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Oct 5, 2020

Corona Cast 8: Live Therapy with Dan. How Could You Treat an “Existential Depression” in the Midst of a Pandemic?

Today David and Dr. Jill Levitt feature live work with Dan, a licensed clinical social worker who’s been struggling with an “existential depression” for 15 years, but it has been recently exacerbated by the COVID-19 pandemic. The session took place in one hour and forty minutes on a Tuesday evening on July 23rd, 2020, in David’s and Jill’s Tuesday training group at Stanford.

Live personal work is one form of training that is vital to professional growth and learning, so it is extremely beneficial for the person who volunteers for the role of “patient.” At the same time, the live work also provides superb learning for those observing the process, since you can see what is really happening during a T.E.A.M. therapy session. Hopefully, you will learn a great deal as you listen to Dan’s live and uncensored therapy session.

Jill and I feel very grateful to Dan for allowing us to publish such an intensely painful and personal experience. You will likely feel grateful to Dan as well!

All live therapy sessions tend to be dramatic and illuminating from a variety of perspectives. Today’s session is unique in that the A = Assessment of Resistance was outstanding and unique. The remarkable changes that occurred would not have been possible without outstanding E = Empathy and A = Assessment of Resistance, which were stellar.

However, the M = Methods portion of the session was also strong, especially in the use of humor and role-reversals during the Externalization of Voices to blast Dan’s Negative Thoughts out of the water. That portion of the session confirmed by the three basic tenants of cognitive therapy:

  1. You FEEL the way you THINK.

All of your negative feelings are caused by your thoughts in the here-and-now, and not by the actual events in your life. In other words, the COVID-19 pandemic cannot “cause” anyone to feel depressed or anxious.

  1. Depression and anxiety are the world’s oldest cons.

When you’re depressed, anxious, or angry, the Negative Thoughts that upset you will not be valid. They’ll be distorted and illogical. Depression and anxiety are the world’s oldest cons. You can see the ten cognitive distortions I first published in my book, Feeling Good, at the bottom of Dan’s Daily Mood Log (link).

  1. You can CHANGE the way you FEEL.

The very instant you stop believing your distorted thoughts, your feelings will change. Recovery is not a long, drawn-out process that requires weeks, months, years or decades, as so many people believe, including the majority of mental health professionals. Recovery happens in a flash, an unexpected “ah-ha” moment when your perceptions of the world are suddenly transformed. You will witness such an event in today’s session.

Now let’s see what actually happened!

T = Testing

Take a look at Dan’s Brief Mood Survey (BMS) at the start of the session. He was feeling moderate to severe depression, no suicidal impulses, and just a little anxiety and anger. His Happiness score was quite low, only 7 out of 20, paralleling his depression score of 12, and his satisfaction with his relationship with his wife was a perfect 30 out of 30. He indicated he’d been doing a lot of psychotherapy homework.

This, by the way, is the latest version of the BMS. We’ll ask him to complete it again at the end of the session to see what changes occurred during the session. Because the BMS asks how Dan is feeling “right now,” it’s like an emotional x-ray machine, allowing therapists to see exactly how much, or how little, a patient is changing at every therapy session. The patient’s scores at the start of the next session also allow the therapist to see exactly what happens between sessions in multiple dimensions.

At the end of today’s session, Dan will also fill out the Evaluation of Therapy Session (ETS), and rate Jill and David on Empathy, Helpfulness, and Session Satisfaction, and indicate how willing he is to do psychotherapy homework, whether he had unexpressed negative feelings during the session, and whether he had difficulty filling out any of the survey questions honestly.

The BMS and ETS are invaluable tools that have been game-changers in psychotherapy. To my way of thinking, it is difficult, if not impossible, to do good therapy, much less outstanding therapy, without these powerful and extremely accurate tools. They have the potential to radically transform clinical work and have been an important key in the evolution of TEAM.

