Anger, Part 1 You suck! Screw you! 

 Jay asks: Are you EVER going to do a podcast on anger?

Dr. Burns,

Also are you EVER going to do a podcast on Anger with Rhonda and Matt? You have done many podcasts on depression, anxiety, interpersonal relationships YET there is not one podcast addressing anger.

Given the world we live in right now maybe it's time to address Anger from a TEAM-CBT perspective and give it the attention you have given anxiety and depression.

All the Best,

Jay

In today’s podcast, Rhonda and David address this important but neglected topic that is perhaps more important than ever in today’s angry and violent world.

David began by pointing out that in the feeling Good App, anger improved as much as six other negative feeling clusters, with fairly dramatic reductions in just a few days. This was completely unexpected and exciting, and has been replicated in numerous beta tests.

Maybe there IS a small glimmer of hope in this troubled, angry world!

David pointed out that anger is addictive

• Depression is not addictive because in depression you are thinking I am no good, and you have negative and painful distortions about yourself.
• Anger, in contrast, is addictive because you are directing the distortions at other people, telling yourself that they are no good, and they will never change, and so forth. These distortions directed at others trigger feelings of moral superiority and those feelings are intensely addictive.

Any group that is at war tends to feel morally superior and sees the “other” as scum, the enemy, and these distortions give you justification for hurting and killing them and feeling good about what you are doing.

What makes the treatment of anger fairly challenging is that most angry people are not looking for help.

• Distortions directed at others are key in conflicts with friends and loved ones as well as racial and religious hatred, and war and violence.

How do you treat a patient who is angry?

You always start with T = Testing. David’s research on therapist accuracy indicates that therapist accuracy is recognizing anger in their patients is incredibly poor. If you want to assess and deal with patient anger,  the Brief Mood Survey at the start and end of every session can be invaluable, and the Evaluation of Therapy session at the end can also help.

E = Empathy comes next. However, empathizing with someone who is angry can be challenging because they are often provocative, or want the therapist to align with them in their belief that the person they are angry with is to blame. We want the client to feel accepted, and have a warm relationship with their therapist so the therapist can easily get sucked into the patient’s blaming mind-set.

David calls this “reverse hypnosis,” and this can sabotage the chance for effective treatment.

Empathy can be challenging if the anger is directed at the therapist, or if the client is saying they are so angry they want to hurt someone. That can be ethically challenging because of the Tarasoff duties to warn the victim and notify the police. That is tough because the client can get upset with the therapist.

A = Assessment of Resistance comes next, starting with the Straightforward or Paradoxical Invitation. With someone who is angry, we nearly always use the Paradoxical Invitation. Here’s an example:

You have been talking about person X, and I can see you are pretty fed up with her. You said, you’ve tried everything and nothing works, and she won’t change.

I have a lot of tools that could be very helpful if you want to do work on the relationship and turn it around. But I did not hear you saying that, and I am assuming that is NOT what you want.

Don’t get me wrong, if you want to work on this relationship, I’d love to do that so you can develop a closer relationship, but at the same time, there’s no law that says you have to get along or like everyone.

I’m assuming you DON’T want to work on your relationship with X, but want to make sure I’m understanding you. Am I reading your right?

M = Methods

Two invaluable tools are the Straightforward or Paradoxical Cost-Benefit Analysis for anger, blame, or for the relationship.

• Anger CBA

What are the Advantages and Disadvantages of feeling intense anger at the other person.

• Blame CBA

What are the Advantages and Disadvantages of blaming the other person for the problem.

• Relationship CBA

What are the advantages and disadvantages of having a relationship with this person?

David provided this example of a Paradoxical Anger CBA. A man was hospitalized involuntarily in Philadelphia who was brought in by the police. He was working at Savings and Loan company with disgruntled customers. A customer came in who was whining and complaining. The patient was a large and powerful man, and he got so angry at the whining customer that he picked him up and threw him against the wall. They called the police who arrested the man, but he seemed psychotic, or in a manic state, so they brought him, instead, to the hospital.

He was sent to Dr. Burns’ cognitive therapy group shortly after he was admitted to the locked unit, and defiantly stated at the start of the group that he was sent here for “anger management!”

Dr. Burns said he never tried to “manage” anger, and instead suggested that they could list some of the advantages and benefits of his anger with the help of the group, and also list what his outburst showed about him that was positive and awesome.

Together, the man and the group listed more than a dozen positives on the white board, including:

• Truth was on his side
• People are too entitled, making demands on other people.
• The patient has a strong value system and was willing to put everything on the line for his beliefs
• He was willing to show his true feelings.
• And many more.

At the end of the group, Dr. Burns reviewed all the really good reasons for his angry outburst, and said he did not see any reason for him to change or to give up his anger.

The patient said he totally agreed.

At the start of the group, the man’s anger had been 100 on a scale from 0 to 100.

Dr. Burns asked him how angry he was now, and the patient said zero!

The dramatic change came about because of the Paradoxical Cost-Benefit Analysis.

That strategy can be tremendously helpful when you are working with an angry patient. You won’t get any buy-in by trying to convince the patient to manage their anger. David was actually siding with the patient’s resistance, and the patient could sense that David actually liked and admired him. This can form the basis of a trusting and productive therapeutic relationship.

But many therapists are afraid of this type of paradoxical strategy and reluctant to let go of their addictions to “helping,” in spite of the high failure rate with that approach.

You and your patient have to be on the same team if you want to use tools for effective change.

If the patient is motivated and wants help, you can work on the inner dialogue or the outer dialogue, or both. The inner dialogue is the way you are thinking about the situation, and the outer dialogue is the way you are communicating with the other person.

Anger always results from your inner dialogue—your thoughts about the other person, and those thoughts will nearly always be distorted. The Daily Mood Log can be very helpful at eliciting and challenging those distortions.

The focus with the DML is on the inner dialogue, which will nearly always include a rich mix of positive and negative distortions including

• All-or-Nothing Thinking: Seeing the other person as a total loser.
• Overgeneralization: Generalizing from a negative moment or characteristic and seeing them in an entirely negative way based on this one negative habit, or feature they have. We all have features that are not likeable. WE generalize from the person’s actions to their SELF. You think the person is bad.
• Mental Filtering: Noticing and focusing and all the things about the other person that you find offensive.
• Discounting the Positive: Ignoring the person’s positive qualities, or telling yourself that they’re fake or don’t count.
• Mind-Reading You imagine the other person’s motives. When you feel angry you nearly always attribute malignant motives to them. Sometimes there are some truths and other times there are no truths.
• Fortune Telling: Telling yourself that the other person will never change.
• Magnification and Minimization: Exaggerating the other person’s “badness” and minimizing their good qualities.
• Emotional Reasoning: I feel angry at you, therefore, you are scum and I want to get back at you. You must be very bad.
• Labeling: We label someone as a terrorist as if the person’s entire person can be reduced to a label. There are terrorist actions but…a terrorist can be considered a freedom fighter by someone else.
• Shoulds He shouldn’t be like that. She shouldn’t have said that.
• Other Blame: Telling yourself the other person is to blame and that you are the innocent victim or their badness.

Once you’ve identified the distortions in a thought, you can use any of the more than 100 M = Methods I’ve developed to challenge it, such as

• Explain the Distortions
• Externalization of Voices with Acceptance Paradox, Self-Defense, and Counter-Attack Technique
• Semantic Technique for Should Statements
• Forced Empathy
• Positive Reframing of the other persons feelings and behaviors
• Individual / Interpersonal Downward Arrow
• Examine the Evidence
• How Many Minutes Technique
• Paradoxical Double Standard
• Many more

If our listeners (meaning you) want a Part 2 podcast on anger, we can describe helping the patient with the Outer dialogue, which is how you actually communicate with the person you’re feeling angry with. This was not discussed in great detail on today’s podcast, but we just touched on a couple points.

The first topic is the difference between Attacking with your anger vs Sharing your anger. It’s not bad to be angry, but it is how you share and express your anger that’s most important. There’s a huge difference between healthy and unhealthy anger.

If your goal is to hurt and demean the other person, it’s unhealthy, destructive anger. You may want to get back at the other person, hurt them, or put them down.

Healthy anger is very different. Martin Buber, a 20th Century Jewish theologian, distinguished an “I-It” vis and “I-thou” relationship. Buddhist philosophy is similar. They say that the cause of all evil is the belief that you are separate from an external reality, so you see other person or group you’re angry with as the “enemy” or the “it,” that is separate from you, and “different,” as opposed to the “thou.” Then you can rationalizing using, hurting, or even killing them in order to advance your own interests, or so you think!

Sharing your anger involves letting the person know directly and openly and respectfully that you are angry with them because of something they DID, and not because of something they ARE. The goal of healthy anger is to develop a deeper and more loving (or satisfying) relationship with the other person.

