Episode 105: Vulnerability and Imposter Syndrome with David Burns

By listening to this episode, you can earn 1.5 Psychiatry CME Credits.

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Article Authors: David Puder, MD

Conflict of interest: Dr. Burns receives royalties for the books he has written Dr. Puder does not have any conflicts of interest.

On this week’s episode of the podcast, I speak to Dr. David Burns M.D. about cognitive behavioral therapy. He’s the author of several industry-leading books on the subject, including Feeling Good and Feeling Great. 

What is CBT?

The basis of cognitive behavioral therapy is that we should put our thoughts on trial and not just believe them. CBT works by digging into the foundation of our thinking patterns so we can rewire the patterns that are messed up. CBT helps address intrusive, distressing thoughts so that they don’t consume our emotional energy every day. 

It is a very accessible form of psychotherapy. There are a variety of CBT strategies that can be used, which allows the therapy to be customized to each person and situation. 

One great thing about CBT is that we can start it by ourselves if seeing a psychotherapist is intimidating. An easy way to begin is through mood journaling, or writing down our thoughts to try and determine if they are actually truthful. We’ll get in to more on that later!

The History of CBT:

Dr. Aaron Beck is known for developing the first methods of cognitive behavioral therapy in the 1960s as he studied patients with depression. However, perhaps in a future episode I will demonstrate how you can see many of the ideas in early philosophy. Dr. Beck coined the phrase “automatic thoughts,” which describes the internal dialogue that his patients seemed to have. A common theme is that they all had some degree of negative thoughts about themselves and the world or their futures.

He documented that unwanted patient behavior could be traced back to thoughts and thought patterns, and often the thoughts were negative and irrational. He reasoned that if he could help his patients change the way they thought about themselves, it would likely help them overcome unhealthy life choices, improve the quality of their relationships, and their ability to deal with stress and increase their capacity to process difficult situations.

Since then, other psychiatrists have added to his work by continuing to develop new methods of CBT. Dr. David Burns is a psychiatrist and author that has spent much of his career doing just that. He has developed more than 50 new CBT strategies and continues his work at the Beck Institute that he and his daughter, Dr. Judith Burns, founded in Philadelphia in 1994.

CBT has been called one of the greatest psychological developments in recent history. It is highly researched, although there is a general consensus in the medical community that there is still much to be researched and learned about CBT. However, it is currently one of the most widely used forms of therapy and considered highly effective with what research has been done to this point. 

The Benefits of CBT: 

• Treats a wide spectrum of mental health disorders including depression, anxiety, PTSD, eating disorders

• Offers coping mechanisms for life—altering circumstances such as loss, trauma, chronic pain  

• Does not involve medication

• Can be easily practiced with or without a therapist  

• Highly effective and produces quick results

• It is a highly studied and proven treatment method

There are really no down sides to CBT beyond maybe enduring a little discomfort from digging through any unpleasant thoughts or memories.  

Why is CBT so Effective?

CBT is regarded by many to be the current gold-standard of therapy. It puts the power of recovery in the hands of the patient. This type of talk therapy gives us a set of skills to apply to every thought pattern we have, as often as we need to. 

CBT works by challenging mindsets we believe to be true. We all have thoughts constantly running through our head (automatic thoughts). We often don’t even realize the thoughts we perpetuate subconsciously. CBT makes us stop on a thought and trace it back to its origin. 

The process of CBT generally involves some fairly straightforward exercises: writing down your thoughts, identifying the distortions, and challenging those thoughts. This is the basic premise of mood journaling.

By learning how to challenge the scope of a thought, we can easily reject wrong thoughts and replace them with correct ones.

Strategies of CBT:

Cognitive Behavioral Therapy uses specific talk therapy techniques. Each technique offers a different pathway to achieving the same end result—improving our emotional and mental health. This has the ripple effect of fixing our behaviors and subsequently, our relationships.

Successive approximation. Have you ever heard the phrase, “Inch by inch, life’s a cinch. Yard by yard, life is hard?” Successive approximation works by breaking down the “yards” into “inches.” It takes an overwhelming task and breaks it down into small steps, making it a less daunting process and one we can more easily accomplish. 

