FEELING GOOD

FEELS WONDERFUL

If you wake up in the morning dreading the day . . . if you have to force yourself to do anything . . . if you believe your work worthless . . . if you wilt under criticism . . . if you avoid intimate contact because you're convinced you're unattractive . . . if you consider yourself a born loser . . . you will probably benefit from the scientific and revolutionary way of brightening your mood and lifting your spirits without drugs or lengthy therapy.

The only tools you need are your own common sense and the easy-to-follow methods clearly spelled out in this book. With them, you can stop seeing things in ways that bring you down. You can say good-bye to procrastination, to sapping away of energy and ambition, to so many other forms of nagging depression, as you at last experience the joy of—

PEELING GOOD

"A book to read and re-read!"---Los Angeles Times

"I will recommend this book to my students, colleagues and patients."—Ari Kiev, M.D., Director,

Social Psychiatry Research Institute

ABOUT THE AUTHOR: DAVID D. BURNS, M.D. was graduated magna cum laude, from Amherst College, received his M.D. from Stanford University, and completed his psychiatric training at the University of Pennsylvania. There he has been one of the prime developers of Cognitive Therapy, upon which Feeling Good is based. In addition to treating patients, he teaches psychotherapy and drug therapy at the University of Pennsylvania and lectures to professional groups around the world. Among his many honors was the A. E. Bennett Award, the top psychiatric award to an investigator under thirty-five.

His most recent book is Intimate Connections available in a Signet edition.

Individuals wishing to contact the author may write to him at: David D. Burns, M.D. Presbyterian—University of Pennsylvania Medical Center 39th and Market Streets Philadelphia, Pennsylvania 19104

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FEELING GOOD: The New Mood Therapy by David D. Burns, M.D.

Preface by Aaron T. Beck, M.D. The clinically proven, drug-free treatment for depression, from the University of Pennsylvania School of Medicine.

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FEELING

GOOD

The New Mood Therapy

DAVID D. BURNS, M.D.

Preface by

AARON T. BECK, M.D.

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Copyright

1980 by David D. Burns, M.D.

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PRINTED IN THE. UNITED STATES OF AMERICA

This book is dedicated to my personal teacher, Aaron T.

Beck, M.D., in admiration of his knowledge and courage

and in appreciation of his patience, dedication and empathy.

Preface

I am pleased that David Burns is making available to the general public an approach to mood modification which has recently stimulated much interest and excitement among mental health professionals. Dr. Burns has condensed years of research conducted at the University of Pennsylvania on the causes and treatments of depression, and lucidly presents the essential self-help component of the specialized treatment that has derived from that research. The book is an important contribution to those who wish to give themselves a "top flight"

education in understanding and mastering 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 psychiatry, I began to investigate the empirical support for the Freudian 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 disturbances. The research seemed to reveal that the depressed individual sees himself as a "loser," as an inadequate person doomed to frustration, deprivation, humiliation, and failure.

Further experiments showed a marked difference between the 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 depression must involve a disturbance in thinking: the depressed person thinks in idiosyncratic and negative ways about himself, 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 control painful mood swings and self-defeating behavior through the application of a few relatively simple principles and techniques. The promising results of this investigation have triggered interest in cognitive theory among psychiatrists, psychologists, and other mental health professionals. Many writers have viewed our findings as a major development in the scientific study of psychotherapy and personal change.

The developing theory of the emotional disorders that under-lie this research has become the subject of intensive investigations at academic centers around the world.

Dr. Bums clearly describes this advance in our understanding of depression. He presents, in simple language, innovative and effective methods for altering painful depressed 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 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

Acknowledgments

I am grateful to my wife, Melanie, for her editorial assistance 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 who have made invaluable contributions in their work with the Mood Clinic and the Center for Cognitive Therapy. These include Drs.

Aaron Beck, John Rush, Maria Kovacs, Brian Shaw, Gary Emery, Steve Hollon, Rich Bedrosian, and numerous others. I would also like to mention current staff members including Ruth Greenberg. and Drs. Ira Herman, Jeff Young, Art Freeman, and Ron Coleman for their many contributions.

Several individuals have given me permission to refer to their work in detail in this book, including Drs. Raymond Novato, 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 research which led to this book, I was a Fellow of the Foundations'

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., Chief of the Clinical Psychology Branch of the National Institute of Mental Health, for his valuable consultation with regard to the role of biological factors and antidepressant drugs in treating mood disorders.

I would also like to thank Arthur P. Schwartz for his encouragement and persistence in bringing about publication of this book.

Contents

Preface

vii

Introduction

1

PART

I. THEORY AND RESEARCH

7

1. A Breakthrough in the Treatment of

Mood Disorders

9

2. How to Diagnose Your Moods: The First

Step in the Cure

19

3. Understanding Your Moods: You Feel

the Way You Think

28

PART II. PRACTICAL APPLICATIONS

49

4. Start by Building Self-Esteem

51

5. Do-Nothingism: How to Beat It

75

6. Verbal Judo: Learn to Talk Back When

You're Under the Fire of Criticism

119

7. Feeling Angry? What's Your IQ?

135

8. Ways of Defeating Guilt

178

PART M. "REALISTIC" DEPRESSIONS

205

9. Sadness Is Not Depression

207

PART IV. PREVENTION AND PERSONAL

GROWTH

231

10. The Cause of It All

233

11. The Approval Addiction

256

12. The Love Addiction

274

13. Your Work Is Not Your Worth

288

14. Dare to Be Average!—Ways to

Overcome Perfectionism

309

PART V. DEFEATING HOPELESSNESS AND

SUICIDE

335

15. The Ultimate Victory: Choosing to Live 337

PART VI. COPING WITH THE STRESSES

AND STRAINS OF DAILY LIVING 357

16. How I Practice What I Preach

359

PART VII. THE CHEMISTRY OF MOOD

373

17. The Consumer's Guide to Antidepressant

Drug Therapy

375

Suggested Reading

399

Index

401

List of Charts

SELF-ASSESSMENT TESTS

Beck Depression Inventory

20

Novato Anger Scale

136

Dysfunctional Attitude Scale

242

SELF-HELP FORMS AND CHARTS

Definitions of Cognitive Distortions

40

Triple-Column Technique

60

(Automatic Thought-Cognitive Distortion-Rational Response)

Daily Record of Dysfunctional Thoughts

62

Double-Column Technique

71

(Automatic Thought-Rational Response)

Daily Activity Schedule

88

Anti-Procrastination Sheet

91

Pleasure-Predicting Sheet

96

But-Rebuttal Form

99

Tic-Toc Technique

101

The Anger Cost-Benefit Analysis

150

Hot Thoughts-Cool Thoughts

152

Revising "Should Rules"

159

Advantages and Disadvantages of Self-Defeating

Belief Systems

263

The Antiperfection Sheet

313

Response-Prevention Form

317

FEELING

GOOD

Introduction

In this book I will share with you some of the latest scientifi-cally tested methods for overcoming blue moods and for feeling good about your life. The techniques are based on a new form of treatment known as cognitive therapy. The treatment is called "cognitive therapy" because you are trained to change the way you interpret and look at things when you feel upset so as to feel better and act more productively.

The mood-elevating techniques can be surprisingly effective. In fact, cognitive therapy is one of the first forms of psychotherapy that has been shown in clinical research studies to be as effective as and in some cases more effective than antidepressant drug therapy in the treatment of severe and mild depression. While antidepressants are often very useful, we now have an effective approach which has helped many people overcome their mood problems without having to take drugs. And even if you are being treated with medications, the self-help techniques described in this book can speed your recovery.

Published investigations have also suggested that cognitive therapy may be superior to several other forms of psychotherapy, including behavior, group, and insight-oriented therapies, in the treatment of depression. These findings have intrigued many psychiatrists and psychologists and have caused a wave of basic and clinical research investigations.

An article by Dr. Myrna Weissman of the Yale University School of Medicine in New Haven, which appeared in a leading psychiatric journal (the Archives of General Psychiatry), concluded that, in general, the completed studies show the superiority of cognitive therapy when compared with other specific therapies. As with all new developments in medicine and mental-health research, the final judgment must await the test of time and further studies, but the initial findings are highly promising.

The new therapy emphasizes interventions based on common sense. Its rapid mode of action has caused skepticism among more than a few traditionally oriented analytic therap-1

David D. Burns, M.D.

ists. Conventional therapeutic approaches, however, often do not work for many mood disorders, and in fact sometimes result in a worsening of the conditions. In contrast, after only three months of treatment, the majority of severely depressed individuals treated by therapists with the techniques described in this book have reported a substantial reduction of the symptoms that brought them to treatment.

I have written this book so that you can learn about the methods which have helped so many to overcome the blues and enhance their happiness and self-esteem. As you learn to master your moods, you will learn that personal growth can be an exhilarating experience. In the process you will develop a more meaningful set of personal values and adopt a philosophy of living that will make sense and bring you the results you want: increased effectiveness and greater joy.

My own road to cognitive therapy research was an indirect one. In the summer of 1973, I packed my family into our Volkswagen and began the long trek from the San Francisco Bay area to Philadelphia. I had accepted a training position as a senior psychiatric resident in mood research at the University of Pennsylvania School of Medicine. I worked initially at the Depression Research Unit of the Philadelphia Veterans Administration Hospital gathering data on the recently popu-larized chemical theories of depression. As a result of this research I was able to extract key information from my experiments on how the brain controls the levels of a certain chemical felt to be important in mood regulation. Because of this work I received the A. E. Bennett Award for Basic Psychiatric Research from the Society of Biological Psychiatry in 1975.

It was a dream come true because I had always considered that award as the zenith of a career. But a crucial element was missing. The discoveries were too remote from the clinical problems I had to confront every day in my treatment of human beings suffering—and sometimes dying—from depression and other emotional disturbances. Too many of my patients were just not responding to the available forms of treatment.

My memory of the old veteran, Fred, stands out. For over a decade Fred had experienced severe, unrelenting depression. He would sit on the ward of the Depression 2

FEELING GOOD

Research Unit and tremble, staring at the wall all day long.

When you attempted to speak to him, he would look up and mutter—"Wunna die, doctor, I wunna die." He stayed on the ward so long I began to wonder if he would just die of old age. One day he had a heart attack and almost did die. He was bitterly disappointed when he survived. After a number of weeks in the Coronary Care Unit he was transferred back to the Depression Research Unit.

The staff treated Fred with all the then-known antidepressant medications as well as a number of experimental drugs, but his depression just couldn't be budged. Finally, and as a last-ditch effort, his psychiatrist decided to administer electroconvulsive therapy (ECT)—a treatment used only when other forms have proven unsuccessful. I had never before participated in the administration of shock therapy, but consented to assist the psychiatrist. I recall that after Fred's eighteenth and final shock treatment, when he was recovering from the anesthesia, he looked around and asked me where he was. I told him that he was in the V.A. Hospital and that we were wheeling him back to his room. I was hopeful I might detect some small sign of improvement, and I asked him how he was feeling. He looked up at me and muttered sadly, "Wunna die."

I realized then that we needed more potent ammunition in order to fight depressive illness, but I didn't know what that might be. About this time Dr. John Paul Brady, Chairman of the Department of Psychiatry at the University of Pennsylvania, suggested I do some work with Dr. Aaron T. Beck, one of the world's foremost authorities on mood disorders.

Dr. Beck was doing research on a revolutionary and contro-versial type of talking treatment for depression he called "

cognitive therapy."

As I said earlier, the word "cognitive" simply refers to how you are thinking and feeling about things at a particular moment. Dr. Beck's thesis was simple: (1) When you are depressed or anxious, you are thinking in an illogical, negative manner, and you inadvertently act in a self-defeating way. (2) With a little effort you can train yourself to straighten your twisted thought patterns. (3) As your painful symptoms are eliminated, you will become productive and happy again, and you will respect yourself. (4) These aims 3

David D. Burns, M.D.

can usually be accomplished in a relatively brief period of time, using straightforward methods.

It seemed quite simple and obvious. Certainly my depressed patients did think about things in an unnecessarily pessimistic and distorted way. But I was skeptical that pro..

found and entrenched mental and emotional habits could be readily eliminated with a training program of the type described by Dr. Beck. The whole idea just seemed too simple!

But I reminded myself that many of the greatest developments in the history of science were not complicated and were initially viewed with intense skepticism. The possibility that cognitive concepts and methods might revolutionize the treatment of mood disorders intrigued me sufficiently that I decided to try the therapy with some of my more difficult patients, just as an experiment. I was quite pessimistic about seeing any substantial results, but if cognitive therapy was hokum, I wanted to find out for myself.

The results surprised me. Many of these individuals experienced relief for the first time in years. Some attested to feeling happy for the first time in their lives. As a result of these clinical experiences, I began to work more closely with Dr. Beck and his associates at the University of Pennsylvania Mood Clinic. This group launched and completed several scientific studies to evaluate the effects of the new treament methods we were developing. The results of these investigations have had an enormous impact on the mental-health pro..

fession throughout the United States and abroad, and will be detailed in Chapter 1.

You don't have to be seriously depressed to derive great benefit from these new methods. We can all benefit from a mental "tune-up" from time to time. This book will show you exactly what to do when you feel down in the dumps. It will show you how to pinpoint the reasons why you feel that way, and will help you devise effective strategies to turn your problems around as quickly as possible. If you're willing to invest a little time in yourself, you can learn to master your moods more effectively, just as an athlete who participates in a daily conditioning program can develop greater endurance and strength. The training will be accomplished in a way that makes clear and obvious sense. These suggestions will be

4

FEELING GOOD

practical, so you can develop a personal growth program that will simultaneously generate emotional relief and an understanding of your upset and its root causes. These methods actually do work, and the effects can be quite profound.

5

PART I

Theory and Research

CHAPTER 1

A Breakthrough in the

Treatment of Mood Disorders

Depression has been called the world's number one public health problem. In fact, depression is so widespread it is considered the common cold of psychiatric disturbances. But there is a grim difference between depression and a cold. Depression can kill you. The suicide rate, studies indicate, has been on a shocking increase in recent years, even among children and adolescents. This escalating death rate has occurred in spite of the billions of antidepressant drugs and tranquilizers that have been dispensed during the past several decades.

This might sound fairly gloomy. Before you get even more depressed, let me tell you the good news. Depression is an illness and not a necessary part of healthy living. What's more important—you can overcome it by learning some simple methods for mood elevation. A group of psychiatrists and psychologists at the University of Pennsylvania School of Medicine has reported a significant breakthrough in the treatment and prevention of mood disorders. Dissatisfied with traditional methods for treating depression because they found them to be slow and ineffective, these doctors developed and systematically tested an entirely new and remarkably successful approach to depression and other emotional disorders. A series of recent studies confirms that these techniques reduce the symptoms of depression much more rapidly than conven-tional psychotherapy or drug therapy. The name of this revolutionary treatment is "cognitive therapy."

I have been centrally involved in the development of cogni-9

David D. Burns, M.D.

tive therapy, and this book is the first to describe these methods to the general public. The systematic application and scientific evaluation of this approach in treating clinical depression traces its origins to the innovative work of Dr.

