Overcoming Loneliness Part 1-- How to Develop Loving Relationships Featuring Dr. Orly Marmur

This is the first of a two-part series on loneliness, featuring the courageous personal work of Dr. Orly Marmur with Drs. David Burns and Jill Levitt as co-therapists.

Orly is a clinical psychologist from Southern California and member of our Tuesday TEAM-CBT training group at Stanford. She loves to hike, and recently went on a 25 mile solo hike from the North to the South Rim of the Grand Canyon, an arduous hike that she planned for a long time  She happened to be hiking on October 7, 2023, the day of the Hamas invasion of Israel.

The hike was a huge victory for Orly, but when she arrived at the top of the South Rim, her cell phone was instantly bombarded with news and emails about the Hamas invasion and brutal murder, beheading, and rape of many innocent Israeli citizens.

For the next several days, Orly’s mind was flooded with flashbacks of her life, growing up in Israel when the country was still young, and living through four wars. Her father and brothers were in one war together, and her brother was wounded, but survived and recovered.

Orly felt guilt and shame because she was not there to help. She said that she wanted to go to Israel to help her brother with his farm, but was conflicted because she did not want to abandon her clinical practice in Southern California.

She explained:

I grew up with the people who started the State of Israel. Those were idealistic, heroic times. My grandmother left Europe when she was 17 and settled in Israel. The focus was on building. We learned to be heroic.

A few days later, in the Tuesday group, David noticed that I was feeling down and lonely unable to focus and “checked out.” I had  a hard time feeling my feelings. I had shut down.

I began being flooded with memories of sexual molestation at my grandparents’ house when I was a girl in Israel. I remember standing next to a tree, and feeling like I was “different” from the other kids,

I started feeling sad and guilty about losing so many relationships over the years. I’ve alienated so many people, and now I want to accept responsibility for that.

When my daughter was 1 year old, I became friends  with other parents at the day care center. We became like an extended family as our kids grew up, getting together on Fridays for dinner, celebrating holidays together and being there for each other.

However, during the pandemic, I began to feel rejected by them. And sometimes there were individual rejections. We had often camped out together over the years, but all of a sudden, I was not invited. I was the only single person. The rest of the group are couples. Over the years, I was told a few times that, at times, my presence makes things difficult.

Since then, I’ve been invited to some but not other functions of our group. I haven’t felt like people are interested in me, or like me.

I also want to feel my feelings and develop a sense of empathy for others and greater pride in myself—after all, I DID survive.

I became very politically active with others interested in supporting Israel after the October 7th invasion. I was hoping to feel close to people, but it didn’t work because I still felt alone. I had hoped they’d be impressed with my political activism, but it didn’t help.

My problem was not the war, but me.

I’m hoping today you can help me to feel my feelings again! I realize that I tend to jump to action rather than feel my feelings. I think that it has to do with my upbringing and the circumstances and culture that I came from. Next week you will hear the exciting conclusion to the work with Orly, and a follow-up several weeks later.

Orly's Daily Mood Log. End of Part 1

Thanks for listening today!

Rhonda, Jill, Orly, and David

The Anxious Child— Three Common Errors Parents Make, and How to Avoid Them!  Featuring Dr. Taylor Chesney

Today we interview Dr. Taylor Chesney who is the Director of the New York office of the Feeling Good Institute. She specializes in the treatment of children and teens, and today will tell us about the three biggest errors parents make in dealing with anxious kids.

Dr. Chesney has been a guest on several of our podcasts in the past (episodes 107 and 263, and Corona Casts 4 and 6) and is a terrific teacher and therapist. She recently taught a 12 week course for therapists working with teens and children (ages 6 to 18) and their parents and brings us some of the highlights today.

She always begins treatment by interviewing the child and the parents and pinpoints what they want help with. Then she assesses how hard they are willing to work to bring about that change. The goals may be quite different for the child and the parents. It’s crucial to develop a meaningful therapeutic contract with the children, as well as the parents, as opposed to thinking your role is to “fix” the child for the parents.

If the child is less than 11 years old, she meets with the parents first. If the child is 12 and up, she meets with the child first. Either way, she empathizes with the child and encourage them to tell their side of the problem.

During or after empathizing, she does Positive Reframing, to show the child what their negative feelings, like depression and anxiety, show about them that’s positive and awesome. For example, if you’re sad about not being invited to a birthday party, it shows that you value friendships, and that you care a lot about other people.

If the child is anxious, she will teach them how their anxiety can be helpful. For example, if the child is a good athlete or student, anxiety can be an important motivating force in their success.

But sometimes we might get too anxious and feel intensely anxious about something that is not actually dangerous. Then you might experience your anxiety as trouble eating, a belly ache, trouble sleeping, or some other symptom that gets in the way of your optimal functioning.

The most important question with parents and children is usually: “Do you want to learn some tools and skills to help you change the way you feel?”

She also teaches children and teens what different kinds of emotions are, and the kinds of thoughts that trigger them. For example, if you feel anxious, you’re probably telling yourself that you’re in danger and that something bad is about to happen. If you feel guilty, you’re probably telling yourself that you’ve done something bad, or that you hurt someone you love; and if you’re feeling angry you may be telling yourself that someone is trying to hurt you or take advantage of you.

Taylor brings the core cognitive therapy ideas to life with examples that children can understand.  Here’s how she explains the idea, taught by Epictetus nearly 2,000 years ago, that our feelings do not result from what happens to us, but from our thoughts about what’s happening. Let’s say that you got a 90 on a test. How would you feel? You might feel overjoyed if you studied hard and felt like you did a good job and got a wonderful grade.

However, if you felt like you had to get a 95 to raise your semester grade in the class to an A, and you even skipped going to the prom to study extra hard, you might feel sad, ashamed, frustrated, angry, and disappointed, telling yourself that you “failed.”

Same grade, but two radically different emotional reactions, depending on how you think about your grade. Conclusion: it’s not what happens, but what you tell yourself, that triggers all of your positive and negative feelings.

Taylor said that anxiety is incredibly common in her clinic population and that surveys indicate that a whopping 25% of children have an anxiety disorder. She teaches her patients that anxiety in children, teens, and adults results from giving in to the urge to escape from a frightening or uncomfortable situation instead of facing your fears and discovering that the monster has no teeth.

For example, Taylor was in the ocean with her 9 year old son, and there were jellyfish in the ocean. Her son was terrified and wanted to get out of the water and back to the shore.

Taylor asked him what he was telling himself, and he said he was thinking that the jellyfish were bad. She also told him, “It’s okay to be afraid and to be careful and avoid the jelly fish, but you can also choose to stay in the ocean. Then we can have some fun together playing in the water.” He decided to stay and have fun and felt proud of himself!

She described Three Common Mistakes parents make in dealing with an anxious child.

Error #1: The Quiet Out Trap

She explained that we love our children, and don’t want them to suffer, so we may give them an easy way out. For example, if your child is afraid to go to the party when you are dropping them off, you might say, “If you don’t want to go to the party, we can go home.”

This seems like a kind and loving thing to do, protecting your child. However, you’re teaching the child that he or she can escape from anxiety through avoidance, so the child’s fear of social interactions actually increases. It also teaches the child that you don’t think they can handle the situation.

An alternate response would be to say, “Let’s go in and sit down together!”

She advised against cheerleading or trying to convince your child that they have nothing to be afraid of (e.g. “it’s not that scary” “there’s nothing to be afraid of.”) Instead, you can tell them that it’s okay to feel the fear but do it anyway, and you can often model that together with them.

