The "Inner vs. Outer Solutions" By David D. Burns, MD*

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1 Page 1 The "Inner vs. Outer Solutions" By David D. Burns, MD* When we are criticized by a patient, friend, or family member, or get negative feedback on during a role play, it s easy to feel anxious and spaced out, or ashamed or annoyed. We may get flooded with all kinds of negative emotions. This makes it far more difficult to respond skillfully, using the Five Secrets of Effective Communication. The Five Secrets represent the outward solution, because that s how you convert a failed relationship or conflict into a vastly improved, trusting relationship. But your own use of the Daily Mood Log will be the key to the inner solution. A colleague might tell you that you got a "B" or a "C" in a role-play, and that while you did certain things really nicely, you made some errors and there is room for improvement. For example, you may be told that you did not acknowledge the patient's anger during the role-play, or did not really grasp or disarm the essence of the patient's criticism, or did not use an "I Feel" statement. These are errors we all tend to make, and these would be some specific areas you can focus on if you want to improve your interpersonal skills. For example, you can practice the Five Secrets, one at a time, repeatedly, until you get really good at each one. If you aren t good at Feeling Empathy, you could do about ten Feeling Empathy responses in a row with the help of a colleague. This would take about ten minutes, and you d get pretty good at acknowledging anger and other negative feelings, if that was one of your blind spots. However, when you get negative feedback, you might get upset, thinking that you "failed," or you might tell yourself that you are no good, or that you SHOULD have done better, or that you will be judged or rejected by other group members. If you want to learn how to minimize those kinds of reactions, you can use the Daily Mood Log, starting with the Event and Emotions, just as you would use with a patient. Then you can record these Negative Thoughts (NTs) using short sentences. Number them and indicate how strongly you believe each one in the Percent Belief column. Then see if you can pinpoint some of the distortions in your thoughts. Here are a few examples of the kinds of distortions you may discover:

2 Page 2 The Ten Distortions that Make it Difficult to Use the Five Secrets of Effective Communication Effectively 1. All-or-Nothing Thinking. You tell yourself that if you re not awesome when using the Five Secrets, you ve failed completely. Shades of gray do not exist. This has also been called the fixed vs. growth model of learning. 2. Overgeneralization. You overgeneralize from some specific problem (such as needing to do more work on the Disarming Technique) to your entire "self," telling yourself that you re "a failure. You are beat up on your self, rather than focusing on the specific skill you need to learn and practice. 3. Mental Filter. You selectively focus on all your errors and shortcomings and overlook your strengths as well as what you are learning. 4. Discounting the Positive. You discount your own capacity to learn and grow through repeated practice. You may also discount the tremendous value of learning from your mistakes and failures. And you may discount your skills, thinking they don t count because you screwed up or made errors in a practice exercise, or during a therapy session with a patient or problematic interaction with a friend of loved one. 5. Jumping to Conclusions. You jump to conclusions not supported by facts. Fortune-Telling. You may predict endless failure and defeat, thinking you will never learn and or develop good therapy skills. You may also tell yourself that when you do a role-play you will blow it completely (Allor-Nothing Thinking, Fortune Telling) and look like a fool (Mind-Reading, Overgeneralization, Labeling, Fortune Telling.) During a conflict with a challenging patient or loved one, you tell yourself that he or she will never change. Then may feel hopeless, frustrated, or overwhelmed. Mind-Reading. You may be thinking that your colleagues and teachers are judging you, or looking down on you, or disliking you when you screw up in a role play exercise or if you ask a foolish question. 6. Magnification and Minimization. You may Magnify your errors, failures, or shortcomings, or Minimize your own strengths. 7. Should Statements. You use shoulds, shouldn ts, musts, ought tos, and have tos. Self-Directed Should Statements. You may be telling yourself, "I should be better at this, or I shouldn t have made that mistake again. Other-Directed Should Statements. You may be telling yourself that your patients or loved ones shouldn t be so unreasonable or critical, or that they should appreciate your efforts, or that they should be more motivated, or that they shouldn t insist on constant venting. 8. Labeling and Mislabeling. You may think of yourself or someone else as a loser, a failure, or inept or unlovable, or a bad father (or mother or teacher or therapist.) 9. Emotional Reasoning. You reason from how you feel to how you are. So if you feel inadequate, inferior, hopeless, or ashamed, so you may conclude that you really are inadequate, inferior, hopeless, or bad. Blame Self-Blame. You may use up your energy beating up on yourself instead of figuring out how to improve in the specific area where you are weak, or where you need to grow. Other Blame. You feel like a victim and tell yourself that the other person is entirely to blame for the problems in your relationship. You may tell yourself that people should be more tactful and respectful, or shouldn t think and feel the way they do. You may tell yourself that your patients, students or children shouldn t be so resistant, needy, lazy or argumentative and that they should take more initiative and should be more willing to work on solving their problems with the wonderful tools you are offering them.

