Either depression or sadness can develop after a loss or a failure in your efforts to reach a goal of great personal importance. Sadness comes, however, without distortion. It involves a flow of feeling and therefore has a time limit. It never involves a lessening of your self-esteem. Depression is frozen—it tends to persist or recur indefinitely, and always involves loss of self-esteem.
When a depression clearly appears after an obvious stress, such as ill health, the death of a loved one, or a business reversal, it is sometimes called a "reactive depression." At times it can be more difficult to identify the stressful event that triggered the episode. Those depressions are often called "
endogenous" because the symptoms seem to be generated entirely out of thin air. In both cases, however, the cause of the depression is identical—your distorted, negative thoughts.
It has no adaptive or positive function whatsoever, and represents one of the worst forms of suffering. Its only redeeming value is the growth you experience when you recover from it.
My point is this: When a genuinely negative event occurs, your emotions will be created exclusively by your thoughts and perceptions. Your feelings will result from the meaning you attach to what happens. A substantial portion of your suffering will be due to the distortions in your thoughts.
When you eliminate these distortions, you will find that coping with the "real problem" will become less painful.
Let's see how this works. One clearly realistic problem involves serious illness, such as a malignancy. It is unfortunate that the family and friends of the afflicted person are often so convinced that it is normal for the patient to feel depressed, they fail to inquire about the cause of the depression, which more often than not turns out to be completely reversible. In fact, some of the easiest depressions to resolve are those found in people facing probable death. Do you know why?
These courageous individuals are often "supercopers" who haven't made misery their life-style. They are usually willing 208
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to help themselves in any way they can. This attitude rarely fails to transform apparently irreversible and "real" difficulties into opportunities for personal growth. This is why I find the concept of "realistic depressions" so personally abhorrent.
The attitude that depression is necessary strikes me as destructive, inhuman, and victimizing Let's get down to some specifics, and you can judge for yourself.
Loss of Life. Naomi was in her mid-forties when she received a report from her doctor that a "spot" had appeared on her chest X ray. She was a firm believer that going to doctors was a way of asking for trouble, so she procrastinated many months in checking this report out. When she did, her worst suspicions were validated. A painful needle biopsy confirmed the presence of malignant cells, and subsequent lung removal indicated that a spread of the cancer had already occurred.
This news hit Naomi and her family like a hand grenade.
As the months wore on, she became increasingly despondent over her weakened state. Why? It was not so much the physical discomfort from the disease process or the chemotherapy, although these were genuinely uncomfortable, but the fact that she was sufficiently weak that she had to give up the daily activities that had meant a great deal to her sense of identity and pride. She could no longer work around the house (now her husband had to do most of the chores), and she had to give up her two part-time jobs, one of which was volunteer reading for the blind.
You might insist, "Naomi's problems are real. Her misery is not caused by distortion. It's caused by the situation."
But was her depression so inevitable? I asked Naomi why her lack of activity was so upsetting. I explained the concept of "automatic thoughts," and she wrote down the following negative cognitions: (1) I'm not contributing to society; (2) I'
m not accomplishing in my own personal realm; (3) I'm not able to participate in active fun; and (4) I am a drain and drag on my husband. The emotions associated with these thoughts were: anger, sadness, frustration, and guilt.
When I saw what she had written down, my heart leaped for joy! These thoughts were no different from the thoughts of physically healthy depressed patients I see every day in my practice. Naomi's depression was not caused by her malig-209
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nancy, but the malignant attitude that caused her to measure her sense of worth by the amount she produced! Because she had always equated her personal worth with her achievements, the cancer meant—"You're over the hill! You're ready for the refuse heap!" This gave me a way to intervene!
I suggested that she made a graph of her personal "worth"
from the moment of birth to the moment of death (see Figure 9-1, opposite page). She saw her worth as a constant, estimating it at 85 percent on an imaginary scale from 0 to 100
percent. I also asked her to estimate her productivity over the same period on a similar scale. She drew a curve with low productivity in infancy, increasing to a maximum plateau in adulthood, and finally decreasing again later in life (see Figure 9-1). So far, so good. Then two things suddenly dawned on her. First, while her illness had reduced her productivity, she still contributed to herself and her family in numerous small but nevertheless important and precious ways. Only all-or-nothing thinking could make her think her contributions were a zero. Second, and much more important, she realized her personal worth was constant and steady; it was a given that was unrelated to her achievements. This meant that her human worth did not have to be earned, and she was every bit as precious in her weakened state. A smile spread across her face, and her depression melted in that moment. It was a real pleasure for me to witness and participate in this small miracle. It did not eliminate the tumor, but it did restore her missing self-esteem, and that made all the difference in the way she felt.
