DAVID: Wait—wait—wait! You're interested in them be cause it's nice to have them succeed?
HAL: Yeah. I said . ..
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DAVID: The standard you apply to them is one that you think would help them succeed?
HAL: Right.
DAVID: And is the standard you apply to yourself the one that will help you succeed? How do you feel when you say, "One missed sale means I'm a failure"?
HAL: Discouraged.
HAvm: Is this helpful?
HAL: Well, it hasn't produced positive results, so apparently it's not helpful.
DAVID: And is it realistic to say "One missed sale and I'm a failure"?
HAL: Not really.
DAVID: So why are you using this all-or-nothing standard on yourself? Why would you apply helpful and realistic standards to these other people who you don't care so much about and self-defeating, hurtful standards to yourself who you do care something about?
Hal was beginning to grasp that it wasn't helping him to live by a double standard. He judged himself by harsh rules that he would never apply to anyone else. He initially defended this tendency—as many demanding perfectionists will—
by claiming it would help him in some way to be so much harder on himself than on others. However, he then quickly owned up to the fact that his personal standards were actually unrealistic and self-defeating because if he did try to sell the building and didn't succeed, he would view it as a catastrophe. His bad habit of all-or-nothing thinking was the key to the fear that paralyzed him and kept him from trying.
Consequently, he spent most of his time in bed, moping.
Hal asked for some specific guidelines concerning things he might do to rid himself of his perfectionistic double standards so that he could judge all individuals, including himself, by one objective set of standards. I proposed that as a first step, Hal might use the automatic-thought, rational-response technique. For example, if he were sitting at home procrastinating about work, he might be thinking, "If I don't go to work early and stay all day and get caught up on all my work, there's no point in even trying. I might as well lie in bed."
After writing this down, he would substitute a rational re-217
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sponse, "This is just all-or-nothing thinking, and it's baloney.
Even going to work for a half day could be an important step and might make me feel better."
Hal agreed to write down a number of upsetting thoughts before the next therapy session at those times he felt worthless and down on himself. (See Figure 9-2, below.) Two Figure 9-2.
Hal's homcwork for recording and challenging his self-critical thoughts. He wrote down the Rational Responses during the therapy session (see text).
Negative Thoughts
Rational Responses
(SELF-CRITICISM)
(SELF-DEFENSE)
1. I am lazy.
1. I have worked hard much of my
life.
2. I enjoy being ill.
2. It's not fun.
3. I am inadequate. I am a failure.
3. I've had some degree of success.
We've had a good home. We've
reared three outstanding children.
People admire and respect me.
I have involved myself in com-
munity activity.
4. This lying around doing nothing 4. I am experiencing symptoms of represents the real me.
an illness. It's not the "real me."
6. I could have done more.
5. At least, I did more than most people. It's meaningless and
pointless to say, "I could have
done more" because anyone
could say this.
days later he received a layoff notice from his employer, and he came to the next session highly convinced his self-criticaT
thoughts were absolutely valid and realistic. He'd been unable to come up with a single rational response. The notice implied that his failure to show up at work necessitated his release from his job. During the session, we discussed how he could learn to talk back to his critical voice.
DAVID: Okay, now let's see if we can write down some answers to your negative thoughts in the Rational Response 218
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column. Can you think of any answer based on what we talked about last session? Consider your statement "I am inadequate." Would this in any way result from your all-or-nothing thinking and perfectionistic standards?
The answer might be clearer to you if we do a role-reversal. It's sometimes easier to speak objectively about someone else. Suppose I came to you with your story and told you that I was employed by my wife's father.
Three years ago we had a fight. I felt I was being taken advantage of. I walked out. I've kinda been feeling blue ever since that time, and I've been tossing around from job to job. Now I've been fired from a job that was purely on a commission basis, and that's really a double defeat for me. In the first place, they didn't pay me anything, and then in the second place, they didn't even figure I was worth that much, so they fired me. I've concluded that I'm inadequate—an inadequate human being. What would you say to me?
HAL: Well, I . . . assuming that you'd gotten up to that point, say the first forty years or more of your life, you obviously were doing something.
DAVID: Okay, write that down in the Rational Response column. Make a list of all the good, adequate things you did for the first forty years of your life. You've earned money, you've raised children who were successful, etc., etc.
HAL: Okay. I can write down that I've had some success.
We've had a good home. We've reared three outstanding children. People admire and respect me, and I have involved myself in community activities.
DAVID: Okay, now those are all the things you've done.
How do you reconcile this with your belief that you are inadequate?
HAL: Well, I could have done more.
DAVID: Great! I was certain you'd figure out a clever way to disqualify your good points. Now write that down as another negative thought: "I could have done more."
Beautiful!
HAL: Okay, I've written it down as number five.
DAVID: Okay, now what's the answer to that one?
