Intended for healthcare professionals

Fillers A memorable patient

Looking at the evidence

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7259.494 (Published 19 August 2000) Cite this as: BMJ 2000;321:494
  1. Paul Blenkiron, specialist registrar in psychiatry
  1. York

    He remained clinically depressed despite medication and took an overly negative view of every event in his life. Fresh from my training course in cognitive behaviour therapy, I felt sure I could help.

    “Imagine you are in bed asleep one night and you are woken by a loud noise downstairs,” I suggested. “What would you think, feel, and do?”

    “It could be a burglar,” he replied. “I'd be terrified—perhaps ring the police or hide.” “What if you have a cat and remember that you left the window open by mistake?”

    “I would feel OK, and just go downstairs to check and close the window.”

    From the discussion that followed, he began to realise that his low mood was kept going by a tendency to interpret everyday situations in a negative way. He faced metaphorical “burglars” around every corner. I suggested that challenging such pessimistic thoughts by coming up with alternative, more positive explanations could offer a route out of his depression. He agreed to test out this approach as homework, and we arranged to meet again one week later with some optimism.

    When he returned for his next therapy session, I started by using an approach favoured by Socrates, who believed that the answers to important questions lie within ourselves. What had been the most important thing he had learnt from his recent experiences?

    “Well doctor,” he began. “Last night, I was lying in bed at 3 am and heard a noise downstairs. Remembering what we said about not jumping to conclusions, I thought perhaps it was the central heating, or perhaps the wind blowing. I went down to check, and found a burglar trying to get in through the kitchen window. He ran off before I managed to ring the police.”

    He sensed the irony in this outcome, one that I was clearly not expecting. “I'm feeling a lot better than last week,” he announced. It was the first time I had seen him smile since we first met.

    This patient taught me two valuable lessons. Firstly, as in so much of medicine, the patient is often proved right. Secondly, cognitive therapy is more than just positive thinking, which can sound simply like an instruction to “look on the bright side” to someone who is feeling depressed. It is about balanced thinking and basing our feelings on the evidence with which we are actually presented. The trouble with optimists is that they are sometimes afraid to face the truth.

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