Moved to Tears by Mark’s Live Therapy Podcast / How do You Treat Habits and Addictions?

Moved to Tears by Mark’s Live Therapy Podcast / How do You Treat Habits and Addictions?

Dear David,

I wanted to contact you to tell you how tremendously informative, interesting, moving and inspiring I find your work and your podcasts.

I have listened to all the podcasts—many twice. I find that on the 2nd listening, I pick more up. I get out on my bike and the miles just fly by as I listen to these!

One day my wife returned just as your wonderful episodes with Mark were concluding. As she walked in, I was weeping tears of relief as I also understood (at the same time as Mark did) that my depression and anxiety said something beautiful and awesome about me, rather than only indicating something broken and weak.

I struggled (through the tears) to tell her that these were tears of joy and relief, and not sadness.

Also, I found your book Feeling Good and the Feeling Good Handbook most helpful for my own depression and anxiety. Your wisdom about Action leading to Motivation is something I use every day personally and professionally.

I would be extremely grateful if you could help me with something that has been bothering me professionally for years. I work at the Scottish Government as a personal trainer specializing in eating for weight loss. I have used your own and other CBT based books to help people with stick to weight loss eating plans with some success. But I really get the sense that your TEAM methods might “turbo-charge” the CBT methods.

Can you detail how the paradoxical agenda setting / outcome and process resistance stage might work in eating for weight loss scenarios to help people get (and stay) motivated to stop overeating (even if it’s not a huge overconsumption, just enough to keep them overweight). How can the TEAM approach help them stick to a sensible weight loss plan?

With 35 million people (in the UK alone) in these overweight/obese categories and no signs of a slowdown, I really feel that a large-scale adoption of a “turbo-charged” approach to motivation may help turn this around.

Your very gratefully,

Greg

P.S. I look forward to watching your next live interview on Sunday which I missed this week.

Hi Greg,

Thank you for your thoughtful email and kind comments about the Feeling Good Podcasts, which I will pass along to our “patient,” Mark, and Dr. Jill Levitt, my co-therapist, and my host, Dr. Fabrice Nye. I was inspired and touched by the tears you experienced while listening to the podcast, and I’m so glad you enjoyed the live therapy with Mark!

You asked some questions about the treatment of habits and addictions, such as overeating. The Outcome Resistance issue for habits and addictions is having to give up your greatest, or only, source of pleasure and reward. The Process Resistance issue involves discipline and deprivation. That’s not a very appealing deal, because you have to give up intense and frequent instant gratification in exchange for discipline and deprivation, and this explains why treatment programs are so ineffective.

Incidentally, most treatment programs focus on trying to “help,” as opposed to focusing on why the patient really does not want to give up the habit or addiction. Without a really strong focus on motivation and resistance, nearly all treatment programs will be doomed to failure, or mediocre results at best.

And that’s what you see if you examine the controlled outcome studies that have been published. I am not aware of any really effective treatment program for any habit or addiction. Of course, every approach has advocates, and every approach works for some folks—but I’m talking about controlled outcome studies with an experimental group and a control group, in terms of short-term and long-term results. Most treatments barely outperform placebo treatment, at best.

Of course, the advocates of these approaches do not like to admit this, because they have a heavy intellectual, emotional, or financial commitment to their approach, which might be AA for alcohol misuse, or this or that commercial weight loss program that’s advertised heavily on television. Once your income, ego, or name gets invested in a particular approach, it can be very difficult, or nearly impossible, to let go and look at things objectively and admit that your favorite approach really doesn’t have much merit! Sadly, the needs of market and the needs of science often clash, and in our field, marketing usually wins.

So what do we do in TEAM-CBT? I can only give you some hints about it here, but I’ll take a stab at it and hope for the best.

Recently, several people I’ve hiked with have asked for help with their overeating. One fairly easy approach to learn is called the “Double Paradox,” and I touched on it briefly in last Sunday’s live Q and A on Facebook. You can do it on paper most effectively. First, I ask the person to list all the advantages of eating as much as you like of whatever you like whenever you like.

