CBT for Hopeless Patients: Expert Tips and Q&A

CBT for Hopeless Patients: Expert Tips and Q&A

IN THIS VIDEO:

Maor Katz: I was preparing for another kind of webinar like today. It was about assigning homework, doing the best practices for assigning homework, getting the most effective results out of assigning homework to our patients. And I was preparing for it, and I went over this with Jill who you've all just heard, and she was saying ahead of time, saying, I think you have a lot of material here. Are you sure that you have enough time to cover it? And so come the day of, I got really nervous as I tend to get in these kinds of presentations, and I start talking really fast, and of course, I go through all the slides within like 30 minutes of our presentation, and then the rest was Q and A. And it was a pretty lively Q and A, and the feedback that we got was, oh, it seems like you kind of ran out of material after 30 minutes, but the Q and A portion was really nice. And so we thought, huh, maybe it's worth kind of learning from that, that a Q and A type of meeting can be very useful, meaningful to people, and more engaging. So that's kind of how we got, we got to today. And as we were thinking of what to do, I had to kind of start off this, maybe a series of here now having some of those Q and As is going to be fairly regular as part of our series every first Wednesday of the month that we provide. The thinking, floating the idea maybe, maybe doing this on hopelessness because we noticed that in our training, which we do about the Feeling Good Institute weekly, we have our consultations. A lot of the toughest cases have to do with what to do when our patients are feeling hopeless or showing signs or feeling hopeless, feeling really stuck a lot of times with that. And so when I floated that idea into the certified list, or got a lot of great responses, and then I thought, but I think we're on to something. This could be great to be able to give some, provide some help and support to the therapists out there. And this is kind of tough topic stuff for everyone. Jill, do you want to take it from here?

Jill Levitt: Yes, I do. I was just muting. Someone had complained about an echo. So when you're not speaking presenters, just mute yourself, and I think that'll help the echo. Yeah, so welcome everyone. We're excited to do this Q and A today, and we hope that you'll learn a lot. I'll just go over a couple of quick things with you, and I'm also going to introduce the presenters to you today, and to my co-hosts. If you do see Erik, you're welcome to Spotlight him and make him a co-host as well so I can introduce him. So we just wanted to say that we'll be recording today so that you all can have access to this recording, and so people who aren't present can have access as well. So if you don't want to be on the recording, then just, you know, don't, don't just hide your video, although I think the way we have it set up, you won't be on the recording anyway, but just to protect yourself, you can do that. And then if you are interested in the recording, we'll post it on the workshop page, so you can access it in the future. So just a few words about who we are at the Feeling Good Institute. So everyone presenting today is from the Feeling Good Institute, and it's our mission to alleviate suffering by nurturing elite therapists. So the way that we feel that we can best help those who are suffering in our community is to deliver really high quality training to therapists. And so the Feeling Good Institute was started by Maor Katz and Angela Prom and myself and a group of therapists who were mentored carefully and closely by David Burns at Stanford University. And we work hard to train and certify therapists in the processes of effective therapy. We train therapists and deliver therapy using routine outcome monitoring or measurement. We teach therapists really powerful empathy tools. We work on increasing motivation and reducing resistance in all of our patients. And we also teach and train and practice in the art of cognitive behavioral therapy, and the therapists who are with Feeling Good Institute are really highly skilled and vetted therapists and trainers as well, some of them. And we all engage in weekly kind of rigorous continuous improvements, so case consultation with deliberate practice so that we're constantly improving our therapy skills. We offer video-based treatment across the United States and Canada and also in person. We have treatment centers in New York City, in the Bay Area, in Canada, and in Israel. And we offer tradition outpatient therapy as well as intensive therapy where we offer therapy to patients for many hours a day, many days a week, and sometimes people come in from out of town to do intensives with us. And we're proud to have some really good loafy options as well. And Maor you need to move the slides for me. So I'm going to introduce our panelists today. I'll only say a word about myself, and then I'll focus on on the rest of our awesome panelists. So I'm a clinical psychologist and one of the co-founders at the Feeling Good Institute and also the director of training, and I've been practicing CBT. I was trying to count for almost 30 years on teaching it for almost 20 years, and I'm excited to be joined by some really fantastic panelists today. So first, join me in welcoming Maor Katz, who is a board certified psychiatrist and the director and founder of the Feeling Good Institute. And Maor completed his residency in Psychiatry at Stanford. This is where he met David Burns and was inspired by David Burns and has been kind of learning and teaching and training in TEAM-CBT since then. And he's still on the adjunct clinical faculty at Stanford. Maor really loves helping patients with addiction, anxiety, and mood disorders and also specializes in couples therapy and relationships. And he's co-authored many papers in the field of depression and mental health and has won many awards for his research and education. And most recently, Maor and Mike Christensen are co-authoring a book that's called Deliberate Practice in TEAM-CBT, which will be published in the coming months. So we're excited about that. Move on to Mike. And Mike is our next featured panelist. Mike Christensen, MACP RCC from Canada. So Mike serves as the Director of professional development at the Feeling Good Institute and plays a really key role in helping others in their growth and development to become really phenomenal therapists. His clinical Specialties include anxiety, depression, and habits and addictions. And he provides really wonderful online training and consultation with the Feeling Good Institute for therapists around the world. So I'm excited that Mike is joining us today. And then next is Richard Lam, LMFT. Richard is the TEAM-CBT certification program manager at the Feeling Good Institute. And he also teaches CBT to therapists worldwide and provides therapy and training in person and online. And his Specialties include OCD, panic disorder, and focusing on relationship problems. And Richard also hosts the Feeling Good therapist, which you can find on YouTube, where he kind of teaches and demonstrates a variety of CBT techniques and and mentorship to help clinicians and patients to learn these CBT techniques. And then finally, I'm going to introduce you to Erik Wilkerson, and Erik is a postdoctoral fellow at the Feeling Good Institute in Mountain View. He's been practicing TEAM-CBT since about 2017 after joining David Burns's Tuesday group at Stanford. And Eric also offers therapy in our low fee Clinic. He loves seeing couples, anxiety disorders, and depression. And Erik graduated from the PGSP Stanford PSYD Consortium in 2022. And a fun fact about Erik that was shared with me recently is that he's featured in something called the Sip of Conflict at San Francisco's Exploratorium Science Museum, which highlights the experience of an OCD patient. So I thought that was a cool thing. So that's our intros. I'm going to turn it over to Maor. I'll also say the plan is that Maor is going to do a presentation for us, kind of a brief presentation, and then we're going to present some vignettes to our panelists and give our panelists a chance to respond about some specific vignettes. We'd also love you to send your questions to me or send your questions in the Q and A box. So that's how you'll submit questions today. You can open the Q and A box at the bottom of your screen, submit questions. You can upvote other people's questions. And then when it comes time after presenting vignettes, I'm going to turn to that Q and A box and read your questions to the presenter. So we really hope that you'll be very interactive today through polls, Q and A, the chat box, etc.

