BLOG of Dr. Edelstein

Depression: Your Elusive Secondary Disturbance

Do you get upset about being upset? Do you feel: guilty about getting angry at a loved one, anxious about being embarrassed in front of an audience, depressed about experiencing ever-increasing panic attacks or having life-long depression? If so, you have experienced secondary disturbance.

Do you get upset about being upset? Do you feel: guilty about getting angry at a loved one, anxious about being embarrassed in front of an audience, depressed about experiencing ever-increasing panic attacks or having life-long depression? If so, you have experienced secondary disturbance.

Getting upset (the secondary disturbance) about initially having been upset (the primary disturbance) tends to be both pervasive and elusive. The primary disturbance occurs (or is anticipated to occur) first, then comes secondary disturbance, since chronologically it occurs second.

Therapists may fail to recognize this secondary disturbance in their clients since it's not anchored in a concrete, external event. In fact, Sigmund Freud mislabeled it as "free-floating." It is, rather, directly tied to irrational thinking.

Use this rule of thumb to nail it: when feeling anxious, depressed, or guilty, ask yourself: am I depressed about my emotion (e.g., anxiety, depression, anger) or about an external situation (e.g., rejection, failure, hassles)? If it's the former, then you probably have a secondary disturbance.

Here's a client's comprehensive Three Minute Exercise (TME). As a result of writing these two or three times a day, he ultimately beat his secondary disturbance blues:

A. I'm feeling depressed and lethargic again about nothing in particular and everything in general.
B. I absolutely MUST not feel depressed and lethargic so much of the time.

C. Even more depressed and lethargic.

D. What is the evidence I absolutely MUST not feel this way so often?

E. There's no evidence to support my demand. Although I keenly PREFER not to feel so miserable, nothing etched in stone states I MUST not. Since I was born with imperfect genes and an imperfect brain, and I was raised by fallible parents, of course, of course, I'll feel depressed at times.

So I'm depressed--too damned bad! It is unpleasant, but hardly the end of the universe. Though I don't like it, it hasn't killed me so I obviously can stand it. I can still enjoy life somewhat feeling depressed, although I'd enjoy it more if I were happy all the time. It may slow me down, but it can't stop me from working toward my goals--as long as I'm determined to keep pushing myself no matter how difficult it seems.

If I'm depressed, I'm depressed--whining and complaining about my depressed state certainly won't help. There's no reason the universe must protect me from the pain of depression. I've been depressed before and I've gotten through it, and I will again. My depression waxes and wanes as do all emotions.

To have the benefits and pleasures of living it's necessary to have the displeasures, including depression. Why not use this situation therapeutically as a golden opportunity to practice viewing my depression realistically as just a great hassle, never a horror? I'll keep pushing, and keep reminding myself to keep pushing!

F. Concerned, not depressed about my depression and lethargy. Pushing myself to get active.

RULE OF THUMB: the more you write at "E" about why your "must" is false or self-defeating, the more effective your TME will be. Try one now!
5 Major Differences Between REBT & CBT
Albert Ellis introduced Rational Emotive Behavior Therapy (REBT) in 1955, a radical change from the traditional therapies popular at the time. It has since spawned a number of offshoots, usually called cognitve-behavioral therapy (CBT). REBT and CBT coincide in a variety of ways. Their core notion affirms human emotions and behavior are predominantly generated by ideas, beliefs, attitudes, and thinking, never by events themselves. Consequently changing one’s thinking leads to an emotional and behavioral change. 

There are also major differences between REBT and CBT: 

1. REBT addresses the philosophic basis of emotional disturbance as well as the distorted cognitions (the focus of CBT), which makes it more powerful. As you uproot your absolutistic demands, your cognitive distortions get corrected. 

