Live Work with Ruben: Part 1 of 2 Working with Performance Anxiety in Real Time Hosts: Kevin Cornelius, LMFT Dr. David Burns Guests: Dr. Jill Levitt Ruben Land In this live work from a recent Tuesday Group, we had the opportunity to work with Ruben, a highly capable and thoughtful clinician, who brought a struggle that many therapists quietly share: intense performance anxiety in evaluative situations, especially in the presence of authority figures or people he deeply admires. What made this work especially powerful is that Ruben was actively experiencing anxiety in the moment, allowing us to "get in the car with him" rather than talk about the problem abstractly. We began, as always in TEAM-CBT, with Testing. Ruben had completed a Brief Mood Survey, which showed relatively low baseline symptoms—just mild anxiety and minimal depression or anger. However, when we reviewed his Daily Mood Log, anchored to a specific situation (leading a group under supervision), we saw a very different picture: anxiety at 70%, feelings of inferiority and defectiveness at 80%, embarrassment at 70%. This contrast highlights a core principle: symptoms are often situational and state-dependent, and without anchoring in a specific moment, we risk missing the true intensity of the problem. From there, we moved into Empathy, where Jill did a beautiful job modeling the Five Secrets of Effective Communication. She captured Ruben's internal experience with precision: the pressure to perform, the fear of saying the wrong thing, the spiral of anxiety leading to cognitive blanking, and the secondary anxiety about appearing anxious. She also identified both the internal loop ("I'm anxious about being anxious") and the interpersonal fears ("they'll think I'm a fraud," "I'm wasting their time"). David complemented this with curiosity and gentle inquiry, helping to deepen the conceptualization without getting lost in theory. Importantly, we conducted an empathy check, asking Ruben to grade us on thought empathy, feeling empathy, and warmth. He gave A+ ratings across the board, with a slight adjustment on thought empathy when he introduced an additional element: a compulsive need to check and recheck, suggesting a subtle OCD-like process. This moment is critical—without the empathy check, we would have missed an important maintaining factor. Only after strong empathy did we move into Agenda Setting, which is often the most counterintuitive and transformative part of TEAM-CBT. David began with the Invitation, asking whether Ruben wanted help or more support. Ruben was ready to "roll up his sleeves," which is essential—no imposed agenda. Then we used the Miracle Question to clarify goals: Ruben wanted to feel less anxious, maintain fluency, and stay present in high-stakes situations. Next came the Magic Button, targeting outcome resistance. When asked if he would eliminate all his negative feelings, Ruben said no—he wanted to keep some anxiety. This is exactly what we hope for. It opens the door to Positive Reframing, where we honor the symptoms rather than pathologize them. Together, we identified numerous positive values and benefits of his anxiety and self-doubt: Anxiety motivates preparation and effort It enhances connection through vulnerability It reflects caring deeply about others and their time Feelings of inadequacy keep him humble and growth-oriented Fear of judgment protects him and signals high standards Even the thought "I might be a fraud" reflects a desire to be authentic and competent At one point, Ruben articulated that his anxiety shows he values others and wants to contribute meaningfully—this is a profound reframe. Jill and David reinforced these insights, helping him see that his "symptoms" are actually expressions of his values system in action. We also explored a key factor: his anxiety is amplified in performative, evaluative contexts, especially with authority figures, and is less intense in vulnerable, non-evaluative settings. This distinction is clinically crucial and guides both conceptualization and intervention. Another powerful moment came when Ruben acknowledged that self-disclosure reduces his anxiety, supporting the idea that "shame requires secrecy." When he hides his anxiety, it intensifies; when he shares it, it softens. This is both a therapeutic tool and a treatment target. After thoroughly addressing resistance, we moved into Goal Setting, asking Ruben not what he wants to eliminate, but what he wants to dial down. This is a hallmark of TEAM: Anxiety: 70 → 30 Shame: 30 → 20 Inadequacy: 80 → 30 Embarrassment: 70 → 20 We then transitioned into Methods, targeting the thought: "My speech is too slow, and I sound foolish, ignorant, and boring." Jill began with a classic but essential step: identify the distortions. Ruben quickly identified all-or-nothing thinking, overgeneralization, mental filter, discounting positives, mind reading, fortune