Feeling Good: The New Mood Therapy

by Burns, David D.

  Patients in the second group were told they would be placed on a four-week waiting list before beginning treatment. This group was called the Delayed Bibliotherapy Group because these patients were not given a copy of Feeling Good until the second four weeks of the study. The patients in the Delayed Bibliotherapy Group served as a control group to make sure that any improvement in the Immediate Bibliotherapy was not just due to the passage of time.

  At the initial evaluation, the researchers administered two depression tests to all the patients. One was the Beck Depression Inventory (BDI), a time-honored self-assessment test that patients fill out on their own, and the second was the Hamilton Rating Scale for Depression (HRSD), which is administered by trained depression researchers. As you can see in Figure 1, there was no difference in the depression levels in the two groups at the initial evaluation. You can also see that the average scores for the patients in the Immediate Bibliotherapy Group and the Delayed Bibliotherapy group at the initial evaluation were both around 20 or above on the BDI and on the HRSD. These scores indicate that the depression levels in both groups were similar to the depression levels in most published studies of antidepressants or psychotherapy. In fact, the BDI score was nearly identical to the average BDI scores of approximately five hundred patients seeking treatment at my clinic in Philadelphia during the late 1980s.

  Every week a research assistant called the patients in both groups and administered the BDI by telephone. The assistant also answered any questions patients had about the study and encouraged the patients in the Immediate Bibliotherapy Group to try to complete the book within four weeks. These calls were limited to ten minutes and no counseling was offered.

  At the end of the four weeks, the two groups were compared. You can sec in Figure 1 that the patients in the Immediate Bibliotherapy Group improved considerably. In fact, the average scores on both the BDI and HRSD were around 10 or below, scores in the range considered normal.

  Figure 1. The patients in the Immediate Bibliotherapy Group (top Chart) received Feeling Good at the intake evaluation. The patients in the Delayed Bibliotherapy Group (bottom chart) received Feeling Good at the four-week evaluation. BDI-Beck Depression Inventory. HRSD=Hamilton Rating Scat for Depression.

  These changes in depression were very significant. You can also see that the patients maintained their gains at the three-month evaluation and did not relapse. In fact, there was a tendency for continued improvement following the completion of the bibliotherapy treatment; the scores on both depression tests were actually lower at the three-month evaluation.

  In contrast, you can see in Figure 1 that the patients in the Delayed Bibliotherapy Group barely changed and were still around 20 at the four-week evaluation. This showed that the improvement from Feeling Good was not just due to the passage of time. Then Drs. Jamison and Scogin gave the patients in the Delayed Bibliotherapy Group a copy of Feeling Good and asked them to read it during the second four weeks of the study. Their improvement in the next four weeks was similar to the improvement in the Immediate Bibliotherapy Group during the first four weeks of the study. You can also see in Figure 1 that the patients in both groups did not relapse but maintained their gains at the three-month evaluation.

  The results of this study indicated that Feeling Good appeared to have substantial antidepressant effects. At the end of the first four-week Bibliotherapy period, 70 percent of the patients in the Immediate Bibliotherapy Group no longer met the criteria for a major depressive episode, according to the diagnostic criteria for a major depressive episode that are outlined in the American Psychiatric Association’s official Diagnostic and Statistical Manual (DSM). In fact, the improvement was so great most of these patients did not need any further treatment at the medical center. To the best of my knowledge, these are the first published scientific studies showing that a self-help book can actually have significant antidepressant effects in patients suffering from episodes of major depression.

  In contrast, only 3 percent of the patients in the Delayed Bibliotherapy Group recovered during the first four weeks. In other words, the patients who did not read Feeling Good failed to improve. However, at the three-month evaluation, when both groups had read Feeling Good, 75 percent of the patients in the Immediate Bibliotherapy Group and 73 percent of the patients in the Delayed Bibliotherapy Group no longer qualified for a diagnosis of major depressive episode according to DSM criteria.

