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…
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