3 Page 3 Underneath those distorted thoughts you will frequently find a number of familiar Self- Defeating Beliefs, such as Perfectionism, the Approval or Achievement Addictions, or Entitlement or Submissiveness, to name just a few. Working on the inner solution gives you the chance to grow significantly when learning the Five Secrets. You may need to spend time on both the inner and outer solutions to do good clinical work, because if you are busy beating up on yourself and feeling anxious, ashamed, defensive, frustrated, or resentful, it makes it harder to respond to the other person with warmth, and harder to use any of the Five Secrets skillfully. Everything I have said is so obvious and basic that I may sound rather ridiculous in writing this. Still, I am convinced that the personal work is (the inner solution) is absolutely necessary if you hope to develop excellent Five Secrets skills, and it will make your learning more fun as well. The problem is almost never our failures, but rather the shame we feel because of our distorted thoughts about our failures. In fact, someone once said that your greatest therapeutic failures are actually your greatest successes in disguise. Do you grasp what that means? If not, ask in group. Once you ve pinpointed your own NTs and identified the distortions in them, you can take one of your NTs and put it in a Recovery Circle. Then you can select ten to fifteen or more techniques to challenge that thought. Of course, you will want to do your own Paradoxical Agenda Setting first. What do your negative thoughts and feelings show about you that is positive and awesome? And what are some advantages or benefits of your negative thoughts and feelings? Working on the Inner Solution can help you with the Outer solution, and may also show you how to help many of your patients who struggle with similar self-doubts. You can find an example of how to set up your Daily Mood Log on pages 5 and 6. This was a man who was upset during a workshop because he kept making errors when he was trying to learn the five Secrets. See if you can identify one or more cognitive distortions in each of his Negative Thoughts, and record them in the Distortions column using abbreviations, as I have done for his first Negative Thoughts. Then see if you can write down a Positive Thought (PT) for each NT that will have two characteristics: David 1. The PT is 100% true. 2. It drastically reduces the belief in the NT.

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6 Common Five Secrets Therapist Errors Page 1 Common Five Secrets Therapist Errors By Jill Levitt PhD and David D. Burns, MD* This table will provide you with an understanding of errors that nearly all therapists make when first trying to learn the five Secrets of Effective Communication. Reading and studying this table with not improve your ability to use the Five Secrets. This can ONLY be achieved through frequent practice with feedback from colleagues. That s because most of these errors such as defensiveness when criticized seem to be hard-wired into our neurologic system. Many, or perhaps most, of these errors arise from the emotional responses of therapists to conflict or criticism or failure. These responses tend to cluster in two patterns. The first pattern is I m no good. This involves anxiety and shame, and results from intense self-criticism. The second patter is You re not good. These responses typically involve should statements and blame directed toward the patient. Overcoming these two patterns may require you to do your own work on a personal Daily Mood Log. You may need some help from your therapist, a trusted colleague, or your training group. There s an incredibly useful practice technique that will help you master the Five Secrets. In training exercises, we ve noticed that different therapists tend to have difficulty with one or another of the Five Secrets. For example, the hardest technique for me (DB) to master was the Disarming Technique, because I naturally tend to have an argumentative tendency. So it was difficult, at first, to see the truth in criticisms I thought were exaggerated or unfair or off-base. I ve seen therapists who ve had extreme difficulties with Thought Empathy, or Feeling Empathy, or I Feel Statements, or any of these techniques. As a first step, see if you can identify your blind spot when you practice with the Five Secrets. You may have trouble with more than one of the techniques, but you can focus on learning them one at a time. Let s say you notice that over and over again you tend to do poorly on Feeling Empathy. You can set up what I call the Zen Exercise, for lack of a better name. Get a copy of my Feeling Words Chart, and hold it in your hand. Then ask one or more colleagues to attack you, using only one or two sentences. For example, they might say, You re not helping me. This therapy is a waste of time! Your job is to respond ONLY with Feeling Empathy. You can use a formula such as, I can imagine you might be feeling X, Y, and Z, where X, Y, and Z are words you ve selected from the Feeling Words chart. For example, you might say something like this: Wow, I can imagine you might be feeling discouraged, disappointed, frustrated, and perhaps even a bit angry with me. It will probably sound artificial, because you re only allowed to use ONE technique. Ask your colleagues if you got it right and did a good job. If you didn t, ask them what you missed and try again. If you did a good job, ask them to attack you again and again. After ten or fifteen iterations, you ll be really good at the technique that you found the most difficult! It only takes about ten minutes or so. Learning to use the Five Secrets requires lots of hard work and practice. The good news is that the process of learning and overcoming your own defensiveness can transform not only your clinical work with patients, but also your personal and professional relationships as well. Another fun way to integrate five secrets practice into your life is to pick one day of the week and designate it the day for the Disarming Technique, or I Feel Statements or whichever secret you need to work on. If Monday is disarming day, try to disarm anything that comes your way. You can disarm people in the grocery store, or your family members, or your patients, or the person who cuts you off in traffic (e.g., You re right, I WAS driving kind of slowly, and you re in a hurry! ) Copyright 2015 by Jill Levitt PhD and David D. Burns, MD

