Making Treatment For Depression and Anxiety More Effective Using TEAM-CBT: A practical introduction for therapists

Making Treatment For Depression and Anxiety More Effective Using TEAM-CBT: A practical introduction for therapists

IN THIS VIDEO:

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Jill Levitt: Hi everyone, I'm going to start the webinar in just a moment but I'm just going to get my screen set up and then do a quick check to make sure that you can all hear me and see me and see the Power Point slides as well.

So just a moment. Okay, so at this point you should be able to hear me and see me and you should also be able to see the slides on my screen. So if someone would just take a moment on your GoToWebinar control panel under the questions tab, you can actually just enter, you know, okay or no problem or hi or something like that and that'll indicate to me that you have good ability to see me. Okay, great. At least a few people have entered that. So that means if there are any issues that you're having in terms of seeing or hearing or seeing the slides that it's probably on your end and you can check your speakers and things like that. So I'm going to get started in just a moment. I'll take a minute to, let's see, it's 11 o'clock. So I'll get started now.

Before I introduce you to the content and introduce myself, I'll just orient you guys a bit to GoToWebinar. So just a few things I want to point out. On the, about halfway down your GoToWebinar control panel, if you're using a computer, if you're using a tablet, maybe slightly different, but you'll notice that there's a little section that says questions. So if you click on that caret or look where you can enter questions and you should be able to enter text and you can type it in and click enter and then I'll be able to see questions throughout. I won't be checking that constantly, but I'll check at different points to see if anyone has any questions. If you have questions or comments, you're welcome to enter them there.

The other thing is a little further down, there's a caret that says handouts and if you click on that, you'll see most likely an orange square with a P in it and that is the copy of this presentation. So PowerPoint slides, so it says free methods webinar and you can click on that and you can download it and that way you have a copy of these slides. I'll mention a few other housekeeping things and then I'll get started. If you are present and you're hoping to get continuing education credit, you do need to stay for the entire presentation. We take attendance using GoToWebinar and we're only able to offer CEs for people who are present from the beginning to the end of the presentation. What happens is after the presentation, 24 hours after the presentation, we'll send you a follow-up email and in that follow-up email will be a survey. If you complete the survey asking you about kind of the quality of the presentation, then you will be emailed a certificate of completion and you can keep that on your records for continuing education and if you have any questions about any of that, you can send me a quick email afterwards. Let's see and the only other thing is in the follow-up email, I'll also send you a copy of the recording of this webinar so if anyone wants to view it again, you're welcome to do that and I'll send you a copy of the recording. Okay, so let me go ahead and introduce myself properly.

Although it says Maor Katz on my screen, I'm actually Jill Levitt. My name is Jill Levitt and I am a clinical psychologist and also the director of training at the Feeling Good Institute in Mountain View, California. I practice CBT with my patients and I do a lot of training of other therapists both online and also in person and finally, I co-teach a therapist training group with Dr. David Burns as part of my role on the adjunct clinical faculty at the Stanford University School of Medicine and my goal for today is we only have an hour together so I'll set some kind of humble and realistic goals.

My goal is to teach you how to set up, well to do cognitive therapy with your patients and I'll also be demonstrating a few fun and useful cognitive role-playing techniques that I've learned from Dr. Burns that I find really helpful in sort of bringing what can be sometimes dry and cerebral techniques kind of more to life. So essentially, I didn't put a time on here because I know that everyone's in different time zones so I decided to indicate the length of time on the slide rather than the time of day so we'll spend about 10 minutes with me introducing the team CBT framework and I'll explain to you what that even means and kind of focusing specifically on methods today. I'll spend about 20 minutes talking with you about what we call the art of the setup so how to set up well using a daily mood log, how to elicit kind of useful negative thoughts from your patients, how to identify cognitive distortions.

I'll then spend about 10 minutes teaching you one method that I think is is fun and you know very useful which is called the double-standard technique and how to do that in a role play. We'll spend about 10 minutes doing another role-playing method called externalization of voices and then we'll have some time at the end to wrap up if there are questions and also kind of to tell you about additional training opportunities if you're interested. Okay I'm just checking to see if there's any questions so, let me tell you a tiny bit about what is Feeling Good Institute. When I say I'm the director of training what are we? So Feeling Good Institute is an organization that we feel like we're dedicated to providing and training people in you know a high level of therapy. We work in kind of three umbrellas. We try hard to train therapists and offer training such as this so training therapists in advanced CBT tools and techniques.

We also have a certification program for therapists that provides a bit of a roadmap for people kind of wanting to advance through different skills and our goal there is to you know support therapists and recognize quality therapists and kind of like I said provide a roadmap so people have ways to progress through training and therapy. We also do clinical work so we have a treatment center in Mountain View and one in New York City and we do individual weekly therapy as well as we have intensive therapy programs where people come in from out of town and work with us for many hours over short periods of time. We also now have a live video therapy program to offer therapy to patients in different states throughout the United States and Canada.

So let me tell you a little bit more about kind of the the framework what is TEAM-CBT. So this is just to have you understand where we're coming from. What I'll be talking about today actually is just down here the M in TEAM but I want you to understand sort of the framework that I use when I'm seeing all of my patients. So TEAM actually is just an acronym for a number of different sort of steps that we walk through that that have been shown to be related to positive treatment outcomes in patients. So the T stands for testing. It means that we use measures of symptoms and the therapeutic alliance before and after every session with every patient in order to measure progress and also to help us to tune in and understand our patients.

