155: Treating Depression, Emotional Eating, and Self-Image Problems with TEAM-CBT

The Story of Lorraine and “Anna”

In today’s podcast, David and Rhonda interview Dr. Lorraine Wong, a board-certified clinical psychologist, and her patient, “Anna,” who sought treatment recently for depression, anxiety, and self-image / self-esteem issues. But first, David and Rhonda answer a question submitted by Estafonia, a “public image consultant,” who asks about the treatment of a woman who sees herself as “fat.”

Estafonia wrote:

“Hi Dr. Burns,

“I am learning TEAM, CBT and implementing your techniques to help my clients change or improve their self-perception. In most cases, your techniques have been very effective. I am very grateful to you and I will happily join your list of fans!

“My question is this—What would be the best method to change someone’s self-image? How can you help people change the idea that they are fat for example?

“I have a patient who can't defeat the thought, ‘I am fat.’ We tried the method called Examine the Evidence,” and she has already found 20 people who see her as thin. So, the evidence clearly did not support her belief that she is fat. But this did not help.

“We also tried the method called Let’s Define Terms, and we both concluded that she is not fat. But now she tells me, ‘I know I am not fat, but I can't stop thinking about it.’

“We also did the Downward Arrow Technique to probe her deepest fears and Self-Defeating Beliefs, but that didn’t seem to help, either, and she keeps ruminating about being fat. I would greatly appreciate your guidance on how to help her overcome that thought!

“Thanks in advance! Estefania”

Lorraine, Rhonda, David and Anna quickly diagnose the most likely cause of Estefania’s stuckness—she is trying to “help” her patient without first melting away her patient’s resistance. This is the cause of practically all therapeutic failure, and you’re not really doing TEAM-CBT if you don’t know how to eliminate the patient’s resistance.

That’s because most people are ambivalent about change. As the Jesuit mystic, Anthony DeMello, has said: “We yearn for change but cling to the familiar.” Recognizing and modifying this inherent ambivalence is the heart of A = Paradoxical Agenda Setting, but you can also think of the A as standing for “Assessment of Resistance.”

How could we melt away this woman’s ambivalence / reluctance to stop bombarding herself with the message, “I’m fat”? It is important to realize that this self-critical thought, and, in fact, all of her negative thoughts and feelings have huge advantages for her, and also indicate some really beautiful and awesome things about her and her core values.

For example, telling herself “I’m fat” may motivate her to diet, to exercise, and to make extra sure that she doesn’t get complacent and gain a tremendous amount of weight. In addition, the thought, “I’m fat,” shows that she has high standards, and her high standards have probably motivated her success in many areas of her life. For example, she probably works really hard to stay in good health and in good physical condition.

The thought, “I’m fat,” also shows that she’s humble, and on and on and on. And that’s just one negative thought. But this woman probably has many negative thoughts and feelings, like anxiety, shame, inferiority and depression, and they ALL have tremendous advantages, and they ALL reveal what is beautiful and awesome about her and her core values.

In addition, the thought may be protecting this patient from things she fears, like intimacy. As long as she tells herself, “I’m fat,” she does have to risk trying to get close, or having sex, or risking rejection. So the thought, in a way, is a form of self-love and self-protection.

Once Estafonia and her patient list all these positives, Estafonia could ask her patient, “Given all these advantages and positive qualities, maybe it wouldn’t be such a good idea to stop telling yourself, ‘I’m fat.’ This thought seems to be working for you in a really positive way, and also reflects your core values.”

That’s the essence of Paradoxical Agenda Setting. We try, in a genuine way, to honor the patient’s resistance, rather than trying to sell the patient on change. This is very difficult for therapists to learn because of the compulsion to save, help, or rescue the patient.

In addition, obsessions (recurring illogical negative thoughts like “I’m fat”) frequently result from the Hidden Emotion phenomenon, and this has to be dealt with skillfully when treating any patient with anxiety. Estafonia’s patient may be upset about something she’s not dealing with in her life, and bringing the hidden problem or feelings to conscious awareness can often be incredibly helpful. For more information, see my book, When Panic Attacks, which you can order from my books page (link).

After focusing on Estafonia’s excellent question, David, Rhonda, Lorraine and Anna talk about the emotional challenges that brought Anna to treatment, including severe feelings of depression which came on when Anna returned to the United States after 13 years working abroad. She was also feeling anxious, stuck, angry, and hopeless, and was comforting herself by binging on her three favorite foods.

Anna describes previous partial treatment failures, and explains that her previous cognitive therapist had “the empathy of a prison guard,” and contrasts those experiences with her successful experience with Lorraine. In fact, Anna describes the TEAM-CBT she received at the Feeling Good Institute as “cognitive therapy on steroids.”

I (David) loved hearing that because this is how I think about TEAM-CBT, too! TEAM really is CBT on steroids! But, I’ve been too embarrassed to describe TEAM-CBT in this way, fearing it might sound crass or unprofessional.

Anna and Lorraine explain why the T = Testing and E = Empathy of TEAM were so critical to the success of the therapy. Anna says that Lorraine was, in fact, the first therapist “who really got me, and really understood me!”

Anna emphasizes the enormous importance of the A = Paradoxical Agenda Setting (aka Assessment of Resistance) as well. Lorraine helped Anna discover what was beautiful and awesome about all of her negative feelings, including severe depression, shame, anxiety, anger, loneliness, and even hopelessness. She said, “My depression and feelings of loss when I moved showed that I really care about what I do, as well as the people around me.”

Anna also said that her anger showed that she was overly nice, out of her love for people, but that she had the right to set boundaries and stick up for herself, and didn’t always have to be a people-pleaser.

The Positive Reframing proved to be a positive shock to the system, and Anna’s symptoms started to improve significantly even before starting the M = Methods phase of the TEAM-CBT treatment.

The Positive Reframing made it relatively easy for Anna to smash the negative, self-critical thoughts that triggered her depression, anxiety, shame, and hopelessness, and then they moved on to other goals, such as using the Five Secrets of Effective Communication in her interactions with colleagues and friends.

Finally, they focused on self-image issues, which brings us back to the question Estafonia had posed at the start of the podcast: How you can help patients with self-image problems and addictions to eating?

Anna explained that when she was depressed, she had gained weight because of her addiction to salami (Mmmm!), ice cream (Yummm!), and rice and beans (WOW!) Lorraine used David’s “Devil’s Advocate Technique,” to help Anna challenge the tempting thoughts that always triggered her overeating.

Rhonda and I are incredibly grateful to Lorraine (aka Dr. Wong) and “Anna” for this opportunity to bring TEAM to life in a very real and personal way. Thank you, Lorraine and Anna!

Dr. Lorraine Wong is a certified Level 4 TEAM-CBT therapist and practices at the Feeling Good Institute in Mountain View, California. She specializes in the treatment of body image concerns and emotional eating, as well as depression and anxiety, with TEAM-CBT.

Thanks for tuning in!

David and Rhonda