7 Common Five Secrets Therapist Errors Page 2 Technique Common Therapist Errors When Trying To Use this Technique Emotional Barriers to Using this Technique Skillfully The Disarming Technique Thought Empathy Feeling Empathy You can t see the truth in what patient is saying because you want to be right, or because you ve been trained to see the patient s criticism as transference or a distortion based on his or her diagnosis. You don t disarm at all (skipping this step) but instead, simply paraphrase what the patient is saying. You use disarming in words only, saying something patronizing, like I can see why you might feel that way. This is a subtle putdown that implies that the patient is wrong. You use the Disarming Technique in a half-hearted way, without seeing the full truth in what the patient is saying. Skillful disarming is usually emphatic, saying things like: "you are absolutely right," or "this makes a lot of sense", or "I have to agree with you on this." You tend to leave out the most important parts of what the patient is saying because you didn t jot the patient s comments down, or because you want the most threatening comments to go away. When you paraphrase the patient s words, you put your own spin on them, instead of using the patient s exact words. You add more on, or make an interpretation, based on your training or school of therapy. You may do this because you want to appear smart, or because you think you re enhancing what the patient says when, in fact, your interpretation is off-base. You paraphrase in a robotic, formulaic way, without I Feel Statements, so your response sounds like a gimmick or a formula. You forget to acknowledge the patient s anger, especially his or her anger with you. This error is almost universal and almost impossible to overcome without considerable determination and practice. Pride / shame--we want to avoid the death of the ego. Defensiveness--Our professional identity may be threatened by the patient s criticism, which implies we are not competent, or sufficiently caring, etc. Fear we think that something bad will happen (escalation, lawsuit, gossip) if we agree with a patient who is angry and critical of us. Anger we label the patient as the enemy, or bad, or unfair, or irrational, and want to get back at him or her. Competition we are afraid we ll seem unprofessional or weak if we give in. Power you feel you must put limits on your patient s criticisms, or counter them, or else you ll reinforce the patient s negative behaviors and the aggressive statements will spiral out of control. Anxiety you feel so anxious and panicky when the patient criticizes you that you concentrate on what you re going to say next. As a result, by the time the patient finishes, you have almost no idea what he or she said, and respond at right angles. This irritates the patient because it s clear you weren t listening, and the problem escalates. Emotophobia this is the fear of negative emotions in general. Conflict Phobia / Anger Phobia this is the fear of anger and conflict. Copyright 2015 by Jill Levitt PhD and David D. Burns, MD

