Incorporating Intensive 1:1 Therapy Sessions Into Your Practice to Improve Patient Outcomes

Kevin Cornelius, M.A., LMFT, presents Incorporating Intensive 1:1 Therapy Sessions Into Your Practice to Improve Patient Outcomes
(hosted by Jill Levitt, Ph.D.), a free 1 hour webinar. 

In this presentation, Kevin Cornelius discusses the incorporation of intensive one-on-one therapy sessions to improve patient outcomes. The Feeling Good Institute, founded by clinicians mentored by Dr. David Burns, focuses on evidence-based cognitive behavioral therapy (CBT) to alleviate suffering and elevate therapy practice. Intensive therapy involves longer, more frequent sessions over a shorter period, tailored to individual needs.

He highlights the benefits, such as rapid patient recovery and personalized treatment, but also addresses challenges like insurance coverage and therapist pressure. He shares his positive experience with intensive therapy, demonstrating significant reductions in depression and anxiety among clients.

He emphasizes the importance of setting achievable goals, consistent practice, and collaboration with other therapists. The presentation underscores intensive therapy's effectiveness for issues like overcoming social anxiety, phobias, panic attacks, and depression while considering client stability and commitment to the process.

IN THIS VIDEO:

Jill Levitt: Welcome everyone to our Wednesday webinar didactic series. And this month, we'll be having Kevin Cornelius present on incorporating intensive one-on-one therapy sessions into your practice to improve patient outcomes. And I'm just going to go through a few things with all of you, and then I'll introduce Kevin and pass over the reins to Kevin. Let me tell you just a little bit about who we are at Feeling Good Institute. So, our mission is to alleviate suffering by elevating the practice of therapy. We were started by a group of clinicians mentored by Dr. David Burns at Stanford. And our goal is to train and certify therapists in the processes of therapy that we know to be effective, evidence-based CBT, focusing on things like measurement and empathy skills, reducing resistance and boosting motivation, and then of course, the cognitive behavioral therapy methods that we all know and love. And those therapists that are with Feeling Good Institute are really highly skilled and vetted. And we all engage in a weekly system of continuous improvement and training using the deliberate practice model to practice and improve our skills kind of week over week. And we offer a variety of services to meet client needs, including video therapy, as well as in-person therapy and one-hour weekly sort of traditional therapy, as well as intensive therapy, which you're going to be hearing about throughout the hour today. And then next slide, Kevin, if I could just tell everybody, if you are here. Next slide. So now let me introduce you to Kevin. If you are here and you're hoping to get continuing education credit, make sure that you stay until the end of the hour. I will drop the link in the chat box today at 1255, five minutes to the end, so that you can complete the continuing education survey right then and there. So please, when I drop it in the chat, I'll let you know and then go ahead and click the link. It will open a new link to complete the CE survey, and you do need to complete it today. And then you'll receive the certificate of completion a week later. So you're not going to get it immediately, but we'll send it to you via email a week later if you complete the CE survey today. Next slide. So now let me introduce you to Kevin.

So Kevin Cornelius is a licensed marriage and family therapist and the intensive therapy manager at the Feeling Good Institute in Mountain View, where we provide efficient therapy using longer and more frequent individual therapy sessions condensed into a shorter period of time for intensive therapy. Kevin has been providing cognitive behavioral therapy to teens and adults for over nine years, and he was trained in the TEAM-CBT model that you'll hear a little bit about today by its creator, David Burns, at Stanford University. And Kevin is also a certified Level 4 advanced therapist and trainer in TEAM-CBT, and he provides both in-person and online case consultation and training to other therapists. So we're very excited to have Kevin lead our presentation today, and I'm going to turn it over to you now.

Kevin Cornelius: Thank you very much, Jill, and thanks, everybody, for being here. It's really great to have you here to hear what I have to say about intensive therapy, and I've got a somewhat aggressive agenda to share with you, so I'm going to get started pretty quickly here. You can see here that we've got a couple of good objectives. We want people to be able to describe the benefits of intensive one-on-one treatment, and then also to be able to understand the characteristics that could make a potential client a good candidate for intensive therapy, and I believe there will be more we're offering here today, too.

What is Intensive 1:1 Therapy?

So let's get started by talking about what is intensive one-on-one therapy, and I'll just give you a brief definition that it's therapy that's designed to provide longer and more frequent therapy sessions over a shorter time span to accelerate patient recovery. It's one-on-one, it's not group therapy, and it's tailored to the patient's individual needs, and what I'd like to do right off the bat, just to learn a little bit of something about everybody who's here today, is Jill and I have prepared this poll for you, so we're going to ask you, have you ever used intensive one-on-one therapy in your work with patients, and there's two options here, so in a moment, we'll share with you what the answers are.

Jill Levitt: Yeah, I'll give everybody a minute or a little less than a minute to just quickly answer yes or no, but I'm super interested, and that's why I'm here.

Kevin Cornelius: Yes, I like that answer. We're getting close to everybody participating. Let's see, are we sharing those results? You can see that this is actually what I was guessing would be the result. That's so funny, 25% said yes, and 75% no, but super interested in learning, so I love that, and I think that we're going to have something to offer everybody, whether you've used intensives before or not today. That's my goal anyway, but I'm happy to know that that's where we stand, and then I'm going to move on to my next slide.

