163: Ask David: Anxiety, Dreams, Cyclical Negative Thoughts, Secrets of Selling, Exposure, and more

163: Ask David: Anxiety, Dreams, Cyclical Negative Thoughts, Secrets of Selling, Exposure, and more

Can you treat anxiety without meds?

How do you interpret dreams?

Are negative thoughts cyclical?

How can I get over anxiety when selling?

How does exposure work?

Will you teach on the East Coast again?

Hi! We’ve had tons of great questions from listeners like you. Here’s the first:

Question #1. TREATING ANXIETY WITHOUT MEDICATIONS

Hi Dr. Burns,

I would love to talk to you!!!

I have been going to a wonderful counselor for several years, and he is the one who recommended your book. My question is how can you overcome anxiety without taking medicine?

I have been on a very low dose medicine for years and would love to discontinue but when I try the anxiety seems to come back.

Thank you.

Lisa

Hi Lisa,

Thank you for your email! This is one of my favorite topics, since I’ve personally had at least 17 different anxiety disorders that I’ve had to overcome. That’s why I love treating anxiety. Whatever you’ve had, I can say, “I’ve had that too, and I know how it sucks! And I can put you on the road to recovery, too!”

Did you read When Panic Attacks, or one of the earlier books? The written exercises would be the way to go, I think.

You will find more than 40 methods in that book. Write back if you have questions after reading it. Focus on one specific moment when you are anxious, and do a Daily Mood Log, as illustrated in Chapter 3.

You can also listen to the free Feeling Good Podcasts on anxiety. Go to my website, FeelingGood.com, and click on the Podcast tab. There, you’ll find a list of all the podcasts, with links. In the right hand panel of every page, you’ll find the search function. You can type in “anxiety,” or “social anxiety,” and so forth, and all the relevant podcasts and blogs will pop right up. You can also sign up in that same right-hand panel of every page so you’ll receive all the new podcasts, along with the show notes.

In addition, withdrawal effects are pretty much inevitable when going off of benzodiazepines, if that is the type of medication you are taking. These are the drugs most often prescribed for anxiety, like Valium, Librium, Ativan, Xanax, and so forth. Typically, the withdrawal, which typically involves insomnia and increased anxiety, take several weeks to wear off.

Your medical doctor can guide you in this. I cannot advise you about medications in this forum, so make sure you check with your doctor!

David

Question #2. How can you interpret dreams?

Hello, Dr. Burns.

I am terrified that this may be the most boring question you have ever received, but, I’ll press on none the less.

I often experience very vivid dreams after listening to your podcasts. In fact, I recently dozed off after listening to one of your podcasts on procrastination (#75) and forgot to turn off my phone. In my dream I was in my childhood house and could hear you talking away in some far corner of the house and I was really getting quite annoyed and angry.

I really wanted to find you to tell you to shut up, but I couldn’t get the words out.

When I awoke, podcast #77 was playing, which seems to explain some of my unconscious hostility. I struggle with most of my relationships and don’t really want to deal with all the hard work I have to do to improve them.

So, there you have it!

Thanks for listening to me and all your Herculean efforts on behalf of all those in the struggle to grow.

Mike

Hi Mike,

I explain how dreams function, and give an example with my dream that I had a broken jaw!

Question #3. Are Negative Thoughts cyclical?

David, I have a question about our strong attraction or inclination to negative thoughts.

Are our psychological processes cyclical? People seem to recycle the same negative thoughts for years. Even if we produce a strong alternative thought or reattribution it may not be a default choice the next time. How can we make the alternative/ positive thoughts a conscious choice?

Thanks,

Rajesh

Hi Rajesh:

Negative Thoughts are not cyclical for the most part, but are an inherent part of our human nature. The podcast on fractal psychotherapy might be useful, since the same Negative Thoughts will tend to come back over and over throughout your life. And once you have learned how to combat those thoughts, you can use the same techniques to smash the thoughts whenever they pop back into your mind.

The written exercises I describe in my books, like the Daily Mood Log, are extremely helpful, even mandatory, in building new brain networks and strengthening them through repeated practice.

Bipolar manic-depressive illness is a little different, and it can be quick cyclical. (David will briefly explain this.)

Thanks Rajesh for yet another great question!

david

Question #4. I’m in sales. How do I combat my Negative Thoughts about each person I approach?

Hi David,

I have been struggling with anxiety for the last 18 months and recently faced up to the fact I have also been suffering from depression. And then I discovered your podcasts.

I have been spending a lot of time on the episodes I believe I can benefit from the most. I have found your solutions to be the most beneficial I have come across. Thank you for sharing your ideas and techniques with all of us!

A couple of questions—How would you advise constructing a work day to reduce anxiety? I work in sales and feel anxious before every phone call or visit I encounter, and the anxiety can be for reasons that seem to be related solely to each sales encounter on individual basis! And my anxiety will grow as the day goes on.