8 Common Five Secrets Therapist Errors Page 3 Inquiry I Feel Statements You say "you must be feeling X, Y, and Z" instead of saying, "I wonder if you might be feeling X, Y, and Z" This sounds like an accusation and may put the patient on the defensive. In addition, you may not be reading the patient s emotions correctly. You minimize the patient s emotions. For example, you might say, "you seem a little bit irritated at person X" instead of "it sounds like you might be feeling furious with person X." But this has to be balanced with the next consideration. You accuse the patient of being angry ( You re clear angry with me ), instead of softening the anger and making it acceptable, as in: Given what you just said, I wouldn t be a bit surprised if you re feeling a bit annoyed or even angry with me, and for good reason. Can you tell me more about how you are feeling? In this case, the four softeners make it easier for the patient to own up to the anger: 1. if you re feeling; 2. a bit; 3. annoyed or even angry: 4. and for good reason. You forget to acknowledge the tender feelings (such as feeling hurt, lonely, sad, lonely, rejected, put down, and so forth) that are nearly always associated with harsh, negative feelings such as anger. You ask questions that lead to problem-solving or helping. For example, you might say, How can I help you more? This is not inquiry, because the patient is not your supervisor and does not know what you should be doing differently. Asking how you could do better is also a form of therapist conflict phobia, because you re trying to make nice, rather than asking about the patient s negative and potentially upsetting feelings about you. Inquiry is encouraging patients to tell you more about how they think and feel, as well as the problems you re not helping them with. You don t express your feelings. Instead, you make a comment about the patient that begins with I feel that you... Examples might be, "I feel that you re not listening, or I feel like you re There are, in general, only two types of feelings that therapists cannot deal with: your own feelings and your patients feelings. However, few therapists are aware of this, and wrongly believe they are good at dealing with feelings. For more information, see the emotional barriers to I Feel Statements below. Codependency you cannot resist the compulsive need to jump in and help. Conflict Phobia / Anger Phobia you are afraid of the patient s negative feelings, so you want to divert the conversation to something that is nicer and more positive. Anxiety you feel threatened by the patient s criticisms because they trigger your own self-criticisms and feelings of inadequacy. You avoid talking about your negative feelings because you ve been trained never to reveal your feelings to your patients. Copyright 2015 by Jill Levitt PhD and David D. Burns, MD

9 Common Five Secrets Therapist Errors Page 4 Stroking wrong. These You Statements involve blaming or criticizing the patient instead of expressing your feelings. You express your feelings in an overly dramatic or self-effacing way that makes the patient feel pity for you. For example, you might say, "Yes, my wife also accuses me of not listening, and she just filed for divorce. I hear this from my other patients, too. In fact, most of them have dropped out of therapy. PLEASE don t leave me! Your comment does not sound genuine. For example, after a severe criticism, you may say, Oh, I m so happy you shared that with me, when in fact you re not feeling at all happy. You re actually feeling defensive, annoyed, anxious, frustrated, and on the spot! Your attempt at a compliment sounds formulaic: "Good for you for coming in here today!" Your comment sounds phony and self-serving: Or I m so glad you told me the therapy has been a waste of time. You re becoming more assertive, just as I ve been teaching you to do. Your comment is non-specific: You are a great person or you are a wonderful patient. This compliment is more specific: I admire how thoughtful you are of your family members, and how hard you work to keep them happy. Your comment does not sound genuine: It was very brave of you to tell me that my comments often sound phony (when it did not take courage at all, and you still sound phony!) You avoid talking about your negative feelings because you ve made the subconscious and automatic judgment that you shouldn t be feeling the way you do. In other words, you think you shouldn t be feeling angry, or anxious, or ashamed. You are convinced that these feelings are inappropriate, or unprofessional, or wrong. You may also be convinced that others would judge you if they knew you felt this way. This emotional censoring happens so quickly and automatically that most therapists simply don t notice they re hiding and suppressing their feelings. Anger / frustration. When you get angry with anyone, including a patient, there s a tendency to think about that person in a globally negative way, so you can t think of anything positive to say about him or her. Love / hate dichotomy. Most humans, including most therapists, act as if there was an all-or-nothing split between positive vs. negative emotions. So if you re angry with someone, it means you can t simultaneously have positive feelings for that person. Defensiveness. You feel hurt by the patient s comments and feel an overwhelming urge to defend yourself. Copyright 2015 by Jill Levitt PhD and David D. Burns, MD