Naomi was not a patient, but someone I spoke with while vacationing in my home state of California during the winter of 1976. I received a letter from her soon after which I share with you here:
David—
An incredibly belated, but really important "P.S." to my last letter to you. To wit: the simple little "graphs" you did of productivity as opposed to self-worth or self-esteem or whatever we shall call it: It has been especially sustaining to me, a plus which I dose out liberally! It really turned me into a psychologist without having to go 210
100— SELF-ESTEEM—WORTH AS A HUMAN BEING
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Figure 9-1. Naomi's worth and work graphs. In the upper figure Naomi plotted her human "worth" from the time of her birth to the time of her death. She estimated this at 85 percent. In the lower figure she plotted her estimated productivity and achievement over the course of her life. Her productivity began low in childhood, reached a plateau in adulthood, and would ultimately fall to zero at the time of death. This graph helped her comprehend that her "worth" and "achievement" were unrelated and had no correlation with each other.
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for my Ph.D. I find that it works with lots of things that badger and bother people. I've tried these ideas out on some of my friends. Stephanie is treated like a piece of furniture by a chit of a secretary one-third her age; Sue is put down constantly by her 14 year old twins; Becky's husband has just walked out; Ilga Brown is being made to feel like an interloper by her boy friend's 17 year old son, etc. To them all I say "Yes, b
ut your personal worth is a CONSTANT, and all the garbage the world heaps on you doesn't touch it!" Of course in many cases I realize its an over-simplification and cannot be an ano-dyne for all things, but boy is it helpful and useful!
Again, thank you, sir!
As ever,
Naomi
She died in pain but with dignity six months later.
Loss of Limb. Physical handicaps represent a second category of problems felt to be "realistic." The afflicted individual—or the family members—automatically assume that the limitations imposed by old age or by a physical disability, such as an amputation or blindness, necessarily imply a decreased capacity for happiness. Friends tend to offer understanding and sympathy, thinking this represents a humane and "realistic" response. The case can be quite the opposite, however. The emotional suffering may be caused by twisted thinking rather than by a twisted body. In such a situation, a sympathetic response can have the undesirable effect of reinforcing self-pity as well as feeding into the attitude that the handicapped individual is doomed to less joy and satisfaction than others. In contrast, when the afflicted individual or family members learn to correct the distortions in their thinking, a full and gratifying emotional life can frequently result.
For example, Fran is a thirty-five-year-old married mother of two, who began to experience symptoms of depression around the time her husband's right leg became irreversibly paralyzed because of a spinal injury. For six years she sought relief from her intensifying sense of despair, and received a variety of treatments in and out of hospitals, including an-212
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tidepressant drugs as well as electroshock therapy. Nothing helped. She was in a severe depression when she came to me, and she felt her problems were insoluble.
In tears she described the frustration she experienced in trying to cope with her husband's decreased mobility: Every time I see other couples doing things we can't do tears come to my eyes. I look at couples taking walks, jumping in the swimming pool or the ocean, riding bikes together, and it just hurts. Things like that would be pretty tough for me and John to do. They take it for granted just like we used to. Now it would be so good and wonderful if we could do it. But you know, and I know, and John knows—we can't.
At first, I too had the feeling Fran's problem was realistic.
After all, they couldn't do many things that most of us can do. And the same could be said of old people, as well as those who are blind or deaf or who have had a limb amputated.
In fact, when you think of it, we all have limitations. So perhaps we should all be miserable . . . ? As I puzzled over this, Fran's distortion suddenly came to my mind. Do you know what it is? Look at the list on page 40 right now and see if you can pick it out . . . that's right, the distortion that led to Fran's needless misery was the mental filter. Fran was picking out and dwelling on each and every activity that was unavailable to her. At the same time the many things she and John could or might do together did not enter her conscious mind. No wonder she felt life was empty and dreary.
The solution turned out to be surprisingly simple. I proposed the following to Fran: "Suppose at home between sessions you were to make a list of all the things that you and John can do together. Rather than focus on things you can't do, learn to focus on the ones you can do. I, for example, would love to go to the moon, but I don't happen to be an astronaut, so it's not likely I'll ever get the opportunity. Now, if I focused on the fact that in my profession and at my age it is extremely unlikely I could ever get to the moon, I could make myself very upset. On the other hand, there are many things I can do, and if I focus on these, then I won't feel dis-213
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appointed. Now, what would be some things you and John can do as a couple?"
FRAN: Well, we enjoy each other's company still. We go out to dinner, and we're buddies.
DAVID: Okay. What else?
FRAN: We go for rides together, we play cards. Movies, Bingo. He's teaching me how to drive . ..
