Live Work with Elizabeth, Part 2 (of 2)
“I’m tired of being terrified. I want to be at peace!”
Last week, we brought you Part 1 of a session with a women who’s been struggling with anxiety and the fear of poverty every since she was 13 years old. that included T = Testing and E = Empathy, including an empathy error that David and Jill corrected. Today, we bring you the conclusion of that amazing session!
After the empathy correction, Elizabeth suddenly said:
“I don’t talk about this stuff very much as an adult. I’m feeling overwhelmed in a good way right now. A sense of peace is opening up.”
You can review the partially completed Daily Mood Log Elizabeth gave us at the start of the sess if you click here. Her goal for the session was to get some relief from the constant pressure she put herself under to function and to keep her practice full.
A = Assessment of Resistance
Together, we did Positive Reframing with her negative thoughts and feelings, asking:
- What does this thought or feeling show about you and your core values that’s positive and awesome?
- What are some benefits, or advantages, of this thought or feeling?
Together, we came up with this list of the positives.
- They keep me moving.
- They are very familiar.
- They show I’ve got a good work ethic.
- They show I’m a responsible human being.
- They show I care deeply about my family and my business.
- They show I’m determined to change the family history of failure and deprivation.
- The anxiety protects me from failure.
- It has kept me alive.
- It has paid the bills.
- Keeps me independent and self-supportive.
- Shows I’m strong and confident.
- Shows my love for my daughter.
You can see Elizabeth’s Daily Mood Log with her goals for each negative feeling cluster if you click here.
M = Methods
Next we helped Elizabeth challenge her negative thoughts using Identify the Distortions, Explain the Distortions, and Externalization of Voices, starting with her seventh Negative Thought, “I need the pressure to function,” which she initially believed 100%.
She identified the following cognitive distortions in this thought: All-or-Nothing Thinking, Jumping to Conclusions (Fortune Telling), Emotional Reasoning, and Magnification / Minimization.
She decided to challenge the Negative Thought with this Positive Thought:
I do not need pressure to function. I have functioned many times without pressure just fine.
She believed this thought 100%, and this reduced her belief in the Negative Thought to 10%.
Then we did Externalization of Voices with this thought and many others.
Then David suggested Cognitive Flooding. The idea is to flood yourself with anxiety by imagining whatever it is that terrifies you the most. Every minute or two you record the time, your anxiety (0 to 100), and any fantasies you are having. The goal is to make yourself as anxious as possible for as long as possible.
Over time, your anxiety falls, and eventually disappears. This can be frightening, and requires some courage on the part of the therapist and patient, but it can be extremely helpful and often works rapidly.
Cognitive Flooding Flow Sheet
|6:34||100||I am looking at my appointment schedule, which is only half full, and the phone is not ringing with new patients|
|6:35||100||Only two patients are scheduled, no one is calling to inquire about therapy|
|6:36||110||My throat is getting tight, and I’m telling myself that other clinicians in our practice rely on me, and I’m letting them down.|
|6:37||Eliz can fill in anxiety ratings, perhaps||I’m asking myself, “What will we do? What’s going to happen?”|
|6:38||Eliz can fill in anxiety ratings, perhaps||My schedule is drying up. My associates don’t have any patients.||Jill begins with the What-If Technique. What’s the worst that could happen?|
|6:39||Eliz can fill in anxiety ratings, perhaps||The economy is crashing. I have to let go of my associates. This is devastating.||And then what? What’s the worst that could happen?|
|6:40||Eliz can fill in anxiety ratings, perhaps||I’m standing in my office by myself. Everyone is gone. I’m alone. No one is calling for training or treatment.||And then what? What’s the worst that could happen?|
|6:42||50||I have to keep working alone in a dark office until I’m 80 years old.||And then what? What’s the worst that could happen?|
|6:43||30||Now I’m 85 years old, still trying to make things worse. My husband has a heart attack and Parkinson’s Disease. Now I have to treat people for free.|
At this point something unexpected happened. Elizabeth burst into tears, and said: “I’m angry because this is what I’ve always wanted to do. . . I don’t want to have to charge people for therapy. I just want to treat people for free.
She said the flooding was powerful, and melted the conflict she’d been experiencing: “I want to embrace therapy, and do something for free. I love doing therapy. And my biggest fear is that I cannot do that!”
David suggested doing the cognitive flooding whenever she felt a pang of anxiety about her practice.
You can see Elizabeth’s end-of-session Daily Mood Log if you click here.
Jill suggested a homework assignment for Elizabeth after the session:
You can develop a cognitive flooding script with the What-If Technique. Record it on your phone, and listen to it daily until you get bored and your anxiety no longer flares up.
Here is Elizabeth’s follow-up report:
I did two rewrites on the script and listen to it daily for about two weeks.
The in vivo exposure was to take my schedule offline for at least two weeks and stop trying to keep it full. I took my schedule offline until Saturday, March 13th thru Tuesday, April 6th. I have not scheduled anyone new or additional clients during this time. And clients have not had access to my online schedule during this time.
I have gone through varying degrees of anxiety and woke up once in the wee hours of the morning to worry, but overall, there has been a significant decline in my anxiety, worry and checking to see if my schedule is full.
This exposure has been very powerful!
Jill added this teaching point about Cognitive Flooding:
You have the patient imagine the worst thing that could possibly happen and tell it in the narrative form, so it sounds like the What-If Technique playing out…For example, someone with OCD and fears of contamination can tell the story of the worst thing that could happen…
“and then I would be dirty, and then I would contaminate my child, and she would get sick, and end up in the hospital, and . . . ” etc.
At the same time, you also focus on the patient’s negative thoughts and feelings and take anxiety ratings every minute or so.
The M = Methods illustrated in the podcast include:
- What’s my grade?
- What-If Technique
- Downward Arrow Technique.
- Daily Mood Log
- Positive Reframing
- Identify the Distortions
- Examine the Evidence
- Externalization of Voices
- Cognitive Flooding (combined with What-If Technique)
- In vivo exposure and response prevention (Jill’s homework assignment for Elizabeth)
After each Tuesday group, we get quantitative and qualitative feedback from the members about the quality of the teaching. You can see some of the teaching feedback for the session if you click here.
Rhonda and I, and all the members of our Stanford Tuesday training group, and all of our thousands of podcast fans, want to thank you, Elizabeth and give you a great virtual hug!
Rhonda and David
I just received this lovely note from Elizabeth to report on what has happened since her session in the Tuesday group.
Last week April 7th, my schedule went back online after being offline for three weeks. The process was seamless, my practice did not fall apart. The other clinician’s schedule did not become empty and we did not get a bad reputation. I no longer fear I will be 80 years old, desperate with a handful of clients and supporting my husband who has a terminal illness. Or my daughter having to financially support us both. Even as I write this I am smiling and laughing a bit. I do not feel driven by the fear of financial ruin nor have I compulsively checked my schedule making sure it is full. I have more brain space for other things. I believe I have the peace I requested in my miracle cure. Of course, I will relapse, I already have a couple of times and I have quickly recentered.
A deep heartfelt Thanks to David, Jill, and all of you who participated with feedback or witnessed my personal work.
My Warmest Regards,
Dr. Rhonda Barovsky practices in Walnut Creek, California, but due to Covid-19 restrictions is working via Zoom, and can be reached at email@example.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 firstname.lastname@example.org.
This is the cover of my new book, Feeling Great. The kindle and audio versions are available now too!