Clinical Case: Individual Experiencing Anxiety and Depression

Individual Experiencing Depression

Stan, a 39 year old, single, accountant, requested counselling saying that he was feeling stressed and burned out on the job. He had started to feel this way shortly after being overlooked for a promotion that he had coveted and believed he deserved. Although he was trying to maintain his usual compulsive work ethic, he was accomplishing little. He reported feeling less motivated, having disrupted sleep, having difficulty concentrating, being less interested in activities, feeling empty and worrying more than usual, particularly about his ability to be promoted in the future. Although he described himself as somewhat introverted, he was avoiding people more as well. He had been spending more time than usual at night on the internet playing games, surfing, and watching Netflix. As well, he had been drinking up to four glasses of wine at night to relax. It was evident that he was struggling with symptoms of anxiety and depression.

I validated his efforts to keep working despite feeling more anxious and depressed, and indicated I would be happy to help him feel better. I stated that I use a comprehensive approach to treat anxiety and depression by helping people change thoughts, feelings and behaviors. Because change is difficult, I said that counselling would require a real commitment of time, effort, and resources on his part. Stan said that he hadn’t felt off like this before and was motivated to try counselling because he wanted to feel himself again. I explained that I would begin by helping him to change thoughts that were contributing to his anxiety and depression.

(To the reader: Please note that, although for didactic purposes I present changing thoughts, behaviors, and feelings in this hypothetical clinical case study in a linear fashion, in actuality the process of change is more fluid and circular with respect to changing thoughts, feelings and behaviors).

Changing Thoughts

As an adult, Stan worked as an accountant in the finance department of a large firm. He took pride in his long hours of work and the recognition he received. He had always aspired to a higher position, and when an opportunity had presented itself recently, he had felt confidant that he would be rewarded for his intelligence and years of service by being promoted. When the company chose to go with an outsider, he felt angry initially but quickly fell into feeling despondent and anxious.

When I asked Stan to describe the thoughts he had toward himself when he felt at his worst, he identified telling himself, “I’m a failure. Now I’ll never get ahead.” When I suggested that Stan was listening to a negative thought process or negative inner voice, and that the more he listened to this voice the more anxious and depressed he felt, he was intrigued and open to learning more about the negative inner voice.

I explained that, as conceptualized by Dr. Robert Firestone in Conquer Your Critical Inner Voice, the negative inner voice or “voice” refers to a well-integrated pattern of negative thoughts and attitudes about self and others. It is a destructive overlay on the healthy self, an alien point of view about the self and others. Because the inner voice is internalized at a young age, people experience it as compelling, highly convincing, and matter of fact. Because the voice is so familiar and only partially in awareness, people are often unaware of it or its adverse impact on their emotional well-being.

Dealing with the voice requires separating this destructive thought process out from one’s healthy point of view about self and others. What is required is a shift from listening uncritically to the voice and falling under its influence to not listening to it and not falling under its influence. Dr. Robert Firestone has developed a procedure for doing this called Externalizing the Voice. He suggests “saying the voice” out loud in the 2nd person, “You“, as if someone else is talking to oneself. He also suggests saying the voice in the 2nd person with the emotional tone that it has in one’s head. By following this procedure, people have an experience of the voice as a hostile, alien point of view about themselves, like an enemy within, which is not in their best interest to listen to. Once people externalize the voice, they are encouraged to talk back to the voice from a clear, compassionate, healthy point of view about themselves. The steps in this procedure, then, are: 1) awareness of the negative voice, 2) externalizing the voice by saying it in the 2nd person “You” and 3) talking back to the voice from one’s healthy point of view about oneself.

Stan learned to say the voices that fueled his anxiety and depression in the 2nd person, as if someone else was addressing him. Rather than telling himself in the 1st person, “I’m a failure! I’ll never get ahead”, he externalized the voice out loud by saying it in the 2nd person: “You’re a failure. You’ll never get ahead.” When I suggested that he say this again, giving it the tone and intensity that it had in his head, he spoke in a louder, harsher voice: “What’s wrong with you! You’re such a failure! You always manage to mess things up!   You’ll never get ahead.”