Reasons Not to Do 1:1 Therapy:

So when you're considering offering intensive therapy, it's important to think about what are good reasons not to, so one reason would be that there's a lot of pressure on the therapist to really perform and deliver big results when we're doing brief goal-oriented treatment. At Feeling Good Institute, a lot of our intensives will be around an average of 12 hours over the course of two weeks. Sometimes we'll do those 12 hours even in one week, especially if somebody is traveling from out of state or from out of the country, so you can imagine that that can put a lot of pressure on the therapist to think, boy, I better deliver the goods here, and that might be a reason to consider not doing intensives. It can have a big impact on the therapist's schedule to carve out so much time for one client in a between one and three-week period.

It requires ongoing marketing because we do have a lot of turnover, since every one to three weeks we've got room in our calendar, we're always going to be reaching out, letting others know about our work, and that might not be something that you want to do. Longer, more frequent sessions take a lot of energy for both the patient and the therapist, and then managing things like cancellations, illness, or emergencies, that can be daunting.

Reasons to Do 1:1 Intensive Therapy:

Let's think about good reasons to do one-on-one intensive therapies, so I included in the handout packet that you can download from the Talent LMS, if you haven't already, about what I included in it was this research brief that I put together last year, which is on a study from 2013, where they were looking at how much therapy is needed to treat depression, and I learned a couple of great things from that study that showed a great argument for doing intensives. The study showed that the same number of hours of therapy done over a shorter period of time can lead to significant improvement in depression, and that treatment outcomes were actually worse if you took the same number of therapy hours but stretched them out over a longer period of time, like one hour weekly, and so those results suggest that intensive therapy is more effective and potentially more economical for the treatment of depression as compared with traditional once-per-week treatment, and in your handout you can also see some additional resources that I put in as far as articles that show why intensives or what's the effectiveness of intensive therapy. I'd like to talk to you a little bit about why I'm here and why I'm excited to share this information with you. So it's been a little over a year now that I've been managing the intensive therapy program for FGI, and it's been an extremely positive experience to do all of the intakes for anybody who does intensives with us and to also do the majority of the goal-setting and helping people with getting set up, and then also doing a lot of the intensives myself and also in partnership with other therapists to really see the huge impact that it can have on a person's life.

It's very rewarding, and also my own skills as a therapist have really improved since I've gotten better at being consistent with setting simple, achievable goals in all of my work with clients, including non-intensive work. I'd like to share a story with you about the first intensive that I ever did, and this would have been five years ago, and I was being encouraged by our clinical director, Angela Crum, to go ahead and take on an intensive, and I was hesitant to. I was feeling nervous about it, and I had all kinds of thoughts going through my mind leading to my anxiety, such as, what if we have all these hours scheduled and it doesn't go well? What if I turn out to not be a good fit for this client, and she doesn't like talking to me, or maybe she won't respond well to the methods that I know how to use? Lots of concerns, and I have to say that once I got into the first session with this client, that melted away, and that's because I was able to put my attention on her and learn about her and what she was there for.

We'll call her Christine. She was a 22-year-old college student who had such severe social and performance anxiety that she actually had to leave college her first semester of her sophomore year. She had to leave early and have a hospitalization because it was so bad, and so she was leaving the hospital and wanting to transition from that higher level of care to then be able to return to college for the next semester, and so that's why she was working with me, so for me, I felt a lot of pressure to do well in this intensive with her, and as I said, once I sat down with her and focused on her and her story, I was able to let go of my own fear and really empathize with her and connect, and then I discovered that I had something that I'd never had before in any of my work with patients, which was this huge luxury of time. I didn't have to wait a whole week to meet with her again. After our first two hours together, we were meeting the next day. We were able to get this great momentum going and to make huge progress in a short amount of time. She responded really well to both cognitive treatment and some exposure treatment, and it wound up being really successful. She was able to go back to school and maintain the progress that she made in treatment, so I felt really great about that, and I was really hooked on doing intensives because I felt like, oh, now I can really use what I've learned to do as a team CBT therapist, and it can be so successful when we don't have to wait a long time in between sessions. I'd like to talk to you about the results of my recent work with patients. In your handout packet, I gave you a chart record that shows 10 recent intensive therapy clients, and you can see that on average, these clients made a 65% reduction in depression and a 64% reduction in anxiety, so they were happy with the treatment, and it was quite successful.

Benefits of 1:1 Intensive Therapy:

Let's think about the benefits of doing intensive therapy:

• As I mentioned before, it can really keep the momentum moving forward and help clients make significant change.
• It can provide relief quickly.
• It's very empowering for clients because we put such a big emphasis on them learning how to use the tools that we introduce them to.
• It can be a great fit for someone who's taking a break from a busy schedule who might not otherwise have time for therapy.
• For some people, they can avoid hospitalization by doing an intensive.
• The treatment is really personalized and customized to meet this individual's needs.

