Cognitive Role Playing Techniques

Cognitive Role Playing Techniques

IN THIS VIDEO:

Jill Levitt: My name is Jill Levitt and I'm a clinical psychologist and also the director of training at the Feeling Good Institute in Mountain View, California. Today I'll be teaching you about cognitive role playing techniques. So let's start with talking about the outline for today's course. First we'll start with reviewing the purpose of cognitive techniques. Next we'll talk about the advantages of cognitive role playing techniques. Then we'll cover one specific really fun and exciting and interesting and helpful cognitive role playing technique that's called the double standard technique. I'll demonstrate the double standard technique for you in a role play with a colleague of mine. Then I'll teach you another cognitive therapy role playing technique that's also fun and exciting and useful that you can use with your patients and that's called the externalization of voices technique. We'll review that. I'll demonstrate it for you again in a role play with a colleague of mine and then we'll talk at the end of this course about what are suggested homework assignments that you can do to improve your skills and how you can start to implement these skills. I'm going to move my picture for this slide.

The first thing we'll talk about very briefly is what is cognitive behavioral therapy. I imagine most people would be quite familiar with what is CBT. Essentially CBT is based on the idea that it's our thoughts about the events in our lives and not the events in our lives themselves that cause our feelings. The idea is that two different people who experience the exact same event may interpret the event differently. They may think differently about themselves and about the world and about the things that happen and as a result of those thoughts they will feel differently. An example that I like to use is imagine there are two different people and they both have an exam and they've both studied the exact same amount for the exam. They both know exactly the same material. They both theoretically are going into that exam exactly equally prepared and one person might be telling themselves I didn't study enough. I should have spent more time studying. This test is really important. If I don't do well it's totally going to mess up my future. Then I want you to ask yourself if you have those thoughts how would you be feeling about the exam? Most people would respond saying nervous, anxious, scared, full of dread and on the other hand if you had studied exactly the same amount and you're exactly the same amount prepared but you were telling yourself I'm totally prepared. I'm going to ace this exam and you know what it's not even that important. I've got lots of exams to take this year. I could always retake it or one bad grade doesn't really make a big difference. If you were thinking those thoughts how might you feel going into the exam? And many people would answer that question that they would feel calm or relaxed even eager to complete the exam. So the idea is that it's not the exam or how much we prepared for the exam that affects how we feel going into it but it's rather what we tell ourselves about how much we've prepared or about the importance of the test itself. So that's just a simple example and the idea here is just to know that when we're teaching you cognitive therapy techniques this is all based on the idea that it's your thoughts that really impact how you end up feeling in a situation and also of course how you act, your behavior that oftentimes stems from negative or anxious thoughts that can also exacerbate your feelings and they're all related together in a cycle and CBT is really all about changing thoughts or perceptions. So what is the purpose of cognitive techniques? We've just started to touch on that but let's talk a little more about it. If what we think determines how we feel then we can actually learn strategies to change the way that we think so that we can feel better. The goal then of cognitive interventions is always going to be to challenge distorted cognitions, kind of faulty thoughts and to replace them with rational thoughts and then a cognitive therapy technique is considered to be successful if the patient no longer believes that original irrational thought and if the patient has successfully replaced it with a totally believable or rational new thought. So the goal then of cognitive therapy is to generate new rational believable thoughts that disprove or dispute the original thought.

Why would you bother to learn cognitive role-playing techniques if you already know lots of cognitive therapy techniques? So one idea is that typical cognitive techniques can feel really dry and kind of overly cerebral. When I was in graduate school I learned lots of great cognitive therapy techniques but many of them involve taking out a piece of paper and writing down your thoughts and writing down rational responses and it can feel kind of cerebral and not very emotionally engaging. On the other hand, kind of putting a voice to the negative thoughts using role-playing can really bring those negative thoughts to life and can help to evoke more emotion, help these techniques to not feel quite so dry. The other thing is that when we do role-playing techniques the therapist actually paradoxically will play the role of the negative voice and have the patient play the role of the positive voice and what's good about this is it can end up actually paradoxically reducing resistance and boosting motivation because the patient is forced to take the role of the positive thoughts while the therapist can kind of argue the role of the negative thoughts. And finally, we find that when we do cognitive therapy role-playing techniques change really occurs at an emotional level, kind of at a gut level rather than at this sort of more cerebral level.