My second point would be, would there be a benefit in monitoring positive thoughts and feelings throughout the day, like happiness and hopefulness, rather than negative feelings?

Hi Rudi,

I’ve done a lot of sales work, including door-to-door sales when I was young. When I was 8 years old, I sold show tickets door to door. When I was a teenager, I sold Fiesta Chips, Cosmo’s Cock Roach Power, tick powder for dogs, and For Econoline Vans door to door in Phoenix. So, I feel a soft spot in my heart for everyone involved in sales! In fact, I’m still involved in sales! But these days I’m selling happiness, self-esteem, and intimacy.

I think it could be useful to do a written Daily Mood Log on the anxiety you feel before one of your calls. I think you will find there are certain themes that are common to each call, such as fears of rejection, disapproval, or failure. Once you’ve dealt with these fears successfully, I think they will help in all of your sales encounters. If you send me a partially filled out Daily Mood Log, perhaps Rhonda and I could provide more specific tips on how to crush your Negative Thoughts. If you listen to Rhonda’s work on performance anxiety, you may find it extremely helpful.

In addition, the Five Secrets of Effective Communication are the keys to successful sales. I used to think that you had to sell yourself, or your product, which is rarely true. I learned that the key is to form a warm relationship with your customers. David will explain what he learned from his mother, who sold women’s clothing part-time at a department store in Phoenix.

Thanks, Rudi, I hope to hear more.

Question #4. Why and how does exposure for anxiety work?

Hi Dr. Burns,

I am a big fan and believe that you are the greatest living psychologist of our time. I have seen you in person and hear your recent PESI presentation (link).

Quick question, when exposure is used to get rid of anxiety, what do you think is the mechanism in the brain? It works paradoxically, instead of strengthening a neuro-network it extinguishes it. Any ideas how.

Thanks for your time, and again I have learned so much from you in my over 30-year career, thank you for that also.

Sincerely, Dr. Mark

Hi Dr. Mark,

With your permission, will include this on an upcoming Ask David on my Feeling Good Podcast, but I think you discover a couple things during exposure:

  1. When you stop running away and confront the monster, you discover that the monster has no teeth, so you go into enlightenment. This is the basis of Buddhism and the teachings in the Tibetan book of the dead.
  2. During exposure, you also discover that after a while the anxiety just kind of wears out, dwindles, and disappears. The brain simply cannot continue creating anxiety for prolonged periods of time, especially when you are doing everything you can to make it as intense as possible.
  3. You discover that you can, in fact, endure the anxiety and survive, and that you do not have to “escape” from the feeling of anxiety via avoidance.

One other thing that is important is that I treat anxiety with four models, not one: 1. The Motivational Model; 2. The Hidden Emotion model; 3. The Exposure Model; and 4. The Cognitive Model. All play vitally important and unique roles in the treatment of anxiety. Exposure alone is NOT a treatment for anxiety, just one tool among many that can be helpful, and often incredibly helpful, as you’ll see in the upcoming podcast on the treatment of Sara, a woman struggling with severe OCD for more than 20 years.

Great question! Hope to catch you in one of my upcoming in-person / online workshops!

Thanks, David

Mark’s reply and a brief final question

Hi Dr. Burns,

Yes, of course you have my permission to use my question! Also, I do understand your impressive approach to treatment (not just exposure), and again it is genius. I also love that you see the connection between Buddhism and cognitive restructuring, where as Dr. Beck only went as far back as Socrates and the Greek Stoic philosophers. I don’t know if you ever read the Dhammapada (best translation I found is Eknath Easwaran) as it clearly states that our life is shaped by our mind, and that our feelings follow our thoughts just like a cart follows the ox that pulls it.

Thanks again! Will you be coming to the East coast again soon?

Hi again, Mark,

Yes, I’ll be coming to Atlanta for a four-day intensive in November! Check my workshop tab at www.feelinggood.com for more information. (https://feelinggood.com/workshops/)

david

David D. Burns, M.D. / Rhonda Barovsky, Psy.D.

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You can reach Dr. Burns at david@feelinggood.com. Dr. Rhonda Barovsky practices in Walnut Creek, California, and can be reached at rbarovsky@aol.com. Today’s featured photo is courtesy of Nancy Mueller–www.nancymuellerphotography.com.

If you like our jingle music and would like to support the composer Brett Van Donsel, you may download it here.

* * *

You may have missed the Calgary and South San Francisco intensives, but there will be one more awesome intensive this fall.

