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 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 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, “1 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 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 constituted 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 envisioned death as the only possible surcease, and she longed for death. She constantly complained and harangued cynically 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 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 woul
d you say?
(I used this maneuver with Holly because I knew her goal in life was to be a therapist. I figured she’d say something reasonable and upbeat, but she outfoxed me in her next statement.)
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.
DAVID:
What would that be like?
HOLLY:
I would be dead, and I think I would be better off being that way.
DAVID:
Do you think being dead is enjoyable?
HOLLY:
Well, I don’t even know what it’s like. I suppose it might be horrible to be dead and to experience nothing Who knows?
DAVID:
So it might be horrible, or it might be nothing. Now the closest thing to nothing is when you are being anesthetized. 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. And 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 again, 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 universe. 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.
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.
HOLLY:
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 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 partin
g 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 goodbye 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 me recently to let me know how things turned out. Although she still struggles with her moods at times, she is now a senior and 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.
Feeling Good: The New Mood Therapy Page 34