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 feel the way you do right now because of the thoughts you are thinking at this moment.
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 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.
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 sec 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.
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 intermittent depression for eight years. Many were absolutely convinced their problems were insoluble, and felt their lives were hopeless. Your own mood 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. The cognitive therapy was at least as effective as, if not more effective than, the antidepressant drug therapy. As you can see (Table 1–1, page 15), fifteen of the nineteen patients 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 a result of the adverse side effects of the medication, and twelve others showed no improvement or only partial improvement.
Table 1–1. Status of 44 Severely Depressed Patients, 12 Weeks After Beginning Treatment
Number who Entered Treatment
Patients Treated with Cognitive Therapy Only 19
Patients Treated with Antidepressant Drug Therapy Only 25
Number who had recovered completely*
15
5
Number who were considerably improved but still experienced borderline to mild depression
2
7
Number who were not substantially improved
1
5
Number who dropped out of treatment
1
8
*The superior improvement of the patients treated with cognitive therapy was statistically significant
Of particular importance was the discovery that many patients treated with cognitive therapy improved more rapidly than those successfully treated with drugs. Within the first week or two, there was a pronounced reduction in suicidal thoughts among the cognitive therapy group. The effectiveness of cognitive therapy should be encouraging for individuals who prefer not to rely on drugs to raise their spirits, but prefer to develop an understanding of what is troubling them and do something to cope with it.
How about those patients who had not recovered by the end of twelve weeks? Like any form of treatment, this one is not a panacea. Clinical experience has shown that all individuals do not respond as rapid
ly, but most can nevertheless improve if they persist for a longer period of time. Sometimes this is hard work! One particularly encouraging development for individuals with refractory severe depressions is a recent study by Drs. Ivy Blackburn and her associates at the Medical Research Council at the University of Edinburgh in Scotland.* These investigators have shown that the combination of antidepressant drugs with cognitive therapy can be more effective than either modality above. In my experience the most crucial predictor of recovery is a persistent willingness to exert some effort to help yourself. Given this attitude, you will succeed.
Just how much improvement can you hope for? The average cognitively treated patient experienced a substantial elimination of symptoms by the end of treatment. Many reported they felt the happiest they had ever felt in their lives. They emphasized that the mood-training brought about a sense of self-esteem and confidence. No matter how miserable, depressed, and pessimistic you now feel, I am convinced that you can experience beneficial effects if you are willing to apply the methods described in this book with persistence and consistency.
How long do the effects last? The findings from follow-up studies during the year after completion of treatment are quite interesting. While many individuals from both groups had occasional mood swings at various times during the year, both groups continued on the whole to maintain the gains they had demonstrated by the end of twelve weeks of active treatment.
Which group actually fared better during the follow-up period? The psychological tests, as well as the patients’ own reports, confirmed that the cognitive therapy group continued to feel substantially better, and these differences were statistically significant. The relapse rate over the course of the year in the cognitive therapy group was less than half that observed in me drug patients. These were sizable differences that favored the patients treated with the new approach.
Does this mean that I can guarantee you will never again have the blues after using cognitive methods to eliminate your current depression? Obviously not. That would be like saying that once you have achieved good physical condition through daily jogging, you will never again be short of breath. Part of being human means getting upset from time to time, so I can guarantee you will not achieve a state of never-ending bliss! This means you will have to reapply the techniques that help you if you want to continue to master your moods. There’s a difference between feeling better—which can occur spontaneously—and getting better—which results from systematically applying and reapplying the methods that will lift your mood whenever the need arises.
How has this work been received by the academic community? The impact of these findings on psychiatrists, psychologists, and other mental-health professionals has been substantial. It has now been twenty years since this chapter was first written. During that time, numerous well-controlled studies of the effectiveness of cognitive therapy have been published in scientific journals. These studies have compared the effectiveness of cognitive therapy with the effectiveness of antidepressant medications as well as other forms of psychotherapy in the treatment of depression, anxiety, and other disorders. The results of these studies have been quite encouraging. Researchers have confirmed our early impressions that cognitive therapy was at least as effective as medications, and often more effective, both in the short term and in the long term.
What does this all add up to? We are experiencing a crucial development in modern psychiatry and psychology—a promising new approach to understanding human emotions based on a cogent testable therapy. Large numbers of mental-health professionals are now showing a great interest in this approach, and the ground swell seems to be just beginning.
Since the first edition of Feeling Good in 1980, many thousands of depressed individuals have been successfully treated with cognitive therapy. Some had considered themselves hopelessly unbeatable and came to us as a last-ditch effort before commmitting suicide. Many others were simply troubled by the nagging tensions of daily living and wanted a greater share of personal happiness. This book is a carefully thought-out practical application of our work, and it is designed for you. Good luck!
