HOLLY: I'd say that I can't argue with you!
DAVID: So, if I were your depressed patient and told you that life is not worth living, you'd advise me to jump out the window?
HOLLY (laughing): Yes. When I think about it, that's the best thing to do. If you think about all the bad things that are going on in the world, the right thing to do is to get really upset about them and be depressed.
DAVID: And what are the advantages to that? Does that help you correct the bad things in the world or what?
HOLLY: No. But you can't correct them.
DAVID: You can't correct all the bad things in the world, or you can't correct some of them?
HOLLY: You can't correct anything of importance. I guess you can correct small things. You can't really make a dent in the badness of this universe.
DAVID: Now, at the end of each day if I said that to myself when I went home, I could really become upset. In other words, I could either think about the people that I did help during the day and feel good, or I could think of
all the thousands of people that I will never get a chance to see and work with, and I could feel hopeless and helpless. That would incapacitate me, and I don't think that it is to my advantage to be incapacitated. Is it to your advantage to be incapacitated?
HOLLY: Not really. Well, I don't know.
DAVID: You like being incapacitated?
HOLLY: No. Not unless I were completely incapacitated.
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DAVID: What would that be like?
HOLLY: I would be dead, and I think I would be better of being that way.
DAVID: Do you think being dead is enjoyable?
HOLLY: Well, I don't even know what it's like. I suppose is might be horrible to be dead and to experience nothinz.
Who knows?
DAVID: So it might be horrible, or it might be nothing. Now the closest thing to nothing is when you are being anes-thetized. Is that enjoyable?
HOLLY: It's not enjoyable, but it's not unenjoyable either.
DAVID: I'm glad you admit that it's not enjoyable. An'
you're right, there's really nothing enjoyable about nothing. But there are some things enjoyable about life.
(At this point I thought I had really made a mark. But agai^-
in her adolescent insistence that things were no good, she continued to outmaneuver me and contradict everything I said. Her contrariness made my work with her challenging and more than a bit frustrating at times.)
HOLLY: But you see, there are so few things that are enjoyable about life, and there is so much other stuff that you have to go through to get those few enjoyable things that it seems to me it just doesn't weigh out.
DAVID: How do you feel when you're feeling good? Do you feel that it doesn't weigh out then, or do you just feel this way when you're feeling bad?
HOLLY: It all depends on what I want to focus on, right?
The only way I get myself not to be depressed is if I don't think about all the lousy things in this universe that make me depressed. Right? So when I am feeling good, that means I'm focusing on the good things. But all the bad things are still there. Since there is so much more bad than good, it is dishonest and phony to look only at the good and feel good or feel happy, and that's why suicide is the best thing to do.
DAVID: Well, there are two kinds of bad things in this uni•
verse. One is the pseudo-bad. This is the unreal bad that we create as a figment of our imagination by the way we think about things.
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HOLLY (interrupting): Well, when I read the newspapers, I see rapes and murders. That seems to me to be the real bad.
DAVID: Right. That's what I call the real bad. But let's look at the pseudo-bad first.
}roux: Like what? What do you mean by pseudo-bad?
DAVID: Well, take your statement that life is no good. That statement is an inaccurate exaggeration. As you pointed out, life has its good elements, its bad elements, and its neutral elements. So the statement that life is no good or that everything is hopeless is just exaggerated and unrealistic. This is what I mean by the pseudo-bad. On the other hand, there are the real problems in life. It's true that people do get murdered and that people do get cancer, but in my experience these unpleasant things can be coped with. In fact, in your life you will probably make the decision to commit yourself to some aspect of the world's problems where you think you can make a contribution to a solution. But even there, the meaningful approach involves interaction with the problem in a positive way rather than getting overwhelmed by it and sitting back and moping.
HOLLY: Well, see, that's what I do. I just get immediately overwhelmed with the bad things I encounter, and then I feel like I ought to kill myself.
DAVID: Right. Well, it might be nice if there were a universe where there were no problems and no suffering, but then there would be no opportunity for people to grow or solve these problems either. One of these days you'll probably take one of the problems in the world, and contributing to its solution will become a source of satisfaction to you.
HOLLY: Well, that's not fair to use problems in that way.
DAVID: Why don't you test it out? I wouldn't want you to believe anything that I say unless you test it out for yourself and find out if it's true. The way to test it out is to begin getting involved in things, to go to classes, do your work, and establish relationships with people.
HOLLY: That's what I am beginning to do.
DAVID: Well, you can see how it works out over a period of time, and you may find that going to summer school and 349
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making a contribution to this world, and meeting with friends and getting involved with activities, and doing your work and getting adequate grades, and experiencing a sense of achievement and pleasure in doing what you can—all of this might not be satisfying to you, and you might conclude, "Hey, depression was better than this." And "I don't like being happy." You might say, "
Hey, I don't like being involved in life." If that's true, you can always go back to being depressed and hopeless.