So let's talk about one cognitive therapy technique that I'd like to teach you guys today. It's called the double standard technique and you'll soon see why it's called that. What is the double standard technique? Well, it's a compassion-based cognitive role-playing technique. The purpose of the double standard technique is to help the patient who has self-critical thoughts to have more compassion for him or herself. So that is a patient who tends to be really hard on himself. We're going to help them to have more perspective and to become less self-critical and more compassionate. The goal here is actually to help to turn the patient's feelings of compassion for others into compassion for the self and finally to generate new believable thoughts that kind of put the lie to the negative thoughts. So of course our goal here is to help the patient to be less self-critical, to be more compassionate, to kind of harness the compassion that patient has for others and turn it into compassion for himself. And then ultimately the goal of any good cognitive therapy technique is going to be to actually generate new believable thoughts that challenge the original negative thoughts. So what are the roles in the double standard technique? These are role-playing techniques. So both of the methods that I show you today are going to involve the patient and the therapist playing different roles. Well in the double standard technique, the patient actually gets to play the role of him or herself and the therapist plays a different role. The therapist plays the role of a friend slash clone of the patient. So I would say something like this. I would say you're going to play the role of yourself in this role-play technique and I'm going to play the role of the best friend slash clone of yours. Someone that you really like and care about who's also exactly like you. So let's imagine then that I grew up in the same family that you grew up in, that I went to the same schools that you went to and right now I'm struggling with exactly the same things that you're struggling with. Let's give me a name. These are the things that I would say to my patient and when I say let's give me a name, I don't want the patient to tell me, you know, my sister Joanne or my friend Joe. Instead, I want the patient to come up with a name that doesn't relate to someone that they already know because I'm not actually playing the role of a real person the patient knows, right? I'm playing the role of someone who's a dear friend, someone they really care about. So give me a name, let's say Jessica, but this has to be a clone of my patients and that's why I don't want them to be named, you know, whoever their current best friend is. So what's the setup of this role playing technique? Well, the therapist will say to the patient after describing the two roles, remember, I'll say, I'll describe the roles I just told you on the last slide. So you patient, you'll be yourself and I will be a dear friend of yours, but I'm also a clone of yours. So I grew up in the same family that you grew up in, I have the same friends that you have, I have the same job that you have, and I'm currently struggling with exactly the thing you've been struggling with. And then I check in with my patients. So just to check in, who am I in this role play? And ideally the patient says, well, you're my best friend who's also a clone of me. I say, great. And who are you in this role play? And the patient's answer should be essentially I am myself, I'm playing myself.

And then what happens is the therapist will start to talk about the patient's situation and the patient's thoughts and feelings and ask the patient questions. Like, so I'll use my own, I'll talk about myself in the first person. I'm the dear friend slash clone, and I'm going to talk about the problems the patient's having. So for example, I'll say to the patient, you know, I recently lost my job and I keep telling myself that I'm a really worthless person. Do you think that I'm a worthless person because I lost my job? So that's an example of what I might say in the setup for a patient who's now beating himself up for having lost his or her job. Right? So I want to start the role play with the two roles. And then I want to basically explain to the patient the exact situation they're in and put their negative thoughts to them. So for example, if the patient is struggling with telling himself that I'm a worthless person because I lost my job, then I'll say, you know, I recently lost my job and I just keep telling myself that I'm a worthless person. Do you think I'm a worthless person because I lost my job? And in this case, I'm giving the patient the opportunity to kind of talk back to that negative thought. So let's talk a little more about the setup here. The therapist will state the patient's negative thoughts clearly so the patient has an opportunity to dispute the thoughts, as I just said. So I keep telling myself that I'm a loser because I lost my job. Do you think that losing my job makes me a loser? So I'm being really pointed. I'm not saying, I keep telling myself that I'm a loser because I lost my job. What do you think I should do? Because that's going to pull for advice giving. That's not a cognitive therapy technique. Or I might say, I've been thinking that I'm a really worthless human being because I lost my job. Do you think the fact that I lost my job makes me a worthless human being? So again, I'm going to ask my patient, do you believe these things about me? And would you say this to a dear friend? So then I want to share with you some tips for developing the argument in the role play.

