Podcast 248

Ask David and Rhonda!

In today's podcast, Rhonda and David answer some fascinating questions submitted by listeners like you! We both thank you for your interest in our show, and for your kind comments and terrific questions!

The Questions

Kati asks: I notice that in your therapy sessions, the negative feelings of most of your patients are reduced all the way to 0%, and many become euphoric. I was wondering whether this somewhat contradicts the idea that our negative feelings are useful to us in some way?
Kati also asks: Do you believe that empathy can be 'taught'?
Yiftah asks: How could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise?
Yiftah also asks: From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective?
Esther asks: You say there is no convincing or consistent evidence to support most psychodynamic claims about the causes of things. What you said resonates, but aren't you also just making claims? I have a psychodynamic supervisor, and am struggling to choose between empirically validated treatments and traditional psychodynamic approaches.
Sean asks: Burns, what can you do when you are using the disarming technique and the person keeps interrupting you?
Ben asks: Since exercise improves the mood of some people who are feeling down, doesn't this prove that physiologic changes can improve mood, as opposed to changing negative thoughts?

The Answers

Note: The answers below were based on David's email exchanges with the people who asked the questions and were created before today's podcast. Therefore, the podcast may contain new and different information from these show notes. Hopefully, both the show and the notes will be helpful to you.

Rhonda and David

Kati asks

I notice that in your live therapy sessions, the negative feelings of most of your patients are reduced all the way to 0%, and many become euphoric. I was wondering whether this somewhat contradicts the idea that our negative feelings are useful to us in some way.

David responds

Hi Kati, thank you for the kind comments!

It is great to get negative feelings to zero and experience enlightenment and joy. However, no one can be happy all the time, so you will have plenty of opportunities to "learn" from negative feelings again. In addition, there is a difference between healthy and unhealthy negative feelings. Healthy sadness is not the same as clinical depression, healthy fear is not the same as a phobia or panic attack, healthy and unhealthy anger are quite different, and so forth. There will bumps in the road of life for all of us at times.

*** * ***

Kati also asks

Do you believe empathy can be "taught?"

As a mum (of a 15 and a 10 year old girls) and a (HS) teacher I notice some people seem to have it more 'innately' than others but would also love to think it is an aspect that can be intentionally developed in others in some way. If you think like me, I would love to hear your thoughts on how that could be done (i.e. what practices or strategies would be most helpful to use with young people in particular).

I am still in awe that we can have a sort of conversation with such a brilliant and creative mind and I humbly hope you can address these two questions either in one of your podcasts or by responding to this message.

In admiration,

Kati

David responds

Thanks again, Kati,

With regard to empathy, it is something that can be learned, but it takes commitment and practice. A good first step is the book I wrote on this topic called Feeling Good together. In addition, there is, as you say, an "aptitude" that people have for this or any skill, with a tremendous variability in the population.

But regardless of your natural aptitude or lack of it, you can learn and grow tremendously. I started out with very poor listening skills. You can also search for Five Secrets of Effective Communication on the website, using the search function, and you'll find lots of podcasts teaching these skills.

david

*** * ***

Yiftah asks

How could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise?

Dear Dr. Burns,

I love your podcast and books. They have completely changed my practice and had helped my personally. In particular it was great to hear you working with Dr. Levitt with cognitive exposure, and your discussion about it.

I have two questions regarding cognitive exposure with PTSD (for the podcast.

First, how could one dangle the carrot effectively and responsibly when offering a cognitive exposure exercise?

David responds

Hi Yiftah,

I try to deal with the Outcome and Process Resistance issues prior to agreeing to help any patient with anxiety. I might say something like this:

"Jim, I'd really love to help you with your fears of X (whatever it is), and I'm pretty convinced that if we work together, you can make some great progress in overcoming your fears. I have more than 30 great tools to help you overcome anxiety, and you're probably going to love all of them except for one, exposure. Confronting your fears is just one tool among many, but is a vitally important part of the process, and cure is usually impossible without exposure.

