The Feeling Good Handbook Page 2
My own road to cognitive therapy research was an indirect one. In the summer of 1973, I packed my family into our Volkswagen and began the long trek from the San Francisco Bay area to Philadelphia. I had accepted a training position as a senior psychiatric resident in mood research at the University of Pennsylvania School of Medicine. I worked initially at the Depression Research Unit of the Philadelphia Veterans Administration Hospital gathering data on the recently popu-larized chemical theories of depression. As a result of this research I was able to extract key information from my experiments on how the brain controls the levels of a certain chemical felt to be important in mood regulation. Because of this work I received the A. E. Bennett Award for Basic Psychiatric Research from the Society of Biological Psychiatry in 1975.
It was a dream come true because I had always considered that award as the zenith of a career. But a crucial element was missing. The discoveries were too remote from the clinical problems I had to confront every day in my treatment of human beings suffering—and sometimes dying—from depression and other emotional disturbances. Too many of my patients were just not responding to the available forms of treatment.
My memory of the old veteran, Fred, stands out. For over a decade Fred had experienced severe, unrelenting depression. He would sit on the ward of the Depression 2
FEELING GOOD
Research Unit and tremble, staring at the wall all day long.
When you attempted to speak to him, he would look up and mutter—"Wunna die, doctor, I wunna die." He stayed on the ward so long I began to wonder if he would just die of old age. One day he had a heart attack and almost did die. He was bitterly disappointed when he survived. After a number of weeks in the Coronary Care Unit he was transferred back to the Depression Research Unit.
The staff treated Fred with all the then-known antidepressant medications as well as a number of experimental drugs, but his depression just couldn't be budged. Finally, and as a last-ditch effort, his psychiatrist decided to administer electroconvulsive therapy (ECT)—a treatment used only when other forms have proven unsuccessful. I had never before participated in the administration of shock therapy, but consented to assist the psychiatrist. I recall that after Fred's eighteenth and final shock treatment, when he was recovering from the anesthesia, he looked around and asked me where he was. I told him that he was in the V.A. Hospital and that we were wheeling him back to his room. I was hopeful I might detect some small sign of improvement, and I asked him how he was feeling. He looked up at me and muttered sadly, "Wunna die."
I realized then that we needed more potent ammunition in order to fight depressive illness, but I didn't know what that might be. About this time Dr. John Paul Brady, Chairman of the Department of Psychiatry at the University of Pennsylvania, suggested I do some work with Dr. Aaron T. Beck, one of the world's foremost authorities on mood disorders.
Dr. Beck was doing research on a revolutionary and contro-versial type of talking treatment for depression he called "
cognitive therapy."
As I said earlier, the word "cognitive" simply refers to how you are thinking and feeling about things at a particular moment. Dr. Beck's thesis was simple: (1) When you are depressed or anxious, you are thinking in an illogical, negative manner, and you inadvertently act in a self-defeating way. (2) With a little effort you can train yourself to straighten your twisted thought patterns. (3) As your painful symptoms are eliminated, you will become productive and happy again, and you will respect yourself. (4) These aims 3
David D. Burns, M.D.
can usually be accomplished in a relatively brief period of time, using straightforward methods.
It seemed quite simple and obvious. Certainly my depressed patients did think about things in an unnecessarily pessimistic and distorted way. But I was skeptical that pro..
found and entrenched mental and emotional habits could be readily eliminated with a training program of the type described by Dr. Beck. The whole idea just seemed too simple!
But I reminded myself that many of the greatest developments in the history of science were not complicated and were initially viewed with intense skepticism. The possibility that cognitive concepts and methods might revolutionize the treatment of mood disorders intrigued me sufficiently that I decided to try the therapy with some of my more difficult patients, just as an experiment. I was quite pessimistic about seeing any substantial results, but if cognitive therapy was hokum, I wanted to find out for myself.
The results surprised me. Many of these individuals experienced relief for the first time in years. Some attested to feeling happy for the first time in their lives. As a result of these clinical experiences, I began to work more closely with Dr. Beck and his associates at the University of Pennsylvania Mood Clinic. This group launched and completed several scientific studies to evaluate the effects of the new treament methods we were developing. The results of these investigations have had an enormous impact on the mental-health pro..
fession throughout the United States and abroad, and will be detailed in Chapter 1.
You don't have to be seriously depressed to derive great benefit from these new methods. We can all benefit from a mental "tune-up" from time to time. This book will show you exactly what to do when you feel down in the dumps. It will show you how to pinpoint the reasons why you feel that way, and will help you devise effective strategies to turn your problems around as quickly as possible. If you're willing to invest a little time in yourself, you can learn to master your moods more effectively, just as an athlete who participates in a daily conditioning program can develop greater endurance and strength. The training will be accomplished in a way that makes clear and obvious sense. These suggestions will be
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practical, so you can develop a personal growth program that will simultaneously generate emotional relief and an understanding of your upset and its root causes. These methods actually do work, and the effects can be quite profound.