And then I'll actually walk you through an example and even demonstrate it with a colleague of mine. So one idea here is that you want to repeat what the patient says right back to them. And you want to encourage elaboration of these new thoughts that the patient is explaining to you. So for example, if the patient responds in a way that's really useful, then I might repeat what the patient says. And oh, so what you're saying is that losing my job really doesn't have anything to do with my self-worth? You said that I have a lot of wonderful qualities and that while it might be true that I wasn't performing as well as the guy that they kept, that doesn't actually mean that I'm a worthless person. That's really helpful. Can you explain that to me a little bit more? How do you know that's true? Or why do you think that's true? So if you can see what we're doing here in this role play, then as we put the negative thought to the patient, the patient will quite frequently kind of talk back to it or argue, no, that doesn't make sense because of this. And then we'll repeat that back to the patient, kind of like, oh, okay, so what you're telling me is that doesn't really make sense. It's actually this. And in doing that, I'm repeating back the patient's positive thoughts, right? And then I'm asking the patient, do you really believe that? I mean, can you explain to me why that's true? I'm asking them to elaborate kind of their response. And then what I might say in addition to, do you really believe that? Or I might say in addition to, can you tell me why that's true or tell me more about that? I might say, do you really believe that about me or are you just trying to make me feel better? Like, I'm not really interested in just kind of randomly you trying to help me feel better. I'd like to know, I'd like you to tell me something that you really believe. So do you really believe that about me? And then ideally, you know, if the patient says, yes, I do really believe that. I mean, that's totally true. I don't actually think that losing your job means that you're totally worthless. Then here you have them basically kind of committing to the fact that they really do believe this new positive thought.

So let's take a clinical example here. So I'm going to ask you to actually answer some questions. I'm going to pose some questions to you. Remember that the only way that you're really going to learn new methods and techniques is if you engage with the material. So I want you to be ready now to answer some questions that I'm going to pose. I'd like you to get out a pen and paper so that you can write down what you would say. And I'd like you not to skip this step. So I'm going to share with you now a sample daily mood log of a patient who is struggling with kind of self-defeating beliefs, who is beating himself up and feeling badly, is lacking in self-compassion, being really self-critical. This is an example of a patient, not a real patient. And then I'm going to ask you to think about some questions or to answer some questions. So here is his daily mood log. Now, you may use this kind of a daily mood log developed by Dr. David Burns, or you may use some other version. But essentially, if you're doing cognitive therapy, then you're surely using paper that involves writing down what the event is, what the negative feelings are or emotions, and what the negative thoughts are. And likely, you're asking your patient to rate how strongly they believe or how strongly they have these feelings, like in this column, and how strongly they believe these thoughts. So the clinical example I'm going to put to you guys is an example of a 32-year-old man who's working in kind of an entry-level job here. And I live in Silicon Valley in the Bay Area, so I'm going to use that as an example. And he's 32 years old. He's had a number of different jobs, and he's been taking his time to really kind of figure out what he wants to do. And so he finds himself here, 32 years old, making $75,000 a year at a sort of entry-level job. And he's at his friend's house, and they're hanging out, and he's having a good time visiting with his friend. And then his friend's younger brother walks in, and he is happy to see him. And they start chit-chatting. And the friend's younger brother is really excited. He graduated from college recently. And he's 22 years old, and he's kind of bragging about his new job or sharing about his new job in an excited way. And he mentions how much he makes. And it turns out that the 22-year-old is making the same amount as this patient, the 32-year-old. And the patient reports to me that immediately his mood tanks, that immediately he feels down and depressed. And he starts beating himself up, and he feels awful about himself. And he says, it's because this 22-year-old is making the same amount that I'm making. And he's 22, and I'm 32. So, of course, I feel awful. So I ask him to tell me what his negative thoughts are. What are the thoughts that are driving all of these feelings that you see at the top of the page? And we get listed these thoughts. I don't make enough money, which is really another way of saying I should make more money. People will look down on me when they realize how little I make. He's telling himself I should have a higher-paying, higher-status job. And he's telling himself something is really wrong with me because I make the same amount as a 22-year-old, and I'll never have a high-status, high-paying job. So he has lots of really negative thoughts, right? So I want you to take this clinical example and answer some questions about it. So this is the negative thought that we're going to take as an example. Something is really wrong with me because I make the same amount as a 22-year-old.

