The Feeling Good Handbook

by David D Burns

  Now I am emotionally and financially depleted. Every doctor has said to me, 'You'll beat this thing. Keep your chin up.'

  But now I realize it wasn't true. They were all lying to me. I'

  m a fighter, so I fought hard. You'd better realize when you are defeated. I've got to admit I'd be better off dead."

  Research studies have shown that your unrealistic sense of hopelessness is one of the most crucial factors in the development of a serious suicidal wish. Because of your twisted 338

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  thinking, you see yourself in a trap from which there seems to be no escape. You jump to the conclusion that your problems are insoluble. Because your suffering feels unbearable and appears unending, you may erroneously conclude that suicide is your only way of escape.

  If you have had such thoughts in the past, or if you are seriously thinking this way at present, let me state the message of this chapter loud and clear:

  You Are Wrong in Your Belief That Suicide Is the Only Solution or the Best Solution to Your Problem.

  Let me repeat that. You Are Wrong! When you think that you are trapped and hopeless, your thinking is illogical, distorted, and skewed. No matter how thoroughly you have convinced yourself, and even if you get other people to agree with you, you are just plain mistaken in your belief that it is ever advisable to commit suicide because of depressive illness.

  This is not the most rational solution to your misery. I will explain this position and help point the way out of the suicide trap.

  Assessing Your Suicidal Impulses

  Although suicidal thoughts are common even in individuals who are not depressed, the occurrence of a suicidal impulse if you are depressed is always to be regarded as a dangerous symptom. It is important for you to know how to pinpoint those suicidal impulses which are the most threatening. In the Beck Depression Inventory in Chapter 2, question nine refers to your suicidal thoughts and impulses. If you have checked a one, two, or three on this question, suicidal fantasies are present, and it is important to evaluate their seriousness and to intervene if necessary (see page 20).

  The most serious error you could make with regard to your suicidal impulses is to be overly inhibited in talking them over with a counselor. Many people are afraid to talk about suicidal fantasies and urges for fear of disapproval or because they believe that even talking about them will bring on a suicide attempt. This point of view is unwarranted. You are more likely to feel a great sense of relief in discussing 339

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  suicidal thoughts with a professional therapist, and consequently you have a much better chance of defusing them.

  If you do have suicidal thoughts, ask yourself if you are taking such thoughts seriously. Are there times when you wish you were dead? If the answer is yes, is your death wish active or passive? A passive death wish exists if you would prefer to be dead, but you are unwilling to take active steps to bring this about. One young man confessed to me, "Doctor, every night when I go to bed I pray to God to let me wake up with cancer. Then I could die in peace, and my family would understand."

  An active death wish is more dangerous. If you are seriously planning an actual suicide attempt, then it's important to know the following: Have you thought about a method?

  What is your method? Have you made plans? What specific preparations have you made? As a general rule, the more concrete and well-formulated your plans are, the more likely you may actually make a suicide attempt. The time to seek professional help is now!

  Have you ever made a suicide attempt in the past? If so, you should view any suicidal impulse as a danger signal to seek help immediately. For many people these previous attempts seem to be "warm-ups," in which they flirt with suicide but have not mastered the particular method they have selected. The fact that an individual has made this attempt unsuccessfully on several occasions in the past indicates an increased risk of success in the future. It is a dangerous myth that unsuccessful suicide attempts are simply gestures or attention-getting devices and are therefore not to be taken seriously. Current thinking suggests that all suicidal thoughts or actions are to be taken seriously. It can be highly misleading to view suicidal thoughts and actions as a "plea for help."

  Many suicidal patients want help least of all because they are 100 percent convinced they are hopeless and beyond help.

  Because of this illogical belief, what they really want is death.

  Your degree of hopelessness is of the greatest importance in assessing whether or not you are at risk for making an active suicide attempt at any time. This one factor seems more closely linked with actual suicide attempts than any other.

  You must ask yourself, "Do I believe that I have absolutely no chance of getting better? Do I feel that I have exhausted 340

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  all treatment possibilities and that nothing could possibly help? Do I feel convinced beyond all doubt that my suffering is unbearable and could never come to an end?" If you answer yes to these questions, then your degree of hopelessness is high, and professional treatment is indicated now! I would like to emphasize that hopelessness is as much a symptom of depression as a cough is a symptom of pneumonia. The feeling of hopelessness does not in fact prove that you are hopeless, any more than a cough proves you are doomed to succumb to pneumonia. It just proves that you are suffering from an illness, in this case, depression. This sense of hopelessness is not a reason to make a suicide attempt, but gives you a clear signal to seek competent treatment. So, if you feel hopeless, seek help! Do not consider suicide for one more minute!

  The last important factor concerns deterrents. Ask yourself, "Is there anything that is preventing me from committing suicide? Would I hold back because of my family, friends, or religious beliefs?" If you have no deterrents, the possibility is greater that you would consider an actual suicide attempt.