Cognitive restructuring. This technique teaches thought tracking and the assessing of thought patterns. This is where we investigate cognitive distortions and put more rational, realistic thought patterns in place. 

Exposure therapy. With a very high effectiveness rate, exposure therapy is one of the most successful strategies. It is the process of providing intentional, guided exposure to our fears and anxiety triggers and bringing coping skills into the situation.  

Mood journaling. Actually putting thoughts down on paper can be a real game-changer. Reading our thoughts can help pass them through more logical filters and make it simple for us to determine what thoughts are true and what thoughts are unhealthy or exaggerated. 

Mindfulness. This strategy is all about focusing on the present and what is currently under your feet, what is in front of your eyes, what you can reach out and touch. By grounding you in the present, it can interrupt obsessive thought cycles and can contribute to increased concentration and emotional regulation. This has, in recent years, been added to something called mindfulness-based cbt.  

Activity scheduling. When something isn’t on our calendar, the likelihood of us actually following through with our intentions is very low. This is about physically scheduling tasks in our calendar. It may include tasks we are not looking forward to, or things we don’t make time for that would improve our quality of life, such as exercising or engaging in a hobby.  

What does a CBT session look like? 

When working with a therapist for cognitive behavioral therapy, a general time frame may be discussed, such as 15-20 sessions, or it can be left open-ended depending on patient preference or the scope of therapy.

In the first session or two, a therapist is going to take the time to learn about the patient and what they hope to gain from counseling. If CBT is determined to be the best plan of care, they will work together to identify the areas of struggle and work through the process of dismantling the contributing thought processes using one or more of the CBT techniques. 

Cognitive distortion filters will also be used and then unhealthy thought patterns can be rebuilt.  A therapist will talk the patient through each step and offer coping strategies appropriate to the struggle or situation.  

What are Cognitive Distortions?  

Cognitive distortions are irrational filters through which we perceive ourselves, others, and the world. They cause us to adopt unhealthy thought patterns and reinforce negative emotions. When our thought patterns are influenced by these cognitive distortions, our realities are not in tune with what is actually true. 

Therapists use CBT techniques to identify the distortions in our thoughts and behaviors and can help eliminate their influence by applying these filters to these negative or irrational thoughts. 

There are many CBT strategies that exist. As we said, Dr. Burns alone has identified over 50 new distortions through his research that have contributed considerable insight and depth to this therapy practice. 

I have outlined a few distortions for you.

Magnification and minimalization.  When struggling with this distortion, we make a big deal over our mistakes in a situation and place little emphasis on the positives and major accomplishments. 

Overgeneralization.  This distortion involves taking an isolated event or occurrence and inflating it into an overall belief about oneself. A one-time failure becomes a blanket “I fail at everything.” 

Magical Thinking. Linking actions and outcomes that are in no way related. This is sort of a “magic wand” distortion, believing that we can wish for or unrealistically influence a scenario without actually being involved.

Personalization. Taking responsibility for other peoples’ actions or events that are outside of our control, believe our behavior is directly responsible for another person’s behavior, or when we take everything another person says or does as a direct attack on us. 

Jumping to Conclusions. When we decide we know how a scenario will turn out while actually having little to no facts. This distortion is all about assumptions and lacking evidence for our reasoning. This may look like assuming you know a person’s motives without asking them 

Emotional Reasoning. Relying on your emotions as the guiding posts for what is true. This is believing that if we feel a certain way, that feeling must accurately depict who we are or the scenario we are facing.

Disqualifying the Positive. When we overlook any positive elements in a situation in favor of focusing on the one or few negative aspects. This distortion keeps us from celebrating achievements or positive experiences because we don’t believe the positive in them outweighs the negative. 

Should Statements. Making blanket statements or creating subconscious rules about the way things “should” happen or be done, instead of applying realistic and situationally-appropriate expectations. Usually violating an internal “should” creates feelings of guilt in us.

