Overcoming Perfectionism: CBT Tools for Mastering the Art of Self-Acceptance

Perfectionism often masquerades as high standards—but underneath it lies a painful cycle of self-criticism, anxiety, fear of failure, and emotional burnout. In this powerful training, Dr. David Burns and Dr. Jill Levitt reveal how to break that cycle using evidence-based CBT techniques that work fast and go deep. Watch real therapy footage of a psychiatrist’s transformation—from believing she was a fraud to embracing self-compassion, joy, and restful sleep. This 2-hour webinar offers practical, immediately usable tools that you can apply with clients—and yourself.

 

What You’ll Learn:

 

✅ The hidden beliefs that drive perfectionism (e.g., “I am my achievements”)

✅ How to melt resistance using Positive Reframing

✅ CBT tools like Cost-Benefit Analysis, Externalization of Voices, and Feared Fantasy

✅ How to turn inner criticism into self-acceptance and emotional freedom

✅ A front-row seat to real, raw therapy moments and breakthroughs Designed for therapists, mental health professionals, and anyone who struggles with perfectionism. Whether you're working with clients or on your own growth, these tools can help you break free from the inner critic and reconnect with your authentic self.

 

IN THIS VIDEO:

 

Jill Levitt: Welcome everyone to our webinar today, Overcoming Perfectionism: CBT Tools for Mastering the Art of Self-Acceptance. I am really excited to be here today presenting with David Burns, and we have a lot of exciting material to cover in the next two hours packed with hopefully some powerful and practical tools. We will be sharing with you some videos, some roleplay demonstrations, and even including some exercises for you to do with us. We will take some questions at the end, and also later in the session I will share with you how you can take your skills even further if you like what you are learning today. So, I’ll start actually by welcoming and introducing David Burns. So David is my dear friend, hi David, want to say hi? David is my dear friend and colleague, and certainly one of the most influential figures in cognitive behavioural therapy and the creator of TEAM-CBT, the model that we will be sharing a lot more with you about today. He is also the author of best-selling book Feeling Good, Feeling Great, the Feeling Great app, which we will also tell you more about today, and really the driving force behind everything that we are teaching at the Feeling Good Institute. So, I am super honoured to have a chance to teach with David today.

 

I will also tell you just a little bit about who we are at Feeling Good Institute. Our mission is to elevate the practice of therapy so that patients can recover faster and more fully. We train and certify therapists in TEAM-CBT, a powerful framework developed by David, and we help therapists progress through a structured, kind of, five-level certification path. The Feeling Good Institute was founded by myself and my colleagues Angela Krumm and Maor Katz, and we all trained with David at Stanford. Back then, when we were training, the only way really to learn TEAM-CBT was with David directly, and oftentimes it took many, many years. And so we kind of started Feeling Good Institute with this dream of helping to make David's framework, TEAM-CBT, and tools and techniques more accessible to more therapists without compromising the quality of the training. And so everything that we do today still reflects that original intention of spreading TEAM-CBT and helping therapists to get better.

 

And we do not just teach TEAM-CBT techniques, we really try hard to replicate David's training style which is built on one idea, which is that therapists only get better through practice and feedback. It might surprise you to hear this, but experience alone, as shown on this slide, does not make therapists better. So, just doing more sessions and having more years under your belt does not actually lead to better outcomes. But what we know actually does work is learning, practicing, getting feedback, and continuously repeating that cycle. And so, that’s what we emphasize in all of our trainings, and that’s actually what you’ll be having a bit of a chance to do today as well. Before we jump in, I just have one kind of thought experiment, kind of question for you. It is really a moment of kind of self-reflection. So, we talked about how experience alone does not lead to better outcomes and that real growth comes from learning in practice. So imagine what would change for you as a therapist if you had a way to continuously improve your skills kind of week after week and would that be worth it to you to explore something like that? And so at the end of the workshop today, if you liked what we taught and if you are interested in improving your skills, we’ll share with you this course that we have developed that is called the FastTrack to TEAM-CBT Level Three where we really help people to learn the skills of TEAM-CBT quickly and efficiently, where it does not take years and years but rather just months. And at the end of the webinar today, we will share with all of you kind of two different things. We are aware that there are a lot of therapists here today but there are also members of the general public. David is going to share with you the awesome Feeling Great app, and then I will share with you the FastTrack course, one of our courses to help you become a better therapist. Just a brief comment about how to get your CE credit today if you are a therapist, so there is a mandatory CE survey. Make sure you are present for the whole two-hour webinar and at 1 o'clock today you can complete the CE survey which we will put in the chat box. And then a week from today you will receive your CE certificate via email.

 

We also have a survey for the general public, so make sure you are filling out the right survey because we would love to hear from both therapists and the general public. So, here is what we’re planning to cover today, these two learning objectives and lots more. Actually, we will start today with a poll so that we can learn a little bit more about who you guys are and why you are attending the webinar today. So, let me launch the poll which is, tell us about yourself. So our first question is, are you here to learn how to help yourself with your perfectionism and your self-critical tendencies? You can answer that with a yes or no. And then in addition, because many people are here for both, are you here to learn how to help someone else, that could be a loved one or that could be your patients, with their perfectionism and self-critical tendencies? And honestly, David and I love teaching this workshop because we are aware that all of us as human beings, or most of us, struggle with perfectionism, being hard on ourselves. So, we gather many of you are here to both learn skills to help others but also to help yourself. So David, I’m going to end the poll and I’ll share the results of the poll here so you can see them. So, we have 74% of people are saying they are here to learn how to help themselves with their perfectionism and self-critical tendencies. So, we are in good company with 74% of people wanting to learn some tools to help themselves, and then even more than that, 93% are here to learn how to help someone else with perfectionism and self-criticism. Okay, let me close the poll and I will cover one more slide here and then I will also turn things over to David so he can share more.This slide kind of covers the TEAM-CBT model. So, TEAM-CBT is not a school of therapy but rather a framework for kind of how all therapy, how all effective therapy works. It is based on these kind of four elements. The T in TEAM stands for Testing, and that means that we use measures at the beginning and end of every session with every patient to really tune in to our patient, understand the symptoms that are coming up for them, and then also to get feedback from our patients after every session about how we are doing.

 

We can look at how patients change from beginning to end of session and then also how patients change over time to make sure that we are doing really good and effective therapy. The E in TEAM stands for Empathy, and that is that we use a kind of toolbox that David has developed called the Five Secrets of Effective Communication to really connect with all of our patients, and especially the ones that are really hard to connect with. The Testing and Empathy we will not be covering today, so that is kind of part of the framework, but what we are going to be focusing on today is the A and the M. Assessment of Resistance, that is the idea that we assume that all patients are at least partly ambivalent about change, that there are sometimes good reasons not to change. So, we bring kind of resistance to conscious awareness, we melt it away, and really boost motivation to change before we move into the M which is Methods. That is we will be sharing with you a lot of methods today actually in a really short period of time for bringing about kind of rapid and profound and meaningful change. So, we will be sharing a lot about the A and M today. Can I turn it over to you for a little bit, David?

 

Dr. David Burns: Yes, the perfectionism is just one of many self-defeating beliefs that can trigger feelings of depression, anxiety or conflict in relationships. But what many self-defeating beliefs are really, they are including perfectionism, perceived perfectionism and the achievement addiction, and so many others, are they are really self-esteem equations. What they are saying is, I need substance X to feel happy and worthwhile. Then substance X could be perfectionism, you know, I have to be perfect, or it could be achievement, my worthwhileness as a human being depends on my achievements. I have often thought of that as a problem in Western civilization, the kind of Calvinist work ethic that you are what you do. I imagine that the Eastern, like Chinese and throughout Asia, that those traditions were different. But recently both of my books, Feeling Good and Feeling Great, have been released in China. I have been doing a lot of interviews in China in the last few weeks and they are very excited about TEAM-CBT. In particular, I think that unfortunately they have that same problem with perfectionism and achievement addiction that we have here in the US with a lot of young Chinese individuals struggling with feeling like they are not good enough, they have not achieved enough, and experiencing symptoms of depression and anxiety. What is really cool is that finally these things are being talked about in China and receiving a lot of excitement and attention. But, X could also be the approval addiction. A lot of us have the fear of disapproval, fear of criticism, and feel like if someone is criticizing me, it means I cannot be happy, it means I am not worthwhile. Then another huge one is the love addiction: I must be loved to feel happy and worthwhile. You can find a list of 23 of these self-defeating beliefs in your handout on page three. You might want to just kind of circle the numbers for some of them that you can identify with. Most people find that they can identify with two, three, four, five, six or eight or even more of these self-defeating beliefs on page three. You might enjoy going through that. That list has become, I would say, almost as popular as my list of the 10 basic cognitive distortions. So, we're going to do a second poll. I'll turn it back to Jill for this poll, but some of the key beliefs in perfectionism are perfectionism perceived per say, and that is the idea that I must be perfect, as well as perceived perfectionism which is a term I coined that has to do with the belief that you expect me to be perfect, I have to impress you with my achievements in order to be loved and cared about and respected. That is perceived perfectionism. The achievement addiction is that you base your self-esteem on your intelligence, your accomplishments, your achievements. Then, the approval addiction is very much related to perfectionism, that other people will not love and approve of me if I screw up, if I am not really a huge achiever, if I am not really doing things perfectly. So, let us know what, if any or many of these key four key beliefs you might have.

