Treating Our Troubled Veterans–Would TEAM-CBT Help?

Hi Web Visitors and friends,

I got a really interesting email from a psychologist I’m calling “JP,” an old friend who treats veterans struggling with PTSD. He had some deeply-appreciated praise for the Feeling Good Podcasts and raised some challenging questions about TEAM as well as the treatment of veterans struggling with trauma who may be motivated to maintain their symptoms, in some cases, due to disability payments. You might enjoy our exchange!

David

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Hi David,

I have listened to 52 Feeling Good podcasts. They’re excellent! Both enjoyable and informative. This is the best podcasts series I have ever heard as far as content that I can put to use as a psychologist. I look forward to listening to them and find them encouraging.

The only downside is that I wish there were more of them. I learn something every time I listen. For example, your talk about the negative impact of unrealistic positive thoughts helped me reframe some of my experiences when I tried to do much more than I could do well (which has had a negative impact on my career). I understand this now and it is helping me take more care regarding what I take on now. Keep up the good work!

I hope to come to the intensive in Canada in July!

If you have time, it would be great if you could respond to the questions below. These questions relate to my concerns regarding using the TEAM model with veterans. Please keep in mind the US VA health care system provides more psychotherapy than any other organization in the world.

In an effort to better serve our veterans by promoting evidence based treatments, the VA has already trained hundreds of clinicians in PE and Cognitive Processing Therapy and continues to provide this type of training on an ongoing basis to hundreds more staff and students as they enter the VA system.

In some ways, VA clinicians could be the perfect TEAM model providers because there seem to be an endless number of veterans seeking treatment for PTSD, depression and anxiety. As a result, there are no financial incentives to keep patients in treatment. If the VA were to promote the TEAM model the way it has promoted PE, then tens of thousands of lives would be affected across the country.

Questions:

  1. Most of the patients you described were highly educated and intellectual. Would these methods work as well on individuals with a high school or less education who have often made their living through manual labor?
  2. Have there been any published studies using the TEAM model?
  3. Are there any studies underway?
  4. How often do you have follow-up testing? TEAM seems to be having a clear impact within these long sessions. How much evidence do you have that these changes last six months or longer?
  5. As we have discussed, the VA both treats PTSD and provides disability payments based on the degree to which a veteran’s ability to work is impaired by his/her military service so there is a disincentive for reporting improvement. How would you address this issue?

Thanks!

JP

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For clarification on my response below:

TEAM is an acronym that stands for T = Testing, E = Empathy, A = Agenda Setting, and M = Methods.

CBT stands for Cognitive Behavioral Therapy.

Dear JP,

Thank you for your wonderful email and excellent questions! I look forward to seeing you at next summer’s intensive. It’s been a while since we have connected! So great to hear from you. There will also be a good intensive in San Francisco in the summer. That one also has evening sessions featuring live work and more practice for participants.

I’ll take a crack at your questions:

  1. The TEAM-CBT methods can work with high functioning individuals, but it is a bit more challenging and takes quite a bit of skill and training on the part of the therapist. Working with lower functioning individuals who have few resources is actually easier, in my experience, and can be extremely rewarding. This is perhaps not the way most mental health professionals think about it!

The best experience I’ve had along these lines was the group CBT program I developed for my hospital when I was still living in Philadelphia. Ours was an inner-city hospital in a gang warfare area, and we treated everyone in groups.

We simplified the cognitive therapy, since many of our patients could not read or write. Most of our patients had severe psychiatric symptoms with limited resources, and some were homeless.

The outcomes were tremendous, and the program was cost-effective as well, since we recruited the group leaders from the community. They worked under supervision of a psychologist.

The patients seemed extremely grateful for the programs we developed, and they were challenging, due to their severity, but actually easy to work with. I wrote the book, “Ten Days to Self-Esteem” as the manual for the patients, and we gave every patient a copy at intake to the program. It is written at about the fifth-grade level, with just a few paragraphs in each chapter, along with the exercises we did in each group. Each chapter was the focus of one of the groups in our ten day program. I also wrote a manual for the group leaders called Ten Days to Self-Esteem: The Leader’s Manual. Both books are available on Amazon, though the leader’s manual is now just an eBook.

