David and Jill's Amazing Exposure Webinar Part 1 of 2

[Music] Hello and welcome to the Feeling Good Podcast, where you can learn powerful techniques to change the way you feel. I am your host, Dr. Rhonda Barovsky, and joining me here in the myriad of studio is Dr. David Burns. Dr. Burns is a pioneer in the development of cognitive behavioral therapy and the creator of the new team therapy. He's the author of Feeling Good, which has sold over five million copies in the United States and has been translated into over 30 languages. His latest book Feeling Great contains powerful new techniques that make rapid recovery possible for many people struggling with depression and anxiety. Dr. Burns is currently an emeritus adjunct professor of clinical psychiatry at Stanford University School of Medicine. Hello David and welcome to all of our listeners. This is the Feeling Good Podcast and it's episode 476. It's a special episode. David, can you explain what it is? Yes, Jill and I, you know, I kind of have this philosophy of giving away things for free. And so Jill and I have recently been doing free two and four hour webinars and also for the general public and for mental health professionals. And it's been kind of fun and this one was on September 11th. And podcast viewers said they like it when we turn these two hour webinars into podcasts. Because we also published them on YouTube. And as afraid we were getting, you know, too much exposure, but people said, no, they want us. So let us know if you change your mind. But this was a two hour webinar on the treatment of anxiety disorders, which is very, very popular. There's just so much anxiety going around and, you know, particularly in this era where there's so much hostility and uncertainty. But I think there was tremendous anxiety even, you know, 50,000 years ago or 50 million years ago when humans were first evolving. And I think there were just as anxious as today. And as somebody who has struggled with, you know, many, many forms of anxiety in my life, I've taken a great interest in treating it. And so Jill and I did this workshop and it's been exciting because we had over 2,000 people registered for the workshop, which was just fantastic. And working with Jill is a little like working with you, Rhonda. It's, I know I'm in working with a pro who is filled with brilliance and warmth and the feedback we got was pretty much over the top. But anyway, in part one of the two hour workshop today, we're going to start out by focusing on the treatment of anxiety in general and going over not only how team works to EAM, but also the four models that we use in treating every patient with anxiety. You see, some people think they can take a method and treat a problem. And I never do that. And I can do them all who do. I think it sucks and I think it's stupid. You'll, you'll, you know, capture some fish, but you'll, you'll lose an awful lot. And I work with everyone with team, TEAM sequentially. And if someone has anxiety, I use four models, not one. And of course, exposure is the big deal. Everyone thinks we, you have to use exposure. And this workshop is going to focus on exposure and all the subtle points of exposure. But we also will talk about the vitally important motivational model dealing with outcome and process resistance. Hmm, what are they? And how do you work with them with someone who's anxious? And why is it so important? Why can't we just ignore that? And then there's the, the cognitive model and, and the, and the distorted thoughts that are always going on when, when, when someone is, is anxious. And, and, and, and also we will show what's familiar to some of you, but not all of you. The, the amazing Terry video, you'll hear it on audio, but if, if I can find the link, we can link, you'll be able to link to it on YouTube and, and watch it. It's one of the most remarkable videos in the history of, of psychotherapy. And you see a woman who struggled with horrible panic disorder for ten years and incredibly severe depression for ten years. Nobody could help her. Psychiatrist couldn't, the cardiologist couldn't, she kept having panic attacks when she thinks she's about to die. And then I, I used a, a powerful cognitive technique, the experimental technique, and you can see her, if you go and watch the video going for, from uncontrollable sobbing to uncontrollable laughing in six and a half minutes that, that, that changed her, her life, but you'll actually see her aha moment, which hit at, you know, about the six minute point when she suddenly realized that her negative thoughts were, were incorrect. And, and so that, that's, you know, really, really important stuff that we also showed the moment I treated a woman with 20 years of severe obsessive-compulsive disorder in the Tuesday group at Stanford. And you'll see the video of the, the, the, the 30 seconds or 15 seconds that, that changed her life, see her at the exact moment of recovery. And, a lot of good stuff like like that. And then, in part two, next week, we'll, we'll go into and feature Jill a lot and her brilliant teaching on, on, you know, exposure therapy techniques and what to do and what not to do and what are safety behaviors and, and all, all kinds of really powerful fine fine points. So, I hope you enjoyed part one today and look forward to part two next week. Hi everyone and welcome to our webinar CBT and exposure techniques that work. We're so glad that you're here joining us today and we have a lot of exciting material to cover in the next two hours packed hopefully with practical and powerful methods that you can begin using right away. We'll take a couple of questions at the end and we'll also share some opportunities for you a little bit later in the workshop as well. And first, I want to say that I am thrilled to be joined with by David Burns today and I imagine that all of you know who David is but I will just let you know in addition to being a world renowned psychiatrist and CBT legend. David is a dear friend and colleague of mine and I always feel really honored to present with you David and David is one of the most influential figures in cognitive therapy and the creator of the team CBT model that will be diving into quite a bit today and he's also the author of Feeling Good and Feeling Great and the creator of the Feeling Great app which will have a chance to learn about a little bit more today. And I'll also just tell you a little bit about who we are at Feeling Good Institute. So our mission at Feeling Good Institute is to elevate the practice of therapy so that patients can recover faster and more fully. We train and certify therapists in team CBT which is this powerful framework developed by David and we help therapists walk through kind of a five level certification path. I'll also just share with you very briefly our sort of origin story. So Feeling Good Institute was founded by Maurek Katz, Angela Prom and myself. We had all trained with David in team CBT at Stanford and back then the only way to learn team CBT and to learn was to study directly with David either in this kind of Tuesday group at Stanford which you often hear people talk about or going to one of David's intensives kind of around the world. And so we started Feeling Good Institute with this big dream to make David's tools, techniques and training style more accessible to more therapists without compromising