Maor Katz: Thank you, Jill. Yeah, I want to start with a poll actually, and I'm launching it right now. So the poll is asking the question, is feeling hopeless good? Is feeling hopeless important and good for you or your patients? And as you're kind of filling of this poll, I'll share with you a story for me, for my life. It was in the winter a few years ago. I went on a ski trip with my kids up to Tahoe. And on our way, it was kind of getting dark. We got stuck in the snow in the middle of nowhere, kind of a few miles away from Kirkwood, if anyone knows where that is. And so I was of course, wasn't phased when I came out of the car, and I started jacking up, yeah, each wheel really, and putting something underneath in order to get out of the snow and be on our way. And so I did this with one, two, three, and four wheels because they're all were stuck. And then that all took me about maybe an hour and 20 minutes to get all the wheels out of the snow. And then I got into the car seat, and I, you know, moved the, start, turn the engine on and move forward two feet and sunk right back into the snow. And that, and then I was filled with complete hopelessness, and that was really good that I was filled with complete hopelessness because then otherwise I would, of course, spend the rest of, I don't know, like the night or my life or something inching forward a foot at a time for, you know, and out for each hour and a half of work. So instead, we spent the night in the car. It was actually really sweet. I was kind of scared, but my kids remember this as like a wonderful experience. And to me, this is a good way to explain why, why feeling hopelessness is important. And let me share the result with you. And so you see that some of you said yes, some of you said no, about 50-50. And of course, the idea is that it's not, the reason that I'm kind of asking this question is because it's kind of counterintuitive to think, but feeling hopeless is in any way a good thing, and it's also going to be counterintuitive for our patients, and that's part of it's going to be part of our challenge.

So as we set out to do this, do this presentation, we got, we asked in a certified listener and TEAM-CBT certified lesson, what are some challenges that you've had with hopelessness? And we got a lot of great response responses here. And seeing how the first kind of first step really is a question number one, like how to respond to someone's feeling hopeless, how to empathize with this with someone who's feeling hopeless without sounding too cheerleading, you know, without being dismissive, but it was still out also being connected and empathic. And thank you, Anne, for for sharing that. And LJ made this really a great question about kind of noticing that there's kind of a correlation between feeling hopeless and people are not doing homework. So we can see that our patients tend to not do their therapy homework when they're feeling hopeless. And then, of course, that's a big problem. And we if we just demand that they do their homework or else kind of thing, that's not going to necessarily help because what's keeping them from doing the homework maybe is just feeling quite hopeless. And there are a number of other answers, really over 20, and these are the main ones that I kind of I think capture a lot of the the challenges that the rest were bringing up. And I kind of I was kind of thinking about this one by Nancy, the how patient is stuck and learn helplessness. I think really what Nancy is saying is when people are feeling hopeless, they're really stuck, and they don't see a way out, and it's like this feeling that both the therapists and the patients get in the room of feeling quite stuck. And so what I'd like to do now is actually launch quickly another poll. And it's going to be almost my last call. But check this out. And one, this this question is which one of these patient statements or situations indicate they're feeling hopeless? And you can answer more than one. So that that's the idea is that you can answer more than one. So see if any one of them all of them some of them give us a sign that maybe those this patient is feeling hopeless. And I'll give it maybe one or maybe five more seconds or so to explain. I see a lot of you have already answered. And the point of this poll is to kind of bring to your awareness, everybody's awareness, that hopelessness has a lot of faces, and this is really kind of my first my first tip to share with you about kind of how to approach feeling hopeless is it's first to to look for it because it really looks in all these very different ways. And usually our patients are not often they won't say, hey, I'm feeling hopeless, but it's something that you might notice and you'll need to kind of help bring it to their conscious awareness. So I see that most of you kind of answered all of those. And we'll go over I think all of those in our in our Q and A and kind of how to approach all of those situations in today's today's meeting. So this is I'm going to go through now a series of six tips and that will come come together to form an approach to how to I suggest to help you approach hopelessness in the room. And the first one is look for it. And then the second thing that I want to suggest is once you notice it as a therapist, I kind of have it in my mind this kind of picture of like clearing the desk, moving everything aside and just focusing on the hopelessness until it's resolved.

