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?
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.
DAVID:
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 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 thinking. 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).
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 excruciati
ng 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 successfully commits suicide is die 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 brother, and so she had gone out of her way to try to compensate for this by providing emotional and financial 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. 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 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 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 contaminated 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 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 bladder. 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 i
ndeed 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 grandfather, 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 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.
Feeling Good: The New Mood Therapy Page 23