Chapter 7
Depression: To Hell and Back

The mind is its own place, and in itself can make a Heav'n of Hell, a Hell of Heav'n.
--JOHN MILTON (1608-1674)

If you saw someone repeatedly hitting himself with a hammer, you would probably assume that, for some mysterious reason, he wanted to hurt himself. If this person complained bitterly that he was covered with painful bruises and would do anything to escape from the torment, you might point out to him that he could accomplish this very easily: all he has to do is stop hitting himself.

Now suppose that this person takes your advice and stops hitting himself with the hammer. And two minutes later, he says: "Well, I still feel lousy. My bruises are still giving me Hell. That didn't seem to work, and I really have a strong urge to start hitting myself again, so that's what I'll do."

If you believed that this person was in earnest, you would explain to him that it takes time for the bruises to go away. But you might also explain that he doesn't really need to keep hitting himself. He doesn't gain anything by it, so he might as well stop, even though this apparently requires an effort.

In reality, we do not often observe such ridiculous behavior. If you hit yourself with a hammer, it hurts physically. The pain is so sharp and immediate that you can hardly fail to notice the connection between the hammer blows and the pain. You would therefore be unlikely to get into the habit of hitting yourself with a hammer without noticing that you were doing so.

It's not so obvious to people that when they're depressed it's directly caused by their "musty" thinking. If you tell yourself you're a worthless clod, there is no piercing, obvious warning that impels you to stop thinking like that. So you may get into the habit of telling yourself this sort of thing. You may even develop this habit without noticing it.

Then, one day, you may start to experience the equivalent of bruises and broken bones. You become aware that you are suffering from depression. And you may refuse to believe that you have brought the depression upon yourself by your "musty" thinking.

To Be Or Not To Be Depressed

Bruce had the appearance of a stage Hamlet, his black turtleneck shirt, black denims, and black shoes and socks contrasting starkly with his shock of wavy blond hair, ashen complexion, and pale mustache.

Although he had taken acting courses, Bruce had been a machine shop foreman for the past two years. He had never been married yet had a five-year-old son, Timmy, from a previous living-together relationship. Both he and Timmy were currently sharing an apartment with Bruce's father and step-mother who were recent immigrants from Latvia. They spoke little English and so they depended on Bruce, who was resourceful and bright, to make many of their decisions.

Bruce had been depressed as far back as he could remember. He would get particularly depressed at times "for no apparent reason" and have difficulty sleeping and concentrating. He sometimes felt isolated and would "put walls up and not let people get close." At other times, he got depressed about not having a relationship with his biological mother (he hadn't seen her for a year and a half), and at work he felt distant from his co-workers and was perfectionistic about his performance.

"But the thing that really gets me down the most," he explained in his resonant actor's voice, "is that I'm incapable of forming a lasting relationship with a woman. In my life, I have had sex with thirty-seven women, and started relationships with eleven of them. I would really like to settle down, but I'm almost thirty, and it will soon be too late."

Six years earlier he had lived with Monique for twelve months. Although they both had Timmy, Monique's severe emotional problems made the relationship very difficult for Bruce. His most recent relationship had ended after five weeks. In response to my queries about why it had terminated, he shrugged and said only: "I don 't know what happened." He seemed genuinely mystified.

We delved further into the details of his past relationships. It soon became apparent that Bruce had a tendency to deify women and quickly to fall hopelessly in love with them. Then he would typically pursue them even as their major psychological problems emerged. We discussed why he did not end these relationships sooner, what he could do about it, and how he could identify and pursue healthier relationships.

Here are some of the thoughts that Bruce had been thinking for years:

  • I MUST not hurt her, and if I do I'm a total louse

  • I SHOULD have had a fulfilling relationship by now, and at the age of twenty-nine it will soon be too late

  • I MUST have a relationship right now or else I'm a cipher

  • I SHOULD be like everyone else; since they're all passionately involved in rewarding relationships and I'm not, this lack shows what a rotten person I am

  • I MUST always have someone around and I can't stand to be alone and lonely

  • I MUST be accepted by someone I care about and because I'm not I'm a pitiable slob

  • I MUST know why it didn't work out, or else I'll never have a satisfactory relationship

  • I SHOULDN'T have so many failed relationships and because I have had them, I'm destined to always fail in relationships

The Great Debate

These "musts," these unreasonable demands upon himself, lay at the root of his depression, insomnia, and isolation. I taught Bruce how to combat these "musty" thoughts with the Three Minute Exercise, but when I saw him next time, he told me that he had "tried the exercise, but it didn't work."

