This podcast features David D. Burns MD, author of "Feeling Good, The New Mood Therapy," describing powerful new techniques to overcome depression and anxiety and develop greater joy and self-esteem. For therapists and the general public alike!
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475: Ask David: Are You Getting Old and Cranky Now? TEAM CBT and Spirituality
Épisode 475
lundi 10 novembre 2025 • Durée 34:31
Ask DavidAre You Getting Old and Cranky Now?TEAM CBT and Spirituality
The answers to today's questions are brief and were written prior to the show. Listen to the podcast for a more in-depth discussion of each question.
Jenn asks: Are you getting old and cranky now?
Jenn also asks: How did you get involved with / develop the spiritual and enlightenment aspect of TEAM?
Dear Dr. Burns,
Let me start by saying thank you for all of your hard work and diligence in creating a method which is so user friendly. Completing the book, When Panic Attacks, changed my life and helped me reach enlightenment.
My Ask David question is inspired by the last few podcasts, the live session with Rhonda and the live session with Madelaine which David just did with Jill.
David has clearly worked so hard to create TEAM and has dedicated so much time to perfect it. I was lucky enough to have been introduced to the podcast when it first started. Some of my favorite episodes to listen to are the live therapy sessions. I've gained insight and felt heard through many of these such as when David told Lee how lonely enlightenment can be because I agree with that!
Recently I have noticed that David's demeanor has changed and was hoping to ask about it. I can imagine David might feel lonely in his expertise sometimes. I might be on the wrong track here too but I wonder if David might be feeling frustrated with the lack of understanding from people around him.
He has been dedicating his life to this and still people do not understand certain aspects of his research and teaching. On recent podcasts, David had mentioned that he gets more irritated with teaching now too and it has seemed like he is irritated with Rhonda at points.
He has mentioned that he feels disappointed if he doesn't see change in 2 hour sessions.
Recently I watched a live session with Madelaine and some of the techniques (for example, calling her negative self sociopath during counter attack) did not seem to land or resonate with her and that wasn't addressed with David's usual love and tenderness and warmth with empathy. It seemed rushed and not necessarily focused on the patient outcome but the timeline.
I did not find it to be David's usual work of patience and warmth. I could be completely off the rails but I am wondering if this is resonating with David and if he could share more about what it's been like for him recently.
I also am wondering if it is difficult to navigate being seen as "a great leader" in a field. Do people see you as "David" simply a dedicated expert in your field or do people treat you like a "God" that has all the answers? I can imagine people would want help from you 24/7 and if you could speak to that.
I am hoping David can look at some of those thoughts and comments he's made on the podcasts and become the client for us listeners! I would love for David to show us how to experience TEAM from the client's perspective for all to hear.
I have used TEAM-CBT for 10 years and recently started the Fast Track Program which I am very excited for! Thank you again for this truly amazing process!
Jenn
David's reply
Thanks, Jenn,
You are right, I DO feel quite a bit of irritation with our field and can identify a bit with Martin Luther, who nailed his treatise / ideas on someone's door hundreds of years ago, and also Jesus who angrily threw the money changers out of the temple a couple thousand years ago. I know that sounds narcissistic, but that's how I feel sometimes.
My frustration has several dimensions:
The field, to my way of thinking, is incredibly screwed up and anti-scientific, divided into irrational cults called "schools" of therapy.
Nobody seems to notice this "elephant" in our room! Hey, are you all sleeping? Did you learn critical thinking in college?
When challenged by research that seriously questions the validity and effectiveness of current psychotherapies for depression and anxiety, for example, no one seems to care or notice. It seems like wrong theories die hard.
People do not like being criticized and got angry when I criticize the field of psychotherapy. So, there is a kind of a "let's be politically correct" and be super "nice" to everyone, so as not to stir them up or hurt their feelings.
There is a potential for massive change and improvements in psychotherapy and psychiatric treatment, but it would require a revolution and the acceptance of totally new approaches which would threaten many therapists' thinking and survival at a very basic level.
Are you or others interested in my thinking? Let me know. If so, more later, maybe on a podcast or two with Jill and Matt, and of course, Rhonda.
And here are the answers to some of your other questions. You say, "He has mentioned that he feels disappointed if he doesn't see change in 2 hour sessions."
We're not on the same page here. I nearly always see dramatic change in 2 hour sessions, and I'm dramatic that I have created a therapeutic approach that makes this possible. When I was a young man, a psychiatric resident, I use to dream about that, and wondered if it was even possible, since I almost never saw meaningful change, much less recovery and joy, in any of my patients using the methods I was talk (supportive listening and antidepressants.)
You also wrote:
I also am wondering if it is difficult to navigate being seen as "a great leader" in a field. Do people see you as "David" simply a dedicated expert in your field or do people treat you like a "God" that has all the answers?
Cool question. I think many people see me as a dedicated expert, but I think a few, particular from some of the Asian countries, to like to see people as "gurus" or something on that level. Sometimes I may even encourage that, as I am a strong believer that therapy, at its deepest level, does become spiritual.
So, questions about spirituality and enlightenment do interest me greatly, and many of the techniques I've created are designed to facilitate rapid improvement, in minutes, vs. years of meditation. The Externalization of Voices would be an example, and it was actually the first CBT technique I created, around or even prior to 1975.
You say,
Recently I watched a live session with Madelaine and some of the techniques (for example, calling her negative self sociopath during counter attack) did not seem to land or resonate with her and that wasn't addressed with David's usual love and tenderness and warmth with empathy. It seemed rushed and not necessarily focused on the patient outcome but the timeline.
You are partially correct and perhaps somewhat "off." Where you are right is that I miscalculated the time for the webinar, and thought we had to stop at 12:30. I later figured out we had until 1 PM, and we could have spent more time on EOV.
Where you're perhaps wrong is that sometimes a confrontation can "jar" a patient into enlightenment. Few therapists use confrontation, but I have always used it, ever since my days in psychodrama as a medical student. Madeleine commented in her follow up evaluation on the things most helpful to her during the session, and that was one of them.
Research has consistently proven that the observers of therapy cannot accurately assess the quality of the therapeutic alliance, as reported by the patient, or the effectiveness of what's happening during a session. I sometimes wish therapist observers had a bit more humility about the accuracy of their observations, based on research that's been replicated over and over!
But there I am, whining again so I will stop!
At any rate, Jenn, thanks for the wonderfully informative critical thinking, and great questions!
Warmly, david
Jenn's response to David
Hi Dr. Burns,
Thank you so much for your fast response. I am really honored that you took the time to reply to me!
Thank you for your honesty too and I can imagine it's super frustrating! I do not think that sounds narcissistic, I think you are right. I find it extremely frustrating too and I am just a user and learner of TEAM. I think I "see it" sometimes since I've done some personal work. I'm still human with many flaws as I am sure you caught on to a few in my email.
I completely agree with all of your points. I genuinely do not understand how TEAM-CBT is not the go-to. It is finally a scientific method that is proven to be effective. It truly leaves me speechless and I could ramble about TEAM for hours to be honest!
