102: Helping the Suicidal Patient

102: Helping the Suicidal Patient

The Prediction and Prevention of Suicide

Dr. Maor Katz, the founder of the Feeling Good Institute in Mt. View, California, asked if we’d do a show on the Prediction and Prevention of Suicide, so his staff could learn about the unique approach I have developed. Dr. Fabrice Nye and I were delighted to devote today’s show to this topic.

Suicidal thoughts and urges are very common among depressed patients. The vast majority of depressed individuals have thoughts of suicide from time to time, and some struggle with serious suicidal urges. The experts tell us that 10% to 15% of chronically depressed individuals do eventually commit suicide, even if they are receiving treatment for depression. It is hard for me to believe that suicide is that common, but even if it is only 2% or 3%, that’s still very significant, especially if you have a large clinical practice and you treat lots of depressed individuals.

Suicide attempts are shocking and devastating for the patient, for the family, and for the therapist as well. The loss of a patient through suicide is the dark side of our profession. The loss of life is a horrible and unnecessary tragedy, since the feelings of hopelessness that trigger suicidal urges are always the result of cognitive distortions; the belief that you are hopeless and cannot improve is never valid. Yet, the depressed patient does not realize this, and sometimes turns to suicide as the only way out of his or her suffering.

Sadly, clinicians’ capacity to assess suicidal urges in patients they are treating is very poor. In fact, in a research study I did, experts estimated how suicidal patients were feeling at the end of a several hour diagnostic interview at the Stanford Hospital. The patients recorded how suicidal they were actually feeling at the exact same time. Surprisingly, the patients’ and experts’ assessments were not significantly correlated. In other words, the experts accuracy in detecting suicidal fantasies and urges was zero. that’s one reason so many patients in treatment do commit suicide–because the therapist simply did not realize the patient was feeling that way.

In this podcast, I describe how you can solve this problem with the use of the EASY Diagnostic System and a systematic suicide interview, if needed, at the initial evaluation, and the use of the Brief Mood Survey at all subsequent sessions, with no exceptions.

In this podcast, I focus on two things. First, how can the clinician identify and evaluate a new (or old) patient who is struggling with suicidal thoughts and fantasies and determine if the patient is at risk for a suicide attempt? Second, how can the therapist make the patient accountable and guarantee that the patient will not now, or ever, make a suicide attempt?

The “defensive psychotherapy” I recommend will sound unfamiliar and maybe even shocking to many therapists but can save lives and make your practice far more peaceful and rewarding. The approach to the suicidal patient involves Paradoxical Agenda Setting techniques, including the Gentle Ultimatum, Sitting with Open Hands, and Fallback Position.

I hope you enjoyed today’s podcast on a very serious topic!

David

 

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101: Therapy Wars–REBT vs TEAM: Mirror, mirror, on the wall . . .

101: Therapy Wars–REBT vs TEAM: Mirror, mirror, on the wall . . .

A fan who wishes to remain anonymous (we’ll call him Jim) wrote a thoughtful question based on an internet video he’d just watched on The REBT Advocate’s YouTube channel, featuring Tommy Bateman and Dr. Michael Edelstein. One of their listeners had asked what they thought about the new TEAM-CBT developed by Dr. David Burns. They said they were not terribly familiar with TEAM, but looked it up on Wikipedia, and had three criticisms:

  1. The T = Testing is not important or desirable since you can just ask patients how they’re doing, and if they keep coming, it must mean you’re doing a good job. Testing, they think, is an artificial attempt to “dress up” the therapy and makes the treatment too clinical and impersonal!
  2. E = Empathy is not important, either, because patients pay good money to get help, and not to feel validated. Self-help books, they say, wouldn’t help if empathy was important.
  3. A = (Paradoxical) Agenda Setting is also unimportant. Resistance does not need to be addressed in treatment, since patients can go elsewhere if they aren’t getting the help they want.

This is what “Jim” concluded after listening to the REBT podcast:

“I don’t think they know as much about TEAM as they claimed. It made me angry that they were dismissing it so flippantly. Maybe you can invite yourself to talk on their podcast!

“I appreciate your approach to therapy a lot, even if I don’t always agree with you. I have watched every episode of your Feeling Good Podcasts and find the live therapy sessions especially intriguing!”

Sincerely, “Jim”

Thanks for the great question, Jim, and I appreciate your comments! Fabrice and I took a quick look at the video you saw on line and I strongly resonated with your assessment. Although there was value in all of their criticisms–there is ALWAYS truth in any criticism– I agree that they perhaps didn’t really grasp TEAM. And, like you, I found the comments flippant and disrespectful, kind of like a series of hurtful put-downs, rather than an attempt to grasp the potential value of something new or an invitation to meaningful and respectful dialogue.

I felt a bit angry, to be honest!

And I might add that in my interactions with Dr. Albert Ellis, the creator of REBT, I always found him to be incredibly respectful, warm, and supportive of my work. He was THE BEST, in my opinion! Toward the end of his career, he actually changed his mind about the importance of empathy, based on my research, and decided that empathy could, in fact, be helpful. I have many fond memories of times we talked and will always be grateful for his work and career; and also for his wonderfully wild, wacky and incredibly genuine and real personality!

