techniques to help Mark challenge his Negative Thoughts, such as “I’ve been a failure as a father,” or “my brain is defective.” Although this might have been effective, there’s a good chance that it might not have worked. That’s because Mark might have “yes-butted” me or insisted that he really was a failure and that I just wasn’t “getting it.”

In fact, the attempt to help the patient without first dealing with the patient’s resistance is the cause of nearly all therapeutic failure. But most therapists make this mistake over and over–and don’t realize that their well-intentioned efforts to help actually trigger and reinforce the patient’s resistance.

Instead, TEAM Therapists use a number of Paradoxical Agenda Setting (PAS) techniques designed to bring the patient’s subconscious resistance to conscious awareness. Then we melt the resistance away before attempting to change the way the patient is thinking and feeling. I (DB) have developed 15 or 20 PAS techniques, and Jill and I  used several of them in our session with Mark:

  • The Invitation Step
  • The Miracle Cure Question
  • The Magic Button
  • Positive Reframing
  • The Acid Test
  • The Magic Dial

When Jill and I use Positive Reframing, we are hoping that Mark will make an unexpected discovery–that his negative thoughts and feelings, such as his sadness, shame, discouragement, and inadequacy actually reflect his core values and show what a positive, awesome human being he is. In other words, he will discover that his core values are actually the source of his symptoms as well as his resistance to change.

This approach represents a radical departure from the way many psychiatrists and psychologists think about psychiatric symptoms as well as resistance.  When I was a psychiatric resident, I (DB) was trained to think about resistance as something negative. For example, we may tell ourselves that resistant patients cling to their feelings of depression and worthlessness because they want attention, because they want to feel sorry for themselves, because they fear change, or because they are afraid will lose their identity if they recover. While there’s some truth in these formulations, they may not be helpful because they tend to cast the patient in a negative light, as if their symptoms and their resistance to change were somehow bad, or childish, or based on some kind of chemical imbalance in their brains. As you will see, the TEAM-CBT approach approaches resistance is radically different manner.

We will give you the chance to pause the podcast briefly and try your own hand at Positive Reframing before you hear it live during the session. Specifically, we will ask you to review Mark’s Daily Mood Log, and ask yourself these two questions about each of his negative thoughts and feelings:

  • What does this negative thought or feeling show about Mark that is beautiful, positive, and awesome?
  • What are some benefits, or advantages, of this negative thought or feeling? Are there some ways that this thought or feeling is helping Mark?

As you so this, make a list of as many Positives as you can on a piece of paper. See what you can come up with.

I want to warn you that it may be difficult to come up with your list of Positives at first. If so, this is good, because when you hear the next podcast, you’ll have many “ah ha!” moments and it will all become quite obvious to you. Then you will have a new and deeper understanding of resistance–an understanding that can help you greatly if you are a therapist or if you are struggling with your own feelings of depression and anxiety.

Jill gives a great overview of why the paradoxical approach is necessary during the Paradoxical Agenda Setting phase of the session.

To learn more about Paradoxical Agenda Setting, you can read David’s featured article in the March / April 2017 issue of Psychotherapy Networker entitled “When Helping Doesn’t Help.” You will see how he helped a woman struggling with intense depression, anxiety and rage due to decades of horrific domestic rape and violence.

 

6 thoughts on “031: Live Session (Mark) — Agenda Setting Phase (Part 3)

  1. What a breath of fresh air you are! I believe many therapists in the past were not willing to see the patient through this lens, were not willing or did not know how to turn the patient around and would basically let the patient talk and talk but not offer the tools that allow the patient to turn a corner, to see things from a different perspective. The result being that the patient would discontinue therapy. Hopefully people will keep trying to find someone like you! Thank you so much for your dedication to helping people feel better about themselves. I am 66 years old, how time flies…But have always had an interest in how our brain works and why it thinks the way it does. You have encouraged me to consider taking classes at the community college on this subject however I would likely be more inspired listening to you.

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    • Thank you, Kate! Your comment was also a breath of fresh air. Much appreciated! And, of course, I strongly agree with you!

