CBT Master Class: How Great Therapy Unfolds

CBT Master Class: How Great Therapy Unfolds | Dr. David Burns, Dr. Jill Levitt & Mike Christensen

What actually helps therapy move forward—and what unintentionally gets in the way?

In this TEAM-CBT training, you'll watch a complete therapy session featuring Dr. David Burns and volunteer Ruben while Dr. Jill Levitt and Mike Christensen provide expert commentary throughout. See how effective therapists build empathy, reduce resistance, create motivation for change, and apply CBT techniques in real time.

What You'll Learn:
• Common therapist mistakes that can slow progress
• How to strengthen empathy and therapeutic connection
• The role of Positive Reframing in reducing resistance
• How the TEAM-CBT model (Testing, Empathy, Agenda Setting, and Methods) works in practice
• Strategies for improving session flow and creating momentum for change
• Techniques for addressing self-criticism, fear of judgment, and performance anxiety

 

In This Video:

 

Mike Christensen: And well, good morning and welcome to CBT Master Class. I'm Mike Christensen and today I'm asking myself the question: What leads to significant change in the therapy room? What are the key elements, the structure, the framework that brings about a shift for our clients and our patients? Today you are going to get an inside look as Dr. David Burns and Dr. Jill Levitt demonstrate the essential skills needed to transform a real, tangible problem with their volunteer client, Ruben, who was struggling. Later in the workshop you'll have an opportunity to meet Ruben and David; they'll be here for Q&A. But I'm going to hand it over to Jill, who David often refers to as the greatest psychotherapy teacher and trainer in the world today. I concur with that assertion. I've learned tremendously from Jill and I'm thrilled to have the opportunity to work together with her today. Ladies and gentlemen, Jill Levitt.

 

Jill Levitt: Thank you, Mike. That was such a nice introduction. I'm very used to introducing myself and David, so it was lovely to have such a nice introduction from you. Welcome, everyone. I'm going to actually start with running a poll. I want to learn a little bit about who's in our audience today. So, you should be able to see the poll just asking... sometimes we have members of the general public in our audience, lots of our audience usually consists of therapists, and some of you may be joining us for the FastTrack course which begins in just a few weeks. So if you could just let us know if you're not a therapist and a member of the general public, if you're a therapist enrolled in the FastTrack course, or if you're not enrolled in the FastTrack course. Hopefully we'll have something great for all of you today. I'll just give you one more minute or 10 seconds to answer the poll. Okay, I'll go ahead and end the poll and share the results.So looks like about 30% of you are members of the general public wanting to learn a little bit about TEAM-CBT, and 10% of you are in the Fasttracrack course, and 60% of you are therapists not in the FastTrack course. Okay, wonderful. Well, thanks so much. I'm glad that you're all here today. Our presentation today is meant to be helpful to therapists in learning about how to do CBT as well as interesting to the general public. Let me welcome those of you who are in the FastTrack course. I'll just say that today is, in a way, a sort of kickoff to a course that begins in just a few weeks. Today all of you will see a therapy session that David and I did with a volunteer, Ruben. We're going to play the therapy session for you live and we're going to stop and make comments along the way. David will be here for a Q&A as well as Ruben, our volunteer. For those of you in the FastTrack course, today begins what will hopefully be a really exciting, interesting and therapy practice-changing experience for you. Today, you'll see this therapy in action and then over the next 25 weeks you'll be watching videos and learning from myself and David. You'll also be joining our live practice groups every single week to practice the skills that you're learning. You'll get 16 hours of on-demand content, lots of CEs, as well as the toolkit. Welcome, and we hope that you enjoy today as well as the next six months with us. If you are not a member of the FastTrack course, we'll let you know at the end of today how you can join if you're interested. Let me also introduce David to you. David probably needs no introduction. Mike commented to me that we probably need to update this slide; he thinks more than 10 million copies have been sold of David's best-selling book. David is one of the creators of CBT and more recently TEAM-CBT, which we'll be sharing with you today. He's really a brilliant clinician, and you'll see in the video too he has a great sense of humour, is super spontaneous, and does just a wonderful job of connecting with patients.I'm excited that you'll get to see David in action today and you'll get a chance to chat with him when we move to the Q&A at the end of the workshop today. I'll also just mention to you who we are at Feeling Good Institute. Our mission at FGI is to help therapists deliver better outcomes so that patients can recover faster and more fully. We train and certify therapists in TEAM-CBT, which is a framework developed by David Burns, and we offer a structured five-level certification path that really reflects the depth of the model. You'll learn about that today. I'll also just mention if you're a therapist wanting your CE credit and you paid for your CEs, you'll get an email today with a link to complete the CE survey. So, you're getting an email from us then you'll complete the CE survey and then you'll get your CE certificate within a week. If you didn't pay for CEs and you're here and you wanted CEs, then it's not too late. There is a link to pay for CEs in the chat box that Mike is going to drop or you can scan the barcode on this slide. I'll turn it over to Mike for just a few comments.

 

Mike Christensen: Well, our goal today is that you'll have the opportunity for four things that you're going to be learning. The first is that you'll be able to describe one benefit of measurement and symptom tracking, the purpose of testing. The second is that we'll be able to identify at least one common empathy error in therapy; what are the mistakes we make when we're trying to do our best empathy? We'll also have you learn how to explain the purpose of positive reframing in reducing resistance. Finally, we'll be looking at some methods and you'll be able to describe at least one strategy for stopping self-criticism, for being able to challenge that negative thinking that we have. Our plan today is a little bit of an overview of TEAM-CBT. Jill's going to walk us through that and then we'll get an inside look by exploring a therapy session with David, Jill, and Ruben. We'll have some time for Q&A and then we're going to do a little bit of teaching and practicing with the positive reframe where you'll get an opportunity to actually learn and practice some skills. Then we'll explore a bit more of the session looking into the methods and how they worked with Ruben there. Finally, David will be joining us for some Q&A and then you can get some insight from Ruben on what the experience was like for him as well.

 

