Transforming Therapeutic Failure Into Success

Transforming Therapeutic Failure Into Success

Jill Levitt: Okay, well welcome everyone to our 90-minute webinar today. I'm here with Dr. David Burns, and we'll be presenting to you on transforming therapeutic failure into success, and hopefully you'll have some fun and learn a lot today. Before we move forward, I am just going to drop something into the chat box for all of you, which is a version of our slides. So it's going to take me one second to just put that in for all of you. Okay, so you should have our slides as handouts now in the chat box. And I'm also going to, you might hear us refer throughout today to an upcoming workshop, and I'm going to put information in that in the chat box right now as well. Okay, so we're going to start right off today actually trying to find out a little bit about you as a therapist, and also if you're a patient, we'll find out a little bit about how you use measurement, how your therapist uses measurement. I'll also just mention two quick things, which is that, sorry, I'm getting some people raising hands, so let me just tell you guys how this is going to work. If you have questions throughout the workshop today, please put your questions in the Q&A box. So if I look at the Q&A box, that's where you're going to answer your questions. Oh, people are telling me that the chat box is disabled. Okay, hold on, give me one second, sorry to everyone, give me one second, and I'll open the chat box, and I'll do that one more time. Just give me a moment, and I'll have it all good for you guys. Okay, okay, so thanks for the feedback. Hopefully you all can now see the handouts and also the information. I am going to disable the chat just so you know throughout the workshop because that's not helpful for us.

David Burns: Well, if you disable the chat, will they still be able to go into it and get the slides?

Jill Levitt: Yeah, just give me a minute. Yeah, so you all should be able to look in your chat box and see the slides and then also see information about the workshop. And just so you know, I'll drop them in the chat again at the end as well.

David Burns: And then after the workshop, if you like, we'll be sending you a link to the video so you can be watching the video or showing it to colleagues or use it in any way you like.

Jill Levitt: Great. So I'll also just let you guys know if you join late, I will be adding everything to the chat box again at the end of the workshop, so don't worry. Okay, so let's move on from that, and you can enter questions in the Q&A if you have questions, and we'll get to your questions later on. So I'm going to share a poll with you right now, and that's how we're going to get started. So let me get the first poll going. So the first question that we have for you just in getting started today is do you use measurement in your therapy practice? So for those of you who are therapists, please answer our poll real quick. You don't, you don't use measurement at all, you occasionally use assessment instruments during sessions, and you consistently use measurement with all of your patients at all of your sessions.

David Burns: Yeah, and what we're talking about is session by session measurement with some kind of psychological instrument measuring symptoms or the alliance or something like that. Do you not use measurement at all? Do you occasionally use measurement? Or do you use assessment with all of your patients at every session?

Jill Levitt: Okay, so I'm, so we can see, oh go ahead, David.

David Burns: Oh, this is cool. Yeah, only 26 percent of you use measurement consistently. 54 of you occasionally use assessment instruments, and 21 of you do not use assessment at all. And that's probably a big improvement from if we've done this seminar five or ten years ago, it probably would have been almost nobody using session by session assessments. So things are changing, and I think in the future things are going to be shifting more and more to more therapists using session by session assessments. But this is interesting information, very cool.

Jill Levitt: And then we figured we would also because for the general public that's here as well as for many therapists who've been in there and therefore right, people are therapists and so we have another poll for you, and that is does your therapist use measurement? Or if you've been in therapy, did your therapist use measurement?

David Burns: And we're talking about session by session measurement, not just something they do at the beginning or end of therapy, but on and on going ongoing basis. And this is for anyone who's currently a therapist, a patient, or has been a patient in the past. And even if your therapist, you may also be a patient, so now you can look at it from the patient perspective.

Jill Levitt: Okay, so I'm going to end this poll, and I'm going to share the results.

David Burns: Yeah, and this is really interesting. It's quite different from the therapist poll, and this is more what we've been thinking. 80 percent of you who are in or have been in the patient role, your therapist never uses session by session assessment. 14 percent occasionally use session by session assessment, and six percent, only six percent of your of you have therapists who consistently, who always use assessment at every at every session. Fantastic information. Thank you.

Jill Levitt: Absolutely. It also suggests that what we're going to be telling you about today might, you know, be very helpful in changing the way that you practice or changing your expectations of your therapist going forward. So we're going to start our presentation today actually with a story, a story of a kind of epic failure of mine, and then we're going to kind of help you to understand how we could improve therapeutic failure. So that's our goal for today is to to help you to learn how to transform your practice using measurement and responding to failures and measurement. So I had a patient that I was seeing many years ago who was about 50 years old, a 50 year old married woman, and she was presenting with symptoms of panic disorder. And until this session, which was about five sessions into treatment, the measurement that I was using with her, measures of symptoms and measures of the Therapeutic Alliance, were showing a really strong Therapeutic Alliance. It seemed like the two of us were getting along well, she seemed to be appreciating therapy, there was a lot of warmth and a lot of empathy, and she was a patient who had had kind of a complicated history and had really wanted some time in therapy to to talk and to get support as we were kind of getting set up and geared up for doing some cognitive and behavioral work with her panic disorder. So in this particular session, we were really kind of shifting gears from talking and getting support to kind of really starting to work on her negative thoughts, on her cognitive distortions. And we got to this thought on a daily mood log that she had that was, "I will end up in a mental institution like my schizophrenic sister."

