Feeling Good: The New Mood Therapy

by Burns, David D.

  The first step is to take a close look at what you say about yourself when you insist you are no good. The evidence you present in defense of your worthlessness will usually, if not always, make no sense.

  This opinion is based on a recent study by Drs. Aaron Beck and David Braff which indicated that there is actually a formal thinking disturbance in depressed patients. Depressed individuals were compared with schizophrenic patients and with undepressed persons in their ability to interpret the meaning of a number of proverbs, such as “A stitch in time saves nine.” Both the schizophrenic and depressed patients made many logical errors and had difficulty in extracting the meaning of the proverbs. They were overly concrete and couldn’t make accurate generalizations. Although the severity of the defect was obviously less profound and bizarre in the depressed patients than in the schizophrenic group, the depressed individuals were clearly abnormal as compared with the normal subjects.

  In practical terms the study indicated that during periods of depression you lose some of your capacity for clear thinking; you have trouble putting things into proper perspective. Negative events grow in importance until they dominate your entire reality—and you can’t really tell that what is happening is distorted. It all seems very real to you. The illusion of hell you create is very convincing.

  The more depressed and miserable you feel, the more twisted your thinking becomes. And, conversely, in the absence of mental distortion, you cannot experience low self-worth or depression!

  What types of mental errors do you make most generally when you look down on yourself? A good place to begin is with the list of distortions you began to master in Chapter 3. The most usual mental distortion to look out for when you are feeling worthless is all-or-nothing thinking. If you see life only in such extreme categories, you will believe your performance will be either great or terrible—nothing else will exist. As a salesman told me, “Achieving 95 percent or better of my goal for monthly sales is acceptable. Ninety-four percent or below is the equivalent of total failure.”

  Not only is this all-or-nothing system of self-evaluation highly unrealistic and self-defeating, it creates overwhelming anxiety and frequent disappointment. A depressed psychiatrist who was referred to me noticed a lack of sexual drive and a difficulty in maintaining erections during a two-week period when he was feeling blue. His perfectionistic tendencies had dominated not only his illustrious professional career but also his sexual life. Consequently, he had intercourse regularly with his wife every other day precisely on schedule for the twenty years of their married life. In spite of his decreased sex drive—which is a common symptom of depression—he told himself, “I must continue to perform intercourse on schedule.” This thought created such anxiety that he became increasingly unable to achieve a satisfactory erection. Because his perfect intercourse track record was broken, he now began clubbing himself with the “nothing” side of his all-or-nothing system and concluded, “I’m not a full marriage partner anymore. I’m a failure as a husband. I’m not even a man. I’m a worthless nothing.” Although he was a competent (and some might even say brilliant) psychiatrist, he confided to me tearfully, “Dr. Burns, you and I both know it is an undeniable fact that I will never be able to have intercourse again.” In spite of his years of medical training, he could actually convince himself of such a thought.

  Overcoming the Sense of Worthlessness

  By now you might be saying, “Okay, I can see that there is a certain illogic which lurks behind the sense of worthlessness. At least for some people. But they are basically winners; they’re not like me. You seem to be treating famous physicians and successful businessmen. Anyone could have told you that their lack of self-esteem was illogical. But I really am a mediocre nothing. Others are, in fact, better looking and more popular and successful than I am. So what can I do about it? Nothing, that’s what! My feeling of worthlessness is very valid. It’s based on reality, so there is little consolation in being told to think logically. I don’t think there’s any way to make these awful feelings go away unless I try to fool myself, and you and I both know that won’t work.” Let me first show you a couple of popular approaches, used by many therapists, which I feel do not represent satisfactory solutions to your problem of worthlessness. Then I’ll show you some approaches that will make sense and help you.

  In keeping with the belief that there is some deep truth in your conviction you are basically worthless, some psychotherapists may allow you to ventilate these feelings of inadequacy during a therapy session. There is undoubtedly some benefit to getting such feelings off your chest. The cathartic release may sometimes, but not always, result in a temporary mood elevation. However, if the therapist does not provide objective feedback about the validity of your self-evaluation, you may conclude that he agrees with you. And you may be right! You may, in fact, have fooled him as well as yourself! As a result you probably will feel even more inadequate.

  Prolonged silences during therapy sessions may cause you to become more upset and preoccupied with your critical internal voice—much like a sensory-deprivation experiment. This kind of nondirective therapy, in which the therapist adopts a passive role, frequently produces greater anxiety and depression for the patient. And even when you do feel better as a result of achieving emotional release with an empathetic and caring therapist, the sense of improvement is likely to be short-lived if you haven’t significantly transformed the way you evaluate yourself and your life. Unless you substantially reverse your self-defeating thinking and behavior patterns, you are likely to slip back again into depression.