Healthy anger is the decision you make to share your anger, rather than to attack with your anger out of vengeance, frustration or rage. Healthy anger is not the choice that most people seem to make, since unhealthy anger gives feelings of vengeance and moral superiority.

A Part 2 podcast on anger might include

Forced Empathy

Relationship Journal (RJ

1. What did the other person say?
2. What did you say next?
3. EAR Checklist / Bad Communication Checklist
4. Consequences
5. Five Secrets of Effective Communication
6. List of 12 GOOD Reasons NOT to

• E = Empathize using Listening Skills
• A = Assertiveness—Sharing vs attacking with your anger
• R = Convey Respect

The RJ Requires insight, communication skill, and the painful death of the “self”

Examples:

• Why does my husband constantly criticize me? Why are men so critical?
• Why does my wife treat me like crap?
• Why can’t men express their feelings?

Thanks for listening!

Rhonda, and David

Ask David The fear of ghosts; the truth about nutritional supplements; the fear of fear; how does anxiety treatment work? And more. 

Today, David and Rhonda answer six cool questions submitted by podcast listeners like you!

1. Joseph asks: How would you use exposure to confront your fear of ghosts?
2. Salim asks: What herbs and supplements will help me become more zen and relaxed?
3. Peter asks: How do you stop fearing the fear and discomfort of anxiety?
4. Jillian asks: How does cognitive therapy work to help reduce anxiety?
5. Sanjay asks: How do you give up wants, needs, and desires?
6. Dana asks for help with the Disarming Technique.

In the following, David’s reply was David’s email response to the person prior to the podcast, just suggesting some directions we might take on the podcast.

The Rhonda comments were based on notes she took during the live podcast.

For the full answers, make sure you listen to the podcast!

Joseph asks: How would you use exposure to confront your fear of ghosts?

Hi David and Rhonda,

Thank you again for your wonderful replies and the amazing podcast.

If you would humor me, I have another question -- I know David talked about exposure therapy in overcoming fears, but I wonder how this could apply to some fears like the fear of ghosts where it is caused by an over-active imagination (in which case, what should one be exposed to?)

Regards

Joseph

 David’s reply

Cognitive flooding would be one approach.

Will give details on podcast. Thanks!

David

 Rhonda’s notes

Find out what is happening in the person’s life, and treat that specific problem.

Maybe someone developed a fear of ghosts after the death of a loved one, so the idea of being around death or dead things may also cause intense anxiety. Going to a cemetery may be part of their exposure.

Other examples of exposure for overcoming the fear of ghosts could be:

• Approaching a scary, abandoned house
• Watching a scary movie about ghosts

Fear of darkness may accompany fear of ghosts so staying in the dark may be part of your exposure.

Fear of sleeping alone may also accompany fear of ghosts so sleeping alone in your home may be part of your exposure.

Salim asks: What herbs and supplements will help me become more zen and relaxed?

Hello Mr. David D Burns,

I want to tell you that i loved "Feeling Good", your book helped me a lot in improving my life, I have a question, can you recommend herbs or supplements that help me be more Zen and more relaxed? I would be eternally grateful. 🙏.

Thank you so much.

Salim

David’s reply.

Hi Salim, I don’t believe in the efficacy of herbs etc. except for their placebo effect. However, the written exercises in the book, like writing down your negative thoughts, can help a lot. You’ll find lots of free resources on my website.

At the same time, the use of herbs and supplements is kind of a “cult” thing, and as you know, cult followers don’t like to have their views challenged!

And our field of mental health is, to my way of thinking, a mine field of cults!

Thanks!

David Burns, MD

Peter asks: How do you stop fearing the fear and discomfort of anxiety?

David’s Reply

Exposure!

However, I don’t “throw” methods at symptoms, but rather work systematically with the TEAM approach, and always incorporate four models in my work with every anxious patient: The cognitive, motivational, exposure, and hidden emotion models.

You can learn more about this in the free anxiety class on my website! You’ll find it right on the homepage for www.feelinggood.com.

Thanks, David

Rhonda added

You don’t stop fearing the fear and discomfort of anxiety before doing an exposure. You do all of the work necessary using the three other models of treating anxiety (see the anxiety question directly below this one) and then you dive into the exposure, embracing the discomfort until it’s reduced or gone.

Jillian asks: How does cognitive therapy work to help reduce anxiety?

Hi David,

I have questions about how using your methods helps people. I’m someone that uses an acceptance method for my anxiety with success and throughout this journey I’ve really been able to catch my mind trying to focus on the negative and trying to spiral into ruminating.

With negative thoughts, how do your methods actually help, does it start to change the way you think or make you automatically think in more of a positive way (eventually without having to “challenge” each thought?) Do you have to believe the challenges to your negative thoughts in order for it to work? What if you believe the original negative thoughts more? Do you actually start viewing things in a more positive light?

Kinds regards,

Jillian

David’s Reply

Hi Jillian,

I can make this an Ask David question for my weekly podcast if you like. You can find the answers, too, in the free anxiety class on my website and in my book, When Panic Attacks. Thanks1

Essentially, and I’ve covered this in detail in a podcast, cognitive techniques can be very helpful in reducing anxiety, but they are only one strategy among many. I actually use four models in treating anxiety: the Motivational Model, the Cognitive Model, the Behavioral (Exposure) Model, and the Hidden Emotion Model. You can learn more about them in Podcasts #22-28. You can find links here: https://feelinggood.com/list-of-feeling-good-podcasts/

I use all four models with every anxious individual I treat.

The Acceptance Paradox is a small but important part of the Cognitive Model.

Positive Thoughts have to be 100% true to be effective, but that does not mean they will be effective. They also have to radically reduce your belief in the negative thoughts triggering your anxiety.

If you still believe your negative thoughts, you need to try a different method to challenge them. I have developed 125 or more methods for challenging negative thoughts, since each person is a bit different!

Thanks!

D

Rhonda’s comments

We do not treat a diagnosis with a formulaic process. We treat a human being, one specific event at a time. Empathy is absolutely necessary for the treatment.

Here are David’s Four Models for treating anxiety:

1. Motivational Model. You need to address the Outcome & Process Resistance with every anxious patient before trying any other methods.

• Outcome Resistance. Reasons clients may not want the change/outcome they are asking for. Or to put this in simple words, anxious patients may not want to let go of their anxiety, fearing something bad will happen. You can use the WHAT IF technique to get to their outcome resistance. What are they the most afraid of? What’s the worst that might happen?
• Process Resistance. What will I have to do that I don’t want to do?

Exposure. No one wants to do exposure. You may also have to feel feelings that you do not want to feel. Feel intense emotions instead of binging, for example.

1. Cognitive Model. Pick a specific moment you were anxious about a thought. Go through the DML, what is going on with your patient? The positive thought needs to be 100% true, and it must drastically lower the belief in the NT to be effective.
2. Exposure and Response Prevention Model. Exposure is necessary and often helpful, both gradual exposure and flooding.
3. Hidden Emotion Model. Nearly all anxious patients tend to be exceptionally nice people because people who are prone to anxiety tend to avoid conflicts and negative feelings. (Wanting something you are not supposed to want, or feeling anger). These feelings are swept under the rug, and they come out indirectly, as some type of anxiety.

Sanjay asks: How do you give up wants, needs, and desires?

Hello David, Rhonda, and Fabrice,

It was really nice to meet Fabrice after a long gap. The topic Fabrice has started is very special of Should , Want and Need. I have heard about this topic in bits and pieces by you in many podcasts and also in your set of 4 podcast of self-deaths.

I kept thinking a lot about this beautiful concept of Want versus Need. And if we are able to learn technique to balance between Want & Need ,our lives will become happier and more stress-free.

Buddhist teachings say that Desire is the cause of suffering, so they want us to achieve a state with zero desires, which is Nirvana.

Also, the Holy book of Hinduism Geeta says further that if the purpose of our desires are to fulfill a duty or to help someone, only in these two cases will desires be good and bring happiness to the person. So, desire to eat a Mango will not fall in any of the two😄

But the penultimate question is that if we don’t have desires, life will be very dull and boring. As you had mentioned in podcast number 348 with Dr. Tom Gedman that unless one is in a very very positive state (which is rare like Buddha himself was) then only you can remain in a state of zero feeling otherwise you are bound to fall down and will lead to a very fast relapse . I also agree that zero feelings or Zero desires state will ultimately lead people into depression therefore I feel the best way is to do positive-reframing of Need and dial it down to Want. So that we get the advantages of desires and leave the disadvantages of it .

As you have mentioned a number of times that FEELING GOOD APP is a very high priority for you but you try to keep it as your “want” and try not to enter this desire in the NEED zone.

Balancing desires on the border between Need and Want is quite challenging I request that please do a podcast for discussing as how to keep desires in check till want and if possible please develop a self-assessment questionnaire in a podcast with Matt May and Rhonda ,sounds i feel this is a valuable topic for exploration. It can provide listeners with tools and insights to strike a balance between fulfilling their desires for happiness and well-being without becoming enslaved by them.

