505: Live Work with Ruben: Part 1 of 2

Live Work with Ruben: Part 1 of 2 Working with Performance Anxiety in Real Time Hosts: Kevin Cornelius, LMFT Dr. David Burns Guests: Dr. Jill Levitt Ruben Land In this live work from a recent Tuesday Group, we had the opportunity to work with Ruben, a highly capable and thoughtful clinician, who brought a struggle that many therapists quietly share: intense performance anxiety in evaluative situations, especially in the presence of authority figures or people he deeply admires. What made this work especially powerful is that Ruben was actively experiencing anxiety in the moment, allowing us to "get in the car with him" rather than talk about the problem abstractly. We began, as always in TEAM-CBT, with Testing. Ruben had completed a Brief Mood Survey, which showed relatively low baseline symptoms—just mild anxiety and minimal depression or anger. However, when we reviewed his Daily Mood Log, anchored to a specific situation (leading a group under supervision), we saw a very different picture: anxiety at 70%, feelings of inferiority and defectiveness at 80%, embarrassment at 70%. This contrast highlights a core principle: symptoms are often situational and state-dependent, and without anchoring in a specific moment, we risk missing the true intensity of the problem. From there, we moved into Empathy, where Jill did a beautiful job modeling the Five Secrets of Effective Communication. She captured Ruben's internal experience with precision: the pressure to perform, the fear of saying the wrong thing, the spiral of anxiety leading to cognitive blanking, and the secondary anxiety about appearing anxious. She also identified both the internal loop ("I'm anxious about being anxious") and the interpersonal fears ("they'll think I'm a fraud," "I'm wasting their time"). David complemented this with curiosity and gentle inquiry, helping to deepen the conceptualization without getting lost in theory. Importantly, we conducted an empathy check, asking Ruben to grade us on thought empathy, feeling empathy, and warmth. He gave A+ ratings across the board, with a slight adjustment on thought empathy when he introduced an additional element: a compulsive need to check and recheck, suggesting a subtle OCD-like process. This moment is critical—without the empathy check, we would have missed an important maintaining factor. Only after strong empathy did we move into Agenda Setting, which is often the most counterintuitive and transformative part of TEAM-CBT. David began with the Invitation, asking whether Ruben wanted help or more support. Ruben was ready to "roll up his sleeves," which is essential—no imposed agenda. Then we used the Miracle Question to clarify goals: Ruben wanted to feel less anxious, maintain fluency, and stay present in high-stakes situations. Next came the Magic Button, targeting outcome resistance. When asked if he would eliminate all his negative feelings, Ruben said no—he wanted to keep some anxiety. This is exactly what we hope for. It opens the door to Positive Reframing, where we honor the symptoms rather than pathologize them. Together, we identified numerous positive values and benefits of his anxiety and self-doubt: Anxiety motivates preparation and effort It enhances connection through vulnerability It reflects caring deeply about others and their time Feelings of inadequacy keep him humble and growth-oriented Fear of judgment protects him and signals high standards Even the thought "I might be a fraud" reflects a desire to be authentic and competent At one point, Ruben articulated that his anxiety shows he values others and wants to contribute meaningfully—this is a profound reframe. Jill and D