(long silence)
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David D. Burns, M.D.
DAVID: What is it? What's the distortion in that thought?
HAL: You're a tricky bugger!
DAVID: What is the answer?
HAL: At least I did more than most people.
DAVID: Right, and what percent do you believe that?
HAL: That I believe one hundred percent.
DAVID: Great! Put it down in the Rational Response column. Now, let's go back to this "I could have done more." Suppose you were Howard Hughes sitting up in his tower, with all those millions and billions. What could you say to yourself to make yourself unhappy?
HAL: Well, I'm trying to think.
DAVID: Just read what you wrote down on the paper.
HAL: Oh. "I could have done more."
DAVID: You can always say that, can't you?
HAL: Yeah.
DAVID: And that's why a lot of people who have won fame and fortune are unhappy. It's just an example of perfectionistic standards. You can go on and on and on, and no matter how much achievement you experience, you can always say, "I could have done more." This is an arbitrary way of punishing yourself. Do you agree or not?
HAL: Well, yeah. I can see that. It takes more than one element really to be happy. Because if it was money, then every millionaire and billionaire would be euphoric.
But there are more circumstances that involve being happy or satisfied with yourself than making money.
That's not the drive that paralyzes me. I've never had a drive to go after money.
DAVID: What were your drives? Did you have a drive to raise a family?
HAL: That was very important to me. Ver
y important. And I participated in the rearing of the children.
DAVID: And what would you do in raising your children?
HAL: Well, I would work with them, teach them, play with them.
DAVID: And how did they come out?
HAL: I think they're great!
DAVID: Now, you were writing down, "I'm inadequate. I'm a failure." How can you reconcile this with the fact that your aim was to raise three children and you did it?
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HAL: Again, I guess I wasn't taking that into account.
DAVID: So how can you call yourself a failure?
HAL: I have not functioned as a wage earner . . . as an effective money-maker for several years.
DAVID: Is it realistic to call yourself a "failure" based on that? Here's a man who has had a depression for three years, and he finds it difficult to go to work, and now it's realistic to call him a failure? People with depressions are failures?
HAL: Well, if I knew more of what caused depression, I would be better able to make a value judgment.
DAVID: Well, we're not going to know the ultimate cause of depression for some time yet. But our understanding is that the immediate cause of depression is punitive, hurtful statements that you hit yourself with. Why this happens more to some people than others we don't know.
The biochemical and genetic influences have not yet been worked out. Your upbringing undoubtedly contributed, and we can deal with that in another session if you like.
HAL: Since there is no final proof yet of the ultimate cause of depression, can't we think of that in terms of a failure in itself? I mean, we don't know where it's coming from
. . . It must be something wrong with me that caused it . . . some way that I have failed myself that causes the depression.
DAVID: What evidence do you have for that?
HAL: I don't. It's just a possibility.
DAvm: Okay. But to make an assumption as punishing as that . . . anything is a possibility. But there is no evidence for that. When patients get over depressions, then they become just as productive as they ever were. Seems to me that if their problem was that they were failures, when they got over the depression they would still be failures. I've had college professors and corporate presidents who have come to me. They were just sitting and staring at the wall, but it was because of their depression. When they got over the depression, they started giving conferences and managing their businesses like before. So how can you possibly say that depression is due to the fact that they are failures? Seems to me that 221
David D. Burns, M.D.
it's more the other way around—that the failure is due to the depression.
HAL: I can't answer that.
DAVID: It's arbitrary to say that you're a failure. You have had a depression, and people with depression don't do as much as when they are undepressed.
HAL: Then I'm a successful depressive.
DAVID: Right! Right! And part of being a successful depressive means to get better. So I hope that's what we're doing now. Imagine that you had pneumonia for the past six months. You wouldn't have earned any dough.
You could also say, "This makes me a failure." Would that be realistic?
HAL: I don't see how I could claim that. Because I certainly wouldn't have willfully created the pneumonia.
DAVID: Okay, can you apply the same logic to your depression?
HAL: Yeah, I can see it. I don't honestly feel that my depression was willfully induced either.
DAVID: Of course it wasn't. Did you want to bring this on?
HAL: Oh boy, no!
DAVID: Did you consciously do anything to bring it on?
HAL: Not that I know of.
DAVID: And if we knew what was causing depression, then we could put the finger someplace. Since we don't know, isn't it silly to blame Hal for his own depression? What we do know is that depressed people get this negative view of themselves. And they feel and behave in accord with this negative vision of everything. You didn't bring that on purposely or choose to be incapacitated. And when you get over that vision and when you have switched back to a nondepressed way of looking at things, you are going to be just as productive or more so than you've ever been, if you're typical of other patients that I've worked with. You see what I mean?
HAL: Yeah, I can see.
