358: Ask David - Depression, schizophrenia, and more!

Are the "physical" symptoms of depression specific or non-specific? How do you treat schizophrenia with TEAM? Why don’t more shrinks help themselves? Healthy vs unhealthy negative feelings-- what's the difference? Questions answered in this podcast: 1. Laura asks: Why don’t you include the physical symptoms of depression in your assessment tests? 2. Fred asks: How would you use TEAM-CBT to treat individuals with schizophrenia? 3. Author not known: Why don’t the therapists you treat with TEAM treat themselves using self-help techniques? 4. Zach: How does David understand the difference between healthy and unhealthy emotions? Is there any overlap between EFT (Emotionally Focused Therapy) and David’s TEAM-CBT?   The following are David’s written responses to these questions. However, in the podcast, Rhonda and David discuss them, and their answers together may differ or enlarge on the material below. Also, in some cases, the written answers contain additional information not included in the live podcast. 1. Laura asks: Why don’t you include the physical symptoms of depression in your assessment tests? Author: Laura asks a question about post #248: “David and Rhonda Answer Your Questions about Exercise, Empathy, Euphoria, Exposure, Psychodynamic Therapy, and more!” Comment: Fabulous, David. Bless you. Have you done a show on assessments? I'll be honest about my confusion. Some of the measures that you have developed almost seem too simple to be accurate. For example, the depression test isn't sensitive to any of the physical manifestations of the illness. Anyway, I was just curious about that. David's Reply Thanks, Laura! Good questions! First, the so-called physical symptoms of depression are non-specific and not uniquely associated with depression. Only the core emotional symptoms are good indicators of depression: feeling down, hopeless, worthless, unmotivated, and not enjoying life. If you want to measure physical symptoms, they won’t give you much information about depression, but at least they need to be worded correctly, which they aren’t in most assessment tols. For example, you can measure weight gain, OR weight loss, in single and separate items, but not in the same item. But if you go to a mall and ask how many people have had weight gain, you’ll probably find that more than 50% report weight gain, but this is rarely due to depression, rather it is due to overeating! Similarly, a significant fraction will say yes to a question about weight loss, and in the vast majority of cases this will be due to dieting, not depression. Similarly with the other poorly thought out physical symptoms, like trouble sleeping. The reliability of my depression measures has typically been .95 or better, as compared with measures like the Beck or PHQ9 that have only .78 to .80 reliability coefficients (called “coefficient alpha.”) I have observed a phenomenal lack of critical thinking behind most current psychological tests for depression, anxiety, and other variables of interest to clinicians and researchers. You also asked about apps for anxiety, like OCD, as opposed to depression. The Feeling Good App causes rapid and significant reductions in, not one, but seven categories of negative feelings, including feelings of depression, anxiety, guilty/shame, inadequacy, loneliness, hopelessness and anger. Thanks so much! Finally, I have to confess my bias toward trying hard to make things simple, so we can all understand what we’re talking about! When things are overly complicated or hard to “get,” I usually feel fairly suspicious about the person who is trying to “teach.” In college I always had the policy that if I can’t understand what the teacher is trying to say, the teacher has a problem! My thinking today is pretty similar! I’ve always appreciated teachers who keep things simple for us mere mortals who appreciate having things explained clearly and in everyday words. Best, david 2. Fred asks: How would you use TEAM-CBT to treat individuals with schizophrenia? Hi David, Do you have any schizophrenia thought experiments? Most of my clients struggle with voices. I tell them there is always a good voice, which I believe is the Holy Spirit woven into every person at birth. I also tell them to welcome the voices and listen for what they need, because the voices need to be welcomed back into the body - the "family" - of the person, according to Internal Family Systems. I welcome your thoughts. I am not a therapist so anything I say or do needs to fit my role as a recovery coach. Fred South Bend, Indiana David’s Reply. Thanks, Fred, great question. I have treated many individuals with schizophrenia, but they have rarely or never asked for help with the voices they hear. I like to set the agenda for each patient, finding out what they specifically want help with. And individuals with schizophrenia respond very well to TEM-CBT, both the individual treatment model for depression and anxiety, as well as the interpersonal model for relationship problems. An experience early in my career highlighted the folly of trying to challenge the delusions of individuals with schizophrenia. A young man, a new patient, seemed uncomfortable and when I inquired, he explained that the receptionist, Lucretia, was listening in because she could “hear” our thoughts and our conversation. I explained that Lucretia did not have much money, and that if he wanted we could do an