The Need to Tell Maggie’s Story
Every year, 1000 college students commit suicide. As many as 1 in 10 college students seriously consider suicide. Even greater numbers, as many as 1 in 4 high school and college students, struggle with anxiety and depressive disorders. What can be done to help such individuals?
The following is an extended blog that tells the true story of Maggie Nelson. Only her name and a few minor details have been changed. I am deeply thankful for Maggie’s willingness to share her story. Our hope is that it helps teens, parents, teachers, and counselors or other professionals both understand how and why serious depressive episodes develop and how effective therapy can work to transform the cycles of negative emotion and self-criticism around and into more virtuous cycles of adaptive growth.
We have given her story the subtitle “the many reasons why not” to counter the narrative in the popular television show, 13 Reasons Why, in which a teenage girl commits suicide and leaves behind a series of video tapes giving the reasons why her suicide was justified. Although I appreciate the need to bring the discussion of suicide out from the shadows, I have deep worries about the impact the show might have on vulnerable minds. A basic message of the show is that people treat you lousy and life sucks, and what can you do but feel horrible about your loneliness and the unfairness of it all? This, of course, is exactly the wrong message we want to be sending.
Our society is experiencing a time of important change when it comes to how we understand and deal with negative emotions. The good news is our society has given people much greater freedoms to share negative feelings than in the past. And we have greatly reduced the stigma of mental health difficulties and many people freely admit to seeing a therapist if they need help. But in opening up pathways to our negative feelings, we have not done a good job framing what such feelings mean and how to process them. Feelings communicate truths, but they are not absolute truth. If we feel rejected or oppressed or abused, these are crucial feeling to listen to. But the feelings themselves do not mean our situation is hopeless, that our oppressors are in fact brutal, or that we are helpless in the face of abuse.
A central ability for effective psychological functioning is to be aware and attuned to our feelings and to have a mature outlook regarding how to use these feelings to guide us toward more adaptive states of being. If we just listen to the feelings and take them at face value, we often are paralyzed. When we started our work together, Maggie would often have extremely strong negative reactions to stressors. We needed to help her learn how to interpret her feelings. One of the most common interventions was the “Is it Syria?” intervention. Syria is a genuine, brutal, horrible, large-scale disaster. Getting rejected from a friend or disappointing a parent or failing a test is tough, but is not Syria. Maggie’s feeling system would react to everyday disappointments as if they were Syria. We had to change that.
As the popular television show reveals, dealing with thirteen disappointments is tough, especially if you are a sensitive, lonely adolescent. But even that is not Syria. My concern is that 13 Reasons potentially justifies the viability of suicide as a solution to life’s (sometimes brutal) problems. But that is not the message we need to be telling vulnerable adolescents. Instead, the message needs to be that the individual has it within them to deal with life’s problems; they just need to learn how to do so in a mature and adaptive way. My hope is that Maggie’s story can justify the reasons why suicide is not a viable option for depressed teens. Instead, it demonstrates that even folks who find themselves swallowed by the darkest depths of depression can find their way out and, ultimately, build a life very much worth living. We hope you benefit from her story.
Preface: Maggie’s Reasons…Because there is darkness all around.
She sat on the edge of the bed, her hand pressed against her wrist. She felt nothing. She felt everything. Then she felt the small trickle of blood seep through her fingers. She had been cutting herself when her roommate walked in and had seen it. So now her roommate knows. And, for Maggie, that meant everyone will know. Everyone will know she is a freak who is experiencing so much craziness inside that she cuts on herself. And she knew that was only a part of her craziness. Deep inside, a black hole of despair had been growing in her for more than four years. Maybe even before that. Maybe she had always known that deep inside she is broken and crazy. She had tried desperately to hide it, tried to live a normal life. But she could not. It erupted when she was fourteen. It had hardened and turned even blacker after “the incident” with her boyfriend at 15. Shortly afterward she tried to hang herself and then was sent to a psych ward, which did not help. Her sophomore and junior years were pure hell. She thought that maybe it had started to soften, that maybe she had a shot at a somewhat normal life when she had moved to a different school for her senior year, and made some new friends and was able to forget about the blackness.
But now, here, during her first year of college, the blackness was returning with a vengeance. The emotional isolation had started almost immediately. And now, eight weeks into her freshman year it was turning into a full boil. She was cutting almost every day now. And she was drinking and having meaningless sex and was feeling more and more distant. More and more despondent. And now her roommate knows. Yes, her roommate knew she was moody and had found her crying. But cutting? Now she would be known as a freak. Now everyone would see she was crazy and she would be even more isolated. And so what would happen? Her roommate would tell her RA, her RA would tell her parents. She winced at the thought of them. Having them know would be intolerable. Then what? Would they force her to drop out? Would she have to be locked up in a hospital again? Her life was a mess. It would always be a mess. There was no escaping that mess. That is, except for one way. There was only one way out. And this time she would make sure she got it right. There would be no aftermath, no facing her parents’ confused and disapproving looks, no lockdown in a mental ward. She was done with this life.
