End Panic and Anxiety for You & Your Patients | CBT + Exposure Techniques That Work

End Panic and Anxiety for You & Your Patients | CBT + Exposure Techniques That Work

with Dr. David Burns & Dr. Jill Levitt, Feeling Good Institute

 

When anxiety takes hold, it can trap clients in a painful cycle of fear, avoidance, and hopelessness. Even experienced therapists may struggle when clients resist exposure—or believe their anxiety will never go away.

 

In this free 2-hour CE webinar, renowned psychiatrist Dr. David Burns and Dr. Jill Levitt of the Feeling Good Institute teach you how to break through that resistance and use exposure therapy in powerful, effective ways.

 

Through real therapy video clips, teaching stories, and practical tools, you’ll learn how to help clients face their fears and experience rapid relief.

 

What You’ll Learn:

 

✅ How to break through resistance to exposure with trust and collaboration
✅ The hidden safety behaviors that sabotage exposure—and how to eliminate them
✅ CBT-based exposure methods including the What-If Technique, Cognitive Flooding, and building a Fear and Avoidance Hierarchy
✅ When to use gradual exposure vs. flooding—and how to tailor your approach
✅ Real-world insights from Dr. Burns' live work with a client overcoming 10+ years of panic and depression

 

Ideal for therapists, counselors, and mental health professionals—plus anyone seeking practical tools to recover from anxiety, fast.

 

IN THIS VIDEO:

 

Jill Levitt: Hi everyone and welcome to our webinar CBT and exposure techniques that work. We are so glad that you are here joining us today and we have a lot of exciting material to cover in the next two hours, packed hopefully with practical and powerful methods that you can begin using right away. We will take a couple questions at the end and we will also share some opportunities for you a little bit later in the workshop as well. First, I want to say that I am thrilled to be joined by Dr. David Burns today. I imagine that all of you know who David is, but I will just let you know, in addition to being a world-renowned psychiatrist and CBT legend, David is a dear friend and colleague of mine and I always feel really honored to present with you David. David is one of the most influential figures in cognitive therapy and the creator of the TEAM-CBT model that we will be diving into quite a bit today. He is also the author of Feeling Good and Feeling Great and the creator of the Feeling Great app, which you will have a chance to learn about a little bit more today. I will also just tell you a little bit about who we are at Feeling Good Institute.

 

Our mission at Feeling Good Institute is to elevate the practice of therapy so that patients can recover faster and more fully. We train and certify therapists in TEAM-CBT, which is this powerful framework developed by David. We help therapists walk through kind of a five-level certification path. I will also just share with you very briefly our sort of origin story. Feeling Good Institute was founded by Mor Katz, Angela Krumm, and myself. We had all trained with David in TEAM-CBT at Stanford. Back then, the only way to learn TEAM-CBT and to learn was to study directly with David, either in this Tuesday group at Stanford, which you often hear people talk about, or going to one of David's intensives around the world. So we started Feeling Good Institute with this big dream to make David's tools, techniques, and training style more accessible to more therapists without compromising depth or quality. Everything that we do today still reflects that original intention, which is to help therapists to get better so their patients can too.

 

At Feeling Good Institute, we do not just teach techniques, but we really try to replicate David's training style, which is built on this foundational idea that you only get better through practice and feedback. It might surprise you to hear this, but experience alone does not make therapists better. Doing more therapy sessions does not necessarily lead to more outcomes. So the question is what does work? Learning, practice, getting feedback, practicing again, that is what actually drives change and that is what we emphasize in all of our trainings. We will tell you a little bit more about how we do that later today. So I will also just ask you this thought experiment, which is we have talked a little bit about how experience alone does not lead to better outcomes and that real growth comes from focused learning and practice and feedback.

 

So I would ask you to think, what would change for you if you had a structure for consistent growth and would that be worth exploring? So we will share with you more at the end of the day today, but we have created a pathway to help therapists learn, practice, and grow and become really experts in this TEAM-CBT model that we will be sharing with you later today. What we will be teaching you is the tip of the iceberg and if it is exciting to you, we hope that you will take the next step with us and join us in the FastTrack program that we have developed. The one other administrative thing I will cover before we jump into the content today is how to get your CE credit. Many people start asking us this question. I will drop in the chat box today a mandatory CE survey that you will need to complete. Access the CE survey in the chat box at the end of the webinar. Mike will drop it in just about five minutes to the end of the webinar, at the end of our two-hour webinar. After you complete the CE survey, you will get your certificate of completion within one week. So you will not get your CE completion today, you will get it within a week. Make sure that you do complete that CE survey at the end of the workshop today and if you have any questions reach out to us at certification@feelinggoodinstitute.com. So now let us tell you a little bit about the framework of TEAM-CBT. This is what has been developed by Dr. Burns. So the T in TEAM stands for Testing. That means that we teach and we use with our patients measures at the beginning and end of every therapy session, measures of symptoms and also measures of the therapeutic relationship so that we can track progress over time, hold our patients and ourselves accountable for really bringing about meaningful change and so we can address alliance ruptures or issues that are coming up in the therapy session right away. We will not really be teaching you more about the T or testing, but we want you to know that we use this with all of our patients and it is an important part of doing effective therapy. The E in TEAM stands for Empathy. That means that we have tools and techniques for really connecting with our patients and especially our difficult-to-connect-with patients and that we do not just jump in and throw methods at our patients, but we actually are measuring and we are connecting and we are empathizing before moving along and using powerful CBT methods. The A in TEAM stands for Assessment of Resistance. That is that we are working on understanding, articulating and then melting away resistance to change and boosting motivation. We will tell you a little bit about that today, but finally, what we will be focusing on most today are the Methods, the M in TEAM, which stands for methods. We will be focusing on cognitive and behavioral methods today. Just to sort of share this slide with you, we want you to understand that there is this really powerful framework that you can learn and work through to help all of your patients. It is transdiagnostic and it is not a manual for doing therapy, but rather a framework that all effective therapy includes. So now we will turn to today's specific topic, which is treating anxiety and specifically, we will talk to you today mostly about treating anxiety using exposure and also some cognitive interventions, but we want to make sure you are aware before we start that there are at least four important models for anxiety causation and treatment. David, I will turn it over to you at this point if you want to just mention the four models on this slide and then walk us through what each of the models are about on the next few slides.

 

Dr. David Burns: Yes, sure. These are four really powerful models for understanding and treating anxiety. The Motivational Model focuses on resistance and there are two kinds of resistance that all anxious patients will have and we will talk about that in just a moment. The Cognitive Model stresses that all anxiety results from distorted thoughts and that it is impossible to change without challenging and crushing those distorted thoughts. The Exposure Model is quite different and it says all this other stuff is a bunch of crap and the cause of all anxiety is avoidance and the cure is exposure and exposure always works and everything else never works. Then there is the Hidden Emotion Model and this states that niceness is the actual cause of anxiety and an important powerful tool is the bringing suppressed feelings to conscious awareness and expressing them and dealing with them. If we will go to the next slide, I will just give a slight expansion on these things. The Motivational Model talks about two types of resistance: Outcome Resistance, which means that the anxious patient comes wanting treatment for OCD or a phobia or social anxiety, but that he or she will actually or they will actually resist a positive outcome. This is because of magical thinking in most cases. They think that my anxiety is painful, but it is protecting me, it is helping me and if my anxiety went away, some catastrophe would occur. Process Resistance is that the patient might really want recovery from anxiety but is unwilling or very reluctant to participate in the process, the thing that they will have to do to recover, which in anxiety is exposure. Exposure is not the only treatment for anxiety, as some of the early exposure therapists were claiming, but it is mandatory for every patient to include exposure in the treatment package.

 

Then the Cognitive Model focuses on distorted thoughts and there are four types of cognitive distortion from my list of ten basic ones that are always present in anxiety. One is Fortunetelling and that is predicting that something terrible is going to happen and it is impossible to feel anxious without fortunetelling. It is also impossible to feel hopeless without fortunetelling. Mindreading of course is the idea that you know how other people are thinking and feeling about you and that is usually not the case, but this is very common in social anxiety when the patient is thinking, "Oh my gosh, everyone here is confident and no one, they could all see how anxious I am and no one would be interested in me or my life or what I have to say." Magnification and Minimization is I also call it the binocular trick. It is when you blow things way out of proportion and patients with panic attacks that you will see in just a few moments are saying, "Oh my gosh, I am on the verge of dying or I am about to lose control and end up in a psychotic episode." Anxious patients also minimize their safety in a situation and their own coping skills. Finally, Emotional Reasoning is reasoning from how you feel and I know most of you are familiar with these distortions, but for anxiety it is by gosh, "I am feeling anxious, I am feeling scared, I must be in danger." So the anxious patient might think, "Oh my gosh, every time I get around an airplane, I get terrified. It must be terrifying to take an airline flight. That is extremely dangerous. I can feel how dangerous it is." Then in the cognitive model, challenging negative thoughts is felt to be the cure for anxiety. The very moment the patient stops believing the thoughts that trigger the anxiety, in that very instant, the anxiety will disappear. You will see this on video this morning. The Hidden Emotion Model is one that I created based a little bit on the psychodynamic or psychoanalytic training I had as a psychiatric resident and that is that if you talk to a thousand anxious patients.