Like nothing else will work basically until we figure out how to handle, how to deal, how to support patient and feeling less hopeless and more hopeful that therapy has something for them to gain from. It's easy to provide a rationale, and I would suggest you kind of practice kind of thinking about it. So here's a suggestion that I some version of it is usually what I say, kind of the reason why we're kind of pushing everything aside and putting it front and center is that that hopelessness is a self-fulfilling prophecy. And so it'll just be a complete wrench in our wheels, and we'll want to focus on it whenever we get even out with of it. And I kind of mention it because I start to start talking about is and I suggest you find your own language and whatever of this is you feel is useful for you by all means, something around getting into the patient's conscious awareness that hopefulness is a self-fulfilling prophecy and that's and and therapy won't badge you won't really progress until we kind of focus on it. Saying that for those of you who are familiar with the TEAM-CBT approach would know that Dr. David Burns always teaches us to first look at the advantages of the symptom or of in this case feeling hopeless. So then the next step after you're kind of making it to the focus, the focus of therapy comes a time to examine, take on a little bit of a paradoxical approach and examine all the good and great things that hopelessness does, you know, and we can think about it together, right? And is whether it's like just saving us some disappointment is one or like the case in um that I had and the snow up in Tahoe, which is kind of realizing that um it's a waste of energy to to do something um or uh whether to kind of communicate to others that we're having a hard time here and we need help, external help, like I needed a tow truck to come, I needed to make sure that I don't like my body was smart enough to tell me, hey, this is not the right avenue, call the towing company. And so there's all these advantages to hopelessness and that we want them to come from the patient in their own words, we just want to help them kind of start to think about it in this kind of counter-intuitive way. Once we have that list of advantages of the good things it says about us, about about the patient, the hopelessness does and what it does uh for them, then we as a therapist you have this in front of you, and you can use it as a as a devil's devil's advocate for hopelessness. So this makes the patient actually argue against the hopelessness. So if you put yourself in this position mistakenly of like a cheerleader kind of saying like, oh you shouldn't feel hopeless because it's it's a it's a total self-fulfilling prophecy, then the patient's job is stuck in being like, well, I hear you, but I think it's so you know, it doesn't help me. I actually feel quite hopeless. But if we switch it around and we become the Devil's Advocate, we've in a way force the patient to be in the role of arguing against hopelessness because if we say to the patient, hey, you sure you want to give up on hopelessness because it's really important that you don't get disappointed it's it's better to feel hopeless and disappointed again, disappointment is so painful, then they can say and they can argue back to it, no, I'd rather be uh I'd rather try I don't want to just like give up. So the idea is that you want to be the Devil's Advocate as soon as you can. And the last tip that I will share with you is to assume that it'll come back again to assume that it's it's not like so usually when when I say like move everything aside and center on that focus on that usually that takes between one and three sessions to work on or one or three hours to work on hopelessness and then we're kind of in a better place but it probably will come back two three sessions down the line and at that point you and the patient already have like a common language about it and you can kind of talk about it's like, oh I wonder if there's a little bit of hopelessness coming up again. So maybe you can take a look at that maybe kind of review our notes or the work that we did before the that was helpful. So putting it all together, here's kind of generally what what I suggest you do as an approach to dealing with hopelessness. First is look for it. And then the next step is going to be to use empathy to bring it to the patient's awareness because it's not always going to be fully aware, usually it's not. So ask kind of these kind of gentle questions that usually it's better to minimize. So to say something like, I wonder if you're feeling even maybe just a little bit hopeless or discouraged right now, is that what's coming what's going on?