Phase one of Treatment: Hope that there might be a map out of the darkness.
Less than twenty-four hours later, I received a call from Chad, one of my first year doctoral students, who was conducting his second-ever intake interview at our Counseling and Psychological Services Clinic.
“What’s up?” I asked.
“I need a clinical consult,” Chad said, his voice a bit shaky.
“Ok, fire away.”
“I have just started an intake with a girl, um, she said she almost jumped off a bridge last night. She said that her roommate walked in on her while she was cutting on herself. Then she ‘freaked out’ and left her dorm and was getting ready to jump off a bridge. But two of her friends had followed her and talked her out of it and then they brought her over to us this morning. She said she does not want to be here. Her friends insisted she come in.”
“I will be right over. Has she tried to kill herself before?”
“Yes,” Chad said. “Three times, including an attempted hanging.”
“Give her some of our symptom forms to fill out. I will be there in ten.”
I told the seminar group I was leading that I needed to run and grabbed my stuff and headed over to CAPS. As soon as I entered the office, Maggie said she did not want to be there and that she was “fine.” She even began to get up out of her chair.
“Actually, Maggie, we are going to need to chat for a bit. If you bolt now, that will suck for both of us. The reason is because my professional obligation will be to call the cops and that can get ugly. I know that chatting with me might not be the most fun way to spend a day, but it probably will be better than dealing with the cops.”
And so, our journey started. During that first two hours, I gathered more about her history. I learned that she was always a bit sensitive and easily stressed. I learned how her levels of anxiety and depression began to get noticeably worse at 13. She talked about hating both her negative feelings and herself for having them and how she tried hiding them from everyone. She said things got worse and worse until 15, when she tried to hang herself, after which she was hospitalized. She felt horrible through much of her sophomore and junior years. She switched schools her senior year and, thankfully, things improved. She had hoped that her depression would be behind her, but that hope came crashing down during her first four weeks at college. She quickly became overwhelmed with the work, the new people, and the freedom to do whatever. Others seemed to adjust so easily. She, on the other hand, was anxious, self-conscious, and confused.
As she got increasingly stressed, her depressed mindset returned. This wave of emotional shutdown came with a voice that told her she was a horrible person, that if anyone really knew the real Maggie they would abandon her. The voice that told her she was ugly, undeserving of love, and was a basket case of nerves who would never amount to anything. As that voice got louder, she shutdown more and more. And then the cutting returned in full force. Three or four times a week. As the depression sank in, she realized that she would never be free from it. She was condemned to a miserable life.
“You have what I call a ‘shame-based’ depression,” I told her.
“What is that?” she asked.
“It is my term for describing folks who are in depressive shutdowns in part because they have “turned against themselves.” It often starts in puberty, when an individual’s identity is being formed. The situation is this: An individual has a sensitive or “neurotic” temperament, which means they are easily upset or stressed and are difficult to sooth after a trigger. Such individuals, especially if they are low in extraversion and high in agreeableness, often begin to develop a war within themselves as their identity develops in adolescence. The identity is the part of a person that reflects on who one is and why and how one wishes to be. If an identity forms where the individual is very upset with their negative feelings and is not taught how to process them and they just want to be seen by others as kind, easy-going, and happy, they will attack themselves for their feelings. Of course, this does not make them feel better, but only charges their emotional system further. So, they create an internal feedback loop of negative feelings and critical self-talk. When this loop “closes” (meaning the criticism drives the feelings and the feelings drive the criticism), the system enters a depressive shutdown. Does that make sense?”
“Yes,” Maggie said, in a neutral tone. “I just have never heard it explained that way before”.
“How has it been explained to you?”
“It really hasn’t. When I was hospitalized in the past I was just told I had severe Major Depression and needed to be put on meds. They had me talk to a counselor who asked me about my feelings, but I did not like talking with her. It just made it worse. Then we just switched schools.”
“Okay, to really get through this thing, we need for you to understand it, understand what drives it, and work through the unfinished emotional business that gave rise to it. Are you willing to work with me and give this a chance?”
And so began the first phase of our treatment, the whole of which would last approximately 15 months and have several watershed moments in it. In retelling it here, I divide the treatment into phases. The first phase involved getting Maggie to begin to wonder if therapy was really possible. My detailed and intellectualized description of her problem helped her to realize I knew what I was talking about, gave her a map of her feelings and conflicts, and worked to down-regulate her emotions a bit, as she was quite dysregulated and overwhelmed.