I'm not going to take anything away from you. But don't knock happiness until you've tried it. Check it out.
See what life is like when you get involved and make an effort. Then we'll see where the chips fall at that time.
Holly again experienced a substantial emotional relief as she realized, at least in part, that her intense conviction that the world was no good and life was not worth living was simply the result of her illogical way of looking at things. She was making the mistake of focusing only on negatives (the mental filter) and arbitrarily insisting that the positive things in the world didn't count (disqualifying the positive). Consequently, she got the impression that everything was negative and that life was not worth living. As she learned to correct this error in her thinking, she began to experience some improvement. Although she continued to have a number of ups and downs, the frequency and severity of her mood swings diminished with time. She was so successful in her summer-school work that she was accepted in the fall as a full-time student at a top Ivy League college. Although she made many pessimistic predictions that she would flunk out because she didn't have the brains to make it in academics, to her great surprise she did outstandingly well in her classes. As she learned to transform her intense negativity into productive activity, she became a top-notch student.
Holly and I had a parting of the ways after less than a year of weekly sessions. In the middle of an argument, she fled from the office, slammed the door, and vowed never to return. Maybe she didn't know any other way to say good-bye. I believe she felt she was ready to try and make it on her own. Perhaps she finally got tired of trying to batter me down; after all, I was just as stubborn as she was! She called 350
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me recently to let me know how things turned out. Although she still struggles with her moods at times, she is now a senior a
nd at the top of her class. Her dream of going to graduate school to pursue a professional career appears to be a certainty. God bless you, Holly!
Holly's thinking represents many of the mental traps that can lead to a suicidal impulse. Nearly all suicidal patients have in common an illogical sense of hopelessness and the conviction they are facing an insoluble dilemma. Once you expose the distortions in your thinking, you will experience considerable emotional relief. This can give you a basis for hope and can help you avert a dangerous suicide attempt. In addition, the emotional relief can give you some breathing room so you can continue to make more substantive changes in your life.
You may find it difficult to identify with a turbulent adolescent like Holly, so let's take a brief look at another more common cause for suicidal thoughts and attempts—the sense of disillusionment and despair that sometimes hits us in middle age or in our senior years. As you review the past, you may conclude that your life hasn't really amounted to much in comparison with the starry-eyed expectations of your youth. This has been called the mid-life crisis—that stage in which you review what you have actually done with your life compared with your hopes and plans. If you cannot resolve this crisis successfully, you may experience such intense bitterness and such profound disappointment that you may attempt suicide. Once again, the problem turns out to have little, if anything, to do with reality. Instead, your turmoil is based on twisted thinking
Louise was a married woman in her fifties who had emi-grated from Europe to the United States during World War II. Her family brought her to my office one day after she had been discharged from an intensive care unit, where she had been treated for an almost successful and totally unexpected suicide attempt. The family was unaware she had been experiencing serious depression, so her sudden suicide attempt was a complete surprise. As I spoke with Louise, she told me bitterly that her life had not measured up. She had never experienced the joy and fulfillment that she dreamed of as a girl:
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she complained of a sense of inadequacy and was convinced she was a failure as a human being. She told me that she had accomplished nothing worthwhile and concluded her life was not worth living.
Because I felt a rapid intervention was necessary in order to prevent a second suicide attempt, I used cognitive techniques to demonstrate to her as fast as possible the illogic of what she was saying to herself. I first asked her to give me a list of things she had accomplished in life as a way of testing her belief that she hadn't succeeded at anything worthwhile.
LOUISE: Well, I helped my family escape from the Nazi terrorism and relocate in this country during World War II. In addition, I learned to speak many languages flu-ently—five of them—when I was growing up. When we came to the United States, I worked at an unpleasant job so that enough money would be available for my family. My husband and I raised a fine young son, who went on to college and is now a highly successful businessman. I'm a good cook; and in addition to perhaps being a good mother, my grandchildren seem to think I'm a good grandmother. These would be the things which I feel I have accomplished during my life.
DAVID: In light of all these accomplishments, how can you tell me you have accomplished nothing?
LOUISE: You see, everyone in my family spoke five languages. Getting out of Europe was just a matter of survival. My job was ordinary and required no special talent. It is a mother's duty to raise her family, and any good housewife should learn to cook. Because these are all the things I was supposed to do, or that anyone could have done, they are not real accomplishments. They are just ordinary, and this is why I have decided to commit suicide. My life is not worthwhile.
I realized that Louise was upsetting herself unnecessarily by saying, "It doesn't count" with regard to anything good about herself. This common cognitive distortion, called "
disqualifying the positive," was her main enemy. Louise focused only on her inadequacies or errors, and insisted that her successes weren't worth anything. If you discount your 352
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achievements in this way, you will create the mental illusion that you are a worthless zero.