  SUMMARY: If you are suicidal, it is of great importance for you to evaluate these impulses in a matter-of-fact manner, using your common sense. The following factors put you in a high-risk group:

  1. If you are severely depressed and feel hopeless; 2. If you have a past history of suicide attempts; 3. If you have made concrete plans and preparations for suicide; and

  4. If no deterrents are holding you back.

  If one or more of these factors apply to you, then it is vital to get professional intervention and treatment immediately.

  While I firmly believe that the attitude of self-help is important for all people with depression, you clearly must seek professional guidance right away.

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  The Illogic of Suicide

  Do you think depressed people have the "right" to commit suicide? Some misguided "humanists" and novice therapists are unduly concerned with this issue. If you are counseling or trying to help a chronically depressed individual who is hopeless and threatening self-destruction, you may ask yourself, "Should I intervene aggressively, or should I let him go ahead? What are his rights as a human being in this regard?

  Am I responsible for preventing this attempt, or should I tell him to go ahead and exercise his freedom of choice?"

  I regard this as an absurd and cruel issue that misses the point entirely. The real question is not whether a depressed individual has the right to commit suicide, but whether he is realistic in his thoughts when he is considering it. When I talk to a suicidal person, I try to find out why he is feeling that way. I might ask, "What is your motive for wanting to kill yourself? What problem in your life is so terrible that there is no solution?" Then I would help that person expose the illogical thinking that lurks behind the suicidal impulse as quickly as possible. When you begin to think more realistically, your sense of hopelessness and the desire to end your life will fade away and you will have the urge to live. Thus, I recommend joy rather than death to suicidal individuals, and I try to show them how to achieve it as fast as possible! Let's see how this can be done.

  Holly was a ninet
een-year-old woman who was referred to me for treatment by a child psychoanalyst in New York City.

  He had treated her unsuccessfully with analytic therapy for many years since the onset of a severe unremitting depression in her early teens. Other doctors had also been unable to help her. Her depression originated during a period of family turbulence that led to her parents' separation and divorce.

  Holly's chronic blue mood was punctuated by numerous wrist-slashing episodes. She said that when periods of frustration and hopelessness would build up, she would be overcome by the urge to rip into her flesh and would experience relief only when she saw the blood flowing across her skin. When I first met Holly, I noticed a mass of white scar tissue across her wrists that attested to this behavior. In addition to these 342

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  episodes of self-mutilation, which were not suicide attempts, she had tried to kill herself on a number of occasions.

  In spite of all the treatment she had received, her depression would not let up. At times it became so severe that she had to be hospitalized. Holly had been confined to a closed ward of a New York hospital for several months at the time she was referred to me. The referring doctor recommended a minimum of three years of additional continuous hospitalization, and appeared to agree with Holly that her prognosis for substantial improvement, at least in the near future, was poor.

  Ironically, she was bright, articulate, and personable. She had done well in high school, in spite of being unable to go to classes during the times she was confined to hospitals. She had to take some courses with the help of tutors. Like a number of adolescent patients, Holly's dream was to become a mental-health professional, but she had been told by her previous therapist that this was unrealistic because of the nature of her own explosive, intractable emotional problems. This opinion was just one more crushing blow for Holly.

  After graduation from high school, she spent the majority of her time in inpatient mental-hospital facilities because she was considered too ill and uncontrollable for outpatient therapy. In a desperate attempt to find help, her father contacted the University of Pennsylvania because he had read about our work in depression. He requested a consultation to determine whether any promising treatment alternatives existed for his daughter.

  After speaking to me by phone, Holly's father obtained custody of her and drove to Philadelphia so that I could talk to her and review the possibilities for treatment. When I met them, their personalities contrasted with my expectations. He proved to be a relaxed, mild-mannered individual; she was strikingly attractive, pleasant, and cooperative.

  I administered several psychological tests to Holly. The Beck Depression Inventory indicated severe depression, and other tests confirmed a high degree of hopelessness and serious suicidal intent. Holly put it to me bluntly, "I want to kill myself." The family history indicated that several relatives had attempted suicide—two of them successfully. When I asked Holly why she wanted to kill herself, she told me that 343

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  she was a lazy human being. She explained that because she was lazy, she was worthless and so deserved to die.

  I wanted to find out if she would react favorably to cognitive therapy, so I used a technique that I hoped would capture her attention. I proposed we do some role-playing, and she was to imagine that two attorneys were arguing her case in court. Her father, by the way, happened to be an attorney who specialized in medical malpractice suits! Because I was a novice therapist at the time, this intensified my own anxious, insecure feelings about tackling such a tough case. I told Holly to play the role of the prosecutor, and she was to try to convince the jury that she deserved a death sentence. I told her I would play the role of the defense attorney, and that I would challenge the validity of every accusation she made. I told her that this way we could review her reasons for living and her reasons for dying, and see where the truth lay: HOLLY: For this individual, suicide would be an escape from life.

  DAVID: That argument could apply to anyone in the world.

