Our ability to identify even the slightest dangers and threats has been a key to our survival as a species, but in modern life this sensitivity comes with a downside: we’re experts at focusing on negative things, including those that are unlikely to occur. Like a mother who continually imagines horrific traumas befalling her young son in even the most unthreatening of situations, this proclivity can take a toll on our well-being.
In fact, an epidemic-worthy number of 40 million Americans deal with diagnosable anxiety-related issues every year, and over 25 million struggle with clinical depression. What’s perhaps more alarming—and yes, I’m focusing on the negative here—is the susceptibility of younger and younger age groups to experience extreme worry, often entrenching them in a cycle of negative thinking.
Of course, we wouldn’t want to take away our precious ability to keep ourselves safe by detecting potential problems. After all, if you can’t identify a problem, how can you hope to overcome it? But many of our clients need to redirect or tame this ability so it doesn’t drag them into out-of-control anxiety and rumination. Over the years, like many practitioners, I’ve put together an extensive clinical toolbox to help my clients do this. But I’ve also found that we often have to get creative in how we apply these basic therapy tools to restore emotional balance, especially when depression has set in and negative cognitions have taken over.
Facing the Negative Inner Voice
In our first session, Jeremy, 45, dragged himself into my office and sank with a thud into my sofa. I sensed a deep despair. When I asked what had brought him in, the heaviness of his answer said it all: “I’m failing.”
“Failing? Well, I hope it’s not fatal,” I smiled, hoping some levity would change his affect or get him talking. It didn’t. I leaned forward in my chair to let him know I was on his side. “Failing is a strong word,” I tried again. “What makes you think that’s the case?”
After biting his lip, he told me that his house-painting business had recently gone under and that he’d never find another job. When I asked why he thought this, his answer was unequivocal. “I don’t know how to use a computer, and I can’t go on interviews; I’m no good at them. I can’t start over at this age. I don’t have the skills to compete with a bunch of young kids for a job. Who would want me?”
As I felt Jeremy’s wave of negativity wash over me, I couldn’t help but feel his fear of what the future might hold. I noticed I was holding my breath, so I let out a long exhale. Slowly, I nodded my head while looking directly at him, acknowledging the difficulty of his predicament. It was clear that Jeremy was stuck.
Getting him unstuck would mean getting him out of an eddy of limiting thoughts while cultivating hope and recognizing his own strengths. I knew we’d be able to work on this over time, but I’d need to get his buy-in, which would prove to be no easy matter. Jeremy seemed determined to focus on the loss of his business as proof that he was inept, even though starting it in the first place must’ve taken a great deal of initiative, know-how, and creativity.
Given my clinical orientation in cognitive behavioral therapy (CBT), I first wanted to understand more about Jeremy’s limiting beliefs and thinking styles. How did these develop? How could I best help him observe his own mind and thoughts? But something told me he wasn’t ready for that yet, at least not directly. Instead, I asked about his hobbies.
At first, Jeremy struggled to come up with anything he enjoyed other than watching TV after work with his housemates. But then he remembered an improv class he’d gone to one weekend on a whim. “The teacher would call out a place, like a ski slope or an airplane or an operating room. Then we had to drop into the scene and riff on whatever random scenario came out. It got pretty wild!”
Jeremy’s energy lifted instantly during this recollection. I laughed along, and then took a chance to see if I could use this shift in energy to get his buy-in on a cognitive-oriented homework assignment. “Getting back to what you said earlier about the problems with finding a new job, it sounds like you have a lot of solid reasons why you can’t move forward,” I said.
“Damn straight,” he shot back.
“When I was listening to how you like comedy, I had a thought. Did you ever watch The Late Show with David Letterman?”
“Yeah, I watched it a lot. Why?” he asked with a furrowed brow.
“Well, when I heard your list of reasons why you couldn’t move forward, it reminded me of Letterman’s Top 10 lists. Once he did a Top 10 list of unsafe gifts for Christmas. It included Hasbro’s Slippery Steps, Black and Decker’s Silly Driller, and Parker Brothers’ Will It Burn? That really made me laugh,” I told him.
“Yeah, lots of those late-night hosts do Top 10s now. I love that.”
