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184: Ask David: What Comes First? Negative Thoughts or Feelings? Solving the Chicken vs. the Egg Problem, and More!

184: Ask David: What Comes First? Negative Thoughts or Feelings? Solving the Chicken vs. the Egg Problem, and More!

Today, Rhonda and David answer several challenging questions submitted by listeners like you.

  1. What schools of therapy are embedded in TEAM?
  2. Do negative feelings cause negative thoughts? Or do negative thoughts cause negative feelings? Or both? Or neither?
  3. “Can TEAM-CBT help bipolar patients during the depressed phase?”
  4. How do you make Externalization of Voices work? I get stuck! For example, my patient said, “It’s unfair that I cannot get a job!”
  5. Is there a cure for OCD?

1. What schools of therapy are embedded in TEAM?

Dear Dr. Burns,

I have some questions specifically about T.E.A.M. therapy. You mention in a blog post that T.E.A.M. therapy “integrates features and techniques from more than a dozen schools of therapy.” I’m aware of many of the CBT techniques you use, but I don’t think I’ve read yet of any technique belonging to any other schools of therapy. Would you be so kind as to mention such techniques?

Madelen

Hi Madelen,

This is important because I believe we need to get away from competing schools of therapy and need to create a new, data-driven structure for therapy based on research on how therapy works, which is what TEAM is. At the M = Methods part of the session, you can include methods from any school of therapy.

Here are some of the schools of therapy that I draw upon TEAM-CBT.

      1. Individual / Interpersonal downward arrow: same (psychoanalytic / psychodynamic)
      2. Flooding / Experimental technique: behavior therapy (exposure)
      3. Externalization of Voices: Gestalt / Psychodrama / Buddhism
      4. Acceptance Paradox: Buddhism
      5. Self-Defense Paradigm: REBT
      6. CBA / Paradoxical CBA / Devil’s Advocate: Motivational techniques
      7. Identify the distortions / examine the evidence: cognitive therapy
      8. Empathy: Rogerian (humanistic) therapy
      9. Five Secrets / Forced Empathy: Interpersonal therapy
      10. Shame-Attacking Exercises: Humor-based therapy / Buddhism
      11. Be Specific / Let’s Define Terms: Semantic
      12. Feared Fantasy: Role-Playing / Psychodrama / Exposure
      13. One-Minute Drill / Relationship Probe: Couple’s Therapy
      14. Time Projection / Memory Rescripting: Hypnotherapy
      15. Anti-Procrastination Sheet: Behavioral activation therapy (Lewinsohn-type therapy)
      16. Brief Mood Survey / Evaluation of Therapy Session: data-driven therapy
      17. Talk Show Host / Smile and Hello Practice / Flirting Training: Modeling / teaching effective social behavior
      18. Storytelling: indirect hypnosis.
      19. Positive Reframing: Paradoxical psychotherapy.
      20. Hidden emotion technique: psychoanalytic / psychodynamic
  1. Do you need more? Can provide if you want. Let me know why you have this particular interest!At any rate, I really enjoyed and appreciate your thoughtful questions, thanks!David

2. Do negative feelings cause negative thoughts? Or do negative thoughts cause negative feelings? Or both? Or neither?

Hello Dr Burns,

I would like to thank you for your podcasts. I greatly enjoy listening to them and find them very much helpful both in my personal life and my work as a psychologist.

I do have a question: you talk about how cognitive distortions cause anxiety and depression. Are cognitive distortions also a result of depression and anxiety? For instance, if a person was to become depressed after experiencing loss, would they then discount the positive in their lives to a larger extent, for example?

Thank you very much!

Audrey

Hi Audrey,

Yes, depression creates a negative bias in perceptions, so you pick out information and details that support your distorted thoughts, like “I’m a loser” or “my case is hopeless.” My research, which I’ll report in my new book, Feeling Great (sept 2020) indicates that negative thoughts trigger feelings of depression and anxiety, which, in turn trigger more negative thoughts. This is a negative vicious cycle. There is also a positive cycle, in that positive thoughts that you believe to be true trigger positive feelings, which, in turn trigger more positive thoughts! Thanks for the question, Audrey.

david 

3. “Can TEAM-CBT help bipolar patients during the depressed phase?”

Name: Sarah

Comment: Hi, Dr. Burns.

