305: Ask David: Relationships, Obsessing, Insomnia, Social Anxiety and More! Featuring Matt May, MD

Feeling Good Podcast | TEAM-CBT - The New Mood Therapy

Ask David: Featuring Matt May, MD 1. Nick asks: “What if you want a positive relationship with someone who does not want the same thing?” 2. Debbie asks: Hi David, I can't stop ruminating and obsessing about weird states of minds or when I was afraid of harming someone or remembering. Everyone says to let go but why do I hang on. Where in your book can you help me? 3. Dean asks: I’m having trouble sleeping. What should I do? 4. Kathy asks a question about social anxiety / panic and the hidden emotion technique. Note: The answers below were generated prior to the podcast, and the information provided on the live podcast may be richer and different in a number of ways. 1. Nick asks many general relationship problems that all need specific examples. Dear David, Thank you for all the amazing work you do. Your books and podcasts have helped me to understand and start to transform a lot of negative and unwanted frames that I carry around. I'm also working with a Level 3 therapist who I found through the Feeling Good Institute. One area I'm working on is building my empathy skills using the Five Secrets model. I see how powerful it is in situations where both people are open to a positive relationship. But I struggle with the idea that each of us creates our own interpersonal reality, and can always create a positive outcome regardless of the other person. Can you help me understand how to apply the technique to some challenging situations? - What happens if you want a positive relationship with the other person, but they fundamentally do not? I find that this situation leads the other person to react to the Five Secrets with anger or indifference. Or they view you as weak for exposing your emotions and vulnerability, and try to exploit them for advantage over you. Is it even worth trying to have a positive relationship with such a person? David’s reply I try not to impose on people who do not want a positive relationship with me. You could also provide a specific example, as I always insist on having! These vague questions to my ear are kind of useless. Matt’s reply David, you’ve said that the cause of all relationship problems is Blame. I agree with this and sense that Nick’s question is driving at that point, as well. If someone doesn’t want to participate in our definition of a ‘positive’ relationship, the approach that is most in line with the 5-Secrets and Empathy is to let go and stop demanding the other person change. That’s the cause of the problem: trying to force people to do things, our way, regardless of what they want. This will cause them to resist and will damage the relationship. David, you have also talked about the opposite mindset of blame, where we can wield 5-Secrets honestly and effectively, the concept of ‘Open Hands’. When we have the attitude of ‘Open Hands’, we can welcome other people and receive them or gracefully let go. This mental state avoids conflict and the ‘blame game’ in a healthy, non-avoidant way. For example, if someone says, “I don’t want to have a relationship with you”. We might reply, using the 5-Secrets, ‘You’re right, I’ve been disrespectful and inappropriately pushing you too hard in the direction of having a relationship with me. I appreciate your letting me know, clearly, that this isn’t something you want. While I can imagine you might be angry with me, I’m sure you don’t want to talk about that, but prefer, instead, to end the relationship as quickly as possible. I’m feeling awkward and would like to get out of your hair as soon as possible, too. What can I do to facilitate ending this relationship in a way you would be satisfied with?” To put it another way, while you can maximize your chances of having a positive interpersonal experience with someone, using these communication skills, the 5-Secrets, they are not ‘mind control’ and trying to use them that way will only make matters worse, hence the importance of the internal mindset of ‘open hands’, accepting others’ preferences and being willing to let go, perhaps grieve, refocus our attention elsewhere, if that’s not what they want. Otherwise, we are in the ‘chasing’ and ‘blaming’ role, which is doomed to fail, as has been discussed on previous podcasts. It may also be useful to consider whether it’s actually possible to ‘not have a relationship’ with someone. My sense is that there is, in fact, a relationship, even between total strangers and between people who have decided, mutually, to end their relationship. We could point out how those two types of relationships might differ, say, if you were to bump into each other in a grocery store. In the latter example, you might be expected to try a bit harder to avoid contact, with an agreed-upon, ‘ex’ than you would, with a stranger. There are rules and expectations and ways in which both people think about the other person and define their ‘relationship’, even if you are saying that it has ‘ended’. The conflict comes when we don’t have the same agenda and don’t agree on the terms and rules of the