We do want to discuss some limitations with billing and insurance, so I want to acknowledge that there's a problem with insurance companies often not covering intensive therapy, and it can really put a financial burden on many patients, and it can really keep some people from being able to participate in intensive therapy, and I think it's important to acknowledge that the cost of therapy and the way that our healthcare system provides funding for mental health treatment is a serious problem with a lot of nuance that I'm not going to have time to really give adequate attention today, but I will give you some things to think about when considering insurance factors. First of all, if you are in network with health insurance, the plan that you're in network with or multiple plans, you're going to want to familiarize yourself with what they will or will not cover when it comes to doing more than one hour of therapy on the same day or even in the same week. Some insurance plans, they're all unique, of course, and they have different ways that they want these things billed, so I've seen an insurance company that wanted a 110-minute session to be billed as two 50-minute sessions back-to-back, and then another company would want that to be billed as one CPT code of 60 minutes or longer for a therapy session, so you just want to check that out in advance so you don't have any hiccups when trying to get the insurance to pay. Then if you're out of network, you would want to not only discuss with the client that they will need to check with their own insurance company to see if they provide out-of-network reimbursement or reimbursement for an out-of-network provider, but also would they reimburse for more than one hour of therapy on the same day or in the same week, because we don't want the patients to be hit with unexpected out-of-pocket costs that would make this a burden for them.

Concerns that are a Good Fit For Intensive 1:1 Therapy:

There are certain concerns that we found have been a great fit for intensives, things like social anxiety, specific fears or phobias, panic attacks, generalized anxiety or chronic worrying, depression, and low self-esteem. I put on here some habit concerns, such as procrastination or other unwanted habits or addictions, but I want to point out that I would never want to give somebody the impression that we were going to provide a 100% cure to their substance abuse addiction in one week of intensive therapy. We're going to be able to make a lot of progress and give them a lot of tools to support them in their sobriety, but it's going to take more. They're going to need some social support, like a 12-step group or something, or it's an alternative. They may even need additional ongoing sessions, but the intensive could still be helpful. We just don't want to set unrealistic expectations when it comes to habits and addictions.

Clients that are a Good Fit For Intensive 1:1 Therapy:

Then we want to think about what factors would make a client a really great fit for doing an intensive:

• This would be for somebody who's stable.
• They're not in crisis.
• Their health is not in danger. There's safety.
• They're going to be willing to set specific goals for therapy and work on one problem at a time and have no hesitations about doing lots of therapy homework before, during, and after the treatment.
• They also are okay and have the stamina for participating in longer, higher-intensity sessions.

There are lots of opportunities for thinking about, really with your own creativity, about situations that would be great fits for intensives. I'll throw out some ideas, but I'm sure you all have many great ideas too. Possible clients might be a high school or college student who's on a break, a person who's getting supportive counseling with another therapist that they have a wonderful working relationship with, but that therapist doesn't use specific tools for things like panic attacks, or they might even need specific cognitive tools for depression. They would work with us briefly in an intensive and then be returned to treatment with that therapist that they already have that great relationship with to continue getting that ongoing support. We love collaborating with other therapists in that way. A person might be on medical leave and they're in intensive care so that they can return to work, or they might be leaving residential addiction treatment and they want to have a step down and address any mood problems that might be getting in the way of their sobriety. Also, somebody who's been in hospitalization for a mood disorder, they might use an intensive as a way to step down and care before they're just on their own outside of the hospital. Then some people are from an area that have very limited therapy resources, and so they may travel to you to learn skills and help themselves with their problems or habits and addictions. Of course, there's a lot more that you may think of too.

Clients that are Not a Good Fit for Intensive 1:1 Therapy:

We do want to be honest about situations where a client wouldn't at that time be a good fit for intensive therapy:

• If their safety is endangered, if somebody doesn't just have suicidal thoughts, but they also have urges, they've discussed means, they've sometimes considered a plan, they're not able to make a commitment to taking suicide off the table as an option today and in the future, we would want to address that before we would do an intensive.
• Some people would really prefer long-term supportive counseling. They're not interested in such outcome-oriented therapy.
• If somebody is actively using substances or they're dependent upon a substance and they would really need detox first, we wouldn't want to work with them in an intensive until that was completed.
• As I mentioned before, not being interested in setting specific goals is definitely not a good fit.
• For some people, a longer session would be burdensome to do several long sessions in a week.
• Sometimes people are being sent here by other family members. One thing that we really want to screen for when we're doing an initial consultation is, is this person here because it's their idea? Do they really want this or are they being in some way coerced or encouraged against their will to give a treatment? In that case, an intensive would not be a good idea. We find this often, for instance, with adolescents.

Parents see, my teenager is so depressed and I learned about this great intensive therapy program and it would be so great if they would participate. Then I'm talking to the adolescent and they're just like, I don't think I have a problem that needs to be addressed. I don't really want to do this.Then I wouldn't sign them up for an intensive. Now, we always want to include some sensitivity to diversity, equity, and inclusion. We want to keep in mind that some people, they may have a cultural background where such outcome-oriented, goal-oriented therapy might not be a good fit for them, or we may need to adapt our way of talking about goals to suit that client. Neurodivergence, I think, is a diversity concern that sometimes is ignored. We want to see how, for instance, that somebody who is neurodivergent might need to have session lengths be adjusted to really fit their needs better. Then anyone with any kind of disability, we want to be sensitive about that when we're setting a schedule for treatment. When we're thinking about DEI concerns, we always want to be flexible and sensitive and responsive to the individual needs of each person and not have a cookie cutter schedule, this is how I work with everybody.

