Podcast 243
Ask David and Rhonda!
David and Rhonda answer your questions about the role of hope, treating court-ordered patients, the impact of suicide threats on the therapist, being a virgin, and moral scrupulosity.
Only you and I are on Episode 243. The questions are:
- V3A asks: What is the role of hope?
- EdG asks: How would you deal with a patient who doesn’t like you?
- Preetika asks: Recently, a client said she felt suicidal and that made me feel suicidal about anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas.
- Dale asks: How would you do Positive Reframing with someone who is suicidal?
- Miho writes: Is it still okay to save yourself for marriage?
- Robyn writes: How would you treat patients suffering from OCD with moral/religious scrupulosity.
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- V3A asks: What is the role of hope?
Hi David, how do you fit the cultivation of hope into TEAM-CBT? Being such an important aspect of recovery, it seems to be most needed in those that most need help, creating a seemingly unwinnable situation for those people.
If someone has enough hope to seek treatment, is that enough to make a recovery?
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- EdG asks: Just listened to Podcast 025 on how to relate to a patient you dislike, Very useful! What about the opposite situation? How do you deal with a patient who may have a hidden agenda, like coming to you in order to avoid a legal problem or because s/he was ordered by an employer or the courts?
Thanks, EdG.
That’s sometimes fairly easy, and might make this an Ask David. I once told such a patient that if he wanted to work with me he’d have to have an agenda of something he really wanted to change, and he would also have to do tremendous amounts of psychotherapy homework, and that this was non-negotiable, and that he or she might prefer going to another therapist who would be more of a pushover!
In my limited experience, this was very effective, and seemed to motivate the man who came to me. He did, in fact, work tremendously hard! david
PS We can get Rhonda’s take on it, as she does forensic work.
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- Preetika asks: Recently, a client said she felt suicidal and that made me feel suicidal about how anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas.
Dear Dr Burns,
Thanks for sharing your wonderful podcasts, they are of immense value.
I have been using your brief mood surveys and though I found it tiresome initially, I realized its value when I I uncovered suicidal thoughts in a patient that came forth only because of repeating the mood survey each session. Further, do you think a brief behavior survey at the start of a session is beneficial to record sleep, eating, and self harm patterns is needed to assess how clients are doing in between sessions? Does it have value?
Recently, a client said she felt suicidal and that made me feel suicidal about how anything untoward happening on my watch! I was ‘scared stiff!’ Please do a podcast if possible on therapist fears and dilemmas.
Thanks for so many continuing insights and for making therapy feel real,
Preetika
Hi Preetika,
Perhaps you can search on website using search function and find the podcast on suicide prevention. Then let know what you think.
When you use the Brief Mood Survey and Evaluation of Therapy Session, you said it was tiresome at first. What were your scores on the Empathy Scale? Scores below 20 are failing grades. Most of my colleagues, and myself, find this anything but “tiresome,” but rather dynamic and fantastically challenging. Also, what percent reduction do you see in patient’s depression scores within sessions? This shows your level of skill and effectiveness. 25% to 35% reduction within a session is a fairly good benchmark of sorts. This is called the Recovery Coefficient.
Have you looked at that? I find it pretty exciting, and also challenging, especially when the scores don’t change, and also when they do1
Thanks for the great question.
David
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- Dale asks: How would you do Positive Reframing with someone who is suicidal? Would you suggest that it says that they have a strong self-awareness of the severity of their hopelessness that protects them from more disappointments? Or perhaps a wake-up call message from there awareness of some kind?
All the best
Dale
Hi Dale,
Suicide is handled differently, in part due to the legal stipulations that make therapists guilty, and you can use the search function to find and listen to my podcasts on this topic. Thanks!
David
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- Miho writes: From church and from my parents, I have been told repeatedly I need to save myself for marriage thus this has been my core belief when I am dating. Although it had never bothered me before, now that I am in my last 20s it seems I have heightened anxiety and misaligned expectations when dating as literally no one around me thinks in this way, and I have been told I do not “look” like I am inexperienced. May I know which would be the best tool for combatting other people’s opinions when it really does seem that their opinion is the “truth” of the world?
Hello Dr. Burns,
First of all, thank you (and Rhonda!) so much for providing us with a great podcast. It has helped me tremendously and it is great to hear both of your voices. Your book “Feeling Great” is amazing as well and I just can’t find enough words to express my gratitude for all that you do.
I have 2 questions regarding romantic relationships and your opinion would be much appreciated if you have time. (I am a female in my late 20s)
1) I feel that I tend to associate past events to the present, for example when a guy tells me that he is busy with work, even if he is genuinely busy and there is proof, I remember the time my ex-boyfriend made that excuse to actually hide the fact that he was going out clubbing and doing drugs. It is not that I don’t trust the person in front of me, but rather the feelings of anxiety from past creeps up on me due to those thoughts and makes me insecure (if that makes sense). I am not sure which tool I should use to get over this kind of thinking, as in the moment when I reframe my thoughts it works, but soon after another example would set me off again.