relationship. There are many other related topics, including the ‘gentle ultimatum’, ‘interpersonal decision making’ and ‘blame CBA’ which could be useful for Nick. Nick continues - What if you believe the other person does have a fundamental desire for a good relationship, but they are so attached to their anger, fear or depression that their only reaction is hostility and defense? Perhaps such a person can't or won't admit to their emotions, and rejects the empathy. Should you keep trying, and at what point if any should you give up? David’s reply Need a specific example! I may have mentioned that! Matt’s reply: A specific example sure would help! The problem seems related to the ‘blame game’ which we just talked about. We are demanding the other person change, and stop being so hostile and defensive. Instead, consider using Interpersonal Decision Making and look at the three options that are available, in any relationship. If you decide to take responsibility for the relationship, try the Relationship Journal, so you can see through the blame that is causing the problem. You could also use positive reframing to admire their hostility, defensiveness, anger, fear and depression. Nick continues: Perhaps there are mistaken or lying about the facts, and unwilling to admit it. Or you disbelieve what they say because it doesn't match their actions or is calculated to deflect blame. For example, you may have a conflict over who cleans the house. The objective fact is that you do this 80% of the time and have done it the last 5 times in a row, while the other person has consistently left garbage lying around. Yet the other person says "I feel like you never do housework and I am always the one cleaning, and I'm sick of it". How can you find truth in such a statement? David’s reply Work this out on a Relationship Journals. Write down what you said next, and follow th steps clearly spelled out in Feeling Good Together. Or, I could send you one. Matt’s Reply Disarming is really challenging because it requires us to let go of our version of the ‘truth’, at least temporarily, in order to see the other person’s truth. People often don’t want to do that, even for a moment! Furthermore, if the other person is angry, they are likely to distort the truth in their statements, for effect, to be more persuasive. The problem with this, is that it will call our attention to the lies they are telling, tempting us away from seeing their truth. Without knowing more about the situation, I could only guess at what their ‘truth’ is. Here are some possibilities, though: Is it possible that they have some reasonable expectation for us to do more of the cleanup than them? Are they offering something else in the relationship that offsets their lack of cleaning? Do they do the majority of the cooking? Do they do the shopping? Do they pay more of the bills? Also, were they the last one to do the cleaning? When they clean, do they spend more time on it or do a more thorough job? When they clean, do they clean up their things as well as yours? Do you do that? You stated that they leave their ’garbage lying around’. Is that how they see it? Is it possible that they put their things precisely where they wanted them to be and didn’t want you ‘tidying up’? The point is that disarming requires seeing the bigger picture, not just the one data point that best supports your blaming them. Try to see past this and, if you can’t, considering Interpersonal Decision making and the Blame CBA, where you would write down the good reasons to blame the other person and insist that your version of the truth is complete and correct and that theirs is wrong and bad. Nick carries on - What should you do in situations where you both have attachments to other incompatible goals? In Lee's case on episodes 96-98 of your podcast and Chapter 27 of Feeling Great, both Less and his wife had the same fundamental values with regard to raising their daughter. So once he applied the Five Secrets, they were able to move past their ego defenses and share the same perspective. But what if there is a zero-sum situation where both of you have different core values? For example, choosing a grade school for your child. One parent sincerely believes in their core values that their child will benefit from attending a rigorous school where they will be challenged and grow. The other parent sincerely believes in their core values that children should be in a relaxed environment where they can play as much as possible. Can the Five Secrets help with this type of conflict? David’s reply Read the chapter in Feeling Good Together on the idea that the attempt to solve the problem IS the problem, and the refusal to solve it is the solution. I think you’ve got some work to do! Now we’ll see if you do it! Matt’s Response In this case, you could agree to disagree and let a professional decide what would be best for your child. Studies conducted longitudinally by Chess and Thomas showed that no one parenting style was ‘best’ overall, but rather that outcomes for human being were determined primarily by how well the parenting style suited the child. 