“How would you feel about creating your own Top 10 list of reasons why you can’t move forward? Just let them flow out like an improv scene. Maybe you could put it together during the week, and when you come back, you can show it to me,” I suggested.
He agreed with a sly grin.
I hoped that in externalizing his thoughts by writing them down, Jeremy could create some distance from that negative inner voice in his head, allowing him to observe his strongly held self-beliefs from a fresh perspective.
In our next session, Jeremy reported there’d been entire days that week when he’d barely gotten off the couch. Thinking about his future prospects, he said, seemed to fill his body with heavy rocks. But then he produced a piece of folded, yellow legal paper from his pocket. “I did what you asked,” he told me. So far so good, I thought.
“Before I show you, I gotta tell you something. A light bulb went off when I looked at these reasons why I can’t get a job,” he said, slapping at the sheet with his hand. “It was like hearing my mother. I couldn’t believe it, but this is how she thinks!” he said emphatically, his mouth agape.
Although it wasn’t a magic bullet for creating change, it was the springboard I was hoping for: Jerry had experienced his thoughts from a completely new awareness.
“If that’s how your mother thinks,” I said, “then tell me this: How do you want to think? What kind of thinking do you want directing your mind and your life?”
Jeremy took a deep breath, as if he were getting himself ready for a race. “I really want to think that I can do things and not be afraid of new situations. I’m still not sure it’s possible, but that’s what I want.”
“That’s actually the first step in thinking differently—wanting to make a change—and there are lots of ways I can help you do that,” I said.
A look of relief spread over Jeremy’s face, telling me that it was time to start working more directly by applying some actual CBT tools.
Embracing the Power of Hope
Over the next few sessions, I introduced Jeremy to cognitive-behavioral concepts and talked to him about how to break out of fixed mindsets by finding a more accurate, balanced view. I noticed that when I’d start to get too technical or theoretical, Jeremy’s attention would wander and his body would slump down into couch. So I decided to use his own Top 10 list as my teaching tool.
One by one, I wrote each item on a whiteboard and together we’d identify and explore the emotions behind it. Then we’d discuss evidence that disputed these limiting statements. For example, one of Jeremy’s nagging beliefs was “I’ll never get a date without a job.” When I asked him what emotions he felt around that statement, he could only muster the words loser and unhappy.
“I think we can help you expand that emotional vocabulary, but that means dropping into the body and tuning into its emotional signals. Are you willing to try that?” I asked.
“Sure,” said Jeremy, squirming in his chair a bit.
I began by modeling the practice for him. As I dropped into my body, I noted aloud what sensations were occurring moment by moment, such as “pulsation in my fingertips,” “tension in my neck,” “pressure on the bottom of my feet.” As a long-time mindfulness practitioner, I’d helped many clients use the body to better understand and navigate emotions in this way.
Although this was new for Jeremy, he immediately noticed a distinct sensation of queasiness in his gut and heaviness in his heart center. When we translated these sensations into emotions, he was surprised to identify feelings of fear, doubt, and loneliness. Naming these feelings made them less overwhelming, so he could start to challenge some of the negative thinking that accompanied them. After we’d gone through this process a few times, I gave him a thinking-styles worksheet to use at home to help him get even more distance from his negative beliefs.
Then one day he came in beaming about a “fun, really good conversation” he’d had with a woman at a party. Apparently, he’d decided to approach it like he would an improv scene, with a sense of flexibility and possibility. I was delighted to hear he’d found his own creative way to think about making changes in his life. This felt like an important moment for Jeremy. At this point, I thought he’d be receptive to integrating the psychology of hope into our work—a concept from positive psychology first defined and studied by researcher Charles “Rick” Snyder. With many clients, I’ll write down the definition of psychological hope as an equation: hope (reaching goals) = willpower + waypower.
Basically, as I explained to Jeremy, hope can be understood as how we cultivate the willpower and waypower necessary to reach our goals when we’ve been blocked by various obstacles. Defined this way, hope directly builds resilience, giving us the tools to bounce back from adversity.
