In today’s podcast, three shrinks discuss many intriguing
questions about anxiety from individuals who attended one of Dr.
Burns' free workshops on anxiety sponsored by PESI more than a year
ago. Several of the questions were answered on the podcast, and a
great many more are answered in the show notes below.
But first, Rhonda opened the podcast by reading an endorsement
from a listener named Rob, with a link. Here it is!
Hi Dr. Burns:
I'm a long-time listener/reader,
first-time caller. I stumbled upon this
endorsement for Feeling
Good today, and I thought it was worth
sharing with you. I can't think of a better endorsement for a book.
I hope you enjoy it!
"I’ve replaced my copy close to ten
times, as I keep lending it to friends who never give it
Thanks, Rob! And now, for the many excellent questions
submitted by listeners like you! Many were answered in depth on the
podcast, but you'll see that all questions have written answers as
When you talk about someone recovering, is that free of panic
attacks and anxiety forever, or a great decrease in symptoms but
you will always be an anxious person to a certain extent?
Especially for someone who has fundamentally been anxious since
they were young so not episodic but continuous.
Some people are anxiety-prone, and that is likely due to a genetic
cause. I am like that, for example. Once you are 100% free of any
form of anxiety, like my public speaking anxiety, you need to
continue with exposure, or the old anxiety will try to come
creeping back in. So, I do public speaking all the time!
What if your client/patient understands the Cognitive
Distortions but doesn’t believe them to be true?
David's Answer. It
is hard for me to comprehend what you mean. But I will say this.
Anxiety and depression and other negative feelings result 100% from
distorted negative thoughts. And the exact moment when you stop
believing the thought that’s triggering your anxiety or depression,
you will almost instantly feel relief.
And here’s the precise answer to
your question. When someone says, “I understand the distortions but
it doesn’t help,” they still believe their negative thoughts.
Resistance, too, is an issue.
Nearly 100% of therapeutic failure results from jumping in and
trying to help the patient without first comprehending the many
reasons why the patient will fight against the therapist’s efforts
Has research been done on the possible relationship in hormone
levels in women and anxiety or depression? Especially during
pregnancy, post pregnancy, and those going through menopause? Also,
can negative thoughts also depend on the person’s nutrition? Could
it be that vitamins that are lacking?
First, I am not aware of any convincing evidence linking
hormone levels with depression, anxiety, irritability, or any other
negative feelings. However, we can say with certainty that whatever
the cause, which is unknown, distorted thoughts will always be
present and will be the trigger for the negative feelings.
In or near the first chapter of my
most recent book, Feeling Great, I describe case of post pregnancy
depression, and you can take a look and see the mother’s negative
thoughts clearly. And you will also see that the moment she crushed
those thoughts, her depression disappeared!
People want to “biologize”
emotional problems, and I started out as a “biological
psychiatrist” and researcher, but found the biological explanations
to be erroneous and unhelpful.
Could you please give a brief overview about Exposure with
Response Prevention for OCD treatment. Thank you!
Sure, these are tools that can be helpful, along with many other
kinds of tools, in the treatment of anxiety, including OCD. They
are not, for the most part, treatments. I use four models in the
treatment of every anxious patient: the Motivational, Cognitive,
Exposure, and Hidden Emotion Models.
Exposure is facing your fears and
enduring the anxiety until the anxiety subsides and disappears.
Response Prevention is refusing to give in to the superstitious
rituals OCD users when anxious, like counting, arranging things in
a certain way, and so forth.
END OF QUESTIONS DISCUSSED
LIVE ON THE PODCAST
The answers to the
questions below were written by Dr. Burns but not discussed on the
Questions can I ask to overcome the Cognitive Distortion
“jumping to conclusions”? That is the toughest for me.
David’s Answer. I
would need a specific example. Jumping to Conclusions includes a
vast array of topics and negative thoughts. Fortune Telling and
Mind Reading are the most common forms of Jumping to Conclusions.
Feelings of hopelessness always result from Fortune Telling. All
forms of anxiety always result from Fortune Telling as well. Social
Anxiety typically includes Mind-Reading, and Mind-Reading is almost
universal in relationship conflicts.
In addition, I never treat a
distortion, an emotion, a diagnosis, or a problem. I treat human
beings systematically, using the T E A M algorithm.
Answer. There are many methods in TEAM that can be
applied in the form of a question. These methods and how they are
carried out, depends on the circumstances and the specific thoughts
a person is having. Below are some examples of negative thoughts
(NT’s) and the types of questions that might help overcome
(NT): ‘Something really bad is
going to happen’
(Be Specific Technique):
‘Like what? What’s going to happen?’
