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Corona Cast 8: Live Therapy with Dan. How Could You Treat an \\u201cExistential Depression\\u201d in the Midst of a Pandemic?

Today David and Dr. Jill Levitt feature live work with Dan, a licensed clinical social worker who\\u2019s been struggling with an \\u201cexistential depression\\u201d for 15 years, but it has been recently exacerbated by the COVID-19 pandemic. The session took place in one hour and forty minutes on a Tuesday evening on July 23^rd, 2020, in David\\u2019s and Jill\\u2019s Tuesday training group at Stanford.

Live personal work is one form of training that is vital to professional growth and learning, so it is extremely beneficial for the person who volunteers for the role of \\u201cpatient.\\u201d At the same time, the live work also provides superb learning for those observing the process, since you can see what is really happening during a T.E.A.M. therapy session. Hopefully, you will learn a great deal as you listen to Dan\\u2019s live and uncensored therapy session.

Jill and I feel very grateful to Dan for allowing us to publish such an intensely painful and personal experience. You will likely feel grateful to Dan as well!

All live therapy sessions tend to be dramatic and illuminating from a variety of perspectives. Today\\u2019s session is unique in that the A = Assessment of Resistance was outstanding and unique. The remarkable changes that occurred would not have been possible without outstanding E = Empathy and A = Assessment of Resistance, which were stellar.

However, the M = Methods portion of the session was also strong, especially in the use of humor and role-reversals during the Externalization of Voices to blast Dan\\u2019s Negative Thoughts out of the water. That portion of the session confirmed by the three basic tenants of cognitive therapy:

1. You FEEL the way you THINK.

All of your negative feelings are caused by your thoughts in the here-and-now, and not by the actual events in your life. In other words, the COVID-19 pandemic cannot \\u201ccause\\u201d anyone to feel depressed or anxious.

2. Depression and anxiety are the world\\u2019s oldest cons.

When you\\u2019re depressed, anxious, or angry, the Negative Thoughts that upset you will not be valid. They\\u2019ll be distorted and illogical. Depression and anxiety are the world\\u2019s oldest cons. You can see the ten cognitive distortions I first published in my book, Feeling Good, at the bottom of Dan\\u2019s Daily Mood Log (link).

3. You can CHANGE the way you FEEL.

The very instant you stop believing your distorted thoughts, your feelings will change. Recovery is not a long, drawn-out process that requires weeks, months, years or decades, as so many people believe, including the majority of mental health professionals. Recovery happens in a flash, an unexpected \\u201cah-ha\\u201d moment when your perceptions of the world are suddenly transformed. You will witness such an event in today\\u2019s session.

Now let\\u2019s see what actually happened!

T = Testing

Take a look at Dan\\u2019s Brief Mood Survey (BMS) at the start of the session. He was feeling moderate to severe depression, no suicidal impulses, and just a little anxiety and anger. His Happiness score was quite low, only 7 out of 20, paralleling his depression score of 12, and his satisfaction with his relationship with his wife was a perfect 30 out of 30. He indicated he\\u2019d been doing a lot of psychotherapy homework.

This, by the way, is the latest version of the BMS. We\\u2019ll ask him to complete it again at the end of the session to see what changes occurred during the session. Because the BMS asks how Dan is feeling \\u201cright now,\\u201d it\\u2019s like an emotional x-ray machine, allowing therapists to see exactly how much, or how little, a patient is changing at every therapy session. The patient\\u2019s scores at the start of the next session also allow the therapist to see exactly what happens between sessions in multiple dimensions.

At the end of today\\u2019s session, Dan will also fill out the Evaluation of Therapy Session (ETS), and rate Jill and David on Empathy, Helpfulness, and Session Satisfaction, and indicate how willing he is to do psychotherapy homework, whether he had unexpressed negative feelings during the session, and whether he had difficulty filling out any of the survey questions honestly.

The BMS and ETS are invaluable tools that have been game-changers in psychotherapy. To my way of thinking, it is difficult, if not impossible, to do good therapy, much less outstanding therapy, without these powerful and extremely accurate tools. They have the potential to radically transform clinical work and have been an important key in the evolution of TEAM.

