Podcast 34: Live Therapy Session with Mark: “I’ve been a failure.”
M = Methods (cont’d)
In the last podcast, David and Jill helped Mark challenge one of his negative thoughts, “There must be a defect in my brain that prevents me from developing a loving relationship with my son,” using Identify the distortions and the Paradoxical Double Standard Technique. In this podcast, they continue encouraging mark to challenge his negative thoughts using additional techniques, including the Externalization of Voices, which is arguably the most powerful Cognitive Therapy technique ever created. The goal of the Externalization of Voices is to create genuine and lasting change at the gut level.
Although it is one of the first cognitive Therapy techniques Dr. Burns created, it is rarely used by cognitive therapists in the United States, perhaps because it is so edgy, or perhaps because it is sophisticated and requires a high degree of therapist skill. The Externalization of Voices is often paired with another technique Dr. Burns created called the Acceptance Paradox. The goal of the Acceptance Paradox is a profound and lasting change in the patient’s core beliefs and values, and it sometimes triggers spiritual enlightenment, although it is an entirely secular method.
Jill and David also use the Semantic Method and Re-attribution in this segment, and end with a brief illustration of how Mark might interact differently with his son using the Five Secrets of Effective Communication. David and Jill emphasize that this is the “External Solution,” and that up to this point in the session they’ve been working on the “Internal Solution.”
In the next podcast, Jill and David will return to T = Testing to find out how Mark feels at the end of the session, and how he rates Jill and David for Empathy, Helpfulness, and other measures of the therapeutic relationship. At the end of the session, Dr. Burns asks Mark if the change was real, or simply something fake for the purpose of the podcast. At that point, something stunning happens, which turned out to be the highlight of the entire session. So stay tuned!
And thank you, so much, for your ongoing support of our efforts! We all greatly appreciate your many kind and encouraging comments and emails on our podcasts. That motivates us to work really hard (and joyously) to bring more of this kind of teaching to you!
One quick note. I do not answer messages from Facebook, as I am getting far more than I could ever attend to. Which is great, but sad for me since I don’t want people to feel ignored. The best way to contact me is to make comments at the end end of my blogs, as I often respond to those, or simply to contact me through my website, feelinggood.com.
Podcast 33: Live Therapy Session with Mark: “I’ve been a failure.”
M = Methods, part 1
So far, the therapy with Mark had focused on
T = Testing: David and Jill review Mark’s feelings at the start of the session
E = Empathy: David and Jill listen and provide empathy as Mark describes his feelings of shame and discouragement because of his failure to develop a loving relationship with his oldest son.
A = (Paradoxical) Agenda Setting: David and Jill find out what, if anything, Mark hopes to get out of this session, which appears to be complete relief from his negative thoughts and feelings. Then the bring his subconscious resistance to change to conscious awareness, and melt it away using the Magic Dial, Positive Reframing, the Acid Test, and the Magic Dial.
In this session, David and Jill began using M = Methods to challenge the Negative Thought Mark wants to work on first: “There must be something defective in my brain that prevents me from forming a loving relationship with my oldest son.” You may recall that Mark believed this thought 90%.
Do you know what the necessary and sufficient conditions are for feeling emotionally upset? The necessary condition is that you have a negative thought in your mind, such as “I’m a failure as a father,” or “There’s something defective in my brain,” but the mere presence of a negative thought will not generally trigger shame, depression, or anxiety. The sufficient condition for emotional upset is that you believe the negative thought. And if you review his Daily Mood Log from the last session, you’ll see that Mark does have a high degree of belief in all his negative thoughts. When you’re feeling depressed, anxious, inadequate, or hopeless, I suspect that your mind is also flooded with negative thoughts that seem entirely true to you.
Do you know the necessary and sufficient conditions for emotional change?
The necessary condition is that you can challenge the negative thought with a positive thought that is 100% true. Rationalizations and half-truths will never help anyone, at least not in my experience. But having a valid positive thought is not sufficient for emotional change. For example, Mark could tell himself that he’s a very high powered physician in a world-famous medical center, and that thought would be 100% true. But that thought won’t help Mark because he’ll still believe there’s something defective in his brain that prevents him from having a loving relationship with his son.
The sufficient condition for emotional change is that you can generate a positive thought that is 100% true, and in addition it has to crush the negative thought. In other words, the very moment you stop believing the negative thought that triggers your angst, in that very instant you will experience emotional relief, and the change will usually be dramatic.
But how can we challenge Mark’s belief in the NT. Remember, he is incredibly intelligent, and he’s been hooked on this NT for decades. So we can’t just tell him to cheer up, or encourage him to think more positively, or reassure him that his brain is A-Okay. Not only will those simplistic approaches fail, they would likely annoy him because they sound patronizing and might convey the message that’s he’s an idiot for believing something so ridiculous.
