Podcast 59, Live Therapy with Marilyn, The Tune-Up
This podcast was recorded eight weeks after the initial session with Marilyn. As you may recall, Marilyn became severely depressed when she discovered that she had Stage 4 Lung cancer. In spite of that horrific and real trauma, she completely overcame her negative feelings in the first session, which was broken down into a series of three consecutive podcasts, with commentaries as the session unfolded.
Sadly, Marilyn experienced severe pain in her left rib cage from a metastasis from her lung cancer roughly two months later. This physical relapse triggered an understandable emotional relapse as well, with an understandable return of severe depression, anxiety and anger, so Marilyn agreed to record another podcast to illustrate how a tune-up works following the initial treatment.
I would like to point out that the Relapse Prevention Training was critically important, so that Marilyn would know that relapses are a certainty, and that they can be dealt with effectively using the same techniques that worked the first time. This message is important so that the patient does not feel broadsided when the negative feelings return. Some patients have the false expectation that they’ll be happy forever after they’ve recovered.
But no one is entitled to be happy all the time! If the therapist and patient know how to deal with a relapse, and have practiced ahead of time, it will still be painful, but the patient and therapist will know what to do to make sure the patient can recover from the relapse quickly, instead of getting caught in another length episode of depression or anxiety.
The entire session has been included in this single podcast. That’s why we’ve offered this as a bonus session between our weekly podcasts. You will need nearly two hours to listen to it, but I think you will find it’s a great investment of your time.
In addition to her anxiety about the metastasis, and the fairly strong physical pain that is now with her constantly, Marilyn was flooded with intense Negative Thoughts and feelings that revolved around a number of familiar themes, including:
Her belief that her life is now over, and that she has nothing more to live for.
Her conviction that she is a burden to Matt, Fabrice, and David, who would prefer (she thought) to be relaxing with their families, instead of sitting down with Marilyn on a Saturday morning.
Her anger that God has abandoned her.
Her belief that she should not be so angry with God.
Her despair and fatigue at constantly struggling with pain.
Her urge to drink again.
Her self-criticisms and feelings of intense shame about her life and her relapse into depression.
Her conviction that things are hopeless.
Her belief that she’s selfish.
He belief that she should not be watching so much TV.
Her ambivalence that on the one hand she is afraid of dying, but at the same time she wants her suffering and struggling to be over.
After the initial T = Testing, Matt and David walked Marilyn through the E = Empathy, A = Agenda Setting, and M = Methods portion of the session, using techniques such as the Five Secrets of Effective Communication, Positive Reframing, the Magic Dial, Identify the Distortions, the Externalization of Voices, Acceptance Paradox, and more.
They also used the Interpersonal Downward Arrow, highlighting Marilyn’s view of her relationship with the two therapists—the “Rules and the Roles” that we’ve discussed in a previous podcast. Keep in mind that in the analyses below, we are talking about how Marilyn views her relationships with two people she cares deeply about. We are not talking about what’s “real,” but rather how we view and experience our relationships with othes.
The adjectives Marilyn used to describe her role in her relationships with David and Matt included:
The adjectives she used to describe the role that David and Matt played in the relationship included:
And the rules that Marilyn believed she must follow in this (and all) relationships included:
I have to suffer in silence.
I am not allowed to ask for help.
I need to stay alone.
I have to be quiet.
I have to behave in an extremely submissive manner.
I have to be guarded at all times.
I have to be invisible and hide all my feelings.
I cannot be assertive or I’ll be put down.
I must always put myself last and put others first.
I cannot be important.
I cannot expect or accept kindness and love.
I can’t be weak, emotional, real or vulnerable in front of you.
I cannot express any anger or loneliness for fear of retaliation.
Once again, Marilyn experienced another rapid, inspiring and rather mind-boggling transformation in her thoughts and feelings during the session. Then, Matt, David and Marilyn discussed the spiritual implications of her “dark night of the soul,” and emphasize the incredible gift Marilyn is giving to all of us through these recordings, as well as the enormous growth she is still experiencing during this phase of her life.