Aaron T. Beck, who began to refine his unique approach to mood transformation in the mid-1950's.* His pioneering efforts began to emerge into prominence in the past decade because of the research that many mental-health professionals have undertaken to refine and evaluate cognitive therapy methods at the University of Pennsylvania Medical Center and at numerous other academic institutions.

Cognitive therapy is a fast-acting technology of mood modification that you can learn to apply on your own. It can help you eliminate the symptoms and experience personal growth so you can minimize future upsets and cope with depression more effectively in the future.

The simple, effective mood-control techniques of cognitive therapy provide:

1. Rapid Symptomatic Improvement: In milder depressions, relief from your symptoms can often be observed in as short a time as twelve weeks.

2. Understanding: A clear explanation of why you get moody and what you can do to change your moods.

You will learn what causes your powerful feelings; how to distinguish "normal" from "abnormal" emotions; and how to diagnose and assess the severity of your upsets.

3. Self-control: You will learn how to apply safe and effective coping strategies that will make you feel better whenever you are upset. I will guide you as you develop a practical, realistic, step-by-step self-help plan. As you

* The idea that your thinking patterns can profoundly influence your moods has been described by a number of philosophers in the past 2500 years. More recently, the cognitive view of emotional disturbances has been explored in the writings of many psychiatrists and psychologists including Alfred Adler, Albert Ellis, Karen Homey, and Arnold Lazarus, to name just a few. A history of this movement has been described in Ellis, A., Reason and Emotion in Psychotherapy.

New York: Lyle Stuart, 1962.

10

FEELING GOOD

apply it, your moods can come under greater voluntary control.

4. Prevention and Personal Growth: Genuine and long-lasting prophylaxis (prevention) of future mood swings can effectively be based on a reassessment of some basic values and attitudes which lie at the core of your tendency toward painful depressions. I will show you how to challenge and reevaluate certain assumptions about the basis for human worth.

The problem-solving and coping techniques you learn will encompass every crisis in modern life, from minor irritations to major emotional collapse. These will include realistic problems, such as divorce, death, or failure, as well as those vague, chronic problems that seem to have no obvious external cause, such as low self-confidence, frustration, guilt, or apathy.

The question may now occur to you, "Is this just another self-help pop psychology?" Actually, cognitive therapy is one of the first forms of psychotherapy which has been shown to be effective through rigorous scientific research under the critical scrutiny of the academic community. This therapy is unique in having professional evaluation and validation at the highest academic levels. It is not just another self-help fad but a major development that has become an important part of the mainstream of modern psychiatric research and practice. Cognitive therapy's academic foundation has enhanced its impact and should give it staying power for years to come.

But don't be turned off by the professional status that cognitive therapy has acquired. Unlike much traditional psychotherapy, it is not occult and anti-intuitive. It is practical and based on common sense, and you can make it work for you.

The first principle of cognitive therapy is that all your moods are created by your "cognitions," or thoughts. A cognition refers to the way you look at things—your perceptions, mental attitudes, and beliefs. It includes the way you interpret things—what you say about something or someone to yourself. You /eel the way you do right now because of the thoughts you are thinking at this moment.

11

David D. Burns, M.D.

Let me illustrate this. How have you been feeling as you read this? You might have been thinking, "Cognitive therapy sounds too good to be true. It would never work for me." If your thoughts run along these lines, you are feeling skeptical or even discouraged. What causes you to feel that way? Your thoughts. You create those feelings by the dialogue you are having with yourself about this book!

Conversely, you may have felt a sudden uplift in mood because you thought, "Hey, this sounds like something which might finally help me." Your emotional reaction is generated not by the sentences you are reading but by the way you are thinking. The moment you have a certain thought and believe it, you will experience an immediate emotional response.

Your thought actually creates the emotion.

The second principle is that when you are feeling depressed, your thoughts are dominated by a pervasive negativity. You You perceive not only yourself but the entire world in dark, gloomy terms. What is even worse—you'll come to believe things really are as bad as you imagine them to be.

If you are substantially depressed, you will even begin to believe that things always have been and always will be negative. As you look into your past, you remember all the bad things that have happened to you. As you try to imagine the future, you see only emptiness or unending problems and anguish. This bleak vision creates a sense of hopelessness. This feeling is absolutely illogical, but it seems so real that you have convinced yourself that your inadequacy will go on forever.

The third principle is of substantial philosophical and therapeutic importance. Our research has documented that the negative thoughts which cause your emotional turmoil nearly always contain gross distortions. Although these thoughts appear valid, you will learn that they are irrational or just plain wrong, and that twisted thinking is a major cause of your suffering.

The implications are important. Your depression is probably not based on accurate perceptions of reality but is often the product of mental slippage.

12

FEELING GOOD

Suppose you believe that what I've said has validity. What good will it do you? Now we come to the most important result of our clinical research. You can learn to deal with your moods more effectively if you master methods that will help you pinpoint and eliminate the mental distortions which cause you to feel upset. As you begin to think more objectively, you will begin to feel better.

How effective is cognitive therapy compared with other established and accepted methods for treating depression? Can the new therapy enable severely depressed individuals to get better without drugs? How rapidly does cognitive therapy work? Do the results last?

Several years ago a group of investigators at the Center for Cognitive Therapy at the University of Pennsylvania School of Medicine including Drs. John Rush, Aaron Beck, Maria Kovacs and Steve Hollon began a pilot study comparing cognitive therapy with one of the most widely used and effective antidepressant drugs on the market, Tofranil (imipramine hydrochloride). Over forty severely depressed patients were randomly assigned to two groups. One group was to receive individual cognitive therapy sessions and no drugs, while the other group would be treated with Tofranil and no therapy.

This either-or research design was chosen because it provided the maximum opportunity to see how the treatments compared. Up to that time, no form of psychotherapy had been shown to be as effective for depression as treatment with an antidepressant drug. This is why antidepressants have experienced such a wave of interest from the media, and have come to be regarded by the professional community in the past two decades as the best treatment for most serious forms of depression.

Both groups of patients were treated for a twelve-week period. All patients were systematically evaluated with extensive psychological testing prior to therapy, as well as at several monthly intervals for one year after completion of treatment. The doctors who performed the psychological tests were not the therapists who administered the treatment. This ensured an objective assessment of the merits of each form of treatment.

13

David D. Burns, M.D.

The patients were suffering from moderate to severe depressive episodes. The majority had failed to improve in spite of previous treatment with two or more therapists at other clinics. Three quarters were suicidal at the time of their referral. The average patient had been troubled by chronic or in-termittent depression for eight years. Many were absolutely convinced their problems were insoluble, and felt their lives were hopeless. Your own moon problems may not seem as overwhelming as theirs. A tough patient population was chosen so that the treatment could be tested under the most difficult, challenging conditions.

The outcome of the study was quite unexpected and encouraging. Cognitive therapy showed itself to be substantially superior to antidepressant drug therapy in all respects. As you can see (Table 1-1, page 14), fifteen of the nineteen patients Table 1-1. Status of 44 Severely Depressed Patients, 12 Weeks After Beginning Treatment

Patients Treated

with

Antidepressant

Patients Treated

Drug Therapy

with Cognitive

Only

Therapy Only

Number Who Entered

25

Treatment

19

Number who had recovered

completely*

15

5

Number who were consider-

ably improved but still

experienced borderline to

mild depression

2

7

Number who were not sub-

stantially improved

1

5

Number who dropped out of

treatment

1

8

* The superior improvement of the patients treated with cognitive therapy was statistically significant.

14

FEELING GOOD

treated with cognitive therapy had shown a substantial reduction of symptoms after twelve weeks of active treatment.* An additional two individuals had improved, but were still experiencing borderline to mild depression. Only one patient had dropped out of treatment, and one had not yet begun to improve at the end of this period. In contrast, only five of the twenty-five patients assigned to antidepressant drug therapy had shown complete recovery by the end of the twelve-week period. Eight of these patients dropped out of therapy as result of the adverse side effects of the medication, and twelve others showed no improvement or only partial improvement.

Of particular importance was the discovery that many patients treated with cognitive therapy improved more rapidly than those successfully treated with drugs. Within the first week or two, there was a pronounced reduction in suicidal thoughts among the cognitive therapy group. The effectiveness of cognitive therapy should be encouraging for individuals who prefer not to rely on drugs to raise their spirits, but prefer to develop an understanding of what is troubling them and do something to cope with it.

How about those patients who had not recovered by the end of twelve weeks? Like any form of treatment, this one is not a panacea. Clinical experience has shown that all individuals do not respond as rapidly, but most can nevertheless improve if they persist for a longer period of time, Sometimes this is hard work! One particularly encouraging development for individuals with refractory severe depressions is a recent study by Drs. Ivy Blackburn and her associates at the Medical Research Council at the University of Edinburg in Scotland.f These investigators have shown that the combination of antidepressant drugs with cognitive ther-

* Table 1-1 was adapted from Rush, A. J., Beck, A. T., Kovacs, M„ and Hollon, S. "Comparative Efficacy of Cognitive Therapy and Pharmacotherapy in the Treatment of Depressed Outpatients." Cognitive Therapy and Research, Vol. 1, No. 1, March 1977, pp. 17-38.

t Blackburn, L M., Bishop, S., Glen, A. I. M, Whalley, L. J. and Christie, J. E. "The Efficacy of Cognitive Therapy in Depression. A Treatment Trial Using Cognitive Therapy and Pharmacotherapy, each Alone and in Combination." British Journal of Psychiatry, Vol. 139, January 1981, pp. 181-189.

15

David D. Burns, M.D.

apy can be more effective than either modality above. In my experience the most crucial predictor of recovery is a persistent willingness to exert some effort to help yourself. Given this attitude, you will succeed.

Just how much improvement can you hope for? The average cognitively treated patient experienced a substantial elimination of symptoms by the end of treatment. Many reported they felt the happiest they had ever felt in their lives. They emphasized that the mood-training brought about a sense of self-esteem and confidence. No matter how miserable, depressed, and pessimistic you now feel, I am convinced that you can experience beneficial effects if you are willing to apply the methods described in this book with persistence and consistency.

How long do the effects last? The findings from follow-up studies during the year after completion of treatment are quite interesting. While many individuals from both groups had occasional mood swings at various times during the year, both groups continued on the whole to maintain the gains they had demonstrated by the end of twelve weeks of active treatment.

Which group actually fared better during the follow-up period? The psychological tests, as well as the patients' own reports, confirmed that the cognitive therapy group continued to feel substantially better, and these differences were statistically significant. The relapse rate over the course of the year in the cognitive therapy group was less than half that observed in the drug patients. These were sizable differences that favored the patients treated with the new approach.

Does this mean that I can guarantee you will never again have the blues after using cognitive methods to eliminate your current depression? Obviously not. That would be like saying that once you have achieved good physical condition through daily jogging, you will never again be short of breath. Part of being human means getting upset from time to time, so I can guarantee you will not achieve a state of never-ending bliss! This means you will have to reapply the techniques that help you if you want to continue to master your moods. There's a difference between feeling better-

16

FEELING GOOD

which can occur spontaneously—and getting better—which results from systematically applying and reapplying the methods that will lift your mood whenever the need arises.

How has this work been received by the academic community? The impact of these findings on psychiatrists, psychologists, and other mental-health professionals has been substantial, and it appears that the main impact is yet to come. As a result of our research, professional publications, lectures, and workshops around the country, an initial skepticism about cognitive therapy is being replaced by widespread interest. Research studies to investigate these findings are now under way at some of the finest academic centers in the United States and Europe. A recent development of great importance was the decision of the federal government to invest millions of dollars over the next several years in a multi-university depression-research program under the spon-sorship of the National Institute of Mental Health. As in the original study, the antidepressant effects of cognitive therapy will be matched against a mood-elevating drug to determine which treatment modality is superior. In addition, a third type of psychotherapy, which focuses on interpersonal factors, will be evaluated. This project, described in a recent issue of Science magazine,* is clearly intended to be the largest and most carefully controlled psychotherapy study in history.

What does all this add up to? We are experiencing a crucial development in modern psychiatry and psychology—a promising new approach to understanding human emotions based on a cogent testable therapy. Large numbers of mental-health professionals are now showing a great interest in this approach, and the ground swell seems to be just beginning.

Since completion of the original study, many hundreds of depressed individuals have become better as a result of treatment with cognitive therapy. Some had considered themselves hopelessly untreatable and came to us as a last-ditch effort before committing suicide. Many others were simply troubled

* Marshall, E. "Psychotherapy Works, but for Whom?" Science, Vol.

207, February 1, 1980, pp. 506-508.

17

David D. Burns, M.D.

by the nagging tensions of daily living and wanted a greater share of personal happiness. This book is a carefully thought-out practical application of our work, and it is designed for you. Good luck!

18

CHAPTER 2

How to Diagnose Your Moods:

The First Step in the Cure

Perhaps you are wondering if you have in fact been suffering from depression. Let's go ahead and see where you stand.

The Beck Depression Inventory (BDI) (see Table 2-1, page 20) is a reliable mood-measuring device that detects the presence of depression and accurately rates its severity. This simple multiple-choice questionnaire will take only a few minutes to complete. After you have completed the BDI, I will show you how to make a simple interpretation of the results, based on your total score. Then you will know immediately whether or not you are suffering from a true depression and, if so, how severe it is. I will also lay out some important guidelines to help you determine whether you can safely and effectively treat your own blue mood using this book as your guide, or whether you have a more serious emotional disorder and might benefit from professional intervention in addition to your own efforts to help yourself.

As you fill out the questionnaire, read each item carefully and circle the number next to the answer that best reflects how you have been feeling during the past few days. Make sure you circle one answer for each of the twenty-one questions.* If more than one answer applies to how you have

* Several questions ask if you have recently been experiencing a particular symptom such as irritability or insomnia, ". .. any more than usual," or ". . . more than before." If the symptom has been present for a long time because of chronic depression, you are to answer the question based on a comparison of how you are feeling now with how you were feeling the last time you were happy and undepressed. If you believe you have never felt happy and undepressed, then answer the question based on a comparison of how you are feeling now with how you imagine a normal, undepressed person would feel.

19

Table 2-1. Beck Depression Inventory •

1. 0 I do not feel sad.

1 I feel sad.

2 I am sad all the time and I can't snap out of

3 I am so sad or unhappy that! can't stand it.

2. 0 lam not particularly discouraged about the future.

1 I feel discouraged about the future.

2 I feel I have nothing to look forward to

3 I feel that the future is hopeless and that things cannot improve.

3. 0 I do not feel like a failure.

1 I feel I have failed more than the average person.

2 As I look back on my life, all I can see is a lot of failures.

3 I feel I am a complete failure as a person.

4. 0 I get as much satisfaction out of things as I used to.

1 I don't enjoy things the way I used to.

2 I don't get real satisfaction out of anything anymore.

3 I am dissatisfied or bored with everything.

5. 0 I don't feel particularly guilty.

1 I feel guilty a good part of the time.

2 I feel quite guilty most of the time.

3 I feel gtulty all of the time.

6. 0 I don't feel l am being punished.

1 I feel' may be punished.

2 I expect to be punished.

3 I feel I am being punished.

7. 0 I don't fed disappointed in myself.

1 I am disappointed in myself.

2 I am disgusted with myself.

3 I hate myself.

8. 0 I don't feel I am any worse than anybody else.