And so if you're kind of minimizing it, it puts the patient in a place where like, yeah, I can kind of normalize it. Yeah, I can see that and maybe I am and then ask him to tell you more about what they're feeling. And so start a conversation about hopelessness, bring it out of them of the patient talking about it. And once you have a little bit of a conversation going and it's kind of clear that they're feeling hopeless in there they're they recognizing that as well, you want to measure it so you know what you're dealing with. So on a scale of zero to 100, how helpless are you feeling right now as we're talking about it? And then can give you a number and you can know where you're going then and they will as well how you're doing as you do some work on it. Then you go to listing the advantages of the hopelessness, feelings and once you have the list of advantages, then you can go back to the disadvantages because sometimes the patient be like, you know, that that keeps me just as stuck. I'm now not only feeling hopeless, but I'm seeing all the advantages of feeling hopeless. That means I'm going to continue to feel hopeless. And so once you kind of did all of that, then you want to go back to the disadvantages of hopelessness. And I would always favor keeping it kind of a milestone in your mind. You want to get the patient to see that it's a self-fulfilling prophecy. You want to hear that from them or kind of an or you can if if they say the words, yeah, I can see how it's a feeling it's a self-fulfilling prophecy, you can say, yeah, I see that too. Can you tell me more? How do you see it becoming a self-fulfilling prophecy? What do you mean by that? You really want to see that the patient has got kind of a buy-in, to the understanding of the problems of hopelessness, the self-fulfilling prophecy, and that kind of counteracts the the advantages. It makes them still want to kind of overcome the advantages of hopelessness to um who overcome the hopelessness itself and move forward with therapy. And once they have that buy-in, then you can go into this Devil's Advocate position of siding with the resistance and and being The Devil's Advocate and having the patient argue against hopelessness. So this is kind of pulling it up, putting it all together. And um so I'm gonna this is my last poll uh and it's kind of more like a review question just to kind of help you just think about it for a minute longer about this kind of approach that I'm suggesting. And so what I'm asking you to do here is say which one is the right is in the right order which of these options is in the right order let's give you a minute for it gonna think about what makes sense to you and I'm going to give you maybe five more seconds but I can see that that there's an overwhelming majority 91 percent are saying that it's a number two and that's exactly right. So we want to start with in your mind realizing okay let's make it the center of therapy I'm noticing hopelessness now here for my patient I'm going to make it the center of therapy I'm going to start by empathizing and bringing that out to conscious awareness and then once I can see that we're talking about the same thing I'm going to measure it discuss the advantages then the disadvantages to then be a devil's advocate to melt it away. So this concludes my yes.

Jill Levitt: I'm gonna I'm gonna interrupt you with a question since it's a Q and A and like a lot of people ask one particular question that feels super appropriate for you to address now and then we'll do the vignettes of course but so I've gotten a lot of um questions actually directed to me specifically in the chat box rather than in the Q and A about suicidality and hopelessness and I felt like it was super important for us to clarify our position on that because I think it makes people feel very anxious totally understandably but so questions such as a patient with intense hopelessness may be suicidal would the therapist be the devil's advocate in this case is this you know unsafe would we be pushing someone toward suicidality and questions about you know safety planning and I think so I'll let you kind of go ahead and answer.

Maor Katz: That's the perfect question I'm so glad you stopped me here and I think we could probably give a whole course not just one hour but probably a full course of of 24 hours or something like that of how to work with people's suicidality and hopelessness in that context as a psychiatrist I can tell you that that's in a way kind of like it's been my my bread and butter right to his work day in and day out assessing people's safety and hopelessness is certainly part of it. If you are so there's there's kind of like two parts to this it's such a complex question but there's in a way as a clinician in these situations you have kind of two hats one hat is first I need to make sure that my patient is safe like so there's this assessment, assessment is this patient safe to go about their day or do they need a higher level of care or even go on an involuntary hold and so there's like this assessment of safety that's always happening and so once you kind of check that I think they're safe I think they're safe for now then I can go on and connect with them and the question that specifically was and we could and then it would be with this approach that I'm suggesting and when you're doing kind of a a cost benefit analysis the advantages of hopelessness it's not the advantages it's never going to be the advantages of committing suicide I've never sit with a patient saying like what in in a therapy room and talk to them about the advantages of them committing suicide or the disadvantage of a committing suicide if that's the thought that I'm having I better have that in the hospital but I can have an event a conversation about something that's close to that and that's actually very apropos this first case that we have here because oftentimes part of the Hallmark of people who struggle with borderline traits is having chronics or subtle ideations and and the idea there is like same kind of thing first you want to assess is this person safe to be in an outpatient setting um or do they need a higher level of care and the set and once that is checked you can you can work with uh therapists with patients um on a slightly but a very importantly different kind of cost-benefit analysis which is what are the advantages and disadvantages of feeling hopeless and also in the case if it's even closer to societality and you know do this only with the appropriate setting and supervision but I have found myself having one of the more meaningful meetings with with some of my patients where we discuss the advantages and disadvantages of having suicide as an option in their lives like they're saying I'm not chronically suicidal don't get me wrong but I have this I'm kind of thinking about that as like I know that if things if things go terribly in my life I kind of it gives me some solace to know that I can exit and that is something that I can work with as a psychiatrist I feel comfortable working with that would be really important it could be very meaningful important work so this is even a step beyond hopelessness. Again, the point that I'm trying to drive is that you never want to be in a situation where you're doing a cost-benefit analysis for or against committing suicide. The cost-benefit analysis that you're doing is to see the advantages and disadvantages of feeling hopeless and you start to help the patient have this perspective. This feeling is something that I may be able to find a way to have some control over, some power over if I'm starting to think about it is something that I may or may not need to have almost as if I can understand why I'm having it and choose to fight back against it. That's my long answer. Really the the the the longer answer is you should probably do a whole series of course about this super challenging kind of scary, right, scary topic.

