049: Live Therapy with Marilyn, Part 1, The Dark Night of the Soul

049: Live Therapy with Marilyn, Part 1, The Dark Night of the Soul

You FEEL the Way You THINK! . . . Or Do You?

The next three podcasts feature a therapy session with Marilyn, a woman recently diagnosed with Stage 4 (terminal) non-smoker’s lung cancer. We are enormously grateful to Marilyn for her courage and generosity in making this extremely private and intensely personal experience available to all of us. I believe the session will inspire you, and give you courage in facing losses, traumas and problems in your own life.

At the beginning of the therapy, Marilyn is in shock, experiencing, quite understandably, extreme levels of depression, anxiety, shame, loneliness, hopelessness, and anger. What’s the cause of her negative feelings?

According to the theory behind cognitive therapy, people are disturbed not be events, but rather by the ways we think about them. This notion goes back nearly 2,000 years to the teachings of the Greek Stoic philosopher, Epictetus, who emphasized the incredible importance of our thoughts—or “cognitions”—in the way we feel.

When you’re upset, you’ve probably noticed that your mind will usually be flooded with negative thoughts. For example, when you’re depressed, you may be beating up on yourself and telling yourself that you’re a loser, and when you’re anxious you’re probably thinking that something terrible is about to happen. However, it may not have dawned on you that your thoughts are the actual cause of your negative feelings.

In addition, you may not be aware that your negative thoughts will nearly always be distorted, illogical, or just plain unrealistic. In fact, in my first book, Feeling Good, I listed the cognitive distortions, such as All-or-Nothing Thinking, Overgeneralization, and hidden Should Statements, that trigger negative feelings. The notion that depression, anxiety, and event anger result entirely from your thoughts, and not upsetting events, can be enormously liberating, because we usually cannot change what’s actually happening, but we can learn to change the way we think—and feel.

But is this notion really true? Can’t traumatic events upset us? And can we really change the way we think and feel when the circumstances of our lives are genuinely awful? Or is this just a lot of pop psychology?

A lot of people don’t buy into the notion only your thoughts can upset you. It just seems to fly in the face of common sense. For example, you might argue that when something genuinely horrible happens, such as failure, losing a loved one, or being diagnosed with terminal cancer, it is the actual event and not your thoughts, that triggers the negative feelings. And you might also argue, perhaps even with some irritation, that your thoughts are definitely not distorted, since the actual event—such as the cancer—is real.

Would you agree? I know that’s what I used to think! If you’re interested, and you have not yet listened to the first Marilyn podcast, you can take the brief poll on the home page and let us know what you think!

The next three podcasts will give you the chance to examine your thinking on this topic, because Marilyn is struggling with a negative event that is absolutely real and devastating. At the end of the third podcast, you’ll have the chance to take the poll again.

In this podcast, Drs. Burns and May go through the T = Testing and E = Empathy phases of the TEAM-CBT session. If you’d like, you can review the Brief Mood Survey and Daily Mood Log that Marilyn completed just before the session began. You will see that her negative feelings are all severe, and that her negative thoughts focus on several themes, including

  • Her fears of cancer, pain, and death.
  • Her thoughts of spiritual inadequacy, doubting her belief in God, wondering if there really is an afterlife, and feeling that she’s perhaps been duped by religions.
  • Her feelings of incompleteness at never having had a truly loving life partner.
  • Her intense self-criticisms, beating up on herself for excessive drinking during her life.

The next Feeling Good Podcast with Marilyn will include the A = (Paradoxical) Agenda Setting phase of the TEAM therapy session, where David and Matt will attempt to reduce Marilyn’s resistance and enhance her motivation using the Miracle Cure Question, the Magic Button, the Positive Reframing Technique, and the Magic Dial. The third and final podcast will include the M = Methods phase, where David and Matt will encourage Marilyn to challenge her negative thoughts using Identify the Distortions, the Paradoxical Double Standard Technique, the Externalization of Voices, and the Acceptance Paradox, followed by Relapse Prevention Training, the end of session testing, and wrap-up.