2. Debbie asks: Hi David, I can't stop ruminating and obsessing about weird states of minds or when I was afraid of harming someone or remembering. Everyone says to let go but why do I hang on? Where in your book can you help me? David’s reply You can read my book, When Panic Attacks. You can use search function on website for many illuminating podcasts on anxiety and OCD. You can sign up for the free anxiety class. Go for it. Then ask specific questions about something you're working on based on these resources. Matt’s reply Well, you’re not alone! Nobody can ‘stop ruminating’. Try a mental experiment, where you try to ‘stop ruminating about a blue-eyed tiger’. Tell yourself, ‘I must stop ruminating about a blue eyed tiger! I must stop ruminating about a blue eyed tiger!’. You will come to realize that it’s Impossible and the harder you try, the more you obsess. One possible solution is to find something else, something better, to become the focus of your attention. Imagine a ‘Miracle Cure’ were possible. What would you most wish to see happen in your life? You could then use the Decision Making Form, to weigh different options, comparing the miracle cure to the status quo, for example. There are, after all, real advantages to ruminating and obsessing. You might have a sense that you’re being responsible, protecting others, preventing yourself from going into weird states of mind and harming people. This is part of your moral nature, doing no harm, being considerate and thoughtful, sacrificing your needs for others. That’s a good thing! Also, you might be afraid of committing to pursuing your dreams, for good reason. There are real disadvantages of doing that. The risk of failure, humiliation, conflict, disappointment and defeat, for example. Until you are convinced that you would want some other version of your life, despite the many advantages of rumination and the disadvantages of change, other methods are unlikely to be effective. If you firmly decide and are committed to change, meaning that you have convinced yourself that this is what you want, on the Decision Making Form, then there are lots of methods that could be helpful. For example, you could use the Get Specific method and an assessment of Process Resistance. When do I want to be cured? What would I be willing to do, to have my dreams come true? What are some small steps I could take to get there (Anti-Procrastination / Little Steps for Big Feats). What time will I do these tasks? Sit down and schedule time in your day to pursue your dreams (Activity Scheduling). If intrusive thoughts come in, try ‘Self Monitoring and Response Prevention’. If temptation is especially tenacious, try the Devil’s Advocate Technique. I’d recommend looking into things like the ‘Hidden Emotion’. Is ruminating a form of ‘niceness’, an avoidance of a conflict? For example, who are you angry with? Have you told them? If you go live your best life, who would object? You can also give yourself a certain amount of time, per day, to obsess, wholeheartedly (worry breaks). How much time would you like to spend ruminating? Schedule this time and if you’re ruminating outside that time, remind yourself that you have plenty of time to ruminate later. Again, there are a lot of methods that could help and finding the right ones will be a bit of trial and error! 3. Dean asks: I’m having trouble sleeping. What should I do? Hi Dr. Burns, I picked up a copy of 'Feeling Great' and am excited to start reading it. I have been battling anxiety, depression, and severe chronic insomnia for the past year. Do I start with TEAM-CBT for anxiety/depression and deal with that first, or do I supplement with CBTi-for Insomnia and do both at the same time? I met with the Mayo Clinic last fall and they said the root cause of the Insomnia is some depression. I have been to a lot of doctors, specialists, and therapists and so far no one has been able to help. Thank you! David’s reply I am not familiar with the insomnia app but it can likely give you some of the basics of sleep hygiene in case you do not already know them. TEAM can be helpful, to say the least, for the mood or relationship issues that may be triggering the troubles sleeping. Often, we may have trouble sleeping because we are upset about something. Sleep difficulties are a non-specific manifestation of being upset about something. There is no special relationship with depression, however. It could be anxiety, anger, anything. Let me know what evolves for you! And, of course, sleep difficulties do not always result from emotional disturbance, but this is often the case. For humans, problems don't usually just come from out of the blue, but from your life! David Matt’s reply The best response to the question, ‘How do I get to sleep at night’, that I’ve heard is, ‘try to stay awake’. Meanwhile, I have a couple of thoughts on diagnosis and treatment planning. Having a diagnosis of ‘anxiety’ or ‘depression’ is like having a ‘diagnosis’ of ‘cough’ or ‘fever’. Our feelings are symptoms, not the source. g. if someone has symptoms of a cough and fever, that could be the result of any number of different underlying causes: bacteria, viruses, fungi, allergic reactions, autoimmune disease, toxin