The end of the first phase emerged as we settled into uncovering her inner world and some of the things that had happened to her. It was clear to me early on she had experienced some sort of unpleasant sexual encounter. I suspected it because she reported having emotionless hook-ups with several guys. Her muted affect told me that she was dissociating from something. I probed a bit and uncovered that there was “an event” that she would tell about when she was ready.
Phase 2: Working Toward and then through the Trauma
Four weeks in to our work, she was doing better and we were about to dive in deeper, when life gave her a nudge. She was still cutting on herself occasionally, and we were working on a plan for that. One day she used a new razor and really sliced herself, such that she needed to see a physician. She ended up going home to see her family doctor, who, in the course of exploring her emotional health asked directly if she had been raped or sexually assaulted.
“Yes,” she told me she heard herself say to him. It was the following Monday and we were meeting as she had just returned from a weekend home and was feeling out of sorts.
“It was clear something had happened to you. Are you ready to talk about it?”
“It is just so awful to think about.”
“I know, Maggie” I said. “But that is part of the healing process. I have known since the first time we met that something happened to you, and that you did everything you could to try not to think about it.”
“Oh God,” she wept.
“It is ok. We can get through this.”
“It was when I was fifteen. My boyfriend at the time. He got me to sneak out and go to this house down the street where they were having a party. And we all got drunk. He coaxed me upstairs. We were fooling around. It was like 2 a.m. No one else was in the room….”. Her voice trailed off.
“And then he started to try to take my clothes off.” Tears were streaming down her face. “I tried to tell him no, that I did not want to. Then he pushed me on the bed. I kept saying I did not want to.” She sobbed.
“I am so sorry, Maggie. That was not right.”
“Then it was over. Just like that. And I was a virgin.” She cried some more. “I barely even remember getting my stuff and walking home. I snuck back into my house. Then I just tried to go to sleep. And then got up the next morning and pretended nothing happened.”
“You did not tell anyone?”
“Who could I tell? I snuck out. I drank. My parents would be super pissed at me. And I was drunk and everything was a haze. And I hung out with mostly his friends. I only told my best friend three weeks later, and I made her swear she would never tell anyone.”
“And what happened with him?” I asked.
“I basically started avoiding him. We never had sex again or anything. I avoided him and the relationship faded”.
“And so you have been dealing with this trauma for years on your own. Part of our work is going to be about working through this event and processing its impact on you.”
“Oh god,” she cried. “I just want to forget about it.”
“I know. But that won’t happen. The memory is in you. And you have not processed the feelings associated with this trauma. And it is tearing you up inside.”
And so we started processing her rape. And, as sometimes happens when people begin to dive into traumas they don’t want to think about, she started to decompensate. It was just too much at first. Indeed, that was why I did not go right at it from the beginning. She was too fragile and lacked enough coping resources to manage the working through process.
And a huge part of Maggie’s problem was that she could not allow herself to share anything with her parents. I began to explore this element of her life.
“No, I just cannot tell them. At all. Ever. They will hate me.”
“Even your mother?”
“Especially my mother. You don’t know her.”
“Well, will you let me talk to her? At least so that I can understand who your mother is. I won’t mention this, but I need to understand where your mother is coming from on this. You think you know her, but I am telling you that you might not really be able to understand where your mother is coming from. You are so afraid of others’ reactions that you often distort where they are coming from. Can I talk with her and see?”
“I don’t know. Not yet.”
When I got in touch with her, she was in a full panic. “I am losing it. This is hell. I need this to stop.”
“I understand. We need to get you to the hospital.”
“Oh God, I don’t want to go back there. I hate hospitals.”
“This time I think it will be different. I will guide you,” I said. “Trust me.”
She called her friend who escorted her over to the emergency room. I met up with her 30 minutes later. When I arrived she was rocking back and forth in her hospital bed, sobbing. Her friend stared up at me with a bewildered look on her face.
“It is ok,” I said. “I know you are overwhelmed right now. But we can process these feelings through. Have your parents been notified?”
“Yes,” she cried some more. “My mom is on her way and will be here in two hours.”
“Good,” I said. “And you will let me talk to her?”
“Listen, Maggie. I know you are in your blackest place right now. Right now, all you feel is the pain of everything you try to block and hide and deny. And, believe me, when the flood gates open up to these kinds of feelings, it sucks. And I am sorry you are feeling it. Be we are safe. And if we listen to your feelings and if we relate to them in the right way, this will be healing.”
For the next two hours, Maggie, her best friend and I went back and forth between tears, pain, joking around, and dazed exhaustion. Then her mother arrived. We had already talked through our game plan. Her mother would touch in with Maggie and then I would touch in with her mother, then I would touch in with Maggie.