There are tons of advantages, including:

  • That Cinnabon (or whatever food you love) will taste SO GOOD!
  • I’m entitled to a little treat after a hard and frustrating day at work.
  • That treat will make me feel so good.
  • Eating will help me cope with negative feelings of depression loneliness, frustration, anxiety, boredom, and disappointment.
  • Eating good food is a deeply meaningful social activity with friends and family, and shows my love for others.
  • Good food tastes SO GOOD, and that’s my favorite kind of mint chocolate (or whatever.)
  • Eating is easy and rewarding.
  • Being overweight gives me an excuse to avoid dating and risking rejection.
  • Cooking and preparing wonderful food for my family is a source of great source of pleasure.
  • I’m too old to have to worry about being thin.
  • Why should I have to follow the rules of society? I have the right to be any way I want to be.
  • etc. etc.

Most individuals who are overweight should be able to come up with at least a dozen overwhelming benefits and advantages of overeating.

If the patient cannot or will not do this, then you might as well give up, because you’re already defeated by his or her denial. The fact is, overeating REALLY IS one of the great pleasures in life. You can prime the pump a little by suggesting one or two benefits of overeating, but the patient should do most of the work on this.

Then I ask the patient to list the many disadvantages of diet and exercise. For example:

  • It’s hard to diet.
  • I’ll have to struggle with cravings and temptations.
  • It’s unfair because life is already hard.
  • It’s no fun to go out and jog when it’s cold and rainy.
  • I never get a runner’s high anyway.
  • I hate exercising and I love eating!
  • It’s way more rewarding to watch TV and eat Doritos.
  • Even if I lose weight, I’ll just gain it all back later on anyway.
  • Losing weight is hopeless, so I might as well give up.
  • Other people can eat whatever they want and still be thin. Why should I have to suffer?
  • Etc etc etc.

Most individuals who are overweight should be able to come up with at least a dozen or more overwhelming disadvantages of diet and exercise.

Once we have these lists, I use another technique I’ve created called the Acid Test, which involves saying something like this:

“Gee, Jim (or Mary), given all those tremendous advantages or overeating, and the many powerful and real disadvantages of diet and exercise, it’s not at all clear to me why you’d want to change.”

Now it’s up to the patient to decide that he or she actually does not want to diet and exercise, or that he or she does want to. In most cases, your work will be done. If the patient decides he or she does not want to change, you can just “Sit with Open Hands” and ask if there’s anything he or she does want help with. This requires a therapeutic attitude of “non-attachment,” which is challenging for co-dependent therapists who are addicted to “helping.”

If the patient can convince you that he or she does want to change, in most cases he or she will run with the ball and not require any further help from you. There are tons of ways to diet, and tons of ways to exercise, and it does not make much difference what approach the patient takes if he or she is motivated. In my experience, most will know what approach they want to pursue.

Notice that this approach requires the therapist to become the voice of the patient’s conscious or subconscious resistance, and give up the role of “helper.” Some therapists can learn how to do this; most cannot, due to their own compulsive addiction to throwing “help” at patients.

I do have many more techniques, but this is getting long so let it be an introduction of sorts. Let me know if you liked this blog, and if you want more techniques to combat habits and addictions.

In addition, if you like or decide to use some of these techniques, such as the Double Paradox, the Acid Test, Sitting with Open Hands, and other approaches I have described in my podcasts, blogs, workshops, and books. I always appreciate some acknowledgement that I created them. I say this because sometimes people have taken my ideas and techniques, given them a slightly different name, and claimed them for their own. Quite a few have even started their own schools of therapy, based on one of the techniques I’ve created, without giving me any credit. I find this annoying!

I’m not criticizing you, just blowing off some steam! One of the reasons I always admired Dr. Albert Ellis is that he never did that. He always gave credit where credit was due, and had tremendous integrity. He was, arguably, a bit eccentric, but totally honest!

Thanks again, Greg!

David

 

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

Was It Real? Or a Hoax?

Was It Real? Or a Hoax?