When a client tells me this, it usually turns out that the client hasn't really tried the exercise, but Bruce had fully written out Three Minute Exercises to show me, and he was disappointed that he had apparently made no progress.

The problem was that when he wrote out stage E ("Effective new thinking"), he didn't really find it convincing. For example, he attempted to dispute the irrational belief (B) "I MUST have a relationship right now, and if I don't, I never will." At D he asked: "Where is the evidence I MUST have this relationship right now, or else I never will?" At E he wrote: "It would be lovely to have a relationship right now, but there's no 'must' about it, and it's entirely possible that I will not start a relationship for a year or more, and will then start one."

But as he wrote this, a voice in the back of his head would comment: "Who are you kidding? You know very well that the kind of bright, attractive, stable woman you're looking for would never be interested in a lowlife like you!" At that point he was stymied.

Our beliefs tend to hang together consistently. One belief may be supported by other beliefs, and these in turn by yet other beliefs. The specific belief we're trying to change may be very resistant, because it is strongly implied by other beliefs that we have done nothing to challenge. The solution is to challenge all the beliefs that lead to irrational demands, and this means engaging in debate.

I recommended to Bruce the technique I call Debating Until You Win. The way this works is that every time you come up with some "reason" for clinging to your old "musty" thoughts, you challenge that "reason." You talk back to that little voice. You can win the argument, because that little voice hasn't thought deeply or reflected critically-it merely expresses unexamined, unscientific notions you have been harboring for years.

It's helpful to commit the debate to paper, so that you can clearly see that you have a good answer to anything the "musty" voice might say. This is how such a debate might look:

MUSTY VOICE: "I MUST have a relationship right now, and because I don' t, I never will."

CLEAR-THINKING VOICE: "It would be lovely to have a relationship right now, but there's no 'must' about it, and it's entirely possible that I will not start a relationship for a year or more, and will then start one."

MUSTY VOICE: "Who are you kidding? You know very well that the kind of bright, attractive, stable woman you're looking for would never be interested in a lowlife like you!"

CLEAR-THINKING VOICE: "You're claiming two things: 1. By calling me a "lowlife" you're saying I'm no good. 2. You're also saying I'm doomed to failure. Can you prove either of these claims?"

MUSTY VOICE: "You've always failed at this so far! You've never had a long-term satisfying relationship. There's the proof! You never will! Give up!"

CLEAR-THINKING VOICE: "It quite frequently happens that people succeed at things after failing for years. So "have not" (past tense) doesn't prove "will not" (future tense)."

MUSTY VOICE: "But in your case you "haven't" had a successful relationship because no one decent would want to have a relationship with you!"

CLEAR-THINKING VOICE: "You're practicing fortune-telling without a crystal ball! Where's your proof? The more women I meet, the better my chances of connecting with someone that's for me. So I plan to start meeting them."

MUSTY VOICE: "That's not good enough! You MUST have a relationship right now."

CLEAR-THINKING VOICE: "Reality is what it is, not what I think it MUST be. The reality is that I don't have a relationship right now. Tough! A relationship sometime in the future is better than no relationship ever, so let's think about what's feasible--a future relationship. The first step toward this goal is to cease moaning about not having a relationship now, and instead take steps to make it more likely I will have a relationship some time.

"Moreover, the fact that I've never yet had the solid type of relationship that I would like doesn't make me a worm or a lowlife. If I have some traits that cause problems in relationships, I can probably figure out what these are and start to improve them. And I'm more likely to do that by meeting women so that I can get practice relating to them."

A Sparring Partner

To help Bruce develop his skills in these debates, I had oral debates with him in which I played the part of the Musty Voice and he played the Clear-Thinking Voice. Given the stimulus of a contest with another person, Bruce quickly became alert to my fallacious "musty" ploys, and was able to refute them with ease. I am happy to report that, before long, he was able to administer the KO in Round One every time.