So now I want to ask you a question. How would you set up the double standard technique? What would you say to your patient to explain the technique to him or her? The next question I want you to answer is, what are the roles in the double standard role play? What role does the patient play? And what role do you, the therapist, play? And these two questions go together. So how would you set it up? Meaning, how would you explain the method? And how would you set up the roles? Then the next question I have, which is a little bit different, is what would you say to your patient to get the role play started? Remember, what you say to your patient to get the role play started has to include the patient's negative thought. In other words, I'm not asking you now how to set up the role play. It's kind of a general description that will be the same for every patient. But rather, how are you going to get this particular role play started with this particular patient who has this particular negative thought? Something is really wrong with me because I make the same as a 22-year-old. So I'd like you to pause the training now and write down what you would say. How would you set up the role play? What are the roles? And what would you say to your patient to get the role play started? So now I'll answer some of the questions that I just posed to you. So I might start the role play by letting the patient know that this is a method that's called the double standard technique. And then it's a role play technique designed to help you to challenge and change your negative thoughts about yourself. And then I would say, I'm going to play the role of a best friend or clone of you. Someone that you really like, but also someone that's exactly like you. So I grew up in the same family as you. I went to the same schools that you went to. And I'm struggling with exactly the same thing that you've been struggling with. I've been beating myself up. I've been really hard on myself. I've been feeling pretty down about kind of where I am in life with this entry-level job. So let's give me a name. Maybe he says your name is Joe. And I say, OK, great. So then who am I in this role play? And my patient should say, you're the best friend clone of mine. Your name is Joe. And I say, great. And who are you in this role play? And then the patient may say, or should say, I am myself, right? OK. And then the question I asked you to think about is, how do you get the role play started? So basically, I say to my patient, you know, can I talk to you for a minute? Whatever the patient's name is. And he says, yeah, sure. And I say, well, so you know, we've been friends for a really long time. And I've been feeling really down about this situation. I wanted to talk to you about it and see what you think. You know, I was at my friend's house the other day. And his brother started talking about this great new job that he has. And you know, my friend's brother is only 22. And I'm 32. And when he told me how much he's making, I realized he's making the exact same amount that I am. And he's 22.