Dr. Ellis was famous for his outrageous–and usually brutally honest and accurate–comments about other schools of therapy. And  I have to confess that sometimes I’ve also been guilty of dismissing competing schools of therapy in a flippant way, and I’ve gotten rightfully battered for that at times. People don’t like that type of adversarial dialogue for the most part. When I slip up and try to promote myself in a narcissistic way, it’s mostly thumbs down! But it sure can be tempting!

The perceived lack of empathy in some REBT therapists was actually one of Dr. Aaron Beck’s motivations for creating Cognitive Behavioral Therapy (CBT), which evolved about ten years after Dr. Ellis created REBT. CBT shares much in common with REBT, but with a greater emphasis on research to find out what really works, and empathy and the therapeutic alliance. CBT was also the first school of therapy to emphasize testing at every session to assess therapeutic progress, or the lack of progress.

The adversarial attitude of putting down the competition is at the heart of the “therapy wars,” with everyone claiming to have the “best” approach and dismissing other approaches. But if you look at all of the outcome studies of psychotherapy for depression or anxiety, for the most part, nothing comes out much better than treatment with placebos. So perhaps an attitude of humility, curiosity, and openness to new approaches would be more productive and appropriate.

The comments of Dr. Edelstein and Mr. Bateman were especially hard for me to hear, since I’ve always been a huge fan of Dr. Albert Ellis and I have so many respected friends and colleagues who are REBT therapists. I’ve always felt the contributions of Dr. Ellis to the field were legendary, and I’ve always supported and admired him.

My goal in TEAM has never been to create yet another competing school of therapy, but rather to create a systematic, data-driven approach to therapy based on process research on what works and what doesn’t work. I am convinced that therapists from any school of therapy who use T = Testing and work hard to improve their E = empathy skills will experience improved outcomes.

A = (Paradoxical) Agenda Setting is also important. Learning to melt away patient resistance and boost patient motivation can dramatically speed recovery, and is one of the most important components of TEAM! And I think that virtually all therapists, and especially REBT therapists, will have to admit that they have many patients who DO “yes-but” them and resist their efforts to help or persuade their patients to change.

But what does the research show? Is there any solid evidence for the various components of TEAM? At the end of these show notes, I have compiled a list of just a few of the published, peer-refereed studies that have led to the development of TEAM, and you can hear a summary of some of these studies on today’s podcast.

In a nutshell, here are a few of the highlights from research:

  • Session-by-session testing has been shown to improve therapeutic outcomes.
  • Research indicates that therapists’ perceptions of how their patients feel, and how their patients feel about them, are not accurate, and are frequently wildly inaccurate. This can have life and death implications, for example, in treating depressed patients with episodic suicidal impulses.
  • Therapeutic empathy has a direct causal impact on reducing depression. However, the magnitude of the effect is small. However, therapeutic empathy and trust can enhance, and even make possible, the therapeutic effects of other more powerful techniques.
  • Patient motivation is the only variable in the world literature that has been shown to have large causal effects on recovery from depression.

Finally, I’ll share an email I just received from another Feeling Good Podcast fan. It kind of cheered me up from the funk I was in after watching the REBT folks rip into TEAM!

Hi Dr. Burns,

I really enjoyed the recent Feeling Good Podcast on how you overcame many challenges to get your book published (podcast #99, the interview with Nicole Bell). I love the fact that you require measurement before and after every session as well as homework. Hope you and your great work will continue to take your field out of the Dark Ages. I suspect you won’t have much difficulty publishing your new book, Feeling Great!

Phil

David

T = Testing, E = Empathy, A = (Paradoxical) Agenda Setting–
What can we learn from research?

Research on Testing

Boswell, JF, Kraus, DR, Miller, SD & Lambert, MJ (2013). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, DOI: 10.1080/10503307.2013.817696 (2013)

Hatcher, R. L., Barends, A., Hansell, J. & Gutfreund, M.J. (1995). Patients’ and therapists’ shared and unique views of the therapeutic alliance: An investigation using confirmatory factory analysis in a nested design. Journal of Consulting and Clinical Psychology, 63(4), 636 – 643.

Research on Therapeutic Empathy

Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive – behavioral therapy: a structural equation model. Journal of Consulting and Clinical Psychology, 60(3): 441 – 449.

Burns, D. D., & Auerbach, A. (1996). Therapeutic Empathy in Cognitive – Behavioral Therapy: Does it Really Make a Difference? Chapter 7 in Frontiers of Cognitive Therapy (P. Salkovskis, ed. ) New York: Guilford Press, pp. 135 – 164.

Eisen, K. P., & Burns, D. D. (2007). Getting specific about “non-specific” factors: The role of therapeutic alliance in cognitive therapy. Psicologia Brasil (Psychology Brazil).

Krupnick, J. L. et al. (1993). The role of the therapeutic alliance in psychotherapy and psychotherapy outcome: Findings in the NIMH treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64(3), 636 – 643.

Orlinsky, D. E., Grawe, K., & Parks, B. K. (1995). Process and outcome in psychotherapy–Noch einmal. Chapter 8 in A. E. Bergin & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavioral Change (pp. 270 – 376). New York: John Wiley & Sons, Inc.

Persons, J., & Burns, D. D. (1985). Mechanisms of action of cognitive therapy: Relative contributions of technical and interpersonal intervention. Cognitive Therapy and Research, 9(5): 539 – 551.