So we have these measures in our waiting rooms and we have our patients complete them and we track progress over time and check in each session with our patients to make sure that they're actually receiving benefit from therapy. Other people refer to this now as routine outcome monitoring. So this is what we mean by the T in TEAM. The E in TEAM stands for empathy. We use kind of a toolbox, a teachable group of empathy skills that we teach therapists and use with our patients that help us to connect quickly with our patients and also to turn difficult moments, moments of disconnect into breakthroughs in therapy. And so the E in TEAM is really important and we do webinars and trainings on teaching therapists how to improve their empathy skills. The A in TEAM stands for agenda setting which we do most commonly kind of in a paradoxical way. So agenda setting typically in CBT refers to the idea of setting an agenda with your patient at every session, making sure you're on the same page and you have a plan that you stick with. And that's certainly a part of what we're talking about here, but agenda setting in our model is broader than that. It's a group of tools that we use that help us to align with our patient's resistance to change, to really kind of put words to and voice the patient's resistance. And paradoxically, we find that that enhances motivation to change. We have a lot of tools and trainings on that. And finally, what I'll be working with you on today and teaching you today is the M in TEAM, which stands for methods. It's what most people think of when they think of CBT. They think of what are all the cognitive and behavioral powerful methods that we use with our patients that actually bring about change.

If it's not obvious, I like to mention that TEAM therapy is transdiagnostic. So it's not a manual for one disorder. It's really just a framework for thinking about doing effective therapy, and it can clearly be tailored for different kinds of diagnoses and presenting to complaints. It's sort of making sure that with every patient, I'm going through each of these four steps. In moving toward methods, because that's what we're going to be focusing on today, this is just sort of a fun chart to throw up. It's almost like a carrot or a teaser, but in working with David Burns, this is a table of all the different methods that we have at our disposal.

And there's many, many more. This is kind of a moment in time with 50 plus methods listed that we can use with our patients with different kinds of difficulties. And I'll only be showing you a few of them today, but we'll be talking a little bit about identify the distortions. We'll be talking about the double standard technique, and we'll be talking about externalization of voices. In shifting gears and thinking a little bit about how to set up for effective therapy with your patients, one of the things that we find really important is the idea of getting specific with our patients. So this is the idea that patients will often come in with many different problems and want help with all of them, which would be impossible for us in any given session to help a patient with many different problems.

As well, even once we get our patients to maybe pick one problem that they want to start with or one category of difficulty, let's say panic disorder or generalized anxiety or OCD, even to say like, oh, great, I can help you with your OCD is a little bit overgeneralizing. We like to get our patients to get even more specific. Since we know, right, as cognitive behavioral therapists that situations don't cause feelings, but actually our thoughts and our beliefs about situations cause our feelings, to help a patient using a cognitive behavioral framework, we need to first understand what the patient is telling themselves in that moment that's driving the feelings.

And so getting specific with a patient, number one, on which problem are we going to work on, but then number two on, can you tell me a moment in time where that was difficult for you, will help us to really get specific about the exact thoughts that are driving the patient's feelings so that we can do effective cognitive interventions, as well as even what the patient is most worried about or afraid of, let's say in the case of anxiety or most down about with depression will help us even to tailor, let's say, behavioral experiments or homework that we're going to give the patient that will involve changing behaviors. So the first thing we need to do is narrow down the problem list and pick one problem. And when I say one problem, you might think of that as one diagnosis, right? One type of problem that the patient wants help with, social anxiety, depression, a relationship problem.

And then even once we've narrowed down, let's say the type of problem. So I understand the patient says, oh, I really want help with my low self-esteem. Before I'm going to presume that I know how to help the patient with their low self-esteem, I'm going to want them to tell me more about it.

So can you tell me about a moment in time when you were beating yourself up or not feeling good about yourself? And I, as a therapist, will learn so much more about that patient when I could just ask them to tell me about a moment in time. So we're going to ask the patient to kind of pick a moment in time where you were struggling with this. And then using whatever kind of, let's say, cognitive worksheet you use, maybe it's the kind of triple column or a piece of paper or the daily mood log, which I'll be showing you today.

Our goal is then to start to elicit the situation or the trigger, the feelings that the patient is experiencing, and their negative thoughts that are driving those feelings. I'll show you what I mean here in the next slide using the daily mood log. I also want to offer a metaphor that I've learned from David Burns that a lot of patients really like, which is that I tell patients that I think of therapy as following a bit of an hourglass. In the beginning, when a patient comes in to see me, they're talking to me about a lot of different things and sharing with me a lot about themselves and what they're looking for help with. And that's kind of the top of the hourglass where we're really kind of wide in general and trying to understand. And then we want to get really kind of narrow and specific.

And that's kind of that middle part of the hourglass. We want to understand, we want to pick a problem of the multiple problems. Of course, I can help them with lots of problems, but only kind of one at a time, right? So we get narrow in type of problem, and then even in kind of moment in time. And then what I tell patients is, look, most people that I work with are actually quite consistent across time. The way that you beat yourself up on Monday is a lot like the way that you beat yourself up on Thursday, or the way that you're criticizing yourself in relation to your parenting is kind of similar to the way that you're criticizing yourself at work. So if we could actually pick a moment in time and understand you really well and give you strategies to challenge or change your thoughts, your behaviors, to work with you in that moment in time, the likelihood is that will generalize those strategies, those tools, those skills will generalize across many moments in time.

They may not generalize across problems, but they'll generalize for that problem across many moments in time. And then we kind of the bottom of the hourglass is where you're working on applying these tools and strategies that we've designed kind of in one moment in time across other moments in time. So that can sometimes be helpful for patients and therapists to think about. So, I'm going to share with you a daily mood log, and I have kind of an example of a theoretical patient that you might work with. And so I'll tell you a little bit about this patient, and then I'm going to walk through with you, again, this is kind of the art of this setup. So I'm going to walk through with you on how to use the daily mood log, how to elicit thoughts, and how to identify cognitive distortions.

