As you know, I have created many powerful communication
techniques, including the Five Secrets of Effective Communication
and more. One of the additional techniques is called “No” Practice,
and it’s designed for people who have trouble saying “no,” or
setting limits with other people. Essentially, you do a role-play
with a colleague or therapist who keeps pestering you with pushy
demands, and you have to practice saying “No” in a polite but firm
and assertive way.
Sounds simple, right? But it’s not! People have many reasons
for not wanting to say “No.” For example, you may be afraid of
hurting the other person’s feelings, or letting them down, or
running the risk that they may get mad at you if you don’t say,
“Yes.” In addition, you may feel like you’ll miss out on some
special activity if you say no, so you end up way
over-committed.
In this session, you will meet an exceptionally compassionate
and highly trained young psychiatrist named Lee, who asked for help
with a problem relating to some of his patients. My co-therapist is
Dr. Jill Levitt, who is the Director of Clinical Training at the
Feeling Good Institute in Mountain View, California.
Lee explained how he struggles with saying “no” when patients
make inappropriate requests, like pushing for a medication they’re
addicted to, and wanting premature discharge from the inpatient
unit when they have unrecognized safety issues. Instead, he seems
to get drawn into long explanations of his thinking and
why he’s declining the other person’s requests, sometimes
for half an hour, and ends up frustrated when the other person
still doesn’t “get it” and with himself for spending the time.
People often think that therapy is easy, and that people just
need encouragement, advice, or behavioral practice to change the
way we interact with others. But as you will vividly see in this
session, that is often not the case, and things that may seem
simple or obvious can seem almost impossibly difficult to
learn.
Why does this happen? Why is it so difficult for people to
learn new and seemingly simple verbal skills? Well, to find the
answer, we have to go back to the teachings of the Buddha and
Epictetus, who taught us that our negative feelings do NOT result
from what’s happening, but from our thoughts.
What does this mean? Well, Lee is an incredibly intelligent and
compassionate young psychiatrist, and he’s clearly highly
motivated, and yet he seems very slow in learning how to say “no.”
Can his thoughts illuminate his apparent resistance to learning a
new approach?
During the session, Dr. Levitt reminded us of the fact that
whenever you are involved in a conflict with someone, or any
interaction for that matter, there are always two dialogues going
on: the Inner and Outer Dialogues, and if you ignore either one of
them, you may have difficulties triggering change.
The Outer Dialogue involves what you say to the other person,
and what they say next, and how you respond. For example,
Patient says: “Doctor, I want to get discharged from the
hospital.”
Lee says: “No, I can’t do that because you’d be in danger and
without a place to live. You’d be living on the streets, and it
wouldn’t be safe for you.”
Patient (who is in a state of psychosis) responds: “No doctor,
I’ll be okay, because I’m living with Michael Jackson.”
Then Lee tries to explain his thinking again, and then the
patient asks to be discharged from the hospital again. And this
cycle repeats itself many times, over and over, for as much as an
hour. And they both end up frustrated and a bit miffed.
Why is it so hard for Lee to say no in a kindly way and then
move on to some other activity?
That’s where the Inner Dialogue can be so important. It appears
that Lee has two types of distortions that interfere with his
ability / willingness to say “no.”
Self-Directed Should Statements. Lee appears
to believe that he “should” be able to explain his thinking to any
patient. He wants to convey respect, responsiveness, and care when
denying a request. This is, of course, an expression of his high
standards, his compassion, and his desire to communicate clearly to
his patients. But, as is so often the case, Lee takes this goal a
little to far, think he should “always” be able to do this,
regardless of how psychotic or confused or demanding a patient
might be. Essentially, the healthy pursuit of excellence as a
psychiatrist has gone a little too far and has arguably morphed
into a self-defeating kind of medical perfectionism.
Self-Directed Shoulds typically trigger feelings of guilt,
shame, anxiety, and inadequacy. They are often accompanied by
several other distortions, including All-or-Nothing Thinking,
Mind-Reading, and Self-Blame, to name just a few.
