The Therapist s Craft Overcoming Therapeutic Resistance. TEAM Therapy. Overcoming Resistance / Burns. Copyright 2013 by David Burns, M.D.

Transcription

1 The Therapist s Craft Overcoming Therapeutic Resistance David D. Burns, M.D. Adjunct Clinical Professor of Psychiatry and Behavioral Sciences, Stanford Medical School 1 TEAM Therapy T = Testing E = Empathy A = Agenda Setting M = Methods 2 Anxiety Use checks ( ) to indicate how you're feeling right now. Session After Session 1. Anxious 2. Frightened 3. Worrying about things 4. Tense or on edge 5. Nervous 0 Not at all 1 Somewhat 2 Moderately 3 A lot 4 Extremely 0 Not at all 1 Somewhat 2 Moderately 3 A lot 4 Extremely Total 17 Total 12 Copyright 2013 by David Burns, M.D. Page 1

2 Session After Session Anger Use checks ( ) to indicate how you're feeling right now. 0 Not at all 1 Somewhat 2 Moderately 3 A lot 4 Extremely 0 Not at all 1 Somewhat 2 Moderately 3 A lot 4 Extremely 1. Frustrated 2. Annoyed 3. Resentful 4. Angry 5. Irritated Total 3 Total 13 Empathy 0 - Not at all true 1 - Somewhat true 2 - Moderately true 3 - Very true 4 - Completely true 1. My therapist was warm, sympathetic, and concerned. 2. My therapist seemed trustworthy. 3. My therapist treated me with respect. 4. My therapist did a good job of listening. 5. My therapist understood how I felt inside. Total Score 17 Helpfulness 0 - Not at all true 1 - Somewhat true 2 - Moderately true 3 - Very true 4 - Completely true 1. I was able to express my feelings during the session. 2. I talked about the problems that are bothering me. 3. The techniques we used were helpful. 4. The approach my therapist used made sense. 5. I learned some new ways to deal with my problems. Total Score 7 Copyright 2013 by David Burns, M.D. Page 2

3 TEAM Therapy T = Testing E = Empathy A = (Paradoxical) Agenda Setting M = Methods 7 What s The Most Common Cause of Therapeutic Failure? Jumping in and trying to help without making the patient accountable Therapist niceness, codependency, and narcissism can be formidable barriers to effective treatment Agenda Setting corrects this problem 8 Goals of Agenda Setting Bring resistance to conscious awareness Melt away the resistance and make the patient accountable before trying to help the patient The failure to do this is BY FAR the most common cause of therapeutic failure 9 Copyright 2013 by David Burns, M.D. Page 3

4 Two Types of Resistance Outcome Resistance Concept of Magic Button Process Resistance There is no Magic Button 10 Depression Resistance in a Nutshell Outcome Resistance You ll have to accept something about yourself that you don t want to accept Process Resistance You ll have to do psychotherapy homework 11 Anxiety Resistance in a Nutshell Outcome Resistance You probably believe the anxiety will protect you from something terrible Process Resistance You will have to confront your worst fears using powerful Exposure Techniques 12 Copyright 2013 by David Burns, M.D. Page 4

5 Relationship Resistance in a Nutshell Outcome Resistance You probably don t want to get close to the person you are complaining about Process Resistance You ll have to Stop blaming the other person Give up the role of victim and pinpoint your own role in the problem Focus entirely on changing yourself 13 Habit and Addiction Resistance in a Nutshell Outcome Resistance You ll have to give up something intensely pleasurable and rewarding Process Resistance You ll have to start doing something uncomfortable and depriving 14 Example of Paradoxical Agenda Setting Therapist who felt intensely ashamed, angry, anxious, and inadequate See Melanie s Daily Mood Log in your syllabus 15 Copyright 2013 by David Burns, M.D. Page 5

6 Melanie s Daily Mood Log Upsetting Situation: Call from a church member offering condolences. Goal After Sad, down, depressed 50 Embarrassed, foolish, humiliated 100 Anxious, worried, panicky, nervous 100 Hopeless, discourage 25 Guilty, ashamed 100 Frustrated, stuck, thwarted 80 Inadequate, defective, incompetent 95 Mad, resentful, annoyed, irritated 75 $ Goal After NT After Dist PT Belief 1. I m a failure She ll tell other people who will judge me I'm defective I can t maintain a relationship People will think that men dump me. 65 Melanie s Daily Mood Log (cont d) NT After Dist PT Belief 6. People will laugh at me My reputation will be tarnished People will wonder how I can help troubled couples when I keep running away from relationship problems. 9. My children will be humiliated at my funeral. 10. People will think I deserve to be punished. 11. My therapist may be feeling shocked and holding back. 12. That would mean the problem may be even worse it would mean I really am defective Outcome and Process Resistance Example Can you think of several possible sources of Outcome Resistance Why might Melanie be reluctant to push the Magic Button? Process Resistance There is no Magic Button. What will Melanie have to do, that she won t want to do, in order to experience a miracle today? 18 Copyright 2013 by David Burns, M.D. Page 6