experiment to test his belief. I put a $20 bill on the desk and said that if Lucretia knocked and came into the office, she could have the money. So I did that and Lucretia did not knock on the door or appear in the office. I asked the young man what he concluded from our “experiment.” He said that she “knew” it was an experiment since she could “hear” our thoughts, and didn’t come in because she didn’t want us to know she was “listening in” on our dialogue! That’s an excellent example of what happens when the shrink tries to set the agenda, as opposed to helping patients with what THEY want help with! In my experience, you can help individuals with schizophrenia with self-esteem, anxiety, and relationship problems with psychotherapy, and they do feel and function somewhat better, but they still, sadly, have schizophrenia. This is my thinking only, and others may differ. I know that Aaron Beck and many of his followers have done research studies claiming they can help schizophrenia with traditional CBT. I am skeptical, but have not read those studies or evaluated the data with a critical eye! So who knows? Maybe they have some decent results. Best, david 3. Author not known asks: Why don’t the therapists you treat with TEAM treat themselves using self-help techniques? Why can't the TEAM-CBT therapists who have done personal work with you on the podcasts do that work themselves in self-help mode?" They know all the techniques and have all the tools. With no qualifications, I have my own theory on that, which is actually based on TEAM. I don't know how to give myself the level of E=empathy required to move on to the next stage. So I guess my question could be reworded as "Is it possible to give yourself sufficient empathy in self-help mode?" or "Are there techniques or tools you can use to give yourself empathy in self-help mode?" David’s Response Thanks, cool question! Blind spot, especially in relationship problems To get experience in the “patient” role Sometimes, we all need a little help from a friend, and that can sometimes be vastly faster than trying to do everything on your own. But in terms of empathy, I believe you CAN treat yourself with empathy, warmth, and compassion, and that is actually one of the keys to recovery, whether or not you’re in treatment with a shrink!   4. How does David understand the difference between healthy and unhealthy emotions? Is there any overlap between EFT (Emotionally Focused Therapy) and David’s TEAM-CBT? Hi Dr. David and Dr. Rhonda, I have a question if you have a chance, and maybe this is better for an Ask David. David talks about healthy emotions sometimes, and this feels like a faint through-line to EFT model. Does David have a framework for understanding healthy emotions or emotional needs? When a client is grieving, David encourages the tears to flow and notes it’s an expression of how much the client valued something. David also demonstrates what EFT would call protective anger, when using the counterattack method, “I’m tired of listening to your BS.” And lastly David demonstrates what EFT labels self-compassion while using the acceptance paradox and 5 secrets responses to critical thoughts. Thanks, Zach David’s Response Thanks for the excellent question. I have to confess that I don’t know much about EFT, but I think there’s a lot of overlap in different “therapies” since many people “borrow” ideas from other experts, and get so excited about them that they call them their own, and simply give them a new name, claiming to have something entirely new. And it sounds like there are some definitely similarities between my TEAM-CBT and what is called “EFT.” If this is true, I’m certain I didn’t do the “borrowing” since I don’t attend to the work of others in the field, for better or worse. At any rate, I have always taught my students that each negative feeling has a healthy and an unhealthy version, as you can see in the following table. The main difference is that the healthy version results from valid negative thoughts, and the unhealthy version results from distorted negative thoughts. However, in the past 25 years or so, I’ve taken a new look at so-called “unhealthy negative feelings” in my TEAM-CBT. There, we reframe the negative feelings, showing what’s beautiful and awesome about each one. IN other words, we genuinely try to sell the patient on NOT changing. Paradoxically, this approach, which I call Positive Reframing, seems to melt the patient’s resistance to change, and that nearly always opens the door to the possibility of rapid change. Healthy vs Unhealthy Negative Feelings Healthy Version Unhealthy Version Sadness, grief when you’ve lost someone or something you loved Depression, worthlessness, hopelessness Healthy fear when you’re in danger Anxiety, nervousness, worry, and panic, and phobias Healthy remorse when you’ve hurt someone you love Neurotic guilt, blaming yourself for something you’re not entirely, or at all, responsible for Healthy inadequacy and awareness of your very real shortcomings and limitations Worthlessness, inferiority Missing someone you love Desperate loneliness, abandonment, feeling unlovable Discouragement when you fail or when things don’t work you Hopelessness Sharing your anger in the spirit of love and respect Unhealthy anger, aggression, acting out your anger with the goal of hurting or upsetting the other person, or getting back at them   Thanks so much for listening today! Warmly, Rhonda and David