depth or quality and everything that we do today still reflects that kind of original intention which is to help therapists to get better so their patients can too. And at Feeling Good Institute we don't just teach techniques but we really try to replicate David's training style which is built on this kind of foundational idea that you only get better through practice and feedback and it might surprise you to hear this but experience alone doesn't make therapists better at doing more therapy sessions doesn't necessarily lead oops to more outcomes. Sorry I just had something else pop up on my screen let me make sure that closes. Sorry about that. And so the question is what does work right so learning a practice getting feedback practicing again that's what actually drives change and that's what we emphasize in all of our trainings and we'll tell you a little bit more about how we do that you know later today. And so I'll also just ask you this kind of thought experiment which is we've talked a little bit about how experience alone doesn't lead to better outcomes and that real growth comes from focus learning and practice and feedback so I'd ask you to think what would change for you if you had a structure for consistent growth and would that be worth exploring. And so we'll share with you more at the end of the day today but we have created a kind of pathway to help therapists learn practice and grow and become really kind of experts in this team CVT model that we'll be sharing with you later today. So what we'll be teaching you is kind of the tip of the iceberg and if it's exciting to you we hope that you'll take the next step with us and join us in the fast track program that we've developed. So now let's kind of tell you a little bit about the framework of team CVT this is what's been developed by Dr. Burns and so the T in team stands for testing and that means that we teach and we use with our patients measures at the beginning and end of every therapy session and measures of symptoms and also measures of the therapeutic relationship so that we can track progress over time hold our patients and ourselves accountable for really bringing about meaningful change and so we can address alliance ruptures or issues that are coming up in the therapy session right away and we won't really be teaching you more about the T or testing but we want you to know that we use this with all of our patients and it's an important part of doing effective therapy and the EN team stands for empathy and that means that we have tools and techniques for really connecting with our patients and especially our difficulties to connect with patients and that we don't just jump in and throw methods at our patients but we actually are measuring and we're connecting and we're empathizing before moving along and using kind of powerful CBT methods and the A in team stands for assessment of resistance that's that we're working on kind of understanding, articulating and then melting away resistance to change and boosting motivation we'll tell you a little bit about that today but finally what we'll be focusing on most today are the methods the M in team which stands for methods and we'll be focusing on cognitive and behavioral methods today and just to sort of share this slide with you is just we want you to understand that there is this really kind of powerful framework that you can learn and work through to help kind of all of your patients it's it's trans diagnostic and it's not a manual for doing therapy but rather kind of a framework that all effective therapy includes so now we'll kind of turn to today's specific topic which is treating anxiety and specifically we'll talk to you today mostly about treating anxiety using exposure and also some cognitive interventions but we want to make sure you're aware before we start that there are at least four important models for anxiety causation and treatment and David I'll turn it over to you at this point if you want to just mention the four models on this slide and then walk us through kind of what each of the models are about on the next few slides yeah sure the these are four really powerful models for understanding and treating anxiety and the motivational model focuses on resistance and there's two kinds of resistance that all anxious patients will have and we'll talk about that in just a moment the the cognitive model stresses that all anxiety results from distorted thoughts and that it's impossible to change without challenging and crushing those those distorted thoughts the exposure model is quite different and it it says all this other stuff is a bunch of crap and the the cause of all anxiety is avoidance and the cure is exposure and exposure always works and everything else never works and then there's the hidden emotion model and this states that niceness is the actual cause of anxiety and an important powerful tool is that the bringing suppressed feelings to conscious awareness and expressing them and dealing with them we'll go to the next slide I'll just give a slight expansion on these things the motivational model talks about two types of resistance outcome resistance which means that the anxious patient comes wanting treatment for OCD or phobia or social anxiety but but that the he or she will actually or they will actually resist a positive outcome and this is because of magical thinking in most cases they they think that my anxiety is painful but it's it's it's protecting me it's it's helping me and if my anxiety went away some catastrophe would occur process resistance is that the patient might really want recovery from anxiety but is unwilling or very reluctant to participate in the process the thing that they'll have to do to recover which in anxiety is exposure and exposure is not the only treatment for anxiety as some of the early you know exposure therapist were climbing but it it is mandatory for every patient to include exposure in the treatment package and then the cognitive model focuses on distorted thoughts and there's four types of cognitive distortion from my list of 10 basic ones that are always present in anxiety one is a fortune telling and that's predicting that something terrible is going to happen and it's impossible to feel anxious without fortune telling it's also impossible to feel hopeless without fortune telling and mind reading of course is the idea that you know how other people are are thinking and feeling about you and and that's usually not the case but this is very common in social anxiety when the the patient is thinking oh my gosh everyone here is confident and know what they could all see how anxious I am and no one would be interested in me or my life or what I have to say magnification and minimization is I also called the binocular trick it's when you blow things way out of proportion and you know patients with panic attacks you'll see in just a few moments are saying oh my gosh I'm on the verge of dying or I'm about to lose control and end up in a psychotic episode and anxious patients also minimize their the safety and a situation and their own coping skills and finally emotional reasoning is reasoning from how you feel and I know most of you are familiar with these distortions but for anxiety it's by gosh I'm feeling anxious I'm feeling scared I must be in danger so the the anxious patient might think oh my gosh every time I get around