Other-Directed Should Statements. Lee appears
to think that his patients “should” understand and acknowledge his
thinking if he’s being reasonable and realistic. He may also
believe that if he’s doing his best, then his patients “should”
argue fairly and acknowledge when they understand what he tells
them and “shouldn’t” be manipulative, unreasonable or
argumentative.
Other-Directed Shoulds often trigger feelings of frustration
and anger, and are often associated with All-or-Nothing Thinking,
Mind-Reading, Emotional Reasoning, and Other-Blame, to name just a
few.
Another teaching point is that we nearly always create our own
interpersonal reality, but we don’t realize that because we feel
like victims and see the problem as coming from outside of
ourselves. Lee’s urge to continue to try to “win” the arguments
with patients actually forces them to keep arguing their case and
trying over and over again to get their way. That’s just human
nature. We’ve all seen that people can be pretty obstinate and
determined to get their way, no matter what. That’s why a focus on
what you can do to change will often lead to a change in other
people; in contrast, repeated efforts to persuade them to change is
almost never effective.
By way of analogy, my wife and I have recently had a bit of a
problem with our cat, SweetiePie. She was a rescue cat, and we love
her to death, and do everything we can to make her happy. She loves
us intensely and shows her gratitude with loud purring almost all
day long when she’s not asleep or out in the back yard
exploring.
BUT, she has been pestering us for cat candy, and has gained
too much weight. Here’s what happens. She jumps up on my desk, and
puts her paw on my keyboard, and stands if front of the computer
terminal so I can’t see. So, I give her two or three pieces of cat
candy on her perch next to me.
She jumps up and greedily devours it.
Next, she jumps back on the desk and puts her paw on the
keyboard. I “explain” to her that she’s eating too much candy, and
try to put her back on her perch, so she swats me with her claws
and draws blood if I’m not quick to pull my hand away.
So, I give her a few more pieces of candy, which she devours
and then goes to sleep.
Similar routine with my wife. She follows her, crying like
she’s on the verge of death, and swatting at her ankles until she
gets cat candy and / or a 30 minute lap snuggle.
So, in short, we have been “forcing” her, inadvertently,
out of love, to manipulate us for cat candy. In other words, we
“reward” her manipulations by giving her cat candy and love. As a
result, our pour girl is gaining too much weight.
Of course, the solution is simple. Melanie has agreed to give
her only four pieces of cat candy per day, and I am limiting her to
two pieces, just so she’ll know she’s still loved. And when she
tries to swat me with her claws, I just explain in a kindly way
that I don’t like that and put her on the floor.
She caught on right away and seems to have accepted the new
routine. Of course, we continue to give her abundant helpings of
love every day, many times a day, as the love has zero
calories!
So, what’s the bottom line? If you’re trying to learn the Five
Secrets of Effective Communication, and you want to change the way
you communicate with others, remember to attend to your Inner
Dialogue, as well as what you are actually saying to the other
person during the conflict, especially if you’re getting anxious,
defensive, angry, frustrated or upset.
If you write down your negative thoughts, I think you’ll find
many similar distortions to the ones described above, and this can
give you another handle on change the way you think, feel, and
connect with the people you care about, as well as the ones you
don’t!
Incidentally, the belief that we are separate from others and
from our environment is the essence of evil, according to some
Buddhists, and perhaps nearly all of the world’s religions have had
similar beliefs, though couched in different language.
But what this means to me is that when we struggle with friends
of loved ones, and we are locked into frustrating conflicts, we
typically feel like we are “separate” from the other person who is
“doing something” to us. And this perception can not only trigger
anger and frustration, but sometimes even violence.
As humans, we seem to have great difficulty “seeing” our own
role in the conflict. And sometimes, we don’t even WANT to, because
the so-called “Great Death” of the self can be very painful. This
is especially true when we see ourselves as morally superior to the
other person who is “bad” or “to blame.”