1 I am critical of myself for my weaknesses or mistakes.

2 I blame myself all the time for my faults.

3 I blame myself for everything bad that happens.

9. 0 I don't have any thoughts of killing myself.

1 I have thoughts of killing myself, but I would not carry them out.

2 I would Me to kill myself.

3 I would kill myself if I had the chance.

• Copyright 1978, Aaron T. Beck, M.D.

20

Table 2-1. Continued.

10. 0 I don't cry any more than usual.

I I cry more now than I used to.

2 I cry all the time now.

3 I used to be able to cry, but now I can't cry even though I want to.

11. 0 I am no more irritated by things than I ever am.

1 I am slightly more irritated now than usual.

2 I am quite annoyed or irritated a good deal of the time.

3 I feel irritated all the time now.

12. 0 I have not lost interest in other people.

1 I am less interested in other people than I used to be.

2 I have lost most of my interest in other people.

3 I have lost all of my interest in other people.

13. 0 I make decisions about as well as I ever could.

1 I put off making decisions more than I used to.

2 I have greater difficulty in making decisions than before.

3 I can't make decisions at all anymore.

14. 0 I don't feel that I look any worse than I used to.

1 I am worried that I am looking old or unattractive.

2 I feel that there are permanent changes in my appearance that make me look unattractive.

3 I believe that I look ugly.

15. 0 I can work about as well as before.

1 It takes an extra effort to get started at doing something.

2 I have to push myself very hard to do anything.

3 I can't do any work at all.

16. 0 I can sleep as well as usual.

1 I don't sleep as well as I used to.

2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.

3 I wake up several hours earlier than I used to and cannot get back to sleep.

17. 0 I don't get more tired than usual.

1 I get tired more easily than I used to.

2 I get tired from doing almost anything.

3 I am too tired to do anything.

18. 0 My appetite is no worse than usual.

1 My appetite is not as good as it used to be.

21

David D. Burns, M.D.

Table 2-1. Continued.

2 My appetite is much worse now.

3 I have no appetite at all anymore.

19. 0 I haven't lost much weight, if any, lately.

1 I have lost more than five pounds.

2 I have lost more than ten pounds.

3 I have lost more than fifteen pounds.

20. 0 I am no more worried about my health than usual.

I I am worried about physical problems such as aches and pains, or upset stomach, or constipation.

2 I am very worried about physical problems and it's hard to think of much else.

3 I am so worried about my physical problems that I cannot think about anything else

21. 0 I have not noticed any recent change in my interest in sex. I I am less interested in sex than I used to be.

2 I am much less interested in sex now.

3 I have lost interest in sex completely.

been feeling, circle the higher number. If in doubt, make your best guess. Do not leave any questions unanswered. Regardless of the outcome, this can be your first step toward emotional improvement.

Interpreting the Beck Depression Inventory. Now that you have completed the test, add up the score for each of the twenty-one questions and obtain the total. Since the highest score that you can get on each of the twenty-one questions is three, the highest possible total for the whole test would be sixty-three (this would mean you circled number three on all twenty-one questions). Since the lowest score for each question is zero, the lowest possible socre for the test would be zero (this would mean you circled zero on each question).

You can now evaluate your depression according to Table 2-2. As you can see, the higher the total score, the more severe your depression. In contrast, the lower the score, the better you are feeling.

Although the BDI test is not difficult or time-consuming to fill out and score, don't be deceived by its simplicity. You 22

FEELING GOOD

Table 2-2. Interpreting the Beck Depression Inventory Total Score

Levels of Depression *

1-10

These ups and downs are considered•normat

11-16

Mild mood disturbance.

17-20

Borderline clinical depression

21-30

Moderate depression

31-40

Severe depression

over 40

Extreme depression

* A persistent score of 17 or above indicates you may need professional treat.

meat.

have just learned to use a highly sophisticated tool for diagnosing depression. Many research studies in the past decade have demonstrated that the BDI test and similar mood-rating devices are highly accurate and reliable in detecting and measuring depression. In a recent study in a psychiatric emergency room, it was found that a self-rating depression inventory similar to the one you just filled out actually picked up the presence of depressive symptoms more frequently than formal interviewing by experienced clinicians who did not use the test. You can use the BDI with confidence to diagnose yourself and monitor your progress.

As you apply the various self-help techniques described in this book, take the BDI test at regular intervals to assess your progress objectively. I suggest a minimum of once a week.

Compare it to weighing yourself regularly when you're on a diet. You will notice that various chapters in this book focus on different symptoms of depression. As you learn to overcome these symptoms, you will find that your total score will begin to fall. This will show that you are improving. When your score is under ten, you will be in the range considered normal. When it is under five, you will be feeling especially good. Ideally, I'd like to see your score under five the majority of the time. This is one aim of your treatment.

Is it safe for all depressed individuals to try to treat themselves using the principles and methods outlined? The answer is—definitely yes! This is because the crucial decision to try to help yourself is the key that will allow you to feel better as 23

David D. Burns, M.D.

soon as possible, regardless of how severe your mood disturbance might seem to be.

Under what conditions should you seek professional help?

If the BDI test showed that you were depressed but your total score was under seventeen, your depression—at least at this time—is mild and should not be a cause for alarm. You will definitely want to correct the problem. but professional intervention may not be necessary. Systematic self-help efforts along the lines proposed in this book, combined with frank communication on a number of occasions with a trusted friend, will probably suffice If your score is above sixteen, you are more seriously depressed. Your moods are apt to be intensely uncomfortable and possibly dangerous While most of us feel extremely upset for brief periods, if your score remains in this range for more than two weeks, you should consider seeking a professional consultation. I am convinced you can still benefit greatly by applying what I teach you, and you might very well conquer your depression entirely on your own, but it might not be smart to insist on trying it out without professional guidance. Seek out a trusted and competent counselor.

In addition to evaluating your total BDI score, be sure to pay attention to question 9, which asks about any suicidal tendencies. If you score a two or a three on this question, you may be dangerously suicidal. I strongly recommend that you obtain professional help right away. I have provided some effective methods for assessing and reversing suicidal impulses in a later chapter, but you must consult a professional when suicide begins to appear to be a desirable or necessary option. Your conviction that you are hopeless is the reason to seek treatment, not suicide. The majority of seriously depressed individuals believe they are hopeless beyond any shadow of a doubt. This destructive delusion is merely a symptom of the illness, not a fact. Your feeling that you are hopeless is powerful evidence that you are actually not!

It is also important for you to look at question 20, which asks if you have been more worried about your health recently. Have you experienced any unexplained aches, pains, fever, weight loss, or other possible symptoms of medical illness? If so, it would be worthwhile to have a medical consultation, which would include a history, a complete physical 24

FEELING GOOD

examination, and laboratory tests. Your doctor will probably give you a clean bill of health. This will suggest that your uncomfortable physical symptoms are related to your emotional state. Depression can mimic a great number of medical disorders because your mood swings often create a wide variety of puzzling physical symptoms. These include to name just a few, constipation diarrhea pain, insomnia or the tendency to sleep too much fatigue, loss of sexual interest. lightheadedness, trembling and numbness As your depression improves, these symptoms will in all likelihood vanish. However, keep in mind that many treatable illnesses may initially masquerade as depression, and a medical examination could reveal an early (and life-saving) diagnosis of a reversible organic disorder.

There are a number of symptoms that indicate—but do not prove—the existence of a serious mental disturbance, and these require a consultation with and possible treatment by a mental-health professional, in addition to the self-adminis-tered personal-growth program in this book. Some of the major symptoms include: the belief that people are plotting and conspiring against you in order to hurt you or take your life; a bizarre experience which the ordinary person cannot understand; the conviction that external forces are controlling your mind or body; the feeling that other people can hear your thoughts or read your mind; hearing voices from outside your head; seeing things that aren't there; and receiving personal messages broadcast from radio or television programs.

These symptoms are not a part of depressive illness, but represent major mental disorders. Psychiatric treatment is a must. Quite often, people with these symptoms are convinced that nothing is wrong with them, and may meet the suggestion to seek psychiatric therapy with suspicious resentment and resistance. In contrast, if you are harboring the deep fear that you are going insane and are experiencing episodes of panic in which you sense you are losing control or going over the deep end, it is a near certainty that you are not. These are typical symptoms of ordinary anxiety, a much less serious disorder.

Mania is a special type of mood disorder with which you should be familiar. Mania is the opposite of depression and 25

David D. Burns, M.D.

requires prompt intervention by a psychiatrist who can prescribe lithium. Lithium stabilizes extreme mood swings and allows the patient to lead a normal life. However, until therapy is initiated, the disease can be emotionally destructive. The symptoms include an abnormally elated or irritable mood that persists for at least two days and is not caused by drugs or alcohol. The manic patient's behavior is characterized by impulsive actions which reflect poor judgment (such as irresponsible, excessive spending) along with a grandiose sense of self-confidence. Mania is accompanied by increased sexual or aggressive activity; hyperactive, continuous body movements; racing thoughts, nonstop, excited talking; and a decreased need to sleep. Manic individuals have the delusion that they are extraordinarily powerful and brilliant, and often insist they are on the verge of some philosophical or scientific breakthrough or lucrative money-making scheme. Many famous creative individuals suffer from this illness and manage to control it with lithium. Because the disease feels so good, individuals who are having their first attack often cannot be convinced to seek treatment. The first symptoms are so hi-toxicating that the victim resists accepting the idea that his or her sudden acquisition of self-confidence and inner ecstasy is actually just a manifestation of a destructive illness.

After a while, the euphoric state may escalate into uncontrollable delirium requiring involuntary hospitalization, or it may just as suddenly switch into an incapacitating depression with pronounced immobility and apathy. I want you to be familiar with the symptoms of mania because a significant percentage of individuals who experience a true major depressive episode will at some later time develop these symptoms. When this occurs, the personality of the afflicted individual undergoes a profound transformation over a period of days or weeks. While psychotherapy and a self-help program can be extremely helpful, concomitant treatment with lithium under medical supervision is a must for an optimal response. With such treatment the prognosis for manic illness is excellent.

Let's assume that your score on the BDI test is under seventeen, and you do not have a strong suicidal urge, hallucinations, or symptoms of mania. Instead of moping and

26

FEELING GOOD

feeling miserable, you can now proceed to get better, using the methods outlined in this book. You can start enjoying life and work, and use the energy spent in being depressed for vital and creative living.

27

CHAPTER 3

Understanding Your Moods:

You Feel the Way You Think

As you read the previous chapter, you became aware of how extensive the effects of depression are—your mood slumps, your self-image crumbles, your body doesn't function properly, your willpower becomes paralyzed, and your actions defeat you. That's why you feel so totally down in the dumps. What's the key to it all?

Because depression has been viewed as an emotional disorder throughout the history of psychiatry, therapists from most schools of thought place a strong emphasis on "getting in touch" with your feelings. Our research reveals the unexpected: Depression is not an emotional disorder at all! The sudden change in the way you feel is of no more casual relevance than a runny nose is when you have a cold. Every bad feeling you have is the result of your distorted negative thinking. Illogical pessimistic attitudes play the central role in the development and continuation of all your symptoms.

Intense negative thinking always accompanies a depressive episode, or any painful emotion for that matter. Your moody thoughts are likely to be entirely different from those you have when you are not upset. A young woman, about to receive her Ph.D., expressed it this way:

Every time I become depressed, I feel as if I have been hit with a sudden cosmic jolt, and I begin to see things differently. The change can come within less than an hour. My thoughts become negative and pessimistic. As I look into the past, I become convinced that everything that I've ever done is worthless. Any happy period seems like an illusion. My accomplishments appear as genuine 28

FEELING GOOD

as the false facade for the set of a Western movie. I become convinced that the real me is worthless and inadequate. I can't move forward with my work because I become frozen with doubt. But I can't stand still because the misery is unbearable.

You will learn, as she did, that the negative thoughts that food your mind are the actual cause of your self-defeating emotions. These thoughts are what keep you lethargic and make you feel inadequate. Your negative thoughts, or cognitions, are the most frequently overlooked symptoms of your depression. These cognitions contain the key to relief and are therefore your most important symptoms.

Every time you feel depressed about something, try to identify a corresponding negative thought you had just prior to and during the depression. Because these thoughts have actually created your bad mood, by learning to restructure them, you can change your mood.

You are probably skeptical of all this because your negative thinking has become such a part of your life that it has become automatic. For this reason I call negative thoughts àutomatic thoughts." They run through your mind automatically without the slightest effort on your part to put them there. They are as obvious and natural to you as the way you bold a fork.

The relationship between the way you think and the way you feel is diagramed in Figure 3-1. This illustrates the first major key to understanding your moods: Your emotions result entirely from the way you look at things. It is an obvious neurological fact that before you can experience any event, you must process it with your mind and give it meaning. You must understand what is happening to you before !

vu can feel it.

If your understanding of what is happening is accurate, Four emotions will be normal. If your perception is twisted and distorted in some way, your emotional response will be abnormal. Depression falls into this category. It is always the result of mental "static"—distortions. Your blue moods can be compared to the scratchy music coming from a radio that is not properly tuned to the station. The problem is not that the tubes or transistors are blown out or defective, or that the 29

David D. Burns, M.D.

Figure 3-1. The relationship between the world and the way you feel.

It is not the actual events but your perceptions that result in changes in mood. When you are sad, your thoughts will represent a realistic interpretation of negative events. When you are depressed or anxious, your thoughts will always be illogical, distorted, unrealistic, or just plain wrong.

THOUGHTS: You interpret the

events with a series of thoughts

that continually flow through

your mind. This Li called your "

internal dialogue."

WORLD: A series of positive, I

MOOD: Your feelings aro

neutral, and negative events.

created by your Martha and not the actual anon AU experiences mutt be proceued through your

brain sad gins • conscious

meaning Were you mains*

any ensthional response.

signal from the radio station is distorted as a result of bad weather. You just simply have to adjust the dials. When you learn to bring about this mental tuning, the music will come through clearly again and your depression will lift.

Some readers—maybe you—will experience a pang of despair when they read that paragraph. Yet there is nothing upsetting about it. If anything, the paragraph should bring hope. Then what caused your mood to plunge as you were reading? It was your thought, "For other people a little tuning may suffice. But I'm the radio that is broken beyond repair. My tubes are blown out. I don't care if ten thousand other depressed patients all get well—I'm convinced beyond any shadow of doubt that my problems are hopeless." I hear this statement fifty times a week! Nearly every depressed person seems convinced beyond all rhyme or reason that he or she is the special one who really is beyond hope. This delusion reflects the kind of mental processing that is at the very core of your illness!

I have always been fascinated by the ability certain people 30

FEELING GOOD

have to create illusions. As a child, I used to spend hours at the local library, reading books on magic. Saturdays I would bang out in magic stores for hours, watching the man behind the counter produce remarkable effects with cards and silks and chromium spheres that floated through the air, defying all the laws of common sense. One of my happiest childhood memories is when I was eight years old and saw "Black-stone—World's Greatest Magician" perform in Denver, Colorado. I was invited with several other children from the audience to come up on stage. Blackstone instructed us to place our hands on a two-feet by two-feet birdcage filled with live white doves until the top, bottom, and all four sides were enclosed entirely by our hands. He stood nearby and said, "

Stare at the cage!" I did. My eyes were bulging and I refused to blink. He exclaimed, "Now I'll clap my hands." He did. In that instant the cage of birds vanished. My hands were suspended in empty air. It was impossible! Yet it happened! I was stunned.