And you know, this is the idea of having a fear of losing control or going crazy when one has panic disorder is a common thought. And so I, you know, listened and empathized a bit and and also continued to move forward. She was a little bit tearful when she was kind of reading this thought to me, "I'll end up in a mental institution like my schizophrenic sister," but she was very responsive to identifying distortions and using a bunch of different strategies to really help her to challenge and change her thoughts in the session. And so I thought at the end of the session and throughout the session that it was really a very productive and very helpful session to her. And that's what I would have thought and continued to think if I didn't have any kind of measures. But let's see what the measures revealed. So this is just a part of the measurement. We'll actually show you the full, you know, measurement scale that we use in a few slides. But on the empathy portion where I was getting feedback about how this session went, it looks like the top of the scale would be 20 out of 20, right? That would be a perfect empathy score, and I got a four out of 20, which is, like I said, kind of an epic failure. She didn't think that I was warm, she didn't think that I was trustworthy, she didn't think that I was treating her with respect, she didn't think I did a good job of listening or that I understood how she felt inside.

David Burns: And let me, can I comment on that? Yes, absolutely. The, the, this scale is very sensitive and very accurate, and the lowest passing score is a 20, a perfect score, because even a 19 is a failing grade. Because if you, if the patient even marks you down in one category like that you weren't warm or you understood how they felt inside, they're telling you that something that, that didn't click. The lowest conceivable score on this scale would be about a 10, would be like the worst therapist in the world, or maybe if we had Putin counseling people, he'd probably get about a 10. And so for Jill, and Jill is one of the most empathetic and skillful therapists in the world, it's just staggeringly shocking, and it's like getting an electric shock as the therapist.

Jill Levitt: Thank you. We're getting a couple questions about the handouts in the chat box. I will send them out again. Just so you know, the handouts are just a copy of the slides, so you don't necessarily need that right now, but I will make sure to get them to you in the chat box in a little bit. So here I am getting this feedback from this patient, which is pretty upsetting feedback, right? I'm realizing that I really missed the mark in terms of connecting with her. And then also we have a scale on helpfulness, and she also clearly did not find the therapy to be helpful, right? I'm sort of failing on many scores here. Didn't feel that we were working well together, didn't feel that my approach made sense.

David Burns: And the same thing here on interpretation, we'd be looking for a 20 on this scale. If you can show the scale just again, and and you know, a 19 on this one is is not too bad, and you can talk to the patient about it. But you get down into a 15, the patient is very unhappy and really thinks you're not helping them much at all. And you got down into a 10 and it's horrible, and you get down to five or below, it's the patient is really pretty irate with you.

Jill Levitt: Yeah, and so, yeah, I'm a therapist. Sometimes you're feeling really, you know, sad and kind of ashamed that you didn't help the patient in the session and also probably a little ashamed at not realizing it during the session, right? I certainly felt that way. And then we ask these open-ended questions, what did you like the least about the session? What did you like the most about the session? And she said, what did she like the least about the session? That Jill paid no attention to my feelings about my sister's mental illness. That is a huge part of my history, and Jill didn't even stop to listen. She just pushed ahead trying to fix my anxiety symptoms without even caring. And what did you like the most about the session? Challenging my negative thoughts, but I couldn't even really engage in that part of therapy together today because I was too angry and upset. So then I have a question for you, which is, do you think that my error was was good or bad for the therapy? And obviously in the moment, it felt pretty bad, right? And I can imagine some people might be thinking like, well, if Jill hadn't made a mistake, that'd be a better thing, right? Like, how could a mistake be a good thing? But I think what our goal is to show you today that any error that you make in therapy can be turned into a breakthrough, can actually improve therapy well beyond where it started, as long as you know about the mistake and as long as you work to be to respond to feedback with humility and kindness, warmth and empathy. The idea that we want you all to know is that we all make errors, right? None of us are perfect for every patient. Our style might be wonderful for one patient and a little bit off-putting for another patient. So the question that you want to ask yourself is, since you all make errors as I do and David does, do you want to know about it, right? Do you want to get feedback from your patients so you actually know that you're making errors so that you can actually turn things around? And to realize that we can actually, I'll show you in a moment, we can actually learn so much about the patient and about the kind of therapy that we need to do with this patient by pinpointing errors and by getting specific feedback. And so I'll kind of bring my story to closure by essentially saying the patient came to the next session. I went through the measures with her. I essentially said, my goodness, you know, it looks like I really messed up in the last session. You were trying to share with me something that felt deeply personal and intimate and upsetting and even kind of traumatic for you about your sister and her mental illness, and I didn't pick up on it all.

And I just kind of rushed you ahead and pushed forward with the methods, and I can see that you were feeling, you know, hurt and misunderstood and also very angry with me for not being a good listener, for not tuning in to what you were really experiencing in the session. And I feel really sad to have made that mistake with you and to have hurt you in that way. I really care about you. I've really enjoyed working with you, and I really want to try and understand better kind of what was going on for you in the session. And you know, I and I also said something like, and while this feels kind of awkward and hard and clunky, you know, I do feel kind of optimistic that talking about this will be an opportunity for the two of us to get even closer and do better work together. And can you tell me what you've been thinking and feeling about this? And she responded, you know, with lots of tears but lots of warmth and thank you so much for caring enough to ask me about this, and I do want to share this with you. And she was very appreciative and really, I think, extremely touched by kind of how responsive and open and humble and caring I was. And it was all totally authentic, and there was no defensiveness in it. I just really wanted to understand more. And then I would just say in closing that really what I did learn about this patient was that part of her panic disorder was truly based on this trauma that she had had with seeing a sister with really major mental illness. And it was important to kind of slow down and talk much more about that. And I think she also real, you know, recognized just how sensitive she is to that and to people not understanding and not tuning in. And so we both learned, you know, a ton from this situation.