Jill Levitt: Thank you, that was wonderful. Just wanted to make sure people felt that that was adequately addressed. So that's great.

Maor Katz: Yeah, and so let's go back to this vignette and this vignette is based both kind of loosely on a number of patients that I've seen that I've worked with that were like this who challenged challenged by similar challenges and also based on the questions that people asked to be answered on on the lists of uh on the on the Lister. And so for this just to bring it to life where uh let's imagine that we're working with Anne who's 32 and she's struggling with bulimia and body dysmorphia and some borderline traits and she says to you, gosh, I'll never be able to show myself in public, right? This body dysmorphia. I'll never be able to show myself in public. My fiance is about to give up on me and you're probably ready to give up on me too. Now, before we turn this to Mike, Mike Christensen to answer some specific questions, I want you to enter in the chat box to Jill, how would you start to talk with Anne about her hopelessness? What would be some of your starting moves, empathy statements ways to get her to talk about hopelessness? I'm sure that all of you can see that Anne is feeling afraid and hopeless. That's part of what's going on and and Jill you can facilitate maybe answering you know letting me know and letting Mike know when and how to proceed.

Jill Levitt: Great, I will do that also just a reminder to people if you have specific questions um enter them in the chat box rather than the I'm sorry enter them in the Q and A rather than the chat box because I'll be looking to the chat box for answers to some of our questions and then your questions might get lost. So one person said it sounds like you're feeling pretty discouraged and somewhat hopeless at this moment. Someone else said it sounds like you might be beginning to feel hopeless. Yeah, I'm wondering if you're feeling hopeless and some people are saying provide empathy and inquire if they're feeling hopeless. So I think you're getting a lot a lot of similar connecting to the hopelessness offering empathy, you're worried that people in your life will give up on you. I wonder if you're feeling a bit discouraged and hopeless. It's hard to imagine that things will ever change.

Maor Katz: Oh, I love that what a great response.

Jill Levitt: Yeah, I can see that you're really suffering with the idea that you can't show your face or be out in public and feeling like people are going to give up on you. This must be really upsetting and maybe you're feeling like you're all alone. So we're getting lots of really beautiful empathic responses. That's fantastic.

Mike Christensen: Well, I'm already loving what I'm hearing and it really leads to the answer to that first question which is how how would you respond to Anne's hopelessness without cheerleading condescending or dismissing and I would say all of those answers would fit the bill for for me. We we empathize we connect with with Anne and some of those are really beautiful responses. I might say something like, you know, Anne, I want to pause for a moment because something you said is so important. Imagine that you're feeling maybe alone, scared, a sense of despair and feeling hopeless. And that seems obviously kind of justified considering you're concerned that you'll never be able to show your face in public and your fiancée’s gonna give up on you and thinking that I'm going to give up on you too. It's got to be incredibly discouraging and sounds painful. Help me understand what this is like for you even talking about it right now. Tell me a little bit more about what you're experiencing.

Maor Katz: I love that. So Jill, are you going to take these questions up with Mike?

Jill Levitt: Yep, and so I'll just I'm just gonna clarify one more time so put your questions in the Q and A and then your answers to our questions in the chat box and that way we can keep them separate so if you put some of your answers in the Q and A I deflected them just so that we can see clearly what your questions are so yeah Mike well I'll I'm going to ask you a question about this vignette um a couple people have asked actually can you tell us more about like what are some examples of the benefits of hopelessness you know or talked about it briefly but I have gotten a bunch of people wondering more about that so I wonder if you could maybe even just speak to what could be if you were having that dialogue that positive reframe with Anne what would be some potential benefits or positives to her hopelessness and then we could maybe go to question number two what if she then struggled to speak back against her hopelessness because that was actually in the Q and A a lot of times.