Jill Levitt: I'll just ask you, Mike, if you can check; someone had mentioned that there was an echo, so I just want to make sure. Mike, when you're not talking, mute yourself and I'll do the same. If you all can send Mike a note if there continues to be an echo. For sure when we play the video I want to make sure there's not an echo. Hopefully we'll have fixed that. Let me just start with kind of an overview of the TEAM model. As Mike said, I'm just going to do a teaching about the model and what you're going to be learning about today for probably the next half an hour, and then we're going to get right into it by showing this video. The TEAM-CBT model is kind of a framework for how all effective therapy works. That means it's not a manual that you're going to take off the shelf; it's not a school of therapy. In fact, it's a framework for how all effective therapy works. The T in TEAM stands for testing. That is that we use measurement at the beginning and end of all of our sessions with all of our patients. This is to measure symptoms so that we know how the patient is doing and I will tell you a little more about that in the next few slides. We also measure the alliance; how our patient is feeling about us at the end of each session. That helps us to track progress over time and also to make sure that we are truly connecting with our patients, that they're feeling good about the therapy that they're receiving. The E in TEAM stands for empathy and I am also gonna teach you in the next few slides a little bit about what that means. Essentially we work really hard to connect with our patients at the beginning of therapy and throughout therapy. We don't rush in and throw CBT tools at our patients without first really connecting with them and understanding them. We also have several really developed empathy tools to help connect with difficult-to-connect-with patients and to heal the sort of ruptures that sometimes happen in therapy sessions. So, we know that measurement is essential to doing effective therapy. We know that we can't do effective therapy with our patients without empathizing and connecting with them. Then next comes what we call assessment of resistance. This is where we address motivation or lack thereof, where we try to help our patients to understand why they might be resistant and why they might not want the change that they think they're coming to therapy for and we’re going to teach you some about that today. You'll see David and I walking through some of those steps. Finally, the M in TEAM stands for methods. That's what most people think of when they think of CBT; they think of cognitive methods and behavioural methods. There's lots and lots of methods that we're going to share with you today and that you can learn if you're learning the TEAM-CBT framework. Again, as you see the session today, I do want you to be thinking a little bit about the model and I shared handouts with all of you through Zoom. On page three of the handout packet there's a TEAM session flow and you can even have that in front of you as you're watching the session today to sort of see where we are in the model. TEAM-CBT is not a school of therapy but really a structure for how all effective therapy works. It's a sequence that we follow in our therapy sessions and it is linear, and at the same time you'll see us often going back to earlier pieces. We use testing throughout our sessions, not just at the beginning and the end. When we use a Daily Mood Log, for example, we fall back to empathy. You'll actually see a moment where that happens when we're in a method with Ruben but we need to fall back and empathize for a bit. It is a sequence that we follow in therapy sessions and it's a framework that helps to keep us anchored so we always know where we are. You'll see us do a longer session today and that's what we call a double session or extended session. Oftentimes, if you set aside more time to see your patients in longer sessions, you'll see a near or a complete elimination of symptoms. Offering longer sessions with patients can make a really big difference, although not everyone is able to do that. Just to flesh out a little bit more about the T equals testing: we often note that therapists think they know how their patients are feeling when in fact they don't. There's pretty good research that shows that if a therapist does an evaluation with a patient and isn't using any kind of measurement, and then you ask the therapist to tell you how depressed or anxious the patient is and you have the patient fill out a survey, those two things are not highly correlated. It essentially means we need to use measurement so that we actually know how our patients are doing. I like to think of it like when you go to the doctor's office and they don't say, "How's your temperature today?" They actually take your temperature using a thermometer. If you turn to page eight in your handout packet... they're not completely essential for today although they are in the Zoom link. The handouts and slides are attached there, and Mike is also sharing them with you in the chat. If we look at page eight, you can see an example of a Brief Mood Survey. We say it's an emotional X-ray machine, like I said, taking your temperature. It's a quick way that we can understand how our patient is doing at the beginning and the end of every session. You'll see us start our session with Ruben actually going over his Brief Mood Survey. We ask about symptoms of depression and anxiety and suicidality etc. Then we can track changes from the beginning to end of each session. You'll actually realise when you start using measurement that sometimes patients change in really profound ways from the beginning to end of a session. That's really helpful to you in understanding what did we do in that session? What methods were exceptionally helpful? Then, of course, you'll also discover sometimes that that isn't the case. You might even think you had a great session but no change occurred. That's really good information for you to have as a therapist so that you can course correct. The goals of testing then, beyond symptom measurement and measuring therapeutic progress, is also to measure the therapeutic alliance. You can see on page nine of the handout the Evaluation of Therapy Session form, and that's kind of a therapeutic alliance measure. Again, this is a question of: How much does a patient perceive the therapist as warm and empathic? How helpful is that therapy session? I will tell you that as a therapist who usually thinks of myself as pretty attuned and connected with my patients, I have been shocked by the feedback that I get on this form in both directions. There have been times where I have thought that a patient was kind of flat in a session and that I wasn't doing a great job of connecting with them or that a session wasn't especially helpful, and then I quickly look at the feedback and discover that wasn't the case. They actually did appreciate the session, there were things that were really helpful. Then, of course, the opposite is the case. You walk out of a session, you think you're a rock star, so helpful and so connected, and then you discover in the feedback that the patient actually didn't feel that you were warm and connecting or that they weren't very satisfied with the session. This is incredibly helpful feedback. I kind of get excited when I discover that a session didn't go well because I know that if I go back in the next session and I process that information with the patient, I'm going to learn so much and I can turn this sort of alliance rupture into understanding how to do better with this patient, whether that's different methods or something I said that I need to acknowledge was hurtful or unhelpful.

 

