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 415). 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 hardworking 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 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 like 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.”
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Figure 16–1. Coping with Hostility.
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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 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 resolve her indeciveness. She was then able to come to a satisfactory decision within fifteen minutes, and felt an instantaneous 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 strenuous 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, page 418).
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 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 appreciative, and that will feel good. But every now and then, someone will not respond the way I want. If the response is unreasonable, this is a reflection on that person, not me, so why get upset over it?” This attitude has made life much sweeter for me, and overall I have been blessed with as much gratitude from patients as I could desire. Incidentally, Susan gave me a call just the other day. She’d done well at college and was about to graduate. Her father had been depressed, and she wanted a referral to a good cognitive therapist! Maybe that was her way of saying thank you!
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Figure 16–2. Coping with Ingratitude.
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Coping With Uncertainty and Helplessness: The Woman Who Decided to Commit Suicide
On my way to the office on Monday, I always wonder what the week will hold in store. One Monday morning I was in for an abrupt shock. As I unlocked the office, I found some papers had been slipped under the door over the weekend—a twenty-page letter from a patient named Annie. Annie had been referred to me several months earlier on her twentieth birthday, after having received eight years of completely successful treatment from several therapists for a horrible, grotesque mood disorder. From age twelve on, Annie’s life had deteriorated into a nightmarish pattern of depression and self-mutilation. She loved to slash her arms to shreds with sharp objects, one time requiring 200 stitches. She also made a number of nearly successful suicide attempts.
I tensed as I picked up her note. Annie had recently expressed a deep sense of despair. In addition to depression, she suffered from a severe eating disorder, and the previous week had engaged in a bizarre three-day spree of compulsive, uncontrollable binge-eating. Going from restaurant to restaurant, she would stuff herself for hours nonstop. Th
en she’d vomit it all up and eat some more. In her note she described herself as a “human garbage disposal,” and explained that she was beyond hope. She indicated that she had decided to give up trying because she realized she was basically “a nothing.”
Without reading further, I called her apartment. Her roommates told me that she had packed up and “left town” for three days without giving any indication of where or why. Alarms sounded in my head! This is exactly what she had done on her last several suicide attempts prior to treatment—she’d drive to a motel, sign in under an assumed name, and overdose. I continued to read her letter. In it she stated, “I’m drained, I’m like a burnt-out light bulb. You can pipe electricity into it, but it just won’t light up. I’m sorry but I guess it’s just too late. I’m not going to feel false hope any longer … During the last few moments I do not feel particularly sad. Once every so often I try to grasp onto life, hoping to clench my hands around something, anything—but I keep grasping nothing, empty.”
It sounded like a bona fide suicide note, although no explicit intention was announced. I suddenly became submerged by a massive uncertainty and helplessness—she had disappeared and left no traces. I felt angry and anxious. Because I could do nothing for her, I decided to write down the automatic thoughts that flowed through my mind. I hoped some rational responses would help me cope with the intense uncertainty I was facing (see Figure 16–3, page 421).
After recording my thoughts, I decided to call my associate, Dr. Beck, for a consultation He agreed that I should assume she was alive unless it was proved otherwise. He suggested that if she were found dead, I could then learn to cope with one of the professional hazards of working with depression. If she was alive, as we assumed, he emphasized the importance of persisting with treatment until her depression finally broke.
The effect of this conversation and the written exercise was magnificent. I realized I was under no obligation to assume “the worst,” and that it was my right to choose not to make myself miserable over her possible suicide attempt. I decided I couldn’t take on responsibility for her actions, only for mine, and that I had done well with her and would stubbornly continue to do so until she and I had finally defeated her depression and tasted victory.
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Figure 16–3. Coping with Uncertainty.
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My anxiety and anger disappeared completely, and I felt relaxed and peaceful until I received the news by telephone on Wednesday morning. She had been found unconscious in a motel room fifty miles from Philadelphia. This was her eighth suicide attempt, but she was alive and complaining as usual in the Intensive Care Unit of an outlying hospital. She would survive, but would require plastic surgery to replace the skin over her elbows and ankles because of sores which had developed during the long period of unconsciousness. I arranged for her transfer to the University of Pennsylvania, where she would be back in my relentless, cognitive clutches again!
When I spoke with her, she was enormously bitter and hopeless. The next couple of months of therapy were especially turbulent. But the depression finally began to lift in her eleventh month, and exactly one year to the day of her referral, her twenty-first birthday, the symptoms of depression disappeared.
The Payoff. My joy was enormous. Women must have this feeling when they first see their child after delivery—all the discomfort of pregnancy and the pain of delivery are forgotten. It’s the celebration of life—quite a heady experience. I find that the more chronic and severe the depression, the more intense the therapeutic struggle becomes. But when the patient and I at last discover the combination that unlocks the door to their inner peace, the riches inside far exceed any effort or frustration that occurred along the way.
