DAVID D. BURNS, M.D. THE FEELING GOOD HANDBOOK

 

DAVID D. BURNS, M.D.

THE FEELING GOOD HANDBOOK

The author of

FEELING GOOD, the breakthrough

2-million-copy bestseller,

shows you how to: OVERCOME DEPRESSION

CONQUER ANXIETY ENJOY GREATER INTIMACY

REVISED WITH UP-TO-DATE INFORMATION THE MOST COMMONLY PRESCRIBED PSYCHIATRIC DRUGS

my wife, Dr.

Creative sug

written to

od Therapy.

eived from

Your ideas

ok. I also

al social

mended

possi

of the

been a

s and

tant

pent

Contents

of

T.

xiii

Preface to Revised Edition

Introduction

xxxi

Part I. Understanding Your Moods 1. You Can Change the Way You Feel 3

2. How to Measure Your Moods 32

3. How to Diagnose Your Moods 49

4. Should You Change the Way You Feel? 61

Part II. Feeling Good About Yourself: How to Conquer

Depression and Build Self-Esteem

5. How to Change the Way You Feel: The Four Steps to Happiness 73

6. Ten Ways to Untwist Your Thinking 97 7. How to Develop a Healthy Personal Value System 120

8. Cognitive Therapy in Action: How to Break Out

of a Bad Mood 137

9. Why People Procrastinate 169 10. A Prescription for Procrastinators

183xil

CONTENTS

Part III. Feeling Confident: How to Conquer Anxiety,

Fears, and Phobias 11. Understanding Anxiety 209

12. How to Fight Your Fears and Win 221 13. Dealing with the Fear of Death 261

14. Social Anxiety: The Fear of People 272 15. Public Speaking Anxiety 297 16. How to Give a Dynamic Interview When

You're Scared Stiff 319

17. Test and Performance Anxiety 340

Part IV. Feeling Good Together: How to Strengthen

Relationships Through Better Communication 18. Good and Bad Communication 363

19. Five Secrets of Intimate Communication 376

20. How to Change the Way You Communicate 21. How to Deal with Difficult People 420

411

22. Why People Can't Communicate with Each Other 442

Part V. Mood-Altering Medications

23. Answers to Your Questions about Commonly Prescribed Medications 467

24. The Complete Consumer's Guide to Antidepressant

Medications 484 25. The Complete Consumer's Guide to Anti-Anxiety Medications 612

Part VI. For Therapists (and Curious Patients) Only:

How to Deal with Difficult Patients 26. The Ingredients of Therapeutic Success-and Failure! 637

27. Empathy: How to Establish Rapport with the Critical, Angry Patient 647 28. Agenda Setting: How to Make Therapy Productive

When You and Your Patient Feel Stuck 657 29. Self-Help Assignments: How to Motivate Patients Who Sabotage the Therapeutic Process 678

Index 705

This b

anxiet

Altho

meani

ever E

think

Depr

ways

for e

havi

and

I

the

abo

pul

rese

ask

spe

the

poxiety,

Preface to Revised Edition

442

This book is about a relatively new type of treatment for depression, anxiety, and other disorders called cognitive behavioral therapy (CBT). Although CBT may seem like a complicated name, it has a simple meaning. A "cognition" is just a fancy name for a thought. If you have ever been very depressed or anxious, you are probably aware that you think about things very negatively when you are down in the dumps. Depressed people also have a tendency to behave in self-defeating ways-you may avoid work, pleasurable activities, and other people, for example. CBT can help you change these negative thinking and be havior patterns so you can experience greater happiness, productivity, and intimacy.

I have been very gratified by the overwhelming positive response to the Feeling Good Handbook. In 1994 the results of a nationwide survey about the use of self-help books by mental health professionals were published in the Authoritative Guide to Self-Help Books. In this study the researchers surveyed 500 American mental health professionals and asked if they "prescribed" books for patients to read between sessions to speed recovery. Seventy percent of the therapists polled indicated that they did use "bibliotherapy" with their patients, and 86 percent re ported that the books were helpful to their patients. The therapistsxvii

PREFACE TO REVISED EDITION

Garland DeNelsky, from the Cleveland Clinic Foundation, recently re viewed these studies in order to answer several basic questions:

• The conventional wisdom holds that depression is a genetic, biolog ical disorder caused by a chemical imbalance in the brain. In addi tion, most people believe that drugs are the most effective treatment for depression. Are these beliefs supported by the facts?