After doing this, when Stan remained quiet with a sad demeanor, I asked him to describe what was happening inside. He said, “Talking to myself out loud like that makes it sound ridiculous”. Then, he added in a subdued voice, “I’m so hard on myself.” I validated his awareness of being hard on himself, and then suggested that, not only was he hard on himself by being self-critical, but also by frightening himself. When he asked for clarification about the latter, I noted that the voice seemed to have not only a critical tone but also a catastrophizing tone. Stan hadn’t realized he had been fuelling his own anxiety by listening to the negative inner voice.

I suggested that he talk back to the voice from his healthy point of view about himself. After some coaching in which I modeled stronger ways of talking back to the voice, he answered back convincingly: “I may have made some mistakes in the interview, but there’s nothing wrong with me and I am not a failure. I will ask for feedback and learn from my mistakes. I know who I am in my work. There will be other opportunities for advancement, if not with this company, then with others.”

When I asked him if the tone of the voice was familiar to him, he said it reminded him of his mother who was often critical toward him and overly worried about him. When I asked him if he thought he had deserved to be treated this way as a boy, he said no. I suggested that, whenever he was aware of the voice attacking him in a critical manner or frightening him by catastrophizing, he remind himself that it belonged to his mother when she was at her worst behavior. Moreover, I noted that he didn’t deserve to feel bad about himself or frightened. Finally, I encouraged him to externalize the voice either by saying it out loud or by writing it down, and then to answer back from a clear, compassionate, healthy point of view about himself.

As Stan started to do this, he became more aware of how much the voice was contributing to his anxiety and depression. Also, he began to feel more in control of his mood as his anxiety diminished and his depression lightened. I validated his effort and progress, suggesting that we shift our focus from changing thoughts to changing behaviors because this also helps us to feel better.

Changing Behaviors

A discussion about how he spent his time outside of work indicated that since feeling depressed, he was spending more time at night playing computer games, surfing, and watching Netflix rather than going to the gym or working on projects. Whereas before he drank only on weekends socially, now he was having up to four drinks daily weeknights. On weekends, now he had little interest in spending time with his friends, none of whom he had confided in about how he was feeling. Because now he had less interest in food, he had let his eating habits slip. Also, because now he found it harder to fall asleep, he was staying up later at night on screens which compounded his difficulty falling asleep.

Empathizing with how hard it was to motivate himself to exercise when his energy was low due to feeling depressed, I initiated a conversation about exercise. Noting the importance of the mind-body connection, I explained that activation of the body through exercise is one of the best ways to improve mood and to reduce anxiety. When Stan said that he couldn’t see himself getting back to the gym at this point, I asked him what other physical activity that he found enjoyable he could see himself doing. He said that he liked to walk, particularly in nature, and agreed to take a short walk over lunch workdays in a park either by himself or when possible with a colleague. I reminded him to be aware of how the negative inner voice might rationalize his not following through on this decision, and to answer back to it.

Next, empathizing with Stan about how he was not inclined to spend time with people when feeling down, I explained how affiliation, and in particular talking, also improves mood and reduces anxiety. I made the corrective suggestion that Stan move toward family and friends for contact and that he reveal his current emotional state. Stan said he didn’t want to burden people with his problems and that he was used to solving his own problems. I acknowledged that talking more openly about himself wouldn’t be easy, and suggested that he take a small step by identifying one or two people he trusted whom he could slowly begin to reveal himself to. More specifically, I suggested that he give them a “job description”; namely, informing them that he wasn’t expecting them to give him advice or cheer him up, but rather wanted them to hear how he was struggling emotionally.   He didn’t feel close enough to his parents to confide in them, but agreed to talk to a male friend about his emotional state. Again, I reminded him to anticipate how the negative inner voice might rationalize his avoiding reaching out and to go against it.

Stan had felt rejected by women he had loved a few times in his life, the most recent being three years ago. Since then he had felt cynical about love, and was reluctant to try again. Empathizing with how painful rejection is, I made the corrective suggestion that he explore contact with women, not necessarily to date but for friendship. Stan joined a hiking group and began enjoying contact with a couple of woman there.

Other corrective, behavioral changes that Stan agreed to were: 1) to limit his use of alcohol (a depressant) to weekends by not keeping it in his house, 2) to learn to meditate using mindfulness meditation, a breath-focused approach to meditation that research shows has numerous health benefits in addition to reducing anxiety by calming the body and quieting the mind, 3) to resume healthier eating by doing meal preparation on the weekend in order to have more nutritious food on hand, 4) to improve sleep hygiene by turning off all screens by 9:00 pm followed by listening to classical music, reading and meditating before lights out, and 5) to limit employment to regular hours by leaving work when his colleagues did.

