DAVID D, BURNS, ML. REVISED AND UPDATED MORE THAN THREE MILLION COPIES IN PRINT NOW WITH THE ALL-NEW CONSUMER'S GUIDE TO ANTIDEPRESSANT DRUGS AND A NEW INTRODUCTION FROM THE AUTHOR TUNG OOD THe New MOobD THERAPY The Clinically Proven Drug-free Treatment for DepressionHEALTH FEELING GOOD FEELS WONDERFUL The good news is that anxiety, guilt, pessimism, procrastination, low self-esteem, and other “black holes” of depression can be cured without drugs. In FEELING GOOD, eminent psychiatrist David D. Burns, M.D., outlines the remarkable, scientifically proven techniques that will immediately lift your spirits and help you develop a positive outlook on life: * Recognize what causes your mood swings + Nip negative feelings in the bud * Deal with guilt * Handle hostility and criticism * Overcome addiction to love and approval + Beat “do-nothingism” + Avoid the painful downward spiral of depression * Build self-esteem * Feel good every day BEGIN NOW, TO EXPERIENCE THE JOY OF FEELING GOOD “A BOOK TO READ AND RE-READ!”—Los Angeles Times TSBN 0-380 ii 2 Quill 9 | | | \ I i 51500> 2 b | is A An Imprint of HarperCollinsP ub 731763 780380! www.harpercollins.com USA $15.00 Canada $23.00Feeling Good: The New Mood Therapy has sold more than 3 million copies worldwide to date. In a recent national survey, Feeling Good was rated as the most helpful book on depression— from a list of over 1,000 self-help books—and was the most frequently recommended book for de- pressed individuals by American mental health professionals. Dr. Burns’ Feeling Good Handbook was rated #2 in the same survey. Although self- help books are quite controversial, five controlled outcome studies published in scientific journals over the past decade indicated that 70 percent of depressed individuals who read Feeling Good improved within four weeks even though they re- ceived no other treatment. In addition, these pa- tients have maintained their improvement during follow-up periods of up to three years. Surpris- ingly, the antidepressant effects of Feeling Good appear to be as strong as antidepressant medica- tions or individual psychotherapy for patients suffering from episodes of major depression! Although Dr. Burns does not recommend any self- help book as a substitute for professional therapy, Feeling Good should prove immensely illu- minating to anyone suffering from depression or anxiety. Feeling Good Feels Wonderful! You Owe It to Yourself to Feel Good! “I would personally evaluate David Burns’ Feeling Good as one of the most significant books to come out of the last third of the Twentieth Century.’’ Dr. David F. Maas, Professor of English, Ambassador UniversityAlso by David D. Burns, M.D. THE FEELING GOOD HANDBOOK INTIMATE CONNECTIONS TEN DAYS TO SELF ESTEEM THE LEADER’S MANUALFEELING (00D THe New Mood THERAPY DAVID D. BURNS, MD Va Quill of HarperCollinsPublishersThe ideas, procedures, and suggestions contained in this book are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. A hardcover edition of this book was published in 1980 by William Morrow and Company, Inc. FEELING GOOD. Copyright © 1980 by David Burns. All rights reserved. Printed in the United States of America. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles and reviews. For information address HarperCollins Publishers Inc., 10 East 53rd Street, New York, NY 10022. HarperCollins books may be purchased for educational, business, or sales promotional use. For information please write: Special Markets Department, HarperCollins Publishers Inc., 10 East 53rd Street, New York, NY 10022. First WholeCare edition published 1999. Reprinted in Quill 2000. Library of Congress Cataloging-in-Publication Data is available. ISBN 0-380-73176-2 09 08 07 06 RRD 30 29 28 27This book is dedicated to Aaron T. Beck, M.D., in admiration of his knowledge and courage and in ap- preciation of his patience, dedication and empathy.Acknowledgments I am grateful to my wife, Melanie, for her editorial assis- tance and patience and encouragement on the many long evenings and weekends that were spent in the preparation of this book. I would also like to thank Mary Lovell for her enthusiasm and for her technical assistance in typing the manuscript. The development of cognitive therapy has been a team effort involving many talented individuals. In the 1930s, Dr. Abraham Lowe, a physician, began a free-of-charge self-help movement for individuals with emotional diffi- culties, called ‘‘Recovery Incorporated,’’ which is still in existence today. Dr. Lowe was one of the first health pro- fessionals to emphasize the important role of our thoughts and attitudes on our feelings and behavior. Although many people are not aware of his work, Dr. Lowe deserves a great deal of credit for pioneering many of the ideas that are still in vogue today. In the 1950s, the noted New York psychologist, Dr. Al- bert Ellis, refined these concepts and created a new form of psychotherapy called Rational Emotive Therapy. Dr. El- lis published over fifty books that emphasize the role of negative