Case Studies

Case Study 1 includes a transcript of a session with Simone. After reading the transcript, evaluate Simone’s behavior using Psychoanalytic Theory.

Case Study 3 includes a transcript of a session with David. Briefly conceptualize David’s symptoms from a Client-Centered perspective.

Case Study 6 includes a transcript of a suicidal and depressed patient. Briefly conceptualize this case from a Cognitive Therapy perspective.

Compare and contrast the main techniques of rational emotive therapy, behavior therapy and cognitive therapy.

Compare and contrast the view of psychopathology described in Freud’s theory with the view described in Rogers’ client-centered theory.Simone case

Simone was a young African American woman with whom I worked for four years. Dur- ing this period, I saw her three times per week. At the time she began treatment, she was 26 years old. Simone initially sought treatment because of a “general feeling of emp- tiness” as well as a moderate problem with bulimia, which involved both binging and purging. She was working in a health-food store on a part-time basis and was primarily supported financially by her father. In college, Simone had majored in fine arts, but she was not doing anything related to her college education in the time she was in treatment with me. She was extremely attractive, intelligent, articulate, and well dressed. From the beginning I was struck by her lively and playful manner and her sense of humor. I also began to notice early on a tendency on her part to vacillate between states of narcissistic grandiosity during which she denied any needs or self-doubts, and (less frequently) states of openness and vulnerability during which she was able to admit to feeling extremely alienated and lonely.

Simone was brought up in a middle-class family in the suburbs. She attended a relatively affluent, predominantly white school. When I asked what the experience of being one of the only black children in the school was like for her, she denied any feel- ings of discomfort or of not belonging. She told me that most of her friends throughout her life had been white and that she had never given it much thought. During the course of treatment, we explored whether being in treatment with a white therapist had any significance for her. At first she denied that this was the case, in the same way that she denied having any feelings about being the one of the few African Americans in a pre- dominantly white school. Gradually over time, however, we were able to explore this issue in greater depth.

Simone had two older brothers and one younger sister. Her father had an MBA and was a business executive when she was growing up. Her mother was a nurse. Simone’s father left her mother when Simone was 6. Her father and mother had maintained an on-and-off again relationship over the years, and her mother had always maintained the hope of reuniting with him.

When Simone was a child, her father’s presence was unpredictable. He would peri- odically (e.g., once every one or two months) come home to spend a weekend and then invariably leave early after having a fight with her mother. Simone described poignant memories of running down the road after his car crying. She maintained that initially she would be excited when she knew that her father would be visiting. Eventually she stopped feeling any excitement (as a form of self-protection) and then transitioned into a third state in which she felt no feelings but pretended to be excited to avoid alienating her father.

Simone’s father continued to maintain a relationship with her as she grew older and even now would periodically contact her, take her out for lunch or dinner, make plans to see her again, and then inevitably disappear from her life again. When Simone spoke about her father, I often had the feeling that there was a semi-incestuous quality to the relationship. It was difficult for me to put my finger on why I felt this way. Simone never acknowledged a literal sexual boundary violation in their relationship (and it seemed to me quite possible that there never was one), but the way she discussed their relationship often had a type of romantically charged quality to it. She conveyed a sense of awkward- ness and shame about their interactions, and her perception was that her father also felt awkward—“as if he was on a date.” Another factor contributing to my speculation that there may have been some time of sexual boundary violation in Simone’s childhood was that she sometimes spoke about experiencing a type of “disgusting energy” emanating from her that drove people away. (My experience has been that the feeling of being disgusting in some fundamental way is not unusual for clients who have been sexually violated as children.) The possibility of a sexual boundary violation having taken place in Simone’s childhood was not a topic that was ever fully explored in work together. I speculated to myself, however, that a boundary violation of this type may have affected her ability to have romantic relationships with men. I also wondered to myself whether some type of sexual trauma with her father or another man in her childhood may have affected her way of relating to me and her difficulty in accepting support and nurturance from me.

Simone maintained that when she was a child her mother had been highly er- ratic, alternating between episodes of intense anger and periods of fragility and de- pendency on her. Simone remembered learning to be vigilant to shifts in her mother’s mood in order to avoid triggering an outburst. She also remembered learning to take care of her mother emotionally—a way of being that had become characteris- tic for Simone. She described her mother as emotionally needy and dependent and felt extremely judgmental of her. This critical perspective on her mother contrasted with an idealized view of her father, who she viewed as independent and with whom she identified.

Simone was extremely shy in school and saw herself as ugly. Her first romantic re- lationship was at the end of high school. She was involved with a boy for a year but had no sexual relationship with him. When he left school to attend college, Simone became briefly involved with his best friend. On one occasion she had sexual intercourse with him and experienced this as traumatic. When she described the reasons why she had experienced the event as traumatic, it was the first point in our work together that I began to get a sense of some pockets of semidelusional ideation in Simone’s thinking that were generally kept well contained. She told me that before this incident she had believed she would give birth to a child through immaculate conception and now this could never happen.

After her relationship with this boy, Simone began to have lesbian relationships and was involved in a lesbian relationship at the beginning of treatment. Before treatment, Simone’s longest romantic relationship (subsequent to her first high school boyfriend) had lasted one month. Her typical pattern would be to end romantic relationships when she began to experience her partner as being too “emotionally needy,” apparently an inevitability in her mind. When Simone began treatment, she did not see the absence of long-term romantic relationships in her life as a problem or as something she wished to change. Over the course of treatment, Simone and I spent considerable time exploring the factors contributing to her feelings of emptiness as well as her binging behavior. She fluctuated dramatically (both within sessions and various stages of the treatment) in her ability to look at her own feelings and actions in a self-reflective fashion. At times when she was feeling safer and more open, however, she was able to express a desire to im- prove the quality of her relationships with people, a wish to be in a long-term romantic relationship, and a curiosity in understanding interfering factors. We explored the way in which her father’s unpredictability had contributed to the development of a counter- dependent stance on her part. In addition, we explored the way in which she had iden- tified with her father (and his apparent emotional aloofness) and repudiated the more vulnerable dependent aspects of herself that she associated with her mother (whom she saw as pathetic). We also explored the way in which her binging was connected to a desire to fill an experience of emptiness inside of her as well as the relationship between her dissociation of dependent feelings related both to her feelings of disgust when she experienced romantic partners as needy and her own difficulty in allowing others to relate to her in a nurturing fashion.

At different points in the treatment, Simone revealed additional elements of semi- delusional ideation (e.g., a continuing belief that she would still give birth to the mes- siah, a belief that certain people she met had special powers, a belief that she could read other people’s minds). At such times Simone disclosed information tentatively and with a somewhat self-deprecatingly humorous style as if to say, “I don’t take this completely seriously.” She vacillated in terms of how trusting of me she felt and how willing she was to reveal beliefs of this type. Her fear that I would not understand or could not fully embrace her beliefs was an ongoing focus of discussion.