Error #2: The Escalation Trap

In this trap, you let your fearful and avoidant child become more and more anxious and demanding, until they freak out and throw a temper tantrum, and then you give in to them. This, again, provides immediate relief, but in the long run you are training them to escalate and throw a tantrum to escape from having to face their fears, and on a broader scale, any time they want to get what they want.

Error #3: The Mental Filtering Trap

Mental Filtering is one of the ten original cognitive distortions, and it means focusing on the negatives in any situation and ignoring, or discounting the positives. It’s a common cause of depression, but can also be a communication error if you focus excessively on what your child is doing wrong.

Instead of pointing out your child’s errors, you might say, “Johnny, I love how you stayed calm when X happened. You’re really getting good at that.” In other words, you can comment on what they are doing right.

She said that showing kids how to be successful is more effective than berating them for what they’re doing wrong. This is an effective and low-stress way of reshaping their self-defeating behaviors.

David mentioned that this positive style of communicating can also be highly effective in a work environment, and that he uses it a great deal in his interactions with colleagues on the app team. If done in a genuine way, it can quickly reduce conflict and enhance morale and mutual respect.

How to Teach Parents

David asked Taylor if many parents resist implementing these kinds of changes. Taylor said that if she calmly and clearly teaches the parents what they’re doing that isn’t working, using the Five Secrets of Effective Communication, most parents quickly become motivated to grasp their mistakes and change their strategies in dealing with their children.

Taylor also “Sits with Open Hands” when making suggestions to parents. She explains it like this:

This means that if what the parents are doing works for them, and they aren’t willing to work hard to make changes, I accept this. But if they’re willing to work hard and change, we can work together to help them implement more effective parenting strategies.

Getting parents to work together as a team can be very important, but some parents may fight over the best way to discipline and raise their kids. These conflicts between mom and dad are one of the major causes of the unhappiness in the kids and get in the way of change.

Taylor emphasizes “Little Steps for Big Feets,” and might set small attainable goals for the parents who are at odds. For example, can they just sit next to each other and perhaps even “fake” a unified front for one conversation? Parents do not have to commit to making these changes “for the rest of their lives,” but make experimental small changes instead, for a small discrete period of time, and then check in and see if the change makes a difference. If it does, they may be motivated to continue to try to implement more changes.

Taylor typically works with children and their parents for 12 to 16 sessions and gives them a tool set to change some specific problem they came to therapy to solve. She has worked virtually for the most part since the start of the pandemic, but is now starting to see some people in person again.

She offers classes for mental health professionals and also runs a monthly case consultation group on the last Wednesday of every month from 12:30 – 2 pm EST. For more information, you can reach Dr. Chesney at [email protected].

Every fall, Taylor teaches a 12-week training course for therapists on TEAM-CBT for children and adolescents. You can also check the www.FeelingGoodInstitute.com website for more information on TEAM-CBT training for children and adults.

Thanks for listening today!

Rhonda, Taylor, and David

Personal Work with Dr. Tom Gedman-- Overcoming Performance Anxiety The Triumphant Conclusion

Last week you heard Part 2 of our personal work with Dr. Tom Gedman, which included T = Testing and E = Empathy. This week you will hear the dramatic and inspiring conclusion of the session, including A = Assessment of Resistance and M = Methods.

Dr. Tom's beloved pal

 

Start of Part 2 A = Assessment of Resistance

We began with the Invitation Step, asking Dr. Gedman what he hoped to accomplish in today’s session. His list included:

1. Develop some clarity on the direction of my business.
2. Become more authentic in my video recordings promoting my clinical work.
3. Increase in self-confidence.
4. Feel accepted by David and Rhonda.
5. My ability to push ahead during recordings instead of stopping and backing down because it isn’t “good enough.”

Dr. Gedman said that he’d gladly push the Magic Button to make his negative thoughts and feelings instantly disappear, but agreed to look at some of the positives in them first by asking these types of questions of each negative thought or feeling.

1. Is there some truth in this negative thought?
2. Could this negative thought or feeling be appropriate or even healthy, given my circumstances?
3. How might this negative thought or feeling be helping me?
4. What does this negative thought or feeling show about me and my core values that’s positive and awesome?
5. Could there be some negative consequences of giving up this negative thought or feeling?

The Positives in My Negatives

Negative thought: “I can’t be authentic on videos. I look like such s smug phony.”

1. I want to be other-centered, and focused on how I might be able to relieve the emotional struggles and health problems of my patients.
2. I value being authentic and genuine.
3. I want to help people who resonate with my message.
4. I don’t want to hide. I want to be open with my flaws.
5. I value honesty and integrity.
6. I value humility.
7. I value compassion.

Negative feeling: sadness

1. I care a great deal about my dream.
2. I don’t want to fail and let my family down.

Negative feeling: shame

1. Motivates me to work harder
2. Shows my love for my family.
3. I’m aware that I’m letting down the very people I want to help.

Negative feeling: inferior, inadequate

1. Show that I respect and admire the many people who have superior skills at talking live in front of a camera.
2. Shows that I’m aware of what others have accomplished.
3. Shows I don’t feel superior to others.

The idea behind the Positive Reframing is to help the patients see that their negative thoughts and feelings are not the expression of what’s “wrong” with them, but what’s right with them. This paradoxically reduces the resistance to change and opens the door to the possibility of rapid recovery.

You can see Dr. Gedman’s goals for each of the negative feelings on his Daily Mood Log if you click here. As you can see, instead of trying to eliminate his negative thoughts and feelings by pushing the Magic Button, he has decided to dial them down to lower levels with the Magic Dial.

Of course, these are only goals. We will need methods to challenge and smash his negative thoughts so we can reduce his negative feelings.

M = Methods

Rhonda, Tom, and David used a variety of methods to work on several negative thoughts Tom wanted to work on first, including numbers 1, 2, and 4 from Tom’s Daily Mood Log..

1. I can’t be authentic. I look like a smug phony. 100%
2. I waste so much time on my videos. I should be quicker. This should be easier. 100%
3. David and Rhonda will judge me for what I’m doing. 80%

We used several methods including Explain the Distortions, Survey Technique, Externalization of Voices (with Self-Defense, Acceptance Paradox, Counter-Attack Technique,) and more

You can see Dr. Gedman’s end-of-session scores on his nine negative feelings on his Daily Mood Log if you click here. As you can see, eight of the feelings fell all the way to zero, and his feelings of inadequacy fell from 100 all the way to 5.

Toward the end of the session, we discussed Tom’s medical and psychological philosophy, which might appeal to some of our podcast fans, especially if you live in England. First, he uses TEAM-CBT in individual two-hour sessions to help help people who are struggling with feelings of depression and anxiety. He finds this work thrilling because you can often see amazing changes within a single session, just like we saw in Tom’s work today.

Dr. Gedman also hopes to develop TEAM-CBT groups as well. This can be difficult because you need many referrals, but in my experience, TEAM groups can be incredibly effective, and cost-effective as well.

In addition, Tom also has a Functional Medical Practice which focuses on developing healthy nutritional and eating habits, consistent exercise, limiting the intake of toxins, developing loving relationships via the Five Secrets of Effective Communication, and enhancing spirituality.

If you would like to contact Dr. Gedman and learn more about his clinical practice, he can be reached at www.DrTomGedman.com.

Toward the beginning of these show notes, I reminded everyone of how anxious and insecure our beloved Rhonda felt at the start of our work together, when she took over for Fabrice. And now, she seems to be the poster child for charm, warmth, humor, and charisma.

That doesn’t usually happen automatically. Rhonda, like Tom, did her hard personal work, using the Daily Mood Log and several TEAM-CBT methods. But one thing that has been especially helpful to her, after initially “beating” her insecurity, has been the constant exposure work, with hours of weekly podcast recordings.