For example, suppose you plan to ask someone for a 2nd date and you're feeling anxious. You tell yourself, “She didn’t talk or smile much on our first date. I know she’s not interested.” Since there are multiple other explanations for her reserved behavior, which you don’t know by her actions, CBT calls this conclusion “mind-reading” and dismisses it as a cognitive distortion. Instead, REBT looks at the underlying reason you jump to this conclusion, for example telling yourself, “I absolutely need her acceptance and if she rejects me this would be awful, I could not stand it, and proves I’m a loser who’ll never succeed with any woman.” Giving up your dire need for acceptance would not only ameliorate you fears of rejection in future dating situations, but in virtually all interpersonal interactions. Going the CBT route of avoiding mind-reading proves to be significantly more limited. 

REBT posits three core demands fueling cognitive distortions and underlying emotional disturbance: 1. “Because I strongly prefer to, I absolutely must do well in life and get the approval of significant others or else I’m no good,” 2. “Because I keenly desire it, others absolutely must treat me well or else they’re no good,” and 3. “Because I passionately wish it, life absolutely must go well and or else it’s no good.” These demands create anxiety, depression, guilt, anger, resentment, procrastination, and addictions. 

2. REBT highlights the significance of secondary disturbance. Disturbing yourself about your disturbance is often the major factor in life-long (endogenous) depression, severe anxiety, and panic attacks. Most CBT ignores secondary disturbance. For example, you feel anxious about appearing anxious when requesting the date. You are worrying about worrying. 

3. REBT presents an elegant solution to the self-esteem problem. It teaches unconditional self-acceptance (USA) rather than any type of self-rating. Most CBT therapists focus on bolstering their clients’ self-esteem by reinforcing some of their positive qualities. This strategy has many pitfalls including having low self-esteem when you do poorly, making invidious comparisons to others, avoiding risk-taking, smug-complacency, and preoccupation with proving, rather than enjoying, yourself. 

USA and avoiding the self-rating trap avoids the many problems with self-rating. USA consists of the philosophy of unconditionally accepting yourself as the imperfect human you are whether you do well or poorly, or others love or hate you. If you get fired, for example, rate your job performance as poor, but never overgeneralize to conclude you’re a poor or worthless person. You’re then able to evaluate your deficient (and positive) behaviors to focus on how to improve in the future. 

4. REBT is unique among CBT therapies in differentiating between self-destructive, inappropriate negative emotions vs. helpful, appropriate negative ones. Anxiety, depression, and anger are examples of the first type and intense sadness, deep sorrow, great concern, and regret instances of the second.   

For example, if you feel slightly anxious about arriving 5-min late, this is an inappropriate negative emotion because, in part, it comes from rigid, absolutistic thinking characterized by demands (musts, shoulds, have tos: “I absolutely must never be late for an appointment”). Alternatively, if you feel intensely sad, you cry, grieve, and mourn over the loss of a loved one, these are appropriate negative emotions. They come from passionate desires and preferences such as, “I strongly wish my lover had not died, how very, very sad and most unfortunate." 

5. REBT maintains that all anger, having a commanding and condemning, dictatorial philosophic core, some form of “others absolutely must treat me well or else they’re no good,” is unhelpful, feels bad, and sometimes quite destructive. It teaches individuals effective assertiveness and other appropriate alternatives to anger. CBT views some anger as healthy and appropriate. Although CBT teaches assertiveness, it fails to address the philosophic root of anger. 

For the above reasons and others, the course of REBT therapy tends to be briefer than CBT.
What Are You Telling Yourself?
I sat down with Johnny Strike, author, musician, former counselor, and founding member of San Francisco's earliest punk band Crime. He conducted a wide-ranging, in-depth interview with me in which we discussed self-esteem, addictions, procrastination, obesity, psychoanalysis, Albert Ellis, REBT/CBT, and more. I wish to share the results with my readers.

Johnny Strike: You have written that panic attacks are best dealt with by realizing that life is full of discomfort, and then convincing yourself of that fact by disputing the "unrealistic musts" they are thinking, but in severe panic attacks the person might not be in a frame of mind to intellectually look at their thinking like that. Wouldn't a better approach be to accept the fact that they are having an attack, and remind themselves that it's time limited, and not the end of the world, and then later work on the musts, and faulty thinking that could make the attacks even worse?