Although the subject matter of these podcasts is exceptionally grim and disturbing, we believe that Marilyn’s story may transform your thinking and touch your heart in a deeply personal way. Because Marilyn is a spiritual person who suddenly finds herself without hope or faith, and totally lost, we have called part one, The Dark Night of the Soul, a concept from William Johnston’s classic book on religious mysticism entitled, The Inner Eye of Love.

We are hopeful these broadcasts will stimulate comments and discussions on the philosophical and spiritual messages embedded in the Marilyn session from you and our other listeners. Is it true that only our thoughts can upset us? And is the total loss of faith a necessary step on the path to enlightenment?

Live Session (Marilyn) — The Dark Night of the Soul (Part 1)

 

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048: Relapse Prevention Training

Relapse Prevention Training

Fabrice reads a question submitted by a reader on how to handle relapses following recovery from depression. David emphasizes the importance of this question, since there is a 100% probably that every patient will relapse following recovery. And if the patient has not been properly prepared, the relapses can be disastrous. But on the other hand, if the patient has been prepared, the relapses do not have to be problematic.

What is a relapse? David defines a relapse as one minute or more of feeling crappy. Given that definition, we all relapse pretty much every day. However, some people can pop out of a bad mood really quickly, while others can get stuck in these “relapses” for weeks, months, or even years.

David describes the Relapse Prevention Training (RPT) techniques he has developed, but cautions that RPT does not make sense until the patient has experienced a complete elimination of symptoms. If the patient is being treated for depression, that means that the score the depression test has fallen all the way to zero (no symptoms whatsoever) and that the patients feel joy and self-esteem.

There are four keys to David’s RPT, including:

  1. The patient must be informed that relapse is an absolute certainty. The question is not “will this patient relapse” but rather, “when will this patient relapse?”
  2. Patients have to know that the therapy technique that worked for them the first time they recovered will always work for them. It might be the Cost-Benefit analysis, Pleasure-Predicting Sheet, Acceptance Paradox, Double Standard Technique, Five Secrets of Effective Communication, Hidden Emotion Technique, or Experimental Technique, or simply recording their negative thoughts on the Daily Mood Log and identifying the distortions in them.
  3. Patients need to identify and modify the Self-Defeating Beliefs (SDBs) that triggered their depression and anxiety in the first place, such as Perfectionism, Perceived Perfectionism, or the Achievement, Love or Approval Addictions. In several previous podcasts, David and Fabrice have described the Uncovering Techniques that can be used to quickly pinpoint any patient’s SDBs.
  4. Patients need to write down and challenge the Negative Thoughts that will inevitably emerge at the time they relapse, such as “This relapse proves I’m hopeless after all,” or “This relapse proves the therapy didn’t work,” etc.

David and Fabrice illustrate step #4 using a powerful technique called Externalization of Voices. David has patients record this role play procedure on a cell phone or other recording device so they can play it and listen if needed during an actual relapse.

David explains that he used this approach with every patient he discharged, and encouraged them all to come back anytime they had a relapse that they couldn’t handle. In spite of having more than 35,000 therapy sessions with individuals with severe depression and anxiety, David says that he can count on two hands the number who every returned for “tune-ups” following termination of therapy, and in most of those cases, the patients were able to recover once again in just or two sessions.

In the next Feeling Good Podcast, David and his highly esteemed colleague, Dr. Matthew May, will begin their live work with Marilyn, a severely depressed colleague who is facing “The Dark Night of the Soul.” Fabrice, as usual, will narrate and elicit enlightening commentaries on the therapeutic strategies that David and Matt are using as the session with Marilyn unfolds.

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039: Uncovering Techniques (Part 1) — The Individual Downward Arrow

039: Uncovering Techniques (Part 1) — The Individual Downward Arrow

Diving Beneath the Surface: The Uncovering Techniques

What are the root causes of depression? Anxiety? Relationship problems? In this, and the next two podcasts, you will discover the answer!

Cognitive Therapists believe that negative thoughts, or cognitions, can exist on two different levels. When you’re upset, you’ll have Automatic Negative Thoughts (ANTs) in the here and now, and they’ll usually be something like this:

  1. Depression: You may be telling yourself that you’re a loser, or a failure, or that you’ll be miserable forever.
  2. Anxiety: You’re probably telling yourself that you’re in danger, and that something terrible is about to happen. “When I get up to give my talk at my church group, my mind will probably go blank and I’ll make a total fool of myself!”
  3. Relationship conflicts: You may be telling yourself that someone you’re ticked off at is a self-centered jerk who only cares about himself or herself and shouldn’t be that way!