I, too, have had the chance to do constant, ongoing exposure for my own extreme feelings of inadequacy in front of live audiences or cameras, since I teach every week at my Stanford psychotherapy training class, as well as frequent  workshops, In addition, I have recorded almost daily for the Feeling Great App, which should be released in the first quarter of 2024. This exposure work has helped me cement and extend my gains in overcoming my own performance anxiety.

I plan to contact Tom to recommend the same. Perhaps in England they have program similar to Toastmasters, where you can have the chance to speak in public frequently and get valuable feedback from peers and colleagues.

I want to give a big hug and thanks to you, Tom, for sharing your intensely personal and real personal work with all of us today, and thanks, too, for reminding us of our own humanity and the magic of humility and the “Great Death” of the “Self.”

Thanks for listening today!

Tom, Rhonda, and David

Personal Work with Dr. Tom Gedman-- Overcoming Performance Anxiety

Have you ever struggled with Performance Anxiety? That can include public speaking anxiety, as well as anxiety when having to perform in an athletic or musical event, or speak on the radio, TV, or internet , etc. This is one of the most common forms of anxiety that we see in mental health professionals, as well, of course, in general citizens, including children, teens and adults.

Today you will hear Part 1 of the live work with Dr. Tom Gedman, a British physician struggling with intense performance anxiety, including the initial T = Testing and E = Empathy. Next week, you’ll hear Part 2 of the session as David and Rhonda do the A = Assessment of Resistance and M = Methods portions of the work with Dr. Gedman.

You may recall Dr. Gedman from our previous podcast (# 348). Recently, Dr. Gedman has wanted to promote his new programs on health and mental health in brief videos he plans to publish on social media sites, but finds himself crippled by negative thoughts that make him freeze up in front of the camera, like these:

1. I’m not good at this. 100%
2. I can’t be authentic. 100$
3. I’ll look like a robot! 100%

Tom practices in England as a family practice doctor, but has decided to work part time for the national health service while he establishes his clinical practice because he is only permitted to spend 10 minutes with each patient. He has developed a love affair and expertise with TEAM-CBT, and wants the freedom to practices in the way he wants, offering two-hour individual and group sessions, where he emphasizes the integration of physical with mental health.

But this means having to advertise his clinical practice to solicit patients, and this is a bit of a treadmill because of the rapid changes he sees in so many of his patients. Hence, his urgent need to overcome his public speaking / performance anxiety.

I have a soft spot in my heart for anyone who’s struggle with these types of anxious thoughts and feelings, because I have encountered them on many occasions in my professional career when I had to present my work in conferences, or even when attending receptions that included other mental health professionals.

In fact, I am the “voice” on the Feeling Great App that I’ve been developing over the past several years, and it took me some time to get comfortable with the recordings, since I told myself that I “had to sound natural, spontaneous, and inspiring.” Of course those internal and external demands caused the exact opposite—feelings of tension, insecurity, pressure, and intense self-doubt, resulting in “robotness” as opposed to spontaneity!

Yikes! It was a dreadful battle for a while! So, I KNOW how Tom has been feeling.

And our beloved Rhonda has been there, too, especially when she took over from Dr. Fabrice Nye as host of the Feeling Good Podcast that you’re listening to right now. If you recall, she was feeling pretty darn insecure! (See Podcasts # 142 and 143.)

Perhaps you’ve also struggled with social or public speaking anxiety, and felt insecure, panicky, frustrated, or ashamed? Have you? Even in our weekly training group at Stanford for mental health professionals, these feelings are rampant and nearly universal.

Part 1 of the work with Tom T = Testing

Tom brought a partially completed Daily Mood Log to today’s session. You can review it if you CLICK HERE. As you can see, he was feeling nine different categories of negative feelings, all intensely, with estimates ranging from 70 to 100.

This is why T = Testing is necessary for all mental health professionals, regardless of your so-called “school” of therapy. People, like Tom, may look attractive and filled with enthusiasm and joy on the outside, and still be experiencing EXTREME levels of distress inside.

The T = Testing vasty improves your accuracy in understanding how your patients are feeling. It also makes you accountable, which can be sobering, because we will again ask Tom how he’s feeling at the end of the session. The improvement, or lack of improvement, will tell us EXACTLY how effective, or ineffective, we were today in our work with Tom.

This is a great bonus for therapists who are courageous enough to use my Brief Mood Survey at the stat and end of every session, with every patient, because your patients become your best teachers, by far. But it’s also a threat, because the numbers don’t lie, and you’ll also be confronted by your ineffectiveness with many of your patients / clients.

Sadly, a great many therapists would prefer not knowing the truth!

E = Empathy

Although Tom had previously defeated these anxiety-provoking thoughts and reached a state of relative enlightenment and joy, the thoughts have come creeping back into his psyche. That’s one of the things about anxiety. Once you’ve beaten it, you have to keep up the assault with frequent, ongoing exposure, or the anxiety will once again invade your brain and body.

But the good news is that the methods that helped you initially are very likely to help you again, and if you continue using exposure after your first recovery, you can greatly reduce the probability of relapse.

These are the methods that helped Tom in the past:

• Positive Reframing of his negative thoughts and feelings following the initial E = Empathy phase of his session.
• Externalization of Voices
• Survey Technique
• Self-Disclosure (vs hiding) of his negative feelings of insecurity

Tom said,

Those techniques worked like magic when David and Mike Christensen did a live demonstration with me several months ago at a TEAM-CBT conference in England. I opened up about how I was feeling inside, and sobbed for several minutes during the session. Then I developed amazing relationships with colleagues at that conference. I was on a high for several months.

The TEAM-CBT session was life-changing. It gave me my life back. But now I’ve lost my way again.

Can those methods help Tom again today? You will get the chance to look behind closed doors as Rhonda and David do some personal TEAM-CBT work with Tom.

Tom continued to explain his situation as Rhonda and David empathized.

I’m very passionate about the work I want to do, but when I try to convey my message, I tighten up. . . I did 18 takes on a brief message to promote my new practice, but I just wasn’t authentic. I felt enormous pressure to entertain.

If I don’t get over this, people will think I’m a quack. I’ll get criticized. The work I do with patients behind closed doors has been amazing.  personal  The last couple patients I saw got their mood scores down all the way to zero.

Those sessions were intensely exciting! But how can I get the word out to the many people who need help with feelings of depression and anxiety, as well as poor habits of exercise and eating?

I’m just not earning much money now. My wife is working long hours to support our family while I’m trying to guild up my clinical practice. I feel so guilty. I take care of our three-year old son. On Monday, I felt so frustrated and discouraged that I felt like I was on the verge of a breakdown.

I feel sad and worried that things won’t pan out. It’s high stakes. . . I’ve always been a perfectionist. It’s helped me, but it’s also held me back.

I’m just angry at myself for not getting myself out of this desperate situation.

Rhonda and David paraphrased Tom’s words and acknowledged his intensely negative feelings as he spoke, without trying to be helpful, and without making interpretations or trying to cheer him up. Then we asked Tom to give us a grade on empathy, thinking of these three aspects of effective:

1. How well did we understand how Tom was thinking?
2. How well did we understand how he was feeling inside?
3. Did we create a sense of warmth, connection and acceptance?

Tom gave us an A. Next week, you’ll hear the dramatic conclusion of our session with Tom, including the A = Assessment of Resistance and the M = Methods, and, of course, the final T = Testing to find out if the session was helpful!

End of Part 1

Thanks for listening today!

Tom, Rhonda, and David

Rhonda Describes the GRIP Program and Interviews GRIP Graduate, Shakur Ross

The Guiding Rage Into Power (GRIP) Training Institute serves incarcerated men and women in California.  Their mission is to create personal and systemic change to turn violence and suffering into opportunities for learning and healing.