Throughout the treatment, Simone was preoccupied with various new age beliefs and ideas. She would spend hours browsing at new age books on bookstore shelves in what seemed a desperate attempt to fill what she described as a “hole” or an “emptiness” inside of her. Inevitably, Simone would leave the store feeling unsatiated—bored with the activity but not fulfilled. In time, we came to understand this activity of hers as simi- lar in function to her binging behavior—that is, a desperate attempt to fill an internal experience of emptiness.

A few months after beginning treatment with me, Simone became involved with a cult, and this involvement continued and intensified over the first two years of her treatment. An important focus of exploration involved her concern that her spiritual interests were incompatible with psychotherapy. In addition, the effects of Simone’s dissociated depen- dency needs emerged more fully in the cult. Although she initially felt quite skeptical of the cult and its leader, over time she became more involved in the cult. The allure of being able to completely surrender to the cult and its leader became more and more apparent to her. The prospect of having somebody completely take charge of her life and tell her what to do and not to do in any given situation was undeniably appealing to her.

As discussed previously, there was a continuous alternation in treatment between periods when Simone seemed quite open and able to engage in an exploratory process and periods when she was highly defended and rejected any attempt on my part to ex- plore underlying feelings or look for deeper meaning. Although these alternating states never completely disappeared, over the course of treatment they became less frequent and intense, and Simone became better able to explore both her internal experience and the meaning of our relationship to her.

At the beginning of treatment, I had the sense that Simone had one foot in treat- ment and one foot out the door. She would often miss sessions (claiming that she had forgotten) or arrive 15 to 20 minutes late for sessions. For the most part, she would resist any attempt to explore feelings or factors underlying her inconsistent and late at- tendance, although occasionally she would be more receptive to exploration. I found myself feeling anxious that she would leave treatment precipitously, and I was concerned that any attempt on my part to explore her ambivalence would hasten her departure. I found myself feeling concerned that she would experience my attempts to explore her ambivalence as reflecting my own neediness, and I was more hesitant than I usually am to explore a client’s ambivalence about treatment.

Over time, part of our work together involved exploring the way in which her skittishness about commitment to treatment evoked anxious feelings in me that in turn made it difficult to bring myself fully into the relationship and express my own feelings of caring toward her. I began to conceptualize what was taking place as an enactment in which Simone’s own anxieties about dependency led to a lack of invest- ment in our relationship, which in turn fueled feelings of anxiety and shame about my insecurity. My own conflicts about dependency and a concern about seeing myself as needy were being triggered by Simone’s avoidant style, and they interfered with my ability to constructively explore Simone’s contribution to what was taking place between us.

Another more subtle element of my countertransference feeling emerged more clearly over time. When I first met Simone, I experienced her as especially attractive and was impressed by her lively, playful manner and sense of humor. I had found myself looking forward to working with her, and I won’t deny that my attraction to her played some role in this. Over time, however, it occurred to me that Simone’s physical attrac- tiveness developed a type of abstract, disembodied quality for me. Although Simone continued to have a playful manner, I did not experience it as flirtatious at all, and I was somewhat surprised by what I experienced as a complete absence of any sexual at- traction on my part toward her, despite the fact that I continued to find her beautiful in an abstract sense. I wondered to myself whether this aspect of my countertransference might be related to a tendency on her part to desexualize me in her mind in order to make our relationship safe for her. This is not a theme that evolved more fully or that we had time to explore during our work together.

Over time, I became aware of a quality of narcissistic grandiosity in Simone—a belief on her part that she had all the answers and that nobody else, including me, had anything of value to say to her. This attitude is not one that emerged explicitly at first but gradually over time as I became aware of my own countertranference feelings of not being able to say things that she really took in, and I was able to use my feelings as a point of departure for exploring what was going on in our relationship. Gradually, Simone was able to acknowledge that she didn’t believe that I might have anything useful to say to her. Ultimately, she was able to articulate an underlying fear that if she did become more receptive, she would become dependent on me and vulnerable to abandonment. Over time, Simone and I were able to collaboratively make sense of her counterdependency and narcissistic defenses in term of her experiences of abandon- ment as a child, and she became more open to input from me. A central dilemma that emerged for her was the conflict between (1) fearing dependency on others and feeling that nobody (including myself) had anything of value to offer her and (2) desperately wishing that others would be able to introduce their subjectivity in a way that would help her feel less alone.

We explored these themes in a variety of different ways throughout the treatment. To provide one example, I will describe the way in which a dream that Simone reported in the fifth month of our work together led to an exploration of her ambivalent feelings regarding dependency in our relationship and provided hints of her complex feelings about sexuality, men and dependency, and our relationship. She reported this dream shortly after her father had invited her to temporarily move into an apartment he owned and in which he would stay periodically when he came to the city on business trips. Simone:

Jeremy: Simone:

Jeremy:

I’m with some people on a beach and they’re playing with a puppy. And they’ve got the puppy partially submerged under the water . . . maybe to soothe it. But it’s not happy. And so I decide to take over. . . . I see a male dog who I think is it’s father . . . but it’s interesting because this male dog has udders. So I take the puppy and put it on its father’s udders and then the puppy seems happy. What do you make of the dream?

Well, maybe the dog is actually my father, and maybe it has to do with me moving into his place. That make sense . . . and I’m also thinking . . . and this is really just playing around with the images . . . so don’t take what I’m saying too seriously, maybe the male dog is me.

I say this in a very tentative way so it will be easy for her to dismiss without feeling too dismissive and also in an attempt to gauge how capable she is of acknowledging feelings of intimacy and dependency in our relationship at this point.

Simone: Jeremy: Simone:

I hadn’t thought of that. How does it feel? I don’t know . . . I’d have to think about it.

She then goes on to tell me another dream fragment.

Simone:

Jeremy: Simone: Jeremy:

And then in the dream, I see my old adviser from college, Emma . . . she’s a woman, but then I look at her shadow and it’s the shadow of a man. What do you make of it? I don’t know.

I know from what you’ve told me previously that the last time you visited Emma you felt uncomfortable with her because she felt needy to you.

Earlier Simone had told me that Emma symbolizes neediness to her.

Simone: Well it’s like the way she was always trying to look after me and offer me guid- ance, it felt like there as a kind underlying desperation . . . or neediness . . . like maybe she needs to relate to me as a daughter or something.

I wonder to myself if this might be another reference to our relationship. Perhaps Sim- one experiences my attempts to help her as representing a form of neediness on my part. But I decide not to explore this potential allusion to our relationship because of a concern that she will find it too threatening. Simone continued to talk about the dream at the following session.

Simone: I was thinking about that dream I had about that male dog with the udders . . . and it makes me feel uncomfortable.