For an example of how we simplified the treatment, we called the first cognitive distortion on my distortion list “black or white thinking” instead of “all-or-nothing thinking” to make it easier to grasp. We illustrated the distortions on posters, and each distortion was represented with an icon to make it easy to comprehend. We used a checkerboard for all-or-nothing thinking, for example, and a magnifying glass for Magnification and Minimization.

I was also very careful to use simple language when running groups, and I avoided any kind of psychological jargon or big words. But other than that, everything applied to this population, just like any other group of individuals struggling with severe depression, anxiety disorders, relationship conflicts, and habits and addictions

2. You asked about research, which is so important. I presented an informal study of TEAM in a keynote address at one of the Brief Therapy Conferences in Anaheim a few years ago, sponsored by the Milton Erickson Foundation in Phoenix. The study involved something like 450 therapy sessions conducted by four therapists at the Feeling Good Institute in Mt. View, California. The goal was to calculate the average rate of anxiety and depression symptom reduction per hour of therapy, which was about 25% to 30% per hour. I was able to make these calculations because in TEAM, we measure symptoms at the start and end of every therapy session, without exception.

I call this measure the “Recovery Coefficient,” and I believe it is a really accurate measure of therapist effectiveness, perhaps the first ever developed.

This rate of change was vastly faster than what is reported in controlled outcome studies using CBT or other forms of treatment, including medications. However, I do two-hour sessions, and typically see a complete or near-complete elimination of symptoms in that period of time. However, was not one of the therapists in that study.

An outcome study is about to begin at the FGI.

You can also read more about the research that triggered my evolution from CBT to TEAM-CBT, including the clinical experience that led to the new developments, at this link:

https://www.psychotherapynetworker.org/blog/details/1160/when-helping-doesnt-help

 

If you need the references to my published research studies, let me know. I developed TEAM-CBT based on process research on how psychotherapy actually works.

It is my belief that the controlled outcome studies have yielded very little useful information, and that the breakthroughs in understanding and in clinical treatment will result from process studies that document procedures and processes that are actually effective with patients.

TEAM-CBT evolved from this research on how psychotherapy works, and my findings, as well as my clinical experiences, pointed to the massive importance of motivation and resistance. TEAM includes many powerful resistance-busting techniques that I have developed in recent years at my weekly psychotherapy development and training group at Stanford.

However, it is not easy to learn how to do TEAM-CBT, due to therapist narcissism and codependency, as well as the fact that therapists have to unlearn much of what they have been taught. In my experience, some therapists are strongly biased and not terribly open to learning that their empathy skills and technical skills are not nearly as effective as they thought! In addition, I believe that some therapists are looking for easy formulas, as opposed to the really hard work of learning world-class therapy skills.

I apologize for my somewhat cynical attitude! And I would have to say that some therapists, like yourself, are absolutely delightful to teach and quick and hungry to learn new and more effective approaches.

3. See #2.

4. Please see my podcasts and blogs on Relapse Prevention Training, including this one: https://feelinggood.com/2017/07/31/048-relapse-prevention-training/

In my clinical practice, I have had about 35,000 to 40,000 therapy sessions, and have always done careful Relapse Prevention Training (RPT) prior to discharge. RPT takes about 30 minutes, and is incredibly important, because all human beings will “relapse” from time to time.

I encouraged all my patients to return anytime they relapsed and needed a tune-up. I can count on two hands the number who have returned for a tune-up, and that was usually just one or two sessions and then they were on their way again.

However, my clinical experiences are clearly not the same as controlled outcome studies, so we need to be cautious until that research can be done. However, short-term and long-term studies of the effects of simply reading my book, Feeling Good, with no other treatment, are outstanding, and comparable to or better than the effects of individual psychotherapy or treatment with antidepressant medications.

I do recall a study by Anne Simons PhD showing that the faster patients recover, and the more complete their recovery, the better the long-term prognosis. This is consistent with common sense. If patients come to you for treatment, and quickly and completely recover, they are getting the message that their depression and anxiety are very treatable, and that they are not hopeless.

