In the book Feeling Good , David Burns, MD, the author, outlines certai

n cognitive techniques an individual suffering from depression could use in comb

ating the disorder. He begins the book by briefly describing the pertinence and
the prevalence of depression. The author captures the audience's attention in
the first paragraph: " In fact depression is so widespread it is considered the
common cold of psychiatric disturbances" (Burns, 1992) p. 9. Burns(1992), conti
nues to suggest that the difference between the common cold and depression lies
in the fact that depression is lethal. Irwing and Barbara Serason (1996) sugge
st that at least 90 percent of all suicide victims suffer from a diagnosable psy
chiatric disorder at the time of their death. Irwing and Barbara Serason (1996)
also state that one of the risk factors in committing suicide is the presence o
f mood disorder. Silverman (1993) states that suicide among young people 15 to
19 years of age has increased by 30 percent from the years 1980 to 1990.
In my opinion David Burns brings up a valid issue in addressing the pert
inence of depression as it pertains to peoples tendencies of committing a suicid
e; other academics have agreed with the same findings. However these academics
have not specifically stated that depression is the only risk factor of committi
ng a suicide. They did not even suggest that depression is the heighest weighte
d risk factor in committing a suicide. The impression the reader gets after rea
ding the introductory paragraph of the Feeling Good book is that severe depressi
on will inevitably result in suicide unless it is cured. Implying that if a per
son has a depressive disorder, it will lead to a suicide can be dangerous and c
ounterproductive for a person who already feels hopeless; this may reaffirm the
ir belief of hopelessness and the inevitability of the disorder.
Once the first paragraph is passed the author indicates that there is ho
pe in curing depression, giving the reader an encouragement to continue with the
book.
According to the Diagnostic and Statistical Manual of Mental Disorders(D
SM-IV), mood disorders are classified into two broad categories, bipolar and uni
polar depressive disorders. The book Feeling Good only talks about the unipolar
depressive disorders, thus, I will only concentrate on that one category. Unip
olar mood disorders are classified under axis I of the DSM-IV. Unipolar depress
ive disorders are further classified into two categories: dysthymic, and major d
epressive disorder. Even though both of the disorders are mood disorders they h
ave some fundamental differences and similarities. According to DSM-IV people e
xperiencing major depression must have depressed moods and/or diminished interes
t for at least two weeks, for most of the day, and for most days than not. They
must also experience four additional symptoms, such as: weigh loss or gain, ins
omnia or hypersomnia, psychomotor retardation or agitation, feelings of worthles
sness, feelings of hopelessness, low self-esteem, difficulty concentrating, or s
uicidal thoughts. This is an acute , and usually recurrent disorder. Around 50
percent of people who experience one major depressive episode will experience a
nother in the course of their life.
Dysthymic disorder is similar to major depressive disorder in that peopl
e experiencing the disorder go through periods of depressed moods. However, int
ensity, and duration of such moods are one among many differences between the tw
o disorders. Dysthymic disorder is a chronic disorder lasting, on average, five
years. In order to be diagnosed with the disorder one has to feel depressed fo
r most of the day, most days than not for at least two years. The person experi
encing this disorder also has to have two of the symptoms mentioned in the secti
on that described major depressive disorder. Due to its chronic nature, dysthym
ic disorder is sometimes difficult to distinguish from a personality disorder.
Feeling Good does not clearly identify the categories of unipolar disor
ders; it groups them together into one category called "depression". The danger
of this is in the reader's perception of what condition they may have. For exa
mple, a person who is expressing a major depressive episode and is incapacitated
may not have the energy or concentration to employ some of the cognitive techni
ques outlined in this book. This person may however benefit more from of an Ele
ctroconvulsive treatment (ECT) which is not outlined in this book. The readers
are not informed of all the options they have to treat the disorder they are exp
eriencing. Rush and Weissemburger (1994), suggest that ECT is very effective in
treatment of the major depressive disorders. Research indicates that in 80 to
90 percent of patients experiencing a major depressive episode, ECT is effective
. However this treatment is shown not to be effective in treatment of milder fo
rms of depressive disorders such as dysthymia. David Burns' neglect to classify
the two separate disorders into distinct categories does not allow him to ident
ify ECT as a successful option in treating major depression.