Testing is really kind of a lifesaver. I'll move on and focus on the E in TEAM, which is stands for empathy. I'm just going to briefly touch on it, but you will actually see David and I probably do about 40 minutes of empathy with Ruben and you're going to see most of that as we show the video today. We say that empathy oftentimes will take only maybe 30 minutes with a new patient. It can take longer than that, but if you're doing a really good job of just listening, not trying to interpret or advice-give, but really tune in, oftentimes you don't need that much time. We also say that empathy is necessary; we can't do effective therapy with a patient if they don't feel understood and supported, but it's not sufficient for change. An empathy-only therapy, where you're just listening and offering support not using any kind of tools for change, is not going to bring about significant change. The specific empathy tools that you'll see us using with Ruben and that we use in all of our therapy sessions is called the Five Secrets of Effective Communication. We say empathy is kind of like the zero technique. What that means is that we're not actually trying to bring about meaningful change; we're sort of offering very little to our patients at this time, although in reality we're offering a lot. We're not trying to come across as smart or that we have all the answers to our patients' problems; we're trying actually really to just tune in to what our patient is sharing with us. We do that by using thought and feeling empathy, that is, paraphrasing what the patient's saying using thought empathy. You'll see that really clearly today in our session. Feeling empathy is wondering aloud how the patient might be feeling. "I'm wondering if you're feeling anxious or panicky or nervous" or "I'm wondering if you're feeling ashamed or embarrassed or humiliated" that's feeling empathy. We're also going to provide compassion and warmth using "I feel" statements and stroking as well, sharing with the patient, "I feel sad to hear this" or "I feel excited to work with you," but bringing ourselves to the table and connecting in that way. Stroking is where we find something genuinely kind or complimentary to say to our patients. Of course, it has to be genuine; we're not BSing our patients, but this is also a great way to connect. When we say go with the patient to the "gates of hell", what do we mean by that? What we mean is that if a patient is feeling very stressed, we don't try to minimise it. We actually are saying, "Wow, it sounds like you're feeling really overwhelmed and stressed," or if a patient is incredibly angry with a spouse or a loved one, we're going to say, "It sounds like you're furious," and we're going to really try and understand and tune in to the range of our patient's experience. David and I created this little acronym to remind therapists of what not to do during the empathy phase. We say do not preach. None of us want to come across as preaching, but what that means is we're not trying to problem solve, we're not rescuing, we're not educating, we're not advice-giving or cheerleading or helping. I would take a moment now to ask yourself: how often do you actually lead sessions or lead a course of therapy with this kind of stuff? It's so easy when you see a patient struggling and you sort of know the answer to problem solve or to rescue or to educate. It's not to say that there isn't ever a place for this in therapy. When I have a patient who's struggling with panic attacks, for example, I feel like psycho-education is incredibly helpful and I do want to give them information about what's happening in their body and how their thoughts are contributing to their feelings. However, what we want to highlight here is when we're empathising, when we're connecting, when you're in this phase of therapy, we're trying not to jump in and fix things too quickly. There's a reason for that; that is that we want to start by really understanding our patient. Then we want to move to what we call agenda setting before we would offer sort of solutions to problems. Again, you can ask yourself, if I'm sharing with someone and they jump in and tell me what they think I should do when I'm not even asking for help, how does that feel? It kind of pushes you away. We really encourage you to work on your empathy skills along with us, and that's something we focus on a lot in our trainings. Then we move along to what we call Assessment of Resistance or Agenda Setting. The A stands for Assessment of Resistance or what we sometimes call more briefly Agenda Setting. Our goal is to not only use measurement and empathise but then to really understand what are good reasons a patient may have not to change, to really kind of see the world through our patient's eyes and honour the fact that many patients are ambivalent about change. There's two types of resistance that we address, and you'll see us really addressing outcome resistance with Ruben today. Outcome resistance is: Does the patient really want the outcome that they say they want? That sounds like a strange question; of course they're coming to therapy, they want to get better. But remember that there actually are some positive things about negative emotions. I'll give you a quick example. Let's imagine you're working with a woman who has contamination OCD and she does a lot of washing and cleaning. She's got young children and she's really worried about their safety and their health, so she has all these rituals for cleaning and showering and things like that. Well, if she buys in and wants the outcome that she's asking for, that would mean she would stop all the rituals, and there are going to be some reasons she wouldn't want that. She's going to be worried that if I were to get better, if I were to no longer worry about contamination, maybe my kids actually would get sick, maybe I wouldn't be a great mom, maybe I wouldn't be protecting my loved ones. So there are lots of reasons a patient may not fully or wholeheartedly want the outcome that they're asking for, and so we spend time exploring that. We do that using many methods, but the one we're going to really highlight for you today is called positive reframing. You'll see us do it with Ruben. Mike and I will demo it and we're also going to give you a chance to practice it briefly with a tool we have that we'll share with you today. Process resistance is, even if the patient convinces you that they really want to change, are they going to be willing to do the work required for meaningful change? There we're talking about things like regular homework, coming to sessions on time and regularly, and doing work between sessions. Or we're talking about, for the example I gave you earlier, this patient is going to have to do exposure; she's going to have to be willing to not shower and not disinfect everything and sit with those feelings of anxiety, maybe even face her fears doing cognitive exposure. There's two different kinds of resistance that we address in the TEAM-CBT model, and the goal there is to anticipate and address resistance so that we can boost motivation. Reducing resistance boosts motivation. I have kind of a nice little graphic here for you, which is what happens if you don't address resistance. Again, I'd ask you to think in your therapy practice, if you're anything like me, there are definitely times where you want your patient to change more than they want to change and you start feeling kind of burnt out and frustrated and annoyed. These are tools that we have so that you don't get there, so that you're not pushing your patients to change, so that you're really just honouring good reasons not to change and kind of putting the ball in their court, asking them, "Given all these good reasons, do you really want to change?" I think those of us who are doing this in all of our sessions with all of our patients, meaning we don't get stuck in this pushing our patients to change, we end up feeling so much more satisfied about the work that we're doing. Because if patients don't want to change, I really believe that it's their right, and I'm not going to be in a position of trying to push them to change. Which means that my practice ends up being pretty full of highly motivated patients who are doing really great and collaborative work. And those who are not ready to change or don't want to do the work of change, then they're not sort of half in and half out of therapy or in a watered-down version of therapy where I'm chasing them. They actually understand that effective therapy is here and available to them if they should choose to want to do the work or if they should choose to want to overcome the symptoms fully. Agenda setting or assessment of resistance is a pretty amazing addition to therapy that I give David all the credit for. These are the questions that we often ask when we're addressing outcome resistance. It's called positive reframing. We're asking our patients to think with us about what do their negative thoughts and feelings say about them that are positive and awesome. In the example I just gave you, we could ask our patient, a mother who has contamination OCD and is showering multiple times a day, cleaning her house, not letting her children come in until they've taken off their shoes and washed their hands: "What does that show about this woman, this patient, that's positive and awesome?" It shows how much she loves her family, how important it is to her to be a good mother, shows that she values safety. We can think of so many positives to her negative emotions. And then again: "What are some benefits or advantages?" That's slightly different, but we could think that her anxiety protects her and it protects her loved ones. Positive reframing again is just an awesome tool for reducing resistance, but it also is helpful in even just sort of being mood elevating in and of itself. If we think that a patient comes to therapy having a lot of negative emotions and also feeling shame or embarrassment about the fact that they're struggling... so many people come to therapy wanting help and also feeling badly about themselves because of their anxiety or their depression. They think they should be feeling differently. But if we actually help them to sort of honour the good reasons to feel the way they're feeling, in a way we're replacing these feelings of shame with feelings of pride, and that actually helps people to feel better right away. It's not BS; we're being completely sincere. And it's not all the work that's needed; if someone is struggling with depression and we help them feel proud of their depression, they're not done, they're not cured. But it's definitely getting them part of the way there. You no longer feel defective or broken or hopeless and we can let go of that resistance to change, which means that all of the methods that we end up bringing in will work that much better and that much faster without resistance or reluctance in the way. The M in TEAM stands for methods. That's what many people think of when they think of CBT: cognitive methods, behavioural methods, interpersonal methods. There actually are probably 50 to 100 methods that we have available in the CBT model and you'll see us use many methods today with Ruben. We're just addressing one particular type of problem so we use just a handful of methods today, but the methods really vary depending on the problem that we're helping with. There's relationship methods, there's methods for dealing with anxiety, there's methods for dealing with depression, low self-esteem etc. We've also found in our experience that if you do excellent assessment of resistance, if you're doing positive reframing, if your patient is arguing for change rather than against it, that oftentimes only a few methods are needed. You'll see in the session that we do with Ruben today we do identify the distortions, we do externalisation of voices, we do the feared fantasy, we use "be specific", we do a survey technique... I mean we probably use five to 10 methods that you'll see in the session today. You'll see a total elimination of symptoms over the course of just one therapy session using just a handful of methods. I'm guessing that many of you know about the cognitive model, but I will just very briefly share with you what that is. The cognitive model, which we will definitely be using with Ruben today, is the idea that it is thoughts and not events that trigger negative emotions. What does that mean? It means that if there were two people that went into exactly the same situation and they had a different set of thoughts... let's say there were two students and they had both studied exactly the same amount for an exam and they had a full grasp of the material. One student was going into that exam thinking, "I got this. I know my stuff, I'm going to rock this." How do you think they're going to be feeling? Confident, eager, enthusiastic, positive, excited, even proud. If a different student had studied exactly the same amount, knew exactly the same material, but was saying to themselves something like, "I didn't study enough. I should know more. I never do well on tests. This is super important; if I don't do well on this I'm not going to get into a good college." Ask yourself how would they be feeling? Anxious and nervous and insecure and maybe depressed. Yet the facts of the situation are exactly the same. We know that what we tell ourselves at every moment of every day impacts how we feel. So the cool thing though is that if it is true that our thoughts drive our feelings, then if we can look at those thoughts and actually challenge and change them, then we can change the way that we feel. You'll see us do that work today. What's also really neat about the cognitive model is that emotional change can happen instantly. I've had this in therapy sessions with patients all the time; the moment that a patient realises that a thought they have is not true, it's distorted, it doesn't make sense, it's not accurate, they instantly feel a shift in emotions. You'll see that today as well. You'll see light bulbs go off; you'll see Ruben go from feeling kind of tortured to feeling really light and happy and enthusiastic. This kind of sudden or rapid change that happens when you crush a distorted thought is really an exciting part of the cognitive model.

 

I'll also just share with you one of the methods that we'll use today, and that we always use with patients to sort of start to see how thoughts are not accurate, is called "Identify the Distortions". If you look at page five of your handout packet... this is actually the bottom of Ruben's Daily Mood Log. You see a list of cognitive distortions. These are really thinking errors that we all make at times: all or nothing or black-and-white thinking, overgeneralisation etc. I want you to keep in mind this idea that if we can take a negative thought like... one of Ruben's thoughts, kind of a performance anxiety thought, is "I'm wasting people's time." If we can see that that is, for example, a mental filter—I'm dwelling on the negatives rather than the positives, I'm only seeing what I'm not doing well rather than what I'm doing well. If we can see that it's emotional reasoning—I'm telling myself that just because I'm feeling insecure, but there's really no evidence for it. Identifying distortions in our thoughts is kind of usually the first step we use with our patients to start to unstick their thinking. The other thing I'll just mention on this slide is that we also do this method slightly differently than we used to. We don't just say, "Identify the distortions." We say, "Explain the distortions to me." We put the patient in the role of teaching us. "Yeah, I agree that is mental filter, but why is it mental filter? Explain that to me. Why is telling yourself 'I'm wasting people's time' mental filter? What are you missing?" And then the patient can explain to you why that's mental filter. "Well, because I don't even know what others are thinking of me and because people have told me before that they find my teaching interesting, because people keep coming back to learn from me, because I'm really only paying attention to what I might not be doing well rather than all the skills that I have to bring to the table." If a patient can explain the distortion to you, they're already partway to kind of untwisting their thinking or generating rational thoughts. That's why this method can be really helpful. You'll see us use "Explain the Distortions" with Ruben today. Just to sort of bring the methods section to closure, something that's really important when you do cognitive therapy is that you're helping patients to generate new alternative thoughts. That new thought, which we sometimes call the positive thought or the rational thought, it has to be completely true. If a patient has a negative thought like "I'm a loser" and then their positive thought is "I'm a winner" and they don't actually believe that, then it's not going to be helpful to them. Or if they have a thought "I'm not a good teacher" and then they have a thought "I'm a fantastic teacher," it's probably not going to be very useful because they don't believe it 100%. We're not looking for BS; we're not looking for make yourself feel better. We're looking for new positive thoughts that are 100% true. We check in with our patients: How true is this thought from 0 to 100? How much do you believe this thought? The other point is that, of course, the positive thought also has to address the problems with the original negative thought. They can't be irrelevant; it can't be "the sky is blue." That's true, but it's not really helpful. That new positive thought actually also has to put the lie to the original thought. The moment that the patient can realise that that negative thought is not true, they will feel considerably less anxious and depressed. We check in with them on the change in emotions using the Daily Mood Log, which you'll see us do with Ruben as well. I'm going to shift gears a little bit and actually share with you a little bit about the story of Ruben. Again, as Mike explained, what's going to happen today is we're going to show you part of a therapy session that David and I did with Ruben. We won't be leaving out any of the session but we'll start with testing, you'll see us move to empathy, and we'll start to address resistance. Then we'll pause the session and we'll take questions from you guys about what you saw about the model and we'll teach a little bit and practice a little bit. Then we'll watch the remainder of the session which focuses on the M in TEAM for methods.