an airplane I get terrified it must be terrifying to to take an airline flight that's that's extremely dangerous I can feel how dangerous it is and then in the cognitive model challenging negative thoughts is felt to be the cure for anxiety the very moment the patient stops believing the thoughts that trigger the anxiety and that very instant the anxiety will disappear you'll see this on on video this this morning the hidden emotion model is one that I created based a little bit on the psycho dynamic or psychoanalytic training I had as a psychiatric resident and that's that if you ask you know if you if you talk to a thousand anxious patients you'll find a thousand extraordinarily nice people and the idea is that the the the actually anxiety prone patient is afraid of conflict afraid of displeasing people and is constantly focused on meeting other people's expectations and and that that is actually causes the anxiety that that there's some hidden problem always that the patient isn't telling you about because they've suppressed it and pushed it down under conscious awareness and the hidden emotion model involves taking bringing that problem to to to conscious awareness and expressing the feelings and this is a super powerful model it's hard for therapists to get it first because they don't they don't believe it and it's not occurring without every anxious patient but it is with a good 60% or 70% of anxious patients and once you learn how to do it it gives you another powerful model for treating anxiety and among these four today we're primarily going to be focusing on the exposure model and the exposure model again is based on the idea that avoidance is the main cause of anxiety and avoidance maintains anxiety and if you've ever struggled with anxiety you know how overwhelmingly valid that this is if you're afraid of elevators you you you you avoid elevators and that avoidance maintains and creates your anxiety and the exposure model states that exposure is the cure now the cognitive therapist will argue and you'll see this today that exposure isn't a cure for anything and that the reason exposure is effective is because of the cognitive dynamic in other words during exposure the patient suddenly sees that their belief that elevators are dangerous for for example that sees that it's it's not true or the panic attack patient sees it's not true that they're about to die of a hard attack or about to go to go crazy and so it's kind of interesting to look at the exposure through these two different lenses lenses the cognitive model and the exposure model and they're two very powerful and helpful helpful models for sure now I'm going to give you an example of the overlap between the cognitive and exposure models with a very severe problem Terry was a woman who came to me for treatment in Philadelphia after 10 years of extreme depression and anxiety and at the time I was using a depression and anxiety test long versions of my depression and anxiety checklists that were scored from 0 to 100 and I think she had a score of a total score of 199 on those two tests and at the time was by far the most severely depressed and anxious patient I'd ever seen in an outpatient setting and her problem was she'd been having five panic attacks each week and during the panic panic attack she develops the gets tightness in her chest and gets dizzy and develops the belief that she's about to die of a hard attack or a stroke or pass out or that she can't breathe properly she'd been to many ER visits have been worked up by many cardiologists pulmonologists eventually the diagnosed panic disorder after five years she referred to psychiatrists and they treated her with massive doses of just about every known psychiatric drugs and that didn't work and psychotherapy didn't work and she felt not only panicky but intensely ashamed demoralized and hopeless now when I'm working with an anxious patient I always work with their daily mood log and you can see here on this slide daily Terry's daily mood log and it's like the upsetting situation is that she senses a panic attack coming on now again this happened to her five times every week and you know she gets somatic sensations and the cognitive model of panic is the misinterpretation of benign physical sensations and but when she when she gets upset about something she hyperventilates subconsciously she doesn't realize she's doing that but if you do that you blow off too much carbon dioxide and your blood pH changes and and that creates the symptoms of anxiety that the numbness the tingling of the fingers the chest feels tight she she gets dizzy and then all of her feelings as you can see that she circled the depressed and terrified and ashamed and for your discouraged embarrassed and frustrated or all at a hundred the worst a human being can have and the anger was the only one that wasn't a hundred and that was twenty five now the cognitive model states that the hundred percent and only cause of these negative feelings are her distorted negative thoughts and she's telling herself I can't breathe properly and she believes that a hundred and if any of you right now believe that that you you couldn't breathe properly you too would suddenly become but panicked so she believes that a hundred and my windpipe is closing off she believes that a hundred if I stand up I'll pass out she believes that that a hundred and I'm about to have a heart attack she believes that a hundred and I'm going to die she believes that a hundred now on the next slide you'll see what I call a recovery circle and this is a cognitive technique and the thought that she wanted to work on we're putting in the middle I'm about to die and I always think of five or ten or fifteen or twenty or in the old days sometimes twenty five or even thirty five cognitive techniques I've learned or developed over a hundred and fifty techniques now for crushing negative thoughts and so I put many many up there on the recovery circle and the idea is called fail as fast as as you can that that the faster we go through these techniques and fail with them the quicker we'll get to the one that that works and so over the course of about the first say I'd say three or four sessions I tried a good fifteen techniques a double standard technique examine the evidence downward arrow hidden emotion examine the evidence you know feared fantasy identify the distortion so all this kind of thing but everything was pretty much zero percent helpful helped not helpful to her she came back every week with the exact same incredible scores on the depression and anxiety test and so I I told her Terry I've used a lot of gentle techniques with you and and they're they're they're just not working which which is okay but next session I'd like to try one of the most powerful of all of the cognitive techniques called for anxiety called the experimental technique and what I'd like to do is induce an actual panic attack during the session and then during the session I I'm going to teach you do some experiments to test to see if what you're telling yourself is valid and she said that she thought that was a wonderful idea and got all excited and went home and called in and left a message that was she was canceling her her next two therapy sessions and I guess she was terrified and was too nice to tell me that I don't want to have a panic attack in your office and she left the