I hope my message is clear and I am eagerly looking forward to the discussions amongst yourself.

Warm regards, Sanjay

New Delhi , India

David’s Reply. We can discuss this on a podcast, and I can tell you the story of a woman who attended a workshop I gave in San Antonio. She was raised as a Buddhist, but her family gave up Buddhism because her mother felt she’d “failed” at giving up wants and needs and desires.

Rhonda added these definitions:

1. Wants are personal preferences for things or experiences.
2. Needs are essential requirements for survival and well-being.
3. Desires are strong longings or aspirations that go beyond basic needs and contribute to a person's happiness and fulfillment.
4. Shoulds are when we scold ourselves because we did or did not do something.

Dana asks for help with the Disarming Technique.

Dear David,

I would like to request that you, Rhonda, and Matt show your listeners how disarming practice would sound with the following statements.

• Are you going to start that again? Or don’t start that again!
• Why are you back peddling again?
• You just want to rest on your laurels.
• Why are you doing this to me again?
• You’re going back on your word.

I feel like when my flight response is in mode I cannot think of how to respond to targeted questions especially. I feel so inferior. Please think of any others you can and add to these to help.

Thank you so much!!!!

Dana

 David’s reply.

Thanks, Dana, We might include these on an Ask David.

It might help, too, if you could provide a brief context for these statements, and what, exactly, you typically say next.

That way, we might be able to point out your errors as well, if you are interested in learning how you might trigger these statements.

Of course, most folks don't want that, preferring to blame. But it can be empowering, at least for the brave!

David

Rhonda described one of the responses we modeled on the podcast.

• Are you going to start that again? Or don’t start that again!

David’s A+++ reply (according to Rhonda)

Ouch, I’m feeling zapped right now, and you’re right. I am starting up on something that’s been very annoying to you. I think it was aggressive on my part. I have to plead guilty as accused.

I love you to death. When we go round and round it is painful for me, too. Clearly, I am to blame for that right now. I am ready to listen.

Maybe you can tell me what it is like for you when I start preaching again and we go round and round. It is clearly disrespectful.

I want to listen. You may be angry, frustrated, and pissed off. Can you tell me what this has been like for you and how you’re feeling right now?

At the end of our answer on the podcast, David added:

Dana, will you please take one of the examples you sent us, give us a context or a few details, and we will illustrate better disarming responses on a future podcast.

Will you also please use the Relationship Journal, and make your own attempt at a 5-Secrets response that we could evaluate and make suggestions on a future podcast?

Thanks for listening!

Rhonda, and David

369 The Invisible Racism We All Deny, Featuring Drs. Manuel Sierra and Matthew May

Today we’re joined by Drs. Manuel Sierra and Matthew May on the sensitive topic of racism.

Manuel Sierra MD is a child and adolescent psychiatrist practicing in Idaho, one of the places where he grew up (he also spent time in Oregon). He was a classmate of Matt May during his residency training days at Stanford, and they remain close friends today.

Rhonda begins today’s podcast with this mail we received from Guillermo, one of our favorite podcast fans:

Guillermo asks: How do you respond to family or friends who make racist comments?

Hello, Dr Burns

Not sure if you have addressed this in any of the podcasts (I don’t recall it being a topic) but:

I was recently in a group chat with some cousins, and I read some really disappointing racist comments about a particular group. Many people ignored it (as I did) and a couple AGREED with the comments.

How can we balance not judging not just any people but our longtime friends and family about overtly racist actions/comments and the thinking that it is not the event but our thoughts that create our emotions?

I don’t care about “judging them” (in the sense that I don’t think it is my place to “change” their views) but just hearing/reading comments like this bothers me when they come from people close to me.

When I see it on tv or the internet, I don’t get affected because I feel it is beyond my control.

I don’t believe they will change their views so do I just remove them from my life? I apologize, the topic is too wide, but I’ve been thinking about this.

Sincerely grateful for all you do,

Guillermo

Manuel kicked off our answer to Guillermo by saying that he has been personally familiar with racism within families and communities, and says that he and Matt have talked about this topic “a lot.” He explained that:

Although I am proud of my Mexican-American heritage, I was born and grew up in Oregon and Idaho, where I’m currently practicing. I encountered considerable racial bias when I was a kid, and later in life as well. I clearly cannot speak for all Mexican-American people, I can only speak for myself and what I’ve personally experienced, and I am extremely aware of how difficult the current times are.

My grandparents didn’t teach my mom Spanish. She was a single mom, and we lived in a small town in Idaho. I also have family through marriage who live on Native American lands.

In grade school I began hearing jokes about Mexican Americans, and this was very awkward, painful, for me. I also got ridiculed for not speaking Spanish.  Even my grandfather asked me, “why aren’t you speaking Spanish?” There were also gangs where the racial bias got worse and frequently turned violent.

After learning more about Manuel’s experiences, we modeled various ways of talking to a friend or family member who has made hurtful racist comments. Manuel cautioned that it might be best to do provide the feedback individually, and not in public, so as not to shame the person. In addition, this can reduce the chance for social posturing and responding in an adversarial way.

Matt agreed and emphasized the importance of combining your “I Feel” Statement with Stroking. For example, you might say something like this, assuming the racial slur comment came from a relative or person you like,

Jim, as you know, you’re one of my favorite people, but I want you to know that when you said X, Y and Z, it really upset me, because it sounded like a put down to people who are (Mexican, Jewish, Moslem, gay, or whatever).

I (David) like this approach because it sounds respectful and direct, but not judgmental or condemning. Rhonda modeled an excellent alternative response which included this type of add-on: “And I’m going to request that you not say that again in my presence. “

I (David) would prefer not to add the directive statement at the end, which could, in theory, rankle some individuals with coercion sensitivity, because it might sound scolding. However, that’s just my take on it, and it’s not some kind of gospel truth. If you want to push your assertiveness and stick up for yourself, it might be effective, and was effective recently for Rhonda because the relative she said this to stopped making similar racial comments in her presence.

I would suggest ending any kind of response to the person who made a racial slur with Inquiry, asking them about their racial feelings as well as the fact that you are criticizing them. Do they feel hurt, angry, anxious, or put down? You might also ask something along these lines--Have they always had negative feelings about this or that racial or religious group?

Manuel described an experience in medical school when an attending doctor was supervising a group of medical students in how to do a particular medical procedure quickly, and said this to him, “You can be like a Mexican jumping bean!”

Then Manuel asked himself, “Should I say something?” Which of course incurs the risk of retaliation from an authority figure in a position of power.

Manuel mentioned that just because you’re working in a prestigious medical setting, this does not protect you from racial slurs. He described hearing people comment on how he and several Mexican-American classmates probably got into medical school because of their ethnicity, implying they weren’t sufficiently intelligent or on par  with their classmates.

He also mentioned an incident during his internship when he checked in on a patient wearing his white lab coat with stethoscope around his neck, and the patient asked him if he was there to pick up the trash and could he please get the doctor.  Manuel humbly replied that he could pick up the trash, and he was the doctor.

I asked Manuel how he felt when hearing these types of belittling and patronizing racist comments. He said that he felt annoyed, embarrassed, angry, put down, anxious, and alone.

He described one of his best friends growing up who was white. However, this fellow grew up poor as well, so they easily formed bond because they’d had similar class-based experiences. His friend sometimes lived in all-black neighborhoods and had also felt out of place at times, not accepted, and targeted.

I asked Manuel how he felt describing these intensely personal experiences on the podcast today, knowing so many people would be listening. He said, “It’s anxiety-provoking. My mouth is dry, my heart is racing, and I’m afraid I’ll sound like an idiot!”

We discussed the differences between being unintentionally or intentionally offensive with racist comments, and also mentioned the related topic of bullying which, of course, is intentionally hurtful. Manuel said that an example might be calling me names or saying terrible things about my mother, or making threats to hurt your family, or your mom. Often the bully is trying to get you to fight, so you’d be beaten up. The bully’s goal is to humiliate you in front of others and make you feel bad about yourself.

Manuel introduced us to some of the approaches he uses when working with kids who are bullied. I’d like to hear more on this topic but we were running out of time. We could address bullying on a future podcast with the same crew, since Manuel and Matt both have a lot to offer on that sensitive and exceptionally challenging topic. Let us know if you’re interested in hearing more.

The response to bullying has to have two dimensions. First, your thoughts, and not the bully’s statements, create all of your moods. So, you can use the Daily Mood Log to record and modify your inner dialogue. The goal would be to support yourself and not buy into the notion that you are somehow “less than” or a loser or coward just because someone is trying to bully and exploit you in a sadistic fashion.

The cognitive work is based on the idea that ultimately, only you can bully yourself. The words of the bully cannot affect you unless you buy into them. But then it’s your own beliefs that are the source of your emotional misery.