 

Who is Ruben? David and I have been leading a therapy training group on Tuesday evenings. David's been leading it for more than 20 years and I had been leading it with him for the past 18 years. We work with therapists on learning the TEAM-CBT model and Ruben's been a member of the Tuesday group for many years. Ruben actually was starting to be what we call a small group leader, so he was actually facilitating breakout groups and helping clinicians and teaching and leading. If you know Ruben, you would think he comes across as articulate, caring, and very thoughtful. But it turns out that Ruben was really suffering and few of us were aware of that. Ruben had reached out to David and I to say, "I've been struggling with some sort of performance anxiety, anxiety about myself in group, not feeling confident, not feeling good about myself in the group, and I wonder if I could do some personal work." Part of our training group involves having therapists put themselves in the role of being the patient and work on ourselves. We can't really help our patients if we've never helped ourselves. Ruben was feeling really anxious, inadequate, and self-conscious. You can see Ruben's Daily Mood Log on page four of your handout packet. Ruben shared with us that the upsetting moment or event—and you're going to see this unfold in just a moment—was leading a small group. Now, he had had an experience where he was leading a small group with David's supervision. Imagine you're trying to lead and support therapists in therapy skills and then your mentor or guru, David, is in the group alongside you. Ruben was feeling very, very anxious, but also Ruben shared with us that this is not just a one-time thing; this is something that comes up for him: feeling anxious, feeling like he should be better, feeling in particular that his speech is slow and that he often sounds foolish or ignorant or boring. He was feeling kind of judged and criticised—not that David was judging or criticising, but he was feeling anxious about being judged or criticised by David. He was worried people would be bored, and then also had this kind of fear that many of us have that we feel like we should sound smart or people will think we're a fraud. I won't go through all of it with you. You're going to get a chance to see it, but this is just to give you a framework, but you're going to see Ruben talk about sort of what he’s been struggling with in the video. I'll just let you know we jump in a little abruptly when we watch the video. David and I are just clunkily going through Ruben's Brief Mood Survey, which he had shared with us before. Also something to be aware of when you watch the video is this is taking place in front of a live audience in front of the Tuesday group. Later on in the video you'll even hear us allow some Tuesday group members to jump in and be a therapist as we use the method "Externalisation of Voices". Let's watch the first part of Ruben's session.

 

Jill Levitt: So Ruben has on the Brief Mood Survey zeros on most of the depression items, just one on somewhat low self-esteem but otherwise zero. Just a one on the depression scale and a zero on the suicidal scale. Ruben has just four ones on the anxiety scale, so a total of four; a little somewhat anxious, worried, tense, nervous. Then just one on the anger scale, so just checked off somewhat annoyed. Not a lot of symptoms, right? Just one in depression, four in anxiety, and one in anger. We'll ask Ruben more about that. On the positive feelings scale, Ruben has twos pretty much down the row, moderately on all these, so like a 20 out of what would be a possible 40 on the positive feeling scale. So, definitely room for improvement in terms of feeling really great. He didn't fill out the relationship satisfaction scale.
Dr. David Burns: I notice that your scores tonight are much improved over the scores on your Daily Mood Log, which of course you filled out a couple of weeks ago. Can you just tell us a little about that? Because at that point the anxiety was 70 out of 100, which is pretty high, and the shame was 30, and then feelings of inferiority and inadequate and defectiveness and so forth was 80—that's pretty intense. Feeling rejected was 40, and then feeling embarrassed and foolish and self-conscious was a 70—that's pretty darn strong. Frustrated and stuck was 30, and resentful and upset was 30. Would you say that some of these feelings have improved from that time?

 

Ruben: Well, so the Daily Mood Log I was filling out for a specific situation. I think the anxieties that I'd love to work on seem to be, at least for me, very situational. I would say right now I'm not feeling very anxious, but occasionally, especially if I'm in a context where I'm supposed to perform in a certain way in front of people that I admire or authority figures or large crowds, I get a lot more anxious. Now, I know that there's a big group and I'm starting to... as I'm talking now, I'm starting to get more anxious thinking about all of the people listening. But I would say this feels like a little bit different of a context and so my anxiety isn't quite as severe as in the Daily Mood Log.

 

Dr. David Burns: Well, tell us more about your anxiety. We care greatly about you and your topic of getting anxious in groups and public speaking anxiety, of course, is near and dear to my heart. So I'm really eager to hear what you have to say and what you've been thinking and what you've been feeling and experiencing.
Ruben: Thank you. I think especially in situations where I'm in front of a group of people and especially including somebody I really admire—David Burns, for example, or a professor that I'm hoping to have a good relationship with—I start to feel pretty intense anxiety. Especially if there's a performative aspect to it, like the event that I chose in the Daily Mood Log was leading a small group under David's supervision. I put a lot of pressure on myself to perform and have this notion that if I don't perform, bad things are going to happen and this person that I admire will reject me. I need to be extra careful what I say and make sure that I do everything right or I'll be rejected and that will make me worthless. I'm kind of getting into some of the thoughts already, but there's this fear of failing in front of people I really admire or authority figures.

 

Dr David Burns: Go Ahead.

 

Ruben: I was just gonna say there's a speaking element to it as well where, as the anxiety increases—and it's happening a little bit now—I'm kind of searching for words and I start to blank out. There are these kind of long pauses where I freeze and kind of choke a little bit and I can feel the heat rising into my face and the butterflies-in-my-stomach sensation. And then it's like, "Oh, you must pick the right words." But then the right word doesn't come and then I'm making these long pauses and then I'm worried that people are going to get bored while I'm searching for the right word. You might be able to tell that it's happening right now, which is probably appropriate.

 

Dr. David Burns: I'm really fascinated by what you're saying, Ruben. Of course, I'm writing everything down and I assume that everyone is writing down what you're saying so that we'll have some specifics to work with. You said that one of the thoughts that comes into your mind is that you must speak the right words and if I don't speak the right words, then people will get bored and reject me. What will happen?

 

Ruben: Sometimes either people will get bored and reject me or they'll realise that I'm a fraud and they'll see that I'm worthless.

 

Dr. David Burns: Can you spread it just a little bit?

 

Ruben: I think sometimes when I get anxious I speak faster and then I forget the words and I speak slower.

 

Jill Levitt: So people will get bored and reject me, or people will realise that I'm a fraud and that I'm worthless.

 

Dr. David Burns: And all of the above, I believe. Right?

 

Ruben: Yeah, totally. Yeah, Exactly.

 

Dr. David Burns: And to what extent might you be feeling this right at this moment?

 

Ruben: Right now, I'd say probably 65-70% anxious.

 

Dr. David Burns: Okay.

 

Jill Levitt: If I could clarify what I heard Ruben saying, which I totally understand and relate to. Tell me if I'm summarising this correctly, Ruben is like you know, and it did come up now in this context, but in the beginning you were saying, "I don't feel it as much now because there's not an expectation that I'm teaching something or that I'm supposed to say something brilliant or articulate or that you're all supposed to learn from me." When you're doing something performative where there's clearly an evaluative component to it, doing it well or not well, right or not right, is when the anxiety is really high. Being a small group leader is one of those instances for you, whereas this is in a way more a moment of vulnerability. There isn't really a right way for you to perform in this situation. My understanding is that's why you were feeling a bit less anxious in this situation than you would be when you would be leading or teaching. Am I getting you right?

 

Ruben: Yeah, 100%.

 

Dr. David Burns: So, the expectation to perform is like a big amplifier that makes it even more intense.