I am a registered nurse and I have a difficult time seeing my patients being "thrown" anti-depressants etc. The biological theory was the go-to in mental health and about 10 years ago as I was finishing my nursing degree I read When Panic Attacks. It was mind blowing to me. At the time I was working on a Stroke Rehab unit and the psychologist would recommend our depressed and anxious patients be put on medication. When I asked if she had heard about your work she scoffed at it and it made me so mad! I wanted to scream at her to read your work but she was resistant to even listening and perhaps that will not surprise you based on your points (and also how I incorrectly tried to sell it to her!). I would see so many of my patients put on antidepressants and left alone afterwards as if that would solve everything. Even recently during my labour and delivery training we had a psychologist speak to us about post partum mood "disorders" and she specifically mentioned her patients "yes-butting" her and made a joke about how resistant they are to change and I just had this thought HELLOOOOO has agenda setting not been around for years????? Do people not search out solutions and try to be better? I could Google "my patient is yes-butting me" and your work would come up and it is not easy but it is spelled-out and so accessible to learn. Anyway, I could rant forever. I'm on the same page with you, Dr. Burns!
Thank you for the follow-up email as well. You are right on this one for sure- my therapist observer totally was inaccurate! And I was thinking "I wonder what her EOV is here and if that was effective". I had asked that question in the chat after the webinar but it was at the end and we did not get to it So next time I will ask that as a question in my email instead. I had not seen confrontation used like that and it did seem off-putting and that just shows how well-versed you are in its use and how I am a learner. Thank you for the feedback. This is making me laugh because I am in the Fast-Track course and I really strive on feedback, and I like getting errors over with. In my nursing career I always had "med error" as the thing I never wanted to do and it felt so good when I finally made one (and it also helps the patient was fine haha). So, I had this thought about learning TEAM and how I know that the therapists are never accurate and how I never want to be the therapist that assumes their thinking. So, I am very happy to have done it already and I have not even started the course really.
I want to comment and ask about the spiritual aspect of TEAM. Did you find the spirituality came after personal work or did you see the spiritual aspect before or just as you were developing the whole process?
Externalization of voices and a daily mood log is what got me to enlightenment, but it is hard to put into words. I had blips of the euphoria enlightenment over the years but about 5 years ago I had this "big one" and it was not euphoric. It was nothing (but everything) and it was like I became an observer and absolutely none of my thoughts had emotional attachments. It was instant relief of human suffering for sure. Sorry if this is bizarre and I am not sure if this resonates or if I sound like a crazy person.
In your podcast with Lee you mentioned that enlightenment is lonely and so I thought maybe you have been here. When it first happened it was an overwhelm of being just matter and being everything and nothing all at once. I could see humanity from an outside perspective almost. I was raised catholic and everything that I learned made sense but in a very different way than I was taught - it was like I understood what Buddha and you and the bible talks about but the deeper meaning if that makes sense. And I sat in the observer role for a couple of days and it was fine because I had no emotional attachment.
Actually, as a test I looked at my husband when he got home from work the day it happened and I recognized him of course but I just felt the baseline contentment or a peace overall. The nothingness and the everythingness all at once. When I looked at him I had no emotions or gut reactions or anything and when I thought "that is my husband" I had no emotional ties but I could recognize that my human self loves him but even that love was all created from nothing and everything. This sounds so bizarre!
Day 3 or 4 I went to a house party and again I was just an observer and recognized that my human ego is very tied to wanting others to like me, when I attempted humor it would be to serve my ego, before I'd try to make people laugh for me rather for them and a lot of our actions are tied to our egos. After this party, maybe the next day or something I also saw that as I was observing that although I had no emotional ties that also means…I had no emotional ties! It came to me that to live a human life I cannot be in this enlightenment stage. It was lonely even though that did not bother me at the time and seeing humans from this outside perspective is incredibly hard to describe and was overwhelming.
So in my enlightenment it was almost like I had to decide to step back into trying to be human so I could carry on with life and try and find these emotional ties and what to do with this awareness of my flaws and what even my personality is. It has rocked me a bit! I have decided to just follow things that I find fun or challenging or have become an interest and the flaws quickly followed!
Have you heard of anyone having a bit of fear in reaching enlightenment again? Although the initial hit was so awesome and a huge relief of suffering, I experienced truly what it is like to not have flaws and not have any emotional ties to thoughts. I do have some interesting anxious thoughts about going "back there" and this was the perfect example of "everything in moderation". I must love my flaws haha.
Thanks for your time, Dr. Burns! I thought I had heard you mention during a podcast that you feel disappointed if you don't see change in a 2 hour session maybe while you were empathizing with another therapist so I apologize that I was wrong there. I am most likely remembering it incorrectly or I presented the context incorrectly -it's a common flaw of mine haha usually I need to write things down.
Looking forward to hearing back,
Jenn
David's response to Jenn
Thanks, Jenn. Awesome email. In the context of my empathizing with another therapist, I could well have said something like that for sure!
You are dipping into enlightenment. Way to go. Very exciting, and now YOU will be the expert.
When I lived in Philadelphia, I was lucky to audit a class by James Arbukcle at Temple University on structural equation modeling. It was unbelievably exciting for me, and even though I was in private practice, I went once a week for the three hour seminar and did 20 hours of homework every week. I could not believe my good fortune, as he made everything super simple and clear. It was a wow experience every week.
For quite a while, I would ask him question when I got stuck or puzzled analyzing my data with his AMOS program, and he seemed to know everything. Which was also cool.
Then, one day, he started answer my questions by saying, "Actually, I don't know the answer to that." Like, the first time this happened I asked him the cause of Heywood cases. That where you get a seemingly impossible result, like a correlation greater than one.
But then, an odd thing happened. I found that if I worked at it, I could figure these things out for myself. And often, the answers would come to me in a dream, in the middle of the night.
So, like James, I probably can't answer all your questions anymore, although hopefully I can still answer a few of them!
By the way, James Arbuckle was one of the most amazing teachers I've ever had, and I will forever be grateful for his generosity in letting me audit his class--I was not even a student at Temple--two years in a row for free. And what I learned forever changed my career and my life, especially my way of thinking about research and statistical analyses.
Warmly, david
Thanks for listening today!
Rhonda, Matt, and David
Awesome November 5 Social Anxiety Webinar for YOU!
lundi 3 novembre 2025 • Durée 02:49
Dr. David Burns and Jill Levitt will teach you seven jaw-dropping techniques to end feelings of shyness and social anxiety. For shrinks AND for the general public.
If you're hurting, or you have patients who are hurting, we want you to join us! It's 100% free. Therapists even get two FREE CE credits if you attend the live event.
Sign up now at CBTforSocialAnxiety.com. This event could change your life.
It's Wednesday, November 5th, 2025, from 11 AM to 1 PM Pacific Coast Time. Be THERE!
467: Ask David: How can I help grandma and my mom?
Épisode 467
lundi 15 septembre 2025 • Durée 53:25
#467 Ask David--How can I help my elderly, demanding grandma?How can I empathize with hostile political figures?
The answers to today's questions are brief and were written prior to the show. Listen to the podcast for a more in-depth discussion of each question.
Today's questions.
Brittany says that her elderly grandmother has become very needy and demanding, and that her mom finds grandmother's behavior irritating. She wants to know how she can help her mom / grandmom.
Jenny asks: How do we empathize with people we are extremely angry with, including prominent political figures?
Brittany says that her elderly grandmother has become very needy and demanding, and that her mom finds grandmother's behavior irritating. Brittany wants to know how she can help her mom / grandmom.