note you know a message saying that she wasn't firing me and that I was the best therapist she'd ever had but but does she have to have a panic attack in my office and she's too terrified to do that and so we spoke on the phone a couple times and and I've she finally I was able to persuade her to come in I said we'll have a double session and we'll have plenty of time and we're here in the hospital the emergency room is right down the hallway from my my office and I really want you to to take a chance and that's one of the teaching points for for today was that I had been getting perfect scores on the empathy scale so I knew she really liked being trusted me and and that gave me a license to really push her when it comes to exposure because almost all patients will strenuously resist exposure and and and so I had to persuade her it was pretty force forcefully to to come in and try this experimental technique and and so what happened she she she came in and I told her to close her eyes and hyperventilate like that because I knew her she'd start getting the symptoms and I said now move your finger when when you feel the symptoms coming on and after about 15 seconds she wiggled her finger and then I said now I'm going to be the voice of of of your panic attacks and I'm you I'm just like that voice in your head and I'm telling you that that you can't breathe properly and your fingers are tingling and you're about to have a heart attack and we're going to have to call for the paramedics and and they're giving you oxygen but even that isn't working and they're panicking and the can you see the red light on on the ambulance going round and round and this triggered a massive panic attack and she started sobbing and I just happened to have a video camera in my office and I I had all my patients record on video or audio all their sessions and either watch them or listen to them at home and she was one who had allowed me to video tape and that's why I have this actual excerpt from that session which of course she's given permission for me to to show and we're just going to cut right into the point where I've just induced the panic attack and she's sobbing and she starts begging me to to stop let let's see what happens oh by the way just stop it for just a second yeah and and I want you to ask yourself whether you're a therapist or general citizen the three questions when you see this video you're going to see wild fluctuations in her feelings ask yourself first of all what is causing the fluctuations in her feelings a second question is that that she's begging me to to stop and if you were the therapist what would you have done she's sobbing say please doctor Burns you're going to see this I can't go on and we must stop and and and then what would have been the consequence of of of stopping or pulling back if you had had done that or the consequence of pushing ahead and at and then if you have any you know general theories about if she's improving or getting worst on this on during this excerpt from her session what what are the causes of that what what's going on here to the best of your understanding now let's let's let's let's see what happens it's very important to find out if it's true that you can't take a deep dive why do you think there's there's no doubt do they feel numb that's another symptom of panic and anxiety and I'm glad that you're allowing yourself to get real anxious how long just when you say you are right now between zero and 100 about 100 about maximum right now if you couldn't breathe right now why would that be a problem to you I think I'm going to tell me what would you die of lack of oxygen and my heart just just hurt so bad and this always happens yeah now what are some experiments that we could do to find out if you're if your heart is working properly and if you're able to breathe properly right now I know what it is anymore please just well I'm going to ask you to to bear with it so you can kind of put an end to this this fear that you have once and for all do you think the person who can't please would be the exercise tremendously did you think that you could exercise strenuously right now and I don't know why don't we find out what would be some some strenuals exercise that you could do here in the office to find out whether or not you're breathing properly your heart is working properly well what's the more most strenuous exercise you do jumping jacks running in place I don't know I walk and I ride my bicycle yeah but we can't do that in here I actually have a unicycle or something a good picture but I don't think we have one here why what's the exercise you could do right here to test the belief that you can't breathe it how strong would you believe right now that you can't breathe it's getting less how strongly did you believe it oh like a hundred okay well I'm just running in place if you'd be willing to do that you ever do jumping jacks running in place push-ups not push-up yeah push-ups running in place jumping jacks well no I'm afraid if I stand up I'm not going to pass out or something okay well let's let's check that out see if you can stand up and and run in place okay now let's see if you can do some let's see if you can do some running in place right now go ahead well run once okay I mean you might have to feel them to get well but it would be worth it I think if you got well now I'm not so I can focus this thing on a exercise there but I feel really dizzy okay we'll just keep going now how strongly do you believe that if you can't breathe if your heart isn't working um that's 70 if you need 70 percent that you can't breathe I mean I shouldn't be breathing it's having to breathe it's heavy that's a little bit of and I still can't take it deep breath and I always it's like see you run more strenuously faster you do aerobics do you do exercising a little bit uh see if you can back up just a little bit hungry here we go I think there's a few known okay uh how strongly do you believe that you can breathe right now how strongly do you believe that you can't breathe um you see I feel better like 60s that I can we leave 60 percent that you can't and I can you can't I can't it's down to 60 how about some jumping jacks let's go to the scene we'll try some jumping jacks anyway we have a lot to die I couldn't believe it well could you do this if you were dying if it was a if you see an emergency room people part attacks doing jumping jacks keep doing the jumping jacks I'm sure you'll pass out at any moment I was like my hands feel weird yeah well how strongly you believe now that you can't breathe that's a deep 50s going down just just teach up the boots with it you've got to keep disconnect and help it out in the throat and we're going to get a zero out of for enough other reason than 50 I do I feel better okay sit down right right right now and now the let's just see what the audience thinks about some of the questions I asked first of all that there was a massive change in six minutes there that that was actually her her first recovery after 10 years of failed medical and psychiatric therapy you know hard evaluations lung evaluations pill after pill and and and you you can see that her her her all of her symptoms went to zero she wasn't just feeling better but it was totally abolished the the system and she was able to blow all of these negative thoughts out of the water but what