telling, labeling, self-blame, and hidden "shoulds." This is an important teaching point: when a thought contains nearly all distortions, it's not a problem—it's a goldmine. From there, rather than staying intellectual, we offered multiple method pathways—Externalization of Voices, Feared Fantasy, Be Specific, and Double Standard—modeling flexibility and collaboration. Ruben chose Externalization of Voices, which became the central method. David stepped in as the Negative Ruben, delivering the attack clearly and forcefully. This is essential—the more vivid the critic, the more powerful the response. Ruben responded using a blend of acceptance ("it's true I sometimes pause"), self-defense, and realism (some people may not like it, and that's okay). He won "big," but not "huge," which is a key TEAM moment—we don't settle for partial wins. They then moved into role reversal, and this is where things deepened. When Ruben played the critic and David responded, David modeled a powerful combination of self-acceptance, counterattack, and refusal to buy into the critic's frame. He highlighted that the real problem wasn't slow speech—it was the constant inner criticism. Ruben immediately recognized this as a "huge" win. Ruben then practiced again, this time integrating acceptance, values ("my heart is in the right place"), and counterattack ("the bigger problem is your nagging voice"). This time it felt huge. Next, they targeted a different thought: "If I screw up, David will be disgusted and see I'm a worthless, selfish fraud." This brought up more anxiety, and Ruben got stuck. Jill did something very important here—she paused the method and returned to empathy, naming the pressure to "do it right" and the performance anxiety happening inside the exercise itself. After empathy, they resumed. Jill modeled a powerful response in role reversal that included radical acceptance of imperfection ("I expect to screw up"), a growth mindset ("that's why I collect feedback"), and a reframe of failure as essential to learning. She also gently challenged the distortion of David as a harsh authority figure and emphasized choosing supportive learning environments. Ruben then extended this insight even further, saying, "the more I fail, the better… the more vulnerable I am, the less I appear like a fraud." This was a genuine shift. They then moved into Feared Fantasy, with David playing "David from Hell," saying things like "you're incompetent," "you're worthless," and "you should find another profession." Ruben responded by using Be Specific, asking what exactly he had done wrong. When the answer became "you paused," the entire structure of the criticism collapsed. Ruben saw the absurdity and described the experience as a weight lifting. This is a classic TEAM moment—when global, harsh judgments are reduced to specific, manageable behaviors, they lose their power. They extended this further with the thought "I'm wasting people's time." Through additional role plays, Ruben practiced self-defense and purpose clarification, David used humor and counterattack, and Jill demonstrated Be Specific in a very precise way—asking exactly how long a pause should be, exposing the irrationality of the standard. The work then expanded to include the group. Participants used Externalization of Voices to challenge Ruben's thoughts, and Ruben responded with increasing strength and clarity, using self-acceptance and reversal of beliefs (for example, recognizing that vulnerability actually increases connection). David then introduced the Survey Technique, asking Ruben to directly check his assumptions with the group. The responses were striking—people reported never noticing pauses, experiencing him as thoughtful and engaging, and feeling more connected because of his style. This directly disconfirmed his mind reading and labeling. At the end, they returned to Testing. Anxiety went from 70 to 0, shame from 30 to 0, inadequacy from 80 to 10, embarrassment from 70 to 0, rejection from 40 to 0, and frustration from 30 to 0. Ruben reported that the change felt real and that his belief in the negative thoughts had dropped dramatically. When asked what created the breakthrough, Ruben identified two key moments. First, a deep emotional realization that the goal is actually to make mistakes—that failure is not something to avoid but something to embrace. Second, a shift in how he saw authority figures—recognizing that the perceived gap between himself and others was distorted. As that sense of separation dissolved, so did much of the anxiety. David highlighted that much of our suffering comes from that artificial separation—seeing others as powerful and ourselves as deficient. Jill added an important layer: when we assume others are harsh, judgmental, and critical, we are also distorting them, not just ourselves. Some key clinical takeaways: Externalization of Voices becomes es