 

Ruben: Yeah, Exactly!

 

Dr. David Burns: Beautifully expressed. When you have that thought that "I must speak the right words," how believable is that from 0 to 100 in those moments?

 

Ruben: In those moments, it feels 100% true.

 

Dr. David Burns: A 100% and then "If I don't, people will get bored"?

 

Ruben: Yeah! will get bored or will judge me. The “people will get bored” that's pretty high, probably 90%.

 

Dr. David Burns: And you just added a new one in there: "They will judge me." Right?

 

Ruben: Yeah, that's right.

 

Dr. David Burns: How strong is that belief in the moment?

 

Ruben: I would say it's 90%.

 

Dr. David Burns: Right. And they'll realise I'm a fraud and worthless? How strong is that one?

 

Ruben: Also probably 90%.

 

Dr. David Burns: I don't want to get overly numerical because I realise this is your heart and your life, but how strongly do you believe those thoughts in this situation right now? Like "I must speak the right words"?

 

Ruben: It's not quite as strong, but it's definitely up there, maybe 70%.

 

Dr. David Burns: Okay great! And "If I don't, people will get bored"?

 

Ruben: That's 75, probably.

 

Dr. David Burns: And "They'll judge me"?

 

Ruben: That's probably 80% right now.

 

Dr. David Burns: That's still pretty high even here and that "I'm a fraud and worthless"?

 

Ruben: Probably 60% right now. I would say in the performative scenario, probably higher, more like 90%.

 

Dr. David Burns: Sure. And the way you're feeling right now is 65 to 70% anxious, is that fair?

 

Ruben: I think I get less anxious when you guys are talking and more anxious when I start to talk more, so it kind of ebbs and flows a little bit. But yeah, overall, probably like 60.

 

Dr. David Burns: Like a roller coaster ride.

 

Ruben: Exactly.

 

Dr. David Burns: And how ashamed are you feeling right now?

 

Ruben: Right now, I think I'm getting a little more comfortable, so maybe not too strong, maybe 30%.

 

Dr. David Burns: How about that inferior or inadequate or defective or incompetent?

 

Ruben: Probably 50%.

 

Dr. David Burns: And how rejected do you feel?

 

Ruben: 0%.

 

Dr. David Burns: Well, that's nice. How embarrassed and foolish are you feeling?

 

Ruben: Probably 60%.

 

Dr. David Burns: That's way up there. Any discouragement?

 

Ruben: I don't think so. I think that's zero.

 

Dr. David Burns: How about frustrated or stuck?

 

Ruben: Maybe 10%.

 

Dr. David Burns: That's pretty low. And then how Resentful or upset?

 

Ruben: 0%.

 

Dr. David Burns: That’s Interesting. A little of this is going on right here in the group. I'm going to just pass the baton over to you, Jill, for a bit. That was beautifully stated, Ruben, and thank you for that. I have one last question before Jill takes over. Jill often says that shame requires secrecy. You're being quite open at the moment. Is that part of why some of your feelings are not as intense? I'm just speculating.
Ruben: No, I think that's exactly right. Coming into this planning to be very open about the anxieties... in those performative situations, I'm not necessarily open or vulnerable about the anxieties. On top of that, I'm trying to conceal that I'm feeling anxious and want to appear that I'm in control. So I think that's definitely part of it.

 

Jill Levitt: The "controller" and "to be cool and awesome".

 

Ruben: Exactly. I have noticed that a little bit of self-disclosure when I'm in those scenarios, like saying, "I'm actually feeling pretty nervous right now," can be really helpful to alleviate some of that.

 

Dr. David Burns: Has this been with you all your life, ever since you were a little boy, or was there a particularly traumatic event that might have been humiliating for you?

 

Ruben: I think the desire to impress and the fear of disappointing authority figures or people I admire has been with me as long as I can remember. The public speaking and speaking in front of people got noticeably worse in college after I gave a wrong answer in front of 100-200 people and was very embarrassed by that. I think participating in crowds and speaking in front of people got worse after that.

 

Dr. David Burns: Can you tell us a little bit about what that was? Was it a class?

 

Ruben: It was a class of probably 100-200 people. They have these poll questions, and I was the only one to raise my hand. For each option they say, "Whoever thinks it's this option, raise your hand." I very confidently raised my hand for the wrong answer and I was the only one in the whole room who raised my hand. I was sitting in the front row and the professor looked at me and said, "Oh, I admire your confidence." Then another option came up and everyone else raised their hands and it turned out the response that I gave was completely wrong. I felt like the eyes were on me from everybody else in the class.

Dr. David Burns: Was there laughter or reaction from the other students or was it mainly something you experienced internally?

 

Ruben: This was a long time ago. Honestly, when the professor said, "I admire your confidence," I think there might have been some laughter there. That might have contributed to my anxious and embarrassed feelings.

 

Dr. David Burns: Like he was making fun of you.

 

Ruben: Yeah, I think so.

 

Dr. David Burns: Do you have any memory of what the question was about?

 

Ruben: It was a microbiology and biochemistry class, something related to that.

 

Dr. David Burns: We’ll let you, to take over here a little bit if you're ready to jump in, Jill.

 

Jill Levitt: Well, Ruben, I just want to say I'm glad that you're reaching out and sharing this part of yourself with us. I have known you for a little while now in the Tuesday group and we'd never have guessed that you were socially anxious. We'd never have picked up on that. While I'm not happy to know that you've been struggling, I'm honoured that you're sharing this really vulnerable, private side of yourself with us. I feel sad to know that in small groups, in places where you're teaching or asked to perform and be evaluated, you can feel anxious and worried and feel like you're grasping at straws for what to say and have that "mind going blank" feeling that many people have when they're intensely anxious. Butterflies in your stomach... and then, of course, when you start to notice that you're anxious, then you're distracted by your anxiety and then the cycle intensifies. Then there's also this worry that you have about others. Internally you're anxious about the fact that you're anxious, and then externally you're worried that other people are bored or that they're judging you, that they're thinking negative thoughts about you like you're a fraud or you're worthless. It sounds like you're really feeling very judged by others in that situation.

 

Ruben: And also that I'm wasting people's time. I think that's a big one too that I didn't mention explicitly. "I don't deserve to be here" as the group leader.

 

Jill Levitt: They sound like really painful feelings. It sounds like it really detracts from what could feel like an enjoyable experience of teaching and learning and growing and connecting. Instead you're feeling really stuck in your head and anxious and worried and concerned about how you're coming across to other people. I maybe skipped one important part, which was also a piece that you were talking about when you're interacting with authority figures. It's especially worse when you're around people that you really admire or look up to like David. You feel even more afraid of failing in that context.

 

Ruben: I've noticed it seems to be especially or more common with male authority figures or male figures that I admire. I was also initially quite anxious in your small group and I think I go through ups and downs in that context as well. There are some small groups where I feel relatively confident about the material and maybe I know the people in the group a little bit better, and then I'm less intensely anxious and I'm able to enjoy a little bit more.

 

Jill Levitt: So there's definitely different levels of comfort. Could we check in with ruben how we are doing in terms of empathy? Tell me what you think?

 

Dr. David Burns: Please, do it Jill.

 

Jill Levitt: So Ruben, how are we doing in our connecting with you? We definitely like to make sure that we're doing a really good job of understanding you, that you're feeling supported and feeling warmth from us.

 

Dr. David Burns: One is thought empathy: how accurately are we understanding how you're thinking inside? The second is feeling empathy: how accurately are we grasping and understanding how you're feeling emotionally as a human being? And then the third is to what extent are we creating feelings of warmth and acceptance and compassion and caring? That intangible human trust and surrender dimension. If you could give us a grade in each of those, that would be helpful.

 

Ruben: I think it's an A+ in all categories, except maybe thought empathy which is an A. The only thing that I would add is that there's often a pretty intense compulsion to check and recheck that I'm doing the right thing. There might be a flavour of what feels a little bit like OCD tendencies there that I maybe hadn't fully expressed.

 

Dr. David Burns: That sounds really important. "I want to check and recheck that I'm doing the right thing." Is that something that you check with other people or more of an internal checking?

 

Ruben: More of an internal checking. Although I often have a strong impulse to apologise or qualify what I'm saying. If I said something that I feel is stupid, there's often an impulse to correct that or apologise for that. "Attack before it happens."