Michael Edelstein: The two are not mutually exclusive. Do both. Also daily write TMEs [Three Minute Exercises] on the problem. I'm not clear why working on musts and faulty thinking would make it worse.

JS: One may too stressed during the attack to find a paper and pencil to write out ABCs. It would seem to me that would be better prep or post work where as getting through the attack would be at the forefront, and repeating almost as a mantra: "This is time limited. This is time limited" could be more effective in the moment.

ME: I recommend whatever works best for any given individual. I suggest a wide variety of strategies. In general, as long as it's meaningful, the more reinforcement the better. The problem is people tend to tell themselves, "I'm too stressed to do it," then give up, thereby turning their misguided conviction into a self-fulfilling prophesy.

JS: How about popping a pill like Xanax to deal with anxiety attacks?

ME: It could be a temporary fix for some people, but usually does not change the underlying anxiety-creating philosophy. It highlights the difference between feeling better for the moment and getting better in the long-term. Clients sometimes request a quick fix. This is a misunderstanding of REBT. Rather, it's a life-long discipline.

Addictions and Procrastination

JS: I found your writings and techniques (disputing the musts) on dealing with those topics outstanding. My questions are:

1. What about the thinking that demands that one must not have musts, or that one must have them?

2. What do you mean by addiction? I may realize that smoking is not good, but I prefer to continue it anyway, let's say I cut down, and only smoke low tar, and feel it's an enhancement to my social life where with my other friends we get together after work for drinks and a smoke.

3. What about the contract idea especially to deal with procrastination?

ME: Excellent questions.

1. These are frequently the most pernicious kind of demands for one to have.

2. An addictive behavior as I define it involves any behavior you repeatedly engage in that blocks, sabotages, or interferes with your long-term goals. In the example you give, smoking is not necessarily an addiction according to this definition.

3. There are many possible strategies that could be effective in overcoming procrastination. Contracts is one. Experiment with many and use those that work the best for you.

JS: Many would argue with you that although it may all be your head, it could take time to realize that. For instance someone finding themselves a third through a box of chocolates before realizing they have failed in their goal. With a drug addict this reflective action could be so quick to seem involuntary.

Consider someone lighting a cigarette offered, and inhaling out of habit, then realizing the lapse, then shrugging it off since they're already smoking.

With aging there's the possibility of memory lapse. How does one problem solve that?

ME: The key involves preparing for these situations by daily practicing, practicing, practicing, cognitive, behavioral, and imaging strategies taught by REBT and CBT therapists.


JS: Today one hears the term self esteem used on a regular basis. it's become part of the language on talk shows and in everyday conversation. A common phrase is: He has low self-esteem, but you rarely if ever hear: He has high self-esteem, which is maybe a clue to what you have written and talked about, namely that the concept of self esteem is not a good one. Would you please elaborate some on your disagreement with popular culture's use and definition of this term.

ME: To esteem means to think highly of. Self-esteem means to think highly of oneself. Some individuals rate themselves as good people thereby giving themselves high self-esteem. However concluding you're a good person when you do well (and a bad person when you do poorly) is unempirical, illogical, and unpragmatic. There's no evidence to support it, it does not follow logically from the data, and it leads to poor results. The solution to the self-esteem problem lies in unconditional self-acceptance (USA), accepting oneself unconditionally as an imperfect human who acts imperfectly, never a god or a devil.

JS: Would you say that “self-esteem” is related to grandiose thinking, ego mania, and depression as well? Isn't it the case that PTSD (Post Traumatic Stress Disorder) is caused by having been the victim of traumatic events, not by thoughts or beliefs?

ME: 1. Yes, rating your total self highly, or high self esteem, is a type of grandiose thinking and can cause ego mania. Alternatively, low self-esteem can result in depression. The solution involves giving up all self-rating. You can work toward this end by recognizing you never can become a good human or a bad human. Rather, you're always an imperfect human who at times does well and at times does poorly. In Piagetian terms, we can call this perspective "Conservation of the Self." Since our emotions are caused by our thinking and since emotional stress is an emotion, this tells us PTSD is caused by our thinking.