 

You will find a thousand extraordinarily nice people and the idea is that the anxiety-prone patient is afraid of conflict, afraid of displeasing people and is constantly focused on meeting other people's expectations and that that actually causes the anxiety, that there is some hidden problem always that the patient is not telling you about because they have suppressed it and pushed it down under conscious awareness and the Hidden Emotion Model involves bringing that problem to conscious awareness and expressing the feelings and this is a super powerful model. It is hard for therapists to get at first because they do not believe it and it is not occurring with every anxious patient, but it is with a good 60% or 70% of anxious patients and once you learn how to do it, it gives you another powerful model for treating anxiety. Among these four today, we are primarily going to be focusing on the Exposure Model. The Exposure Model again is based on the idea that avoidance is the main cause of anxiety and avoidance maintains anxiety and if you have ever struggled with anxiety, you know how overwhelmingly valid that this is. If you are afraid of elevators, you avoid elevators and that avoidance maintains and creates your anxiety. The Exposure Model states that exposure is the cure. Now the cognitive therapists will argue and you will see this today that exposure is not a cure for anything and that the reason exposure is effective is because of the cognitive dynamic. In other words, during exposure the patient suddenly sees that their belief that the elevators are dangerous, for example, that sees that it is not true or the panic attack patient sees it is not true that they are about to die of a heart attack or about to go crazy. So it is kind of interesting to look at the exposure through these two different lenses, the cognitive model and the exposure model. They are two very powerful and helpful models for sure. Now I am going to give you an example of the overlap between the cognitive and exposure models with a very severe problem. Terri was a woman who came to me for treatment in Philadelphia after ten years of extreme depression and anxiety and at the time I was using a depression and anxiety test, long versions of my depression and anxiety checklists that were scored from zero to 100.

 

I think she had a score of a total score of 199 on those two tests and at the time was by far the most severely depressed and anxious patient I had ever seen in an outpatient setting. Her problem was she had been having five panic attacks each week. During the attack, she develops tightness in her chest and gets dizzy and develops the belief that she is about to die of a heart attack or a stroke or pass out or that she cannot breathe properly. She had been to many ER visits, had been worked up by many cardiologists, pulmonologists, eventually they diagnosed panic disorder and after five years she was referred to a psychiatrist and they treated her with massive doses of just about every known psychiatric drug and that did not work and psychotherapy did not work and she felt not only panicky but intensely ashamed, demoralized and hopeless. When I am working with an anxious patient, I always work with their Daily Mood Log and you can see here on the slide, Terri's daily mood log and it is like the upsetting situation is that she senses a panic attack coming on. Again, this happened to her five times every week. She gets somatic sensations and the cognitive model of panic is the misinterpretation of benign physical sensations. When she gets upset about something, she hyperventilates subconsciously. She does not realize she is doing that, but if you do that, you blow off too much carbon dioxide and your blood pH changes and that creates the symptoms of anxiety: the numbness, the tingling of the fingers, the chest feels tight, she gets dizzy and then all of her feelings, as you can see that she has circled, depressed and terrified and ashamed and inferior, discouraged, embarrassed and frustrated, are all at 100, the worst a human being can have and the anger was the only one that was not 100 and that was 25. Now the cognitive model states that the 100% and only cause of these negative feelings are her distorted negative thoughts and she is telling herself, "I cannot breathe properly." And she believes that 100. If any of you right now believe that you could not breathe properly, you too would suddenly become panicked. So she believes that 100 and "my windpipe is closing off," she believes that 100. "If I stand up, I will pass out," she believes that 100.

 

"I am about to have a heart attack," she believes that 100 and "I am going to die," she believes that 100. Now on the next slide, you will see what I call a Recovery Circle and this is a cognitive technique and the thought that she wanted to work on was putting in the middle, "I am about to die." I always think of five or ten or fifteen or twenty or in the old days sometimes twenty-five or even thirty-five cognitive techniques. I have learned or developed over 150 techniques now for crushing negative thoughts. So I put many up there on the Recovery Circle and the idea is called fail as fast as you can. The faster we go through these techniques and fail with them, the quicker we will get to the one that works. So over the course of about the first, oh say, I would say three or four sessions, I tried a good fifteen techniques, you know, double standard technique, examine the evidence, downward arrow, hidden emotion, examine the evidence, feared fantasy, identify the distortions, all this kind of thing, but everything was pretty much 0% helpful, not helpful to her. She came back every week with the exact same incredible scores on the depression and anxiety test. So I told her, "Terri, I have used a lot of gentle techniques with you and they are just not working, which is okay, but next session I would like to try one of the most powerful of all of the cognitive techniques called for anxiety, called the Experimental Technique." "What I would like to do is induce an actual panic attack during the session and then during the session, I am going to teach you to do some experiments to test to see if what you are telling yourself is valid." She said that she thought that was a wonderful idea and got all excited and went home and called in and left a message that she was canceling her next two therapy sessions. I guess she was terrified and was too nice to tell me that she did not want to have a panic attack in my office and she left the note, a message saying that she was not firing me and that I was the best therapist she had ever had, but did she have to have a panic attack in my office and she is too terrified to do that? So we spoke on the phone a couple times and I, she finally I was able to persuade her to come in. I said, "We will have a double session and we will have plenty of time and we are here in the hospital. The emergency room is right down the hallway from my office and I really want you to take a chance." That is one of the teaching points for today, that I had been getting perfect scores on the empathy scale so I knew she really liked me and trusted me and that gave me the license to really push her when it comes to exposure because almost all patients will strenuously resist exposure. So I had to persuade her pretty forcefully to come in and try this experimental technique.

 

So what happened, she came in and I told her to close her eyes and hyperventilate like that because I knew her, she would start getting the symptoms and I said, "Now move your finger when you feel the symptoms coming on." After about fifteen seconds, she wiggled her finger and then I said, "Now I am going to be the voice of your panic attacks." "I am you, I am just like that voice in your head and I am telling you that you cannot breathe properly and your fingers are tingling and you are about to have a heart attack and we are going to have to call for the paramedics and they are giving you oxygen, but even that is not working and they are panicking and can you see the red light on the ambulance going round and round?" And this triggered a massive panic attack and she started sobbing and I just happened to have a video camera in my office and I had all my patients record on video or audio all their sessions and either watch them or listen to them at home and she was one who had allowed me to videotape and that is why I have this actual excerpt from that session, which of course.

 

She has given permission for me to show and we are just going to cut right into the point where I have just induced the panic attack and she is sobbing and she starts begging me to stop. Let us see what happens. Oh, by the way, just stop it for just a second. I want you to ask yourself, whether you are a therapist or a general citizen, three questions when you see this video. You are going to see wild fluctuations in her feelings. Ask yourself first of all, what is causing the fluctuations in her feelings? A second question is that she is begging me to stop and if you were the therapist, what would you have done? She is stopping, saying, "Please Dr. Burns, I cannot go on, we must stop." And then what would have been the consequence of stopping or pulling back if you had done that or the consequence of pushing ahead? Then if you have any general theories about if she is improving or getting worse on this during this excerpt from our session, what are the causes of that? What is going on here to the best of your understanding? Now, let us see what happens.

 

Dr. David Burns: "Experiment and find out if it is true that you cannot take a deep breath." "My fingers feel numb." Do they feel numb? That is another symptom of panic and anxiety and I am glad that you are allowing yourself to get real anxious. How anxious would you say you are right now between zero and 100?

 

Terri: About 100.

 

Dr. David Burns: About maximum right now. Now, if you could not breathe right now, why would that be a problem to you?

 

Terri: I feel like I am going to die.

 

Dr. David Burns: What would you die of?

 

Terri: Lack of oxygen and my heart, my chest hurts, my chest hurts so bad and this always happens.

 

Dr. David Burns: Now, what are some experiments that we could do to find out if your heart is working properly and if you are able to breathe properly right now?

 

Terri: I do not want this anymore, please just.

 

Dr. David Burns: Well, I am going to ask you to bear with it so you can kind of put an end to this fear that you have once and for all. Do you think a person who cannot breathe would be able to exercise strenuously? Okay? Do you think that you could exercise strenuously right now?

 

Terri: I do not know.

 

Dr. David Burns: Why do not we find out what?

 

Dr. David Burns: Would be some strenuous exercise that you could do here in the office to find out whether or not you are breathing properly, your heart is working properly? What is the most strenuous exercise you do? Jumping jacks, running in place?

 

Terri: I do not know. I walk and I ride my bicycle.

 

Dr. David Burns: Yes, but we cannot do that in here unless you have a unicycle or something. Make a good picture, but I do not think we have one here. What is some exercise you could do right here to test the belief that you cannot breathe? How strongly do you believe right now that you cannot breathe?

 

Terri: It is getting less.

 

Dr. David Burns: How strongly did you believe it?

 

Terri: Oh, like 100.

 

Dr. David Burns: Okay. Well, how about just running in place? Would you be willing to do that? You ever do jumping jacks, running in place, push-ups?