High-Speed Treatment of Depression
and Anxiety Disorders

A Four-Day TEAM-CBT Advanced Intensive

November 4 – 7, 2019
The Atlanta, Georgia Intensive

Sponsored by Praxis

* * *

I also have two tremendous one-day workshop scheduled with my colleague, Dr. Jill Levitt, next year–

Coming up in 2020

High Speed Methods to Reduce Resistance
and Boost Motivation

This is the most important, and least understood, topic in the behavioral sciences. Nearly all therapeutic failure results from the failure to address resistance. Therapists do not understand what causes resistance or how treat it effectively.

Come to this workshop and learn how to melt away resistance for incredibly high-speed recovery!

With Drs. David Burns and Jill Levitt

Feb 9. 2020 |  7 CE hours. $135

Learn More & Register

 

The Cognitive Distortion Starter Kit:
How to Crush Negative Thoughts

TEAM-CBT includes more than 100 powerful techniques to change the distorted thoughts that trigger negative emotions. But what techniques should I select for my patient who feels depressed, anxious, or angry?

As you know, in my book, Feeling Good, I listed the ten most common cognitive distortions, like All-or-Nothing Thinking, Should Statements, Emotional Reasoning, and more, and you probably use that list all the time in your clinical work. But do you know which techniques work the best for each distortion?

Come to this workshop and find out! You’ll learn with tons of cool techniques you can use every day to boost your clinical effectiveness.

With Drs. David Burns and Jill Levitt

May 17, 2020 | 7 CE hours. $135

Learn More & Register

058: Ask David — Third-Wave Therapies & Exposure for OCD

058: Ask David — Third-Wave Therapies & Exposure for OCD

 

Podcast 58, Ask David

David and Fabrice begin by reading several incredibly touching reader comments on the live therapy with Marilyn. Marilyn experienced a severe depression relapse eight weeks after her initial session with Matt and David, because of a painful metastasis to her rib cage which frightened and demoralized her. She graciously agreed to come in for a tune-up with David and Matt which will be published as a special podcast within the next week or so. You will not want to miss this session!

David addresses two questions posed by listeners. The first question has to do with so-called “third wave” CBT as well as Mindfulness-Based CBT and other innovations in CBT. David stresses the difference between specific and non-specific therapeutic techniques. He also discusses the distressing but exciting fact that few or no therapies have proven to be much more effective than placebos in the treatment of depression, and why this is the case.

Another listener asked why David did not use Exposure initially in his treatment of the woman who was afraid that her baby would be switched at the hospital, and that she’d end up with the wrong baby. David concedes that if he’d thought of using Cognitive Flooding initially, it likely would have been effective. He also argues that Exposure and Response Prevention are not treatments for OCD, or for any anxiety disorder, but are simply tools one can use in treatment. David argues that for an optimal outcome, he combines four treatment models with every anxious patient: the Motivational Model, the Cognitive Model, the Exposure Model, and the Hidden Emotion Model. These models are discussed in detail on previous podcasts.

David and Fabrice appreciate your questions, and also encourage you to leave podcasts reviews on iTunes if you like what they are doing, since your reviews will help to popularize the Feeling Good Podcasts!

 

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 Podcasts 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.

Thanks! David

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042: Shame-Attacking Exercises

042: Shame-Attacking Exercises

Picture 9Making a Fool of Yourself — On Purpose!

In this podcast, David and Fabrice discuss a mind-blowing technique developed by the late Dr. Albert Ellis to help individuals struggling with shyness. It’s called Shame-Attacking Exercises. Essentially, you do something bizarre in public to overcome your fear of making a fool of yourself; and you will probably discover that the world doesn’t come to end. When used skillfully, this method can be incredibly liberating.

However, there are several ethical considerations. First, before therapists can ask their patients to do Shame Attacking Exercises, therapists have to do Shame-Attacking Exercises themselves! David explains his first, terrifying Shame-Attacking Exercise in a Chinese restaurant in New York after giving a talk at a workshop sponsored by Dr. Ellis.

In addition, therapists have to be careful in the way they use Shame Attacking Exercises, and who they use them with. You have to have an excellent therapeutic alliance with your patient, and the patient has to trust you. In addition, the exercises have to be in an appropriate location—for example, it would be disrespectful to do them in a hospital. And you have to be careful that the Shame Attacking Exercises is not aggressive or frightening to other people.

He also describes how Shame-Attacking Exercises helped a man and a woman he treated who were both afraid to flirt with people they were attracted to, and in both cases, he had to push fairly hard since the patients put up stiff resistance to the idea.

TEAM-CBT includes many powerful techniques, and while they have the potential to bring about rapid and often fantastic change, they also have the potential to hurt if not used skillfully and appropriately. Any listeners who are interested in using these techniques should first consult with a mental health professional to make sure the techniques are appropriate and likely to be helpful to you.

All that being said, you will (we hope) LOVE this podcast!