The last corrective, behavioral suggestion in particular triggered increased voice attacks and associated anxiety. For example, Stan externalized a voice, “If you only work regular hours, you won’t get ahead.” With my support, he “sweated out” the anxiety triggered by this voice. With time, he began to like the benefits of a healthier, work-life balance.

As Stan acted on the above corrective, behavioral suggestions, his symptoms of anxiety and depression lifted further and he began to feel more himself. I complimented Stan for his commitment to change and suggested we now turn to changing feelings.

Changing Feelings

I explained that changing feelings is the most challenging and time consuming aspect of treating anxiety and depression, and that before helping him to change the distressing feelings that underlay his emotional state, it was important to learn more about his past and to teach him about intrusive feelings. When Dan said that he was up to the challenge, we started with an exploration of his childhood through early adulthood.

In learning about his background, when I asked if it was okay to talk about what he knew about his parent’s circumstances when his mother was pregnant with him, his birth, and the first year of his life, he seemed surprised but was cooperative when I explained that recent research shows that this early part of life has an enduring impact on our happiness and adjustment as adults. After trying to conceive for years, he had come along when his parents had resigned themselves to being childless. His parents had been ambivalent about having him because they were in their late 30’s, but decided there must have been a reason that they had conceived when they did and went through with the pregnancy.

From what Stan knew about his birth, he had had been delivered by forceps after a long labour. His mom had returned to work after about six months because her career was important to her. Lacking the support of extended family, he had been cared for by a neighbour while his mom was at work. Although his mother had attempted breastfeeding, he had been bottle fed early on. Apparently he was a fussy baby, difficult to feed, and a poor sleeper. His mom said his sleep improved after they let him “cry it out”.

When asked to describe his parents through the eyes of himself as a five to seven year old, Stan, an only child, stated that his father was a “great guy” and that his mom was “always there”. Deeper probing indicated that his dad had been absent largely because of his job as a salesman, and not very involved in Stan’s life. Deeper exploration indicated that his mother had been career focused as well as critical and somewhat anxious.

When asked to describe what his childhood was like, Stan stated he had had a normal childhood. Deeper probing indicated that he had had difficulty separating from home when he started kindergarten. Although his initial anxiety about going to school subsided gradually, Stan didn’t like elementary school very much because he was teased for being smart and felt rejected by his peers.

Stan couldn’t recall his parents showing affection to him. He remembered how frightened he felt when they were fighting. Although his parents never separated, often he feared this would happen and tried hard not to be a bother so that they would stay together. He recalled how bad he felt about himself when his mom was critical of his making a mess or not living up to her high standards. When Stan felt upset, he didn’t recall either of his parents being sensitive to his feelings.

When asked how he spent his time, he reported having an active imagination and playing alone a lot. Also, he read voraciously, distracting himself from feelings by escaping into books and comics.

As a teenager, Stan was not involved in sports and didn’t date much. However, he had a more positive experience in high school than elementary school, because he received recognition for his intelligence from some of the jocks whom he helped with homework. He took pride in his intelligence and continued to find solace in reading.

Having explored Stan’s childhood and later development, I proceeded to introduce him to Dr. Geoffrey Carr’s theory of intrusive feelings in order to help him better understand his feelings.

Intrusive Feelings

Stan could recall distressing feelings growing up – such as the fear he felt when his parents fought, the anxiety he felt going to kindergarten, the shame (not being good enough) he felt when he failed to meet his mother’s high standards, the pain and shame he felt when teased at school, and the loneliness he felt when his mom was preoccupied and his dad was absent. He seemed surprised when I suggested that these distressing feelings reinforced earlier trauma feelings that he couldn’t remember.

I explained how Dr. Geoffrey Carr’s book, Making Happiness, presents research showing that infants are much more sensitive and aware of their environments than previously thought, and that all infants to some extent experience intense trauma feelings. In addition, I indicated there is evidence that the fetus is affected by the mother’s level of stress and anxiety, and that the birth experience can be highly traumatic if there are complications and unnecessary medical interventions.

According to Dr. Carr, in order to understand how an infant is traumatized, it is important to recognize that it is an infant’s experience of the event rather than the event itself that is traumatizing. From an adult’s point of view, if an infant is in a high level of distress crying alone in its crib, there is no danger. However, it is an infant’s experience that matters. Infants don’t understand why they are in distress, or when or if the distress will stop. An infant’s experience of mild distress quickly escalates into overwhelming feelings of helplessness and pain if an infant isn’t responded to in a timely and sensitive manner.