Individual Downward Arrow

But why do we get these ANTs in the first place? Cognitive therapists believe that Self-Defeating Beliefs, and other deeper structures in the brain, make us vulnerable to painful mood swings and conflicted relationships with the people we care about. To help you pinpoint your own Self-Defeating Beliefs, David has created two uncovering techniques called the Individual Downward Arrow and the Interpersonal Downward Arrow, and Albert Ellis, the noted New York psychologist, created a third called the “What-If” Technique. In today’s podcast, Drs. Burns and Nye illustrate the Individual Downward Arrow technique, using as an example a psychologist named Harold who was understandably devastated when his patient unexpectedly committed suicide.

You can follow along on this PowerPoint presentation starting with Harold’s Daily Mood Log with David and Fabrice while they illustrate the Individual Downward Arrow technique.

Harold’s Daily Mood Log and Downward Arrow

Once they come to the “bottom of the barrel,” they will ask you to pause the recording, and see if you can pinpoint five or six or more of Harold’s Self-Defeating Beliefs, using the list of 23 Common Self-Defeating Beliefs.

David emphasizes that we create our own emotional and interpersonal reality at every moment of every day, but we aren’t aware of this, so we often feel like victims of forces beyond our control. We are really talking about emotional and interpersonal enlightenment, and the uncovering techniques will make this ancient Buddhist concept more understandable for you.

If you’d like more tips on precisely how to do the Individual Downward Arrow Technique, you can read David’s recent Feeling Good Blog on this topic!

In our next Feeling Good Podcast, David and Fabrice will illustrate the Interpersonal Downward Arrow Technique, which will allow you to complete a course of psychoanalysis in just 5 to 7 minutes, rather than the 5 to 7 years free associating on the couch. It is truly psychoanalysis at warp speed, and is pretty amazing! And when you change the beliefs that trigger interpersonal conflicts, you can change them and enjoy greater satisfaction in your relationships with the people you care about. But sometimes, that requires a little bit of courage!

And in the third Feeling Good Podcast on the uncovering techniques, David and Fabrice will illustrate Dr. Albert Ellis’ famous “What-If Technique.” If you struggle with any type of anxiety, including fears and phobias, this technique can help you uncover the feared fantasy at the root of your fears, so you can challenge the monster and attain freedom from the fears that hold you back!

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Uncovering Self-Defeating Beliefs (SDBs)–For Therapists (and Interested Patients) Only!

Uncovering Self-Defeating Beliefs (SDBs)–For Therapists (and Interested Patients) Only!

oThis is a technical memo for therapists who use a technique I developed years ago called the Individual Downward Arrow Technique. The goal of this technique is to uncover each patient’s (client’s) Self-Defeating Beliefs (SDBs), such as Perfectionism, Perceived Perfectionism, or the Brushfire Fallacy. I developed this memo for my Tuesday evening TEAM-CBT group at Stanford following a session practicing this technique earlier in the week.

Why would a therapist want to uncover SDBs? Cognitive Therapists work with (at least) two types of cognitions that can cause emotional distress. First, Negative Thoughts happen in the here and now and only cause emotional distress at specific moments in time. Let’s say you have public speaking anxiety, and you’re about to walk up to the podium. You are probably telling yourself things like this: “I’ll blow it. My mind will go blank. I’ll make a total fool of myself. People will laugh at me and judge me.” These kinds of Negative Thoughts happen in there here-and-now, when you are feeling anxious or depressed. The Negative Thoughts are usually not present when you are feeling happy and confident.

The SDBs represent a second category of cognition. These belief systems represent some of our core values, and they are always there in the background, whether or not we are upset. So, for example, you may have a belief called Perceived Perfectionism, thinking that people will not accept, respect or love you if you screw up or appear vulnerable. Or you may have the Approval Addiction, thinking you need everyone’s approval to feel happy and fulfilled. Or you may have the Achievement Addiction, basing your self-esteem on your intelligence or accomplishments. There are a great many kinds of SDBs.

