Melting Away Resistance and Boosting Motivation Using TEAM-CBT: A practical introduction for therapists

Melting Away Resistance and Boosting Motivation Using TEAM-CBT: A practical introduction for therapists

Learn how to boost motivation and address resistance in clients with CBT techniques

Boosting motivation in clients can be challenging, but addressing their resistance can help. In this video, Jill Levitt provides practical tools to increase motivation in therapy. She highlights a core skill of agenda setting—understanding a patient's reluctance to change. Therapists often push clients too hard or let them talk without focusing on one problem. Agenda setting helps avoid this situation.

Let's look at some key strategies discussed in the video:

Using the 'Invitation': Ask clients if they want to work on a specific issue, to avoid jumping straight into solving their problems.

Getting Specific: Guide clients to describe their issue in detail. This helps in shifting their focus from general issues to a particular issue.

Addressing Low Motivation: Understand the reasons behind why the client is reluctant to change. This means finding the hidden advantages of their problems. For example, someone with anxiety might worry because they care about others.

Paradoxical Approach: Give your clients reasons not to change, instead of directly challenging their resistance. This can encourage them to make a change.

Considering Resistance Type: Understand that resistance in therapy can be due to two reasons. First, about the outcome, such as not wanting to give up on symptoms. Second, the process, such as not wanting to do the hard work of therapy.

Tools for Working with Resistance: Strategies like magic button scenario and cost-benefit analysis can help clients understand their feelings about change. A daily mood log can be helpful in identifying their negative thoughts.

The webinar concludes with the goal to create a collaborative environment. In this space, the client feels understood and actively participates in the process. Watch the webinar to gain practical insights and boost motivation in your clients.

IN THIS VIDEO:

Jill Levitt: Hi everyone. I'm going to start the presentation in just a minute, but I just want to get the screen set up for all of you and I just want to do a quick technology check. So, just a second. Okay. So, at this point, I'm just going to ask those of you who are present to just send me a quick note in your question box that just indicates that you can see me and hear me on your screen and also that you can see my presentation. So, even if I just see a few people entering, yes. That's perfect. Okay, great. Enough people have indicated that we're all set. So, you should be able to see me on your screen and hear me and also follow along with the slides throughout the presentation today. I'll introduce myself in just a second. If you are having difficulty hearing or seeing me, you can definitely send me a note, but if if it's just it's helpful for you to do that in case there's some large scale tech problem, which I haven't ever had, but um if you are at this point having difficulties, you'll need to kind of look into it on your end. I want to orient people for one moment to the Go to Webinar control panel on the right side of your screen. There's just two things I want to draw your attention to. One is that about halfway down you'll see questions and there's a little caret there and, that's a place where you can it says that you can enter a question there. And so if you have a question, you can enter it there. There'll also be times throughout where I will ask you guys questions and that's where I'll want you to answer it and I'll take a look at the answers and share them with people. The next thing is toward the very bottom you'll see handouts. So this is where you can get a copy of this presentation if you'd like the PowerPoint slides. They're not additional or different handouts. They're just a copy of these slides that you can download if you'd like to. So at the bottom you'll see an orange P and it says agenda setting webinar one hour and that's where you can get a copy of this presentation if you'd like to and lastly uh just housekeeping I will say that you do need to stay for the entire webinar in order to get continuing education credit.

So the presentation will go from 11 to 12 and go to webinar takes attendance and we're only able to offer continuing education credit if you stay for the entire presentation. Tomorrow about 24 hours from now you'll get an email from me. It will have a copy of the recording of this presentation and it will also have the continuing education survey that you need to complete. So you complete that online and submit it and then within a week we'll send you the certificate that goes with your attendance today. So, I'll introduce myself now and get started with the content of the presentation. My name is Jill Levitt and I'm a clinical psychologist and also the director of training at the Feeling Good Institute in Mountain View, California. I practice CBT with my patients and I also do a lot of training of other therapists both online and in person. and I co-teach 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 so many of the ideas that I'll be sharing with you today are ideas that I've learned from Dr. Burns. So my goal for you today is to teach you about some motivational obstacles that seem to get in the way of doing CBT successfully. Because we only have an hour today, my hope is that you'll learn to identify some obstacles to change in your patients and learn a few things that you can do to in to avoid engaging in power struggle with your patients. In a nutshell, I I hope that you'll learn by the end of today that when you can side with the voice of your patients resistance to change and not push your patients to change that often paradoxically your patients will be more motivated to change. So, I will stop throughout at different points to take a look at the question. But I won't be able to present and also read questions at the same time. Let me just do one quick thing on my screen. Okay. So, roughly this is kind of how I plan to do things today from we'll spend about 10 minutes with me giving you a little bit of an overview of what's called the TEAM-CBT model and I'll explain that to you in just a minute and the five steps of agenda setting which I'll be talking to you about today.

