159: Live Therapy with Marilyn: "What if I die without having lived a meaningful life?"

The Secret of a Meaningful Life

One of my favorite podcasts of all time, and one of the most frequently downloaded, was the live session with Daisy (podcast #79): “What’s the Secret of a Meaningful Life?” You may recall that Daisy and her husband, Zane, were looking forward with dread to the possibility of childlessness, since their efforts at pregnancy had so far failed, and Daisy was asking if she could possibly have a joyful and meaningful life without children.

In today’s podcast we return to the same type of question from the other end of the spectrum. When we age and look back on our lives, and realize that our days are numbered, we may once again, "Have I lived a meaningful life?"

Do you know how to answer this question? What, in your opinion, is the secret of a meaningful life?

If the answer to this question is important to you, you might enjoy today’s podcast, which features, once again, two beloved friends and colleagues, Dr. Marilyn Coffee and Dr. Matthew May.

Matt and I first treated Marilyn for intense depression, anxiety, and anger two years ago at the time of her unexpected and shocking diagnosis of Stage 4 non-smoker’s lung cancer. Marilyn was incredibly depressed and panicky, as you might imagine. If you are interested, you can listen to our initial treatment of Marilyn in podcast #49, “The Dark Night of the Soul.”

One of Marilyn's concerns at that time was that she had lost her faith in God and had begun to doubt the existence of an after-life. She was intensely self-critical and ashamed, and was also extremely angry because she began doubting her spiritual teachers and thinking of them as frauds.

These doubts were all the more troubling to Marilyn, since she’d been a devout Catholic for her entire life. In fact, she  even has a Master’s Degree in theology, along with several additional Master’s Degrees plus a PhD in clinical psychology! But now she was terrified by the prospect of her own death.

During that initial treatment session, Marilyn overcome her fears, depression, and doubts, and ended up in a state of joy, and even laughter. This rapid transformation confirmed the basis of cognitive therapy, that our emotional pain results from our thoughts, and not from what is actually happening to us. And the thoughts that cause depression and anxiety will be distorted and cruel--I've often said that depression and anxiety are the world's oldest cons.

Following that session, we were flooded with emails praising Marilyn. Oddly enough, many people said she was their spiritual hero. They said they were stunned and grateful her raw courage, testimony, and honesty.

Now, it’s two years later. Sadly, Marilyn has just learned from her doctors that she’s had numerous metastases, and that her lung cancer has spread to the opposite lung, as well as to her bones, brain, liver, and lymph nodes. Marilyn is understandably paralyzed once again by overwhelming feelings of depression, anxiety, shame, hopelessness, and anger.

Today’s podcast is based on our most recent session with Marilyn about two weeks ago. I have to warn you that the session may be sobering, and even a bit terrifying, but hopefully you will find it to be inspirational and helpful, because sooner or later, we’ll all have to share the prospect of facing our own inevitable death, and asking ourselves, “Have I had a meaningful life?”

We scheduled this follow-up live therapy podcast for three reasons. First, we hoped to provide Marilyn with some relief from the devastating depression that had returned when she learned of her metastases. Second, we wanted to give you, and all of Marilyn’s many fans, an update on what’s happened in the past two years. And third, Marilyn wanted the chance to tell you about some of the positives in her life, since she so often mentions her failures, such as her bouts with alcoholism, and the fact that she never found a loving partner.

Every TEAM session begins with T = Testing. You can see her scores on the Brief Mood Survey she filled out just before the session began. (link) All her scores reflect the most severe negative feelings a human being can experience. Marilyn has extraordinarily severe depression, anxiety, and anger, and her positive feelings are totally absent.

Marilyn brought a partially completed Daily Mood Log to the session. If you take a look, you'll see all of her intensely Negative Thoughts and devastating feelings about the spread of her cancer. 

During the E = Empathy phase, Matt, Rhonda and I gave Marilyn the space she needed to vent and describe her despair and feelings of terror. We did not try to help or cheer her up. Marilyn cried as she described her fear of dying alone, and vividly recalled a friend who died a horrible death from lung cancer 20 years ago. Marilyn says he could barely breathe, and fears a similar horrific fate.

Marilyn cries, and confesses that she has not been able to cry up until now. She says she suddenly felt a spiritual presence being around Matt, Rhonda, and David.