"For example, I may ask you to do is (I explain the type of exposure we might use.) I know that will be terrifying, and it needs to be terrifying to be effective. I'll be with you every step of the way, of course. But I need to know if you'd be willing to do that type of thing if I agree to work with you.

"I know you've told me that you've had many therapists in the past who did not use exposure, and that might be why their treatments were not as effective as you'd hoped. And if you absolutely don't want to use exposure, I would totally understand and support you, but sadly could not agree to treat your fear of X."

*** * ***

Yiftah also asks

From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective?

You have a lot of experience with successful exposure treatments, but I had never worked with PTSD. And I hear some "PTSD experts" say that cognitive exposure is a dangerous process that can backfire. And according to papers I've read it doesn't always help.

In other words, assuming that one had worked correctly with the Empathy and Assessment of resistance phases: how safe and how effective is prolonged cognitive exposure with severe PTSD?

From your experience can you give examples of cases in which cognitive exposure may not be as safe or as effective? I mean are there some conditions or distorted thoughts that categorically need to be dealt with successfully before going for exposure?

For example, would there be any special considerations when working with patients with thoughts connected to shame, self-blame and hopelessness, as well as habits and addictions, or relationship issues?

Thank you

Yiftah

David responds

Thanks again!

Let's assume that you are treating a veteran who is paranoid and living alone in the woods, who tells you that he is afraid of "losing it" and blowing people away with his automatic rifle. I would not want to have him fantasize blowing people away in order to overcome his fear, especially if he is prone to violence and has poor impulse control, and is psychotic. This could conceivably trigger him to do something violent, and I'd have a hard time explain my therapy methods to the police after he kills many people in the local mall.

At the same time, the vast majority of anxious people who are afraid of doing something horrible or violent have OCD, and are totally safe. So, it takes judgment. Powerful techniques require therapists with exceptional skills, training, and thoughtfulness.

It ALWAYS pays to be thoughtful and cautious! And this has nothing to do with cognitive exposure per se, but all of the > 100 techniques that I use. They can all hurt, including empathy, if not done skillfully, and with compassion.

Backfiring occurs when therapists don't do or know how to prepare the patient for the methods you plan to use. Anytime you "throw" techniques at patients, you are asking for trouble.

Remember, TEAM is a systematic, step-by-step package that is done as a sequence. Your patient has to give you an "A" on empathy before you can even go on to the Assessment of Resistance. My experience has shown me that most therapists, including the so-called experts, do not know how to get an A grade on empathy, and may not have outstanding empathy skills.

Trust is so important in the treatment of anxiety, and always has to come first. Before using any M = Methods, you will need to address the patient's Outcome and Process Resistance, and get some agreement on what you plan to do and how you plan to do it.

Should we not use a technique because it doesn't always work? All techniques often fail. TEAM is based on "failing as fast as you can!" If you can't use a technique that sometimes fails, then you can't use ANY technique!

Also, I never treat anxiety with one technique. I use a great many techniques drawn from four very different treatment models:

the Cognitive Model
the Motivational Model
the Exposure Model
the Hidden Emotion Model

I sometimes get tired / annoyed with so-called experts who love to spout off, saying things that to my ear sound like half-truths. But then again, I do the exact same thing!

At any rate, neither Jill nor I have ever had a bad outcome with any form of exposure, but we are both pretty careful, and try hard to be compassionate and to prepare the patient. You have to be thoughtful and careful. For example, Shame Attacking Exercises can be life changing, but they require half a brain on the part of the therapist. For example, I wouldn't throw someone with poor interpersonal skills into a potentially awkward or hurtful Shame Attacking Exercise.

All powerful techniques have the potential to heal or harm. The same scalpel that a surgeon uses to save a life can also be used by a murderer to slit someone's throat.

*** * ***

Esther asks

You say there is no convincing or consistent evidence to support most psychodynamic claims about the causes of things. What you said resonates, but aren't you also just making claims? I have a psychodynamic supervisor, and am struggling to choose between empirically validated treatments and traditional psychodynamic approaches.