David Burns: I've sometimes said that your worst therapeutic failure is your greatest success in disguise if you'll only relax and absorb and grasp what happened and what might have been going on. In this case, is one of the causes of panic disorder is excessive niceness on the part of the patient or what I call the hidden emotion phenomenon. This might be an individual who tends not to express her feelings and to get angry with people, sweep it under the rug, and then it comes out as as panic attacks. And so the the fact that Jill was able to the Jill that you were able to pick up on this and process it with her could have been an extraordinarily important part of of the cure or the healing processes as well. It's not just recovering from a rupture, but seeing the failure as the doorway to a much deeper and profound level of success and effectiveness with the patient.

Jill Levitt: So yeah, David, why don't you take it from here for a little bit?

David Burns: Oh sure. So here's how we deal with measurement and therapy. We use something called the brief mood survey that we ask patients to fill it out just before the session begins and right after the session is over. And these are brief, extremely reliable, extremely valid scales that measure depression severity, suicidal urges, anxiety severity, anger severity, happiness, relationship satisfaction, and sometimes other dimensions as well. And the after the session, the patients also fill out something called the Evaluation of Therapy Session. What you saw excerpts from that already, and they rate you on empathy, they rate you on helpfulness, and other measures as well. Let's take a look at the these instruments. This is the brief mood survey, and this is a one-page document, can be used electronically or paper and pencil. And you can see this patient started out the depression with a score of 14. Now that's important because if the therapist was guessing how the patient felt at the start of the session, your estimate would not be accurate because therapists' perceptions of how patients feel are not at all accurate, generally less than 10 percent accurate. I did a study in the Stanford inpatient unit, and experts in interview between techniques had only a three percent accuracy in detecting changes in depression in the the patient they were were speaking to. And this patient might have looked very chipper and happy on the outside, but a score of 14 indicates a very severe depression. You can see in the upper left corner, the 14 would be the worst imaginable depression, but a 14 is is quite severe. Now that's how the patient felt right at the beginning. You can see at the end of the session, the patient score was three. So this showed a dramatic reduction. And again, on your own, you wouldn't be able to detect this or to estimate the end of session depression score at all accurately. So this you can also use this to calculate your what's called recovery coefficient, and that's a measure of your effectiveness as a therapist, and you may and may not be be willing to look at that. But this therapist got, as you can see, an 11 point reduction in one therapy session. And so 11 / 14 is 79%, so this therapist got a 79 reduction in depression in one hour, which would be a phenomenally successful and effective therapist. The suicidal urges were not present at the beginning or end of the session, that's a relief to to know that. The anxiety went down by a similar amount, you know, 11 / 15, similar to the depression reduction. And the anger reduction was a hundred hundred percent. And so the the this therapist can have a feeling of satisfaction that you've had a really mind-blowingly effective therapy session. In addition, the patient's positive feelings or happiness went from 9 out of 40, which was very poor, to 25 out of 40, which is a almost a tripling of happiness, like a almost 300 percent increase in in happiness.

There's room for a little further improvement both in depression and anxiety and happiness, but most of the work of therapy has been completed in a single session. Now it's also, you can get all kinds of information from this. The relationship satisfaction patient was with her sister started out at 16 on a 0-30 scale, so it's very poor, and there was no change in the relationship satisfaction. And this is very interesting for multiple perspectives. One thing this proves that the causes of relationship problems have nothing to do with the causes of depression. It's a completely independent system because and and depression is not a cause of problems in relationships. This patient had a massive reduction in depression, but there were no causal effects on relationship satisfaction. So you can get a tremendous amount of information from one brief mood survey with one patient. And I did a large study at the Feeling Good Institute, and we demonstrated that your reduction in sessions the first time you sit down with a patient will predict all the subsequent course of the therapy. It has a massive causal effect on changes right up to the end of of treatment. So it's an extraordinarily important measure of that your your recovery coefficient. That's the measure of how good you are as a therapist. And this can also be heartbreak. I ask the people in our Tuesday training group at Stanford to to bring in their brief mood surveys from the previous couple weeks so I could see how people were doing, and one woman showed me the patient she was the most proud of treating. She'd been working with her for a year, and I saw her depression score a year ago and our depression score today, and they were exactly the same. It was a patient was severely depressed and there had been no improvement whatsoever in a year. And it can really hurt your feelings as a therapist when you see you're you're not being effective. But if you have humility and you're open to learning, then your patients can become by far the greatest teachers you've ever had because they're going to show you exactly how effective you are at every minute of ever of every day if you're using this with every patient you see, you'll get constant information how effective you were in every single session. And then if and then this is the full Evaluation of the Therapy Session that the patient fills out at the end, and you can see here the empathy was 20, that's the minimum passing score, but this patient really felt cared about and understood. The helpfulness again was a perfect 20.

