The Feeling Good Handbook
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At one time I remember feeling annoyed and saying to myself that perhaps he would be better off dead. I feel terrible guilt for this. Maybe I wanted him to die! I know that I let him down, and so I feel that I deserve to die."
Kay was convinced that her guilt and agony were appropriate and valid. Being a highly moral person with a strict Catholic upbringing, she felt that punishment and suffering were expected of her. I knew there was something fishy about her line of reasoning, but I couldn't quite penetrate her illogic for several sessions because she was bright and persuasive and made a convincing case against herself. I almost began to 225
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buy her belief that her emotional pain was "realistic." Then, the key that I hoped might free her from her mental prison suddenly dawned on me. The error she was making was number ten discussed in Chapter 3—personalization.
At the fifth therapy session, I used this insight to challenge the misconceptions in Kay's point of view. First of all, I emphasized that if she were responsible for her brother's death, she would have had to be the cause of it. Since the cause of suicide is not known, even by experts, there was no reason to conclude that she was the cause.
I told her that if we had to guess the cause of his suicide, it would be his erroneous conviction that he was hopeless and worthless and that his life was not worth living. Since she did not control his thinking, she could not be responsible for the illogical assumptions that caused him to end his life. They were his errors, not hers. Thus, in assuming responsibility for his mood and actions, she was doing so for something that was not within her domain of control. The most that anyone could or would expect of her was to try to be a helping agent, as she had been within the limits of her ability.
I emphasized that it was unfortunate she did not have the knowledge necessary to prevent his death. If it had dawned on her that he was about to make a suicide attempt, she would have intervened in whatever manner possible. However, since she did not have this knowledge, it was not possible for her to intervene. Therefore, in blaming herself for his death she was illogically assuming that she could predict the future with absolute certainty, and that she had all the knowledge in the universe at her disposal. Since both these expectations were highly unrealistic, there was no reason for her to despise herself. I pointed out that even professional therapists are not infallible in their knowledge of human nature, and are frequently fooled by suicidal patients in spite of their presumed expertise.
For all these reasons, it was a major error to hold herself responsible for his behavior because she was not ultimately in control of him. I emphasized that she was responsible for her own life and well-being. At this point it dawned on her that she was acting irresponsibly, not because she "let him down"
but because she was allowing herself to become depressed and was contemplating her own suicide. The responsible thing 226
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to do was to refuse to feel any guilt and to end the depression, and then to pursue a life of happiness and satisfaction. This would be acting in a responsible manner.
This discussion was followed by a rapid improvement in her mood. Kay attributed this to a profound change in her attitude. She realized we had exposed the misconceptions that made her want to kill herself. She then elected to remain in therapy for a period of time in order to work on enhancing the quality of her own life, and to dispel the chronic sense of oppression that had plagued her for many years prior to her brother's suicide.
Sadness Without Suffering. The question then arises, What is the nature of "healthy sadness" when it is not at all con-taminated by distortion? Or to put it another way—does sadness really need to involve suffering?
While I cannot claim to know the definitive answer to this question, I would like to share an experience which occurred when I was an insecure medical student, and I was on my clinical rounds on the urology service in the hospital at Stanford University Medical Center in California. I was assigned to an elderly man who recently had had a tumor successfully removed from his kidney. The staff anticipated his rapid discharge from the hospital, but his liver function suddenly began to deterioriate, and it was discovered that the tumor had metastasized to his liver. This sad complication was untreatable, and his health began to fail rapidly over several days. As his liver function worsened, he slowly began to get groggier, slipping toward an unconscious state. His wife, aware of the seriousness of the situation, came and sat by his side night and day for over forty-eight hours. When she was tired, her head would fall on his bed, but she never left his side. At times she would stroke his head and tell him. "You're my man and I love you." Because he was placed on the critical list, the members of his large family, including children, grandchildren, and great-grandchildren, began to arrive at the hospital from various parts of California.
In the evening the resident in charge asked me to stay with the patient and attend the case. As I entered the room, I realized that he was slipping into a coma. There were eight or ten relatives there, some of them very old and others very young. Although they were vaguely aware of the seriousness 227
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of his condition, they had not been informed of just how grave the imminent situation was. One of his sons, sensing the old gentleman was nearing the end, asked me if I would be willing to remove the catheter which was draining his blad-der. I realized the removal of the catheter would indicate to the family that he was dying, so I went to ask the nursing staff if this would be appropriate to do. The nursing staff told me that it would because he was indeed dying. After they showed me how to remove a catheter, I went back to the patient and did this while the family waited. Once I was done, they realized that a certain support had been removed, and the son said, "Thank you. I know it was uncomfortable for him, and he would have appreciated this." Then the son turned to me as if to confirm the meaning of the sign and asked, "Doctor, what is his condition? What can we expect?"
