M. K. was a 40-year-old, hard-driving director of a research institute at a major university. He was admitted to a hospital because of a major depressive disorder and generalized anxiety disorder. During the depressive episode he had strong beliefs, such as, "I am worthless. I am useless. I am a burden to my family." The therapist transformed those ideas into hypotheses about himself that could be tested. Through Socratic questioning, the application of logic, and empirical testing, the patient was able to regard the notions as testable beliefs, rather than as reality. The cognitive interventions effectively contradicted his notions; as those beliefs were attenuated, his depressive and anxious symptoms dissipated.
Both the patient and the therapist realized that the patient was skating on thin ice because of his personality problems, which consisted of a mixture of compulsive and narcissistic features. The patient put tremendous emphasis on achievement, systems, high productivity, efficiency, and perfectionism. At first, he regarded those values as normal, healthy, and adaptive, but he came to see himself as driven by his beliefs relevant to the necessity for high-level achievement. When those traits were translated into beliefs, he began to see how dysfunctional they were. In order for him to fully understand his beliefs and to gain perspective on them, the therapist explored their origin during the developmental period of the patient's life so that he could see that they were not beliefs that he arrived at on the basis of rational decision but, rather, that they had been imprinted on him by his parents.
The patient, an only child, had a tough, demanding father who imposed high expectations on him. The patient observed his father withdraw approval from him when he did not perform extremely well in school; also, the patient observed his mother criticize his farther for his supposed inadequacies. The patient learned the following rule as a child: "I must do extremely well to be accepted, or else I risk others' disapproval and withdrawal of their respect and caring." At times--for example, when his best friend was promoted ahead of him--he had the thought, "I'm inadequate."
The patient coped with the painful beliefs of inadequacy and fear of rejection by developing and living up to extremely high standards. He crystallized a cluster of beliefs: "I must be the best at everything I do. It isn't enough to excel at one thing. If I have the potential in any area, I must live up to that potential in each of those areas."
For many years he did fulfill his potential in professional areas as a biochemical researcher. That success strengthened the belief "I can and should excel at everything now and in the future." But there were problems inherent in that belief. He paid a tremendous personal price for overvaluing professional achievements. He had no time to smell the roses, to nurture his wife and children, to appreciate the joys of nature, to replenish himself physically and emotionally. He suffered from chronic anxiety, sleep problems, and psychosomatic symptoms, and he could not continue to increase his scientific achievements over a long period of time.
External factors interfered with achievement: increased administrative demands, scarcer funding, changes in the attitude and the loyalty of faculty members who wished to go elsewhere, and increased requirements from a new institute president. His time and energy were finite, yet the external factors, over which he had no control, continued to escalate. And he could not gracefully accept the real limitations on high-level productivity. Instead, he blamed hmself [sic]--"I'm inadequate."
He was particularly vulnerable to an anxiety disorder when he perceived that he might not have the resources to cope with a situation in which his achievement was at risk. He was vulnerable to depressive disorders when he was forced to take time out because of overwork. When anxious, he felt as though he were on a tightrope, fearing that, with one misstep, he would fall all the way down. When depressed, he saw himself as inadequate or as a failure: "If I were really adequate, I could continue to achieve. Since I can't achieve to the same level as previously, it means I'm inadequate."
The therapy consisted of delineating and modifying the dysfunctional beliefs. The therapist explored with him his perfectionistic, dichotomized view of success: "Either I live up to my potential in all areas, or I've failed." (Again, one misstep felt fatal to him.) He believed that he must continuously drive himself to stay at the top because even one step below the top was equal to failure (in his mind). In addition, he was hypersensitive to and became either anxious or irritated at perceived obstacles to smooth functioning: signs of physical or emotional illness in himself, a secretary's mistake, the lateness of others' reports--in short, anything that could interfere with his optimal achievement.
The therapist helped the patient fashion more functional beliefs: (1) "It is rewarding to succeed highly, but less success is rewarding also and has no bearing on my adequacy or inadequacy. I am adequate, no matter what." (2) "Scientific achievement is important but not vital." (3) "What is vital is a reasonable mix of achievement, emotional and physical well-being, an enriching family and social life, joy in recreation, relaxation, nature, and spiritual and personal growth." (4) "It is impossible for anyone to achieve that vital balance if any one area is overvalued."
In the course of therapy, extending over a year, the patient's dysfunctional attitudes were gradually attenuated, and the new attitudes were incorporated. He continued to have a few miniepisodes of anxiety and depressive disorders but no full-blown recurrences of the clinical disorders.