At most of my workshops, I do a live demonstration with a volunteer from the audience who has been struggling with feelings of depression, anxiety, or just simply being “not good enough.” That includes nearly all of us, including mental health professionals! I know I’ve felt like that on many occasions.

I’m a firm believer that when you do your own personal work, and heal yourself, you have vastly more to offer your patients. You are no longer just a technician but a healer, and you say this to your patients: “I know how you feel, because I’ve been there myself. And I can show you the way out of the woods, as well!”

That’s why I always include personal work in the training I offer in TEAM-CBT, both at Stanford, and at my workshops around the US and Canada, and on the Sunday hikes as well. Live demonstrations have proven to be one of the most effective and inspiring teaching methods–but they aren’t entirely without controversy.

The main problem is that when I do live demonstrations, I often see  a dramatic reduction in symptoms, or even a complete elimination of symptoms, in a single therapy session lasting approximately two hours. And sometimes, the results are so dramatic that some people in the audience insist that it could not be real.

That’s what happened at my summer intensive in Burlingame, California, this year. A wonderful young woman who we can call “Holly” volunteered for the live demonstration. Although she’d been struggling with intense feelings of anxiety and low self-esteem throughout her entire life, she responded so dramatically that a few people in the audience thought it was a hoax, and that she was a paid actress. I know this because I received some angry comments on the written feedback form that participants filled out at the end of the demonstration. Most people were thrilled and inspired by what they saw, fortunately, but some were clearly not convinced.

Well, now you can judge for yourself. Our “Holly” kindly volunteered to do a brief video describing her experiences at the workshop, and how she’s been feeling ever since. I think you’ll enjoy it, and find her comments to be mesmerizing. The video was shot, unknown to me, by a colleague, Lisa Kelley, who happened to run into Holly a week or two after the workshop.

You can watch the video here. Then afterwards, you can read more below and I’ll show you exactly what happened, step by step, when Jill and I were working with Holly.

 

Some mental health professional are understandably very skeptical about such extremely rapid recovery because most of us have been trained to believe that recovery from depression is an inherently slow process that unfolds only after many years of treatment, or may even require more than a decade of treatment. So when they see an extremely rapid elimination of symptoms, they simply cannot accept it, and feel the need to explain it away. There was a time when I felt this way, too!

In addition, when I was growing up in Phoenix, faith healers often came to town, or appeared on television, doing miraculous healing in front of huge audiences of true believers. But most people realized that these charismatic faith healers in white suites with Bibles in hand were, for the most part, frauds.

My co-therapist for the session at the workshop was Dr. Jill Levitt, who teaches with me at the Tuesday group at Stanford. Jill is a phenomenally skillful and compassionate clinical psychologist, and I always treasure the opportunity to work with her. When we work together, magic seems to happen. I feel very fortunate to teach with Jill and to have her as a colleague. We will be presenting two workshops together this fall at the ABCT conference in San Diego. Here’s the link if you want to check it out!

The before session testing indicated that our “patient,” Holly, was struggling with very significant depression and anxiety, and she said she’d struggled with these painful feelings unsuccessfully for many years. You can see Holly’s scores on the Brief Mood Survey that she completed just before the session began if you click here.

Although her depression score is only moderate, you can see that her feelings of worthlessness and low self-esteem were extreme, and that her feelings of anxiety were quite also intense. In addition, her score on the Positive Feelings test was very low, indicating very few positive feelings about herself and her life.

Jill and I started the TEAM-CBT session with T = Testing. If you click here, you can see the Daily Mood Log that Holly filled out just before the session started. As you can see, Holly was struggling with a myriad of negative feelings and intensely negative thoughts. Holly told us that she’d really always felt like that and had never really felt happy or good about herself, although she usually kept her negative thoughts and feelings hidden. This was especially sad.

At the start of the session, Jill and I empathized (E = Empathy), and we seemed to develop excellent rapport with Holly very quickly. After only about 20 minutes or so, she gave us an “A” on empathy, and said she felt understood and accepted.