Ten months after ending therapy, Bruce wrote to me. His feelings of depression were now rare and brief. He had met a woman who was more emotionally stable than any of his previous girlfriends, and they were considering marriage when she finished business school in four months. He thanked me and wrote: "At times I can still hear your voice in the back of my head, saying 'Past failure doesn't cause future failure.' "

Myths About Depression and Relationships

A common misconception is that depression always means lethargy, so that people who are energetic and active cannot be depressed. But this is to confuse one possible consequence of depression with depression itself. Some depressed people are very hard-working and conscientious, and some, like Bruce, have had lots of relationships.

Another misconception, fostered by the old post-Freudian style of psychotherapy, is that people who repeatedly have failed relationships "unconsciously" seek out those partners who will be bad for them. But there is a simpler explanation that seems to fit the facts better.

We are not suited for long-term relationships with many of the individuals we date. Most people recognize this and terminate unpromising relationships at an early stage, many almost before they have begun. By contrast, people with many failed relationships, like Bruce, are inclined to persist with unpromising relationships, because of unrealistic, "musty" thinking. They may, for example, think "I MUST avoid discomfort, therefore I couldn't face the prospect of telling my partner it's over." Or: "If the relationship isn't perfect (the way it SHOULD be) it's my fault, so I will never find anyone who'd be any better."

Other people bring to their relationships such unrealistic assumptions that they are bound to be disappointed. They may think: "A good relationship will be continually easy, pleasurable, and hassle-free. If my present relationship isn't like that, then it's unworkable."

Nursed Back To Health

One of the most common obstacles to overcoming depression is that sufferers insist on a dramatic, immediate improvement. If this doesn't happen, they start to think, "It's hopeless; nothing will do any good." This applies to all emotional problems, but is particularly marked with depression.

At 31, glowing in soft pink designer sweats, Carla looked as if she had just stepped out of a health and fitness magazine. She was head nurse at a Fortune 500 firm; evenings and weekends she taught yoga at a health club.

Carla described herself as "terribly depressed" and had begun to entertain thoughts of suicide. She likened her marriage of four years to a yo-yo: "Whenever things start to go well, a crisis hits big time." She felt insecure about her career, all the more since rumors of downsizing had begun circulating at work.

After I had helped her to separate her practical and emotional problems and to practice Three Minute Exercises to combat her "musty" thinking, she became impatient and started telling herself: "I SHOULD be entirely cured of depression by now. Since I'm not, I've accomplished nothing. Nothing works. I give up."

Day By Day

But as with learning a musical instrument, daily progress is often imperceptible. Since Carla found it hard to believe she really was making progress, I recommended Daily Mood Ratings. Every night, Carla would estimate just how depressed she had been that day, on a scale from 0 to 100 percent. She would later enter the score on a chart. For a ten-week period, her chart looked like this:

  Week
#1		 Week
#2		 Week
#3		 Week
#4		 Week
#5
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday		 60%
80%
70%
60%
60%
90%
80%		 80%
80%
60%
50%
70%
70%
60%		 50%
80%
80%
60%
40%
70%
60%		 60%
50%
70%
40%
60%
60%
40%		 50%
40%
30%
50%
50%
60%
40%

  Week
#6		 Week
#7		 Week
#8		 Week
#9		 Week
#10
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday		 50%
40%
40%
10%
30%
60%
40%		 40%
40%
40%
20%
30%
50%
30%		 50%
40%
20%
20%
0%
40%
30%		 30%
10%
0%
0%
0%
30%
10%		 0%
0%
0%
0%
0%
20%
10%

During the first few weeks she frequently scored 70 and 80 percent, indicating that she was quite depressed. However, as she did her daily Three Minute Exercises, relentlessly disputed her "musty" thinking, and pushed herself to face discomfort, her mood slowly lifted. After two months (it seemed like a lifetime to Carla) she was feeling only mildly depressed only some of the time, and then only infrequently.

Carla succeeded in holding her depression at bay and living a fuller life. She later came back to me, bringing her husband, to work on their "yo-yo" marriage.

