389: The Story of Amy, Part 2 of 2

Featured Photo is Dr. Amy Huberman The Amy Story, Part 2: The Joys of Doing the Laundry! Amy and her exuberant son, Sasha, and wife, Alena Last week you heard Part 1 of the Amy session, which included T = Testing, E = Empathy, and A = Assessment of Resistance. Today, you will hear Part 2 of Amy's exciting journey from perfectionism to JOY. M = Methods We used a variety of Methods to help Amy challenge her negative thoughts, starting with the first, “I’m failing my patients.” We started with Identify and Explain the Distortions, then went to the Double Standard Technique, and ended up with the Externalization of Voices. As a reminder, you can see Amy's  Daily Mood Log at the start of her session here.. As an exercise, see how many distortions, or thinking errors, you can find in her first Negative Thought, “I’m failing my patients,“ using the list of cognitive distortions on the bottom of her Daily Mood Log. You’ll find the list of the ten cognitive distortions if you click here.  After you’ve identified each distortion, see if you can explain two things about it: Why is this distortion in Amy’s thought unrealistic and misleading? Why might it be incredibly unfair and hurtful? You’ll find my list of the distortions in this thought at the end of the show notes. But don’t look until you’ve made your list! These techniques we used were effective , as you’ll hear on the podcast, especially the Externalization of Voices. You’ll hear us doing role-reversals with Amy, and the method that “won the day” was the CAT, or Counter-Attack Technique, combined with the Acceptance Paradox. The Acceptance Paradox involves finding truth in a negative thought with a sense of peace or even humor. The CAT involves confronting the hostile voice in your head and tell it to go fly a kite, or other gentle but firm message You’ll enjoy seeing some striking changes in Amy, as her tears and feelings of intense self-doubt are suddenly transformed into joy and laughter. Those changes created strong feelings of joy for Jill and me as well. We both have incredibly fondness and admiration for Amy, and feel great joy as well when she feels joy. Here are Amy’s final scores at the end of the session. Emotions % Now % Goal % After Sad, blue, depressed, down, unhappy 80 25 0 Anxious, worried, panicky, nervous, frightened 80 20 0 Guilty, remorseful, bad, ashamed 90 5 0 Worthless, inadequate, defective, incompetent 100 15 5 Lonely, unloved, unwanted, rejected, alone       Embarrassed, foolish, humiliated, self-conscious       Hopeless, discouraged, pessimistic, despairing 90 5 0 Frustrated, stuck, thwarted, defeated 80 5 5 Angry, mad, resentful, annoyed, irritated, upset, furious       Other         The Joyous Dr. Amy! Sudden and dramatic change is pretty trippy, but it isn’t much good if it doesn’t last. And it won’t! Negative thoughts and feelings will always return, because no one can be happy all the time. That’s why some relapse prevention training and ongoing practice and refinement of what you’ve learned can be vitally important. In our follow-up session with Amy one week later she said she’d felt way better during the week, but did, in fact, have some relapses and had to challenge her negative thoughts again. She’d been helped a lot by the idea that it was okay to fail, to seek consultation, and learn, and that failing with patients gave us endless opportunities to learn and grow as therapists. And it was also okay not to have to listen so intently to the attempts of the negative self to put her down. In fact, our misery almost never results from our failures, but from telling ourselves that we “shouldn’t” ever fail, and from punishing ourselves mercilessly when we do. One of her most exciting statements in our follow-up session was that she discovered that even something as humble as putting the dirty clothes into the washing machine could be a joyous experience without that negative voice in her brain constantly hollering at her that she wasn’t good enough! Teaching points It was hard, at first, for Amy to “see” how distorted and unfair her negative thoughts were. She is an extremely intelligent, accomplished, and beloved colleague, and yet most of us cannot “see” or really “grasp” that we can be pretty mean to when we’re feeling down and anxious. I have often said that feeling anxious and depressed is a lot like being in a deep hypnotic trance, telling yourself and believing things that just aren’t true. For example, Amy is doing beautiful work with the great majority of her patients, and is doing the exact same thing with the patients who are responding beautifully as she is with the two who are stuck. So, when she tells herself she’s a failure, she’s clearly involved in All-or-Nothing Thinking. In other words, she’s thinking that if she’s not perfect, she’s a complete failure and a fraud. She also seems to have many Hidden Shoulds (e.g. I SHOULD be able to help every single patient quickly) and Mental Filtering (focusing only on the negatives) and Discounting the Positive (ignoring the positives, as if they didn’t count.) The techniques that were the most helpful for Amy were Positive Reframing: that’s where we pointed out the positive aspects of Amy’s Negative Thoughts and feelings. The Externalization of Voices with Self-Defense, the Acceptance Paradox, and the CAT. Be Specific: Amy was Labeling herself as a “fraud” and a “failure,” and she was Overgeneralizing from two patients to her entire self and career. Jill emphasized Be Specific. In other words, focus on and accept what’s real. What’s real is that Amy has been valiantly struggling to help two patients who are stuck. She can just accept that, and get some consultation and guidance from a colleague, which would probably help her get unstuck. So, instead of labelling yourself as “a failure” and “a fraud,” which are just mean, vague words, you can tell yourself that you have a specific problem—in Amy’s case, getting stuck with two very anxious patients. Then you can focus on getting some help in solving that specific problem—for example, by seeking consultation from a colleague. Jill said that’s what she does when she gets stuck. I used to do that every week, especially when I was first learning cognitive therapy. Getting stuck, then, can simply be an opportunity for growth and learning cool new tools. If we never got stuck, we’d never learn anything new! The very moment Amy stopped believing her negative thoughts, her feelings instantly and dramatically changed. That change happened suddenly, over the course of about 30 seconds, and you can SEE it in her face and hear it in