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.
Part IV
Prevention and Personal Growth
Chapter 10
The Cause of It All
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 relationships 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 and 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 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 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?
* * *
Figure 10–1.
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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 265). This downward arrow is a form of shorthand which tells Art to 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 see, 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.
* * *
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.
* * *
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.
5. This disapproval will mean I am a bad, worthless person.
Once you have generated your own chain of automatic thoughts and clarified your silent assumptions, it is crucial to pinpoint the distortions and substitute rational responses as you usually do (see Figure 10–3, page 268).
The beauty of the downward-arrow method is that it is inductive and Socratic: Through a process of thoughtful questioning, you discover on your own the beliefs that defeat you. You unearth the origin of your problems by repeating the following questions over and oven “If that negative thought were true, what would it mean to me? Why would it upset me?” Without introducing some therapist’s subjective bias or personal beliefs or theoretical leanings, you can objectively and systematically go right to the root of your problems. This circumvents a difficulty that has plagued the history of psychiatry. Therapists from all schools of thought have been notorious for interpreting patients’ experiences in terms of preconceived notions that may have little or no experimental validation. If you don’t “buy” your therapist’s explanation of the origin of your problems, this is likely to be interpreted as “resistance” to the “truth.” In this subtle way, your troubles get forced into your therapist’s mold regardless of what you say. Imagine the bewildering array of explanations for suffering that you would hear if you went to a religious counselor (spiritual factors), a psychiatrist in a Communist country (the social-political-economic environment), a Freudian analyst (internalized anger), a behavior therapist (a low rate of positive reinforcement), a drug-oriented psychiatrist (genetic factors and brain-chemistry imbalance), a family therapist (disturbed interpersonal relationships), etc.!
A word of caution when you apply the vertical-arrow method. You will short-circuit the process if you write down thoughts that contain descriptions of your emotional reactions. Instead, write down the negative thoughts that cause your emotional reactions. Here’s an example of the wrong way to do it:
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Figure 10–3. After eliciting his chain of automatic thoughts, using the downward-arrow method, Art identified the cognitive distortions and substituted more objective responses.
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First Automatic Thought: My boyfriend didn’t call me this weekend as he promised he would.
↓
“Why is that upsetting to me? What does it mean to me?”
Second Automatic Thought: Oh, it’s awful and terrible because I can’t stand it.
This is useless. We already know you feel awful and terrible. The question is—what thoughts automatically crossed your mind that caused you to feel so upset? What would it mean to you if he had neglected you?
Here’s the correct way to do it:
1. My boyfriend didn’t call me this weekend as he promised he would.
↓
“Why would that be upsetting to me? What does it mean to me?”
2. That means he’s neglecting me. That means he really doesn’t love me.
↓
“And suppose that were true. What would that mean to me?”
3. That would mean there’s something wrong with me. Otherwise he’d be more attentive.
↓
“And suppose that were true. What would that mean to me?”
4. That would mean I was going to be rejected.
↓
“And if I were in fact rejected, what then? What would that mean to me?”
5. That would mean I was unlovable and I would always be rejected.
↓
“And if that happened, why would it upset me?”
6. That would mean I’d end up alone and miserable.
Thus, by pursuing the meaning rather than your feelings, your silent assumptions became obvious: (1) If I’m not loved I’m not worthwhile; and (2) I’m bound to be miserable if I’m alone.
This is not to say your feelings aren’t important. The whole point is to deliver the real McCoy—valid emotional transformation.
The Dysfunctional Attitude Scale (DAS). Because of the crucial importance of eliciting the silent assumptions that give rise to your mood swings, a second, simpler method for eliciting them called the “Dysfunctional Attitude Scale” (DAS) has been developed by a member of our group. Dr. Arlene Weissman. She has compiled a list of one hundred self-defeating attitudes that commonly occur in individuals predisposed to emotional disorders. Her research has indicated that while negative automatic thoughts are reduced dramatically between episodes of depression, a self-defeating belief system remains more or less constant during episodes of depression and remission. Dr. Weissman’s studies confirm the concept that your silent assumptions represent a predisposition to emotional turbulence that you carry with you at all times.