Research on Therapeutic Resistance / Motivation

Burns, D. D., Adams, R., & Anastopolous, A. (1985). The role of self – help in the treatment of depression. Chapter 19 in Handbook for the Diagnosis, Treatment and Research of Depression, (Beckham, E. E. and Leber, W. R., eds. ), Homewood, II: Dorsey Press, pp. 634 – 669.

Burns, D. D., Shaw, B. F., & Crocker, W. (1987). Thinking styles and coping strategies of depressed women: An empirical investigation. Behavior Research and Therapy, 25(3): 223 – 225.

Burns, D. D., & Nolen-Hoeksema, S. (1991). Coping styles, homework compliance and the effectiveness of cognitive – behavioral therapy. Journal of Consulting and Clinical Psychology, 59(2): 305 – 311.

Burns, D. D., & Spangler, D. (2000). Does psychotherapy homework lead to changes in depression in cognitive behavioral therapy? Or does clinical improvement lead to homework compliance? Journal of Consulting and Clinical Psychology, 68(1): 46 – 59.

Burns, D. D., & Spangler, D. (2001). Can We Confirm Our Theories? Can We Measure Causal Effects? A Reply to Kazantzis et al. (2001). Journal of Consulting and Clinical Psychology, 69(6), 1084-1086.

Burns, D. D., & Auerbach, Arthur H. (1992). Do self – help assignments enhance recovery from depression? Psychiatric Annals, 22(9): 464 – 469.

Burns, D., Westra, H., Trockel, M., & Fisher, A. (2012) Motivation and Changes in Depression. Cognitive Therapy and Research DOI 10.1007/s10608-012-9458-3 Published online 22 April 2012

Burns, D. D. (March / April, 2017). When helping doesn’t help. Psychotherapy Networker, 41(2), 18 – 27, 60. https://www.psychotherapynetworker.org/blog/details/1160/when-helping-doesnt-help

Persons, J.B., Burns, D.D., & Perloff, J.M. (1988). Predictors of dropout and outcome in cognitive therapy for depression in a private practice setting. Cognitive Therapy and Research, 12, 557 – 575.

 

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100: The New Micro-Neurosurgery–A Remarkable Interview with Dr. Mark Noble!

100: The New Micro-Neurosurgery–A Remarkable Interview with Dr. Mark Noble!

How Does TEAM-CBT Affect the Brain?

The famed neuroscientist, Dr. Mark Noble, from the University of Rochester, has developed a strong interest in TEAM-CBT and has visited our Tuesday group and Sunday hikes on three occasions this year. I (David) feel very fortunate to have his collaboration and interest!

IMG_2402

Mark and David at the Cupertino Plaza for a sumptuous dim sum feast at the Joy Luck Palace following a Sunday hike.

Mark is a Stanford-trained geneticist and molecular biologist who is considered one of founders of the field of stem cell research. He has been developing a model of how TEAM-CBT affects the brain, and graciously agreed to present his model at our Tuesday evening Stanford TEAM-CBT seminar last week. Although his model is not yet fully polished and refined, and involves considerable speculation, it is an exciting first step, kind of like the time when astronomers broke away from the Catholic church and started trying to make sense of the universe. In this instance it is the “inner universe” Dr. Noble, all of us, are trying to understand. His model will evolve and get more and more refined over time.

The participants in the seminar really liked his concept that we are doing micro-neurosurgery for depressed patients with TEAM-CBT! He is convinced that the rapid recovery we see with TEAM-CBT will probably never be equaled by medication, since the brain circuits that modulate happiness and unhappiness tend to use the same neurotransmitters. But with language, you can affect brain circuits far more selectively and effectively, almost like a micro-neuro-surgeon.

Dr. Noble describes brain function in terms of the SNEFF model. This stands for Structures, Networks, Emotions, Frames and Filters, and links these concepts to the prefrontal cortex, amygdala and sympathetic nervous system. Then he describes the four steps of TEAM (T = Testing, E = Empathy, A = (Paradoxical) Agenda Setting, and M = Methods), and links each step to the SNEFF model, making interesting speculations on how TEAM works and what makes it so effective.

Dr. Noble also discusses David’s “fractal” theory about psychotherapy and relates that to brain function as well as to the mathematics of complex structures. He describes how and why some people get stuck in the “homeostasis” of chronic, refractory depression and explains why TEAM-CBT is usually able to trigger sudden and dramatic changes in the brain, as well as in the way the depressed and anxious individual thinks, feels, and behaves. He also explains why conventional talk therapy is unlikely to be helpful for individuals struggling with depression and anxiety, and may, in some cases, make the depression worse.

This is because neurons that “fire together wire together.” In other words, if you go to therapy and complain or emote about your life and your problems over and over, without taking action to change, the circuits in your brain that support complaining and feeling depressed will just get more and more intensely wired together.

Dr. Noble also speculates on why Paradoxical Agenda Setting is such an important key in ultra-rapid-recovery and in the sudden transformation of brain function as well.