I felt a sudden surge of grief. I had felt close to this gentle, courteous man because he reminded me of my own grandfa-ther, and I realized that tears were running down my cheeks.
I had to make a decision either to stand there and let the family see my tears as I spoke with them or to leave and try to hide my feelings. I chose to stay and said with considerable emotion, "He is a beautiful man. He can still hear you, although he is nearly in a coma, and it is time to be close to him and say good-bye to him tonight." I then left the room and wept. The family members also cried and sat on the bed, while they talked to him and said good-bye. Within the next hour his coma deepened until he lost consciousness and died.
Although his death was profoundly sad for the family and for me, there was a tenderness and a beauty to the experience that I will never forget. The sense of loss and the weeping reminded me—"You can love. You can care." This made the grief an elevating experience that was entirely devoid of pain or suffering for me. Since then, I have had a number of experiences that brought me to tears in this same way. For me the grief represents an elevation, an experience of the highest magnitude.
Because I was a medical student, I was concerned that my behavior might be seen as inappropriate by the staff. The chairman of the department later took me aside and informed me that the patient's family had asked him to extend their appreciation to me for being available to them and for 228
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helping make the occasion of his passing intimate and beautiful. He told me that he too had always felt strongly toward this particular individual, and showed me a painting of a horse the elderly man had done which was hanging on his wall.
The episode involved a letting go, a feeling of closure, and a sense of good-bye. This was in no way frightening or terrible; but in fact, it was peaceful and warm, and added a sense of richness to my experience of life.
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PART IV
Prevention and
11
Personal Growth
CHAPTER 10
When your depression has vanished, it's a temptation to enjoy yourself and relax. Certainly you're entitled. Toward the end of therapy, many patients tell me they feel the best they've ever felt in their lives. It sometimes seems that the more hopeless and severe and intractable the depression seemed, the more extraordinary and delicious the taste of happiness and self-esteem once it is over. As you begin to feel better, your pessimistic thinking pattern will recede as dramatically and predictably as the melting of winter's snow when spring arrives. You may even wonder how in the world you came to believe such unrealistic thoughts in the first place. This profound transformation of the human spirit never ceases to amaze me. Over and over I have the opportunity to observe this magical metamorphosis in my daily practice.
Because your change in outlook can be so dramatic, you may feel convinced that your blues have vanished forever.
But there is an invisible residue of the mood disorder that remains. If this is not corrected and eliminated, you will be vulnerable to attacks of depression in the future.
There are several differences between feeling better and getting better. Feeling better simply indicates that the painful symptoms have temporarily disappeared. Getting better implies:
1. Understanding why you got depressed.
2. Knowing why and how you got better. This involves a mastery of the particular self-help techniques that worked specifically for you so that you can reapply them and make them work again whenever you choose.
3. Acquiring self-confidence and self-esteem. Self-confidence is based on the knowledge that you have a good chance of being reasonably successful in personal rela-233
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tionships and in your career. Self-esteem is the capacity to experience maximal self-love and joy whether or not you are successful at any point in your life.
4. Locating the deeper causes of your depression.
Parts I, II, and III of this book were designed to help you achieve the first two goals. The next several chapters will help you with the third and fourth goals.
Although your distorted negative thoughts will be substantially reduced or entirely eliminated after you have recovered from a bout of depression, there are certain "silent assumptions" that probably still lurk in your mind. These silent assumptions explain in large part why you became depressed in the first place and can help you predict when you might again be vulnerable. And they contain therefore the key to relapse prevention.
Just what is a silent assumption? A silent assumption is an equation with which you define your personal worth. It represents your value system, your personal philosophy, the stuff on which you base your self-esteem. Examples: (1) "If someone criticizes me, I feel miserable because this automatically means there is something wrong with me." (2) "To be a truly fulfilled human being, I must be loved. If I am alone, I am bound to be lonely and miserable." (3) "My worth as a human being is proportional to what I've achieved." (4) "If I don't perform (or feel or act) perfectly, I have failed." As you will learn, these illogical assumptions can be utterly self-defeating. They create a vulnerability that predisposes you to uncomfortable mood swings. They represent your psychological Achilles' heel.
In the next several chapters you will learn to identify aid evaluate your own silent assumptions. You might find that an addiction to approval, love, achievement, or perfection forms the basis of your mood swings. As you learn to expose and challenge your own self-defeating belief system, you will lay the foundation for a personal philosophy that is valid and self-enhancing. You will be on the road to joy and emotional enlightenment.