Although a complete presentation of the lengthy Dysfunctional Attitude Scale would be beyond the scope of this book, I have selected a number of the more common attitudes and have added several others which will be useful. As you fill out the questionnaire, indicate how much you agree or disagree with each attitude. When you are finished, an answer key will let you score your answers and generate a profile of your personal value systems. This will show your areas of psychological strength and vulnerability.
Answering the test is quite simple. After each of the thirty-five attitudes, put a check in the column that represents your estimate of how you think most of the time. Be sure to choose only one answer for each attitude. Because we are all different, there is no “right” or “wrong” answer to any statement. To decide whether a given attitude is typical of your own philosophy, recall how you look at things most of the time.
EXAMPLE:
In this example the checkmark in the Agree Slightly column indicates that the statement is somewhat typical of the attitudes of the person completing the inventory. Now go ahead.
The Dysfunctional Attitude Scale*
Now that you have completed the DAS, you can score it in the following way. Score your answer to each of the thirty-five attitudes according to this key:
Now add up your score on the first five attitudes. These measure your tendency to measure your worth in terms of the opinions of others and the amount of approval or criticism you receive. Suppose your scores on these five items were +2; + 1; – 1; + 2; 0. Then your total score for these five questions would be +4.
Proceed in this way to add up your score for items I through 5, 6 through 10, 11 through 15, 16 through 20, 21 through 25, 26 through 30, and 31 through 35, and record these as illustrated in the following example:
SCORING EXAMPLE:
RECORD YOUR ACTUAL SCORES HERE:
Each cluster of five items from the scale measures one of seven value systems. Your total score for each cluster of five items can range from + 10 to – 10. Now plot your total scores on each of the seven variables so as to develop your “personal-philosophy profile” as follows:
SCORING EXAMPLE:
As you can see, a positive score represents an area where you are psychologically strong. A negative score represents an area where you’re emotionally vulnerable.
This individual has strengths in the areas of approval, perfectionism, and entitlement. His vulnerabilities lie in the areas of love, omnipotence, and autonomy. The meanings of these concepts will be described. First, plot your own personal-philosophy profile here.
Interpreting Your DAS Scores
I. Approval. The first five attitudes on the DAS test probe your tendency to measure your self-esteem based on how people react to you and what they think of you. A positive score between zero and ten indicates you are independent, with a healthy sense of your own worth even when confronted with criticism and disapproval. A negative score between zero and minus ten indicates you are excessively dependent because you evaluate yourself through other people’s eyes. If someone insult
s you or puts you down, you automatically tend to look down on yourself. Since your emotional well-being is exquisitely sensitive to what you imagine people think of you, you can be easily manipulated, and you are vulnerable to anxiety and depression when others criticize you or are angry with you.
II. Love. The second five attitudes on the test assess your tendency to base your worth on whether or not you are loved. A positive score indicates you see love as desirable, but you have a wide range of other interests you also find gratifying and fulfulling. Hence, love is not a requirement for your happiness or self-esteem. People are likely to find you attractive because you radiate a healthy sense of self-love and are interested in many aspects of living.
A negative score indicates you are a “love junkie.” You see love as a “need” without which you cannot survive, much less be happy. The closer your score is to minus ten, the more dependent on love you are. You tend to adopt inferior, put-down roles in relationships with people you care about for fear of alienating them. The result of this, more often than not, is that they lose respect for you and consider you a burden because of your attitude that without their love you would collapse. As you sense that people drift away from you, you become gripped by a painful, terrifying withdrawal syndrome. You realize you may not be able to “shoot up” with your daily dose of affection and attention. You then become consumed by the driving compulsion to “get love.” Like most junkies, you may even resort to coercive, manipulative behavior to get your “stuff.” Ironically, your needy, greedy love addiction drives many people away, thus intensifying your loneliness.
Feeling Good: The New Mood Therapy Page 24