Stop Depressing Yourself

Depression can be mild or severe. The depressed person feels worthless, helpless, and hopeless; the severely depressed person sees everyday life as a living Hell. Gloom and despair seem to pervade every waking moment, and preoccupation with suicide is common, sometimes leading to actual suicide. Severe depression restricts the capacity to enjoy life-the sufferer finds that things she used to really enjoy and look forward to, like a certain kind of food or music, no longer thrill or inspire. Everything seems flat and stale.

Many people who have suffered severe depression for years report that they would far rather undergo serious physical pain than the extreme mental anguish of depression. Some sufferers say, and sincerely believe, that they would do anything to escape depression.

But there is something they can do-they can stop depressing themselves. This is easier said than done, but it can be done. It will very likely do little good, however, for the sufferer to take the obvious commonsense approach of focussing his mind on cheerful topics. If, for instance, the sufferer keeps telling himself he is a worthless clod, he believes that he is a worthless clod, and this belief generates his depression. Making an effort to "put on a happy face" does nothing to combat this entrenched belief. It is more effective to challenge that false belief, root it out, and replace it with a more rational belief using Three Minute Exercises.

Circumstances by themselves have no power to depress you. No matter how extreme the misfortune a person faces, the objective facts in that person's environment don't by themselves cause emotional upset. There are numerous examples showing the power of the mind to remain composed under any circumstances. Consider a few of them:

Ingrid Bergman, the three-time Academy Award winner and star of the classic movie "Casablanca," said of her terminal cancer: "I have accepted it, and will make the most of what's left of my life while I can. Cancer victims who don't accept their fate, who don't learn to live with it, will only destroy what little time they have left."

Bergman matter-of-factly accepted her pain-filled day-to-day existence and her imminent death. She went on to give an outstanding performance in her final movie on the life of Golda Meir.

David Hume, the great Scottish philosopher who died in 1776, knew his death was coming soon and announced the fact in a good-humored short autobiography written four months before his demise. His doctor reported that at the end of his life, though very weak, he was "quite free from anxiety, impatience, or low spirits."

True, the individuals in these examples were faced with nothing worse than physical deterioration followed by death. Can people avoid being upset when they're in real trouble? What's the worst situation imaginable? Some would suggest being an inmate in a Nazi concentration camp--physically abused and always under the threat of death. Yet we know from reports of camp survivors that inmates in the same circumstances did not all respond in the same way. Some became anxious, depressed, frantic, or suicidal. Others behaved utterly differently, refusing to upset themselves needlessly about their plight. For evidence see Man's Search for Meaning by Victor Frankl.

Pamela's Self-Pity Party

Pamela, a 26-year-old counselor at a methadone day-treatment facility, had a gaunt, underweight appearance, which she was quick to attribute to "job stress." She wore a southwestern-design vest with a collarless shirt and black jeans. Her quick smile vanished within a split second, to be replaced by a gloomy stare.

Although not highly paid, Pamela, who lived with her lesbian partner Megan and their two young children, contributed most of the household income. She was vocally dissatisfied with her work, yet after three years was still at the same job. "The work is meaningless, the pay isn't much to live on, the hours are too long, and the prospects are zilch," she told me. Pamela had completed two years of college and declared, unconvincingly: "One day I plan to go back and study computer science."

Years of worsening depression finally motivated her to seek therapy. She readily made herself depressed about daily inconveniences. Over the last month these included catching the flu, an increasing client load at work, some of these clients getting worse, one of the kids crying most of the night, fights with Megan over whether Pamela should do more with the children, and a flat tire while driving home from work one evening.

Pamela irritably described her previous day. After breakfast she was about to leave home and go to work. Unfortunately, she couldn't find her car keys. She frantically searched her house--inside pockets, under tables, chairs, and couches, and in and around the car-all to no avail. She finally gave up in disgust and hastily called a taxi to take her to the train station. As luck would have it, just as the cab pulled into the station, Pamela heard her train pulling out. She ultimately arrived at work forty minutes late, wallowing in self-pity. When her boss criticized her for her lateness, she felt utterly defeated.

I explained to Pamela that she had two different types of problems. The series of inconveniences were Practical Problems, whereas her depression was a self-created and gratuitous Emotional Problem.