I (Rhonda) was introduced to the GRIP program when two of my dearest friends, Steve Zimmerman and Vicki Peet, invited me to a yearly celebration of the GRIP Training institute.  I was blown away by who I met and what I learned that I wanted to share it with the Feeling Good Podcast listeners.  Thank you, David, for letting me deviate from our typical subjects.

The GRIP program is a different subject for the Feeling Good Podcast, because it is not about TEAM-CBT.  What the GRIP Program and TEAM-CBT have in common is that they are both evidence-based programs that incorporate CBT theory and methods into their treatment methodology.  But the main thing they have in common is that people who engage in these two therapies experience profound, enlightening changes in their lives.

From their program:

“The GRIP program is an evidence-based methodology developed over 25 years of work with 1000’s of incarcerated people and many victim/survivors. Rooted in Restorative Justice principles, the program’s trauma informed model integrates cutting-edge neuroscience research.  Students engage in a yearlong, in-depth journey to comprehend the origins of their violence and develop skills to track and manage strong impulses rather than acting out in harmful ways.  They transform destructive beliefs and behaviors into an attitude of emotional intelligence that prevents revictimization.”

The GRIP Training Institute was started in 2011.  As of October 2020, nine years after running its first group, 915 students have graduated.  Of the 915 graduates, 369 were released from prison.  Only 1 graduate in nine years returned to prison, which is a recidivism rate of 0.3%, which is very impressive considering the recidivism rate for California is between 44-46%.  Many, if not all of the graduates, say that GRIP saved their lives.  Something many people who have benefitted from TEAM-CBT echo.

At the GRIP celebration, I was standing in line waiting for the buffet.  A man got in line behind me.  It was confusing where the line ended, which was not directly behind me.

In another circumstance I might have mentioned to him that the line ended somewhere else, but he was kind of scary looking, big, buff with obvious prison tattoos on his neck so I didn’t say anything.  But the line moved slowly and I was curious so I asked him what his connection to GRIP was.  He told me he was a graduate of the program and then politely asked me the same question.

It has been my experience that often people love to talk about themselves more than they are interested in other people so I was immediately impressed that he was as interested in me as I was in him.  When I told him I was a therapist, he asked me what kind of therapy I practiced.  I explained TEAM-CBT, and he was super interested!

He told me he loved CBT, and had learned a lot about himself through that kind of therapy because GRIP incorporated it in their program.  I asked him about his experience in GRIP and his tough exterior transformed right in front of me as he talked about how GRIP saved his life.

I talked to several other men (so far only men have graduated from the GRIP program because the services have only recently been brought to a women’s prison), and had the same experience.  I met our guest on this podcast, Shakur Ross, who kindly agreed to share his journey of transformation with us.

GRIP graduates continue to do the work and live as Peacemakers.  Shakur works for GRIP and returns to San Quentin and other prisons to provide the same lessons that he received.

The podcast starts with an interview with Kim Moore, the Executive Director of the GRIP Training Institute, who explains some of the key concepts of the program.

Thanks for listening today!

Rhonda

Jessica Malvicino Live Work With Jessica-- Living with Regrets

Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our “patient” was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you’ve also looked back on your life and thought, “If only I would have . . . “ done something I didn’t do,” as well as, “I wish I hadn’t done X, when I was young.”

Last week you heard the initial Testing and Empathy portions of the session with Jessica. Today you'll hear the Assessment of Resistance, Methods, and final Testing..

 

  Part 2 of the Jessica Session A = Assessment of Resistance

Jessica said her goal for the session was learning to accept life and move on, and not have such constant feelings of emptiness, with so many “I should have” thoughts running through her brain.

Although Jessica, like most people, said she’d press the Magic Button to make all of her negative thoughts and feelings disappear, we decided to do some Positive Reframing first, to see if there were some positives hiding in her negative feelings. We asked the following questions about a number of her negative feelings and thoughts:

1. Why might this thought or feeling be appropriate and healthy?
2. Why might this thought or feeling be helpful to you?
3. Why does this thought or feeling show about you and your core values that’s positive and awesome. ?

As you probably know, the goal of there are two goals for this paradoxical exercise: First, we want to bring the patient’s subconscious resistance to conscious awareness. Second, we want her to see that her struggling and suffering is NOT the result of what’s WRONG with her, but rather, what’s RIGHT with her.

The moment that people really “see” and “get” this, there’s often a sharp and sudden reduction in feelings of shame, and a strong burst of motivation to crush the negative thoughts at the heart of her misery.

Here are some of the Positives we listed:

SADNESS

My sadness shows my passion and love of dancing.

It shows my dedication to the idea of having a fulfilling career.

It shows that I’m a very loving person.

ANXIETY, WORRY, NERVOUSNESS

These feelings

• show that I’m responsible
• motivate me to complete tasks
• help me avoid procrastination
• make me vigilant and protect me from danger

SHAME

• These feeling show that
• I’m concerned about others
• I’m human
• I want to please others with my career
• I admire my mom and want to make her proud
• I want her to admire me
• I’m humble
• I want to feel close to others

ANGER

• These feelings show that
• I’m a caring and passionate person
• I have character
• I have a moral compass
• I’m feisty and strong
• I’m accountable
• My anger also empowers me

After listing these and other positives, Jessica decided to use the Magic Dial to reduce her negative feelings to lower levels, but not necessarily all the way to zero, as you can see in the goal column on her emotions table:

Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90 20   Foolish 100 0   Anxious, worried, nervous 90 10   Discouraged 97 5   Bad, ashamed 95 0   Frustrated, stuck, defeated 100 5   Inadequate 90 0   Angry, mad, resentful, annoyed 95 10   Lonely 92 5   Other      

 

Then we went on to

M = Methods

These were some of the negative thoughts that Jessica wanted to challenge, along with the percent she initially believed each of them:

1. I’m a failure. 90%
2. My mom is to blame for not understanding the career path that I wanted. 90%
3. I was an idiot for not following my dreams. 100%
4. Nothing will truly fulfill my professional career. 100%
5. I have to “settle” for my professional career now.100%

She had many others ad well.

We used a variety of techniques to challenge and crush these thoughts, including the Externalization of Voices with Self-Defense, the Acceptance Paradox, and the CAT (Counter-Attack Technique), and used frequent role reversals to help Jessica get to “huge” wins when she was in the role of her positive thoughts.

Here you can see Jessica’s scores in the “% After” column. As you can see, her scores were extraordinarily low, which is terrific.

Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90 20 0 Foolish 100 0 3 Anxious, worried, nervous 90 10 0 Discouraged 97 5 0 Bad, ashamed 95 0 0 Frustrated, stuck, defeated 100 5 10 Inadequate 90 0 0 Angry, mad, resentful, annoyed 95 10 5 Lonely 92 5 0 Other      

 

Typically, such drastic and sudden reductions in negative feelings not only indicate “recovery,” but the experience of feelings of joy and enlightenment.

At the end we asked Jessica two questions:

1. Are the scores valid, or is she just trying to please us?
2. If they are valid, what were the most healing and helpful aspects of the session?

As you listen to the end of the live session, you’ll find out what she said!

Rhonda and I hope you enjoyed the session with Jessica. We believe that live work with real people, and not role players who are pretending to be in therapy, is invaluable, and one of the best—and only—ways to learn many of the subtleties of rapid and effective treatment. And if you are a general citizen, and not a therapist, I hope your found our work with the brave and wonderful Jessica to be inspirational and educational, especially if you have also sometimes felt depressed, anxious, or ashamed, and if you have found that regrets about the past can put a real damper on your capacity to live and enjoy your precious present moments!