Hi Dr. Burns,
A few months ago my grandma fell down her stairs and broke some ribs. She was in a nursing home for a short while since she needed physical therapy and assistance doing daily tasks. Before the accident, she lived alone and was completely independent.
During her recovery, she pretty much had round the clock visitors. More than any other person in the nursing home. My grandma complained constantly and anytime someone would say "you look good" or "you seem to be doing better" she would very quickly respond with how terrible she feels etc. Having listened to your podcast on how to deal with complainers, I could see it was because nobody was acknowledging her feelings. They just wanted to say things to cheer her up.
She is now recovered and back home, but she refuses to do things on her own again that she is capable of and the doctor cleared her to do. She has a terrible attitude and is constantly calling up family members and her friends to run errands for her. Example: my mom picked up some lettuce she asked for her. Then my grandma called her friend to go get her one afterwards, saying the one my mom bought was too small. She acts completely ungrateful. She texted me that she has been so lonely with no visitors but then my mom tells me that is not true. That she has had people coming over every day and taking her places.
Special Episode #1: The GRIP Program
Épisode 1
jeudi 4 janvier 2024 • Durée 01:10:16
Rhonda Describes the GRIP Programand Interviews GRIP Graduate, Shakur Ross
The Guiding Rage Into Power (GRIP) Training Institute serves incarcerated men and women in California. Their mission is to create personal and systemic change to turn violence and suffering into opportunities for learning and healing.
I (Rhonda) was introduced to the GRIP program when two of my dearest friends, Steve Zimmerman and Vicki Peet, invited me to a yearly celebration of the GRIP Training institute. I was blown away by who I met and what I learned that I wanted to share it with the Feeling Good Podcast listeners. Thank you, David, for letting me deviate from our typical subjects.
The GRIP program is a different subject for the Feeling Good Podcast, because it is not about TEAM-CBT. What the GRIP Program and TEAM-CBT have in common is that they are both evidence-based programs that incorporate CBT theory and methods into their treatment methodology. But the main thing they have in common is that people who engage in these two therapies experience profound, enlightening changes in their lives.
From their program:
"The GRIP program is an evidence-based methodology developed over 25 years of work with 1000's of incarcerated people and many victim/survivors. Rooted in Restorative Justice principles, the program's trauma informed model integrates cutting-edge neuroscience research. Students engage in a yearlong, in-depth journey to comprehend the origins of their violence and develop skills to track and manage strong impulses rather than acting out in harmful ways. They transform destructive beliefs and behaviors into an attitude of emotional intelligence that prevents revictimization."
The GRIP Training Institute was started in 2011. As of October 2020, nine years after running its first group, 915 students have graduated. Of the 915 graduates, 369 were released from prison. Only 1 graduate in nine years returned to prison, which is a recidivism rate of 0.3%, which is very impressive considering the recidivism rate for California is between 44-46%. Many, if not all of the graduates, say that GRIP saved their lives. Something many people who have benefitted from TEAM-CBT echo.
377: Living with Regrets, Part 2 of 2
Épisode 377
lundi 1 janvier 2024 • Durée 01:03:09
Jessica Malvicino Live Work With Jessica--Living with Regrets
Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our "patient" was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you've also looked back on your life and thought, "If only I would have . . . " done something I didn't do," as well as, "I wish I hadn't done X, when I was young."
Last week you heard the initial Testing and Empathy portions of the session with Jessica. Today you'll hear the Assessment of Resistance, Methods, and final Testing..
Part 2 of the Jessica SessionA = Assessment of Resistance
Jessica said her goal for the session was learning to accept life and move on, and not have such constant feelings of emptiness, with so many "I should have" thoughts running through her brain.
Although Jessica, like most people, said she'd press the Magic Button to make all of her negative thoughts and feelings disappear, we decided to do some Positive Reframing first, to see if there were some positives hiding in her negative feelings. We asked the following questions about a number of her negative feelings and thoughts:
Why might this thought or feeling be appropriate and healthy?
Why might this thought or feeling be helpful to you?
Why does this thought or feeling show about you and your core values that's positive and awesome. ?
As you probably know, the goal of there are two goals for this paradoxical exercise: First, we want to bring the patient's subconscious resistance to conscious awareness. Second, we want her to see that her struggling and suffering is NOT the result of what's WRONG with her, but rather, what's RIGHT with her.
The moment that people really "see" and "get" this, there's often a sharp and sudden reduction in feelings of shame, and a strong burst of motivation to crush the negative thoughts at the heart of her misery.
Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our "patient" was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you've also looked back on your life and thought, "If only I would have . . . " done something I didn't do," as well as, "I wish I hadn't done X, when I was young."
Today you'll hear the initial Testing and Empathy portions of the session, and next week you'll hear the Assessment of Resistance, Methods, and final Testing..
Part 1T = Initial Testing
DAVID WILL SUMMARIZE SCORES ON BMS AND DML
You can also see her scores on the emotions table of her Daily Mood Log here.
As you can see, these negative feelings were all incredibly intense.
E = Empathy
Jessica, who grew up in Florida, explained that she started ballet dancing at the age of 3, and when she was 17, she won a prestigious full scholarship to study and have the chance to join a world renowned ballet company. Jessica was incredibly excited, but her mom did not see ballet as a "true career." In addition, her mother was quite protective, which was not uncommon in the Cuban community, and told Jessica she could only accept the scholarship if she agreed to live with her grandparents in New York.
Jessica angrily rebelled and turned down the offer. Although she continued to dance professionally until her first daughter was born 14 years ago, she battled with feelings of anger and regret the entire time, while also blaming her mother for her. unhappiness.
375: Ask David Live: I'm Struggling!
Épisode 375
lundi 18 décembre 2023 • Durée 01:40:23
Today's special guest, Brittany. Podcast 375. I'm Struggling!Ask David Live: a New Podcast Twist
We start today's podcast with a visit from Dr. Jacob Towery. You might recall that one year ago he offered an amazing and (almost) totally free two-day workshop for shrinks and the general public on overcoming social anxiety. Roughly 90 people attended, and it was a huge success. The only "cost" was a $20 contribution to a charity of your choice, including Doctors Without Borders and several others.
Dr. Jacob Towery
This year, Dr. Towery will be repeating this incredible program on March 16 and 17, 2024, which will be on a Saturday and Sunday, in Palo Alto. Once again, the title will be "Finding Humans Less Scary." Jacob and Michael Luo will lead the program and will be assisted by 10 - 20 expert therapists who will lead the break-out groups.
Last year, people described the program as "transformative" and "life-changing." Social anxiety can have a significant impact on your life, so you owe it to yourself to attend if you or a loved one has struggled with any of the five common forms of social anxiety:Shy Bladder Syndrome
Shyness in social situations
Public Speaking Anxiety
Performance Anxiety
Test Anxiety
You'll learn and practice tons of awesome anxiety-busting techniques, including Smile and Hello Practice, Flirting Training, Rejection Practice, Talk Show Host, Shame-Attacking Exercises, and much more.
Social anxiety rarely exists alone, but is nearly always associated with other mood problems, such as loneliness, shame, depression, and substance misuse with alcohol and benzodiazepine pills to try to combat the symptoms, to name just a few.
If you attend, let us know how it worked out for you, what you learned, and how you grew. Thanks so much, Jacob, for making this kind of world-class experience available to everyone who's looking for some help, and some wild, life-changing and zany fun in March!
