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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.

-44: P-44:

T-45: P-45: T-46:

P-46: T-47: P-47:

T-48:

P-48: T-49: P-49: T-50: P-50: T-51:

P-51: T-52:

P-52: T-53: P-53: T-54: P-54:

T-55:

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.

P-55: T-56:

P-56: T-57:

P-57: T-58: P-58:

T-59:

P-59: T-60:

P-60: T-61:

P-61: T-62:

P-62: T-63:

P-63: T-64:

(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.

Simone case