The only protection that an infant has from experiencing intense trauma feelings is a highly attuned caregiver who responds sensitively to its needs before it becomes highly distressed and “freezes”. The freezing response is a biologically in-wired physiological reaction that occurs in the animal kingdom whenever an animal can’t fight or flee from a predator and is utterly helpless. This response, in which an animal looks dead from the outside but is highly activated internally, is adaptive biologically because an animal has a greater likelihood of survival by appearing dead.

The freezing response in humans is called dissociation. When humans dissociate, they detach from their experience and feel numb. Dissociating provides relief from overwhelming, intense feelings of fear, shame, and pain. Unfortunately, when infants dissociate, the distressing feelings do not go away but are stored in implicit memory, ready to be triggered by way of a conditioned response whenever there is a reminder internally (thoughts, feelings, memories) or externally (the environment) of the trauma feelings.

All of our distressing feelings are best understood as intrusive feelings; that is, feelings that when triggered, intrude from the past into the present, colouring our experience of the world and causing us distress to varying degrees (see the article, Intrusive Feelings). Although we are so accustomed to trauma feelings that intrude at a low level chronically in the form of mild tension and dullness that we accept this as normal, it is when these feelings are triggered and intrude at high levels of fear, shame, and pain that we feel most distressed and are at risk of suffering depression and anxiety.

Stan and I discussed the trauma feelings that he may have experienced while in the uterus, during the birth experience, and the first year of his life. I suggested that likely he would have been affected by his parent’s ambivalence about whether or not to terminate the pregnancy. I indicated that likely he would have experienced excruciating pain during the protracted labour and the delivery by forceps. I stated that likely he would have experienced the freezing response as an infant when he was left to “cry it out” at night. Also, I intimated that he may have experienced the freezing response in order to avoid the intense feelings of anxiety and helplessness of being separated from his mother when she returned to work six months after his birth (once we experience the freezing response, we re-experience it subsequently at lower levels of distress).

Initially, Stan had a hard time believing that experiences he did not remember could have traumatized him. However, when I told him that we learn a lot in the first year of life that we don’t remember – such as how to walk, talk, and recognize our parents – he was more open to accepting that the source of the intense feelings that underlies his anxiety and depression is intrusive feelings. Knowing this also helped him to start feeling more compassion for himself.

We also discussed how the later painful events in his life that he could remember after about age three likely reinforced the early trauma feelings. Stan remembered vividly how bad he felt when his mother was critical, how anxious he felt when he started kindergarten, how scared he felt when his parents fought, how ashamed he felt when he was teased at school, and how lonely he felt as a teenager. Having introduced Dan to intrusive feelings, I then proceeded to help him understand how he had learned to avoid these feelings at the expense of his own happiness.

Avoidance of Intrusive Feelings

The freezing response that we experience as infants helps us to avoid being overwhelmed by intense feelings of helplessness, fear, and pain by partially numbing these feelings. As Dr. Carr explains in Making Happiness, as we grow up we learn other ways to avoid our intrusive feelings though a process called avoidance learning. With avoidance learning, whatever behaviors we perceive reduce our feelings of anxiety, shame, and pain are reinforced, whether or not the particular behaviors actually are effective or not. Unfortunately, how we avoid our intrusive feelings leads to more suffering (see the article, How We Avoid Our Trauma Feelings Can Also Hurt Us)

Some of the earliest behaviors that Stan learned to avoid his intrusive feelings were sucking his thumb, clinging to his stuffed animals, and rocking in his chair. He also avoided feelings through creating imaginary friends whom he played with when lonely. After he discovered books when he was about seven, he avoided feelings by spending countless hours in the imaginary worlds books opened up to him.

In addition to avoiding feelings through these behaviors as a child, he learned to avoid feelings of anxiety and insecurity through a fantasy bond with his parents. As Dr. Robert Firestone writes, the fantasy bond is an imagined connection with one’s parents in which the child imagines that the parents are more ideal and loving than they really are. The fantasy bond gives the child an illusion of security and safety, but at the expense of his own view of himself; that is, the only way a child can see his parents as more loving than they are in reality is by seeing himself as bad.