Hi David,

I absolutely love your stuff! I've used some parts of feeling good in my practice as a therapist and in my personal life for some time, but I've recently gotten much more into your teachings and I've been thinking a lot about TEAM-CBT. And thank you for providing all these free resources for the public!

In episode 230 (about 22 minutes in) Rhonda asked you about a common psychodynamic type of claim-

"a child of alcoholics either become an alcoholic, marries an alcoholic or becomes a therapist of an alcoholic."

You responded by saying

"people love those kinds of theories because people want to think they know the causes of things."

Then you went on to disagree, claiming that there isn't much evidence to support these types of claims.

At first what you said very much resonated with me, and yet I began to think about it and realized the irony in your response: you had explained people's tendency to come up with such theories with your own cause ("people want to think they know the causes of things"), something which I doubt you've been able to test in a research study (though perhaps I'm wrong!)

And yet what you said still resonates with me and highlights the crux of my question: isn't there any value in intuition (without any evidence) in determining the causes of things? For instance, I think your causal explanation here is highly intuitive. (Even though an alternative explanation could have involved something not inherently psychological, like "people err because they think correlation implies causation" or something.

This is not just a theoretical question for me. I currently work under a wonderful supervisor who takes a psychodynamic approach to many issues, and I am very suspicious of some his theories, but it seems that he is a great therapist. Further, I think that many people in school and in the early stages of practice (including myself) are conflicted about whether or not they wish to train further in evidence-based approaches or in a psychodynamic type of school.

I think this important question is sometimes at the root of the issue. (Although psychodynamic theories are sometimes not at all intuitive.)

For a practical example- something I always found intuitive is the role low self-esteem seems to play in people with inflated egos or the role it can play with those who have anger issues (In which the ego or anger serve to "compensate" for the low self-esteem).

When I was working with a client who suffered in these two areas, I began by educating him about this notion (which resonated with him) and we began to address his low self-esteem. Later, however, I happened across an article claiming that this intuitive notion is not supported by research. It called into question many of my intuitions when conceptualizing cases and treating my clients.

Finally, I just picked up a copy of "Feeling Great" (it's awesome, by the way!) and I noticed you talked about the hidden emotion technique. Once we're on the topic of evidence; do you have any evidence that this particular technique is helpful? Is there research backing such a technique? (I'm particularly suspicious of it given its psychodynamic flavor :)

I apologize if you've addressed these questions somewhere already- I've only just begun to avidly read your stuff and listen to your podcast.

Thank you so much!

Esther

David responds

Hi Esther,

This is an important email and if I can find the time, and may address it in an Ask David. You write:

"This is not just a theoretical question for me. I currently work under a wonderful supervisor who takes a psychodynamic approach to many issues, and I am very suspicious of some his theories, but it seems that he is a great therapist."

It's great that he is a great therapist, and it will be fun for you to learn from him. There are two caveats, perhaps. First, therapists' views of changes in the negative feelings of their patients, like depression, are not especially accurate, so his self-report of his effectiveness may not have a lot of credibility. I have measured therapist accuracy in a study at the Stanford Hospital, and found an accuracy of only 3% in detecting changes in depression, even after exhaustive, systematic interviews with patients about how they feel.

Second, most therapists have only a placebo effect, although they will strenuously insist it ain't true! And their effectiveness is almost definitely not the result of the specific tools they are using, but other factors. Many outcome studies have been consistent with this type of conclusion.

But still, learning from the wisdom of an older therapist can be awesome!

With regard to the Hidden Emotion Technique, it IS a kind of modernized psychodynamic technique. I don't think it has been studied, but I no longer keep up with research. I find it exceptionally helpful in myself (I am anxiety prone) and in about 50% or more of anxious patients. And I have found I can engage in really rewarding conversations with psychodynamic therapists when I describe this technique.

I enjoy this type of dialogue, challenging our favorite ideas. Have you ever heard of the "confirmation paradox?"

My memory is that if theory A predicts observation B, and you see observation B, you may wrongly conclude that theory A is confirmed.