 

Jill Levitt: I will just remind people that the poll is running and I will end it in just a moment. The handout packet was actually in the confirmation email that people received this morning, an hour before the webinar. So, an email went out and it had the handout packet in it. In addition, Mike has dropped the handout packet in the chat box for you guys if you would like that. So, let me end the poll here and share the results and we can see, David, that 56% of people said they have perfectionism, 45% perceived perfectionism, 53% achievement addiction, and 56% approval addiction. Again, they are not mutually exclusive, many people have many of these self-defeating beliefs.

 

Dr. David Burns: Awesome, thank you.

 

Jill Levitt: Okay, let me get rid of the poll.

 

Dr. David Burns: Now the cognitive model, which is really a beautiful model and I think it is not appreciated nearly enough. People think, "Oh, cognitive therapy, something has something to do with thoughts," and they do not go much further with that than that, but it is a very precise model. The way the self-defeating beliefs (SDBs) – Albert Ellis called them irrational beliefs, Karen Horney talked about them in the early 1900s as well, she was a famous feminist psychiatrist, talked about the approval addiction and the achievement addiction – but the way it works is that the self-defeating beliefs are a part of your value system, they are always operating in the background. But it is the combination of a self-defeating belief plus an upsetting event that triggers distorted thoughts. So, for example, let us say I have the achievement addiction and perfectionism, which is a very common combo. I screw up in today's workshop and get some kind of hostile or sharp question at the end or some feedback which is kind of biting. Then I have, I need to be perfect, I need everyone's approval, but I do not get it, and that then triggers the distorted thoughts which come up only when we are upset. And that I might be telling myself, "Wow, I really screwed up today, I am a loser". These thoughts we are going to feel about 100% true and that is why they are so painful because we believe them as much as the fact that there is skin on our hands. It seems obvious. We do not realise that they are just stemming from a self-defeating belief and that they are chock full of distortions. I would be thinking, "Boy, people are going to be looking down on me, I am just not good enough," and end up with, "I am a failure". And So those thoughts will then be triggering all kinds of negative feelings such as depression, anxiety, shame, powerful feelings of shame, feelings of inadequacy, feelings of loneliness as well as feelings of hopelessness. Now Jill, do you want to dive into ‘A’?

 

Jill Levitt: Yes, sure. So, now you have a sense of what are self-defeating beliefs and kind of how they operate. And so the A in TEAM, we said, is the Assessment of Resistance. It is really the reducing resistance kind of step and boosting motivation. And so kind of overall in the TEAM-CBT model, when we are working on resistance with patients, our goal is to help our patients to feel proud of their symptoms. We do not think of resistance as what is wrong with our patients, but actually kind of what is right about our patients. If we can help them to identify kind of good reasons to hang on to their self-defeating beliefs and what they show about them that are kind of beautiful and awesome or how they are a reflection of their values, how they work for them, then oftentimes they will actually be in the role of arguing for change. Our goal is to become the voice of our patients' subconscious resistance and that often opens the door to rapid change by transforming their shame, you know, "I shouldn't be so hard on myself," to actually feeling kind of proud of themselves for having, let us say, high standards or expecting great things of themselves.

 

Dr. David Burns: And that dimension, I would say, was totally absent from early cognitive therapy. That was why all the outcome studies with cognitive therapy, as well as every other known form of psychotherapy for depression, have only limited effectiveness, giving substantial improvement in only half of patients. It is because half of patients will subconsciously or consciously resist, and so then the cognitive techniques or any helpful techniques are not going to be very effective. So, the Assessment of Resistance or Paradoxical Agenda Setting is a dimension that I added after years of research and clinical work, and it’s really the most unique and key part of TEAM-CBT. It is also a paradoxical technique because it does not work through helping the patient but rather persuading the patient not to change. And it’s really incredibly powerful but hard for many therapists and many patients to grasp at first because it is so unfamiliar to the regular helping role that we think therapists are always supposed to be in.

 

Jill Levitt: Yeah, and so we are going to share with you actually a couple of different tools today for addressing resistance and for reducing your own resistance if you are here to work on yourself. The first one that we are going to share with you guys is called the Perfectionism Cost-Benefit Analysis. Of course, you can do a cost-benefit analysis actually with any negative thought or feeling, but we are showing you how to do one with a self-defeating belief, the perfectionism CBA today. So, if you turn to page six in your handout packet, and again if people arrive late, the handout was sent to you this morning in the reminder email and Mike has also dropped it in the chat box today. I will also remind people that while you cannot chat with audience members because it is too distracting for people, you can send a message to us in the chat box, not that we encourage you to send us messages but you can send questions to the host and panelists in the chat. Mike is going to be collecting the questions and then at the end of the webinar today, toward the end of the webinar today, we will answer your questions out loud or some of your questions. So, turn to page six in the handout packet, and then let me turn to the next page here. So the perfectionism cost-benefit analysis, we’re going to encourage you to try this exercise with us right now where you are going to list the advantages as well as the disadvantages of telling yourself, "I should always try to be," either like, "I should always be perfect," or you could be more specific, "I should always try to be a perfect therapist or teacher or mother, daughter," etc. So, at the top of the page it says actually that the belief you are trying to change is, "I should always try to be perfect". Then we want you to take a minute to try to write down what are some benefits of telling yourself, "I should always try to be perfect," and start with that side and then we can always move on to the costs or the disadvantages. Something that is so important and that so many people make a mistake of is this is not the advantages or disadvantages of being perfect. I gather many of us could think of lots of great reasons to be perfect. It is the advantages and disadvantages of always trying to be perfect, right, of putting that pressure on myself that I should be perfect.

 

Dr. David Burns: Ask yourself, how will that belief help you emotionally, behaviourally, in terms of your the quality of your work, in terms of your relationships with other people, and so forth? There are probably at least 10 or 20 or 30 or more overpowering advantages of perfectionism, and that is one of the reasons for resistance. It is because sometimes the very thing that is the root of our horrific despair and intense negative feelings and frustrations is something that has been secretly rewarding us in many, many ways. So, first in the left-hand column list the advantages of trying to be perfect, like, does it motivate you? What happens when you achieve something great? How do you feel? List all of those things. Then once you have listed at least three or five or more benefits of this belief, "I should always try to be perfect," in my therapy work, in my research, in my teaching, and then ask yourself, is there a downside? What price do I pay for that belief in terms of my emotions, my self-esteem, my relationships with other people, my work, the quality and quantity of my product, my productivity and my spirituality really as a human being? There are plenty of disadvantages and we are not trying to stack the game here in favour of the advantages or disadvantages. I just want you to write down a number of advantages that click for you and a number of disadvantages that seem realistic as well.

 

Jill Levitt: Then what we are going to ask you to do is, if you would like to share your perfectionism cost-benefit… Actually, sorry, we have one more step and then we will ask for you to share. After you have listed the advantages of telling yourself, "I must be perfect," and the disadvantages of that belief system, then you are going to take 100 points and divide them. Take 100 points and divide it into two, right? How many points would you give to the advantages side, how many points would you give to the disadvantages side? It does not mean that you are adding up how many items because sometimes one really powerful advantage can weigh more than several disadvantages or vice versa. So, take 100 points and divide them between the two. Is it 60/40, is it 20/80? Then once you have done that, if you would like to share with us, and it will just be a very brief share, you will tell us kind of what were some advantages and what were some disadvantages and how you rated the points. Send a note to in the chat box just, "I would like to volunteer," and then Mike will call on someone to actually share using, we will enable your audio and give you a chance to share with the group your perfectionism cost-benefit analysis. So, we are not asking you to share the details of it in the chat but rather just put in the chat, "I would like to share mine," and then Mike can unmute you.

 

Mike Christensen: Well, it looks like we have got Rachel here. I am just going to highlight Rachel, allowed to talk and I am just going to.

 

Rachel: I think I have been unmuted.

 

Mike Christensen: There we go, hi Rachel.

 

Rachel: Hi.

 

Dr. David Burns: Hi Rachel.

 

Rachel: Hi, how are you?

 

Dr. David Burns: Good, thank you.

 

Jill Levitt: So, yeah, go ahead. If, does your top of your CBA does it just say, "I should always try to be perfect," did you, was it a perfect mother, perfect, you know, anything?

 

Rachel: Yes, so I actually did perfect therapist parent. So, I kind of was keeping it as both to try to keep the ideas in mind so we could either pick one or do both but I think they apply to both. Then same thing, the drawbacks or disadvantages of telling self, "I should always try to be the perfect therapist or parent".

 

Jill Levitt: Perfect, so perfect. So, share with us what were some advantages? How to start with the advantages?

 

Rachel: Okay, so for advantages I said it pushes me to do and learn more. I also said it helps to make me a better parent or therapist by, you know, trying to push myself to be the quote unquote perfect parent or therapist.

 

Jill Levitt: Yeah, so pushes me to do and learn more, kind of pushes me to be better, is it?

 

Rachel: Yes, yes.

 

Dr. David Burns: And then another advantage, how do you feel when you score a home run, Rachel?

 

Rachel: I feel good. Yeah, that is a good point.

 

Dr. David Burns: Is that a benefit?

