Jan 13, 2020
Rhonda and David address a question from Karolina, a therapist in Poland who was failing with a depressed patient who felt totally convinced he was a “useless” human being. I think you will find their discussion of this case fascinating, as it deals with the cause of practically ALL therapeutic failure, and illustrates the solution al well, using TEAM-CBT methods and concepts.
Today’s podcast is intended for therapists and patients alike!
For the show notes, we are including the email David received from Karolina, as well as his initial response.
Dear Dr. Burns,
I've been listening to your podcast for 6 months now and it's been so helpful with my work as a therapist as well as in my personal life. I'm starting to develop a habit of considering every unwanted state with a "what does it say that's awesome about me?" and I'm much happier now :).
I'm wondering if you'd consider helping me some more. I have a client who's been struggling with depression for many years. At the moment he's doing ok and his mood is up. Lately the topic of his uselessness came up again and he's willing to work on that. He said he'll consider the possibility that he's not a useless human being and asked me to not to dismiss the possibility that he is - that's how he'll know that I'm not just trying to cheer him up.
It's been bugging me ever since. Although I've agreed, I really can't find in me any part that is ready to think that. I strongly believe he's not a useless person. I can't imagine labeling anyone in that way and in his case it feels so personal as I like him very much and I care about him.
I'm starting to have dreams about our next session when I fail him by trying to convince him to think as I do. How can I be open about our conclusion when my mind is already fixed? Any thoughts on this would be deeply appreciated.
Best wishes from Poland
Karolina
Hi Karolina,
Thanks! The term has no meaning. It is just a vague put down, like what a bully might say.
I might ask him what time of day he was feeling useless, and then have him fill out a Daily Mood Log for that moment, step by step. We can only help him at one specific moment.
You can use a large number of techniques but must first get an A on Empathy, and then do effective paradoxical agenda setting, starting with the Paradoxical Invitation Step and then asking “what type of help would you be looking for?” then you can do the Magic Button and Positive Reframing.
All of the negative thoughts and feelings on the Daily Mood Log will be advantageous and will show something about him that is awesome and positive. You should be able to generate a list of at least 25 overwhelming positives. Then you can use the Magic Dial.
When you get to M = Methods, you can put the thought, “I am a useless human being” in the middle of a recovery circle, and then select a minimum of 16 methods to challenge it.
You can start with Identify the Distortions. There are likely at least 9 distortions in the thought, including AON, OG, MF, DP, MAG / MIN; ER; LAB; SH; SB.
You can try, “let’s define terms,” and ask what’s the definition of a “useless human being”? You’ll find that no matter how you try to define it,
You can do this as a role-play, being a close friend trying to find out if you’re useless, and asking him for guidance on how to find out.
You can do the Paradoxical Double Standard Techniques, Downward Arrow, Hidden Emotion, Externalization of Voices, Acceptance Paradox / Self-Defense Paradigm, Examine the Evidence, Semantic Method, and on and on.
The problem is NOT that he’s a “useless human being” but rather that he’s obsessing and wasting time on a meaningless construct, and beating up on himself.
The whole key to success will be agenda setting. You can take the position that maybe this is not something that he really wants to challenge, since it may be working for him, and also reflects all those 25 wonderful things about him.
The whole key to success will be agenda setting. You can take the position that maybe this is not something that he really wants to challenge, since it may be working for him, and also reflects all those 25 wonderful things about him. Remember that just about 99.9% of therapeutic failure results from Agenda Setting errors. Is this something you want to help him with, or something he is desperately asking you for help with? I am almost 100% positive that this is your agenda, not his. In fact, your need to “help” him with this may actually keep him stuck.
In fact, here is the proof. You write: “I'm starting to have dreams about our next session when I fail him by trying to convince him to think as I do. How can I be open about our conclusion when my mind is already fixed?”
If you don’t understand this, I recommend some supervision from a TEAM therapists or join one of the online classes, or attend my workshop on resistance, coming up in a month or so, check out my website workshop page for details. You can join online.
David D. Burns, M.D.
Hi Dr. Burns,
Thank you so much for your quick and thorough response!
I kinda felt that my "helping" is the issue here as I've felt my own frustration rising...
Thanks for reminding me that uselessness is just a meaningless concept, I needed that. And I love the idea of role-playing as a friend asking for help with defining his uselessness. I'll pace myself, though, and give us time to walk through all the steps, especially Empathy and Agenda Setting and check how it goes and what my clients wants, not I.
I appreciate information on the resources and supervision I can access online, so good to know there are options!
You can use my real name, can't wait to hear the podcast :).
Karolina
Thanks for listening today! By the way, if you are looking for CE credits or training in TEAM-CBT, my upcoming workshop on therapeutic resistance on February 9, 2020 will be a good one. You'll learn how to use the techniques described in today's podcast.
See below for details and links!
David