In order to demonstrate her mental error in a dramatic fashion, I proposed that Louise and I do some role-playing. I told her that I would play the role of a depressed psychiatrist, and she was to be my therapist, who would try to find out why I have been feeling so depressed.
Louisa (as therapist): Why is it you feel depressed, Dr. Burns?
DAVID (as depressed psychiatrist): Well, I realize that I've accomplished nothing with my life.
Louisa: So you feel you've accomplished nothing? But that doesn't make sense. You must have accomplished something. For example, you care for many sick depressed patients, and I understand you publish articles about your research and give lectures. It sounds like you have accomplished a great deal at such a young age.
DAVID: No. None of those things count. You see, it is every doctor's obligation to care for his patients. So that doesn't count. I'm just doing what I'm supposed to do.
Furthermore, it is my duty at the university to do research and publish the results. So these are not real accomplishments. All the faculty members do this, and my research is not very important, at any rate. My ideas are just ordinary. My life is basically a failure.
Louisa (laughing at herself—no longer being the therapist): I can see that I have been criticizing myself like that for the past ten years.
DAVID (as therapist again): Now, how does it feel when you continually say to yourself, "It doesn't count" whenever you think about the things you have accomplished?
Louisa: I feel depressed when I say this to myself.
DAVID: And how much sense does it make to think of the things that you haven't done that you might have liked to do, and to overlook the things that you have done which turned out well and were the result of substantial effort and determination?
LinnsE: It doesn't make any sense at all.
As a result of this intervention, Louise was able to see she
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had been arbitrarily upsetting herself by saying over and over, "What I have done isn't good enough." When she recognized how arbitrary it was to do this to herself, she experienced immediate emotional relief, and her urge to commit suicide disappeared. Louise realized that no matter how much she had accomplished in her life, if she wanted to upset herself she would always be able to look back and say, "It wasn't enough." This indicated to her that her problem was not realistic but simply a mental trap she had fallen into. The role-reversal seemed to evoke a sense of amusement and laughter in her. This stimulation of her sense of humor appeared to help her recognize the absurdity of her self-criticism, and she achieved a much needed sense of compassion for herself.
Let's review why your conviction that you are "hopeless" is both irrational and self-defeating. First, remember that depressive illness is usually, if not always, self-limiting, and in most cases eventually disappears even without treatment. The purpose of treatment is to speed the recovery process. Many effective methods of drug therapy and psychotherapy now exist, and others are being rapidly developed. Medical science is in a constant state of evolution. We are currently experiencing a renaissance in our approaches to depressive illness. Because we cannot predict yet with complete certainty which psychological intervention or medication will be most helpful for a particular patient, a number of techniques must sometimes be applied until the right key to the locked-up potential for happiness is found. Although this does require patience and hard work, it is crucial to keep in mind that nonresponse to one or even to several techniques does not indicate that all methods will fail. In fact, the opposite is more often true. For example, recent drug research has shown that patients who do not respond to one antidepressant medication often have a better than average chance of responding to another. This means if you fail to respond to one of the agents, your chances for improvement when you
are given another may actually be enhanced. When you consider that there are large numbers of effective antidepressants, psychotherapeutic interventions, and self-help techniques, the probability for eventual recovery becomes tremendously high.
When you are depressed, you may have a tendency to con-354
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fuse feeling with facts. Your feelings of hopelessness and total despair are just symptoms of depressive illness, not facts.
If you think you are hopeless, you will naturally feel this way. Your feelings only trace the illogical pattern of your thinking. Only an expert, who has treated hundreds of depressed individuals, would be in a position to give a meaningful prognosis for recovery. Your suicidal urge merely indicates the need for treatment. Thus, your conviction that you are "hopeless" nearly always proves you are not. Therapy, not suicide, is indicated. Although generalizations can be misleading, I let the following rule of thumb guide me: Patients who feel hopeless never actually are hopeless.
The conviction of hopelessness is one of the most curious aspects of depressive illness. In fact, the degree of hopelessness experienced by seriously depressed patients who have an excellent prognosis is usually greater than in terminal malignancy patients with a poor prognosis. It is of great importance to expose the illogic that lurks behind your hopelessness as soon as possible in order to prevent an actual suicide attempt. You may feel convinced that you have an insoluble problem in your life. You may feel that you are caught in a trap from which there is no exit. This may lead to extreme frustration and even to the urge to kill yourself as the only escape. However, when I confront a depressed patient with respect to precisely what kind of trap he or she is in, and I zero in on the person's "insoluble problem," I invariably find that the patient is deluded. In this situation, you are like an evil magician, and you create a hellish illusion with mental magic. Your suicidal thoughts are illogical, distorted, and erroneous. Your twisted thoughts and faulty assumptions, not reality, create your suffering. When you learn to look behind the mirrors, you will see that you are fooling yourself, and your suicidal urge will disappear.
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