 

Rachel: Yes, definitely. I feel good when I have gone to something like this and I feel like I get more CEUs or I feel good when I read a book like the Let Them Theory and I feel like, "Okay, this is good for my parenting and for my being a therapist," so, yeah, I do feel good.

 

Dr. David Burns: Yeah, That is huge. Any disadvantages you found in that mindset?

 

Rachel: Yeah, so I think leaning toward the idea of perfect, I think that can bring on lower self-esteem because obviously like I am never going to be the perfect parent or therapist because I believe there is no such thing, and so it can lead me to feeling worse about myself. I can never really feel like I am having an achievement or a success because I am, yes, like these are minor successes but I am not going to achieve perfection so I feel like I would never actually like fully achieve being the perfect therapist. And then kind of some like depressed negative feelings like feeling down about myself as a parent or therapist, and also I wrote, "I may not have as good of a work-life balance," because if I am like constantly trying and trying, trying to let us say, be a better therapist and focus so much on that, then I might not be as quote unquote good of a parent because I am not as available because I am focused more on being the quote unquote perfect therapist.

 

Dr. David Burns: That, those are beautiful lists. Was there anything about relationships on the advantages side or disadvantages side? For example, on the advantages side, if you are trying to be perfect and then you, you know, you do some awesome work, you know, some people are going to admire you?

 

Rachel: Yes, definitely. I feel, yes, I appreciate feeling admired and even with my kids if I am kind of hitting home runs with spending time with them and making them, you know, a focus and so that feels really good. Also a disadvantage though, if I am spending more time on one than the other that could be not feeling so good in my relationships.

 

Dr. David Burns: Right, as well perhaps as not having a chance to experience real closeness. There can sometimes be a little bit of loneliness with being a high achiever. How did you rate these two? Is it 50/50, 60/40, 40/60?

 

Rachel: I actually gave, again I think it is a piece of focusing on like the word perfectionism or perfect but, I gave the drawback disadvantages 60 and I gave the benefits 40.

 

Dr. David Burns: Great.

 

Rachel: Because it just felt weighted in the like negative more than weighted in the positive.

 

Dr. David Burns: Well that is,

 

Rachel: But I do feel like I get benefits from it professionally and also personally.

 

Dr. David Burns: Yeah, that is a beautiful analysis. Now Jill, you know, when you give us this 40/60, you are giving us permission to continue working with you to change this belief and we have a lot of wonderful techniques to do that. But what would we do, Rachel, or Jill, if it was the other way around and if it was 60/40? What position would we take? What would we say to our patient or colleague or son or daughter or whatever?

 

Jill Levitt: Would you like to take a stab at it, Rachel?

 

Rachel: I mean, obviously that this is working for you. Like, overall, you are getting, you are gaining more benefit than you are losing and so this is bigger picture working for you more but not completely. So, should we look at the other side and figure out if there is work to be done there and some any change that you would want to make?

 

Dr. David Burns: That, that was really great except for right at the end. What is another way we could bring it to conclusion, Jill?

 

Jill Levitt: Yeah, and Rachel, by the way, I do love what you said. But yeah, you started out strong in this idea of if the advantages are greater than the disadvantages, then this must actually be working for you more than it is hurting you, and so maybe that is not something that we should actually try to change. Right, it is actually serving you well and we do what we call sort of sitting with open hands. I am not going to try to convince you to change this perfectionism, it kind of sounds like it is working for you. So, is there something else you might want my help with? And then quite often the patient will kind of chase you and go, "No, no, no," you know, "Actually, let me revise that a little bit because it actually is super painful or it is not that motivating," or, "You know, but if they do not and they are in agreement that it is working more than it is costing, then kind of we do not, we do not want to push them to give it up".

 

Dr. David Burns: This is called sitting with open hands and it is the key mindset in TEAM-CBT. It is one of the things that is hardest for therapists to accept because therapists do not want to accept that a patient might not want to, want whatever they are marketing according to their most recent workshop. But all the power of team comes from grasping and endorsing this idea of sitting with open hands. This is not a game. I can remember when I was a psychiatric resident, I was walking with John Rush who was a wonderful person. He is a famous biological psychiatrist, I think at the Southwestern Medical School in Dallas, and he has had a very illustrious career and he was in my class. I remember him saying, "David, I feel so sorry for these therapists who think they have to be perfect and cure everybody". I said, "Oh, yes, John, it is so pathetic, you know, you are absolutely right about that, there is no mileage in trying to be perfect". That is what I said to him because it seemed like the socially correct thing to say, but what I was thinking in my head was that is okay for you, John, you shouldn’t try to be perfect but David is quite a different kettle of fish and I am going to try to see if I can cure every one of my patients. I was hooked on perfectionism in my clinical work and in my research and it took me a number of years before it finally dawned on me that John was right in his wisdom and that I had fallen into a kind of a trap but it was very, very rewarding. So, you do not want to minimize the potential power of the resistance, and if you honour that rather than try to manipulate it, you will have much greater effectiveness as a therapist and much greater satisfaction in your clinical work.

 

Jill Levitt: And David, the third one, right, we were going to talk about which is what happens if the two are equal?

 

Dr. David Burns: Yeah, What are we going to do there, Jill or Rachel?

 

Jill Levitt: I’ll take Rachel off the hot seat.

 

Rachel: Well, I feel like you have the perfect answer.

 

Jill Levitt: No, but first actually, I was just going to say thank you to Rachel for volunteering. That was an awesome example that you walked us through, so we really appreciate that. Mike can take you out of the hot seat and let you go back to being a participant. But thanks so much, that was, that was.

 

Rachel: You are welcome, my pleasure. Thank you.

 

Dr. David Burns: Thank you, Rachel.

 

Jill Levitt: Yeah, and so, what do we do if they are equal? Well, in truth, it is pretty similar to what we just said, which is I would say something like, "Well, I can see that there are definitely some disadvantages and that it is hurting you and at the same time there are some really significant benefits to this perfectionism and it is serving you really well". "Since it is so much work to actually change, you know, perhaps it does not make sense for us to change that, you know, you would have to really convince me that it was worth it to you to change at this point, it is looking kind of equal". So, again, kind of a sitting with open hands while acknowledging that both sides are looking similar.

 

Dr. David Burns: As an aside, I might say that some of the techniques we teach are really well set up to be done in groups. In fact, we did this one in groups. It is just that we will not have time to talk with each of you about your analysis and brainstorm. This could go into a whole, you know, 30 or 45 minute discussion. But this is a great tool to use in groups whether you are a teacher in a high school or in a college or even in a middle school. This is a great way to connect because just so many young people in America and in China and worldwide are struggling with perfectionism and there is so much pressure in our society for achievement and having a perfect body and a perfect this and a perfect that, that this is a very painless and fun way for people to ease in into this topic.

 

Jill Levitt: Okay, and so there are lots of methods that we have for changing self-defeating beliefs. Someone even messaged me around, "Can you hold on to some parts of the belief and change others," which is kind of called the semantic technique. But we are going to share with you a couple of methods for changing perfectionism in particular in just a minute. But we are going to walk through before we do that kind of other resistance busting tools that you can use as well. This kind of sequence is dealing with again what we call outcome resistance. It is this idea of like, would you really want to give up your perfectionism and be feeling good about yourself exactly as you are right now? And so we’ll talk you through right now the magic button, the pivot question, the positive reframing, and the magic dial. But we are going to do that by first introducing you to a therapist that we did some personal work with named Amy who was struggling with perfectionism. So, David, do you want to say a little bit about Amy and then Amy will introduce herself in this slide as well?

 

Dr. David Burns: Amy was a beloved member of our Tuesday group for a couple of years at least and has still a practice on the East Coast and she is on the voluntary faculty of one of the top medical schools in the country. She was specializing in short-term treatment of anxiety disorders but she came to Jill and David not long ago really in tears after being having a sleepless night and days of extreme anxiety and beating up on herself tremendously. You will learn more about this in just a few minutes because she was stuck with two of her patients. Although she was doing great in her clinical practice, had a booming practice of many patients getting just blow away ratings and doing rapid recovery with the vast majority of her patients, she was ripping herself to shreds because of the fact that she was stuck with these two patients. And the intensity of her emotions, which you will see in just a few minutes, was off the chart. But let us hear what Amy has to say. She was, she is one of, always been one of my favorite people. She is such a beautiful, down-to-earth, kindly person.

 

Amy: I guess I have always been somebody who really spends a lot of time thinking about my patients sort of outside of session and sort of worrying about how they are doing and very invested in how they are, you know, whether they are feeling better or not. So, when I have a session where they, you know, they leave feeling really good, I just feel great. Then when, especially when there is somebody that I have been working with for a while who is then feeling stuck, that just is like this weight that I carry all the time in the rest of my life to sort of, you know, as I am doing things with my family, it is still there, this weight of there is this person I am working with who is struggling and I just feel that so heavily and I am constantly thinking about that person and sort of what can I, what can I do differently? What have I not thought of yet? What, different perspective might be helpful here, what different method could I try, what might I be missing? And so, I am spending lots of time just ruminating about that, especially as I am trying to fall asleep at night, that is just a constant sort of broken record in my head.

 

Dr. David Burns: What, what is the worst part about all of this to you.

 

Amy: When I am worried, you know, thinking about my patients who are not doing well? So, I have sort of done a sort of downward arrow for myself with that.

 

Jill Levitt: What if?

