“I Don’t Deserve It”

We all need positives in our life, whether it is an occasional treat or a regular pleasurable event. Behavioural activation, or encouraging people to build new positive experiences is a recognised treatment for depression. But what do we do when the client is aware of that, and although rewarding activities are available they are inhibited from accessing them by the belief, “I don’t deserve it”?

This obstacle comes up a lot when the client has high shame, perhaps they feel bad because of their mental health problems, or because of previous behaviour. When I consult to prison Mental Health teams they often report clients saying; “How can I deserve anything good when I’ve committed a crime?” Sometimes, though, there is no logical reason at all. Clients with low self-worth maintain that it’s as if everything has to be earned, and they are all out of ‘deserving’ points.

There was a time when I would engage in providing contradictory evidence to the client, reasons to justify that they did indeed deserve whatever was on offer. As you might guess, half the clients experienced this as invalidating. The other half found it pseudo-reassuring; “My therapist thinks I deserve it” works briefly, until the next time, when further encouragement is required. We sometimes help people to side-step this dilemma by asking “what would you say to a friend?” but then the client may maintain a covert rebuttal, visibly agreeing, whilst all the time thinking yes, but it’s not the same for me…blog2b

As a behaviourist I now enquire much more about the nature of this phenomenon. How does this undeservedness manifest? Can the client describe it mindfully?  A familiar pattern is that a physiological sensation in the gut happens first, almost like that sign outside a supermarket – ‘Trollies will stop suddenly as they are wheeled past this point.’ It is an uncomfortable sensation accompanied by the thought, “I don’t deserve it” and an irresistible urge to cease or recoil from the activity.

For a number of clients in addition to the sensations and thoughts there will be an association. One of my clients could momentarily ‘hear’ in her mind her mother saying, “You’ve caused us so much misery”. For another there was an image of her stepfather glowering at her. A third would picture her children as they were taken into care. These were very powerful inhibitors, allowing me to validate; “If that happened to me every time I was going to do something nice for myself, I would also think twice.”

Sometimes there are additional controlling variables within the environment. One client told me her partner asked “why didn’t you buy that scarf if you liked it?” when she said “I don’t deserve it” he become irritated and said she was not doing enough to help herself. Sadly his annoyance was entirely consistent with her own view of herself, inadvertently confirming her ‘undeserving’ status.

There is one more inhibitor to recognise; clients have past experience of enjoyment being paired with guilt. This sets up conditions where anticipatory guilt produces the involuntary stomach-clenching which then sets off the thoughts and images, plus the urge to avoid. And so the cycle persists.

It can be really helpful to summarise these very valid reasons for not doing pleasant activities; “You get some anticipatory guilt, a horrid sensation in your stomach, a thought about being undeserving, and associations with unpleasant memories. These factors strip away any pleasure while even considering the activity. Then, if you decide not to do it, all those aversive things vanish. No wonder you feel reluctant.”

So we encourage the client to accept that for them, at least at first, this is going to be unpleasant. The key phrase is, “You are going to have to learn how to do these things even in the presence of the urge to avoid doing them”. This strategy has two helpful components, firstly it is congruent with the person’s subjective experience, and secondly it relieves them of the notion that they are doing something inherently enjoyable, so they don’t have to worry about being ‘deserving’.

Next we can advise clients to simply observe the thought, “I don’t deserve it” whenever it crops up, and return their focus to doing the activity mindfully. This means if either a body sensation, another thought, an association or an emotion shows up they reorient their attention away from it and onto the required task. Breaking it down into these components allows them to label, “That’s a thought” or “that’s a sensation” as an aid to unhooking from it.

So why would they do this at all? Well, we encourage them to use their mindfulness skills to capture even one moment of reward before any guilt kicks in. That’s all, one moment.  We will foster curiosity about it; invite them to just notice any pleasure as it arrives, and also to accept whatever follows. The person learns that whilst ignoring the obstacle of “I don’t deserve it” they can still experience joy. Over time the vicious cycle is broken and the client’s capacity to be open to the whole range of emotion increases.