Process of Intensive 1:1 Therapy:

What I included here is an outline from beginning to end of what happens in an intensive. I put this in here so that when you're reviewing notes later, if you're considering using intensive therapy in your practice, you can see this outline and refer to it. I'm going to go into all the details of each step as we go along with the cases I'm going to present. I'm going to kind of glide past this quickly, but you can look back at this list when you're reviewing your notes. Now, when we're bringing up the option of intensive one-on-one treatment, this can sometimes cause people a lot of anxiety. We find that some therapists don't do intensives because they don't really know how to present this idea to patients. I've got a couple of ideas for you here. We really do want to let potential clients know that this is something that we offer and why it could be a great option for them. When someone is showing some interest in intensives, it's a good idea to have a survey for them to take before you meet so you can gather some information to see if they would potentially be a good fit for an intensive. What goals would you like to achieve? Would you have to travel in order to do therapy in the state where I'm licensed? Are you okay with meeting in person or virtual therapy? What would be your preference? When do you want to get started? Those are things that kind of help us understand how we're going to work with this person. Then in the consultation, we would want to be careful to screen out any of those rule-out factors that we were talking about earlier.

Also, give the client some hope and tell them about our intensive therapy program in a compelling way that helps them see that it could be something that would be useful for them. It's a good idea to practice describing intensive therapy that we offer in under a minute so that we can do that effectively and concisely. We also would probably want to do a good job of letting other therapists that we collaborate with know that we offer this service and that we're available to collaborate with them so people start thinking of us when they think of therapy intensives. I put in here just one way of describing intensives that I've used with clients. We might say intensive therapy is a great opportunity to make a lot of change in a short amount of time. The frequency and extended length of the sessions allows us to keep momentum going and give you a powerful reduction in your symptoms. You'll come away from the intensive with skills you can use for the rest of your life whenever negative moods become a problem again. It'll be kind of like learning how to become your own best therapist and the treatment is individual and totally customized to be the best fit for you.

Now, let's talk about when we're making a treatment plan in collaboration with a client. The key to a successful intensive will be setting specific achievable goals. Let's talk about why. I found this article that I really liked that included some great research on how goals are effective in treatment. Goals can help focus and direct clients' and therapists' attention in the therapeutic work. It's very important when we're doing short-term work like an intensive where interventions have to be tightly focused to achieve results within the time limits. Setting goals for therapy may also give hope, energize clients towards their goals, boost persistence, and help them find more effective strategies for achieving their goals. Research shows that people are more likely to achieve what they want if they set explicit goals and there are better clinical outcomes that are associated with therapist and client agreement on the therapy goals. When a client comes in, they probably have some pretty large, almost vague ideas about what they'd like to get out of the treatment. I've been very unhappy. I don't want to be unhappy anymore. I'm afraid all the time. We can use a process to help boil that down to between one and three specific achievable therapeutic goals. One way to do that is to ask what's called the miracle cure question. I'd like you to imagine that we had a magic wand here that you could wave and a miracle would happen and you would get exactly what it is that you need out of this intensive therapy treatment. What would you be doing differently? How would your life be different so that you would know that this miracle had occurred? They describe to you how they want their life to be different and then that helps us translate that into the goals for treatment. We're going to want to discuss with the client the homework, the fact that we're going to be providing relapse prevention. I'll give you some more details about that in a little bit and then of course there will be additional homework when the treatment is complete. I'd like to bring this to life by giving you a case example.

Case Example of Cynthia:

We'll call this client Cynthia. A 40-year-old African-American cisgender lesbian married woman living in Los Angeles with her wife and three elementary and middle school-aged children. She's had a successful career in television writing and recently had a dream breakthrough in her career after a very lucrative script deal. In her words, paradoxically the more successful she gets financially, the more anxious she becomes about money. Recently she and her wife were looking at buying a new car as the cars they have are quite old and too small for their family. After looking at cars and getting close to buying one while at a dealership, she went into what she called an anxiety spiral that now impacts every area of her life. She pulled out of the car deal and then has been wracked with guilt, depression, and anxiety since then. When I asked her that miracle cure question, she said if the treatment was successful, I'd be able to spend my hard-earned money without becoming overwhelmed by fear. I want to lower my anxiety and depression and have skills to prevent this from happening again in the future. So when we looked at the treatment plan together, we decided that the goals for treatment then would be to learn and practice the skills for lowering and tolerating anxiety. I included tolerating there because what we're really looking at is lowering avoidance of the things that cause anxiety rather than actually focusing on, I must feel less anxious. We're also going to focus on learning and practicing the skills for lowering depression.