We'll spend about 10 minutes giving some examples of and talking about the invitation step, about 10 minutes talking about the specificity step, and about 20 minutes talking about how to address motivation, what we call outcome and process resistance and then we'll have some time at the end for wrap up and Q&A. If I see questions throughout at different break points um, that are relevant to what I've just talked about, I'll also try to read those questions out loud and answer them throughout. You are also always welcome, if I don't answer a question that you raised today, you're welcome to reach out to me after the fact by email. I'll have my email on the last slide. So, I'll start briefly by just letting you guys know what is Feeling Good Institute because I mentioned that I'm the director of training at Feeling Good Institute. And so, I'll just tell you a tiny bit about what we are. We're a treatment and training center for cognitive behavioral therapy, a framework for doing therapy that we call TEAM-CBT, which I'm going to explain in just a minute. Our mission is to help therapists to improve their therapy skills and to deliver high quality CBT to our patients. Our teaching staff are all team CBT certified trainers. All of us have worked with and uh trained with Dr. Burns and have been teaching TEAM-CBT for many years. And our facility is located in the heart of Silicon Valley in Mountain View, but we do a lot of teaching and training, both locally and also online. So, we're able to reach people across the globe. What is TEAM therapy? I'm going to just touch on this for just a moment because my goal is really just to talk to you guys about agenda setting which is the A in in TEAM therapy. So TEAM therapy is an acronym for really just a framework that we believe leads to kind of effective therapy. It's sort of like what are the active ingredients to doing effective therapy and putting them together in a framework. Many of you actually may be kind of following this framework without necessarily calling it you know TEAM-CBT. So just to explain to you a little bit about what we're talking about here the T in TEAM stands for testing.

This just means that people who practice this kind of therapy are always using measurement. We use measures of symptoms and the therapeutic alliance before and after every session with every patient in order to measure progress over time and also to help us to understand how our patients are perceiving us and perceiving therapy. The E in TEAM stands for empathy. We have kind of teachable empathy skills um that we practice and also teach therapists that will help you to learn to connect quickly with your patients and also to learn to kind of skillfully address disconnects in your therapy sessions. And often times by sort of bravely and warmly addressing disconnects in therapy, we can lead to this can lead to breakthroughs in therapy. And so this is what we mean when we talk about empathy. The A in TEAM, which is what I'm going to be focusing with you on today, is agenda setting and in parenthesis we have paradoxical agenda setting because these are somewhat paradoxical tools. I'll be sharing some of them with you today that will help us to align with our patients resistance and enhance their motivation to change. And so, um, some of agenda setting is fairly straightforward, and I'll be showing that to you today. And some of it is paradoxical, meaning that rather than kind of trying to push our patient to set an agenda, we actually side with the voice of the patient's resistance. What are good reasons not to change? And we find that this kind of paradoxically actually boosts motivation. We put our patients in the role of arguing for change. Then the M in TEAM stands for methods. This is what many people think of when they think of CBT. The many very effective cognitive, behavioral, interpersonal methods that we have that are clearly laid out for different kinds of treatment targets. If it's not obvious, TEAM therapy would be transdiagnostic, meaning it's not a manual for a particular disorder, but it's a way of thinking about our framework for conducting therapy that involves each of these kind of active ingredients that we can tailor to the particular diagnosis or presenting complaint of the patient. So let's talk a little bit about what is agenda setting.

We call this the motivational skill set or toolbox. So agenda setting is kind of all about the art of setting up effective therapy. I would say that we can be extremely empathic and we can have fabulous methods but if we don't set up therapy effectively, if we don't hold our patients accountable for change, then therapy can fail or can at least stall at some point. So before kind of using methods with our patients, even patients that we have a really good alliance with, we think it's helpful to explore reasons not to change or reasons not to do the work of therapy. And what I like about agenda setting is I think it addresses common errors that all of us make and that even though I practice this form of therapy and I'm very aware of it and it's the front of my mind, I still make these errors from time to time. So these are the errors such as pushing your patients to change, advice giving or problem solving too quickly without the patients buy in or the opposite which is allowing patients to talk on and on but never actually choosing a problem and getting to work on it. So you might want to ask yourself kind of which of these errors do I make most frequently? I sometimes chuckle here because a lot of therapists if I'm doing this live will respond by saying both if they're being really honest. And that's to say that you know there are times where if you're if you're like me, I tend to make the the error of being more aggressive kind of pushy and and I can see the problem. I know the methods that I want to use and I kind of forge ahead sometimes leaving my patient behind or sometimes I end up doing too much work. And so then sometimes you can catch that error that you're making. You're being maybe overly aggressive and throwing methods at your patients and then you decide, oh, I'm going to change course. I'm going to kind of back off. And then you end up making the other error which is you sort of follow your patient around. The opposite order can occur. You're following your patient around for so long and then you get frustrated, you want to get to work and then you kind of push methods onto your patient.

So, the idea here is that I'm going to show you today just simply using a method called the invitation. You can avoid making either of these two errors and kind of gently guide your patient towards setting an agenda very collaboratively. Agenda setting is kind of an ongoing process. It's not like you check the box and you're done. It's an ongoing process of getting and staying on the same same page with your patient and both being accountable for choosing something specific to work on and doing the work of therapy. So, something we'll be talking about today is kind of aligning with your patients resistance, thinking with your patient about what are good reasons not to change and what do your patients symptoms say about them that's really positive or beautiful or an expression of their value system. And just to give you an example here, you know, imagine that you have a patient who has OCD. Maybe a mom who has OCD and does lots and lots of cleaning and is worried that her children will be contaminated or catch a disease or illness, if she doesn't follow through on all of her compulsions, well, she might not want to give up her compulsions, her rituals because she thinks that they keep her safe. Someone with depression, although of course they'll on some level want to feel better, they might also be a little bit ambivalent or not so motivated because if they were to recover fully from their depression, they'd get less social support or more would be expected of them. An anxious, worried, perfectionistic patient might not want to give up that anxiety because they might think that it keeps them sharp. It keeps them working hard and achieving at a high level. And so, these are the ideas that we want to talk to our patients about because the idea is that if we don't identify and help our patient to see real reasons, real good reasons not to change, they'll probably end up kind of sneaking up later and leading to to stall therapy. So as you can see, identifying resistance often times involves looking for sort of hidden advantages or positive values to our patients symptoms.