Willpower can be understood as the reservoir of energy and determination anyone needs to move toward a goal, the driving force that gets us off the couch when we feel stymied by adversity. Waypower is the ability to be mentally flexible enough to find new approaches and pathways for getting around the obstacles that stand in our way. You might be the most energetic person in the world, but without any creative problem-solving skills, you wouldn’t have a clue about how to approach difficult situations. You need both willpower and waypower when you’re stuck.
Energized after expounding this small bit of psychoeducational wisdom, I waited for validation from Jeremy. But that’s not what I got. “Some people are just more hopeful than others,” he said skeptically. “It’s just who they are.”
I paused. Part of me wanted to argue the point, but then I realized that this was a good opportunity to engage him in a more useful way. “That’s an interesting point, and I’m glad you brought that up,” I said. “There may very well be a personal inclination toward hope, but hope as we’re using it is also a skill, just like those thinking-style skills we’ve been working on. That means anyone can learn it. Sure, some people learn it earlier than others. Parents who are patient and offer support when their children face challenges are teaching them to be confident about reaching their goals. They’re giving them a roadmap for how to bounce back and keep going,” I explained. “When you were a child, how did you learn to deal with frustrations and roadblocks? How did you learn the skills for reaching your goals?”
Jeremy was quiet, his head tilted upward as he thought. Finally, he shared with me how his parents had usually been absent or preoccupied whenever he’d asked for help. “Eventually, I just gave up and stopped asking,” he said. I could sense the pain behind his memories of growing up. I waited, not wanting to jump in too early. “Do you really think I could learn to have hope?” he asked after a while.
“Yes, Jeremy, absolutely.”
He nodded and his posture relaxed at bit. To lay the foundation, I told Jeremy a bit about the research showing that high-hope people are less discouraged by negative outcomes than low-hope people. As a self-proclaimed “numbers guy,” this caught his attention. He was intrigued and willing to take the Adult Hope Scale inventory, which comprises 12 simple questions. Afterward, we discussed his results—which were low in willpower and about average in waypower. Rather than being discouraged, he seemed ready to learn more.
During the next few sessions I led Jeremy through a series of basic exercises designed to build his understanding of how to generate and strengthen his willpower and waypower in concrete ways. For willpower, I invited him to reflect and journal on how he could recharge when feeling depleted, times he was able to view roadblocks as challenges rather than failures, and stories from other people that inspired him.
He explored waypower in a similar manner. I asked him to think and write about how any goal can be broken down into smaller steps, how any plan can be reworked when met by an obstacle, and how consistent effort and building the right skills are critical to attaining any goal. As we focused on turning the mental roadblocks of “can’t” into “can,” and embracing the elements of hope, Jeremy’s affect brightened. He seemed more willing to examine new ways of approaching the roadblocks in his life.
As our work progressed, we homed in on his goal to find a new job, culminating in the day Jeremy declared that he wasn’t too old to return to school. After enrolling in a program at the local community college designed for adults, he even got excited about the prospect of learning computer skills. I was excited for him.
Meeting Challenges with Strengths
Not long after starting his training program, Jeremy came in, sank down on the couch, and announced, “I’m failing. Again.” I felt my heart sink with him for a moment. “I bombed my first exams, and I need some serious waypower. I can’t seem to study, and I don’t know what to do.”
This was an opportunity to work with Jeremy on acknowledging and putting his strengths into play. I knew he lived in a group house with some friends and often got pulled into watching TV or going out with them to play pool at a bar down the street. I thought he might need help managing his time and creating a study plan, but rather than tell him that directly, I asked him what he considered his biggest strength.
“I’m street smart, and I can usually think on my feet,” he answered.
“Being street smart is definitely an important strength. It means you can find resources in your environment. I’m a little street smart, too,” I winked. “And this is one of the resources I use.” I grabbed The Strengths Book from my bookshelf and handed it to him. In it are 60 strengths with examples of how to use them. As a homework assignment, I asked Jeremy to find his top five and pick one to put into action for the entire week. He’d journal about the impact and how this made him feel along the way. “Let’s start with putting your street smarts to work,” I suggested.
When Jeremy returned the next week, he proudly opened a three-ring binder, where he’d printed out a weekly study schedule for all his classes.
“That’s impressive. Nicely organized. How’d you do that?” I asked.