Years ago, when I was kid on vacation in Minnesota, I saw an article in a small newspaper published in a rural area. A local scientist had speculated that one day we would have guided missiles and satellites and drew a simple diagram for the newspaper of how they would work. At the time it seemed a bit like science fiction, and I wondered if an unknown scientist from a small rural Minnesota town could actually predict a major scientific development. But now we see that he was right.

Will we someday think about Dr. Noble in the same way? Listen to this exciting podcast, and you can decide for yourself!

You might be interested in some of the comments from individuals who attended the Stanford seminar and heard Dr. Noble’s talk:

  • Mark’s work was wonderful in helping me understand the map of TEAM onto the brain. We’re all micro-neurosurgeons!! Everyone has honorary MDs!
  • Loved the presentation!
  • Mark’s presentation was fascinating! I got really excited about all of the interesting research that could come out of it.
  • I absolutely appreciated Mark’s presentation on his research and how made the connections with TEAM. This was truly very interesting and helpful, and made me realize how fortunate I am to belong to this Tuesday group!
  • Interesting new perspectives brought in by our guest speaker
  • I highly enjoyed Mark’s visit and was captivated by the information! Thank you!
  • Loved learning how frames and filters interact to build experience.
  • AWESOME PRESENTATION! It was wonderful to hear Mark’s presentation. He did an outstanding job and I was extremely fascinated with the information he presented to us. He did a fantastic job in describing brain functioning in relation to TEAM CBT. Loved every minute of it!
  • I loved the concept of fractals in creating the concentrated surge of change into the next “valley” rang true.
  • I resonated with the importance of “storytelling” and the value of a client being heard and respected when the therapist uses the Five Secrets of Effective Communication, and how this induces a sense of the client being equal, and how that can quiet the agitated brain!

David

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Attend my 2018 Summer Intensive in San Francisco!

This year, I am again offering my annual SF summer intensive in August at the South San Francisco Conference Center. This four-day intensive is almost always my most exciting and rewarding workshop of the year.

Here are the details:

David’s TEAM-CBT Summer Intensive

August 6 – 9, 2018, South San Francisco Conference Center, California

For more information, click here, or call IAHB.org at 800-258-8411

Here are just a few of the really cool things about this intensive:

  • You will have the chance to practice techniques in small groups after I demonstrate each technique with a live demonstration in the front of the room.
  • You will get immediate feedback and personal grooming from me and from many of my colleagues from my weekly TEAM-CBT training group at Stanford. They’ll be there to help you, and I’ll be there to help you, too!
  • There will be a live demonstration on the evening of day 1. The amazing Dr. Jill Levitt will be my co-therapist. Last year’s live demonstration, and in fact all of them in recent years, have been jaw-dropping and incredibly inspirational!
  • You’ll get a chance to practice TEAM-CBT in real time the evening of day 3. This will be an incredibly challenging but rewarding “solo flight.”
  • You will be able to do your own personal work on the last day of the workshop using the Externalization of Voices and Acceptance Paradox. In previous workshops, at least 60% of the participants indicated they experienced jubilant enlightenment during this exercise. Their fears and insecurities suddenly vanished!
  • You’ll learn how to do Relapse Prevention Training (RPT).
  • You’ll learn how to improve your empathy skills.
  • You’ll learn tons of powerful cognitive, behavioral, and motivational treatment techniques for depression and all of the anxiety disorders.
  • You will have the abundant opportunities to schmooze with colleagues, network, and have fun.
  • You will have two fabulous free luncheon banquets featuring talks by Sunny Choi, LCSW, who is using TEAM-CBT successfully with an underserved population in primary care with limited resources and language skills (“I must apologize for my success.”), and the wonderful Vandana Aspen, PhD, who will speak on “New Treatment Strategies for Eating Disorders.”)
  • And much more.

If you can only attend one of my workshops this year, the South San Francisco August intensive is the one to attend!

 

099: Nicole Bell’s Incredible Interview with Dr. David Burns

099: Nicole Bell’s Incredible Interview with Dr. David Burns

Behind His Brilliance: Critical Thinking

Lisa Nicole Bell is the host of the highly regarded podcast, Behind the Brilliance. In this lively interview, Nicole and David talk about

  • David’s path into the mental health field
  • the difficulties and rejections David faced getting his first book, Feeling Good, published
  • David’s advice to listeners interested in therapy
  • how he approaches perfectionism, depression, and anxiety with patients
  • the joys of a life free from the need to be special—
  • and much more!

Click here if you’d like to learn more about Nicole and hear more of her fantastic interviews! Lisa’s show delivers a smart and funny take on pursuing ambitions, designing a life, and living joyfully. Lisa’s most recent media work includes producing an Australian documentary on identity and gender politics within sports and a digital docu-series produced by Academy Award-winning actress Viola Davis.

092: Feeling Good Now

092: Feeling Good Now

David and Stephanie James, part 1

Hi everybody!

I recently did the first of three interviews with Stephanie James on her superb radio show and podcast, The Spark.  Here’s how Stephanie described the interview (with minor changes):

We have amazing power within us to change our thoughts, our feelings, our actions, and our lives.

This episode is an inspirational way to take control of your automatic negative thoughts today and transform them in order to create a more joyful present and a more fulling future.

Join us as we talk with the legendary Dr. David Burns about how we can break through the old thinking habits that bind us and begin to live a more happy, harmonious life where we can feel good now.