Jeremy: Are you willing to explore what feels uncomfortable about it? This is a form of defense analysis.

Simone:

Jeremy: Simone:

Well there’s something yucky about it. I don’t really like to think of myself as getting nurtured by you. There’s something scary about it. Scary in what way? Well it would mean that I’m dependent on you and that brings up a whole bunch of feelings.

We continue to explore the range of feelings it brings up: fear, yearning, revulsion, fear of abandonment, and so on.

Simone: You’re not really a father figure for me . . . it’s like you’re not really male. It’s like you just exist in my head

Jeremy: Simone: Jeremy: Simone: Jeremy: Simone:

Can you say more about me not being male? Well you don’t give me advice or tell me what to do. Would you want me to give you advice? No. Why not? Because then I would become dependent on you. You’re not like my father that way. Things are complicated with him.

At this point, Simone transitions into talking about her complicated feelings about what she refers to as “the sexual energy” between her and her father. She speaks about how her father always makes it clear to people that she is his daughter when he takes her out for dinner—as if to make sure that they don’t assume they have a romantic re- lationship. She speaks about the fact that on occasion she has slept at her fathers’ place when he is out of town and that she feels uncomfortable sleeping in his bed because she knows that he “entertains people there.”

I speculate to myself that it is important for Simone to desexualize me in her mind because the potential of my playing a paternal role with her is threatening because of the sexual connotations for her. But again, I don’t say anything at this point because I feel it would be premature.

The following session Simone spontaneously brought up the possibility that maybe the male dog with udders in her dream does represent me. We continued to explore what this possibility meant to her during this session, and the intertwined threads of conflict around dependency, sexuality, and romantic relationships with both men and women continued to unfold and become further illuminated through- out the treatment.

Approximately halfway through treatment, Simone became romantically involved with Jim, a 30-year old African American musician. Jim was the first male Simone had been romantically involved with since her adolescence. Over a period of time, Simone was able to genuinely contact her desire for Jim and her hope that things would work out between them. I never expressed a preference for Simone to become romantically involved with men rather than women, nor was I aware of experiencing such a prefer- ence. Although Simone was not able to explain her new interest in a romantic relation- ship with a man, I speculated to myself that the process of beginning to become more trusting of me, a male therapist, helped her to begin to experience men in general as safer and less likely to abandon her in the same way that her father had. This possibility was not, however, something I felt Simone was ready and able to explore explicitly in treatment, so I did not introduce it.

Ultimately, Jim rejected Simone. My impression was that she experienced this as ex- cruciatingly painful, and she subsequently shut down and began once again to deny her need for him or for anyone else, including me. During this period, she flirted with the idea of leaving treatment and leaving the city to join an ashram associated with the cult she had joined. After a futile and extended attempt on my part to explore what was going on for her, I settled into providing more of a supportive, containing environment for her in which I would by and large attempt to mirror or empathize with the manifest level of her experi- ence. After approximately two months of this, Simone began to become more emotionally open again, more receptive to exploration, and stopped talking about leaving treatment.

Subsequent to this, Simone began dating a number of men and ultimately settled into a relationship with a man named Scott. It was in the context of this relationship that she had sexual intercourse with a man for the first time since her adolescence. She subsequently moved in with Scott in a rather precipitous fashion and lived with him for approximately three months. During this period, she struggled with intensely am- bivalent feelings about the increased intimacy and fears of dependency and engulfment. We spent considerable time in therapy exploring the difficulty she had in negotiating between his needs and her own, and we also explored the parallel between the issue emerging in the relationship with Scott and the transference.

Over time, Simone found living with Scott increasingly intolerable, alternating between feeling that he was too needy and very occasionally acknowledging fears of abandonment and rejection. Eventually, she left him and then moved in with another man who was a member of the cult. At the same time she began to discuss the possi- bility of leaving treatment again, maintaining that she was feeling better and that she had accomplished the goals she had at the beginning of treatment. Over a period of time, I gently and tentatively explored with her the possibility that her wish to leave treatment was motivated (at least in part) by a desire to avoid the type of intensely ambivalent feelings evoked by the intimacy of our relationship. Gradually, she came to acknowledge that this was true and then began to settle in a phase of treatment during which she remained considerably more trusting and open for an extended period of time.

Although even during this phase Simone continued to vacillate between periods of self-reflection and periods of shutting down and emotional withdrawal from me, the in- tensity of these swings decreased considerably. During this phase, Simone substantially decreased her binging behavior and became less preoccupied with eating. She began to work on her art for the first time since ending college and was able to experience this as a source of satisfaction. Simone and I continued to explore her feelings of ambivalence about intimacy and her fear of dependency in both our relationship and relationships in general. She also began to talk more openly about feelings of being “different” because most of her friends were not black, and we began to explore ambivalent feelings about being in therapy with a white therapist. We explored the way in which Simone did not feel completely at home in either the white or black worlds and the way this contributed to her general feeling of alienation and isolation.

In the final six months of our work together, Simone became romantically involved with a new man named Jamal, and this relationship developed a more stable quality than her previous relationships had. Although she was not without feelings of ambivalence, she was better able to tolerate her feelings of dependency on Jamal and was less self- critical of her need for him. She began working on a more consistent basis in the health- food store and developed a plan to save up enough money to return to college with the help of her father’s financial assistance and take courses.

Two months before ending treatment, Simone began to raise the possibility of ter- mination. This time, however, things had a different feeling about them than they had previously. It was clear to both of us that she had made some important changes in her life. Although it was far from clear what the future would hold in terms of her current romantic relationship or her plans to return to college, there was a mutual sense that she had started on a different path than the one she had been on at the beginning of treat- ment. We set a termination date in advance, and over the remaining time together we explored both ways in which she had changed over the course of our work together as well as her feelings about termination.

At first, Simone denied any ambivalent feelings about leaving treatment and ex- pressed an eagerness to “do things on her own” now that she no longer needed my help. I wondered to myself whether it might be a bit premature for her to leave treatment and had some concern that she would not be able to maintain the gains she had made. I also wondered whether her plans to terminate were once again related to her fears of intimacy and abandonment and distaste for dependency. At the same time, however, I considered the possibility that my reactions reflected my own reluctance to let go of her and perhaps a certain narcissism on my part and an overestimation of the significance of my own role in her life. I disclosed some of these feeling to her, and this facilitated an ability on her part to begin to explore some of her ambivalent feelings about leaving treatment. She was ulti- mately able to acknowledge anxiety about becoming too dependent on me, fears about how her life would go after she left treatment, and, also toward the end, feelings of sad- ness about ending our relationship. When we ended treatment, I made it clear that she was welcome to contact me any time just to let me know how things were going or to schedule another session if she wished.