 

Dr.David Burns: It's just  "Attack before it happens."

 

Ruben: Yeah, Exactly!

 

Jill Levitt: I'm glad you said that. So you're saying A+ on feeling empathy and warmth and thought empathy was an A because of that part you hadn't yet shared. You feel a compulsion to check and recheck that you're doing the right thing. Does that mean if you were a small group leading, you're checking with the group if they understand what you're saying? How are you literally checking and rechecking?

 

Ruben: I think I probably check more than I should for understanding. Maybe part of it is internal where a word comes and then I think, "No, that's not quite the right word," and then I keep searching for a word that is just the right fit. Then often I get anxious and forget what I was talking about entirely.

 

Dr. David Burns: Does this affect you almost all the time, or only if there's an authority figure? If you were teaching fourth graders, would it be much less?

 

Ruben: Much less in front of fourth graders, I would say. Still to some extent there, especially if it was material that I'm not super familiar with. It's especially in high-stakes situations, but it's similar if I have to write an email to an authority figure, for example. I'll often reread it and it'll take me a long time to go over what I've said to make sure it's perfectly clear and it doesn't make me seem foolish.

 

Jill Levitt: OCD can be very vicious and very irrational. It can have us get stuck in lots of irrational thought loops for sure. Very painful and life-destroying. I hear you saying there's sort of a touch of that, a way in which you're certainly doing that mental compulsion of checking and reviewing and thinking really thoroughly and that gets you stuck too.

 

Dr. David Burns: Well, Ruben, we love you and admire you and would love to offer you something more than just talk and support, although that's incredibly important. I'm wondering, is there some part of what you've been telling us tonight or some part of your Daily Mood Log that you'd actually like some help with? If so, would this be a good time to roll up our sleeves and get to work on it, or do you need more time to talk and get support?

 

Ruben: I'm ready to roll up my sleeves. Let's do it.

 

Dr. David Burns: If we work together tonight and it was helpful to you, and at the end of the evening you said, "Wow, that really blew my socks off," what might happen that would be helpful to you? If a miracle happens tonight, what miracle would you be hoping for?

 

Ruben: I think being able to be in those high-stakes situations without such intense anxiety. A little bit of anxiety would be good, but anxiety that allows me to maintain my fluency of speech and allows me to maintain my presence and doesn't get me looping in these anxious thoughts.

 

Dr. David Burns: If we could make that happen, what would that be worth to you?

 

Ruben: It would be worth a lot. It would be huge for me. Big relief.

 

Dr. David Burns: So Jill, can you take it from here?

 

Jill Levitt: So, Ruben, if we had a button right here and we pressed that button and you walked right out of here today and all these thoughts and feelings would go to zero—you'd feel amazing, no longer anxious, worried, panicky, nervous, defective, incompetent, embarrassed—would you push that button?

 

Ruben: Maybe I wouldn't push it for it to all go completely to zero. Maybe I'd want to hang on to some of those a little bit.

 

Jill Levitt: Beautiful. I'm glad you said that. You're stepping right into the next step, which is that maybe there are some good reasons to hang on to some of these feelings. Let's talk about that. This is called positive reframing, where we want to think about what these feelings show about you and your value system. What's important to you? What's beautiful about you? And also how are these feelings maybe working for you? We can all write down on a piece of paper "positive values and benefits". Which feeling or thought might you want to start with?

 

Dr. David Burns: As a teaching point, we've been leaning more in the direction of positive reframing for thoughts. It's equally powerful for thoughts or feelings, but the thoughts cause the feelings and the thoughts are more individual to the patient.

 

Ruben: I'm looking at my Daily Mood Log here and I'm noticing there's a little bit of my tendency to say "must pick the right thought, the right emotion".
Jill Levitt: Make sure you get the right one, Ruben. No pressure.

 

Dr. David Burns: There's a lot of super juicy ones here, Ruben.

 

Ruben: I'm going to go with "inferior, inadequate, defective, incompetent".

 

Jill Levitt: That was at an 80, so that's pretty strong. Right? What are some benefits of feeling inadequate, defective and incompetent and also what do they show about you thats beautiful and awesome.

 

Ruben: One benefit of feeling incompetent is that it helps me, it keeps me humble and keeps me working towards improving myself and improving my skills.

 

Dr. David Burns: Let's write those down. Some of the benefits of "inadequate" and "incompetent": it keeps me humble and keeps me motivated.

 

Ruben: It means I'm realistic to some extent about my imperfections.

 

Dr. David Burns: That seems totally true. What are some other really great things? What are some other great things about Ruben feeling inadequate? You're here in a group with 25 colleagues and feeling inadequate around these people.

 

Ruben: It means I care about what other people think and I really admire the people in this group.

 

Jill Levitt: David, you had something you wanted to add there?

 

Dr. David Burns: No. It's like King Tut’s tomb and in every turn, there’s some beautiful gold.

 

Jill Levitt: What Ruben can we pick another feeling or thought and think about how that might be benefiting you?

 

Ruben: Let's do "anxious, worried, panicky, nervous, frightened".

 

Jill Levitt: Yeah. Let’s do that. How do you think this feeling of anxiety and nervousness is working for you ?

 

Ruben: The anxiety motivates me to prepare for these kinds of high-stakes situations. It also shows that I'm human.

 

Dr. David Burns: Tell us how that works.

 

Ruben: It's easier for me to relate to people who show a little bit of vulnerability and anxiety because they feel more human and more real to me. So it improves connections with others.

 

Dr. David Burns:Yeah, It improves connections with others.

 

Jill Levitt: I love that. It's so true that displaying some anxiety and sharing that anxiety out loud helps you to be much more human and vulnerable and easier to connect with. And again, feeling anxious about pleasing other people shows that I value those people. Feeling anxious about getting it right shows that I value the audience. I want to do well by them.

 

Ruben: Especially feeling anxious about not wasting other people's time; it shows that I care about their time and want to contribute in a positive way.

 

Jill Levitt: Yeah. Maybe we could pick a thought. Telling yourself that you're wasting other people's time is really a translation for "I value other people's time".  What about any other thought we can look at here?
Ruben: What about: "If I screw up David will be disgusted and see I'm a worthless, selfish fraud"?

 

Dr. David Burns: Ruben, we’re just looking for distorted through here. So though, if i screw up David will be disappointed. Is that right?

 

Ruben: In this one, I have said “David will be disgusted and see I'm a worthless, selfish fraud”?

 

Dr. David Burns: No. That's a good one. What does that show about you positive and awesome? And how does that help you?

 

Ruben: It shows that I have high standards for myself. It shows that I want to do right by David and the group members and I value David's opinions. It motivates me to work harder and keeps me humble.

 

Dr. David Burns: Does it keep you safe as well? Because if you don't screw up, you can avoid this punishment. I guess.

 

Ruben: Yeah right, I think it keeps me safe for sure.

 

Jill Levitt: Is there anything we should look out for in terms of feelings and thoughts?

 

Dr. David Burns: Ruben, I think you're saying that teaching and feedback should be in a loving construct and David is too harsh in the feedback he gives you.
Ruben: I think that is an advantage for ruben in this high state of anxiety. I think that's right.

 

Jill Levitt: What David said also shows that I'm aware of David's shortcomings; that David can be sometimes abrasive or harsh or critical or something like that. Is that what you are saying David?Dr. David Burns: Yeah.

 

Jill Levitt: I'm going to keep my guard up and feel sort of anxious and guarded and worried.

 

Dr. David Burns: Because the thought implies it's very dangerous. I can't relax around David because really bad things will happen.

 

Ruben: Yeah, it definitely keeps me safe. Let me just see looking down the list here.

 

Jill Levitt: So now we're turning to like, anything else we should do before we move on. Anyone that you wanted to pick David or we just see if ruben had anything else he wanted to work on?

 

Dr. David Burns: What about: "If people don't like my contributions, I'll never make it as a therapist"?

 

Jill Levitt: That was David  "If people don't like my contributions, I'll never make it as a therapist".

 

Dr. David Burns: In other words. They won’t send me referrals. no.  Again, its the i have to impress people in general to survive as a health professional.

 

Jill Levitt: What are some benefits of that ruben?