 

Terri: Not push-up. Yes, push-ups, running in place, jumping jacks. I do not know, I am afraid if I stand up, I am going to pass out or something.

 

Dr. David Burns: Okay, well let us check that out, see if you can stand up and run in place. Okay. Now let us see if you can do some, let us see if you can do some running in place right now. Go ahead. You feel dumb? Well, run. That is okay. I mean, you might have to feel dumb to get well, but it would be worth it if you got well.

 

Terri: I feel really dizzy.

 

Dr. David Burns: Okay, we will just keep going. Now, how strongly do you believe that you cannot breathe, your heart is not working?

 

Terri: About 70.

 

Dr. David Burns: You believe 70% that you cannot breathe?

 

Terri: Yes. I mean, I should not be breathing, it is having to breathe, it is heavy, It is a little bit. And I still cannot take a deep breath and I always.

 

Dr. David Burns: It is like, can you run more strenuously, faster? Do you do aerobics? Do you do exercising?

 

Terri: A little bit.

 

Dr. David Burns: See if you can back up just a little bit.

 

Terri: My fingers feel numb. Okay.

 

Dr. David Burns: How strongly do you believe that you can breathe right now? How strongly do you believe that you cannot breathe?

 

Terri: Let us see. I feel better, like 60 that I cannot.

 

Dr. David Burns: You believe 60% that you can or cannot?

 

Terri: That I cannot.

 

Dr. David Burns: Cannot? Okay, it is down to 60. How about some jumping jacks?

 

Terri: I feel too dizzy.

 

Dr. David Burns: Try some jumping jacks anyway.

 

Terri: I am dying. I could not move.

 

Dr. David Burns: Well, could you do this if you were dying? This is what you see in emergency rooms, people heart attacks.

 

Dr. David Burns: Doing jumping jacks?

 

Terri: No.

 

Dr. David Burns: Keep doing the jumping jacks. I am sure you will pass out at any moment.

 

Terri: My hands feel weird.

 

Dr. David Burns: How strongly you believe now that you cannot breathe?

 

Terri: About 50.

 

Dr. David Burns: 50. It is gone down. Just keep up the 50. You have got to keep it going down to zero. We are going to get a zero out of you for no other reason than fatigue.

 

Terri: I feel a lot better.

 

Dr. David Burns: Okay, sit down right now. Now, let us just see what the audience thinks about some of the questions I asked. First of all, there was a massive change in six minutes there. That was actually her first recovery after ten years of failed medical and psychiatric therapy, heart evaluations, lung evaluations, pill after pill. You can see that all of her symptoms went to zero. She was not just feeling better, but it was totally abolished, the system and she was able to blow all of these negative thoughts out of the water. But what was it about that experience was one question that, why did her feelings go from uncontrollable sobbing to uncontrollable laughter in six minutes? What was the healing mechanism? Secondly, how many of you would have backed off if you were the therapist rather than pushed ahead and what would have been the implications of that? And maybe Jill, you can check the chat and see if we have got some answers to those questions.

 

Jill Levitt: Exactly. Yes, so I have some, I will read to you right now, so it seemed really helpful to ask again and again to rate her strength in the belief. Someone proposed, was it that she was distracted from her symptoms? Someone said the exposure led to a shift in her thinking. Someone said because the more you pushed her to do it, she could run and talk and that helped her realize that she was still alive. You also got some, tell me if you, I was going to put a couple other comments out there, but mostly so some people said distraction, other people said change in thinking, realizing she was not dying since she was able to do jumping jacks.

 

Dr. David Burns: Yes, I think you, most of you have it pretty much on target. This distraction is a mildly helpful technique for all negative emotions, but it is very temporary and a weak sister of the 150 techniques I use. I would say it is the least effective. That was not the reason why she had this profound change in her emotions. But it was because when she was doing the jumping jacks, she said, "I wonder if I could do this if I was having a heart attack." And then I said, "Is this what you see in the emergency rooms of hospitals, patients with massive heart attacks doing jumping jacks next to their gurneys in the emergency room?" And then she started laughing so heavily that she doubled over with laughter. And then when she stood up, I said, "Keep up the jumping jacks, I am sure you will pass out at any moment." And then she said, "Oh, hey, I am feeling a lot better." And then in the session, I repeated that demonstration one more time. I kind of induced a second panic attack with her permission and just so she could see that it was something she could reproduce. She again thought she was on the verge of death and did. I got her to do the jumping jacks and then her emotions went all the way to zero. Then she had some questions about what if she gets a panic attack at home and a few other things that were kind of fun and funny to deal with. But in the interest of time, I will just say that one question you might have is does this last? Was this responsible, the therapy, because it seems kind of scary and it definitely takes courage on the part of the patient and courage on the part of the therapist. I knew, of course, that her negative thoughts were distorted and just not possible.

 

It would have been impossible for her to pass out when she stood up because her heart was racing and her blood pressure was elevated and fainting is associated with a drop in blood pressure and a slowing of the heart. Everything she is telling herself is just extremely distorted, but it also shows the hypnosis of the patient. She is trying hard to hypnotize me into believing what she is saying and giving up. And if I had given up, it would have torpedoed the treatment. I have had to call her, that was thirty-five years ago or almost in 1988, you can calculate the years, forty years anyway. I call her every year or two to say, "How are you doing?" And she says, "Tell your audiences, can I show this?" Because she was so ashamed initially and she said, "I hope you show it to everyone in the United States and just tell them that I am still doing great." She had another child, which was one of her goals, because they had four children and the previous psychiatrist said she could not become pregnant because of all the psychiatric drugs she was on, that he said they might cause a birth malformation. But she was able to go off of all of those drugs and had only one panic attack in the last thirty-five years. She called me for an emergency, it was years after this. I said, "Well, do your jumping jacks." I have, I am out doing a workshop today. I just showed this video at a workshop and then she called with an emergency and I said, "I will be home tonight and I can see you tomorrow." And then she called again at the end of the day and said, "Cancel the appointment." "I did my jumping jacks and I started laughing again and my panic attack disappeared." But anyway, that is a thumbnail of that should teach you a great deal about the cognitive model and exposure and the question is was it the exposure or the change in her belief and her negative thoughts that triggered the sudden change in her feelings? And I would argue that in this case, in many cases, the reason the exposure worked was because she suddenly realized the nonsense of what she had been telling herself.

 

Jill Levitt: David just wanted to point out, lots of people brought up some things that we will be talking about throughout the day today, which is, people saying, "Oh, I would have given up because I would have been anxious." Also, people realizing, "If I had given up, I would have perpetuated her belief that she was unsafe." Another failed therapy.

 

Dr. David Burns: Yes, if I had stopped, she would have said, "Even my doctor who is a medical doctor is frightened. This must be a real thing." So by backing off, which we are all tempted to do, it would have been horribly destructive for her.

 

Jill Levitt: Yes, exactly. So yes, a lot of people realizing that. People also saying, "Wow, that is amazing, you are so brave." And also commenting on your sense of humor being a part of what was effective as well, which I think is really true.

 

Dr. David Burns: Yes, just to comment briefly on that, the Buddhists have a form of enlightenment called Laughing Enlightenment and that is when you finally confront the monster that has been ruining your life and all of your previous reincarnations, you discover that the monster has no teeth and you go into uncontrollable laughter and then go to Nirvana or some kind of Buddhist heaven and that is exactly what Terri was experiencing, was laughing enlightenment and I use a lot of humor in my therapy.

 

Jill Levitt: Yes, and I will also just tell people, if you have questions for us throughout the webinar, we will not be looking at the chat, but Mike Christensen is helping us and so if you do send questions about the content or questions about exposure in the chat box, Mike will be compiling them and at the end of the two-hour webinar, we will go through some of your questions. We will have a chance to answer some, although probably not all of your questions. So we have a lot to cover here. I think you probably covered this David, but is there anything else you wanted to say?

 

Dr. David Burns: Well, I just think that some of the teaching points is that thoughts are the cause of negative feelings and that when you are upset, generally your thoughts will be greatly distorted as hers were and that recovery can happen rapidly at the very moment you stop believing those thoughts and the way you find the technique that works is by failing as fast as you can. Also, patients will fear and resist exposure. She was begging me to stop and the consequences of stopping would have been catastrophic. But exposure requires strong empathy and trust. The empathy alone will not do her any good. I was getting perfect empathy scores for several weeks before we did this, but her symptoms did not change. Empathy is not curative for anything, but without it, you cannot go on to the powerful techniques that will cure the patient. And the reverse hypnosis is what you will be telling yourself as a therapist. The patient will be convincing you, "Oh, my patient is too fragile for exposure. What if I retraumatize him and her?" And I saw a lot of people talking about, "Oh, is David going to retraumatize her?" And, "You know, this is so terribly dangerous." And it is responsible to think about those things for sure, but not get trapped by them. Some therapists might think, "Well, what if my patient acts out violently or attempts suicide?" These are some of the consequences of reverse hypnosis.