I received a letter from her about two years later. In it she told me that things were basically going well in her life. Apparently, she had left Jamal approximately four months after she had terminated treatment with me. Three months later, she had become ro- mantically involved with another man, and they were still in a stable relationship. She was working for a small group as a graphic designer and was finding the work challeng- ing but satisfying. Simone wrote that periodically she would still lapse into periods of binging, especially during difficult periods in her life (e.g., breaking up with Jamal). She wrote that in general, however, her binging was much more in control than it had been when she began treatment. Overall, Simone felt that her treatment with me was helpful, and I concurred. I had a sense that our work together reached a level of depth that al- lowed her to make significant changes in her life and significant internal changes as well. I also had the sense that there were many themes left unexplored and that Simone could potentially have benefited from more treatment. It seems possible that she may go into treatment again at some future point in her life, and she might even contact me at some point to explore the possibility of further treatment. At the same time, however, I be- lieve that no story ever completely unfolds in any treatment. At any given point in time, a specific client and therapist are only able to go as deep and accomplish what they are both ready and able to accomplish at that time.4/28/2016 Copyright | CENGAGE Learning | Case Studies in Psychotherapy | Edition: 7 | stacynmarc214@yahoo.com | Printed from www.chegg.com

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Creating Print Version6

88

Cognitive therapy

an interview

with a depressed

and suicidal patient

Aaron T. Beck

Perhaps the most critical challenge to the adequacy of cognitive therapy is its efficacy in dealing with the acutely suicidal patient. In such cases the therapist often has to shift gears and assume a very active role in attempting to penetrate the barrier of hopeless- ness and resignation. Since intervention may be decisive in saving the patient’s life, the therapist has to attempt to accomplish a number of immediate goals either concurrently or in rapid sequence: establish a working relationship with the patient, assess the sever- ity of the depression and suicidal wish, obtain an overview of the patient’s life situation, pinpoint the patient’s “reasons” for wanting to commit suicide, determine the patient’s capacity for self-objectivity, and ferret out some entry point for stepping into the pa- tient’s phenomenological world to introduce elements of reality.

Such a venture, as illustrated in the following interview, is taxing and demands all the qualities of a “good therapist”—genuine warmth, acceptance, and empathetic understanding—as well as the application of the appropriate strategies drawn from the system of cognitive therapy.

The patient was a 40-year-old clinical psychologist who had recently been left by her boyfriend. She had a history of intermittent depressions since the age of 12 years, and had received many courses of psychotherapy, antidepressant drugs, electroconvul- sive therapy, and hospitalizations. The patient had been seen by the author five times over a period of 7 or 8 months. At the time of this interview, it was obvious that she was depressed and, as indicated by her previous episodes, probably suicidal.

In the first part of the interview, the main thrust was to ask appropriate questions in order to make a clinical assessment and also to try to elucidate the major psychological problems. The therapist, first of all, had to make an assessment as to how depressed and how suicidal the patient was. He also had to assess her expectations regarding be- ing helped by the interview (T-1; T-8) in order to determine how much leverage he had. During this period of time, in order to keep the dialogue going, he also had to repeat the patient’s statements.

It was apparent from the emergence of suicidal wishes that this was the salient clini- cal problem and that her hopelessness (T-7) would be the most appropriate point for intervention.

Several points could be made regarding the first part of the interview. The therapist accepted the seriousness of the patient’s desire to die but treated it as a topic for further examination, a problem to be discussed. “We can discuss the advantages and disadvan- tages” (T-11). She responded to this statement with some amusement (a favorable sign). The therapist also tried to test the patient’s ability to look at herself and her problems

with objectivity. He also attempted to test the rigidity of her irrational ideas and her acceptance of his wish to help her (T-13–T-20).

In the first part of the interview the therapist was not able to make much headway because of the patient’s strongly held belief that things could not possibly work out well for her. She had decided that suicide was the only solution, and she resented attempts to “get her to change her mind.”

In the next part of the interview, the therapist attempted to isolate the participat- ing factor in her present depression and suicidal ideation, namely, the breakup with her boyfriend. It becomes clear as the therapist tries to explore the significance of the breakup that the meaning to the patient is, “I have nothing” (P-23). The therapist then selects, “I have nothing” as a target and attempts to elicit from the patient information contradictory to this conclusion. He probes for a previous period of time when she did not believe “I have nothing” and also was not having a relationship with a man. He then proceeds (T-26) to probe for other goals and objects that are important to her; he seeks concrete sources of satisfaction (T-24–T-33). The therapist’s attempt to establish that the patient does, indeed, “have something” is parried by the patient’s tendency to discount any positive features in her life (P-32).

Finally, the patient does join forces with the therapist, and it is apparent in the lat- ter part of the interview that she is willing to separate herself from her problems and consider ways of solving them. The therapist then moves to a consideration of the basic assumption underlying her hopelessness, namely, “I cannot be happy without a man.” By pointing out disconfirming past experiences, he tries to demonstrate the error of this assumption. He also attempts to explain the value of shifting to the assumption, “I can make myself happy.” He points out that it is more realistic for her to regard herself as the active agent in seeking out sources of satisfaction than as an inert receptacle depen- dent for nourishment on the whims of others.

The taped interview, which was edited down from 60 minutes to 35 minutes for practical reasons, is presented verbatim. (The only changes made were to protect the identity of the patient.) The interview is divided into five parts.

Reinforce independence (T-106), self-help, optimism.

Therapist (T-1): Well, how have you been feeling since I talked to you last? . . . Patient (P-1): Bad. T-2: You’ve been feeling bad . . . well, tell me about it? P-2: It started this weekend . . . I just feel like everything is an effort. There’s just

completely no point to do anything. T-3: So, there are two problems; everything is an effort, and you believe there’s no

point to doing anything. P-3: It’s because there’s no point to doing anything that makes everything too hard

to do. T-4: (Repeating her words to maintain interchange. Also to acknowledge her feelings.)

Because there’s no point and everything feels like an effort . . . And when you

were coming down here today, were you feeling the same way? P-4: Well, it doesn’t seem as bad when I am working. It’s bad on weekends and espe-

cially on holidays. I sort of expected that it would happen. T-5: (Eliciting expectancy regarding session) You expected to have a hard time on holi- days . . . And when you left your office to come over here, how were you feeling

then?

P-5:

T-6: P-6: T-7: P-7:

T-8: P-8:

T-9: P-9: T-10: P-10:

T-11:

P-11: T-12:

P-12: T-13: P-13:

T-14: P-14:

T-15: P-15: T-16: P-16: T-17:

P-17: T-18:

P-18: T-19: P-19:

Kind of the same way. I feel that I can do everything that I have to do, but I don’t want to. You don’t want to do the things you have to. I don’t want to do anything.