  Just as emotional ventilation for its own sake is usually not enough to overcome the sense of worthlessness, insight and psychological interpretation generally don’t help either. For example, Jennifer was a writer who came for treatment for panic she experienced before publication of her novel. In the first session she told me, “I have been to several therapists. They have told me that my problem is perfectionism and impossible expectations and demands on myself. I also have learned that I probably picked up this trait from my mother, who is compulsive and perfectionistic. She can find nineteen things wrong with an incredibly clean room. I always tried to please her, but rarely felt I succeeded no matter how well I did. Therapists have told me, ‘Stop seeing everyone as your mother! Stop being so perfectionistic.’ But how do I do this? I’d like to, I want to, but no one ever was able to tell me how to go about it.”

  Jennifer’s complaint is one I hear nearly every day in my practice. Pinpointing the nature or origin of your problem may give you insight, but usually fails to change the way you act. That is not surprising. You have been practicing for years and years the bad mental habits that helped create your low self-esteem. It will take systematic and ongoing effort to turn the problem around. Does a stutterer stop stuttering because of his insight into the fact that he doesn’t vocalize properly? Does a tennis player’s game improve just because the coach tells him he hits the ball into the net too often?

  Since ventilation of emotions and insight—the two staples of the standard psychotherapeutic diet—won’t help, what will? As a cognitive therapist, I have three aims in dealing with your sense of worthlessness: a rapid and decisive transformation in the way you think, feel, and behave. These results will be brought about in a systematic training program that employs simple concrete methods you can apply on a daily basis. If you are willing to commit some regular time and effort to this program, you can expect success proportionate to the effort you put in.

  Are you willing? If so, we’ve come to the beginning. You’re about to take the first crucial step toward an improved mood and self-image.

  I have developed many specific and easily applied techniques that can help you develop your sense of worth. As you read the following sections, keep in mind that simply reading them is not guaranteed to bolster your self-esteem—at least not for long. You will have to work at it and practice the various exercises. In fact, I recommend that you set some time aside each
day to work at improving your self-image because only in this way can you experience the fastest and most enduring personal growth.

  Specific Methods for Boosting Self-Esteem

  1. Talk Back to That Internal Critic! A sense of worthlessness is created by your internal self-critical dialogue. It is self-degrading statements, such as “I’m no damn good,” “I’m a shit,” “I’m inferior to other people,” and so on, that create and feed your feelings of despair and poor self-esteem. In order to overcome this bad mental habit, three steps are necessary:

  a. Train yourself to recognize and write down the self-critical thoughts as they go through your mind;

  b. Learn why these thoughts are distorted; and

  c. Practice talking back to them so as to develop a more realistic self-evaluation system.

  One effective method for accomplishing this is the “triple-column technique.” Simply draw two lines down the center of a piece of paper to divide it into thirds (see Figure 4–1, page 63). Label the left-hand column “Automatic Thoughts (Self-Criticism),” the middle column “Cognitive Distortion,” and the right-hand column “Rational Response (Self-Defense).” In the left-hand column write down all those hurtful self-criticisms you make when you are feeling worthless and down on yourself.

  Suppose, for example, you suddenly realize you’re late for an important meeting. Your heart sinks and you’re gripped with panic. Now ask yourself, “What thoughts are going through my mind right now? What am I saying to myself? Why is this upsetting me?” Then write these thoughts down in the left-hand column.

  You might have been thinking, “I never do anything right,” and “I’m always late.” Write these thoughts down in the left-hand column and number them (see Figure 4–1). You might also have thought, “Everyone will look down at me. This shows what a jerk I am.” Just as fast as these thoughts cross your mind, jot them down. Why? Because they are the very cause of your emotional upset. They rip away at you like knives tearing into your flesh. I’m sure you know what I mean because you’ve felt it.

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  Figure 4–1. The “triple-column technique” can be used to restructure the way you think about yourself when you have goofed up in some way. The aim is to substitute more objective rational thoughts for the illogical, harsh self-criticisms that automatically flood your mind when a negative event occurs.

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  What’s the second step? You already began to prepare for this when you read Chapter 3. Using the list of ten cognitive distortions (page 42), see if you can identify the thinking errors in each of your negative automatic thoughts. For instance, “I never do anything right” is an example of overgeneralization. Write this down in the middle column. Continue to pinpoint the distortions in your other automatic thoughts, as shown in Figure 4–1.

  You are now ready for the crucial step in mood transformation—substituting a more rational, less upsetting thought in the right-hand column. You do not try to cheer yourself up by rationalizing or saying things you do not believe are objectively valid. Instead, try to recognize the truth. If what you write down in the Rational Response column is not convincing and realistic, it won’t help you one bit. Make sure you believe in your rebuttal to self-criticism. This rational response can take into account what was illogical and erroneous about your self-critical automatic thought.

  For example, in answer to “I never do anything right,” you could write, “Forget that! I do some things right and some wrong, just like everyone else. I fouled up on my appointment, but let’s not blow this up out of proportion.”

  Suppose you cannot think of a rational response to a particular negative thought. Then just forget about it for a few days and come back to it later. You will usually be able to see the other side of the coin. As you work at the triple-column technique for fifteen minutes every day over a period of a month or two, you will find it gets easier and easier. Don’t be afraid to ask other people how they would answer an upsetting thought if you can’t figure out the appropriate rational response on your own.