I waited outside as Maggie first spoke with her mother. Ten minutes passed. And then her mother came out to see me. She approached me and said, “Maggie said that you had been working with her and that it had helped some and that you wanted to talk with me.”
“Thank you. And yes, I do want to speak with you.”
We found a conference room and for the next half an hour we talked. My goal was to assess Maggie’s mother, her love for Maggie, and to develop an understanding of why there was such a boundary between them. The news was very good after this encounter. My assessment was that Maggie’s mother deeply loved Maggie. She was just confused in how to deal with Maggie. She was not fully to blame for this. Our culture is not helpful in guiding folks in this way. Consider that she received no guidance in all the previous hospitalizations and suicide attempts. And Maggie was so sensitive and cutoff at times that her mother just did not know what to say.
“I don’t know what it is,” Maggie’s mother told me. “But it is like the life went out of her eyes at some point.”
“About when?” I asked.
“Three years ago, maybe. Just before the suicide attempts started.”
“Can I share that with Maggie?”
“Yes, absolutely,” she said.
I was back in the room with Maggie, as her mother waited outside. “Maggie,” I said. “I have good news. Your mother loves you. Deeply. She just does not know how to connect with you, because she does not know what is going on with you. She told me she feels like ‘a light went out’ in your eyes. She wants to know why.” Maggie stared at the wall, thoughtfully digesting what I was telling her.
It was getting late in the evening. I told Maggie I needed to head out. But I would be back. I would check in with her at lunch and then come back for visiting hours.
I returned at noon the next day, finding Maggie sitting in hospital room eating lunch. She looked in a much different place.
“How has the morning been?”
“Wow. That is pretty big news. Do you want me to be here for that?”
And so I came back to the hospital four hours later. Her mother was with Maggie when I arrived. We agreed I would speak to Maggie alone for a brief time.
“I told her I had something to tell her,” she said, as her mother closed the door behind her.
“What did she say?”
“She said she wanted to know whatever I wanted to tell her. And that she loved me.”
“I am really proud of how brave you are being. I know how scary this is.”
“Yeah, well, I just think it is time.”
We brought Maggie’s mother back in, and the story unfolded from Maggie fairly quickly. She reminded her mother about the boy she was dating when she was fifteen. Then she told her about the party, told her she snuck out and got drunk. She started crying.
“He took me upstairs. He started taking off my clothes. I told him ‘no’, but he did not stop.” Tears were streaming down her face when she said to her mother, “I am so sorry I snuck out and got drunk.”
“Oh honey,” her tearful mother said. “I am so sorry this happened to you. I knew something had happened to you. But I did not know what. I am just so sorry I was not there to protect you.”
They cried and hugged.
The healing impact that the next two hours would have on Maggie’s psychological system is hard to overstate. Prior to the rape, she had been depressed and had started process of “closing the loop,” which is the term I use for an individual who has strong negative feelings and then gets very self-critical about those feelings. This creates a vicious intrapsychic cycle of negativity. Then there was the trauma of the rape, which means that Maggie was devalued and disrespected at her core. On the heels of this, she was not protected or respected and justice was not served. Instead, she had imagined her parents would blame her, that her friends would blame her, and, indeed, she had basically blamed herself. So, her sense of worth and value were completely shattered by the fact that the rape could not be processed and there were no consequences.
Now, finally, she was giving voice to this experience with her most important attachment figure. And instead of getting what she feared (punishment, rejection and disapproval), she received love and validation of her experience. In other words, she was getting love and validation for who she was as a person, which is something she had come to fundamentally believe she did not deserve and would never get.
Being known and valued by important others is the core psychosocial need. It is the foundation upon which our psychosocial systems operate. This was a fundamentally transformative moment for Maggie. And this fact showed clearly in the weeks that followed.
She stayed in the hospital two more days. Her mood settled down dramatically. The next month saw a fairly radical transformation, both in her mood and her relationship with her mother. In fact, she would never again become dangerously suicidal. And the tone and tenor of her relationship with her mother was qualitatively different from that moment onward. They finally could talk to each other about what was really going on. She could finally be seen and known and feel valued in that light.
I explained to both of them how Maggie had a fairly distorted view of her mom as a function of all the inner battles that she engaged in. I explained to them both how Maggie had a “neurotic temperament,” which simply meant that she had a sensitive and reactive negative affect system. I explained how she had turned against herself and then that created all sorts of private-to-public filtering and that she hid her “true self.” And I taught them both how to talk to one another. First, giving a few lessons in the hospital, and then as I worked with Maggie in outpatient individual therapy during the following weeks.
Phase 3: Learning CALM MO to deal with conflict and distress.