  The researchers compared the magnitude of the improvement in these groups with the amount of improvement in published outcome studies using antidepressant medications or psychotherapy or both. In the large National Institute of Mental Health Collaborative Depression study, there was an average reduction of 11.6 points on the HRSD in patients who received cognitive therapy from highly trained therapists for twelve weeks. This was very similar to the 10.6-point change in the HRSD observed in the patients who read Feeling Good after just four weeks. However, the bibliotherapy treatment seemed to work significantly faster. My own clinical experience confirms this. In my private practice, very few patients have recovered during the first four weeks of treatment.

  The percentage of patients who dropped out of the bibliotherapy therapy was also very small, around 10 percent. This is less than most published outcome studies using drugs or psychotherapy, which typically have dropout rates from 15 percent to over 50 percent. Finally, the patients developed significantly more positive attitudes and thinking patterns after reading Feeling Good. This was consistent with the premise of the book; namely, that you can defeat depression by changing the negative thinking patterns that cause it.

  The researchers concluded that the bibliotherapy was effective for patients suffering from depression and might also have a significant role in public education and in depression prevention programs. They speculated that Feeling Good bibliotherapy might help prevent serious episodes of depression among individuals with a tendency toward negative thinking.

  Finally, the researchers addressed another important concern: would the antidepressant effects of Feeling Good last? Skillful motivational speakers can get a crowd of people excited and optimistic for brief periods of time—but these brief mood-elevating effects often don’t last. The same problem holds for the treatment of depression. Following successful treatment with drugs or psychotherapy, many patients feel tremendously improved—only to relapse back into depression after a period of time. These relapses can be devastating because patients feel so demoralized.

  In 1997, the investigators reported the results of a three-year follow-up of the patients in the study I’ve just described.7 The authors were Drs. Nancy Smith, Mark Floyd, and Forest Scogin from the University of Alabama and Dr. Christine Jamison from the Tuskegee Veterans Affairs Medical Center. The researchers contacted the patients three years after reading Feeling Good and administered the depression tests once again. They also asked the patients several questions about how they had been doing since the completion of the study. The researchers learned that the patients did not relapse but maintained their gains during this three-year period. In fact, the scores on the two depression tests at the three-year evaluation were actually slightly better than the scores at the completion of the bibliotherapy treatment. More than half of the patients said that their moods continued to improve following the completion of the initial study.

  The diagnostic findings at the three-year evaluation confirmed this—72 percent of the patients still did not meet the criteria for a major depressive episode, and 70 percent did not seek or receive any further treatment with medications or psychotherapy during the follow-up period. Although they experienced the normal ups and downs we all feel from time to time, approximately half indicated that when they were upset, they opened up Feeling Good and reread the most helpful sections. The researchers speculated that these self-administered “booster sessions” may have been important in maintaining a positive outlook following recovery. Forty percent of the patients said that the best part of the book was that it helped them chang
e their negative thinking patterns, such as learning to be less perfectionistic and to give up all-or-nothing thinking.

  Of course, this study had limitations, like all studies. For one thing, not every patient was “cured” by reading Feeling Good. No treatment is a panacea. While it is encouraging that many patients seem to respond to reading Feeling Good, it is also clear that some patients with more severe or chronic depressions will need the help of a therapist and possibly an antidepressant medication as well. This is nothing to be ashamed of. Different individuals respond better to different approaches. It is good that we now have three types of effective treatment for depression: antidepressant medications, individual and group psychotherapy, and bibliotherapy.

  Remember that you can use the cognitive bibliotherapy between therapy sessions to speed your recovery even if you are in treatment. In fact, when I first wrote Feeling Good, this is how I imagined the book would be used. I intended it to be a tool my patients could use between therapy sessions to speed up the treatment and never dreamed that it might someday be used alone as a treatment for depression.

  It appears that more and more therapists are beginning to assign bibliotherapy to their patients as psychotherapy “homework” between therapy sessions. In 1994, the results of a nationwide survey about the use of bibliotherapy by mental health professionals were published in the Authoritative Guide to Self-Help Books (published by Guilford Press, New York). Drs. John W. Santrock and Ann M. Minnet from the University of Texas in Dallas and Barbara D. Campbell, a research associate at the university, conducted this study. These three researchers surveyed five hundred American mental health professionals from all fifty states and asked whether they “prescribed” books for patients to read between sessions to speed recovery. Seventy percent of the therapists polled indicated that they had recommended at least three self-help books to their patients during the previous year, and 86 percent reported that these books provided a positive benefit to their patients. The therapists were also asked which self-help books, from a list of one thousand, they most frequently recommended for their patients. Feeling Good was the number-one-rated book for depressed patients, and my Feeling Good Handbook (published as a Plume paperback in 1989) was rated number two.