A patient was totally satisfied with the session, was committed to doing homework, had no negative feelings during the session, and said that he or she was honest in filling out the scales. And then they can write down at the bottom what they liked and and didn't like. So that that's how the the measurement system works. If we can go on to the next slide and in spite of how transformative that can be for your clinical practice and how fantastic it can be for you and for your patients as we've seen in our survey those of you who are patients only five percent of you have therapists who who are doing this using this approach and therapists have tons of reasons to resist measurement, first the belief that the patient won't be honest and they say oh you know patients won't fill out these scales honestly and often when you use instruments you find out that most of your thinking is off is incorrect theories you believe aren't actually valid and your assessments of your patients will not be valid and this belief that your patients don't be honest is not valid either we do have a big problem with patient honesty and the problem is really that your patients are going to be honest and the real issue is can you take it as a therapist you have the courage to to see what's what's really what's really going on now there's very if the patient is coming in voluntarily you're going to be getting tremendously accurate data and then the idea that therapists have is oh we don't need it I I'm really accurate you know I'm a sensitive empathic therapist and one of the things that you'll be shocked to discover when you use these instruments if you use the ones we're recommending uh when you use them for the first time most therapists discover that you have failing scores on empathy and helpfulness from at least 50 to 75 percent of your patients and most therapists find out they fail with every patient at every session and so it's not the case that you don't need these instruments in addition as I say I did a study in the Stanford inpatient unit I I had experts interview nearly 178 newly admitted patients for up to three to four hours and then guess how depressed the patient is and the patient filled out how depressed they were feeling at that moment how suicidal is the patient how angry is the patient how anxious is the patient how does the patient feel about you the interviewer the therapist how caring does the patient think you are how helpful and the results were shocking you know the accuracy on Depression was only three percent, the accuracy on suicidal urges was zero percent, the accuracy on anger was zero percent, the accuracy on anxiety was like five percent and the accuracy on empathy was only an iron person out and the accuracy on helpfulness was Zero percent the therapist top trained experts their perceptions had almost nothing to do with how the patients actually feel another resistance is and if you know how they feel like you saw in a beautiful example with Jill you can act on it. It still requires skill and training to learn how to interpret those results how to respond to them compassionately that you'll have a chance not only to transform the therapy but to increase your skills dramatically. Therapists say oh it'll take too much time well the total time required for this kind of testing is between 15 and 30 seconds per session because the patients do all the fill it out before and after the session all you have to do is look at it you can instantly see exactly how you're doing in in many dimensions.

Jill Levitt: And I'll make a couple extra comments on this slide so regarding the time yeah so if you're seeing patients in person we leave a clipboard in the waiting room with measures on the clipboard and the patient completes it before a session and then they walk in and hand you you know the filled out instrument this you can think of this just like when you go to see your doctor and they take your temperature right they don't talk to you until they take your temperature and they take your blood pressure it's exactly the same thing and then after the session we hand it back to the patient and then in the waiting room after the session they complete the after session form including measures of symptoms and the Therapeutic Alliance and they can leave it for us and you know like a lock box, David can also tell you at the end of the workshop today there are electronic versions of all of these tools we've all had to Pivot to teletherapy and video therapy and there are ways of sharing measures with patients electronically um if you use you know some sort of EMR you can actually have your electronic medical record system push these measures to your patients and so have them you you know sent automatically so that has to do with the it takes too much time and then I also just want to make a comment that we've been talking so much about sort of the bad news that you learn when you use measures right which obviously is super important and then you can turn that around into you know true connection and transformation but actually there also are times where I'll have a session with a patient and I'm thinking at the end of the session that it was kind of a mediocre session I can't maybe pinpoint it but I'm thinking we spent too much time talking about this and I'm not sure that we got to the thing the patient wanted to work on or didn't completely get to our agenda and then I see the patient's feedback which was really really high marks right that the patient thinks it was an excellent session that we worked on just what the patient wanted to work on and even that is useful information which I talked to the patient about in the next session it helps us to get aligned about what the patient really wants or what therapeutic style even I used in that session that was especially helpful. So you can really like constantly be learning feedback that helps you to refine your approach with your patients.

David Burns: Right, somebody wrote that they can't see me I can see me on my video so I don't know why I apologize for that but I'm not that cute or anything so listen to my voice because the words hopefully the words will be of value to you.

Jill Levitt: Yeah you should be able to see just David and myself there's a webinar out of gallery you should be able to see me and and David if lots of people are having problems then then let me know that but I think um I don't think that's a that is a problem other resistance I'm getting I'm getting enough chats that say I can see you both so oh yeah good like.

David Burns: Glad you can see me hi everybody.

Jill Levitt: And if you are having trouble it means you need to change the settings on your screen.

David Burns: Sure now another resistance from therapists is patients won't won't like it I've found that patients love the this if the the scales are worded in a very user-friendly and polite way and and if you interpret them in a way that's helpful to patients they they love it I've had only three or four patients. I've had over 40 000 hours of therapy with patients from all over the world with the most severe imaginable depression and anxiety and only three or four ever refused initially to to use the measures they said it's too upsetting for them or they don't like to be told what to do or whatever. All of them had borderline personality disorder murder and I just told them you know I apologize but I can't free you without the measures that would be like going to an emergency room and saying that you won't take blood tests or x-ray or anything like that I need this information to to do a good job and and but if you want to go to someone else 99 of the therapists in our community don't use measurement and you I'm sure you'll find plenty that'll love to have you but I hope you stay and work with me all of them stayed and once they began using the measures they decided that they really liked them after all. Another source of resistance is people think that what you're doing is too mystical too deep you can't really measure trust you can't really measure empathy you can't really measure depression but psychometrically that that's been proven to to be false like the empathy measure that we use is 94 reliable it's extraordinarily accurate and and valid as well let's push on to the next thing. The big source of resistance is is maybe you don't want to be criticized maybe you don't want to be accountable I'm pretty narcissistic. One of my many flaws maybe hopefully one of the worst but I find it painful to be criticized I I feel ashamed I feel disappointed I feel shocked but I find that when I find the truth and the patient's criticism and she'll use the word humility yet 99 of the time draws us much closer and but I think again therapists don't want to want to be accountable and and I think I mean my wife is a clinical psychologist she's the brains in our family and she and I both talk about wanting to schmooze indefinitely with full fee patients with you know you occasionally throw in some advice and I think that's what therapy therapy used to be and you didn't have to be accountable but personally I like being accountable I like seeing the measures because it gives me a yardstick to to gauge my skill my progress my and and my growth and and then another thing and this can take training is I won't know how to respond to negative feedback from the patients and we we offer lots of trainings for therapists to show you exactly how you do that we'll illustrate it in a few minutes on with slides and with an actual role play um and then the benefits of symptom measures it's really like having an emotional x-ray machine for the first time and uh I can't emphasize enough how powerful that is the X-ray machine transformed emergency medicine.