NT: ‘I’ll fail my biology
What-If Technique: ‘What if I
failed my biology test, why would I be worried about that? (write
down any new thoughts) What if those things happened, too, what
then? (write down any new thoughts) What’s the absolute worst thing
that could happen? (write this down).
Measurement: How certain am
I, that these things will happen? On a scale from 0 – 100%, how
likely are each of these predictions, in the form of negative
thoughts, to occur?
Socratic Outcome Resistance:
What do each of these negative thoughts say about my values that I
can feel proud of? (write these down) What is appropriate about how
I’m feeling and thinking? (write these down) What are the
advantages of having these thoughts? (write these down). What would
I be afraid of, if I didn’t have this thought? (write these
Pivot Question: Given the
many positive values related to worrying, the advantages of doing
so, the disadvantages of a carefree existence and the many reasons
why my worry is appropriate, why would I change this?
(Double-Standard Amnestic Technique for Outcome Resistance): What
would you say, to a dear friend, in an identical situation, when
they asked these questions: ‘I’m really worried about failing my
biology test, would you be willing to help me? (if ‘yes’, then
continue) … Don’t I need to keep worrying? Won’t that protect me
from failing? Don’t I need to worry, so that I’m highly motivated
to succeed? Don’t I need to worry, so I avoid making mistakes?
Don’t I need to worry, to maximize my rate of learning new
material? Won’t I get lured into a false sense of security, if I
stop worrying? Won’t I jinx it, if I get too confident? What would
you recommend to me? How much do you think I should worry? I am
prepared to do so … would it be helpful for me to go into a
sustained panic, at this time?’
Cost-Benefit Analysis: Is
worrying about failure worth the price? How would you weigh the
advantages of worrying about failure against the disadvantages?
What are the pro’s and con’s? How would you divide 100 points, to
reflect the power of these two arguments?
Examine the Evidence,
Motivational: What evidence is there that worrying improves
academic performance, concentration and learning? What evidence is
there that worrying worsens academic performance, concentration and
Magic Dial Question: ‘‘Should I
remain maximally worried, at all times, forever? (If not, keep
going) ’What amount of worry is best, for me, in this moment?’,
‘How about future moments? How frequently do I need to worry and
for how long?’
Process Resistance for
Activity Scheduling, Worry Breaks/Cognitive Flooding,
Self-Monitoring/Response Prevention: ‘Would it be alright to ignore
my worry most of the time and only focus on it during scheduled
times? Let’s say I could learn how to be extremely calm and focused
most of the day, without worry … would I be willing to worry as
intensely as possible, for ten minutes, three times per day, to
achieve this? When my worry comes up at other times, would I be
willing to observe and record that event, then return to the task
on my schedule?
Socratic Questioning: Am I
absolutely certain that this thought is true, that I will fail? How
do I know that I will fail? What specific questions will be on the
Biology test that I will get wrong? What number grade will I get? A
60? 58? 39?’, ‘Would I bet money on my getting precisely that
grade? Why not?’.
Examine the Evidence
(cognitive): ‘What evidence is there that I will fail? What
evidence is there that I will pass?
Reattribution: Let’s say that
I fail. Would that be entirely my fault? Are there any other
factors, outside my control, that might have contributed to this
outcome? My genetics, for example? Or the nature of the world, into
which I was born? Did I choose my genetics? Did I choose the world
into which I was born, when I was born, my parents, teachers, etc.?
Could any of these factors have played any role in the outcomes in
Other examples of
Inquiry-based methods, using different NT’s:
Negative Thought: ‘People
will be angry and judge me, if I fail’
Interpersonal Downward Arrow:
‘What kind of people are they, if they judge me and look down on
me, when I fail? How would I feel towards those types of people? Is
it possible I feel angry? How do I express that feeling? What
‘rule’ am I following, in my relationships?’
Outcome Resistance: What’s
good about me, for feeling anxious, rather than angry? What are the
advantages of keeping my feelings inside? What would I be afraid
of, if I expressed my feelings?
5-Secrets: Would I be willing to spend the time to learn the skills
required to express my feelings, including anger, to people, in a
way that made them feel good?
Negative Thought: ‘I’ll get
sick and die’
Be Specific: ‘When? What time
of day will that occur? What illness is going to kill me?’
Negative Thought: ‘I’ll lose
my mind, crack up and go crazy’
Examine the Evidence: Has
that ever happened to me? When was the last time?
When you are working with clients, how do you handle it when
they can challenge their thoughts very convincingly using a variety
of techniques, state that they can see the logic in their
restructured thought BUT they are still experiencing heightened
anxiety and state that this hasn’t helped them?