  I was not aware this survey was being conducted, and was thrilled to learn about the results of it. One of my goals when I wrote Feeling Good was to provide reading for my own patients to speed their learning and recovery between therapy sessions, but I never dreamed this idea would catch on in such a big way!

  Should you expect to improve or recover after reading Feeling Good? That would be unreasonable. The research clearly indicates that while many people who read Feeling Good improved, others needed the additional help of a mental health professional. I have received many letters (probably more than ten thousand) from people who read Feeling Good. Many of them kindly described in glowing terms how Feeling Good had helped them, often after years and years of unsuccessful treatment with medications and even electroconvulsive therapy. Others indicated that they found the ideas in Feeling Good appealing but needed a referral to a good local therapist to make these ideas work for them. This is understandable—we are all different, and it would be unrealistic to think that any one book or form of therapy would be the answer for everyone.

  Depression is one of the worst forms of suffering, because of the immense feelings of shame, worthlessness, hopelessness, and demoralization. Depression can seem worse than terminal cancer, because most cancer patients feel loved and they have hope and self-esteem. Many depressed patients have told me, in fact, that they yearned for death and prayed every night that they would get cancer, so they could die in dignity without having to commit suicide.

  But no matter how terrible your depression and anxiety may feel, the prognosis for recovery is excellent. You may be convinced that your own case is so bad, so over-whelming and hopeless, that you are the one person who will never get well, no matter what. But sooner or later, the clouds have a way of blowing away and the sky suddenly clears and the sun begins to shine again. When this happens, the feelings of relief and joy can be overwhelming. And if you are now struggling with depression and low self-esteem, I believe this transformation can happen for you as well, no matter how discouraged or depressed you may feel.

  Well, it’s time to get on to Chapter 1 so we can start to work together. I want to wish you the very best as you read it, and hope you find these ideas and methods helpful!

  David D. Burns, M.D.

  Clinical Associate Professor of Psychiatry

  and Behavioral Sciences,

  Stanford University School of Medicine

  References

  1. Antonuccio, D. O., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26(6), 574–585.

  2. Baxter, L. R., Schwartz, J. M., & Bergman, K. S., et al. (1992). Caudate glucose metabolic rate changes with both drug and behavioral therapy for obsessive-compulsive disorders. Archives of General Psychiatry, 49, 681–689.

  3. Scogin, F., Jamison, C., & Gochneaut, K. (1989). The comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting and Clinical Psychology, 57, 403–407.

  4. Scogin, F., Hamblin, D., & Beutler, L. (1987). Bibliotherapy for depressed older adults: A self-help alternative. The Gerontologist, 27, 383–387.

  5. Scogin, F., Jamison, C., & Davis, N. (1990). A two-year follow-up of the effects of bibliotherapy for depressed older adults. Journal of Consulting and Clinical Psychology, 58, 665–667.

  6. Jamison, C., & Scogin, F. (1995). Outcome of cognitive bibliotherapy with depressed adults. Journal of Consulting and Clinical Psychology, 63, 644–650.

  7. Smith, N. M., Floyd, M. R., Jamison, C., & Scogin, F. (1997). Three-year follow-up of bibliotherapy for depression. Journal of Consulting and Clinical Psychology, 65(2), 324–327.

  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 conventional psychotherapy or drug therapy. The name of this revolutionary treatment is “cognitive therapy.”

  I have been centrally involved in the development of cognitive 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 Drs. Albert Ellis and Aaron T. Beck, who began to refine their unique approach to mood transformation in the mid-1950’s and early 1960’s.* Their pioneering efforts began to emerge into prominence in the past decade because of the resear
ch that many mental-health professionals have undertaken to refine and evaluate cognitive therapy methods at academic institutions in the United States and abroad.

  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 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.