 

Jill Levitt: So we will do a quick poll here with you guys just to understand. Some of you answered this, but we will do it in the version of a poll so you can all actually answer. So the first question on the poll is, would you have been tempted to back off when Terri begged David to stop? So go ahead and answer that, yes, no, or maybe. But try and answer yes or no. The second question on the poll is, do you resist and do you fear and resist using exposure with your patients? So if you are a therapist, are you fearing and avoiding exposure? So either, yes, I avoid exposure, no, I do not avoid it, meaning I use it happily, or I sometimes avoid it due to my own fear. And the last one, since we are all human here and some of you are not therapists, just members of the general public, but also as therapists, we all have fears. So do you fear and resist using exposure with yourself? Whether you are a therapist or a patient. Yes, I do avoid exposure, no, I do not, or sometimes I do. And I am going to give you guys another ten seconds, let us say, to answer quickly. Try to get maximal participation here in the poll and then I will end the poll and share the results. Okay, so we can see, 50% of you said, I would have backed off when Terri was begging David to stop. And we have, let us say, do you fear and avoid using exposure with your patients? We have 16% yes, I do and 47% saying, sometimes I avoid. So only about 39 or let us say 40% of therapists saying, I never avoid using exposure, I am confident in using exposure. So 60% still needing to be convinced. And then, do you avoid it yourself? Again, we have got just, let us say 30% saying, I do not avoid and the rest saying either I do or I sometimes do.

 

Dr. David Burns: So I think the poll was great in showing that a lot of patients and therapists alike are really fearful of exposure and avoid using it.

 

Jill Levitt: Absolutely. So hopefully we are going to help you to feel less afraid of using exposure with your patients and with yourself and also give you some tools and techniques to actually make exposure more effective. Our take-home message so far is that exposure can be incredibly powerful as you could see in the video, but also can be really challenging for patients and therapists alike. We have talked a little bit about this, but some of the keys for successful exposure are empathy. Some of you commented that in the chat box as well that Terri must have had an immense amount of trust in David. Also a skillful assessment of resistance. David, I do not know if you want to comment on that as it relates to Terri.

 

Dr. David Burns: Well, there are the two forms, there is outcome and process resistance and you have to do those before you go into any method. That is the key to team therapy. First of all, you have got to get an A or an A+ on empathy and then you have got to have skillful, the outcome resistance is that if I lose my anxiety, something terrible is going to happen. You know, I am suffering but I need this anxiety or I will flunk out of college.

 

Jill Levitt: In the case of a panic attack, quite often that outcome resistance is, if I am not hypervigilant, then maybe something bad really will happen.

 

Dr. David Burns: Yes, exactly. I need this anxiety or I am going to have a heart attack, I have to sit here emotionless type of thing. And then of course, the process resistance is the very intense and totally understandable resistance to exposure. The patient and therapist get involved in a folie à deux, in other words, an insanity shared by a patient and the therapist that somehow exposure is highly dangerous and needs to be avoided and that you have to really persist when the patient resists during actual exposure. Terri begged me to stop and therapist confidence, your self-confidence, your persistence is the crucial key to success and the patient's resistance is not just for panic attacks, it is for every single type of exposure. One you come to the point that social anxiety, you want them. To smile and say hello to strangers, but you can go out with them doing this and they are going to stop and resist and you are going to have to push them and that is where you need the trust and the empathy so you can push them and you have to have the determination with yourself that you are going to push them. If you are the kind of therapist who just thinks that support and talking are the key to therapy, you are going to have a lot of long-term patients, but you are not going to have a lot of cures.

 

Jill Levitt: Yes, and I was going to say that in this particular training today, we are not focusing on tools and techniques for overcoming resistance, but we think those things are incredibly important and we do a lot of teaching and training in the FastTrack program in our free trainings, where we really focus on outcome resistance and process resistance, but we will be focusing now more on methods.

 

Dr. David Burns: Yes, and if you want, Jill and I might offer another one of these free webinars on the resistant patient and then because we have a ton of new innovative techniques for dealing with resistance and most therapists are not familiar with them.

 

Jill Levitt: And one other thing we will highlight here and then we will also give you some clinical examples of throughout the webinar today is this concept of safety behaviors. I will mention it now because it relates to something you saw in the Terri video and then we will talk some more about it with some other clinical examples. But a safety behavior is essentially anything your patient does in the moment when they are anxious to reduce anxiety. We use that very general term because very often patients will come into therapy thinking that they have all these great coping strategies. When I feel anxious, I make sure I have my medication with me, I say a prayer or a mantra, I wiggle my.

 

Dr. David Burns: Let us see the next slide Jill.

 

Jill Levitt: I Okay, I will do that in a minute. But essentially, the thing about safety behaviors is that in the short term, they make patients feel better. In the short term, they give you a sense of relief and even a kind of illusion of control over your anxiety. But in the long term, safety behaviors actually make anxiety worse because they do not allow you to learn that nothing terrible actually would happen, that you do not need the safety behavior in order to feel better, so they prevent new learning. As you saw in the example, new learning is what happened for Terry. She needed to experience an intense amount of anxiety and to do those jumping jacks to learn that she was in fact safe. So on this slide, I have some examples of safety behaviors and so for some people it could be carrying a lucky charm that makes them feel less anxious. For a patient that I actually just evaluated this past week, he told me that even though he did not take benzodiazepines, he carried his container of benzodiazepines around with him and he did not see that as harmful. But see, in my mind, I am seeing that he is telling himself, I am not okay and I know that I have this like escape valve just in case and so he is not actually learning that he is safe, that nothing terrible would happen. For some people, a meditation or a mantra or a ritual, again, nothing wrong with waking up in the morning and doing some deep breathing or meditation as a sort of strategy for feeling good. But if it is something you feel like you need to do in the moment in order to not feel anxious, it is counterproductive. We have a couple other examples. I do not think I need to go through all of them. But patients with OCD quite often will be seeking reassurance from others and they will repeatedly ask for reassurance. It makes them feel better in the short term, but of course, maintains their anxiety in the long term. Patients who have a fear of illness or a contamination anxiety will often carry hand sanitizers, they will wash their hands repeatedly. So we just want you to get the sense and realize in your mind that there are a lot of things patients will do during exposure that is actually really counterproductive and we need to be aware of them and we need to address those things. So just to make it a little more interactive, we will invite you, you can share just a few with us in the chat box and I will read a few of them. So any safety behaviors that you have seen in your patients that I did not mention already or that you yourself sort of rely on to get through things when you feel anxious.

 

So I saw someone say, leaving the room in social anxiety. Often times leaving the room, avoiding eye contact. Someone said, carrying a water bottle. Exactly. So someone else might be like, what is wrong with carrying a water bottle? Well, intrinsically there is nothing wrong with carrying a water bottle, but if one thinks, I have got to carry this water bottle in case my mouth is dry, then it becomes a safety behavior and counterproductive. Carrying around a doll from childhood, eating sweets, looking at their phone, so distracting oneself. People are asking, is breathing or things like that problems? Yes, if during an exposure exercise someone is doing something to try to calm down, ask yourself, is that productive? No, because the point of exposure is being kind of all in. Bring it on, I want to feel as anxious as I possibly can when I am doing exposure. So if I am doing grounding exercises or breathing exercises, I am actually interfering with the effectiveness of exposure. There are ways, I will say, I have actually been contacted by therapists who say, "Can you integrate safety behaviors into a hierarchy?" And we will get into that in a few slides, but the answer is yes, you can, as long as you are aware of the fact that these are things that need to be dropped out and changed over time and that they can get in the way of new learning occurring. So you guys added tons of great examples in the chat box, but I am not going to read all of them. We will move on and we will give you some more examples of them a little bit later on. I will just cover this slide David and I can turn it back to you for the next example. But there are at least four types of exposures. There is in-vivo exposures, which is when we are going to have our patients face the thing they are most afraid of in reality. So if a patient is afraid of a dog, they are going to hang out with dogs. If we are afraid of heights, we are going to go to high places. There is cognitive exposure, which is where you are helping the patient to confront the thing they are most afraid of in their mind and we are going to walk you through an example and kind of teach you how to do cognitive exposure.

 

That is especially helpful for exposure to things that you cannot actually face in reality. Fears of things that might happen in the future, for example. There is interpersonal exposure, which we are going to do our next webinar, I think on, or one in the future on, which is kind of a social anxiety exposure, smile and hello. Shame attacking exercises, so a variety of exercises to confront social anxiety and interact with people socially. And then virtual reality exposure, which is where you can use virtual reality equipment, sort of similar to mimicking an in-vivo exposure. It can help use all the senses to actually make exposure more realistic and helpful for things that again, you cannot easily confront sort of in real life. Then David, if you want, you can talk about gradual versus flooding here.

