193: Sarah Revisited: A Hard Fall--and a Triumphant Second Recovery

On February 24, 2020 we published Podcast 181, "Live Therapy with Sarah: Shrinks are Human, Too!" This was a live session with Sarah, a certified TEAM-CBT therapist, conducted at my Tuesday psychotherapy training group, because Sarah was struggling with intense anxiety, bordering on panic, during  therapy sessions with her patients. It was a phenomenal session with outstanding results. The Hidden Emotion technique was the main focus of that session, bringing to conscious awareness some feelings of anger and resentment that she'd been sweeping under the rug. This is a common cause of anxiety. But a month or so after that session, Sarah relapsed in a big way, so I agreed to treat her again during the psychotherapy training group at Stanford, and Dr. Alex Clarke was my co-therapist. This time, we used very different treatment techniques. Once you've recovered, the likelihood of relapse is 100%--that's because no one can be happy all the time. We all hit bumps in the road from time to time, and when you do, your "fractal" will come into prominence again. This means that the same kinds of negative thoughts and feelings will return in an almost identical form. This can give you the chance to defeat them again and strengthen the positive circuits in your brain. That's exactly what happened to Sarah. Approximately one month after the first treatment session, she had a viral infection, and began taking large amounts of Advil to combat the symptoms. This led to severe feelings of nausea, followed by panic. Multiple trips to the doctor failed to reveal any diagnosable cause for her somatic symptoms, aside from the possibility of Advil side effects. However, the discomfort was so severe that she panicked, fearing that she had a more severe medical problem that the doctor had overlooked. She lost 13 pounds over the next two months, and requested an emergency TEAM-CBT session, which Dr. Clarke and I were very happy to provide, since live work almost always make for superb teaching. If you take a look at Sarah's Daily Mood Log, you'll see that the upsetting event was waking up Sunday morning still sick and anxious for the 100th day in a row. She circled nine different categories of negative emotions, and all were intense, with several in the range of 80 to 100. and she had many negative thoughts, including these. Please note that she strongly believe all of these thoughts: Negative Thoughts % Now 1.    I should be able to defeat my anxious thinking and reduce my suffering. 95 2.    If I can’t heal my own anxiety, I’m an inadequate hack of a TEAM-CBT therapist. 95 3.    I was strong, confident, vivacious. Now I’m fragile, weak, and self-doubting. 100 4.    My anxiety is slowing me down—I should be able to do more and take on more. 100 5.    Something serious is wrong with my stomach, but now with Covid-19, I won’t be able to get medical intervention and testing. 70 6.    I’m not as effective in my clinical work when I’m upset and anxious. 85 7.    I might get panicky during a session and screw up. 80 8.    I should always do more. 85 After empathizing, I asked Sarah about her goals for the session. She said she wanted greater self-confidence and less anxiety, and said her husband had theorized that if the anxiety disappeared, her somatic symptoms would also go away. But when we did Positive Reframing, Sarah was able to pinpoint more than 20 overwhelming benefits of her intense negative feelings, including many awesome and positive qualities and core values that her negative thoughts and feelings revealed about her. This always seems to be a shocking and pleasant discovery for the patient! At this point, we used the Magic Dial to see what Sarah wanted to dial her negative feelings down to, as you can see here. Then we went on to the Methods portion of the session, using techniques like Identify the Distortions, Externalization of Voices, Acceptance Paradox, and more. We also had to revert back to the Assessment of Resistance once again when Sarah began to fight strenuously against giving up her self-critical internal voice. We did a Cost-Benefit Analysis on the advantages and disadvantages of being self-critical and not accepting her fragileness, weaknesses, and flaws.  Once we "sat with open hands" and listed all the reasons for her to continue criticizing herself, she suddenly had a change of heart and really poured herself into crushing her negative thoughts. It was interesting that as she began to blow her negative thoughts away, she suddenly got hungry for the first time in months!  If you click here, you can see how she felt at the end of the session. It was a mind-blowing session, with much potential for learning. Rhonda, Dr. Clarke and I hope you enjoy it! Here were some "teaching points I sent to the tuesday group members after the session. This could not have been done in a single session. At least in my hands, a two hour session is massively more cost-effective than a bunch of single sessions. But even then, you have to have a plan and move quickly. Although you all said wonderfully admiring things to our “patient” during the E = Empathy phase of the session, few or none of you used Thought Empathy or Feeling Empathy, which is vitally important. I thought that Fabrizio did a magnificent job with “I Feel” Statements, expressing genuine warmth and compassion. As usual, resistance was the key, and could not have been overcome with efforts to “help” or attempts to use more M = Methods. Learning the dance of reverting instantly to A = Assessment of Resistance is key (revisiting this when the patient resists during M = Methods. But this requires “sensing” that the patient is resisting during Externalization of Voices, for example. You have to kind of “smell” what is happening, and then suddenly change direction. You also have to be able to “see” that the patient is absolutely committed to some underlying schema or belief, like “I should always be strong and vivacious,” etc. The Assessment of Resistance cannot just be an intellectual exercise, as it might then revert to “cheer-leading.” Emotion and tears are crucial, and amazing work was done by Sarah, our “patient,” during the tears. She gave herself compassion at that moment. But tears alone without the structure would not have had nearly the impact. Skillful therapy integrates multiple dimensions at the same time. It cannot be formulaic. It's an art form, based on science, and it is data-driven, based on the patient's ratings at the start and end of the session. During the Externalization of Voices, I would recommend that you NEVER settle for a “big” win. Shoot for huge, and stick with the same thought for as many sessions as necessary to get to “huge.” During the role playing I switched back and forth from Ext of Voices to Paradoxical Double Standard and then back frequently, as they both draw on different sources of pretty incredible healing power. As a therapist, I never give in to a patient’s feelings of hopelessness, because rapid and dramatic recovery is usually possible. Relapse Prevention Training (RPT) will now be necessary, since NTs always return. RPT only takes about 30 minutes. I apologize for taking over last night, but felt my strongest commitment is to provide relief for the person in the “patient” role. Sometimes what you think of as your worst “flaw” (eg being suddenly weak and fragile and fearful) can be your greatest asset in disguise, once you accept your flaw(s). But we fight against acceptance, thinking that if we beat up on ourselves enough, something wonderful will happen. And, of course, the self-criticism can sometimes reap big dividends. At the same time, I try to remind myself that self-acceptance is the greatest change a human being can make. The goal of therapy is not just feeling somewhat better, but getting to enlightenment and joy. That's what happened tonight! After the session, I received this awesome email from Sarah: Thank you from the bottom of my heart, David, Alex, and all members of our training group who were present tonight. Such beautiful contributions from all, and I appreciate so deeply this 2nd opportunity to do personal work, especially given that we are ALL going through difficulties during this Covid-19 crisis (or in general). I feel so much lighter, even enlightened, ate some pot roast for dinner (What??? I haven't had an appetite for something like that in a LONG time... and find myself looking forward to my sessions with my patients tomorrow). And I also know I'll have moments of relapse, but I really felt like I finally defeated those thoughts and especially the core belief. Stay healthy and safe everyone, I look forward to opportunities in the future when we reunite, to be in support of YOU. Best, Sarah Rhonda, Alex and I want to thank you, Sarah, once again, for your tremendous courage and generosity! David and Rhonda

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