Now I know that his ability as an illusionist was no greater than that of the average depressed patient. This includes you.

When you are depressed, you possess the remarkable ability to believe, and to get the people around you to believe, things which have no basis in reality. As a therapist, it is my job to penetrate your illusion, to teach you how to look behind the mirrors so you can see how you have been fooling yourself.

You might even say that I'm planning to dis-illusion you! But I don't think you're going to mind at all.

Read over the following list of ten cognitive distortions that form the basis of all your depressions. Get a feel for them. I have prepared this list with great care; it represents the distilled essence of many years of research and clinical experience. Refer to it over and over when you read the how-to-do-it section of the book. When you are feeling upset, the list will be invaluable in making you aware of how you are fooling yourself.

Definitions of Cognitive Distortions

I. All-or-Nothing Thinking. This refers to your tendency to evaluate your personal qualities in extreme, black-or-white 31

David D. Burns, M.D.

categories. For example, a prominent politician told me, "Be-cause I lost the race for governor, I'm a zero." A straight-A student who received a B on an exam concluded, "Now I'm a total failure." All-or-nothing thinking forms the basis for perfectionism. It causes you to fear any mistake or imperfection because you will then see yourself as a complete loser, and you will feel inadequate and worthless.

This way of evaluating things is unrealistic because life is rarely completely either one way or the other. For example, no one is absolutely brilliant or totally stupid. Similarly, no one is either completely attractive or totally ugly. Look at the floor of the room you are sitting in now. Is it perfectly clean?

Is every inch piled high with dust and dirt? Or is it partially clean? Absolutes do not exist in this universe. If you try to force your experiences into absolute categories, you will be constantly depressed because your perceptions will not con-form to reality. You will set yourself up for discrediting yourself endlessly because whatever you do will never measure up to your exaggerated expectations. The technical name for this type of perceptual error is "dichotomous thinking." You see everything as black or white—shades of gray do not exist.

2. Overgeneralization. When I was eleven years old, I bought a deck of trick cards at the Arizona State Fair called the Svengali Deck. You may have seen this simple but impressive illusion yourself: I show the deck to you—every card is different. You choose a card at random. Let's assume you pick the Jack of Spades. Without telling me what card it is, you replace it in the deck. Now I exclaim, "Svengalil" As I turn the deck over, every card has turned into the Jack of Spades.

When you overgeneralize, this is performing the mental equivalent of Svengali. You arbitrarily conclude that one thing that happened to you once will occur over and over again, will multiply like the Jack of Spades. Since what happened is invariably unpleasant, you feel upset.

A depressed salesman noticed bird dung on his car window and thought, "That's just my luck. The birds are always crapping on my windowl" This is a perfect example of overgeneralization. When I asked him about this experience, he 32

FEELING GOOD

admitted that in twenty years of traveling, he could not remember another time when he found bird dung on his car window.

The pain of rejection is generated almost entirely from overgeneralization, In its absence, a personal affront is temporarily disappointing but cannot be seriously disturbing, A shy young man mustered up his courage to ask a girl for a date. When she politely declined because of a previous engagement, he said to himself, "I'm never going to get a date, No girl would ever want a date with me. I'll be lonely and miserable all my life." In his distorted cognitions, he concluded that because she turned him down once, she would always do so, and that since all women have 100 percent identical tastes, he would be endlessly and repeatedly rejected by any eligible woman on the face of the earth, Svengalil 3. Mental Filter. You pick out a negative detail in any situation and dwell on it exclusively, thus perceiving that the whole situation is negative, For example, a depressed college student heard some other students making fun of her best friend, She became furious because she was thinking, "That's what the human race is basically like—cruel and insensitivel"

She was overlooking the fact that in the previous months few people, if any, had been cruel or insensitive to herl On another occasion when she completed her first midterm exam, she felt certain she had missed approximately seventeen questions out of a hundred. She thought exclusively about those seventeen questions and concluded she would flunk out of college. When she got the paper back there was a note attached that read, "You got 83 out of 100 correct. This was by far the highest grade of any student this year. A.+"

When you are depressed, you wear a pair of eyeglasses with special lenses that filter out anything positive. All thal you allow to enter your conscious mind is negative. Because you are not aware of this "filtering process," you conclude that everything is negative. The technical name for this process is "selective abstraction." It is a bad habit that can cause you to suffer much needless anguish.

4. Disqualifying the Positive. An even more spectacular mental illusion is the persistent tendency of some depressed individuals to transform neutral or even positive experiences 33

David D. Burns, M.D.

into negative ones. You don't just ignore positive experiences, you cleverly and swiftly turn them into their nightmarish opposite. I call this "reverse alchemy." The medieval alchemists dreamed of finding some method for transmuting the baser metals into gold. If you have been depressed. you may have developed the talent for doing the exact opposite—you can instantly transform golden joy into emotional lead. Not intentionally, however—you're probably not even aware of what you're doing to yourself.

An everyday example of this would be the way most of us have been conditioned to respond to compliments. When someone praises your appearance or your work, you might automatically tell yourself, "They're just being nice." With one swift blow you mentally disqualify their compliment.

You do the same thing to them when you tell them, "Oh, it was nothing, really." If you constantly throw cold water on the good things that happen, no wonder life seems damp and chilly to you!

Disqualifying the positive is one of the most destructive forms of cognitive distortion. You're like a scientist intent on finding evidence to support some pet hypothesis. The hypothesis that dominates your depressive thinking is usually some version of "I'm second-rate." Whenever you have a negative experience, you dwell on it and conclude, "That proves what I've known all along." In contrast, when you have a positive experience, you tell yourself, "That was a fluke. It doesn't count," The price you pay for this tendency is intense misery and an inability to appreciate the good things that happen.

While this type of cognitive distortion is commonplace, it can also form the basis for some of the most extreme and intractable forms of depression. For example, a young woman hospitalized during a severe depressive episode told me, "No one could possibly care about me because I'm such an awful person. I'm a complete loner. Not one person on earth gives a damn about me." When she was discharged from the hospital, many patients and staff members expressed great fondness for her. Can you guess how she negated all this? "

They don't count because they don't see me in the real world. A real person outside a hospital could never care 34

FEELING GOOD

about me." I then asked her how she reconciled this with the fact that she had numerous friends and family outside the hospital who did care about her. She replied, "They don't count because they don't know the real me. You see Dr.

Burns, inside I'm absolutely rotten. I'm the worst person in the world. It would be impossible for anyone to really like me for even one moment!" By disqualifying positive experiences in this manner, she can maintain a negative belief which is clearly unrealistic and inconsistent with her everyday experiences.

While your negative thinking is probably not as extreme as hers, there may be many times every day when you do inadvertently ignore genuinely positive things that have happened to you. This removes much of life's richness and makes things appear needlessly bleak.

5. lumping to Conclusions. You arbitrarily jump to a negative conclusion that is not justified by the facts of the situation. Two examples of this are "mind reading" and "the fortune teller error."

MIND READING: You make the assumption that other people are looking down on you, and you're so convinced about this that you don't even bother to check it out. Suppose you are giving an excellent lecture, and you notice that a man in the front row is nodding off. He was up most of the night on a wild fling, but you of course don't know this. You might have the thought, "This audience thinks I'm a bore."

Suppose a friend passes you on the street and fails to say hello because he is so absorbed in his thoughts he doesn't notice you. You might erroneously conclude, "He is ignoring me so he must not like me anymore." Perhaps your spouse is unresponsive one evening because he or she was criticized at work and is too upset to want to talk about it. Your heart sinks because of the way you interpret the silence: "He (or she) is mad at me. What did I do wrong?"

You may then respond to these imagined negative reactions by withdrawal or counterattack. This self-defeating behavior pattern may act as a self-fulfilling prophecy and set up a negative interaction in a relationship when none exists hi the first place.

THE FORTUNE TELLER ERROR: It's as if you had a crystal 35

David D. Burns, M.D.

ball that foretold only misery for you. You imagine that something bad is about to happen, and you take this prediction as a fact even though it is unrealistic. A high-school librarian repeatedly told herself during anxiety attacks, "I'm going to pass out or go crazy." These predictions were unrealistic because she had never once passed out (or gone crazy!) in her entire life. Nor did she have any serious symptoms to suggest impending insanity. During a therapy session an acutely depressed physician explained to me why he was giving up his practice: "I realize I'll be depressed forever. My misery will go on and on, and I'm absolutely convinced that this or any treatment will be doomed to failure." This negative prediction about his prognosis caused him to feel hopeless. His symptomatic improvement soon after initiating therapy indicated just how off-base his fortune telling had been.

Do you ever find yourself jumping to conclusions like these? Suppose you telephone a friend who fails to return your call after a reasonable time. You then feel depressed when you tell yourself that your friend probably got the message but wasn't interested enough to call you back. Your distortion?—mind reading. You then feel bitter, and decide not to call back and check this out because you say to yourself, "He'll think I'm being obnoxious if I call him back again. I'll only make a fool of myself." Because of these negative predictions (the fortune teller error), you avoid your friend and feel put down. Three weeks later you learn that your friend never got your message. All that stewing, it turns out, was just a lot of self-imposed hokum. Another painful product of your mental magic!

6. Magnification and Minimization. Another thinking trap you might fall into is called "magnification" and "mini-mization," but I like to think of it as the "binocular trick" because you are either blowing things up out of proportion or shrinking them. Magnification commonly occurs when you look at your own errors, fears, or imperfections and exaggerate their importance: "My God—I made a mistake. How terrible! How awful! The word will spread like wildfire! My reputation is ruined!" You're looking at your faults through the end of the binoculars that makes them appear gigantic and grotesque. This has also been called "catastrophizing" be-36

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cause you turn commonplace negative events into nightmarish monsters.

When you think about your strengths, you may do the opposite—look through the wrong end of the binoculars so that things look small and unimportant. If you magnify your imperfections and minimize your good points, you're guaranteed to feel inferior. But the problem isn't you—it's the crazy lenses you're wearing!

7. Emotional Reasoning. You take your emotions as evidence for the truth. Your logic: "I feel like a dud, therefore I am a dud." This kind of reasoning is misleading because your feelings reflect your thoughts and beliefs. If they are distorted—as is quite often the case—your emotions will have no validity. Examples of emotional reasoning include "I feel guilty. Therefore, I must hive done something bad"; "I feel overwhelmed and hopeless. Therefore, my problems must be impossible to solve"; "I feel inadequate. Therefore, I must be a worthless person"; "I'm not in the mood to do anything.

Therefore, I might as well just lie in bed"; or "I'm mad at you. This proves that you've been acting rotten and trying to take advantage of me."

Emotional reasoning plays a role in nearly all your depressions. Because things feel so negative to you, you assume they truly are. It doesn't occur to you to challenge the validity of the perceptions that create your feelings.

One usual side effect of emotional reasoning is procrastination. You avoid cleaning up your desk because you tell yourself, "I feel so lousy when I think about that messy desk, cleaning it will be impossible." Six months later you finally give yourself a little push and do it. It turns out to be quite gratifying and not so tough at all. You were fooling yourself all along because you are in the habit of letting your negative feelings guide the way you act.

8. Should Statements. You try to motivate yourself by saying, "I should do this" or "I must do that." These statements cause you to feel pressured and resentful. Paradoxically, you end up feeling apathetic and unmotivated. Albert Ellis calls this "masturbation." I call it the "shouldy" approach to life.

When you direct should statements toward others, you will usually feel frustrated. When an emergency caused me to be five minutes late for the first therapy session, the new patient 37

David D. Burns, M.D.

thought, "He shouldn't be so self-centered and thoughtless.

He ought to be prompt," This thought caused her to feel sour and resentful.

Should statements generate a lot of unnecessary emotional turmoil in your daily life. When the reality of your own behavior falls short of your standards, your shoulds and shouldn'ts create self-loathing, shame, and guilt. When the all-too-human performance of other people falls short of your expectations, as will inevitably happen from time to time, you'll feel bitter and self-righteous. You'll either have to change your expectations to approximate reality or always feel let down by human behavior. If you recognize this bad should habit in yourself, I have outlined many effective "

should and shouldn't" removal methods in later chapters on guilt and anger.

9. Labeling and Mislabeling. Personal labeling means creating a completely negative self-image based on your errors. It is an extreme form of overgeneralization. The philosophy behind it is "The measure of a man is the mistakes he makes." There is a good chance you are involved in a personal labeling whenever you describe your mistakes with sentences beginning with "I'm a . . ." For example, when you miss your putt on the eighteenth hole, you might say, "Pm a born loser" instead of "I goofed up on my putt." Similarly, when the stock you invested in goes down instead of up, you might think, "I'm a failure" instead of "I made a mistake."

Labeling yourself is not only self-defeating, it is irrational.

Your self cannot be equated with any one thing you do. Your life is a complex and ever-changing flow of thoughts, emotions, and actions. To put it another way, you are more like a river than a statue. Stop trying to define yourself with negative labels—they are overly simplistic and wrong. Would you think of yourself exclusively as an "eater" just because you eat, or a "breather" just because you breathe? This is nonsense, but such nonsense becomes painful when you label yourself out of a sense of your own inadequacies.

When you label other people, you will invariably generate hostility. A common example is the boss who sees his occasionally irritable secretary as "an uncooperdtive bitch." Because of this label, he resents her and jumps at every chance to criticize her. She, in turn, labels him an "insensitive chau-38

FEELING GOOD

vinist" and complains about him at every opportunity. So, around and around they go at each other's throats, focusing on every weakness or imperfection as proof of the other's worthlessness.

Mislabeling involves describing an event with words that are inaccurate and emotionally heavily loaded. For example, a woman on a diet ate a dish of ice cream and thought, "How disgusting and repulsive of me. I'm a pig."

These thoughts made her so upset she ate the whole quart of ice cream!

10. Personalization. This distortion is the mother of guilt!

You assume responsibility for a negative event when there is no basis for doing so. You arbitrarily conclude that what happened was your fault or reflects your inadequacy, even when you were not responsible for it. For example, when a patient didn't do a self-help assignment I had suggested, I felt guilty because of my thought, "I must be a lousy therapist.

It's my fault that she isn't working harder to help herself. It's my responsibility to make sure she gets well." When a mother saw her child's report card, there was a note from the teacher indicating the child was not working well. She immediately decided, "I must be a bad mother. This shows how I've failed."

Personalization causes you to feel crippling guilt. You suffer from a paralyzing and burdensome sense of responsibility that forces you to carry the whole world on your shoulders.

You have confused influence with control over others. In your role as a teacher, counselor, parent, physician, salesman, executive, you will certainly influence the people you interact with, but no one could reasonably expect you to control them. What the other person does is ultimately his or her responsibility, not yours. Methods to help you overcome your tendency to personalize and trim your sense of responsibility down to manageable, realistic proportions will be discussed later on in this book.

The ten forms of cognitive distortions cause many, if not all, of your depressed states. They are summarized in Table 3-1 on page 40. Study this table and master these concepts; try to become as familiar with them as with your phone number. Refer to Table 3-1 over and over again as you learn about the various methods for mood modification. When you 39

David D. Burns, M.D.