In order to unearth the origins of your mood swings, most psychiatrists, as well as the general public, assume that a long and painfully slow (several years) therapeutic process is 234
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necessary, after which most patients would find it difficult to explain the cause of their depression. One of the greatest contributions of cognitive therapy has been to circumvent this.
In this chapter you will learn two different ways to identify silent assumptions. The first is a startlingly effective method called the "vertical-arrow technique," which allows you to probe your inner psyche.
The vertical-arrow technique is actually a spin-off of the double-column method introduced in Chapter 4, in which you learned how to write down your upsetting automatic thoughts in the left-hand column and substitute more objective rational responses. This method helps you feel better because you deprogram the distortions in your thinking patterns. A brief example is shown in Figure 10-1. It was written by Art, the Figure 10-1.
Automatic Thoughts
Rational Responses
1. Dr. B said the patient found
1. Mind reading; mental filter;
my comment abrasive. He --,
labeling.
probably thinks Fm a lousy
Just because Dr. B pointed out
therapist.
my error it doesn't follow ha
thinks rm a "lousy therapist."
I'd have to ask him to sea
what he really thinks, but on
many occasions he has praised
me and said I had outstanding
talent
psychiatric resident described in Chapter 7, who became upset after his supervisor tried to offer a constructive criticism.
Putting the lie to his upsetting thoughts reduced Art's feelings of guilt and anxiety, but he wanted to know how and why he made such an illogical interpretation in the first place.
Perhaps you've also begun to ask yourself—is there a pattern
inherent in my negative thoughts? Is there some psychic kink that exists on a deeper level of my mind?
Art used the vertical-arrow technique to answer these questions. First, he drew a short downward arrow directly beneath
his automatic thought (see Figure 10-2, page 236). This downward arrow is a form of shorthand which tells Art to
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Figure 10-2. Exposing the silent assumption(s) that give rise to your automatic thoughts with the use of the vertical-arrow method. The downward arrow is a form of shorthand for the following questions: "If that thought were true, why would it upset me? What would it mean to me?"
The question represented by each downward arrow in the example .appears in quotation marks next to the arrow. This is what you might ask yourself if you had written down the automatic thought. This process leads to a chain of automatic thoughts that will reveal the root cause of the problem.
Automatic Thoughts
Rational Responses
1. Dr. B. probably things I'm a -,
lousy therapist.
♦
"If he did think this,
why would it be upset-
ting to me?"
2. That would mean I was a lousy -, therapist because he's an expert.
♦
"Suppose I was a lousy
therapist, what would
this mean to me?"
3. That would mean I was a total -,
failure. It would mean I was no
good.
.1, "Suppose I was no good.
Why would this be a
problem? What would
it mean to me?"
4. Then the word would spread
and everyone would find out
what a bad person I was. Then
no one would respect me. I'd
get drummed out of the medical
society, and I'd have to move to
another state.
.1, "And what would that
mean?"
5. It would mean I was worthless.
I'd feel so miserable I'd want
to die.
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FEELING GOOD
ask himself, "If this automatic thought were actually true, what would it mean to me? Why would it be upsetting to me?" Then Art wrote down the next automatic thought that immediately came to mind. As you can s
ee, he wrote, "If Dr. B. thinks I'm a lousy therapist, it would mean I was a lousy therapist because Dr. B. is an expert." Next Art drew a second downward arrow beneath this thought and repeated the same process so as to generate yet another automatic thought, as shown in Figure 10-2. Every time he came up with a new automatic thought, he immediately drew a vertical arrow beneath it and asked himself, "If that were true, why would it upset me?" As he did this over and over, he was able to generate a chain of automatic thoughts, which led to the silent assumptions that gave rise to his problems. The downward-arrow method is analogous to peeling successive layers of skin off an onion to expose the ones beneath. It is actually quite simple and straightforward, as you will see in Figure 10-2.
You will notice that the vertical-arrow technique is the opposite of the usual strategy you use when recording your automatic thoughts. Ordinarily you substitute a rational response that shows why your automatic thought is distorted and invalid (Figure 10-1). This helps you change your thinking patterns in the here and now so that you can think about life more objectively and feel better. In the vertical-arrow method you imagine instead that your distorted automatic thought is absolutely valid, and you look for the grain of truth in it. This enables you to penetrate the core of your problems.
Now review Art's chain of automatic thoughts in Figure 10-2 and ask yourself—what are the silent assumptions that predispose him to anxiety, guilt, and depression? There are several:
1. If someone criticizes me, they're bound to be correct.
2. My worth is determined by my achievement.
3. One mistake and the whole is ruined. If I'm not successful at all times, I'm a total zero.
4. Others won't tolerate my imperfection. I have to be perfect to get people to respect and like me. When I goof up, I'll encounter fierce disapproval and be punished.