2019 is coming to an end and with it the path we have traced through our blog on Single Session Therapy .
In this year we have focused on some specific topics that have ranged from how to implement TSS in Walk-In Services or psychological first aid to the approaches with which to integrate it, sharing theoretical insights, case studies and practical experiences from around the world.
So what are we going to talk about today?
To conclude the course, we will once again focus on a new way of doing psychotherapy , born from the need to overcome the patient’s concept of resistance and intervene quickly on complex and disabling problems such as anxiety , depression and addictions .
This new way of doing therapy integrates the TSS method with some cognitive behavioral therapy (CBT) techniques developed by psychiatrist David Burns who he defined as CBT – TEAM .
Who is David Burns?
David Burns is a psychiatrist who, after researching biological psychiatry, dedicated himself to the study and development of cognitive behavioral therapy (CBT) .
Interest in CBT arose above all for the practical , action-oriented and skill-development tools that this form of therapy offers.
The use of the techniques allowed him to help patients who for many years had received long treatments for depression problems without obtaining results in a rapid, “almost magical” and without the use of drugs. His studies were later reported in the book Feeling Good: The New Mood Therapy published in 1980.
But why did Burns at a given moment decide to go beyond CBT to come to consider yet another way of doing psychotherapy?
Burns reflected that our purpose as therapists is nothing less than to help people who are ill feel better in the shortest amount of time possible . This usually requires them to make an effort to change dysfunctional thought patterns, self-defeating behaviors, and self-defeating ways of relating to others.
So what do we do to help people?
If we are action-oriented therapists, we generally try to persuade people to engage in some task or to use a tool or technique that we know will help them change.
What happens then is that people follow our suggestions and the resulting changes can often be rapid.
But does this always happen?
Well the answer is no!
Instead, it happens that some customers seem to do everything to undermine the help we offer them and we can safely say that more or less we have all had to deal with people who, when faced with our indications, answered “yes, but…” or who have consistently forgotten to do their psychotherapy homework, complaining that they are not understood.
What consequences does all of this have?
Often therapy with these people ends in a stalemate, the client leaves without having solved his problem and the confused therapist feels inadequate, frustrated, even angry, many times accusing the client of being “resisting!” .
From this Burns asked a number of important questions for the therapist.
But what if the problem was really with us?
- What if we have become so confident in our approach that we ignore the aspects of clients’ inner ecology that trigger resistance?
- What if we discovered that the negative thought patterns, feelings, and behaviors that keep people stuck have powerful, unconscious benefits that serve to preserve their lives?
- What if resistance to change reveals something positive, beautiful, and even healthy about them?
Let’s see concretely what determined Burns’ change of perspective on psychotherapy.
The need to rethink his therapy arose from a case Burns was working with a depressed person named Karen.
She was a New York professional software developer who was very successful at her job, yet she constantly complained about her life and the men she dated.
Burns offered her many tools during therapy to help her overcome depression and improve her relationships with men, but she didn’t seem interested. When he encouraged her to identify and challenge her own distortions of her negative thoughts or when he showed her how to improve her relationships, she angrily insisted that it was not her that should change, but others. She also accused the therapist of being more interested in her techniques than in her, causing him enormous frustration. One day, tested by this resistance, Burns forcefully emphasized that using the tools of CBT and doing psychotherapy homework between sessions was mandatory for life change. In a hostile manner, the woman told him that if she asked her to do her psychotherapy homework again,
Terrified and embarrassed, Burns thought that he was probably pushing too hard and that perhaps he hadn’t provided the right listening and empathetic support. After another two years, she Karen was still bitching and refusing homework, and she was still as angry and depressed and lonely as ever. Ultimately, she walked off the therapy with no real improvement.
What types of resistance are there?
From clinical work Burns has determined that there are two main types of resistance : resistance to results which consists of the fear of abandoning dysfunctional thoughts and behaviors and resistance to the process which concerns the difficulty of applying oneself to the required tasks. With respect to the more common problems presented in therapy such as depression, anxiety, relationship problems and habits/addictions, Burns identified eight types of resistance.
- resistance to outcomes for depression almost always involves a client’s non-acceptance of some internal problem or external circumstance that keeps the depression going;
- with process resistance clients may want to recover, but do not want to engage in what is required to do so such as psychotherapy homework between sessions. Perhaps that would force them to focus on difficult aspects of their lives.
- outcome resistance for anxiety always involves magical thinking. Most anxious clients secretly believe that something terrible they are anxious about will happen if they recover. So even if they ask for help, they are afraid to let go of the anxiety;
- Process resistance for anxiety means that a client may want to recover, but doesn’t want to engage in therapy because it would involve facing their fears through exposure techniques, which is incredibly scary.