Right . . . and what kind of feeling did you have? Feel low? (Hopelessness to be target) I feel that there’s no hope for me. I feel my future . . . that everything is futile, that there’s no hope. And what idea did you have about today’s interview? I thought that it would probably help as it has always happened in the past . . . that I would feel better—temporarily. But that makes it worse because then I know that I am going to feel bad again. That makes it worse in terms of how you feel? Yes. And the reason is that it builds you up and then you get let down again? (Immediate problem—suicide risk) I feel like it’s interminable, it will just go this way forever, and I am not getting any better . . . I don’t feel any less inclined to kill myself than I ever did in my life . . . In fact, if anything, I feel like I’m coming closer to it. Perhaps we should talk about that a little bit because we haven’t talked about the advantages and disadvantages of killing yourself. (Smiles) You make everything so logical. (Testing therapeutic alliance) Is that bad? Remember you once wrote something . . . that reason is your greatest ally. Have you become allergic to reason? But I can’t try anymore. Does it take an effort to be reasonable? (Typical “automatic thoughts”) I know I am being unreasonable; the thoughts seem so real to me . . . it does take an effort to try to change them. Now, if it came easy to you—to change the thoughts, do you think that they would last as long? No . . . see, I don’t say that this wouldn’t work with other people. I don’t try to say that, but I don’t feel that it can work with me. So, do you have any evidence that it did work with you? It works for specific periods of time, and that’s like the Real Me comes through. Now, is there anything unusual that happened that might have upset the apple cart? You mean this weekend? Not necessarily this weekend. As you know, you felt you were making good progress in therapy and you decided that you were going to be like the Cowardly Lion Who Found His Heart. What happened after that? (Agitated, bows head) It’s too hard . . . it would be easier to die. (Attempts to restore objectivity. Injects perspective by recalling previous mastery experience.) At the moment, it would be easier to die—as you say. But, let’s go back to the history. You’re losing sight and losing perspective. Remember when we talked and made a tape of that interview and you liked it. You wrote a let- ter the next day and you said that you felt you had your Heart and it wasn’t any great effort to reach that particular point. Now, you went along reasonably well until you got involved. Correct? Then you got involved with Jim. Is that correct? And then very predictably when your relationship ended, you felt terribly let down. Now, what do you conclude from that? (Anguish, rejects therapist’s venture) My conclusion is that I am always going to have to be alone because I can’t stay in a relationship with a man. All right, that’s one possible explanation. What other possible explanations are there? That’s the only explanation.

T-20: P-20A: P-20B:

T-21: P-21:

T-22:

P-22: T-23:

P-23: T-24: P-24: T-25:

P-25: T-26: P-26: T-27:

P-27: T-28: P-28: T-29: P-29: T-30:

P-30: T-31:

P-31: T-32:

P-32:

T-33: P-33: T-34:

Is it possible you just weren’t ready to get deeply involved and then let down? But, I feel like I’ll never be ready. (Weeps) I have never given up on him, even when I couldn’t see him for a year at a time. He was always in my mind, all the time. So how can I think now that I can just dismiss him. This was never final until now. There was always the hope that . . . There wasn’t, and he told me very clearly that he could not get involved with me. Right, but before January, it was very quiescent. You weren’t terribly involved with him. It started up in January again. He did show serious interest in you. For the first time in four years. (Attempts to restore perspective) All right, so that’s when you got involved again. Prior to January, you weren’t involved, weren’t thinking of him every minute and you weren’t in the situation you are in now, and you were happy at times. You wrote that letter to me that you were happy, right? Okay. So that was back in January, you were happy and you did not have Jim. Now comes May, and you’re unhappy because you have just broken up with him. Now, why do you still have to be unhappy, say, in July, August, or September? (Presents specific target belief) I have nothing. You weren’t unhappy in January, were you? At first I was, that’s why I called. All right, how about December? December you weren’t unhappy. What did you have in December? You had something that made you happy. I was seeing other men. That made me happy. There are other things in your life besides men that you said you liked very much. Yes and I . . . (Aims at target beliefs. Shows she had and has something.) Well, there were other things you say were important that are not important right now. Is that correct? What were the things that were important to you back in December, November, and October? Everything was important. Everything was important. And what were those things? It’s hard to even think of anything that I cared about. Okay, now how about your job? My job. Your job was important. Did you feel that you were accomplishing something on the job? Most of the time I did. (Still aiming) Most of the time, you felt you were accomplishing something on the job. And what about now? Do you feel you are accomplishing on the job now? (Discounts positive) Not as much as I could. (Reintroduces positive) You’re not accomplishing as much as you could but even when you are “off,” I understand that you do as well [as] or better than many of the other workers. Is that not correct? (Disqualifies positive statement) I can’t understand why you say that. How do you know that? Because I told you that. How do you know that’s true? I’m willing to take your word for it. From somebody who is irrational. (Presents positive evidence of satisfactions and achievements.) Well, I think that somebody who is as irrationally down on herself as you, is very unlikely to say something positive about herself unless the positive thing is so strong that it is unmistakable to anybody . . . In any event, you do get some satisfaction out of

the job right now and you do feel you are doing a reasonably good job, although you are not doing as well as you would like to, but as well as you are capable. You’re still doing a reasonably good job. You can see for yourself. Your clients’ plans are improving? Are they being helped? Does anyone say they are apprecia- tive of your efforts?

Yes. They do tell you? Yet you are saying you are so irrational that I can’t believe any- thing you say. Do you say, “You’re just a dumb client . . . no judgment at all,” to your clients? I wouldn’t say that about somebody. Well, do you think it about yourself? Yes. (Points out inconsistency. Underscores her capacity for rationality. Fortifies her professional role.) So, you trust the word of your clients, but you won’t trust your own word. You won’t think of your clients as being irrational, and yet, you think of you—when you are the client—as being irrational. How can you be rational when you are the therapist and irrational when you are the patient? I set different standards for myself than what I set for anybody else in the world. Suppose I’ll never get over it? (Changes the options—consider nonsuicidal solutions. Sweat it out or fight to solve problem.) Suppose you’ll never get over it? Well, we don’t know whether you’ll never get over it or not . . . so there’re two things you can do. One is, you can take it passively and see, and you might find that you will get over it, since almost everybody gets over grief reactions. Or, you can attack the problem aggressively and actively build up a solid basis for yourself. In other words, you can capitalize on the chance . . . (Thinks of finding another man.) I feel desperate. I feel that I have to find some- body right now—right away. All right, now if you found somebody right away, what would happen? The same thing would happen again. (Omits suicide as one of the options.) Now, remember when we talked about Jim and you said back in January you decided that you would take that chance and you’d chance being involved, with the possibility that something would come of it positively. Now, you have two choices at this time. You can either stick it out now and try to weather the storm with the idea that you are going to keep fighting it, or you can get involved with somebody else and not have the oppor- tunity for this elegant solution. Now, which way do you want to go? (Compulsion to get involved with somebody.) I don’t want to, but I feel driven. I don’t know why I keep fighting that, but I do. I’m not involved with anybody now and I don’t want to be, but I feel a compulsion. That’s right, because you’re hurting very badly. Isn’t that correct? If you weren’t hurting you wouldn’t feel the compulsion. But I haven’t done anything yet. (Emphasizes ideal option. Also turning disadvantage into advantage.) Well, you know it’s your decision. If you do seek somebody else, nobody is going to fault you on it. But I’m trying to show that there’s an opportunity here. There’s an unusual opportunity that you may never have again—that is to go it alone . . . to work your way out of the depression. That’s what I’ll be doing the rest of my life . . . that’s what worries me. You really just put yourself in a “no-win” situation. You just acknowledged that if you get involved with another man, probably you would feel better. Temporarily, but then, I’d go through the same thing.

