It would be naive to say that depressed and suicidal individuals never have "real" problems. We all have real problem, including finances, interpersonal relationships, health, etc. But such difficulties can nearly always be coped with in a reasonable manner without suicide. In fact, meeting such challenges can be a source of mood elevation and personal growth. Furthermore, as pointed out in Chapter 9, real prob-355
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lems can never depress you even to a small extent. Only distorted thoughts can rob you of valid hopes or self-esteem. I have never seen a "real" problem in a depressed patient which was so "totally insoluble" that suicide was indicated.
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PART VI
Coping with the
Stresses and Strains
of Daily Living
CHAPTER 16
How I Practice What I Preach
'Physician, heal thyself."—Lnke 4:23
A recent study of stress has indicated that one of the world's most demanding jobs—in terms of the emotional tension and the incidence of heart attacks—is that of an air-traffic controller in an airport tower. The work involves precision, and the traffic controller must be constantly alert—a blunder could result in tragedy. I wonder however if that job is more taxing than mine. After all, the pilots are cooperative and intend to take off or land safely. But the ships I guide are sometimes on an intentional crash course.
Here's what happened during one thirty-minute period last Thursday morning. At 10:25 I received the mail, and skimmed a long, rambling, angry letter from a patient named Felix just prior to the beginning of my 10:30 session. Felix announced his plans to carry out a "blood bath," in which he would murder three doctors, including two psychiatrists who had treated him in the past! In his letter Felix stated, "
I'm just waiting until I get enough energy to drive to the store and purchase the pistol and the bullets." I was unable to reach Felix by phone, so I began my 10:30 session with Harry. Harry was emaciated and looked like a concentration camp victim. He was unwilling to eat because of a delusion that his bowels had "closed off," and he had lost seventy pounds. As I was discussing the unwelcome option of hospitalizing Harry for forced tube feeding to prevent his death from starvation, I received an emergency telephone call from a patient named Jerome, which interrupted the session. Jerome informed me he had placed a noose around his neck and was seriously considering hanging himself before his wife
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came home from work. He announced his unwillingness to continue outpatient treatment and insisted that hospitalization would be pointless.
I straightened out these three emergencies by the end of the day, and went home to unwind. At just about bedtime I received a call from a new referral—a well-known woman VIP referred by another patient of mine. She indicated she'd been depressed for several months, and that earlier in the evening she'd been standing in front of a mirror practicing slitting her throat with a razor blade. She explained she was calling me only to pacify the friend who referred her to me, but was unwilling to schedule an appointment because she was convinced her case was "hopeless."
Every day is not as nerve-racking as that ones But at times it does seem like I'm living in a pressure cooker. This gives me a wealth of opportunities to learn to cope with intense uncertainty, worry, frustration, irritation, disappointment, and guilt. It affords me the chance to put my cognitive techniques to work on myself and see firsthand if they're actually effective. There are many sublime and joyous moments too.
If you have ever gone to a psychotherapist or counselor, the chances are that the therapist did nearly all the listening and expected you to do most of the talking. This is because many therapists are trained to be relatively passive and nondirective—a kind of "human mirror" who simply reflects what you are saying.* This one-way style of communication may have seemed unproductive and frustrating to you. You may have wondered—"What is my psychiatrist really like?
What kinds of feelings does he have? How does he deal with them? What pressures does he feel in dealing with me or with other patients?"
Many patients have asked me directly, "Dr. Burns, do you actually practice what you preach?" The fact is, I often do pull out a sheet of paper on the train ride home in the evening, and draw a line down the center from top to bottom so I can utilize the double-column technique to cope with any nagging emotional hangovers from the day. If you are curi-
*Some of the newer forms of psychiatric treatment, such as cognitive therapy, allow for a natural fifty-fifty dialogue between the client and therapist, who work together as equal members of a team.
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ous to take a look behind the scenes, I'll be glad to share some of my self-help homework with you. This is your chance to sit back and listen while the psychiatrist does the talking! At the same time, you can get an idea of how the cognitive techniques you have mastered to overcome clinical depression can be applied to all sorts of daily frustrations and tensions that are an inevitable part of living for all of us.
Coping With Hostility:
The Man Who Fired Twenty Doctors
One high-pressure situation I often face involves dealing with angry, demanding, unreasonable individuals. I suspect I have treated a few of the East Coast's top anger champions.
These people often take their resentment out on the people who care the most about them, and sometimes this includes me.
Hank was an angry young man. He had fired twenty doctors before he was referred to me. Hank complained of episodic back pain, and was convinced he suffered from some severe medical disorder. Because no evidence for any physical abnormality had ever surfaced, in spite of lengthy, elaborate medical evaluations, numerous physicians told him that his aches and pains were in all likelihood the result of emotional tension, much like a headache. Hank had difficulty accepting this, and he felt his doctors were writing him off and just didn't give a damn about him. Over and over he'd explode in a fury, fire his doctor, and seek out someone new. Finally, he consented to see a psychiatrist. He resented this referral, and after making no progress for about a year, he fired his psychiatrist and sought treatment at our Mood Clinic.
