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:
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.
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.
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, http://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!
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.
The responses to the Marilyn session were extremely positive. At the start of the podcast, Fabrice reads a response from a listener who was moved and inspired by the work Marilyn did.
David and Fabrice discuss two questions commonly raised by people who have seen David’s live demonstrations with individuals experiencing severe depression and anxiety. Since the change in Marilyn’s scores were so fantastic, some skeptical listeners have asked, “Was this real, or was it staged?” Others have asked if patients are simply giving favorable answers on the Brief Mood Survey and Evaluation of Therapy Session forms as a way of being “nice” to the therapist.
David points out that the opposite is true. If patients are in treatment voluntarily, without some kind of hidden agenda such as applying for disability, they tend to be exceptionally honest in the way they fill out the forms. In fact, most therapists find that they get failing grades from nearly every patient on every scale at every session at first. This can be very upsetting, especially to therapists who are narcissistic and defensive about criticism. But if the therapist is humble and open to the feedback, the patient’s feedback on the Brief Mood Survey as well as the Evaluation of Therapy Session forms can provide a fabulous opportunity for growth and learning.
So in short, it is not true that patients fill out the forms just to be “nice” and to please the therapists. The scores are brutally real! If you are a therapist and a doubters, you can give the assessment instruments a try, and I think you’ll be surprised, and perhaps even shocked when you review the data!
Still, David acknowledges that the rapid and phenomenal changes he now sees most of the time when using TEAM-CBT are hard to believe, especially when you’ve been trained to think that recovery is a long, slow process. David discusses a model of brain function proposed by a molecular biologist / geneticist, Dr. Mark Noble, that allows for extremely rapid change.
David and Fabrice also address the question—can these kinds of miraculous results last, or are they only a flash in the pan? David emphasizes the importance of ongoing practice whenever the negative thoughts return. The “one and done” philosophy is not realistic. Part of being human is getting upset during moments of vulnerability, and that’s when you have to pick up the tools and use them again!
David describes experiencing three hours of panic just a few days ago, and Fabrice asks what techniques he used to deal with his own negative feelings, including Identify the Distortions, Examine the Evidence, Reattribution, and the Acceptance Paradox.
David agrees with the Dalai Lama that happiness is one of the goals of life, but emphasizes that it is not realistic to think one can be happy all the time. Fortunately, you can be happy most of the time–but you have to be willing to pick up the tools and use them from time to time when you fall into a black hole!
David and Fabrice
If you are reading this blog on social media, I appreciate it! I would like to invite you to visit my website, http://www.FeelingGood.com, as well. There you will find a wealth of free goodies, including my Feeling Good blogs, my Feeling Good Podcast with host, Dr. Fabrice Nye, and the Ask Dr. David blogs as well, along with announcements of upcoming workshops, and tons of resources for mental health professionals as well as patients!
Once you link to my blog, you can sign up using the widget at the top of the column to the right of each page. Please forward my blogs to friends as well, especially anyone with an interest in mood problems, psychotherapy, or relationship conflicts.
Part 7: T = Testing Revisited, Conclusion of the Live Therapy Session with Mark
This is the last live therapy podcast with Mark, the physician who was convinced he was a failure as a father because of his difficulties forming a close, loving relationship with his oldest son. Although the session appeared to go well, we can’t be sure until we see Mark’s end of session mood ratings on the Daily Mood Log and on the Brief Mood Survey and and Evaluation of Therapy Session. David emphasizes that therapists’ perceptions of patients are notoriously inaccurate, but most therapists are unaware of this because they don’t use the rigorous testing procedures at the start and end of sessions.
To review Mark’s partially completed Daily Mood Log, CLICK HERE. Jill and David will ask him to complete the additional negative thoughts on his own after the session.
To review mark’s end of session Brief Mood Survey and Evaluation of Therapy Session, CLICK HERE.
After David review’s the phenomenal changes Mark reported from the start to the end of the session, David asks if the ratings were genuine, or, as some listeners might suspect, faked in order to try to please the therapists. Mark bursts into tears and says, in a choked voice, that it was a life-changing experience.
After the end of the session, David and Fabrice discuss a number of highlights from the work with Mark:
The testing indicated a complete or near-complete elimination of symptoms. In 2 ½ hours, Jill and David have essentially completed an entire course of psychotherapy. Although there may still be some work to be done with Mark, the hard part has already been completed.
David emphasizes that he now views psychotherapy as a procedure to be done at one sitting, much like surgery, with brief follow-up visits, rather than a long, drawn out procedure meeting once pre week for months or even many years. And although a single 2 or 2 1/2 hour session may be more costly than a traditional 50-minute hour, it can be vastly more cost-effective Than dozens of sessions with little or no progress. In addition, it is vastly better for the patient who walks out feeling good today, rather than having to endure weeks, months, or even many years of traditional talk therapy or antidepressant drug therapy.
David and Fabrice talk about the fact that no one is permitted to feel happy all the time, and that Mark’s negative thoughts and feelings WILL return, David defines a “relapse” as one minute or more of feeling lousy. Given that definition, we will ALL relapse forever! But it doesn’t have to be a problem for Mark if he is prepared for this, and knows how to pop out of the relapses quickly, rather than getting stuck in them. This is where Relapse Prevention Training (RPT) becomes so important following the initial dramatic recovery. RPT only takes about 30 minutes and is easy to learn, and will perhaps be the topic for a future Feeling Good Podcast if our listeners express an interest in it.
David discusses the difference between an Internal Solution and an External Solution. In this session, David and Jill have guided Mark in the Internal Solution—this means crushing the negative thoughts that triggered Mark’s feelings of unhappiness, anxiety, shame, failure, and anger for years, if not decades. Now that he is feeling so much better about himself, he may want some help with the External Solution. This will involve learning how to develop a more loving relationship with his son using tools like the Relationship Journal and the Five Secrets of Effective Communication. This will be far easier now that Mark is no longer using up all his energy beating up on himself and feeling depressed and inadequate.
David wraps up by talking about the true wealth we have as therapists. Although we won’t develop the riches of a Bill Gates doing psychotherapy, we do have the fabulous and precious opportunity to see people as they really are inside, and to witness miracles like the one we saw in the session with Mark.
David expresses the hope that listeners have benefitted by listening. Although we are all different, most of us have had the painful experience, like Mark, of believing we were somehow failures, or inferior, or defective, or simply not good enough. We are deeply indebted to Mark’ courage and generosity in giving us the opportunity to see the solution to this ancient and almost universal human problem!
There are many resources for listeners who want to learn more about TEAM-CBT, including:
David’s exciting two-day and four-day training workshops, listed on his website, feelinggood.com.
Tons of free resources for patients and therapists at feelinggood.com. Please sign up using the widget in the upper right hand corner of any page on his website and you will receive email notifications and links to every post.
David’s psychotherapy eBook entitled Tools, Not Schools of Therapy.
David’s Tuesday psychotherapy training groups at Stanford, which are co-led Jill Levitt, PhD and Helen Yeni-Komshian, MD. The training is free of charge to Bay Area and northern California therapists. You will have the chance to do free personal work, too!
David’s famous Sunday hikes, also free to members of the training groups.
Paid online and in-person weekly TEAM-CBT training groups, plus intensive TEAM-CBT treatment programs, at the Feeling Good Institute in Mt. View California.