This podcast features David D. Burns MD, author of "Feeling Good, The New Mood Therapy," describing powerful new techniques to overcome depression and anxiety and develop greater joy and self-esteem. For therapists and the general public alike!
Anger, Part 2: You Have Always Hated Me!
Featured photo is Mina
as a child (more pics below!) 374 Anger, Part 2 You Have Always Hated Me! In the Anger Part 1 podcast (371 on November 20), Rhonda, Matt and David discussed the fact that when you’re feeling angry, there’s always an inner dialogue—this is what you’re saying to yourself, the way you’re thinking about the situation—and an outer dialogue—this is what you’re saying to the other person.
In Part 1, we focused on the inner dialogue and described the cognitive distortions that nearly always fill your mind with anger-provoking inner chatter about the ‘awfulness” of the person you’re mad at. Those distortions include All-or-Nothing Thinking, Overgeneralization, Labeling, Mental Filtering, Discounting the Positive, Mind-Reading, Fortune Telling, Emotional Reasoning, Other-Directed Should Statements, and Other-Blame.
That’s a lot—in fact, all but Self-Blame. And sometimes, when you’re ticked off, you might also be blaming yourself, and feel mad at yourself at the same time.
Matt suggested I add these comments on Self-Blame or it's absence::
Another possible addition would be when you identify the absence of Self Blame when we’re angry. For me, it’s been easier to think of that as a positive distortion, because you are blind to, or ignoring, your own role in the problem. In other words, when I’m blaming someone else, it’s me thinking my poop smells great and tit's all the other person's fault..
I’ve wondered if we fool ourselves like this because of the desire to have a special and perfect “self,” which we then defend. Because nobody’s perfect, our "ideal self," as opposed to our "real self," is just a pleasant, but potentially destructive, fantasy.
Still, we try to preserve and project the fantasy that we are free of blame and the innocent victim of the other person's "badness," , and we imagine there we have a perfect “self” to defend. Or, as you’ve said, at times, David, “anger is often just a protective shell to hide and protect our more tender and genuine feelings.”
We also discussed the addictive aspect of anger, since you probably feel morally superior to the “bad” person you’re ticked off at when you’re mad, and this makes it fairly unappealing to change the way you’re thinking and feeling. Your anger also protects you from the risk of being vulnerable and open and genuine.
Today we discuss the Outer Dialogue, and how to express angry feelings to another person, as well as how to respond to their expressions of anger. The main concept is that you can express anger in a healthy way, by sharing your anger respectfully, or you can act out your anger aggressively, by attacking the other person. That’s a critically important decision!
Toward the start of today’s podcast, Rhonda, Matt and David listed some of the distinctions between healthy and unhealthy anger. The following is just a partial list of some of the differences:
Healthy Anger Unhealthy Anger You treat the other person with respect, even if you’re angry. You want to put the other person down. Your goal is to get closer to the other person. You want to get revenge or hurt or humiliate the other person. You hope to improve the relationship. You want to reject or distance yourself from the other person. You want to understand the other person’s mindset and find the truth in what they’re saying, even if it sounds ‘off’ or ‘disturbing’ or offensive. You want to prove that the other person is ‘wrong’ and persuade them that you are ‘right’. You want to understand and accept the other person. You insist on trying to change the other person. You express yourself thoughtfully. You express yourself impulsively. You come from a mindset of humility, curiosity, and flexibility. You come from a position of moral superiority, judgement, and rigidity. You are patient. You are pushy and demanding. Optimism that things can improve and that ther
Why Therapy Fails
Why Therapy Fails One of the most common reasons patients contact me is to find out why the therapy isn't working. They may be TEAM-CBT patients or patients of therapists using other approaches. Therapists also ask for consultations on the same problem--why am I stuck with this or that patient who isn't making progress?