  One note of caution: Do not use words describing your emotional reactions in the Automatic Thought column. Just write the thoughts that created the emotion. For example, suppose you notice your car has a flat tire. Don’t write “I feel crappy” because you can’t disprove that with a rational response. The fact is, you do feel crappy. Instead, write down the thoughts that automatically flashed through your mind the moment you saw the tire; for example, “I’m so stupid—I should have gotten a new tire this last month,” or “Oh, hell! This is just my rotten luck!” Then you can substitute rational responses such as “It might have been better to get a new tire, but I’m not stupid and no one can predict the future with certainty.” This process won’t put air in the tire, but at least you won’t have to change it with a deflated ego.

  While it’s best not to describe your emotions in the Automatic Thought column, it can be quite helpful to do some “emotional accounting” before and after you use the triple-column technique to determine how much your feelings actually improve. You can do this very easily if you record how upset you are between 0 and 100 percent before you pinpoint and answer your automatic thoughts. In the previous example, you might note that you were 80 percent frustrated and angry at the moment you saw the flat tire. Then, once you complete the written exercise, you can record how much relief you experienced, say, to 40 percent or so. If there’s a decrease, you’ll know that the method has worked for you.

  A slightly more elaborate form developed by Dr. Aaron Beck called the Daily Record of Dysfunctional Thoughts allows you to record not only your upsetting thoughts but also your feelings and the negative event that triggered them (see Figure 4–2, page 66).

  For example, suppose you are selling insurance and a potential customer insults you without provocation and hangs up on you. Describe the actual event in the Situation column, but not in the Automatic Thought(s) column. Then write down your feelings and the negative distorted thoughts that created them in the appropriate column. Finally, talk back to these thoughts and do your emotional accounting. Some individuals prefer to use the Daily Record of Dysfunctional Thoughts because it allows them to analyze negative events, thoughts, and feelings in a systematic way. Be sure to use the technique that feels most comfortable to you.

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  Figure 4–2. Daily Record of Dysfunctional Thoughts*

  Explanation: When you experience an unpleasant emotion, note the situation that seemed to stimulate it. Then, note the automatic thought associated with the emotion. In rating degree of emotion, I = a trace; 100 = the most intense possible.

  *Copyright 1979, Aaron T. Beck.

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  Writing down your negative thoughts and rational responses may strike you as simplistic, ineffective, or even gimmicky. You might even share the feelings of some patients who initially refused to do this, saying, “What’s the point? It won’t work—it couldn’t work because I really am hopeless and worthless.”

  This attitude can only serve as a self-fulfilling prophecy. If you are unwilling to pick up the tool and use it, you won’t be able to do the job. Start by writing down your automatic thoughts and rational responses for fifteen minutes every day for two weeks and see the effect this has on your mood, as measured by the Burns Depression Checklist. You may be surprised to note the beginning of a period of personal growth and a healthy change in your self-image.

  This was the experience of Gail, a young secretary whose sense of self-esteem was so low that she felt in constant danger of being criticized by friends. She was so sensitive to her roommate’s request to help clean up their apartment after a party that she felt rejected and worthless. She was initially so pessimistic about her chances for feeling better that I could barely persuade her to give the triple-column technique a try. When she reluctantly decided to try it, she was surprised to see how her self-esteem and mood began to undergo a rapid transformation. She reported that writing down the many negative thoughts that flowed thr
ough her mind during the day helped her gain objectivity. She stopped taking these thoughts so seriously. As a result of Gail’s daily written exercises, she began to feel better, and her interpersonal relationships improved by a quantum leap. An excerpt from her written homework is included in Figure 4–3.

  Gail’s experience is not unusual. The simple exercise of answering your negative thoughts with rational responses on a daily basis is at the heart of the cognitive method. It is one of the most important approaches to changing your thinking. It is crucial to write down your automatic thoughts and rational responses; do not try to do the exercise in your head. Writing them down forces you to develop much more objectivity than you could ever achieve by letting responses swirl through your mind. It also helps you locate the mental errors that depress you. The triple-column technique is not limited to problems of personal inadequacy, but can be applied to a great range of emotional difficulties in which distorted thinking plays a central role. You can take the major sting out of problems you would ordinarily assume are entirely “realistic,” such as bankruptcy, divorce, or severe mental illness. Finally, in the section on prophylaxis and personal growth, you will learn how to apply a slight variation of the automatic-thought method to penetrate to the part of your psyche where the causes of mood swings lurk. You will be able to expose and transform those “pressure points” in your mind that cause you to be vulnerable to depression in the first place.

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  Figure 4–3. Excerpts from Gail’s daily written homework using the “triple-column technique.” In the left column she recorded the negative thoughts that automatically flowed through her mind when her roommate asked her to clean up the apartment. In the middle column she identified her distortions, and in the right-hand column she wrote down more realistic interpretations. This daily written exercise greatly accelerated her personal growth and resulted in substantial emotional relief.