In upcoming podcasts, David and Fabrice will address questions on OCD (Obsessive-Compulsive Disorder) submitted by several listeners. Is OCD an organic illness? Are drugs necessary in the treatment? What’s the prognosis? David will describe powerful, drug-free treatment methods based on the four models he uses to treat all anxiety disorders: the Motivational, Cognitive, Exposure, and Hidden Emotion Models.

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An Anxiety Question and a Blessing from Turkey for “David Uncle!”

An Anxiety Question and a Blessing from Turkey for “David Uncle!”

Hi Dr. Burns,

whenpanicattacks-sm  Thank you for your life-saving books and blogs. They really help. I have given your book, When Panic Attacks, to others. It is so good! What I admire the most is your empathy and your desire to seek the truth.

I have a simple request. Can you clarify the use of cognitive flooding and thought-disputing? I find these two methods to be quite useful but confusing at times. For example, it doesn’t seem logical to flood my mind with panic thoughts and then turn around and dispute them. Perhaps morning flooding and evening disputing?

I don’t know that a general answer is possible but any thoughts you have are sincerely appreciated. I understand you do not give personal advice and that if you do answer, it will be for the help of many others who follow your blogs and appreciate your insights.

Bill

Hi Bill, Thanks for your kind comments and question. I am embarrassed that I can’t give you a good clear answer. But I’ll try to babble briefly. Remember that there are four treatment models for anxiety, and I use all four with every anxious patient I treat.

  • The Motivational Model—where you bring the anxious patient’s Outcome and Process Resistance to conscious awareness and melt them away.
  • The Cognitive Model—where you challenge the distorted negative thoughts that trigger the anxiety, using a wide variety of techniques such as Identify the Distortions, Externalization of Voices, the Experimental Technique, and so forth. You call this “thought disputing,” but there are more than 50 ways of disputing and crushing negative thoughts.
  • The Hidden Emotion Model—often the overly “nice” anxious individual is sweeping some feeling, conflict, or problem under the rug and not dealing with it. When the patient brings the problem to conscious awareness and deals with it, the anxiety often disappears completely.
  • The Exposure Model—where you flood yourself with anxiety by facing your fears. If you stick with it, in most case the anxiety will diminish over time and then disappear. You call this “cognitive flooding,” although that’s just one of many exposure techniques.

I describe these four models and methods in my recent series of Feeling Good Podcasts on the treatment of anxiety (Podcasts 22 to 28). You might enjoy listening to them, and can link to the first one if you CLICK HERE. All four treatment methods are helpful, but they work in different ways. You never know which method or methods will be the most helpful to any individual.

But I have to confess I don’t “schedule” them as you have suggested. However, that’s not a bad idea! In my experience, depressed and anxious individuals who work with these techniques, and actually try them, including the written exercises, as opposed to just reading about them, nearly always have the best outcomes. So stick with it!

And of course, if you need help or guidance, it never hurts to check with a mental health professional. However, I would personally tend to avoid a psychiatrist as my first choice, as you are likely to get drugs, drugs, drugs. Although I am a psychiatrist, and have prescribed medications on occasion, I find that most depressed and anxious individuals can now be treated quickly and effectively without medications. In addition, research studies indicate that many people recover from depression anxiety on their own after reading one of my books, but if you need a little guidance from an expert, there’s no shame in that at all! Sometimes, we all need a little help from our friends!

Sincerely,

David

 

Hi Dear David Burns,

feelinggood  Firstly, I want to say thanks a lot for you book, “Feeling Good: the New Mood Therapy”! This book has changed my life! Now I love life and enjoy everything in life.

My story started after reading your book second time! Thanks very much! God bless you David uncle!

Sedef (from Turkey)

Hi Sedef,

Thank you so much for your kind and incredible comments, and for your blessing! I am thrilled that you are now loving life and enjoying life! That is like a miracle and the greatest gift a human being can receive.

It is many years since I wrote Feeling Good as a young man, editing it while we were on summer vacation in California, at Lake Tahoe. You might not have even been alive at that time! It seems like a miracle that my words have now touched you, so many miles away. God bless you, too, Sedef!

All the best,

David Uncle

026: Scared Stiff — The Exposure Model (Part 4)

026: Scared Stiff — The Exposure Model (Part 4)

In this Podcast, David and Fabrice discuss the Exposure Model for treating anxiety. They begin by briefly describing the three different deaths of the ego that are required for recovery from depression, anxiety, or a relationship conflict, respectively. For depression recovery often results from the “Great Death,” A Buddhist concept that involves the discovery that there is no such thing as a “self” that could be worthless, or inferior, or judged by another person. David and Fabrice only touch on this theme and promise an entire future podcast on this fascinating and helpful spiritual notion that can lead to recovery from depression.