In the Feeling Good App, my colleagues and I have been looking into this as well. Most app users report excellent and often rapid results, but some get stuck, in just the same way they might get stuck in treatment with a therapist. I have tried to organize my thinking on this topic, because if you can diagnose the cause of therapeutic failure, you can nearly always find a solution. Of course, the app is not a treatment device, but a wellness device, but the same principles apply.
So today, Rhonda, Matt and I discuss a couple reasons why therapists and patients alike sometimes get stuck. Matt described a patient who was misdiagnosed with a psychotic disorder who turned out to have sleep apnea. When the proposer diagnosis was made and treated, the patent suddenly recovered.
Rhonda described a patient who jumped from topic to topic and always brought up a new problem before completing work on the previous problem. This problem was solved when Rhonda explained the importance of sticking to one problem for several sessions, until the problem was resolved. The patient then began to make progress.
David described a depressed woman from Florida who was stuck in treatment, and not making progress, and then the therapist said "I just can't help you," This hurt and confused the patient who wrote to me. There were essentially two problems--the patients depression what brought her to therapy in the first place, and her unresolved hurt feelings when the therapist "gave up" on her. This problem reflected many failed relationships is the patient's life. This was resolved when the patient took the initiative to schedule a session to talk about the conflict more openly with excellent results.
In addition, the patient had heard that she "should" accept herself, but didn't know how to accept her constant self-critical troughs and intensely negative feelings. I suggested she make a list of the benefits of her negative thoughts and feelings, as well as the many positive things they showed about her and her core values as a human being.
She came up with an extremely impressive and long list! For example, her criticisms showed her high standards, her humility, her dedication to her work, her accountability, and much more. In addition, she'd achieved a great deal because of her relentless self-criticisms.
I asked her why in the world she'd want to accept herself, given all those positive characteristics
She decided NOT to accept herself, and was delighted with her decision. She said she felt profound relief!
An unusual, but awesome, path to acceptance! In other words, she ACCEPTED her "non-acceptance."
I hope you find today's podcast interesting and helpful. Of course, ultimately therapy is part science and part human relationship art. That's why Rhonda and I offer free weekly training groups for therapists who wish to develop their therapeutic skills. The groups are on zoom so therapists from around the world are welcome. Matt offers a consultation group (free to Stanford psychiatric residents) every other Tuesday for therapists who want help with difficult, challenging cases. To learn more, you'll find details and contact information at the end of the show notes.
When Therapy Doesn’t Work-- And How to Get Unstuck (for Therapists and Patients) By David Burns, MD Here’s are some of the most common reasons why therapy might fail or appear to be stuck / without progress. Some of them will be of interest primarily to clinicians, while others will be of interest to clinicians and patients alike. And many of these reasons will also apply to individuals using the Feeling Good App who are stuck in their attempts to change
At Last! An Outcome Study!
At Last! An Outcome Study! One of the wonderful things about TEAM-CBT is the dramatic and rapid changes we see in so many of our patients. But we've had a huge problem-no published outcome studies. And that has definitely limited the general acceptance and recognition of TEAM-CBT.
Today, that era has come to an end, thanks to Dr. Elise Munoz, who joins our beloved Feeling Good Podcast to discuss a remarkable outcome study conducted at her Feeling Good Psychotherapy clinic in New York City. She wanted to evaluate the effectiveness of TEAM-CBT with teens and young adults.
Dr. Munoz is the Founder and Lead Therapist at Feeling Good Psychotherapy and Adjunct Assistant Professor at New York University. She is also a Level 4 Certified TEAM-CBT Therapist & Trainer, and specializes in the treatment of anxiety, depression and life transitions.
Elise conducted a “naturalistic” study of data from 116 teenagers and young adults aged 13 -24 years of age who were treated by 15 therapists between 2017 and 2022. In a “naturalistic” study, you simply analyze all the data from your patients to evaluate the effectiveness of the treatment. This is in contrast to a “controlled outcome study” where patients are randomly assigned to two treatments to see which treatment delivers the best results. Elise conducted the research study as part of her work for a Doctorate in Clinical Social Work at the University of Pennsylvania in Philadelphia.
