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)
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:
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?”
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.
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.
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.
After reviewing Mark’s scores on the Brief Mood Survey, the Empathy phase of the session unfolds. During this phase of the session, David and Jill will not try to help, rescue, or save Mark. They will simply try to see the world through his eyes and provide some warmth and compassion.
Mark explains that he had two goals in life when he was a young man. He hoped to have a large, loving family; and wanted to become a skillful and compassionate physician. Although he has achieved the second goal, he has felt sad and guilty for decades because of his failure to develop a loving relationship with his oldest son from a previous marriage.
While Mark tells his story, David and Jill encourage him to record his negative thoughts and feelings on a form called the Daily Mood Log, and to rate how strong each feeling is, on a scale from 0% (not at all) to 100% (the most extreme).
As you can see, Mark has many different kinds of negative feelings ranging in severity from 30% (moderate) to 80% (severe).
If you’ve been listening to the Feeling Good Podcasts, you know that negative feelings do not result from what’s actually happening in our lives, but rather from our negative thoughts about what’s happening. David and Jill encourage Mark to record his negative thoughts on the Daily Mood Log as well, and to indicate how strongly he believes each one on a scale from 0% (not at all) to 100% (completely).
You can also see that Mark is telling himself that he’s been a failure as a father, that his brain is defective, and that he is not doing a good job for David and Jill. These thoughts all involve self-blame. You’ll notice that he also has two other-blaming thoughts. This is not unusual. When you’re not getting along with someone, you may spend part of your time telling yourself that the problem is all your fault, and part of your time telling yourself that it’s someone else’s fault. As a result, your negative feelings may shift back and forth from guilt and shame to anger and resentment.
Most therapists would not interrupt and ask their patients to record their negative thoughts and feelings while they are venting. However, this information will prove to be incredibly valuable later in the session.
Jill and David ask Mark how they’re doing on empathy. If Mark gives them a high rating, they will go on to the next phase of the session, called Paradoxical Agenda Setting. That’s where they will find out what, if anything, Mark wants help with, and see if he has any conscious, or subconscious, resistance to change.