As a teenager, Stan continued to avoid intrusive feelings of anxiety, shame, and pain (loneliness) through excessive reading. He also discovered that masturbation helped relieve these feelings. However, his main defense was pride. Having pride in his intellectual superiority helped him to avoid feelings of inadequacy and inferiority, which are aspects of shame. He took pride in knowing more than everyone else and in having the jocks come to him for help with their homework.

As an adult, Stan continued to use pride to avoid feelings of shame. He prided himself with how others consulted him for his expertise and how he received glowing performance reviews. Also, he prided himself with how he worked longer hours than other employees. In addition, Stan avoided feelings by distracting himself with work and the internet.

Identifying how he had learned to avoid intrusive feelings was new information for Stan. He also found it helpful when I explained that it is when intrusive feelings are triggered and intrude intensely, overwhelming our defenses, we become depressed. In other words, following Dr. Carr, I suggested that depression may be understood as a partial freezing response, a way of shutting down to numb intrusive feelings but at a cost to one’s happiness and ability to function in life. I suggested that not receiving the promotion he had expected had triggered intrusive shame, pain and anxiety, and that becoming depressed was his way of avoiding these intrusive feelings, albeit imperfectly, because the feelings continued to intrude to some extent despite this defense. I indicated that the more we are able to feel rather than avoid the intrusive feelings, the more these feelings resolve and the depression lifts.

With an understanding of his intrusive feelings, the defenses he had learned to avoid them with, and how his defenses had been overwhelmed resulting in depression, I turned to providing him with an approach to changing his intrusive feelings.

Bringing Presence to Feelings

The basic approach for changing intrusive feelings is bringing presence to feelings. This involves three steps: first, bringing attention to our feelings and observing or witnessing them; second, symbolizing our feelings in words, and third, relating to our feelings with wisdom and compassion. Although this procedure seems simple, as Stan discovered, it isn’t, and requires effort and practice.

I taught Stan the first step, bringing attention to feelings and observing them, by directing him to close his eyes, and to imagine himself back in the manager’s meeting in the corporate board room with his peers, superior, and CEO of the company when he had first learned that he hadn’t been promoted, something that was already known to others. I instructed him to focus his attention inside his body on his midsection where we feel things and when he was ready, to tell me what he was experiencing. Although often we are able to observe only vague sensations or partially formed feelings initially when we bring our attention to feelings, this was not the case for Stan. He was aware immediately of strong, fully formed feelings.

The second step in changing intrusive feelings involves symbolizing feelings in words. The more we are able to identify in words what we are feeling, the more control and relief we feel. Finding the correct word to symbolize what we are feeling often involves trial and error. As we witness or observe a sensation, partially formed feeling or fully formed feeling in the body, we try out different feeling words to see what word best matches our inner experience. When we find the right word, we have an internal experience akin to, “Ah! That’s what I’m feeling”, often accompanied by a sense of relief and control.

In Stan’s case, he was able to symbolize in words immediately the feeling of anger. I validated his anger, saying that it is understandable that he felt angry about an outsider being selected by his company given his years of dedicated service. I directed him to focus inside on what else he might be feeling in the moment as he reexperienced the meeting. Stan identified that he was feeling “stupid”. When I suggested that perhaps the word, “ashamed”, might also fit his feeling, he nodded. When I wondered if the word, “humiliated”, might also capture his feeling, he exclaimed, “Yes! That’s it. I feel humiliated”.

The third step in changing intrusive feelings involves relating to them with wisdom and compassion (see the article, Listening to Feelings from a Wise Perspective). Relating to our intrusive feelings with wisdom involves reminding ourselves that, although our distressing feelings are being triggered in the present (by way of a stimulus and a conditioned response), the intensity of our feelings is not about the present, but is an echo from the past. Telling ourselves this won’t stop the distressing feelings, but reduces their intensity, making it easier for us to contain them (not feel overwhelmed) and to soothe them.

Relating to intrusive feelings with compassion involves experiencing real feeling for ourselves when we have distressing feelings. Reminding ourselves that we didn’t deserve to experience overwhelming feelings of anxiety, pain, and shame when we were little, and we don’t deserve to have these feelings now, helps us to have compassion for ourselves. An attitude of compassion helps us to soothe and resolve intrusive feelings.