Second, your verbal response to the bully can also be helpful to you, or it can serve to make the situation worse. But these techniques, based in part of the Five Secrets of Effective Communication, can be challenging to learn, especially during the heat of battle, so considerable practice is vitally important.

The goal of changing your thoughts as well as the way you respond is not to blame you for the problem, but to give you some reasonably effective coping skills, perhaps similar to the verbal karate I mentioned in my first book, Feeling Good.

At the end of the podcast, we did a survey among the four of us on whether meanness and aggression and exploitation is one of the inherent and genetically based drives in human nature, along with our more loving impulses and drives, or whether humans are basically good and all the hostility and killing is the result of adverse influences along the way. There was a sharp difference of opinion, and you can listen to the podcast to find out what everyone thought!

We were, of course, just speculating, as this question is partly scientific and partly philosophical.

I asked Manuel how he felt at the end of the podcast, and he said he was feeling a lot better. He was powerful and informative, and I was grateful he could appear with our team and teach us from the heart today! I hope you enjoyed today’s program as well.

Thanks for listening!

Manuel, Matt, Rhonda, and David

A Strange Paradox-- The Incredible Impact of Compassion + Accountability Featuring Adam Holman, LCSW

We want to remind our listeners about the upcoming Mexico City TEAM intensive from November 6 – 9, 2023, organized by Level 5 TEAM therapist, Victoria Chicural, and Level 4 TEAM therapist Silvina Bucci. The Intensive will be held in a beautiful part of Mexico City (Sante Fe) at the Hotel Camino Real. There will be lots of opportunities to practice every aspect of TEAM-CBT along with many excellent, internationally renown TEAM-CBT trainers.

I (David) will do a keynote address on Day 1,  On Day 2 Rhonda and I will do a live TEAM demonstration with a volunteer attending the conference. On Day 3 everyone will have the opportunity to practice the TEAM model from start to finish.  And on Day 4 Leigh Harrington and I will answer questions about the TEAM treatment model.

This promises to be an Intensive not to be missed!  To learn more and register, please visit their website: https://teamcbt.mx,

Today we are joined by Adam Holman, LCSW, whose podcast 288 on April 22, 2022 was a big hit. He shared his strategies for working with kids with video game addictions, and his no-nonsense, patient-focused approach made good sense and resonated with many of our podcast fans.

Today, he talks about what he calls a “Strange Paradox,” which is:

If you treat people like they’re fragile, they act and behave like someone who’s fragile. If, in contrast, you hold them accountable, with compassion, they will discover their strengths.

He began by commenting on hearing David talk about how therapists often get hypnotized by our clients without realizing it. When that happens, we buy into the clients’ beliefs that they’re helpless and hopeless. And, I (David) might add, worthless.

When that happens, we start to treat them as if the beliefs are true, further proving to them that they’re helpless, hopeless, and worthless. This became incredibly evident after Adam had a unusual encounter with a child  while on a hike with his partner near Prescott, Arizona.

The child was shrieking in terror at the top of his lungs. As they got approached the child, they saw that he was paralyzed by fear of a swarm of flies near his head. They also realized that his family had already walked past, and were about 45-seconds down the trail, hoping that he would become brave and walk through the flies and catch up with them.  But that clearly wasn’t happening.

Adam walked past the flies and stood next to him before saying, “I know you’re scared, that’s okay. I just walked past the flies and it’s safe. You can walk through.” Then, the boy immediately stopped crying and walked past the flies on his own.

The boy willingly chose to walk past them the moment that his suffering was acknowledged. He heard the message that there was nothing wrong with him or the fear that he was feeling.

In other words, the acknowledgement of his fear send the message: “It IS scary, and you can do it. You’re capable of doing scary things.”

And he immediately found his courage and became capable.

Adam continued:

My partner and I began thinking about the suffering that the boy had experienced in that moment, and how little he needed in order to become strong and courageous. We felt close to the boy, and talked about our own suffering, and our parents’ suffering that was passed on to us.

We cried for three hours that day and began to think about all the suffering in the world. It felt incredibly relieving, I felt so connected to all of the people in my life, and naturally began thinking more about the suffering experienced by my clients.

I realized that with many of them, I’ve just given in to listening without holding them accountable. I had been standing next to them, but I was treating them as if they could not walk past the flies.  . . . I loved your podcast on stories from the 60’s, especially your experience when you were crying for hours when driving through the Nevada desert.

All the same kinds of feelings bubbled up in me. I saw that his parents were just doing what they’d learned to do; to try to discourage the uncomfortable feelings by walking away from them. Unknowingly, this was sending the message that he isn’t strong enough and that he is weak for feeling so fearful.

Like many of us, they had learned that it’s not okay to suffer, that experiencing feelings like fear is not acceptable. This, ironically triggers more suffering because you learn to avoid and fear your negative feelings, and you don’t gain the courage to sit with your painful feelings and the feelings of others You can say (to the little boy), it’s okay that you’re suffering and afraid, and that’s not a problem.

I related to that boy. My dad was very critical, and would berate me for feeling anything other than happiness. Feelings like fear or sadness were signs of weakness, and eventually I stopped realizing that I was even feeling them.

Then my feelings came out in the form of a lot of anxiety that I was avoiding, and the avoidance of that anxiety didn’t allow me the opportunity to see that I had strengths.

Rhonda, Adam and David discussed the role of tears in healing. Rhonda mentioned the immense value of exposure in recovery from anxiety, as opposed to avoidance, and the importance of making her patients accountable.

David mentioned that our field is based on the idea that your negative feelings, like depression, or fear, show that there’s something “wrong” with you, like a “mental disorder,” so you need to be fixed, by some pill, or some new school of psychotherapy. But if you’re trying to “fix” someone, you’re giving them the message that they’re “broken.”

TEAM, in contrast, is based on the opposite idea, that our negative thoughts and feelings will always be the expression of what’s right with us, and not what’s wrong with us. “Getting this,” which may not be easy at first, can paradoxically open the door to rapid change, just as we saw with the frightened boy that Adam encountered on the hike.

Finally, Adam discussed how he ended up applying what he realized to a client he had been working with. The client was diagnosed with “Treatment-Resistant OCD,” and had years of therapy and medication that had not brought him to much relief. Adam had been working with him for a few months and they were able to recognize some outcome resistance.

Outcome resistance is when the client has one or many good reasons not to give up their symptoms. Specifically, this client had an intense fear of rejection, and was making sure that his appearance was absolutely perfect in order to prevent rejection.

Adam discusses sadness and frustration over the term “Treatment Resistant”, noting that it often keeps people feeling more stuck. Once the client saw this, he decided that they wanted to go forward and let go of his compulsions and agreed to include exposure in his treatment. This would mean that he would have to let his appearance be imperfect, and allow himself to feel anxious. Thinking back on the treatment, Adam realized that he had been providing listening and support without making the patient accountable and insisting on exposure.

The next session, Adam recognized that just like the boy, he needed to treat his client with compassion and accountability. Adam re-invited the client to address the OCD and offered the gentle ultimatum, reminding the client that in order to go forward, we’re going to have to do exposure.

The client agreed, then started to hesitate as a result of his fear when he realized that the exposure would be taking place right at that moment. Adam messed up his own hair and invited the client to do it along with him.

Adam reiterated that getting over it requires the use of exposure. The client then messed up his hair, and expressed feeling anxious for a few minutes before erupting into laughter. Then the client proceeded with his day without fixing his hair. He also decided to do more exposure on his own after session without giving into the anxiety.

When he returned for the next session, he explained that his compulsions were gone for the first time in his life. The moment he was treated with compassion and accountability, he also found the strength to recover.

So, what’s the bottom line? When working with your own fears, or the fears of your clients or friends, two things are required. First, respect and compassion can help you accept your fear without feeling broken, or ashamed, or less than. And second accountability can give you the courage to confront your fears for the first time, and make the magical discovery that the monster really had no teeth!

This is one form of enlightenment, going back 2500 years to the teachings of the Buddha on the “Great Death” of the “Self.”

Thanks for listening today!

Adam, Rhonda, and David

TEAM for Troubled Couples A New Twist!

Today we are joined by a favorite guest, the brilliant Thai-An Truong. Thai-An is a Licensed Professional Counselor (LPC) and Alcohol and Drug Counselor (LADC). She is the first Certified TEAM-CBT Therapist and Trainer in Oklahoma. She has found TEAM-CBT to be life-changing professionally and personally and is passionate about training other therapists in this “awesome approach.”

In her private practice, Thai-An specializes in the treatment of trauma and OCD. To learn more about her TEAM-CBT Trainings, visit www.teamcbttraining.com

Thai-An has been featured on many Feeling Good Podcasts focusing on

• Depression and social anxiety (Live demonstration, 187)
• Postpartum Depression and Anxiety ( 218)
• How to Get Laid (Ep. 264)
• OCD ( 283)
• Grief (Ep 344)

Now Thai-An adds an important dimension to the TEAM Interpersonal Model—working with trouble couples, as opposed to working with individuals with troubled relationships. She also describes a new way to use Positive Reframing to reduce patient resistance to giving up David’s famous list of “Common Communication Errors,” and she adds five new errors to the list.