E = Empathy

After briefly reviewing Dan\\u2019s starting scores on the BMS, Jill and David empathized while reviewing the Daily Mood Log that Dan filled out prior to the start of the session. The upsetting event was sitting at home on a Friday night with nothing to do, since his wife was studying for an upcoming exam. He points out that when he\\u2019s busy doing therapy, he generally feels fine, but sometimes when he has nothing specific to do, intense negative feelings suddenly hit him and take all the joy out of life. As you can see, his feelings on his Daily Mood Log are similar to his feelings on the Brief Mood Survey\\xa0but some are far more intense, since he\\u2019s focusing on a moment of angst.

If you look at his Negative Thoughts, you will see that they all revolve around a common theme that life has no meaning, since people are suffering and dying all over the world, and since all of us will also die one day. He says, \\u201cthe good things that happen are just like dust in the wind,\\u201d and tells himself that \\u201clife is unfair.\\u201d

Dan explains that in the last couple of years he\\u2019s experienced several painful events. He got married, but got divorced after just three months when things did not work out with his wife. But he\\u2019d sold his condo, and his practice was not going well, and he could barely pay his bills, so he had to move back home with his mother, who then died of cancer.

Then, right after she died, things suddenly took a turn in a far more positive direction. He began dating and found an extremely loving and wonderful woman in 2017, whom he married last October, and his clinical practice began to blossom around the same time, so he and his wife were able to purchase a new home.

But still, the Negative Thoughts kept popping unexpectedly into his mind, and they can turn feelings of joy (\\u201cWow! I really came back\\u201d) into despair in an instant (\\u201cI\\u2019ll probably lose everything again, and it makes no difference because I\\u2019ll eventually die.") David pointed out this is a little like PTSD, when you\\u2019re suddenly reminded of a previous trauma and get overwhelmed by angst. And the frequency and intensity of these sudden despair attacks have increased since the start of the pandemic.

Dan gave Jill and David an \\u201cA\\u201d on empathy after about 30 minutes of listening without trying to \\u201chelp,\\u201d and this was a sign that we could move on to the next portion of the session.

A = Assessment of Resistance

Jill asked Dan if he wanted help tonight, or needed more time to talk and vent. He said he was ready to roll up his sleeves and get to work. His goal was to reduce or eliminate his negative thoughts and feelings, if that was possible.

Jill asked if he\\u2019d press a \\u201cMagic Button,\\u201d if that would cause all of his negative thoughts and feelings to instantly disappear completely, with no effort, and he said he would. Almost everyone says they\\u2019d push it\\u2014which is completely understandable. When you\\u2019re in great pain, we all want relief!

Jill indicated that we did have powerful tools, but weren\\u2019t convinced it would be such a good idea to use them to eliminate Dan\\u2019s feelings, and suggested we might first make a list of indicating:

1. What each negative thought and feeling showed about Dan and his core values that were positive and awesome.
2. How his negative thoughts and feelings might be helping him.

Doing this skillfully is an art form, since it is radically different from the inept \\u201ccheerleading\\u201d so many therapists and family members attempt when a loved one is feeling down.

You will hear this process unfolding when you listen to the audio of the session. Notice how Dan\\u2019s memories of the death of his older brother when he was just three years old and the recent death of his mother bring tears to his eyes, and help him change the way he thinks about his angst, not as something \\u201cbad,\\u201d but as something beautiful that honors his mother and his brother who passed away.

But this is just the tip of the iceberg, as a long list of positives emerges during this portion of the session, which is designed to melt away subconscious \\u201cresistance\\u201d to change. The A = Assessment of Resistance is really the secret key that opens the door to the possibility of rapid, profound, and lasting change.

David and Jill make it look easy, but it is, in reality, quite challenging to learn, because it goes against the very grain of our human inclination to try to \\u201chelp.\\u201d Instead, Jill and David are assuming the role of Dan\\u2019s resistance, and showing him, in a gentle and loving way, that his negative thoughts and feelings are not actually symptoms of a defect or \\u201cmental disorder, but are really the manifestation of something positive and beautiful about Dan. David and Jill are selling Dan on the status quo and are still NOT trying to \\u201chelp.\\u201d

Paradoxically, this procedure typically has the opposite effect of greatly intensifying the patient\\u2019s determination to change.