Mike Christensen: Yeah, it's such a good question and it really you need that set up ahead of time and it can be hard to think of what are the benefits of hopelessness, what are the advantages of feeling hopeless. And so when I'm working with the patient or client and they're stuck on figuring that out I actually draw from some of my own personal experience and the experience of other clients that I've worked with and lean on a couple of things one is the hopelessness actually has a protective quality to it. You know if you get your hopes up too high when you've been disappointed over and over again that seems like a bit of a setup right like when like in you've struggled with a number of things and have probably reached out in a variety of ways for help and it hasn't been helpful every time you've got your hopes up you were disappointed and so now this hopelessness that you're hanging on to keeps you a little more realistic keeps your expectations in check and so it shows that you kind of value being honest and genuine and it it protects you from that disappointment. The other thing that it can do and you know there's literally you know a number of them but one that really resonated for me when I look back on my experience of having a really difficult time was I'd been through an incredibly challenging time and was feeling really awful and if somebody said oh just be hopeful and be happy about life it would have been like dismissing the difficulty that I've been through the pain and the struggle and minimizing it and so the hopelessness in a way validated my struggle and validated the pain I've been through and it was a little bit of a self-loving compassionate way of looking at and in my life. One other one is it you know just kind of points to the fact that you value this integrity and this honesty about the situation everything isn't wonderful you're being obviously genuine and honest your hopelessness points to that and it can provide a bit of temporary relief. It can give you a bit of a break right can give you a bit of a free pass it's like oh it's not going to work anyway you know so why bother trying, can allow you a bit of a bit of a rest in the moment and when we're really struggling that rest can be a wonderful thing. So acknowledging those things is is really important it's powerful for me in in my journey and for many companies patients and clients that I work with.

Jill Levitt: Wonderful and Mike one of the questions that we got which I think is question two on this slide but that several people put in the Q and A was you know what happens if you do this kind of beautiful positive reframing that we're talking about really leaning on kind of the benefits of hopelessness in a very authentic and and warm and caring way and then you kind of as more suggested you maybe go to the other side and say yeah I'm wondering if there are any disadvantages any reasons to give up your hopelessness and what if your patient says not really you know they kind of side with the hopelessness and we did get a couple people asking that in the chat box and and in the Q and A as well.

Mike Christensen: Yeah and I'm so glad this question came up because in those moments it can feel like oh no what do I do now right yeah LED them down this road and so I think this is where for me you're you're going to really hone in on what the specific advantage is and clarify that with them and then do a little bit of measurement with the hopeless as well so if if I'm doing kind of The Devil's Advocate and saying yeah but you're hopelessness really is protective of you you're not going to get your expectations to too high and they say yeah that's right then my response would be well maybe it would make sense for you to continue to feel hopeless you said you're feeling 80 hopeless before and and maybe we'd actually want to hang on to that and and not change it. Why would you want to let that go and and then allow them to to ponder that and we want to be careful not to kind of suggest all the disadvantages other than there might be that educational piece that Maor talked about before right where we're looking at the self-fulfilling prophecy where it can undermine the work which is I think we're going to touch on a little bit later but.

Jill Levitt: Yeah and I'll ask if any of the other presenters want it you know Richard or Erik I'm going to turn to you with some other questions too but if either of you have anything else to to add to what Mike has has said please do feel free to you know unmute and and join in great.

Erik Wilkerson: You know I just love to riff a little bit on what Mike and Maor have said one of the reasons why we do the the positive reframe table, the cost benefit analysis is sort of the secret sauce at TEAM is this idea that if you come directly at a client and the symptoms or the the problems in this case hopelessness it it elicits resistance right and that resistance comes from that sort of unarticulated part of ourselves that recognizes that behavior actually serves us in important ways and so hopelessness is one of the stickiest behaviors because it does serve us even though it it kind of it's It's counterintuitive so that's the purpose of the positive reframe table and so in this moment we're a client is not arguing for change or arguing against the hopelessness, one beneficial sort of method that we use in TEAM is like sitting with open hands right like it's not my role in the sounds very untherapeutic but it's not our role to argue or convince a patient to change. Our role is to be an invitation right if you want to I will I will help make these these sort of um unarticulated reasons for hopelessness I'll help make the implicit explicit and then you can make the change or you can decide to make the change and if you don't want to make the change I'm happy to to offer empathy that's that's in itself the research shows this therapeutic right it has benefits but at the end of the day kind of sitting with open hands and I've even said like I'm here to be an invitation if you want to think and be um differently in the world I have methods that can help you and I also recognize that hopelessness serves based on what we just discussed the positive reframe table and and believe it or not that actually helps a lot right because hopeless people have heard from Mom and Grandma and their boyfriends and their spouses like I'll just just feel better right everyone's trying to push them to change but to have somebody say Hey you know you can you can be hopeless it's okay and and you tell me why why you want to change that that kind of changes the the feel of therapy and actually changes the dynamics a lot so.

Mike Christensen: I often will say you know when I think back to my journey hopelessness was my best friend and right now it's kind of yours too and it would seem cruel of me to take that away from you, so I'm right with you well tell me what what this is like.

Jill Levitt: Yeah and what both of you are saying and beautifully sad Erik is you know that we're not trying to help patients against their will right that we're only going to be effective in therapy to the extent that we're collaborating with our patients and that we have an agenda that we both agree on and so if the patient is clinging to their hopelessness and the therapist is trying to convince them away from it you know then we're at odds with each other and not going to make any progress so if we can kind of join with our patients and wonder why would you want to give it up then quite often our patients will jump to the other side and kind of argue for change.