Hank was quite depressed, and I began to train him in cognitive techniques. At night when his back pain flared up, Hank would work himself up into a frustrated rage and impulsively call me at home (he had persuaded me to give him my home number so he wouldn't have to go through the answering service). He would begin by swearing and accusing me of misdiagnosing his illness. He's insist he had a medical, not a psychiatric problem. Then he'd deliver some unreasonable demand in the form of an ultimatum: "Dr. Burns, either
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you arrange for me to get shock treatments tomorrow or go out and commit suicide tonight." It was usually difficult, if not impossible, for me to comply with most of his demands.
For example, I don't give shock treatments, and furthermore I didn't feel this type of treatment was indicated for Hank.
When I would try to explain this diplomatically, he would explode and threaten some impulsive destructive action.
During our psychotherapy sessions Hank had the habit of pointing out each of my imperfections (which are real enough). He'd often storm around the office, pound on the furniture, heaping insults and abuse on me. What used to get me in particular was Hank's accusation that I didn't care about him. He said that all I cared about was money and maintaining a high therapy success rate. This put me in a dilemma, because there was a grain of truth in his criticisms—he was often several months behind in making pay-ments for his therapy, and I was concerned that he might drop out of treatment prematurely and end up even more disillusioned. Furthermore, I was eager to add him to my list of successfully treated individuals. Because there was some truth in Hank's haranguing attacks, I felt guilty and defensive when he would zero in on me. He, of course, would sense this, and consequently the volume
of his criticism would increase.
I sought some guidance from my associates at the Mood Clinic as to how I might handle Hank's outbursts and my own feelings of frustration more effectively. The advice I received from Dr. Beck was especially useful. First, he emphasized that I was "unusually fortunate" because Hank was giving me a golden opportunity to learn to cope with criticism and anger effectively. This came as a complete surprise to me; I hadn't realized what good fortune I had. In addition to urging me to use cognitive techniques to reduce and eliminate my own sense of irritation, Dr. Beck proposed I try out an unusual strategy for interacting with Hank when he was in an angry mood. The essence of this method was: (1) Don't turn Hank off by defending yourself. Instead, do the opposite—urge him to say all the worst things he can say about you. (2) Try to find a grain of truth in all his criticisms and then agree with him. (3) After this, point out any areas of disagreement in a straightforward, tactful, nonargumentative
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manner. (4) Emphasize the importance of sticking together, in spite of these occasional disagreements. I could remind Hank that frustration and fighting might slow down our therapy at times, but this need not destroy the relationship or prevent our work from ultimately becoming fruitful.
I applied this strategy the next time Hank started storming around the office screaming at me. Just as I had planned, I urged Hank to keep it up and say all the worst things he could think of about me. The result was immediate and dramatic. Within a few moments, all the wind went out of his sails—all his vengeance seemed to melt away. He began communicating sensibly and calmly, and sat down. In fact, when I agreed with some of his criticisms, he suddenly began to defend me and say some nice things about me! I was so impressed with this result that I began using the same approach with other angry, explosive individuals, and I actually did begin to enjoy his hostile outbursts because I had an effective way to handle them.
I also used the double-column technique for recording and talking back to my automatic thoughts after one of Hank's midnight calls (see Figure 16-1, page 364). As my associates suggested, I tried to see the world through Hank's eyes in order to gain a certain degree of empathy. This was a specific antidote that in part dissolved my own frustration and anger, and I felt much less defensive and upset. It helped me to see his outbursts more as a defense of his own self-esteem than as an attack on me, and I was able to comprehend his feelings of futility and desperation. I reminded myself that much of the time he was damn hard working and cooperative, and how foolish it was for me to demand he be totally cooperative at all times. As I began to feel more calm and confident in my work with Hank, our relationship continually improved.
Eventually, Hank's depression and pain subsided, and he terminated his work with me. I hadn't seen him for many months when I received a message from my answering service that Hank wanted me to call him. I suddenly felt apprehensive; memories of his turbulent tirades flooded my mind, and my stomach muscles tensed up. With some hesitation and mixed feelings, I dialed his number. It was a sunny Saturday afternoon, and I'd been looking forward to a much needed 363
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Figure 16-4. Coping with Hostility.
Automatic Thoughts
Rational Responses
1. I've put more energy into work- 1. Stop complaining. You sound ing with Hank than nearly any-like Hank! He's frightened and
one, and this is what I get—
frustrated, and he's trapped in
abuse!
his resentment. Just because you
work hard for someone, it doesn't
necessarily follow that they'll
feel appreciative. Maybe he will some day.