Relationship Conflicts :
- resistance to outcomes in this case means that the client does not really want to get close to the person with whom he is at odds;
- Process resistance for a relationship problem is different. If you want a more loving or fulfilling relationship, you probably need to stop blaming the other person and start examining your own role in the problem, but this can be painful.
Habits and Addictions:
- resistance to results simply means that the person is unwilling to give up a source of immediate pleasure or gratification;
- resistance to the process means that the client does not want to go through the discipline and deprivation that will be required to get a good result.
What to do?
Based on this insight, Burns decided to make some radical changes in the way he does psychotherapy. Instead of using more and more tools and techniques to help clients change, he decided to focus on the reasons that push them not to engage in coping activities and developed the CBT-TEAM which stands for Test, Empathy , Setting the ‘ Agenda (paradoxical) and Methods ( click here ).
Here is an example of applying the method!
In a seminar Burns taught the case of an Asian woman in her 50s named Christine. The woman had been the victim of violent abuse by her ex-husband for thirty years, as she was too scared and demoralized to save herself.
At the time of the session, she had been divorced for a decade but was still severely depressed, anxious, and angry despite having undergone many years of psychotherapy with a wide variety of approaches.
Before the session, Burns asked Christine to record her negative thoughts and feelings on a form called the Daily Mood Log (DML), a CBT tool that helps clients pinpoint their negative thoughts and feelings at a specific time, e.g. example, when they are angry.
Having identified the upsetting event, Christine rated all of her negative feelings on a scale of 0 (not at all) to 100 (extremely serious). Here is the example:
- I’m not safe – 100
- I can’t trust men – 95
- I should have stopped the abuse – 90
- I victimized myself – 100
- I must be defective – 90
- I lived a lie and I shouldn’t have – 100
Burns began the session:
- compassionately listening to the woman and empathizing with her pain;
- setting the paradoxical agenda setting (PAS) which with the use of specific techniques tries to bring the resistance of the processes and outcomes to awareness and work to reduce them.
The first maneuver was to ask the following question “If you walked out today at the end of the session feeling like something miraculous had happened, what kind of miracle would you like to happen?”
And then “Let’s imagine there’s a magic button right here on the desk. If you press it, you will be instantly healed without any effort and all your negative thoughts and feelings will completely disappear. You will be flooded with feelings of joy. Do you want to press that button? “
To the patient’s affirmative response, Burns explained that she didn’t have a magic button, but some pretty powerful techniques they could use. And while she couldn’t promise any specific results or miracles, there was a strong chance for improvement. At the same time, however, she said she was reluctant to use those techniques because of her negative thoughts, which could still reveal some positive things about her.
Then for every negative thought he suggested making a list of positives. This step is called positive retraining, and it’s a gentle, non-threatening way to bring resistance to outcomes into awareness.
For example, Burns got her to think about the role of anxiety through the following maneuvers: “Suppose you press the magic button and at the end of this session you walk away feeling completely anxiety-free and safe. Do you really want it? Can you think of some reasons why you might not want to do this? Are there any benefits to your intense anxiety? “
Since at the beginning of the session, Christine had told of a flirtation with a man, Burns after asking her to press the magic button, made her reflect on the fact that abandoning anxiety prematurely would also make her abandon her defenses and finish in another abusive relationship. After a moment, she replied, “So maybe my anxiety is keeping me alert.”
Burns and the woman completed the positive aspects list of all the negative thoughts emerging from the initial test in about 20 minutes, and concluded this phase by telling her “Christine, maybe it’s not a good idea to push that magic button and make all this disappear. negativity. Let’s imagine that you have a magic dial and can lower your negative feelings to a healthier level, instead of making them disappear completely. You may still have their benefits, but without being so totally overwhelmed and defeated.”
Once resistance was overcome, the remainder of the two-hour session involved working with a variety of standard cognitive techniques to help Christine challenge her negative thoughts. This is the part of the CBT Methods – TEAM.
Finally, after what has been explored, could we begin to see resistance from a radically different perspective?
Team Psychotherapist of the Italian Center
for Single Session Therapy
Burns, D., (2017). When Helping Doesn’t Help Why Some Clients May Not Want to Change, from https://www.psychotherapynetworker.org/magazine/article/1076/when-helping-doesnt-help
Burns, D., (2016). Can Depression Really Be Treated in a Single, Two-Hour Therapy Session?, from https://feelinggood.com/team-vs-cbt/