All-or-Nothing Thinking/Black and White Thinking/Polarized Thinking. Labeling overall infrequent behaviors as something we “always” or “never” do or don’t do. This also can be used to label the actions of others. A person with this distortion views things as extremes and as all or nothing.

Always Being Right. When the fear of being wrong overtakes our ability to acknowledge any rightness of others, even loved ones. People struggling with this distortion will go to any length to win an argument. 

Heaven’s Reward Fallacy. Creating an impractical link between behaviors and perceived rewards. “If I work the hardest, I will be rewarded the greatest.” This can cause bitterness in those who spend so much energy on denying themselves and don’t reap the equal reward.

Fallacy of Change. A person with this tendency believes that others will change to suit them. Instead of accepting people for who they actually are, we instead see what we could change about them to satisfy our own needs and happiness.

Blaming. When we subscribe to blaming, we are either suggesting that nothing is within our control or that everything is. We believe that every emotion we have is someone else’s fault, or conversely believe that everything is our fault, even things that are beyond our control.

Fallacy of Fairness. The fallacy of fairness makes us believe that we know the ultimate standard for what is fair and expect the world to live up to this standard. When something happens that we perceive as not fair, it can lead to resentment and anger.

Control Fallacies. Control fallacies would have us believe that nothing is within our control (externally controlled) or that everything, such as the emotions and actions of others, is our responsibility (internally controlled).

Filtering. Dr. Burns describes filtering as though we are wearing glasses that filter out anything positive. We only see the negative in a situation and/or immediately assume a negative outcome.

Mood Journaling and How it Works:

Mood journaling is the act of recording the emotions and thoughts we have about our actions and life scenarios. This kind of record keeping catches our automatic thoughts and breaks the subconscious cycle that keeps us believing them.  

Everyone has automatic thoughts. They are not something we have control over. They can come from external sources or from our own internal thoughts, memories or beliefs. 

When we write these down, we are able to identify patterns and triggers. Understanding what causes us to feel or react certain ways gives us the ability to better avoid and cope when we encounter them.

Seeing thoughts written down allows us to apply more logic to them, versus having them swirling around in our subconscious. When we break the thought process down, it’s easier to see how they are incorrect.

Once they are identified, we can apply the cognitive distortions to these beliefs. Applying the filters can quickly absolve the thoughts of their power. Seeing how irrational they sound after passing through these filters, it becomes easier to adopt a thinking pattern that is more truthful and accurate.

The process of mood journaling is pretty simple. It can be as basic or as detailed as we want it to be. An example of mood journaling might look like writing down the emotion, ask ourselves what the cause was, how we responded, if it was an appropriate emotion. Then we could consider ways to react next time if we believe our reaction needs to be adjusted. 

 CBT for Psychotherapists (therapists getting therapy): 

Therapists hold a unique occupation in that they cannot share details of their day with their partners or friends. If they counseled a difficult client that day, or are drained from heavy emotional loads, they can’t process the details of the case, but they can process the emotions they feel.   

So should therapists get therapy? 

It used to be common practice for therapists to get their own therapy. But now I am surprised often when I meet therapists who have never done their own work. Sometimes in order for a therapist to avoid burnout or to continue to be able to hold space for their clients, they may need to do some processing and rewiring of their own.  

Therapists are not exempt from unhealthy thinking patterns. For example, many psychotherapists struggle with imposter syndrome. They don’t believe they are good enough. They feel afraid that they are inadequate and judged for being inadequate. Applying CBT techniques and distortion filters to a thought like this has great potential to give therapists more confidence in their well-earned abilities. 

Therapists should be encouraged to take inventory of their own thoughts and consider if they would benefit from CBT therapy. With only positives to gain, CBT can help therapists navigate the challenging aspects of their career and help them grow as a person at the same time. 

Conclusion:

I hope you enjoy how this episode goes beyond some of the things commonly thought of when you consider CBT. These things included vulnerability and doing our own work as therapists and psychiatrists. I have really enjoyed doing therapy for providers and find that even several sessions can break someone out of a funk or burnout. I hope if you are reading this you consider finding a provider who can help you through our difficult profession.