The revelation of the rape to her mother and the healing that followed was transformative. However, Maggie still had a way to go to find mental health. She was still anxious and frequently caught in self-critical loops. And she was very reactive to negative events. She had stopped cutting, stopped being suicidal, and had started having positive experiences. But was still regularly “freaking out” and was not happy much of the time.
There was also the fact that her father knew something had happened, but did not know what. Maggie finally disclosed to him what had happened during the Christmas break. The exchange went fine, but was not quite as healing as the exchange with her mother. I made the mistake of not coaching and preparing Maggie for how her dad would likely react. Fathers not infrequently react a bit differently. They get more activated regarding justice and retribution and making things right, which is what happened here. Her father began to talk seriously about bringing legal charges, which was something that just was not an option for several reasons, the most significant being that it was not where Maggie was at all.
Our therapy was focused on improving her emotional health by finding her emotional sweet spot. The emotional sweet spot is the “space” between being aware and attuned to her emotions on the one hand and adaptively regulating them on the other. My primary strategy for training folks in finding the emotional sweet spot is to coach them on cultivating a CALM MO.
Cultivating a CALM MO is an approach to psychological mindfulness I developed that has lots in common with ACT and Dan Siegel’s interpersonal neurobiology. I teach folks that when they experience a negative event, what PT blogger Susan Heiter calls a “bump,” they need to activate a CALM MO perspective to help adaptively process the feelings, thoughts, and actions that follow. It is an acronym. M. O. stands for two things, one being “Modus Operandi” (mode of operating), and “Meta-cognitive Observer.” CALM refers to the attitude of the meta-cognitive observer. Instead of being critical and controlling (which is how many get when they feel a bump), the goal is to become Curious, Accepting, Loving/Compassionate toward self and others, and Motivated to grow toward adaptive outcomes.
Maggie was working on developing a CALM MO capacity when an event with her dad would really teach her how to employ it. Maggie was home, and her family was touring another college, as she had wondered in the fall if JMU was right for her. Her dad had been in a grumpy mood all day, which made her feel very tense. After the tour her plan was to go see a concert with a male friend. And she was planning on spending the night in a hotel in D.C. with him as a friend. After they got home from the tour, she told her dad about her plan.
“No way,” he said. “Just not happening.”
“Dad, I know this guy well. It is fine. Nothing is going to happen.”
“Nothing is going to happen because you are not going,” he proclaimed.
“Dad, I have really been looking forward to this.”
“You want to go? You are 18. Actually, that is old enough to make decisions. So go. By the way, it also means you are old enough to pay for your own college. So, you go, you pay your own way in college—from here on out!”
It was a harsh exchange and completely unsettled her. A short time later she was alone in her room, crying and feeling completely overwhelmed. She had told her friend she was not going and he was pretty upset. So now she felt completely trapped. How could her father do this to her? Everything sucked.
Her mom came up into her room an hour later or so. “I know you are pretty upset, dear. I understand.”
“Mom, it is just not fair,” Maggie proclaimed.
“Sometimes life is not fair. What would Dr. Henriques tell you?”
“He would tell me to activate my CALM MO.” It was the first time she had really thought about it as she was in a panic.
“That sounds interesting, what is that?” her mother asked.
“It says when you get stressed, take a perspective that is curious about what is happening, accepting of negative emotion, loving and compassionate toward self and others, and motivated to get the best outcome.”
“Ok,” her mother said. “Can we apply that here?”
And so they did. And it immediately began to transform how she was experiencing the event. One major shift was that she turned her “curious” attention to her father. She asked herself, with a curious attitude, what was he feeling and why. She quickly recalled he had been grumpy all day. It started when they had gotten lost, and the family was late to the tour. Her dad hates getting lost. And he was not happy about the transfer; he loved JMU and was really hoping she would graduate from there. And, of course, there was the rape incident that hung between them. Clearly, her going to a city and spending a night in a hotel with a boy activated that thought. What was he really trying to do? She asked herself. And a little voice told her that he was just trying to protect her.
This awareness immediately led to another insight. She had unacknowledged fears about what the rape would mean for her life. Would she always need to be looked after? Would she always be seen as vulnerable? Would others try to control her? Would she be judged as not being able to make good decisions? Yes. These thoughts resonated. This was why his reaction was so upsetting to her. It meant all of these things she secretly had feared.
With a much deeper understanding available, then the other pieces fell into place. She was in a much better place to accept her feelings. Yes, this sucked, but it was hardly torture. And both her father’s feeling and her own made perfect sense. So, she could hold a loving attitude toward both in the midst of the conflict. And the path forward seemed clear. Make the best out of the night and find a time to process this event with her father going forward. A half an hour later she and her mother were making popcorn and getting ready to watch a movie.