"The results," she says, "were encouraging." That's perhaps a humble description of her findings. David and Rhonda might say that the results were pretty awesome!
Elise told us that although the average number of treatment sessions was 27, most of the patients made maximal gains after just 10 weeks (2.5 months) of treatment, and many achieved maximal improvement by the 5th session. Specifically, by the tenth session. 80% of the patients scored in the "subclinical" range on the depression scale of my Brief Mood Survey (with scores of 0 to 4) and 87% scored in the subclinical range on the anxiety scale (scores from 0 to 4) . These scales range from 0 (no symptoms) to 20 (extremely severe.) Prior to the study, only 30% were in the subclinical range.
According to Elise, the rapid improvement suggested that most patients will not need long-term treatment, although some will need more time to incorporate their gains following their initial improvement, and many will want to remain in treatment to deal with other problems, such as relationship issues that are so important in this (or any) age range.
Prior to the study, Elise trained the therapists in a weekend TEAM-CBT "boot camp," along with two hours per week of group training and 1 hour per week of individual consultation/supervision. My own view (David) is that learning TEAM-CBT is very challenging, requiring a minimum of one to two years of intensive training. However, the fact that therapists can get excellent results with a relatively small amount of training is encouraging.
One of the key components of TEAM is T = Testing. We test every patient at the start and end of every therapy session, asking, "How are you feeling right now?" This provides the therapist with a kind of emotional X-ray machine that allows you to see the precise degree of improvement, or lack of improvement, at every session in multiple dimensions. Therapists can use the information to fine-tune the treatment on an ongoing basis. Many other research studies have demonstrated that session by session monitoring of symptoms, consisting of measurement and feedback, significantly improves outcomes in mental health treatment. (please contact Elise for a list of research studies you can look up online).
Research indicates that roughly half of adolescents and young adults will suffer from some mental health problem. Therefore, it is essential to provide accessible, effective treatments to prevent the development of long-term mental health problems.
We salute Elise for g
Anger, Part 1: You SUCK!
Anger, Part 1 You suck! Screw you! Jay asks: Are you EVER going to do a podcast on anger?
Also are you EVER going to do a podcast on Anger with Rhonda and Matt? You have done many podcasts on depression, anxiety, interpersonal relationships YET there is not one podcast addressing anger.
Given the world we live in right now maybe it's time to address Anger from a TEAM-CBT perspective and give it the attention you have given anxiety and depression.
All the Best,
In today’s podcast, Rhonda and David address this important but neglected topic that is perhaps more important than ever in today’s angry and violent world.
David began by pointing out that in the feeling Good App, anger improved as much as six other negative feeling clusters, with fairly dramatic reductions in just a few days. This was completely unexpected and exciting, and has been replicated in numerous beta tests.
Maybe there IS a small glimmer of hope in this troubled, angry world!
David pointed out that anger is addictive
Depression is not addictive because in depression you are thinking I am no good, and you have negative and painful distortions about yourself. Anger, in contrast, is addictive because you are directing the distortions at other people, telling yourself that they are no good, and they will never change, and so forth. These distortions directed at others trigger feelings of moral superiority and those feelings are intensely addictive. Any group that is at war tends to feel morally superior and sees the “other” as scum, the enemy, and these distortions give you justification for hurting and killing them and feeling good about what you are doing.
What makes the treatment of anger fairly challenging is that most angry people are not looking for help.
Distortions directed at others are key in conflicts with friends and loved ones as well as racial and religious hatred, and war and violence. How do you treat a patient who is angry?
You always start with T = Testing. David’s research on therapist accuracy indicates that therapist accuracy is recognizing anger in their patients is incredibly poor. If you want to assess and deal with patient anger, the Brief Mood Survey at the start and end of every session can be invaluable, and the Evaluation of Therapy session at the end can also help.
E = Empathy comes next. However, empathizing with someone who is angry can be challenging because they are often provocative, or want the therapist to align with them in their belief that the person they are angry with is to blame. We want the client to feel accepted, and have a warm relationship with their therapist so the therapist can easily get sucked into the patient’s blaming mind-set.