The idea is that it involves a set of tools that gets our patients to argue for change rather than the therapist arguing for change. And of course, if you put your patient in the role of arguing for change, your patient's going to seem kind of more motivated. They're asking for help and I found, you know, personally and clinically in working with therapist. It also decreases therapist burnout because you don't feel like you're working with unmotivated patients and working against them and you don't feel like you're working harder than your patients because you're always kind of taking a step back and checking in and making sure that your patient is the one that's that's convincing you that they want to change. So, we'll talk to you more today about kind of how to do that. So, let me briefly I'm just kind of looking at my time schedule here. So, let me briefly go over this slide and then we can get into the nuts and bolts of each of these five steps. So the invitation step, which is what I'll be talking to you about next, is where we move from kind of an empathy phase of therapy where maybe you're doing assessment or listening and offering support to kind of the hard work phase. It's like the bridge um from empathy toward doing work. We're going to ask the patient, you know, you've talked to me about A and B and C and I'm wondering would now be a good time for us to kind of shift gears and pick something and start to get to work on something in particular today or do you feel like you need some more time to talk and get support? So, it's got kind of two options there. And I'll talk to you about why we do that in just a minute. The specificity step, if your patient accepts the invitation and says, "Yes, I'd love to get to work. Let's do it." Is where we're going to really kind of get the patient to narrow down. We're going to ask, "Which of these many problems did you want help with?" And then even further, let's get specific. Could you tell me about a moment in time when you were struggling with this? And again, we're trying to move from kind of vague complaints to kind of specific actionable problems that we can help the patient work on.

The conceptualization step, which I will only touch on today, is where we ask, where the therapist is going to ask themself and sometimes we do this in collaboration with the patient, but kind of to categorize which kind of problem is the patient looking for help with. The conceptualization step is probably better described as a categorization step. It's where we're just trying to think, you know, which kind of problem does a patient have? Is it an individual mood problem? Is it a relationship problem? And that helps me to think, what tools am I likely to use or offer this patient? As well as what are the likely forms of resistance because it appears to us that there are pretty different sort of flavors of resistant, resistance depending on the conceptualization, depending on the category of the problem the patient has and of course depending on the patient as well. And then the motivation step which I'll be talking to you about a bit today is exploring with the patient the many good reasons not to change or not to do the hard work that therapy requires. We talk about five steps of agenda setting but the fifth step is really moving to methods. And so this is maybe not exactly a step of agenda setting but kind of the next step in the model which is that after kind of making sure that the patient wants to work and after knowing what it is they want help with and kind of collaboratively identifying resistance and reasons not to change and being convinced by your patient that they want to change. Then we bring in kind of the big guns which are the methods and actually bring about change with our patients. So let's talk a little bit then about what are some common obstacles that we see when we're doing therapy and each of these obstacles kind of corresponds to one of these steps in agenda setting. Sort of we see an obstacle and each of these steps is kind of a solution to an obstacle that we might see. So here's one possible obstacle. That is that you know you can ask yourself how many of you have an experience where your patient seems to want to talk and talk and get support but doesn't seem to want to kind of get to work.

So some patients will naturally really kind of be focused and specific and clearly lead you toward what they're wanting help with or answer questions about what they're wanting help with in very specific and straightforward ways. Others seem to talk and talk and talk and it's very hard to at them to to kind of shift gears and start to work and so our solution to this, this may seem like a very simple problem. You might think, well, the answer is you know, tell your patient it's time to get to work. But our solution is a little more even-handed. So to offer the invitation before jumping in and trying to just help your patient. So let me show you what what that means or what that looks like. I'm just going to take a second here to check these questions. and see. Okay, just a couple people have asked that they can't see the download. So, I'll just say one more time if you joined us a few minutes late at the bottom of the Go to Webinar control panel it should say handouts one of five and there's a little caret there and if you click on the caret you should be able to see um the agenda setting webinar PowerPoint. So, if you try hard and can't get it you can email me and ask me for a copy of the presentation. Okay. So, let's talk about what the invitation is. So, the goal of the invitation step then is to move the patient from empathy toward kind of change. But also making it clear that it's the patient's choice so you don't end up getting yes budding or resistance from the patient. So, after you've listened to the patient for a while, you can ask them if they're ready to kind of roll up their sleeves and get to work on the problems that are bothering them or if they feel like they need you to listen for a little while longer. And the reason that we do this is because it conveys the idea that listening alone will not be sufficient. So we're not just going to kind of follow them around and at the same time so that listening won't be sufficient and that an active effort on their part will be required that we're going to need to kind of get to work. But it also leaves them with the option to talk some more if they're not ready yet.