Table 3-1. Definitions of Cognitive Distortions 1. ALL-OR-NOTHINC THINKING You see things in black-and-white categories It yow performance falls short of perfect, you see yourself as a total failure.

2. OVERGENERALIZATION: You see a single negative event as a never-ending pattern of defeat.

3. MENTAL FILTER: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolors the entire beaker of water.

4. DISQUALIFYING THE POSITIVE: You reject positive experiences by insisting they "don't count" for some reason or other. In thb way you can maintain a negative belief that is contradicted by your everyday experiences.

5. JUMPING TO CONCLUSIONS: You make a negative interpretation even though there are no definite facts that convincingly support your conclusion.

a. Mind reading. You arbitrarily conclude that someone is reacting negatively to you, and you don't bother to check this out.

b. The Fortune Teller Error. You anticipate that things will turn out badly, and you feel convinced that your prediction is an already-established fact.

6. MAGNIFICATION (CATASTROPHIZING) OR MINIMIZATION: You exaggerate the importance of things (such as your goof-up or someone else's achievement), or you inappropriately shrink thing until they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called

the "binocular trick."

7. EMOTIONAL REASONING: You assume that your negative emotions necessarily reflect the way things really are: "I feel it, therefore it must be true."

8. SHOULD STATEMENTS: You try to motivate yourself with shoulds and shouldn't:, as if you had to be whipped and punished before you could be expected to do anything "Musts" and "

oughts" are also offenders The emotional consequence is guilt.

When you direct should statements toward others, you feel anger, frustration, and resentment.

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Table 3-1. Continued.

9. LABELING AND MISLABELING: This is an extreme form of overgeneralization Instead of describing your error, you attach a negative label to yourself. "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him: "He's a goddam louse." Mislabeling involves describing an event with language that is highly colored and emotionally loaded.

10. PERSONALIZATION: You see yourself as the cause of some negative external event which in fact you were not primarily responsible for.

become familiar with these ten forms of distortion, you will benefit from this knowledge all your life.

I have prepared a simple self-assessment quiz to help you test and strengthen your understanding of the ten distortions. As you read each of the following brief vignettes, imagine you are the person who is being described. Circle one or more answers which indicate the distortions contained in the negative thoughts. I will explain the answer to the first question. The answer key to subsequent questions is given at the end of this chapter. But don't look ahead! I'm certain you will be able to identify at least one distortion in the first question—and that will be a start!

1. You are a housewife, and your heart sinks when your husband has just complained disgruntledly that the roast beef was overdone. The following thought crosses your mind: "I'

m a total failure. I can't stand it! I never do anything right. I work like a slave and this is all the thanks I get! The jerk!"

These thoughts cause you to feel sad and angry. Your distortions include one or more of the following:

a. all-or-nothing thinking;

b. overgeneralization;

c. magnification;

d. labeling;

e• all the above.

Now I will discuss the correct answers to this question so you can get some immediate feedback. Any answer(s) you 41

David D. Burns, M.D.

might have circled was (were) correct. So if you circled anything, you were right! Here's why. When you tell yourself, "

I'm a total failure," you engage in all-or-nothing thinking.

Cut it out! The meat was a little dry, but that doesn't make your entire life a total failure. When you think, "I never do anything right," you are overgeneralizing. Never? Come on now! Not anything? When you tell yourself, "I can't stand it," you are magnifying the pain you are feeling. You're blowing it way out of proportion because you are standing it, and if you are, you can. Your husband's grumbling is not exactly what you like to hear, but it's not a reflection of your worth. Finally, when you proclaim, "I work like a slave and this is all the thanks I get! The jerk!" you are labeling both of you. He's not a jerk, he's just being irritable and insensitive.

Jerky behavior exists, but jerks do not. Similarly, it's silly to label yourself a slave. You're just letting his moodiness sour your evening.

Okay, now let's continue with the quiz.

2. You have just read the sentence in which I informed you that you would have to take this self-assessment quiz.

Your heart suddenly sinks and you think, "Oh no, not another test! I always do lousy on tests. I'll have to skip this section of the book. It makes me nervous, so it wouldn't help anyway." Your distortions include:

a. jumping to conclusions (fortune teller error); b. overgeneralization;

c. all-or-nothing thinking;

d. personalization;

e. emotional reasoning.

3. You are a psychiatrist at the University of Pennsylvania. You are attempting to revise your manuscript on depression after meeting with your editor in New York.

Although your editor seemed extremely enthusiastic, you notice you are feeling nervous and inadequate due to your thoughts, "They made a terrible mistake when they chose my book! I won't be able to do a good job. I'll never be able to make the book fresh, lively, and punchy. My writing is too drab, and my ideas aren't good enough." Your cognitive distortions include:

a. all-or-nothing thinking;

b. jumping to conclusions (negative prediction); 42

FEELING GOOD

c. mental filter;

d. disqualifying the positive;

e. magnification.

4. You are lonely and you decide to attend a social affair for singles. Soon after you get there, you have the urge to leave because you feel anxious and defensive. The following thoughts run through your mind: "They probably aren't very interesting people. Why torture myself? They're just a bunch of losers. I can tell because I feel so bored. This party will be a drag." Your errors involve:

a. labeling;

b. magnification;

c. jumping to conclusions (fortune teller error and mind reading);

d. emotional reasoning;

e. personalization.

5. You receive a layoff notice from your employer. You feel mad and frustrated. You think, "This proves the world is no damn good. I never get a break." Your distortions include:a. all-or-nothing thinking;

b. disqualifying the positive;

c. mental filter;

d. personalization;

e. should statement.

6. You are about to give a lecture and you notice that your heart is pounding. You feel tense and nervous because you think, "My God, I'll probably forget what I'm supposed to say. My speech isn't any good anyway. My mind will blank out. I'll make a fool of myself." Your thinking errors involve:

a. all-or-nothing thinking;

b. disqualifying the positive;

c. jumping to conclusions (fortune teller error); d. minimization;

e. labeling.

7. Your date calls you at the last minute to cancel out because of illness. You feel angry and disappointed because you think, "I'm getting jilted. What did I do to foul things up?"

Your thinking errors include:

a. all-or-nothing thinking;

43

David D. Burns, M.D.

b. should statements;

c. jumping to conclusions (mind reading);

d. personalization;

e. overgeneralization.

8. You have put off writing a report for work. Every night when you try to get down to it, the whole project seems so difficult that you watch TV instead. You begin to feel overwhelmed and guilty. You are thinking the following: "I'm so lazy I'll never get this done. I just can't do the darn thing. It would take forever. It won't turn out right anyway." Your thinking errors include:

a. jumping to conclusions (fortune teller error); b. overgeneralization;

c. labeling;

d. magnification;

e. emotional reasoning.

9. You've read this entire book and after applying the methods for several weeks, you begin to feel better. Your BDI score went down from twenty-six (moderately depressed) to eleven (borderline depression). Then you suddenly begin to feel worse, and in three days your score has gone back up to twenty-eight. You feel disillusioned, hopeless, bitter, and desperate due to thinking, "I'm not geting anywhere. These methods won't help me after all. I should be well by now. That 'improvement' was a fluke. I was fooling myself when I thought I was feeling better. I'll never get well." Your cognitive distortions include: a. disqualifying the positive;

b. should statement;

c. emotional reasoning;

d. all-or-nothing thinking;

e. jumping to conclusions (negative prediction).

10. You've been trying to diet. This weekend you've been nervous, and, since you didn't have anything to do, you've been nibbling, nibbling. After your fourth piece of candy, you tell yourself, "I just can't control myself. My dieting and jogging all week have gone down the drain. I must look like a balloon. I shouldn't have eaten that. I can't stand this. I'm going to pig out all weekend!" You begin to feel so guilty you push another handful of candy into your mouth in an abor-tive effort to feel better. Your distortions include: 44

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a. all-or-nothing thinking;

b. mislabeling;

c. negative prediction;

d. should statement;

e. disqualifying the positive.

ANSWER KEY

1. ABCDE

6. ACDE

2. ABCE

7. C D

3. ABDE

8. ABCDE

4. ABCD

9. ABCDE

5. A C

10. ABCDE

Feelings Aren't Facts

At this point you may be asking yourself, "Okay. I understand that my depression results from my negative thoughts because my outlook on life changes enormously when my moods go up or down. But if my negative thoughts are so distorted, how do I continually get fooled? I can think as clearly and realistically as the next person, so if what I am telling myself is irrational, why does it seem so right?"

Even though your depressing thoughts may be distorted, they nevertheless create a powerful illusion of truth. Let me expose the basis for the deception in blunt terms—your feelings are not facts! In fact, your feelings, per se, don't even count—except as a mirror of the way you are thinking.

If your perceptions make no sense, the feelings they create will be as absurd as the images reflected in the trick mirrors at an amusement park. But these abnormal emotions feel just as valid and realistic as the genuine feelings created by undistorted thoughts, so you automatically attribute truth to them.

This is why depression is such a powerful form of mental black magic.

Once you invite depression through an "automatic" series of cognitive distortions, your feelings and actions will reinforce each other in a self-perpetuating vicious cycle. Because you believe whatever your depressed brain tells you, you find 45

David D. Burns, M.D.

yourself feeling negative about almost everything. This reaction occurs in milliseconds, too quickly for you even to be aware of it. The negative emotion feels realistic and in turn lends an aura of credibility to the distorted thought which created it. The cycle goes on and on, and you are eventually trapped. The mental prison is an illusion, a hoax you have inadvertently created, but it seems real because it feels real.

What is the key to releasing yourself from your emotional prison? Simply this: Your thoughts create your emotions; therefore, your emotions cannot prove that your thoughts are accurate. Unpleasant feelings merely indicate that you are thinking something negative and believing it. Your emotions follow your thoughts just as surely as baby ducks follow their mother. But the fact that the baby ducks follow faithfully along doesn't prove that the mother knows where she is going!

Let's examine your equation, "I feel, therefore I am." This attitude that emotions reflect a kind of self-evident, ultimate truth is not unique to depressed people. Most psychotherapists today share the conviction that becoming more aware of your feelings and expressing them more openly represent emotional maturity. The implication is that your feelings represent a higher reality, a personal integrity, a truth beyond question.

My position is quite different. Your feelings, per se, are not necessarily special at all. In fact, to the extent that your negative emotions are based on mental distortions as is all too often the case—they can hardly be viewed as desirable.

Do I mean you should get rid of all emotions? Do I want you to turn into a robot? No. I want to teach you to avoid painful feelings based on mental distortions, because they are neither valid nor desirable. I believe that once you have learned how to perceive life more realistically you will experience an enhanced emotional life with a greater appreciation for genuine sadness—which lacks distortion—as well as joy.

As you go on to the next sections of this book, you can learn to correct the distortions that fool you when you are upset. At the same time, you will have the opportunity to reevaluate some of the basic values and assumptions that create your vulnerability to destructive mood swings. I have outlined 46

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the necessary steps in detail. The modifications in illogical thinking patterns will have a profound effect on your moods and increase your capacity for productive living. Now, let's go ahead and see how we can turn your problems around.

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PART II

Practical Applications

CHAPTER 4

Start by Building Self-Esteem

When you are depressed, you invariably believe that you are worthless. The worse the depression, the more you feel this way. You are not alone. A recent survey by Dr. Aaron Beck revealed that over 80 percent of depressed patients expressed self-dislike.' Furthermore, Dr. Beck found that depressed patients see themselves as deficient in the very qualities they value most highly: intelligence, achievement, popularity, attractiveness, health, and strength. He said a depressed self-image can be characterized by the four D's: You feel Defeated, Defective, Deserted, and Deprived.

Almost all negative emotional reactions inflict their damage only as a result of low self-esteem. A poor self-image is the magnifying glass that can transform a trivial mistake or an imperfection into an overwhelming symbol of personal defeat. For example, Eric, a first-year law student, feels a sense of panic in class. "When the professor calls on me, I'll probably goof up." Although Eric's fear of "goofing up" was foremost on his mind, my dialogue with him revealed that a sense of personal inadequacy was the real cause of the problem: DAVID: Suppose you did goof up in class. Why would that be particularly upsetting to you? Why is that so tragic?

ERIC: Then I would make a fool of myself.

DAVID: Suppose you did make a fool of yourself. Why would that be upsetting?

* Beck, Aaron T. Depression: Clinical, Experimental, & Theoretical Aspects. New York: Hoeber, 1967. (Republished as Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1972, pp. 17-23.)

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David D. Burns, M.D.

ERIC: Because then everyone would look down on me.

DAVID: Suppose people did look down on you? What then?

ERIC: Then I would feel miserable.

DAVID: Why? Why is it that you would have to feel miserable if people were looking down on you?

ERIC: Well, that would mean I wouldn't be a worthwhile person. Furthermore, it might ruin my career. I'd get bad grades, and maybe I could never be an attorney.

DAVID: Suppose you didn't become an attorney. Let's assume for the purposes of discussion that you did flunk out. Why would that be particularly upsetting to you?

ERIC: That would mean that I had failed at something I've wanted all my life.

DAVID: And what would that mean to you?

ERIC: Life would be empty. It would mean I was a failure.

It would mean I was worthless.

In this brief dialogue, Eric showed that he believed it would be terrible to be disapproved of or to make a mistake or to fail. He seemed convinced that if one person looked down on him then everyone would. It was as if the word REJECT would suddenly be stamped on his forehead for everyone to see. He seemed to have no sense of self-esteem that was not contingent upon approval and/or success. He measured himself by the way others looked at him and by what he had achieved. If his cravings for approval and accomplishment were not satisfied, Eric sensed he would be nothing because there would be no true support from within.

If you feel that Eric's perfectionistic drive for achievement and approval is self-defeating and unrealistic, you are right.

But to Eric, this drive was realistic and reasonable. If you are now depressed or have ever been depressed, you may find it much harder to recognize the illogical thinking patterns which cause you to look down on yourself. In fact, you are probably convinced that you really are inferior or worthless.

And any suggestion to the contrary is likely to sound foolish and dishonest.

Unfortunately, when you are depressed you may not be alone in your conviction about your personal inadequacy. In many cases you will be so persuasive and persistent in your 52

FEELING GOOD

maladaptive belief that you are defective and no good, you may lead your friends, family, and even your therapist into accepting this idea of yourself. For many years psychiatrists have tended to "buy into" the negative self-evaluation system of depressed individuals without probing the validity of what the patients are saying about themselves. This is illustrated in the writings of such a keen observer as Sigmund Freud in his treatise "Mourning and Melancholia," which forms the basis for the orthodox psychoanalytic approach to treating depression. In this classic study Freud said that when the patient says he is worthless, unable to achieve, and morally despicable, he must be right. Consequently, it was fruitless for the therapist to disagree with the patient. Freud believed the therapist should agree that the patient is, in fact, uninteresting, unlovable, petty, self-centered, and dishonest. These qualities describe a human being's true self, according to Freud, and the disease process simply makes the truth more obvious:

The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished. . . . It would be equally fruitless from a scientific and therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way [emphasis mine] and be describing something that is as it seems to him to be. Indeed we must at once confirm some of his statements without reservation. He really is as lacking in interest and incapable of love and achievement as he says [emphasis mine]. . . . He also seems to us justified in certain other self-accusations; it is merely that he has a keener eye for the truth than other people who are not melancholic [emphasis mine]. When in his heightened self-criticism he describes himself as petty, egoistic, dishonest, lacking in independence, one whose sole aim has been to hide the weaknesses of his own nature, it may be so far as we know, that he has come pretty near to understanding himself [emphasis mine]; we only 53

David D. Burns, M.D.

wonder why a man has to be ill before he can be acces-sible to truth of this kind.