Chapter 2
How to Diagnose Your Moods: The First Step in the Cure
Perhaps you are wondering if you have in fact been suffering from depression. Let’s go ahead and see where you stand. The Burns Depression Checklist (BDC) (see Table 2–1, page 20) is a reliable mood-measuring device that detects the presence of depression and accurately rates its severity.* This simple questionnaire will take only a few minutes to complete. After you have completed the BDC, I will show you how to make a simple interpretation of the results, based on your total score. Then you will know immediately whether or not you are suffering from a true depression and, if so, how severe it is. I will also lay out some important guidelines to help you determine whether you can safely and effectively treat your own blue mood using this book as your guide, or whether you have a more serious emotional disorder and might benefit from professional intervention in addition to your own efforts to help yourself.
As you fill out the questionnaire, read each item carefully and put a check in the box that indicates how you have been feeling during the past few days. Make sure you check one answer for each of the twenty-five items.
If in doubt, make your best guess. Do not leave any questions unanswered. Regardless of the outcome, this can be your first step toward emotional improvement.
Table 2–1. Burns Depression Checklist*
*Copyright © 1984 by David D. Burns, M.D. (Revised, 1996.)
**Anyone with suicidal urges should seek help from a mental health professional.
Interpreting the Burns Depression Checklist. Now that you have completed the test, add up the score for each of the twenty-five items and obtain the total. Since the highest score you can get on each of the twenty-five symptoms is 4, the highest score for the whole test would be 100. (This would indicate the most severe depression possible.) Since the lowest score for each item is 0, the lowest score for the test would be zero. (This would indicate no symptoms of depression at all.)
You can now evaluate your depression according to Table 2–2. As you can see, the higher the total score, the more severe your depression. In contrast, the lower the score, the better you are feeling.
Although the BDC is not difficult or time-consuming to fill out and score, don’t be deceived by its simplicity. You have just learned to use a highly sophisticated tool for detecting depression and measuring its severity. Research studies have demonstrated that the BDC is highly accurate and reliable. Studies in a variety of settings, such as psychiatric emergency rooms, have indicated that instruments of this type actually pick up the presence of depressive symptoms far more frequently than formal interviews by experienced clinicians.
Table 2–2. Interpreting the Burns Depression Checklist
Total Score
Level of Depression*
0–5
no depression
6–10
normal but unhappy
11–25
mild depression
26–50
moderate depression
51–75
severe depression
76–100
extreme depression
*Anyone with a persistent score above 10 may benefit from professional treatment. Anyone with suicidal feelings should seek an immediate consultation with a mental health professional.
You can use the BDC with confidence to monitor your progress as well. In my clinical work, I have insisted that every patient must fill out the test on his or her own between all sessions and report the score to me at the beginning of the next session. Changes in the score show me whether the patient is getting better, worse, or staying the same.
As you apply the various self-help techniques described in this book, take the BDC test at regular intervals to assess your progress objectively. I suggest a minimum of once a week. Compare it to weighing yourself regularly when you’re on a diet. You will
notice that various chapters in this book focus on different symptoms of depression. As you learn to overcome these symptoms, you will find that your total score will begin to fall. This will show that you are improving. When your score is under ten, you will be in the range considered normal. When it is under five, you will be feeling especially good. Ideally, I’d like to see your score under five the majority of the time. This is one aim of your treatment.
Is it safe for depressed individuals to try to help themselves using the principles and methods outlined in this book? The answer is—definitely yes! This is because the crucial decision to try to help yourself is the key that will allow you to feel better as soon as possible, regardless of how severe your mood disturbance might seem to be.
Under what conditions should you seek professional help? If your score is between 0 and 5, you are probably feeling good already. This is in the range of normal, and most people with scores this low feel pretty happily contented.
If your score was between 6 and 10, it is still in the range of normal, but you are probably feeling a bit on the “lumpy” side. There’s room for improvement, a little mental “tune-up,” if you will. The cognitive therapy techniques in this book can often be remarkably helpful in these instances. Problems in daily living bug all of us, and a change of perspective can often make a big difference in how you feel.
If your score was between 11 and 25, your depression, at least at this time, is mild and should not be a cause for alarm. You will definitely want to correct this problem, and you may be able to make substantial progress on your own. Systematic self-help efforts along the lines proposed in this book, combined with frank communication on a number of occasions with a trusted friend, may help a great deal. But if your score remains in this range for more than a few weeks, you should consider professional treatment. The help of a therapist or an antidepressant medication may considerably speed your recovery.
Feeling Good: The New Mood Therapy Page 3