I would say none of us are great mind readers. We don't actually know unless we ask our patient kind of if they're ready to get to work. And and why do we do that? Because if I instead listen and then say, "Great, I've got some great methods for you." And we start working. It's possible that the patient actually didn't even want help with the thing that I start offering them help with. Sometimes patients will come in and start talking to you about something that's bothering them that's actually not consistent or not in line with their therapy goal. You know, an argument with a co-worker, a friend, and actually, if you take time to stop and offer the invitation and then do the specificity step, you might discover that the thing they're venting about is not actually the thing they want help with today. So, let's go through an example. So, I might say something like, "Seth, you've mentioned several issues that are causing you significant distress. I wonder if you'd like to work on one of these today, or maybe even something else you haven't told me about, or if you'd rather that I listen some more and understand better how you've been feeling before we get to work." So, that's an open-handed invitation. I'm not saying it's time to get to work. I'm saying I'd love to help you with one of these problems. Let's get to work. Or am I rushing you? You know, do you need a little bit more? time. And how you say this will depend on on kind of your patient and your therapy style and things like that, but I like to think of it like a fork in the road that I'm making very transparent. Shall we kind of shift gears and get to work and pick something? Or do you feel like you need some more time to talk and get support? So, here's another way of saying it. Jennifer, you've mentioned problems with depression, anxiety, and procrastination at work, and I can see how much pain these difficulties are causing you. I'd like to offer for you more than just listening and support. And I believe we could solve these problems if we work together. I'm wondering if you'd like help with one of these problems today or if you feel like you need some more time to talk and have me listen.

And so here I would say I'm doing kind of a little empathy around you've talked to me about these problems and how much pain and difficulty they're causing you. I'm also kind of dangling a carrot saying I'd like to offer you more than just listening and support and I think we could do some great work together. But before we kind of push ahead and do this work. I want to check in with you and see am I am are we on on the same page. Are you ready to get to work? This would obviously stem from the idea that I believe that if the patient kind of isn't ready to get to work if they say no no there's more I want to tell you that if you had just forged ahead that would have come out in the form of kind of disinterest or low motivation on part of the therapist on part of the patient. So you know that's kind of the invitation and I'm not going to belabor it. It seems seems straightforward to many people. And at the same time, when I teach therapists, when we take time and we practice this, it turns out that therapists are not all that good at either kind of asking patients if they're ready to get to work or if you're the type who likes to just kind of forge ahead, are not that great at offering that second option like sort of or did you feel like you needed more time to talk? Is there more you wanted me to hear before we get to work? So you can ask yourself kind of are you doing this? And if not, you know, give it a try and see if it helps you. to feel more collaborative with your patients. So let's move on to the next obstacle which is you know you can ask yourself how many of you have patients who will talk about so many different problems and never sort of settle on one thing to work on. A lot of patients will come in with a number of things going on and a number of things that potentially they could benefit from work on and therapists can sometimes make the mistake of staying on sort of a very vague level and talking about all the stressors rather than kind of working on them one at a time and getting really specific. So, we like to get specific on two levels. One level is which problem and then the next level is could you tell me about a moment in time when this was a problem for you?

And I'll tell you a little bit about why we do you know kind of each of the levels in just a minute. So, if you think about it, the the one goal that we would have would be to move the patient from kind of yeah, I want to do some work toward the actual work like what did you want to work on? What did you want my help with? Which of these problems would you like to work with me on today? And another goal though is even once the patient says, you know, I'd really like help with my low self-esteem. I just always feel so badly about myself. I still feel as a therapist like I don't I still don't actually know what that means to this patient. For one patient, low self-esteem might be that they're beating themselves. up for not being smart enough, not being good enough. For another patient, it might be that they're beating themselves up because they're not patient enough with their children. For another patient, it could be low self-esteem, you know, stems from critical thoughts about their body or something like that. So, I still don't want to assume that I know really what the patient's looking for help with, even when they say, "I want help with my panic attacks. I want help with my worrying. I want help with my low self-esteem." So, to avoid talking about problems in generalities, will ask the patient to pick a moment in time when this was a problem for them. Again, really simple but actually fairly profound. If you find that you're struggling to kind of talking about problems in generalities and you feel like you you spend half a session trying to really figure out what your patient is even talking about or even wants to get help with. So, let's I'm going to involve you guys actually and ask you to do a little work with me here on the specificity step. So, One problem or challenge that you'll face when you're doing specificity with patients is you might ask your your patient, which of these problems would you like to work with me on today? And let's say your patient says, you know, I don't know. I feel awful about everything. I can't really pick between them. I need help with everything. So, I'm going to ask you, don't look ahead, but what would you say?

So, write in your question box, what would you say? I'm giving you a second. So, when I said the the question is, "Which of these problems would you like to work with me on today?" And then the therapist says, "I don't know. I feel awful about everything. I I can't even pick between them. I need help with everything." And so I'm just going to read you answers I got which was you could ask your patients to rate these problems on a scale from 1 to 10. Absolutely, you can ask someone said can you tell me about a recent situation during which you felt awful? And let's say someone says which is causing you the most distress right, absolutely, so we just kind of want to narrow down on on which of these problems seems most problematic and I have a lot of answers along those lines. Which one is the one that comes up more often? Which is the one that impacts you greater, which is the one that's weighing most heavily on you today. And so many great answers, so I'm not going to read all of them. But all along these lines of kind of like trying to encourage the patient to actually pick one and to help them to pick one maybe by which one is causing them the most distress. Let's see. So, I have I'm sorry, I'm trying to move ahead, but I'm in the wrong box here. Okay, so The patient says, "I don't know. I feel awful about everything. I can't really pick between them. I need help with everything." Yeah. My my response to that is empathy plus kind of guidance toward specificity. I definitely air on the side of the kind of which one is more of a problem for you. But first, I I wanted to share with them because in some ways you can think about failure to pick a problem as a as a form of resistance too. Like I want to stay general. I just can't pick. I don't know. I can't decide. It's so hard. So I would offer some empathy and then say you my hope is that we'd work on all of these problems over the course of our work together, but I don't know how to help you with all of them at once. And so in order to be most effective, let's pick one problem to start with and then we can move to another problem area once we make um progress with this one.