• Are drugs or psychotherapy more effective in the treatment of mild

or severe depression? • Which type of treatment-drugs or psychotherapy-is associated

with fewer relapses following recovery? • What guidelines should we have for the treatment of depressed adults as well as depressed children or adolescents?

These investigators published their findings in an article entitled, "Antidepressants vs. Psychotherapy in the Treatment of Depression: Challenging the Conventional Wisdom with Data." They concluded that for depressed adults, cognitive behavior therapy is at least as good as, and probably better than, antidepressant drugs for severe or mild depressions. For depressed children and adolescents, they concluded that there is little or no convincing evidence that antidepressants are ef fective and that psychotherapy should be used first.

Based on their analysis of long-term follow-up studies, the authors concluded that patients treated with CBT do better than patients treated with medications or other forms of psychotherapy-they re main undepressed longer and have fewer relapses following recovery. The authors also suggested that for some patients, long-term drug creatment might have negative effects. For example, new data suggest that the effects of the newer antidepressants sometimes seem to "wear off after a while, so that a medication that once worked no longer does. Although this does not always happen, sometimes it can leave the pa cient mor vulnerable to relapses of depression and treatment resist ance. If you would like to learn more abour this and have access to the Innerer, you might find a recent article from New York magazine in eing You can read it at this web site: http://www.nymag.com/

De Ansaccio and his colleagues emphasized that these findings have largely be ignored by the media and by the general public. This strong societal bias chat depression is a biological and

PREFACE TO REVISED EDITION

genetic disorder and that antidepressant drugs represent the most pow erful form of treatment-beliefs that are not solidly grounded in the facts.

You might question these conclusions and wonder if Dr. Antonuccio and his co-authors interpreted the literature in a fair and unbiased man ner. Certainly, their conclusions are controversial. Yet there have been several other scholarly review articles summarizing research studies on antidepressant drugs versus psychotherapy in the treatment of depres sion, and their conclusions are consistent with those of Dr. Antonuc cio and his colleagues. There is strong evidence from many independent studies that CBT is at least as good as antidepressant med ications. For many patients CBT actually seems to work better.

Is there any evidence that a cognitive therapy self-help book such as this one can have antidepressant effects? If you are feeling down in the dumps and you diligently study this book and complete the exercises in it, what is the chance that your mood will improve?

Self-help books are quite controversial. Many people are skeptical about the motives of the individuals who write them. They believe that self-help authors are primarily out to help themselves make money. In addition, self-help authors are often criticized for offering overly sim plistic formulas for the complex problems of daily living. I think these impressions are justified. When I look through the self-help sections of popular bookstores, the superficial jargon and quick fixes that are promised in many books turn me off as well.

However, there are two sides to every coin, and academic researchers have begun to take a serious look at self-help books as a new form of therapy. This type of treatment is called bibliotherapy, or reading ther apy. It can be administered in one of two ways. First, therapists can "prescribe" a self-help book for their patients to read between therapy sessions to increase the speed of learning and recovery. Second, individ uals suffering from depression or anxiety can be given a self-help book to read as a self-administered treatment without any other drug ther apy or psychotherapy.

The second approach-bibliotherapy without other therapy-has been recently evaluated in five published studies over the past decade

"Dobson, KS 1989. A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Comalting and Clinical Psychology, 37(3), 414-19.