Instead, as a TEAM-CBT therapist, I think of 15, 20 or even more powerful and innovative techniques that I can use to gently guide the patient to his or her own discovery that the negative thought is simply not true. That’s what we do during the M = Methods portion of a TEAM-CBT session.
You will listen as David and Jill generate Next, Jill and David generate a Recovery Circle, selecting 16 techniques they could use to help Mark challenge the Negative Thought in the middle of the Recovery Circle. To see the Recovery Circle, CLICK HERE. David and Fabrice discuss the rationale for the Recovery Circle–you never know what technique is going to work, since people are quite different. One of the many unique and arguably powerful aspects of TEAM-CBT is the use of more than 75 techniques drawn from more than a dozen schools of therapy.
One of the first methods we use is so basic that it is programmed right into the Recovery Circle, and it’s called Identify the Distortions. Fairly early in today’s recording, Jill and David will ask Mark to identify the distortions in his Negative Thought (NT), “There must be something defective in my brain that prevents me from forming a loving relationship with my oldest son.” At that point, Fabrice will ask you to pause the recording and see how many distortions you can identify in the thought. You can write them down on a piece of paper, or simply print the linked PDF and identify them with check marks on the list of 10 cognitive distortions from my book, Feeling Good: The New Mood Therapy. CLICK HERE FOR TEN COGNITIVE DISTORTIONS
After Mark identifies the distortions in his Negative Thought, Jill and David encourage him to challenge it, using a variety of techniques on the Recovery Circle, starting with the Paradoxical Double Standard Technique. This is a gentle technique that is often effective for people who are compassionate. Because this technique seems to be helping, they ask Mark to record his positive thought in the Daily Mood Log, and to indicate how strongly he believes it. Then you will see that Mark’s belief in the Negative Thought is reduced to zero if you CLICK HERE.
In the next podcast, David and Jill will continue with the Methods portion of the session using additional techniques on the Recovery Circle. This will be a unique opportunity to hear many of these techniques in real time with a real person, as opposed to simply reading about them in a book. So–stay tuned to our Feeling Good Podcasts–and thank you so much for your enthusiastic support!
Part 4—A = Paradoxical Agenda Setting (PAS, cont’d
As the session continues, Jill and David encourage Mark to develop his list of positives. Mark draws a blank at first. This is very common among patients and therapists alike. Most of us have not been trained to think about depression, anxiety, shame, defectiveness, hopelessness and anger as being good or positive. In fact, we think of them as symptoms of “mental disorders,” according to the DSM (Diagnostic and Statistical Manual of the American Psychiatric Association.) So we think of them as bad, something to get rid of, something needing treatment.
But after David and Jill prime the pump, Mark is surprised that they quickly come up with a list of 16 positives that are real and powerful. At this point, they ask Mark why in the world he’d want to press the Magic Button and have all of his symptoms suddenly disappear–given all these positives. This is called the Acid Test and it’s also paradoxical. David and Jill have now become the resistant part of Mark’s subconscious mind–the part that clings to these symptoms. And when the therapists become the voice of the resistance, the patient will nearly always become the voice that argues for change.
The paradox is resolved with the Magic Dial. Toward the end of this podcast, you will want to review Mark’s Daily Mood Log, with the Goal column filled out on the table of negative emotions.
David points out that there is no single tool or technique that triggers recovery in patients. Instead, each component of T E A M contributes in radically different ways to the substantial or even dramatic improvement the therapists are hoping to bring about it today’s session.
In the next Podcast, David and Jill will begin the M = Methods portion of the session.
Part 3—A = Paradoxical Agenda Setting (PAS), Initial Segment
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
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.
After reviewing Mark’s scores on the Brief Mood Survey, the Empathy phase of the session unfolds. During this phase of the session, David and Jill will not try to help, rescue, or save Mark. They will simply try to see the world through his eyes and provide some warmth and compassion.
Mark explains that he had two goals in life when he was a young man. He hoped to have a large, loving family; and wanted to become a skillful and compassionate physician. Although he has achieved the second goal, he has felt sad and guilty for decades because of his failure to develop a loving relationship with his oldest son from a previous marriage.
While Mark tells his story, David and Jill encourage him to record his negative thoughts and feelings on a form called the Daily Mood Log, and to rate how strong each feeling is, on a scale from 0% (not at all) to 100% (the most extreme).
As you can see, Mark has many different kinds of negative feelings ranging in severity from 30% (moderate) to 80% (severe).
If you’ve been listening to the Feeling Good Podcasts, you know that negative feelings do not result from what’s actually happening in our lives, but rather from our negative thoughts about what’s happening. David and Jill encourage Mark to record his negative thoughts on the Daily Mood Log as well, and to indicate how strongly he believes each one on a scale from 0% (not at all) to 100% (completely).