So, let's look at the daily mood log here. Again, regardless of the sheet you're using, you're going to gather information about like the upsetting event or the trigger. And here, once I've gotten specific with my patient, I actually take out a copy for myself, and I hand a copy, a blank copy to the patient. And I say, let's both write this down. So we'll have a copy of it, right? So tell me about a moment in time where you were being really self-critical and feeling kind of down on yourself. And the patient says, well, recently I was at my friend's house, and we were hanging out and having a pretty good time together, and we were going to watch a movie. And before we started the movie, my friends, I should back up and say, let's imagine this is a 30-year-old single young man who has shared with you that he's feeling really down. And I'll give you a little more background information, actually, that'll be helpful. Let's imagine he's working at a job, but it's kind of an entry-level tech job.

So this is important to the relevance of the daily mood log. He's earning something like $75,000 a year. And he's around 30, and he's had a couple of different entry-level jobs, sort of not really found something that he's really liked or decided to stick with. And he's feeling down on himself. He wishes that he were earning more money, feels like he should be further in his life, kind of given his age, and feels a little bit embarrassed also with regards to dating and things like that, because he feels like he's maybe not that appealing, because he's not, by the age of 30, some super powerful, high-paid executive. So he's over at his friend's house, and he's hanging out with his friend, and his friend's younger brother comes in and starts talking about his new job. And the friend's younger brother just graduated from college and got this new job and shares with this friend that, you know, oh, and I'm so excited about my new job, and I'm making like $75,000. And as soon as the patient hears that this kind of 22-year-old is making the same that he is, his mood tanks. And he shares that with you, the therapist, saying, yeah, this is what happened. And then I started to feel really awful about myself, and I couldn't really enjoy the movie or enjoy my friend's company. So we're right at the top. The upsetting event is my friend's younger brother is talking about his new job, which pays the same as mine, and I'm 32, and he's 22. So then I asked him, you know, great, let's write that down. That's a perfect example of the kind of thing that triggers, you know, negative mood in you. Great, you know, and we both write that down. And then I say, so let's walk through each of the feelings in each of these rows, and I want you to circle what feelings are coming up for you in that moment. What were you feeling? And then also let's write down kind of how strong that feeling was from zero to 100. These don't have to add up to 100.

Each one is on a zero to 100 scale. So I bolded, I'm not sure if it's super clear, but I bolded on this slide that he circled sad, depressed, down, unhappy. And when I asked him, how strongly were those feelings for you? He said, 85%. I was feeling really, really strongly. And then he circled anxious, worried, and nervous at about 80%. Then he circled ashamed at about 80%. So we go through each row, and actually my experience is this is so much more useful to patients than just taking out a piece of paper and drawing lines down and saying, what was the event? How were you feeling? Because patients don't typically have this many feeling words at their disposal. And actually it can be incredibly helpful. He might've been aware of the fact that he felt down, but he might not have been aware of the fact that he felt ashamed, or worthless, or inadequate, or self-conscious, discouraged, or even angry, like annoyed and irritated.

So it's really helpful to me to have a form like this, where I can ask the patient to go through each row of feelings and then circle what feelings were coming up for them and how strongly. The other thing is having the feelings down, like this specificity of feelings also helps patients to generate thoughts. Because what I say to the patient is now looking at this list of feelings, I want to think through with you kind of what were the thoughts that were driving these feelings, right? I want to be able to help you with those thoughts, and I've got lots of great strategies, but in order to really help you to feel better, I need to sort of understand what you as an individual, what were you telling yourself that was causing you to feel these different feelings? And you can do this in different ways.

Some people ask an open-ended question, like, what were you telling yourself, you know, on Tuesday night when this happened? I like to be more specific. I'll even go through each feelings row and say, what do you think you were telling yourself that was making you feel sad, depressed, down, unhappy? And write those thoughts down over here. And what was a feeling that was causing you to feel ashamed? Like, if you're feeling ashamed, what are you telling yourself that's making you feel ashamed? Like, for example, this thought, people will look down on me when they realize how little I make.

What you also want to be aware of is that every patient will have very different thoughts that will drive their feelings. They might have the same feeling as another patient you've treated, but their thoughts are going to be very specific to them, and their circumstance, and their life experience, right? So I'll give you more examples of thoughts that this patient was telling himself in just a moment. But first, I'm going to go through a couple of kind of pointers for the daily mood log, and then we'll come back to the daily mood log and look at some other things. Let me just see if there was a question. Oh, someone asked, how about when a child is having difficulty admitting to having these feelings? So that was a question that someone just asked. How about when a child is having difficulty admitting to having these feelings? So one thing I would say is, obviously, a lot of the methods that I'll be showing you today I'm thinking about is using for teens and adults.

Kids will need different forms, basically, with different language. Although, we're trying to do the same work with kids. You might have a feelings page that has different feelings. You might need to do more education around the fact that feelings are really normal, and oftentimes, we have a range of feelings. We might feel excited about something and nervous, or we might feel excited about something and irritated. So you probably need to do more gentle guidance with kids. I, myself, haven't seen that kids are necessarily ashamed or afraid to express their feelings when you do it in this kind of a way, but you may need to spend more time and more practice. The other thing I'll say is, if you are interested in learning how to adapt these tools for kids, then we do actually have specific trainings that are focused on people who want to use CBT with children, teens, adolescents. So I would look at our website, which is down here, feelinggoodinstitute/cbtacademy, and you can check out where there are more kids-specific trainings as well.