During the Empathy phase, Matt made many tender comments to Marilyn, shared his own profound sadness, and told Marilyn that joining us today is a gift to him, and to all of us.

Matt and I asked Marilyn how we were doing in Empathy, in terms of understanding how she was thinking and feeling, and whether we were providing warmth, acceptance and support. She gave us high grades. When you listen, please notice that we didn’t do anything to try to help Marilyn, or to try to cheer her up. You can hear Matt simply paraphrasing much of what Marilyn had been saying, acknowledging her feelings, and sharing his own feelings of sadness and warmth toward Marilyn.

After about 25 minutes of empathy, we moved on to the next phase of the session called A = Assessment of Resistance (formerly called Paradoxical Agenda Setting.) We started by asking Marilyn if she wanted any help with the problems she'd been describing, or if she needed more time to talk while we listened and provided support. 

She said that she did want help. Since her remaining time was potentially short, she said she didn’t want to spend it in the misery of overwhelming depression, anxiety, worthlessness, shame, loneliness, hopelessness, and rage.

Then I asked the Magic Button question—If we had a Magic Dial, and all of her negative thoughts and feelings would instantly disappear, with no effort at all, simply by pressing it, would she press the button?

Marilyn immediately said that she WOULD press the button. Almost everybody says this. And it seems obvious. Why would anyone want to feel intense, relentless and overwhelming negative emotions?

Matt, Rhonda, and David debated about whether or not the A = Assessment of Resistance would be needed, since it seemed like Marilyn was suffering so much that she would OBVIOUSLY want help.

We decided to address the resistance, since whenever we’ve skipped it, we’ve usually regretted it.

So just to be safe, we decided to do some Positive Reframing, and asked these two questions about each of the nine categories of intense negative feelings on Marilyn's Daily Mood Log, such as depression, anxiety, guilt, inferiority, loneliness, hopelessness, rage, and so forth.

1. What does this negative feeling show about you and your core values that’s beautiful, positive and even awesome?
2. What are some benefits of this negative feeling? How might it help you?

Surprisingly, Marilyn came up with a list of more than 20 positives with some help from Rhonda, Matt and me. You can take a look at her Positive Reframing List. This process seemed to have a profound calming effect on Marilyn, just as it does on most people.

I think one reason is that culture / society have trained all of us \to think about our negative feelings as defects, or “mental disorders,” like the many that are listed in the DSM5. Positive Reframing turns all of this upside down, and makes you proud of your negative feelings. Paradoxically, this make it possible for you to get rid of the feelings quickly.

We concluded with the Magic Dial, and asked Marilyn what she might want to dial her feelings down to, without getting rid of them completely, since they did have many benefits, and since they also reflected what was most beautiful about her.

You can see the result of the Magic Dial on her Daily Mood Log, in the “% Goal” column of her table of negative emotions. For example, she wanted to dial her depression down to 10%, but thought that she'd want to keep the anxiety in the range of 20 - 25. But she said she'd be happy to dial the guilt and shame all the way to zero!

After the A = Assessment of Resistance, which seemed to lift her mood considerably, we went on to M = Methods. After easily identifying the distortions in her thoughts, like All-or-Nothing Thinking, Self-Blame, hidden Should Statements, and more, Marilyn was able to challenge and crush her Negative Thoughts pretty quickly using the Paradoxical Double Standard Technique as well as Externalization of Voices. Two strategies seemed important—the Self-Defense Paradigm and the Acceptance Paradox.

I emphasized the overlap between the Acceptance Paradox and Marilyn’s Catholic faith. It is the idea that you cannot, and not have to, earn your way to heaven through your good works. Christianity is based on the idea that we are not saved by our achievements or good work, but rather by the grace of God--which is simply the acceptance of our flawed nature. David emphasizes that these ideas are not exclusive to Christianity, but are woven into most if not all religions.

During this phase of the session, Marilyn reflected on some of the experiences that she’s proud of, things she would like you to know about, like her trip to Nicaragua to attend seminary at the Franciscan School of Theology. During that time, she worked with the oppressed indigenous people in relocation camps following the bombings, and joined the Witness for Peace group.  She describes this as "one of the most transformative and spiritual experiences of my life."