I am a big fan of your work and very much enjoy reading your blogs and listening to you and Fabrice on you weekly podcasts.

I am writing with a question that has to do with the depression side of bipolar disorder and the potential usefulness of CBT. I have not heard you speak about this topic before.

My sister in law lives in Switzerland and has been diagnosed with a fairly severe case of bipolar disorder. She does not cycle rapidly, but her manic and depressive states are quite severe. In fact, she has been hospitalized several times during her manic episodes.

For the first time in her life, I believe my sister in law has finally accepted the fact that she is bipolar, and she is actively pursuing treatment and trying to get better. After hearing me talk about all the great information I have learned from you, my husband has hunted down several CBT practitioners in Switzerland, in the hopes that changing my sister in law’s thoughts will help her navigate the overwhelming depression she is currently experiencing. Unfortunately, most of the practitioners she has contacted have said that they cannot help her, because she has bipolar disorder. Of course, this is only adding to her sense of hopelessness.

In your opinion, could CBT and challenging negative thought distortions be helpful to someone who is bipolar and currently experiencing the depressive side of the disease?

In my mind (a layperson who has used CBT to help with panic disorder) it seems so obvious that it could help, but several Swiss psychotherapists seem to disagree with me! Are these therapists afraid to take on a complicated case or is there really nothing they can do?

I would love to hear your take on it. Thank you so much for your endless work helping people to feel good!

Sarah

David will describe his experience running the lithium clinic in Philadelphia at the VA hospital, and will discuss the very important role of good psychotherapy for bipolar patients, although medications will also play an important role in the treatment.

4. Externalization of Voices: How do you make it work? I get stuck! “It’s unfair that I cannot get a job!”

Dear Dr Burns and Rhonda,

I’ve just finished listening to all of the Feeling Good Podcasts. What a gift! My immense gratitude to you and Fabrice for the time and effort that has gone into these podcasts, as well as the wonderful show-notes.

I am a family physician and I work with impoverished patients, many of them refugees. Depression and anxiety are common. We can’t find CBT therapists for our patients within their means, so I end up trying to provide some counselling despite not having much background or training (a dangerous proposition, I know, but we have little choice.) Medications tend not to be too helpful, as David points out. I am starting to try to integrate TEAM concepts.

I have a question about Externalization of Voices. In all of the examples you’ve shared in the podcast, whenever David does a role reversal and models the positive voice, he always seems to “win huge”. I’m less experienced and find I’m not batting 1000. What do you do when neither you nor the patient have been able to win huge?

Many thanks again for all you do,

Calvin

PS The episode on How to Help and How Not to Help was one of the best yet!

Hi Calvin,

Thanks for the kind comments! Can you tell me what the thought is that you’ve failed with?

All the best,

David D. Burns, M.D.

Hi David,

There have been a couple of examples where we could only get a small win.

With the first patient, the thought he was tackling was: “It’s not fair that I’ve worked so hard in life, but I can’t get a job.”

I tried modelling self-defense, along the lines of “I’ve accomplished a lot given how many challenges I’ve faced.” I also tried suggesting the Acceptance Paradox with something like: “It’s true that life’s not fair. Who said it should be fair?” This was only a ‘small win.’ I felt stuck.

Another patient felt her chronic insomnia was driven by anxiety. She feared she would never sleep well again. The though was “I’m going to be chronically tired and no longer able to enjoy life the way I used to.” We tried: “Sure, I may be more tired than I used to be, but I’ll still be able to enjoy life to some extent.” Again, this was a small win, not enough to crush it.

Thanks again for your willingness to help!

Calvin

David’s response

Hi Calvin,

All therapeutic failure, pretty much, results from a failure of agenda setting. I’m not sure you’ve been trained in A = Paradoxical Agenda Setting. The A of TEAM is now also called Assessment of Resistance. When people can’t easily crush a Negative Thought, it is nearly always because they are holding on to it. This is called “resistance.”

Let’s focus on the first thought, “It’s not fair that I’ve worked so hard in life, but I can’t get a job.”

This thought triggers anger, and anger is the hardest emotion to change because it makes us feel morally superior and often protects us from feelings of inadequacy, failure, or inferiority. If you do not deal with the underlying resistance to change, the patient will defeat your efforts.