—Sigmund Freud, "Mourning and Melancholia"

The way a therapist handles your feelings of inadequacy is crucial to the cure, as your sense of worthlessness is a key to depression. The question also has considerable philosophical relevance—is human nature inherently defective? Are depressed patients actually facing the ultimate truth about themselves? And what, in the final analysis, is the source of genuine self-esteem? This, in my opinion, is the most important question you will ever confront.

First, you cannot earn worth through what you do.

Achievements can bring you satisfaction but not happiness.

Self-worth based on accomplishments is a "pseudo-esteem,"

not the genuine thing! My many successful but depressed patients would all agree. Nor can you base a valid sense of self-worth on your looks, talent, fame, or fortune. Marilyn Monroe, Mark Rothko, Freddie Prinz, and a multitude of famous suicide victims attest to this grim truth. Nor can love, approval, friendship, or a capacity for close, caring human relationships add one iota to your inherent worth. The great majority of depressed individuals are in fact very much loved, but it doesn't help one bit because self-love and sell-esteem are missing. At the bottom line, only your own sense of self-worth determines how you feel.

"So," you may now be asking with some exasperation, "

how do I get a sense of self-worth? The fact is, I feel damn inadequate, and I'm convinced I'm really not as good as other people. I don't believe there's anything I can do to change those rotten feelings because that's the way I basically ant"

One of the cardinal features of cognitive therapy is that it stubbornly refuses to buy into your sense of worthlessness. In my practice I lead my patients through a systematic reevaluation of their negative self-image. I raise the same question Freud, S. Collected Papers, 1917. (Translated by Joan Riviere, Vol. IV, Chapter 8, "Mourning and Melancholia," pp. 155-156.

London: Hogarth Press Ltd., 1952.)

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over and over again: "Are you really right when you insist that somewhere inside you are essentially a loser?"

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 either be 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."

55

David D. Burns, M.D.

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 conso-lation 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

56

FEELING GOOD

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 em-pathetic 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 57

David D. Burns, M.D.

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? M 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 propor-tionate 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 58

FEELING GOOD

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 60). 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.

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 40), 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.

59

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.

Automatic Thought

Cognitive Distortion

Rational Response

(SELF-CRITICISM)

(SELF•DEFENS2)

1. I never do anything right.

1. Nonsense! I do a lot of things right.

1. Overgeneralizatioa

2. I'm always late.

2. Fm not always late. That's ridiculous. Think of 2. Overgeneralizatioa

all the times I've been on time. If Fm late more often than rd like, work on this problem and

develop a method for being more punctual.

3. Everyone will look down on me.

3. Mind reading

3. Someone may be disappointed that Fm late but Overgeneralization

it's not the end of the world. Maybe the meeting Al-or-nothing thinking

won't even start on time.

Fortune teller error

4. This shows what a jerk tam.

4. Labeling

4. Come on, now, Fm not "a jerk."

5. I'll make a fool of myself.

5. Labeling

5. Ditto. Fm not "a fool" either. I may appear foolish Fortune teller error

RI come in late, but this doesn't make me a fool.

Everyone is late sometimes.

FEELING GOOD

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

61

Figure 4-2. Daily Record of Dysfunctional Thoughts *

Automatic

Cognitive

Rational

Situation

Emotion(s)

Thought(s)

Distortion(s)

Response(s)

Outcome

Briefly describe the 1. Specify sad/

Write the auto-

Identify the distor-

Write rational re-

Specify and rate

actual event leading

anxious/

matic thought(s)

tion(s) present in

sponse(s) to the auto- subsequent

to the unpleasant

angry, etc.

that accompany the

each automatic

matic thought(s).

emotions,

emotion.

2. Rate degree of

emotion(s).

thought.

0-100%.

emotion, 1-

100%.

Potential customer Angry, 99%

1. rii never sell a

1. Overgenerali-

1. rve sold a lot of

Angry, 50%

hangs up on me

policy.

zation

policies.

Sad, 10%

when I call to de-

Sad, 50%

2. I'd like to

2. Magnification;

2. He acted like a

scribe our new in-

strangle the

labeling

pain in the butt.

surance program.

bastard.

We all do at times.

He said, "Get out

Why kt this get to

of my goddam

•

me?

hair!"

3. I must have said the

3. Jumping to

3. I actually didn't do

wrong thing.

conclusions;

anything different

personalization

from the way I

usually approach a

new customer. So

why sweat It?

Explanation: When you experience an unpleasant emotion, note the situation that seemed to stimulate it. Then, note the auto-made thought associated with the emotion. In rating degree of emotion, 1= a trace; 100 = the most intense possible.

FEELING GOOD

"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 62).

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.

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 Beck Depression Inventory. 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 63

David D. Burns, M.D.

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 through 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.

2. Mental Biofeedback. A second method which can be very useful involves monitoring your negative thoughts with a wrist counter. You can buy one at a sporting-goods store or a golf shop; it looks like a! wristwatch, is inexpensive, and every time you push the button, the number changes on the dial.

64

FEELING GOOD

Click the button each time a negative thought about yourself crosses your mind; be on the constant alert for such thoughts.

At the end of the day, note your daily total score and write it down in a log book.

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 cleadup 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.

Automatic Thoughts Cognitive Distortion

Rational Response

(sup-carnets/A)

(SELF-DEFENSE)

1. Everyone knows

Jumping to conclu-

1. I'm disorganized at

bow disorganized

sions (mind reading);

times and I'm or-

and selfish I am.

overgeneralization

ganized at times.

Everybody doesn't

think the same way

about me.

2. Fm completely

All-or-nothing think-

2. Fm thoughtless at

self-centered and

ing

times, and at times I

thoughtless. I'm

can be quite thought-

just no good.

ful. I probably do act

overly self-centered at

times. I can work on

this. I may be imper-

fect but I'm not "no

goodl"

3. My roommate

Jumping to conclu-

3. My friendships are

probably hates me. sions (mind reading);

just as real as any-

I have no real

allornothing

-

-

thinking

one's. At times I take

friends.

criticism as rejection

of me, Gail, the per-

son. But others are

usually not rejecting

me. They're just ex-

pressing dish le for

what I did (or said)

—and they still ac-

cept rat afterward.

65

David D. Burns, M.D.

At first you will notice that the number increases; this will continue for several days as you get better and better at identifying your critical thoughts. Soon you will begin to notice that the daily total reaches a plateau for a week to ten days, and then it will begin to go down. This indicates that your harmful thoughts are diminishing and that you are getting better. This approach usually requires three weeks.

It is not known with certainty why such a simple technique works so well, but systematic self-monitoring frequently helps develop increased self-control. As you learn to stop haranguing yourself, you will begin to feel much better.

In case you decide to use a wrist counter, I want to emphasize it is not intended to be a substitute for setting aside ten to fifteen minutes each day to write down your distorted negative thoughts and answering them as outlined in the previous pages. The written method cannot be bypassed because it exposes to the light of day the illogical nature of the thoughts that trouble you. Once you are doing this regularly, you can then use your wrist counter to nip your painful cognitions in the bud at other times.

3. Cope, Don't Mope—The Woman Who Thought She

Was a "Bad Mother." As you read the previous sections, the following objection may have occurred to you: "All this deals with is my thoughts. But what if my problems are realistic?

What good will it do me to think differently? I have some real inadequacies that need to be dealt with."

Nancy is a thirty-four-year-old mother of two who felt this way. Six years ago she divorced her first husband and has just recently remarried. She is completing her college degree on a part-time basis. Nancy is usually animated and enthusiastic and quite committed to her family. However, she has experienced episodic depressions for many years. During those low periods she becomes extremely critical of herself and others, and expresses self-doubt and insecurity. She was referred to me during such a period of depression.

I was struck by the vehemence of her self-reproach. She had received a note from her son's teacher stating that he was having some difficulty in school. Her immediate reaction was to mope and blame herself. The following is an excerpt from our therapy session:

66

FEELING GOOD

NANCY: I should have worked with Bobby on his homework because now he is disorganized and not ready for school. I spoke to Bobby's teacher, who said Bobby lacks self-confidence and doesn't follow directions adequately.

Consequently, his schoolwork has been deteriorating. I had a number of self-critical thoughts after the call and I felt suddenly dejected. I began to tell myself that a good mother spends time with her kids on some activity every night. I'm responsible for his poor behavior—lying, not doing well in school. I just can't figure out how to handle him. I'm really a bad mother. I began to think he was stupid and about to flunk and how it was all my fault.

My first strategy was to teach her how to attack the statement "I am a bad mother," because I felt this self-criticism was hurtful and unrealistic, creating a paralyzing internal anguish which would not help her in her efforts to guide Bobby through his crisis.

DAVID. Okay. What's wrong with this statement, "I am a bad mother"?

NANCY: Well ...

DAVID: Is there any such thing as a: "bad mother"?

NANCY: Of course.

DAVID: What is your definition of a "bad mother"?

NANCY: A bad mother is one who does a bad job of raising her kids. She isn't as effective as other mothers, so her kids turn out bad. It seems obvious.

DAVID: So you would say a "bad mother" is one who is low on mothering skills? That's your definition?

NANCY: Some mothers lack mothering skills.

DAVID: But all mothers lack mothering skills to some extent.

NANCY: They do?

DAVID: There's no mother in this world who is perfect in all mothering skills. So they all lack mothering skills in some part. According to your definition, it would seem that all mothers are bad mothers.

NANCY: I feel that I'm a bad mother, but not everybody is.

DAVID: Well, define it again. What is a "bad mother"?

67

David D. Burns, M.D.

NANCY: A bad mother is someone who does not understand her children or is constantly making damaging errors. Errors that are detrimental.

DAVID: According to this new definition, you're not a "bad mother," and there are no "bad mothers" because no one constantly makes damaging errors.

NANCY: No one ... ?

DAVID: You said that a bad mother constantly makes damaging errors. There is no such person who constantly makes damaging errors twenty-four hours a day. Every mother is capable of doing some things right.

NANCY: Well, there can be abusive parents who are always punishing, hitting—you read about them in the papers.

Their children end up battered. That could certainly be a bad mother.

DAVID: There are parents who resort to abusive behavior, that's true. And these individuals could improve their behavior, which might make them feel better about themselves and their children. But it's not realistic to say that such parents are constantly doing abusing or damaging things, and it's not going to help matters by attaching the label "bad" to them. Such individuals do have a problem with aggression and need training in self-control, but it would only make matters worse if you tried to convince them that their problem was badness. They usually already believe they are rotten human beings, and that is part of their problem. Labeling them as "bad mothers" would be inaccurate, and it would also be irresponsible, like trying to put out a fire by throwing gasoline on it.

At this point I was trying to show Nancy that she was just defeating herself by labeling herself as a "bad mother." I hoped to show her that no matter how she defined "bad mother," the definition would be unrealistic. Once she gave up the destructive tendency to mope and label herself as worthless, we could then go on to coping strategies for helping her son with his problems at school.

NANCY: But I still have the feeling I am a "bad mother."

DAVID: Well, once again, what is your definition?

68

FEELING GOOD

NANCY: Someone who doesn't give her child enough attention, positive attention. Pm so busy in school. And when I do pay attention, Fm afraid it may be all negative attention. Who knows? That's what I'm saying.

DAVID: A "bad mother" is one who doesn't give her child enough attention, you say? Enough for what?

NANCY: For her child to do well in life.

DAVID: Do well in everything, or in some things?

NANCY: In some things. No one can do well at everything.

DAVID: Does Bobby do well at some things? Does he have any redeeming virtues?

NANCY: Oh yes. There are many things he enjoys and does well at.

DAVID: Then you can't be a "bad mother" according to your definition because your son does well at many things.

NANCY: Then why do I feel like a bad mother?

DAVID: It seems that you're labeling yourself as a "bad mother" because you'd like to spend more time with your son, and because you sometimes feel inadequate, and because there is a clear-cut need to improve your communication with Bobby. But it won't help you solve these problems if you conclude automatically you are a "

bad mother." Does that make sense to you?

NANCY: If I paid more attention to him and gave him more help, he could do better at school and he could be a whole lot happier. I feel it's my fault when he doesn't do well.

DAVID: So you are willing to take the blame for his mistakes?

NANCY: Yes, it's my fault. So I'm a bad mother.

DAVID: And you also take the credit for his achievements?

And for his happiness?

NANCY: No—he should get the credit for that, not me.

DAVID: Does that make sense? That you're responsible for his faults but not his strengths?

NANCY: No.

DAVID: Do you understand the point I'm trying to make?

NANCY: Yep.

DAVID: "Bad mother" is an abstraction; there is no such thing as a "bad mother" in this universe.

69

David D. Burns, M.D.

NANCY: Right. But mothers can do bad things.

DAVID: They're just people, and people do a whole variety of things—good, bad, and neutral. "Bad mother" is just a fantasy; there's no such thing. The chair is a thing.

A "bad mother" is an abstraction. You understand that?

NANCY: I got it, but some mothers are more experienced and more effective than others.

DAVID: Yes, there are all degrees of effectiveness at parenting skills. And most everyone has plenty of room for improvement. The meaningful question is not "Am I a good or bad mother?" but rather "What are my relative skills and weaknesses, and what can I do to improve?"

NANCY: I understand. That approach makes more sense and it feels much better. When I label myself "bad mother," I just feel inadequate and depressed, and I don't do anything productive. Now I see what you've been driving at. Once I give up criticizing myself, I'll feel better, and maybe I can be more helpful to Bobby.

DAVID: Right! So when you look at it that way, you're talking about coping strategies. For example, what are your parenting skills? How can you begin to improve on those skills? Now that's the type of thing I would suggest with regard to Bobby. Seeing yourself as a "bad mother" eats up emotional energy and distracts you from the task of improving your mothering skills. It's irresponsible.

NANCY: Right. If I can stop punishing myself with that statement, I'll be much better off and I can start working toward helping Bobby. The moment I stop calling myself bad mother, I'll start feeling better.

DAVID: Yes, now what can you say to yourself when you have the urge to say "I'm a bad mother"?

NANCY: I can say I don't have to hate my whole self if there is a particular thing I find I dislike about Bobby, or if he has a problem at school. I can try to define that problem, and attack that problem, and work toward solving it.

DAVID: Right. Now, that's a positive approach. I like it.

You refute the negative statement and then add a positive statement. I like that.

70

Figure 4-4. Nancy's written homework concerning Bobby's difficulties at school. This is similar to the "triple-column technique," except that she did not find it necessary to write down the cognitive distortions contained in her automatic thoughts.

Automatic Thought

Rational Response

(SELF-CRITICISM)

(SELF-DEFENSE)

1. I didn't pay attention to Bobby.

1. I really spend too much time with

him; I'm overprotective.