374: Anger, Part 2: You Have Always Hated Me!
Épisode 374
lundi 11 décembre 2023 • Durée 01:26:41
Featured photo is Mina as a child (more pics below!) 374 Anger, Part 2You Have Always Hated Me!
In the Anger Part 1 podcast (371 on November 20), Rhonda, Matt and David discussed the fact that when you're feeling angry, there's always an inner dialogue—this is what you're saying to yourself, the way you're thinking about the situation—and an outer dialogue—this is what you're saying to the other person.
In Part 1, we focused on the inner dialogue and described the cognitive distortions that nearly always fill your mind with anger-provoking inner chatter about the 'awfulness" of the person you're mad at. Those distortions include All-or-Nothing Thinking, Overgeneralization, Labeling, Mental Filtering, Discounting the Positive, Mind-Reading, Fortune Telling, Emotional Reasoning, Other-Directed Should Statements, and Other-Blame.
That's a lot—in fact, all but Self-Blame. And sometimes, when you're ticked off, you might also be blaming yourself, and feel mad at yourself at the same time.
Matt suggested I add these comments on Self-Blame or it's absence::
Another possible addition would be when you identify the absence of Self Blame when we're angry. For me, it's been easier to think of that as a positive distortion, because you are blind to, or ignoring, your own role in the problem. In other words, when I'm blaming someone else, it's me thinking my poop smells great and tit's all the other person's fault..
I've wondered if we fool ourselves like this because of the desire to have a special and perfect "self," which we then defend. Because nobody's perfect, our "ideal self," as opposed to our "real self," is just a pleasant, but potentially destructive, fantasy.
Still, we try to preserve and project the fantasy that we are free of blame and the innocent victim of the other person's "badness," , and we imagine there we have a perfect "self" to defend. Or, as you've said, at times, David, "anger is often just a protective shell to hide and protect our more tender and genuine feelings."
We also discussed the addictive aspect of anger, since you probably feel morally superior to the "bad" person you're ticked off at when you're mad, and this makes it fairly unappealing to change the way you're thinking and feeling. Your anger also protects you from the risk of being vulnerable and open and genuine.
You treat the other person with respect, even if you're angry. You want to put the other person down. Your goal is to get closer to the other person. You want to get revenge or hurt or humiliate the other person. You hope to improve the relationship. You want to reject or distance yourself from the other person. You want to understand the other person's mindset and find the truth in what they're saying, even if it sounds 'off' or 'disturbing' or offensive. You want to prove that the other person is 'wrong' and persuade them that you are 'right'. You want to understand and accept the other person. You insist on trying to change the other person. You express yourself thoughtfully. You express yourself impulsively. You come from a mindset of humility, curiosity, and flexibility. You come from a position of moral superiority, judgement, and rigidity. You are patient. You are pushy and demanding. Optimism that things can improve and that there's a great potential for a more meaningful and loving connection. Hopelessness and feelings of certainty that things cannot improve. Open to what I've done wrong and how I've hurt you. Focus on what you've done wrong and how you've hurt me. I-Thou mindset. I-It mindset. You're vulnerable and open to your hurt feelings. You put up a wall of toughness and try to hide your vulnerable true feelings.. You look for positive motives, if possible, and don't assume that you actually understand how the other person is thinking and feeling.. You attribute malignant motives to the other person and imagine that you can read their mind and know exactly why they feel the way they do. You accept and comprehend the idea that you can feel intensely angry with someone and love them at the same time.. You may believe that anger and love are dichotomies, and that conflict and anger, in some way, are the 'opposite' of love or respect..
373: Why Therapy Fails
Épisode 373
lundi 4 décembre 2023 • Durée 56:59
Why Therapy Fails
One of the most common reasons patients contact me is to find out why the therapy isn't working. They may be TEAM-CBT patients or patients of therapists using other approaches. Therapists also ask for consultations on the same problem--why am I stuck with this or that patient who isn't making progress?
In the Feeling Good App, my colleagues and I have been looking into this as well. Most app users report excellent and often rapid results, but some get stuck, in just the same way they might get stuck in treatment with a therapist. I have tried to organize my thinking on this topic, because if you can diagnose the cause of therapeutic failure, you can nearly always find a solution. Of course, the app is not a treatment device, but a wellness device, but the same principles apply.
So today, Rhonda, Matt and I discuss a couple reasons why therapists and patients alike sometimes get stuck. Matt described a patient who was misdiagnosed with a psychotic disorder who turned out to have sleep apnea. When the proposer diagnosis was made and treated, the patent suddenly recovered.
Rhonda described a patient who jumped from topic to topic and always brought up a new problem before completing work on the previous problem. This problem was solved when Rhonda explained the importance of sticking to one problem for several sessions, until the problem was resolved. The patient then began to make progress.
David described a depressed woman from Florida who was stuck in treatment, and not making progress, and then the therapist said "I just can't help you," This hurt and confused the patient who wrote to me. There were essentially two problems--the patients depression what brought her to therapy in the first place, and her unresolved hurt feelings when the therapist "gave up" on her. This problem reflected many failed relationships is the patient's life. This was resolved when the patient took the initiative to schedule a session to talk about the conflict more openly with excellent results.
In addition, the patient had heard that she "should" accept herself, but didn't know how to accept her constant self-critical troughs and intensely negative feelings. I suggested she make a list of the benefits of her negative thoughts and feelings, as well as the many positive things they showed about her and her core values as a human being.
372: At Last! An Outcome Study!
Épisode 372
lundi 27 novembre 2023 • Durée 57:28
At Last! An Outcome Study!
One of the wonderful things about TEAM-CBT is the dramatic and rapid changes we see in so many of our patients. But we've had a huge problem-no published outcome studies. And that has definitely limited the general acceptance and recognition of TEAM-CBT.
Today, that era has come to an end, thanks to Dr. Elise Munoz, who joins our beloved Feeling Good Podcast to discuss a remarkable outcome study conducted at her Feeling Good Psychotherapy clinic in New York City. She wanted to evaluate the effectiveness of TEAM-CBT with teens and young adults.
Dr. Munoz is the Founder and Lead Therapist at Feeling Good Psychotherapy and Adjunct Assistant Professor at New York University. She is also a Level 4 Certified TEAM-CBT Therapist & Trainer, and specializes in the treatment of anxiety, depression and life transitions.
Elise conducted a "naturalistic" study of data from 116 teenagers and young adults aged 13 -24 years of age who were treated by 15 therapists between 2017 and 2022. In a "naturalistic" study, you simply analyze all the data from your patients to evaluate the effectiveness of the treatment. This is in contrast to a "controlled outcome study" where patients are randomly assigned to two treatments to see which treatment delivers the best results. Elise conducted the research study as part of her work for a Doctorate in Clinical Social Work at the University of Pennsylvania in Philadelphia.
"The results," she says, "were encouraging." That's perhaps a humble description of her findings. David and Rhonda might say that the results were pretty awesome!
Elise told us that although the average number of treatment sessions was 27, most of the patients made maximal gains after just 10 weeks (2.5 months) of treatment, and many achieved maximal improvement by the 5th session. Specifically, by the tenth session. 80% of the patients scored in the "subclinical" range on the depression scale of my Brief Mood Survey (with scores of 0 to 4) and 87% scored in the subclinical range on the anxiety scale (scores from 0 to 4) . These scales range from 0 (no symptoms) to 20 (extremely severe.) Prior to the study, only 30% were in the subclinical range.