2) From church and from my parents, I have been told repeatedly I need to save myself for marriage thus this has been my core belief when I am dating. Although it had never bothered me before, now that I am in my last 20s it seems I have heightened anxiety and misaligned expectations when dating as literally no one around me thinks in this way, and I have been told I do not “look” like I am inexperienced. May I know which would be the best tool for combatting other people’s opinions when it really does seem that their opinion is the “truth” of the world?
Warmest regards,
Miho
Hi Miho,
Thanks. I will add this to the Ask David list. It will take some time, as we have lots of great questions listed at the moment. I resonate, though, as I was raised in a religious family and told not to kiss girls, etc. which was, I think, damaging.. Sex is natural and inevitable, and perhaps best left “undemonized.”
At any rate, you would need to decide on your own moral values, and then we could deal with any fears of disapproval from one side or the other.
Really love and appreciate your openness.
d
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- Robyn writes:
I would very much like to hear about how you treat patients suffering from OCD with moral/religious scrupulosity.
Dear David and Rhonda: Thank you so much for your calming, effective and often laugh-out-loud funny podcasts, filled with a generosity of wisdom. I deeply appreciate them and recommend them to others also. They have helped shape my view of CBT into something far more empathetic and human.
I would very much like to hear about how you prefer to treat patients suffering OCD with moral/religious scrupulosity. I understand that exposure with response prevention is considered the standard treatment, but I don’t understand how this works directly with fears about things that are unethical or immoral. For example, a deeply law-abiding person who is afraid of accidentally breaking the law (“was I speeding? I need to check if that was a police camera! what if I was doing something illegal and I didn’t realise it?”) or a very kind person who goes out of their way not to kill anything due to fear of consequences in the afterlife (“did I just step on an ant? I’d better check the soles of my shoes in case! I don’t want to wash my hands in case it kills skin mites!”) And would it change anything in your approach if the patient was someone who had had negative experiences with the law through no fault of their own (ie validating their fear)? Or who had a sincere belief that they should pray to be forgiven or purified for their perceived “sins” (a coping behavior which isn’t negative in itself)? How do you even go about creating willingness in the patient to see these behaviors as problematic?
It seems like it is much easier to treat for a fear of cats – it’s easy to make an exposure ladder to the actual fear, it’s ethical and safe to expose the patient, and the experience can ultimately be very positive – which is quite reinforcing. But what do you do when the patient is suffering from a good quality taken too far (obeying the law, refraining from killing etc.)? Obviously you can’t invite them to break the law or kill things because that’s not moral or ethical, so I’m assuming you can only ask them to sit with the discomfort of uncertainty? Is that just as good as working with the direct object of fear itself? Or have I missed something? I’d love it if you could talk about scrupulosity sometime!
Thank you very much again.
Kind regards
Robyn
Hi Robyn,
If you like, I will include in an ask david. The short answer is one that I give every week on the podcasts—I don’t throw techniques at folks based on a diagnosis or problem. As often as I say it, people don’t seem to get it, and this is the biggest problem in our field—trying to figure out how to “help” or rescue our patients.
Of course, cognitive flooding might be one of 15 or 20 methods I might use, and there are tons of others, but first one has to find out what, if anything, the patient wants, and then deal skillfully with Outcome and Process Resistance. This MUST come before trying any methods.
More on this when Rhonda and I discuss your excellent question.
d
Next week, The fabulous Dr. Matthew May will join us for a fascinating podcast on the paradoxical Nature of TEAM-CBT! Don’t miss it!
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!
Wow!! Fantastic answers, as usual. Thanks so much for the kind comments. In the words of Mike Myers from Sat.Nite Live: “i’m verklempt!!!”
Thanks, Ed! Warmly, david
I work in a large public school system in CA and it seems like a sign of privilege for a therapist to say that they won’t work with someone who is suicidal. The latest research shows that 19% of HS kids and 48% of LGBTQ adolescents have had suicidal thoughts in the last year.
We couldn’t provide inpatient care for even a tiny % of them and telling them you won’t work with them seems like a sign of your own fears (of being sued). Perhaps we all need to develop more skills vs showing them the door?
He Sharon, Your note sounds pretty angry, if I am reading you right! When someone is at significant risk for suicide, then they need to be treated in a way that is safe and effective. Voluntary outpatient treatment with someone who will not take suicide off the table is, to my way of thinking, neither safe, effective or ethical. The Hippocratic Oath is “do not harm.” And, as you point out, our laws will often hold the therapist responsible. To say I won’t work with someone with suicidal thoughts and fantasies would not be correct, however. I have had more than 30,000 hours of therapy with depressed individuals who feel hopeless and who have suicidal thoughts and fantasies. But when someone is at risk for an imminent suicide attempt, then they need more intensive therapy than voluntary weekly outpatient sessions. This is a life and death matter, and I will not play Russian roulette with the life of any patient.