2. I should have worked with him 2. Homework is his responsibility, on his homework, and now he is

not mine. I can explain to him

disorganized and not ready for

how to get organized. What are

school.

my responsibilities?

a. Check homework;

b. Insist it be done at a certain

time;

c. Ask if he's having any diffi-

culties;

d. Set up a reward system.

3. A good mother spends time with 3. Not true. I spend time when I her kids on some activity every

can and want to, but it isn't

night.

feasible always. Besides, his

schedule is his.

4. I'm responsible for his poor be- 4. I can only guide Bobby. It's up to havior and not doing well in

him to do the rest.

school.

5. He wouldn't have gotten into

5. That is not so. Problems will

trouble at school if I had helped

occur even if I'm around to over-

him. If I had supervised his

see things.

homework earlier, this problem

wouldn't have occurred.

6. I'm a bad mother. I'm the cause

6. I'm not a bad mother; I try. I of his problems.

can't control what goes on in all

areas of his life. Maybe I can

talk to him and his teacher and

find out how to help him. Why

punish myself whenever someone

I love has a problem?

7. All other mothers work with

7. Overgeneralization! Not true.

their kids, but I don't know how

Stop moping and start coping.

to get along with Bobby.

71

David D. Burns, M.D.

We then worked on answering several "automatic thoughts" she had written down after the call from Bobby's teacher (see Figure 4-4, page 71). As Nancy learned to refute her self-critical thoughts. she experienced much-needed emotional relief. She was then able to develop some specific coping strategies designed to help Bobby with his difficulties.

The first step of her coping plan was to talk to Bobby about the difficulties he had been having so as to find out what the real problem was. Was he having difficulties as his teacher had suggested? What was his understanding of the problem? Was it true that he was feeling tense and low in confidence" Had his homework been particularly hard for him recently? Once Nancy had obtained this information and defined the real problem, she realized she would then be in a position to work toward an appropriate solution. For example, if Bobby said he found some of his courses particularly difficult, she could develop a reward system at home to encourage him to do extra homework. She also decided to read several books on parenting skills. Her relationship with Bobby improved, and his grades and behavior at school underwent a rapid turnabout.

Nancy's mistake had been to view herself in a global way, making the moralistic judgment that she was a bad mother.

This type of criticism incapacitated her because it created the impression that she had a personal problem so big and bad that no one could do anything about it. The emotional upset this labeling caused prevented her from defining the real problem, breaking it down into its specific parts, and applying

appropriate solutions. If she had continued to mope, there was the distinct possibility that Bobby would have continued to do poorly, and she would have become increasingly ineffectual.

How can you apply what Nancy learned to your own situation? When you are down on yourself, you might find it helpful to ask what you actually mean when you try to define your true identity with a negative label such as "a fool," "a sham," "a stupid dope," etc. Once you begin to pick these destructive labels apart, you will find they are arbitrary and meaningless They actually cloud the issue, creating confusion and despair. Once rid of them, you can define and cope with any real problems that exist.

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FEELING GOOD

Summary. When you are experiencing a blue mood, the chances are that you are telling yourself you are inherently inadequate or just plain "no good." You will become convinced that you have a bad core or are essentially worthless.

To the extent that you believe such thoughts, you will experience a severe emotional reaction of despair and self-hatred.

You may even feel that you'd be better off dead because you are so unbearably uncomfortable and self-denigrating. You may become inactive and paralyzed, afraid and unwilling to participate in the normal flow of life.

Because of the negative emotional and behavioral consequences of your harsh thinking the first step is to stop telling yourself you are worthless However, you probably won't be able to do this until you become absolutely convinced that these statements are incorrect and unrealistic.

How can this be accomplished? You must first consider that a human life is an ongoing process that involves a constantly changing physical body as well as an enormous number of rapidly changing thoughts feelings, and behaviors.

Your life therefore is an evolving experience, a continual flow. You are not a thing; that's why any label is constricting, highly inaccurate, and global. Abstract labels such as "

worthless" or "inferior" communicate nothing and mean

nothing.

But you may still be convinced you are second-rate.

What is your evidence? You may reason, "I feel inadequate.

Therefore, I must be inadequate. Otherwise, why would I be filled with such unbearable emotions?" Your error is in emotional reasoning. Your feelings do not determine your worth, simply your relative state of comfort or discomfort.

Rotten, miserable internal states do not prove that you are a rotten, worthless person, merely that you think you are; because you are in a temporarily depressed mood, you are thinking illogically and unreasonably about yourself.

Would you say that states of mood elevation and happiness prove you are great or especially worthy? Or do they simply mean that you are feeling good?

Just as your feelings do not determine your worth, neither do your thoughts or behaviors. Some may be positive, creative, and enhancing; the great majority are neutral. Others may be irrational, self-defeating, and maladaptive. These can

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David D. Burns, M.D.

be modified if you are willing to exert the effort, but they certainly do not and cannot mean that you are no good. There is no such thing in this universe as a worthless human being.

"Then how can I develop si sense of self-esteem?" you may ask. The answer is—you don't have to! You don't have to do anything especially worthy to create or deserve self-esteem; all you have to do is turn off that critical, haranguing, inner voice. Why? Because that critical inner voice is wrong! Your internal self-abuse springs from illogical, distorted thinking.

Your sense of worthlessness is not based on truth, it is just the abscess which lies at the core of depressive illness.

So remember three crucial steps when you are upset: 1. Zero in on those automatic negative thoughts and write them down. Don't let them buzz around in your head; snare them on paper!

2. Read over the list of ten cognitive distortions. Learn precisely how you are twisting things and blowing them out of proportion.

3. Substitute a more objective thought that puts the lie to the one which made you look down on yourself. As you do this, you'll begin to feel better. You'll be boosting your self-esteem, and your sense of worthlessness (and, of course, your depression) will disappear.

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CHAPTER 5

Do-Nothingism: How to Beat It

In the last chapter you learned that you can change your mood by changing how you think. There is a second major approach to mood elevation that is enormously effective.

People are not only thinkers, they are doers, so it is not surprising that you can substantially change the way you feel by changing the way you act. There's only one hitch—when you're depressed, you don't feel like doing much.

One of the most destructive aspects of depression is the way it paralyzes your willpower. In its mildest form you may simply procrastinate about doing a few odious chores. As your lack of motivation intensifies, virtually any activity appears so difficult that you become overwhelmed by the urge to do nothing. Because you accomplish very little, you feel worse and worse. Not only do you cut yourself off from your normal sources of stimulation and pleasure, but your lack of productivity aggravates your self-hatred, resulting in further isolation and incapacitation.

If you don't recognize the emotional prison in which you are trapped, this situation can go on for weeks, months, or even years. Your inactivity will be all the more frustrating if you once took pride in the energy you had for life. Your do-nothingism can also affect your family and friends, who, like yourself, cannot understand your behavior. They may say that you must want to be depressed or else you'd "get off your behind." Such a comment only worsens your anguish and paralysis.

Do-nothingism represents one of the great paradoxes of human nature. Some people naturally throw themselves into life with great zest, while others always hang back, defeating 75

David D. Burns, M.D.

themselves at every turn as if they were involved in a plot against themselves. Do you ever wonder why?

If a person were condemned to spend months in isolation, cut off from all normal activities and interpersonal relationships, a substantial depression would result. Even young mon-keys slip into a retarded, withdrawn state if they are separated from their peers and confined to a small cage. Why do you voluntarily impose a similar punishment on yourself?

Do you want to suffer? Using cognitive techniques, you can discover the precise reasons for your difficulties in motivating yourself.

In my practice I find that the great majority of the depressed patients referred to me improve substantially if they try to help themselves. Sometimes it hardly seems to matter what you do as long as you do something with the attitude of self-help. I know of two presumably "hopeless"

cases who were helped enormously simply by putting a mark on a piece of paper. One patient was an artist who had been convinced for years that he couldn't even draw a straight line. Consequently he didn't even try to draw. When his therapist suggested he test his conviction by actually attempting to draw a line, it came out so straight he began drawing again and soon was symptom-free! And yet many depressed individuals will go through a phase in which they stubbornly re fuse to do anything to help themselves. The moment this crucial motivational problem has been solved, the depression typically begins to diminish. You can therefore understand why much of our research has been directed to locating the causes of this paralysis of the will. Using this knowledge, we have developed some specific methods to help you deal with procrastination.

Let me describe two perplexing patients I treated recently.

You might think their do-nothingism is extreme and wrongly conclude they must be "crazies" with whom you would have little in common. In fact, I believe their problems are caused by attitudes similar to yours, so don't write them off.

Patient A, a twenty-eight-year-old woman, has done an experiment to see how her mood would respond to a variety of activities. It turns out that she feels substantially better when she does nearly anything. The list of things that will reliably give her a mood lift includes cleaning the house, playing ten-76

FEELING GOOD

nis, going to work, practicing her guitar, shopping for dinner, etc. Only one thing makes her feel reliably worse; this single activity nearly always makes her intensely miserable. Can you guess what it is? DO-NOTHINGISM: lying around in bed all day long, staring at the ceiling and courting negative thoughts. And guess what she does weekends. Right! She crawls right into bed on Saturday morning and begins her descent into inner hell. Do you think she really wants to suffer?Patient B, a physician, gives me a clear, definite message early in her therapy. She says she understands that the speed of improvement is dependent on her willingness to work between sessions, and insists she wants to get well more than anything else in the world, having been wracked by depression for over sixteen years. She emphasizes she'll be happy to come to therapy sessions, but I must not ask her to lift one finger to help herself. She says that if I push her to spend five minutes on self-help assignments, she'll kill herself.

As she describes in detail the lethal, gruesome method of self-destruction she had carefully planned in her hospital's operating room, it become obvious that she is deadly serious.

Why is she so determined not to help herself?

I know your procrastination is probably less severe and only deals with minor things, like paying bills, a trip to the dentist, etc. Or maybe you've had trouble finishing a relatively straightforward report that is crucial to your career.

But the perplexing question is the same—why do we frequently behave in ways that are not in our self-interest?

Procrastinating and self-defeating behavior can seem funny, frustrating, puzzling, infuriating, or pathetic, depending on your perspective. I find it a very human trait, so widespread that we all bump into it nearly every day. Writers, philosophers, and students of human nature throughout history have tried to formulate some explanation for self-defeating behavior, including such popular theories as: 1. You're basically lazy; it's just your "nature."

2. You want to hurt yourself and suffer. You either like feeling depressed, or you have a self-destructive drive, a "

death wish."

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David D. Burns, M.D.

3. You're passive-aggressive, and you want to frustrate the people around you by doing nothing.

4. You must be getting some "payoff" from your procrastination and do-nothingism. For example, you enjoy getting all that attention when you are depressed.

Each of these famous explanations represents a different psychological theory, and each is inaccurate! The first is a "

trait" model; your inactivity is seen as a fixed personality trait and stems from your "lazy streak." The problem with this theory is that it just labels the problem without explaining it. Labeling yourself as "lazy" is useless and self-defeating because it creates the false impression that your lack of motivation is an irreversible, innate part of your makeup. This kind of thinking does not represent a valid scientific theory, but is an example of a cognitive distortion (labeling).

The second model implies you want to hurt yourself and suffer because there is something enjoyable or desirable about procrastination. This theory is so ludicrous I hesitate to include it, except that it is widespread and vigorously supported by a substantial percentage of psychotherapists. If you have the hunch that you or someone else likes being depressed and doing nothing, then remind yourself that depression is the most agonizing form of human suffering. Tell me—what is so great about it? I haven't yet met a patient who really enjoys the misery.

If you aren't convinced but think you really do enjoy pain and suffering, then give yourself the paper-clip test.

Straighten out one end of a paper clip and push it under your fingernail. As you push harder and harder, you may notice how the pain becomes more and more excruciating. Now ask yourself—is this really enjoyable? Do I really like to suffer?

The third hypothesis—you're "passive-aggressive"--rep-resents the thinking of many therapists, who believe that depressive behavior can be explained on the basis of "in-ternalized anger." Your procrastination could be seen as an expression of that pent-up hostility because your inaction often annoys the people around you. One problem with this theory is that most depressed or procrastinating individuals simply do not feel particularly angry. Resentment can sometimes contribute to your lack of motivation, but is usu-78

FEELING GOOD

ally not central to the problem. Although your family may feel frustrated about your depression, you probably do not intend them to react this way. In fact, it is more often the case that you fear displeasing them. The implication that you are

intentionally doing nothing in order to frustrate them is insulting and untrue; such a suggestion will only make you feel worse.

The last theory—you must be getting some "payoff" from procrastination—reflects more recent, behaviorally oriented psychology. Your moods and actions are seen as the result of rewards and punishments from your environment. If you are feeling depressed and doing nothing about it, it follows that your behavior is being rewarded in some way.

There is a grain of truth in this; depressed people do sometimes receive substantial support and reassurance from others who try to help them. However, the depressed person rarely enjoys all the attention he receives because of his profound tendency to disqualify it. If you are depressed and someone tells you they like you, you will probably think, "He doesn't know how rotten I am. I don't deserve this praise." Depression and lethargy have no real rewards. Theory number four bites the dust with the others.

How can you find the real cause of motivational paralysis?

The study of mood disorders gives us the unique opportunity to observe extraordinary transformations in levels of personal motivation within short periods of time. The same individual who ordinarily bursts with creative energy and optimism may be reduced during an episode of depression to pathetic, bedridden immobility. By tracing dramatic mood swings, we can gather valuable clues that unlock many of the mysteries of human motivation. Simply ask yourself, "

When I think about that undone task, what thoughts immediately come to mind?" Then write those thoughts down on a piece of paper. What you write will reflect a number of maladaptive attitudes, misconceptions, and faulty assumptions. You will learn that the feelings that impede your motivation, such as apathy, anxiety, or the sense of being overwhelmed, are the result of distortions in your thinking.

Figure 5-1 shows a typical Lethargy Cycle. The thoughts on this patient's mind are negative; he says to himself, "

There's no point in doing anything because I am a born

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David D. Burns, M.D.

SELF-DEFEATING

THOUGHTS: "There's no

point In doing anything. I don't

have the energy. I'm not in the mood. Fit probably fail if I try.

Things are too difficult. There

wouldn't be any satisfaction if I

did anything anyway. I don't feel

like doing anything, so I don't

have to. FE just lie here in bed

for a while. I can sleep and forget

about things. It's much easier.

Rest is best."

T

SELF-DEFEATING EMO-

SELF-DEFEATING ACTIONS!

TION& You feel tired, bored,

You stick to bed. You avoid

apathetic, self-hating, discour-

■Iel,

— people, work, and all potentially

aged, guilty, helpless, worthless,

satisfying activities.

and overwhelmed.

CONSEQUENCES OF THE

LETHARGY CYCLE: You

become isolated from friends.

This convinces you that you

really are a loser. Your decreased

productivity convinces you that

you actually are inadequate. You

sink deeper and deeper into an

unmotivated state of paralysis.

Figure 5-1. The Lethargy Cycle. Your self-defeating negative thoughts make you feel miserable. Your painful emotions in turn convince you that your distorted, pessimistic thoughts are actually valid. Similarly, self-defeating thoughts and actions reinforce each other in a circular manner.