Our best teaching is usually through live work, and so we give you, Jessica, a warm thanks and salute for the great teaching YOU have done today!

Thanks for listening, everybody!

Jessica, Rhonda and David

 

Live Work With Jessica-- Living with Regrets

Rhonda and I recently did live work at a TEAM-CBT intensive in Mexico City. Our “patient” was a 40 year old mental health professional named Jessica with many years of unhappiness because of a decision she made when she was just 17. Perhaps you’ve also looked back on your life and thought, “If only I would have . . . “ done something I didn’t do,” as well as, “I wish I hadn’t done X, when I was young.”

Today you'll hear the initial Testing and Empathy portions of the session, and next week you'll hear the Assessment of Resistance, Methods, and final Testing..

Part 1 T = Initial Testing

DAVID WILL SUMMARIZE SCORES ON BMS AND DML

You can also see her scores on the emotions table of her Daily Mood Log here.

Emotions % Now % Goal % After Emotions % Now % Goal % After Sad, depressed, unhappy 90     Foolish 100     Anxious, worried, nervous 90     Discouraged 97     Bad, ashamed 95     Frustrated, stuck, defeated 100     Inadequate 90     Angry, mad, resentful, annoyed 95     Lonely 92     Other      

 

As you can see, these negative feelings were all incredibly intense.

E = Empathy

Jessica, who grew up in Florida, explained that she started ballet dancing at the age of 3, and when she was 17, she won a prestigious full scholarship to study and have the chance to join a world renowned ballet company. Jessica was incredibly excited, but her mom did not see ballet as a “true career.” In addition, her mother was quite protective, which was not uncommon in the Cuban community, and told Jessica she could only accept the scholarship if she agreed to live with her grandparents in New York.

Jessica angrily rebelled and turned down the offer. Although she continued to dance professionally until her first daughter was born 14 years ago, she battled with feelings of anger and regret the entire time, while also blaming her mother for her. unhappiness.

She eventually got a bachelor’s degree in journalism, and worked in television for a period of time. Then she got a master’s degree in counseling, and found that she loves clinical work and helping people. However, she continued to live with feelings of regret and anger directed at her mom from age 17 to her current age of 40, for a total of 23 years, and explained that she frequently “takes it out” on her mom during periods of irritability.

She also has feelings of grief about what she’s lost when she see her young niece dancing ballet beautifully now. This statement brought tears to her eyes.

Jessica described all the sacrifices she’d made when growing up in order to become a top dancer, including periods of bulimia to maintain the thinness that her teachers always stressed. She explained that “everyone did it—they weighted us frequently and would grill us if we were even a little bit overweight. . .” and this was all in order to fulfill her ultimate dream of becoming a world class ballerina, a dream that vanished.

Jessica gave Rhonda and David an A on Empathy, and said that the self-disclosure felt uncomfortable, but helpful. Next week, you'll hear the inspiring conclusion of the work with Jessica!

Today's special guest, Brittany. Podcast 375. I'm Struggling! Ask David Live: a New Podcast Twist

We start today’s podcast with a visit from Dr. Jacob Towery. You might recall that one year ago he offered an amazing and (almost) totally free two-day workshop for shrinks and the general public on overcoming social anxiety. Roughly 90 people attended, and it was a huge success. The only “cost” was a $20 contribution to a charity of your choice, including Doctors Without Borders and several others.

Dr. Jacob Towery

This year, Dr. Towery will be repeating this incredible program on March 16 and 17, 2024, which will be on a Saturday and Sunday, in Palo Alto. Once again, the title will be “Finding Humans Less Scary.” Jacob and Michael Luo will lead the program and will be assisted by 10 - 20 expert therapists who will lead the break-out groups.

Last year, people described the program as “transformative” and “life-changing.” Social anxiety can have a significant impact on your life, so you owe it to yourself to attend if you or a loved one has struggled with any of the five common forms of social anxiety:Shy Bladder Syndrome

• Shyness in social situations
• Public Speaking Anxiety
• Performance Anxiety
• Test Anxiety

You’ll learn and practice tons of awesome anxiety-busting techniques, including Smile and Hello Practice, Flirting Training, Rejection Practice, Talk Show Host, Shame-Attacking Exercises, and much more.

Social anxiety rarely exists alone, but is nearly always associated with other mood problems, such as loneliness, shame, depression, and substance misuse with alcohol and benzodiazepine pills to try to combat the symptoms, to name just a few.

How do you sign up? It’s easy! Just go to

FindingHumansLessScary.com

If you attend, let us know how it worked out for you, what you learned, and how you grew. Thanks so much, Jacob, for making this kind of world-class experience available to everyone who’s looking for some help, and some wild, life-changing and zany fun in March!

Brittany, an enthusiastic podcast fan, asked for help with a conflict with her husband. She wrote:

Hi Dr. Burns,

I’m struggling a bit. My husband reads a ton of articles and feels that the media has been portraying a lot of the current events incorrectly, especially the horrifying Israel/Palestine conflict. He is extremely frustrated by this and has become depressed because none of his friends or family seems to want to talk about it. He says he feels alone & isolated. I have never been much into politics, abd I don’t know enough to have a real opinion on things to say who is right.

I try to be a good listener to whatever he says. For example, I may say “yeah, that sounds really frustrating,” and then I agree with what he says. But I’m obviously doing a bad job at the empathy because he says the support he gets from me is not satisfactory at all. Sometimes I feel like a parrot, just repeating back what he says.

I think you had an example before on an Ask David where you showed how to empathize with someone who says how awful everyone is and how awful all the liberals are. Something like that. But I can’t find it.

When I empathize my husband says I just don’t get it and nobody is doing anything to help these innocent people who are being attacked, and he says that I am not doing anything either.

I’m at a loss on how to reply? Maybe you could do an example on an Ask David. Sorry for the long message.

- Brittany

Hi Brittany,

Sorry you’re struggling, this is a common but important problem.

Yes, we can and will do that. Can you give me an example of something he says to you, and exactly what you say next? You can use the attached Relationship Journal I you like.

Try to complete steps 1 and 2 at least, and mail back to me ASAP. Lots of people with this problem these days, so could be great ASK D question.

Weren't you on the show live once a few years back? I know you’ve sent us some great questions. I'm thinking MAYBE you could join and practice with us, using your example.

Do you have / have you read my book, Feeling Good Together?

Best, david

It turned out that Brittany was eager and willing to join us live on today’s podcast . This is kind of an experimental podcast where we not only respond to a great question by one of our fans, but actually invite that person to get our “expert” help in real time and live on a podcast.

You can let us know if you like this format.

To get us started, Brittany sent us an example of a Relationship Journal she had prepared. I thought this was really well done, and gave her revised version a grade of A-, which is way better than most people can do. I sent her an email saying that she could probably add more acknowledgement of his feelings and her feelings, like feeling alone and hurt and a bit lonely, and also a bit more Stroking, like "I want you to know how much I love you, and how special you are to me. And that's why it's so had for me to realize that I've really been letting you down."

We practiced with Brittany using my Intimacy Drill, which you'll hear on the podcast. Essentially, one of us would play the role of Brittany's husband, and we would say something she wanted help responding to, and she used the Five Secrets to respond. Then Rhonda, Matt and David gave her an overall grade (from A to F), along with fine tuning suggestions, emphasizing what she did that was especially effective and if there were any changes that might make her excellent responses even better. Then we did role reversals so we could demonstrate ow we might respond, followed by additional role plays until she was satisfied with her response.