Then we had some pre-intensive homework, reading and doing exercises from the book When Panic Attacks by Dr. David Burns for 30 minutes each day. You're going to hear Dr. Burns' name come up quite a bit for the rest of the presentation because he created the Team Therapy approach that we're using at Feeling Good Institute. I have a tendency to lean on his books and tools because I was trained by him and I found it to be so powerful. I want to make it clear that, for you, you may have different tools that you like using and different books that you've found to be effective with your patients. I’m not saying Dr. Burns is the only way, it's just what I’ve been taught to focus on. The schedule that we set was 12 hours over 2 weeks plus 2 1 hour weekly follow up sessions and that 12 hours that number was come up with because I've learned that using our team CBT model, we can make significant progress in addressing anxiety and anxiety problems in 8 hours. And then with depression, because a lot of the skills that the client is going to learn to address anxiety, they are also going to apply to the depression problem. So we can schedule 4 hours for that. And all that's going to also include the relapse prevention that we'll do to wrap up the treatment. The 2 weekly follow up sessions are simply to maintain and build upon progress by making sure that the client is really using the tools on their own effectively. So we were going to be focusing with cognitive therapy methods, changing the way that we feel by changing the way we think. Exposure methods, facing fears and not avoiding the things that cause us anxiety in order to break free from the trap of anxiety. Resistance reducing methods. A very unique part of TEAM-CBT, they are a set of tools that help clients lower the normal human resistance to change that most of us bring with us into therapy. And I won't be able to teach you that in detail today, but I'll put it out there that there are some wonderful opportunities to learn about addressing resistance. If you do some additional training with the Feeling Good Institute. And then we would end the treatment with relapse prevention training and ongoing homework. So all of that Cynthia agreed to when we were done with our goal setting session before we would move forward with the actual intensive treatment.

Preparing to Start:

Okay, when we're preparing to start with any client, we do want to use pre-intensive homework. So books I've typically used, and other therapists at FGI would use these books probably too for depression. Feeling Great by Dr. Burns is a great option. There's also his original book Feeling Good or the Feeling Good handbook. Those would all be great options for depression. For anxiety we would probably use When Panic Attacks. For habits and addictions, there are some great tools that are available in free chapters that are available at this website, www.feelinggood.com. And then during the intensive, we're going to want to use testing throughout in order to track progress towards reaching the client's goals.

During the Intensive:

So before assessment, we would use a thorough diagnostic survey and Dr. Burns has a survey that we use called the easy diagnostic survey where we're really testing the patient for all of the most common concerns that people come into treatment for. And that's just so that we can learn as much as possible about what the patient has been struggling with and so that we can really help them find the best goals for the treatment when we're creating the treatment plan. Before and after every session, we have the patient take a brief mood survey to test for things like depression, suicidal thoughts and urges, anxiety, anger, their positive feelings, and their relationship satisfaction. We want to see change within one session and we also want to see what's happening over the course of several sessions and that can help guide the treatment and also show the patient what they've been doing, how they've been progressing in the therapy. A month after termination, it's a good idea to send out a mood survey and see how the patient has done at maintaining the progress they made.

When we're in the actual intensive, we're going to begin by focusing on empathy. So listening well, providing warmth, empathy, understanding, that's always a huge key to effective therapy and especially in an intensive because there's going to be so much focus on goals that we don't want to forget to connect with this person on a human level and have them really trust us and provide them with the kind of support and understanding that they would be seeking. So that whole initial phase of treatment is going to involve building trust and connection. And then we're going to want to work at melting away resistance to change. I mentioned before that having some skills to assess and address the resistance that we encounter in therapy has been a key to successful treatment, especially in intensives. And that's a unique part of the training that we offer at FGI. And really making our methods effective depends upon lowering resistance. So let's go back to Cynthia and talk about what happened in this treatment. So at her very first session, before that session, she took the brief mood survey and she had a 12 out of 20 for depression and a 13 out of 20 for anxiety. So that would be very strong. That's a moderate score for depression on that scale. And we spent about the first 30 minutes focusing just on empathy, devoted about 45 minutes to melting away resistance. And then for 30 minutes, we were looking at cognitive methods for changing feelings. And then we wrapped up that session by assigning homework and using post-session testing. And at the end, she had brought her depression score down by 50% to 6 and her anxiety score down 46% to 7. Still room for improvement there, but that's obviously a significant decrease that she was very excited about. And then let's go back and talk about during treatment for depression. We're going to be focusing on cognitive methods. A lot of work looking at changing the thoughts that lead to depression in order to change feelings. We're going to include behavioral methods to address the behaviors that may be exacerbating depression, like procrastination, self-isolating, poor diet and sleep habits. And then we would want to make sure that there's some pre-intensive homework that we mentioned before. If it's an anxiety problem, we're going to be focusing a lot on exposures. As I'm sure everybody has learned before, a hallmark of anxiety is avoidance. And really to break free from anxiety, we would need to end that avoidance. And so we could do that with imaginative exposure or cognitive flooding. In Vivo Exposure, that would be in real life facing the things that we're afraid of. Interoceptive exposure, which is exposure to the physical sensations of anxiety. And shame attacking exercises could be a great way of using exposure for social anxiety. We could have initial homework be involved with reading and doing written work and when panic attacks. If it's a habit addiction problem, motivation is going to be the number one priority. I mean, you think about somebody who's been struggling with alcohol use. We're asking them to give up the one surefire thing in their life that gives them pleasure. They're going to have a lot of resistance to encounter. And we're going to really need to focus on motivation as a number one priority. We could do that with a tool called the triple paradox. And I put this on here to talk about it a little bit because I want to give you an idea of what we mean by lowering resistance. If somebody came, let's say somebody came into treatment with me and they wanted, they were a high school student and they had been really struggling with procrastinating their schoolwork. And they were really falling behind and their parents were really on them. And they were just in real trouble, maybe even in danger of not graduating. If I just focus on telling them all the good reasons for them to end their procrastination and try to convince them to use the methods that I have to help them with changing. I'm probably going to encounter a nice big wall of resistance because I'm going to really hit up against their coercion sensitivity. So I would not do that. I would use a tool called the triple paradox where we would look at all of the advantages of their procrastination and all the good reasons to keep doing other things other than schoolwork. I would look at the disadvantages of getting started on their schoolwork and of all the discipline and deprivation that it would take for them to end the procrastination habit. And then look at all of their beautiful positive values that are shown by this procrastination that they've been doing. And I genuinely and honestly take the side of them not changing when we look at all these things thoroughly together. And then they're going to have to convince me why it would be important for them to end their procrastination, even though everything on this triple paradox is true. That's a lot more effective than trying to talk people into using our methods. We want to focus on the plan for day one after treatment is finished. What's it going to be like for this person when they're no longer meeting with us and they're faced with the temptations that they used to give into in order to keep using a substance or another unwanted habit that they want to change? It's most likely going to be followed up with some weekly therapy or some other form of follow-up to monitor progress and maintain change. And then I mentioned that there are some free tools on Dr. Burns's website that teach you about things like the triple paradox and other really great methods for helping patients with habits and addictions.