E = Empathy

After briefly reviewing Dan’s starting scores on the BMS, Jill and David empathized while reviewing the Daily Mood Log that Dan filled out prior to the start of the session. The upsetting event was sitting at home on a Friday night with nothing to do, since his wife was studying for an upcoming exam. He points out that when he’s busy doing therapy, he generally feels fine, but sometimes when he has nothing specific to do, intense negative feelings suddenly hit him and take all the joy out of life. As you can see, his feelings on his Daily Mood Log are similar to his feelings on the Brief Mood Survey but some are far more intense, since he’s focusing on a moment of angst.

If you look at his Negative Thoughts, you will see that they all revolve around a common theme that life has no meaning, since people are suffering and dying all over the world, and since all of us will also die one day. He says, “the good things that happen are just like dust in the wind,” and tells himself that “life is unfair.”

Dan explains that in the last couple of years he’s experienced several painful events. He got married, but got divorced after just three months when things did not work out with his wife. But he’d sold his condo, and his practice was not going well, and he could barely pay his bills, so he had to move back home with his mother, who then died of cancer.

Then, right after she died, things suddenly took a turn in a far more positive direction. He began dating and found an extremely loving and wonderful woman in 2017, whom he married last October, and his clinical practice began to blossom around the same time, so he and his wife were able to purchase a new home.

But still, the Negative Thoughts kept popping unexpectedly into his mind, and they can turn feelings of joy (“Wow! I really came back”) into despair in an instant (“I’ll probably lose everything again, and it makes no difference because I’ll eventually die.") David pointed out this is a little like PTSD, when you’re suddenly reminded of a previous trauma and get overwhelmed by angst. And the frequency and intensity of these sudden despair attacks have increased since the start of the pandemic.

Dan gave Jill and David an “A” on empathy after about 30 minutes of listening without trying to “help,” and this was a sign that we could move on to the next portion of the session.

A = Assessment of Resistance

Jill asked Dan if he wanted help tonight, or needed more time to talk and vent. He said he was ready to roll up his sleeves and get to work. His goal was to reduce or eliminate his negative thoughts and feelings, if that was possible.

Jill asked if he’d press a “Magic Button,” if that would cause all of his negative thoughts and feelings to instantly disappear completely, with no effort, and he said he would. Almost everyone says they’d push it—which is completely understandable. When you’re in great pain, we all want relief!

Jill indicated that we did have powerful tools, but weren’t convinced it would be such a good idea to use them to eliminate Dan’s feelings, and suggested we might first make a list of indicating:

  1. What each negative thought and feeling showed about Dan and his core values that were positive and awesome.
  2. How his negative thoughts and feelings might be helping him.

Doing this skillfully is an art form, since it is radically different from the inept “cheerleading” so many therapists and family members attempt when a loved one is feeling down.

You will hear this process unfolding when you listen to the audio of the session. Notice how Dan’s memories of the death of his older brother when he was just three years old and the recent death of his mother bring tears to his eyes, and help him change the way he thinks about his angst, not as something “bad,” but as something beautiful that honors his mother and his brother who passed away.

But this is just the tip of the iceberg, as a long list of positives emerges during this portion of the session, which is designed to melt away subconscious “resistance” to change. The A = Assessment of Resistance is really the secret key that opens the door to the possibility of rapid, profound, and lasting change.

David and Jill make it look easy, but it is, in reality, quite challenging to learn, because it goes against the very grain of our human inclination to try to “help.” Instead, Jill and David are assuming the role of Dan’s resistance, and showing him, in a gentle and loving way, that his negative thoughts and feelings are not actually symptoms of a defect or “mental disorder, but are really the manifestation of something positive and beautiful about Dan. David and Jill are selling Dan on the status quo and are still NOT trying to “help.”

Paradoxically, this procedure typically has the opposite effect of greatly intensifying the patient’s determination to change.