It was a relief for Hal to realize that although he had been financially unsuccessful for several years, it was nonsensical to label himself as "a failure." This negative self-image and his sense of paralysis resulted from his all-or-nothing think-222
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ing. His sense of worthlessness was based on his tendency to focus only on the negatives in his life (the mental filter) and to overlook the many areas where he had experienced success (
discounting the positive). He was able to see that he was aggravating himself unnecessarily by saying, "I could have done more," and he realized that financial value is not the same as human worth. Finally, Hal was able to admit that the symptoms he was experiencing—lethargy and procrastination—
were simply manifestations of a temporary disease process and not indications of his "true self." It was absurd for him to think his depression was just punishment for some personal inadequacy, any more than pneumonia would be.
At the end of the session, the Beck Depression Inventory test indicated that Hal had experienced a 50 percent improvement. In the weeks that followed, he continued to help himself, using the double-column technique. As he trained himself to talk back to his upsetting thoughts, he was able to reduce the distortions in his harsh way of evaluating himself, and his mood continued to improve.
Hal left the real-estate business and opened a paperback bookstore. He was able to break even; but in spite of considerable personal effort, he was unable to show enough profit to justify continuing beyond the first year's trial period. Thus, the marks of external success had not changed appreciably during this time. In spite of this, Hal managed to avoid significant depression and maintained his self-esteem. The day he decided to "throw in the towel" on the bookstore, he was still below the zero point financially, but his self-respect did not suffer. He wrote the following brief essay which he decided to read each morning while he was looking for a new job:
Why Am I Not Worthless?
As long as I have something to contribute to the well-being of myself and others, I am not worthless.
As long as what I do can have a positive effect, I am not worthless.
As long as my being alive makes a difference to even one person, I am not worthless (and this one person can be me if necessary).
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If giving love, understanding, companionship, encouragement, sociability, counsel, solace means anything, I am not worthless.
If I can respect my opinions, my intelligence, I am not worthless. If others also respect me, that is a bonus. If I have self-respect and dignity, I am not worthless. If helping to contribute to the livelihood of my employees'
families is a plus, I am not worthless.
If I do my best to help my customers and vendors through my productivity and creativity, I am not worthless.
If my presence in this milieu does makes a difference to others, I am not worthless.
I am not worthless. I am eminently worthwhile!
Loss of a Loved One. One of the most severely depressed patients I treated early in my career was Kay, a thirty-one-year-old pediatrician whose younger brother had committed suicide in a grisly way outside her apartment six weeks earlier. What was particularly painful for Kay was that she held herself responsible for his suicide, and the arguments she proposed in support of this point of view were quite convincing.
Kay felt she was confronted by an excruciating problem that was entirely realistic and insoluble. She felt that she too deserved to die and was actively suicidal at the time of referral.A frequent problem that plagues the family and friends of an individual who successf
ully commits suicide is the sense of guilt. There is a tendency to torture yourself with such thoughts as, "Why didn't I prevent this? Why was I so stupid?" Even psychotherapists and counselors are not immune to such reactions and may castigate themselves: "It's really my fault. If only I had talked to him differently in that last session. Why didn't I pin him down on whether or not he was suicidal? I should have intervened more forcefully. I murdered him!" What adds to the tragedy and irony is that in the vast majority of instances, the suicide occurs because of the victim's distorted belief that he has some insoluble problem which, viewed from a more objective perspective, would seem much less overwhelming and certainly not worth suicide.
Kay's self-criticism was all the more intense because she felt that she had gotten a better break in life than her 224
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brother, and so she had gone out of her way to try to compensate for this by providing emotional and finanical support for him during his long bout with depression. She arranged for his psychotherapy, helped pay for it, and even got him an apartment near hers so that he could call her whenever he was very down.
Her brother was a physiology student in Philadephia. On the day of his suicide, he called Kay to ask about the effects of carbon monoxide on the blood for a talk he was to give in class. Because Kay is a blood specialist, she thought the question was innocent and gave him the information without thinking. She didn't talk to him very long because she was preparing a major lecture to deliver the following morning at the hospital where she worked. He used her information to make his fourth and final attempt outside her apartment window while she was preparing her lecture. Kay held herself responsible for his death.
She was understandably miserable, given the tragic situation she confronted. During the first few therapy sessions she outlined why she blamed herself and why she was convinced that she would be better off dead: "I had assumed the responsibility for my brother's life. I failed, so I feel I am responsible for his death. It proves that I did not adequately support him as I should have. I should have known that he was in an acute situation, and I failed to intervene. In retrospect, it's obvious that he was getting suicidal again. He'd had three prior serious suicide attempts. If I had just asked him when he called me, I could have saved his life. I was angry with him on many occasions during the month before he died, and in all honesty he could be a burden and a frustration at times.
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