Stephanie is a superb therapist and dynamic radio personality from Colorado. It was an honor to be on her show. She is co-authoring a book on how to live a “spark-filled life.” It should be completed soon, so you’ll likely be hearing from Stephanie a lot next year!

Following the interview, Stephanie visited my Tuesday training group at Stanford and participated in one of our Feeling Good Podcasts with some students in the group. She suggested we might want to broadcast the Tuesday group live so that therapists from all over the world could join us. We are thinking about that, but will have to check with the powers that be to see if we could get permission to broadcast from Stanford, as well as our Tuesday group members who may have mixed feelings, due to the intensely personal nature of the training.

Let me know what you think about this idea!

My second interview with Stephanie was on the evolution of traditional Cognitive Behavioral Therapy (CBT) into the new TEAM-CBT. Fabrice and I will publish it for you shortly. My third interview with Stephanie will be on the interpersonal TEAM model—how to convert conflicted relationships into loving, rewarding ones.

* Copyright © 2018 by David D. Burns, MD

 

Fabrice and I hope you like our Feeling Good Podcasts, and also hope you can leave some positive comments for us and five star ratings if you like what we’re doing!

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Attend a Summer Intensive!

This year, I am offering a July summer intensive in Whistler, Canada, and one in August at the South San Francisco Conference center. The intensives are almost always my most exciting and fun workshops of the year. Hope you can join us at one of these locations.

Here are some details:

Advanced Cognitive Behavioral Therapy: 

A Four-Day Intensive Training in TEAM-CBT

July 3 – 6, 2018 Whistler, BC, Canada

For more information, contact Jack Hirose & Associates Inc.
Phone: 604.924.0296, Toll-free: 1.800.456.5424

* * *

High Speed, Drug Free Treatment of Depression and Anxiety Disorders–

A Four-Day

Advanced TEAM-CBT Intensive

August 6 – 9, 2018, South San Francisco Conference Center, California

For more information, click here, or call IAHB.org at 800-258-8411

If you can only attend one of my workshops, consider attending one of these intensives!

 

 

 

091: The Celebration of Failure

091: The Celebration of Failure

Feeling Good: The Real Story

Hi everybody!

In the interview with Roy Germano in the last podcast you learned about how challenging it was to get my first book, Feeling Good, published. In this podcast, you’ll hear the story of what happened after it was published.

I had a magical fantasies of what would happen once I was an “author.” The reality was quite the opposite and quite painful, with almost endless rejections accompanied by feelings of self-pity and defeat. For example, soon after publication, I learned my book was at the top of my publisher’s “loser list.” Then I discovered that magazines, newspapers, and TV and radio shows had no interest in it whatsoever.

I hope you enjoy the story. It’s all about the celebration of failure and the conversion of failure into success.

* Copyright © 2018 by David D. Burns, MD

Fabrice and I hope you like our Feeling Good Podcasts, and also hope you can leave some positive comments for us and five star ratings if you like what we’re doing!

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Attend a Summer Intensive!

This year, I am offering a July summer intensive in Whistler, Canada, and one in August at the South San Francisco Conference center. The intensives are almost always my most exciting and fun workshops of the year. Hope you can join us at one of these locations.

Here are some details:

Advanced Cognitive Behavioral Therapy: 

A Four-Day Intensive Training in TEAM-CBT

July 3 – 6, 2018 Whistler, BC, Canada

For more information, contact Jack Hirose & Associates Inc.
Phone: 604.924.0296, Toll-free: 1.800.456.5424

* * *

High Speed, Drug Free Treatment of Depression and Anxiety Disorders–

A Four-Day TEAM-CBT Advanced Intensive

August 6 – 9, 2018, South San Francisco Conference Center, California

For more information, click here, or call IAHB.org at 800-258-8411

If you can only attend one of my workshops, consider attending one of these intensives!

 

 

090: Interview from The Other Side

090: Interview from The Other Side

Finding Happiness without Antidepressants

Hi everybody!

I was recently interviewed by author, professor, and documentary filmmaker Roy Germano for his outstanding Other Side Podcast. Fabrice and I thought you might enjoy this interview, and Roy graciously gave us permission to share it with you.

You will get some personal glimpses into the early days of my career, including why I left academics to pursue a full-time private practice, along with some of controversies about antidepressants. You will also hear a story of what happened when I was trying, rather unsuccessfully, to get my first book, Feeling Good, published. It wasn’t easy, and it almost didn’t happen!

Roy is terrific and his podcasts cover a wide range of topics. You can find his podcasts on iTunes,

* Copyright © 2018 by David D. Burns, MD

 

Fabrice and I hope you like our Feeling Good Podcasts, and also hope you can leave some positive comments for us and five star ratings if you like what we’re doing!

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At least one listener has had problems leaving an iTunes review from his i-phone, so Fabrice has created some simple to follow instructions if you need help.

Coming in June! One of my best two-day workshops ever!

Register Now!

“Scared Stiff: Fast, Effective Treatment for Anxiety Disorders”

A two-day workshop Sponsored by Jack Hirose & Associates

Mike Christensen and several others will be joining me at both locations to help out with supervision of the small group exercises. You’ll LOVE this workshop and you’ll learn TONS of powerful techniques to treat every type of anxiety. You’ll learn how to heal your clients and your own feelings of insecurity and self-doubt as well!