self-talk (such as ‘‘shoulds’’ and ‘‘oughts’’) and irrational beliefs (such as ‘‘I must be perfect’’) in a wide viiviii Acknowledgments variety of emotional problems. Like Dr. Lowe, his brilliant contributions are sometimes not sufficiently acknowledged by academic researchers and scholars. In fact, when I wrote the first edition of Feeling Good, I was not especially fa- miliar with the work of Dr. Ellis and did not really appre- ciate the importance and magnitude of his contributions. I want to set the record straight here! Finally, in the 1960s, my colleague at the University of Pennsylvania School of Medicine, Dr. Aaron Beck, adapted these ideas and treatment techniques to the problem of clin- ical depression. He described the depressed patient’s neg- ative view of the self, the world, and the future, and proposed a new form of ‘‘thinking therapy’’ for depression, which he called ‘‘cognitive therapy.’’ The focus of cogni- tive therapy was helping the depressed patient change these negative thinking patterns. Dr. Beck’s contributions, like those of Drs. Lowe and Ellis, have been substantial. His Beck Depression Inventory, published in 1964, allowed cli- nicians and researchers to measure depression for the first time. The idea that we could measure how severe a pa- tient’s depression was, and track changes in response to treatment, was revolutionary. Dr. Beck also emphasized the importance of systematic, quantitative research so we could get objective information on how well the different kinds of psychotherapy actually worked, and how effective they are in comparison to antidepressant drug therapy. Since the time of those three early pioneers, many hun- dreds of gifted researchers and clinicians throughout the world have contributed to this new approach. In fact, there has probably been more published research on cognitive therapy than on any other form of psychotherapy ever de- veloped, with the possible exception of behavior therapy. Clearly, I cannot mention all the individuals who have made important contributions to the development of cog- nitive therapy. In the early days of cognitive therapy, during the 1970s, I worked with several colleagues at the Univer- sity of Pennsylvania School of Medicine who helped to create many of the treatment techniques still in use today.Acknowledgments ix They included Drs. John Rush, Maria Kovacs, Brian Shaw, Gary Emery, Steve Hollon, Rich Bedrosian, Ruth Green- berg, Ira Herman, Jeff Young, Art Freeman, Ron Coleman, Jackie Persons, and Robert Leahy. Several individuals have given me permission to refer to their work in detail in this book, including Drs. Raymond Novaco, Arlene Weissman, and Mark K. Goldstein. I would like to make special mention of Maria Guarnas- chelli, the editor of this book, for her endless spark and vitality which have been a special inspiration to me. During the time I was engaged in the training and re- search which led to this book, I was a Fellow of the Foun- dations’ Fund for Research in Psychiatry. I would like to thank them for their support which made this experience possible. And my thanks to Frederick K. Goodwin, M.D., a former chief at the National Institute of Mental Health, for his val- uable consultation with regard to the role of biological fac- tors and antidepressant drugs in treating mood disorders. Two Stanford colleagues, Drs. Greg Tarasoff and Joe Bel- lenoff, provided helpful feedback about the new drug chap- ters. I would like to thank Arthur P. Schwartz for his encour- agement and persistence. I would also like to thank Ann McKay Thoroman at Avon Books for editorial help on the new psychopharmacology chapters. Finally, I would like to thank my daughter, Signe Burns, for extraordinarily helpful suggestions and meticulous ed- iting of the new material in this 1999 edition.Preface I am pleased that David Burns is making available to the general public an approach to mood modification which has stimulated much interest and excitement among mental health professionals. Dr. Burns has condensed years of re- search conducted at the University of Pennsylvania on the causes and treatments of depression, and lucidly presents the essential self-help component of the specialized treat- ment that has derived from that research. The book is an important contribution to those who wish to give them- selves a ‘‘top flight’? education in understanding and mas- tering their moods. A few words about the evolution of cognitive therapy may interest readers of Feeling Good: The New Mood Therapy. Soon after I began my professional career as an enthusiastic student and practitioner of traditional psychoanalytic psychi- atry, I began to investigate the empirical support for the Freud- ian theory and therapy of depression. While such support proved elusive, the data I obtained in my quest suggested a new, testable theory about the causes of emotional distur- bances. The research seemed to reveal that the depressed in- dividual sees himself as a ‘‘loser,’’ as an inadequate person doomed to frustration, deprivation, humiliation, and