“I was hanging around the student center, and I started talking with a classmate. I told him about how I needed help organizing my study time, and he showed me how he does it.” Having put his street smarts to good use, I knew he could continue to use other strengths to build his skills around hope. The following week, he passed a quiz on Excel formulas—and then redid his study guide in a spreadsheet.
My hope that Jeremy would eventually attain his goal and find a new job grew stronger each week. He was no longer in crisis and was feeling good about his progress. Having developed a passion for using Excel, he even organized his finances into a spreadsheet and announced one session that rather than continuing our work together, he’d like to put more money toward getting his own apartment. I was thrilled to hear this and invited him to come back any time for a check-in session if he felt like he wanted a boost of support. In our last session, we wrapped things up and talked about integrating the work we did so he’d continue to find new strengths.
Six months later, I got an email from Jeremy. The subject line was “I Got a Job!” He said he’d be putting his Excel skills to use as a finance assistant with a large construction company. I must admit that I felt a little like a proud parent. His starting salary was high, and it came with full benefits. Jeremy’s success at building willpower and waypower had paid off.
Of course, for all of us, old “I can’t” storylines can always reinsert themselves, especially during times of stress. Jeremy said he still has days when he experiences setbacks, feels like a failure, and gets lured into watching TV on his couch. It’s for times like these, now that he lives alone, that he’s started keeping his journal out on the coffee table. That way it’s easy to remind himself not only of all his strengths, but the ways he’s already put them into action.
I think of him every time I hear my own internal “I can’t” voice when working with a challenging client. He reminds me that the resources in my clinical toolbox are most effective when I can present them in a personal and interesting way—and, as Jeremy found in his life, using a bit of improv adds a crucial dimension to how I approach this work.
By David Treadway
Donald Altman’s opening comments about the growing “epidemic” of anxiety seem particularly timely as we face the nightmare of the COVID-19 pandemic that threatens us all. I wrote my commentary two weeks ago, which already seems a long time past. Now, we’re in the new normal of being homebound, perhaps terrified, and certainly a little stir-crazy. Suddenly, my comments seem hopelessly irrelevant given the current circumstances. But I’m sharing them with you because one of the ways to manage our anxiety is captured in the old AA phrase, “Keep on keeping on.” Part of what we must do during this dreadful time is to keep showing up. So to honor and support this author, the Networker, and each of you, I thought it was best to carry on.
Although there are myriad creative and smart aspects of Altman’s work with Jeremy, I felt the key ingredient to his success was Altman’s own “improv skills” in tailoring his interventions to custom fit Jeremy. As clinicians, we know one size doesn’t fit all. Customizing our interventions is often the heart and the art of our craft.
A great example of this is when Altman discovers that Jeremy enjoys David Letterman and suggests he write a Top 10 list of reasons he feels like a failure. This homework connects to a pleasurable part of Jeremy’s life without asking him to try to change any of his feelings, thereby opening the door for forward movement. Indeed, the therapy is truly launched when Jeremy produces his list on folded-up yellow legal paper.
Despite the possibility for emotional breakthroughs or profound insight in our sessions, the positive changes we generate often don’t last past a client’s car ride home. People are creatures of habit. And for most of my couples and families, their habitual patterns reassert themselves pretty quickly. So over the years, I’ve become passionately committed to helping couples do “homework” as an essential part of therapy. I believe the work done between sessions is even more important for sustained and meaningful change than what we do in our offices.
Yet we all know how hard it is to get clients to do homework. Often we throw out good suggestions at the end of the sessions, but clients don’t follow through; frequently, we don’t follow up either. From Altman and other CBT therapists, I’ve found that I have to be committed to my clients’ homework.
In the first phone call, I tell them that homework is an important part of what I do. I help them practice homework exercises in the room. I always review homework first in the following session. But most importantly, I help them come up with homework that they choose and feels doable to them.
Clearly, engaging Jeremy in doing homework right from the first session was essential. However, what I so appreciated about Altman’s case is how he engaged Jeremy in doing the doable, helping the self-defined ”failure” build on each of his successes. In other words, he created homework that works.
ILLUSTRATION BY SALLY WERN COMPORT
CategoriesIn the Therapy Room Clinical Practice & Guidance Anxiety & Depression Clinical Skills & Experience Mind, Body, Brain Professional Development
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