Hallon, S. D. & Beck, A. T. 1994. Cognitive and cognitive behavioral therapies, in A. E. Bergin & SL Garfield (eds.), Handbook of Pychberapy and Babazioral Change New York John Wiley Robinson, L. A, Berman, J. S, & Neimeyer, R. A. 1990. Psychotherapy for the treatment of de pression: A comprehensive review of controlled outcome research. Prychological Bulletin, 108, 30-49.xix

xvili

PREFACE TO REVISED EDITION

conducted by a team of investigators headed by Dr. Forrest Scogin from the University of Alabama. These researchers evaluated the effective ness of my first book, Feeling Good: The New Mood Therapy as well as Dr. Peter Lewinsohn's Control Your Depression, as self-administered treat ments for depression. Their first study was published in the medical journal The Gerontologist, and the next four were published in the pres tigious Journal of Consulting and Clinical Psychology. To make a long story short, the investigators concluded that Feeling Good was as effec tive as a full course of individual psychotherapy or as treatment with the best antidepressant drugs. Given the tremendous pressures to cut health care costs, this finding is of considerable interest, since a paper back copy of Fading Good costs less than one day of antidepressant drug treatment and is presumably free of any troublesome side effects as well!

By the way, I don't want you to get panicky and think you are read ing the wrong book. Although all these studies were conducted using Feeling Good, The Feeling Good Handbook is ten years newer and should be at least as effective, if not better. The Feeling Good Handbook shows you how to apply these new methods to a much broader range of prob lems. These include depression, all the anxiety disorders, and interper sonal conflicts as well (such as how to repair a troubled marriage or get along with an overly critical boss or colleague).

What did these bibliotherapy studies demonstrate? In the first study Dr. Scogin and his colleagues, David Hambling and Dr. Larry Beutler, randomly assigned 29 adults with mild to moderate depres sion to one of three treatment conditions for a four-week period. The researchers gave the depressed individuals in the first group a copy of Feeling Good and asked them to read it within four weeks. This was the Feeling Good bibliotherapy group. The researchers gave the patients in the second group a copy of a book that was not expected to have any antidepressant effects. It was Victor Frankl's classic book about con centration camps entitled Man's Search for Meaning. This was the "placebo" bibliotherapy group. The patients in the third group were not given any book to read. This was the no-bibliotherapy group. All the patients in this study were over 60 years of age, because the re searchers wanted to determine if bibliotherapy would help older adults who are depressed.

At the beginning of the study, all the patients in the three groups were given two highly regarded depression tests used in research. As you can see in Figure 1, there were no statistically significant differ

PREFACE TO REVISED EDITION.

ences in the measures in the three groups, indicating that the average depression levels in these groups were similar at the start of the study. At the end of four weeks, the researchers administered the depression tests again to assess any changes that might have occurred. As shown in Figure 1, the patients in the Feeling Good group improved consider ably, but the patients in the placebo and no-bibliotherapy groups did not improve. These differences were statistically significant, indicating that the superior improvement in the Feeling Good group was not sim ply due to chance. In addition, the lack of improvement in the patients who read the Victor Frankl book indicated that the antidepressant ef fects of Feeling Good were not just "placebo" effects, but specific anti depressant effects.

It is important to understand this last point. It is possible, at least in theory, that any book depressed patients read would help to im prove their moods, by virtue of merely the activity or the distraction. In addition, the expectation that the book might help could raise the patients' hopes, and this could lead to a reduction in depression. This is what is meant by the "placebo" effect. However, the Victor Frankl book did not seem to help the patients who read it. The researchers concluded that while a self-help book could have significant antide pressant effects, this would not necessarily be true of any self-help book. The book must contain sound information about how to over come depression.

Next, the researchers gave Feeling Good to the patients in the no bibliotherapy group. You can see in Figure 2 that they improved dur ing the next four weeks when they were reading Feeling Good. These results replicated the findings from the first four weeks of the study. In addition, the mood scores of the patients who read Feeling Good were not significantly different at the follow-up evaluation two months later. This indicated they did not simply relapse back into depression after reading the book but maintained their gains, at least for a two-month period.