For anxiety, the death of the ego is quite different, and involves surrendering to the monster the patient has always feared and avoided using a wide variety of exposure techniques. David traces the origin of Exposure Therapy to teachings in the Buddhist hold scriptures, the Tibetan Book of the Dead, more than 2,000 years ago. David describes the amazing and hilarious phenomenon of “laughing enlightenment,” which often happens when anxious individuals confront their fears.

David describes how he used Flooding, an extreme form of exposure, to get over his own blood phobia, which he’d had since childhood. His fear of blood caused him to drop out of medical school at Stanford for a year on two separate occasions. He finally decided to confront his fear by working for a month in the Emergency Room of Highland Hospital, a major trauma treatment center, in Oakland, California. David explains what happened when a totally bloody man on the verge of death was rushed into the ER after a bomb he was building in his basement blew up.

In the podcast David forgot to mention something fascinating about his experience at Highland. David had had a blood phobia since he was child, and blood phobia is thought to have genetic causes, and perhaps be inherited. And yet, David was totally cured in roughly 15 minutes without any medication at all. The important point is that even if things are biologically caused, they can often be treated with psychological techniques.

Most therapists hate the word, “cure.” David explains why he sometimes uses this term when treating anxious patients, and also explains the difference between a 100% cure and a 200% cure.

David emphasizes the importance of motivation and resistance in the treatment of anxiety, since few patients, if any, will want to use exposure techniques, because it is so terrifying. David and Fabrice will describe the Motivational Model in the next podcast.

David and Fabrice raise questions about the mechanism of recovery during exposure. Why does it work? Is it due to the change in thinking, or is there some other healing mechanism at work?

Fabrice asks about patients who resist exposure and protest that it won’t work. For example, a patient with the fear of heights might say, “Oh, exposure can’t possibly help, because every time I get in a situation where I’m exposed to heights, like when I’m in looking over a railing on the third floor of a building or hiking on a mountain trail, I get terrified. This has happened hundreds of times and it never helped!”

Finally, David describes a humorous but real example of his 8-minute treatment of a therapist with 20 years of failed therapy (several times a week of psychoanalysis) for her elevator phobia.

David and Fabrice end by talking about the enormous amount of information they have to share with listeners, including large numbers of creative exposure techniques that fall into three categories:

  1. Classical Exposure
  2. Cognitive Exposure
  3. Interpersonal Exposure

They promise future podcasts describing these fascinating techniques with more amazing vignettes based on patients Dr. Burns has treated, as well as his treatment of his own many fears and phobias!

 

Treatment of Hypochondriasis / Health Anxiety

Treatment of Hypochondriasis / Health Anxiety

Hi Dr. Burns,

I have read feeling good and listened to all your podcasts as of today. I have a history of hypochondria and depression and your book helped me tremendously in overcoming my anxiety. I am beyond happy that I can finally have control over my emotions.

I used to go to psychotherapy sessions with multiple different psychotherapists and more often than not the solutions they offered were along the line of “keep as busy as possible not to give in to the thoughts” or “imagine the obsessive thoughts as a spoiled brat that you should not give into” which all failed dramatically. And believe me when I say they even made it worse than before!

Recently I was listening to some your anxiety podcasts in which you introduced the exposure technique. You described how it worked in the case of Pedro, the young man with OCD who was having intrusive thoughts of Jesus having sex with Mary in all the positions of the Kama Sutra. And the harder he tried to control these forbidden thoughts, the more intense they became!

You also described the Experimental Technique you used in your panic attack patients. I was wondering if these techniques can be helpful in the case of patients dealing with health anxiety.

I read a research paper of a psychiatrist treating her hypochondriac patients with exposure techniques. For example, in my case, if I’m always scared of contracting HIV, I might volunteer to work with HIV positive patients so I could confront my fear. I was wondering if that could help with the urge to get tested very often and if there are any other techniques you specifically find useful in this case.

I used the exposure technique successfully to eliminate my frightening thoughts of slitting my wrists or throat with a razor. These thoughts used to give me a tremendous amount of anxiety and I would always try to eliminate them from my mind as soon as they appeared, almost automatically thinking that’s the way to protect myself. That didn’t work! But now they are completely gone as I spent a full half-day just repeating those images in my mind, over and over again. I tried to imagine all the graphic details until I was completely bored with them! I would like to thank you for reaching out and sharing your knowledge and expertise with people despite the fact that you don’t practice anymore.

And by the way that jumping jacks story with your patient who thought she was about to die during a panic attack has become an inside joke between me and my husband!

Sincerely,

Mona

Hi Mona,

Thank you for your kind comments about the Feeling Good podcasts! I know that my host, Fabrice, will be thrilled to hear that you like them and find them helpful!

There are so many things I appreciate about your wonderful email that I’m not sure where to begin. I do want to emphasize that I cannot treat anyone or give medical advice in this medium, so my answer, as always, will consist of general teaching.