So let's talk a little bit, and thanks for the question. It's helpful, actually, to get questions from people and make sure this is useful to you guys. So let's talk a little bit more about the Daily Mood Log and some pointers that I have, and then we'll come back to the one that I was showing you. So our goal is, like I said, to list the event, the feelings, and how strong the feelings are first. And then we want to ask the patient, in whatever language is comfortable to you, kind of what are you telling yourself when you're feeling hopeless? Or what are the thoughts that drive these feelings of anxiety? What are you saying to yourself when you feel lonely, for example? Now, for kids, again, you might need to do more suggesting. It's not like, I bet you're telling yourself this, but, you know, I'm trying to sort of think what you might be thinking. I wonder if you might be thinking this. Or I can imagine I might have been thinking this. You can also draw cartoons with thought bubbles, you know, for adults or kids to sort of really demonstrate we're saying, what are you telling yourself? The difference between feelings and thoughts, that's a very easy way of thinking about it, is that feeling is just a one word, right? We can't give a paragraph about a feeling. It's one word. It's angry, hurt, neglected, happy, excited, right? So they're one word. They're feeling words, whereas a thought is more of a sentence, right? You're not making enough money, or people won't love you because you're poor, or something like that.

So you want to list the thoughts that the patient gives you spontaneously. But also, typically, in the beginning, you'll need to ask more questions to elicit additional thoughts. And one way to do that is a method that's called the downward arrow. Now, if you know cognitive therapy, you may know the downward arrow as what's called like an uncovering technique to try to get at self-defeating beliefs. That's not exactly how I'd be using it here, although it's the same question, right? We say to a patient, let's say we get one thought on the daily mood log, and we want to find a way to get at maybe like a deeper level thought. And I'll give you an example of this.

So we say to the patient, you know, let's imagine that were true. Like, let's write that down. And let's imagine that were true. Why would that be upsetting to you? What would it mean to you? Or what would it mean about you? So if the patient says something like, even like a statement of fact, like, I'm only making $75,000 a year, or I make the same as a 22-year-old. These are true, right? We can't actually challenge those. They're not distorted thoughts. They're facts. So the question is, why is that upsetting to the patient, right? Someone might be thrilled, and lots of people will be thrilled to be making $75,000 a year. So that could bring joy to one person.

If it's bringing distress or embarrassment to this guy, the question is, why? What are you telling yourself about this, right? And so you can ask, let's imagine that's true, or it is true that you're making $75,000 a year. Help me to understand why that's upsetting to you. What does it mean to you? Or what does it mean about you? Sorry. So this is called the downward arrow technique, and this is how you can get at the meaning behind patients' thoughts. And this is really important, right? We don't want to just settle for statements of fact. You're not going to get anywhere with that.

You need to understand, why is that fact upsetting to the patient? Other thoughts I have for you is, you need to turn questions into statements. So if a patient has a question on a daily mood log, like, why is this happening to me? Or why is life so unfair? We can't challenge a question either. Cognitive strategies are not going to really work to challenge a question. So you have to turn that question into a statement. So the statement of, why is this happening to me, might be like a should statement. Like, life should be easier, or bad things shouldn't be happening to me, or I deserve better, or something like that. A statement, right? And those would be likely distorted thoughts, that you could look for distortions and help patients to challenge and change them if they wish. You also want to make sure you don't write down feelings in the thoughts section. So if you're in the thoughts section, the patient says, I'm telling myself, I'm hopeless. That could sound a little bit like a thought. I might ask a little bit more information about that. But you just don't want to write down, hopeless, or anxious, or something like that in the thoughts column. If the patient says, I'm hopeless, I might ask them, tell me more about what you mean about that. Because hopeless sounds like a feeling. But if you're telling yourself, like, I'll never get better, or I'll never make more money, that's a thought, right? So we want to help the patient to turn these into thoughts. And again, the reason for that is because the purpose of the daily mood log is to help the patient to understand their feelings and their thoughts, and then to teach them strategies to challenge and change those thoughts, or in some cases, accept those thoughts. But we need to have the right kinds of thoughts, useful thoughts, in the thoughts column in order to actually do good therapy with patients. So you don't want to write down feelings.

You don't want to write down questions. You don't want to write down statements of fact. And you want to be looking for what are called hidden should statements. Oftentimes, those will be statements of fact, like I only make this much money, or the date went badly, right? These might be statements of fact, but maybe underneath them is a hidden should statement, like I should be making more money. Or another kind of should statement, like life should be easier for me, or all dates should go well, or this should be easier, right? So you want to look for hidden should statements. And the reason is those you can write down as negative thoughts, and then you can actually help the patient to kind of challenge them and change them. Now, after listing all of the thoughts on the daily mood log, you want to turn to the list of distortions and you want to have the patient identify the distortions by asking your patient to explain the distortions to you. And I'm going to show you what I mean about that. So here's the daily mood log after doing these tips, right? After asking more questions, doing the downward arrow.

So now we see the patient has thoughts like, I should have a higher paying, higher status job. Something's really wrong with me because I make the same as a 22 year old. This is leading to the patient feeling self-conscious and embarrassed. I will never have a high paying, high status job. This would be a thought that would lead a patient to feel discouraged or hopeless, right? I am defective. Women will not be attracted to me if they know how much I make and what I do. I will be alone for the rest of my life. No one will ever love me. I will never be a success in life. So these thoughts come from the therapist kind of artfully asking, you know, if that were true, why would that be upsetting to you? Tell me more. And also going through each feeling and asking for more negative thoughts. In my opinion, it's most helpful to have a bunch of negative thoughts because now I've done some legwork.