So the idea is not to kind of take the bait of like sort of overanalyzing either like which problem is most important, which you know I would definitely go with the problem that seems most pressing but when a patient says, "I don't know. I feel awful about everything. I just can't even pick between them because I need help with everything." I think they're showing a little of a resistance to pick. And that's where my response is a little more along the lines of like I want to help them to see that it it doesn't matter too much. Like, let's pick one and hopefully we'll work on each of these in sequence, but we can't stay general, right? We can't help you with everything at once. So, let's pick one and work on that and then we'll choose another and we'll continue down the list. So, the next thing that sometimes is a challenge and one of you actually answered this in in your answer to the last one which is the patient says or the therapist says great you know the patient picks my worrying I want help with my constant worrying so I say great that sounds like a great thing for us to start with, can you tell me about a recent time where you were feeling really worried so in my mind I'm starting to think toward using you know a daily mood log, some sort of thought record or just some sort of analysis understanding cognitive and behavioral what's happening in the moment in time where they're feeling worried and then the patient says, "I don't know. I'm always worried. It's just constant. I can't even think of a specific example." So, if you can see guys, I'm I'm trying to show you the resistance that people have to getting specific. Right? So, I'm offering this specificity. I'm trying to ask for a moment of time. The patient says, "I don't know. I'm always worried. It's just constant. I can't even think of a specific example." So, here I'm putting to you guys, what would you say to this? Go ahead again in your chat box or question box. What would you say to that? So, I'll read a couple answers that I've gotten.

So one person said kind of what I was indicating on some level like you know a mood log to help them to get to the theme of the thoughts. Sure. Some people also suggested empathy like I can imagine it's really difficult to choose when you're feeling this worry is constant you know and then some people have this can you remember the last time you felt worried or are you feeling worried right now um and people also ask when's the most recent time that you felt worried right so what I would again try to avoid is the trap of picking the exact right time, you know, or this idea that you know, almost like that we can't deal with the specific time because it's so constant. So I have one response although yours are all you know lovely and totally in line with what I'm talking about. So the next what I would say is you know so the patient's prompt is I don't know I'm always worried it's just constant. I can't even think of a specific example. I would definitely offer some empathy around how they might feel kind of overwhelmed and that it's really hard to think of an example. But I my inclination would be to ask, you know, are you even feeling worried right now? We could even pick right now as a moment in time. And here's the important part. It isn't really that important which moment that we choose because we're going to learn a lot from looking at any one moment in time when you are struggling with worry. And that's kind of the point I'm trying to drive home to my patient. We don't need to obsess about is it, you know, should we pick this problem or that problem. We don't need to obsess about should we pick, you know, yesterday, the day before this. What I often times will say to patients that seems to go well is like if you're anything like me and the rest of the people I know, you're kind of consistent in the way that you beat yourself up or you're consistent in the way that you worry. You know, the thoughts that you have about yourself on Tuesday are kind of like the thoughts you have on Thursday. The kind the way in which you're worrying about your day today is probably quite similar to the way that you worried about your day a week ago. So, in a way, it doesn't matter which moment we pick.

But it is important that we pick a moment and start to get really specific so that we can understand kind of the thoughts and the behaviors that are going on. And the good news is that likely any moment we pick will be incredibly useful and then kind of the thoughts that we understand and then the methods that we use will likely be helpful across a whole range of situations where you feel worried. Right? So the work we do is very specific but then it becomes very generalizable as well. And that's kind of what we're trying to tell our patients they when they resist, you know, getting specific. So I'm going to move on also from specificity. I'm just checking the the question box, but lots of great responses here. So moving forward, we've sort of talked about how do we invite patients into doing the work without pushing them? How do we encourage them to get specific and kind of not fall for uh staying at the general level? Again, I think of all of this as like the art of setting up effective therapy, the bridge from empathizing and connecting to kind of doing the work. So, another thing we can think about that sometimes happens is sometimes this happens in when you if you're not doing agenda setting or if you haven't identified resistance, you'll get a lot of yes, buts when you're trying to use methods. You're maybe trying to help your patient to challenge negative thoughts and they're kind of yes budding you or really sticking to their original belief. You're trying to get a patient to change their behavior and they're you know again kind of yes budding you or not doing their homework or in some way showing you that um they're they're kind of not quite on board right and so instead of having to then backtrack which is a perfectly reasonable thing to do but we like to be kind of proactive and anticipate forms of resistance. So that's what I'll talk to you about for the next 20 minutes here. So If you find your patient tends to yes but you or displays resistance or a lack of motivation, we say the solution here is what we call paradoxical agenda setting. So we actually are going to proactively kind of honor the patients resistance to change.