David calls this “reverse hypnosis,” and this can sabotage the chance for effective treatment.
Empathy can be challenging if the anger is directed at the therapist, or if the client is saying they are so angry they want to hurt someone. That can be ethically challenging because of the Tarasoff duties to warn the victim and notify the police. That is tough because the client can get upset with the therapist.
A = Assessment of Resistance comes next, starting with the Straightforward or Paradoxical Invitation. With someone who is angry, we nearly always use the Paradoxical Invitation. Here’s an example:
You have been talking about person X, and I can see you are pretty fed up with her. You said, you’ve tried everything and nothing works, and she won’t change.
I have a lot of tools that could be very helpful if you want to do work on the relationship and turn it around. But I did not hear you saying that, and I am assuming that is NOT what you want.
Don’t get me wrong, if you want to work on this relationship, I’d love to do that so you can develop a closer relationship, but at the same time, there’s no law that says you have to get along or like everyone.
I’m assuming you DON’T want to work on your relationsh
Ask David The fear of ghosts; the truth about nutritional supplements; the fear of fear; how does anxiety treatment work? And more.
Ask David The fear of ghosts; the truth about nutritional supplements; the fear of fear; how does anxiety treatment work? And more. Today, David and Rhonda answer six cool questions submitted by podcast listeners like you!
Joseph asks: How would you use exposure to confront your fear of ghosts? Salim asks: What herbs and supplements will help me become more zen and relaxed? Peter asks: How do you stop fearing the fear and discomfort of anxiety? Jillian asks: How does cognitive therapy work to help reduce anxiety? Sanjay asks: How do you give up wants, needs, and desires? Dana asks for help with the Disarming Technique. In the following, David’s reply was David’s email response to the person prior to the podcast, just suggesting some directions we might take on the podcast.
The Rhonda comments were based on notes she took during the live podcast.
For the full answers, make sure you listen to the podcast!
Joseph asks: How would you use exposure to confront your fear of ghosts?
Hi David and Rhonda,
Thank you again for your wonderful replies and the amazing podcast.
If you would humor me, I have another question -- I know David talked about exposure therapy in overcoming fears, but I wonder how this could apply to some fears like the fear of ghosts where it is caused by an over-active imagination (in which case, what should one be exposed to?)
Cognitive flooding would be one approach.
Will give details on podcast. Thanks!
Find out what is happening in the person’s life, and treat that specific problem.
Maybe someone developed a fear of ghosts after the death of a loved one, so the idea of being around death or dead things may also cause intense anxiety. Going to a cemetery may be part of their exposure.
Other examples of exposure for overcoming the fear of ghosts could be:
Approaching a scary, abandoned house Watching a scary movie about ghosts Fear of darkness may accompany fear of ghosts so staying in the dark may be part of your exposure.
Fear of sleeping alone may also accompany fear of ghosts so sleeping alone in your home may be part of your exposure.
Salim asks: What herbs and supplements will help me become more zen and relaxed?
Hello Mr. David D Burns,
I want to tell you that i loved "Feeling Good", your book helped me a lot in improving my life, I have a question, can you recommend herbs or supplements that help me be more Zen and more relaxed? I would be eternally grateful. 🙏.
Thank you so much.
Hi Salim, I don’t believe in the efficacy of herbs etc. except for their placebo effect. However, the written exercises in the book, like writing down your negative thoughts, can help a lot. You’ll find lots of free resources on my website.
At the same time, the use of herbs and supplements is kind of a “cult” thing, and as you know, cult followers don’t like to have their views challenged!
And our field of mental health is, to my way of thinking, a mine field of cults!
David Burns, MD
Peter asks: How do you stop fearing the fear and discomfort of anxiety?
However, I don’t “throw” methods at symptoms, but rather work systematically with the TEAM approach, and always incorporate four models in my work with every anxious patient: The cognitive, motivational, exposure, and hidden emotion models.