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I understand that. So now, you have an opportunity to not have to be dependent on another guy, but you have to pay a price. There’s pain now for gain later. Now are you willing to pay the price? I’m afraid that if I don’t involve myself with somebody right away . . . I know that’s dichotomous thinking . . . I think if I don’t get immediately involved, that I will never have anybody.

That’s all-or-nothing thinking. I know. (Seeking a consensus on nonsuicidal option.) That’s all-or-nothing thinking. Now, if you are going to do it on the basis of all-or-nothing thinking, that’s not very sensible. If you are going to do it on the basis of, “The pain is so great that I just don’t want to stick it out anymore,” all right. Then you take your aspirin tem- porarily and you’ll just have to work it out at a later date. The thing is—do you want to stick it out right now? Now, what’s the point of sticking it out now? I don’t know. You don’t really believe this. (Reaching a consensus.) Theoretically, I know I could prove to myself that I could, in fact, be happy without a man, so that if I were to have a relationship with a man in the future, I would go into it not feeling desperate, and I would probably eliminate a lot of anxiety and depression that have in the past been connected to this relationship. So, at least you agree, theoretically, on a logical basis this could happen. If you try to stick it out . . . Now, what do you think is the probability that this could happen? For me? For you. For another person I’d say the probability is excellent. For one of your clients? Yeah. For the average depressed person that comes to the Mood Clinic . . . most of whom have been depressed 7 years or more. You would still give them a high probability. Listen, I’ve been depressed all of my life. I thought of killing myself when I was 14 years old. (Undermining absolutistic thinking by suggesting probabilities.) Well, many of the other people that have come here too have felt this way. Some of the people that have come here are quite young and so have not had time to be depressed very long . . . Okay, back to this. Hypothetically, this could happen. This could happen with almost anybody else, this could happen with anybody else. But you don’t think it can happen to you. Right . . . It can’t happen to you. But what is the possibility . . . (you know, when we talked about the possibility with Jim, we thought it was probably five in a hundred that a good thing could come from it) . . . that you could weather the storm and come out a stronger person and be less dependent on men than you had been before? I’d say that the possibility was minimal. All right, now is it minimal like one in a hundred, one in a million . . . ? Well, maybe a 10% chance. 10% chance. So, you have one chance in ten of emerging from this stronger. (More perspective; disqualifies evidence.) Do you know why I say that . . . I say that on the basis of having gone through that whole summer without a man and being happy . . . and then getting to the point where I am now. That’s not progress. (Using database.) I’d say that is evidence. That summer is very powerful evidence.

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(Discredits data.) Well, look where I am right now. The thing is, you did very well that summer and proved as far as any scientist is con- cerned that you could function on your own. But you didn’t prove it to your own self. You wiped out that experience as soon as you got involved with a man. That experience of independence became a nullity in your mind after that summer. (Mood shift. A good sign.) Is that what happened? Of course. When I talked to you the first time I saw you, you said “I cannot be happy without a man.” We went over that for about 35 or 40 minutes until I finally said, “Has there ever been a time when you didn’t have a man?” And you said, “My God, that time when I went to graduate school.” You know, suddenly a beam of light comes in. You almost sold me on the idea that you couldn’t function without a man. But that’s evidence. I mean, if I told you I couldn’t walk across the room, and you were able to demonstrate to me that I could walk across the room, would you buy my notion that I could not walk across the room? You know, there is an objective reality here. I’m not giving you information that isn’t valid. There are people . . . I would say, how could you negate that if it didn’t happen? What? (Asks for explanation. A good sign.) I’d say what’s wrong with my mind, having once happened, how can I negate it? (Alliance with patient’s rationality.) Because it’s human nature, unfortunately, to negate experiences that are not consistent with the prevailing attitude. And that is what attitude therapy is all about. You have a very strong attitude, and any- thing that is inconsistent with that attitude stirs up cognitive dissonance. I’m sure you have heard of that, and people don’t like to have cognitive dissonance. So, they throw out anything that’s not consistent with their prevailing belief. (Consensus gels.) I understand that. (Optimistic sally.) You have a prevailing belief. It just happens, fortunately, that that prevailing belief is wrong. Isn’t that marvelous? To have a prevailing belief that makes you unhappy, and it happens to be wrong! But it’s going to take a lot of effort and demonstration to indicate to you, to convince you that it is wrong. And why is that? I don’t know. (Since patient is now collaborating, he shifts to didactic strategy. Purpose is to strengthen patient’s rationality.) Do you want to know now why? Because you’ve always had it. Why? First of all, this belief came on at a very early age. We’re not going into your childhood, but obviously, you made a suicide attempt or thought about it when you were young. It’s a belief that was in there at a very young age. It was very deeply implanted at a very young age, because you were so vulner- able then. And it’s been repeated how many times since then in your own head? A million times. A million times. So do you expect that five hours of talking with me is going to reverse in itself something that has been going a million times in the past? Like I said, and you agreed, my reason was my ally. Doesn’t my intelligence enter into it? Why can’t I make my intelligence help? Yeah, that’s the reason intelligence comes into it, but that’s exactly what I’m try- ing to get you to do. To use your intelligence. There’s nothing wrong with my intelligence. I know that. I understand that. Intelligence is fine, but intelligence has to have tools, just as you may have the physical strength to lift up a chair, but if you don’t believe at the time that you have the strength to do it, you’re not going to try. You’re going to say, “It’s pointless.” On the other hand, to give you a stronger example, you

have the physical strength to lift a heavy boulder, but in order to really lift it, you might have to use a crowbar. So, it’s a matter of having the correct tool. It isn’t simply a matter of having naked, raw intelligence, it’s a matter of using the right tools. A person who has intelligence cannot solve a problem in calculus, can he? If she knows how to. (Smiles.)

(Reinforces confidence in maturity.) All right. Okay. You need to have the formu- las, that’s what you’re coming in here for. If you weren’t intelligent, you wouldn’t be able to understand the formulas, and you know very well you understand the formulas. Not only that, but you use them on your own clients with much more confidence than you use them on yourself.

