Podcast 237: The Gentle Ultimatum:
Can We Make Our Patients Accountable?
April 12, 2021
At the top of the podcast, Rhonda reads several beautiful and thoughtful comments from listeners like you. One was an enthusiastic listener who found us on YouTube and wondered why we don’t have vastly larger audiences, since the quality of what we offer is not only free, but it beats out all the other “self-help gurus” by a large margin.
Thanks for that. We are not experts in market and could use all the help we can get. So if you can spread the word for us, we’d appreciate it!
David announced that his next workshop with Dr. jill Levitt will be on May 16, 2021, featuring David and Dr. Jill Levitt working with two audience volunteers who are struggling with depression and anxiety.
Link to Registration Information
It should be dramatic, inspiring, and profoundly educational, so you can see how TEAM-CBT really works in a live and spontaneous setting with no role-playing. This will be the real thing!
One of the unique features of TEAM Therapy is the Gentle Ultimatum. At the beginning of therapy, we tell patients what will be required of them, and how the therapy works, if we accept them as patients. That way, they can make an informed decision about whether or not they want to work with us.
This table illustrates what they’ll be asked to do.
| Problem | What the “Gentle Ultimatum” involves | Rationale |
| Depression | Psychotherapy homework | David’s published research indicates that psychotherapy compliance has massive causal effects on recovery from depression. |
| Anxiety | Exposure | Extensive research shows that Exposure is effective in the treatment of all forms of anxiety. Clinical experience indicates that full recovery from depression is difficult, if not impossible, without exposure. |
| A Relationship Problem | Giving up blame and focusing on your own role in the problem | Research and clinical experience indicate that blame is probably the main cause of troubled relationships. |
In the podcast, David and Rhonda discuss the rationale for the Gentle Ultimatum, as well as how to do it skillfully, and when.
David describes his own reluctance to make patients accountable during the first seven or eight years of his practice, and what happened to change his mind, and how that led to the emergence of TEAM-CBT. David also describes the correct and incorrect way of presenting this to patients at the initial evaluation in a kindly, collaborative way. This requires therapist integrity, skill, and compassion. You cannot simply issue a crude “my way or the highway” demand.
David also describes the Concept of Self-Help Memo that he created and began sending to patients prior to their first visit. The memo explains the rationale for requiring psychotherapy homework, briefly describes the ten most common forms of homework, and asks patients if they are willing to do homework if accepted into the clinical. The memo also asks how many days per week they’ll agree to, how many minutes per day, and how many weeks she or he will keep it up.
The memo concludes with a list of “35 GOOD Reasons NOT to do Psychotherapy Homework,” and patients indicate how strongly they agree with each one. David illustrates how he discusses the memo, and the topic of homework, with new patients.
David compares the Gentle Ultimatum with what happens when you go to the doctor with a broken leg. He or she might say you have to get an X-ray, and then we’ll give you a cast.
If they patient protests and says that she or he is against X-rays and casts, and wants to be treated with “talk therapy,” the doctor would politely decline and explain that s/he is using a medical model of treatment, and that “talk therapy” is not offered for broken limbs.
David and Rhonda explore the fairly intense resistance of many, and perhaps most therapists to making patients accountable. Rhonda describes her own inner fight about this, and how she had to terminate a patient recently because s/he refused to do homework, and opted for pure “talk therapy” from another therapist instead.
The table above indicates that if the patient is struggling with anxiety, Exposure is the focus of the Gentle Ultimatum. If the patient wants effective treatment, Exposure will be required, and not an option.
If, in contrast, you want help with a relationship problem, like a troubled marriage, you will have to agree to stop blaming the other person, and focus on pinpointing your own role in the problem, which can be immensely painful and humiliating. But it’s also liberating, because when you change yourself, instead of blaming the other person, you can transform trouble relationships into loving ones.
Rhonda points out a potential conflict of interest with TEAM-CBT and the Gentle Ultimatum. It can lead to such rapid recovery that therapists need a large flow of patients.
David mentions that one of the therapists in Rhonda’s FeelingGreatTherapyCenter.com, Sunny Choi, has this exact problem. His patients are getting better so fast he can’t keep his practice full. David urges potential patients to contact him, if interested, since Sunny is not only remarkably skillful, but he has a big heart and low fees, with a sliding fee scale, too.
Thanks for listening today!
Rhonda and David
Dr. Rhonda Barovsky practices in Walnut Creek, California, but due to Covid-19 restrictions is working via Zoom, and can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 4 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. Check out her new website: www.feelinggreattherapycenter.com.
You can reach Dr. Burns at david@feelinggood.com.
This is the cover of my new book, Feeling Great. The kindle and audio versions are available now too!
Oh wow, it made my day to hear that someone really appreciated my question in the last Ask David. Thank you for answering the question so thoughtfully, as well as for taking the time to communicate the endorsement from the listener.
You are welcome, Adam! d
Hello Dr David Burns! Thank you so much all the helpful resources you have created to help lay people deal with their mental issues, your books, your podcasts, everything!
I am in my early 20s and have just known about your books few weeks ago. I have read feeling good, and found the techniques helpful for my depressive symptoms. Just purchased feeling great yesterday and I am already loving it. I am also on meds.