Ending the Treatment:

When we're ending the treatment, we're going to want to focus on relapse prevention training. When we help someone, for instance, stop believing the thoughts that caused their depression or their anxiety, they get relief from those symptoms. They bring their symptoms down either all the way to zero or close to it, and they feel this tremendous sense of recovery. That is a moment of recovery. Does that mean that they're never going to feel depressed or anxious again in the future? No, negative feelings are a normal part of life. And we actually want people to be able to experience and even celebrate some of their very legitimate negative feelings. But just because they feel sad or anxious again, does that mean that they never recovered from a depression problem or an anxiety problem? That's not true either, right? So we want them to understand that they can feel all of the full range of human emotions, including the negative ones, and still be okay. The difference is now that they've gone through their intensive treatment with us, they've got tools that they can use to help themselves so that a return of negative feelings don't have to develop into a full-blown relapse. And so the patient's been trained to know what to do when those negative symptoms inevitably return, so that they don't get sent into discouragement and despair when they do have negative feelings again. Let's wrap up Cynthia and what happened with her treatment. So there were some challenges that happened with this case. We had to extend the treatment two additional weeks because she became sick and then also had to do some traveling for work that was unexpected. So we added two hours. So instead of 12 hours initially, we had to go to 14 due to the loss of momentum by extending the length of treatment. And then we met that challenge with effective homework that she followed through on diligently, and that enabled the momentum of the progress in sessions to continue. So what I learned from that as a tip for myself and for anybody doing intensives is that schedule challenges can be handled with flexibility without derailing progress. Specific achievable homework goals can be very successful when an intensive has to be expanded. And overall, when we look at the testing before her first session and after her last session, we saw a 67% reduction in depression and a 77% reduction in anxiety. And you see that depression score of 4 and anxiety of 3 on this scale, that's really in a healthy range of between 0 and 4 for negative feelings. Because again, we're encouraging the patient to understand that negative feelings are normal. Okay. Ending the treatment with Cynthia, we gave her a treatment summary, and the full treatment summary is in your handout. But we share with her, you know, the goals, the skills that she learned, what the recommended ongoing homework will be, and then what's our follow-up plan for supporting them to maintain their progress.

Case Example of Mark:

I'm going to briefly present to you one other case to show you some other challenges that came up and also give you a clear example of setting some helpful therapy goals. This one we'll call Mark. He was a 50-year-old Caucasian heterosexual cisgender married male, father of two middle school-aged children living with his family in Irvine, and a stay-at-home dad running a small part-time business. And when he described the problem, it was that, you know, his whole life, everybody assumed he was going to be this enormous success because he was very, very smart and competent. Was he going to be a doctor or a lawyer was sort of the conversation amongst all adults around him. And then he wound up having to drop out of graduate school so that his family could move to California for his wife's career. And ever since then, he's been on this downturn of low self-esteem, struggling with depression, anxiety, and procrastination, especially since his business took a big hit during the pandemic. And in his own words, his goals were to lower his depression and anxiety, stop criticizing himself so much, and stop procrastinating. So we were able to set treatment goals of learning skills for lowering and tolerating anxiety and depression and to learn and practice skills for ending procrastination problems. So in this treatment plan, we were focusing on cognitive therapy methods, exposure, resistance melting methods, and then specific methods for helping a client with habits and addictions. And then we would end the intensive with relapse prevention training. For this particular person, you know, you can see that, like before, we would want to schedule 12 hours for anxiety and depression. And then for the procrastination, we added an additional 8 hours because that's a very different model of therapy where they would be learning new skills. So we wanted additional time for that. And then, very honestly, letting Mark know that after we're done, you know, the procrastination is not going to just disappear forever without extra work. So there may be some follow-up sessions to really support him and stay true to his new healthier habits. So what challenges did we face with Mark? Well, he was really struggling with organizing his notes during the intensive. I could just see that he was getting really lost when I was teaching him how to do cognitive therapy or to use an exposure. And so I slowed down and I focused on him teaching me how to use things. So if I showed him how to use a method on his daily mood log, he'd have to show me how to do it also so that I knew that he knew how to use the methods. And that was really effective. And it really helped him be able to focus in the sessions and get a sense of security that he was going to know how to use these tools himself when we were done. And so what I learned from that is that, you know, a big goal of intensive therapy is to make sure that the patient leaves the treatment knowing how to use these tools themselves. And we may need to slow down and make sure that the learning is happening. How did Mark do? Well, when we look before the first session and after the last session, we see a 50% reduction in depression and anxiety. He was really happy with the depression and anxiety improvement, and he did pretty well with his procrastination problem. We did need to do several sessions afterwards to maintain that progress, and he was on a good path forward when we were done.