Many of you are probably not familiar with Marilyn's fairly extensive arrest record, which she is equally proud of! She explains:

"During the 80s and early 90s, I was arrested several times for political protests, primarily at the Federal Building in San Francisco.  For example, I participated in a major non-violent prayful march at Lawrence Livermore Laboratory.  Several of us were arrested and spent a month in jail (tents on the grounds of Santa Rita Jail.)"

Marilyn also wants to know that she was "a damn good therapist." That's something I can attest to, having presented with Marilyn on many occasions, including our empathy workshop at one of the prestigious Evolution of Psychotherapy conferences in Anaheim, California.

And still, all of her amazing accomplishments and contributions do not protect her, or any of us, from falling into a black hole of self-doubt and despair from time to time, and when Marilyn falls, the pain she inflicts on herself can be intense. You may notice that the Negative Thoughts on her Daily Mood Log today are very similar to the Negative Thoughts on her Daily Mood Log from two years earlier, during our first session with Marilyn. This confirms the concept of “fractal psychotherapy.” In other words, all of your suffering will be encapsulated in any one brief moment when you are upset. And when you suffer again in the future, it will be that same fractal--the same exact pattern of negative thoughts, distortions and feelings. This is really good news, because the methods that helped you recover initially will be helpful for you when you again fall into the black hole of depression.

The goal of TEAM-CBT is NOT eternal happiness--no human being is capable of that! Rather, the goal is to understand and master the tools that will be helpful for you.

One important teaching point is that Marilyn’s suffering, once again, does not result from her cancer, but rather from her self-critical thoughts, which are both cruel and distorted. She’s been telling herself that she is not religious enough, that she has lost her faith, and that her life has not been meaningful. Fortunately, these Negative Thoughts can easily be challenged and defeated, as you will hear on the podcast.

The entire basis of cognitive therapy is a spiritual idea, that “the truth shall make you free.” Although this is a core Christian teaching from the New Testament (John 8: 32), it is an idea that’s embedded in many religions, including Buddhism, and probably in every religion.

Toward the end of the session, Marilyn described inspiring moments when she feels the most spiritual and the most alive. It’s when she notices and profoundly appreciates the simple things in her life, like seeing a sliver of the moon in the evening when walking her dogs, watching a sunset on the beach at Santa Cruz, her first sip of latte in the morning or a bite of a delicious peach!

Marilyn also described the intense mourning she feels for people throughout the world who are in poverty or pain. She also grieves for animals who are suffering, and feels devastated by the destruction of our natural resources, such as the rain forests in Brazil.

You can see the final T = Testing . As you can see, she met or exceeded her goals for all of her negative feelings. You may be puzzled by the end of session rating for sadness and depression was "50%, but a GOOD 50%!"

Sometimes, feelings of sadness and grief, once the distortions have been eliminated, are are the experiences that can wake us up, and provide the profound sense of meaning we are craving in our lives. The highest human experience, perhaps, is the compassion we sometimes feel for ourselves and others who are suffering. In fact, this may be the true meaning of spirituality.

I call this feeling, "Sadness as Celebration," and hope to write and talk more about it in a future podcast. 

At the end of the session, Marilyn said, “I feel light!” And gave us all big hugs.

Will it last? Matt wisely suggests some terrific Relapse Prevention Training that you will hear when you listen to the session. Of course, it will be up to Marilyn--and to all of us--to pick up these tools and use them when we again fall into a black hole. This is also an inherently spiritual idea, and is based on the idea that we have the freedom to chose light or darkness.

After the session, Marilyn emailed me and asked if I could include a few additional comments in the show notes. Here’s what she wrote:

Greetings David, my dearest friend,

Words cannot express my gratitude for you, Matt, & Rhonda - what special gifts you are.

I hope the podcast was ok. I am deeply embarrassed because I forgot to express my gratitude and surprise from all the e-mails we received - the compassion and support was/is overwhelming. I hope I can give back! I could never had done this, if I weren’t for you & Matt - and your amazing & compassionate skills.

I also forgot to mention that I probably will never get to New York or Ireland because of finances. I take one day at a time and try to be grateful for the small miracles.

I go to Stanford next Tuesday. I will definitely be in touch.

Thank you again.

I also forgot to mention this - which is VERY important is that I am going through this process sober - not avoiding with alcohol. I am going to more meetings & speaking up.

Thank you again. I cherish our friendship.

With deep gratitude and love. dear friend,

Marilyn

Thank you, Marilyn, for this incredible gift to all of us!

Matt, David, and Rhonda