My recommendations for treatment are not for everybody, that’s for sure! I do want to say that your comments struck me as a bit dismissive! I do, however, understand your concerns, and there is tremendous injustice and hatred in our society, especially for anyone who is a bit “different.”
Sincerely, david
Hi Sharon I also would agree with this, I am training to be a CBT therapist and I have a lot of past experiences of depression and suicidal Thoughts, and attempts and I can say from my point of view that back then if I had been turned away from this kind of therapy it would have made me worse (am I that broken?) is the question I would be asking myself. This rejection would have then acted as a resistance to team therapy.
Kind regards
Dale
Hi Dale,
I totally agree too! I never turn anyone away, except when people need to be involuntarily hospitalized, which is rare but it does happen.
At the initial evaluation, the patient is trying to decide if she or he wants to work with me, and I am trying to decide if I have the tools to treat someone effectively. The patient is not my patient until I have completed my evaluation, and proposed a course of treatment, and the patient agrees and decides to work with me.
During the initial evaluation time, i tell the patient how the treatment works, and what will be required. I also do a careful assessment for suicidal or homicidal urges. If I decide that the person is at risk for an active suicide attempt or violent action, I do not take chances but refer the patient to a more intensive treatment facility, or to an emergency room for evaluation for voluntary or involuntary treatment.
For example, my published research and clinical experience has indicated that psychotherapy homework compliance has a large causal effect on recovery. This effect can be so large that it kind of tells me who is going to benefit and recover, and who is not. So I inform new patients that IF they want to work with me, that the homework is absolutely necessary for effectiveness.
I am, in a sense, like a coach for the mind, and the exercises between sessions are necessary to learning the new skills. Same as tennis. You can talk to a coach once a week, but if you don’t practice the new shots between lessons, your game will not improve.
So I tell patients that I HOPE they will decide to work with me, and if they do, reasonably consistent psychotherapy homework will be necessary. I also remind them that there are tons of therapists out there, most, in fact, who will not require homework between sessions. And if they prefer to select that type of therapist, they are always welcome to return if it does not work out.
That puts the decision ALWAYS in the hands of the patient. Most of the time, the patient decides to work with me. If the patients decides he or she does not want what I’m offering, I feel like I’ve been really fair and open and letting them know up-front how the treatment works. To me that seems only fair!
I am a physician, and it is exactly the same in medicine. If you come to the emergency room with a broken arm, I will tell you that we wish to do an X-Ray to see what type of treatment to offer, possibly a cast.
If the patient says that he or she does not want to take an X-ray and does not believe in casts, that is also the patient’s decision.
I realize that not everybody will like or use the techniques and approaches I have developed! And I realize, sadly, that many mental health professionals are vehemently opposed to making patients accountable. My thinking is radically different, although when I was young, I also would have been opposed to making patients accountable. As my experience evolved, my thinking evolved as well.
So I’m not trying to “sell” my approach to anyone! However, I do want to emphasize that people sometimes like to put a rather negative (and insulting) “spin” on what I say. To my ear, it’s a bit annoying, in all honesty! People sometimes like to jump to conclusions and get very excited about finding this or that “flaw” in someone’s approach, and thinking one has all the “right” answers.
Sincerely, david
Hi David
Apologies if I seem over critical. I highly respect you and your work and is largely one of the reasons I got into wanting to learn more and to become a CBT therapist as your book feeling good especially helped me relieve some of my own feelings of despair and hopelessness. I guess what I should have said is that I’m finding it hard to distinguish why your work can’t be used to help someone even if they are in clinical care or hospital. I understand why it would be too risky for an independent therapist, but when I was suicidal and feeling at my worst, your book and other work helped me understand myself more then conventional CBT did. Would you be able to do a pod cast on how you could help someone with mild suicidal fantasies, if they are not at danger to themselves or other.
Again apologies if I seemed over critical.
Kind regards
Dale
Hi Dale, thanks, will do! Have you searched the podcasts for suicide. I did one I’m pretty sure on an inpatient I treated in a group at Stanford who had decided to commit suicide. All the TEAM-CBT stuff works great with patients with suicidal thoughts and fantasies as long as everyone, including the therapist, is protected! Warmly, david
Hi David
Thank you that would be fantastic, especially when using the assessment of resistance with these fantasies of suicide, I will also search the previous podcasts on suicide. Again thank you for been so helpful.
Warmest regards
Dale
Thanks, you might try searching for “burden.” Don’t know if it will work. The woman planned to kill herself because she had rapidly cycling bipolar disorder and told herself she was “a burden to my husband, my children, my parents, and my doctors, and they’d all be better off if I were dead.” The story is very dramatic and inspiring! Warmly, david