According to Elise, the rapid improvement suggested that most patients will not need long-term treatment, although some will need more time to incorporate their gains following their initial improvement, and many will want to remain in treatment to deal with other problems, such as relationship issues that are so important in this (or any) age range.
My mom is at her wits end dealing with her demanding attitude and ungratefulness. I know Jill had an example before where her mom was saying how hard things are and nobody is there for her and Jill used the five secrets. This situation feels a little different. How can my mom get her life back and get my grandma to do things on her own again?
-Brittany
David's reply
Hi Brittany,
How about including this as another Ask David? One problem, as I see it, is that your mom is not asking David for help. So I could only help you with your response to your mom, acknowledging how difficult things are for her. In other words, use the Five Secrets of Effective Communication. Of course, this assumes you want help with your interaction with your mom.
It can be hard not to "HELP" when a loved one, like grandma, AND your mom, are suffering and struggling. Sadly, I have learned that trying to help third parties is not satisfying or effective most of the time. But modifying the way I interact with people is almost always helpful.
Don't know if this make sense. Certainly we can see what Matt and Rhonda have to add / suggest.
Warmly, david
Brittany's response to David:
Sure, I think it would be a great ask David. I would be interested in your approach if it were my mom asking you for help. What would you tell her and what your five secrets approach might be.
-Brittany
David's response:
I always prefer have a specific example to a hypothetical question. I can only help you with YOUR responses to your mom, or to anyone. Can you give an example of something she has said to you that you want help responding to effectively?
Warmly, david
Jenny asks: How do we empathize with people we are extremely angry with, including prominent political figures?
Dear David and Rhonda, Your session on dealing with cancer was incredibly heart-warming and so compassionate. I will be sharing that with my sister who is in a similar situation and now completely healed from her cancer!
My question deals with anger. Many of us are dealing with anger and frustration at our country, president, and White House, who are taking rights away from us that we have earned over the past 80+ years. I find applying your positive ideas about anger to be very helpful: to view anger as having a high moral sense of justice and fairness, and to view frustration as keeping vigilant and to not get discouraged.
But I want to investigate further how these anger/frustration ideas can be applied to White Supremacists and Steven Miller. Because when you hear these people talk they are so incredibly angry, and are directing their anger at other people in destructive ways. How could we, if given the opportunity, talk to them and feel empathy with them?
Thanks so much, Jenny
David's response: If you like, we can include your excellent and highly relevant question in an upcoming Ask David podcast.
Thanks for listening today!
Matt, Rhonda, and David
At the GRIP celebration, I was standing in line waiting for the buffet. A man got in line behind me. It was confusing where the line ended, which was not directly behind me.
In another circumstance I might have mentioned to him that the line ended somewhere else, but he was kind of scary looking, big, buff with obvious prison tattoos on his neck so I didn't say anything. But the line moved slowly and I was curious so I asked him what his connection to GRIP was. He told me he was a graduate of the program and then politely asked me the same question.
It has been my experience that often people love to talk about themselves more than they are interested in other people so I was immediately impressed that he was as interested in me as I was in him. When I told him I was a therapist, he asked me what kind of therapy I practiced. I explained TEAM-CBT, and he was super interested!
He told me he loved CBT, and had learned a lot about himself through that kind of therapy because GRIP incorporated it in their program. I asked him about his experience in GRIP and his tough exterior transformed right in front of me as he talked about how GRIP saved his life.
I talked to several other men (so far only men have graduated from the GRIP program because the services have only recently been brought to a women's prison), and had the same experience. I met our guest on this podcast, Shakur Ross, who kindly agreed to share his journey of transformation with us.
GRIP graduates continue to do the work and live as Peacemakers. Shakur works for GRIP and returns to San Quentin and other prisons to provide the same lessons that he received.
The podcast starts with an interview with Kim Moore, the Executive Director of the GRIP Training Institute, who explains some of the key concepts of the program.
Thanks for listening today!
Rhonda
Here are some of the Positives we listed:
SADNESS
My sadness shows my passion and love of dancing.
It shows my dedication to the idea of having a fulfilling career.
It shows that I'm a very loving person.
ANXIETY, WORRY, NERVOUSNESS
These feelings
show that I'm responsible
motivate me to complete tasks
help me avoid procrastination
make me vigilant and protect me from danger
SHAME
These feeling show that
I'm concerned about others
I'm human
I want to please others with my career
I admire my mom and want to make her proud
I want her to admire me
I'm humble
I want to feel close to others
ANGER
These feelings show that
I'm a caring and passionate person
I have character
I have a moral compass
I'm feisty and strong
I'm accountable
My anger also empowers me
After listing these and other positives, Jessica decided to use the Magic Dial to reduce her negative feelings to lower levels, but not necessarily all the way to zero, as you can see in the goal column on her emotions table:
Emotions
% Now
% Goal
% After
Emotions
% Now
% Goal
% After
Then we went on to
M = Methods
These were some of the negative thoughts that Jessica wanted to challenge, along with the percent she initially believed each of them:
I'm a failure. 90%
My mom is to blame for not understanding the career path that I wanted. 90%
I was an idiot for not following my dreams. 100%
Nothing will truly fulfill my professional career. 100%
I have to "settle" for my professional career now.100%
She had many others ad well.
We used a variety of techniques to challenge and crush these thoughts, including the Externalization of Voices with Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique), and used frequent role reversals to help Jessica get to "huge" wins when she was in the role of her positive thoughts.
Here you can see Jessica's scores in the "% After" column. As you can see, her scores were extraordinarily low, which is terrific.
Emotions
% Now
% Goal
% After
Emotions
% Now
% Goal
% After
Typically, such drastic and sudden reductions in negative feelings not only indicate "recovery," but the experience of feelings of joy and enlightenment.
At the end we asked Jessica two questions:
Are the scores valid, or is she just trying to please us?
If they are valid, what were the most healing and helpful aspects of the session?
As you listen to the end of the live session, you'll find out what she said!
Rhonda and I hope you enjoyed the session with Jessica. We believe that live work with real people, and not role players who are pretending to be in therapy, is invaluable, and one of the best—and only—ways to learn many of the subtleties of rapid and effective treatment. And if you are a general citizen, and not a therapist, I hope your found our work with the brave and wonderful Jessica to be inspirational and educational, especially if you have also sometimes felt depressed, anxious, or ashamed, and if you have found that regrets about the past can put a real damper on your capacity to live and enjoy your precious present moments!
Our best teaching is usually through live work, and so we give you, Jessica, a warm thanks and salute for the great teaching YOU have done today!
Thanks for listening, everybody!
Jessica, Rhonda and David
She eventually got a bachelor's degree in journalism, and worked in television for a period of time. Then she got a master's degree in counseling, and found that she loves clinical work and helping people. However, she continued to live with feelings of regret and anger directed at her mom from age 17 to her current age of 40, for a total of 23 years, and explained that she frequently "takes it out" on her mom during periods of irritability.
She also has feelings of grief about what she's lost when she see her young niece dancing ballet beautifully now. This statement brought tears to her eyes.
Jessica described all the sacrifices she'd made when growing up in order to become a top dancer, including periods of bulimia to maintain the thinness that her teachers always stressed. She explained that "everyone did it—they weighted us frequently and would grill us if we were even a little bit overweight. . ." and this was all in order to fulfill her ultimate dream of becoming a world class ballerina, a dream that vanished.