 

Amy: What if? And it sounds, I mean I feel a little embarrassed sharing it because I realize how sort of absurd it is. But it sort of gets down to, I mean, what if I am somehow responsible for them feeling so hopeless that they kill themselves and then like I could never live with that, that guilt?

 

Dr. David Burns: Yeah, by the way, we had some.

 

Jill Levitt: Go ahead.

 

Dr. David Burns: I have had some beautiful comments from Michael Harmon and others how touched that they are. I wish you were here to read that and to hear that. Amy also, one person said she was having trouble hearing and I hear it here in my computer with my speakers very loud.

 

Jill Levitt: If anyone is having difficulty, unfortunately it is on your end, needing to either increase the volume or something, but yeah, we know everyone can hear it in general.

 

Dr. David Burns: Right? But that, there you met the, you know, got a glimpse of Amy's inner beauty as well as the intensity of her suffering. Her daily mood log that she presented us with was that being unable to sleep at night and then the next day she saw two patients in a row who were feeling very stuck and discouraged. She did this on paper and this is a tool that you always want to do on paper because when you write down your negative thoughts at a specific moment, there is tremendous illumination and learning and growth as possible. If you try to do this in your head, you will not have much luck. I remember that is one of the first things I included in my book Feeling Good that came out in 1980, I must have written that in 1978 or 1979 but it is just as true today. You can see that she was feeling sad 80%; anxious, worried and nervous 80%; guilty, remorseful and bad 90%; incompetent and inadequate 100%; discouraged 90%; and stuck 80%. And although she is a fully functioning psychiatrist carrying a heavy load of patients and an active family life, at the same time these scores are comparable to someone if you went into the Stanford inpatient psychiatric unit and ask these estimates from somebody who is receiving electroconvulsive therapy, that they would not be a whole lot more severe than this. And this helps us greatly initially when working with someone to appreciate just the incredible intensity of their feelings because otherwise you can be deceived by Amy's warmth and smile and think that she is mildly distressed but she is not, it is major league. Then what is causing these feelings? This is another key point of the theory of cognitive therapy or TEAM-CBT, and that is that all of your emotions result from only one cause, and that is your thoughts. That idea has been around since the time of the Buddha 2,500 years ago, in the time of the Greek philosopher Epictetus nearly 2,000 years ago. It is not the events of our lives, it is not the fact that she has two stuck patients that is not the cause of her distress. It is her interpretation, it is what she is telling herself. What she is telling herself she is saying, "I am failing my patients". She gives that a hundred. "I should give them their money back," she believes that one 50%. "I am not competent enough to practice psychotherapy and should find a new career," how devastating is that? I think on that one I am seeing 60% belief. "I should know what to say and how to help them and how to get them unstuck and feeling hopeful," and she believes that 80%. "I should extend the session a little longer and keep going on until they feel better," and that is a 90%. We will see, she has a whole slew of these negative thoughts. "I should extend this session a little longer," and I think you will find this on page five of your handouts, and beating up on herself in a variety of ways.

 

Then very coming down to the bottom of it, "I am too slow and compulsive to help my patients," 80%. "I am a fraud and a failure," how devastating is that? And she believes that 100%. "I am a fraud and a failure". "If anyone sees me in this video they will think that I am not a competent Frank and will not want to work with me," and she believed that one 80%. And part of the magic of the daily mood log and what I, in my old age I am getting more and more irritable and willing to show my irritation, which is probably a poor choice because everyone thinks I am so warm all the time and friendly and I try to be. But when I hear of therapists who do not use the daily mood log and treat people with, "Oh, you should go out in nature and spend time with loved ones," and all this bull crap that has been known for over 2,000 years to be just garbage, that you need a daily mood log to find out what the person is thinking because we all think differently. These are the thoughts that are causing her distress and that is where we want to target the therapy if we hope to bring Amy relief and hopefully rapid relief and hopefully rapid profound relief. So, there is one of my rants for the day. I am sure my ratings just went down considerably, but anyway, that is how I feel. But to put it in a positive light, if you look at the negative thoughts of your patients or your loved ones or yourself when you are upset, you will see the truth about what is really going on and you will know exactly where to focus your therapeutic efforts. Back to you, Jill.

 

Jill Levitt: Sure. So, now that you guys have a glimpse of kind of who Amy is, we are going to walk through a couple things we did with Amy. Before getting to the methods, right, before kind of working on challenging and changing the beliefs that are driving Amy's distress, we first are going to address some resistance. So, we showed you how you can do a perfectionism cost-benefit analysis, but you also having that daily mood log in front of you after identifying the feelings and the negative thoughts, but before using any kind of change methods, we could turn to Amy and say, "Amy, let us imagine that there was a magic button right here, right in front of you, and if you could press that magic button, you would instantly feel joy and self-esteem without any effort whatsoever". "You would feel fantastic right now in this moment, would you press that button"? Most patients say, "Yeah, show me the button". Right, that is why I am here. Amy and some patients too actually had a more nuanced response, which was like, "Well, I am not, I am not so sure". That means that Amy actually understood what we were trying to say, which is there might be some good reasons for me to be so hard on myself. So, we ask that magic button question and then we kind of move to positive reframing. In Amy's case we would say, "Yeah, maybe it is not a great idea to just press that button and instantly feel joy and self-esteem when you have got these two stuck patients". So, we can say, "You know, we do have some really powerful techniques to share with you, Amy, but first let us just think a little bit, what do your thoughts and feelings show about you and your value system that is really positive and awesome"? "Can we talk about how some of these negative thoughts and negative emotions actually show something really beautiful about you"? "Can we also think for a moment about how your negative thoughts and feelings might actually be working for you, might be benefiting you"? And so, there is some similarities to this and the cost-benefit analysis, but we are going to invite you right now to enter in the chat box and I can read some of those, some of your responses. What do Amy's negative thoughts and feelings show about her that is really beautiful and awesome and how do her thoughts and feelings benefit her? Do you want me to go back and show the daily mood log, David?

 

Dr. David Burns: No, I just had a quick comment that this again is where TEAM goes in the diametrically opposite direction of most direction that most therapists and family members would go into, is to trying to help her, to cheer her up, to get her away from these terrible negative thoughts and painful feelings. We’re not doing that because that will only trigger up resistance. So, instead we are going to become the voice of her subconscious mind, the part of her that does not want to change, and we are going to give a respectful voice to that and talk about all the good reasons not to change. So, it is the opposite of how 99% of mental health professionals are trained.

 

Jill Levitt: So, I have got a couple here. I will read just, "The negative thoughts and feelings show that she cares deeply about her patients and their well-being". I got lots of people saying that she cares so much about her clients. I also got that shows that she is very hardworking, that she is dedicated to her patients. Some of her negative emotions show the depth of her compassion and her concern. They help her know areas that she might need to work on. Shows that she greatly cares about her clients. That she is honest about how helpful or not helpful she is. Shows her high standards, shows her to be a caring and passionate person. Helps her to be alert to errors that she might be making or ways that she could improve. So, there is lots more here, and I also just want to point out, you can turn, let us see, wait, do we have this here, yes, page seven in your handout packet is where you can see the positive reframing tool. We have a couple examples you guys came with so many amazing once’s, but let’s also we can share with you a couple of slides and you can see a few more in page seven in the handout packet that her high standards motivate her, you guys hit a lot of these. Her beating up on herself shows her humility and also her honesty. I do not have to settle for mediocrity. Let’s see, we in the handout packet we have, it keeps me from being over my feelings of inadequacy, keeps me being overly confident, keeps me humble so I am open to what I might be missing. Anything else you want to add here, David?

 

Dr. David Burns: No, just to say though, what a beautiful thing this is and how beautifully you all did this exercise. And again, it is the opposite of the direction that our training takes us in because we are supposed to diagnose mental disorders. Like we could say Amy has generalized anxiety disorder or obsessive-compulsive personality disorder or something like that. These diagnoses while they have certainly some value to know the kinds of symptoms our patients struggle with and the differences between different kinds of problems that people have, they also have a tendency to trigger feelings of shame and the idea somehow we have got to fight against these feelings and defeat them. That is like trying to get out of one of these Chinese finger traps, the harder you try to pull against it the tighter your fingers get trapped. That is why in team we always go in the opposite direction and try to see realistically, not as a gimmick, what is beautiful about the patient's suffering. And you can see that for absolute slam dunk certainty in Amy's case that she is a beautiful, gentle human being, incredibly intelligent and gifted but with fabulous high standards and she is a humble person. She is someone that is one thing I always loved about her in the group, I did not realize just what a star she was, but I always realized that she was always smart in what she said but she was always humble and so easy to feel close to and to connect with and to feel comfortable with. We want to bring out that beautiful side of the patient's suffering, whatever the patient's suffering happens to be.