was it about that experience was one question that you know why did her feelings go from uncontrollable sobbing to uncontrollable laughter in six minutes what what was the healing mechanism and secondly how many of you would have backed off if you were the therapist rather than pushed ahead and what would have been the implications of that and and maybe Jill you can check the chat and see if we've got some answers to those questions exactly yep so I have someone I'll read to you right now so it seemed really helpful to ask again and again to rate her strength in the belief someone proposed was it that she was distracted from her symptoms someone said the exposure led to a shift in her thinking someone said because the more you pushed her to do it she could run and talk and that helped her realize that she was still alive you also got some tell me if you I was going to put a couple of other comments out there but mostly so some people said distraction other people said like change in thinking realizing she was not dying since she was able to do jumping ducks yeah the I think you most of you have it pretty much on target this distraction is a mildly helpful technique for all negative emotions but it's very temporary and and a weak sister of the 150 techniques I use I would say it's the least effective and and and that was not the reason but it's great thinking on your part why why she had this profound to change in her emotions but it was because when when she was doing the jumping jacks she she said I wonder if I could do this if I was having a hard attack and then I said is this what you see in the emergency rooms of hospitals patients with massive heart attacks doing jumping jacks next to their gurneys in the emergency room and then she started laughing so heavily that she doubled over with laughter and then when she stood up I said keep up the the the the jumping jacks I'm sure you'll pass out at any moment and then she said oh hey I'm feeling a lot better and then in this session I repeated that demonstration one more time I induced a second panic attack with her permission and just so she could see that it was something she could reproduce and she again thought she was on the verge of death and did I got her to do the jumping jacks and then her emotions went all the way all the way to zero then she had some questions about what if she gets a panic attack at at home and a few other things that were kind of fun and funny to deal with but in the interest in time I'll just say that the one question you might have is does did this is last was this responsible responsible therapy because it seems kind of scary and it definitely takes courage on the part of the patient and courage on the part of the of the therapist I knew of course that her negative thoughts were distorted and just not possible it would have been impossible for her to pass out when she stood up because her heart was racing and her blood pressure was elevated and fainting is associated with a drop in blood pressure and a slowing of of the heart and you know everything she's telling herself is just extremely distorted but it also shows the hypnosis of the patient to she's trying hard to hypnotize me into believing what she's saying and giving up and if I had given up it would have torpedoed the treatment and I've had to call her that was 35 years ago or almost 1988 you can calculate the years and 40 years anyway and I call her every year or two to say you know how are you doing and she says tell your your audiences and can I show this because she was so ashamed initially and she said I hope you show it to everyone in in the United States and just tell that I'm still doing great and she she had another child and which was one of her goals because they had four children in the previous psychiatrist that she couldn't become pregnant because of all the psychiatric drugs she was on to that he said they might cause a birth malformation but she was able to go off of all of those drugs and had only one panic panic attack in the last 35 years and she called me for an emergency it was years after this and I said well do your jumping jacks and I'm doing a workshop today I just showed this video at a workshop and then she called and with an emergency and I said I'll be home tonight and I can see you tomorrow and then she called again at the end of the day and said cancel the appointment I did my jumping jacks and I started laughing again on my panic attack disappeared but anyway that's that's a thumbnail of the teach you a great deal about the cognitive model and exposure and the question is was it the exposure or the change in her belief and her negative thoughts that triggered the sudden change in her feelings and I would I would argue that in this case in many cases the reason the exposure work was because she suddenly realized the nonsense of what she'd she'd been been telling herself and David just wanted to point out lots of people brought up some things that we will be talking about throughout the day today which is you know people saying oh I would have given up because I would have been anxious you know and also people realizing I if I had given up I would have perpetuated her belief that she was unsafe you know right another failed yeah yeah if I'd stop she would have said even my doctor who's a medical doctor is frightened this must be a real thing so by backing off which you know we're all tempted to do it would have been horribly destructive for her yep exactly um so yeah it's a lot of people realizing that people also saying wow that's amazing you're so brave and also commenting on your sense of humor being a part of what was effective as well which I think is really true and yeah just just a comment briefly on that the Buddhist have a form of enlightenment called laughing enlightenment and that's when you finally confront you're the the monster that's been ruining your life and all of your previous reincarnations you discover that the monster has no teeth and you go into uncontrollable laughter and and then go to nirvana or some kind of Buddhist heaven and that's what exactly what Terry was experiencing was laughing and enlightenment and I use a lot of humor in my therapy yes and I'll also just tell people if you have questions for us throughout the webinar we won't be looking at the chat but Mike Christensen is helping us and so if you do send questions about the content or questions about exposure in the chat box Michael be compiling them and at the end of the two hour webinar we'll go through some of your questions we'll have a chance to answer some although probably not all of your questions um so we've got a lot to cover here um I think you probably covered this David but is there anything else you wanted to say? Well I just just think that some of the teaching points is that thoughts are the cause of negative feelings uh and that when you're upset generally your thoughts will be greatly distorted as as hers were and that recovery can happen rapidly at the very moment you stop believing those thoughts and and the way you find the technique that works is by failing as fast as you can and also uh patients will fear and resist exposure as she was begging me to stop and you know the consequences of stopping would have been catastrophic but exposure requires strong empathy and for us the empathy alone won't do her any good I was getting