They still have a strong belief in their negative thoughts. It is
100% untrue that they have “challenged them very
Here’s an example. Let’s say you
have an intense fear of glass elevators. You will say, “I can see
that they are unsafe, but I am still terrified of going in
The moment you get on the elevator
your belief that you are in danger will suddenly skyrocket to 100%.
In other words, you still believe your negative thoughts.
Of course, it is nearly always easy
to overcome phobias, including an elevator phobia. As stated above,
I use four models in treating every anxious patient. Simplistic
formulas are just that—Simplistic! Treating humans is not like
changing the oil in your car!
Matt’s Answer: I
am hard pressed to add anything of value to David’s awesome
response, above. I might just reiterate that the Cognitive model,
challenging the logic behind negative, anxiety-producing thoughts,
is the least powerful of the approaches we have to anxiety. It is
necessary, but almost always insufficient. Exposure, motivational
methods and Hidden emotion are the real heavy-hitters. Until trying
these, it is likely that the negative thoughts can be disproven
‘intellectually’ but not at the emotional level.
How do you work with clients who state they are anxious all the
time, experience strong somatic symptoms (body sensations) and
cannot identify specific thoughts. They don’t catastrophize these
somatic symptoms but really, really dislike them and want them
David’s Answer. I
just ask them to make up some negative thoughts. That works well.
For example, they may have the belief that the anxiety must be
avoided because it may never disappear, or may believe that they
are on the verge of going crazy, and so forth.
Answer, Anxiety can cause people’s brains to shut
down, experiencing the ‘deer in the headlights’ phenomenon. Try to
identify just one upsetting thought, then use the ‘what-if’
technique to expand on that. You’ll be off and running!
How do you do techniques with a person who has active suicidal
David’s Answer. I
don’t “do techniques.” I find out if they’re actively suicidal and
in danger. If I know for certain that the person is safe, I treat
them like human beings, with T E A M. I’m not a formula person.
Each person will be different, and will respond to different
methods. My books and podcasts are chock full of examples of
actively suicidal people who responded.
Answer. I let them know that I don’t have the skill
to help them unless I know they’re safe. If I’m worried for their
safety, I’ll be afraid to use aggressive methods that may be
required for them to recover. I’d need them to convince me of their
safety before agreeing to work with them. If they can do so, I
offer TEAM. If not, I ask if they’re willing to escalate the level
of their care, e.g. to meet with me while hospitalized in a safe
setting. I don’t work with patients who are at risk of harming
themselves because I don’t believe in my ability to be helpful to
Is it really okay to keep continuing the experimental technique
when the patient does not want to continue? And, what if the
therapist is not confident and something goes wrong in this
David’s Answer. I
would need a specific example, but you are right that 75% or so of
therapists are afraid of exposure and will not use it, fearing that
something will “go wrong!”
Answer. It’s important to identify the resistance
before initiating the method of exposure and to talk it through.
Why would they not want to continue? What are they afraid of, if
they get really anxious, during exposure? Write this down.
Then, surrender, acknowledging that
these are some excellent reasons to avoid exposure, in which case
we can’t help them with their anxiety. Perhaps there’s something
else they want help with? If they can convince you, and themselves,
that exposure is precisely what they want to do, and they’re
willing to keep doing it, even if it makes them very anxious, it’s
appropriate to push a bit, in the moment of their doing exposure,
to bolster them and help them through the rough patch. That said, I
always give my patients a way out, if they don’t want to continue.
That’s their choice, I just want them to be aware of the
consequences, including a worsening of their anxiety.
When doing experimental method, or the exposure method for
example with who has sweating issue, how do you handle the
hyper-vigilance he would have with people around, especially if
someone actually laughed at him?
David’s Answer. I
would use the Feared Fantasy Technique, and Self-Disclosure. I
would likely go with the patient into the real world to do these
things, and have done so on hundreds of occasions.
How would you work with someone who suffers from
David’s Answer. I
have not run into that in my clinical practice. But 100% of the
time, I would want to know what the patient’s agenda is. I would
also want to know if there are powerful motivational factors that
need to be addressed, looking at the whole person rather than the
How different are Team CBT treatments for teens as compared to
David’s Answer. My
experience is limited, but I would say no difference, really. I
have loved working with teens, even though my main focus was on
When working with little kids, I
think you need to incorporate play and games, although the basic
concepts are the same. For example, you can do Externalization of
Voices with puppets, the “Bad, Mean Self” and the “Positive, Loving
Self,” or some such.
We have featured shrinks who work
with kids on many times on our podcasts.
Thanks for joining us today!
Matt, Rhonda, and David
About the Podcast
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!