The experience of the neurologist and psychiatrist Victor Frankl highlights this. In his book, Man's Search for Meaning, he relates how creating a meaning for himself during his Holocaust death camp suffering led him to ameliorate his own emotional stress and help his fellow victims with theirs. He called this "Logotherapy."

In addition, if we consider soldiers returning from war we recognize not all of them, perhaps a minority, have PTSD. If the risks of injury and death directly caused PTSD, then all veterans would be suffering from it.

Surrealism and the unconscious mind (short article)

JS: I know among your various projects you are working on a book about Sigmund Freud. I figure you are comparing his methods against Albert Ellis's. Three questions:

1. How far along are you, and is it being co-authored?

2. What do you see as the main shortcomings to Freud's theories and therapy?

3. I know that he inspired the Surrealist artists in Paris in the Twenties, mostly do to his work with dreams, and the unconscious. For me, anyone who inspired that movement has some value. Beyond this though do you find any other redeeming value?

ME: 1. The book, Psychotherapy Breakthrough, details the history of the psychotherapy movement, from Freud to Ellis. My co-authors are David Ramsay Steele and Richard Kujoth. It was published in August.

2. Freudian therapy is very superficial. Rather than helping the client overcome the core of his psychological disturbance, his irrational beliefs, it focuses on childhood memories, dreams, free association, and feelings.

3. Nothing substantive in the realm of psychotherapy.

JS: What about talk therapy? He is credited with developing this, and it is still part of many different therapeutic techniques.

ME: Good question. Talk therapy was around before Freud. Adolf Meyer, who developed psychobiology, was one of its noted early practitioners.

JS: And REBT was around with the Greek Stoics, but, I think we can safely say that he popularized it, as he did psychology itself.

ME: What he popularized was a toxic form of talk therapy. The world would have been better off without this.

JS: Albert Ellis finally called Freudian psychoanalysis "horse shit" but I find it interesting they he practiced it himself for six years. Ellis noted that most psychotherapists use some elements of unconscious thinking that Freud originally emphasized.

"One of the main things he did was point out the importance of unconscious thinking. Freud pointed out that when people are motivated to do things, that they unconsciously think, and even feel, certain things. We use that concept," Ellis said, adding, "Although Freud, as usual, ran it into the ground."

ME: Ellis seems to be using "unconscious" to mean tacit thoughts, rather than in the classical Freudian sense meaning thoughts that are repressed due to psychosexual conflicts threatening to the ego.

JS: Regardless, he gives him credit for it, at least in that interview.

JS: In your excellent interview on with David Van Nuys, Ph.D., you discussed psychoanalysis, and Van Nuys claimed that psychoanalytic thought and practice have evolved over the years and referred you to a paper by Dr. Jonathan Shedlera professor at the University of Colorado Medical School to support his position. Along with Shedler's paper on the "efficacy of psychodynamic therapies" based on a meta-analysis which he concludes that "psychodynamic therapies (are) as effective as CBT."

Have you followed up by listening to the interview Van Nuys conducted with him on Shrink Rap Radio? Or have you read Dr. Shedler's paper? If so what is your critique? Did you find any of it valid, or did you find it just more poppycock?

ME: I read The Efficacy of Psychodynamic Psychotherapy by Jonathan Shedler. In a sense, it's a meta-meta analysis in that it reports on a number of meta-analyses. He fails to describe the original studies in sufficient detail to evaluate their methodologies from his paper. He gives citations for some of these studies, but they're only available electronically to subscribers of the respective journals. Consequently, I was unable to read them and render an opinion.

In his detailed description of psychodynamic therapy, he fails to mention ascertaining the client's goals and working with the client to attain them. Moreover, he fails to include the use of homework or practice as an essential aspect of the therapeutic process. These appear to be essential aspects of successful psychotherapy, which leads me to remain skeptical of his conclusions.

I sat down with Johnny Strike, author, musician, former counselor, and founding member of San Francisco's earliest punk band Crime. He conducted a wide-ranging, in-depth interview with me in which we discussed self-esteem, addictions, procrastination, obesity, psychoanalysis, Albert Ellis, REBT/CBT, and more. I wish to share the results with my readers.