her voice. But it won’t last forever! Jill pointed out that the belief at the root of Amy’s problem was Perfectionism, and the idea that “I should know exactly what to do with all of my patients.” That may be a pleasant fantasy, and it might even motivate us to work hard and achieve, but it’s also a recipe for misery! Follow-up Rapid recovery is great, but will it stick? You will hear excerpts from our brief follow-up session one week later for Relapse Prevention Training. The idea is that none of us can feel happy forever, and negative thoughts will creep back into our minds sooner or later. However, you can anticipate this and prepare for it by challenging your negative thoughts with the same techniques that helped you the first time you improved. That’s because the details will usually be different every time you’re upset, but the pattern of self-critical negative thoughts will usually be the same. And this DID happen to Amy, just as it will happen to you. But this was an opportunity for her to deepen her understanding of perfectionism and to refine and enhance her ability to respond to her negative thoughts. During the weeks following the recording of this podcast, Amy found that she experienced some resistance to using the counterattack technique. She began to feel like she was relating to her perfectionism as an enemy and attacking it—and in doing so, was discounting all the good in it, including the values that came shining through during the Positive Reframing. She found that a better fit for her, instead of the counterattack, was to disarm her perfectionistic thoughts by seeing the truth in them. In fact, you could view this as yet another form of acceptance. When she did this, the perfectionistic voice in her head naturally backed down and gave her the space to do what matters to her unencumbered by self-criticism. I thought it was cool when she described experiencing waves of joy while doing the laundry—an activity that had always felt like a chore to her before, when it was accompanied by thoughts like “I should have finished this laundry days ago.”   She discovered that without beating up on herself, something as humble as doing the laundry could be incredibly rewarding! After our follow-up meeting, I got a lovely email from Amy about the joys of giving up the need for perfection, and sent this follow-up reply to Amy: Thank you, Amy, you are the BEST! I did a four-day intensive in San Antonio years ago with a small group of about 25 therapists. As you know, I always BS and say “As the Buddha so often said . . . “ followed by something goofy or quasi-mystical or whatever, and most people seem to kind of like that and see it as fun or humorous or whatever. Well, I was doing that at the workshop, and at one of the breaks a woman approached me and said she was interested in my Buddhist remarks because she had been raised as a Buddhist in an Asian country where Buddhism is prominent. I panicked and thought I’d been found out and exposed as a fraud. She went on to say that their family gave up Buddhism, however, and she was sad. I asked why they gave up Buddhism, and she explained that her mother suffered from severe depression, and the Buddhists taught that’s because you think you “need” things, and if you’re a good Buddhist you won’t think that way and you won’t ever suffer. Since she suffered, she felt like a failure as a Buddhist, so the family gave up Buddhism. I told her that she might not be aware that there are actually two schools of Buddhism. There’s low-level Buddhism and high-level Buddhism. In low-level Buddhism, you’re not allowed to want or need anything, and you’re not allowed to suffer. That’s sounds like that was the school of Buddhism your family was raised in. But there’s another type of high-level Buddhism. In high level Buddhism you’re allowed to suffer and struggle, and screw up, and fail, and all sorts of stuff. She got animated and said, “I didn’t know that. Thank you so much. You’ve restored my faith in Buddhism, and I can’t wait to tell my mother!” Aside from my being elderly and half-demented, I hope that makes some sense in light of our work together with Jill! So, if you need any translation or explanation, Amy, I’m inviting you to join the high-level Buddhist therapist group where you’re allowed to screw up with some of your patients, or even many! Warmly, david Subsequent Follow-Up I forgot to tell you what happened to Amy’s two “stuck patients.” Well, she got some consultation about why these patients might be stuck, which is nearly always an Agenda Setting problem—the therapist is working harder than the patient due to the need to “help,” and this plays into the patient’s ambivalence. This struck a chord, and Amy was very excited to see her patients again, and both suddenly got “unstuck,” although in somewhat different ways. And that is why I call it the Acceptance Paradox. The moment YOU change, and accept yourself, your world will also change! Or, to put it differently. We often see the world as “different” or as “other,” thinking we are separated. The Buddhists see the world as “one,” and that is certainly true in therapy as well. Answers to the Quiz Question David’s list of Distortions in Amy’s Negative Thought: “I’m failing my patients.” 1.     All-or-Nothing Thinking. This is not realistic because Amy is not stuck with all of her patients. And even though she's still far short of her hopes for these two patients, they may feel they are getting lots of TLC and support from Amy. 2.     Overgeneralization. This is misleading because she’s overgeneralizing from her two failures to her “self,” and labeling herself as “a fraud and a failure.” She also overgeneralizing to the future, thinking things will never change or improve so she should get a new career. 3.     Mental Filtering. She only focusing on the two patients who are stuck. 4.     Discounting the Positive. She’s overlooking the fact that she’s going excellent work with a great many people, and has tremendous integrity, skill, and commitment to her patients. 5.     Magnification and Minimization. She’s kind of blowing things out of proportion, although it’s always good to focus on patients who aren’t yes improving. 6.     Emotional Reasoning, She FEELS like a failure so thinks she IS a failure. 7.     Hidden Should Statement. She thinks she SHOULD be perfect! 8.     Labeling. Same as Overgeneralization. See above. 9.     Self-Blame. She’s blaming herself instead of loving herself and focusing on getting she help she needs and deserves! Thanks for listening today! Rhonda, Amy, and David  

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