David

 

 

Enjoy David’s Fabulous Canadian Summer Intensive!*

Enjoy David’s Fabulous Canadian Summer Intensive!*

Coming in July! My annual Canadian summer intensive!

“Advanced Cognitive Therapy for
Depression and Anxiety Disorders”

Whistler, BC, Canada
July 3 – 6, 2018

This brief video will explain why you should attend!

For workshop description / registration details, click–Jack Hirose & Associates Inc.
Phone: 604.924.0296, Toll-free: 1.800.456.5424

You’ll LOVE this workshop and you’ll learn TONS of helpful techniques to treat depression, anxiety disorders, and habits and addictions.

You’ll have your evenings free to enjoy the beautiful Whistler countryside, and I will likely offer optional evening hikes as well, with opportunities for personal work and consultation.

You’ll learn how to heal your clients and your own feelings of insecurity and self-doubt as well!

Mike Christensen and several others will be joining me at Whistler to help out with supervision of the small group exercises. Mike and I will also be doing a live therapy demonstration with an audience volunteer on the morning of day 2. Mike is a tremendous teacher and therapist, and a highly esteemed friend and colleague.

I hope you can join us in Whistler!

Solution to David’s Tuesday Tip #3*

Solution to David’s Tuesday Tip #3*

Here’s yesterday’s paradoxical tip #3

Therapists’ perceptions of how patients feel–the severity of symptoms–tend to be extremely inaccurate, at best, but most therapists are not aware of this.

What does this mean? Is it true? And if so, what are the consequences?

Is there a solution to this problem? And what, if anything, does the solution have to do with the first of four “Great Deaths” of the therapists ego?

Here’s Dr. David’s solution

My research and clinical experience have indicated that therapists’ perceptions of how their patients feel, and their patients feel about them, can be (and usually are) extremely inaccurate. What this means, in practical terms, is that a patient may be feeling intensely depressed and even suicidal, and yet the therapist thinks the patient is doing well. Or, the patient may be doing reasonably well, but the therapist thinks he or she is still severely depressed.

This inaccuracy involves all the negative emotions–such as depression, anxiety, and anger–and all the positive emotions as well. But since most therapists do not routinely assess patients’ feelings with brief accurate tests at every session, therapist do no know how “off” their perceptions can sometimes be. And while I do not mean to be alarmist, this can sometimes result in a failure of the therapy, or even the death of a suicidal patient.

In addition, although most therapists feel they are experts at communication, my research and clinical experience have indicated that therapists perceptions of the therapeutic alliance are also typically way off. In addition, many therapists grossly overestimate their clinical and communication skills, but they do not realize this!

To solve this problem, I have developed the Brief Mood Survey (BMS), and require all my patients to complete it in the waiting room before each session begins, and once again after the session is over. The BMS asks patients how depressed, suicidal, anxious, and angry they are feeling “right now,” at the start and end of the session. The comparison of the scores gives therapists an extremely accurate assessment of how effective, or ineffective, the session was.

It is, in a sense, like having an emotional X-ray machine available for the first time. The data are extremely valuable, regardless of whether you are doing psychotherapy, psychopharmacology, or a combination of the two.

At the end of the session, patients also complete the Evaluation of Therapy Session in the waiting, and rate the therapist on empathy, helpfulness, and other important dimensions. This only takes about one or two minutes of the patient’s time and provides the therapist with more invaluable, but potentially shocking, information.

So what does all of this have to do with the first of the four “deaths” of the therapist’s ego? Therapists who use these scales will probably make a number of uncomfortable discoveries, including, but not limited, to these:

  1. Therapists will discover that their perceptions of how their patients feel, and how their patients feel about them, will often be wildly and alarmingly inaccurate.
  2. They will often discover that the session was not at all helpful to the patient–in other words, there was little or no improvement in how the patient felt during the session.
  3. The therapist will likely receive failing grades on the Empathy and Helpfulness Scales most patients at every single session, especially if they are using these scales for the first time.

And that’s what I mean by the “death” of the therapist’s ego. You may discover, to put it in street language, that you suck! It’s happened to me often, and I usually find it painful to discover that my perceptions were off and my efforts were not effective.

But here’s the cool thing. This information can empower you to grow and change your therapeutic approach, so you can begin to deliver true healing. If you review the information with your patients in a warm and open way, it can transform the quality of the therapeutic relationship and vastly boost your effectiveness. And that’s pretty darn cool! I’ve been doing this for forty years, and my patients have proven to be my best teachers–by far!

Well, that’s it for today. Thanks so much for reading this, and if you like my blogs and Feeling Good Podcasts and FB Broadcasts, and the many other free features on my website, www.feelinggood.com, please use your sharing buttons to tell your friends. I am trying to build up my numbers as much as possible, and don’t know a great deal about social media, so anything you can do to spread the word will help.

AND you HAVE BEEN helping a lot already! Last month, (April 2018) my Feeling Good Podcasts with my esteemed host, Dr. Fabrice Nye, had more than 52,000 downloads. That’s a new record for us, so THANK YOU! I’d love to see those numbers soar even higher!

David

* Copyright © 2018 by David D. Burns, MD.

Coming in less than three weeks!