And this tool is going to transform the future of psychotherapy as well as medication treatment for patients with psychiatric problems and the most important thing it you contract within session changes and see how effective you are and there will be big surprises there sometimes you think you're effective and you're screwed up terribly sometimes you think you've screwed up terribly and it turns out you were extremely effective you can also track in between session changes what happens from the end of today's session to the beginning of next week's and way back probably 35 years ago when I was teaching at University of Pennsylvania Medical School I raised the question with with residents you know we don't even know when patients change do they change within sessions or between sessions or both or neither and now we have the answer you get the answer with every single patient with every single session to see what happens to them within sessions what happens to them between sessions and it's it's fascinating data. Next slide, any yeah another thing that's huge is you can it will identify suicidal thoughts for you the patient will be filling out we now have a three item of suicide screener at the beginning and end of every single session and so if and you will forget and you can't recognize suicidal patients that's that's what the the research has shown but the the scale will show you and most the time they'll be honest with you and if suddenly they're having suicidal thoughts and suicidal urges you can jump on that right away and prevent not only the death of a patient but also prevent lawsuits and then the most important thing is you can fine-tune your treatment strategies because if you're using treatment methods that aren't getting rapid and dramatic results will change learn new techniques try try other methods I've developed more than a hundred techniques to crush the negative thoughts that cause depression and anxiety so I have a never and in supply of fresh and different methods and strategies so I when something isn't working I don't keep pounding on that thing over and over again I say let let's try another angle angle until I find the one that breaks it open for the patient.

Jill Levitt: I also wanted to add a benefit of symptom measure we talked about one thing is that patients may not like it and I find quite the opposite that patients like it that they appreciate it I think it's all in how you share it with your patients and I just wanted to share with you all that when I first meet with patients I let them know right off the bat that I use measurement that it's a part of therapy, that it's an active ingredient in helping them to get better and I can use that thermometer metaphor just like if you went to the doctor and you weren't feeling well they take your temperature they take your blood pressure how could they help you and how would they know they were helping you unless they were taking measures and that's the same thing and I also let them know that the measure that we use after session this Therapeutic Alliance measure the evaluation of therapy session measure kind of like a quality assurance measure right. Like I care so much about you and you getting better that I want to know how you're doing it every session and I want to know how I'm doing it every session so that I can pivot and course correct and I think if I introduce it to patients in a way that I feel proud of it right I think it's kind of amazing that I use measurement and I think it's like an amazing gift to the patients that I really don't find that patients have resistance to completing it I think they appreciate it and oftentimes you get that kind of feedback from patients as well.

David Burns: Beautiful well stated a Jill and and then in addition if you use these measures you're turning that scientist practitioner model into a practical reality everyone believes in that during graduate school I'm going to be a scientist practitioner that's fantastic but nobody does it then you get into practice you're not measuring you're working on your own intuition. You join some cult which is what a school of therapy is and you keep doing what the cult leader says this is probably sounding a little negative and I apologize but this the positive is with measure you are a scientist practitioner and every session becomes a mini outcome study. Think about it you're measuring exactly what happened in the session and you can see what the effect was and so you can move away from cult driven or schools of therapy driven field to a data-driven science-based form of treatment. I am not a cognitive therapist some people say oh you put cognitive therapy on the map all over the world with your book feeling good well that's true but I've never viewed myself as a this or that I'm just a human being trying to help people who are human beings who come to me and I use a lot of cognitive techniques I use techniques from a dozen different different schools of therapy and the only Criterion of importance is is this changing someone's life and quickly and dramatically that's what I want to do with every patient at every session if possible. One last thing if you go back to the previous slide is you know last night our Golden State Warriors won the third game in a row against Denver so they may they're doing great in the playoffs but we have players who have fantastic ability to shoot the basketball three-point shots of some of the greatest players in history well how did they became come so great because they can see when the ball goes through the hoop ever since they're five years old and start playing with the basketball they can see what it's working when it's not working and that's the only way you can improve and and so your clinical practice becomes like your clinical work becomes like deliberate practice because you see every session is like shooting the basketball and you see did it go through the whole hoop and you cannot improve as a therapist this is shocking but true without measurement without data you'll just keep doing the same thing and tell your old I guess but you're you won't have the pleasure of developing improved or Superior extraordinary or world-class therapy skills to do that you must be using these kinds of Assessments it's impossible to improve without them that would be just like going out on a basketball court and trying with the blinders on so you can't see and trying to improve your shooting you can't improve because you don't know when it goes through the hoop.