5
PART I
Theory and Research
CHAPTER 1
A Breakthrough in the
Treatment of Mood Disorders
Depression has been called the world's number one public health problem. In fact, depression is so widespread it is considered the common cold of psychiatric disturbances. But there is a grim difference between depression and a cold. Depression can kill you. The suicide rate, studies indicate, has been on a shocking increase in recent years, even among children and adolescents. This escalating death rate has occurred in spite of the billions of antidepressant drugs and tranquilizers that have been dispensed during the past several decades.
This might sound fairly gloomy. Before you get even more depressed, let me tell you the good news. Depression is an illness and not a necessary part of healthy living. What's more important—you can overcome it by learning some simple methods for mood elevation. A group of psychiatrists and psychologists at the University of Pennsylvania School of Medicine has reported a significant breakthrough in the treatment and prevention of mood disorders. Dissatisfied with traditional methods for treating depression because they found them to be slow and ineffective, these doctors developed and systematically tested an entirely new and remarkably successful approach to depression and other emotional disorders. A series of recent studies confirms that these techniques reduce the symptoms of depression much more rapidly than conven-tional psychotherapy or drug therapy. The name of this revolutionary treatment is "cognitive therapy."
I have been centrally involved in the development of cogni-9
David D. Burns, M.D.
tive therapy, and this book is the first to describe these methods to the general public. The systematic application and scientific evaluation of this approach in treating clinical depression traces its origins to the innovative work of Dr.
Aaron T. Beck, who began to refine his unique approach to mood transformation in the mid-1950's.* His pioneering efforts began to emer
ge into prominence in the past decade because of the research that many mental-health professionals have undertaken to refine and evaluate cognitive therapy methods at the University of Pennsylvania Medical Center and at numerous other academic institutions.
Cognitive therapy is a fast-acting technology of mood modification that you can learn to apply on your own. It can help you eliminate the symptoms and experience personal growth so you can minimize future upsets and cope with depression more effectively in the future.
The simple, effective mood-control techniques of cognitive therapy provide:
1. Rapid Symptomatic Improvement: In milder depressions, relief from your symptoms can often be observed in as short a time as twelve weeks.
2. Understanding: A clear explanation of why you get moody and what you can do to change your moods.
You will learn what causes your powerful feelings; how to distinguish "normal" from "abnormal" emotions; and how to diagnose and assess the severity of your upsets.
3. Self-control: You will learn how to apply safe and effective coping strategies that will make you feel better whenever you are upset. I will guide you as you develop a practical, realistic, step-by-step self-help plan. As you
* The idea that your thinking patterns can profoundly influence your moods has been described by a number of philosophers in the past 2500 years. More recently, the cognitive view of emotional disturbances has been explored in the writings of many psychiatrists and psychologists including Alfred Adler, Albert Ellis, Karen Homey, and Arnold Lazarus, to name just a few. A history of this movement has been described in Ellis, A., Reason and Emotion in Psychotherapy.
New York: Lyle Stuart, 1962.
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apply it, your moods can come under greater voluntary control.
4. Prevention and Personal Growth: Genuine and long-lasting prophylaxis (prevention) of future mood swings can effectively be based on a reassessment of some basic values and attitudes which lie at the core of your tendency toward painful depressions. I will show you how to challenge and reevaluate certain assumptions about the basis for human worth.
The problem-solving and coping techniques you learn will encompass every crisis in modern life, from minor irritations to major emotional collapse. These will include realistic problems, such as divorce, death, or failure, as well as those vague, chronic problems that seem to have no obvious external cause, such as low self-confidence, frustration, guilt, or apathy.
The question may now occur to you, "Is this just another self-help pop psychology?" Actually, cognitive therapy is one of the first forms of psychotherapy which has been shown to be effective through rigorous scientific research under the critical scrutiny of the academic community. This therapy is unique in having professional evaluation and validation at the highest academic levels. It is not just another self-help fad but a major development that has become an important part of the mainstream of modern psychiatric research and practice. Cognitive therapy's academic foundation has enhanced its impact and should give it staying power for years to come.
But don't be turned off by the professional status that cognitive therapy has acquired. Unlike much traditional psychotherapy, it is not occult and anti-intuitive. It is practical and based on common sense, and you can make it work for you.
The first principle of cognitive therapy is that all your moods are created by your "cognitions," or thoughts. A cognition refers to the way you look at things—your perceptions, mental attitudes, and beliefs. It includes the way you interpret things—what you say about something or someone to yourself. You /eel the way you do right now because of the thoughts you are thinking at this moment.
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David D. Burns, M.D.