First, I resonated when you described previous therapists who gave you advice, thinking that would help. To my way of thinking, an awful lot of “psychotherapy” consists of schmoozing behind closed doors with the occasional piece of advice thrown in, and in most cases, that just doesn’t get the job done. In fact it can make people feel worse, because it is often sounds patronizing.

Second, I have a current series of several Feeling Good podcast on the treatment of anxiety using four models that are all described in my book, When Panic Attacks. They are the Motivational Model, the Cognitive Model, the Exposure Model, and the Hidden Emotion Model. All four models have tremendous healing power, and I integrate all four into my treatment of each individual with anxiety, because you never know which one, or which combination, will give you the “ah-ha” moment when the anxiety suddenly disappears completely. You can listen to those podcasts right now if you like, either on iTunes or right here on my website, feelinggood.com.

In the treatment of OCD, the Exposure Model usually has two components: Exposure and Response Prevention. So if a person has an irrational fear of HIV, as you described in your email, they could use Cognitive Exposure or Classical Exposure. Cognitive Exposure might involve fantasizing dying of HIV until the fantasy becomes totally boring. Classical Exposure might involve volunteer work with HIV patients, as you mentioned.

In therapy, I work with the patient to figure out what type of Exposure will be the most effective. The Exposure has to be anxiety-provoking, or it won’t be helpful. And, as you say, the goal of exposure is not to control the anxiety—which makes it worse—but simply to flood yourself with the anxiety until it finally loses its power over you.

Response Prevention would mean, in this case, refusing to give in to the urge to get repeated blood tests, if that’s what you are doing to deal with your fear of HIV. But the Response Prevention has to be tailored to your compulsion. Let’s assume that you had OCD with a handwashing compulsion, so you are washing your hands repeatedly all day long to get rid of the imagined “contamination.” Response Prevention would mean refusing to give in to the urge to wash your hands repeatedly. The anxiety will increase for several days, but if you refuse to give in, the compulsion will generally diminish and disappear. This is a bit like drug withdrawal, actually.

But Exposure is just one of four effective treatment models. I treated a medical student with severe OCD who also had the fear of HIV, and Exposure and Response Prevention were only somewhat helpful, and definitely not curative. In his case, the Hidden Emotion Technique ruled the day. If you are interested, you can read about that fantastic technique in my book, When Panic Attacks, and of course, one of the Feeling Good podcasts on anxiety will focus on this technique.

I have treated many patients with health anxiety / hypochondriasis and the Hidden Emotion Technique almost always contributed greatly to their (frequently rapid and complete) recovery. But in therapy, I use more than 75 techniques to help folks—it just isn’t the case that you can have one “formula” that works for everyone, since we are all individuals and our negative thoughts and feelings will be unique—so that requires an individualized approach to treatment, namely TEAM-CBT. (That’s my commercial message!)

All the best,

David

023: Scared Stiff — What Causes Anxiety? What’s the Cure? (Part 2)

In this Podcast, David and Fabrice describe four powerful treatment models for anxiety, including

  • The Cognitive Model
  • The Exposure Model
  • The Motivational Model
  • The Hidden Emotion Model

Each approach has a completely different theory about the causes of anxiety and utilizes completely different treatment techniques. For example, cognitive therapists believe that distorted thoughts trigger all anxiety, and that the most effective treatment involves challenging these distortions. In contrast, exposure therapists argue that avoidance is the cause of all anxiety, and that exposure is the only effective treatment. Those who adhere to the Motivational Model emphasize the role of resistance. In other words, anxious individuals are reluctant to let go of the anxiety because they secretly believe that the anxiety will protect them from danger.  And those who adhere to the Hidden Emotion Model claim that “niceness” is the true cause of all anxiety in the United States at this time, and that hidden problems and feelings may need to be brought to conscious awareness before the patient can recover.

Dr. Burns argues that, in fact, all four theories are correct, and that if you skillfully integrate all four approaches, you will often see a rapid and total elimination of anxiety in the great majority of your patients.

Dr. Burns describes how he created the Hidden Emotion Model when he was treating a woman with mysterious and intractable case of Panic Disorder. Every time her boss walked past her desk, she became nauseous and panicky, and had the overwhelming urge to vomit on him. Then she would have to rush to the ladies’ room to rest until the nausea and panic diminished, and she sometimes had to go home because the symptoms were so severe. This was all the more puzzling because she insisted she had the best boss in the world and that there were no problems at work. She explained that her boss constantly praised her and gave her promotions and generous raises, and that she had no complaints whatsoever.

Cognitive and exposure techniques were only partially effective, until an unexpected discovery suddenly emerged during a therapy session that led to a surprising outcome. What do you think the hidden emotion was? Tune in and you’ll find out!