Mike Christensen: One significant thing I just wanted to share and a little concerned about time but I wanted to share a little bit of I think this is probably the most respectful thing that we can do for our patients you know a lot of times people might feel like it's manipulative like some sort of like I guess being a little paradoxical might feel a little manipulative but I think it's also or it is actually more of a respectful thing because you really get to know someone's cultural background you understand their point of view of how they perceive the world what is important to them and who is it like as a therapist I don't know if it's my role to tell them this is not important so you should give it up and when we dive a little bit deeper we understand why this is important to them and it's up to them to convince us if this is something they want to give up too because there's a lot of meaning behind each one of these emotions and it speaks to the person that they are their background how they grew up and their their culture their religion whatever it may be so I do think this is a very important part of treatment.

Jill Levitt: Let me ask Richard sorry I know we're jumping around a little bit but I think this is the nature of a Q A that we get to do this so I'm going to ask Richard a question that he just kind of partly answered but I got several questions about this I think it's super important and I know Richard you really wanted to speak to this as well so the question is I'll state it the way Julia stated it my concern with labeling hopelessness as a self-fulfilling prophecy is it that it might diminish the external hardships or suffering that could be outside of their control for clients especially for marginalized clients people of color who face racism in the workplace and then feel hopeless so is there a way to honor these circumstances that doesn't put the onus on them entirely. So there was a concern about the self-fulfilling prophecy and just sort of how do we honor hopelessness in environments that are you know to some extent beyond the person's control I'll turn that to you Richard.

Richard Lam: Yeah I I'm so glad that that's a question in this on this training here I think it's just so important to know that every person is in different situations different economic backgrounds different um different cultures and different struggles and sometimes it kind of makes sense to feel this way and that's why when people are telling me I'm hopeless for a reason and there's so many good reasons I want them to highlight that they can feel really good about actually there's importance while I'm healing these emotions and it's kind of like a way to kind of protect myself or to motivate myself to try something different and a big part of hopelessness is there's so many good things about it personally for me I wouldn't want to give up my hopelessness completely I know Mike spoke to this a little bit but just to share a little bit with myself I came up from a really challenging background where very low social economic status and always worried about money and feeling hopeless all the time about what are the next steps when are we going to get food on our table next. And hopelessness and anxiety really helped us motivate ourselves to kind of get to the next step like what are we going to do next worry about and think about what to do next, hopelessness of things not working so therefore we have to try something different so that way we give up on that thing and try to find a different solution and a big part of this is maybe it doesn't make sense to give up hopelessness or so and it's really up to them because they know their background more than we know it they live a day after day we only know a snippet of it one hour each week and it's going to be important to understand more during this process.

Jill Levitt: Wonderful I'm gonna ask one more question or actually can you go back one there was one question that was asked a couple times, sorry yeah so the question that a couple of people asked which is the fourth question which is what if Anne said are you giving up on me because I got a couple people that in the chat box said what if the patient says so are you giving up on me when you're sort of siding with the voice of their hopelessness and then we'll do the next vignette with with Richard and Erik feel free to jump in.

Mike Christensen: Yeah this is a this is a tough one to respond to and I've had this happen in in the moment you're like oh and so once again we we make sure we're empathize and connecting with them because there's some sense that they're feeling like we've given up on them so I might say something like well in my heart just sank a little when you asked if I was giving up on you and or you've come to therapy and trusted me to support and help you and to question whether I'm giving up on you I'm I'm sensing that you might be feeling worried and frustrated maybe discouraged maybe alone and hurt and tell me what you're experiencing right now help me understand this is this is important.

Jill Levitt: Wonderful yeah so we'll want to empathize and disarm and and try to understand more about what the patient is thinking and feeling or I'll let you thank you so much Mike for your answers to many of those questions I'll let you introduce the next vignette and we'll just spend a few minutes on that and then we'll wrap up we're running out of time.

Erik Wilkerson: Yeah and I I just want to add to that previous beautiful statement or a response by by Mike to say that I probably would start my empathetic response to say in saying something like oh Anne never I'm never giving up on you you always as far as I'm concerned you always have me on your team and then I'll go into the rest of it because I think that maybe it would be a little bit harder for her to receive it without first kind of getting that relief and then okay it's not just cheerleading then let's go and talk about it. So talk about Steve is also kind of a similar case where I can think of several patients what some of my toughest patients that kind of fit this profile who is a person who's had some success in life in his career but is really is very in a very tough spot recently divorced struggling with depression and alcohol overuse and to a point where he's not even showing up at work most of the time and now every time you meet with Steve he asks for tools to battle his depression he says something like I did I did some work it didn't really help me that much I need something else and uh you've been coming back each of the past six sessions feeling just as depressed and pleading for more help with a technique that maybe is more effective and so this is a tough case right and so very suitable for Richard to answer some of those questions that kind of come up here and the little bit of time that we have Jill do you want to take those questions to Richard.