I've done some setup. It doesn't take me all that long, maybe 15 minutes of just to sort of get a full, complete list of negative thoughts. And now I'm all set, right? I now know what the work is. I'm going to have to help the patient with these negative thoughts, but I don't have to go back and ask for more. I've done a lot of sort of uncovering here. And then I ask the patient, you know, can you take a look at this list of cognitive distortions? And let's pick one of the thoughts that you really want help with and look at the list of distortions. And I say to the patient, I want you to tell me which distortions you see in this thought. And then what I do that I find really useful is I ask the patient, let's say the patient has the thought, I'm defective. So let me ask you guys to take a moment and tell me what cognitive distortions do you see in that thought? And just go ahead and enter it in the question box. So I'm going to give you a minute. So your patient has this thought, I am defective. List for me in the question box, what distortions using this checklist you see in that thought. Let's see if I can even make this a little bigger for you. Great. So I've got enough here that I'll just read off to you guys.

So a bunch of people said labeling. Now, if my patient said labeling, I would say, great, I totally agree with you. Now, tell me, why is it labeling? And I'm looking for an answer like, well, because instead of saying, I don't make as much money as I would like, I'm kind of putting a label on myself and telling myself that I'm defective. So I asked my patient to explain it to me. So someone else said, all or nothing. So I'd say, great, I agree with you. It's all or nothing thinking. Why is it all or nothing thinking? The patient would say, because again, instead of kind of seeing that it's not ideal, but it's not awful, I'm just kind of saying, I'm defective. I'm going to such an extreme, absolute place. Now, the goal, why do I do this? And there are other distortions too. People said discounting the positive, totally. That would be a really useful one.

Because if I said to the patient, yeah, I agree with you, it's discounting the positive. Now, tell me, why is telling yourself I am defective based on your income, why is that discounting a positive? So then your patient might say, well, because it's only looking at my income as an indicator of my whole person, right? Instead of being able to see that maybe I'm a good friend, or I have good assets, I'm just, I'm discounting anything good about me or something. And I'm trying to really think about what a patient would say. So my main take home message here is that if you let the patient do their own work in identifying the distortions, and if you ask your patient, yeah, totally, I agree. Now tell me why is it, explain to me why it's that distortion, then your patient is already challenging their negative thoughts, right? You just get a lot more bang for your buck using cognitive distortions if you make your patient do the work. They have to explain it to you.

And in explaining it to you, they're already starting to kind of talk their way out of it. And that can be really useful. So I'm going to just shrink this down a little bit, but you can certainly put in the question box if it's difficult to read any of these slides, but hopefully that was helpful. Okay, so I'm going to move on and show you some other methods. But in terms of the daily mood log, thinking about kind of step one is being really specific. Step two is identifying all the different feelings. Step three is what are the thoughts that are driving those feelings. And then we actually usually using the TEAM framework, we'll take a step back and do a little bit of agenda setting with the patient to make sure that they actually want to challenge and change these thoughts, want to feel happy about themselves while making $75,000 a year. So it's not the topic of my presentation today, but if people are aware of that, then yeah, there's another step usually in there. But then we move to change oriented methods and identify the distortions is typically the first change oriented method I'll use because I just find it so easy to do because I'm already right there. And also useful in getting the patient to just take a step back and start to think, ooh, like are these thoughts totally accurate? And if not, why not? And verbally explaining to me why they're not is kind of the first step in getting some separation from those negative thoughts and starting to get some perspective and challenge them. So I'm going to now move on to the first method I'm going to show you guys, which is called the double standard technique.

And I'm just trying to watch my clock here too. So the double standard technique is what we call a compassion-based cognitive role-playing method. The purpose of it is to help your patient who has self-critical thoughts to have more compassion for him or herself. So it's not a method that you're going to use for every single patient, for every single problem. You want to think to yourself, is this a patient who's beating themselves up, being really self-critical, hard on themselves? You also want to think, is this a patient who tends to have compassion for other people? Because this is a method where you're going to turn the patient's compassion for others into compassion for the self. And your goal, like in any cognitive therapy method, would be to help the patient to generate new, believable thoughts that kind of put the lie to the original negative thoughts.

So we're always going to work toward generating new thoughts that are totally believable and that are actually useful. Like the sky is blue is totally believable, but it's actually has nothing to do with the original negative thoughts. So it's got to be believable. And it's also got to challenge or change the original negative thought in order for it to be useful to the patient. And that's the case with all cognitive therapy methods. So here's what happens. It's a role-playing technique. So there are always going to be two roles in all role-playing technique. The patient's going to play a role and the therapist is going to play a role. So essentially we say to the patient, I'd like to show you this cognitive therapy or role-playing method. It's called the double standard technique. And my goal is to help you with this thought, like the patient will first pick a thought.

So this thought that you've been telling yourself, for example, let's see, let me pick a thought first and then I'll show you something is really wrong with me because I make the same as a 22 year old. So then I'm going to say I will play the role of a best friend or clone of yours. This would be someone that you really like and care about. So I want you to try to imagine that you really like me and you really care about me, that I'm a dear friend of yours. But the trick is I'm also a clone of yours. So I'm a dear friend who's exactly like you. I grew up in the same family that you grew up in under the same circumstances. I went to the same schools that you did. And I'm struggling with the same thing that you're struggling with right now.

So let's give me a name. No, I don't want to be your current best friend, but let's just give me a name. So let's say my name is Joe and my patient's name is Dave or something. I'll just write these down so I can keep consistent with them. So I say, you know, so Dave, how does that sound to you? So Dave, you get to be the role of yourself, right? And I'm going to be the role of a dear friend of yours. And I'm going to talk to you about what I've been struggling with. And I just want to kind of ask you some questions and see if you can be helpful to me. And remember that I'm someone that you really care about, but I'm also just like you. Okay.