And I'm 32. I'm thinking something's really wrong with me if I'm making the same amount as a 22-year-old. Do you think that's true? Or don't you think there's something wrong with me or really wrong with me if I make the same amount at 32 that this guy's making at 22? So this is what I was looking for you to say and how you would set it up. So recall, you'll outline the method. You'll assign roles. And then you'll put that negative thought to the patient as if it were your own negative thought, asking, do you think that's true? So then what happens next? Remember that you're going to keep elaborating and encouraging elaboration of these new thoughts. So I might say to the patient something like, if the patient responds with something helpful, like, oh, so let's see. What you're saying is the fact that we both make the same amount probably reflects something about the kind of job my friend's brother got. And I guess you're right. He did get a pretty great job right out of college. And then it's not something that's terribly wrong with me. And you're saying that you don't really think you can judge someone based on their salary. Yeah, I mean, I guess that's true. That's really helpful. What makes you think that? And then maybe your patient says, well, I mean, I think that because I know some people who don't make that much money. And I still think they're great people. Or lots of people choose to do really interesting and meaningful work, even volunteer and not make any money. And I still think they're worthwhile. So the idea is you get your patient to really challenge this notion, but you're not suggesting the answer. You're kind of paradoxically saying, yeah, I don't know. I think I'm pretty worthless because I'm making the same amount at 32 as this guy at 22. Don't you think I'm worthless? And then you put the responsibility on your patients to generate alternative thoughts. And so again, if the patient says something that seems useful, I'm going to repeat it back to them. I'm going to kind of elaborate the idea. And I'm also going to ask a little more about it. Why is that true? I mean, are you saying you know people who like don't make that much money and you still think they're valuable and like worthwhile? Is that really true? And then finally, you really do want to say, even if this seems a little hokey, like, do you really believe that? Are you just like trying to make me feel better? Because if they are just blowing smoke, then it's not going to be useful. They have to actually commit that they really do believe what they're saying. They're not just BSing or else, obviously, the whole method will fall apart. They need to be saying something that they really believe to be true, even if in this moment they only believe it to be true about another person. So then I'm going to say at the end, the question is, how do we bring this method to closure? So I'm covering something new here. I didn't cover this yet. How do we bring the method to closure? The therapist says something like, you know, Joe, after several rounds back and forth of this, they say to the patient, you know, you've been really helpful and compassionate with me. You've defeated all of my negative thoughts. And so could we put all these new thoughts that you just generated on your daily mood log in the positive thoughts column? Since I am a clone of yours, these thoughts apply to you as well, right? So again, this is what I say as a therapist. I'm no longer in the role play, right? I'm stepping out of the role play. I'm saying you've been really helpful and compassionate to me in this role play, and you defeated all my negative thoughts. And since I was a clone of yours, I'm thinking that means you defeated your negative thoughts. So can we put these new thoughts on your daily mood log, right? Since I'm a clone of you, these thoughts would apply to you too. And so in that way, I do not end this method by saying, oh, did you notice that you had a double standard? You were compassionate with me, but you're not compassionate with yourself. Because then the patient sort of says, yeah, right. So what? I knew that already, right? I mean, that's not that enlightening. However, it's more like you've gotten the patient to challenge the negative thoughts of another person. And since that person was a clone of theirs, these thoughts should apply to the patient as well. And so you kind of just assume and you say, hey, you were able to challenge my negative thoughts. That was super helpful. I agree with you. So should we go ahead and put these new positive thoughts, rational thoughts on your daily mood log since they apply to me and I'm a clone of yours, right? Then you write these new responses on the daily mood log in the positive thoughts column. And again, if you don't use the exact sheet that I use, it doesn't matter. But if you're doing cognitive therapy, you're always looking at challenging negative thoughts and replacing them with rational thoughts. That's what makes it cognitive therapy. So on whatever form you use, you're going to write out the new responses.

Some people will just have a piece of paper and on the left side are the negative thoughts and on the right side would be the rational responses. So in the case of the daily mood log that I use, I always write the positive thoughts over here. And then I ask them to rate how much they believe these new positive thoughts. Because again, if they don't believe them, then the method wasn't actually useful, right? You can generate lots of great thoughts if you don't believe them, not very helpful. So assume or work toward the patient actually totally believing the new thoughts, the positive or rational thoughts. And then you can ask them to re-rate their relief in the original thoughts, which are usually negative thoughts. The idea for this cognitive therapy intervention to have been successful is that they generate new positive thoughts that are totally believable and that the original negative thoughts are no longer believable, that they drop to somewhere close to zero. Okay, so now what I'm going to do is invite my colleague Richard Lamb on screen with me and Richard and I are going to do a role play demonstration for you of the double standard technique. So now I'm going to do a role play of the double standard technique with a colleague of mine from the Feeling Good Institute, Richard Lam, who's an excellent TEAM-CBT therapist and trainer. So I'm going to have Richard introduce himself to all of us in the role of the patient. And at the same time, I'll share the patient's daily mood log with all of you. And then we'll get started in the role play.