For example, the theory that the sun revolves around the earth predicts that the sun will come up in the east in the morning and set in the west in the evening. So, we do see that every day, and we wrongly conclude that we have confirmed our theory that the sun revolves around the earth.

Same is true for psychological theories about the causes of depression or whatever. The problem is that your observations also confirm a large number of alternative theories that all would have predicted the same thing.

You can disconfirm a causal theory with data based on an experiment or natural observation, but you cannot actually confirm any theory in science. You can only say that your data are consistent with this or that theory, and that you have failed to disprove your theory based on your observations.

I tested many theories about the linkages between Self-Defeating Beliefs (SDBs), like Perfectionism, and changes in negative feelings over time in several hundred patients treated at my clinic in Philadelphia. The data was not consistent with causal linkages between SDBs and negative feelings, even though there were strong correlations between them at both time points, and even though changes in SDBs were strongly correlated with changes in SDBs.

david

You might enjoy this psychoanalysis poem by another Esther who is a member of our Tuesday TEAM training group at Stanford.

GOODBYE TO ALL THAT:

THE JOY OF PRACTICING PSYCHOANALYSIS

No more forms, no need for technique

No more brain strain week after week,

Ditch those methods — fifty, a hundred,

A thousand ways I might have blundered.

So long agenda, don't mention homework

Just perfect that withering shmirk.

Surveys, grades, throw them away

You know it's sex, whatever they say.

Gone for good are your twelve distortions,

Out with charts and their crazy proportions.

Is that a purse I see before me? Nope!

It's your mother's vagina. You think that's a joke?

Such progress we are making you must admit

Only ten years and we are ready to dip

Into that complex where troubles all lie

The mom you must marry, the dad who must die.

Two hundred sessions a year and each one two hundred

Over ten years $400,000! I sundered… WHAT?

I was…er… giving thought to your dream

(And the cabbage I missed doing TEAM.)

How can you say you're worse off than before

While standing in front of Enlightenment's door?

You say you've awakened to find I'm a nitwit,

& at last you're done with all of this horseshit!

Goodbye, my patient, there's the door,

A pity you are so very sore.

But let me say just one thing more —

You really are a frightful bore.

— Esther Wanning

*** * ***

Sean asks

Dr. Burns, what can you do when you are using the disarming technique and the person keeps interrupting you?

I've recently been practicing the 5 secrets and I am still learning how to apply the techniques. I listened to many podcasts and I'm reading your books/doing the exercises. I'm a complete believer in your method!

Thank you!

During the disarming, if the person continues to aggressively interrupt and ask pointed questions, how do I continue to stay engaged in the conversation? I repeat the steps. I agree/try and find the truth, paraphrase the comments, along with practicing feeling/thought empathy. The person continues to interrupt, argue, blame, and ask questions to prove their point. Do I just continue to try the secrets? In the moment it seems like it's impossible, but I stay committed.

Thanks

Sean

David responds

Hi Sean, I have often said that these abstract questions have very little value. The devil is in the details, the specific example. If you give me an example of what the other person said, and what, exactly, you said next, I will probably, or almost certainly, be able to show you what your errors were, and how you are forcing the person to keep attacking you.

However, this can be painful, to suddenly see how you are causing the exact problem you are complaining about. But also freeing.

So, the answer, in short, is that you are probably not using the Five Secrets correctly, but you get lots of credit for your efforts, and some feedback may help you.

PS Sadly, I never got a specific example from Sean. That is too bad, because abstract questions and answers never have much, if any, practical value or impact. All the learning is in the specific example, which becomes a mind-blowing learning experience.

But, sometimes people don't seem to "get" this message!

*** * ***

Ben asks

Since exercise improves the mood of some people who are feeling down, doesn't this prove that?

Hello David!

I am a frequent listener of your podcast, and am currently going through your new book, "Feeling Great". The importance of treating depression at specific moments in time, addressing self-defeating beliefs, and the death of the "self" are all topics that are of particular interest to me.