When you do Positive Reframing, you start with a Daily Mood Log with one specific moment when the patient was upset and wants help. The anger will be only one of a large number of negative emotions the patient circles and rates, and there will always be numerous negative thoughts as well.

The negative feelings might also include sad and down, anxious, ashamed, inadequate, abandoned, embarrassed, discouraged / hopeless, frustrated, and a number of anger words like annoyed, resentful, mad, and so forth.

This is super abbreviated, but you would then do A = Paradoxical Agenda Setting (also now called Assessment of Resistance.)

You would start with a Straightforward or (better in this case) Paradoxical Invitation—does the patient want help with how he’s feeling? You might tell him he has every right to feel angry and upset and might not want help with his negative feelings as long as he has no job.

If he insists he DOES want help, you can ask the Miracle Cure Question, and steer him toward saying he’d like all of his negative thoughts and feelings to disappear, so he’d feel happy.

Then you can ask the Magic Button question. If like most patients, he says he WOULD push the button, you can tell him there is no Magic Button, but you DO have lots of powerful techniques that could be tremendously helpful. But you’re not sure it would be a good idea to use these techniques.

When he asks why not, you could say it would be important to look at the positive aspects of his negative thoughts and feelings first. Then you do Positive Reframing, and together you can list up to 20 or more positives that are based on each negative emotion and each negative feeling. To generate the list of positives, you can ask: 1. What are some benefits, or advantages, of this negative thought or feeling? 2. What does this negative thought or feeling show about me, and my core values, that’s positive and awesome?

For example,

      1. My sadness is appropriate, given that I don’t have a job. If I was feeling happy about this, it wouldn’t make sense.
      2. The sadness shows my passion for life, for work, and for being productive.
      3. My anger shows that I have a moral compass and value fairness.
      4. My anxiety motivates me to be vigilant and to look for a job, so I don’t get complacent and starve.
      5. My anxiety, in other words, is a form of self-love.
      6. My anger shows self-respect, since I have a lot to offer and contribute.
      7. My hopelessness or discouragement shows that I’m honest and realistic, since I have tried so often and failed.

This is just an example, and with a real patient, it can be very powerful as I have the facts and know the patient, whereas in this example I am just making things up.

Then once you have a long and incredibly compelling list, you can ask, “Well, given all of those positives, why would you want to press that Magic Button? If you push it, all these positives will go down the drain at the same time that your negative thoughts and feelings disappear.

Then you resolve the patient’s dilemma with the Magic Dial.

All this is done AFTER E = Empathy (you have to get an A from your patient) and BEFORE using any M = Methods, like externalization of voices.

If you do this skillfully, the Ext of Voices will go way better, because the person will be determined to reduce the anger and other negative feelings. But if the patient says he or she does not want to change, and wants to be intensely angry, that’s fine, too!

If this is not clear enough, you could also get some paid case consultations from someone at the Feeling Good Institute, which could be invaluable. This is the most challenging and valuable tool of all!

Not sure how much training you’ve had in TEAM. Rhonda and I can discuss these two examples when she returns from India in a month or so, but there are online classes that are excellent. Also, on my workshop page you can check out my upcoming workshop with Dr. Jill Levitt on resistance.

There are podcasts, too, on resistance / paradoxical agenda setting as well as fractal psychotherapy.

Thanks!

David

5. Is there a cure for OCD?

Hi Dr. Burns,

I have been suffering from OCD and depression post the delivery of my daughter and have been on antidepressants for the last 7 years. I have recently start going for counselling too with a psychologist. In fact, she is the one who recommended your book which I am finding very useful. Your website is very helpful too.

I had just one general question: Are OCD and Depression 100% curable or are they only controllable and one has to be on medicines for the rest of their lives?

Reason why I am asking this is the last time we tried to taper down the medicines I ended up having a worse relapse. I want to know if I can plan for a second pregnancy.

I know you do not reply to personal messages but would really be grateful if you could reply to this mail

Looking forward to hearing from you

Regards

“Betsy”

In my dialogue with Rhonda, I emphasize that I rarely use medications in the treatment of anxiety and depression, including OCD, and I would urge this listener to use the search function on my website to search for podcasts and blogs on antidepressants, anxiety, OCD, and Relapse Prevention Training, and you will find lots of specific resources. For example, if you type in OCD, you will find the Sara story plus lots of additional great resources on OCD, including podcasts 43 – 45 (this page provides links to all the podcasts), and more.