The author however discusses some alternative options in the treatment
of depression. He describes one study that was done at the University of Pennsy
lvania school of Medicine. Doctors John Rush and Aaron Beck, and some other sp
ecialists were involved in the study which compared the effectiveness of cogniti
ve therapy and pharmacological treatment of depression. Individuals suffering f
rom major depression were randomly assigned to two groups. One group received i
ndividual cognitive psychotherapy while the other group was treated with a tricy
clic antidepressant drug called Tofralin. Both groups were treated for twelve w
eeks before the symptoms were re-evaluated. The results showed that cognitive t
herapy was superior to the pharmacological treatment in almost all of the condit
ions measured( number of people recovered completely, number of people who recov
ered considerably but still experiencing borderline to mild depression, number o
f people who did not substantially improve, number of people who dropped out of
treatment). The empirical findings indicated that fifteen out of nineteen peopl
e who were treated with the cognitive therapy completely recovered. Only five o
ut of twenty five people treated with antidepressants completely recovered. The
only category where pharmacological treatment was superior was the category tha
t measure the number of people who recovered considerably but are still experien
cing border line to mild depression. Only two individuals recovered partially u
nder the cognitive treatment, where 7 people recovered partially under the pharm
acological treatment.
Similar research was done in 1992 by the National Institute of Mental He
alth(NIMH), NIMH did not find significant difference between the two therapies
immediately after the treatments. They however did find in a 24 month follow up
study that patients who were treated with cognitive therapy were much less like
ly to have the disorder return than the patients who were treated with antidepre
ssants.
Even though cognitive therapy seemed to have been superior in both studi
es, the findings from the two studies were not corroborative. The study David B
urns describes in order to support cognitive therapy indicated that significantl
y more patients recovered in cognitive therapy than in pharmacological therapy
immediately after the twelve week treatment. NIMH study found no significant di
fference between the two treatment immediately following the therapy. The reaso
ns the two studies came up with different results may be numerous. It is imposs
ible to conclude which one of the two studies is more valid. However both studi
es have experimentally demonstrated that cognitive therapy is a superior form of
treatment whether immediately following the therapy or after 24 month follow up
period.
In order to make a stronger point about the superiority of cognitive the
rapy, David Burns could have offered at least one more experiment that corrobora
ted the results. In addition the methodology of the experiment he illustrated
has some obvious flaws. The group sizes of the two compared conditions(Cognitiv
e therapy and Pharmacological therapy) were not equal. The cognitive therapy gr
oup had 19 individuals where the drug therapy group had 25 individuals. In calc
ulating the significant difference between the two group means, using the t-test
, would require the groups to be of equal sizes. Therefore, due to the group si
ze inequality, the results may have been interpreted more liberally than if the
group sizes were the same. On the other hand having a smaller degree of freedom
in the cognitive therapy group required a greater t score in order to infer sig
nificance. As a result it is difficult to conclude whether the methodology of t
he experiment had anything to do with the significance of the results. However,
if the study is to be replicated, it would be beneficial to keep the sample siz
es the same. This would make the study stronger, and results more interpretable
.
The author of this book has been greatly influenced by the theories and
studies of Aaron Beck MD. Specifically, the author has based the theoretical pa
rt of the book on Beck's cognitive distortion model. This model postulates tha
t depression is best described as a cognitive triad of negative thoughts ( Saran
son & Saranson 1996). Beck suggests that a person who is depressed focuses on n
egative thoughts, interprets situations in a negative way, and is pessimistic an
d hopeless about the future. In other words people who are depressed might blam
e themselves for their actions in the past and continue to believe that the futu
re is just as gloomy. Beck also believes that any misfortune that happens to a
depressed person is internalized and attributed to their own character. These i
nternal and stable interpretations of negative events leaves the person feeling
hopeless and in turn depressed. On the other hand, according to Beck's theory,
any positive events in the depressed person life are externalized or considered
to be "lucky". In a sense, such people may feel that only bad things happen to
them and that if anything good does happen it is due to a circumstance that is
beyond their control. However, people who are not depressed tend to do the oppo
site, they blame the situation for anything bad in their life and accept full re
sponsibility for the positive aspects of their life. Beck describes the above a
s the attributional model of depression.