(Self-praise, confirms therapist’s statement.) You wouldn’t believe me if you heard me tell things to people. You’d think I was a different person. Because I can be so optimistic about other people. I was encouraging a therapist yesterday who was about to give up on a client. I said, “You can’t do that.” I said, “You haven’t tried everything yet,” and I wouldn’t let her give up.

All right, so you didn’t even have a chance to use the tools this weekend because you had the structure set in your mind, and then due to some accidental factor you were unable to do it. But you concluded on the weekend that the tools don’t work since “I am so incapable that I can’t use the tools.” It wasn’t even a test was it? Now for the next weekend . . .

(Agrees.) . . . It wasn’t a true test . . . No, it wasn’t even a fair test of what you could do or what the tools could do. Now for weekends, what you want to do is prepare yourself for the Fourth of July. You prepare for the weekends by having the structure written down, and you have to have some backup plans in case it gets loused up. You know you re- ally do have a number of things in your network that can bring you satisfaction. What are some of the things you have gotten satisfaction from last week? I took Margaret to the movies. What did you see? It was a comedy. What? A comedy. That’s a good idea. What did you see? (Smiles) It was called Mother, Jugs and Speed. Yeah, I saw that. Did you see that? Yeah, I saw that on Friday. (Smiles) I liked it. It was pretty good. A lot of action in that. So you enjoyed that. Do you think you could still enjoy a good movie? I can. If I get distracted, I’m all right. So what’s wrong with that? Because then what happens . . . while I’m distracted the pain is building up and then the impact is greater when it hits me. Like last night I had two friends over for dinner. That was fine. While they’re there . . . I’m deliberately planning all these activities to keep myself busy . . . and while they were there I was fine. But when they left . . . That’s beautiful. The result was that the impact was greater because all this pain had accumulated . . . We don’t know because you didn’t run a control, but there is no doubt there is a letdown after you’ve had [a] satisfactory experience . . . so that what you have to do

is set up a mechanism for handling the letdown. See what you did is you downed yourself, you knocked yourself and said, “Well . . . it’s worse now than if I hadn’t had them at all.” Rather than just taking it phenomenologically: “They were here and I felt good when they were here, then I felt let down afterward.” So then obviously the thing to pinpoint is what? The letdown afterward. So what time did they leave? About 9.

And what time do you ordinarily go to bed? About 10. So you just had one hour to plan on. To feel bad . . .

All right, one hour to feel bad. That’s one way to look at it. That’s not so bad, is it? It’s only one hour. But then I feel so bad during the hour. That’s when I think that I want to die. All right, what’s so bad about feeling bad? You know what we’ve done with some of the people? And it’s really worked. We’ve assigned them. We’ve said, “Now we want to give you one hour a day in which to feel bad.” Have I told you about that? “I want you to feel just as bad as you can,” and in fact sometimes we even rehearse it in the session. I don’t have time today but maybe another time. It’s time-limited.

(Alliance with patient as a fellow therapist.) Yeah, and we have the people—I’d say, “Why don’t you feel as bad as you can—just think of a situation, the most horribly devastating, emotionally depleting situation you can. Why don’t you feel as bad as you possibly can?” And they really can do it during a session. They go out and after that they can’t feel bad again even though they may even want to. It’s as though they’ve depleted themselves of the thing and they also get a certain degree of objectivity toward it.

(Helping out.) It has to be done in a controlled . . . It has to be done in a structured situation. It has to be controlled. That’s true. It has to—that’s why I say, “Do it in here, first.” Yes.

Then, I can pull them out of it . . .You need to have a safety valve. If you do it at home . . . you might . . . Right, the therapist has to structure it in a particular way. I’m just saying that one hour of badness a day is not necessarily antitherapeutic. And so it doesn’t mean you have to kill yourself because you have one bad hour. What you want to do is to think of this as “my one bad hour for today.” That’s one way of looking at it. And then you go to sleep at 10 o’clock and it’s over. You’ve had one bad hour out of 12. That’s not so terrible. Well, you told yourself during that time some- thing like this. “See, I’ve had a pretty good day and now I’ve had this bad hour and it means I’m sick, I’m full of holes, my ego is . . .” See I’m thinking, “It never ends.” For one hour, but yeah, but that’s not even true because you thought that you couldn’t have any good times in the past, and yet as recently as yesterday you had a good day. But what gives it momentum is that thought that it’s not going to end. Maybe the thought’s incorrect. How do you know the thought is incorrect? I don’t know. (Retrospective hypothesis-testing.) Well, let’s operationalize it. What does it mean, “It’s not going to end?” Does that mean that you’re never going to feel good again in your whole life? Or does that mean that you’re going to have an unre- mitting, unrelenting, inexorable sadness day in, day out, hour after hour, minute after minute. I understand that is your belief. That’s a hypothesis for the moment.

Well, let’s test the hypothesis retrospectively. Now you have that thought: “This is never going to end.” You had that thought when? Yesterday at 9 a.m. Yes. Now that means that if that hypothesis is correct, every minute since you awoke this morning, you should have had unending, unrelenting, unremitting, inevi- table, inexorable sadness and unhappiness.

(Refutes hypothesis.) That’s not true. It’s incorrect. Well, you see, when I wake up in the morning, even before I’m fully awake the first thing that comes to my mind inevitably is that I don’t want to get up. That I have nothing that I want to live for. And that’s no way to start the day. That’s the way a person who has a depression starts the day. That’s the perfectly appropriate way to start the day if you’re feeling depressed. Even before you’re awake? Of course. When people are asleep they even have bad dreams. You’ve read the article on dreams. Even their dreams are bad. So how do you expect them to wake up feeling good after they have had a whole night of bad dreams? And what happens in depression as the day goes on? They tend to get better. You know why? Because they get a better feel of reality—reality starts getting into their beliefs. Is that what it is? Of course. I always thought it was because the day was getting over and I could go to sleep again. Go to sleep to have more bad dreams? The reality encroaches and it disproves this negative belief. That’s why it’s diurnal. Of course, and we have already disproven the negative belief, haven’t we? You had that very strong belief last night—strong enough to make you want to commit suicide—that this would be unremitting, unrelenting, inevitable, and inexorable. (Cheerful) Can I tell you something very positive I did this morning? (Kidding) No, I hate to hear positive things. I’m allergic. Okay. I’ll tolerate it. (Laughs.) (Recalls rational self instruction.) I got that thought before I was even awake, and I said, “Will you stop it, just give yourself a chance and stop telling yourself things like that.” So what’s wrong with saying that? I know. I thought that was a very positive thing to do. (Laughs.) (Underscores statement.) That’s terrific. Well, say it again so I can remember. I said, “Stop it and give yourself a chance.” (More hopeful prediction. Self-sufficiency.) When you had your friends over, you found intrinsic meaning there. This was in the context of no man . . . Now when the pain of the breakup has washed off completely, do you think you’re going to be capable of finding all these goodies, yourself, under your own power, and at- taching the true meaning to them? I suppose if the pain is less . . . Well, the pain’s less right now. Does it matter? Yeah. But that doesn’t mean it won’t continue. Well, in the course of time, you know, it’s human nature that people get over painful episodes. You’ve been over painful episodes in the past.