Just before the movie started, her mother commented, “That CALM MO thing really works, huh?” and they both chuckled and sank comfortably into the couch.
Gaining mastery in moments of intense emotional activation are the crucial learning events that lead to lasting change. And indeed, this event allowed Maggie a profound sense of mastery of her intrapsychic and interpersonal world. And it set the stage for two months of continued growth. She got a job. She altered her appearance, such that she starting leaning in to her physical attractiveness rather than trying to hide it. (Importantly, she now started to actually believe she was physically attractive). She also made many new friends and was really starting to flourish.
Her improvement was so dramatic that I thought we were basically ready to move to a more maintenance phase. However, real life isn’t about riding off into the sunset.
Phase 4: The Vicious Return of PTSD Nightmares
In the back half of the spring semester, Maggie was really starting to feel confident that the majority of her troubles were behind her. She heard about a sexual assault awareness event on campus and decided to go over and give a show of support. So, without much forethought, she went.
She was alone. The event was taking place in a large room. A primary activity was that folks were making T-shirts representing the assault in some way. She walked into a large room. She saw hundreds of T-shirts. The lights were bright. There were so many T-shirts. The room started to spin. She lost her breath. Images flashed. She felt a pain in her gut. She valiantly tried to activate a CALM MO perspective, but it was overloaded. She made her way to a counselor at the table and tried to say something, but nothing came out. She almost fainted. Then she saw a classmate she had talked to once or twice. She was also alone. The classmate said hi. She said hello back and they started talking. They spent two hours together sharing their stories.
She felt much calmer as she left. However, that night her nightmares returned. With a vengeance. The next day she was in a bit of a haze. She maintained her perspective and carried on. However, the following night, the same thing. And again on the third night. She called me and we moved our appointment up.
The next three weeks were tough. Nightmares every night. Exhaustion during the day. My frame was that we got a little over-confident, given how much progress she made. The nightmares were telling us there was still unfinished emotional business related to the rape. We talked more about what it could be. We hung in there. It was hard because it seemed her conscious self was largely at peace with it. But her subconscious self was not.
Eventually, the nightmares subsided. She was brave and strong and courageous and her system began to settle back down. But a problem had emerged that would give Maggie one additional lesson in working to adaptively regulate her feelings.
Phase 5: Learning Effective Self-Talk in the Moment
During the period in the spring semester when Maggie had been growing emotionally, she had been spending less time on her classes. Indeed, if there had been a positive point of focus for Maggie in the fall, it was her studies. The one positive attribute about herself she could (sort of) acknowledge was that she was smart. And so, she would focus on her studies in times of stress to prove to herself that she could get good grades. In the middle of the spring, with a much more active social life, she had started to fall behind on her studies. She figured that she could cram during the final month and really bring her grades up. And then she was bulldozed by the return of her nightmares and other PTSD symptoms. This had thrown her off her academics, as she was chronically fatigued and easily distracted. As her PTSD symptoms finally started to abate, it began to dawn on her she was seriously behind. She knew she was not going to do as well as she would like. In fact, she was so behind in chemistry that realized she might fail.
Her intelligence and good grades had been her anchor. When she was in her dark places, it was the one hook she could hang some pride on. As she came down from the PTSD resurgence, she awoke to the realization that the spring semester might bring a truly poor performance in her grades. This created a brutally strong negative wave of emotion.
The final phase of our treatment would be to teach her how to direct her cognitive system of justification toward effective self-talk.
“I am freaking out,” she told me. “I have no idea what I am doing in chemistry. The final is today. I am going to fail. My parents are going to kill me. I can’t function. What am I going to do?” Sobbing followed.
The Beckian cognitive approach teaches folks to separate the known, empirical facts from one’s interpretations and expectations. We went through what we knew factually of Maggie’s situation. The basic fact was that she did not understand several relevant concepts in chemistry and that her final was that day. That was the situation. But that was not really what Maggie was responding to emotionally. What was causing her to panic was the way she was interpreting and narrating her situation. She inferred that her difficulty understanding chemistry concepts meant that she would fail the final. And then, if she failed the final, she would fail the course. From that, she then came to believe that she would be “killed” by her parents. This image was horrible and intolerable because she believed that she would then be a failure as a person because she would have greatly disappointed the people that she loves. In other words, Maggie was in a panic because she had made a string of interpretations that led to a catastrophic expectation for the future.
I encouraged her to come on in for a special session. We spent two hours together, in which she was taught in the moment how to understand and gain insight into the vicious cycle of panic, how to identify her pattern of catastrophic thinking and how to replace those extremely negative interpretations with more realistic narratives about her situation.