Pamela quickly conceded that the Practical Problems, though troublesome, were not what was really upsetting her. Rather, she soon acknowledged, it was her unrealistic view, specifically, "Life MUST not give me these headaches or else all is hopeless," that caused her upset. She saw, also, that by repeating this thought to herself whenever faced with unpleasant or unfair situations, she re-indoctrinated herself, thereby maintaining her disturbance.

Pamela's Three Minute Exercise

  1. (Activating event): Today I had many hassles: I lost my keys, I missed my train, and the boss unfairly criticized me.

  2. (irrational Belief): Life MUST not give me these headaches or else all is hopeless.

  3. (emotional Consequences): Depression, self-pity.

  4. (Disputing): What is the evidence life MUST not give me enormous headaches?

  5. (Effective new thinking): There is simply no evidence demonstrating that life MUST not give me such nuisances. Life often consists of one hassle after another. Too bad! It's not the inconveniences themselves, but rather my catastrophizing about them that depresses me.

    Hassles are just that--hassles, never horrors. Since I'm not a privileged super-being, the universe will not protect me from troubles. I can considerably enjoy life with them, even if they increase. By pushing myself, I can still accomplish things while hassled. I've always had hassles, I always will, and no reason exists why I MUST not.

    Simply because it would be lovely if life did not give me inconveniences does not mean it MUST not. It's sad that reality gives me these difficulties, but hardly the end of the world. I can view hassles as blocks to be overcome. Many will prove to be challenging and stimulating, rather than tragedies.

    I'm an imperfect human being, so I will be inefficient sometimes and lose my keys or otherwise create problems for myself. I can greatly enjoy life even with this inefficient tendency, as long as I refuse to moan and groan about it.

  6. (new Feeling): Concern rather than depression and self-pity about life's nuisances.

Three Second Knockouts

At this juncture, I decided the technique of the Three Second Knockout would be helpful for Pamela. Here, you devise a pithy, dramatic statement that challenges and contradicts a major irrational belief you're fighting. Throughout the day, when your mind is not otherwise engaged, meaningfully and persuasively say the "knockout" statement to yourself. The repetition will help reinforce the statement, etching it into your brain. Then, when "musty" thoughts appear, they can be quickly clobbered.

For example, in Pamela's case we devised the "knockout" statement, "If I have hassles, I have hassles. Too damn bad!" I instructed her to repeat this "knockout" statement to herself throughout the day. To help motivate and focus her we set up a goal--one hundred repetitions each day. We got the "knockout" statement going around in her head so that it would eventually become part of the way she viewed hassles.

Pamela reported that after hundreds of repetitions this particular phrase began to get clichéed and stale. So we devised another to use for variety: "Hassles are only hassles, NEVER horrors!" For an entire day she would use one or the other "knockout" statement, whichever seemed more meaningful to her at the time. Alternating between the two solved the problem of staleness.

Pamela found the Knockout technique particularly helpful. She got to the point where, as a result of using the Knockout statements, she would stop upsetting herself about inconveniences for weeks. But eventually, for no apparent reason, she would start depressing herself all over again.

We discovered the explanation. Once Pamela began accepting hassles more gracefully, she would stop using the Knockout technique. She did so on the grounds that she was finally cured, once and for all. But soon her "musts" would slowly creep back into her head, and she would become depressed again. So we developed a pre-emptive strike to practice when things were going well: "Life will consist of one hassle after another, and it should!"

Pamela's Progress

One morning, about a year after Pamela had completed therapy, I was pleasantly surprised to receive a phone call from her. She happily informed me that her depression was largely gone. On the one or two occasions that it had started to emerge, she had practiced her Three Minute Exercises and Three Second Knockouts and soon vanquished it.

Moreover, Pamela was applying to college to follow through on her dream to study computer science. She had some money saved and felt ready to face the disruptions of a major career change. She asked if I would write a reference for her. I said I would be delighted.

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Dr. Michael R. Edelstein
Clinical Psychologist, San Francisco
415-673-2848 (24 hours)
DrEdelstein@ThreeMinuteTherapy.com
www.ThreeMinuteTherapy.com