I have a question for you. You make the claim that depression & anxiety always result from distorted thoughts -- that our thoughts always cause our feelings. If that is the case, what do you make of the research that shows that aerobic exercise can be an effective treatment for them? Doesn't that indicate that there could be a physical basis for some cases of anxiety & depression?

I have certainly found exercise to be tremendous help for me in keeping my anxiety at bay -- a vigorous session of exercise just seems to "slow down" my mind or reduce the volume of the voice that's always chattering away in the background for hours afterward. Could people be getting more depressed and anxious because they simply don't move as much or as vigorously as our bodies have evolved to?

Thank you for your amazing work and the generosity with which you share it. I've recommended your podcast to many people, and will continue to do so!

Take care,

Ben

David responds

Hi Ben,

Great question. I like your critical thinking!

To test this idea, we would, of course, have to measure the positive and negative thoughts of individuals who are, and individuals who are not, helped by exercise. You cannot just assume something either way. I believe that all change in moods, regardless of the treatment intervention, is mediated by a reduction in the distorted thoughts that trigger the depression. This is a testable hypothesis.

Many people tell themselves things like, "Oh, I'm exercising now, this will really help me, I'm keeping up with my commitments to my health," and so forth.

I, for one, have never had a mood elevation from exercise. My daughter finds exercise very helpful. I suspect you will find a sharp reduction in negative thinking in individuals who are helped by exercise.

We have to be careful about jumping to conclusions about causality. I have a mild case of sciatica, and a medication like Tylenol makes the pain disappear. Does this mean that sciatica is due to a Tylenol deficiency?

I did a study with an N of 1. I asked a severely depressed man to fill out a part of a Daily Mood Log every evening. He recorded the situation, then circled and rated his feelings, and then recorded his negative thoughts and how much he believed them.

Then he flipped a coin and either jogged for 45 minutes or worked on challenging his distorted thoughts for 45 minutes. In both cases, after 45 minutes he recorded any reductions in his negative thoughts and feelings.

The days when he worked with the DML he experienced pronounced reductions in his belief in his negative thoughts and in his negative feelings. The days he jogged, in contrast, there were no reductions in his negative thoughts or feelings. analysis of the data with structural equation modeling confirmed that the change in his negative feelings was caused by the reduction in his belief in his negative thoughts.

Just a small pilot study, and could be done on a larger group. However, the researcher would have to have a sophisticated understanding of how the DML works, and how to elicit distorted thoughts from people who are depressed and anxious.

david

Ben's reply

Wow! I didn't expect such a quick and thorough reply! Thank you, David.

Love the Tylenol example. Such a powerful way to demonstrate the hazards of assuming causality, and also show me how easy it is to assume causality without even realizing I am doing so.

Your study of the severely depressed man was ingenious as well. It gave me some good food for thought about *why* exercise might be so helpful for me -- that I can't assume that it's because I've manipulated my physiology in some way. It could very well be that I end up feeling good because I have pursued a difficult activity that I value, and thus feel as though I have accomplished something. I can see why someone who *doesn't* rely on accomplishments to feel "worthwhile" or doesn't even think of exercise is an accomplishment might not get the same boost.

Indeed, there have almost *certainly* been times that I've exercised and felt WORSE afterward, but I'm mentally filtering those instances out. Like when I've gone for a run even though I was supposed to be getting dinner ready, and then the family is frustrated w/ me and hungry! ;-) I don't really get to bask in the glow of Accomplishment(tm) then!

Take care, and thanks again!

-Ben

David responds again

Hi Ben, Thanks.

I 've always said the thing about exercise raising brain endorphins was just something someone made up, but people wouldn't listen to me for the most part. I pointed that human brain endorphins cannot be measured, so there cannot be any evidence all for this theory.

I recently said an article where they blocked brain endorphin receptors in people who got the runner's high. They still got the runner's high, proving brain endorphins could not possibly be involved!

People tend to believe what they want to believe, regardless of the evidence. We see this in politics and in religion in a big way, but it is true in all walks of life.

david

Rhonda and David

Russ Harris