So then I say to the patient, to Dave, I say, so who am I in this role play? And Dave should say something like, you're my best friend, Joe, who's also a clone of me, right? So I'm not your true best friend. I'm kind of your best friend, someone you really care about and are compassionate with, but I'm actually just exactly like you. And then who are you in this role play? And he says, I am myself, right? And then I'm going to start to talk in the role of Joe, the dear friend. I'm going to start to talk about the patient situation as if it's mine and my thoughts and my feelings in the role of the friend clone. And I'm going to ask the patient things about my situation. So I'm going to ask them about the thoughts, since this is a cognitive therapy exercise, I'm not just going to say, do you have any advice for me, but I'm going to ask them about my thoughts.

So an example might be, and this is not exactly the one I'm setting up for you. An example you can imagine would be, you know, I recently lost my job and I keep telling myself that I'm a really worthless person. You know, do you think I'm a worthless person because I lost my job? So you realize I'm putting the negative thoughts to the patient and asking for help with right. So in the case of Joe and Dave here, I might say, you know, Dave, remember I'm your dear friend Joe. And I just wanted to tell you what I've been going through and see if you could share some thoughts with me. And Dave says, okay, sure. What? So I say, you know I have this kind of entry-level job that I've been at in a tech company. And actually I really like this job. It's interesting. I'm pretty happy there. But I'm only making like $75,000 a year. And I just discovered that my best friend's younger brother is making the same amount as me. And he's 22 and I'm 32. And I keep telling myself that I'm totally worthless because I'm not making enough money. You know, do you think that's true? Do you think I'm worthless because of my income? And then I'm the patient will respond.

And so the goal, you know, ideally the patient says something like, well, that doesn't really make sense. I mean, I like you and you're a good guy and you're a fun friend to hang out with. And, you know, I don't see why making $75,000 a year makes you worthless. You know, I know you'd love to make more money, but that doesn't really make sense to me. And then I would push him a little more and say, but well, you know, I mean, a 22 year old can make the same amount as me. Don't you think that makes me kind of worthless? And again, I want to make sure that I'm sticking with the patient's thoughts.

I'm not just trying to say awful stuff to the patient. Don't you think that makes me an idiot? For example, if that's not the patient's thought and the patient knows he's perfectly bright, I'm not going to just lay on criticism, but I'm going to be using his exact thoughts from the daily mood bug. So in this case, I'd be saying, you know, I keep, yeah, I discovered that I'm making the same amount as this 22 year old.

And I just keep telling myself that something's wrong with me because I make the same amount as a 22 year old. Do you think that there's something wrong with me? And then the patient might say, well, you know, again, it's not ideal. Like I know that you'd like to make more money, but actually, I mean, I think you've done a really good job of trying to find a job that you actually really like. You're not just in it for the money. You want to do something that you feel good about and interested in and where there is upward mobility. And so you're making the same as a 22 year old, you know, that doesn't mean there's something wrong with you. It just means you've taken some time to figure out what you want to do. Now, let me give you a couple more tips on developing the argument here. So you want to repeat and encourage elaboration of the new thoughts.

So here, the patient gives me something that's useful. Then I would say something like, oh, and this is not the exact, sorry, example on the, on the slide here. Hold on. Sorry. But we, you know, you, you want to repeat what the patient says. Oh, so what you're saying is that losing my job really doesn't have anything to do with my self-worth. You said I have a lot of wonderful qualities and that while it might be true that I was not performing as well as the guy that they kept, it doesn't mean that I'm worthless. You know, that's really helpful. Can you tell me more about that? Why do you think that's true? So you ask more questions, right? Until the patient is giving you helpful kind of comebacks or defeating the negative thought.

And then you also want to say, well, so Joe or Dave, sorry, do you really believe that about me? Are you just saying that to make me feel better? I mean, I know you're a good friend. So do you really believe that that's true? And you're trying to get Joe or Dave, the patient to say, yes, I believe that's true. You know, this is true about you. And then you want to be able to bring the method to closure. And so when you do that, if the patient has given you some useful kind of responses or positive thoughts, you write them down. And then you say to the patient, something like, you know, you've been really helpful and compassionate with me.

You've defeated these negative thoughts. And so can we put all these new thoughts that you just told me in your daily mood log? Because, you know, since I'm a clone of you, these thoughts that apply to me, these would apply to you as well, right? So you don't end the method by saying, ha ha, do you see that you have a double standard? You're critical of yourself and you're not critical of me. That's not really the point of the method is not to realize you have a double standard. It's really to use the momentum of the patient talking compassionately to a friend to let the patient apply that to himself. So you don't want to ask them a question like, you know, don't you think you could talk to a friend? Don't you think you could talk to yourself the way that you talk to a friend? I kind of more want to slip it in and say, hey, you, you gave me these great thoughts. And since they apply to me, and I was actually a clone of yours, they would apply to you too, right? So like, let's write them down.

And then I can ask the patient, do you believe this thought? You know, you said in the role play, that's totally true. And you totally believed it. So do you believe this thought? You could discover that a patient does not want to hold himself to the same standard that he holds other people to. And that's kind of what we consider an agenda setting problem. In other words, he doesn't actually want to let himself off the hook. That's a different sort of problem. But if the patient actually wants to be more compassionate with himself, then a method like this could be really useful. And in bringing it to closure, what you want to do is write those new responses on the daily mood log in the positive thoughts column. And I'll show you where that is here.