 

Jill Levitt: And you guys did an amazing job of coming up with many examples, many positives in the chat box. A couple of people said, "But perfectionism is so bad for you". That is true, but the point of this exercise is first to align with all the positives and what it shows about the patient that is beautiful and awesome because again that is really where the resistance lies. Like why would I not be able to give up my perfectionism if I know that it is hurting me, why am I struggling to be kinder to myself? Because of all of the ways in which it is actually working for me. So, after we get this good, kind of, hearty, true, beautiful list of all of the positives, then we can ask our patient what we call the pivot question. Which is, "Given all these benefits, all these positive values," and we kind of read them out loud to the patient authentically, "Why would you want to give up your depression, your guilt, your inadequacy, you know, why would you want to feel good about yourself?” In that sense, the therapist is siding with the voice of the resistance, right? We are reading this list of all the beautiful and saying, "Yeah, why, why in the world would you want to give this up, it sounds like it is working for you." And then paradoxically, the patient gets in the role of arguing for change, right? Like what some of you are putting in the chat box like, "But, you know, it is hurting me and it is getting in my way and it is on my mind all the time, it is interfering in my ability to parent or to enjoy myself, I am not sleeping well," right? And there you have the patient then really arguing for change. This is why I want to give it up. Once the patient is in the role of arguing for change then we can say, "You know that makes sense to me too". So, how about instead of just pushing that button and getting rid of your these negative feelings altogether, could we instead work to dial down these feelings to some level that really makes sense? We can hang on to some of the benefits but also reduce some of your distress. Then we move to the back to the daily mood log and we move to the goal column on the daily mood log. We are asking, "How sad would you want to feel, what is the kind of the right amount of sadness where you are not going to be suffering so much but you are going to hold on to your humility, you are going to keep yourself on your toes"? We are going to walk through kind of each row of the emotions asking how strong, how anxious and worried and nervous would you want to feel? Amy started at an 80 and she said that her goal was a 20. Guilty, remorseful, bad started at a 90 and she said her goal would be to bring that down to a five. Her inadequacy and incompetence started at 100, she wanted to bring that down to a 15. She was feeling 90% discouraged, she wanted that to go down to a five, and 80% stuck and she wanted that to go down to a five. So, at that point Amy is aware that, "I am not just trying to make myself feel better and get rid of everything willy-nilly but like I actually understand that this is kind of the right level of sadness or anxiety where I can hang on to some of my values but also experience a lot less distress".

 

Dr. David Burns: Yes, she can, she can see that, "Yeah, I want to feel 25% sad, I do not want to feel 0% sad when I have two stuck patients" and it is such a beautiful thing. I would say that Freud spent his career trying to understand resistance and trying to develop a technique to analyze and reduce resistance and he came up with five days a week on the analyst's couch free associating. But I don’t, the Freudian formulations to resistance are interesting and kind of a tremendous intellectual achievement, but I am not aware of them being very helpful. Again, I hate to say this because it sounds critical and people will probably bust me for saying it, but what we have developed is a method for dealing with resistance in a therapy session in 30 minutes rather than many, many years. So, the patient can let go. The paradox is that the very moment the patient really sees the beauty in their, in his or her symptoms, which is not the Freudian view of resistance at all, this is radically different way of looking at it. The moment they get that, then rapid and dramatic recovery is just a stone's throw away. That is a paradox. The paradox is that when the therapist, this is called the death of the therapist's helping self, that is one of the four deaths of the self in TEAM-CBT, and the moment you let go of that and see the world through the patient's eyes and see why the patient has all of these symptoms in a positive and caring way, it melts away the resistance. Then the patient becomes a partner when we come to methods and we can generally blow the negative thoughts out of the water very quickly.

 

Jill Levitt: And someone oftentimes people ask this, so I’ll answer this question now. In Amy's case, when we offered that magic button, she said, "I am not sure," and then we kind of explored the resistance. But if someone answers, "Yes, show me the button," then we still do exactly the same sequence. We say, "Yes, I would love that for you too, I can totally understand why you would want to feel no longer depressed and anxious. But before we do that, I would like to invite you to think with me a little bit about how these might be serving you well". So, we still go to positive reframing. So, whether they want to push the button or they are skeptical about the button, it does not matter, we move into positive reframing. The pivot question and then the magic dial. So David, I wouldn’t get caught up with the chat while we are presenting because it is going to be very distracting. But we are going to move on now and kind of leave agenda setting or assessment of resistance, as we say, and actually share with you a whole bunch of methods right now for addressing perfectionism. So, we will start with Identify and explain the Distortions. We are going to show you a video of Amy doing externalization of voices. We’ll do a demo of the feared fantasy, and we will share with you some anecdotal stories about the self-disclosure technique and the experimental technique and get through all of that and some questions in the next hour. So, David, do you want to talk briefly about Identify and explain the Distortions?

 

Dr. David Burns: Yes, identifying the distortions has been around since I wrote Feeling Good, but I never thought of it as being very helpful to people, just kind of a fun thing to do to get the door open a little bit but nothing major. I would say in the last five or 10 years, I have developed the technique called Explain the Distortions, and that is where Identify the Distortions becomes a powerhouse healing technique and more than just a game at seeing why a thought is distorted. And the way you do it is you ask the patient, say, "I am failing my patients," and then you ask them to identify the distortions in that thought. Well, Amy found eight or nine of the distortions in that thought alone. Then you take one of them, like, let us say you say this is all or nothing thinking. You ask three questions of the patient. The first question is, why in general is all or nothing thinking considered distorted thinking, why does it not map on to reality? The answer to that is because pretty much nothing in the universe is all one way or the other way, everything is shades of gray. Today's presentation is unlikely to be the greatest presentation in the history of the human race, that would be a hundred, but it is also not going to be zero. David might have irritated a few people with his somewhat challenging comments, but a lot of people might appreciate a little controversy and a lot of people might have learned a lot and love this presentation. So, it is somewhere in between. Then the next question for Amy would be, why is when you say, "I am failing with my patients," why is the all or nothing thinking and that thought a gross distortion of reality? And the answer to that comes fairly readily, "Well, because I am doing great with nearly all of my patients". And to say, "I am failing my patients," is a great distortion, sounds like all of my patients are dying and committing suicide or something, and nothing could be further from the truth. That is the second question. Then the third question you ask in Explain the Distortions is, why is that unfair to you, Amy, to use that distortion? Then the answer to that might be, "Because it is cruel to beat myself up like this, because I have got two patients who are stuck". "I would never beat up a colleague I loved and say that kind of thing to someone who was stuck with two patients," that type of thing, and that is called Explain the Distortions.

 

And often you will come up with a good positive thought just from that procedure, particularly if you have done the assessment of resistance effectively and the patient has seen the beauty in their negative thoughts and feelings, and that makes it paradoxically much easier to blow away these distorted thoughts. And this is just one technique, of course. And you can also see each distortion is a different lens through which or a window that you are looking at why the thought is screwed up. And so overgeneralization would be another way to do it. "You are overgeneralizing from two patients to all of my patients and all of my career and telling myself I need a new career," you see? So that is a gross overgeneralization and that leads to another series of explain the Distortions that come another way to come up with powerful positive thought. And t he purpose is that you see it is the patient's belief in the negative thoughts that creates the pain. And the positive thought has to have two characteristics to help the patient. First of all, it has to be 100% true. Half-truths and rationalizations are just a lot of BS and positive affirmations are worthless for the most part. But you need true positive thoughts that directly confront the negative thought, “I'm failing my patience”. And if the positive thought is 100% true, then the second criterion for an effective positive thought is it radically lowers the patient's belief in the thought I'm failing my patients. I think her belief in that was 80 or 90%. The moment the patient stops believing the thoughts, in that very moment, the patient's feelings will change. Back to you, Jill.

 

Jill Levitt: Yes, no, that was beautifully explained. What’s so cool about doing Explain the Distortions is it goes from being just kind of this little cerebral exercise where you circle the distortions to really getting the patient in explaining why, you know, all or nothing is a cognitive distortion and then why their thought is an example of it and why that thought is unreasonable or unfair or hurtful. You already get your patients starting to generate those positive thoughts, right? And so it becomes a highly kind of interactive method. And so, let us just share with you guys that in that one thought, "I am failing my patients," Amy was able to identify one, two, three, four, five, six, seven, eight, nine of the cognitive distortions. And in talking back, in basically explaining these distortions, Amy was able to generate this positive thought: In fact, I am doing well with nearly all of my patients, but it is impossible to be perfect and I will always fail some of my patients, and that will always give me opportunities to get consultations when I am stuck so that I can learn and grow. That was a belief that she said she believed 100% which then made that original negative thought go to zero. So, that is what David was talking about that it has to be a total truth that new positive thought, totally believable and it also has to bring that original negative thought to zero or close to zeroo. So, let us move on from that, there is so much work we can do with Identify and explain the Distortions. But we are going to share with you one of the most powerful techniques I think you have developed, David, that is called Externalization of Voices. And I will let you say, you want to say a little bit about it and then maybe I can walk through the steps of it?

 

Dr. David Burns: Well, sure, it is probably the most powerful CBT technique ever developed. It was the first technique I developed when I started going to Beck's weekly seminars and I was trying to learn CBT for the first time. I developed it because some of the techniques, they were all interesting but some of them felt a bit dry and intellectual, like, you know, like explain examine the evidence and the experimental technique. I wanted something that would hit people at the gut level. I had done a lot of psychodrama in medical school and that appealed to me but it was kind of unregulated and kind of almost too powerful at times. And so, I was trying to take the power of psycho drama and put it into a beautiful safe method and that became the Externalization of Voices. And you can model a lot of ways to crush a negative thought with Externalization of Voices and especially you can model the acceptance paradox. Acceptance when the patient really gets it, if they get it, is the same as what the Buddha called enlightenment. So, often a few minutes with the Externalization of Voices can accomplish what should be accomplished maybe with years or decades of meditation. It is not only a healing technique but it is kind of a spiritual technique. And the way it works is you tell the patient, "I am going to become the negative you and you are going to be the positive you," that will be the same person, we have the same name, you are Amy and I am Amy, and I am going to talk to you in the second person, you. So instead of, "I am failing my patients," I might say to you, "You know, Amy, you are failing your patience". Then Amy has to take the positive role and try to defeat this negative voice. It is a very powerful and intimidating technique with tremendous healing power. And when you do it, you only attack the patient with their exact negative thoughts. You do not just make up mean things to say to somebody, that is not Externalization of Voices. But she was telling herself, "I am a fraud and a failure". So, that is one I would want to attack her with in the Externalization of Voices. Now when she defends herself, she has the choice of three strategies.