A few potentially important teaching points include:
We will all “relapse” back into spells of depression, anxiety, shame, hopelessness, and anger from time to time. No one is entitled to be happy all the time! This is a practical and spiritual reality for human beings. But it does not have to be a problem if you have the tools to climb back out whenever you fall into a black hole of self-doubt or despair.
Our painful feelings do not result from the events in our lives–in this case, a painful metastasis–but from out thoughts about these events.
Even when an event is genuinely horrific, the negative thoughts that trigger our feelings of depression and anxiety will nearly always be distorted and unrealistic. However, we may not realize this, and firmly believe that our negative thoughts are absolutely true. This way of thinking may contain a grain of truth but makes us victims of forces beyond our control.
For each of us, the negative thoughts that trigger our occasional “relapses” into depression and anxiety will usually be very similar, if not identical, from episode to episode. Of course, we will all have our own unique patterns of negative thinking, and no two people will have the exact same negative thoughts. That’s why formulaic approaches to treatment may sometimes fall short–because the therapist does not pinpoint or target the specific negative thoughts that trigger the patient’s distress.
The techniques that worked for the patient the first time s/he recovered will nearly always work for the patient when the negative thoughts return.
David and Matt were grateful and thrilled to receive this email from Marilyn the day after they recorded the podcast:
Much gratefulness to you, Matt, and Fabrice. It was a profound experience. At my AA meeting this am, a number of people came up to me and commented on how good I looked—relaxed & glowing. Yesterday was magical! It is a privilege working with you. Matt, and Fabrice. Thank you for taping.
Thank you also for the book, The Inner Eye of Love. It is very good. I also left a bag of honey somewhere in your home – one for you & Melanie, one for Matt, and one for Fabrice.
I will listen to the podcast of our first therapy session (two months ago) tomorrow—today was busy. I will get back to you with feedback.
Thank you also for your company at the Intensive and paying for my meals. I so enjoy your company, and if I may be so bold, your friendship.
Lastly, please e-mail the Therapist’s Toolkit upgrade.
Don’t worry about my not feeling hungry at lunch. I ate a big breakfast for me. I did eat dinner!
Again, thank you for helping me. Please thank Melanie for making your home available. Pets and kisses to your new kitty, Ms. Misty.
I hope you’re having a rest-filled weekend. Enjoy the Sunday hike! I look forward to listening to the podcasts.
oThis is a technical memo for therapists who use a technique I developed years ago called the Individual Downward Arrow Technique. The goal of this technique is to uncover each patient’s (client’s) Self-Defeating Beliefs (SDBs), such as Perfectionism, Perceived Perfectionism, or the Brushfire Fallacy. I developed this memo for my Tuesday evening TEAM-CBT group at Stanford following a session practicing this technique earlier in the week.
Why would a therapist want to uncover SDBs? Cognitive Therapists work with (at least) two types of cognitions that can cause emotional distress. First, Negative Thoughts happen in the here and now and only cause emotional distress at specific moments in time. Let’s say you have public speaking anxiety, and you’re about to walk up to the podium. You are probably telling yourself things like this: “I’ll blow it. My mind will go blank. I’ll make a total fool of myself. People will laugh at me and judge me.” These kinds of Negative Thoughts happen in there here-and-now, when you are feeling anxious or depressed. The Negative Thoughts are usually not present when you are feeling happy and confident.
The SDBs represent a second category of cognition. These belief systems represent some of our core values, and they are always there in the background, whether or not we are upset. So, for example, you may have a belief called Perceived Perfectionism, thinking that people will not accept, respect or love you if you screw up or appear vulnerable. Or you may have the Approval Addiction, thinking you need everyone’s approval to feel happy and fulfilled. Or you may have the Achievement Addiction, basing your self-esteem on your intelligence or accomplishments. There are a great many kinds of SDBs.