At the start of the podcast, Thai-An described a woman who complained that her husband often “shuts down” when they are communicating about a sensitive topic, and she wondered why. Thai-An decided to invite him to join the session so his wife could find out why.

This really opened things up, and the wife discovered that her husband shut down because he was feeling inadequate when she pointed out all the things that were wrong with the house, and he was taking her comments as criticism. However, the more he shut down, the more she complained, and this pushed him away even further since her criticisms intensified his feelings of inadequacy.

Thai-An then used Positive Reframing to help her see why he shut down.

One of Thai-An’s new ideas was to use Positive Reframing to cast our list of “errors” on the “Bad Communication Checklist” in a positive light, just as we do with the negative thoughts and feelings of people who are using the Daily Mood Log. By siding with the patient’s resistance and listing all the good reasons NOT to change, nearly all patients paradoxically let down their guard and powerful urges to oppose change. Instead, they open up and become receptive to the many methods for challenging distorted thoughts.

Thai-An has observed the same phenomena with troubled couples. When they see the GOOD reasons to why they or their partners use dysfunctional ways of communicating, they paradoxically let down their guard and become more willing to use the Five Secrets of Effective Communication.

She says:

Positive reframing started to open them up to each other, and helped them see each other in a more positive light. At the same time, they discovered that they shared the same values.

Voicing the good reasons to maintain the communication errors as well as the cost of change (e.g., it’ll be hard work, I’ll have to focus on changing myself, it’ll be vulnerable) allowed each partner to melt away their resistance to change.

David comment: This is an excellent example of a “double paradox.” Once again, instead of trying to “help,” which often triggers intense resistance, the therapist sides with the resistance, and this paradoxically triggers strong motivation to change!

Thai-An reminded us that it’s important to go through the TEAM structure before moving forward with tools to help the couple change. For testing, she asks both partners to complete the version of David’s Brief Mood Survey that includes the Relationship Satisfaction Scale, and asks both to complete the Evaluation of Therapy Session at the end. She makes sure both partners rate her empathy toward them at 20/20 (perfect scores) before proceeding to the next steps.

During the Assessment of Resistance, she begins to work with David’s Relationship Journal to get a specific moment in time of conflict. Then when they do Steps 3 and 4, where they identify their own communication errors and their impact on their partners, she does positive reframing of the bad communication errors, which you can see here, along with five new errors that Thai-An has listed below.

 

The Bad Communication Checklist*

Instructions. Review what you wrote down in Step 2 of the Relationship Journal. How many of the following communication errors can you spot? Communication Error (ü) Communication Error (ü) 1.      Truth – You insist you're "right" and the other person is "wrong."   10.   Diversion – You change the subject or list past grievances.   2.      Blame – You imply the problem is the other person's fault.   11.   Self-Blame – You act as if you're awful and terrible.   3.      Defensiveness – You argue and refuse to admit any imperfection.   12.   Hopelessness – You claim you've tried everything and nothing works.   4.      Martyrdom – You imply that you're an innocent victim.   13.   Demandingness – You complain when people aren’t as you expect.   5.      Put-Down – You imply that the other person is a loser.   14.   Denial – You imply that you don't feel angry, sad or upset when you do.   6.      Labeling – You call the other person "a jerk," "a loser," or worse.   15.   Helping – Instead of listening, you give advice or "help."   7.      Sarcasm – Your tone of voice is belittling or patronizing.   16.   Problem Solving – You try to solve the problem and ignore feelings.   8.      Counterattack – You respond to criticism with criticism.   17.   Mind-Reading – You expect others to know how you feel without telling them.   9.      Scapegoating – You imply the other person is defective or has a problem.   18.   Passive-Aggression – You say nothing, pout or slam doors.  

 

* Copyright ã 1991 by David D. Burns, MD. Revised 2001.

 

Thai-An Truong’s 5 Additional Communication Errors:

1. Shut down—You shut down and ignore the other person or give them the silent treatment.
2. Avoidance—You hide your feelings and avoid talking about hard topics, or disconnect through some form of escape.
3. Rejection—You make threats to leave – “I’m done with you,” or “I can’t deal with this anymore,” or “I want a divorce.”
4. Control—You insist that the other person “needs” to behave or communicate differently, or “should” or “shouldn’t” behave the way they do.
5. Invalidation—You tell the other person they shouldn’t feel the way they feel.

Here’s how Thai-An did the Positive Reframing with this couple. First she asked the wife, “Why might your partner suddenly want to “shut down” and stop communicating during a conflicted exchange?” She also asked, “What does this do for the person who is shutting down?”

This is the list of positives they came up with. Shutting down . . .

1. Keeps me safe and protects me from more criticism
2. Protects my partner from hurtful comments I might make.
3. Shows that I value our marriage and my partner’s feelings.
4. Shows my love for my partner, and for myself.
5. It shows that I’m feeling hurt and want to be appreciated.
6. Guarantees that I won’t make things worse.
7. Shows that I want to protect myself from becoming overly vulnerable and getting invalidated again.
8. Shutting down feels less risky than sharing my feelings.

Once she saw why he shut down, she realized the negative impact of her complaints, and began to provide more genuine words of appreciation to him. He said that this meant so much to him and made all the hard work worth it.

Her common communication errors included “truth” and “making complaints.” He realized, again through positive reframing, that she also wanted validation, that raising children can be hard, and that she ALSO wanted appreciation for how well she was keeping up with the home and the care of their children.

So, when she wasn’t getting validation and appreciation from him, she was even more likely to complain to try to voice her perspective. Once he was able to stop shutting down, and instead began to make more disarming statements, use feeling empathy, and stroking, she was much less likely to complain. They also realized they had the same values of wanting healthier communication and to provide a safe and happy home for their children.

Was this effective? Both went from 10/30 and 11/30 on the relationship satisfaction scale (shockingly poor scores) to 26/30 by the end of the relationship work together (extremely high scores indicating outstanding scores on my Relationship Satisfaction Scale.)

Thai-An provided us with a cool Positive Reframing document for all of the communication errors. You can check it out if you CLICK HERE.

I (David) pointed out that Positive Reframing can also be used in conjunction with the Relationship Journal in another way. In step one of the RJ, you write down one thing the other person said, and you circle all the many feelings they were probably having, like hurt, alone, anxious, angry, sad, unloved, and many more. In step two you write down exactly what you said next, and circle all the feelings you were having.

This would be an ideal time to do Positive Reframing of your partner’s negative feelings, so as to shift you perception that the other person is “bad” or “to blame” or some negative interpretations that you may be making. This reframing might be helpful in the same sense that my technique, Forced Empathy, can sometimes cause a radical shift in how you see the person you’re at odds with.

Announcements

On January 4, 2024, Thai-An Truong will be offering a 14-week training program in TEAM couples therapy for mental health professionals. The class will meet weekly from 11:30 to 1:30 East Coast time. To learn more, please go to Courses.teamcbttraining.com/relationships

There will be a 4-day TEAM-CBT Intensive November 6-9, 2023, in Mexico City, at the Hotel Camino Real.  To learn more, please go to:  https://teamcbt.mx/welcome

Thanks for listening today! Let us know what you thought about our show!

Thai-An, Rhonda, and David

AI and Psychotherapy— Doomsday or Revolution?

Featuring Drs. Jason Pyle and Matthew May

Today we feature Jason Pyle, MD, PhD and our beloved Matthew May, MD on a controversial, exciting and possibly anxiety-provoking podcast on the future of AI in psychotherapy and mental health. Will AI shrinks replace humans in a doomsday scenario for shrinks? Or will AI serve shrinks and patients in a revolutionary way that sees the dawning of a new age of psychotherapy?

You are all familiar with Matt, due to his frequent and highly praised appearances on our Ask David segments, but Jason Pyle, MD, PhD, will probably be new to you. Jason joined the Evolve Foundation as Managing Director in 2022 to focus his work on the mass mental health crisis and the rampant diseases of despair, which afflict tens of millions of Americans. The Evolve Foundation is a private foundation dedicated to the advancement of human consciousness. Evolve is active in philanthropy and venture investments in the mental health fields.

Jason is an accomplished biotechnology executive with over twenty years of executive management and technology development experience. He is committed to developing healthcare technologies and bringing science-backed healing to the most important problems of our generation.

Jason is a veteran who served as a US Ranger, and earned an Engineering degree from the University of Arizona. He received both his MD and PhD in Neurosciences from the Stanford University School of Medicine, where he met Matt May and they became close friends. At the start of today’s podcast, Matt and Jason reflected on their long friendship, starting as classmates at the Stanford Medical School 20 years ago.

The following questions were submitted by Jason, Matt, and David prior to the start of today’s podcast.