I would just like to ask you a question not related to this podcast session regarding maladaptive daydreaming. I used to suffer from it ( as you already know it’s not a diagnosable condition yet) but meds (SSRIs and SNRIs) have tremendously helped with controlling my urges to daydream more than my depressive symptoms. In fact, I rarely daydream anymore. I wonder if you have thoughts on this condition and if you have ever come across patients who report having urges to daydream while pacing around the room with headphones on and loud music repetitively. If so, how did you help them?
Thank you so much.
Thanks, that’s a new one, but glad to hear you’re doing better now! Warmly, david
Hi David! Branching off the gentle ultimatum, do you think a depressed person could benefit from doing exposures like shame attacking? Or would they be likely to filter these exposures through a negative lens and maintain negative feelings and anxiety?
I have said this often, but sometimes folks don’t “hear” what I’m saying. I DON’T chase symptoms (depression) with methods (shame attacking.) That is the old fashioned and ineffective approach to treatment. I use T E A M in that order. I treat the person, not the diagnosis. If someone is struggling with shyness, then shame attacking MIGHT be one of 20 M = Methods I might use depending on their DML, their negative thoughts, their resistance, and a lot more. I’ve NEVER used Shame Attacking for any problem other than social anxiety. d
I see. Sorry that your message has fallen on my deaf ears. What you said reminds me of another time where on a consultation call, I was told that my therapist was chasing my depression with the method of positive reframing. It made sense as the method felt forced and was ineffectual, but at the same time I thought it was the tool for melting my resistance. So, I was just left confused as to what is done before that. It seems to fall under the A part of TEAM, but I’m not sure what else is out there other than the magic button, reframing, and magic dial?
There are tons of resources for learning TEAM, like my new book, Feeling Great, as well as the free Feeling Good podcasts. d
Thanks. I have read Feeling Great front and back, and heard most of the podcasts. I’ve heard you say before that there are about 10-20 methods for melting resistance. Unless I’ve missed something in the podcasts and book, I can only think of reframing, the magic dial, the acid test, magic button, gentle ultimatum mentioned here, is there a list somewhere of more so I can try to work with them?
Hi Adam,
Here are some of them, from the therapists perspective. Straightforward Invitation; Paradoxical INvitation; Miracle Cure Question; Magic Button; Positive Reframing; Magic Dial; Acid Test; Blame Cost-Benefit Analysis; Interpersonal Decision-Making; Externalization of Resistance; Gentle Ultimatum; Dangling the Carrot; Sitting with Open Hands; the Devil’s Advocate Technique; the Decision-Making Tool; and quite a few more. Plus, the Concept of Self-Help Memo; Paradoxical CBA; etc. Also Ten GOOD Reasons NOT to Listen; Ten GOOD Reasons NOT to Empathize; Ten GOOD Reasons NOT to Treat the Other Person with Respect; and more. This list must be close to 20 or so, and there are even more. This is just off the top of my head.
Hope this helps validate my statement to some extent, and thanks for the excellent question. As you can see, it is not the case that everything is in one book.
david
David and Rhonda,
Another great episode that addresses perhaps the most important topic in all of psychotherapy … doing the work. I’d give David’s argument for homework (depression) and exposure (anxiety) a solid B+ which may represent the limit of his approach. What prevents it from moving into the A’s??? The use of his career observations versus proven scientific fact. Consider describing technically, “why” the patient must do the work. We scientists, therapists, and doctors must do the work required to comprehensively answer that question such that it becomes established scientific fact, rather than opinion. As a start, we may simply state… because that’s the way our human nervous system operates. It changes through adaptation to exposure, in the case of anxiety for example. In fact, it’s always doing that in every moment of life.
Thoughts?
Richard
Thanks! Not sure what you want. There is an abundance of published research on the causal effects of homework on recovery from depression and exposure on recovery from anxiety. It is not just my opinion. As for the “why,” the why of homework is that the brain and thinking must be reprogrammed, and that can only happen through practice. In addition, exposure reveals to the anxious person that the monster has no teeth, and this discovery causes instant reduction of the anxiety.
Hope this helps! But maybe I don’t “get” the essence of your thoughtful and excellent question! d
David,
On the contrary, you got the essence of my question very well. I understand that it’s not just your opinion and that previous research has in fact noted strong causal effects. Unfortunately, this has not yet convinced the public at large or many in the mental health field. Of course, we can certainly appreciate the various motivations of both groups to maintain the status quo. Your upcoming Feeling Great App may generate the depth and breadth of experimental data required to comprehensively explain these causal effects and more. It represents a critical entryway for the application of data analytics such that the entire field is “forced” to finally adhere to the scientific method, and not a moment too soon.
Very exciting future David
Regards,
Richard
Hi Richard, you are right. Both mental health professionals, and patients as well, often think they are experts, and reject ideas and techniques that threaten their notions about causality and treatments. I am happy, though, to work with folks who are interested in what I’m offering. I am hoping that int he long run, good money (science-based, data-driven therapy) will drive out bad money (the competing schools of therapy now in vogue.) david