Jill Levitt: It just so happens David I think this is so funny but last night after this webinar was all prepared and everything I happened to have gone for a walk with a friend of mine who's a documentary producer and she was saying to me I just had this great meeting with this film editor and you know it's so funny basically he contacted me and said I loved working for you on this project but I would really love you know just a half hour of your time if you can give me some specific feedback on what you thought I did well what you really liked about my work and how I could improve I'm just always trying to improve she literally just told me that story last night and I thought oh that is the funniest thing essentially what she's saying is you know the person that I think is the most incredible on this team that I've been working with is the one who came to me and said can you give me feedback like this is the only way that I will learn my craft and so we ended up having this whole conversation about basically feedback and in you know kind of in all areas right in school and in sports and in careers and things like that so it's idea that if you're brave enough to ask for feedback you can dramatically improve no matter what you're doing.

David Burns: Beautifully stated and and then the benefits of the alliance measures is you you'll find out for the first time how your patients really feel about you if you dare to look and as I say if you're using these measures for the first time you have to prepare for the death of your ego the the great death of the self because you may find that you're failing with almost every patient or every patient at every session every day and so you may find out that you're never doing anything even minimally adequate as a therapist and that's that's huge it's mind-blowing to see that but we have all kinds of trainings available to transform show you how to transform your therapeutic failures and into breakthroughs and and therapeutic failure in my opinion is where most therapeutic transformation comes from it's through that cauldron of failure that success emerges if you know how to how to deal with that.

Jill Levitt: And just so resources as well if you want to get a hold of David's measures both paper and pencil measures and electronic measures and I'll also drop in the chat an upcoming Workshop that we have and we'll tell you more about that at the end as well if you'd like to see us really bring some of this to life we're going to be doing a workshop in just a few weeks where we'll be doing live work with patients and really showing you how to to use measurement and respond and do great therapy.

David Burns: Yeah and that's going to be May 22nd and we're going to actually treat two people live before your very eyes people we don't know so it's kind of like a high wire rack without a net and we'll be attempting to complete an entire course of psychotherapy in one session with each of them it'll be an extended two-hour session we'll be using measurement and in other other new techniques so we hope some of us some of you will want to join and see how this works in real time with real people. But the benefits of the alliance measures is they're vastly more sensitive than human observation and you can transform your your patients in into your greatest into your greatest teachers if if you have if you have the courage and you have the humility amazing things can happen.

Jill Levitt: So, this is probably needless to say there's actually a lot of research in the field I just chose one to throw up here in case people want to do a little more reading about it but there's lots of research that supports the benefits of measurement and this is a review article that talks about many studies that have been done where the only thing that was changed was the introduction of symptom measures at every session and in you know introducing symptom measures at every session will lead to a decrease in patient Dropout. The therapist's ability to address symptom worsening right if you're not measuring symptoms you don't actually know if your patients are getting worse and then ultimately leading to better therapy outcomes, this is certainly clear in our work anecdotally but it's nice to know that there's a lot of data out there that supports the use of measurement.

David Burns: Now just quickly if your patients are coming voluntarily you get absolutely stunning accurate data from every patient at every session now there are cases where patients fake good if it's a child custody dispute they are not going to fill out any scale accurately or if they're involuntarily hospitalized they want to get out of the hospital so they can commit suicide or murder somebody or whatever that they won't be there's a high likelihood they they're not going to answer scales accurately. Do patients ever fake bad.

Jill Levitt: Sorry I was responding to something in the chat sorry about that.

David Burns: Okay yeah and so let's say a patient has a lawsuit they're suing somebody or they're seeking disability then they're going to make themselves look worse than they than really are these are not problems with scales or instruments these These are issues involving the clinicians ethics and and judgments for example if you're filling out disability papers on a patient that you're seeing clinically. That's an Ethics violation because that's the Dual role conflict so but but you know if you're seeing a patient voluntarily then your your data is going to be extremely accurate. Now we're going to show you a little bit just an equipment sampler quick preview of how you might respond to negative feedback using a system I've created called the five secrets of effective communication and you won't learn this from our brief demonstration a lot of practice is required and willingness to to learn and change is needed. But there are five techniques that we use.

Jill Levitt: Ops sorry let me I'm sorry okay I just want to make a quick comment to people which is I did disable the chat Bots very early people did send a bunch of chats that got through initially when I was trying to share the slides with you all um but then I changed it so that the chats only go to myself and David because a lot of people were saying that chats are very distracting it was constantly rolling. So if you noticed that your chats are not going to everyone no one's chats are going to everyone all the chats are only going to me and David I also ask that you don't put any questions in the chat box that you see the uh that you put all of your questions in the Q a so the chat box has been disabled you won't be able to send chats to the group only to David and myself and and we probably won't see them during the workshop but you can send questions to the Q a and we will have time definitely within the 90 minutes to go and answer questions so I'll open the Q a and I'll read questions out loud and David and I will answer your questions, okay so now we're going to talk to you a little bit about the five secrets of effective communication and how you can respond like warmly and empathically to your patients criticisms and feedback.