failure. Further experiments showed a marked difference between the xixii Preface depressed person’s self-evaluation, expectations, the aspira- tions on the one hand and his actual achievements—often very striking—on the other. My conclusion was that depres- sion must involve a disturbance in thinking: the depressed person thinks in idiosyncratic and negative ways about him- self, his environment, and his future. The pessimistic mental set affects his mood, his motivation, and his relationships with others, and leads to the full spectrum of psychological and physical symptoms typical of depression. We now have a large body of research data and clinical experience which suggests that people can learn to con- trol painful mood swings and self-defeating behavior through the application of a few relatively simple prin- ciples and techniques. The promising results of this in- vestigation have triggered interest in cognitive theory among psychiatrists, psychologists, and other mental health professionals. Many writers have viewed our find- ings as a major development in the scientific study of psychotherapy and personal change. The developing the- ory of the emotional disorders that underlies this research has become the subject of intensive investigations at ac- ademic centers around the world. Dr. Burns clearly describes this advance in our under- standing of depression. He presents, in simple language, innovative and effective methods for altering painful de- pressed moods and reducing debilitating anxiety. I expect that readers of this book will be able to apply to their own problems the principles and techniques evolved in our work with patients. While those individuals with more severe emotional disturbances will need the help of a mental health professional, individuals with more manageable problems can benefit by using the newly developed ‘‘common sense’’ coping skills which Dr. Burns delineates. Thus Feeling Good should prove to be an immensely useful step-by-step guide for people who wish to help themselves. Finally, this book reflects the unique personal flair of itsPreface xiii author, whose enthusiasm and creative energy have been his particular gifts to his patients and to his colleagues. Aaron T. Beck, M.D. Professor of Psychiatry, University of Pennsylvania School of MedicineContents Part I. Part Il. Part Ill. 9. Introduction THEORY AND RESEARCH A Breakthrough in the Treatment of Mood Disorders How to Diagnose Your Moods: The First Step in the Cure Understanding Your Moods: You Feel the Way You Think PRACTICAL APPLICATIONS Start by Building Self-Esteem Do-Nothingism: How to Beat It Verbal Judo: Learn to Talk Back When You're Under the Fire of Criticism Feeling Angry? What's Your IQ? Ways of Defeating Guilt “REALISTIC” DEPRESSIONS Sadness Is Not Depression xvii 19 28 51 53 81 131 198 229 231xvi Contents Part IV. Part V. 15. Part VI. 16. Part VII. 17. 18. 19. 20. PREVENTION AND PERSONAL GROWTH The Cause of It All The Approval Addiction The Love Addiction Your Work Is Not Your Worth Dare to Be Average! Ways to Overcome Perfectionism DEFEATING HOPELESSNESS AND SUICIDE The Ultimate Victory: Choosing to Live COPING WITH THE STRESSES AND STRAINS OF DAILY LIVING How | Practice What | Preach THE CHEMISTRY OF MOOD The Search for “Black Bile” The Mind-Body Problem What You Need to Know about Commonly Prescribed Anti- depressants The Complete Consumer's Guide to Antidepressant Drug Therapy Notes and References {Chapters 17 to 20) Suggested Resources Index 259 261 290 311 327 352 381 383 407 409 425 427 455 474 513 682 688 693Introduction (Revised Edition, 1999) I have been amazed by the interest in cognitive behavioral therapy that has developed since Feeling Good was first published in 1980. At that time, very few people had heard of cognitive therapy. Since that time, cognitive therapy has caught on in a big way among mental health professionals and the general public as well. In fact, cognitive therapy has become one of the most widely practiced and most intensely researched forms of psychotherapy in the world. Why such interest in this particular brand of psychother- apy? There are at least three reasons. First, the basic ideas are very down-to-earth and intuitively appealing. Second, many research studies have confirmed that cognitive ther- apy can be very helpful for individuals suffering depression and anxiety and a number of other common problems as well. In fact, cognitive therapy appears to be at least as helpful as the best antidepressant medications (such as Pro- zac). And third, many successful self-help books, including my own Feeling Good, have created a strong popular de- mand for cognitive therapy in the United States and throughout the world as well. Before I explain some of the exciting new developments, let me briefly explain what cognitive therapy is. A cogni- xviixviii Introduction tion is a thought or perception. In other words, your cog- nitions are the way you are thinking about things at any moment, including this very moment. These thoughts scroll across your mind automatically and often have a huge im- pact on how you feel. For example, right now you are probably having some thoughts and feelings about this book. If you picked this book up because you have been feeling depressed and dis- couraged, you may be thinking about things in a negative, self-critical way: ‘‘I’m such a loser. What’s wrong with me? I’ll never get better. A stupid self-help book like this couldn’t possibly help me. I don’t have any problem with my thoughts. My problems are real.’ If you are feeling angry or annoyed you may be thinking: ‘“This guy Burns is just a con artist and he’s just trying to get rich. He prob- ably doesn’t even know what he’s talking about.’’ And if you are feeling optimistic and interested you may be think- ing: ‘‘Hey, this is interesting. I may learn something really exciting and helpful.’’ In each case, your thoughts create your feelings. This example illustrates the powerful principle at the heart of cognitive therapy—your feelings result from the messages you give yourself. In fact, your thoughts often have much more to do with how you feel than what is actually happening in your life. This isn’t a new idea. Nearly two thousand years ago the Greek philosopher, Epictetus, stated that people are dis- turbed ‘‘not by things, but by the views we take of them.”’ In the Book of Proverbs (23: 7) in the Old Testament you can find this passage: ‘‘For as he thinks within himself, so he is.’” And even Shakespeare expressed a similar idea when he said: ‘‘for there is nothing either good or bad, but thinking makes it so’’ (Hamlet, Act 2, Scene 2). Although the idea has been around for ages, most de- pressed people do not really comprehend it. If you feel depressed, you may think it is because of bad things that have happened to you. You may think you are inferior and destined to be unhappy because you failed in your work orIntroduction — xix were rejected by someone you loved. You may think your feelings of inadequacy result from some personal defect— you may feel convinced you are not smart enough, suc- cessful enough, attractive enough, or talented enough to feel happy and fulfilled. You may think your negative feelings are the result of an unloving or traumatic childhood, or bad genes you inherited, or a chemical or hormonal imbalance of some type. Or you may blame others when you get up- set: “‘It’s these lousy stupid drivers that tick me off when I drive to work! If it weren’t for these jerks, I’d be having a perfect day!’’ And nearly all depressed people are con- vinced that they are facing some special, awful truth about themselves and the world and that their terrible feelings are absolutely realistic and inevitable. Certainly all these ideas contain an important germ of truth—bad things do happen, and life beats up on most of us at times. Many people do experience catastrophic losses and confront devastating personal problems. Our genes, hormones, and childhood experiences probably do have an impact on how we think and feel. And other people can be annoying, cruel, or thoughtless. But all these theories about the causes of our bad moods have the tendency to make us victims—because we think the causes result from some- thing beyond our control. After all, there is little we can do to change the way people drive at rush hour, or the way we were treated when we were young, or our genes or body chemistry (save taking a pill). In contrast, you can learn to change the way you think about things, and you can also change your basic values and beliefs. And when you do, you will often experience profound and lasting changes in your mood, outlook, and productivity. That, in a nutshell, is what cognitive therapy is all about. The theory is straightforward and may even seem overly simple—but don’t write it off as pop psychology. I think you will discover that cognitive therapy can be surprisingly helpful—even if you feel pretty skeptical (as I did) when you first learn about it. I have personally conducted more than thirty thousand cognitive therapy sessions with hun-xx Introduction dreds of depressed and anxious individuals, and I am al- ways surprised about how helpful and powerful this method can be. The effectiveness of cognitive therapy has been con- firmed by many outcome studies by researchers throughout the world during the past two decades. In a recent landmark article entitled ‘‘Psychotherapy vs. Medication for Depres- sion: Challenging the Conventional Wisdom with Data,”’ Drs. David O. Antonuccio and William G. Danton from the University of Nevada and Dr. Gurland Y. DeNelsky from the Cleveland Clinic reviewed many of the most carefully conducted studies on depression that have been published in scientific journals throughout the world.' The studies re- viewed compared the antidepressant medications with psy- chotherapy in the treatment of depression and anxiety. Short-term studies as well as long-term follow-up studies were included in this review. The authors came to a number of startling conclusions