We're going to generate a list with the patient collaboratively of good reasons not to change. We're going to look for hidden advantages to the patient's symptoms. We're going to look for positive aspects of the patient's symptoms. Not just how they're working for them, but kind of what they show about the patient that's beautiful or honorable or really valuable. And also, and I won't be going into this today, but when we talk about what's called process resistance, like resistance to engage in the hard work of therapy, we also can work with patients to identify good reasons not to have to do the work of therapy, right? Like exposure therapy which is so effective but also very challenging, doing homework when you feeling really depressed is very challenging and so again if we can paradoxically side with good reasons not to do hard work then we put our patients in the role of convincing us that they want to or need to. I should also mention, and I I will get to this, I'll touch on this a little bit in the future, but if anyone is thinking, but what if they don't? I mean, what if they can't convince me that they want to change or don't convince me that they want to do the hard work involved? Well, then I'll I'll talk to you about this in a minute, but just so you understand, then we end up doing something we call sitting with open hands which is we back off, right? We say, you know, maybe this isn't something that you're actually wanting my help with. Maybe this isn't something that you really want, you know, to change and we don't do that in a snarky way. We actually authentically, you know, we we say that because we see it and we believe it and we understand it. So, we don't kind of go back to then saying, "Oh, but you should change." Right? If a patient actually can can come to an understanding that they don't want to change, that the advantages of their symptoms outweigh the disadvantages, then I don't see it as my role to convince them that they should change, right? So here's we'll talk a little bit about the motivation step and then I'll go through some exercises with you guys. So you guys have been a great audience in sharing your ideas with me. So we'll keep doing that together.

So we think about the the motivation step then dealing with resistance as two kinds of resistance. So outcome resistance is where we're asking ourselves and the patient what are some good reasons that the patient may not want the outcome that she says she wants. What are some advantages to your anxiety? For example, what are some things that your anxiety actually says about you that are really positive or beautiful? And process resistance. What are some things a patient is going to need to have to do in therapy to get better that are going to be hard? And so, this stems from you as a therapist knowing for me to help a patient with anxiety, I know that I'll do some cognitive work, but I also know I'm going to expect them to do exposure. I'm pretty sure they're not going to get way, you know, get fully better without doing exposure. And I would anticipate that some patients will have some resistance to that. So that's what we talk about with process resistance. Like I'd love to help you with your anxiety. In order to overcome your anxiety and panic, you're going to need to face your fears. Are you willing to do that work with me? What are some good reasons not to do the work? Again, from now forward, I'll just focus on outcome resistance. But just to kind of put this out there, there are a lot of tools that we have that help us to identify and reduce process resistance in patients. as well. So, we're we're just going to cover outcome resistance for depression and anxiety. Kind of bite off a small chunk here, but we have kind of different we notice different themes of outcome resistance for relationship problems and for habits and addictions as well. But I'm just going to invite you now to think with me about outcome resistance for depression.

So, let's take a case and think imagine that you have a patient who comes to see you like a 19-year-old boy who's done very well in high school academically. Always kind of a straight A student, high achiever, worked really hard, did really well, goes to college, a really excellent school, and, you know, couple, let's say, months and, isn't doing that well, isn't getting great grades, is is working, but his work isn't doesn't seem to be paying off in the same way that it was in high school. And he's starting to feel really down and depressed and kind of beating himself up and feeling really badly about himself. So, let me ask you, ask yourself right now, can you think of any reasons if if I'm saying this as if I were saying it to the patient, but can you think of any reasons that this patient might want to hang on to his feelings of sadness? Are there any advantages to his feelings of shame, sadness, feelings of worthlessness? And also ask yourself, do his thoughts, I'm no good. And his feelings of worthlessness or shame or sadness say anything about him that's really positive. How are his thoughts and feelings an expression of his values? So, take a minute and enter some ideas you have in the question box. So, ask yourself both of these questions if you had a a teenager who's, you know, have really high standards, expects a lot of himself and is feeling down as his grades aren't what he wants them to be. What does his sadness, what if his shame show about him that's really kind of beautiful and an express of his values and how is it possible that his low mood is actually working for him on some level. So I'll read some answers. One person said he can justify his poor performance. So on one level that's true. On the other level I'd ask you how could you say that in a way that's flattering to the patient or that's palatable if you were to say that to the patient? Like maybe you would say you know it sounds like the way that I I pose these questions anyways it sounds like you'd really like my help in overcoming your depression you'd like to feel better about yourself but I can think of some reasons maybe to hold on to these feelings of depression ways in which your your feelings might be working for you or might even show something value that's really beautiful or awesome. You know, can you think of any? And then we might help the patient to see you know, perhaps if your patient if your parents are being really hard on you, perhaps your low mood or your depression is an explanation to them of your low grades and and maybe there's a way in which that's helping you um in your relationship with your parents at least. My point is we don't want to be saying this in any kind of snarky or critical way, but really thinking honestly. Someone else said a positive kind of the positive reframe or the positive value is that it shows that he really values doing a good job. And that I agree with. If a patient is struggling with his grades and feeling badly that he's struggling with his grades, doesn't it show that he cares deeply about getting good grades, that he values being a good student? He's not okay being kind average or mediocre. And could we say that in a way that's actually flattering to him?