Also, my books, When Panic Attacks, and the Feeling Good Handbook, could be very helpful, and you can link to them from my books page. I use four models in the treatment of OCD, and you can find them if you listen to the basic podcasts on anxiety and its treatment. They are the Hidden Emotion Model, the Motivational Model, the Exposure Model, and the Cognitive Model. All are crucial important for recovery, and clearly explained in the podcasts on anxiety.

Thanks for listening today, and thanks for all the kind comments and totally awesome questions!

David and Rhonda

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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. She is a Level 4 Certified TEAM-CBT Therapist and Trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems.

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

 

Coming up in 2020

I will present two workshops at the upcoming

Psychotherapy Networker Conference!

Saturday, March 21, 2020
Feeling Great—A New, High-Speed
Treatment for Depression

Sunday, March 22, 2020
Overcoming Magical Thinking with the Anxious Client—
A Paradoxical Approach

Plus, my new book, Feeling Great,
will be officially announced with banners and such!

CoverFeelingGreat1

* * *

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.

This workshop will be live-streamed (and in person in Palo Alto, CA) so you can join from anywhere in the world! There will be many expert online helpers to assist you with the small-group exercises.

Move rapidly if you want to come. We are already SOLD OUT in person, but there are still slots available online.

There will be many helpers from the Feeling Good Institute to assist and guide you in the small group exercises in person and online as well.  Our last workshop on resistance in February was our most highly rated ever! We hope to make this a terrific and fun learning experience for you, too!

With Drs. David Burns and Jill Levitt

May 17, 2020 | 7 CE hours. $135 (online only)

Learn More & Register

* * *

2-Day Clinical Master Class

Rapid Recovery from Anxiety Disorders–
GAD, Phobias, Panic Attacks, Social Anxiety,
OCD, PTSD and Health Anxiety

by David D. Burns, MD

June 4 – 5, 2020, Seattle, Washington

* * *

The All-New Annual South San Francisco Intensive!

Enhanced Empathy Training

August 10 – 13, 2020

It’s Going to Be Awesome!

Videos, Live Demonstrations

Small Group Practice with

Personal Feedback and Mentoring,

and Chances for Personal Work and Healing

During this four-day intensive workshop you will learn:

  • How to develop deeper and more meaningful relationships with challenging, difficult clients.
  • How to deal skillfully with people who refuse to open up and talk to you; won’t listen; are relentlessly critical, narcissistic or controlling; always have to be right; use, abuse, or exploit you; complain endlessly; are hostile, threatening or violent; as well as clients who are overwhelmed, hopeless and suicidal.
  • How to develop more loving relationships with the people you care about—as well as the ones you don’t.
  • Powerful new techniques to help clients who are struggling with conflicts with loved ones, friends, or colleagues.
  • How to deal with the inner chatter and powerful feelings that make it so difficult to deal with conflict when you feel angry or hurt.
  • How to identify and modify the self-defeating beliefs that make us vulnerable to conflicts with others.
  • How to identify and melt away the intense outcome and process resistance that make the treatment of relationship problems so challenging.

Learn More and Register

* * *

Watch for the Awesome

December Evolution of Psychotherapy Conference

Anaheim, December 9 – 13, 2020

Sponsored by the Erikson Institute

It is always spectacular and I’ll be presenting, too!

Details TBA

162: High-Speed Cure for OCD (Obsessive-Compulsive Disorder)

162: High-Speed Cure for OCD (Obsessive-Compulsive Disorder)

“Yikes! I might get contaminated!”

The Treatment of Sara

Today we are joined by a woman named Sara, who will be featured in one of the chapters from my new book, Feeling Great.

Rhonda begins today’s podcast by reading two heart-warming endorsements from podcast fans. Then we did a brief overview of OCD. OCD consists of two components, obsessions and compulsions. The obsessions are intrusive, anxiety provoking thoughts, like “what if I forgot to turn off the burners on the stove.” Compulsions are rituals that temporarily relieve the anxiety, such as going back into the kitchen repeatedly to make sure that the burners really are turned off. This problem can become more and more severe until the obsessive thoughts and compulsive rituals consume massive amounts of the patient’s time and become crippling.