But now, the therapists have put Dan into a confusional state, and bind. On the one hand, he desperately wants to change. He doesn\\u2019t want to continue throwing cold water on the cherished positive moments in his life. But at the same time, if he presses the Magic Button, all of the positives will go down the drain along with his negative feelings.

This is resolved with the Magic Dial. David and Jill ask Dan if he\\u2019d be willing to dial his negative feelings down to some lower level instead of lowering them all the way to zero. You can see his goals for each negative feeling on the \\u201c% Goal\\u201d column of his Daily Mood Log.

M = Methods

Now David asks Dan which Negative Thought he wants to work on first. He chooses this one:

\\u201cIt\\u2019s pointless in life to strive towards anything, because, in the end, we are all going to die.\\u201d

\\xa0Dan believes this thought 80%.

While identifying some of the many distortions in this thought, he comes up with this Positive Thought:

\\u201cSome things are worth striving for!\\u201d

This thought is 100% true, and his belief in the Negative Thought suddenly drops to 10%, as you can see on his Daily Mood Log (Daily Mood Log.)

Next, he wants to work on this thought, which he believes 60%:

\\xa0\\u201cPeople are dying in the world right now, so I don\\u2019t deserve to relax and have fun.\\u201d

After identifying five distortions in this thought, he challenges it with this Positive Thought:

\\u201cAlthough the deaths of so many people are tragic, it isn\\u2019t my fault that people are dying all over the world.\\u201d

Dan rates his belief in this thought at 100%, and his belief in the Negative Thought drops to zero.

Then he decides to work on this thought:

\\u201cI\\u2019ve had so many good things happen in the last several years, but I can\\u2019t enjoy them, since it\\u2019s inevitable that I\\u2019ll lose those things.\\u201d

He adds, \\u201cAfter all, what goes up, must come down!\\u201d

After a couple of rounds of Externalization of Voices with Jill, he still couldn\\u2019t completely crush this thought, so David steps in to give it a try, with Dan playing the role of the Negative Thoughts and David playing the role of Dan\\u2019s Positive Thoughts. David interrupts Dan\\u2019s verbalization of this thought with some irreverent Buddhist humor. At that moment, Dan suddenly \\u201cgets it,\\u201d and the floodgates open up as Dan crushes the thought.

Some people have called this \\u201cah-ha\\u201d moments the \\u201ccognitive click.\\u201d It\\u2019s like waking up from a trance or nightmare, and the patient suddenly sees the world in a radically new and far more realistic light.

Jill and David complete the M = Methods portion of the session by challenging the rest of Dan\\u2019s Negative Thoughts using Externalization of Voices, including role-reversals with the Self-Defense Paradigm and the Acceptance Paradox. I think you will find these exchange fascinating, and you will hear the tides coming in and the tides going out as Dan sometimes struggles and then defeats all of his Negative Thoughts.

You can review Dan\\u2019s end-of-session mood ratings on his Daily Mood Log\\xa0as well as his end-of-session Brief Mood Survey and his ratings of Jill and David on the Evaluation of Therapy Session.

The Necessary and Sufficient Conditions for Emotional Change

If you look at Dan\'s Daily Mood Log at the end of the session , you will see that the belief in each Positive Thought was high, and that his belief in the corresponding Negative Thoughts was drastically reduced. This is exactly why his feeling suddenly changed so dramatically. Cognitive Therapy (including TEAM) is NOT about telling yourself positive things or uttering positive affirmations. Instead, it\'s about crushing the distorted thoughts that trigger all of your negative feelings. The very moment you stop believing your Negative Thoughts, your feeling will instantly change.

At the end of the session, Jill gives Dan a critically important \\u201chomework\\u201d assignment. Listening to the audio of a session and doing written work with the Daily Mood Log are vitally important aspects of TEAM. What happens between sessions is just as important as what happens within sessions!

Thank you for listening today, and a HUGE thanks to Dan!

I hope you learned a ton, on many different practical plus philosophical levels, and enjoyed today\\u2019s live therapy session!

The Tuesday group at Stanford is free to all Bay Area mental health professionals as well as graduate students in some form of mental health training. The only \\u201cfees\\u201d involve a commitment to consistent attendance and the willingness to use the BMS and ETS with all patients, plus the willingness to do homework between Tuesday groups so you can really learn and master the very challenging TEAM techniques.

Rhonda and David