 

Dr. David Burns: Okay, well, all exposure techniques pretty much can be done gradually or in a flooding way. As Jill has mentioned, for gradual exposure, you can create a feared hierarchy and have the patient start with the easiest thing. And once they are used to that, go up to the next highest, the next most intensely feared thing on their hierarchy and then do that over and over again. For example, if you are afraid of heights, you could just go, the first few times, just go up the first rung of the ladder. And then the second time, once you are not afraid of that, you go to the second rung on the ladder and you continue this gradually until you can stand on the top of the ladder. Flooding would be hitting your worst fear all at once and that is what I did with Terri. Also when I had a fear of heights in high school, I wanted to be on the play, the stage crew of the play Brigadoon and the drama instructor teacher said, "You have to do work at heights to be at the in on the stage crew." And I said, "Well, I have a fear of heights." And so he said, "If you would like to get over it, we can do it right now." And so he took me into the theater and there is a big V ladder there and he said, "Just stand on the top of that ladder for," and then, "I will wait here at the bottom of the ladder until your anxiety disappears." And that was flooding and I stood up there for ten, twelve, thirteen minutes and my anxiety was 100 out of a 100. I was just standing on the top of the thing and I kept saying, "Mr. Kershack, I am still 100 on anxiety." He said, "Well, just it will go down pretty soon, just keep standing there." And then suddenly after about fourteen or fifteen minutes, the anxiety dropped to zero and I was no longer afraid of heights. And then I loved being on the stage crew and I would work up at the ceiling and working on the lights and the curtains and all of that. And I could not even remember why I had been afraid of heights. But both techniques are effective and it is personal choice.

 

Jill Levitt: Yes, I was just going to say one other thing David while we are talking about exposure, is that when I learned and I will share a little bit about this later, but when I first learned to do exposure, which was actually kind of one of the first methods that I learned in graduate school, I thought of it in a way as like a way of life for myself, which is, I did not think I could ask my patients to do something that I was not willing to do myself and so I kind of set out to identify were there any things that I was fearing and avoiding and could I go ahead and face those using the same techniques that I was encouraging my patients to face and David, I think that is you and I both have a lot of confidence in exposure therapy and I think that is also because we walk the walk, right? When we do see that there are things that we fear and avoid, we go ahead and we are kind of all in and we face them.

 

Dr. David Burns: Yes, I have had over seventeen anxiety disorders since I was little, so I know very well what all the kinds of anxiety are like and I know very well how to get rid of them and get cured from them.

 

Jill Levitt: So we will talk a little bit about gradual exposure now and we will cover flooding in a little bit. But with gradual exposure, the goal then is that we are going to break down the fear into a hierarchy or like a list of examples of situations where the patient might fear and avoid this thing and this can be done with any type of fear. So if one is afraid of dogs, we are trying to make sort of a hierarchy of least anxiety-producing to most anxiety-producing situations, it could be little to big dogs, but it could even be watching a movie about a dog. So I will share with you guys a fear and avoidance hierarchy that I developed for a patient that I treated for a fear of driving. I have actually treated a lot of patients in my career who have a fear of driving and I will say I kind of have a soft spot for it because the very first patient I ever treated in graduate school had a fear of driving and I was a grad student at Boston University and my office was right in, right near Fenway Park, right in the middle of Kenmore Square, very busy, lots of driving going on and this first patient that I ever treated, her name was Patty and she had this intense fear of driving. Interestingly, a lot of people think people with a fear of driving it is because they are afraid of having an accident, maybe they had a traumatic experience, but actually many patients I treat it is just that they had a panic attack while driving and that scared them tremendously and the fear is that I will lose control, that I will crash the car, that I will pass out while I am driving. So just to stick with the fear and avoidance hierarchy, we kind of created a hierarchy together from least anxiety-producing to most anxiety-producing. So something that felt kind of easy, but still a little scary to her was just simply driving to the end of her street because she had completely stopped and avoided driving even though she used to drive all the time. And the next step would be driving to her kids' school which was a couple blocks away, driving to the grocery store. So the point is that you are kind of creating this hierarchy, you can even add things like during the day or at night, in a crowded time or at a busy time and the goal is that you are just creating this list from sort of least distressing to most distressing and in her case, driving over bridges and in tunnels in Boston was the most anxiety-producing thing that she could imagine. And then we essentially use exposure and I can say with this patient, of course, like with all of our patients, I am integrating other models. I always start with testing and empathy and also a lot of cognitive therapy to understand what was she most afraid of. In her her case, she was most afraid of passing out, losing control, getting into an accident because of her intense anxiety. So then what we did was we practiced together each thing on the hierarchy and I would do it with her in session and then I would assign it to her for homework so she could do it with me, but then she needed to repeat it daily for homework and we would move on to the next step on the hierarchy when her anxiety rating would drop.

 

So the goal is that you kind of stick with each activity till the anxiety goes down. There is no magic number, but I always say till it is maybe around a 20 or something like that. I also want to just point out, I was super aware with Patty as I am with all my patients of what she was doing when we did exposure that might have actually been sabotaging her success and so she wanted to distract herself and that was the strategy that she had been using to sort of white knuckle it and get through the driving on her own. She would turn on the radio and try to just pay attention to the radio so she was not paying attention to her sensations. She would open the window because she was hot and sweaty and she thought, "Oh, that will make me feel better, I will be able to breathe better." She would carry medication even though she would not take it. Say mantras to herself like, "You are okay, you are okay, you are okay." And sometimes even use the phone to talk to a support person. I also want to point out something that I think is really interesting. My experience with driving phobic patients is sometimes their safety behaviors make them feel better in the short term, but actually were interfering in their driving, which is kind of fascinating. It was making her a more dangerous driver that she was doing some of these things because she was distracted from the road. And that is how you know it is a true safety behavior, right? It is actually causing more harm than good. So we integrated those in the hierarchy. It was important that she dropped out these safety behaviors both for her actual safety, but also so that she could realize that I can drive and feel anxious and still drive safely. The other thing that I integrated in my work with her is what we call hypothesis testing. And I know David, you love this technique and so I am happy to let you describe it. Did you want to?

 

Dr. David Burns: It is just something I recalled from when I was going to Beck's weekly seminars when I was first learning cognitive therapy and he just mentioned a patient who had a driving phobia and had had the thought, "I will lose control of the car." And so he had her do experiments while driving, not to distract herself, but to test that hypothesis, the same as what I did with Terri. Like, "Can you turn the radio on and off or change the station, the radio station? Can you speed up by five miles an hour? Can you change lanes?" And then when she reported back, "Could you do all of these things if you had lost control?" And so it is just a way of integrating a cognitive dimension into the exposure.

 

Jill Levitt: And even with the Terri video, she said, "I am afraid I am going to pass out." It is like, "Well, what can we do to test that?" And so if you have a patient who is saying, "I am afraid I am going to lose control," we are saying, "What is an experiment we could do to test that? Can you do A, B, and C?" And I do find that to be very effective with particularly driving phobia, but in general with doing exposure is making sure that you are kind of testing that hypothesis. I will do this slide as well. So tips for successful exposure. Well, longer sessions can be helpful because if we want to do an exposure with a patient and make sure that they stay in the situation until their anxiety comes down, then having more time to do that can be really helpful.

 

Dr. David Burns: I often schedule double sessions when I am doing exposure. That is what I did with Terri. She was one of the first people I scheduled a double session for and it just it worked like a charm.

 

Jill Levitt: And more frequent sessions can be helpful, particularly if you have patients who have a lot of anticipatory anxiety. They are worried about doing exposure, the more we do it, then the more we can kind of get the hard work out of the way, the better off they are going to be. So treating them for longer sessions and more frequent sessions just during this kind of exposure phase can be helpful. Having them do daily homework, so basically repetition can be really helpful for patients. I do always ask patients to practice what they are doing in session out of session, not limiting your treatment to the office setting if you can. And I know a lot of people are doing video therapy with patients that maybe do not even live close to them and so you have to do the best that you can. But if you have the ability to meet your patient outside of the office session and do exposure with them, that can be extremely helpful. As we have already talked about, persisting when inevitably in the moment the patient will want to back out. And really that is just encouraging them, it is showing them you believe that they can do this hard thing and get better. And sometimes modeling the behavior for the patient. So in the case of David and Terri, if that were my patient, I might have even done jumping jacks with the patient. If a patient is afraid of spiders, we might hold spiders together. So there is something that can be helpful about therapists being willing to face, the fear along with the patient. I did see some questions coming in about safety behaviors and maybe we can answer those at the end of the presentation since I know we have a lot of other things that we want to cover. So I talked about kind of the fear and avoidance hierarchy and moving through things methodically and slowly and then David is going to share with you a story about someone we worked with together in the Tuesday group where we did flooding rather than gradual exposure.