David Burns: Now there's three empathy techniques it's we I use the EAR acronym you know talk with your EAR, and the three empathy techniques or the disarming technique and the disarming technique means you find truth in the patient's criticism and it's based on the law of opposites and that's if if you defend yourself against a false criticism you'll actually prove the criticism as valid and the patient will attack you even more strongly in contrast if you genuinely agree with the criticism that's exaggerated untrue, unfair, impossibly, ridiculous and if you genuinely agree with it and see that it really is true the moment you agree with it the patient won't believe it anymore and you'll have a transformation of the therapeutic relationship thought and feeling empathy thought empathy is repeating the patient's words feeling empathy is acknowledging how the patient feels based on what the patient said. Inquiry is asking questions general questions to learn more to see if you got it right, the assertiveness skill is I feel statement sharing how you the therapist feel and then the respect tool is stroking saying something positive and admiring about the patient even in the heat of argument now these aren't formulas they're not used in this order almost ever these are more like the keys on a musical instrument like a piano and learning to play a piano requires lots of commitment and time and practice and the same is true with the five secrets but we can demonstrate to them to you right now but and and let's say you have a patient you look at the scores and and at the end of the session uh the the your last session there was no change in the depression or anxiety score or the anger score or the happiness Corp and the patient is giving you a bad a failing grade on empathy and helpfulness and you ask about it the patient may say something like like you well tell you the truth doctor you're not helping me. You know my wife has been pointing that out and you know I feel that way too and then how would you respond and do you want to be the shrink here and.

Jill Levitt: Sure yeah this is unscripted we like to do these things kind of impromptu so yeah so so David go ahead and say it to me one more time.

David Burns: I already told you you're not listening. You're doing it again. You're not helping me, and you don't listen to me, and you're all just talk about yourself all the time.

Jill Levitt: You know, David, I think you're right. I really haven't been doing a good job of listening to you, and I can see on your scores and your forms that I really haven't been helping you, that our therapy really hasn't been bringing about significant change for you and the things that you want to be working on. And it sounds like I've really let you down. You're also saying that I've been kind of talking about myself and that I haven't been doing a good job of tuning in and understanding you and listening to you. And I wouldn't be surprised if you're feeling, you know, kind of hurt and insulted, and also it sounds like you're feeling pretty angry with me, and I don't blame you for that at all. You know, I feel sad realizing that this has been going on. I really care about you. I'd really love to be able to do good work with you and to really help you with your depression and I'm wondering if we could take a few minutes now to really try and have me try and really listen and understand. And would you be willing to tell me a little bit about how therapy's been feeling for you? How this has been? What you've been thinking and what you've been feeling?

David Burns: Yeah, and then when we do this in our practice groups, then we we give the therapist a grade and say, Here's what worked, here's what didn't work. What grade would you give yourself on that?

Jill Levitt: I think I would give myself like an A minus. I felt like it was pretty good, but it didn't feel like it flowed great. It felt a little clunky.

David Burns: I also gave it an A minus, although your A minus would be vastly Beyond how 99.9 percent of therapists would be able to respond. It was actually very, very effective, but at the end, the only thing I would have said, because I mean you disarmed me, you did feeling empathy, you know did stroking etcetera. I just say in the inquiry in inquiry I might have added a little positive reframing and urge the patient more strongly to to go into the negatives that have taken a few minutes that's too nice I think but to say something like that maybe I really it's painful to hear these things because they're true and and while I'm feeling kind of sad and disappointed because you know I think the world of you and it's just shocking to see how I'm screwing up at the same time this can transform our work together this is a very very conversation we need to have to get on the same page to do the kind of work you want the kind of work that I want so with that in mind tell me more what this is like been like for you how I've screwed up how angry and hurt you feel and and I'm ready and and willing to to listen does that add anything.

Jill Levitt: Totally yes I think that's exactly what I was feeling the ending I sort of trailed off and yeah it's much stronger inquiry and yeah sort of warmer more positive more interested yeah that was that was an A-Plus yeah.

David Burns: Yeah Frisk gave us an A plus too thank you Chris whoever you are I like Eucharist but yeah but that's how how you do it you can see even a an expert like Jill I mean when you're under this kind of pressure it's very easy not to do a a terrific job but if you practice and practice and practice you'll your skills can consort.

Jill Levitt: And the cool thing too though is that we always like to show the a plus response but the therapist should know that even a b response right yeah she can even just some really good disarming like you're right I think that's really true and I'm glad that you're bringing it up you know I'm realizing I I even like I should have brought it up I see it on the forums whatever anything that's sort of like warm and non-defensive is going to be a whole lot better right than no measurement or no no empathy. Yeah so it's awesome to see the a plus but if that feels kind of out of range know that a b or a B plus is gonna bring about really I think lots of connection between you and your patients as well.

David Burns: And as a therapist you have to do your personal work too so you're not so threatened by the criticism so that you can really use that as an opportunity to hit the ball out of the park and just give you a quick.

Jill Levitt: Oh I'm going to say one thing before you say that is just something that if therapists are thinking wow that that does look really powerful, like we said you know there are a lot of opportunities to to train and to learn with us and I think David in in the last time that we did a David Burns live we even found that within the session itself we kind of checked in with the patient on how we were doing with empathy we got feedback from her and we had to course correct so I just think something that's cool about kind of watching us do live work is you also get to watch us uh make mistakes and then correct mistakes right and kind of learn from our mistakes on the fly.