 

One is called self-defense, and that is kind of like explain the Distortions. You argue that the negative thought is distorted and it is not really consistent with the facts and that is extremely powerful and many people think that is all that cognitive therapy amounts to and they are really wrong in that belief. But it is certainly a tool, but if it is your only tool you are not going to get very far. The self-acceptance is weaving in at the same time accepting a part of the negative thought, finding the truth in it with a sense of peace or even humor. So, if the negative thought is, "Amy, you are failing your patients," you can say, "It is heartbreaking to me that I have two people who I love and care about as patients who are stuck". And "I am definitely going to get some consultations and see if there is some way I can get them unstuck, but the idea that I am, you know, failing my patients is just grossly unfair and grossly untrue". And "In fact, I am doing beautiful work with nearly all of my patients, and even the two who I am failing with give me perfect ratings on empathy every session and they always tell me how much it means to them to be coming to the therapy".

 

And then the third one is called the counterattack technique. This is the newest dimension of the Externalization of Voices and an extraordinarily valuable dimension, and you point out to the negative self that is attacking you and you say, "My real problem, friend, is not that I am failing two of my patients, not at all. I have another problem far greater than that, and that is listening to your constant BS beating up on me and telling me that I am not good enough. That is the whole key to my problem". So, this is really kind of a radical implementation in a dramatic format of the basic key of cognitive therapy. It is not the circumstances of our life but these distorted thoughts that cause our suffering. It is not that Amy has two patients she is stuck with that has no negative effect on her at all, in fact could even be a source of joy because it can tell her, "Hey, it is time to get some talk to some experts and learn some new techniques". But her despair results from her interpretation of that, "I am a fraud, I am a failure, I need a new career". Those thoughts are devastating.

 

Dr. Jill Levitt: And so, in Externalization of Voices, the therapist is going to play the role of let’s say, negative Amy and the patient is going to play the role of positive Amy. If we are going to hit the patient with her negative thoughts and these are three options the patient has for how to respond to the negative thoughts, and oftentimes a combination of those three is what is needed. So, if the patient is responding with purely self-defense only kind of justifying themselves and they are not winning huge, then the therapist could suggest maybe adding some self-acceptance. Or the therapist could even model adding some self-acceptance. If the patient is mostly accepting it, you know, "You are right, I really am so far from perfect and I make mistakes all the time," but without any kind of self-defense or suggesting that some of that is distorted or untrue, you can add some self-defense to the response to strengthen it. And sometimes patients we say here need a little more spice, a little oomph, and that is what the counterattack can be really helpful for. So, these are all just different ways of responding within the roleplay. So, we start out Externalization of Voices by making sure the patient understands we are not just hurling insults at them. We’re asking, you know, "What role am I in and what role are you in?” So, we can start by just saying, "What is my name?" and in this case the patient would say, "You are negative Amy," right, and "What is your name," and Amy would say, "I am positive Amy". We need to make sure we both have the same name, and again that is to avoid Amy or my patient from thinking that I the therapist am just being insulting to them, right. Then we will do one exchange.

 

So, I would hit Amy with that negative thought, "You are a fraud and a failure," and then Amy would respond, using any of these strategies that we have just talked about. Then we will kind of pause, we do not just keep going back and forth and say, "Great, Amy, who won that exchange, was that kind of me, negative Amy, or you, positive Amy?” Then let us say she says, "I won," I would say, "Well, is it small or big," and she can answer. If she says “big”, I can say “big or huge”. The goal is that we’re trying to get the patient to huge, we are not trying to eke out a little win, we’re trying to get the patient to kind of completely crush or annihilate that negative thought. And quite often the patient will start with maybe a big or a small win and we can ask them if they want to try it out again or if they want to do a role reversal. That is where we as the therapist can kind of change roles and the patient can then be negative Amy and I can be kind of positive Amy and model for Amy maybe some piece of the response that was missing. And the point is we’ll keep doing role reversals back and forth until Amy or the patient gets to huge. Right? It’s not that I the therapist have to be really good at my cognitive therapy tools, it’s that ultimately my patient has to internalize whatever it is that’s been super helpful so that my patient can really crush the negative thoughts. And so, we have a video here of Amy and us doing Externalization of Voices. So, should we go ahead and play the video, David?

 

Dr. David Burns: Yes, absolutely.

 

Dr. Jill Levitt: Okay, let us see what we are going to see.

 

Dr. David Burns: Let us just see if there is any weak spots for you right now, Amy. Would you be willing to do that? Jill and David will be tag team and we will be the negative Amy and attack you with some of this stuff and see if you can defeat us.

Amy: That sounds good. Yeah.

 

Dr. David Burns: You know, Amy, you’re stuck with a couple of your patients. I‘ve heard through the grapevine. Of course, I‘m the negative Amy, I am you talking to you, but I just want to know that you should have figured this out by yourself already without having to get consultation or help.

 

Amy: It would have been great if I figured that out by myself, but it is actually a wonderful thing that I can seek out some assistance from other people and that I am not actually all alone in having to figure everything out. I love that it is actually an opportunity to connect with my colleagues and learn new things, and so, yeah, you know what, it is just totally not helpful when you tell me I should have already figured it out. So, bug off, I’m going to go seek some help.

 

Dr. David Burns: Okay, who won?

 

Amy: I won.

 

Dr. David Burns: Big or small?

 

Amy: I felt like that was huge.

 

Dr. David Burns: Huge, Awesome. Your turn, Jill.

 

Dr. Jill Levitt: Yes, but Amy, you know, you should be able to help every patient all the time.

 

Amy: Again, it would be wonderful if I could instantly help every patient every time. But, you know what, my problem is not actually that I am not able to help every patient every time. You know, that can be again dealt with by seeking help. The problem is that I have been listening to you, and that is when I get really stuck. So, yeah, again, bug off.

 

Dr. Jill Levitt: And who won that, you or me?

 

Amy: I won.

 

Dr. Jill Levitt: Was that big or small?

 

Amy: That was huge too.

 

Dr. David Burns: Okay, my turn, yeah. I am the negative Amy again and I just want to point out that this is a foolish thing making this video because your patients will see this and they will say, "I don’t want to work with her, I want to find a competent psychiatrist to work with".

 

Amy: Let me think about that one. First, let me just say, once again, this input that you are giving me is just not helpful. So, once again, bug off. I am actually having fun doing this video, and if some patients decide they do not want to see me, that’s fine. I actually, you know, feel bad when I have to turn people away because I’m too busy. And so, yeah, not helpful.

 

Dr. David Burns: Okay, so who won?

 

Amy: I won that.

 

Dr. David Burns: Big or small?

 

Amy: I think it came around to huge. I felt a little stuck initially but, yeah.

 

Dr. David Burns: let's just see if there's any weak.

 

Dr. Jill Levitt: Sorry, let me just progress to the next slide so it doesn't start over. Okay, David, you wanted to make any comments before we talk about feared fantasy?

 

Dr. David Burns: Well, I thought that was beautiful and one thing you are looking for when you are doing Externalization of voices is the body language as well as the words. And you can see in that video we had done quite a bit of work with her by the time we shot that video and she was pretty much knocking it out of the park, she was not perturbed and that’s a huge change that we’re looking for and that’s not only you can think as complete recovery whatever that means but also some enlightenment mixed in. Now one can push it even to a higher level if you like and the feared fantasy is another very powerful technique I created that is designed to help patients confront their worst fears when they cannot confront it in reality. You can create a fantasy for them to confront their worst fears. And often people with perfectionism, and including Amy, are having perceived perfectionism and that is the idea that others will not love me or accept me if I am flawed or if I make mistakes or if I am not perfect. And when you do the feared fantasy you explain to the patient, someone asked about teaching the three strategies to the patient on Externalization of voices and yes we do teach while we are doing therapy, there is a learning process as well as the therapeutic process. But in feared fantasy, you invite the patient to enter an Alice in Wonderland nightmare world where their worst fears are actually going to come true. So, for example, if they are afraid of disapproval, they are going to go into a world where suddenly everyone is disapproving of them. But in addition, not only do people have all these negative thoughts about you that you are afraid they are going to have, they get right up in your face and they say them to you and this allows you to face the thing you have feared the most often since you were a child. And when you do it, you suddenly discover that the monster has no teeth and you can read more about this on page 10 of your handout, but we will demonstrate it now.