Johnny Strike: We are each subject to a host of biological and psychological mechanisms that lead us to make decisions we might otherwise regret. A simple example of this is obesity. Many obese people are not happy with their life decisions, but they still give in to their innate biological impulses, and more than this, we don’t see that a similar number of people from all walks of society make these regrettable decisions, instead we see that obesity is deeply tied to demographic factors such as socioeconomic status and mental health – this is not the sign of a capability to act freely and responsibly, it is a sign of our decisions being determined by things beyond our control over though, in the moment, we sense the illusion that we are in control. Some would say that laws restricting poor eating choices would serve us well. Your thoughts?

Michael Edelstein: Intuitively that position seems to make sense. It feels as if, when we're attempting to diet while eating another slice of pizza, we can't control ourselves.

Yet if this were the case, then clinical psychologists like myself would be out of business. To the contrary, I teach compulsive eaters how to use the free will they have to choose, for example, green salads over pizza.

You're correct, biological impulses and similar influences all play into an individual's food choice. The major point here is these factors all influence the compulsive eater's behavior, but never control it. The thoughts in their head at the decision point is the ultimate control. I teach my clients how to change their thinking thereby learning to refrain from self-destructive eating. I agree with you, "we need restrictions." We're better served when we generate these restrictions for ourselves, rather than having the State do it to us.

JS: Reviewing Chapter 4, "Marriage: Vicious and Delicious Circles" from your book, Three Minute Therapy, I am first reminded of the old saying: "Men want their women never to change, and women think they can change their men." Getting the musts out of the relationship as you point out is wise to attend to pronto, in fact is it not the guiding principle for all emotional disturbances?

ME: Yes. However keep in mind a "want" does not equal a must. The desires you cite of men and women cannot, in and of themselves, cause emotional disturbance.

JS: In one of your case studies the woman wanted more conversation from her husband and he wanted sex on a regular basis. This seemed to me tailor made for the contract. He gives her one hour of sincere, engaging conversation and she gives him an hour of steamy sex, win-win as they say, and if they're both honest in their intentions their relationship could go from on the rocks to skyrocket fantastic. Would this be another delicious circle achieved simply by being rational?

ME: A rational couple may or may not think of this practical solution, although it's often worth a try. The REBT therapist normally suggests many practical techniques such as this one on a trail-and-error, experimental basis.

JS: Congratulations on your first e-book Rational Drinking. Would you tell us more about it and your co-author?

ME: Rational Drinking: How to Live Happily With or Without Alcohol describes Rational Emotive Behavior Therapy (REBT) and applies it to compulsive drinking. Will Ross, my co-author, is an REBT expert. He's responsible for the excellent REBT site, 

JS: What is your thinking about the AA twelve step system for getting sober? One thing I've noticed is that many who use that approach: meetings, sponsors, "working the steps" etc., become addicted to that system and although they move on with their life, they drag that along, often telling everyone they meet that they're "in recovery" and "have been sober for such and such amount of time." They don't seem to care that others might find this neediness and self-obsession off-putting or annoying.

ME: AA fails to address the fundamental cognition's which cause alcohol problems. These consist of demands and usually take the form of, "My life absolutely must be fair, easy, and hassle-free, otherwise I'll be miserable forever." Drinking follows as an escape from an imagined intolerable existence. REBT helps drinkers identify their irrational demands and teaches them powerful tools to uproot them. In addition to REBT books, websites, and individual counseling, there's SMART Recovery, self-help groups for overcoming all addictions, including the addiction to 12-step meetings.

JS: Twelve steppers would be quick to point to your title and claim that an alcoholiccannot drink rationally, that even one drink could send him or her back into full blown alcoholism, because it's a "disease". What would you say to them?

ME: The evidence demonstrates that when humans change their thinking, they change their behavior. Since drinkers are human, they're governed by this principle. Rational Drinking shows them how to stop after one drink.