In addition, it is crucial that they know that they will have relapses from time to time, and that the methods they learned in therapy that worked for them will likely always work for them. So they must be willing to pick up the tools and use them again when they fall back into a black hole of depression and self-doubt.

5. You and I have discussed this thorny issue of treating veterans receiving disability years ago, and I will repeat the solution I proposed at that time. You might consider giving veterans an option to select between two treatments:

  1. Treatment as Usual, which could include medications and a weekly chat about their symptoms, but no homework, no demands, no anxiety providing interventions, and so forth. This treatment would not threaten their disability.
  2. Rapid Recovery, which requires consistent homework between sessions, consistent attendance, and so forth. This treatment might threaten their disability, since the focus will be on recovery.

Then you could find out what group each veteran selected, and this might give you crucial information about motivation / resistance. At any point, too, veterans could change groups.

This approach might allow you to focus your creative efforts and energy on the patients who select the training in which they are accountable. I find that disability money can be a challenging obstacle to effective treatment. If a patient is involved in a lawsuit, hoping to get a settlement due to psychiatric symptoms, you will run into the same problem.

People are easily corrupted by money. In addition, I believe it is an ethics violation to treat individuals and to certify them for disability at the same time. This is a classic dual-role ethics conflict. If the veterans know that your therapy notes and records will be used in the evaluation of their disability, you will have the same problem. To my way of thinking, this is a therapy “non-starter” of the highest magnitude.

Good to hear from you, JP, and hope to see you before long!

David D. Burns, M.D.

Dear Web visitors,

I would like to invite you to some exciting events coming up in the near future. My relationship workshops will take place in three east coast cities at the end of October, and the first will be live-streamed, so you can “attend” from anywhere in the world. Here’s a new development: When you register, if you use the code Burns50, you will receive a $50 discount. Not a bad deal! Here are the details:

“And It’s All Your Fault!” Transforming Troubled Relationships Into Loving Ones

October 30 – 31, 2017–Raleigh, NC: Double Tree Raleigh Brownstone-University
November 1 – 2, 2017–Atlanta, GA: Atlanta Marriott Century Center
November 3 – 4, 2017–Denver, CO: Double Tree by Hilton Denver-Westminster
For more information, click here, or contact IAHB, phone: 800-258-8411

The Raleigh workshop on Oct 30 – 31 INCLUDES A LIVE WEBCAST–
Click here for more information

In addition, my Feeling Good talk will be sponsored by Stanford and is free to Stanford-affiliated health professionals. Three is a $40 fee for the general public. I’ll be discussing CBT as well as the developments led to the birth of TEAM-CBT, with a dramatic video clip of a patient having a full-blown panic attack. You will see the actual moment of her recovery during the session!

I will also present some inspiring vignettes illustrating patient’s recoveries from severe depression and hopelessness. I’m honored to have this opportunity to present at Stanford! Here are the details.

Feeling Good
Friday, October 27, 2017, 8 to 10 AM
Stanford University Li Ka Shen Center, Room 130
For health professionals as well as the general public

Sponsored by the Stanford Health Promotion Network, this presentation by David D. Burns, M.D., will focus on fast, effective, drug-free treatments for depression and anxiety disorders. This event is free for Stanford-affiliated individuals and $40 for others who wish to attend. Click here for registration and more information

I sincerely hope you can join me for one of these exciting events!

All the best,

David

 

 

 

If you are reading this blog on social media, I appreciate it! I would like to invite you to visit my website, http://www.FeelingGood.com, as well. There you will find a wealth of free goodies, including my Feeling Good blogs, my Feeling Good Podcasts with host, Dr. Fabrice Nye, and the Ask Dr. David blogs as well, along with announcements of upcoming workshops, and tons of resources for mental health professionals as well as patients!

Once you link to my blog, you can sign up using the widget at the top of the column to the right of each page. Please forward my blogs to friends as well, especially anyone with an interest in mood problems, psychotherapy, or relationship conflicts.

Thanks! David

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