Five Secrets of Effective Communication

This approach is called "Deliberate Practice" and it is by FAR the best way to master the Five Secrets so you can use them successfully in real time.

We also discussed her concern that at home she'd been feeling like "a parrot" when she tried the Five Secrets. That is always caused by the absence of "I Feel" Statements in your statements, and we modelled how to correct this error.

One of the biggest problems in the way people communicate during a conflict or argument is defensiveness, and given in the urge to argue and defend your territory, so to speak. Matt explained that this nearly always results from thinking you have a "self" that you have to defend.

Another common Five Secrets error is the failure to acknowledge the other person's anger. Therapists and the general public nearly always make this error, because of a mindset I call "anger phobia" or "conflict phobia." However, Brittany did really beautiful work during the podcast exercises, as you'll see when you listen.

We (the so-called "experts") also practiced what we preached and took turns responding to criticisms, which is always fun and challenging, and often humbling when we goof up!

Let us know what you think about this new format of having someone who asks a question actually appear live on the podcast so you can actually learn through practice while we answer your question.

Thanks for listening today, and thank you Brittany for blazing new trails on our podcasting adventure!

Brittany, Rhonda, Matt, and David

Featured photo is Mina as a child (more pics below!) 374 Anger, Part 2 You Have Always Hated Me!

In the Anger Part 1 podcast (371 on November 20), Rhonda, Matt and David discussed the fact that when you’re feeling angry, there’s always an inner dialogue—this is what you’re saying to yourself, the way you’re thinking about the situation—and an outer dialogue—this is what you’re saying to the other person.

In Part 1, we focused on the inner dialogue and described the cognitive distortions that nearly always fill your mind with anger-provoking inner chatter about the ‘awfulness” of the person you’re mad at. Those distortions include All-or-Nothing Thinking, Overgeneralization, Labeling, Mental Filtering, Discounting the Positive, Mind-Reading, Fortune Telling, Emotional Reasoning, Other-Directed Should Statements, and Other-Blame.

That’s a lot—in fact, all but Self-Blame. And sometimes, when you’re ticked off, you might also be blaming yourself, and feel mad at yourself at the same time.

Matt suggested I add these comments on Self-Blame or it's absence::

Another possible addition would be when you identify the absence of Self Blame when we’re angry. For me, it’s been easier to think of that as a positive distortion, because you are blind to, or ignoring, your own role in the problem. In other words, when I’m blaming someone else, it’s me thinking my poop smells great and tit's all the other person's fault..

I’ve wondered if we fool ourselves like this because of the desire to have a special and perfect “self,” which we then defend. Because nobody’s perfect, our "ideal self," as opposed to our "real self," is just a pleasant, but potentially destructive, fantasy.

Still, we try to preserve and project the fantasy that we are free of blame and the innocent victim of the other person's "badness," , and we imagine there we have a perfect “self” to defend. Or, as you’ve said, at times, David, “anger is often just a protective shell to hide and protect our more tender and genuine feelings.”

We also discussed the addictive aspect of anger, since you probably feel morally superior to the “bad” person you’re ticked off at when you’re mad, and this makes it fairly unappealing to change the way you’re thinking and feeling. Your anger also protects you from the risk of being vulnerable and open and genuine.

Today we discuss the Outer Dialogue, and how to express angry feelings to another person, as well as how to respond to their expressions of anger. The main concept is that you can express anger in a healthy way, by sharing your anger respectfully, or you can act out your anger aggressively, by attacking the other person. That’s a critically important decision!

Toward the start of today’s podcast, Rhonda, Matt and David listed some of the distinctions between healthy and unhealthy anger. The following is just a partial list of some of the differences:

 

Healthy Anger Unhealthy Anger You treat the other person with respect, even if you’re angry. You want to put the other person down. Your goal is to get closer to the other person. You want to get revenge or hurt or humiliate the other person. You hope to improve the relationship. You want to reject or distance yourself from the other person. You want to understand the other person’s mindset and find the truth in what they’re saying, even if it sounds ‘off’ or ‘disturbing’ or offensive. You want to prove that the other person is ‘wrong’ and persuade them that you are ‘right’. You want to understand and accept the other person. You insist on trying to change the other person. You express yourself thoughtfully. You express yourself impulsively. You come from a mindset of humility, curiosity, and flexibility. You come from a position of moral superiority, judgement, and rigidity. You are patient. You are pushy and demanding. Optimism that things can improve and that there’s a great potential for a more meaningful and loving connection. Hopelessness and feelings of certainty that things cannot improve. Open to what I’ve done wrong and how I’ve hurt you. Focus on what you’ve done wrong and how you’ve hurt me. I-Thou mindset. I-It mindset. You’re vulnerable and open to your hurt feelings. You put up a wall of toughness and try to hide your vulnerable true feelings.. You look for positive motives, if possible, and don’t assume that you actually understand how the other person is thinking and feeling.. You attribute malignant motives to the other person and imagine that you can read their mind and know exactly why they feel the way they do. You accept and comprehend the idea that you can feel intensely angry with someone and love them at the same time.. You may believe that anger and love are dichotomies, and that conflict and anger, in some way, are the ‘opposite’ of love or respect..

To bring some dynamics and personality to today’s podcast, Mina, who’s made a number of noteworthy appearances on the podcast, agreed to describe what she learned on a recent Sunday hike. (I’ve started up my Sunday hikes again, but in a small way now that the pandemic has subsided, at least for the time being. I’m struggling with low back pain when walking and that severely limits how far I can go.)

Mina began by explaining that when she was talking to her mom on the phone. Her mom described a conflict with woman friend who seemed angry with Mina’s mom. Mina said, “I can see why that woman got angry with you.“

Mina explained that her mother, who is “conflict phobic,” paradoxically ends up with conflicts with a lot of people. However, Mina’s mother sounded hurt by Mina’s comment, and said, “You’ve always hated me since you were a little girl! You always looked at me hatefully!”

Here are some of Mina’s "angry" childhood photos:

 

Mina explained how she felt when her mom said, "You’ve always hated me.”

My jaw dropped when she said that! It was such a shock. I’ve always felt like she was my best friend! . . .

I hate feeling angry. It makes me every bit as uncomfortable as anxiety. If I express my anger, it goes away, and I feel better. But I don’t usually express it, and then it comes back disguised as weird neurologic symptoms.

And that, of course, is the Hidden Emotion phenomenon that is so common in people who struggle with anxiety. When you try to squash or hide negative feelings your think you’re not “supposed’ to have, they often resurface in disguised form, as phobias, panic, OCD symptoms, chronic worrying, or any type of anxiety, including, as in Mina’s case Health Anxiety—that’s where you become convinced you have some serious neurologic or medical problem, like Multiple Sclerosis.

Matt suggested that I might remind folks of my concept that “anger allays get expressed, one way or the other.” He’s found this idea to be both true and incredibly helpful for “us nice folks who think we can get away without expressing our anger, thinking we can avoid conflicts, entirely. This always backfires, in my experience!”

On the recent Sunday hike, Mina practiced how to talk with her mom, using the Five Secrets of Effective Communication. After that, she used what she’d practiced on the hike to talk to her mom about their relationship, and then got an “I love you” message from her mom the next morning.

This made Mina very happy, but because she had a full day of back to back appointments, Mina decided to spend time crafting a thoughtful reply at the end of the day, when she had a little free time. But when she went back to her computer at the end of the day to send a message to her mom, she discovered that her mother had deleted the loving message she sent early in the day, and Mina felt hurt.

When Mina asked her mom about it, her mom said that deleting the message was just an error due to ‘old age.” However, Mina did not really buy this, and thought her mom probably felt hurt and angry because Mina had not responded sooner.