Richard Lam: Hey, so my name is John and I recently got in my performance review at work and I was reading through it and there was a lot of positive stuff in there. But I got to the end and there was some criticism about my communication with my team and I feel like I'm not doing a great job at work. It kind of created a lot of like worry for me and anxiety and just feeling really sad and down and like really inadequate. And at the same time, kind of like pessimistic about what's going on at work and really frustrated and kind of like rejected too. And I'm just thinking that it's like not smart enough to be an engineer at this job. And I don't really do anything right at all. And I think everyone really thinks I can’t do this job and eventually they’re going to just fire me and I’m gonna lose my job and because of the criticism getting them really thinking that nobody likes making their.

Jill Levitt: So I'm going to stop sharing my screen for a moment so I can see you on my screen and the audience can see you bigger, Richard, and I'll start calling you John when we do the role play, but this is just to give you all a sense of what the daily mood log might look like and all the different feelings that might be circled and all the different thoughts that the patient has, and then we'll jump into the double standard role play and show you how we might work on one of these negative self-critical thoughts. So I'll start setting up the role play with you now. So John, you and I both have the daily mood log in front of us, and I think you had told me that you'd really like to work on this thought, I never do anything right. And so I'd like to try a method with you that's called the double standard technique, and this is a cognitive therapy role playing technique where you and I are each going to have a different role to play. And the goal, just like all the other cognitive methods we've been working on, would be to try to help you to come up with alternative, positive, believable thoughts that make this original thought no longer true for you. Are you willing to give this method a try?

Richard Lam: Yeah, absolutely.

Jill Levitt: Great. So in this method, you get to be yourself, so you'll be John, and I'm going to be a dear friend of yours, who is also a clone of yours. So when I say a dear friend, I want you to think of me as someone that you care about, that you feel compassion for, that you really like and care about. And at the same time, though, I'm not going to be a particular friend of yours, I'm going to be a clone of yours. So that means, John, that I went to the same school that you went to, that I grew up in the same family that you grew up in, and that I've been struggling with just the same kinds of problems and thoughts and feelings that you've been struggling with. Does that make sense to you?

Richard Lam: Yeah, that makes a lot of sense.

Jill Levitt: So then remind me before we get started, who are you in this role play?

Richard Lam: I'm me, I'm John.

Jill Levitt: Right. And who am I in this role play?

Richard Lam: You're a really dear friend of mine who's kind of like the same thing as me.

Jill Levitt: Exactly, a friend slash clone of yours. Okay, so should we get started?

Richard Lam: Yeah. Okay.

Jill Levitt: So, you know, John, you know that I've been working at this job for a couple of years and I'm an engineer and we do these performance reviews once every six months. And, you know, I just had this meeting with my boss, my manager, and I got this performance review that was, you know, kind of a meets expectations performance review. He actually told me about some things that he thinks that I'm doing well, but he also gave me some negative feedback that I'm not communicating as well as he'd like with the rest of the team. And so people aren't really aware of some of the work that I've been doing. And when I got that negative feedback, I just felt really awful. And I've been telling myself that I never do anything right. Do you think it's true that because my boss had some, you know, suggestions for me, do you think it's true that I never do anything right?

Richard Lam: Well, that's actually not true at all. A big part of it is you've been doing a lot of things right. Actually on the performance review, it shows a lot of great things that you did. And kind of like the last few sentences is what you can improve on. And in all my performance reviews, they always, well, in all your performance reviews, they always tell you like what you do well and something that you can improve on. So a big part of it is I don't think you never do anything right. You do a lot of things right. And they always want you to improve a little bit more. I mean, that's how the structure of the company works.