High-Speed TEAM-CBT for Depression and Anxiety Disorders 

I warmly invite you to attend this fabulous, one-day workshop by Drs. David Burns and Jill Levitt on Sunday, May 20th, 2018. Click on the link above for registration information.

  • 6 CE Credits
  • The cost is $135
  • You can join in person or online from wherever you live!

You will enjoy learning from David and Jill, working together to bring powerful, healing techniques to life in a clear, step-by-step way. Their teaching style is entertaining, funny, lucid, and inspiring. This is a day you will remember fondly!

In the afternoon, you will have the chance to do some personal healing so you can overcome your own feelings of insecurity and self-doubt. David and Jill promise to bring at least 60% of the audience into a state of spiritual and psychological enlightenment, WITHOUT years of meditation. That’s not a bad deal!

You will also leave this workshop with renewed confidence as well as specific, powerful tools that you can use right away to improve your clinical outcomes!

You will LOVE this workshop. Seating for those who attend live in Palo Alto will be strictly limited, and seats are filling up fast, so move rapidly if you are interested. Online slots are also limited.

Jill and I hope you can join us!

 

 

086: Role-Play Techniques (Part 4) — Feared Fantasy

086: Role-Play Techniques (Part 4) — Feared Fantasy

This is the fourth in a series of podcasts on several powerful role-playing techniques we use in TEAM-CBT. Today, we’re going to highlight the Feared Fantasy Technique.

Here, in a nutshell, is why I created this technique. In order to get over any form of anxiety, exposure is absolutely necessary. Exposure is not a complete treatment for anxiety, and is only one of 40 methods I use to treat anxiety, but it always MUST be included in the treatment package.

However, sometimes, people have fears that you cannot easily confront in reality. For example, you may have the hidden fear that others would judge you if they knew how insecure you felt inside, or if you failed at something, or if they were way more successful than you. You can’t just say to someone, “Do you think less of me because I’m actually quite insecure?” They’ll just deny it, and you’ll feel like a nut!

So I created the Feared Fantasy Technique. Essentially, you invite the patient to enter an Alice-in-Wonderland Nightmare World where their worst fear comes true, and where people not only think of you what you most dread, but they also mercilessly tell it to your face. This gives patients the chance to face the monster. In most, if not all cases, they suddenly discover, at the gut level, that the monster has no teeth.

Like the Externalization of Voices, this is a two-person technique, although I’ve sometimes done it with many people in groups. In this case, there can be numerous feared “monsters.”

In the two-person version, you and another person, who could be your therapist, go into the Alice and Wonderland Nightmare World and act out one of your worst fears, such as being rejected by an exceptionally hostile critic because you aren’t smart enough or good enough. When you face your worst fear, you often gain liberation from it because you discover that the monster has no teeth. Your worst fears don’t usually turn out to be real monsters, but figments of your imagination that you can defeat with a little logic, compassion, and common sense. You use frequent role-reversals until the monster has been totally crushed.

I am joined in this podcast by our own beloved Dr. Fabrice Nye, and two members of my Tuesday training group at Stanford, Liz Richard, a Licensed Marriage and Family Therapist, and Dr. Rhonda Barovsky, a Forensic / Clinical Psychologist, along with Stephanie James, an LCSW psychotherapist and radio talk show host from Fort Collins, Colorado, who is visiting the group. Liz is a member of the “newbie” TEAM training group at Stanford and agreed to bring a list of her own negative thoughts that trigger her feelings of insecurity in the group. I am grateful to all of them for helping out with this podcast!

Sometimes, when I am helping a patient challenge a Negative Thought, like “I’m a bad mother” or “I’m a failure as a father,” or “my colleagues would look down on me if they knew how screwed up I actually am,” I start with a gentle technique like the Paradoxical Double Standard that we illustrated in the first podcast on role-playing techniques. It’s a gentle technique that would almost never threaten or upset a patient.

Once the patient has totally crushed the thought, I typically move up to the Externalization of Voices. This is a more challenging and powerful technique that provides a deeper level of recovery / enlightenment and allows me to model the differences between the Self-Defense Paradigm vs. the Acceptance Paradox.

Once the patient has knocked the ball out of the park with the Externalization of Voices, I often move up to the Feared Fantasy. This is the most extreme and powerful technique of all. And the moment the patient again defeats his or her most terrifying fear, the impact can be positive and extreme, and often ends in a kind of uncontrollable laughter The Buddhists call this “laughing enlightenment. It often happens the moment you suddenly realize that your worst fear was nothing more than a gigantic cosmic hoax!

You may want to read a brief description of how to use the Feared Fantasy Technique that I created several years ago for my training groups and workshops. At the end, you’ll find a comparison of the Externalization of Voices, Paradoxical Double Standard, and Feared Fantasy, along with a table contrasting the Self-Defense Paradigm with the Acceptance Paradox.

The example I am using in the write-up below is not the example in the podcast, but one I sometimes use in teaching. Often, participants are afraid to do role-playing in front of the group because of thoughts like these:

  1. I’ll probably look foolish and make a fool of myself.
  2. I’ll screw up and fail.
  3. People will judge me and think less of me.
  4. They’ll laugh at me and tell other people about what a loser I am!