You can learn more about this in the free anxiety class on my website! You’ll find it right on the homepage for www.feelinggood.com.
You don’t stop fearing the fear and discomfort of anxiety before doing an exposure. You do all of the work necessary using the three other models of treating anxiety (see the anxiety question directly below this one) and then you dive into the exposure, embracing the discomfort until it’s reduced or gone.
Jillian asks: How does cognitive therapy work to help reduce anxiety?
The Invisible Racism
369 The Invisible Racism We All Deny, Featuring Drs. Manuel Sierra and Matthew May Today we’re joined by Drs. Manuel Sierra and Matthew May on the sensitive topic of racism.
Manuel Sierra MD is a child and adolescent psychiatrist practicing in Idaho, one of the places where he grew up (he also spent time in Oregon). He was a classmate of Matt May during his residency training days at Stanford, and they remain close friends today.
Rhonda begins today’s podcast with this mail we received from Guillermo, one of our favorite podcast fans:
Guillermo asks: How do you respond to family or friends who make racist comments?
Hello, Dr Burns
Not sure if you have addressed this in any of the podcasts (I don’t recall it being a topic) but:
I was recently in a group chat with some cousins, and I read some really disappointing racist comments about a particular group. Many people ignored it (as I did) and a couple AGREED with the comments.
How can we balance not judging not just any people but our longtime friends and family about overtly racist actions/comments and the thinking that it is not the event but our thoughts that create our emotions?
I don’t care about “judging them” (in the sense that I don’t think it is my place to “change” their views) but just hearing/reading comments like this bothers me when they come from people close to me.
When I see it on tv or the internet, I don’t get affected because I feel it is beyond my control.
I don’t believe they will change their views so do I just remove them from my life? I apologize, the topic is too wide, but I’ve been thinking about this.
Sincerely grateful for all you do,
Manuel kicked off our answer to Guillermo by saying that he has been personally familiar with racism within families and communities, and says that he and Matt have talked about this topic “a lot.” He explained that:
Although I am proud of my Mexican-American heritage, I was born and grew up in Oregon and Idaho, where I’m currently practicing. I encountered considerable racial bias when I was a kid, and later in life as well. I clearly cannot speak for all Mexican-American people, I can only speak for myself and what I’ve personally experienced, and I am extremely aware of how difficult the current times are.
My grandparents didn’t teach my mom Spanish. She was a single mom, and we lived in a small town in Idaho. I also have family through marriage who live on Native American lands.
In grade school I began hearing jokes about Mexican Americans, and this was very awkward, painful, for me. I also got ridiculed for not speaking Spanish. Even my grandfather asked me, “why aren’t you speaking Spanish?” There were also gangs where the racial bias got worse and frequently turned violent.
After learning more about Manuel’s experiences, we modeled various ways of talking to a friend or family member who has made hurtful racist comments. Manuel cautioned that it might be best to do provide the feedback individually, and not in public, so as not to shame the person. In addition, this can reduce the chance for social posturing and responding in an adversarial way.
Matt agreed and emphasized the importance of combining your “I Feel” Statement with Stroking. For example, you might say something like this, assuming the racial slur comment came from a relative or person you like,
Jim, as you know, you’re one of my favorite people, but I want you to know that when you said X, Y and Z, it really upset me, because it sounded like a put down to people who are (Mexican, Jewish, Moslem, gay, or whatever).
I (David) like this approach because it sounds respectful and direct, but not judgmental or condemning. Rhonda modeled an excellent alternative response which included this type of add-on: “And I’m going to request that you not say that again in my presence. “
I (David) would prefer not to add the directive statement at the end, which could, in theory,
Yes one more episode please !
Love the podcast. It always feels so personal and as a listener I almost feel like part of the conversation. Great work keep it up!!
Helping me to feel better 🙂
Life is stressful right now. Feel like I have all these disorders. At least 3 or 4. The advice and techniques shared here are good!!