In the next several podcasts, Drs. Burns and Nye will bring these four models to life, using real life examples, including some of Drs. Burns’ personal struggles with anxiety early in his career.

Error #3: Reverse Anxiety Hypnosis

* ©2012 by David D. Burns, MD

Do not copy, publish or reproduce without the written permission of Dr. Burns.

In my last blog, I discussed something I call “Reverse Depressive Hypnosis.” That’s where the patient inadvertently “hypnotizes” the therapist into believing that she or he REALLY IS hopeless, worthless, and so forth. It is sometimes hard to resist falling into this potentially destructive trance, or even noticing that it has happened. Today, I will describe “Reverse Anxiety Hypnosis.” In a nutshell, that means that the anxious patient persuades you that she or he is too fragile (or not yet ready) to confront his or her fears using powerful exposure techniques.

In my book, When Panic Attacks, I describe several models I use in treating anxiety disorders, such as chronic worrying, phobias, PTSD, Panic Disorder, Agoraphobia, OCD, shyness, public speaking anxiety, and others, including:

  • The Motivational Model—Although anxiety can be exceedingly painful, you may secretly believe that your anxiety is helping you, or protecting you, so you are reluctant to give it up. A simply example would be the fear of flying. You may think that your fear protects you from getting on a plane and crashing.
  • The Cognitive Model—You learn how to challenge the distorted negative thoughts that trigger the anxiety.
  • The Exposure Model—You confront your worst fears, rather than running away from them.
  • The Hidden Emotion Model—You bring hidden feelings and conflicts to conscious awareness. When they express these feelings and solve the problems you’ve been avoiding, the feelings of anxiety often improve dramatically or totally disappear.

If you combine all four models, you can often achieve a complete elimination of the anxiety rather quickly. Patients love the Motivational, Cognitive and Hidden Emotion Models because they can be enormously helpful and fun to learn, but they typically hate Exposure Model. That’s understandable—we all avoid the things that terrify us. I can vouch for that, as I have personally experienced and overcome more than a dozen kinds of anxiety.

Patients will often hypnotize their therapists into believing that they are too fragile to use exposure techniques. If the therapist falls into this trance, and buys into that notion, the treatment will be doomed. It is practically impossible to overcome any form of anxiety without using exposure techniques. Exposure alone will rarely be enough—the Motivational, Cognitive and Hidden Emotion Models will also play vital roles in the treatment—but exposure will be mandatory.

When I give workshops on the treatment of anxiety, I ask the therapists in the audience to raise their hands if they routinely use exposure techniques when treating anxious patients. Usually, only about 25% of the hands go up, at most. This means that most therapists are NOT using exposure techniques in the treatment of anxiety disorders.

This might seem surprising, or even disturbing, since exposure is one of the most researched and validated psychotherapy techniques in history. So why aren’t all therapists using and requiring exposure? There are many reasons. Some therapists do not believe in using powerful techniques like exposure, thinking that empathy and talk therapy alone will be sufficient. But the most common reason patients and therapists avoid exposure is fear. The therapist thinks the patient is too fragile for powerful exposure techniques. In other words, the therapist has been hypnotized by the patient. So the therapist and patient talk and talk and talk in a general way, exploring the past, but the symptoms do not improve much, if at all.

Dr. Matt May is a former student of mine at Stanford, and we now teach together on the voluntary faculty. He is terrific hypnotist. He is also very suggestible and easy to hypnotize. He has told me that he often falls into trance when treating patients and then has to snap himself out of it.

Matt recently treated a young woman whom I’ll call Susan. Susan came all the way from Cleveland for intensive treatment with Matt because she’d been struggling for years with severe social anxiety. (The details are always disguised to protect patient identities.)

Susan showed up at Matt’s office dressed quite formally, in a business suit. She described how she’d been treated for more than 15 years with conventional talk therapy plus a wide variety of medications with no improvement. Although she was an attractive and talented young professional, her crippling shyness in social situations, coupled with severe public speaking anxiety had severely hampered her social life and her career. She felt ashamed, lonely, hopeless, and defective.

Matt asked what she was the most afraid of. What was her greatest fear? She explained that she was intensely afraid of making a fool of herself in public, or saying or doing the wrong thing, and having people look down on her and see how crazy and defective she was. This fantasy was so terrifying to her that she avoided interacting with people in practically all social situations and refused to give talks at work.

Ten minutes into their first session, which was devoted to clinical history-taking and assessment, Susan asked if there was any hope for her, given the severity of her problems, and how long the treatment might take. On impulse, Matt said that if she wanted, they could just take a ten minute break from taking the clinical history and cure her, and then he could complete the history. She seemed shocked and asked how he could possibly cure her in ten minutes, especially given so many years of unsuccessful treatment from numerous psychologists and psychiatrists.