Then we went on to A = (Paradoxical) Agenda Setting. The goal is to find out what, if anything, the patient wants help with during the session, and then to melt away his or her resistance to change. Holly said that she wanted to feel better about her life, if possible, so Jill and I used the Magic Button. Essentially, we asked Holly to imagine there was a Magic Button, and if she pressed it, all of her negative thoughts and feelings would instantly disappear, with no effort, and she’d be flooded with feelings of joy.

Would she press it?

Like almost every person I’ve worked with, she said she’d press it immediately!

Then Jill and I said that while we had some fabulous tools to help her, we weren’t convinced it would be such a good idea to press that Magic Button, because we might lose something very valuable at the same time.

Then we introduced a tool that proved exceptionally helpful called Positive Reframing. We asked Holly to list, with our help, two things about each of her negative thoughts and feelings:

  1. What does this negative thought or feeling show about me and my personal values that’s beautiful and positive, or even awesome?
  2. What are some advantages, or benefits, of this negative thought or feeling?

If you like, you can take a look at Holly’s Daily Mood Log and see what you can come up with! Make your own list before you continue reading.

This exercise may be really hard for you at first, because this is not the way we usually think about psychiatric “symptoms!” We don’t usually ask ourselves what’s really GREAT about feelings worthless, or hopeless, or ashamed or enraged. And we don’t usually ask ourselves what’s really wonderful about our own self-critical thoughts, such as “I’m an idiot” or “I’m fat and ugly.”

It was also hard for Holly, but she got into the swing of things pretty quickly, and together, we came up with a pretty impressive Positive Reframing List that you can review by clicking here after you’ve completed your own list.

The idea is that since your negative thoughts and feelings are beneficial, and reflect your core values, it might not be such a good idea to press the Magic Button and make them disappear entirely. To resolve this dilemma, we introduced the idea of the Magic Dial. We explained that since Holly’s negative thoughts and feelings revealed so many awesome things about her, and had helped her tremendously during her life, may she might instead prefer to dial her negative feelings down to some lower level, rather than getting rid of them entirely.

Holly listed her ideal levels for each negative feeling in the “% Goal” column of her Daily Mood Log, as you can see if you click here. Her ideal levels for each feeling were much lower, in the range of 10% to 30% for each feeling.

Essentially, Jill and I have made a “deal” with Holly’s subconscious mind. We’ve said, “We’ll lower them only to these levels.” This also puts Holly in charge of the session, so that we’re not pushing or selling anything, and so that we’re following her agenda. This is one of the most important parts of TEAM-CBT.

The “% Goal” column on the Daily Mood Log is not written in stone, and is actually a kind of illusion. That’s because Holly’s goals for each negative feeling might change once she begins to crush her negative thoughts.

We then went on to the M = Methods phase of the TEAM-CBT session, and helped Holly challenge each of her Negative Thoughts using several powerful techniques, including:

  1. Identify the Distortions
  2. Externalization of Voices
  3. Acceptance Paradox
  4. Self-Defense Paradigm

As it turned out, these techniques were incredibly effective, and her recovery was rapid and, I think it is fair to say, fantastic, and almost immediate. This is why some in the audience found it so hard to accept or believe. What happened, really, was like a miracle.

You can see Holly’s end of session scores on the Brief Mood Survey if you click here. In addition, all of her negative feelings on the Daily Mood Log fell all the way to zero. Holly was more than simply “improved” by the end of the session. I think it is fair to say that she was (and still is) jubilant.

And she now has so much more to bring to her own patients, the troubled teenagers she treats. And that’s why I’m a firm believer that doing your own personal work is vitally important to therapists. Because then, like Holly, you can tell your own patients, “I know what you feel like, because I’ve been there myself, and know what that pain is like. And I can show you the path out of the woods, and what a joy that will be!”

Fortunately, by the end of the four day program, most of the participants had changed their thinking and realized that the live demonstration had been absolutely real. I hope you feel the same way! I was humbled and thrilled to receive a standing ovation, something that only occasionally happens, and something that means a lot to me.

Holly graciously gave me permission to post the video here for you. I hope you have enjoy it!

I am very indebted to Holly for her courageous and deeply meaningful contribution to the workshop, and now you will have a chance to share the joy that she is feeling!

