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 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!
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.
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?
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!
Question #4. I’m in sales. How do I combat my Negative Thoughts about each person I approach?
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?
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:
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.
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.
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!
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?
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!
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.
What can you do when you can’t identify your negative thoughts?
Is it really true that our feelings always result from negative thoughts?
How can I get over my public speaking anxiety?
Rubens, a faithful and enthusiastic Feeling Good Podcast fan, sent me an email with a terrific question that has both practical and theoretical implications. He wrote:
Dear Mr. David,
I’ve read “Feeling Good” and I’m reading “When Panic Attacks” now. Both have and are helping me immensely.
However, the one thing I have never understood is that my anxieties and worries often don’t come as a thought. For instance, I have an academic presentation tomorrow, and I’m suffering from much anxiety because of that. But the symptoms did not appear because I thought in my mind the sentence “you are going to fail!”. In my case, it is usually silent. I just remember that I have a presentation tomorrow, then I immediately feel worried. My chest hurts before any thought. How do I counter-argument my thoughts, if I have none?
Thank you for replying, Mr. David!
In today’s podcast, Rhonda and I address this question and explain what to do when you can’t pinpoint your negative thoughts. There are two really good methods.
We will also demonstrate how to deal with some of the negative thoughts that typically trigger public speaking anxiety. The cure involves changing the way you think, and changing the way you communicate with the people in your audience. If you’ve ever struggled with public speaking anxiety, this podcast may be helpful for you!
Thank you again, Rubens, for your excellent question!
David D. Burns, MD / Rhonda Barovsky, PsyD
You can reach Dr. Burns at firstname.lastname@example.org. Dr. Rhonda Barovsky practices in Walnut Creek, California, and can be reached at email@example.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 intensive, but there will be two more awesome intensives for you this summer and fall.
The incredible SF intensive will be here in one week!
Answers to More Great Questions from Listeners Like YOU!
Kevin asks: After your initial improvement from treatment or from reading your book, Feeling Good, what can one do moving forward to give yourself “booster shots?”
Umatsagir asks a related question: I feel great right after reading your book, Feeling Good, but the effect diminishes over time. What should I do?
Umatsagir also asks: Is there an anxiety masterpiece equivalent of your book, Feeling Good?
Kyle asks: What can I do, as a therapist, about the passive patient who just shrugs when I ask what he wants to work on, and says, “My Mom thinks I should come to see you.” When I try to dig deeper to try to find out what patients like this want help with, I run into resistance and then they typically drop out of therapy. What should I do?
Benjamin asks a somewhat related question: How do you treat chronic laziness? In your book, Feeling Good, you call this “Do-Nothingism,” which is a lack of motivation that you often see in depression. In your book, you talk about ten different types of procrastination, with a different approach for each. If the patient feels overwhelmed by many things he or she is procrastinating on, how can you help that person, since he or she probably can’t do the psychotherapy homework, either! It’s a Catch-22, since they cannot find the motivation to do anything, but have to do the homework to improve!
Jim asks another related question: How about doing a podcast on psychotherapy homework? “What do you have your patients do for homework? This is particularly important since I have 45 minute sessions and can only see my patients for 45 minutes every two or three weeks.”
Dr. Fabrice Nye currently practices in Redwood City, California and treats individuals throughout the world via teletherapy. You can reach him at firstname.lastname@example.org. You can reach Dr. Burns at David@feelinggood.com. If you like our jingle music and would like to support the composer Brett Van Donsel, you may download it here.
Answers to Great Questions from Listeners Like YOU!
Dylan asks: Do you believe in Freud’s “secondary gain,” in which patients resist change because they benefit from their symptoms?
Juleann asks: Is Seasonal Affective Disorder (SAD) a real thing?
Ismail asks: Should I use the Daily Mood Log just when I’m upset, or at the end of the day, or when? Do I have to stop what I’m doing when I get negative thoughts so I can write them down and work on them?
Abe asks: What about negative thoughts that are valid? For example, I was interested in astronomy and physics as a teenager, but my SAT scores showed I had no aptitude for a career in these areas.
Kevin asks: Can positive flooding be used to change the object of our desires—for example, our sexual desires, like the man in one of your books who had lost sexual interest in his wife?
Valentina asks: Where do cognitive distortions come from? Our parents? Our genes? Societal messages?
Dr. Fabrice Nye currently practices in Redwood City, California and treats individuals throughout the world via teletherapy (but not across U.S. state lines). You can reach him at email@example.com. You can reach Dr. Burns at firstname.lastname@example.org. If you like our jingle music and would like to support the composer Brett Van Donsel, you may download it here.
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:
I’ll probably look foolish and make a fool of myself.
I’ll screw up and fail.
People will judge me and think less of me.
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!
This is a form of Cognitive Exposure
Some fears are not easily confronted in reality
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
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.
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.”
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*
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.
Externalization of Voices
His or her real name
Same name as the patient
His or her real name
You play the role of some judgmental or critical person the patient is afraid of.
Comparing the Self-Defense Paradigm with the Acceptance Paradox*
Example of How to Defeat the NT
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.”
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.
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 http://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!