Someone also said perhaps feeling down about your grades is a motivation to better yourself to reach your maybe high standards. which I definitely agree with. Someone also by by the way wrote time for drug testing, which is kind of a I'm chuckling although not off base, but um surely we want to be thoughtful of that in this age group and if there were kind of a sudden decline in grades or something like that, but we're we're assuming that's not the case for this. Yeah, someone said it could be a way for the client to show that they really care and um in a way way to punish himself for not being as good as as he'd like to be. So, let's see. I I had a couple of ideas here to share with you as well. So, possibly if I continue to be depressed, then then people won't expect as much from me. Maybe I to justify taking easier classes and um you know not have to work as hard and get some social support. There's the positive value piece which I think is so important with adults and adolescence who have high standards which is saying hey the fact that you're feeling really badly when you have bad grades shows that you have really high standards that you're not happy being kind of mediocre or a B student that you expect a lot of self. And isn't that something you could potentially feel proud of? You know, is that true about you? What does that show about you? And then I'll show you what you can do with that. You might be wondering, yeah, so what? So, I'll show you kind of where that leads in just a minute. But we'll do one more um one more example here. So, how about anxiety? Let's imagine now that you're seeing let's say maybe a 40-year-old woman who's working in a tech company and she feels a lot of anxiety about doing well at work and a lot of anxiety about kind of nailing her presentations and a lot of worry um about work and also about her children and how they're doing. So, can you think of any reasons that she might want to hang on to her worrying and her anxiety and again think about saying it in a way that would be palatable to a patient to hear?

Are there any advantages to these symptoms of anxiety and worry and any ways that her anxiety and worry and her thoughts show something about her that's positive or an expression of her values. So, let's see what you guys have to have to say. So, I've got someone saying the anxiety might be keeping this person motivated to make sure they do their best. Right? Some level of anxiety can be very useful. If I hadn't been at all anxious before giving this presentation, maybe I wouldn't have prepared as much as I did. Right? So, feeling some level of anxiety can be very useful and motivating. I'm looking to see. So, we've got a lot of people saying that. Also, her anxiety shows if she's worried deeply about her children, it probably shows that she's a really caring mom, that she cares deeply about the people that she worries about. Exactly. I have worry and anxiety drives you to succeed and achieve your goals. Right. So and and I'll skip ahead here. Lots of great ideas and if I didn't read yours know that I still think it has great value. So here's my brief answer. Some advantages to worrying would be worrying about the future can help me to plan. There's also the belief people have whether you think it's true or not that worrying can protect me from bad things happening. And again, I'm not going to say to my patient, "No, no, no, that's not true." I'm going to say to my patient, "It sounds like worrying, you know, is you feel like your worrying is protecting you from bad things happening to you." And ideally, if that is not the case, my patients will we'll sort of figure that out together. But again, I'm not trying to correct these beliefs. I'm trying to say, "Huh, you know, there might be some good reasons that you're not going to want to let go of your worrying or your anxiety. You know, if you're always worried about work. You're kind of anticipating the problems. Maybe it catches you won't be caught off guard. And as you all said, it'll motivate you to prepare and work hard. The positive value kind of what is your worrying show about you? That's beautiful.

It shows that you're conscientious, that you care deeply about the people that you worry about, that you take your job and your responsibilities seriously. So, we did sort of a brainstorm so you'd understand what I even mean by kind of good reasons not to change. what these symptoms show about you that are really beautiful. So what I'll I'll do now is show you a I'll talk you a little bit through kind of how you can talk to your patients about this. So I will say that you know within one hour I'm not able to share a lot of strategies with you but we have actually a number of different ways that you can kind of make use of this material. A a lot of different tools out resistance tools. And so I'll show you a little bit about that now. So one idea is and I don't have this exactly spelled out here, but one idea is that I'll I'll say to a patient something like um let's let's take the let's take the the woman who's anxious about work. I might say, you know, Jennifer, you know, you've talked to me a lot about how stressed and anxious and worried you are about your performance at work and about your children and if I had a a button here sitting next to you and you could press that magic button and you could walk out of here and none of the none of the facts of your life would change but you would no longer feel anxious, worried. You'd feel really kind of fabulous and and free. None of the stress, anxiety, and worry. Would you press that button? And almost 100% of your patients will say, "Yeah, absolutely. That that's why I'm here, you know, show me the button." Um and then I'd say, "Right, totally. That makes sense to me, Jennifer." And I kind of dangle a carrot here. I'd say, you know, and I'd love to do that work with you. And I do think that I have a lot of great tools that I'd love to show you that could help you to kind of turn this around and help you to feel less anxious and stressed and pressured all the time. But kind of before we do that, I want to invite you to think with me. Are there any reasons not to push that button? Any reasons to kind of hang on to your anxiety and worry? Any ways your anxiety and worry are working for you?

Or even ways in which they show something about you that's really kind of beautiful and and awesome. And usually your patient will look at you like, "What are you crazy?" So then you do kind of a collaborative process. I say, "Well, so let me see if I can show you what I mean." You know, think to yourself, are there any any any anything positive that comes from worrying? Any way that you're thinking if I worry, this will be helpful to me. You know, for example, do you ever think that, you know, if you weren't so worried, maybe wouldn't get so much done at work. Do you think that your worrying drives you? So, I kind of prompt the patient and then they usually kind of get on the same page and go, "Oh, yeah, yeah, yeah, right." Like, my worrying, you know, pushes me to succeed and my worrying, you know, oftentimes helps me be kind of more careful with my kids. So, it probably actually protects my kids. So, I'm saying great, let's write that down. And together, we're going to make this list and we're both going to write these down. We say like advantages of worrying. And then I also want to urge them not just to think about the advantages or the adaptive value, but what does it show about them that's positive or beautiful? And that's where I'm coming up with things like um you know that I have high standards that I'm loving, that I'm caring, that I'm conscientious. I can even look at the list of their negative thoughts if I have kind of a daily log and say, you know, when you tell yourself this might not be good enough, or this isn't good enough, what does that show about you that you value? And then we'll we'll write that down. So then we have the this big long list and then I'll say here this question. Given all of these powerful reasons to hang on to your anxiety and all of the ways that your anxiety is actually potentially kind of working for you, why would you want to give it up? And this is where one of two things will happen. Your patient will argue for change.