The first thing I did to help Maggie was to identify how she wanted to be. That is, what was her valued state of being, given her capacities and situation? The current situation was that she was not understanding chemistry, that she was three hours away from taking her final and was fearful that if she failed chemistry bad things would happen. I basically narrated for Maggie two options. Option one was that we could focus on the worse possible outcome, blame her and the school for the unfairness of it all, and crawl up into a little ball, and weep like a baby. Option two was that we can see the difficult situation for what it was currently, understand what it might (or might not) mean for the future, and try to adapt to it in a way that minimized bad outcomes and taught her how to cope more effectively with stress.
Framed with the option, Maggie said, “Obviously, I want option two. But I don’t know how!”
To which I replied, “Exactly. You don’t know how. So we will teach you. Let’s get to work. Whatever your final grade is in chemistry, we can turn this into a growth experience because you don’t know how to cope with stressful life events without decompensating. But it is one of the most important things to learn living life as an adult.”
So Maggie came on down to my office, and I told her that we would start by doing what she would normally do. I had her bring in her chemistry book and so I told her to go ahead and proceed to study the part she wanted to learn about. She opened the book to the page, and within 30 seconds tears were running down her face. “I don’t know this. I missed two classes when I went home, remember? And besides, he sucks as an instructor. I barely understand it when I am there. I don’t know what I am doing. I am definitely going to fail this course.”
“See what happened, there?” I ask. “Looking at chemistry problems you don’t know gets you into a catastrophic narrative. Remember what I have taught you about thinking about your thinking. When you find yourself in a narrative like this, what are you supposed to ask yourself?”
Taking a deep breath she replied, “I am supposed to ask myself, ‘Is my thought accurate?’ and ‘Is it helpful?’.”
“So, is thinking that you are guaranteed to fail this course an accurate statement?”
“Well, I think so!” Then she chuckles through her tears, knowing what I would say. “I guess I don’t know for a fact I will fail. And, you are right, it does not help me to think I am going to fail. It only makes me panic.”
“Actually, it is appropriate for you to be concerned that it might happen, because it might. There is a grain of possible truth here. But focusing on it now and claiming it is certainly going to happen is neither fully accurate nor helpful. Given your situation, what would be most helpful?”
“I don’t know.” A pause. “I guess, based on what you’ve said, I need to focus on doing what I can to take the test with the best mindset I can and then try to cope with whatever happens.”
“Exactly. So, what can we do to get you into a better mindset.”
“I have no clue.”
“Well, is your final cumulative?”
“Did you understand any of it?”
“Well the stuff on covalent bonding was pretty straight forward. I also did well on that stuff on entropy and thermodynamics.”
“Teach me some of that stuff.” So, for the next 15 minutes she reviews stuff she knows. Her mood shifts.
“What are you thinking and feeling now?” I ask.
“I don’t know, I guess I feel a little better. I know some of this stuff pretty well and it will be on the final.”
“Do they ever curve the grades?” I ask.
“Yes, they curve the grades.”
“Listen, I have no idea what you are going to get on your chemistry final or for your final grade. But what I do know is that focusing on what you don’t know and catastrophizing future outcomes makes you miserable and puts you in no position to take the exam in an effective way. Remember what we talked about in earlier sessions regarding arousal and performance. Extreme anxiety is horrible for effective performance. Keep that in mind. Ok, let’s look at another section.” Maggie turns to a different chapter that is difficult for her. Again the tears begin to flow.
“Ok,” I ask. “What are the tears about?”
“My being smart is one of my good features. Looking at this tells me I am not smart. If that is true, then what do I have? Nothing!"
“Here again, notice how you frame your interpretations. Whereas before the negative focus was on your future and disapproval from your parents, now you are focusing on something fundamental about your character. Let’s test out this conclusion you have reached, namely that if someone can’t understand this section of your book, they are not fundamentally smart. Here, pass me the book.”
She hands it too me and I stare at the complicated chemical formula on the page. “I have no idea what this means. I guess I am an idiot, then.”
“No, of course, not” she says.
“But why not?”
“Because you are a professor of psychology.”
“But you’re a student who has blown off several classes for lots of different reasons and stopped paying attention to developing your chemistry skills. No one can learn this stuff who doesn’t try to learn it. As we both know, for a host of reasons you have not really been focused on your studies the last two months. The point here, Maggie, is that you are engaging in what I call a ‘character assassination’, which is that because you are in a less than ideal spot, you see yourself as fundamentally bad or unworthy in some way. A different and I believe more adaptive frame is that the situation is not ideal and we will learn from it. But that doesn’t mean you are fundamentally worthless or incompetent.”
“I know that at one level. But that just makes me feel like a loser. Why am I this way? Why can't I just think like a normal person?”