The cognitive theory of emotional distress works like this: the combination of a Self-Defeating Belief (such as the Achievement Addiction) plus a negative event (such as screwing up or doing poorly when you give a talk) triggers emotional distress. That’s when you are flooded with negative thoughts and feelings, such as “Gosh, my talk was kind of a dud. People seemed bored. I’m a loser,” etc.
So the SDBs appear to explain the timing and reason for episodes of depression and anxiety. And if we can pinpoint and change the patient’s (client’s) SDBs, we can not only help the patient to feel better in the here-and-now, but we may also help to prevent painful mood crashes in the future.
In this memo, I discuss the finer points of how to use the Individual Downward Arrow Technique to pinpoint each patient’s Self-Defeating Beliefs. If you are interested, I could address how to change SDBs in a future blog or in an upcoming Feeling Good Podcast.
I will be curious to find out if this type of information is of interest to my readers, so please let me know what you think! If the information that follows is too technical, no problem! I just want to get a feel for what people like and want so I can serve you in the best possible way. Thanks!
Tips for Therapists When Using the Individual Downward Arrow Technique
By David Burns, MD*
I would like to thank Daniele Levy, PhD for conceptual and editing help!
What is the Individual Downward Arrow Technique? This technique will help you pinpoint the Individual Self-Defeating Beliefs (SDBs) that make the patient vulnerable to depression and anxiety. For example, the patient may base his or her self-esteem on accomplishments, the so-called “Achievement Addiction,” or may struggle because of Perfectionism, Perceived Perfectionism, Entitlement, or the Approval or Love Addiction. You can find a list of “23 Common Self-Defeating Beliefs” in the Therapist’s Toolkit or my Feeling Good Handbook. The Individual SDBs are often “self-esteem equations,” of the form, “To be a worthwhile human being I need substance X.” Substance X could be great achievement, wealth, love, perfection, approval, or always pleasing others, for example.
To use this technique, draw a downward arrow under a Negative Thought on a Daily Mood Log and ask your patient, “Why would it be upsetting to you if this thought were true? What would it mean to you?” This will trigger a new Negative Thought. Tell the patient to write it down under the arrow and repeat the process several times. The NTs you and your patient generate will lead to the underlying beliefs at the core of his or her suffering.
There are three additional Uncovering Techniques. The Interpersonal Downward Arrow Technique helps you pinpoint the beliefs and attitudes that trigger conflicts and difficulties in the patient’s personal relationships. The What-If Technique helps you pinpoint a core feared fantasy that trigger’s the patient’s anxiety. And the Hidden Emotion Technique helps you bring suppressed hidden problems and conflicts to the patient’s conscious awareness.
Here are some important tips to keep in mind when using the Individual Downward Arrow technique:
Always start with a Negative Thought (NT) from a Daily Mood Log when doing the Downward Arrow Technique. Don’t do the Downward Arrow Technique for some problem the patient has, or based on some emotion the patient has.
Both patient and therapist must be writing during the Downward Arrow Technique. Usually, I use a blank sheet of paper, because the DML gets too filled up with the chain of NTs. But keep in mind that your blank sheet of paper is really an extension of the NT column on the DML.
Remember to be compassionate when doing the Downward Arrow, and not overly harsh or intellectual. For example, if the patient says, “That would mean I was a total failure,” you can say, “Of course, that would be pretty painful for almost anyone to feel like you were a total failure, but I’m wondering what it would mean to you? Why might that be upsetting you?”
If the patient becomes tearful, perhaps recalling a painful childhood memory during the Downward Arrow process, put your techniques on the shelf and empathize, encouraging your patient to vent and open up. These moments can be quite important to the patient.
WORDING OF NTs
Convert rhetorical questions into statements. “Why am I so screwed up?” can become “I’m screwed up,” or “I shouldn’t be so screwed up.”
When doing a Downward Arrow from a “Should Statement,” such as “I shouldn’t have left my husband,” you can say, “Let’s assume it’s true that you shouldn’t have left your husband, but you did. What does that mean to you? Why is that upsetting to you?”