Jessica gave Rhonda and David an A on Empathy, and said that the self-disclosure felt uncomfortable, but helpful. Next week, you'll hear the inspiring conclusion of the work with Jessica!
Brittany, an enthusiastic podcast fan, asked for help with a conflict with her husband. She wrote:
Hi Dr. Burns,
I'm struggling a bit. My husband reads a ton of articles and feels that the media has been portraying a lot of the current events incorrectly, especially the horrifying Israel/Palestine conflict. He is extremely frustrated by this and has become depressed because none of his friends or family seems to want to talk about it. He says he feels alone & isolated. I have never been much into politics, abd I don't know enough to have a real opinion on things to say who is right.
I try to be a good listener to whatever he says. For example, I may say "yeah, that sounds really frustrating," and then I agree with what he says. But I'm obviously doing a bad job at the empathy because he says the support he gets from me is not satisfactory at all. Sometimes I feel like a parrot, just repeating back what he says.
I think you had an example before on an Ask David where you showed how to empathize with someone who says how awful everyone is and how awful all the liberals are. Something like that. But I can't find it.
When I empathize my husband says I just don't get it and nobody is doing anything to help these innocent people who are being attacked, and he says that I am not doing anything either.
I'm at a loss on how to reply? Maybe you could do an example on an Ask David. Sorry for the long message.
- Brittany
Hi Brittany,
Sorry you're struggling, this is a common but important problem.
Yes, we can and will do that. Can you give me an example of something he says to you, and exactly what you say next? You can use the attached Relationship Journal I you like.
Try to complete steps 1 and 2 at least, and mail back to me ASAP. Lots of people with this problem these days, so could be great ASK D question.
Weren't you on the show live once a few years back? I know you've sent us some great questions. I'm thinking MAYBE you could join and practice with us, using your example.
Do you have / have you read my book, Feeling Good Together?
Best, david
It turned out that Brittany was eager and willing to join us live on today's podcast . This is kind of an experimental podcast where we not only respond to a great question by one of our fans, but actually invite that person to get our "expert" help in real time and live on a podcast.
You can let us know if you like this format.
To get us started, Brittany sent us an example of a Relationship Journal she had prepared. I thought this was really well done, and gave her revised version a grade of A-, which is way better than most people can do. I sent her an email saying that she could probably add more acknowledgement of his feelings and her feelings, like feeling alone and hurt and a bit lonely, and also a bit more Stroking, like "I want you to know how much I love you, and how special you are to me. And that's why it's so had for me to realize that I've really been letting you down."
We practiced with Brittany using my Intimacy Drill, which you'll hear on the podcast. Essentially, one of us would play the role of Brittany's husband, and we would say something she wanted help responding to, and she used the Five Secrets to respond. Then Rhonda, Matt and David gave her an overall grade (from A to F), along with fine tuning suggestions, emphasizing what she did that was especially effective and if there were any changes that might make her excellent responses even better. Then we did role reversals so we could demonstrate ow we might respond, followed by additional role plays until she was satisfied with her response.
This approach is called "Deliberate Practice" and it is by FAR the best way to master the Five Secrets so you can use them successfully in real time.
We also discussed her concern that at home she'd been feeling like "a parrot" when she tried the Five Secrets. That is always caused by the absence of "I Feel" Statements in your statements, and we modelled how to correct this error.
One of the biggest problems in the way people communicate during a conflict or argument is defensiveness, and given in the urge to argue and defend your territory, so to speak. Matt explained that this nearly always results from thinking you have a "self" that you have to defend.
Another common Five Secrets error is the failure to acknowledge the other person's anger. Therapists and the general public nearly always make this error, because of a mindset I call "anger phobia" or "conflict phobia." However, Brittany did really beautiful work during the podcast exercises, as you'll see when you listen.
We (the so-called "experts") also practiced what we preached and took turns responding to criticisms, which is always fun and challenging, and often humbling when we goof up!
Let us know what you think about this new format of having someone who asks a question actually appear live on the podcast so you can actually learn through practice while we answer your question.
Thanks for listening today, and thank you Brittany for blazing new trails on our podcasting adventure!
Brittany, Rhonda, Matt, and David
Today we discuss the Outer Dialogue, and how to express angry feelings to another person, as well as how to respond to their expressions of anger. The main concept is that you can express anger in a healthy way, by sharing your anger respectfully, or you can act out your anger aggressively, by attacking the other person. That's a critically important decision!
Toward the start of today's podcast, Rhonda, Matt and David listed some of the distinctions between healthy and unhealthy anger. The following is just a partial list of some of the differences:
Healthy Anger
Unhealthy Anger
To bring some dynamics and personality to today's podcast, Mina, who's made a number of noteworthy appearances on the podcast, agreed to describe what she learned on a recent Sunday hike. (I've started up my Sunday hikes again, but in a small way now that the pandemic has subsided, at least for the time being. I'm struggling with low back pain when walking and that severely limits how far I can go.)
Mina began by explaining that when she was talking to her mom on the phone. Her mom described a conflict with woman friend who seemed angry with Mina's mom. Mina said, "I can see why that woman got angry with you."
Mina explained that her mother, who is "conflict phobic," paradoxically ends up with conflicts with a lot of people. However, Mina's mother sounded hurt by Mina's comment, and said, "You've always hated me since you were a little girl! You always looked at me hatefully!"
Here are some of Mina's "angry" childhood photos:
Mina explained how she felt when her mom said, "You've always hated me."
My jaw dropped when she said that! It was such a shock. I've always felt like she was my best friend! . . .
I hate feeling angry. It makes me every bit as uncomfortable as anxiety. If I express my anger, it goes away, and I feel better. But I don't usually express it, and then it comes back disguised as weird neurologic symptoms.
And that, of course, is the Hidden Emotion phenomenon that is so common in people who struggle with anxiety. When you try to squash or hide negative feelings your think you're not "supposed' to have, they often resurface in disguised form, as phobias, panic, OCD symptoms, chronic worrying, or any type of anxiety, including, as in Mina's case Health Anxiety—that's where you become convinced you have some serious neurologic or medical problem, like Multiple Sclerosis.
Matt suggested that I might remind folks of my concept that "anger allays get expressed, one way or the other." He's found this idea to be both true and incredibly helpful for "us nice folks who think we can get away without expressing our anger, thinking we can avoid conflicts, entirely. This always backfires, in my experience!"
On the recent Sunday hike, Mina practiced how to talk with her mom, using the Five Secrets of Effective Communication. After that, she used what she'd practiced on the hike to talk to her mom about their relationship, and then got an "I love you" message from her mom the next morning.
This made Mina very happy, but because she had a full day of back to back appointments, Mina decided to spend time crafting a thoughtful reply at the end of the day, when she had a little free time. But when she went back to her computer at the end of the day to send a message to her mom, she discovered that her mother had deleted the loving message she sent early in the day, and Mina felt hurt.
When Mina asked her mom about it, her mom said that deleting the message was just an error due to 'old age." However, Mina did not really buy this, and thought her mom probably felt hurt and angry because Mina had not responded sooner.
In the podcast, we practiced responding to mom using the role-play exercise I developed years ago. Essentially, one person plays the role of Mina's mom, and says something challenging or critical.