 

Dr. Jill Levitt: Yes, and I was just going to say that whereas the Externalization of voices I think is really helpful for essentially all kinds of negative thoughts, the Feared Fantasy is especially helpful for worries about other people judging you. So, this is going to be a really good method if you have patients with perfectionism or social anxiety or other kinds of things where they are really worried about negative evaluation from the outside. The Feared Fantasy not only can we use this for perfectionism and social anxiety but for really any kind of self-defeating belief that is a self-esteem equation, so "I must be perfect in order for to to be worthwhile," or, "I must be perfect in order for others to love me". Essentially the roles then in the Feared Fantasy is that the therapist is going to play the role of someone who enacts that self-defeating belief. So, in this case, David is going to be the therapist and he is going to play the role of someone who is totally perfect and has achieved a tremendous amount and also who looks down on people who aren’t perfect, right, because that is part of that belief system. I will play the role of the patient in the role play. And David will kind of be that over-the-top really highly perfectionistic and judgmental other and I will play myself in the role play and I will be trying to defeat that kind of feared fantasy monster that David will be playing.

 

And you know like Externalization of voices there is a variety of ways that we can respond in kind of the patient role and in essence my role as the patient is not to defend against some actual person in reality because if someone were really being a jerk to me I might actually just think the best move would be to walk away, right? But my role, my goal in this feared fantasy is really to blow a hole in the idea that this is true, right, that people are more or less worthwhile when they are perfect or not perfect. So, my role in the patient role is to be kind of commenting in ways that are kind of pointing out the illogic of this over-the-top kind of belief system. I can use things like inquiry and stroking and disarming, these are the Five Secrets of Effective Communication that we teach in other kinds of trainings, or the acceptance paradox, I can accept some truth in what this kind of mean perfectionistic person is saying to me. And then similar to Externalization of voices, after each exchange David the therapist can ask me who won, you know, was it me and did I, was it big or small or big or huge? Of course, we want the patient to get to huge to have a total victory. And if the patient gets kind of stunned or overwhelmed in this role play you can always just do a role reversal and invite the patient to be that over-the-top perfectionistic person. And in fact that can be super useful because the patient can oftentimes realize when they are in the role of being the perfectionistic critical other that it is kind of absurd, right, that no one would actually be that mean or over the top. So, a lot of learning can happen regardless of which role the patient is going to be playing. So, should we do our roleplay, David?

 

Dr. David Burns: Yeah, and I have to say that now I’m playing a role in a movie and I’m the evil ogre. So, please remember that I am doing what I am supposed to do to teach a technique and I am not trying to be my natural self here. So, give me a little slack because I am going to look like a mean son of a bitch.

 

Dr. Jill Levitt: But that’s David, what we have to do as therapists too. And we explain to our patients this is not me in the roleplay like I am being this perfectionistic critical other that you imagine in your mind right, be kind of beating you up.

 

Dr. David Burns: And so, you can play the role of Jill, we’ll just assume that Jill is a therapist who’s less than perfect. But hey Jill, could I talk to you for a minute?

 

Dr. Jill Levitt: Yes, sure, David.

 

Dr. David Burns: You know how you were doing this workshop on how people will really love you and accept you if you are, you know, flawed or that you do not have to be perfect? You remember you were doing that kind of BS workshop with Burns?

 

Dr. Jill Levitt: I do, yeah.

 

Dr. David Burns: Yeah. Well, I have heard through the grapevine that you have a couple of patients right now who are, who you have not been able to help. And I don’t think it is true that everyone is going to love you, you know, if you are screwed up like that. Like I do not, I judge you, Jill, because of those two patients you are stuck with. I used to think you were something terrific but now I see that I was all wrong about you.

 

Dr. Jill Levitt: Yes, well, David, no, you are right. I do have two patients that I am stuck with right now and actually I have been getting some consultation from some amazing colleagues and learning to get unstuck. I have been kind of feeling excited about the fact that there is a lot of amazing learning here. It is kind of boring when you are good at everything and do not have anything to learn. So, what is it about me, you know, struggling with some patients here and there that is really bothering you?

 

Dr. David Burns: Well, I heard you were some tremendous therapist at the Feeling Good Institute and, you know, virtually always successful with everyone. I just thought that that is the way you were and now I see that you’re very flawed.

 

Dr. Jill Levitt: Yeah, totally part of the human race. I win some and I lose some and I am working hard to keep, you know, keep growing. So, are you do not really like flawed people? You just like to hang out with the only people who are super perfect? I do know that you are an amazing therapist and teacher and trainer and I sure imagine you have lots of things to teach. I would love to learn from you but is it, is it true that you look down on all your students when you hear that they sometimes struggle a bit with their patients?

 

Dr. David Burns: Yes, I look down on all of them including you. You are right at the top of the list, I judge you.

 

Dr. Jill Levitt: I could keep going.

 

Dr. David Burns: So, okay, so anyway who won, who looked like the ass?

 

Dr. Jill Levitt: Right. I think I won with my humility and my interest in learning and growing and I think the more that I questioned your belief system, the more you seemed like an ass.

 

Dr. David Burns: Yeah, and it’s kind of a humorous technique but it has a serious purpose and it’s to reveal to the patient something that they could never get out of real life because it will never happen in real life. But that even if there was some judgmental person who was going to love them less or respect them less because they were flawed or imperfect, that is not your problem, that is the problem of the person who is doing the judging. It can help the patient grasp this on the gut level and this is incredibly helpful for many patients especially patients with social anxiety and patients who have intense fear of disapproval or criticism or judgment from other people.

 

Dr. Jill Levitt: And it can feel, it can look kind of brutal but at the same time it is actually really a fun method and if the patient can get to that place of realizing just how over-the-top and ridiculous it would be for someone to be so judgmental for them to not be perfect, it can be really kind of illuminating and again sort of fun. And like I said, the therapist can really bring that to life whatever their role in, right, because the role of David being so over the top I think highlights just how ridiculous this belief system is. But if, you know, we role reversed and David just modeled as a therapist like a great way of responding to the critic that would also be helpful to the patient and you can just kind of keep roll reversing until you get to that enlightenment where this just seems absurd and where making mistakes seems very reasonable and yeah, and a positive experience. So, let David move on, we have a couple more methods to cover and then we have got some questions and some more material to share with you guys.

 

So, we shared Externalization of Voices and then the Feared Fantasy, and then there is another method that is very often helpful for people who are really hard on themselves and kind of feel ashamed of their flaws and that is called Self-Disclosure. So, the idea with self-disclosure is that oftentimes when we think we need to be perfect, we kind of hide the ways in which we are not perfect, in which we are failing. We think we need to keep projecting this perfect essence, you know, out into the world and the more that we hide, the more anxious we feel others might see my imperfections and really look down on me and judge me. So, the problem we realize is not having flaws, like David said, the problem is not being less than perfect but the shame that I feel about my flaws. And at the same time shame really cannot exist without the secrecy, right? If I keep hiding my flaws I will keep feeling ashamed of them. But the opposite is true, if I were to share with people kind of in a humble and caring and maybe even compassionate way a little bit about my flaws or my feelings of inadequacy, I quite often times will feel better and also one way of thinking about this is who would you rather like be friends with, you know, someone who projects perfection all the time or someone who is willing to be open and humble and share some of their flaws. And so, I will just, you know, by way of, I will just share an example of my own personal example with you, a way to kind of show how you could use self-disclosure and there are so many stories we have of patients using self-disclosure.

 

But I just remember when my kids were really young, they are pretty old now, but when they were young and I had one in kindergarten, so about five years old, and a two-year-old at home and working etc, and getting my kids to school in the morning was quite an ordeal. You know, getting everybody up and ready and out the door and, you know, you kind of drop them off at kindergarten and moms or dads could in drop off, you know, say, "Hey, how are you doing," and everyone kind of says, "Oh, great," you know, and kind of moves on with their day. Well, I made it a point when people would say, "How are you doing," especially when I had had kind of a tough morning getting out the door of saying like, "I have been better". "Actually, it was, it was a lot of work this morning, I mean Alex was kind of throwing a bit of a temper tantrum and I do not think I handled it well and it was kind of all I could do to get my kids out the door this morning". "But it is kind of, you know, glad, glad this part of my day is over and now I am heading to work or something," just really kind of humble and open and flawed and vulnerable. What I found was, you know, on the days where I just said, "Oh, great," and walked on my way, I had no connection and I felt kind of crappy about myself. On the days where I would, you know, be open and talk about my struggles and just I had not handled that very well was when I felt really close and connected to people and when people would respond saying, "Oh my God, you are telling me this morning this happened and that happened," and I just felt like I built so much closeness and community by just being open and vulnerable. So, we can encourage our patients to do that and model it for them and roleplay it with them and then give it to them for homework so that they can turn their feelings of shame into actual opportunities for connection. And David, you want to share with people a little bit about Experimental Technique?

 

Dr. David Burns: Sure, yeah, and Again, we are just hitting you with the tip of the iceberg because we have dozens and dozens of techniques to help people who are struggling with self-defeating belief like perfectionism or any of the others and we are just kind of giving you a feel for it because what each person finds enlightenment by a different route and what that is what we are really trying to bring people to enlightenment as much as recovery. And the Experimental Technique was one that would happen to be very helpful to a man that I worked with early in my career. He came to me because he was kind of unhappy and he showed me his CV at the first session and he was only about maybe five or eight years older than I was but he handed me his CV and it was about 50 pages long with all kinds of publications and keynote addresses all over the world. He was just this extraordinarily accomplished physician and I will just disguise his identity as I always do when I tell a story. But he told me that, you know, he was the head of two departments of medicine, two different medical divisions at the Yale Medical School. But he said that he was not ever really satisfied with his accomplishments and he said, "It is like I am always out hiking and I say, 'Oh my God, I have got to go to the top of that highest mountain,' and then I got in at the top and I look out at the distance instead of feeling an accomplishment I see an even higher peak and I say, 'Oh my God, I have got to keep hiking,' and I just, you know, nothing is really rewarding to me". That was the thing that he wanted help with and one of his beliefs was, "Nothing is worth doing unless I do it perfectly".