Jason’s Questions:

1. How important is the role of therapist rapport with patients? If it is important, how might AI accomplish or fail to accomplish this?
2. Given the limitations of AI, what parts or pieces of the therapeutic process might it best serve?
3. One of AI's potentially best features is that it can interact with a person anytime/anyplace, how could this be useful to augment the current therapeutic paradigm?
4. We talk a lot about patients using AI, but how could therapists use it to better serve their needs?

Matt’s Questions about AI:

1. What is AI? How does it work?
2. If therapists strengths tend to be their weaknesses and vice-versa, what might we expect to be the strengths and weaknesses of an AI therapist?
3. How do these expectations match up with what David is seeing in the data?
4. Is AI safe? Can it be made to be safe?
5. What would be the best case scenario for AI, in therapy?

David’s question about AI:

1. Will AI replace human therapists?

Jason kicked off the discussion with a brief description of AI and machine learning, and outlined four potential roles for AI in psychiatry and psychology:

1. An AI therapist full replaces the human therapist
2. An AI helper augments human therapist, acting as a 24 / 7 therapist helper in a myriad of ways involving ongoing support for patients between therapy sessions and support for patients during crises.
3. AI helps the therapist with rudimentary tasks like record-keeping, recording, and summarizing sessions.
4. AI can study transcripts of therapy sessions for research purposes, rating what procedures were done as well as degree of adherence to the therapeutic methods, and the skill of the therapist.

The ensuing dialogue was illuminating and exciting. In fact, I got so engrossed that I stopped taking notes, so you’ll have to give it a listen to find out. However, one thing that was interesting and unexpected was highlighting the strengths and weaknesses of AI. For example, a patient with social anxiety might benefit greatly from armchair work, focusing on ways to combat distorted negative thoughts, but will still have to interact strangers in social situations to conquer this type of fear.

David and Matt nearly always go with the patient out into the world for interpersonal exposure exercises, and find that the presence and trust and “push” from the human therapist can be invaluable and necessary. It is not at all clear that an AI therapist working via a smart phone could have the same effect, but that might require an experiment to find out.

Jumping to conclusions without data is rarely safe or accurate! Maybe an AI “helper” could be very helpful to individuals with social anxiety!

Jason raised the question of whether AI could replicate the trust and warmth and rapport of a human therapist, and whether the warmth and rapport of the therapeutic relationship was necessary to a good therapeutic outcome. I (David) summarized some of the findings with our Feeling Good App showing that app users actually rated the “Digital David” in the app substantially higher on warmth and understanding that the people in their lives. And now that we are incorporating AI into the Feeling Good App, the quality of the empathy / rapport from our app may be even higher than in our prior beta tests.

We have not done a direct comparison between the rapport of human therapists and the rapport experienced by our Feeling Good App users. Many people might jump to the conclusion that human shrinks have better rapport than would be possible from a cell phone app, but this might be the opposite of the truth! In my research (David), I’ve seen that most human shrinks believe their empathy and rapport skills are high, when in fact their patients do not agree!

In my research on the causal effects of empathy on recovery from depression in hundreds of patients at my clinical in Philadelphia, and also in more than 1300 patients treated at the Feeling Good Institute in Mountain View, California, it did not appear that therapist empathy had substantial causal effects on changes in depression.

The late and famous Karl Rogers believed that therapist empathy is the “necessary and sufficient” condition for personality change, but most subsequent research has failed to support this popular belief.

I (David) believe that AI therapists are likely to outperform human shrinks in rapport, warmth, trust, and understanding, but it remains to be seen whether this will be sufficient to make much of a dent in the patient’s symptoms of depression, anxiety, marital conflict, or habits and addictions. Other techniques are likely to be required.

However, we may have new data on this question shortly, as we will be directly studying the effectiveness of AI empathy on the reduction in negative feelings. We might be surprised, as our research nearly always gives us some unexpected results!

Rhonda gave a strong and appreciated pitch for the idea that there is something about a person to person interaction, like a hug, that will never be duplicated by an app. If this is true, or even believed to be true, then there will likely never be a complete replacement of human shrinks by AI apps.

But once again, you can believe this on a religious, or a priori, basis, or you can take it as a hypothesis that can easily be tested in an experiment. We do have very sensitive and accurate tests of therapists’ warmth and empathy, so “rapport” can now be measured with short, reliable scales, making head to head comparisons of apps and humans possible for the first time. At one time, it was thought that AI would never be able to beat human chess champions, but that belief turned out to be false.

The podcast group also discussed some of the potential shortcomings of an AI shrink. For example, the AI does not yet have the insight of how to “see through” what patients are saying, and takes the patient’s words at face value. But a human therapist might often be thinking on multiple levels, asking what’s “really” going on with the patient, including things that the patient might be intentionally or unintentionally hiding, like feelings of anger, or antisocial behaviors.

At the end, all four participants gave their vision, or dream, for what a positive impact of AI might have on the world of mental illness / mental health. Rhonda had tears in her eyes, I think, over the suggestion that an effective and totally automated AI therapist would be scalable and might have the potential to bring ultra low-cost relief of suffering to millions or even hundreds of millions of people around the world who do not currently have access to effective mental health care.

And I would add the individuals who now have access to mental health care, often cannot find effective treatment due to severe limitations in therapists as well as all current schools of therapy.

Jason described his vision for an AI shrink as the helper of human therapists, extending their impact and enhancing their effectiveness. Jason is super-smart and wise, and I found his vision very inspiring! I have trained over 50,000 therapists who have attended my training programs over the past 35 years, and one thing I have learned is that most shrinks, including David, have tons of room for improvement.

And if a brilliant and compassionate AI helper can enhance our impact? Hey, I’m all for that!

Thanks for listening today! Let us know what you thought about our show!

Jason, Matt, Rhonda, and David

Where Do Feelings Come From? Getting Unstuck from Apathy Ancient Stoic Philosophers--and More! Ask David Questions for Today

Bystad: Why is it so helpful to write down your negative thoughts when you’re upset?

Anyinio: Do we have to have a thought every time we have an emotion? What if I see a car coming fast and about to hit me? Would I have to have a fast automatic thought?

Raghav: How can I get unstuck from apathy?

Anita: What are the necessary and sufficient conditions for emotional distress as well as escape from emotional distress?

Louisa: Can you tell us some more about the ancient and modern Stoic philosophers who influenced the development of CBT and TEM-CBT?

Answers to today’s questions. The following answers were written before the podcast. The information on the podcast may be quite different in some cases, and will typically provide much more information than the brief answers below. David

 

Bystad asks: Why is it so helpful to write down your negative thoughts when you’re upset?

Dear David!

I have practiced the paradoxical approach where I just write down my thougts / worries without challenging them.

I think I learned that approach from your great book «When Panic Attacks».

This is something that really works for me, especially for worries. It is almost like I «get the worries out of my head».

Can you talk about this approach in your lovely podcast, why is it so effective for some people??

Best regards from Martin

David’s reply

Great question. Will address it the next time we record an Ask David podcast!

 

Anyinio asks: Do you ALWAYS have a thought before you can experience an emotion / feeling?

David’s response

The word “thought” is just a form of shorthand for perception. Perception can take many forms. When you see a car about to hit you, you already HAVE a negative and alarming thought!

If you like, you can check out the railroad track story in my Feeling Good Handbook. It is a story about a man who became euphoric after his car was hit by a train going 60 MPH because of his thoughts about it!

When a deer spots a pack of howling wolves, it runs in terror. It does not have a “thought” in English, but it DOES have the perception of being in imminent danger, and it DOES experience intense, sudden fear. However, the deer did NOT feel fear / anxiety until s/he SAW and correctly interpreted the pack of wolves.

Thanks, best, david

 

Raghav asks: How can I get unstuck from apathy?

Hi Dr. Burns,

I hope you’re doing well and thank you so much for all of your incredible work! It has really helped me pull myself out of some of the deepest depressions and anxieties I’ve had.

I wanted to ask for your help with a problem I’ve been facing recently:

I seem to get stuck in depressive cycles at times where I don’t want to do a DML even though I know it will make me feel better. When I start doing the positive reframing, it helps melt away this resistance, but I still mope around for a while before I start the positive reframing. My thoughts during this time are generally “There’s no point to getting better,” “Doing a DML is like forcing myself to cheer up,” “I should care about getting better more than I do right now,” and “There’s no meaning to life.” How would you recommend I go about dealing with this apathetic state?

I would greatly appreciate any help in this matter!

Thanks,

Raghav

David’s reply:

You could perhaps list:

1. 1. All the really GOOD reasons NOT to do a DML.
   2. What the procrastination / avoidance shows about you and your core values that positive and awesome.
   3. How the avoidance helps you.

Something along those lines.

I might make this an Ask David question if that’s okay with you. Could use your first name only, or a fake name if you prefer.

Thanks! Good question, as so many can relate to it!