In the podcast, we practiced responding to mom using the role-play exercise I developed years ago. Essentially, one person plays the role of Mina’s mom, and says something challenging or critical.

Mina plays herself and responds as skillfully as possible with the Five Secrets, acknowledging the other person’s anger and expressing her own feelings as well.

We practiced responding to mom’s statement, “You’ve always hated me.” Matt played the role of mom and Mina gave a beautiful Five Secrets response. You’ll enjoy hearing her response, and Matt’s and Rhonda’s helpful feedback, when you listen to the podcast.

Then Mina asked for help responding to another statement from her mom, who had also said:

All of the kids your age are angry, because you were neglected a lot of the time because of the war in Iran, and your dad and I were busy doing what we had to do to survive and avoid being arrested. All of my Iranian friends with children your age are experiencing the same thing.

Matt and Rhonda did more role plays with Mina, followed by excellent feedback on Mina’s Five Secrets response. Again, I think you’ll enjoy the role-playing and fine tuning when you listen to the podcast.

One of the obvious take-home messages from today’s podcast is to use the Five Secrets of Effective Communication when you’re feeling angry and talking to someone who’s angry with you as week, As a reminder, these are the Five Secrets.

LINK TO 5 SECRETS

And to make it simple, you can think of talking with your EAR:

E = Empathy (listening with the Disarming Technique, Thought and Feeling Empathy, and Inquiry)

A = Assertiveness (sharing your feelings openly with “I Feel” Statements)

R = Respect (showing warmth and caring with Stroking)

However, here’s the rub: People who are angry will usually NOT want to do this! When you’re ticked of, you will almost always have a huge preference for expressing yourself with the Unhealthy Anger described above.

Matt urged me to publish my list of 36 reasons why this intense resistance to healthy communication. LINK HERE for the LIST

• 12 GOOD Reasons NOT to Empathize
• 12 GOOD Reasons NOT to Share your Feelings
• 12 GOOD Reasons NOT to Treat the Other Person with Respect.

So, as you can see, there’s a lot more to skillful communication of anger than just learning the Five Secrets of Effective Communication, although that definitely requires tremendous dedication and practice. But motivation is the most important key to success or failure.

When you’re upset with someone, you can ask yourself, “Do I want to communicate in a loving, or in a hostile way?”

The reward of love are enormous, but the seduction of hostility and lashing out is at least as powerful! This battle between the light and the dark is not new, but has been blazing for tens of thousands of years.

And, of course, the decision will be yours.

Thanks for listening today,

Mina, Rhonda, Matt, and David

Why Therapy Fails

One of the most common reasons patients contact me is to find out why the therapy isn't working. They may be TEAM-CBT patients or patients of therapists using other approaches. Therapists also ask for consultations on the same problem--why am I stuck with this or that patient who isn't making progress?

In the Feeling Good App, my colleagues and I have been looking into this as well. Most app users report excellent and often rapid results, but some get stuck, in just the same way they might get stuck in treatment with a therapist. I have tried to organize my thinking on this topic, because if you can diagnose the cause of therapeutic failure, you can nearly always find a solution. Of course, the app is not a treatment device, but a wellness device, but the same principles apply.

So today, Rhonda, Matt and I discuss a couple reasons why therapists and patients alike sometimes get stuck. Matt described a patient who was misdiagnosed with a psychotic disorder who turned out to have sleep apnea. When the proposer diagnosis was made and treated, the patent suddenly recovered.

Rhonda described a patient who jumped from topic to topic and always brought up a new problem before completing work on the previous problem. This problem was solved when Rhonda explained the importance of sticking to one problem for several sessions, until the problem was resolved. The patient then began to make progress.

David described a depressed woman from Florida who was stuck in treatment, and not making progress, and then the therapist said "I just can't help you," This hurt and confused the patient who wrote to me. There were essentially two problems--the patients depression what brought her to therapy in the first place, and her unresolved hurt feelings when the therapist "gave up" on her. This problem reflected many failed relationships is the patient's life. This was resolved when the patient took the initiative to schedule a session to talk about the conflict more openly with excellent results.

In addition, the patient had heard that she "should" accept herself, but didn't know how to accept her constant self-critical troughs and intensely negative feelings. I suggested she make a list of the benefits of her negative thoughts and feelings, as well as the many positive things they showed about her and her core values as a human being.

She came up with an extremely impressive and long list! For example, her criticisms showed her high standards, her humility, her dedication to her work, her accountability, and much more. In addition, she'd achieved a great deal because of her relentless self-criticisms.

I asked her why in the world she'd want to accept herself, given all those positive characteristics

She decided NOT to accept herself, and was delighted with her decision. She said she felt profound relief!

An unusual, but awesome, path to acceptance! In other words, she ACCEPTED her "non-acceptance."

I hope you find today's podcast interesting and helpful. Of course, ultimately therapy is part science and part human relationship art. That's why Rhonda and I offer free weekly training groups for therapists who wish to develop their therapeutic skills. The groups are on zoom so therapists from around the world are welcome. Matt offers a consultation group (free to Stanford psychiatric residents) every other Tuesday for therapists who want help with difficult, challenging cases. To learn more, you'll find details and contact information at the end of the show notes.

When Therapy Doesn’t Work-- And How to Get Unstuck (for Therapists and Patients)  By David Burns, MD

Here’s are some of the most common reasons why therapy might fail or appear to be stuck / without progress. Some of them will be of interest primarily to clinicians, while others will be of interest to clinicians and patients alike. And many of these reasons will also apply to individuals using the Feeling Good App who are stuck in their attempts to change the way they think and feel.

But what does “stuck” actually mean? The definition, of course, is subjective. I believe that a substantial or complete elimination of depression and anxiety can typically be achieved in five sessions with a skilled TEAM therapist. I use two-hour sessions, and can usually see dramatic change in a single session, although follow-ups may be needed for Relapse Prevention Training or other problems the patients might want help with.

In my experience, the treatment of relationship problems and habits and addictions usually takes much longer than the treatment of anxiety or depression. The techniques to treat relationship problems and habits and addictions actually work just as fast as the techniques to treat depression and anxiety, but the resistance can be far more intense. For example, someone may be ambivalent about leaving a troubled relationship or giving up a favored habit for many months or years before making a decision to move in a new direction.

And, of course, the treatment of biological problems like schizophrenia and bipolar I disorder will nearly always require a long term therapeutic relationship, often requiring medications in addition to therapy.

The problems and errors I’ve listed below are mostly correctable. And although there are many traps that therapists and patients fall into, the vast majority of therapeutic failure the patient's hidden 'resistance' to change and the therapist's lack of skill addressing it. This is true in clinical practice and in psychotherapy outcome studies, as well.

On the one hand, a great many patients will feel ambivalent about change. For example, a patient with low self-esteem may not want to stop being self-critical and accept themselves, as-is, but to have a better version of themselves, first. Or they may want to overcome their fears without facing them. Or they might want a better relationship but would want the other person to do the changing.

Unfortunately, most therapists lack the skills to address resistance and, in fact, often make it worse by trying to motivate the patient to change, rather than understand their hesitation to change and discuss it with them. This is one area where TEAM training has a great deal to offer, including over 30 skills therapists can learn to address motivation and resistance.

The following list of 37 reasons why therapy fails follows the structure of T, E, A, M.

