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 emigrated 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: 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 fluently—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 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.
LOUISE
(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.
LOUISE:
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.
LOUISE
(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?
LOUISE:
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?
LOUISE:
It doesn’t make any sense at all.
As a result of this intervention, Louise was able to see she 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 confuse 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 me
aningful 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.
It would be naive to say that depressed and suicidal individuals never have “real” problems. We all have real problems, 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 problems 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.
Part VI
Coping with the Stresses and Strains of Daily Living
Chapter 16
How I Practice What I Preach
“Physician, heal thyself.”—Luke 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 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 one! 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 non-directive—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 curious 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’d 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 you arrange for me to get shock treatments tomorrow or I’ll 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 payments 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 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.
Feeling Good: The New Mood Therapy Page 35