Best, david

Raghav’s response to David

Here’s the answers I came up with:

Good Reasons NOT to do a DML

1. Doing a DML might be difficult and take a long time.
2. I might not be able to answer some of my thoughts.
3. Even if I do a DML, I might not be able to change my mood.
4. Even if I change my mood, there’s no point in being happy.
5. There’s no sense of meaning in doing a DML.
6. It feels inauthentic to try to change my mood.
7. Even if I do a DML now, I will return to this state again.
8. Doing a DML is like forcing myself to cheer up and I don’t want to be forced to do anything.
9. I want to be able to get better without doing a DML.
10. I might have to confront really negative and distressing thoughts.

Core Values it shows about me

1. I care about doing things successfully — I don’t want to half-ass it.
2. I want to put my best foot forward when doing tasks — i.e. not do them when I’m tired.
3. I want to be self-reliant and be able to solve all my problems myself.
4. I care about being able to change my mood.
5. I care about having meaning in life.
6. I care about being authentic to my emotional states — I can honor my apathetic/bored side.
7. I can sit with my sadness and apathy rather than trying to escape it.
8. I care about having lasting solutions rather than short-term fixes.
9. I’m my own man — I’m not going to be forced to do something I don’t want to do.
10. I care about being able to deal with my emotional problems without “crutches.”

How the Avoidance Helps Me

1. It means that I don’t have to do the hard work of doing a DML.
2. I don’t have to engage in the ups and downs of life if I’m apathetic/avoidant.
3. I can keep engaging in avoidance and distracting myself.
4. It feels like there are no consequences to my actions so I feel more free.
5. I don’t have to do the hard work required to build meaning into my life.
6. I can fully engage and honor my apathy and boredom.
7. I’ll push myself to search for lasting solutions to my problems.
8. It pushes me to improve my mental capabilities of solving my problems.
9. It helps me avoid the pain and anguish of actually addressing really negative thoughts.
10. It pushes me to find more interesting things to fill my life with.

Raghav

David’s reply

Great work, thanks! So now my question is this: Given all these positives, it is not clear to me why you’d want to do a DML. What’s your thinking about this?

Best, david

 

 Anita asks about the necessary and sufficient conditions for emotional distress as well as escape from emotional distress?

Dear David

While revisiting Feeling Great I was thinking further about the interplay of necessary and sufficient conditions that are correlated to emotional distress.

Necessary condition: You must have a negative thought

Sufficient condition: You must believe in the negative thought

I was thinking of another sufficient condition that may account for the behavioural component of emotional distress:

Sufficient condition: You must act in way that reinforces your negative thought.

For me this additional sufficient condition unlocks another philosophical underpinning why exposure is a key to overcoming anxiety.

For example, if I have a negative thought I’m going to screw up in a presentation and then I believe it 100%. I can still summon up the courage to go ahead and do the presentation. Thus, I’m behaving in a way that doesn’t fulfil the second sufficient condition, and therefore another way to reduce emotional distress. More often than not, the presentation is not as calamitous as I anticipated anyways.

Thanks for reading.

Warm Regards

Anita

David’s reply

Hi Anita,

Great question, thanks. I greatly appreciate folks who think more deeply about these things.

Exposure is a desirable tool in the treatment of anxiety, for sure, but if you point is “necessary and sufficient” for emotional distress, then the action thing is an unnecessary and erroneous, to my way of thinking, add-on. For example, many people who are severely depressed and believe themselves to be worthless do very little, and others do a great deal, but both feel the same severity of distress.

Could we use this for an Ask David, with or without your first name? If so, we could also discuss the “necessary and sufficient” for emotional change. Here the sufficient condition is that you no longer believe  the negative thought, or your belief has gone down significantly.

You can respond, too, if you like to my comments.

Warmly, david

Anita’s Response to David

Thanks David, sure I’d be pleased if you find any of what I wrote useful for your listeners. Feel free to use my first name. I’m also curious to know more about the depth of belief in a negative thought as a sufficient condition for emotional distress. Is there a particular intensity or tipping point that might lead to the emotional distress?

David’s Response: The greater you belief in a negative thought, the greater the emotional impact. There’s no “tipping point.”

I loved the premise of your book: “When you change the way you think, you can change the way you feel” It got me pondering about the possibility other things such as some behaviours in addition to thoughts that could be associated with emotional distress.

David’s Response: Your own or someone else’s behaviour won’t have any effect on you until you have a thought, or interpretation, of what’s happening. This is the basic premise of CBT, going back 3500 years or more.

An example I’m thinking of is workplace procrastination. Let’s say I have been given two weeks to tackle a laborious project. I might initially have thoughts there is plenty of time and I can procrastinate for the first week doing things I find more satisfying at work.

Towards the end of the second week, panic sets in as I rush through the project so I can still meet the deadline.

After the event, I start ruminating and believing self-critical thoughts such as “I shouldn’t have been so lazy” and “I’m never able to handle projects well.”

Is it to say, the behaviours before the event has little to no bearing on the negative thoughts or belief after the event? And if so why is it really the case that the negative thinking comes into play after the event happens?

David’s Response: Negative thinking can happen before, during, or after an event.

I really have gained much from many of your books. I’m inquiring to deepen and refine my own thought processes.

Thankyou

Warm Regards

Anita

David’s Response

Thanks so much for you kind and thoughtful comments.

 

Louisa asks: I’d like learn more about the ancient and modern Stoic philosophers who influenced the development of CBT and TEM-CBT.

Hello Rhonda and David,

I am a Belgium based listener thoroughly enjoying the podcast and sharing it far and wide! I love the TEAM CBT structured approach.

I find in particular that many of the methods are (relatively) easy to remember and administering self-help feels much easier than I ever imagined.

Well-done, David!

I wonder if David could talk one time about the different influences various figures in the development of CBT right from its inception with (it seems to me) the Roman Stoics until this century.

Some names that come to mind are Seneca, Epictetus, Marcus Aurelius, to Albert Ellis, Aaron Beck & William Glasser (these last three all since passed away.)

Are they any particular names that stick out as having been particularly useful in the development of TEAM CBT and why or how? Do the Roman Stoics still have anything to offer us?

Thanks for the great show!

Louisa

David’s Response

Hi Louisa,

Thanks, will include in the list of questions for the next Ask David, depending on time constraints.  Best, david

PS Albert Ellis documents much of the history in his book, Reason and Emotion in Psychotherapy. I believe that Karen Horney, the feminist psychiatrist of the first part of the 20 th century, discuss lots of the current ideas as well, especial the “need” for love, success, etc. and the idea that we have an “ideal” self and a “real” self. We get upset when we realize that the two don’t match!

David and Rhonda are grateful that Matt can join us often on the podcast.

Self-Esteem, Self-Confidence, and Self-Acceptance What's the Difference? What's More Important?

Questions for today’s Ask David podcast

David asks: What’s the difference between self-confidence, self-esteem, and self-acceptance?

Guillermo asks: How do you help people who are not asking for help or don’t even know they need help with depression?

The answers to today’s questions in these show notes were written before the podcast. The information on the podcast may be quite different and will typically provide much more information than the brief answers below. David

David asks: What’s the difference between self-confidence, self-esteem, and self-acceptance?

Hello David,

The mental health world seems to like or argue about the meaning of terms like self-confidence, self-esteem, and self-acceptance? What’s the difference between them, and which one is the best thing to have?

David’s response: Great question, David. I think of self-confidence as the conviction that you’re probably going to win because you’re very good at something. Self-esteem, in contrast, is the decision to love yourself whether you win or lose. Between those two, I’d say that self-confidence is more fun, but self-esteem is more important.

But where does self-acceptance fit in? That’s the big buzz word these days, although the concept has been around for ages. We’ll have to ask the experts today to find out where it fits in! I’m a bit confused at the moment!

 Guillermo asks: How do you help people who don’t know that they need help with depression?

Hello, Dr Burns

I was curious as to how you would help someone who isn’t aware (or capable to know--but not in a medical sense) that they need help. You've said before that the worst thing you can do is try to help (especially when no one asked for help), but how have you handled in the past cases when someone isn’t aware that they need help for depression?

Seems like it would be very tough without the person being motivated.

As always, thank you for all you do,

Guillermo Campos

Rhonda, Matt, and David will reply on the podcast.

David and Rhonda are grateful that Matt can join us often on the podcast.