David Burns: Absolutely and just give you two quick vignettes Jill and I are on the slave labor faculty at the Stanford Medical School where the volunteer faculty and one of the things I did as part of my volunteer work was to establish a daily hour and a half group cognitive therapy group for the inpatients and that I would be used to go in once a week and lead the groups and teach the staff and see how the groups are going with this very severe population and one day when I used the scales at the start and end of every group obviously and at the beginning of the group there was a woman who had been just admitted and she was very severe on depression and she had some some strong uh you know suicidal thoughts and moderate suicidal urges and what had happened she her husband had walked out on her and she got fired at work at the same time and so I ended up working with her in in the group because she felt worthless and many of the patients had had similar negative thoughts and I I was convinced I'd really hit the ball out of the park with with her and and I could just see that that I had transformed her depression. Reduced or if not eliminated it completely just there in the group and so I was very excited to see her ratings at the end of the session and as she was walking out you know she handed me her end of session mood ratings and rated me on empathy and I was shocked because she'd gone from severe depression to extreme and from Suicidal Thoughts to definite suicidal immediate plans and everything had gone to the worst rating possible and on the empathy and helpfulness she she had all zeros as like I was worse than Hitler or something and I stopped her I said you know Sarah just stop for it for a second. We're using this data in a research study and I I it's easy he got confused when you fell out the scales on the depression one the good ones are on the left and on the empathy and helpfulness the good ratings are on the right could you just maybe correct your answers there and she took it and she looked at it and and she says that doctor I filled it out correctly and I said I that I don't know what you were talking about I said we just had a fantastic session. She says well good for you maybe wasn't so good for me. I said what what are you talking about and she said well when you said that I had a double whammy and what I had what I had meant was that she lost these two sources of self-esteem at the same time but she said when you said that I thought you were making fun of me and I said oh my gosh I feel devastated I'm so sad that that had happened and and we talked it over and just took you know four or five minutes and got back on on track together that if I hadn't been using the assessment instruments I would have just thought boy what a wonderful session that was and it was actually one of the worst sessions in terms of outcome that I've ever had but yet that was an opportunity then to to show humility and and to connect with her and then the next week I went back for my weekly thing and there was a woman at the beginning who had just been admitted from the Intensive Care Unit she had made a nearly completed suicide attempt and then they sent her over to the inpatient unit and at the beginning I could see that she had the highest possible scores on depression, anger, suicidal urges, anxiety everything was the worst imaginable and when I went around to to talk to the patients a little bit she said she was an intravenous amphetamine addict that she'd had 10 hospitalizations, multiple suicide attempts and that apparently she had was in a rehab house to get over her methadone addiction and had flanked if she had flubbed up she and used amphetamines and they uh threatened to kick her out and she made attempted a serious suicide attempt to kind of get revenge really was one on the staff for threatening to to kick her out of this this house and I asked her if she'd like some help if if she'd ever had any cognitive therapy because she'd had all Phil therapy and she started cursing at me and said she'd heard about this effing stupid cognitive therapy and I could stick it up my effing ass and and shut the f up and you know I felt about two inches high she's just ripping me to shreds and so I looked away from her and I worked with the woman on the other edge of the group it was a big circle but I could just feel her pouring hatred in my direction during the entire group. And then in the end I worked with another woman who felt worthless and suicidal and and at the end I I again I forced myself to look at the feedback of every patient and but I didn't want to look at hers because I knew it would be terrible and I looked at it and all of her scores had gone to zero and then on the empathy and helpfulness everything was perfect score and then what did you like the least about the session she said she put nothing and what did you like the best Jesus Dr Burns I want you to know that when you were working with that other woman I felt like you were working with me and I didn't even know before today what a cognitive distortion was I just thought I was a worthless horrible human being and now I see it's my thoughts that that create my feelings and this is the first happy moment I've had in my entire life Dr Burns God bless you Dr Burns you changed my life and saved my life today this is the greatest hour I've ever had. And I couldn't believe it and if I hadn't gotten the feedback you know I would have avoided her, I wouldn't want to look her in the eye if we meet in the hall on the inpatient unit that that type of thing and so the the messages is that your perceptions these are two extreme examples of something that's happening and lesser but significant degrees all the time not only with our patients, with our families with you know people in in general. And if you want to get the the information then the assessment instruments can make a tremendous benefit that can be a very powerful tool to transform your personal life and your clinical work as well.

Jill Levitt: I love your stories and moving and they just highlight that you know even the best of therapists with you know amazing experience and amazing tools are not always aware of what's happening or often not aware of what's actually happening for each of our patients so we've we've mentioned a few times and this is definitely not the end of our Workshop it's a 90-minute workshop but before we move to q a we've mentioned a few times that we have an upcoming Workshop we'd love you to join us for so we'll just tell you a little bit more about it. It's called David Burns Live, although David kindly likes to call it David and Jill Live, but I always think of David as the real star, rapid recovery in real time. And the way this workshop will work is that we are going to have two volunteers from the audience that we'll get in touch with us ahead of time. And so we'll know a little bit of information about them, and we will do live therapy with them. So we'll start the day doing some didactic teaching. We'll talk to you about the whole TEAM-CBT model that includes testing and empathy that we've talked about today and also addressing resistance and methods. So we'll teach you a little bit about the the model and do an overview of it. And then we'll actually work with one patient, and then we'll process that work. And then we'll send you guys into breakout groups to practice a piece. We'll give you a chunk, we'll teach you something, and have you practice it. And we'll have a lunch break. And then we'll do the same thing in the afternoon. We'll do a full treatment with a patient in two, two and a half hours therapy session, and then process and then give you something to practice. So you'll get a little bit of everything: didactic, live treatment, and then an opportunity to practice. And we we also have a lot of Feeling Good Institute volunteers that will help with practice groups, so you'll actually get some kind of expert feedback along the way as well. And it's on May 22nd. It's an eight hours, seven hours of teaching, so it's seven CEs. And if you register by Monday the 25th, you can get 15 dollars off. So it's only a 120 dollars for that good deal.