Jill Levitt: Oops sorry I was unmuted already yes, so we'll just spend a couple minutes here and then we have one slide we want to share at the end as well and we'd like people as well to go back to the workshop page and give us some feedback at the end so yeah let me maybe move to uh I'm gonna ask you question number three first if that's okay Richard just because it's more unique in terms of what we've covered so far Richard how do you think you would connect this request you know people might not even pick up on it that this kind of constant request for new tools, how would you connect that to feelings of hopelessness for this patient.

Richard Lam: I think it's kind of like the elephant in their room kind of situation where we kind of see this pattern play out of we asked them to do some homework and they do a little bit of it and they're like what's next they don't fully commit to it and I think um there's a skill that we use and some of you might know it called change the focus where we share what we've noticed in within the session and the pattern that keeps happening and just to talk and empathize about it a little bit more rather than giving more methods and then kind of going into letting them know how the treatment looks like and what we would need in order to make it successful in order to move to the next process.

Jill Levitt: Great and I think also again sometimes these questions depend on context and so you know it's very different if a patient is engaging in therapy and doing their homework and using methods and the methods we've used hasn't worked you know then maybe we're thinking we'll move on to other methods versus the patient is not really putting in effort and energy and engaging in the methods but keeps asking for new things and that feels more like a sign of hopelessness and and kind of lack of effort and connection and therapy. So how about one more question for you Richard or do you want me to go on to the next one more because of time.

Richard Lam: Yeah no we can we can I think elaborate on this question or have more one more question.

Jill Levitt: Okay great let me just see um uh yeah so actually so someone asked I thought this is a good question Richard do you I don't know if you feel comfortable answering this I can turn into someone else but would you use what we call changing the focus and then were you using sort of a gentle ultimatum we don't need to use our team language but like share more about what you might how you might address that if the maybe that's the second one but how that hopelessness is interfering with doing homework and making progress and therapy how might you address that.

Richard Lam: Absolutely I want to give a quick answer to this one but at the same time I know it's more elaborate so essentially what we would do is for example if you were if you needed surgery and you told your doctor not to use a niche like surgical tools I think that'd be very challenging and in the same way a big part of what we're doing is we're going to help them with their depression and in order to do it we have to make that or allow them to do some homework and also to give up hopelessness and how the gentle ultimatum works is I can give a really quick version of it would sound something like so Stephen just imagining we're doing our work together and I can't help but feel really sad to kind of hear what you're going through and on the other hand in some strange way or another I can't help but feel a little excited at imagining you kind of getting your life back together going to work again having extra skipping your step every day and just flip a big smile on your face and feeling really happy and now that I'm thinking about it. I can't help but I feel a little sad because I'm thinking maybe you wouldn't want that because what that would mean is you would have to give up the hopelessness and work on the hopelessness with me and also do very consistent homework of an hour a day of homework even though you don't feel like it's working you're gonna do it anyways and when I think of that I'm thinking maybe I'm asking too much of you and don't get me wrong of course my preference is that you do want to do this work and tackle this with me together and at the same time I'm also thinking maybe I am asking too much am I getting that right and it's just the gentle ultimatum in a really quick version.

Jill Levitt: Yeah and what I'll say is and we'll we'll move we'll move to wrap up here but I I want to say we have so many creative ways and we could spend many hours I think addressing this which is clear to me based on the number of questions and comments and so I'll just say and and then I'll just say a few things in closing but thank you to the presenters um we have so much to offer our hopeless patients including empathy but way beyond empathy and thanks for laying this out for us Maor we'd love to invite you all to join us next month every month on the first Wednesday of the month we'll be doing either a Q and A like this or actually a CE presentation and next month our presentation is going to include one CE it's on September 6th at noon Pacific and focusing on CBT for anxiety in children and adolescents presented by Taylor Chesney from FGI New York so we hope you can join us for that and kind of put a bookmark on the first Wednesday of the month at noon Pacific to join us every month and next slide Maor so we'd like to say thank you for joining and also just tell you a few things about what we have to offer if you're considering getting more expertise in TEAM-CBT we offer certification and training programs and if you have any questions about them you can reach out to us at certification feelinggoodinstitute.com and find our trainings on the Feeling Good Institute website if we've inspired you and you're interested in joining us at some point and interested in a career in private practice you can get in touch with Sanya and her email address is on this slide we believe in fostering a community of passionate and compassionate therapists and we'd be delighted to tell you more about becoming a feeling good Institute therapist and lastly if you know someone who could benefit from our services whether that's a friend a family member or a client you can also find therapists on our website at feelinggoodinstitute.com so we really hope that you enjoyed us today we'd love to hear from you. We can put a survey on the workshop page so if you have a moment to complete that give us some feedback let us know what you liked what you didn't like what you'd like to see more of we'd love to hear from you so thanks so much to the presenters and thanks to everyone for joining us today. We look forward to more with you in the future thanks everyone.

Maor Katz: Thank you Jill for doing a wonderful job and seeing this event