You are probably aware that OCD plagued the life of the billionaire playboy, Howard Hughes, featured in the recent film, “The Aviator.” During the last years of his life, he became totally consumed by concerns about germs, and ended up isolated in the penthouse suite at the top of a hotel in Las Vegas. According to a “psychological autopsy” (https://www.apa.org/monitor/julaug05/hughes) published by the American Psychological Association, Hughes lay naked in bed in darkened hotel rooms in what he considered a germ-free zone. He even wore tissue boxes on his feet to protect them, and burned his clothing if someone near him became ill.

Sara, today’s guest, was a victim of the same type of OCD. She describes how her intense fears of germs and contamination came on more than 20 years ago, and the devastating impact of the OCD on her as well as her relationships with friends and family. She also describes her shame about her rituals of constantly washing her hands and desperately trying to avoid contamination.

Sara also describes, in vivid detail, her remarkable and inspiring five minute “cure” one evening at David’s Tuesday evening training group at Stanford earlier this year. She had courageously volunteered to be the patient so David could to demonstrate TEAM-CBT with a problem generally thought to be exceptionally challenging and refractory. And although Sara’s dramatic and mind-blowing recovery only took about five minutes, the treatment required a lifetime of courage!

Fortunately, one of my students had his cell phone in hand, and made a brief video of the last phase of her treatment at the Tuesday group, which involved putting her hands into a slimy, dirty garbage can right outside the front door of our Behavioral Sciences Building at Stanford and then rubbing her fingers on her face. Check it out!

And yes, the effects DID last! Her treatment was many months ago, and she’s been a totally changed person!

Following the podcast, Rhonda and I got two beautiful emails from Sara:

Wow! What a beautiful day! Thank you, Rhonda and David for the amazing opportunity to share my story! I feel very selfish but I enjoyed every minute of it. You both made me feel so comfortable and welcome. You two are so incredibly AWESOME! You make a superb team! 🙂

And here is the second wonderful email:

David, I hope you are feeling better and that you recover from your cold soon, very soon.

I wanted to share an afterthought I had a couple of days after we recorded the podcast. I wish I had thought about it before the podcast because this was so much part of my OCD.

Anyway, for years (many years) I bought sanitized hand wipes and carried them in my purse, car, briefcase, you name it—I had hand wipes everywhere. I was known for having wipes with me all the time.

Not long after the magical treatment of my OCD, I was at the grocery store and proceeded to add three packets of sanitized hand wipes to my basket and I burst into laughter, even though I was by myself! I, then, put them back on the shelf, as I told myself, “I don’t need these anymore!”

Since then, I no longer carry them NOR NEED THEM!

Funny enough, I have been approached on different occasions by family members and friends saying something like, “You always have wipes, can we have one, please?” I have to say, “Sorry, I don’t carry wipes anymore since I’ve been cured!”

What a wonderful feeling that is—not to feel dependent nor a slave to the sink and hand wipes. Not to mention, all the money I am saving by not buying wipes!!!

Anyway, I thought I should share that with you and I’m sad I didn’t remember it until after the recording of the podcast.

Once again, thank you both for the amazing recording, all your support, and all you do for our Tuesday training group and humanity in general!

With Immense Gratitude,

Sara

Sara Shane is a certified TEAM-CBT therapist practicing in the central valley of California (Stockton). She is multi-lingual and offers intensives—extended, single-session treatment of depression and all of the anxiety disorders. And, here’s something fantastic—although Sara is a superb therapist, her fees are modest, thus bucking the current trend of charging outrageous fees for psychotherapy in California. This is something I really admire and appreciate!

If you would like to contact Sara, you can reach her at: 209-476-8867.

David and Rhonda

Subscribe

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. She is a Certified TEAM-CBT therapist and specializes in the treatment of trauma, anxiety, depression, and relationship problems. She also does forensic work in family court, but finds TEAM-CBT to be way more rewarding!

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 summer intensives, but there will be one more awesome intensive in November.

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

 

* * * 

Coming up in 2020

High Speed Methods to Reduce Resistance
and Boost Motivation

With Drs. David Burns and Jill Levitt

Feb 9. 2020 |  7 CE hours. $135

Learn More & Register

and

 The Cognitive Distortion Starter Kit:
How to Crush Negative Thoughts

With Drs. David Burns and Jill Levitt

May 17, 2020 | 7 CE hours. $135

Learn More & Register