 

Dr. David Burns: Yes, this was a beautiful woman, a wonderful woman in our Tuesday training group and she used to bug me that she wanted me to treat her contamination phobia, her OCD. So one Tuesday we decided to do it in the group and I am going to skip the empathy part, but it was critically important. I am going to skip the assessment of resistance, getting her over her outcome resistance and her process resistance. But her story was she had, the same thing that Howard Hughes had, an intense fear of germs and elaborate rituals in the shower, washing her hands and cleaning herself for an hour or two hours. She was especially afraid of touching doorknobs and whenever she went into a building, she would have a tissue paper that she would use to open the door and this type of thing and she had been struggling with it for twenty to twenty-five years. She knew that I was going to be making some strong demands on her in the methods section. And so once we came to the methods, I said, "Okay, now we are going to confront the monster you fear the most." So we left the seminar room and there were about twenty-five or thirty students there in the seminar and we went into the women's bathroom in the behavioral sciences building and fortunately there was no one else in there. So all thirty people went crowding in there and we went over to one of the toilets. I said, "I want you to touch this toilet seat with your hands." And she said, "Oh no, I could not possibly do that." And I said, "Oh, you can. You just move your hands and you start touching the toilet seat and rub your hands all over the toilet seat." And she said, "I would like to see you do it." So I said, "Okay." So I started rubbing my hands all over the toilet seat and then she saw that nothing happened to me. So she did the same thing and then she picked up the toilet seat and rubbed her hands around the inside of the toilet, which I thought was very brave. And I asked her how anxious she was because she had estimated it initially at 100 on a zero to 100 and she said it had gone up to 120. And I said, "Okay, we are moving in the right direction." And one of the ideas is you do not try to help the patient relax or feel better during exposure. So you do the opposite. Say, "You got it up to 120 out of 100 is good, but now let us see if we can get it up to 150. Let us walk out to the front of the building and there will be a lot of door handles along the way and I am going to have you touch every door handle without tissue paper." And so this was really freaking her out and she was a good egg and she was doing it and all these thirty students were traipsing after us and it was kind of fun for them to see something live and happening in real time.

 

Then we got out in front of the building and there was an empty garbage can there right outside next to the entrance to the behavioral sciences building. I said, "Now I want you to put your hands in here and rub your hands around in that grimy black stuff." And it was really disgusting and she said, "Oh no, I could not possibly do that." And I said, "Oh yes, you possibly could do that. You are going to do that." Again, I am pushing her. I am insisting that she does this and that is one of the important keys to do that with compassion. Again, I had gotten a perfect score from her on my empathy, so she really admired me and trusted me. So she said, "No, if I put my hands in there, I am going to vomit." And I said, "That would be even better. Just put your hands in there and then vomit all over everything and rub your hands around in the all that grime." Because it was like a millimeter of black grime all inside that garbage container. And she said, "Well, I would like to see you do it." So I put my hands in and rubbed them around and they got all black and then I rubbed it all over my face. And then I said, "Okay, Sarah, now I want you to do that." And I will show you what happened in the next screen. This, one of my students had an iPhone there and there is Sarah next to the garbage can and you see her sticking her hands in right now. This is an ultra short video.

 

Jill Levitt: It is a super short video, so you get to hear the story and you just get to watch the last few seconds here. So I will press play right now. Oh, beautiful. And then we went all back into the seminar room and sat down and I saw that she was crying. I said, "Sarah, what are you crying about?" And she said, "Dr. Burns, I am cured of my OCD." "And I am just unbelievably grateful. I am not afraid of germs or contamination anymore." And that was just an awesome experience. Then again, by way of follow up, because some people say, "Oh well, you know, anyone can do that but does it last?" And she is now been free of OCD and germ phobia for it was at least two, three, four, five years ago. She unfortunately has the flu or she would have joined us today to be happy to talk to you or answer any questions that you had. But she is just a delightful person. But again, it was the curative thing and just like Terri, it took courage on my part. It took courage on her part. She kept trying to tell me this is too dangerous, but you have to push ahead, but you get pushy in a kindly and loving way and that is part of the art of therapy is to know how to balance those two forces.

 

Jill Levitt: And I was going to say David, you know, some people have questions and we will not be addressing these kinds of questions about like, "How isn't it dangerous?" Or, "Isn't driving inherently dangerous?" "Aren't germs inherently dangerous?" What I will say if you want to make a quick comment David, you can, but what I will say is, of course, life is inherently dangerous and so you know we are not ever promising our patients that they are protected from danger. This is part of what we call agenda setting or assessment of resistance. We are making the decision with the patient that it is worth it to them to tolerate some level of risk to gain freedom in their life. We are doing a cost-benefit analysis. We are looking at how much it is costing them to do the things that they are doing and we are making that choice ahead of time. So we are not taking patients and saying, "You must do this to get better." We are having a whole conversation with them about what change looks like, what they really want. Is it worth it to them to do the work it is going to take to get there and we decide all of that ahead of time. But then when we are in the moment and we are actually doing exposure that we have decided upon with the patient and resistance shows up, that is when we are confidently forging ahead because we know we have made the decision that this is the right thing to do and that the only way the patient is going to get over it in this moment is to by going through it.

 

Dr. David Burns: But I think those questions just show how all you folks are being hypnotized by our patients too, thinking, "Oh my goodness, it is dangerous to touch a garbage can." Yes. I know a lot of therapists used to say, "Wasn't it dangerous? You asked Terri to stand up when she said, 'If I stand up, I am going to pass out.'" "And you asked her to stand up, wasn't that terribly dangerous?" Well, let me ask you folks, is it dangerous to stand up from a chair? Have any of you ever sat in a chair and then stood up and is that a terribly dangerous thing to do? You see the patients are putting us in this hypnotic state. I will check it out right now. I will see if I can stand up. Yes, surprisingly I could stand up.

 

Jill Levitt: And then of course, people will have questions like, "What if someone has a heart condition?" Well, all of those things are very specific, of course, we are never intentionally putting our patients in danger. I will say for patients who have panic attacks that come to see me, they have usually the people who have had the full cardiac workup, they have been to the ER many times, like you have evidence that they do not have a heart condition, they have already ruled that out. We know that it is anxiety. But I think we should forge ahead because we have got more to share. We can always, we can always answer more questions at the end if we got more questions.

 

Dr. David Burns: Yes, thank you for all these questions. It means you are engaged and you are touching on the most important things and issues emotionally for therapists and for patients, like what is the price of a cure? Okay. The "What if" technique is a great, it is a cognitive technique, but it is a cognitive exposure technique, you might say. You want to uncover a patient's core fear using the "What if" technique and then once you uncover the core fear, you have them confront that using exposure. To give you an example of that, a man was once referred to me by a colleague in Philadelphia. He said he thought this guy was the top courtroom attorney in the United States, that he had lost only one case in his entire career, but he was very unhappy. He was a very nice fellow. I just liked him tremendously. He had only lost one case in court during his entire career and he was in his sixties and that is so very unusual because every time an attorney wins, the other attorney loses and so for him to have a record like that was pretty unbelievable and he took on giant corporations in environmental contamination cases and he brought them to his knees. He worked solo on these incredibly difficult cases and virtually nearly always won. But he told me that he had been unhappy since he was a little boy and he had not had one minute of happiness in his whole life and when he came to me, he had just completed thirty years of five day a week psychoanalysis. And I asked him, "What did you find out? Did you find out why you have been so unhappy?" He says, "Well, the psychoanalyst told me it was because my, I had a baby brother who died when I was little, died in a fire and I have subconsciously blaming myself for his death." And I said, "Was that true and was that helpful?" He says, "I have no idea if it was true. I can tell you it never helped me. Nothing helped me." And so his thought that on his daily mood log that kept coming up was, "What if I lose a case in court?" And he told me that he would just work seven days a week preparing for cases, that he could not even go on vacation anymore because he just worked constantly on vacation. And so I wanted to see what was his worst fear and so I did the "What if" technique and this is an easy technique to do, which you might enjoy incorporating it in your practice if you have not already. It is one of three powerful uncovering techniques and we will, we go to the next slide. I will show you how it works. So he was saying, "What if I lose a case in court?" I say, "Write that down on a daily mood log in the negative thought column and put an arrow under it." And the arrow means this is the downward arrow. If that were true, what would it mean to you? Why would it be upsetting to you?

 

And whatever the patient says next, you say, "Good, write that down." And then you keep doing it until you get to the core belief. And so he said, "Well then people will lose confidence in me." And then I, he wrote it down and I wrote it down and I said, "Let us suppose that happened. What would happen next? People lose confidence in you. What are you the most afraid of?" And, "Then people will stop referring clients to me." And then, "What is the worst that could happen if they stop referring clients to you? What are you the most afraid of?" "Well then I will go bankrupt." Which was kind of absurd because the guy was pretty darn wealthy because he was such a successful attorney. "And then but if you went bankrupt, then what? Then what are you afraid of?" And he, his, "Then my wife will leave me and my daughters will stop loving me." And then what is the worst that could possibly happen? And he said, "Then I will end up homeless and alone." And his core fantasy was being a homeless man on the streets of Philadelphia and begging with a tin cup and then attorneys he beat in court walk past and kick sand at him and say, "Oh there is the great Jeffrey. He used to think he was so fantastic and look, look at him now. He is pathetic." Although he rationally knew this was not going to happen, emotionally he believed this would happen, that he was in danger. And so this downward arrow not only showed me his core belief but his self-defeating beliefs, which was perfectionism. He believes, "I must be perfect," but especially perceived perfectionism, "People will not accept, respect or love me if I fail." And I was trying to find how can I get him to crush these core beliefs. And the answer is, find a way for the patient to confront his worst fear using some form of exposure. And so when he was working with me, he coincidentally lost his second case in court and it was just a trivial case he took on pro bono as a favor to a friend and the reason he lost is the man he was defending was as guilty as sin and deserved to lose the case. But he was terrified that people would find out and he was thinking, "How am I going to hide this so people do not find out?" And so the then the experiment came to me and he was the chairman or the law board or whatever it is called. He was the head of it in Pennsylvania. And they were having a meeting that week and I said, "At the meeting, tell ten of your colleagues that you just lost a case in court and then find out how they respond to you." "And you can keep a three by five card in your suit pocket."