Never put emotion words or descriptions of upsetting events in the NTs column when doing the Downward Arrow. Instead, ask for the NT that is associated with the emotion or event. For example, if the patient says, “Then I’d feel ashamed,” you can say, “What is the NT that would make you feel ashamed? What would you be telling yourself?”
If the patient comes up with a wish or a positive thought when you’re doing the Downward Arrow Technique, you can convert it to an NT. For example, let’s say a patient has this thought about dropping out of school: “I’ll be letting my parents down. I’ll be a disappointment to them.” Then you ask, “If this were true, what would it mean to you? Why would it be upsetting to you?” The patient might say, “Well, I really want my parents to be proud of me.” You can easily convert it by saying, “So let’s assume you really want your parents to be proud of you, but they’re actually disappointed in you for dropping out of school. What would that mean to you? Why would that be upsetting to you?”
If the patient says, “I don’t know,” use Multiple Choice Empathy. For example, the patient may have the NT, “Then I’d be all alone forever,” when you are doing the Downward Arrow Technique, but when you ask, “And what would that meant to you, and why would that be upsetting to you,” he or she might say, “I don’t know.” Using Multiple Choice Empathy, you might say, “Of course, probably no one would want to be alone forever, but it could mean different things to different people. Some people might think that if they’re alone, they can’t survive, or if they’re alone, it means they’re unlovable and worthless, and others might think it’s impossible to feel happy and fulfilled when you’re alone. Do any of those possibilities ring true for you?”
You can also use the “Man (or Woman) from Mars” approach if the patient says, “I don’t know why that would be upsetting for me.” Let’s say the patient comes up with this thought during the Downward Arrow Technique: “That would mean I failed,” but can’t explain why failure would be upsetting or bad. You can say, “Let’s assume I’m a man (or woman) from Mars, and I don’t know how things work here on the surface of the earth. So I might ask you to explain why failure is considered a negative thing here on the earth. What happens to people who fail at something?” This will usually make it easier for the patient to continue the Downward Arrow Chain.
Using Bracketing when the patient cycles back and forth between two NTs. For example, the patient might say, “Then I’d be a failure,” followed by “Then no one would love me,” followed by “Then I’d be a failure,” etc. You can bracket them in this way: “And suppose you were a failure, and no one loved you. What would that mean to you? Why would that be upsetting to you?”
The purpose of the Downward Arrow Techniques is uncovering the patient’s SDBs, not change. You can change SDBs, but change is not the goal when you are doing an Uncovering Technique. If you think about an NT on a Daily Mood Log, most of the time we are doing horizontal arrow techniques. In other words, we want to move from the NT column on the left to the Positive Thought (PT) column on the right, and this involves trying to challenge and crush the NT so that emotional change will suddenly happen. In contrast, when you use a downward arrow technique, you are drilling down deeper into the patient’s psyche to uncover the beliefs that give rise to the negative thoughts and feelings. You are moving to a deeper level.
Sometimes, a patient will begin to recognize the absurdity of the NTs when doing the Downward Arrow, and will begin to come up with convincing and effective Positive Thoughts (PTs). This is okay, and you can encourage the patient to write the PTs in the PT column on the Daily Mood Log.
The Self-Defeating Beliefs are the logic behind the negative thoughts on the Downward Arrow Chain, since the thoughts do not logically follow from one another. For example, a psychologist’s favorite patient unexpectedly committed suicide, and one of his NTs was: “I should have seen this coming. I should have known he was suicidal.” His next thought on the downward chain was, “This means I’m a failure and a fraud.” Notice that the second thought does not follow logically from the first thought, but the SDB that links them is Perfectionism. His third thought was, “My colleagues will judge me and reject me.” Again, this does not follow logically, and the SDB that links them is Perceived Perfectionism—namely, the belief that others will not accept, love, or respect him if he is vulnerable, or human, or makes a mistake.
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