This study was quite encouraging but needed replication for several reasons. First, a positive outcome could be due to chance. Scientists be lieve a result is real only if they can replicate the same finding over and over again in different settings. Second, the study was conducted with older individuals, and it would be useful to know if bibliotherapy is helpful for people of all ages. And third, the follow-up period was too short. Depression tends to become a chronic disorder for many indi viduals, marked by relapses. Follow-up studies of patients treated withPREFACE TO REVISED EDITION

HAMILTON DEPRESSION TEST

xxi

PREFACE TO REVISED EDITION

drugs and with psychotherapy have often been disappointing, since a substantial percentage of the patients always seem to relapse, often within the first year or even sooner. The crucial question was this: would the results of the new bibliotherapy treatment last? And finally, many of the patients in the bibliotherapy study were only mildly or moderately depressed. How effective would this new bibliotherapy treatment be with patients with more severe depressions?

In a study published in the Journal of Consulting and Clinical Psy chology in 1995, Drs. Christine Jamison and Forrest Scogin changed the design in order to address these concerns. First, they expanded the number of depressed individuals to 80. Second, they studied patients for three months following the completion of the four weeks of biblio therapy, and then they initiated a three-year follow-up study. Third, the study was not limited to individuals over 60 years. Fourth, all the patients in the new study had to meet the criteria for a major depres sive episode. This is the type of depression normally treated by psy chiatrists in outpatient and inpatient settings. This allowed the researchers to determine if the bibliotherapy treatment helped indi viduals with more serious depressions, as opposed to those with only mild mood swings.

Otherwise, the design of the new study was similar to the first. The investigators randomly assigned the 80 patients to one of two groups. The researchers gave the patients in the first group a copy of Feeling Good and encouraged them to read it within four weeks. This group was called the Immediate Bibliotherapy Group. These patients also received a booklet containing blank copies of the self-help forms in the book in case they decided to do some of the suggested exer cises.

The 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 Feeling Good until the second four weeks of the study. These patients served as a control group to make sure that any improvement in the Immediate Bibliotherapy Group was not just due to the passage of time.

At the initial evaluation the researchers administered two depres sion 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 Depres sion (HRSD), which is administered by trained depression researchers.

20

15

Intake

4 Weeks

10

5

0

Feeling

Good

Placebo

Book

No

Book

GERIATRIC DEPRESSION TEST

20

15

10

5

Intake 4 Weeks

0

Feeling Good

Placebo Book

Figure 1. Scores on the Hamilton Depression Test and the Geriatric Depression Scale for all patients at initial evaluation and after four weeks. Higher score indicate more severe depression. As can be seen, the patients who were given a copy of Feeling Good improved significantly, but the patients who read the placebo book and the patients on the waiting list (no book) did not. *p<.05

No

BookPREFACE TO REVISED EDITION

DELAYED BIBLIOTHERAPY GROUP

No Book

Feeling Good

PREFACE TO REVISED EDITION

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. As

shown in Figure 3, the patients in the Immediate Bibliotherapy Group improved considerably. The average scores on both the BDI and HRSD were around 10 or below, scores in the range considered normal. These changes in depression were statistically and clinically very significant. You can also see that these 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 "treatment." The scores on both depression tests were actually lower at the three month evaluation.

In contrast, the patients in the Delayed Bibliotherapy Group barely changed, remaining 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 that in the Immediate Biblio therapy Group during the first four weeks. You can see in Figure 3 that both groups did not relapse but maintained these gains at the three month evaluation.

The results of this new study confirmed the results of the first study-Feeling Good appeared to have substantial and lasting antide pressant effects. The investigators did several additional analyses to as sess the strength of the antidepressant effects of Feeling Good. First, they determined the percentage of the patients who actually recovered ac cording to the diagnostic criteria for a major depressive episode, as out lined in the American Psychiatric Association's official Diagnostic and Statistical Manual (DSM). At the end of the first four-week period, 70 percent of the patients in the Immediate Bibliotherapy Group no longer met the criteria for a major depressive episode. In contrast, only 3 percent of the patients in the Delayed Bibliotherapy Group recovered during the first four weeks. These results paralleled the results from the Hamilton and Beck depression tests. At the three-month evaluation, when both groups had read Feeling Good, 75 percent of the patients in the Immediate and 73 percent of the patients in the Delayed Biblio therapy Groups no longer qualified for a diagnosis of major depressive

episode according to DSM criteria. Second, the researchers compared the magnitude of the improve