Part VII
The Chemistry of Mood
NOTE: Numbered Notes and References for Chapters 17–20 can be found on pages 682–687. Because some References are cited more man once, the superscript numbers assigned to those References will appear in these chapters more than once.
Chapter 17
The Search for “Black Bile”
(Notes and References appear on pages 682–687.)
Some day, scientists may provide us with frightening technology that will allow us to change our moods at will. This technology may be in the form of a safe, fast-acting medication that relieves depression in a matter of hours with few or no side effects. This breakthrough will represent one of the most extraordinary and philosophically confusing developments in human history. In a sense, it will almost be like discovering the Garden of Eden again—and we may face new ethical dilemmas. People will probably ask questions like these: When should we use this pill? Are we entitled to be happy all the time? Is sadness sometimes a normal and healthy emotion, or should it always be considered an abnormality that needs treatment? Where do we draw the line?
Some people think such technology has already arrived in the form of a pill called Prozac. When you read the next few chapters, you will see that this is not really the case. Although we have large numbers of antidepressant medications that work for some people, many people do not respond to antidepressant medications in a satisfactory way, and when they do improve, the improvement is often incomplete. Clearly, we are still a long way from our goal.
In addition, we still do not really know how the brain creates emotions. We do not know why some people are more prone to negative thinking and gloomy moods throughout their lives, whereas others seem to be eternal optimists who always have a positive outlook and a cheerful disposition. Is depression partially genetic? Is it due to some type of chemical or hormonal imbalance? Is it something we’re born with, or something we learn? The answers to these questions still elude us. Many people wrongly believe we already have the answers.
The answers to questions about treatment are equally unclear. Which patients should be treated with medications? Which patients need psychotherapy? Is the combination better than either type of treatment alone? You will see that the answers to questions as basic as these are more controversial than you might expect.
In this chapter, I address these issues. I discuss whether depression is caused more by biology (nature) or the environment (nurture). I explain how the brain works, and review evidence that depression might be caused by a chemical imbalance in the brain. I also describe how antidepressant drugs attempt to correct this imbalance.
In Chapter 18, I discuss the “mind-body problem” and address the current controversies about treatments that affect the “mind” (for instance, cognitive therapy) versus treatments that affect the “body” (for instance, antidepressants.) In Chapters 19 and 20, I will give you practical information about all the antidepressant drugs that are currently prescribed for mood problems.
Do Genetic or Environmental Influences Play a Greater Role in Depression?
Although much research is being conducted to try to tease out the relative strengths of the genetic and environmental influences on depression, scientists do not yet know which influences are the most important. With regard to bipolar (manic-depressive) illness, the evidence is quite strong: genetic factors seem to play a strong role. For example, if one identical twin develops bipolar manic-depressive illness, the odds are high that the other twin will also develop this disorder (50 percent to 75 percent). In contrast, when one of two nonidentical twins develops bipolar (manic-depressive) illness, the odds that the other twin will develop the same illness are lower (15 percent to 25 percent). The odds of developing bipolar illness if a parent or nontwin sibling has this disorder are around 10 percent. All these odds are considerably higher than the odds that someone in the general population will develop bipolar illness—the lifetime risk is estimated at less than I percent.
Keep in mind that identical twins have identical genes, whereas nonidentical twins share only half their genes. This is probably why the likelihood of bipolar (manic-depressive) illness is so much higher if you have an identical twin than if you have a nonidentical twin with this disorder, and why the
se rates are so much higher than the rates for bipolar illness in the general population. The increased risk for bipolar illness among identical twins is even true if the identical twins are separated at birth and raised by different families. Although the adoption of identical twins by separate families is rare, it does happen on occasion. In some cases, scientists have been able to locate the twins later in life to determine how similar or different they are. These “natural” experiments can tell us a great deal about the relative importance of genes versus environment because the separately raised identical twins have identical genes but their environments are different. Such studies highlight the importance of strong genetic influences in bipolar disorder.
With regard to the far more common garden-variety depression without episodes of uncontrollable mania, the evidence for genetic factors is still quite fuzzy. Part of the problem facing genetic researchers is that the diagnosis of depression is much less clear-cut than the diagnosis of bipolar (manic-depressive) illness. Bipolar manic-depressive illness is such an unusual disorder, at least in its more severe forms, that the diagnosis is often obvious. The patient has a sudden and alarming change in personality that comes on without drugs or alcohol, along with symptoms such as:
Feeling Good: The New Mood Therapy Page 36