But now, the therapists have put Dan into a confusional state, and bind. On the one hand, he desperately wants to change. He doesn’t want to continue throwing cold water on the cherished positive moments in his life. But at the same time, if he presses the Magic Button, all of the positives will go down the drain along with his negative feelings.

This is resolved with the Magic Dial. David and Jill ask Dan if he’d be willing to dial his negative feelings down to some lower level instead of lowering them all the way to zero. You can see his goals for each negative feeling on the “% Goal” column of his Daily Mood Log.

M = Methods

Now David asks Dan which Negative Thought he wants to work on first. He chooses this one:

“It’s pointless in life to strive towards anything, because, in the end, we are all going to die.”

 Dan believes this thought 80%.

While identifying some of the many distortions in this thought, he comes up with this Positive Thought:

“Some things are worth striving for!”

This thought is 100% true, and his belief in the Negative Thought suddenly drops to 10%, as you can see on his Daily Mood Log (Daily Mood Log.)

Next, he wants to work on this thought, which he believes 60%:

 “People are dying in the world right now, so I don’t deserve to relax and have fun.”

After identifying five distortions in this thought, he challenges it with this Positive Thought:

“Although the deaths of so many people are tragic, it isn’t my fault that people are dying all over the world.”

Dan rates his belief in this thought at 100%, and his belief in the Negative Thought drops to zero.

Then he decides to work on this thought:

“I’ve had so many good things happen in the last several years, but I can’t enjoy them, since it’s inevitable that I’ll lose those things.”

He adds, “After all, what goes up, must come down!”

After a couple of rounds of Externalization of Voices with Jill, he still couldn’t completely crush this thought, so David steps in to give it a try, with Dan playing the role of the Negative Thoughts and David playing the role of Dan’s Positive Thoughts. David interrupts Dan’s verbalization of this thought with some irreverent Buddhist humor. At that moment, Dan suddenly “gets it,” and the floodgates open up as Dan crushes the thought.

Some people have called this “ah-ha” moments the “cognitive click.” It’s like waking up from a trance or nightmare, and the patient suddenly sees the world in a radically new and far more realistic light.

Jill and David complete the M = Methods portion of the session by challenging the rest of Dan’s Negative Thoughts using Externalization of Voices, including role-reversals with the Self-Defense Paradigm and the Acceptance Paradox. I think you will find these exchange fascinating, and you will hear the tides coming in and the tides going out as Dan sometimes struggles and then defeats all of his Negative Thoughts.

You can review Dan’s end-of-session mood ratings on his Daily Mood Log as well as his end-of-session Brief Mood Survey and his ratings of Jill and David on the Evaluation of Therapy Session.

The Necessary and Sufficient Conditions for Emotional Change

If you look at Dan's Daily Mood Log at the end of the session , you will see that the belief in each Positive Thought was high, and that his belief in the corresponding Negative Thoughts was drastically reduced. This is exactly why his feeling suddenly changed so dramatically. Cognitive Therapy (including TEAM) is NOT about telling yourself positive things or uttering positive affirmations. Instead, it's about crushing the distorted thoughts that trigger all of your negative feelings. The very moment you stop believing your Negative Thoughts, your feeling will instantly change.

At the end of the session, Jill gives Dan a critically important “homework” assignment. Listening to the audio of a session and doing written work with the Daily Mood Log are vitally important aspects of TEAM. What happens between sessions is just as important as what happens within sessions!

Thank you for listening today, and a HUGE thanks to Dan!

I hope you learned a ton, on many different practical plus philosophical levels, and enjoyed today’s live therapy session!

The Tuesday group at Stanford is free to all Bay Area mental health professionals as well as graduate students in some form of mental health training. The only “fees” involve a commitment to consistent attendance and the willingness to use the BMS and ETS with all patients, plus the willingness to do homework between Tuesday groups so you can really learn and master the very challenging TEAM techniques.

Rhonda and David