Jill Levitt: Huh. So what you're saying is you don't think that's true at all, that I never do anything right. And even that in the performance review, there were a number of things that my boss told me that I am doing pretty well or very well. And I guess I also heard you saying that that's the nature of the performance review, that kind of the idea of the performance review is to give you things to work on and to improve. Do you think that's, is that what you're saying?

Richard Lam: Yeah, exactly.

Jill Levitt: What are some things that you, I mean, that's helpful, but I was wondering if you could be more specific, like what are some things that you think I am doing right?

Richard Lam: Yeah, well, on your performance review, they say you give really great presentations, really detail oriented, and you're always in the chat on the systems, just communicating in that way. They just want you to communicate more in person. And after that, you're golden.

Jill Levitt: Well, thanks. You know, what you're saying is actually really helpful. It sounds kind of rational and well-rounded and kind of taking everything into account here. But I'm wondering, are you just, you know, trying to be nice to me? My boss just gave me this performance review, and I'm feeling crappy. Maybe you're just like trying to cheer me up, and this isn't really true. Is that what's going on?

Richard Lam: No, this is absolutely true. All these things, I totally mean it. It makes logical sense to me.

Jill Levitt: All right, awesome. So, John, I'm stepping out of the role play for a moment. I'm going to now be your therapist again. You know, what you said in that role play sounded really convincing and effective and quite different from thinking I never do anything right. And if what you said to me, you know, if all of that was absolutely true, and you totally believed it, and I'm really just a clone of yours, then I guess these things you just said would also apply to you as well. Is that right?

Richard Lam: Yeah. Yeah, absolutely. That would apply to me. I mean, we're essentially clones, right? We're the same person essentially.

Jill Levitt: Yeah. So then what about on your daily mood log here? You have this negative thought, I never do anything right, which you said you believe 90%. We just came up with a bunch, or you just came up with a bunch of kind of responses to that. Let's write those down on the daily mood log in the positive thoughts column. Like you said, I do give really good presentations, and I communicate a lot on the chat function at work, that there are several things that I'm doing well, and it's okay that there's some room for improvement. That's the nature of getting feedback. Is that right?

Richard Lam: Yeah, absolutely.

Jill Levitt: Okay, so we'll both write that down now in the positive thoughts column. And then I want to know, John, how much do you believe that thought? Like from zero to 100, how true is this new thought that you generated for me?

Richard Lam: Oh, this is absolutely 100% true.

Jill Levitt: Awesome. So let's write that down. Your percent belief is 100%. And then when you think about that and you realize kind of everything that you told me in the role play, how true is this thought, I never do anything right? You had said you believed it 90%. How true is that for you now?

Richard Lam: I don't think it's true at all. I've been doing so many things, right, and like constantly improving.

Jill Levitt: All right. So then we'll put a zero percent in the percent after column.

Richard Lam: Great.

Jill Levitt: Okay, so we'll wrap up that role play. Thanks for doing that with me, Richard. And I hope that helped to show our audience what it looks like to do the double standard technique. So now that you've had a chance to observe our role play of the double standard technique, I hope you have a better sense of how that works and feel more confident to be able to use that method with your patients. I'm now going to share with you a different role playing technique. This one is called externalization of voices. And it has some similarities with the double standard technique, but it also has some distinct differences. The similarity is that it is a cognitive therapy role playing method. So, again, its purpose is to help the patient to generate new, rational, believable thoughts that the patient totally believes and to put the lie to the original negative thoughts. The other purpose of externalization of voices technique is to put a voice to the anxious or negative thoughts and really externalize them so that the patient can see them from the outside. Again, this is what I talked about earlier when I talked about how cognitive therapy role playing techniques can help the patient in a way that's different from just writing it down because the patient gets to have sort of a different perspective. They get to hear their thoughts spoken to them. So when you do this role playing technique, the patient really gets a chance to hear his negative thoughts from the outside. I've sometimes just had patients say, wow, I didn't realize how harsh I was being on myself or I didn't realize how distorted my anxious thoughts were until I heard you say them. And lastly, the goal of the externalization of voices technique is to paradoxically voice the patient's negative or anxious thoughts to allow the patient to powerfully argue against his or her own negative thoughts. I would say there are a lot of similarities between this one and the double standard technique. However, I think of the externalization of voices technique as a bit more aggressive than the double standard technique.