 

He used to wear these very expensive suits and bow at the beginning of session. It is very formal, like some powerful attorney. "And then if they respond negatively, you put it in the negative column. If they respond positively, you put it in the positive column and if you are not sure, you put it in the third column." And he resisted this intensely that he did not want them to find out he had lost a case in court. But again, I had to say, "You must do this if you wish to continue working with me. This is not a negotiation, this is a demand." And he was a good egg. He had suffered his entire life. He said he had never had one minute of happiness and he would do anything if he could overcome this. Oh, I see. Okay, yes, we will come back then to it. And the next week he came in and he said that he was stunned by what happened. And he pulled out his three by five card and he told ten attorneys, "I just lost a case in court." And he said, "Five of the ten appeared not to have heard what I said and they just kept talking about how great they were and all of the cases they had won and kind of bragging the way," he said, "attorneys tend to do." "And I realized I had been involved in the distortion of magnification and minimization, magnifying my importance in the eyes of other people and minimizing the extreme narcissism of American attorneys." So he said that was a relief to, that reaction that they had. But he said the other five was even more powerful. He said, "Not only were they not critical of me, they opened up right away and they said, 'Oh Jeffrey, God bless you for telling me this. It is a relief to know that someone as great as you, one of maybe the greatest attorneys in American history, can lose a case in court.' "And I feel so much closer to you now. Let me tell you about all the cases I have been losing in court and let me tell you about my wife who is about to divorce me and let me tell you about my children who are using drugs and hanging out with the wrong crowd and I do not know how to talk to them. He said, "Dr. Burns, tears came to his eyes, he said, it was the weirdest thing in the world.

 

I felt joy for the first time in my life. I felt that I had something to give people and my anxiety, my fear disappeared finally after sixty years and it was such a heartwarming thing. His whole persona changed and he stopped acting so formal and because I actually did not like him because he was so formal and I was afraid and he was so formal, I thought maybe he is getting ready to sue me or something like that. Then when he showed his vulnerability and reported that back, he became like a regular fellow, like a friend and I felt so close to him and felt so much warmth and admiration and gratitude. I think that is one of the beautiful things about our work is we are not just treating symptoms, but we are trying to save the life of a human being and cause a meaningful transformation in someone to try to bring someone actually like Jeffrey to a state of enlightenment. Sometimes recovery has a kind of a philosophical or almost spiritual dimension and it was certainly the case for Jeffrey.

 

Jill Levitt: It is also a beautiful example of how therapy is such an art form, you know that we can teach you all the different components and different strategies and methods and it is also somehow you know there are just times where you decided to do the "What if" technique to uncover what you know what that core fear was and probably did not know ahead of time what you would end up finding and once you found it, you had to be creative, like how can we actually figure out if this is true or not? You did some interpersonal exposure with him, again, that kind of the self-disclosure and a survey technique and sort of each method built on the other to end up with such a kind of beautiful outcome. So you know, we are going to talk to you a little bit about kind of two forms of cognitive exposure that can be really helpful when you are working with patients and one of them is cognitive flooding and I will talk to you guys a bit about cognitive flooding and the other one is memory rescripting and David will share with you a story where he is memory rescripting. Some of you have asked in the chat, what do we do when we have things that patients are afraid of that they cannot really confront in reality? Someone texted, you know that they have a patient who is really afraid of getting a terrible illness and so these are the examples where cognitive exposure can be incredibly effective. So cognitive flooding in particular is where we would have the patient actually close their eyes and imagine the worst thing, the thing they are most afraid of happening and in fact the "What if" technique that David just shared with you can be really useful in getting to that core fear. What is it the patient is most afraid of? And then once you get there, you can have the patient close their eyes and imagine that terrible thing happening. So if it were that they were afraid they would get sick and even suffer and eventually die of a particular illness, they could actually imagine that. We will have the patient, we will do it with the patient in session and we will actually ask the patient throughout the cognitive exposure, telling what their anxiety rating is from zero to 100 every minute or two. That is really so we can understand what are the hardest parts of the exposure for them and also so we know if they are not really doing it, meaning if they are not very anxious, we want to try to encourage them to think about it in a way that is going to bring on more anxiety. Can you get yourself to be more anxious or worried about it? So you can tell if the patient is avoiding because you are asking them for their anxiety rating. We are encouraging them to constantly try to intensify the anxiety and we are going to have them continue doing it until the anxiety goes away. We also record the exposure with them in session, so nowadays that is pretty easy because most patients have a recording device on their phone and then we can actually assign it to them to listen to that recording over and over again for homework and I am going to walk you through an example of this. I actually do like to have my patients write out a script. Some people will just have them close their eyes and imagine it on the spot. I just think sometimes it can be helpful to have people write out the script and so they are asking themselves, "And what happens next?" "And what am I most afraid of?" And they can kind of write it out, then they can actually read the script in session.

 

Also just to address some therapist questions, sometimes an exposure might be ten minutes long and I usually try to get my patients or assign my patients to do their exposure for thirty minutes a day every day. So if it is a short script, I say then you just keep listening to it over and over again until the thirty minutes are up. If it is a fifteen-minute script, you can listen to it twice. But the goal is to really get them to kind of lean in and bring on all of what they are afraid of. I will give you an example. There was a patient that I was working with many years ago who actually had contamination OCD. So she was worried about contracting an illness and she was worried that it was going to get her sick and get her children sick and she had very kind of classic contamination OCD. But what kept coming up in sessions was she was also so worried about the idea that her OCD was going to lead her to lose her mind. And so while we were doing different exercises using hierarchies and things like that and exposure and response prevention to work on her OCD, what kept getting in the way of therapy actually was her ruminating and obsessing about the fact that this OCD would never go away and that she would ultimately lose her mind. So I thought, you know, maybe we need to address this kind of category of anxiety before continuing on with this contamination exposure. And so I did the "What if" technique with her to understand what is it that she was most afraid of? You might be thinking losing her mind is bad enough, is not it? Like, is not that what she could imagine? But I was curious and I asked her, "Let us imagine that you did lose your mind, what would that look like and then what are you most afraid of?" And it turned out that she was actually most afraid, she had two young children. She was most afraid that she would end up being hospitalized and institutionalized and that her children would grow up without a mother and when she got to that admission, she was sobbing and that was truly the thing that she felt most afraid of, that she would abandon her children and that they would be left kind of not alone but without a mother for the rest of their lives.

 

And so we decided to address that using cognitive exposure. So I had her write this script and then record it with me and I will tell you that doing cognitive exposure with patients can be extremely painful. You will have patients who are imagining the most terrible things happening to them and sobbing in your office and that is what happened with her and again, just like David, I had to be confident and kind of pushy and saying, "I know this feels awful now but this is what we need to do to kind of get you to the other side." So I had her record it and her anxiety was up at 100 and she was crying and skeptical that this would actually be effective. But I, we did it in session and then I assigned it to her for homework and asked her to listen to that recording thirty minutes a day every day and I said, "It does not matter how long it takes, we are just going to keep doing it until this recording no longer bothers you." Which sounded kind of incomprehensible to her, but a week later she came back having listened to her recording every day. She was happy to report that honestly it bored her. She just did not really think about it very much anymore. She kind of got used to listening to herself and the story seemed ridiculous and unlikely and it just did not bother her anymore and we needed to then kind of shift gears and get back to working on her contamination OCD, but she no longer brought up this fear that she was going to lose her mind and end up abandoning her children. So it was incredibly effective, but also I relate to that therapist experience of worrying in the moment, am I actually making my patient feel worse? But it is this idea that more anxiety in the short term is going to bring relief in the long term. And David, did you want to share your story about memory rescripting? We do have time for you to do that and then we can shift gears and do some questions and some follow-up information.

 

Dr. David Burns: Well, I will see if I can give a quick story of it. But essentially with memory rescripting, you have the patient close their eyes and go into the past and relive some horrible traumatic experience, but you can also have them change the script, have it come out a little bit differently, so that they are in control and it is just a concept and you can do it in a hundred different ways. But I was doing an intensive for a small group of maybe thirty-five therapists in Southern California a number of years ago and that is a four-day training experience and we work from morning till late at night and have dinners together and it is very intense and people's defenses break down and they open up and we start feeling close to each other by the second and definitely third day of the intensive while learning techniques. But there was one fellow that did not fit in very well. He said that he was a pastoral counselor from New Mexico, but he was very formal and always trying to impress people. I remember my father was a minister and when he prayed, he used to pray with a warbling voice like, "Dear Lord, please bless us thy people," like that. And I should probably not be critical because he had a congregation who really loved him. But I used to think, "Dad, why do you have your such a stupid warbly voice when you pray? Does it go through the clouds better and get up to God if you are warbling? And why do you speak in medieval English? Does not God understand modern English?" And it was irritating and this guy was like that, talking this warbly voice all the time. And he was not connecting with people and I was doing a segment on what we are doing now, like cognitive flooding and I was talking about how a picture in your mind and you focus on it will often bring powerful emotions. The pictures are almost like sentences that upset you, upsetting pictures. And I was about to go on to the next technique and this fellow, this pastoral counselor, raised his hand and said, "Could I ask you a question?"