      Have fun if you take some courses, and keep tuned because we’ll keep the podcasts (and written blogs) flowing along!

      David

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  2. Hi, Dr. Burns. Thank you so much for your podcasts. As a layperson who deals with anxiety and panic attacks (and who has a 13 year old daughter who does, as well), I have been fascinated by the idea of treatment resistance. I have been through a course of CBT, seen a traditional therapist, have read a multitude of books (including yours, “When Panic Attacks”) and have researched the physiological aspect of fight or flight. I know that the panic won’t harm or kill me and I understand that if I wait for it to pass, it will. I have always been a star student when it comes to doing my therapy homework. I am practically an expert on the treatment of panic disorder! Yet still, after a decade of short term recoveries and longer term relapses, I avoid many situations that I believe may cause me to panic. I must be resisting treatment somehow. And as for my 13 year old…..? I am certain that she is resisting treatment, as well, and she is very open about it! You have given me lots to ponder. Thank you (and merci, to Fabrice!) for making your podcasts available to the general public. I feel so fortunate to have found them!

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    • Thank you Sarah for your note! I appreciate your interest and thoughtfulness. To learn more about resistance, you might want to read my article in the March / April issue of Psychotherapy Networker called “When Helping Doesn’t Help.” I don’t know how to put links in these comments and replies, but you can easily find it if you search Google. I also had an article touching on anxiety resistance in the same journal a couple years back, and you may be able to link to it as well. Here are the references:

      Burns, D. D. (2013). Living with the Devil We Know. Psychotherapy Networker, 37(1): 28 – 35, 56.

      Burns, D. D. (in press, March, 2017). When Helping Doesn’t Help. Psychotherapy Networker.

      In a nutshell, the Outcome Resistance for all anxiety disorders involves magical thinking. Although you suffer with the anxiety, you think something terrible will happen if you suddenly were totally free of anxiety. The Process Resistance issue involves Exposure. You must be willing to confront your fears to be cured.

      One of the Relapse Prevention Techniques for anxiety, once you have totally recovered, is ongoing Exposure. For example, I used to have pretty severe public speaking anxiety, and have even had horrible experiences where my worst fears of making a total fool of myself in front of an audience of experts actually came true. But now I do a tremendous amount of public speaking, and I keep it up, too.

      I never throw methods, such as “Exposure,” at any “diagnosis” like Panic Disorder. Instead, I work systematically with the Daily Mood Log, so I can see the precise negative thoughts trigger the patient’s anxiety and panic, as well as the other negative feelings. After I Empathize and do Paradoxical Agenda Setting to melt away the resistance, I ask the patient what negative thought he or she would like to work on first, and put it in the middle of a Recovery Circle. The I select 15 or 20 techniques to help the patient challenge and crush the negative thought. This is usually quite effective. Some of former students (now colleagues) report that they can usually complete the treatment for panic disorder in a single session, although the session may require two hours. Recently, I have been thinking that panic attacks are perhaps the easiest thing to treat in all of psychiatry and psychology, but of course everyone is different and sometimes things turn out to be a bit more complex when I get to know a patient, and how she or he is thinking and feeling.

      All the best,

      David

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  3. Thank you for your thoughtful and thorough response, Dr. Burns. I read both of the articles you referenced. I am fairly certain that Process Resistance is my issue. I have done hundreds of exposures, but boy, do I hate it! It sounds like it’s time for me to dive back in to “When Panic Attacks”, make some photocopies of the Recovery Circle, and start pinpointing, then crushing my negative thoughts. Thank you again for taking the time to respond to my comment!

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    • You are welcome. Remember to use all four models when selecting methods to attack the Negative Thought in the middle of the Recovery Circle, and not just exposure. They are the Hidden Emotion Model, the Cognitive Model, the Exposure Model, and the Motivational Model. Thanks so much, and best of lunch, and kudos on your courage! If I knew the Negative Thought, I might be able to make more specific and enlightened suggestions. d

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