2. Why doesn't he trust me about 2. Because he's in a panic, he's exhis diagnosis and treatment?
tremely uncomfortable and in
pain, and he hasn't yet gotten
any substantial results. He'll be-
lieve you once he starts getting
well.
3. But in the meantime, he should 3. Do you expect him to show re-at least treat me with respect!
spect all the time or part of the
time? In general, he exerts tre-
mendous effort in his self-help
program and does treat you with
respect. He's determined to get
well—if you don't expect perfec-
tion, you won't have to feel frus-
trated.
4. But is it fair for him to call me 4. Talk it over with him when so often at home at night? And
you're both feeling more relaxed.
does he have to be so abusive?
Suggest that he supplement his
individual therapy by joining a
self-help group in which the vari-
ous patients call each other for
moral support. This will make it
easier for him to cut down on
calls to you. But for now, re-
member that he doesn't plan
these emergencies, and they are
very terrifying and real to him.
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rest after an especially taxing week. Hank answered the phone: "Dr. Burns, this is Hank. Do you remember me?
There's something I've been meaning to tell you for some time . ." He paused, and I braced for the impending explosion. "I've been essentially free of pain and depression since we finished up a year ago. I went off disability and I've gotten a job. I'm also the leader of a self-help group in my own hometown."
This wasn't the Hank I remembered! I felt a wave of relief and delight as he went on to explain, "But that's not why I'm calling. What I want to say to you is .. ." There was another moment of silence--"I'm grateful for your efforts, and I now know you were right all along. There was nothing dreadfully wrong with me, I was just upsetting myself with my irrational thinking. I just couldn't admit it until I knew for sure. Now, I feel lice a whole man, and I had to call you up and let you know where I stood . . . It was hard for me to do this, and I'm sorry it took so long for me to get around to telling you."
Thank you, Hank! I want you to know that some tears of joy and pride in you come to my eyes as I write this. It was worth the anguish we both went through a hundred times over!
Coping With Ingratitude:
The Woman Who Couldn't Say Thank You
Did you ever go out of your way to do a favor for someone only to have the person respond to your efforts with indifference or nastiness? People shouldn't be so unappreciative, right? If you tell yourself this, you will probably stew for days as you mull the incident over and over. The more inflammatory your thoughts and fantasies become, the more disturbed and angry you will feel.
Let me tell you about Susan. After high-school graduation, Susan sought treatment for a recurrent depression. She was very skeptical that I could help her and continually reminded me that she was hopeless. She had been in a hysterical state for several weeks because she couldn't decide which of two colleges to attend. She acted as though the world would come 365
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to an end if she didn't make the "right" decision, and yet the choice was simply not clear-cut. Her insistence on eliminating all uncertainty was bound to cause her endless frustration because it simply couldn't be done.
She cried and sobbed excessively. She was insulting and abusive to her boyfriend and her family. One day she called me on the phone, pleading for help. She just had to make up her mind. She rejected every suggestion I made, and angrily demanded I come up with some better approach. She kept insisting, "Since I can't make this decision, it proves your cognitive therapy won't work for me. Your methods are no damn good. I'll never be able to decide, and I can't get better." Because she was so upset, I arranged my afternoon schedule so that I could have an emergency consultation with a colleague. He offered several outstanding suggestions; I called her right back and gave her some tips on how to resolv
e her indeciveness. She was then able to come to a satisfactory decision within fifteen minutes, and felt an instan-taneous wave of relief.
When she came in for her next regularly scheduled session, she reported she had been feeling relaxed since our talk, and had finalized the arrangements to attend the college that she chose. I anticipated waves of gratitude because of my strenu-ous efforts on her behalf, and I asked her if she was still convinced that cognitive techniques would be ineffective for her. She reported, "Yes, indeed! This just proves my point.
My back was up against the wall, and I had to make a decision. The fact that I'm feeling good now doesn't count because it can't last. This stupid therapy can't help me. I'll be depressed for the rest of my life." My thought: "My God!
How illogical can you get? I could turn mud into gold, and she wouldn't even notice!" My blood was boiling, so I decided to use the double-column technique later that day to try and calm my troubled and insulted spirits (see Figure 16-2, opposite page).
After writing down my automatic thoughts, I was able to pinpoint the irrational assumption that caused me to get upset over her ingratitude. It was, "If I do something to help someone, they are duty-bound to feel grateful and reward me for it." It would be nice if things worked like this, but it's simply not the case. No one has a moral or legal obligation to credit 366
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me for my cleverness or praise my good efforts on their behalf. So why expect it or demand it? I decided to tune in to reality and adopt a more realistic attitude: "If I do something to help someone, the chances are the person will be apprecia-Figure 16-2. Coping with Ingratitude.
Automatic Thoughts
Rational Responses
The Feeling Good Handbook Page 40