perfect empathy score for several weeks before we did this but her symptoms didn't change empathy is not curative for anything but if without it you can't go on to the powerful techniques that will cure the patient and the reverse hypnosis is what you'll be telling yourself as a as a therapist uh you know the patient will be convincing you oh my patient is too fragile for exposure what if I retraumatize him and her and I saw a lot of people talking about oh David gonna retraumatize her and you know this is so terribly dangerous and responsible to think about those things for sure but not get trapped by them and you know some therapists might think well what if my patient acts out violently or attempts suicide these are some of the consequences of of reverse hypnosis so we'll we'll do a quick poll here with you guys just to understand some of you answered this but we'll do it in the version of a poll so you can all actually answer so the first question on the poll is would you've been tempted to back off when Terry begged David to stop so go ahead and answer that yes no or maybe but try and answer yes or no the second question on the poll is do you resist and do you fear and resist using exposure with your patient so if you're a therapist are you fearing and avoiding exposure so either kind of yes I avoid exposure no I don't avoid it meaning I use it happily or I sometimes avoid it due to my own fear and the last one since we're all human here and some of you are not therapists just members of the general public but also as therapists we all have fear so do you fear and resist using exposure with yourself whether you're a therapist or a patient kind of yes I do avoid exposure no I don't or kind of I sometimes do and I'm going to give you guys another 10 seconds outside to answer quickly try to get maximal participation here in the poll and then I'll end the poll and share the results okay so we can see 50% of you said I would have backed off when Terry was was begging David to stop and we have let's say do fear and avoid using exposure with your patients we have 16% yes I do and kind of 47% saying sometimes I avoid right so only about 39 or let's say 40% of therapists saying I never avoid using exposure I'm kind of confident in using exposure right so 60% still needing to be convinced and then do you avoid it yourself again we've got just let's say 30% saying I don't avoid and the rest saying either I do or I sometimes do so I think the poll was great in showing that the a lot of patients in therapists like are really fearful of exposure and avoid using it absolutely and so hopefully we're going to help you to feel less afraid of using exposure with your patients and with yourself and also give you some tools and techniques to actually make exposure more effective but yeah our take home message so far is that exposure can be incredibly powerful as you could see in the video but also can be really challenging for patients and therapists alike and we've talked a little bit about this but some of the keys for successful exposure or empathy right some of you commented that in the chat box as well that Terry must have had an immense amount of trust in David also a skillful assessment of resistance David I don't know if you want to comment on that as it relates to Terry. No there are the two forms there's outcome and process resistance and and you have to do those before you go into any method that's that's the key to to team therapy first of all you've got to get an A or an A plus on empathy and then you've got to have skillful and then the outcome resistance is that if I lose my anxiety something terrible is going to happen you know I'm suffering but I need this anxiety or I'll flunk out of college or you know panic attack quite often that outcome resistance is if I'm not hypervitalinth and maybe something bad really will happen. Yeah yeah exactly I need this anxiety or I'm going to have a heart attack. I have to sit here motionless type of thing and then of course the process resistance is the very intense and totally understandable resistance to to to to expose exposure and the patient and therapist get involved in a fully ado in other words an insanity shared by patient and the therapist that somehow exposure is is highly dangerous and needs to be avoided and and that you have to really persist when the patient resists during actual exposure Terry beg me to stop and therapist confidence yourself confidence your persistence is the crucial key to success and the patient's resistance is not just for panic attacks it's for every single type of exposure that one you come to the point that the social anxiety you want them to smile and say a load of strangers you can go out with them doing this and and they're going to you know stop and resist and you're going to have to push them and that's where you need the trust and the empathy so you can push them and you have to have the determination with yourself that you are going to to push them and if you're the kind of therapist who just thinks that you know support and and talking are the are the key to therapy you're going to have a lot of long term patients but you're not going to have a lot of cures. Yeah and yeah and I was going to say that in this particular training today we're not focusing on tools and techniques for overcoming resistance but we think those things are incredibly important and we do a lot of teaching and training in the fast-track program in our free trainings you know where we really focus on outcome resistance and process resistance but we will be focusing now more on methods. Yeah and and if you want Jill and I might offer another one of these free webinars on the resistant patient and then because we have a ton of tech new innovative techniques for dealing with with resistance and most therapists are not familiar with them. And one other thing we'll highlight here and then we'll also give you some clinical examples of throughout the webinar today is this concept of safety behaviors and so I'll mention it now because it relates to something you saw in the Terry video and then we'll talk some more about it with some other clinical examples but a safety behavior is essentially anything your patient does in the moment when they're anxious to reduce anxiety and we use that very general term because very often patients will come into therapy thinking that they have all these great coping strategies right when I feel anxious I make sure I have my medication with me I say a prayer or a mantra I you know wiggle my head. Let's see the next slide Jill. Okay I'll do that in a minute um but but essentially the the thing about safety behaviors is that in the short term they make patients feel better right in the short term they give you a sense of relief and even a kind of illusion of control over your anxiety but in the long term safety behaviors actually make anxiety worse because they don't allow you to learn that nothing terrible actually would happen that you don't need the safety behavior in order to feel better so they prevent new learning and as you saw in the example new learning is what happened for Terry right she needed to experience an intense amount of anxiety and to do those jumping jacks to learn that she was in fact safe. So on this slide I have some examples of safety behaviors and so for some people it could be you know carrying a lucky