 

And of course, that had paid off for him because he was, you know, an extremely famous and accomplished medical professional. But the one thing that was kind of interesting was the pleasure predicting sheet. And I had him write this at the top and we, I modified it a little, I called it the Pleasure Perfection Balance Sheet. I wrote his belief at the top, "Nothing is worth doing unless I do it perfectly". And then I said, "Bill, why do not you just schedule a bunch of activities in the next week that you could do for pleasure, learning, personal growth or whatever and predict how satisfying each activity will be? Write down afterwards how satisfying it turned out to be on a zero to 100 and then also write how perfectly you did it, that way we on 0 to 100 we can see if there is a connection between perfection and satisfaction in your work". "You can do things you are used to doing as well as some things that you are not used to doing". So, two things he brought in the next week. He was giving a welcoming lecture to the new medical school class was one thing and he predicted 90% because he always got extended standing ovations because he was such a charismatic public speaker. And then the other thing was to fix a broken pipe in the toilet because he had never done anything like that and the toilet broke at home and he decided to fix it. And then his actual satisfaction was the from the welcoming lecture, if we can go to the next slide, was he said it was only 5% satisfying and his perfection rating was 75% and he had the note, "I only got a 30 second standing ovation". I said, "My God, man, you got a 30 second standing ovation and you only had a 5% satisfaction?" He said, "Well, you see, Dr. Burns, I give lectures all around the world all the time and I always get standing ovations and so I time them and keep records and last year the students stood and cheered for 45 seconds and this year they only cheered for 30 seconds and I thought, 'My God, I am over the hill". Then the second thing was even more interesting, fixing the broken pipe in the toilet, we would have to go to the next slide. He said it was 100% satisfying but the perfection was 5% because he says a plumber could have fixed it in 5 minutes but it took me nearly 10 hours. He had to keep going to the hardware store and buying you know, wrenches and asking for instructions and it took him until late at night to fix that toilet but then he became euphoric. I said, "Well, here, now we can see the cause of your problems, you went into the wrong profession, Bill". And it’s not too late to change, you could still become a plumber, which he had a lot of fun with that. But he really loved this pleasure perfection balance sheet and he showed me other things like playing squash with his son who was 12 years old. He said, "We are neither of us were not champion squash players but it was 100%, I just loved it". "And then I took my wife for a walk in Philadelphia in an average autumn day and we were not champion hikers, we were just walking through the woods and it was 100% rewarding". And he said that that blew his mind that many things that were beautifully rewarding to him were not when he was doing things perfectly.

 

He had been doing all of these things perfectly and had 50 pages of incredible accomplishments that did not make him feel good at all. So that was just another way of getting to enlightenment. And I looked him up just recently because I always wondered what happened to him because I always felt so affectionate toward him after he completed his treatment because one thing he told me, he said, "Although I have published a lot there is a book I have wanted to write that I have never had the courage to write because I know a lot of people are not going to want to hear what I have to say about medical care in the United States". He was an expert on delivery of medical care and I discovered that he had died a few years back and they said he died happily with his family and he was in his 80s. But the obituary was just amazing and I learned a lot about him that I did not know that he was revered as one of the giants of medicine in the era that he lived, he was world famous. But I also discovered something that I did not know and I think it happened after he worked with me that he had consulted with Congress and with the President and I think he was the one who brought in a lot of the Medicare and the health delivery to people who couldn’t afford it because I think he saw that there is a conflict of interest between medicine and private practice and free enterprise and that there was too much money and not enough heart in the delivery of mental care. So, I felt, I felt so proud of him for having done something that he really believed in and something that made a fantastic impact once he decided he no longer had to be perfect.

 

Dr. Jill Levitt: Yeah, such a beautiful story, David. I’ll just kind of highlight that, you know, this is, we called this the Experimental Technique because really he did, David and this patient designed this kind of Pleasure Predicting Balance Sheet to experiment to test the validity of the belief, "Nothing is worth doing unless I do it perfectly," right? So, it is like try something that you do perfectly and try something, turns out you did so far from perfectly and realizing that actually the enjoyment and satisfaction was far greater for this patient when he did something so far from perfectly.

 

Dr. David Burns: I’ve had to learn the same thing myself and this was my teacher Obie, my cat. I will not talk about him but I have written about him in my books and I have talked about him a lot. He told me, "You know, David, we do not have to be perfect but when we love each other it is mind-blowing," and I will never forget my little Obie, a feral cat we adopted.

 

Dr. Jill Levitt: We just have 10 minutes left and we’ve got to cover a lot and also answer some questions. So, I'll let you do this slide, David and then.

 

Dr. David Burns: Yes, sure. So, essentially where we have been, and some of you have asked if you will get the slides and the video, and you will. If you want access the slides, I am sure we can provide that. But this first step is you identify a self-defeating belief. The second step you have to boost motivation. You cannot attack self-defeating belief or distorted thoughts without boosting motivation and reducing resistance, which is what we did with Amy. Then at that point it becomes relatively easy to crush the negative thoughts. You saw Amy crushing the negative thoughts, not combating them but blowing them out of the water, that is what we are looking for, that is enlightenment, not just total recovery but it is a spiritual enlightenment. Then step four, feel great.

 

Dr. Jill Levitt: And so, I’m going to go to the next pieces and then we will take your questions, Mike. That way we will know we can do questions till the end. So, I really hope that you guys learned something today and, you know, learned some methods and some techniques and kind of a therapeutic stance as well. I love, always love hearing your stories too, David, so much heart. So, if you would like to learn more, we are going to just share a few things with you briefly and then we will take some questions. So if today's training sparked something for you, we would be really excited if you wanted to join us for the FastTrack to Level Three Certification Course. This is kind of our most efficient and powerful way to help therapists learn TEAM-CBT quickly. What we shared with you today was just the tip of the iceberg and in the FastTrack course we teach these, you know, 50 plus CBT methods and help therapists to master them too. And I will share with you just one testimonial, we always have people emailing us really awesome things that they learned and what they love about the FastTrack course and this is just from Stacy who said it was, it was the kind of training that she wished she had had in grad school.

 

And so, we hear things like that all the time and it is, you know, super rewarding for us and there is a lot on this slide but I will just say the FastTrack course is packed with lots of goodies. This slide gives you a little bit of a picture of what is included so it starts, the next round will start on September 11th and it is a hybrid course designed for really busy professionals. So, it is 16 hours of asynchronous on-demand content. There is a 4-hour live training, David and I are going to work with a participant live doing a David Burns live and that is kind of our kickoff event. Then 25 weeks of small group coaching and live practice with awesome trainers and therapists. It also includes free certification, free access to the level three certification exam and David's full therapist toolkit. There is a 30-day money back guarantee, so if you are not happy in the first 30 days you can always get a refund. Then today we are offering you guys a coupon so at the very bottom of the page it has this coupon, SkillUp50. Yes, so we would love for you guys to join us and sort of learn more with us in the FastTrack course. I also want David to have a chance to tell you about the Feeling Great app which I know is free this summer which is kind of amazing.

 

Dr. David Burns: Yeah, the we have trained the AI to do just what I would do with you or what Jill and I, you know, did with Amy just to go through the TEAM steps. It is, we came up with a new version just recently. The old version was incredibly powerful and the new version is even 50% more powerful. People are reporting 60 to 70% reductions in seven different negative feelings within the first 90 minutes on the app. We have decided that the best things in life are free and so it is kind of probably crazy from a business point of view but we are just giving the app away for free now and so we are hoping you will try it yourself and recommend it to friends and loved ones. It will be free at least through the summer. So, you have got nothing to lose and your life to gain, the world to gain, also. Yeah Well, yeah, you can do the next slide.

 

Dr. Jill Levitt: Also, we have lots of other free opportunities for people to learn and grow and I will do this very quickly so we can get to some questions for the next few minutes. But we have weekly training groups David and I offer on Tuesday nights from 5:00 to 7 Pacific where therapists can join for free kind of unlimited psychotherapy training with us. The contact info is on this slide and as well Wednesday mornings with Rhonda and Kai a similar kind of free therapist training group. David does the Feeling Good podcast and there are more than 400 episodes of free podcast there that you can find on the Feeling Good website. Then David also has the Feeling Great YouTube channel where you can watch David's favorite stories and some trainings and videos by searching Feeling Great YouTube. If I did not say it, you can learn more about the FastTrack course on the Feeling Good Institute website and we can also drop the link to that in the chat box. And as David and I are taking questions, Mike is putting the link to the continuing education survey in the chat box right now. So, if you are a therapist, make sure you are doing the CE survey not the general public survey and if you are not a therapist and you want to give us some feedback you can do the general public survey but if you are a therapist, make sure you are clicking on the CE credit survey.

 

Q&A Session