The double standard technique allows the patient to use their feelings of compassion toward others and apply them toward themselves, whereas the externalization of voices technique is a bit more kind of straightforward. It can be more dramatic. And I think it oftentimes leads to really powerful and meaningful change. So, again, let's talk about the roles because this is a role playing technique. The therapist is going to play the role of the patient's negative thoughts, using exactly the patient's negative thoughts from the daily mood blog or the paper where the patient wrote down their negative thoughts. The patient is going to play the role of the positive or rational thoughts. So the patient is going to talk back to the negative thoughts that are voiced by the therapist. So this is actually a less complicated method to set up and to deliver because it's fairly easy for the therapist to keep straight, oh, one of us is your negative thoughts, one of us is your positive thoughts. You also can reverse roles.

If the patient gets stuck, since the patient is supposed to be in the role of the positive thoughts, if the patient gets stuck, the therapist can switch roles with the patient, have the patient kind of hit the therapist with the negative thoughts and the therapist can play the role of the positive thoughts. So you can do a role reversal with externalization of voices technique.

You can watch Externalizaion of Voice Technique here.

Jill Levitt: So we hope that you found this training helpful. And since we know that homework is highly correlated with positive outcomes in therapy. We also imagine that homework would be highly correlated with positive outcomes on the part of the therapist. So if these are methods that you're not familiar with yet, and this is presented some new information to you, the best way to actually change your practice, meaning have this new information have an impact on your practice, and therefore an impact on your outcomes is to do some homework. So we'd recommend that you'd review the steps of each of the cognitive therapy role playing techniques that we taught you in this video. Make sure that you're really familiar with who is who in each role play, that is, what role the therapist plays and what role the patient plays, remembering that they're quite different in the two role plays. Make sure that you review the setup or the explanation of each role play technique. When I consult with therapists and role plays or methods, CBT methods don't go that well. Oftentimes, they haven't really explained the nature of the method to the patient. They've just kind of jumped in and then the patient feels lost. Then I recommend that you practice each technique with a friend or a colleague of yours to improve your confidence. I know that when I was learning some new cognitive therapy techniques, I actually used to practice them with my husband. I also always recommend that therapists who are learning methods find another therapist who's also learning new methods and practice, or if you have a therapist friend who doesn't know these methods, teach them to them and then practice together. I also recommend that you go ahead and introduce a new technique to your patient and let your patient know that it's a new technique that you'd like to try. I always find that when I tell patients now, I just went to a great workshop this weekend and I learned a new method. I don't know it that well, but if you're open to it, I think it could be really useful. I'd love to try this new method. Patients generally really admire therapists who are open to learning new things. I think there's no shame in trying, even if it's a bit clunky, especially if you share with your patient that you're excited about enhancing treatment and bringing about better outcomes, helping him faster, and that you'd like to try a new method. Remember that the goal is always to prompt your patient to generate new believable thoughts that challenge the original distorted thought. You always want to write down those new thoughts because it's so hard to keep track of all that happens in a therapy session. So, if you do have a successful role play with a patient and then they leave the session and nothing was written down, and you have no recording of what that new positive believable thought was, chances are the patient might forget it. On the other hand, if it's written down, the patient can then reference it and read it during the week. I also very frequently have my patients take out their cell phone and record the session if they have access to a phone. They can record the session and then they can actually listen to the session for homework. Finally, we hope that you have fun with these methods. I've had a really great time learning these methods. I really enjoy using cognitive therapy role-playing methods with my patients. We really hope that you have fun with these techniques with your patients as well.