The cognitive theory of emotional distress works like this: the combination of a Self-Defeating Belief (such as the Achievement Addiction) plus a negative event (such as screwing up or doing poorly when you give a talk) triggers emotional distress. That’s when you are flooded with negative thoughts and feelings, such as “Gosh, my talk was kind of a dud. People seemed bored. I’m a loser,” etc.

So the SDBs appear to explain the timing and reason for episodes of depression and anxiety.  And if we can pinpoint and change the patient’s (client’s) SDBs, we can not only help the patient to feel better in the here-and-now, but we may also help to prevent painful mood crashes in the future.

In this memo, I discuss the finer points of how to use the Individual Downward Arrow Technique to pinpoint each patient’s Self-Defeating Beliefs. If you are interested, I could address how to change SDBs in a future blog or in an upcoming Feeling Good Podcast.

I will be curious to find out if this type of information is of interest to my readers, so please let me know what you think! If the information that follows is too technical, no problem! I just want to get a feel for what people like and want so I can serve you in the best possible way. Thanks!

David

Tips for Therapists When Using the Individual Downward Arrow Technique

By David Burns, MD*

I would like to thank Daniele Levy, PhD for conceptual and editing help!

What is the Individual Downward Arrow Technique? This technique will help you pinpoint the Individual Self-Defeating Beliefs (SDBs) that make the patient vulnerable to depression and anxiety. For example, the patient may base his or her self-esteem on accomplishments, the so-called “Achievement Addiction,” or may struggle because of Perfectionism, Perceived Perfectionism, Entitlement, or the Approval or Love Addiction. You can find a list of “23 Common Self-Defeating Beliefs” in the Therapist’s Toolkit or my Feeling Good Handbook. The Individual SDBs are often “self-esteem equations,” of the form, “To be a worthwhile human being I need substance X.” Substance X could be great achievement, wealth, love, perfection, approval, or always pleasing others, for example.

To use this technique, draw a downward arrow under a Negative Thought on a Daily Mood Log and ask your patient, “Why would it be upsetting to you if this thought were true? What would it mean to you?” This will trigger a new Negative Thought. Tell the patient to write it down under the arrow and repeat the process several times. The NTs you and your patient generate will lead to the underlying beliefs at the core of his or her suffering.

There are three additional Uncovering Techniques. The Interpersonal Downward Arrow Technique helps you pinpoint the beliefs and attitudes that trigger conflicts and difficulties in the patient’s personal relationships. The What-If Technique helps you pinpoint a core feared fantasy that trigger’s the patient’s anxiety. And the Hidden Emotion Technique helps you bring suppressed hidden problems and conflicts to the patient’s conscious awareness.

Here are some important tips to keep in mind when using the Individual Downward Arrow technique:

SET UP

  1. Always start with a Negative Thought (NT) from a Daily Mood Log when doing the Downward Arrow Technique. Don’t do the Downward Arrow Technique for some problem the patient has, or based on some emotion the patient has.
  2. Both patient and therapist must be writing during the Downward Arrow Technique. Usually, I use a blank sheet of paper, because the DML gets too filled up with the chain of NTs. But keep in mind that your blank sheet of paper is really an extension of the NT column on the DML.
  3. Remember to be compassionate when doing the Downward Arrow, and not overly harsh or intellectual. For example, if the patient says, “That would mean I was a total failure,” you can say, “Of course, that would be pretty painful for almost anyone to feel like you were a total failure, but I’m wondering what it would mean to you? Why might that be upsetting you?”
  4. If the patient becomes tearful, perhaps recalling a painful childhood memory during the Downward Arrow process, put your techniques on the shelf and empathize, encouraging your patient to vent and open up. These moments can be quite important to the patient.

