This podcast features Elizabeth Dandenell, LMFT, who runs a successful treatment clinic in Alameda, California for anxiety disorders, The East Bay Center for Anxiety Relief (www.eastbayanxiety.com.). She is a certified Level 4 TEAM therapist and trainer, and also helps teach mental health professionals at our Tuesday psychotherapy training group at Stanford.
We are deeply indebted to Elizabeth for allowing us to publish the very personal, dramatic and inspiring work she did that evening. I also want to thank Jill Levitt, PhD, who was my co-therapist in the work with Elizabeth. Jill practices at the Feeling Good Institute in Mt. View, California (link) where she is Director of Clinical Training, and teaches with me at Stanford.
Like most mental health professionals, Elizabeth occasionally struggles with feelings of anxiety, stress, and self-doubt, and wanted to do some personal work in a recent Stanford Tuesday group. The personal work takes courage, but is crucial to the training and personal growth of all therapists.
She was hoping for help with fears that have haunted her since her father died when she was just 13 years old. She explains:
I started working when I was 13 years old and that is when the pressure to make money began because my father was an unsuccessful businessman. We were all just scraping by.
I started working because my father was unable to pay basic bills at times like phone and electric. Or our car didn't always run. He was not good at running his own business and money flow was very inconsistent.
I discovered when I started working that I could have some control with financial stability if I had my own money and would help out paying the phone bill occasionally. This is when the anxiety of not having enough to survive kicked in and developed the" pressure" I discussed in the podcast and in my daily mood log.. This pressure to survive has has fueled my anxiety for years.
My father died from Parkinson's Disease in a nursing home when he was 77. He wa on Medicaid because he had lost everything. I was 50 when he died.
You will hear many techniques that Jill and I used during the session, including Cognitive Flooding. This is, to the best of my knowledge, one of the first times that we have captured this type of Exposure live on a Feeling Good Podcast. Combining Cognitive Flooding with the What-If Technique (pioneered by Dr. Albert Ellis) makes the confrontation with your deepest fears especially powerful. Listening to that portion of the session will be illuminating for many therapists and patients alike, especially if you are not familiar with, or confident in, the use of exposure in the treatment of anxiety.
Elizabeth's anxiety was triggered by an exercise we did called "No Practice" in one of the David and Jill workshops for mental health professionals. Essentially, you practice saying "no" to someone who is pressuring you and making unreasonable demands on you.
But in Elizabeth's case, and perhaps for you, too, those demands are internally generated.
If you click here, you can see the partially completed Daily Mood Log that Elizabeth brought to the session.
T = Testing
We began our session by reviewing Elizabeth's scores pre-session scores on the Brief Mood Survey. The scores indicated only mild anxiety and minimal anger, but these scores probably do not reflect the intensity of the anxiety and terror she often feels.
We then went on to:
E = Empathy
Elizabeth said, "That workshop exercise ("No Practice") got me thinking about an unresolved issue I've been struggling with my entire life." She explained that
I'm doing too much in my life. I complain and then I take too much on and get overwhelmed. I fill my plate too much, and I tell myself that my patients need me, so I'm always taking on new patients to keep my schedule full . . .
At times I get really anxious and don't feel competent or confident. Who I am today is due to constant pushing, pushing, pushing, and never letting up.
She explained that the problem started when she was 13:
We didn't have much money, and my father died penniless, in poverty in a skilled nursing facility. I'm always pushing for fear of meeting the same fate, telling myself that if I slow down I might not have enough money for my daughter's college education, or for our retirement.
I work so hard I was once even treated for adrenal fatigue. But my husband and I are not in any financial danger now, and things are fine, and I'd love to have time for more walks, for more meditation. But I'm terrified of slowing down.
We did the What-If Technique to explore Elizabeth's fear of slowing down. What was at the root of her fears?
David: What would happen if you slowed down? What are you the most afraid of?
Elizabeth: We might not have enough for my daughter's college and for our retirement.
David: And then what?
Elizabeth: Our daughter would have to take out student loans.
David: And if you did not have enough for your retirement, and your daughter had to take out student loans, what then? What are you the most afraid of?
Elizabeth: My father's life collapsed at the end, and he ended up in a skilled nursing facility with nothing. (tears)
Jill pointed out a belief at the root of Elizabeth's fears. "If I slow down, we won't have enough money for survival. This fear has been haunting and driving me since I was 13."
Elizabeth said it felt unjust, and that she was angry that she could not take a break without feeling a sense of panic. She said, "it's all about family values. I wish the work ethic hadn't been driven into me so hard."
She said she's struggled with constant worries about money, and wondering whether she can pay her bills ever since she was 13. She said,
"It's not about having fancy things—that doesn't interest me. It's all about survival."
Although Elizabeth and her husband are doing really well, and her treatment center is doing really well, she constantly worries, keeps her schedule more than full, and cannot say no to a new patient. She gives herself the message that she should be working longer hours, and that she can work overtime to make room for every new patient.
She said,
"For years I've wanted not to be so overwhelmed, and I'm still stuck with so much on my plate. . .
'I'm tired of being terrified and want to be at peace. I want to learn to let go of this constant fear, but I don't know if I can let it go. I want to feel differently, and not just do differently.
"I want to be at peace with my business. I want the freedom to say yes or no. I want the freedom of choice.
"If I have a day off, I don't know what to do. It feels weird. My greatest fear is ending up in a nursing home on Medicaid, like my father."
I decided to explore this fear once again, using the Downward Arrow Technique.
David: And then what would happen? What would that mean to you?
Elizabeth: My daughter would see me and realize she would have to support herself.
David: And then what? What would that mean to you?
Elizabeth: That would mean I was worthless. (tears) That would mean I was not enough. And then I'd be rejected.
Now I'm feeling so ashamed! (more tears)
At this point, we summarized what Elizabeth and been saying and feeling, and asked her to grade us on our empathy so far. Would she give us an A, a B, a C, a D, or what? This "What's My Grade" technique is powerful and helpful, but a bit intimidating for the clinician.
Elizabeth said she'd give us an A- or B+. That's not bad, but it is really a failing grade, because we're aiming for an A.
When this happens you can ask, "What am I missing?"
Elizabeth explained that we'd done a great job on the thought and feeling empathy, but she did not feel as much warmth and acceptance as she was hoping for because she was feeling very ashamed about her story
Jill reminded us of the need to include "I Feel" Statements to our empathy (my bad), and then we shared our feelings of sadness and admiration for Elizabeth, and quickly got an A.
As a teaching point, your perceptions of how empathic you are, if you are a therapist, will not be accurate. That's why the "What's My Grade" technique can be so valuable. When you fall short, the patient will tell you why, and can easily make a correction and greatly enhance the therapeutic relationship.
Superb empathy is desirable, and necessary if you want to do top-notch clinical work, but it won't cure much of anything. So we'll need something more!
Next week you will hear the amazing last half of the session, starting with A = Assessment of Resistance and then going on to M = Methods, and end of session T = Testing.
In next week's podcast, you'll hear the final half of Elizabeth's session and, if you like, you can also listen to some of the Q and A from the participant's in the Tuesday group who watched the session live.
Rhonda and David