Suppose I keep on missing him forever. What? Suppose I keep on missing him forever? There’s no reason to expect you to miss him forever. That isn’t the way people are constructed. People are constructed to forget after a while and then get in- volved in other things. You had them before.

You spoke of a man who missed a mother for 25 years. (Emphasizesself-sufficiency.)Well,Idon’tknow…thismayhavebeenonelittle hang-up he had, but, I don’t know that case . . . In general, that isn’t the way peo- ple function. They get over lost love. All right? And one of the ways we can speed the process is by you, yourself, attaching meaning to things that are in your envi- ronment that you are capable of responding to . . . You demonstrated that . . . Not by trying to replace a lost love right away? (Reinforcing independence.) Replace it? What you’re trying to do is find another instrument to happiness. He’s become your mechanism for reaching happiness. That’s what’s bad about the whole man hang-up. It is that you are interposing some other unreliable entity between you and happiness. And all you have to do is to move this entity out of the way, and there’s nothing to prevent you from get- ting happiness. But you want to keep pulling it back in. I say, leave it out there for a while, and then you’ll see. Just in the past week you found that when you didn’t have a man, you were able to find happiness without a man. And if you leave the man out of the picture for a long enough period of time, you’ll see that you don’t need him. Then if you want to bring him in as one of the many things that can bring satisfaction, that’s fine, you can do that. But if you see him as the only conduit between you and happiness, then you are right back to where you were before. Is it an erroneous thing to think that if I get to the point where I really believe that I don’t need him, that I won’t want him? Oh, you’re talking about him. I think it will just . . . Any man . . . any man? (Undermines regressive dependency.) . . . Well, you might still want him, like you might like to go to a movie, or read a good book, or have your friends over for dinner. You know, you still have to have relationships with your friends. But if they didn’t come over for dinner last night it wouldn’t plunge you into a deep despondency. I’m not underestimating the satisfaction that one gets from other people . . . but it’s not a necessity . . . It’s something that you, yourself, can relate to on a one-to-one basis . . . but one does, as one individual to another. You’re relating to a man the way a child does to a parent, or the way a drug addict does to his drugs. He sees the drug as the mechanism for achieving happiness. And you know you can’t achieve happiness artificially. And you have been using men in an artificial way. As though they are going to bring you happiness . . . rather than they are simply one of the things external to yourself by which you, your- self, can bring yourself happiness. You must bring you happiness. I can . . . I’ve been focusing on dependency. (Emphasizing available pleasures.) Well, you’ve done it. You’ve brought your- self happiness by going to the movies, by working with your clients, by having friends over for dinner, by getting up in the morning and doing things with your daughter. You have brought you happiness . . . but you can’t depend on some- body else to bring you happiness the way a little girl depends on a parent. It doesn’t work. I’m not opposed to it . . . I have no religious objection to it . . . It just doesn’t work. Pragmatically, it is a very unwise way to conduct one’s life. And in some utopian society after this, children will be trained not to depend on

others as the mechanism for happiness. In fact, you can even demonstrate that to your daughter . . . through your own behavior, she can find that out. She’s a very independent child. (Probing for adverse reaction to interview.) Well, she’s already found that out. Okay, now do you have any questions? Anything that we discussed today? Is there anything that I said today that rubbed you the wrong way?

You said it would be damaging . . . not damaging . . . but you think it would de- prive me of more opportunity to test this out if I were to go to another man. Well, it’s an unusual opportunity . . . It’s not so unusual, because I might get involved with somebody else. (Turningdisadvantageintoadvantage.)Well,yes,butthisisliketheworst—you said this is the worst—depression you felt for a long time. It’s a very unusual op- portunity to be able to demonstrate how you were able to pull yourself from the very deepest depths of depression onto a very solid independent position. You may not have that opportunity again, really, and it would be such a very sharp contrast. Now, you don’t have to do it, but I’m saying it’s really a very rich chance, and it does mean possibly a lot of gain. I don’t want to make any self-fulfilling hy- potheses, but you’ve got to expect the pain and not get discouraged by it. What are you going to say to yourself . . . if you feel the pain tonight? Suppose you feel pain after you leave the interview today, what are you going to say to yourself? “Present pain for future gain.”

Now where are you now on the hopelessness scale? Down to 15%. It’s down to 15% from 95%, but you have to remember that the pain is handled in a structured way, the way I told you about the people who make themselves feel sad during that one period. It has to be structured. If you can structure your pain, this pain is something that’s going to build you up in the future, and, in- deed, it will. But if you see yourself as just being victimized by these forces you have no control over, . . . you’re just helpless in terms of the internal things and external things . . . then you are going to feel terrible . . . And what you have to do is convert yourself from somebody who feels helpless, right? . . . And you are the only person who can do it . . . I can’t make you strong and independent . . . I can show you the way, but if you do it, you haven’t done it by taking anything from me; you’ve done it by drawing on resources within yourself. How does it follow then that I feel stronger when I have a man? If things are going . . . (Counteracts assumption about getting strength from another person. Empirical test.) You mean you make yourself feel strong because you yourself think, “Well, I’ve got this man that’s a pillar of strength, and since I have him to lean on, therefore, I feel strong.” But, actually, nobody else can give you strength. That’s a fallacy that you feel stronger having a man, but you can’t trust your feelings. What you’re doing is just probably drawing on your own strength. You have the definition in your mind. “I’m stronger if I have a man.” But the converse of that is very dangerous . . . which is, “I am weak if I don’t have a man . . .” What you have to do, if you want to get over this is to disprove the converse, “I am weak if I don’t have a man.” Now, are you willing to subject that to the acid test? Then you will know. Okay, well suppose you give me a call tomorrow and let me know how you’re going and then we can go over some of the other assignments.

It was apparent by the end of the interview that the acute suicidal crisis had passed. The patient felt substantially better, was more optimistic, and had decided to confront and solve her problems. She subsequently became involved in cognitive therapy on

more regular basis and worked with one of the junior staff in identifying and coping with her intrapersonal and interpersonal problems.

This interview is typical of our crisis intervention strategies but is a departure from the more systematic approach used during the less dramatic phases of the patient’s de- pression. We generally attempt to adhere to the principle of collaborative empiricism in our routine interviews and deviate from standard procedures for a limited period of time only. Once the crisis is over, the therapist returns to a less intrusive and less active role and structures the interview in such a way that the patient assumes a greater respon- sibility for clarifying and devising possible solutions to problems.

 
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