  By itself, it is not a convincing reason to die.

  HOLLY: The prosecutor replies that the patient's life is so miserable, she cannot stand it one minute longer.

  DAVID: She has been able to stand it up until now, so maybe she can stand it a while longer. She was not always miserable in the past, and there is no proof that she will always be miserable in the future.

  HOLLY: The prosecutor points out that her life is a burden to her family.

  DAVID: The defense emphasizes that suicide will not solve this problem, since her death by suicide may prove to be an even more crushing blow to her family.

  HOLLY: But she is self-centered and lazy and worthless, and deserves to die!

  DAVID: What percentage of the population is lazy?

  HOLLY: Probably twenty percent . . . no, I'd say only ten percent.

  DAVID: That means twenty million Americans are lazy. The defense points out that they don't have to die for this, so there is no reason the patient should be singled out for 344

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  death. Do you think laziness and apathy are symptoms of depression?

  HOLLY: Probably.

  DAVID: The defense points out that individuals in our culture are not sentenced to death for the symptoms of illness, whether it be pneumonia, depression, or any other disease. Furthermore, the laziness may disappear when the depression goes away.

  Holly appeared to be involved in this repartee and amused by it. After a series of such accusations and defenses, she conceded that there was no convincing reason she should have to die, and that any reasonable jury would have to rule in favor of the defense. What was more important was that Holly was learning to challenge and answer her negative thoughts about herself. This process brought her partial but immediate emotional relief, the first she had experienced in many years. At the end of the consultation session, she said to me, "This is the best that I have felt in as long as I can remember. But now the negative thought crosses my mind, This new therapy may not prove to be as good as it seems.' "

  In response to this she felt a sudden surge of depression again. I assured her, "Holly, the defense attorney points out that this is no real problem. If the therapy isn't as good as it seems to be, you'll find out in a few weeks, and you'll still have the alternative of a long-term hospitalization. You'll have lost nothing. Furthermore, the therapy may be partially as good as it seems, or conceivably even better. Perhaps you would be willing to give it a try." In response to this proposal, she decided to come to Philadelphia for treatment.

  Holly's urge to commit suicide was simply the result of cognitive distortions. She confused the symptoms of her illness, such as lethargy and loss of interest in life, with her true identity and labeled herself as a "lazy person." Because Holly equated her worth as a human being with her achievement, she concluded she was worthless and deserved to die.

  She jumped to the conclusion that she could never recover, and that her family would be better off without her. She magnified her discomfort by saying, "I can't stand it." Her sense of hopelessness was the result of the fortune-telling error—

  she illogically jumped to the conclusion that she could not 345

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  improve. When Holly saw that she was simply trapping herself with unrealistic thoughts, she felt a sudden relief. In order to maintain such improvement, Holly had to learn to correct her negative thinking on an ongoing basis and that took hard work! She wasn't going to give in that easily!

  Following our initial consultation, Holly was transferred to a hospital in Philadelphia, where I visited her twice a week to initiate cognitive therapy. She had a stormy course in the hospital with dramatic mood swings, but was able to be discharged after a five-week period, and I persuaded her to enroll as a part-time summer-school student. For a while her moods continued to oscillate like a yo-yo, but she showed an overall improvement. At times Holly would report feeling very good for several days. This const
ituted a real breakthrough, since these were the first happy periods she had experienced since the age of thirteen. Then she would suddenly relapse into a severe depressive state. At these times she would again become actively suicidal, and would try her best to convince me that life was not worth living. Like many adolescents, she seemed to carry a grudge against all mankind, and insisted there was no point in living any longer.

  In addition to feeling negative about her own sense of worth, Holly had developed an intensely negative and disillusioned view of the entire world. Not only did she see herself as trapped by an endless, untreatable depression, but like many of today's adolescents, she had adopted a personal theory of nihilism. This is the most extreme form of pessimism.

  Nihilism is the belief that there is no truth or meaning to anything, and that all of life involves suffering and agony. To a nihilist like Holly, the world offers nothing but misery. She had become convinced that the very essence of every person and object in the universe was evil and horrible. Her depression was thus the experience of hell on earth. Holly en-visioned death as the only possible surcease, and she longed for death. She constantly complained and harangued cyni-cally about the cruelties and miseries of living. She insisted that life was totally unbearable at all times, and that all human beings were totally lacking in redeeming qualities.

  The task of getting such an intelligent and persistent young woman to see and admit how distorted her thinking was provided a real challenge to this therapist! The following lengthy 346

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  dialogue illustrates her intensely negative attitudes as well as my struggles to help her penetrate the illogic in her thinking: HOLLY: Life is not worth living because there is more bad than good in the world.

  DAVID: Suppose I was the depressed patient and you were my therapist and I told you that, what would you say?

  (I used this maneuver with Holly because I knew her goal hi life was to be a therapist. I figured she'd say something reasonable and upbeat, but she outfoxed me in her next statement.)