I helped Stan to relate to the intense humiliation with wisdom and compassion using a technique I developed called the “Heart Ritual”. With his eyes closed, while imagining himself in the corporate boardroom, and while focusing on the intrusive feeling of humiliation in his body, I suggested he repeat after me a number of times, “This is an old feeling. I don’t deserve to feel so humiliated. I am safe now”. Doing this helped the intrusive feeling to ease.

I explained that humiliation is an aspect of the intrusive feeling of shame that we experience when our pride is lowered, often publicly. Shame is the feeling that one is bad, defective, not good enough or unworthy. It is particularly distressing because it implies the threat of being cast out. For our ancestors, to be cast out from the tribe would have meant certain death.

I went on to explain that because shame is so distressing, we avoid it at all costs. Pride is a common way of avoiding shame. Unfortunately, pride is accompanied by self-hate. They are like two sides of the same coin. We can’t have the one without the other. The more we base our worthiness on a particular quality or characteristic that we take pride in, the more the negative inner voice attacks us in a self-hating manner and often others in a hostile manner whenever this quality fails us.

I suggested to Stan that pride in his intelligence had enabled him to avoid feelings of inadequacy and shame, but when his intelligence failed him by not being promoted, he experienced self-hating voice attacks (see the section above, Changing Thoughts) as well as anger toward the company (see the article, Avoiding Feelings with Anger) as a way of avoiding his shame. I indicated that, although people attempt to avoid intrusive shame through pride in their status, power, and wealth, no amount of these removes intrusive shame. The only way to address intrusive shame is by bringing our presence to the shame.

As we bring our presence to intrusive feelings with wisdom and compassion, earlier memories of these feelings come to mind, allowing us to bring our presence to them in order to resolve them as well. For example, while focusing inside on the humiliation he felt in the corporate boardroom, he recalled crying in the washroom after his peers had mocked his clumsiness by mimicking how he threw a baseball in elementary school. When I encouraged him to reexperience this memory and to bring his attention to the feelings in the moment, he said: “I feel so foolish and ashamed.” As he allowed himself to feel the shame, he recalled an even earlier memory, when his mother criticized him in front of his peers in kindergarten for inconveniencing her when he urinated his pants and had to go home. As he attended to the feelings in the moment, he commented in a small, childlike voice, “I feel so humiliated.” He soothed this feeling using the Heart Ritual.

I validated him for the courage to experience these feelings on an emotional level rather than merely on an intellectual level, because it is emotional experiencing more so than intellectual insight that resolves intrusive feelings.

Because shame is linked inextricably to intrusive feelings of fear and pain, I suggested that even though he didn’t remember feeling shame as an infant and young child, likely he would have felt bad about himself whenever he wanted nurture from his mother and she was unresponsive or insensitive, or whenever his parents were angry or impatient with him. The only way he could feel safe would have been to blame himself and to see his parents as god-like. To have viewed his parents as inadequate would have left him feeling utterly scared and insecure.

I asked him to imagine what it would have been like for him as a helpless and dependent baby when his mother was insensitive to his feelings and needs or his parents were angry with him. Doing this helped Stan to have more feeling for himself as an infant and young child, and more compassion for himself as an adult in the current situation.

Although I focused primarily on Stan’s intrusive feelings of shame (shame is typically the dominant intrusive feeling underlying depression), I also helped him to bring presence to intrusive anxiety and emotional pain. With respect to intrusive anxiety, whenever he worried about his career, I encouraged him to bring wisdom and compassion to the feelings of helplessness (loss of control) triggered by his failure to be promoted. With respect to emotional pain, I promoted his feeling the loss regarding not being promoted with wisdom and compassion.

As Stan learned to bring his attention to intrusive feelings of shame, anxiety, and emotional pain, symbolize them in words, and relate to them with wisdom and compassion, slowly these feelings shifted, passed, and resolved. Finally, because depression is a way of numbing ourselves to avoid intrusive feelings, the more he brought his presence to intrusive feelings such that they resolved, the more his depression lifted.

Conclusion

As Stan worked on changing his thoughts by externalizing the negative inner voice, changing behaviors by acting on corrective suggestions for behavioral change, and changing feelings by bringing his presence to intrusive feelings, his symptoms of depression and anxiety lifted. He terminated counselling saying he not only felt himself again, but also felt better equipped with tools to maintain his emotional health as he moved forward. I congratulated him on his hard work, noting that he would likely hit some bumps, but expressing confidence in his ability not only to cope with setbacks but also to live a fuller life.