We are indebted to Lee for giving us this superb example of a
problem that nearly all human beings struggle with, and also
sharing his vulnerability and humanness with all of us in such an
open and generous way! And we salute and thank Lee for courageously
showing us the way with an intensely personal and real
example.
Contact info
Dr. Rhonda Barovsky practices in Walnut Creek and Berkeley,
California. She can be reached at
rhonda@feelinggreattherapycenter.com. She is a Level 5 Certified
TEAM-CBT therapist and trainer and specializes in the treatment of
trauma, anxiety, depression, and relationship problems.
You can reach Jill Levitt, Ph.D. at
jilllevitt@feelinggoodinstitute.com. She is the Director of
Clinical Training at the Feeling Good Institute in Mountain View,
California (www.feelinggoodinstitute.com)
The following are a few of the comments in the feedback at the
end of the Tuesday class. These are comments from the mental health
professionals who observed the session with Lee.
Please describe what you specifically disliked
about the training? What could have been improved? Were there some
things you disagreed with or did not understand?
LOVED it!
NOTHING
Can't think of anything
I only wish that we could have more time for this work with
Lee.
I kept feeling like I wanted to jump in and try some of these
skills myself.
Please describe what you specifically liked
about the training? What was the most helpful? Were there some
things you learned?
I liked the externalization of resistance and would've like to
see more with that or maybe even a “rules & roles” regarding
patient/doctor relationships.
I really liked Lee’s work. I also struggle with saying no, and
I liked all of the role reversals and honest feedback from everyone
involved.
I found Jill's insight at the end of the session regarding the
conceptualization of the problem, particularly the internal versus
external solution (during the “no” practice), to be quite valuable.
It was clear that Lee was facing conflicting desires - the need to
act in the best interests of his clients while also seeking
acceptance and approval. Taking the time to delve deeper into those
internal factors may have further strengthened the effectiveness of
the external solution (the “no” practice).
Was helpful to see the miracle cure/goal clarified, as well as
the 'acid test'.
Good to see the model in action!
I just enjoyed Lee's honesty , caring and professionalism. He
brought up an issue that has been close to my heart as I worked
with schizophrenic patients in clinic and day hospitalization
settings and have experienced EXACTELY what Lee described. You feel
between the devil and the deep blue sea when the medical staff
conveniently toss responsibility to the less professional staff and
when those in the trenches need to be there for the patients by
saying NO. I LOVED David's comment about being disrespectful to
patients with schizophrenia by going on and on with lofty brainy
arguments while the loving thing to do is to be empathic stroking
and firm. From my experience when I am real with my patients, they
feel the best. Thank you, Lee, David and Jill. This was beautiful ,
heartwarming, and I am so touched to belong in this group.
David and Jill's exquisite empathy, the Positive Reframe, and
the NO practice.
EVERYTHING!!! This was truly incredible! David and Jill are an
unbeatable tag "TEAM!" Jill's warmth and empathy and teasing out
the variables of Lee's story that were not always apparently
obvious. Lee's vulnerability and seeing his depth and caring as a
Psychiatrist was heartening and impressive.
It helped me understand the flow of TEAM CBT and how things fit
together better by seeing a live session from the beginning.
I LOVED that Dr. Burns and Jill had to go down several
different avenues to see what would work best. This closely
reflects my own experience of therapy with my patients. Seeing them
struggle a little made me feel even more sure that TEAM is the only
approach that makes sense and cures people.
This was a really wonderful session. I appreciate Lee
volunteering, sharing with us his work challenges, and allowing us
to see his kind and caring personality. I loved the masterful work
of Jill and David. It seems to me that practicing responding to his
patients with the use of the 5 secrets was imperative and I was
amazed to see how that helped dropping down the feelings on the DML
before we got to work on the Negative Thoughts. Once again, TEAM
works like a charm!
That this was a powerful real life issue that Lee shared. I
enjoyed the empathy and how that led to sorting out
conceptualization and miracle cure.
David and Jill's combined efforts to go in many directions to
help Lee see where he is stuck.