 

Ruben: It shows that I want to be a good therapist and I really care about making contributions that people find valuable and want to contribute in a positive way towards people's recovery. It's also motivating to help keep me practicing the techniques and questioning my own competence so that I'm staying on that growth edge and consistently checking myself so that I can be there for my patients.

 

Jill Levitt: Is that true about you, Ruben, that you do wanna always be a good therapist and make good contributions and keep on that growth edge to help your patients?

 

Ruben: Yeah, That's true. I am glad you picked that one david that was really helpful.

 

Dr. David Burns: They are all juicy in different ways.

 

Jill Levitt: We've been given all these benefits of your anxiety and inadequacy and shame. They're helping you in so many ways and showing truly beautiful things about you. Why would you want to work on this?

 

Ruben: These benefits are real and there are a lot of awesome things about these thoughts and feelings. At the same time, I think the extent to which these thoughts and feelings are present sometimes is overwhelming and paralysing. I end up shooting myself in the foot rather than actually realising the benefits underlying them.

 

Jill Levitt: Great yeah, and David i am happy if you’d like to, walk through the goal column on the Daily Mood Log with Ruben.

 

Dr. David Burns: Let's fly through the goal column on the Daily Mood Log. The anxiety was 70. What would be a nice amount to have?

 

Ruben: Maybe 30 would be a healthy amount.

 

Dr. David Burns: Lets write a 30 in the goal column. And is that high enough

 

Ruben: I think so. Yeah.

 

Dr. David Burns:  And then How ashamed do you wanna feel? What would be an ideal amount of shame? Shame was 30. Ideal amount?

 

Ruben: Maybe 20.

 

Dr. David Burns: Okay and how inferior, inadequate, defective, incompetent that was 80.

 

Ruben: I think there's a lot of good stuff in there. Maybe 30.
 

Dr. David Burns: And how Rejected do you wanna feel? That was 40.

 

Ruben: Maybe 20.

 

Dr. David Burns: And how embarrassed, foolish, self-conscious? That was 70.

 

Ruben: Let's do 20 for that one.

 

Dr. David Burns: And then frustrated and stuck that was 30.

 

Ruben: Let's do 10 for that one.

 

Dr. David Burns: 10 okay, then for Resentment and upset that was 30.

 

Ruben: Let's go 5 on that one.

 

Dr. David Burns: Oh okay, Great. So now let’s dive in, and we are going from step three which is the assessment .

 

Jill Levitt: This is an opportunity to ask us questions about what you just saw in the video. Know that there's still a lot to come; we're still going to show you the whole method section which is where you see Ruben actually change.

 

Q and A Session

 

Jill Levitt: Let's move forward and watch part two, which is methods.

 

Dr. David Burns: If you'll choose a negative thought you'd like to work on first, Jill will lead the charge in some of the many ways that we can challenge that thought. Because our hypothesis is that those thoughts actually cause these negative feelings, and if we can reduce your belief in these negative thoughts, we can reduce the intensity of these negative feelings.

 

Ruben: Let's start with "My speech is too slow and I sound foolish, ignorant, and boring."

 

Jill Levitt: Can you take a look at the distortions and tell us what distortions do you see in that thought?

 

Ruben: I would say it's all-or-nothing thinking, overgeneralisation, mental filter, discounting the positive, mind reading, and fortune telling.

 

Jill Levitt: I even see a hidden should in here like "I should always speak eloquently" in the perfect pace, always sound intelligent and exciting or something like that.

 

Ruben: Totally, Yeah.

 

Dr. David Burns: I would ask you about still self blame is one of the 10.

 

Ruben: Yeah, definitely self-blame is kind of blaming myself for screwing up and speaking slowly. Labelling myself as boring, ignorant and foolish.

 

Jill Levitt: There is a lot in there.

 

Ruben: Yeah, I think externalization of voices sounds like a good place to stop me.

 

Jill Levitt: Okay, lets do it, David, you want me to get us started?

 

Dr. David Burns : Either way. Who would you like to attack, Ruben?

 

Ruben: Let’s go with David.

 

Dr. David Burns: Ruben, can I talk to you for a minute? I'm Ruben, your negative Ruben. It's just a fact of the universe that your speech is just too slow and you sound foolish, ignorant, and boring.

 

Ruben: I think honestly I think it is true that I speak very slowly sometimes and I have some long pauses which certainly feel awkward. At the same time, people have also said that sometimes the pauses are helpful. I'm doing the best I can and I think my heart's in the right place.

 

Dr. David Burns: Let's do a role reversal. And you want to do it David or Jill?

 

Ruben: Lets keep it with David for Now and then next one

 

Dr. David Burns: Okay.

 

Jill Levitt: Ruben is playing the role of his negative voice and David is going to play the role of positive Ruben.

 

Ruben: Ruben, can I talk to you for a minute?

 

Dr. David Burns: Oh your never stop talking to me. You're almost very happy in life. I’’ll never be alone

 

Ruben: I wanted you to know that your speech is too slow and you sound foolish, ignorant, and boring.

 

Dr. David Burns: I have a couple of things to say about that my speech is what it is and it's pretty awesome, actually. I have a kind of a British-type accent that almost everyone finds charming. But I have another problem much greater than my speech problem.

 

Ruben: What's that?

 

Dr. David Burns: That is listening to your bullshit constantly putting me down. I think I'm going to celebrate myself, slow speech and all and teach you a little Buddhism 101.

 

Ruben: Yeah

 

Dr. David Burns: You know what that means. You can take your criticisms and stick them where the sun doesn't shine.

 

Ruben: Yeah, I think that won huge

 

Dr. David Burns: Huge and how did I get too huge?

 

Ruben: You used some of the techniques. I did use some self acceptance. You also threw in some defence, but I think it was the counter attack. I may have slow speech and that may be an issue, but it's not really the thing that's bringing me down. The thing that's bringing me down is you criticizing voices constantly ragging on me for talking slow.

 

Dr. David Burns: Oh, yeah. I love that. I love what you're saying. Let's see if you can do it. Are you ready?

 

Ruben: Ready, yeah.

 

Dr. David Burns: Ruben, your effing speech is too slow and you sound foolish, ignorant, and boring.

 

Ruben:  It's totally true that I sometimes have really long pauses and that my speech is slower than I'd like it to be. Maybe there's some people that don't like it, but honestly I'm doing the best I can. I have a much bigger problem than speaking too slow, and that's your voice constantly nagging me in my head telling me how worthless I am.

 

Dr. David Burns: Who won that one?

 

Ruben: I won. That felt huge to me. Over to you Jill.

 

Dr. David Burns: Way to go I love that.

 

Jill Levitt: Ruben, let's do another round. You are going to be positive Ruben and I'm going to be negative Ruben.

 

Jill Levitt: Ruben, if you screw up in the Tuesday group, David is going to be disgusted and he's going to think that you're a worthless, selfish fraud.

 

Ruben: It's kind of amazing how much you admire David and want to impress him. It really shows how much you care about the Tuesday group and TEAM-CBT. At the same time, telling myself this is not going to do anything to help me improve. David is one of the warmest, kindest human beings that you know. This notion that he's this horrible ogre is completely distorted. I think I was winning but I got anxious and was having trouble finding words.

 

Jill Levitt: You got stuck in Externalisation of Voices and couldn't come up with a good response. You're telling yourself, "I need to do it right and I'm not doing it right," and that causes you to feel kind of stuck and anxious.

 

Ruben: That was such a nice example of dropping back to empathy. That's exactly what I feel like I needed at that moment.

 

Jill Levitt: Do you want to try a role reversal with me?

 

Ruben: Let's try a role reversal.

 

Jill Levitt: Do you wanna hit Jill or David? In this youre going to be negative ruben and i or david will going to be positive ruben

 

Ruben: I hit Jill.

 

Jill Levitt: Okay.

 

Ruben: (Negative Ruben): if you screw up, David will be disgusted and see that you're a worthless, selfish fraud.

 

Jill Levitt (as positive Ruben): I think I will screw up from time to time. In fact, that's why I collect feedback. I expect that I'm going to make plenty of mistakes and I'm hoping to make them here and learn and grow. If David is disgusted with me because I made errors, then I don't think he would be my guru anymore. I want to be in an environment where people support making errors and mistakes.