18

16

14

12

10

8

6

4

Hamilton

Geriatric

Intake

Figure 2. Scores at 4 and 8 weeks on the Hamilton Depression Test and the Geriatric Depression Scale in the Delayed Bibliotherapy Group. Higher scores indicate more severe depression. These patients did not receive Feeling Good during the first four weeks of the study and failed to improve. They were then given a copy of Feeling Good and improved significantly during the second four weeks. *p<.05

As you can see in Figure 3, there was no difference in the depression levels in the two groups at the initial evaluation. The average scores for both groups were around 20 or above. These levels indicate that the patients were more severely depressed than those in the first study, and were similar to patients in most controlled-outcome stud ies of antidepressants or psychotherapy. For example, this score is nearly identical to the average depression score at intake of approxi mately 500 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 Beck Depression Inventory by telephone. The as sistant also answered any questions patients had about the study and encouraged the patients in the Immediate Bibliotherapy Group to

4 Weeks

8 WeeksXxxvi

PREFACE TO REVISED EDITION

Christine Jamison from the Tuskegee Veterans Affairs Medical The researchers contacted the patients three years after the completion of the bibliotherapy study and administered the depression tests once again. They also asked the patients several other questions about how they had been doing since the study. The researchers learned that the patients had not relapsed but maintained their gains during this three year period. The scores on the two depression tests at the three-year evaluation were slightly better. Many of the patients (58 percent) said that their moods continued to improve following the completion of the initial study. Center.

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 had not sought or received any further treatment with medications or psychotherapy during the follow-up period. Although they experienced the rmal 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-adminis tered "booster sessions" may have been important in maintaining a pos itive outlook following recovery. Forty percent of the patients said what they liked about the book was that it helped them change their nega tive thinking patterns, such as learning to be less perfectionistic and to give up all-or-nothing thinking.

Of course, the study had limitations, like all studies. For one thing, nor every patient was "cured" by reading Feeling Good. No treatment is a panacea. A 70 percent recovery rate is similar to the improvement rates reported for antidepressant medications as well as for cognitive behavioral therapy and for interpersonal therapy. It is encouraging that so many patients seem to respond to self-help therapy alone, but it is also clear that patients with more severe or chronic depressions need the help of a therapist and possibly an antidepressant medication This is nothing to be ashamed of, because different individuals respond well. better to different approaches. It is good that we now have three types of effective treatment for depression: antidepressant medications, indi vidual and group psychotherapy, and bibliotherapy.

If you seek professional therapy, remember that you can use cogni tive bibliotherapy between therapy sessions to speed your recovery. In fact, when I first wrote Feeling Good, this is how I intended the book to be used. I never dreamed that it might someday be used alone as a treatment for depression.

xxvii

PREFACE TO REVISED EDITION

You may be wondering about antidepressant drugs versus CBT or some other form of psychotherapy-which type of treatment is better? Al though research studies are often set up to compare the effectiveness of a drug therapy with a psychotherapeutic treatment, therapists who are not researchers often combine the two treatment methods. Many patients re ceive antidepressants or other needed medicines at the same time they re ceive counseling. The combination can often be quite effective.

However, a number of recently published studies raise serious ques tions about the effectiveness of antidepressant medications, especially if they are used alone without psychotherapeutic intervention. These studies suggest that antidepressants, including the new, expensive medications, may not be as effective as we have been led to believe. In fact, a number of investigators have concluded that antidepressants may not be much more effective than placebos, if at all.

You can read one of these articles yourself if you have a computer with a modem, because it was recently published on-line in a new all electronic scientific journal published on the Internet by the American Psychological Association. The name of this journal is Prevention and Treatment. Anyone can go to the web address and read the articles with out a subscription (http://journals.apa.org/prevention).