For further insights into helping clients to have more compassion for themselves see Paul Gilbert on Compassion-Focused therapy  http://bit.ly/1l9BpYo

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“I just woke up that way”

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If your client or patient reports that suicidality occurs immediately on waking, it can be helpful to do an analysis of those initial moments in which the urge occurs.

First – was that the very first thought that went through the person’s mind? Like; Wham! – I’m awake, now I want to kill myself. Usually it doesn’t happen that way. Sometimes the client wakes and gets a physical sensation – perhaps pain due to illness or injury. Is there some physically draining health condition that just wears this person down? So much so that becoming conscious of it immediately prompts the desire to escape. Can this be problem-solved or can the physical pain be mitigated in some way? How long is it since they had a pain review?

Although early morning low mood is a symptom of depression, don’t assume that’s all there is to it.  On waking is the person predicting an unwanted event. In my experience this often consists of social circumstances in which the person feels trapped; The abusive partner, financial problems, childcare issues, work stress. Can the therapist and client make a plan to change this thing or if not, add in some other factors to make it more bearable? Is there something the client says they cannot face that is likely to happen in that particular day? There is nothing worse than predicting an unpleasant event and then having to actually deal with it. The golden rule – help the person both deal with the problem when they get to it, and also cherish the moments in which it is not happening.

Sometimes it is not a feared event, but anticipation of non-events. The client can see nothing that has meaning for them in the day to come. Even if they can identify such a thing, they can’t work out how to get it. The hardest part here for the therapist is that it always (always) takes time to build those positives, and it is hard to get ones feet on the path when the destination feels impossibly far away. This problem sometimes presents as a kind of regret-paralysis, wishing to turn back the clock and make different decisions. When this happens it is energy-sapping, and so the client has no reserves to put into creating the new future. Mindfulness can really help here. Sometimes the patient can see a better future but feels blocked from it, “I want to leave my partner but it would cause too much heartache”. But hey, ALL not-dying options trump the others, right? Even the world-rocking ones.

For some the fear is in the past – manifesting as traumatic memories. If this is a symptom of PTSD then the client should be encouraged to seek proper prolonged exposure therapy. This can be a daunting prospect so is it possible for them to speak to someone who has had the same treatment and recovered?

Finally some clients deal with relentless pressure on a daily basis without being suicidal, and then exhaustion just crashes through their resilience. This is the equivalent of running 20 miles of a marathon and then crumbling under the weight of one’s backpack with 6 miles still to go. Suicide masquerades as a comfy resting place. Is there something that has overtaxed the client’s resources on this particular day? Can the therapist help them to get some respite without quitting the race? Has a protective factor been lost? Can it be replaced?

From my experience clients really appreciate the feeling that whatever problem they face, they and the therapist or care worker are in it together – getting their two detective heads on the issue and working on solving it. To really feel this co-bearing effect the therapist needs to add in non-routine contacts, an extra call, a card, a text. Genuine human connection with the client, honouring their problem. Just to say, “I’m thinking of you, I’m sending good vibes, I think we can work this out together, stay in this, we can do it.” in this way the therapist is lending their own energy and resources to the client to effect problem-solving until the suicidal crisis passes. “Let’s break this thing down into what we can do today to move closer to a better future, and what we can do after that, one step at a time.” Suicidality is transient. It WILL pass.

When working with upon-waking suicidality I have always suggested the client make an environmental change immediately to remind them we’re now problem-solving; Turn their bed 90 degrees, or put their head at the foot end, pull the mattress onto the floor if necessary. Wake up in a different physical space to begin the journey to a different mental space. Mostly clients’ predictions and fears have a lot of validity, but that does not mean they are unsolvable. It’s a journey, and one that is better shared.