 

Ruben: That was huge. I really liked that you flipped it around to "I hope I screw up." The more I fail in front of David the better because he can then give me more specific feedback. The more I fail, the less I will appear a fraud.

 

Dr. David Burns: Ready to jump into the group from hell? I'll be the David from Hell. Ruben, you're incompetent and you're a worthless human being.

 

Jill Levitt: This is the Feared Fantasy.

 

Dr. David Burns: Ruben, what are you afraid that David's going to be thinking about you?

 

Ruben: That I'm incompetent and worthless and should find another profession, and that I have no business being a small group leader.

 

Dr. David Burns: You’re going too fast.

 

Ruben: Yes, sorry!

 

Dr. David Burns: Yeah, that you're incompetent and worthless. You should find a new profession. Yeah, that should not be a small group leader. And what else?

 

Ruben: You don't deserve to be here.

 

Dr. David Burns:  Would you start out as David from hell or as Ruben?

 

Ruben:  I think I can start out as Ruben.

 

Dr. David Burns: And you want me to David from hell?

 

Ruben: Yeah.

 

Dr. David Burns (as David from hell): Ruben you said that you want my feedback for today group. The most honest thing I can say is you're incompetent and you're a worthless human being.

 

Ruben: Can you be a little bit more specific? Is there a certain thing that I did that displayed my incompetence and worthlessness?

 

Dr. David Burns: You had a long pause at one point during the group.

 

Ruben: Yeah, I'm sure there are people who get exhausted with the pauses, but if there are people who are that distraught by the pauses, then maybe I should be in a different group.

 

Dr. David Burns: Okay, who won?

 

Ruben: I win

 

Dr. David Burns: Big or small?

 

Ruben: Big!

 

Dr. David Burns: Big or Huge?

 

Ruben: I think it was huge

 

Dr. David Burns: How did you get too huge?

 

Ruben: I think be specific was very helpful because the sort of incompetence and worthlessness loses all meaning and kind of keeping in mind what we said before about how helpful it is to fail. You know that made me excited to hear specifics and then when the specifics was you pause for too long I just realized the ridiculousness of that.

 

Jill Levitt: Non-pausing group here we don’t really want you in our group if you pause you know

 

Dr. David Burns: Ruben, can you see now that the emperor has no clothes? Is that exciting for you to see?

 

Ruben: Totally. It's really exciting. Feels like a weight has lifted for sure.

 

Dr. David Burns: Are you having the moment of enlightenment?

 

Ruben: Yeah, definitely.

 

Dr. David Burns:  Is there anything else here that Jill or I could hit you with any negative thought or any feared fantasy thing that we could say to you that would be upsetting to you. We're looking to blow this system out of the water completely and not just to be feeling a little less anxious or a little less inadequate or whatever.

 

Dr. David Burns: Do you want me to be Ruben and And you can be the group member from hell or what? Who are you?

 

Ruben: I'll be the group member from hell. Yeah, let's go with I'm wasting people's time. So, Ruben, why do you even come here? you're just wasting people's time with your poses.

 

Dr. David Burns: Okay. Well, I'm coming here to learn and overcome my anxiety and my fears. And this kind of interaction is actually helpful to me because this is the kind of interaction I have feared the most. But yes, I have a lot of strengths and many shortcomings and weaknesses as well. And so I guess Your problem here is just because I'm wasting your time.

 

Ruben: Yeah, that's right. You're wasting my time and you're wasting everybody else's time.

 

Dr. David Burns: Would you say time at this moment? We're talking about a conflict between the two of us.

 

Ruben: Yes, you're wasting my time.

 

Dr. David Burns: Talk about conflicts with people.

 

Ruben: No, talking about conflicts is such a waste of time.

 

Dr. David Burns: Yeah. Talking about conflicts is a waste of time. You mentioned someone needs to find a new profession, but I don't think I'm the one. I think you.

 

Ruben: Nice. Beautiful.

 

Dr. David Burns: Isn't that cool?

 

Ruben: You won. Yeah. That's very cool. You won huge on that.

 

Jill Levitt: Could I also try a very different angle with the same one and even just around more specific? Will you hit me with that one too, Ruben? You can be the group member from hell. Yeah.

 

Ruben: Yes. Reuben, you're just wasting people's time whenever you come to a group.

 

Jill Levitt: Got it. You were looking for someone who talked faster. Was that the problem or exactly? Yeah. share with me what you were looking for in a small group leader? Why do you feel like I'm wasting your time?

 

Ruben: Yeah, small group leaders shouldn't pause so much. They should have the answers ready at the drop of a hat.  We shouldn't waste our time with long-winded, slow responses.

 

Jill Levitt: How much time did you want me to take with my responses? Was there a precise number of minutes my responses should take? Or do you lose interest when people talk for like more than 10 seconds at a time or 15 or 20?

 

Ruben: You got me. Yeah. Nice. I love that.

 

Jill Levitt: I was laughing because I was also thinking about Ruben. I just have to share you know, in this group people nail me because I talk too fast. So this whole topic makes me laugh so hard because in the chat box people will put like slow down Jill or like can you please talk slower. So anyway it makes me laugh like you know so really exactly how many minutes we should each take on our explanations right?

 

Dr. David Burns: Do any of these perfect hold any sway over you or would you like to have the group members take a thought from your daily mood log and attack you with externalization of voices? Have several of them do that?

 

Ruben: Yeah, that would be great if uh if people have the daily mood log in front of them and want to chime in.

 

Dr. David Burns: Yes. i have  Ruben's daily mood log in front of you. Okay, Laurel, will you start out and then let's see, it's so at the bottom there can go second and hit Ruben with one of his negative thoughts using the second person. You.

 

Laurel: All right, Ruben? People will not love you and accept you as a flawed and vulnerable human being. They just will not accept you.

 

Ruben: Yeah. Well, what I'm learning is exactly the opposite, that the more vulnerable and flawed I can be, the more human I will appear to everybody and the more people will accept me and love me and be able to relate to me so I think yeah, what you're saying just doesn't hold any water.

 

Laurel: So who won there?

 

Ruben: I did

 

Dr. David Burns: Let's go through your end-of-session negative feelings. Anxiety was 70. What is it right now?

 

Ruben: Zero.

 

Dr. David Burns: Shame was 30?Now?

 

Ruben: Zero.

 

Dr. David Burns: Inferior and incompetent was 80?Now?

 

Ruben: 10.

 

Dr. David Burns: Rejected was 40? Now?

 

Ruben: Zero.

 

Dr. David Burns: Embarrassed, foolish, and self-conscious was 70? Now?

 

Ruben: Zero.

 

Dr. David Burns: And then frustrated and stuck. That had been 30. What is it now?

 

Ruben: Zero.

 

Dr. David Burns: Were these changes real or you just being nice?

 

Ruben: No, definitely. I feel very different. The belief in their reflection about me as a person is completely gone.

 

Dr. David Burns: What was the healing element? would you say because we did so many things. We did, you know, measurement and we did empathy and we did positive reframing and we did, you know, a lot of techniques with externalization of voices and and and you know, the counterattack and the acceptance paradox and we did a lot of things and but you had moments of illumination uh when you suddenly saw something you hadn't seen before and can you can you talk about what those might have done and what were the things that kind of opened your eyes?

 

Ruben: I think one significant moment was really the deep-down recognition that part of what we're here to do in group is make mistakes. There really isn't a separation between me and the person I admire. In being so afraid of that person, I make that person into a monster and myself into a nothing, and both of those views are equally distorted. We're all part of a sort of a greater web that um that there really isn't any separation and and without that separation a lot of these sort of thoughts and feelings kind of melt away.

 

Jill Levitt: Well, and I think that point is also that when we are so self-conscious and so anxious and and so convinced that others are looking down on us, we're also thinking something pretty terrible about the other person, right? Like to think that David or Jill or someone else in the group would be so essentially critical and harsh and judgmental, it doesn't make them look too very good either, right? So in putting yourself down in your mind, you're also kind of putting the other person down too. It hurts you. It hurts us too, right? I think. Is that right, David? Am I capturing what you're at?

 

Dr. David Burns: Absolutely. And that is where life exists, which is okay.

 

Q & A Session