 

I said, "Yes, sure, no problem." He said, "Are you saying that a picture in your mind can create a lot of powerful emotions?" I said, "Yes, pastor that." That is right. And he says, "Well, I have a picture in my mind right now." And I could see he was getting real shaky, like he was about to start sobbing or something like that. I said, "What is the picture of?" He says, "My nephew Jimmy." He says, "You see, I have been telling you I am a pastoral counselor from New Mexico, but that is not my true identity. I am actually someone different from that." And I said, "Oh my." I got shocked. I said, "Well, what are you doing at the workshop and who are you in reality?" He says, "Well, my name is Johnson and I am working as a pastoral counselor, but I am actually a pilot." I said, "Oh, what airline do you fly with?" And he says, "No, I have not flown a plane for twenty-five years or thirty years or something like that." And I said, "Tell us about that." And he said, "Well, I was a pilot in Vietnam and I became the head of the thing and so I was supervising the bombing missions over North Vietnam and Cambodia." And he said, "My nephew Jimmy was one of my pilots and that is my wife's only child, or my sister's only child, my nephew." And she wrote to me a letter, said, "We pray to God everything every night, please do not let anything happen to our Jimmy." And he said that that night Jimmy came back in a body bag. And I went down to identify the body, make sure it was Jimmy and I opened up the body bag and I looked in and his face had been blown off, but I knew that it was Jimmy. And I thought I would start sobbing and something happened in my brain and my emotions got turned off. And I have had no emotions for thirty years. I cannot feel anything Dr. Burns. That is partially why I came to this conference because I like, I am a human being, but I do not have emotions. And I do not know why I cannot feel anything. And he was just shaking. And I said, "You looked to me like you are on the verge of tears right now. Maybe you need to go ahead and let those feelings out right now." And then he just started sobbing uncontrollably and just shaking and snot was going down out of his nose and tears were flowing down his cheeks and he put his head in his hands and he was just shaking and half the workshop started sobbing.

 

And then he pulled himself back together and a woman sitting opposite him said, "Pastor Johnson, I want you to know that during the Vietnam War, I was one of the protesters here in Los Angeles and we hated people like you and we protested against people like you. But I can see you that you gave your best for the country and I just wanted to say thank you." And then she started sobbing and he started sobbing again. And then afterwards he said, "You have all heard about the Medal of Honor the US gives out the Medal of Honor. Well, so did the Vietnam government and I received the Medal of Honor for the things I did in Vietnam from the Vietnamese government." "And when we came back to America, and we got off the plane, there was no one there in the airport waiting for us. My sister was not there, our friends were not there, our family were not there, none of us, nobody was there to greet us and when we walked through the airport, people started spitting on us." "And Jan, you are the, thank you, just gave me is the first one I have received in the last thirty-five years, the only thank you I have ever gotten." And then everyone just burst out sobbing at that point. And that was it, but we did not need to do the rescripting. All he needed to do was to visualize the face of his nephew and that brought all the emotions out. And that night when we went out for dinner, we got pizza someplace as a group and he sat next to me and all that warbly voice thing had disappeared and he was just so cool and awesome and funny and friendly and down to earth. But that is how you can bring people into the past and then work with the memories and images in a just a huge variety of ways. But that is just to give you a feel for the power of pictures as well as thoughts. Pictures are cognitions just as thoughts are cognitions and they can contain potential emotion and as a therapist, you do not want to be afraid of emotion, but let go with the patient to the gates of hell because that is often where the miracles occur.

 

Jill Levitt: Absolutely such a beautiful story David and you are such a talented storyteller too. I think we could all sit and listen to you for hours. So I think what we will kind of cover just some brief take-home messages and then we will share with you some follow-up training opportunities and then we will go to the Q&A until the end of the hour. I am happy to talk about this David and unless you want to.

 

Dr. David Burns: No, you go ahead.

 

Jill Levitt: Yes, I think we have highlighted these points throughout. So maybe this is all pretty clear to you guys, but clearly we are asking our patients to do really hard things and so trust and rapport are super important as is hope and confidence on the part of the therapist. Instilling hope in our patients that they actually can get a cure, that they can get relief and get over this thing they have been afraid of for so long and our confidence and belief that we have the tools to be able to help them. I would say if you are a therapist who is like, "But I do not have that confidence." Well then get more training, seek out training, consultation. It just occurred to me, I did not even put a slide about this, but I run an exposure consultation group where we just talk about how to implement exposure. We have lots of other consultation groups and trainings on the topics in general, but get support, get consultation, get supervision. Do not forget that it is super important to initially address outcome and process resistance and come to another training where we teach you how to do that. But recognize that we are not just jumping in and doing exposure with our patients. Exposure is one of many ways of treating anxiety and in any case, you definitely need to be addressing resistance and motivation. Remember that you can use gradual exposure or you can use flooding. Make sure that you pay attention to safety behaviors because they can really sabotage exposure and overall treatment and do not settle for partial recovery. Know that your patient can get over their fears and that you can help them to do that and again that exposure is a really powerful method that you can have in your toolbox to help that along the way. So I will do a little bit of sort of like if you would like to learn more and then we will take your questions and Mike has been collecting them throughout. So if today's training sparked something in you and if you feel excited about what you learned and you would like to take your skills deeper, we would love to invite you to join our FastTrack to level three certification course. It is our most efficient and powerful way to help therapists that are interested in learning and growing and mastering these strategies. What we covered today was literally one of fifty plus methods that we teach in the FastTrack course to help therapists become better therapists and to help patients to recover faster. I will just share this one testimonial that Sarah Chickering shared with us, which was that this course was one of the best decisions that she had made for herself professionally because it really grew her confidence and her toolbox. This slide is packed, but just to give you the full picture of what is involved, our FastTrack course begins on September 11th and it is a hybrid format. It is designed for busy professionals. So you get to watch videos of me and David teaching. I am doing a lot of the didactic teaching and David and I have a lot of interviews and cool stories to share with you and you kind of consume all of that asynchronously at your own pace and then we meet weekly where you can actually practice the tools that you are learning and so you have a weekly practice group. We also start out with a David Burns live so there is a four-hour live teaching session where we are actually working with a therapist who is functioning as a patient and you get to see us kind of bring this model to life live. You also get a certification, you get the therapist toolkit and right now there is a $50 off coupon for it that you can use if you sign up. Mike is sharing the link with you in the chat box and beyond the FastTrack course, there is David's app and I am going to let David tell you a little bit about the Feeling Great app.

 

Dr. David Burns: Yes, the Feeling Great app is free for the summer, between now and probably the end of September. And it is both classes and lessons. It is for you and your patients. But there is also, we have trained the AI to function pretty much the same way I function in an actual therapy session. We have gotten beautiful endorsements from people that it has been life-changing. We have looked at the research data and the reduction in negative feelings, not only depression, but anxiety and anger and hopelessness and loneliness and inadequacy, all diminish with most patients within a couple of hours the first time they sit down with the app. So if you are an individual wanting help with depression or anxiety here, jump on the thing right now. I do not know if we will be around forever. But it is in existence now, the Feeling Great app and it can be helpful. It can be an adjunct if you are in therapy with someone. But it can also help you if you do not have a therapist. It is not trying to be therapy, it is a self-help tool much like my books Feeling Good and Feeling Great and When Panic Attacks, but it is a new tool and it is quite different from anything else and it is beautiful. The empathy that it does is mind-blowing. It will melt away resistance and it knows many of these techniques we have been talking about in today's seminar.

 

Jill Levitt: Yes, and also the Feeling Great app is great for therapists as well and you can get the app and your patients can get the app and then you can actually be giving patients homework and things like that to really enhance the therapy that you are doing with your patients. And then we also just put this slide up and now we are going to do some Q&A, but there are other ways you can learn and grow with us. We have a free weekly practice group David and I run on Tuesday evenings from 5 to 7:00 p.m. And if you are interested in that, you would contact Ed Walton at that email address. That is a, it is not a drop in group though, you need to make a commitment that you are going to come regularly if you would like to be a part of it. That is only for therapists. There is also one on Wednesday mornings with Rhonda and Kai, similar kind of format for therapists.

 

Dr. David Burns: And I want to emphasize, if some of you want to learn more about what we have taught you today and really learn the fine points, that is unlimited free training every week from David and Jill. So if you would like to, and it is virtual, so there you can join from anywhere in the world.

 

Jill Levitt: Yes, and then you can also get David's podcasts and the Feeling Great on YouTube and so those are other options for additional free training. We are going to go to Q&A now and then at 55 Mike will drop the link to the CE survey. So you have to complete the CE survey today when we drop it in the chat box because you have to be present for the whole time and then you will get your CE certificate via email within one week. But now we will move on to some Q&A.

 

Q&A Session