Tips I’ve Learned from Challenges with Intensives:

So I want to just, in summary, share with you tips I've learned from challenges with intensives before we open up for questions:

• We do want to keep a pace that fits the client and slow down if necessary.
• Keep things flexible and adjust the treatment to fit each individual.
• Resist the urge to jump straight to methods. Sticking with empathy and lowering resistance before using methods is really important.
• We want to lean on homework because homework in between sessions really helps deepen the learning for the patients and makes it more likely that they'll be able to use the methods on their own.
• And insist on relapse prevention, and that's because when patients recover quickly and try to end the treatment without preparing to handle relapse, the recovery would not be likely to be maintained.

And I'll just end today by letting you know that our intensive therapy program is available for referrals. So if you know a patient that would benefit from intensive treatment with us, we would love to talk to you about that. And of course, we would like to collaborate with you and involve you by sharing with you our treatment plan and also the treatment summary when treatment is complete. Okay, that ends my material.

Questions:

Jill Levitt: We're definitely not done, but now we want to share with Kevin some of the questions that we got. Thank you, Kevin. And so just make sure, for those of you who are wanting your CE credit to stick around until the end, and we'll work on some of the questions you have for Kevin. And then I will drop the CE survey in the chat box at about five minutes until the end, and we'll continue to do questions through that timeThat was just a wonderful and thorough and kind of inspiring presentation. So thanks so much for that. Someone asked, I thought this was a great question. Do you have these kinds of results with online clients as well? Do you do online intensives?

Kevin Cornelius: Yes. In fact, I would say for those particular 10 clients, at least half of those were online, if not more. A lot of people have chosen to do online therapy, even when it wasn't necessary after the pandemic, because they found it to be very convenient.

Jill Levitt: Someone, while we're asking about that, someone also asked, I've never seen this question, but could intensive therapy be done in groups? And I mean, I think that's probably the difference between our program and an IOP, but any thoughts about that?

Kevin Cornelius: Yeah, well, I think that traditionally in an IOP, the treatment would be done in a group, right? So I think that TEAM-CBT, if we're thinking about that approach specifically, has been shown to be really great in groups. That's not what the focus of today's presentation was, and that's not what I'm skilled at doing, but I know that it seems like intensives could be done in groups. It seems like that might be a good fit for an organization to provide, because you'd need the right size space, and coordinating everything would be challenging for an intensive.

Jill Levitt: Someone also asked, Kevin, do we have data on relapse in the intensive program?

Kevin Cornelius: For our particular program, I would say we don't have that data.

Jill Levitt: I think the answer is we're collecting it, but we don't have it yet, right? So we definitely are sending out surveys months in different increments to collect that kind of data, but I don't think we have it to report on yet.

Kevin Cornelius: That's true.

Jill Levitt: Someone asked, I think you must have made a comment about intensive therapy maybe not being appropriate for a client in crisis. Someone asked if you could speak more to why that would be the case.

Kevin Cornelius: Yeah, because if somebody is actually in danger of attempting to end their life, putting them in therapy sessions that are so intense for long hours could be not a great idea. It could be actually not addressing their safety concerns. So if somebody actually has suicidal, not just thoughts and urges, but they've chosen a means and a plan, and you're realizing, oh, they've got weapons in the home. This is something that they're likely to be in danger of falling through on. Address that before you would do an intensive with them. That's what I meant by somebody in crisis. Of course, when people are coming in and they're struggling deeply with depression and anxiety, that is a form of crisis. So I don't mean that they're struggling really deeply with depression. But I mean, if they're potentially their safety is in danger.

Jill Levitt: Wonderful. We have a couple of questions about trauma. So I guess one question here is it sounds like intensives are great for anxiety and depression. Would you also recommend it for people who've gone through a recent traumatic event?

Kevin Cornelius: Yes, I would. I think that our model of TEAM-CBT is wonderful for addressing trauma. And certainly there are other methods that might not be within our model that would also be great for addressing trauma. And doing longer sessions and providing a lot of therapy in a short amount of time has been shown to be helpful for trauma.

Jill Levitt: Absolutely. And we definitely have therapists that are trained in trauma informed therapies. Someone said, and I can answer this one too. It's a quick yes, but do you also treat patients with obsessive thoughts? And for sure. And someone else made a comment about OCD being really amenable to intensive therapy. So, yes, I think when we say depression and anxiety, I think of PTSD, OCD as falling within the anxiety disorder umbrella. And definitely things that are totally amenable to intensive therapy. Someone also asked a couple of questions about homework. So people were worried, like, is there enough time for homework between sessions? You know, if you're having longer sessions more frequently, do people really have enough time to do homework?