charm that makes them feel less anxious for a patient that I actually just evaluated this past week he told me that even though he didn't take benzodiazepines he carried his container of benzodiazepines around with him and he didn't see that as harmful but see in my mind I'm seeing that he's telling himself I'm not okay and I know that I have this like escaped valve just in case and so he's not actually learning that he is safe that nothing terrible would happen um for some people you know a meditation or a mantra or ritual again nothing wrong with waking up in the morning and doing some deep breathing or meditation as a sort of strategy for feeling good but if it's something you feel like you need to do in the moment in order to not feel anxious it's counterproductive we have a couple other examples I don't think I need to go through all of them but you know patients with OCD quite oftentimes will be seeking reassurance from others and they'll repeatedly ask for reassurance it makes them feel better in the short term but of course maintains their anxiety in the long term patients who have a fear of illness or a contamination anxiety will oftentimes carry hand sanitizers they'll wash their hands repeatedly so we just want you to get the sense and realize in your mind that there are a lot of things patients will do during exposure that's actually really counterproductive and we need to be aware of them and we need to address those things and so just to make it a little more interactive we'll invite you you can share just a few with us in the chat box and I will read a few of them so any safety behaviors that you've seen in your patients that I didn't mention already or that you yourself sort of rely on to kind of white knuckle or get through things when you feel anxious so I saw someone say leaving the room right right in social anxiety oftentimes leaving the room avoiding eye contact someone said carrying a water bottle exactly so someone else might be like what's wrong with carrying a water bottle well intrinsically there's nothing wrong with carrying a water bottle but if one thinks I've got to carry this water bottle in case my mouth is dry then it becomes a safety behavior and counterproductive um carrying around a doll from childhood eating sweets um looking at their phone right so distracting oneself um yeah and people are asking is is breathing or things like that are those problems yes if during an exposure exercise someone is doing something to try to calm down ask yourself is that productive no because the point of exposure is being all in bring it on I want to feel as anxious as I possibly can when I'm doing exposure so if I'm doing grounding exercises or breathing exercises I'm actually interfering with the effectiveness of exposure um there are ways I will say I've actually been contacted by therapists to say can you integrate safety behaviors into a hierarchy and we'll get into that in a few slides but the answer is yes you can as long as you're aware of the fact that these are things that need to be dropped out and changed over time and that they can get in the way of new learning occurring um so you guys added tons of great examples in the chat box but I'm not going to read all of them um we'll move on and we'll give you some more examples of them a little bit later on um so and uh I'll just kind of cover this slide David and I can turn it back to you for the next example but there's at least four types of exposures there's in vivo exposures which is when we're going to have our patients face the thing they're most afraid of in reality right so if a patient is afraid of a dog they're going to hang out with dogs if we're afraid of heights we're going to go to high places there's cognitive exposure which is where you're helping the patient to confront the thing they're most afraid of in their mind and we're going to walk you through an example and kind of teach you how to do cognitive exposure that's especially helpful for exposure to things that you can't actually face in reality um fears of things that might happen in the future for example there's interpersonal exposure which we're going to do our next webinar I think on or one in the future on which is kind of a social anxiety exposure smile and hello um uh shame attacking exercises so a variety of exercises to confront social anxiety and interact with people socially and then virtual reality exposure which is where you can use virtual reality equipment sort of similar to mimicking and in vivo exposure it can help use all the senses to actually make exposure more realistic and helpful for things that again you can't easily confront sort of in real life and then David if you want you can talk about kind of gradual versus flooding here okay well I mean all exposure techniques pretty much can be done gradually or in a flooding way and and as Jill has mentioned for gradual exposure you can create a feared hierarchy and have the patient start with the easiest thing and and once they're used to that go up to the next highest the most intensely feared thing on their hierarchy and and then do that over and over again like like for example if you're afraid of heights you could just go you know the first few times just go up the first brung of the ladder uh and then the second time once you're not afraid of that you go to the second rung on the ladder and you continue this gradually until you can stand on the top of the ladder flooding would be uh hitting your worst fear all at once and that's what I did with with with Terry and also when I had a fear of heights in high school the I want to be on the play the stage crew of the play brigadon and the drama instructor teacher said you have to do work at heights to be at the in on the on the stage crew and I said well well I have a fear of heights and and so he said if you'd like to get over it we can do it right now and so he took me into the theater and there was a big V ladder there and he said just stand on the top of that ladder for and then I'll wait here at the bottom in the ladder until your anxiety disappears and and that was flooding and I stood up there for you know 10 12 13 minutes and my anxiety was 100 out of 100 I was just standing on the top of the thing and I kept saying Mr. Kershack I'm still a hundred on on anxiety he said well just just just it'll go down pretty soon just just keep standing there and then I suddenly after about 14 or 15 minutes the anxiety dropped to zero and I was no longer afraid of heights and then I love being on the stage crew and I would work up with the ceiling and working on the lights and the curtains and all of that and I couldn't even remember why I'd been afraid of heights but both techniques are effective and it's kind of personal choice yeah I was just gonna say one other thing David while we're talking about exposure is that I when I learned and I'll share a little bit about this later but when I first learned to do exposure which was actually kind of one of the first methods that I learned in graduate school I thought of it in a way as like a way of life for myself which is you know I was I didn't think I could ask my patients to do something that I wasn't willing to do myself and so I set out to identify were there any things that I was fearing and avoiding and could I go ahead and face those using the same techniques that I was encouraging my patients