7 Daily Mood Log Upsetting Situation: Call from a church member offering condolences. $ Goal After Goal Sad, down, depressed Embarrassed, foolish, humiliated Anxious, worried, panicky, nervous Hopeless, discourage 25 0# Guilty, ashamed Frustrated, stuck, thwarted 80 0 Inadequate, defective, incompetent Mad, resentful, annoyed, irritated 75 0 After NT After Dist PT Belief 1. I m a failure. 2. She ll tell other people who will judge me. 100 AON OG MF DP MAG LAB SB 100 AON OG MF DP MR FT MAG ER SB 3. I'm defective I can t maintain a relationship People will think that men dump me. 65 AON OG MF DP MAG ER LAB SB AON OG MF DP MAG SB AON OG DP MR FT ER First Video Excerpt Illustrates Several Outcome Resistance Techniques Straightforward Invitation Miracle Cure Question Dangling the Carrot Magic Button Acid Test Positive Reframing Magic Dial Sitting with Open Hands 20 First Video Excerpt Illustrates Several Process Resistance Technique Dangling the Carrot Gentle Ultimatum Sitting with Open Hands 21 Copyright 2013 by David Burns, M.D. Page 7

8 TEAM Therapy T = Testing E = Empathy A = (Paradoxical) Agenda Setting M = Methods 22 Flooding Self- Disclosure Survey Technique Empathy 2 Agenda Setting Feared Fantasy 9 She ll tell other people who will judge me Identify the Distortions Acceptance Paradox 8 7 Externalization of Voices Double Standard Straightforward Technique Downward Arrow Second Video Excerpt Paradoxical Double Standard Technique 24 Copyright 2013 by David Burns, M.D. Page 8

9 Daily Mood Log Upsetting Situation: Call from a church member offering condolences. $ Goal After Goal Sad, down, depressed Embarrassed, foolish, humiliated Anxious, worried, panicky, nervous Hopeless, discourage 25 0# Guilty, ashamed Frustrated, stuck, thwarted 80 0 Inadequate, defective, incompetent Mad, resentful, annoyed, irritated 75 0 After NT After Dist PT Belief 1. I m a failure. 2. She ll tell other people who will judge me. 100 AON OG MF DP MAG LAB SB 100 AON OG MF DP MR FT MAG ER SB Some people may judge me. 100 Most people will see the beautiful parts of my personality Those who judge me will make themselves look bad Daily Mood Log Upsetting Situation: Call from a church member offering condolences. $ Goal After Goal Sad, down, depressed Embarrassed, foolish, humiliated Anxious, worried, panicky, nervous Hopeless, discourage 25 0# Guilty, ashamed Frustrated, stuck, thwarted 80 0 Inadequate, defective, incompetent Mad, resentful, annoyed, irritated 75 0 After NT After Dist PT Belief 1. I m a failure. 2. She ll tell other people who will judge me. 100 AON OG MF DP MAG LAB SB AON OG MF DP MR FT MAG ER SB Some people may judge me. 100 Most people will see the beautiful pars of my personality Those who judge me will make themselves look bad Daily Mood Log Upsetting Situation: Call from a church member offering condolences. $ Goal After Goal Sad, down, depressed Embarrassed, foolish, humiliated Anxious, worried, panicky, nervous Hopeless, discourage 25 0# Guilty, ashamed Frustrated, stuck, thwarted 80 0 Inadequate, defective, incompetent Mad, resentful, annoyed, irritated 75 0 After NT After Dist PT Belief 1. I m a failure AON OG MF DP MAG LAB SB 2. She ll tell other people who will judge me AON OG MF DP MR FT MAG ER SB I ve successfully rebounded from past mistakes and unwise choices. I was successful in refraining from allowing adversity to rob me of my current happy eight-year marriage. Besides, no one has ever said I m a failure because of my three marriages. Some people may judge me. Most people will see the beautiful parts of my personality. Those who judge me will make themselves look bad Copyright 2013 by David Burns, M.D. Page 9

10 Daily Mood Log Upsetting Situation: Call from a church member offering condolences. $ Goal After Goal After Sad, down, depressed Embarrassed, foolish, humiliated Anxious, worried, panicky, nervous Hopeless, discourage 25 0# 0 Guilty, ashamed Frustrated, stuck, thwarted Inadequate, defective, incompetent Mad, resentful, annoyed, irritated NT After Dist PT Belief 1. I m a failure AON OG MF DP MAG LAB SB 2. She ll tell other people who will judge me AON OG MF DP MR FT MAG ER SB I ve successfully rebounded from past mistakes and unwise choices. I was successful in refraining from allowing adversity to rob me of my current happy eight-year marriage. Besides, no one has ever said I m a failure because of my three marriages. Some people may judge me. Most people will see the beautiful parts of my personality. Those who judge me will make themselves look bad Five Steps in Agenda Setting Invitation Step Specificity Step Conceptualization Step Motivation Step Methods Step 29 Two Types of Invitations Straightforward Invitation Depression and anxiety disorders Paradoxical Invitation Anger / relationship problems 30 Copyright 2013 by David Burns, M.D. Page 10