Kevin Cornelius: They do. So, for instance, if I'm setting up an intensive for 12 hours over two weeks, I might want to space it out so that there is a day in between sessions for doing homework. So I might do like Monday, Wednesday, Friday for two hours for two weeks. But even if it's, you know, one day and then we're meeting the next day, I can give them something to work on that night before they come back in for the next session. Because the idea is we want them to get in the habit of doing something to help themselves every day.

Jill Levitt: Absolutely. And also just for people to remember that we discuss these things with people when we're sort of assessing motivation for an intensive, right? We do this with therapy too, but like we describe sort of all the benefits, but then also the hard work that's going to be involved to make sure that people are, you know, kind of willing to do the work that it takes. Not only showing up for the longer sessions, but doing some work in between sessions. Some questions about just dividing the hours. I'll end on this question. I'll also put the link in the chat box and then I'll follow up with a couple extra slides that we have at the end here. Have you ever divided 12 hours over two weeks or, you know, will you sometimes change the hours based on the needs of, you know, the patient, which I think you touched on a little bit.

Kevin Cornelius: We absolutely would. And that's one of the things that I think is most important to convey to the client when we're, you know, telling them about the treatment is that they do not have to fit into a set schedule in order to work with us. It's very customized. So I've even done intensives with someone who couldn't meet for two hour sessions because of other things going on in their life. So we did one hour, five days a week, right? And they got a lot of work out of that. I prefer to work with a longer session if I can, but I was able to be flexible and adjust to this patient's needs. So we always want to customize the treatment and the schedule to be what's just right for that person.

Jill Levitt: Wonderful. And some people were asking about specific methods, and I think I'll just say, I did put a chat message in the chat about learning more methods, attending our free webinars. So I already addressed that, but I also just wanted to add that when Kevin talked a little bit about the TEAM-CBT model, when we get to the M, as in methods, we use a variety of methods from a variety of schools. So yes, those of us who are trained and treat OCD, we use exposure and response prevention. Many of us incorporate acceptance and commitment therapy. Many of us have been trained in prolonged exposure for PTSD. So when people were asking about the methods, I think we have training from a variety of different sort of evidence-based protocols and things like that. So, Kevin, will you forward so I can cover just a few more slides before we wrap up and thank everybody for their time? But we got to most of the questions. Actually, I'll ask you one more, but you can go ahead and switch to the next slide, and then I'll cover the remaining slides. One last quick question is, if someone's working with another therapist, but they refer for an intensive, let's say that therapist is stuck, do you tend to put that pre-existing treatment on pause or hold while they work with us or you for an intensive? How do you typically manage that?

Kevin Cornelius: I've seen a couple of different things happen. So on the one hand, we would put it on hold so that the client could focus their energy on the intensive. And sometimes if you're working with two different therapists at the same time, you might be getting different information that puts the patient in an unusual and unfair position. So we would want to not have that happen. But I don't want to say that it's a hard and fast no, because sometimes someone got some real value out of going and just getting some support for what it was like for them to be in intensive from their current therapist. And that was okay. And we just collaborated with each other on that. And I let them know this is what I've been working on with this patient so that there were no surprises or any conflicts of information.

Jill Levitt: Okay, wonderful. And you can forward the next slide. I think I'll just let people know that the link is in the chat now. You should see the link. I'll put it in again. But it's in the chat box. So just click on the link to complete the CE survey now. And then in about a week's time, you will receive the Certificate of Completion. So you will not get that sooner than a week and click on the survey now. I just wanted to let people know about a couple of other training opportunities before we say goodbye. And thank you to Kevin and to all of you. David Burns and I are going to be putting on intensive training for therapists. It's three and a half days of really fun and connected training that's going to be happening live in South San Francisco as well as live streamed online. And it's 30 hours of training and 30 CE credits for therapists. We had a discount running and the discount is over, but we're kind of adding a discount for those of you who are at this webinar. So the discount codes are at the bottom of this slide. Maybe take a picture of it if you want. If you register on our website for the intensive training, you can get $100 off using the code 100OFF if you attend in person or 100OFF online if you attend online. And we'll be sending you an email following up with those codes as well. So if you don't have a chance to jot them down now, we hope that we'll get to see some of you who  are super excited about that. There'll be lots of opportunities for learning, for practice, for connecting with colleagues. It's very exciting. If I can go to next slide, Kevin, we love to see you here monthly for our webinars, this is the July webinar, we moved our July webinar up to today so we won’t be seeing you in July, we are also taking August off because we all are gearing up for this intensive. We’ll see you next in September 4th usually the first Wednesday of the month, we’ll give you your July, August off and we look forward to see you in September and will send you an email and we’ll post on our website once we have the September one ready to go, we don’t have our whole fall lineup totally arranged yet. Thank you to everybody for joining us today. Thank you so much to Kevin. We hope that you all found it valuable and that we provided you with some practical tools for thinking about what is intensive therapy and how to do intensive therapy with your patients and if you’re considering furthering your expertise in TEAM-CBT we offer CBT certification and training programs. If you have any questions about them, you can email certification@feelingoodintitute.com and lastly if you know anyone who could benefit from our services whether they are a friend, family member, a client, you can see therapists who are available at our website https://feelinggoodinstitute.com/. It's our commitment to hopefully be helpful to you and share knowledge and build meaningful connections. If you have any more feedback feel free to send an email to me or Kevin. Thank you so much for joining, thank you so much Kevin.