You want to have the patient rate their belief in those new thoughts, and then you want to have them go back and re-rate their belief in the original thoughts. Because again, the goal is to generate new thoughts that are believable and that challenge the original thought. So if we came up with a positive thought about this thought, something is really wrong with me because I make the same as a 22-year-old. And he said, you know, something, it doesn't mean that something's wrong with you. You've chosen to take your time, et cetera. Whatever the patient said, I would say, so could we write that over here in the positive thoughts column? Now, how much do you believe that thought? How true is that thought? And then we write the belief. We want it to be highly believable. And then we're going to say, and given this new thought and this information, this conversation we've had, how much do you believe this thought that something's really wrong with you? Because you make the same as a 22-year-old. Now, if the belief and the thought doesn't go down much, then it wasn't a very useful method.

And that could mean one of two things. It could mean I got to try other methods. It just wasn't that helpful. Or it could be what we call an agenda setting error, where, in fact, the patient doesn't really want to believe more kind or compassionate things about himself. Maybe he thinks it motivates him to be self-critical. Maybe he doesn't want to accept himself or his reality. Again, that's beyond the scope of what I'll be teaching you today. But that's another thing that we often teach and train about, kind of motivational issues. So I have one more method that I want to show you and also have time for wrapping up. Let's see. Someone asked, are you going to send out the handouts? I, in the very beginning, said that at the bottom of the GoToWebinar control panel, you can take a look at the handout and you can download it yourself. So the handout is simply a copy of these PowerPoint slides.

And so, yes, it's available to you. If you click on free methods webinar, you can actually download it right now during the presentation. So let's move on. I'll show you one more method. So I just want to check in here. So I'll show you one more method and then we'll have a little bit of time to wrap up. The next method I want to show you is also a role playing method. So I want you to try to think of these. They're different, although oftentimes I'll try the double standard method first. And if that's useful, I might move on to the externalization of voices technique to sort of seal the deal on these same negative thoughts. And I'll show you what I mean. So this other method I'm going to show you now is called externalization of voices.

It's really just a way of bringing a typical cognitive therapy to life using role play. The purpose is to help the patient to talk back to their negative thoughts verbally, to kind of put a voice to the anxious or negative thoughts and externalize them so the patient can see them from the outside and get perspective. It's also kind of paradoxically to have the therapist voice the patient's negative or anxious thoughts and put the patient in the role of arguing against them. So I think it's an error if you do this method and you try to get your patient to speak their negative thoughts and you try to talk back to their negative thoughts right off the bat. We're trying to actually get the patient in the role of arguing against their negative thoughts. But I will show you what you do if you get stuck because you can offer a role reversal and help your patient out a little bit.