All the best,

David

 

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

Subject: Cure!

Subject: Cure!

IMG_1033Hi Webvisitors and friends,

I thought you might enjoy this email that I just received from Sunny Choi, who was a member of our Tuesday TEAM-CBT training group for about two years. Sunny just completed his licensure requirements and testing for licensed clinical social worker in California. Congratulations Sunny on the fabulous work you are doing!  David

Hi David,

Another one session (45 min) success for a patient with panic attack and agoraphobia!  She came back 2nd time with her face glowing and no phobia. Thank you for your amazing technique!

Sunny

Questions from a thoughtful listener

The following is an email I received from Dan Prine, a therapist receiving TEAM-CBT training from Dr. Maor Katz at the Feeling Good Institute in Mt. View, California. Dan had several questions about my recent podcast on single-session therapy with Fabrice Nye and Lisa Kelley.

Good morning David,

As I continue to learn and study the TEAM approach to CBT, I find it challenging and see it as so complex that it will present itself as a career long learning process. I have attended several of your intensive workshops, am currently involved in 2 web based programs and am receiving 1:1 supervision with Dr. Katz. I have several questions / thoughts I would like to get your thoughts on.

  • In the 1999 introduction to your workbook, “Ten Days To Self Esteem,” your referred to patients with schizophrenia and to those experiencing hallucinations who were treated at your hospital in Philadelphia (page 8). Most of the rest of your introduction has a focus on depression and anxiety. Perhaps you were referring to improvement in psychotic individuals who also were experiencing depression. If not, I am interested in knowing if your workbook was found to be helpful with symptoms of psychotic disorders without concurrent depression.
  • There was recently a challenge to your copyright policy on the list serve. [David’s explanation: Several therapists were rather forcefully asking permission to distribute the assessment tests and treatment tools from my Therapist’s Toolkit electronically. This would put me at great risk for online piracy, which is a huge problem for me already, and also risks violating HIPAA laws about sending confidential patient information electronically, with potentially huge fines, including jail time. I responded in strong language that this was not going to work for me.]
  • Dan Prine continues: I 100% understand and agree with all your arguments to maintain status quo. Based on the writer’s response, I think he now also agrees with your stance. It is refreshing in your books when you describe your humanness and talk about when you decide to back up, rethink your response and employ the Five Secrets to get a more productive result. You were “right” and your approach to the writer’s thoughts seem to have changed his perspective. I wonder if upon reflection you would convey the same message in a more gentle way. Just wondering.
  • In response to your recent post and podcast about the 2 hour “miracles” we see in your workshops, I am wondering if think a clinician in a private practice, offering a 2 or 3 hour initial sessions, could achieve the same results you have experienced so frequently?
  • Do you administer the EZ Diagnostic survey and /or the BMS before and after your demonstrations?
  • Could the following, in addition to the TEAM CBT, be responsible, at least in part, for the rapid changes you are seeing in your clinical demonstrations in workshops?
  1. Since your workshops are for therapists, your volunteers are psychologically-minded and reasonably high functioning—could this be a factor?
  2. Could there be a placebo effect, since the “patients” are receiving treatment from an expert?
  3. Could increased motivation play a role, since they are willingness to volunteer for personal work in front of a live audience, which takes courage and determination?
  4. Could your empathy and acceptance of them as humans be a contributing factor?
  5. How important is it that you melt away their resistance during the live session?

If these factors play a major role in the improvements you have been experiencing, do you really believe that we, as private practice therapists, could ever achieve the same kinds of phenomenal results in 2 hour therapy sessions? I do acknowledge you made it clear none of us could ever expect these purported results consistently, no matter how skilled.

Thanks in advance for any response you might offer.

And as I have mentioned before, thank you for your kindness, perseverance and pioneering efforts you offer in promoting therapists worldwide to help the many who suffer from mental illness and their distortions.

dan prine

If you’d like to read my response to Dan Prine’s thoughtful questions, and the email exchanges that followed, CLICK HERE. I really enjoyed the correspondence with Dan (aka Danny) and hope you enjoy it as well!