Matt explained that she simply had to confront her fears, rather than running away from them. He said he wanted her to do a Shame Attacking Exercise. When you do a Shame Attacking Exercise, you make a fool of yourself in public on purpose by doing something foolish or bizarre, so can discover that the world doesn’t come to an end after all. I believe this fantastic technique was developed by the late Dr. Albert Ellis.

He told her he wanted her to go to the Starbuck’s which was just a half a block away from his office. Once inside, she was to lead the customers in singing and cheering, much like a cheerleader at a football game.

She was shocked and indignant, and insisted that this assignment sounded like malpractice, and that someone proper should NEVER do something as socially inappropriate as that!

Matt suddenly became ashamed and profoundly apologetic. He said he couldn’t believe he had asked her to do that, and went back to taking the history, all the while feeling intensely anxious. Do you know what happened? Susan had instantly hypnotized him into believing that she COULDN’T and SHOULDN’T have to confront her worst fears.

After ten minutes, Matt realized what had happened and snapped himself out of the trance. He told her that what she said was a lot of BS, and that she COULD and MUST do the Shame Attacking Exercise. In fact, they were going to go and do some Shame Attacking Exercises together—RIGHT NOW. So he led her out of the office and suggested they could start by doing something even more extreme outside the grocery store across the street.

So they both lay down on the sidewalk right in front of the front door of the grocery store, so that people would have to step over them to get inside. Matt asked her how intense her anxiety was, between 0% and 100%, and she replied “95%.” Matt said that wasn’t high enough, and he wanted her to push it to 100%.

Next, they pretended to be making snow angels, and then they pretended to be riding invisible bicycles while lying on their backs. It started to rain slightly, but they stuck with it.

A customer stepping over them to get inside asked what they were doing on the ground. She announced, “Oh, this is my shrink. We’re having a psychotherapy session. He often has his sessions on the sidewalk rather than in his office.”

Then Matt said, “You can join us if you like. It’s really nice lying here, kind of like being on the beach in Miami!”

Susan noticed that the people inside the grocery store were pointing at them, which made her anxiety even worse. This was her worst fear coming true—that people would think she was some kind of weirdo.

Then the store clerk came out and asked, “Are you guys okay?” She explained that they were fine and just enjoying themselves on the sidewalk. The clerk explained that the manager wanted them to leave. So they got up and left. Matt asked how she felt, and she said, “That was awesome!” She said that her anxiety had suddenly dropped to zero!

Why did that happen? It was because she confronted her worst fear, but nothing really terrible happened. She started laughing and said she felt triumphant.

Matt said, “Great! You’re cured now, and it only took ten minutes. Now we can go back to my office and I can finish your history.”

Susan said, “No! We’re not done yet. We still have to go into Starbuck’s and do our thing!” So they went into Starbuck, where a long line of people were waiting to buy coffee. Her anxiety suddenly spiked when Matt said, “Okay, time to do your thing.”

In spite of the intense anxiety she once again felt, she locked the fingers of her right and left hands together, and inverted her hands in the air above her head, and waved them like a victory fist, and then ran around in circles, saying, “It’s such a wonderful day. I’m so happy to be here. I’m so glad to be alive. Life is wonderful! I love the coffee here in Starbucks.”

Then she led the customers in cheerleading and got many people dancing and running around the store with her. Matt said he felt so proud it brought tears to his eyes.

During her several-day intensive with Matt, Susan did other Shame Attacking Exercises as well, including wearing an extremely sexy outfit in public, and confronting her fears of how people would think about her.

Coincidentally, I spoke with Matt on the phone this morning and asked him about Susan, since the treatment was more than a year ago. He had just received an email from her with a progress report on how she’s been doing since she finished her intensive. She said she was still on a high and that her life had opened up in incredible ways. One of the most significant changes was that even though she’d been very successful in her professional career, she had decided to switch careers and go back to graduate school so she could become a therapist. I have included some excerpts from her email below, printed with her permission, so you can read her personal account of the Shame Attacking.

The exposure techniques are not always that dramatic or extreme, but they nearly always require tremendous courage and commitment, both on the part of the therapist as well as the patient. This means that therapists will have to avoid falling into the anxious patient’s trance. If you combine Exposure Techniques with the Motivational, Cognitive and Hidden Emotion treatment models, the rewards can be tremendous.

In my next blog, I will discuss a third type of reverse hypnosis—relationship hypnosis. That’s where the angry patient, or the patient who simply isn’t getting along with his or her spouse, or a family member, or a friend or colleague, convinces you that he or she is an innocent victim and that the other person is to blame for the problems in the relationship. It is very difficult not to succumb to this trance, but if you get hypnotized in this way, the prognosis for effective treatment becomes very low.