Mina plays herself and responds as skillfully as possible with the Five Secrets, acknowledging the other person's anger and expressing her own feelings as well.
We practiced responding to mom's statement, "You've always hated me." Matt played the role of mom and Mina gave a beautiful Five Secrets response. You'll enjoy hearing her response, and Matt's and Rhonda's helpful feedback, when you listen to the podcast.
Then Mina asked for help responding to another statement from her mom, who had also said:
All of the kids your age are angry, because you were neglected a lot of the time because of the war in Iran, and your dad and I were busy doing what we had to do to survive and avoid being arrested. All of my Iranian friends with children your age are experiencing the same thing.
Matt and Rhonda did more role plays with Mina, followed by excellent feedback on Mina's Five Secrets response. Again, I think you'll enjoy the role-playing and fine tuning when you listen to the podcast.
One of the obvious take-home messages from today's podcast is to use the Five Secrets of Effective Communication when you're feeling angry and talking to someone who's angry with you as week, As a reminder, these are the Five Secrets.
And to make it simple, you can think of talking with your EAR:
E = Empathy (listening with the Disarming Technique, Thought and Feeling Empathy, and Inquiry)
A = Assertiveness (sharing your feelings openly with "I Feel" Statements)
R = Respect (showing warmth and caring with Stroking)
However, here's the rub: People who are angry will usually NOT want to do this! When you're ticked of, you will almost always have a huge preference for expressing yourself with the Unhealthy Anger described above.
Matt urged me to publish my list of 36 reasons why this intense resistance to healthy communication. LINK HERE for the LIST
12 GOOD Reasons NOT to Empathize
12 GOOD Reasons NOT to Share your Feelings
12 GOOD Reasons NOT to Treat the Other Person with Respect.
So, as you can see, there's a lot more to skillful communication of anger than just learning the Five Secrets of Effective Communication, although that definitely requires tremendous dedication and practice. But motivation is the most important key to success or failure.
When you're upset with someone, you can ask yourself, "Do I want to communicate in a loving, or in a hostile way?"
The reward of love are enormous, but the seduction of hostility and lashing out is at least as powerful! This battle between the light and the dark is not new, but has been blazing for tens of thousands of years.
And, of course, the decision will be yours.
Thanks for listening today,
Mina, Rhonda, Matt, and David
She came up with an extremely impressive and long list! For example, her criticisms showed her high standards, her humility, her dedication to her work, her accountability, and much more. In addition, she'd achieved a great deal because of her relentless self-criticisms.
I asked her why in the world she'd want to accept herself, given all those positive characteristics
She decided NOT to accept herself, and was delighted with her decision. She said she felt profound relief!
An unusual, but awesome, path to acceptance! In other words, she ACCEPTED her "non-acceptance."
I hope you find today's podcast interesting and helpful. Of course, ultimately therapy is part science and part human relationship art. That's why Rhonda and I offer free weekly training groups for therapists who wish to develop their therapeutic skills. The groups are on zoom so therapists from around the world are welcome. Matt offers a consultation group (free to Stanford psychiatric residents) every other Tuesday for therapists who want help with difficult, challenging cases. To learn more, you'll find details and contact information at the end of the show notes.
When Therapy Doesn't Work--
And How to Get Unstuck
(for Therapists and Patients)
By David Burns, MD
Here's are some of the most common reasons why therapy might fail or appear to be stuck / without progress. Some of them will be of interest primarily to clinicians, while others will be of interest to clinicians and patients alike. And many of these reasons will also apply to individuals using the Feeling Good App who are stuck in their attempts to change the way they think and feel.
But what does "stuck" actually mean? The definition, of course, is subjective. I believe that a substantial or complete elimination of depression and anxiety can typically be achieved in five sessions with a skilled TEAM therapist. I use two-hour sessions, and can usually see dramatic change in a single session, although follow-ups may be needed for Relapse Prevention Training or other problems the patients might want help with.
In my experience, the treatment of relationship problems and habits and addictions usually takes much longer than the treatment of anxiety or depression. The techniques to treat relationship problems and habits and addictions actually work just as fast as the techniques to treat depression and anxiety, but the resistance can be far more intense. For example, someone may be ambivalent about leaving a troubled relationship or giving up a favored habit for many months or years before making a decision to move in a new direction.
And, of course, the treatment of biological problems like schizophrenia and bipolar I disorder will nearly always require a long term therapeutic relationship, often requiring medications in addition to therapy.
The problems and errors I've listed below are mostly correctable. And although there are many traps that therapists and patients fall into, the vast majority of therapeutic failure the patient's hidden 'resistance' to change and the therapist's lack of skill addressing it. This is true in clinical practice and in psychotherapy outcome studies, as well.
On the one hand, a great many patients will feel ambivalent about change. For example, a patient with low self-esteem may not want to stop being self-critical and accept themselves, as-is, but to have a better version of themselves, first. Or they may want to overcome their fears without facing them. Or they might want a better relationship but would want the other person to do the changing.
Unfortunately, most therapists lack the skills to address resistance and, in fact, often make it worse by trying to motivate the patient to change, rather than understand their hesitation to change and discuss it with them. This is one area where TEAM training has a great deal to offer, including over 30 skills therapists can learn to address motivation and resistance.
The following list of 37 reasons why therapy fails follows the structure of T, E, A, M.
Errors at or before the initial evaluation
Patient is just window shopping
Patient does not buy into the cognitive model
Incorrect conceptualization of type of problem, so you end up using the wrong techniques. To simplify things, I think of four conceptualizations:
Individual mood problem (depression or anxiety)
Relationship Problem
Habit / Addictions
"Non-problem": healthy negative feelings such as the grief you might feel when a love one dies
Patient is not in treatment out of choice. For example, a teenager might be brought in by parents to be "fixed," like bringing in your car to the local garage for a tune up, and you don't have an agenda with your patient. Or a parent might be court-ordered to go to therapy if he wants to have custody of his children.
Failure to ask patients to complete the Concept of Self-Help Memo, the How to Make Therapy Rewarding and Successful memo, and the Administrative Memo prior to the start of therapy. These memos fix a great many therapeutic problems that are likely to emerge later on, like homework non-compliance, premature termination, and policies about confidentiality, last minute cancelling of sessions, conflicts of interest (eg patient is seeking disability) and more. Most therapists ignore the use of these memos, only to pay a steep price later on.
Failure to mention the requirement for homework and similar issues the at initial contact with the patient.
Failure to explore the patient's motivation for treatment.
T = Testing
Diagnostic errors: not recognizing additional problems which patient may have in addition to the initial complaint, such as drug or substance abuse, psychosis, intense social anxiety, past trauma or abuse, or hidden problems the patient is ashamed to disclose. This is easily solvable by the use of my EASY Diagnostic System prior to your initial evaluation. It screens for 50 of the most common DSM "diagnoses" and only takes ten minutes or so out of a therapy session to review and assign the "Symptom Cluster Diagnoses."
Failure to use Brief Mood Survey before and after each session. This error makes the therapist blind to the severity or nature and severity of the patient's feelings, which cannot be accurately identified by a patient interview or therapy session. As a result, the therapist's understanding will not be accurate, and the therapist will not be to pinpoint the degree of change (or failure to change) during and between therapy sessions.