So typically when we set this up the roles are that the therapist will play the role of the patient's negative thoughts. Again using exactly the patient's thoughts on the daily mood bug. I will never hit the patient with some negative thought that is not their own because my purpose is not to be abusive or mean to my patients. It's simply to voice their own negative thoughts. And so you want to make sure you don't get off track. The patient will then play the role of the positive thoughts. So the patient's role is to talk back to the negative thoughts that are being voiced by the therapist. As I said you can reverse roles if the patient gets stuck and then the patient can hit you with the negative thoughts and you can play the role of the positive thoughts as long as you then do a quick role reversal and always make sure that the patient has a turn and ends with the patient playing the role of the positive thoughts not you the therapist doing all the hard work. So the setup here after I've described the method to the patient and who's going to be playing which role I can do a quick check-in and say so then who am I in this role play and ideally the patient's saying oh you're playing the role of my negative thoughts you're going to read those negative thoughts to me. And I say great, right and who are you in this role play the answer would be I am going to argue against my negative thoughts right so that means I would be playing the role of the positive thoughts. And then I say exactly perfect so I'm going to kind of hit you or attack you with these negative thoughts on your daily mood log right these are not Jill's negative thoughts they're Joe's negative thoughts and you're going to respond if you get stuck and you have trouble responding we can do a role reversal and then that means you can say the negative thoughts to me and I'll be you and I will respond with the positive thoughts and then we can keep switching roles until you come up with something that's really believable and powerful and helpful to you. Remember then we're both just versions of you right kind of negative you positive you or negative you rational you okay and here are some tips that I also will give patients for defeating the negative thoughts so we can say to our patients you know there are many ways you can respond to your negative thoughts you can even use identify the distortions to respond to your negative thoughts but here are a couple categories or ideas for you one way is self-defense you can argue against your negative thoughts by refuting them so if you were to say you know you're worthless because you're only making as much as a 22 year old I could say something like you know just because I feel worthless doesn't mean that I am actually I have a lot to offer this world I'm a really caring friend, I'm a great karate instructor etc. you could also teach the patient and explain to them the concept of self-acceptance you can agree with some aspects of negative thoughts with kind of humility and humor it doesn't mean that you say you're right I'm totally worthless but you could say something like you know you're right I do have a lot of flaws in fact I discover new flaws about myself kind of every day I really am very far from perfect and that would be a self-acceptance way of responding and that can be incredibly helpful so you don't always have to be disagreeing or defending yourself and sometimes a combination of the two is really useful so in this case you could say it's true that I have a lot of flaws and I think I could always be improving upon myself and yet making mistakes or you know the case of the the case like earning $75,000 a year doesn't make me a worthless person you know it just makes me human. The idea is that we're sharing with the patient that we can argue against thoughts and say hey that's not true kind of like cross-examine your thoughts you can also accept some truth to the thought and there may be some truth to it it may be really useful to just sort of use practice and self-acceptance or we can integrate the two where we're kind of disagreeing with certain parts of the negative thought maybe it was kind of extreme or all or nothing and yet there may be some pieces of it that are true and that are helpful to agree with and so we can educate the patient about tips for defeating negative thoughts before we do the exercise and then basically we'll pull out this daily mood log and I'll say okay so if my patient in this case is Dave then I'll say okay Dave remember I'm going to be kind of negative Dave and you're going to be positive Dave or kind of rational Dave let's say and I'm going to hit you with a negative thought and we'll ask Dave maybe which thought he wants to start with and again if we go with this thought like something is really wrong with me then remember I need to say it in the second person here so I say hey Dave I just wanted to remind you that something is really wrong with you because you make the same as a 22 year old now again I've set the method up to show this is not Jill speaking Jill's thoughts this is you know negative Dave, criticizing Dave so I'm putting a voice to the thoughts that you're telling yourself so I say hey Dave something's really wrong with you because you make the same as a 22 year old and then Dave responds by saying well you know sometimes I feel kind of crappy that I'm not earning as much money as other people but it doesn't mean that something is wrong with me you know I've taken some time and I'm trying to sort of find my way I'd certainly love to have picked the right job right off the bat but you know I think I'm doing okay and in time I will earn more money and and that's something to look forward to or something like that and then I I'm gonna stop so that's kind of one round and then I'm gonna stop and if the patient talked back to the negative thought I'm not gonna keep going I'm gonna say kind of okay Dave great so who won that exchange was it kind of me negative Dave or or you kind of rational Dave and if he thinks he won I can even ask was it kind of a big win or a small win and if he feels like it was a big win and it was like an effective response I said great let's write that down and then um we can write it down in the the positive thoughts column on the daily wheel log and we can go through the whole rating thing or I can just say great let's write that down now let me hit you with another negative thought and we go on because sometimes once once someone has the the kind of motivation and the excitement around having challenged negative thought just hitting them with another one and another one another one and writing down their positive responses can be really useful sometimes once someone has a success they'll then be really successful in kind of defeating all of their negative thoughts um if the patient didn't do a great job that's where if they say I thought that was kind of a small win or I don't know I thought you won I couldn't really come up with anything then I can say you know okay would you like to do a role reversal um or I might say you know let's think about it for a minute do you want to review the distortions can you think of another way to challenge that negative thought but you as a therapist do need to be in the position where you're prepared and ready to offer a challenge so if the patient says yeah let's do a role reversal then the patient has to hit you with the negative thought so I am now Dave and the patient says hey Dave and basically reads this thought um something is really wrong with you because you make the same as a 22 year old and then I as Dave need to respond with kind of a positive or rational thought and I can ask the patient how did that work for you who won me or you was it big or small and if it was useful to the patient if I came up with something that was useful then I have to say great I love it but I want to switch roles and you need to make it your own right this is not about Jill being good at challenging Dave's negative thoughts we need to make sure Dave is so Dave if you liked what I said write it down and then let's practice it and see if you know you can put your own words to it so again the goal is to come up with new thoughts right that are totally believable and that kind of put the lie to the original negative thought and then you'll again rate the belief in the new thought and the belief in the original thought afterwards the goal is always to be coming up with positive thoughts or acceptance thoughts right that are 100% believable and that reduce the belief in this original thought to some pretty low level and sometimes again we'll decide that a method wasn't especially useful and as I said it when a method isn't useful I think of three possibilities one is that I didn't set it up very well or I didn't do it well and then I need help in making sure I can do it better next time the other might be as I said agenda setting the patient really doesn't have an agenda to actually let themselves off the hook or to feel less anxious or whatever and then the third might be just that that wasn't a great fit for the patient and so I've got tons of other methods I can try so I set my work up with patients to say I'll try we'll be ready to try lots of different methods if the first one kind of falls flat or isn't useful we'll switch to another one and then in my mind I'm always wondering which of these three is it did I not do a great job with it do I need a new method or do I need to go back and check in with the patient and review kind of good reasons not to change and do good paradoxical agenda setting so I have a couple last minute slides to share with you this is what I shared with you today the the I want to make sure that you all feel like you know the purpose of the daily mood log right to help the patient to organize and elicit negative thoughts negative feelings and to set up successfully for whatever cognitive interventions you're going to use.

Also, I hope I taught you how to identify useful negative thoughts on the daily mood log and we talked also about identifying distortions how to use the downward arrow technique to pull for additional thoughts meaningful thoughts and then I taught you these two role-playing techniques and how after you do any method that it's really important to re-rate the beliefs on your daily mood log or whatever method you're using I want to say one more quick thing which is if you did find this useful and helpful and you want to do more than just a one-hour training on this we have lots of different math lots of different courses trainings and you can find them on our website so it's feelinggoodinstitute/cbtacademy and if you're interested there are a lot of other free webinars that we offer there's also an upcoming six-week course entitled practical CBT methods for depression anxiety and unwanted habits which goes into what I've reviewed here but in much greater detail and also shares many other cognitive and behavioral and motivational methods and there's lots of other other courses too I mentioned that we have a course that helps people specifically adapting CBT methods for working with children and teens and lots of other things case case-based learning and things like that so rather than going through all of that with you I'll just invite you to check out the website feelinggoodinstitute/cbtacademy and I also just want to throw up one more slide here in case you want to reach me this is my email jilllevitt@feelinggoodinstitute.com and if you came late today, I did tell everyone in the first five minutes that you can get the copy of the handout on the GoToWebinar control panel and also informed everyone that in a day, in 24 hours you will get a follow up email, look for that and that will have a link to the CE survey that you need to complete in order to get your certificate of completion. It will also have a copy of a recording of this webinar if you'd like to re-watch it and keep that to see in the future. I'm just going to take a look and see if there's any more questions. If you tried and could not get a copy of the presentation, you can send me an email and ask me for a copy of it. Please try first, but if you can't, then go ahead and ask me. And lots of nice thank yous that people are typing. So thank you guys.

It's been an hour, and so I will wrap up on time. Again, if you have questions, if you can't download the handout, go ahead and send me an email. And if you posted a question that I didn't respond to, you're welcome also to reach out and email me.

Okay,