WORDING OF NTs

  1. Convert rhetorical questions into statements. “Why am I so screwed up?” can become “I’m screwed up,” or “I shouldn’t be so screwed up.”
  2. When doing a Downward Arrow from a “Should Statement,” such as “I shouldn’t have left my husband,” you can say, “Let’s assume it’s true that you shouldn’t have left your husband, but you did. What does that mean to you? Why is that upsetting to you?”
  3. Never put emotion words or descriptions of upsetting events in the NTs column when doing the Downward Arrow. Instead, ask for the NT that is associated with the emotion or event. For example, if the patient says, “Then I’d feel ashamed,” you can say, “What is the NT that would make you feel ashamed? What would you be telling yourself?”
  4. If the patient comes up with a wish or a positive thought when you’re doing the Downward Arrow Technique, you can convert it to an NT. For example, let’s say a patient has this thought about dropping out of school: “I’ll be letting my parents down. I’ll be a disappointment to them.” Then you ask, “If this were true, what would it mean to you? Why would it be upsetting to you?” The patient might say, “Well, I really want my parents to be proud of me.” You can easily convert it by saying, “So let’s assume you really want your parents to be proud of you, but they’re actually disappointed in you for dropping out of school. What would that mean to you? Why would that be upsetting to you?”

PROBING

  1. If the patient says, “I don’t know,” use Multiple Choice Empathy. For example, the patient may have the NT, “Then I’d be all alone forever,” when you are doing the Downward Arrow Technique, but when you ask, “And what would that meant to you, and why would that be upsetting to you,” he or she might say, “I don’t know.” Using Multiple Choice Empathy, you might say, “Of course, probably no one would want to be alone forever, but it could mean different things to different people. Some people might think that if they’re alone, they can’t survive, or if they’re alone, it means they’re unlovable and worthless, and others might think it’s impossible to feel happy and fulfilled when you’re alone. Do any of those possibilities ring true for you?”
  2. You can also use the “Man (or Woman) from Mars” approach if the patient says, “I don’t know why that would be upsetting for me.” Let’s say the patient comes up with this thought during the Downward Arrow Technique: “That would mean I failed,” but can’t explain why failure would be upsetting or bad. You can say, “Let’s assume I’m a man (or woman) from Mars, and I don’t know how things work here on the surface of the earth. So I might ask you to explain why failure is considered a negative thing here on the earth. What happens to people who fail at something?” This will usually make it easier for the patient to continue the Downward Arrow Chain.
  3. Using Bracketing when the patient cycles back and forth between two NTs. For example, the patient might say, “Then I’d be a failure,” followed by “Then no one would love me,” followed by “Then I’d be a failure,” etc. You can bracket them in this way: “And suppose you were a failure, and no one loved you. What would that mean to you? Why would that be upsetting to you?”

GOAL CONSIDERATIONS

  1. The purpose of the Downward Arrow Techniques is uncovering the patient’s SDBs, not change. You can change SDBs, but change is not the goal when you are doing an Uncovering Technique. If you think about an NT on a Daily Mood Log, most of the time we are doing horizontal arrow techniques. In other words, we want to move from the NT column on the left to the Positive Thought (PT) column on the right, and this involves trying to challenge and crush the NT so that emotional change will suddenly happen. In contrast, when you use a downward arrow technique, you are drilling down deeper into the patient’s psyche to uncover the beliefs that give rise to the negative thoughts and feelings. You are moving to a deeper level.
  2. Sometimes, a patient will begin to recognize the absurdity of the NTs when doing the Downward Arrow, and will begin to come up with convincing and effective Positive Thoughts (PTs). This is okay, and you can encourage the patient to write the PTs in the PT column on the Daily Mood Log.
  3. The Self-Defeating Beliefs are the logic behind the negative thoughts on the Downward Arrow Chain, since the thoughts do not logically follow from one another. For example, a psychologist’s favorite patient unexpectedly committed suicide, and one of his NTs was: “I should have seen this coming. I should have known he was suicidal.” His next thought on the downward chain was, “This means I’m a failure and a fraud.” Notice that the second thought does not follow logically from the first thought, but the SDB that links them is Perfectionism. His third thought was, “My colleagues will judge me and reject me.” Again, this does not follow logically, and the SDB that links them is Perceived Perfectionism—namely, the belief that others will not accept, love, or respect him if he is vulnerable, or human, or makes a mistake.

* Copyright © 2017 by David D. Burns, MD

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Thanks! David