DAVID: You see, in less than thirty seconds you've already listed six things you can do together. Suppose I gave you between now and next session to continue the list. How many items do you think you could come up with?
FRAN: Quite a lot of them. I could come up with things we've never thought of, maybe something unusual like skydiving.
DAVID: Right. You might even come up with some more adventurous ideas. Keep in mind that you and John might in fact be able to do many things you are assuming you can't do. For example, you told me you can't go to the beach. You mentioned how much you'd like to go swimming Could you go to a beach that's a little more secluded so you wouldn't have to feel quite so self-conscious? If I were on a beach and you and John were there, his physical disability wouldn't make one darn bit of difference to me. In fact, I recently visited a fine beach on the North Shore of Lake Tahoe in California with my wife and her family. As we were swimming, we suddenly happened upon a cove that had a nude beach, and here were all these -young people with no clothes on. Of course, I didn't actually look at any of them, I want you to understand! But in spite of this I did happen to notice that one young man had his right leg missing from the knee down, and he was there having fun with the rest of them. So I'm not absolutely convinced that just because someone is crippled or missing a limb they can't go to the beach and have fun. What do you think?
Some people might scoff at the idea that such a "difficult and real" problem could be so easily resolved, or that an intractable depression like Fran's could turn around in response to such a simple intervention. She did in fact report a com-214
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plete disappearance of her uncomfortable feelings and said she felt the best she had in years at the end of the session. In order to maintain such improvement, she will obviously need to make a consistent effort to change her thinking patterns over a period of time so she can overcome her bad habit of spinning an intricate mental web and getting trapped in it.
Loss of lob. Most people find the threat of a career reversal or the loss of livelihood a potentially incapacitating emotional blow because of the widespread assumption in Western culture that individual worth and one's capacity for happiness are directly linked with professional success. Given this value system, it seems obvious and realistic to anticipate that emotional depression would be inevitably linked with financial loss, career failure, or bankruptcy.
If this is how you feel, I think you would be interested in knowing Hal. Hal is a personable forty-five-year-old father of three, who worked for seventeen years with his wife's father in a successful merchandising firm. Three years before he was referred to me for treatment, Hal and his father-in-law had a series of disputes about the management of the firm. Hal resigned in a moment of anger, thus giving up his interests in the company. For the next three years, he bounced around from job to job, but had difficulty finding satisfactory employment. He didn't seem to be able to succeed at anything and began to view himself as a failure. His wife started working full time to make ends meet, and this added to Hal's sense of humiliation because he had always prided himself on being the breadwinner. As the months and years rolled on, his financial situation worsened, and he experienced increasing depression as his self-esteem bottomed out.
When I first met Hal, he had been attempting to work for three months as a trainee in commercial real-estate sales. He had rented several buildings, but had not yet finalized a sale.
Because he was working on a strict commission basis, his income during this break-in period was quite low. He was plagued by depression and procrastination. He would at times stay at home in bed all day, thinking to himself, "What's the use? I'm just a loser. There's no point in going to work. It's less painful to stay in bed."
Hal volunteered to permit the psychiatric residents in our training program at the University of Pennsylvania to observe 215
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one of our psychotherapy sessions through a one-way mirror.
During this session, Hal described a conversation in the locker room of his club. A well-to-do friend had informed Hal of his interest in the purchase of a particular building.
You might think he would have jumped for joy on learning this, since the commission from such a sale would have given his career, confidence, and bank account a much needed boost. Instead of pursuing the contact, Hal procrastinated several weeks. Why? Because of his thought, "It's too complicated to sell a commercial property. I've never done this before. Anyway, he'll probably back out at the last minute.
That would mean I couldn't make it in this business. It would mean I was a failure."
Afterward, I reviewed the session with the residents. I wanted to know what they thought about Hal's pessimistic, self-defeating attitudes. They felt that Hal did in fact have a good aptitude for sales work, and that he was being unrealistically hard on himself. I used this as ammunition during the next session. Hal admitted that he was more critical of himself than he would ever be toward anyone else. For example, if one of his associates lost a big sale, he'd simply say, "It's not the end of the world; keep plugging." But if it happened to him he'd say, "I'm a loser." Essentially, Hal admitted he was operating on a "double standard"—tolerant and supportive toward other people but harsh, critical, and punitive toward himself. You may have the same tendency. Hal initially defended his double standard by arguing it would be helpful to him:
HAL: Well, first of all, the responsibility and interest that I have in the other person is not the same as the responsibility that I have for myself.
DAVID: Okay. Tell me more.
HAL: If they don't succeed, it's not going to be bread off my table, or create any negative feelings within my family unit. So the only reason I'm interested in them is because it's nice to have everybody succeed, but there ...
The Feeling Good Handbook Page 24