to face and David I think that's you and I both have a lot of confidence in exposure therapy and I think that's also because we walk the walk right when we do you know there are things that we fear and avoid we go ahead and we're kind of all in and we face them yeah I've had over 17 anxiety disorder since I was little so I know very well of what I all the kinds of anxiety are like and I I know very well how how to get get rid of them and get cure from them so we'll talk a little bit about gradual exposure now and we'll cover flooding in a little bit but with gradual exposure the goal then is that we're going to break down the fear into a hierarchy or like a list of examples of situations where the patient might fear and avoid this thing and and this can be done with any type of fear so if one is afraid of dogs we're trying to make sort of a hierarchy of least anxiety producing to most anxiety producing situations right it could be little to big dogs but it could even be watching a movie about a dog and so I'll show it share with you guys a fear and avoidance hierarchy that I develop for a patient that I treated for a fear of driving I've actually treated a lot of patients in my career who have a fear of driving and I will say I kind of have a soft spot for it because the very first patient I ever treated in graduate school had a fear of driving and I was give her example I was a grad student at Boston University and my office was right in right near Fenway Park right in the middle of Kenmore Square very busy lots of driving going on in this first patient that I ever treated her name was patty and she had this intense fear of driving and interestingly a lot of people think people with a fear of driving it's because they're afraid of having an accident maybe they had a traumatic experience but actually many patients I treat it's just that they had a panic attack while driving and that scared them tremendously and the fear is that I'll lose control that I'll crash the car that I'll pass out while I'm driving and so just to stick with with the fear and avoidance hierarchy we kind of created a hierarchy together from least anxiety producing to most anxiety producing so something that fall busy but still a little scary to her was just simply driving to the end of her street because she had completely stopped and avoided driving even though she used to drive all the time and the next step would be driving to her kid's school which was a couple blocks away driving to the grocery store so the point is that you're creating this hierarchy you can even add things like during the day or at night in a crowded time or at a busy time and the goal is that you're just creating this list from least distressing to most distressing and in her case driving over bridges and in tunnels and Boston was the most anxiety producing thing that she could imagine and then we essentially use exposure and I can say with this patient of course like with all of our patients I'm integrating other models I always start with testing and empathy and also a lot of cognitive therapy to understand what was she most afraid of right in her case she was most afraid of passing out losing control getting into an accident because of her intense anxiety and so then what we did was we practiced together each thing on the hierarchy and I would do it with her in session and then I would assign it to her for homework so she could do it with me but then she needed to repeat it daily for homework and we would move on to the next step on the hierarchy when her anxiety rating would drop so the goal is that you stick with each activity till the anxiety goes down there's no magic number but I always say till it's maybe around a 20 or something like that I also want to just point out and I can say that with Patty it was incredibly effective actually and I did do the driving with her and she was also willing to do the driving on her own for homework I was super aware with Patty as I am with all my patients of what she was doing when we did exposure that might have actually been sabotaging her success and so she wanted to distract herself and that was this strategy that she had been using to sort of wipe knuckle it and get through the driving on her own she would turn on the radio and try to just pay attention to the radio so she wasn't paying attention to her sensations she would open the window because she was hot and sweaty and she thought oh that'll make me feel better I'll be able to breathe better she would carry medication even though she wouldn't take it say mantras to herself like you're okay you're okay you're okay and sometimes even use the phone to talk to a support person I also want to point out something that I think is really interesting my experience with driving phobic patients is sometimes their safety behaviors make them feel better in the short term but actually we're interfering in their driving which is kind of fascinating it was making her a more dangerous driver that she was doing some of these things because she was distracted from the road and that's how you know it's a true safety behavior right it's actually causing more harm than good so we integrated those in the hierarchy it was important that she dropped out these safety behaviors both for her actual safety but also so that she could realize that I can drive and feel anxious and still drive safely the other thing that I integrated in my work with her is what we call hypothesis testing and I know David you love this technique and so I'm happy to let you describe it did you want to do it? It's just something I recalled from when I was going to beck's weekly seminars when I was first learning cognitive therapy and he just mentioned a patient who had a driving phobia and had had the thought I'll lose control of the car and so he had her do experiments while all driving not to distract yourself but to test that hypothesis the same as what I did with Terry like can you turn the radio on and off change the station the radio station can you speed up by five miles an hour can you change lanes and then you know when she reported back you know could could you do all of these things if you had lost control and so it's just a way of integrating a cognitive dimension into the exposure and even yeah with the Terry video you know she said I'm afraid I'm going to pass out it's like well what can we do to test that right and so if you have a patient who's saying I'm afraid I'm going to lose control or saying what what's an experiment we could do to test that can you do a b and c and I do find that to be very effective with you know particularly driving phobia but in general with doing exposure is making sure that you're testing that hypothesis this has been another episode of the feeling good podcast for more information visit doctor burns website at feelinggood.com where you will find the show notes under the podcast page you will also find archives of previous episodes and many resources for therapists and non-therbists we welcome your comments and questions if you want to support the show please share the podcast with people who might benefit from it you could also go to itunes and leave a five-star rating I am your host Ronda Barovsky the director of the Feeling Great Therapy Center we hope you enjoyed this episode I invite you to join us next time for another episode of the feeling good podcast.