They'll kind of convince you, oh because, you know, it helps like in some ways, but it's actually really interfering um in my getting my work done some of the time because I'm sitting there and I feel kind of paralyzed by worry and fear or you know maybe it is helping me at work but I'm not getting enough sleep and I'm cranky during the day or my health is suffering or my relationship is suffering. So basically they're going to tell you why do they want your help? Why do they want to change? So again here you've kind of honored good reasons not to change and now they're kind of arguing for change and then we actually do and I'm not going to go through this with you today but then we we we try to kind of make a deal with the patient. it say great. So maybe instead of having like a button where you just like worry free or saying well screw it I'll just keep all my worry maybe we could work on sort of like a dial we could say that our goal would be to reduce your worry to some sort of useful level like if you're worrying now at you know 90% let's say the patient had this written down on their daily mood log kind of what would be your goal what would be kind of the ideal level of anxiety or worry and we go through something called a a magic dial where we try to kind of make a deal with a patient. And if you think about it, we're just making a deal with the patient's resistance, right? I mean, I don't actually think that I'm going to now like tweak each method to help them to reduce their anxiety to 60%. It's like a theoretical concept that the patient can feel like, oh, you're not trying to take my conscientiousness away from me. You're actually allowing me to hold on to it and we can still challenge these anxious thoughts and change these behaviors. So, that's kind of where we're going with this. Now, the other possibility here, and it's important, for me to say this is that the patient doesn't argue for change. They say when you say, "Well, given all these, you know, great reasons to keep worrying and all the ways that your worrying is really working for you." You know, why would you want to give it up? Why would you want to work with me on this goal of of of reducing your worry?

And maybe the patient says, "You know, I don't actually. I think you're right. I think it's kind of helping me a lot and I don't think it's hurting me that much." Well, then I can say, "Oh, well, Actually, I'm glad we had this conversation that it sounds like maybe you thought you needed to work on your worry or maybe someone else is pushing you to work on it or maybe there are some negative consequences of it, but they're not nearly as strong as kind of the positive value that your worrying brings to you and if that's the case, kind of like for be for me to try to steal your worrying from you, perhaps there's something else that you were looking for help with. And that's what we call kind of sitting with open hands. I'm not going to turn around and try to convince the patient that they should change. I'm going to sit with open hands. And what you'll notice is either then your patient feels very respected and like, "Okay, well, we can set a collaborative agenda to work on something else or maybe I don't even need therapy." Or your patient kind of reels you back in and it's like, "No, no, no, no. I I don't think that's quite right." And then starts to kind of argue for change. And again, the goal here is not to fall into that therapist trap of convincing your patient why they actually need to change. I'm going to look real quick and see if there's questions and then there are a few more slides that I want to share with you. Um, okay. So, I'm not seeing any questions, but if you and also let's see like 70 people on the webinar and so I have lots of answers to the previous questions that I posed to you. So, if you put a question in there and I didn't see it, you're welcome to enter it again. Someone said, can we do a CBA, meaning a cost benefit analysis? Yes, 100%. So, I kind of threw this I just did a little demo of like a magic button and a kind of voicing the positive or we call it the positive reframe and the magic dial. But another way of doing this absolutely is a CBI. But I would encourage you to do it paradoxically. So, I would always encourage you to look at what are all the advantages of hanging on to your symptoms. Write those all down.

And then you can say, I would still do it in a paradoxical way. I'd say, huh, given all these advantages, there's so many of them. Like, are there any reasons that you'd actually want to change? Any disadvantages, if you will, to your symptoms. And then your patient will list all the disadvantages, right? And then you can ask them, well, so then if you had a 100 points, you needed to divide them between the two kind of which side weighs more, like the advantages to your symptoms or the disadvantages And so again, this is very kind of collaborative and curious. I'm not telling them the answer. So, yeah, CBI is is great. Let's see. Someone said, "Is this method applicable to population seen at community mental health or county mental health clinics?" So, here's what I think. I think the this is applicable to anyone. The question is I don't know the your I don't know your mandate from above. If you're in a position where you are told you must, you know, treat every patient that walks in your door for x number of sessions, well, then it's going to be very challenging to have a good collaborative agenda, ight? You're going to feel kind of obligated to treat someone against their will. If you're in a position where that's not the case, where you you and the people who you know are above you, let's say, want you to be able to help the people that want help in the way that they want help. Then I think this is all very applicable and it's applicable for teens as well. The the issue with teens is that you also need to be setting an agenda with their parents. And I won't be going into that today, but I'm sure there are particular situations where this is challenging. I think ultimately you want to be asking yourself, what kind of work do I want to be doing?

Q&A Session