that are at odds with the conven- tional wisdom: ¢ Although depression is conventionally viewed as a medical illness, research studies indicate that genetic influences appear to account for only about 16 percent of depression. For many individuals, life influences ap- pear to be the most important causes. Drugs are the most common treatment for depression in the United States, and there is a widespread belief, popularized by the media, that drugs are the most ef- fective treatment. However, this opinion is not consis- tent with the results of many carefully conducted outcome studies during the past twenty years. These studies show that the newer forms of psychotherapy, especially cognitive therapy, can be at least as effective as drugs, and for many patients appear to be more ef- fective. This is good news for individuals who prefer to be treated without medications—due to personal preferences or health concerns. It is also good news forIntroduction xxi 4 the millions of individuals who have not responded ad- equately to antidepressants after years and years of treatment and who still struggle with depression and anxiety. Following recovery from depression, patients treated with psychotherapy are more likely to remain unde- pressed and are significantly less likely to relapse than patients treated with antidepressants alone. This is es- pecially important because of the growing awareness that many people relapse following recovery from de- pression, especially if they are treated with antidepres- sant medications alone without any talking therapy. Based on these findings, Dr. Antonuccio and his coau- thors concluded that psychotherapy should not be consid- ered a second-rate treatment but should usually be the initial treatment for depression. In addition, they empha- sized that cognitive therapy appears to be one of the most effective psychotherapies for depression, if not the most effective. Of course, medications can be helpful for some individ- uals—even life-saving. Medications can be combined with psychotherapy for maximum effect as well, especially when the depression is severe. It is extremely important to know that we have powerful new weapons to fight depression, and that drug-free treatments such as cognitive therapy can be highly effective. Recent studies indicate that psychotherapy can be helpful not only for mild depressions, but also for severe depres- sions as well. These findings are at odds with the popular belief that ‘‘talking therapy’’ can only help people with mild problems, and that if you have a serious depression you need to be treated with drugs. Although we are taught that depression may result from an imbalance in brain chemistry, recent studies indicate that cognitive behavioral therapy may actually change brain chemistry. In these studies, Drs. Lewis R. Baxter, Jr., Jef-xxii Introduction @ frey M. Schwartz, Kenneth S. Bergman, and their col- leagues at UCLA School of Medicine, used positron emission tomography (PET scanning) to evaluate changes in brain metabolism in two groups of patients before and after treatment.* One group received cognitive behavioral therapy and no drugs, and the other group received an an- tidepressant medication and no psychotherapy. As one might expect, there were changes in brain chemis- try in the patients in the drug therapy group who improved. These changes indicated that their brain metabolism had slowed down—in other words, the nerves in a certain region of the brain appeared to become more ‘‘relaxed.’’ What came as quite a surprise was there were similar changes in the brains of the patients successfully treated with cognitive behavioral therapy. However, these patients received no medications. Further, there were no significant differences in the brain changes in the drug therapy and psychotherapy groups, or in the effectiveness of the two treatments. Because of these and other similar studies, investigators are starting for the first time to entertain the possibility that cognitive behavior therapy—the methods described in this book— may actually help people by changing the chemistry and architecture of the human brain! Although no one treatment will ever be a panacea, re- search studies indicate that cognitive therapy can be helpful for a variety of disorders in addition to depression. For example, in several studies patients with panic attacks have responded so well to cognitive therapy without any medi- cations that many experts now consider cognitive therapy alone to be the best treatment for this disorder. Cognitive therapy can also be helpful in many other forms of anxiety (such as chronic worrying, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder), and is also be- ing used with some success in the personality disorders, such as borderline personality disorder. Cognitive therapy is gaining popularity in the treatment of many other disorders as well. At the 1998 Stanford Psy- chopharmacology Conference, I was intrigued by the pres- entation by a colleague from Stanford, Dr. Stuart Agras. Dr.