Errors at or before the initial evaluation

1. Patient is just window shopping
2. Patient does not buy into the cognitive model
3. Incorrect conceptualization of type of problem, so you end up using the wrong techniques. To simplify things, I think of four conceptualizations:
   1. 1. Individual mood problem (depression or anxiety)
      2. Relationship Problem
      3. Habit / Addictions
      4. “Non-problem”: healthy negative feelings such as the grief you might feel when a love one dies
4. Patient is not in treatment out of choice. For example, a teenager might be brought in by parents to be “fixed,” like bringing in your car to the local garage for a tune up, and you don’t have an agenda with your patient. Or a parent might be court-ordered to go to therapy if he wants to have custody of his children.
5. Failure to ask patients to complete the Concept of Self-Help Memo, the How to Make Therapy Rewarding and Successful memo, and the Administrative Memo prior to the start of therapy. These memos fix a great many therapeutic problems that are likely to emerge later on, like homework non-compliance, premature termination, and policies about confidentiality, last minute cancelling of sessions, conflicts of interest (eg patient is seeking disability) and more. Most therapists ignore the use of these memos, only to pay a steep price later on.
6. Failure to mention the requirement for homework and similar issues the at initial contact with the patient.
7. Failure to explore the patient’s motivation for treatment.

T = Testing

1. Diagnostic errors: not recognizing additional problems which patient may have in addition to the initial complaint, such as drug or substance abuse, psychosis, intense social anxiety, past trauma or abuse, or hidden problems the patient is ashamed to disclose. This is easily solvable by the use of my EASY Diagnostic System prior to your initial evaluation. It screens for 50 of the most common DSM “diagnoses” and only takes ten minutes or so out of a therapy session to review and assign the “Symptom Cluster Diagnoses.”
2. Failure to use Brief Mood Survey before and after each session. This error makes the therapist blind to the severity or nature and severity of the patient’s feelings, which cannot be accurately identified by a patient interview or therapy session. As a result, the therapist’s understanding will not be accurate, and the therapist will not be to pinpoint the degree of change (or failure to change) during and between therapy sessions.

E = Empathy

1. Failure to ask patients to complete the Evaluation of Therapy Session after each session. As a result, it will not be possible for therapists to understand their level of empathy, helpfulness, and several other relationship dimensions critical to good therapy.
2. Failure to use the “What’s My Grade” technique while empathizing with the patient.
3. Failure to receive training in the Five Secrets of Effective Communication and the three advanced communication techniques. These techniques are difficult to learn, requiring lots of practice and commitment, but can be invaluable in therapy and in the therapist’s personal life.

A = Assessment of Resistance (also called Paradoxical Agenda Setting)

1. Failure to recognize and deal with Outcome Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
2. Failure to recognize and with Process Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
3. The “because” factor: I won’t let go of my depression until “I’ve lost weight,” or “I’ve found a loving partner,” or “I’ve achieved something special,” or “I’ve found a better job / career,” or “I’ve achieved my goals at X.” This is another type of Outcome Resistance.

M = Methods--errors using the Daily Mood Log

1. Patient “cannot” identify any Negative Thoughts
2. The way you worded your Negative Thought. The common errors include thoughts describing events or feelings, rhetorical questions, long rambling thoughts, or thoughts consisting of a few words or phrases, like “worthless.”
3. No Recovery Circle / many need many techniques combined with the philosophy of “failing as fast as you can.” This allows you to individualize the treatment for each patient. It is simply not true that there is one school of therapy or method (like meditation, mindfulness or daily exercise, etc.) that will be helpful, much less “the answer,” for all patients!
4. The way you did the technique / incorrect use of technique. Many of the most powerful techniques, like Interpersonal Exposure, Externalization of Voices, Paradoxical Double Standard, Feared Fantasy, and many more require considerable sophistication and training. They can be fantastic when used skillfully, but they aren’t easy to learn!
5. Trying to challenge your negative thoughts in your head / vs on paper or computer. This is associated with Process Resistance for depression—refusing to do the written homework, and it is exceptionally common.
6. Trying to challenge the negative thoughts of someone else or encouraging them to think more positively: won’t work! In my first book, Feeling Good, I spelled out the warning that cognitive techniques are for you, and NOT for you to use on other people, including friends, family, and so forth. It is my impression that many people ignore this warning. When they discover that the person they are trying to “help” does take kindly to identify the cognitive distortions in their thoughts, both end up frustrated.
7. Failure to “get” the Acceptance Paradox / using too much self-defense in your positive thoughts, especially Technique when doing Externalization of Voices
8. Using the Acceptance Paradox in a defeatist, self-effacing way
9. Failure to include the Counter-Attack Technique when doing Externalization of Voices. This techniques is not always necessary, but can sometimes be the knock out blow for the patient’s endless inner criticisms.
10. Not understanding the necessary and sufficient conditions for emotional change when challenging distorted thoughts.
11. Too much focus on cognitive / rational techniques when far more dynamic techniques are needed, such as the Experimental Technique (e.g. exposure) in treating anxiety or the Externalization of Voices or Hidden Emotion Techniques
12. Not recognizing that the patient’s negative thoughts might be valid (I think that my partner is cheating on me) and trying to get your patient to challenge the “distortions” in the thoughts

Other therapist errors

1. Codependency: addiction to trying to “help” / cheer up the patient / solve some problem the patient has
2. Need to be “nice” and refusal to hold patients accountable
3. Narcissism: unwilling to be criticized, unwilling to fail, needing to stay in the expert role
4. Difficulties “getting” the patient’s inner feelings, due to lack of skill with Five Secrets and the failure to use Empathy Scale
5. Difficulties forming a warm and vibrant therapeutic relationship, which can sometimes result from strong (and nearly always unexpressed) dislike of the patient
6. Commitment to a favored “school” of therapy / thinking you are superior to colleagues and have the one “correct” approach
7. Failure to use assessment tools with every patient at every session
8. Failure to make patients accountable for homework
9. Four types of reverse hypnosis: this is where the patient hypnotizes the therapist into believing things that simply aren’t true.
   1. 1. Depression: the patient may really be hopeless or worthless
      2. Anxiety: the patient is too fragile for exposure
      3. Relationship problems: the patient is too fragile for / not yet ready for exposure
      4. Habits / addictions: not making the patient accountable or assuming patient isn’t yet “ready” to give up the addiction, or the patient needs to have emotional / relationship problems fixed first
10. Unrecognize, unaddressed conflicts with therapist that need to be addressed with Changing the Focus. This error often results from the therapist’s fear of conflict or patient anger, and is usually accompanied by a failure to use the Evaluation of Therapy Session, which would send a loud signal to the therapist that something is wrong.
11. Failure to do Relapse Prevention Training prior to discharge.
12. Conceptualization errors. Failure to use or select the most effective therapeutic approach and techniques for the patient’s problem. For example, the Daily Mood Log and Recovery Circle are great for depression and anxiety, although there will be some important differences in the choice of methods for depression vs. anxiety. For example, Exposure and the Hidden Emotion Technique are great for anxiety, but rarely useful for depression. The DML has only a secondary role in the treatment of relationship problems (the Relationship Journal is more direct and useful) or habits and addictions (the Triple Paradox and Habit and Addiction Log (HAL) are far more useful.
13. The therapist may be committed to a school of therapy, like Rogerian listening, without addressing resistance or using methods. Or therapist may believe that psychodynamic or psychoanalytic therapy, or ACT, or traditional Beckian cognitive therapy, will be the “answer” for everybody. The schools of therapy function much like cults, causing feelings of competitiveness (our guru is better than your guru) and sharply limiting the critical thinking and narrowing the consciousness of the faithful “followers.”
14. Conflicts of interest. The therapist may subconsciously want to keep the patient in a long-term “talking” relationship due to emotional or financial needs.
15. The therapist may have been taught that therapeutic change is inherently slow, requiring many years or more. This belief will always function as a self-fulfilling prophecy.

Thanks for listening!

Matt, Rhonda, and David