11 Straightforward Invitation You ve mentioned a number of problems that you ve been struggling with. I d like to offer you more than just listening and support. I have a number of powerful tools that I believe could help you tremendously... (Dangling the Carrot) 31 Straightforward Invitation (cont d) I m wondering if this would be a good time for us to roll up our sleeves and get to work on one of the problems you ve described, or if you need more time to talk and have me listen. Listening is important, and I don t want to jump in prematurely, before you feel ready. 32 What the Invitation Step Conveys I m aware that you are suffering. Solutions exist the situation is not hopeless. We will have to work together in an active way, as opposed to simply venting and listening. You will have to ask me for help if you want to change your life. 33 Copyright 2013 by David Burns, M.D. Page 11

12 Paradoxical Invitation You ve been telling me about how frustrated you feel with your sister. You ve mentioned how she never listens, and always has to be right, and always puts you down. I m wondering if you want some help with your relationship with her, or if you mainly just wanted to let me know how annoying she is. (Sitting with Open Hands) 34 Straightforward vs. Paradoxical Invitation Straightforward Invitation The therapist s assumption is that the patient probably does want help and is willing to collaborate Paradoxical Invitation The therapist s assumption is that the patient probably does not want help and is not willing to collaborate 35 Workshop Exercise: The Invitation Step Work in groups of 3 One patient, one therapist, and one observer 36 Copyright 2013 by David Burns, M.D. Page 12

13 Invitation Exercise (cont d) Patient will whine and complain about his or her life, but must NOT express anger toward the therapist We will assume that the therapist has done an excellent job of empathizing and has a warm and caring relationship with the patient. 37 Invitation Exercise (cont d) After the patient has finished complaining, the therapist will say empathy, empathy, empathy This is a form of shorthand. It means that the therapist has done a superb job of empathizing for 20 or 30 minutes, and the patient feels accepted and understood. Empathy, empathy, empathy is NOT something you would say during a real session! 38 Invitation Exercise (cont d) Now the therapist will do one last round of thought and feeling empathy, followed by the Invitation Step: Jim, you ve mentioned problems X, Y and Z, and I can see how depressed and worthless you ve been feeling. I d love to help you turn some of these problems around, and I m wondering if this would be a good time for us to get started, or if you need some more time to talk and just me have me listen. 39 Copyright 2013 by David Burns, M.D. Page 13

14 Therapist Instructions Summary The therapist will do four things after the patient has complained: Say empathy, empathy, empathy Do one last brief round of thought and feeling empathy Issue a Straightforward or Paradoxical Invitation Now STOP so the patient and observer can provide feedback 40 How to Give Feedback Patient and observer will Give therapist a letter grade A, B, C, D, or F Provide intuitive feedback Here s what I liked and disliked. Model a more effective response 41 If the Therapist Does Not Get an A You can repeat the exercise as many times as you like so that the therapist Can see improvement in his or her technique Can feel a sense of accomplishment, rather than demoralization 42 Copyright 2013 by David Burns, M.D. Page 14

15 If the Patient Accepts the Invitation Specificity Step Which of the many problems you ve described would you like to work on today? Can you give me a specific time when you were struggling with that problem? 43 If the Patient Accepts the Invitation Conceptualization Step Individual mood problem Relationship problem Habit or addiction Non-problem 44 Motivation Step Pinpoint and Eliminate Outcome Resistance Process Resistance 45 Copyright 2013 by David Burns, M.D. Page 15

16 Four Types of Outcome Resistance Depression Anxiety Relationship Problems Habits and Addictions 46 Four Types of Process Resistance Depression Anxiety Relationship Problems Habits and Addictions 47 When Learning Paradoxical Agenda Setting (PAS) Remember It s harder than it looks Be patient with yourself Ongoing study and practice will be needed Check your ego at the door You can only learn through repeatedly failure 48 Copyright 2013 by David Burns, M.D. Page 16

17 Additional Resources If you are intrigued with these concepts, read the material in your handout This is your homework Dr. Burns T.E.A.M. Therapy ebook Send an to Dr. Burns Therapist Toolkit Send an to 49 Additional Resources (cont d) 2-day and 4-day workshops by Dr. Burns Listed at Interactive training videos (you saw a brief excerpt during today s workshop) TeamTherapyTraining.com Mentoring / Consultation FeelingGoodInstitute.com 50 Copyright 2013 by David Burns, M.D. Page 17