E = Empathy
Failure to ask patients to complete the Evaluation of Therapy Session after each session. As a result, it will not be possible for therapists to understand their level of empathy, helpfulness, and several other relationship dimensions critical to good therapy.
Failure to use the "What's My Grade" technique while empathizing with the patient.
Failure to receive training in the Five Secrets of Effective Communication and the three advanced communication techniques. These techniques are difficult to learn, requiring lots of practice and commitment, but can be invaluable in therapy and in the therapist's personal life.
A = Assessment of Resistance (also called Paradoxical Agenda Setting)
Failure to recognize and deal with Outcome Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
Failure to recognize and with Process Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
The "because" factor: I won't let go of my depression until "I've lost weight," or "I've found a loving partner," or "I've achieved something special," or "I've found a better job / career," or "I've achieved my goals at X." This is another type of Outcome Resistance.
M = Methods--errors using the Daily Mood Log
Patient "cannot" identify any Negative Thoughts
The way you worded your Negative Thought. The common errors include thoughts describing events or feelings, rhetorical questions, long rambling thoughts, or thoughts consisting of a few words or phrases, like "worthless."
No Recovery Circle / many need many techniques combined with the philosophy of "failing as fast as you can." This allows you to individualize the treatment for each patient. It is simply not true that there is one school of therapy or method (like meditation, mindfulness or daily exercise, etc.) that will be helpful, much less "the answer," for all patients!
The way you did the technique / incorrect use of technique. Many of the most powerful techniques, like Interpersonal Exposure, Externalization of Voices, Paradoxical Double Standard, Feared Fantasy, and many more require considerable sophistication and training. They can be fantastic when used skillfully, but they aren't easy to learn!
Trying to challenge your negative thoughts in your head / vs on paper or computer. This is associated with Process Resistance for depression—refusing to do the written homework, and it is exceptionally common.
Trying to challenge the negative thoughts of someone else or encouraging them to think more positively: won't work! In my first book, Feeling Good, I spelled out the warning that cognitive techniques are for you, and NOT for you to use on other people, including friends, family, and so forth. It is my impression that many people ignore this warning. When they discover that the person they are trying to "help" does take kindly to identify the cognitive distortions in their thoughts, both end up frustrated.
Failure to "get" the Acceptance Paradox / using too much self-defense in your positive thoughts, especially Technique when doing Externalization of Voices
Using the Acceptance Paradox in a defeatist, self-effacing way
Failure to include the Counter-Attack Technique when doing Externalization of Voices. This techniques is not always necessary, but can sometimes be the knock out blow for the patient's endless inner criticisms.
Not understanding the necessary and sufficient conditions for emotional change when challenging distorted thoughts.
Too much focus on cognitive / rational techniques when far more dynamic techniques are needed, such as the Experimental Technique (e.g. exposure) in treating anxiety or the Externalization of Voices or Hidden Emotion Techniques
Not recognizing that the patient's negative thoughts might be valid (I think that my partner is cheating on me) and trying to get your patient to challenge the "distortions" in the thoughts
Other therapist errors
Codependency: addiction to trying to "help" / cheer up the patient / solve some problem the patient has
Need to be "nice" and refusal to hold patients accountable
Narcissism: unwilling to be criticized, unwilling to fail, needing to stay in the expert role
Difficulties "getting" the patient's inner feelings, due to lack of skill with Five Secrets and the failure to use Empathy Scale
Difficulties forming a warm and vibrant therapeutic relationship, which can sometimes result from strong (and nearly always unexpressed) dislike of the patient
Commitment to a favored "school" of therapy / thinking you are superior to colleagues and have the one "correct" approach
Failure to use assessment tools with every patient at every session
Failure to make patients accountable for homework
Four types of reverse hypnosis: this is where the patient hypnotizes the therapist into believing things that simply aren't true.
Depression: the patient may really be hopeless or worthless
Anxiety: the patient is too fragile for exposure
Relationship problems: the patient is too fragile for / not yet ready for exposure
Habits / addictions: not making the patient accountable or assuming patient isn't yet "ready" to give up the addiction, or the patient needs to have emotional / relationship problems fixed first
Unrecognize, unaddressed conflicts with therapist that need to be addressed with Changing the Focus. This error often results from the therapist's fear of conflict or patient anger, and is usually accompanied by a failure to use the Evaluation of Therapy Session, which would send a loud signal to the therapist that something is wrong.
Failure to do Relapse Prevention Training prior to discharge.
Conceptualization errors. Failure to use or select the most effective therapeutic approach and techniques for the patient's problem. For example, the Daily Mood Log and Recovery Circle are great for depression and anxiety, although there will be some important differences in the choice of methods for depression vs. anxiety. For example, Exposure and the Hidden Emotion Technique are great for anxiety, but rarely useful for depression. The DML has only a secondary role in the treatment of relationship problems (the Relationship Journal is more direct and useful) or habits and addictions (the Triple Paradox and Habit and Addiction Log (HAL) are far more useful.
The therapist may be committed to a school of therapy, like Rogerian listening, without addressing resistance or using methods. Or therapist may believe that psychodynamic or psychoanalytic therapy, or ACT, or traditional Beckian cognitive therapy, will be the "answer" for everybody. The schools of therapy function much like cults, causing feelings of competitiveness (our guru is better than your guru) and sharply limiting the critical thinking and narrowing the consciousness of the faithful "followers."
Conflicts of interest. The therapist may subconsciously want to keep the patient in a long-term "talking" relationship due to emotional or financial needs.
The therapist may have been taught that therapeutic change is inherently slow, requiring many years or more. This belief will always function as a self-fulfilling prophecy.
Thanks for listening!
Matt, Rhonda, and David
Prior to the study, Elise trained the therapists in a weekend TEAM-CBT "boot camp," along with two hours per week of group training and 1 hour per week of individual consultation/supervision. My own view (David) is that learning TEAM-CBT is very challenging, requiring a minimum of one to two years of intensive training. However, the fact that therapists can get excellent results with a relatively small amount of training is encouraging.
One of the key components of TEAM is T = Testing. We test every patient at the start and end of every therapy session, asking, "How are you feeling right now?" This provides the therapist with a kind of emotional X-ray machine that allows you to see the precise degree of improvement, or lack of improvement, at every session in multiple dimensions. Therapists can use the information to fine-tune the treatment on an ongoing basis. Many other research studies have demonstrated that session by session monitoring of symptoms, consisting of measurement and feedback, significantly improves outcomes in mental health treatment. (please contact Elise for a list of research studies you can look up online).
Research indicates that roughly half of adolescents and young adults will suffer from some mental health problem. Therefore, it is essential to provide accessible, effective treatments to prevent the development of long-term mental health problems.
We salute Elise for going the extra mile to evaluate the effectiveness of the treatment and to identify the therapists who get the best results. This requires courage and also allows our field to move forward based on real data rather than subjective impressions.
Dr. Munoz's fascinating work adds to the body of evidence supporting the effectiveness of TEAM-CBT. and also sets a commendable example of dedication to improving mental health outcomes through research and ongoing professional development in a private practice environment. The famous and idealistic "Boulder Model" of the "scientist / practitioner" is highly touted in graduate school graining programs for mental health practitioners, but is rarely practiced in real life. Dr. Munoz shows that the integration of science with clinical treatment in community settings is not only possible, but extremely important.
Dr. Munoz's research also indicates that the TEAM model offers an exciting path to improved mental health for teens and young adults!
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