Let me illustrate this. How have you been feeling as you read this? You might have been thinking, "Cognitive therapy sounds too good to be true. It would never work for me." If your thoughts run along these lines, you are feeling skeptical or even discouraged. What causes you to feel that way? Your thoughts. You create those feelings by the dialogue you are having with yourself about this book!
Conversely, you may have felt a sudden uplift in mood because you thought, "Hey, this sounds like something which might finally help me." Your emotional reaction is generated not by the sentences you are reading but by the way you are thinking. The moment you have a certain thought and believe it, you will experience an immediate emotional response.
Your thought actually creates the emotion.
The second principle is that when you are feeling depressed, your thoughts are dominated by a pervasive negativity. You You perceive not only yourself but the entire world in dark, gloomy terms. What is even worse—you'll come to believe things really are as bad as you imagine them to be.
If you are substantially depressed, you will even begin to believe that things always have been and always will be negative. As you look into your past, you remember all the bad things that have happened to you. As you try to imagine the future, you see only emptiness or unending problems and anguish. This bleak vision creates a sense of hopelessness. This feeling is absolutely illogical, but it seems so real that you have convinced yourself that your inadequacy will go on forever.
The third principle is of substantial philosophical and therapeutic importance. Our research has documented that the negative thoughts which cause your emotional turmoil nearly always contain gross distortions. Although these thoughts appear valid, you will learn that they are irrational or just plain wrong, and that twisted thinking is a major cause of your suffering.
The implications are important. Your depression is probably not based on accurate perceptions of reality but is often the product of mental slippage.
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Suppose you believe that what I've said has validity. What good will it do you? Now we come to the most important result of our clinical research. You can learn to deal with your moods more effectively if you master methods that will help you pinpoint and eliminate the mental distortions which cause you to feel upset. As you begin to think more objectively, you will begin to feel better.
How effective is cognitive therapy compared with other established and accepted methods for treating depression? Can the new therapy enable severely depressed individuals to get better without drugs? How rapidly does cognitive therapy work? Do the results last?
Several years ago a group of investigators at the Center for Cognitive Therapy at the University of Pennsylvania School of Medicine including Drs. John Rush, Aaron Beck, Maria Kovacs and Steve Hollon began a pilot study comparing cognitive therapy with one of the most widely used and effective antidepressant drugs on the market, Tofranil (imipramine hydrochloride). Over forty severely depressed patients were randomly assigned to two groups. One group was to receive individual cognitive therapy sessions and no drugs, while the other group would be treated with Tofranil and no therapy.
This either-or research design was chosen because it provided the maximum opportunity to see how the treatments compared. Up to that time, no form of psychotherapy had been shown to be as effective for depression as treatment with an antidepressant drug. This is why antidepressants have experienced such a wave of interest from the media, and have come to be regarded by the professional community in the past two decades as the best treatment for most serious forms of depression.
Both groups of patients were treated for a twelve-week period. All patients were systematically evaluated with extensive psychological testing prior to therapy, as well as at several monthly intervals for one year after completion of treatment. The doctors who performed the psychological tests were not the therapists who administered the treatment. This ensured an objective assessment of the merits of each form of treatment.
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David D. Burns, M.D.
The patients were suffering from moderate to severe depressive episodes. The majority had failed to improve in spite of previous treatment with two or more therapists at other clinics
. Three quarters were suicidal at the time of their referral. The average patient had been troubled by chronic or in-termittent depression for eight years. Many were absolutely convinced their problems were insoluble, and felt their lives were hopeless. Your own moon problems may not seem as overwhelming as theirs. A tough patient population was chosen so that the treatment could be tested under the most difficult, challenging conditions.
The outcome of the study was quite unexpected and encouraging. Cognitive therapy showed itself to be substantially superior to antidepressant drug therapy in all respects. As you can see (Table 1-1, page 14), fifteen of the nineteen patients Table 1-1. Status of 44 Severely Depressed Patients, 12 Weeks After Beginning Treatment
Patients Treated
with
Antidepressant
Patients Treated
Drug Therapy
with Cognitive
Only
Therapy Only
Number Who Entered
25
Treatment
19
Number who had recovered
completely*
15
5
Number who were consider-
ably improved but still
experienced borderline to
mild depression
2
7
Number who were not sub-
stantially improved
1
5
Number who dropped out of
treatment
1
8
* The superior improvement of the patients treated with cognitive therapy was statistically significant.
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treated with cognitive therapy had shown a substantial reduction of symptoms after twelve weeks of active treatment.* An additional two individuals had improved, but were still experiencing borderline to mild depression. Only one patient had dropped out of treatment, and one had not yet begun to improve at the end of this period. In contrast, only five of the twenty-five patients assigned to antidepressant drug therapy had shown complete recovery by the end of the twelve-week period. Eight of these patients dropped out of therapy as result of the adverse side effects of the medication, and twelve others showed no improvement or only partial improvement.