David Burns summarizes this theory in a way that is very easy to follow
and conceptualize. He identifies the process that is going on in the depressed
person/s mind as the process of cognitive distortions. He identifies the ten m
ost common cognitive distortions. Most of them are self explanatory therefore I
will name all of them and only elaborate on some. The first cognitive distorti
on mentioned is "All or Nothing Thinking", a tendency to evaluate personal quali
ties in black or white categories. Second is "Overgeneralization". Third is a "M
ental Filter", which is a way of picking out a negative part of a situation and
thus assuming that the situation as a whole is negative. Forth is "Disqualifyin
g the Positive". Fifth is "Jumping to Conclusions". Sixth is "Magnification an
d Minimization", which is the way a depressed person magnifies the bad elements
of their life and minimizes the good. The seventh cognitive distortion mention
ed in the book is "Emotional Reasoning", which is interpreting emotions as proof
of how bad the situation is ( i.e., I feel stupid, therefore I am stupid). Ei
ght is "Should Statements". Ninth is "Labeling and Mislabeling", a way of creat
ing a negative self-image based on the errors of the person's errors. The last
cognitive distortion David Burns mentiones is "Personalization", which is assumi
ng responsibility for negative events even though there is no basis for doing so
.
Once the author identified and explained the cognitive distortions, he t
hen attempts to illustrate how they are used in every day life, which makes th
e book much more relevant to the reader; this is one of the crucial differences
between academic writing and self-help books, such as Feeling Good; the reader
automatically understands the relevance of the theory and feels compelled to ap
ply it.
The strength of the cognitive theory of depression is that it concentrat
es on the obvious problem at hand. The person who is depressed often does not h
ave the energy or will to search deeper than the problem that is facing them. T
herefore, this theory seems very useful especially in its ability to raise motiv
ation in patients. Patients usually understand the thoughts and resulting feeli
ngs more clearly as a result of this approach. However the cognitive theory of
depression does not break the surface of the problem; the theory does not go de
ep enough into the "wound"( in order to try to conceptualize and "fix" the root
of the problem). The psychodynamic approach is far superior to the cognitive ap
proach when the nature of the problem is deeply rooted and stems from the person
's childhood. If the patient who is experiencing depression has an unresolved c
onflict inside their psyche, the depression may recur if such conflict is not ad
dressed. Unfortunately the original idea behind the cognitive theory would not
support that. Fortunately some cognitive therapists, such as Beck, have recogni
zed the importance of this issue and have appropriately reconstructed the clinic
al application of the cognitive theory so that provision for such deep rootted p
roblems are made.
David Burns implements the cognitive theory of depression by suggesting
some simple to use self help techniques. These techniques are similar to some o
f the therapeutic approaches clinicians use in cognitive therapy. For example,
a clinician may try to coach the person who is depressed to identify some automa
tic thought that leaves them feeling depressed, and substitute it with thoughts
that evaluate the situation more realistically. David Burns implements this ap
proach in a similar way. He first identifies the importance of gaining self est
eem in order to deal with depression. Burns presents some cases where he first
identifies what the patient is saying about themselves, and then challenges the
ir statements. This shows the patient how unrealistic their negative self evalu
ations are and in turn boosts their self image from hopeless to somewhat hopeful
. The second step was to help the patient overcome their sense of worthlessness
. This was done in a way that the patient is encouraged to identify thoughts t
hat lead them to feel depressed. This approach is concurrent with other cogniti
ve therapists' approaches. The cognitive therapist reasons with the person, en
couraging them to understand why these thought are distorted, and finally helps
them to implement more realistic self-evaluatory statements. As a result, the a
pproach of combating distorted thoughts by talking back and implementing more r
ealistic thoughts corroborates David Burns' therapy with other cognitively orien
ted clinicians.
This book seems to be very effective in identifying some common thoughts
and feelings depressed people might experience. As such, this book would be ve
ry appealing to people experiencing depressed moods as well as anyone who feels
hopeless about their day-today life. The author describes everyday feelings and
thoughts in a way that is very comprehensive. The reader is left with the enco
uraging impression that their feelings are common and curable. However, for a p
erson experiencing clinical depression, this book may present a false sense of
hopefulness. The reader who is in this predicament, may solely rely on this boo
k and ris failing at implementing the techniques suggested by the author. The t
herapeutic techniques suggested are best utilized under the supervision of a cli
nician. The author does not encourage the person to get help beyond this book.
Therefore, the therapeutic techniques illustrated in this book are left to be
interpreted by the patient. This might be dangerous if the depressed person is
in a frame of mind where he or she is hanging on any breath of hope put forth.
In short, the book itself may not completely accomplish its purpose; which may b
ring the patient back to their original state if not leave them feeling even mor
e hopeless about their future.