The first issue of Prevention and Treatment features a highly controver sial article called "Listening to Prozac but Hearing Placebo" by Irving Kirsch, Ph.D., from the University of Connecticut, and Guy Sapirstein, Ph.D., from the Westwood Lodge Hospital in Massachusetts. These au thors carefully reviewed 19 controlled-outcome studies comparing a large variety of antidepressant medications, including the new SSRIs like Prozac, with two kinds of placebos (pills with inert ingredients) in the treatment of depression. "Inactive" placebos are like pills with no ac tive ingredients at all. In contrast, an "active" placebo is a drug that pro duces side effects, like an antihistamine that produces dry mouth and sleepiness, but it is not an antidepressant. Patients who take active placebos are more likely to believe they are taking a real antidepressant because of the side effects.

These investigators concluded that inactive placebos are usually 75 percent as effective as the best current antidepressants. What does this mean? Well, let's suppose you start out with a score of 25 on a depres sion test such s my own Depression Checklist number one in Step One of this program. This score would indicate you have a moderately se vere depression. Now let's imagine that you participate in a research study comparing an antidepressant, such as Prozac, with a placebo, butPREFACE TO REVISED EDITION

depressants, and in these instances I was grateful to have the medica tions available. But many others improved only a little or not at all. Certainly they did not return to joyous, productive living when they took these drugs. This is why I have spent so much of my career re searching and developing new psychological treatments, to have more weapons to fight depression than just drugs.

Keep in mind that Feeling Good is not a panacea any more than any other approach. If it works for you, that's great. But 30 percent of the individuals who read Feeling Good did not recover. If you find that your mood does not improve when you read this book, it should not be a problem, because we now have so many helpful types of interventions. These negative thinking patterns can be immensely deceptive and per suasive, and change is rarely easy. But with patience and persistence, I believe that nearly all individuals suffering from depression can improve and experience a sense of joy and self-esteem once again. Observing this has always given me tremendous satisfaction, and I hope it is something you will experience as you begin to understand and apply the ideas in this book.

-David D. Burns, M.D.

Clinical Associate Professor of Psychiatry and

Behavioral Sciences,

Stanford University School of Medicine

you don't know whether you are getting the antidepressant placebo or the

If you received the antidepressant, the expected reduction in your depression score might be 8 points, judging from data of published studies. This would represent a significant improvement, but with a score of 17 you would still be quite depressed. Keep in mind that a score under 10 is normal, and a score under 5 is even better. So there would be a need for some additional treatment, such as cognitive be havioral therapy, to get the job done.

Now suppose you were in the placebo group, and you got only an inert pill that looked like Prozac. The expected reduction in your de pression score would be 6 points, or almost as much as the expected re duction if you had received the antidepressant. Furthermore, the difference between the real drug effect and the placebo effect would be only 2 points a small amount by anyone's accounting.

What was even more shocking was the discovery that active place bos may be 100 percent as effective as antidepressants. One likely in terpretation is that active placebos do a better job of fooling patients and their doctors because of their side effects. Finally, the strength of the antidepressant effects in the studies reviewed by Drs. Kirsch and Sapirstein correlated highly with the strength of the placebo effects. In other words, in some studies the antidepressant medications had somewhat stronger effects, but in these studies the placebo medica tions also had stronger effects. The actual size of the correlation was so large as to suggest that antidepressants and placebos might be the

same. Clearly these findings are highly controversial. They are not consis tent with the impressions abour antidepressants conveyed in the media and in popular books and shared by the general public. I do not know what the final word on this will be-new and better studies are needed to sort this out. I think one fact is certain, however, and this has been clear to me since I began treating depression in the mid-1970s. Al though some people respond to antidepressants (just as they respond to placebos), the current antidepressants are not sufficiently effective for many people, and other types of psychological treatments are usually needed.

I have never been opposed to antidepressants; I started out my career as a full-time researcher in this area. However, many of the patients I treated with antidepressant medications over the years did not respond in a satisfactory manner. Some patients responded beautifully to anti