You can also see that Mark is telling himself that he’s been a failure as a father, that his brain is defective, and that he is not doing a good job for David and Jill. These thoughts all involve self-blame. You’ll notice that he also has two other-blaming thoughts. This is not unusual. When you’re not getting along with someone, you may spend part of your time telling yourself that the problem is all your fault, and part of your time telling yourself that it’s someone else’s fault. As a result, your negative feelings may shift back and forth from guilt and shame to anger and resentment.
Most therapists would not interrupt and ask their patients to record their negative thoughts and feelings while they are venting. However, this information will prove to be incredibly valuable later in the session.
Jill and David ask Mark how they’re doing on empathy. If Mark gives them a high rating, they will go on to the next phase of the session, called Paradoxical Agenda Setting. That’s where they will find out what, if anything, Mark wants help with, and see if he has any conscious, or subconscious, resistance to change.
Podcast Live Therapy Session: “I’ve been a failure.”
This is the first in a series of podcasts that will feature live therapy. As you listen, you’ll have the opportunity to peak behind closed doors to see how TEAM-CBT actually works in a real-world setting, and not role playing.
The patient is a physician named Mark who has been haunted for decades by a problem with his oldest son, and he feels like a failure as a father. Although the facts of your life are likely to be very different, you might understand what it’s like to feel like a failure, or to tell yourself that you’re defective, or simply not good enough.
The two co-therapists include David and his highly-esteemed colleague, Dr. Jill Levitt. We have broken the session down into a number of podcasts that will include excerpts from the session along with commentaries on the thought patterns of these two master therapists as the session unfolds.
Part 1—T = Testing
As the session begins, David and Jill review of Mark’s scores on the Brief Mood Survey (BMS), which he completed just before the session began. The scores indicate that Mark is only feeling mildly depressed, anxious, and angry, but is extremely dissatisfied with his relationship with his son.
At the end of the session, David and Jill will ask Mark to complete the BMS again. By comparing his patient’s scores at the start and end of the session, they will be able to see exactly how effective, or ineffective, the session was. Mark will also rate David and Jill on Empathy, Helpfulness, and several other important dimensions.
Testing at the start and end of every therapy session is one of the new and unique components of TEAM therapy. The testing can revolutionize psychotherapy, because therapists can fine-tune their therapeutic strategies based on the scores, and make critical important changes if the session was not particularly helpful. However, the assessment instruments are extremely sensitive and pick up the smallest therapeutic errors. This can be quite threatening to therapists who don’t want to be held accountable.
In this Podcast, David and Fabrice discuss the fourth powerful model in the treatment of anxiety—the Motivational Model. The key here is bringing the patient’s subconscious resistance to conscious awareness, and melting it away with paradoxical techniques. This is absolutely critical if you are hoping to see a complete elimination of symptoms in any type of anxiety.
You may recall that the Outcome Resistance for anxiety disorders usually results Magical Thinking—the anxious patient may be suffering intensely and asking for help, but secretly believes that something terrible will happen if the treatment is successful and the anxiety disappears. In other words, most anxious individuals are convinced that the anxiety is protecting him or her from some catastrophic event.
David brings this concept to life with a dramatic description of his treatment of a young man named Sam who’d been struggling with intense PTSD—Post-Traumatic Stress Disorder— for six months following a traumatic interaction with two sadistic gunmen.
David and Fabrice also discuss metaphors for understanding how healing actually occurs. Most therapists think of depression and anxiety as mountains that have evolved slowly, over years or decades. They sometimes also believe that treatment and recovery will also requires years and years of treatment, with very slow progress. Of course, if the therapist and patient believe this it will function as a self-fulfilling prophecy.
In sharp contrast, David describes a new way to think about recovery, as something extremely rapid, a personal transformation that happens suddenly, within a very brief time period within a therapy session. But this remarkable phenomenon is only possible when the patient’s resistance to change has been skillfully and compassionately addressed by the therapist. At that point, the patient and therapist are on the same TEAM, working together collaboratively. Then, amazing changes can often unfold quickly.
Plans for future Feeling Good Podcasts will include a series of fascinating podcasts that will feature an actual live therapy session, with David and his colleague, Dr. Jill Levitt, acting as co-therapists, including commentaries on how each step of T.E.A.M. is being implemented. This will give you the unique opportunity to look behind closed doors so you can observe actual healing taking place.
In addition, a future “Ask David” podcast is planned, as well as a podcast on “The Truth about Benzodiazepines,” plus podcasts featuring more treatment methods for anxiety such as Interpersonal Exposure Techniques and Cognitive Flooding. Dr. Burns also promises a fascinating Feeling Good Podcast on the use of the Five Secrets of Effective Communication with violent individuals who are threatening, hostile, and dangerous.