It is difficult to confront these fears in reality since people generally don’t have these kinds of negative judgements toward colleagues in the group who are feeling insecure. In addition, if someone did have these kinds of thoughts they would deny having them. But in the Alice-in-Wonderland Nightmare World, people DO have these kinds of thoughts about you, and they DON’T deny them! So, it can be challenging at first to have to confront these kinds of mean-spirited perceptions, and incredibly freeing once you defeat them!

Feared Fantasy*

This is a form of Cognitive Exposure

  • Some fears are not easily confronted in reality

General instructions

Work in dyads. Decide who will play the role of therapist and who will play the role of patient

  • Use the workshop / seminar performance anxiety example

Therapist Instructions

  1. Explain that you’re going to enter an Alice-in-Wonderland Imaginary world where there are two strange rules:
  • If you think people are looking down on you, they really are.
  • Furthermore, they get right up in your face and verbalize all their negative thoughts about you. They aren’t at all nice. They try to humiliate.
  1. Ask the patient which role she or he wants to play first. Explain that you’ll do role-reversals, so the choice is not terribly important.

We’ll assume that you’ve chosen the performance anxiety example, and that you, the therapist, will start out in the role of a rejecting, judgmental audience member or friend. Your patient will play the role of himself or herself.

Now criticize your patient, saying the things that he or she would be afraid to hear, such as:

  • “Hey, I was in the audience when you did that role-play with Dr. Burns. You really looked foolish and I’ve been laughing at you ever since.”
  1. After your patient responds to each attack, ask who won the exchange. If the patient did not “win big,” do a role-reversal and see if you can come up with a more powerful response.

Tips on Defeating the Imaginary Critic

When you’re under attack, try to defeat the imaginary critic

  • You can use Self-Defense, the Acceptance Paradox, or a combination of the two

If the Self-Defense Paradigm was ineffective, try

  • The Acceptance Paradox
  • Or a combination of Acceptance and Self-Defense

If the Acceptance Paradox was ineffective, try

  • The Self-Defense Paradigm
  • Or a combination of Acceptance and Self-Defense

Comparing the Paradoxical Double Standard,
Externalization of Voices and Feared Fantasy*

Technique Patient’s Name Your Name Role-Reversals?
Paradoxical Double Standard His or her real name The name of an imaginary dear friend of the same gender as the patient. Preferably, it is not someone the patient actually knows. No
Externalization of Voices His or her real name Same name as the patient Yes
Feared Fantasy His or her real name You play the role of some judgmental or critical person the patient is afraid of. Yes

 

Comparing the Self-Defense Paradigm with the Acceptance Paradox*

Strategy

General Concept Negative Thought

Example of How to Defeat the NT

Self-Defense Paradigm You defeat the NT by arguing with it and insisting that it’s distorted and not true. A patient who suddenly relapses several weeks after recovery will often have this thought, “This shows that the therapy didn’t work and that I really am a hopeless case.” “That’s ridiculous. I had a fight with my wife last night, so it’s not surprising that I’d be feeling upset. The therapy was very effective, and this would be a good time to pull out the tools I learned and get to work.”
Acceptance
Paradox
You defeat the NT by buying into it and insisting that it is true, but you do this with a sense of humor or inner peace. During a moment of insecurity, a therapist may have the thought, “I’m not as good as I should be.” “As a matter of fact, I still have tons of flaws and a great deal to learn. Even when I’m 85 years old, there will still be tons of room for learning and improving, and that’s kind of exciting.”

The Self-Defense Paradigm is especially helpful for the types of NTs patients have during relapses, and it’s a good idea to prepare them to talk back to these thoughts when they first recover, and before they actually relapse, using the Externalization of Voices.

The Acceptance Paradox is especially helpful for the types of NTs that lead to feelings of worthless, inferiority, or a loss of self-esteem.

* Copyright © 2018 by David D. Burns, MD

Fabrice and I hope you like our Feeling Good Podcasts, and also hope you can leave some positive comments for us and five star ratings if you like what we’re doing!

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Some Cool Upcoming Workshops

Coming in May!

May 20th, 2018  Advanced, High-Speed CBT for the Treatment of Depression and Anxiety A one day workshop by Drs. David Burns and Jill Levitt. 6 CE Credits, $135
You can join in person or online from wherever you live!

There are only a few spots left for the live workshop in Palo Alto, but we still have room for you to join us for the online version. We will have helpers to guide the small group exercises for those online, as well as those who attend in person.

Coming in June! One of my best two day workshops ever!

“Scared Stiff: Fast, Effective Treatment for Anxiety Disorders”
a two-day workshop Sponsored by Jack Hirose & Associates
June 4 -5, 2018 Calgary, Canada
June 6 – 7, 2018 Winnipeg, Canada
Mike Christensen and several others will be joining me at both locations to help out with supervision of the small group exercises. You’ll LOVE this workshop and you’ll learn TONS of powerful techniques to treat every type of anxiety. You’ll learn how to heal your clients and your own feelings of insecurity and self-doubt as well!

I greatly appreciate your support, and hope you will continue to spread the word about TEAM-CBT and www.feelinggood.com. i am trying hard to reach as many people as possible with my free programming and blogs designed to help individuals struggling with depression, anxiety, relationship conflicts, and habits and addictions, as well as the therapists who treat them!

David