I struggle in exactly the way Lee does in these sorts of
situations, and it was so helpful and inspiring to me to see him do
this work. Thank you, Lee! I was deeply moved by your deep caring
for your patients and values around wanting your patients to have
agency and understanding when there's so little in their world that
they can control. I wish every psychiatrist had more Lee in
him/her/them!
I appreciate that Lee opened up himself in the group and I
could observe the personal work of David and Jill, the amazing
masters of TEAM-CBT. I admire Lee's compassion and warm heart
toward his patients and I owed a lot to Lee who has very high
standards to make things clear, just as he has done in his teaching
in our Newbie group. And I think his sadness and anger might be an
expression of his passion toward justice and dignity of his
hospitalized patients.
Appreciated Lee sharing with the group and doing personal work
on a challenging problem. Liked when Jill brought up the internal
versus external solution and then the session switched gears to
work on the negative thoughts that made it so difficult for Lee to
say no.
Really enjoy the personal work, and getting to see the TEAM
process unfold in skillful hands. I appreciate that you gave Lee
time to explain his points, and that he was able to be truthful and
disagree at times, and then you asked why and he explained further.
This led to a more nuanced exploration and conceptualization of his
issues and goals. I liked the focusing of a major part of the
problem of "saying no" to a relationship / Five Secrets
issue...resulting from internal and external shoulds. I appreciated
the comparison with parent/child discipline, and not getting sucked
into arguments. I also appreciate that you were able to pinpoint
the problems around trying to get desperate, even schizophrenic
patients, to understand one's point of view.
It was great seeing the modeling of how to respond to some of
these difficult patient situations. And how to clearly define the
agenda when a patient is unclear about their goals. Also, so
admiring of Lee.
I liked how Jill and David navigated figuring out what Lee
wanted to work on (when they came up with the three options).
Issues that have "internal" and "external" components to them are
difficult for me, and I often get confused. Seeing Jill and David
work that out helps me wrap my head around how to go about it,
thanks.
Please describe what you learned in today’s
group.
I appreciate Lee's vulnerability and I have so much respect for
how he cares for his patients. I appreciated seeing the multiple
role-playing attempts and was bummed when we ran out of time. I
have so much admiration for Lee and feel for how much he's
struggling.
Personal work, externalization of voices, magic dial, Daily
Mood Log (DML), 5 secrets, etc.
How Five Secrets and No practice fit within the DML work
That they could have started on the internal work of negative
thoughts or the external work of "NO practice"
TEAM at it's best!
I observed NO practice and would like to learn more
specifically about it ...
Seeing the TEAM model unfold step by step in real time is
always an incredibly valuable learning experience. Hearing Jill
entertain potential directions to go in (i.e. crushing negative
thoughts vs. No practice.) Learning challenging scenarios in
context of "NO" practice was really awesome! Just magnificent
overall! THANK YOU!!! Always feel so privileged to be part of this
uniquely wonderful community of like-minded professionals! We are
so lucky!
I don't have to be smooth and have all the right answers
immediately. This process is highly collaborative.
How to employ the team model especially conceptualization and
role play with NO practice and Five Secrets practice.
How dealing with severely mentally ill pts can be so
difficult.
There's a sixth secret in effective communication: the
willingness to use one's power in a kindly way to give the shot and
get it over with. It's so helpful to me to add this secret to my
armamentarium!
Positive reframing and No practice, along with Externalization
of Voices and Externalization of Resistance.
I learned something about Lee, and about the difficulties of
psychiatric hospital work for doctors! Also, seeing the process
unfold skillfully, teasing out the problem to work on,
Externalization of Resistance, Positive Reframing, Externalization
of Voices, No/5 Secrets Practice, etc.
How to be clear on agenda setting when patients are unclear on
their goals.
I was reminded about how to ask about a client's goal in order
to guide agenda-setting.
It was nice seeing the five secrets role-play / no practice.
I've been inspired to start practicing daily like David said he
did. Can never get enough of that!
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!