exposures, etc., etc. To make more accurate guesses about an appropriate treatment regimen, we need greater specificity. In the treatment of symptoms like depression, anxiety and insomnia, we would need to know much more about a specific moment in time when you were having these symptoms, what you were doing, what you were thinking and details about the feeling state you were in before deciding how to prioritize the methods that would be part of a treatment plan, which we call a ‘recovery circle’ in TEAM. In medical school, they train physicians to ‘cast a very wide net’, when considering all the possible causes of the symptoms a patient is experiencing. This list of possible causes is referred to as a ‘differential diagnosis’ by physicians. The idea is to organize this list according to what is statistically most likely given all the information we have on hand and to conduct various tests to narrow down these options, in order to prioritize a treatment strategy that is most likely to be effective. Meanwhile, we want to keep open in our minds that our diagnosis could be wrong and that we will need to monitor the outcome carefully, with frequent testing, rather than assume we know the ‘root’ problem with 100% certainty, so we can modify the treatment strategy based on results. While it’s tempting to try to try to optimize treatment results by matching the diagnosis with a ‘school’ of therapy, (ERP for OCD, EMDR for trauma, DBT for BPD, etc.), there are several problems with this ‘schools’ vs. ‘tools’ approach to therapy. For one, the reality is that people are quite complex beings and diagnostic labels are quite imprecise and limited. Even when we have an accurate diagnosis, we can’t predict precisely which specific set of methods will be required to help someone recover. Furthermore, even if someone has the exact same set of upsetting negative thoughts related to their anxiety, depression and insomnia, perhaps their thoughts circle from ‘I must get some sleep, I’ll never get to sleep, I’ll feel terrible tomorrow, Everything will go wrong, I’m a hopeless case, I’m a loser…I must get some sleep (repeat)’, even if the thoughts are the same in multiple different people, we can only make informed guesses, rather than predict, perfectly, what method(s) will suit that individual best. Will it be the double standard technique, or cognitive flooding, sleep restriction, the hidden emotion, the Socratic technique or memory rescripting, self-monitoring or response prevention, something else? The solution to this uncertainty is the Recovery Circle. The ‘recovery circle’ is a customized list of at least twenty methods, that are selected based on the specific feelings, thoughts or behaviors someone would like to see change. Each of these methods will have some reasonable chance to help an individual, with their particular thoughts and feelings and behaviors. The idea is then to ‘fail our way to success’, using trial-and-error, with measurement in between, to discover, scientifically, what is the best method for that individual. Once we do, we focus on practicing that method regularly to gain skill with it, until our patients are not only cured, but able to recover from relapses on their own, because they know the methods that are most helpful to them. Another consideration is that, in general, folks benefit from an approach that is kind, empathic, respectful, grounded in science and measurement, and attentive to resistance and motivational barriers to change. One reason I would recommend TEAM to a family member or friend is that it contains each of these necessary elements of therapy and also has the greatest diversity of tools to help someone, as well as a customized approach to treatment. I think that’s why TEAM has been shown to be much more effective than other forms of therapy. All that said, it’s important to realize that TEAM itself is incomplete and we would want to continue to expand up the model and, when you’re in treatment, know that it’s fine to get a second, third or fourth opinion on what methods and approaches are most likely to benefit you. 4. Kathy asks about social anxiety, panic and the hidden emotion technique. Hi Dr. Burns, Thank you so much for all the great information you put out there! I had a question about hidden emotion. If I experienced dizziness in a social setting ten years ago and now I panic whenever I am in a similar situation anticipating the dizziness. Is there still a connection to the original emotion that is still hidden or is it a habit at this point? Thank you so much David’s reply Were you upset with somebody or something in that situation? Matt’s reply: You could use uncovering techniques, like the ‘What If’ Technique and the ‘Interpersonal Downward Arrow’, among others, to figure that out. For example, ‘what if you got dizzy? What’s the worst that could happen? You can write down your answer, and continue to ask yourself, ‘what if that happened, what would I be anxious about?’. Then, as yourself, if that happened, what would other people think about me? How would they treat me? What kind of people are these people, I’m imagining? How do I feel about people like that?