JS: In your book Three Minute Therapy, Change Your Thinking Change Your Life you begin Chapter 8 "Overeating and Smoking: It's All in Your Head" with a quote from the French theorist, and economist Frédéric Bastiat who is often named as a great influence to libertarian thinking. "The very nature of man impels him to satisfy his desires with the least possible pain." Do you see other similarities in libertarian thinking and the principles of REBT?

ME: They both have the objective of freeing the individual. REBT addresses emotional freedom, libertarianism addresses political freedom.

Emotional freedom involves being free of psychopathological, self-created shoulds, oughts, and musts. Political freedom involves being free of State mandates.

JS: Is anger different than stress? Do both release cortisol or only stress? I have seen prominent REBT psychologists including Albert Ellis show a display of anger, I'm assuming to get a point across. I've noticed a number of current studies that have popped up on the internet that claim as long as it's not a consuming (life view type) anger, it is actually good for you in some ways. Have you changed your view at all on this subject over the years?

ME: "Stress" in the general sense includes all emotional disturbance such as anger, anxiety, depression, guilt, etc. Anger is at its root a philosophy, a way of looking at things. It stems from an attitude of commanding and demanding, running the universe, and tyrannically dictating what's "Right" to others. It says, "You absolutely must do my bidding and if you don't you're a total louse who deserves to roast in Hell for all eternity and I've just appointed myself your roaster." As long as I've been a therapist I've viewed anger as fundamentally self-defeating. It feels bad, clouds your thinking, and leads to poor results. 

JS: As a side note this reminds me some of the sixties fad Primal Therapy which John Lennon and Yoko Ono tried and found valuable. I have no doubt screaming on a bridge or in a tunnel can be releasing, but I don't see it freeing up problems like they claim. I understand there's something of a rebirth of PT and they’re now saying (among other things) it will boost the immune system. Do you agree with my take on Primal Therapy?

ME: Yes I agree with you. Primal Therapy fails to teach individuals how to identify their irrational thinking and how to change it. Perhaps worse, it reinforces the wrong-headed Freudian view that emotional disturbance is caused by the repressed pain of childhoodtrauma. 

JS: Here’s an example of one of the studies that claim that “Anger Is Good for You”: 

A new study from Carnegie Mellon University shows anger may help people reduce the negative impact of stress.

"Here getting emotional is not bad for you if you look at the case of anger," said Jennifer Lerner of Carnegie Mellon. "The more they are displaying anger, the lower the stress responses."

“Subjects were told they were being tested for intelligence. They were asked to count backward from 6,200 by increments of 13, then taunted, corrected and told to go faster. Researchers measured the biological responses as the subjects become more and more stressed.

Stress leads to biological responses such as an increase in heart rate and a release of hormones. Both can have lasting effects such as diabetes, heart disease, depression and excess weight gain.

When people feel fear, those negative impacts spike, but when they get angry, those negatives go down, according to the study.

"Having that sense of anger leads people to actually feel some power in what otherwise is a maddening situation," Lerner said.

The researchers say they plan to look at whether people can train themselves to feel a certain way when under stress.
ME: It's not surprising the physiological markers accompanying stress and fear appear more intense than those accompanying anger, since emotions vary in their intensity. There is a third option, no stress or anger. Rather, great concern, displeasure, disappointment, and frustration are helpful, not harmful, negative emotions. REBT teaches individuals how to change their disturbed thinking in order to avoid self-destructive emotions, including stress, anger, depression, and anxiety.

JS: For closing, and to change the subject radically: I know you are a Bob Dylan aficionado, and have followed his long career. Regardless of where you were in 1965 would you have been with the ones who booed or the ones who cheered when he surprised the Newport Folk Festival crowd by going electric

ME: The first time I heard the electric Dylan in 1965, I rather liked it. I did not relate to the disdain of his detractors.

JS: Thank you for all your insightful and straightforward answers.

ME: It’s been a pleasure.


Dr. Edelstein was mentored by Albert Ellis and now teaches REBT to clients and therapists. 

Let’s talk to see what might work for you.