“Good question. And we have done lots of work together that I think helps you answer that question. You turned against yourself when you were 13 and developed a very strong inner critic. Because of your unique learning history, you build justification narratives for what is happening that tend to be pessimistic, catastrophizing, and self-blaming. There are lots of reasons for this. It keeps you somewhat submissive in conflict, it often drives you to perfection in ways that are associated with past success, and it has become a bit of a habit. But regardless of why you have learned to be this way, now the key point is that when you think this way, you feel like shit and when you feel like shit, your thoughts shift more toward thinking this way, so it is a cycle. The main issue that I want to help you see is that your narrator is a key part of your mental health. I want to help you see its connections between your feelings and your actions and how they are all interrelated. I want to help you see how those interrelations get you in maladaptive spaces. Through awareness of your thoughts, acceptance of where you are and who you are, and the idea of what is a realistically adaptive way of being that will move you toward your goals in the future, we can learn new pathways of dealing with stress.”
Maggie and I spent the next few hours together, practicing distraction (i.e., going for a walk), the CALM MO acceptance of her thoughts and feelings in the moment, the cognitive intervention of replacing extreme negative interpretations with more helpful ones, and going over the most adaptive game plan for the test (i.e., focus on the questions she knew, emphasize the thought that she can tolerate whatever the outcome might be, and stay with the test for as long as she can tolerate it, and hand it in before she decompensates into a full blown panic). Just before the test, she described herself as being in a “pretty good” mindset.
Maggie later returned to my office just to let me know she stayed fairly regulated during the exam. She felt like she probably failed it, but at least she was doing okay. The next day she wrote to tell me that she told her parents she probably failed chemistry, but actually was doing ok with it because she was training herself on how to cope. She said her parents were surprisingly cool with it.
A couple of days later, she returned home for the summer. A week later she wrote and told me she “somehow” ended up with a C in the course and was having a great summer. To which I wrote her the note: “I guess you did not ‘know’ you were going to fail after all. :o).”
The Final Phase: Consolidation and Maintenance with Chad
When Maggie came back in the fall we met for a few sessions. She had had a good summer. There had been a few bumps in the road with some family stressors, but nothing she had a difficult time managing. She had realized that because she does have a “sensitive” system, she will often have strong initial reactions, but everything changes when she relates to these feelings in the manner in which she had learned. And she was free of PTSD symptoms.
Given how well she was doing, we decided to transfer her over to Chad, the doctoral student she first encountered. Her work with Chad largely involved retelling the stories of the previous year and the lessons she learned from them. She also would use the space to develop new notions about herself and who she could be. She was really coming into her own as a computer programmer. She had experienced some sexist encounters, as computer programing is a very male dominated field. She worked with Chad on some of those issues and on basically building a sense of self on a very different foundation than she had during her early teenage years.
One day she came in with a big announcement. She had Chad keep it a secret and swung by my office.
“I am going to NASA for an internship next semester!” She was heading down to Florida in the next couple of months, where she would train with them in advanced computer engineering. Over the next few years, Maggie would continue to check in and update me on her latest. Her trajectory had changed.
She had re-written her narrative. Her relationships were different. Her emotions were different. Her self was different.
I asked Maggie if I could tell her story.
“Absolutely,” she said. “If it can give one person hope that there is something on the other side, I would be thrilled.”
“Pretty remarkable”, I said in a way that she knew honored her character. “Recall that at first, we could not even tell your mother.”
She chuckled. “Yeah, well, a lot has changed.”
Conclusion: Maggie’s Reasons for Living
I spoke briefly with Maggie about 13 Reasons before posting this article. “I hate that show,” she said. I asked Maggie to offer a summary of her experience as a way of reaching out to all those suffering individuals who are boxed in and feel like they have every reason to kill themselves. Here is what she said:
The treatment that I received from Dr. Gregg Henriques was lifesaving. This is not an exaggeration—I would not be here today if I had never met Gregg. After dealing with severe depression and the aftermath of a sexual assault, I wanted to kill myself. Indeed, I had tried several times previously and was convinced this time I would succeed. I came to Dr. Henriques in October of 2014, as I started to spiral out of control into another suicidal crisis̉—one I thought would be my last. The effects of this therapy were already visible by December, when I was hospitalized. Had I not been in treatment with Gregg, I would have killed myself then, but instead I checked myself into an inpatient treatment center because some hope had started to emerge deep inside of me. While it has not been an easy battle, I have since made a huge recovery. Years later I am not only glad that I did not end my life, but I am very happy to be living the life I am, as I am feeling hopeful and fulfilled in a way that I would have never guessed possible when I entered therapy. I know many college students are suffering with profound emotional problems and I hope that my story can help raise awareness and get them the help they need.