Shoulds and More with our Beloved Fabrice! Three little words that will make your life miserable are “shoulds,” “wants,” and “needs,” says Dr. Fabrice Nye, the father / creator of the Feeling Good Podcast several years ago. But for the purpose of this episode, we’ll add a fourth word, “Musts,” which was popularized by Dr. Albert Ellis, who referred to it as “Musterbation.” Fabrice says that, “Shoulds are a trap. . . . There’s no such thing as a should, except for the laws of nature. For example, if I drop my pen, it “should” fall to the floor because of the effects of gravity. And sure enough, it does! “But when I say, ‘I should get an A on my upcoming exam,’ i may just be setting myself up for frustration. That’s because there’s no laws of the universe saying that people will always get As on their exams. "Similarly, if I say it SHOULDN’T be raining today, I'm involved in fiction, not reality. The clouds don’t obey our whims, they are just obeying the laws that govern the weather.” Fabrice explained that when you apply shoulds to some past event, telling yourself that your shouldn’t have made some mistake, you just make yourself guilty because it sounds like you’re scolding yourself. Again, you’re living in some fictitious reality where things are always the way you want them to be, because it’s impossible to change the past Fabrice reminded us that the Anglo-Saxon origin of the word, “should,” is “scolde.” So when you “should” on yourself, you’re actually scolding yourself. Fabrice also explained that the concept of “needs” can also get us into emotional hot water, since we sometimes tell us that we “need” things that we may want but don’t really “need.” So, if you tell yourself that someone “needs” to do something for you, you are simply applying pressure to the situation. For example, you might want or prefer for the person to be on time for appointments or planned activities, but you don’t “need” them to be on time. Similarly, you might want to find someone to love, or someone to love you, but you don’t “need” love, according to Fabrice. . . . and David agrees! It has been shown in research studies that infants and young children need love to grow and develop in a healthy way, but love is not an adult human need. According to the Buddhists, “needs” are not real. They’re just cravings, or intense desires that we’ve elevated to some godly state. Of course, there ARE things that we really do “need.” For example, we “need” to breathe to stay alive, and we “need” to have gas in the car if we want to drive to San Francisco. Those things are needed to fulfill a particular goal. So the key to an actual need is adding the phrase, “...in order to...” Fabrice also described some “want” traps. For example, you may sit at your computer cruising the internet or playing digital games, all the while telling yourself “I really want to get to work on my paper,” or taxes, or whatever. But in point of fact, you DON’T want to get to work on the thing you’re putting off. You WANT to be doing exactly what you are doing. Fabrice explains that we “trick ourselves into thinking we want something (like doing our taxes) when we really want to be doing something else (watching TV, playing computer games.) So, once again, we are telling ourselves stories that don’t map onto reality." Our real “wants” are the result of an unconscious cost-benefit analysis we make in our head, where the choice that comes out on top is our real want. It’s only when I really start doing my taxes that I’ll know this is what I want to be doing (probably because the urgency of the matter made the cost-benefit analysis tip in that direction). David was trying to see if this concept of “wants” can be helpful in therapy but had trouble seeing how this might help someone who’s procrastinating. Fabrice explained it like this: First, we need to realize that we are doing what we want in the moment; so, it’s a choice. Next, we can make our cost-benefit analysis conscious and see that we’re only considering short-term factors (e.g., it’s a lot more comfortable right now to be watching TV than doing taxes). Finally, we can develop some empathy for our future self (the one who will be pulling an all-nighter three weeks from now, or who will have to pay late fees) to reevaluate our cost-benefit analysis with more complete data. Fabrice also explained that procrastination can sometimes be difficult to treat because it’s an addiction. Rhonda also commented on the use of these concepts in therapy. Fabrice concluded the podcast by saying that he watches out for those three little words in his own thinking: “should, need, or want.” Thanks for listening today. Fabrice, Rhonda, and David

Menopause-- The End? . . . or the Beginning? Rhonda starts today’s podcast, as usual, with a warm endorsement from Sally, a podcast fan who really liked Podcast 355 on the topic of “Relationship Problems: Be Gone!” She said the role-play demonstrations were “incredible” and especially helpful. We’ll keep that in mind and see if we can do some more role-playing demonstrations in future podcasts, along with instructions so you can practice at home, as well. This can be extremely helpful if you want to master the techniques we describe. They may sound simple, but they’re not! In our recent podcast on free practice groups (put LINK), you can find many virtual practice groups you can join from home to practice many of the techniques in TEAM-CBT with like-minded colleagues and become part of the growing TEAM-CBT community. We now have many excellent and free practice groups for the general public as well as and training groups for shrinks. Today, Mina returns to the show with a new problem—pre-menopausal symptoms that are scaring her and casting a shadow on her future as well as her marriage with her husband, Maurice. Menopause is a topic that freaks many people out, due to feelings of anxiety and shame which can sometimes be intense. Today, menopause will be out in the open and front and center. However, Meina is confused because so many problems and feelings are swirling around in her head, and she doesn’t quite know where to start. At the start of the session, Mina's Brief Mood Survey indicated mild depression, severe anxiety, moderate to severe anger, and greatly diminished feelings of happiness and relationship satisfaction, thinking of her husband, Maurice.f If you review Mina’s Daily Mood Log. you can see that the Upsetting Event is irregular periods due to menopause. You can also see that Mina is struggling with fairly feelings of depression, anxiety, shame, inadequacy, loneliness, embarrassment, hopelessness, frustration and anger, and she’s giving herself some intensely negative messages, like “My body is falling apart,” and “My husband will leave me,” and “I’ll get osteoporosis and die in pain like my grandmother,” and more. During the initial Empathy phase of the session, Mina described quite a lot of personal and professional concerns, as well as somatic complaints of various kinds. Sometimes, in the past, Mina has developed numerous somatic complaints that terrify her, because she has interpreted them as possible serious diseases, like multiple sclerosis. However, excellent physical evaluations rarely or never provide any medical evidence or explanation for her symptoms. This pattern of obsessing about somatic symptoms is actually quite common. Many general practice doctors report that as many as a third of their patients complaining of pain, dizziness, and so forth do not have any medical disease that could possibly explain the symptoms. In fact, in his classic book, Caring for Patients, the late Dr. Allen Barbour from Stanford reported that about half of these types of patients experience a disappearance of their somatic symptoms when they identify some conflict or problem that they've been avoiding, and then take steps to express their feelings or solve the repressed problem. Pretty much every time, this has been true of Mina, too. It often turns out that she is upset about something she is sweeping under the rug, and the Hidden Emotion Technique has proved extremely helpful in pinpointing the hidden feeling or conflict. Then, as soon as she acts on this information, and expresses her feelings, the somatic problems immediately disappear. So, our first task in today's session was to see if the same thing was happening. It turned out that she was quite upset with her husband, Maurice, so we did a Relationship Journal to see if we could get a better understanding of what was going on. Her complaint was that Maurice did not want to talk about “difficult feelings.” Instead, he suggests they go for a nature walk or watch a movie. So, she felt sad, anxious, rejected, hurt, frustrated, and alone. But, as is the case nearly 100% of the time, when we examined a brief interaction between them—what did he say and what did she say next—it became clear that she was actually pushing him away and putting him down. This was understandably painful for Mina to see, and a bit embarrassing, but she was super brave, and saw how she could use the Five Secrets to respond to Maurice in a radically different and more inviting manner. As an aside, the person who seeks treatment for a relationship problem will nearly always discover that they have actually be causing the very problem they’re complaining about. If Mina’s husband had come to us for help, he would have made the exact same shocking discovery—that HE was causing the problem he was complaining about. I call this strange but fascinating phenomenon the “theory of interpersonal relativity.” Mina feared abandonment, but discovered that her real problem was that she was rejecting her husband, and forcing him to reject her! Although this type of sudden insight can be tremendously painful, it is also liberating at the same time. That's because people discover that they have far more power than they thought. Mina felt helpless, but was actually pulling the strings. Once you “see” this, you have the option of moving in a radically new and more rewarding direction. Mina promised to send a follow up once she’s had the chance to try a new approach during her interactions with Maurice. We have our fingers crossed! In addition, we worked with Mina's negative thoughts and feelings on her Daily Mood Log, starting with Positive Reframing, which she found helpful. What did her negative thoughts and feelings show about her that was positive and awesome, and how were they helping her? Then we did several rounds of Externalization of Voices and she was quickly able to knock her negative thoughts out of the park, with incredible results that you can see if you examine the emotions goal and outcome columns on her emotions table HERE. As you can see, there was an immediate and dramatic reduction in all of her negative feelings. We publish these TEAM-CBT sessions because we believe that the vast majority of mental health professionals do not know how to trigger rapid and extreme changes in how people think, feel, and interact with others. It is our hope that these podcast live therapy sessions, in conjunction with our weekly training groups, will make mental health professionals aware of what’s now possible, and how TEAM-CBT actually works. We try to make it look simple, but it requires tremendous training, practice, and commitment. Rhonda and I have strong, tender feelings toward our dear colleague, Mina, and we are deeply indebted to her for making herself vulnerable in a public forum so that we can all learn and feel much closer to one another. Personal work is one of our finest teaching tools. In addition, feelings of respect, love, and connection are so often missing in our embattled and hostile political and world environment these days. We cannot change the world, but we can definitely make our own small ripples in the pond, and work on changing ourselves. If you'd like, you can take a look at Mina's Brief Mood Survey and Evaluation of Therapy Session at the end of the session.  Thanks so much for listening today! Rhonda, Mina, and David