The unpleasant consequences of do-nothingism make your problems even worse.

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FEELING GOOD

loser and so I'm bound to fail." Such a thought sounds very convincing when you are depressed, immobilizing you and making you feel inadequate, overwhelmed, self-hating, and helpless. You then take these negative emotions as proof that your pessimistic attitudes are valid, and you begin to change your approach to life. Because you are convinced you will botch up anything, you don't even try; you stay in bed instead. You lie back passively and stare at the ceiling, hoping to drift into sleep, painfully aware you are letting your career go down the drain while your business dwindles into bankruptcy. You may refuse to answer the phone for fear of hearing bad news; life becomes a treadmill of boredom, apprehension, and misery. This vicious cycle can go on indefinitely unless you know how to beat it.

As indicated in Figure 5-1, the relationship between your thoughts, feelings, and behaviors is reciprocal—all your emotions and actions are the results of your thoughts and attitudes. Similarly, your feelings and behavior patterns influence your perceptions in a wide variety of ways. It follows from this model that all emotional change is ultimately brought about by cognitions; changing your behavior will help you feel better about yourself if it exerts a positive influence on the way you are thinking. Thus, you can modify your self-defeating mental set if you change your behavior in such a way that you are simultaneously putting the lie to the self-defeating attitudes that represent the core of your motivational problem. Similarly, as you change the way you think, you will feel more in the mood to do things, and this will have an even stronger positive effect on your thinking patterns. Thus, you can transform your lethargy cycle into a productivity cycle.

The following are the types of mind-sets most commonly associated with procrastination and do-nothingism. You may see yourself in one or more of them.

1. Hopelessness. When you are depressed, you get so frozen in the pain of the present moment that you forget entirely that you ever felt better in the past and find it in-conceivable that you might feel more positive in the future.

Therefore, any activity will seem pointless because you are absolutely certain your lack of motivation and sense of oppression are unending and irreversible. From this perspective

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David D. Burns, M.D.

the suggestion that you do something to "help yourself"

might sound as ludicrous and insensitive as telling a dying man to cheer up.

2. Helplessness. You can't possibly do anything that will make yourself feel better because you are convinced that your moods are caused by factors beyond your control, such as fate, hormone cycles, dietary factors, luck, and other people's evaluations of you.

3. Overwhelming Yourself. There are several ways you may overwhelm yourself into doing nothing. You may magnify a task to the degree that it seems impossible to tackle.

You may assume you must do everything at once instead of breaking each job down into small, discrete, manageable units which you can complete one step at a time. You might also inadvertently distract yourself from the task at hand by obsessing about endless other things you haven't gotten around to doing yet. To illustrate how irrational this is, imagine that every time you sat down to eat, you thought about all the food you would have to eat during your lifetime. Just imagine for a moment that all piled up in front of you are tons of meat, vegetables, ice cream, and thousands of gallons of fluids! And you have to eat every bit of this food before you die! Now, suppose that before every meal you said to yourself, "This meal is just a drop in the bucket. How can I ever get all that food eaten? There's just no point in eating one pitiful hamburger tonight." You'd feel so nauseated and overwhelmed your appetite would vanish and your stomach would turn into a knot. When you think about all the things you are putting off, you do this very same thing without being aware of it.

4. lumping to Conclusions. You sense that it's not within your power to take effective action that will result in satisfaction because you are in the habit of saying, "I can't," or "I would but . . ." Thus when I suggested that a depressed woman bake an apple pie, she responded, "I can't cook anymore." What she really meant to say was, "I have the feeling I wouldn't enjoy cooking and it seems like it would be awfully difficult." When she tested these assumptions by attempting to bake a pie, she found it surprisingly satisfying and not at all difficult.

5. Self-labeling. The more you procrastinate, the more you 82

FEELING GOOD

condemn yourself as inferior. This saps your self-confidence further. The problem is compounded when you label yourself

"a procrastinator" or "a lazy person." This causes you to see your lack of effective action as the "real you" so that you automatically expect little or nothing from yourself.

6. Undervaluing the Rewards. When you are depressed you may fail to initiate any meaningful activity not only because you conceive of any task as terribly difficult, but also because you feel the reward simply wouldn't be worth the effort"Anhedonia" is the technical name for a diminished ability to experience satisfaction and pleasure. A common thinking error—your tendency to "disqualify the positive"—may be at the root of this problem. Do you recall what this thinking error consists of?

A businessman complained to me that nothing he did all day was satisfying. He explained that in the morning he had attempted to return a call from a client, but found the line was busy. As he hung up, he told himself, "That was a waste of time." Later in the morning he successfully completed an important business negotiation. This time he told himself, "

Anyone in our firm could have handled it just as well or better. It was an easy problem, and so my role wasn't really important." His lack of satisfaction results from the fact that he always finds a way to discredit his efforts. His bad habit of saying, "It doesn't count" successfully torpedoes any sense of fulfillment.

7. Perfectionism. You defeat yourself with inappropriate goals and standards. You will settle for nothing short of a magnificent performance in anything you do, so you frequently end up having to settle for just that—nothing.

8. Fear of Failure. Another mind-set which paralyzes you is the fear of failure. Because you imagine that putting in the effort and not succeeding would be an overwhelin'ng personal defeat, you refuse to try at all. Several thinking errors are involved in the fear of failure. One of the most common is overgeneralization. You reason, "If I fail at this, it means I will fail at anything." This, of course, is impossible. Nobody can fail at everything. We all have our share of victories and defeats. While it is true that victory tastes sweet and defeat is

83

David D. Burns, M.D.

often bitter, failing at any task need not be a fatal poison, and the bad taste will not linger forever.

A second mind-set that contributes to the fear of defeat is when you evaluate your performance exclusively on the outcome regardless of your individual effort. This is illogical and reflects a "product orientation" rather than a "process orientation." Let me explain this with a personal example. As a psychotherapist I can only control what I say and how I interact with each patient. I cannot control how any particular patient will respond to my efforts during a given therapy session. What I say and how I interact is the process; how each individual reacts is the product. In any given day, several patients will report that they have benefited greatly from that day's session, while a couple of others will tell me that their session was not particularly helpful. If I evaluated my work exclusively on the outcome or product, I would experience a sense of exhilaration whenever a patient did well, and feel defeated and defective whenever a patient reacted negatively. This would make my emotional life a roller coaster, and my self-esteem would go up and down in an exhausting and unpredictable manner all day long. But if I admit to myself that all I can control is the input I provide in the therapeutic process, I can pride myself on good consistent work regardless of the outcome of any particular session. It was a great personal victory when I learned to evaluate my work based on the process rather than on the product. If a patient gives me a negative report, I try to learn from it. If I did make an error, I attempt to correct it, but I don't need to jump out the window.

9. Fear of Success. Because of your lack of confidence, success may seem even more risky than failure because you are certain it is based on chance. Therefore, you are convinced you couldn't keep it up, and you feel your accomplishments will falsely raise the expectations of others. Then when the awful truth that you are basically "a loser" ultimately comes out, the disappointment, rejection, and pain will be all the more bitter. Since you feel sure you will eventually fall off the cliff, it seems safer not to go mountain climbing at all.

You may also fear success because you anticipate that people will make even greater demands on you. Because you 84

FEELING GOOD

are convinced you must and can't meet their expectations, success would put you into a dangerous and impossible situation. Therefore, you try to maintain control by avoiding any commitment or involvement.

10. Fear of Disapproval or Criticism. You imagine that if you try something new, any mistake or flub will be met with strong disapproval and criticism because the people you care about won't accept you if you are human and imperfect.

The risk of rejection seems so dangerous that to protect yourself you adopt as low a profile as possible. If you don't make any effort, you can't goof up!

11. Coercion and Resentment. A deadly enemy of motivation is a sense of coercion. You feel under intense pressure to perform—generated from within and without.

This happens when you try to motivate yourself with moralistic "shoulds" and "oughts." You tell yourself, "I should do this" and "I have to do that." Then you feel obliged, burdened, tense, resentful, and guilty. You feel like a delinquent child under the discipline of a tyrannical probation officer.

Every task becomes colored with such unpleasantness that you can't stand to face it. Then as you procrastinate, you condemn yourself as a lazy, no-good bum. This further drains your energies.

12. Low Frustration Tolerance. You assume that you should be able to solve your problems and reach your goals rapidly and easily, so you go into a frenzied state of panic and rage when life presents you with obstacles. Rather than persist patiently over a period of time, you may retaliate against the "unfairness" of it all when things get tough, so you give up completely. I also call this the "entitlement syndrome" because you feel and act as if you were entitled to success, love, approval, perfect health, happiness, etc.

Your frustration results from your habit of comparing reality with an ideal in your head. When the two don't match, you condemn reality. It doesn't occur to you that it might be infinitely easier simply to change your expectations than to bend and twist reality.

This frustration is frequently generated by should statements. While jogging, you might complain, "For all the miles I've gone, I should be in better shape by now." Indeed? Why should you? You may have the illusion that such punishing, 85

David D. Burns, M.D.

demanding statements will help you by driving you on to tr harder and to put out more effort. It rarely works this wa:, The frustration just adds to your sense of futility and increases your urge to give up and do nothing.

13. Guilt and Self-blame. If you are frozen in the conviction you are bad or have let others down, you naturally feel unmotivated to pursue your daily life. I recently treated a lonely elderly woman who spent her days in bed in spite of the fact that she felt better when she shopped.

cooked, and socialized with her friends. Why? This sweet woman was holding herself responsible for her daughter's divorce five years earlier. She explained, "When I visited them. I should have sat down and talked things over with my son-in-law. I should have asked him how things were going. Maybe I could have helped. I wanted to and yet I didn't take the opportunity. Now I feel I failed them."

After we reviewed the illogic in her thinking, she felt better immediately and became active again. Because she was human and not God, she could not have been expected to predict the future or to know precisely how to intervene.

By now you may be thinking, "So what? I know that my do-nothingism is in a way illogical and self-defeating. I can see myself in several of the mental sets you've described.

But I feel like I'm trying to wade through a pool of molasses. I just can't get myself going. You may say all this oppression just results from my attitudes, but it feels like a ton of bricks. So what can I do about it?"

Do you know why virtually any meaningful activity has a decent chance of brightening your mood? If you do nothing, you will become preoccupied with the flood of negative, destructive thoughts. If you do something, you will be temporarily distracted from that internal dialogue of self-denigration. What is even more important, the sense of mastery you will experience will disprove many of the distorted thoughts that slowed you down in the first place.

As you review the following self-activation techniques, choose a couple that appeal most to you and work at them for a week or two. Remember you don't have to master them all! One man's salvation can be another's curse. Use the methods that seem the most tailored to your particular brand of procrastination.

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FEELING GOOD

The Daily Activity Schedule. The Daily Activity Schedule (see Figure 5-2, page 88) is simple but effective, and can help you get organized in your fight against lethargy and apathy. The schedule consists of two parts. In the Prospective column, write out an hour-by-hour plan for what you would like to accomplish each day. Even though you may actually carry out only a portion of your plan, the simple act of creating a method of action every day can be immensely helpful. Your plans need not be elaborate. Just put one or two words in each time slot to indicate what you'd like to do, such as "dress," "eat lunch," "prepare résumé," etc. It should not require more than five minutes to do this.

At the end of the day, fill out the Retrospective column.

Record hi each time slot what you actually did during the day. This may be the same as or different from what you as planned; nevertheless, even if it was just staring at the wall, write it down. In addition, label each activity with the letter M for mastery or the letter P for pleasure. Mastery activities are those which represent some accomplishment, such as brushing your teeth, cooking dinner, driving to work, etc.

Pleasure might include reading a book, eating, going to a movie, etc. After you have written M or P for each activity, estimate the actual amount of pleasure, or the degree of difficulty in the task by using a zero to five rating. For example, you could give yourself a score of M-1 for particularly easy tasks like getting dressed, while M-4 or M-5 would indicate you did something more difficult and challenging, such as not eating too much or applying for a job. You can rate the pleasure activities in a similar manner. If any activity was pleasurable in the past when you were not depressed, but today it was nearly or totally devoid of plesaure, put a P-1/2

or a P-0. Some activities, such as cooking dinner, can be labeled M and P.

Why is this simple activity schedule likely to be helpful?

First, it will undercut your tendency to obsess endlessly about the value of various activities and to debate counterproductively about whether or not to do something. Accomplishing even a part of your scheduled activities will in all probability give you some satisfaction and will combat your depression.

As you plan your day, develop a balanced program that provides for enjoyable leisure activities as well as work. If 87

Figure 5-2. Daily Activity Schedule.

PROSPECTIVE:

RETROSPECTIVE:

Plan your activities on an

At the end of the day,

hour-by-hour basis at the

record what you actually

start of the day.

did and rate each activity

with an M for mastery or

a P for pleasure.*

Date

TIME

8-9

9-10

10-11

11-12

12-1

1-2

2-3

3-4

4-3

5-6

6-7

7-8

8-9

9-12

• Mastery and pleasure activities must be rated from 0 to 5: The higher the number, the greater the sense of satisfaction.

88

FEELING GOOD

you are feeling blue, you may want to put a special emphasis on fun, even if you doubt you can enjoy things as much as usual. You may be depleted from having asked to much of yourself, causing an imbalance in your "give-and-get" system.

If so, take a fine days of "vacation" and schedule only those things you want to do.

If you adhen to the schedule, you will find your motivation increasing As you start doing thing you will begin to disprove your belief that you are incapable of functioning effectively As one procrastinator reported "Be scheduling my day and comparing the results, I have become aware of how I spend my time This hay helped me take charge of my life once again I realize that I can be in control if I want to."

Keep this Daily Activity Schedule for at least a week. As you review the activities in which you participated during the previous wed you will see that some have giver you a greater sense of mastery and pleasure. as indicated by higher scores As you continue planning each upcoming dm use this information to schedule more of those activities and avoid other!, which are associated with lower satisfactior levels.

The Daily Activity Schedule can be esper 'alb helpful for a common syndrome I call the "weekend/holidas blues" This is a pattern of depression most often reflected it people who are single and have their greatest emotional difficulties when alone. If you fit this description. you probably assume these periods are bound to be unbearable, so you do very little to care for yourself creatively. You stare at the walls and mope, or lie in bed all day Saturday and Sunday: or, for good times, you watch a boring TV show and eat a meager dinner of a peanut-butter sandwich and a cup of instant coffee. No wonder your weekends are tough! Not only are you depressed and alone but you treat yourself in a way that can only inflict pain. Would you treat someone else in such a sadistic manner?

These weekend blues can be overcome by using the Daily Activity Schedule. On Friday night, schedule some plans for Saturday on an hourly basis. You may resist this, saying, "

What's the point? I'm all alone." The fact that you are all alone is the very reason for using the schedule. Why assume you're bound to be miserable? This prediction can only function as a self-fulfilling prophecy! Put it to the test by adopting 89

David D. Burns, M.D.

a productive approach. Your plans need not be elaborate in order to be helpful. You can schedule going to the hair-dresser, shopping, visiting an art museum, reading a book, or walking through the park. You will discover that laying out and adhering to a simple plan for the day can go a long way toward lifting your mood. And who knows—if you are willing to care for yourself, you may suddenly notice that others will act more interested in you as well!

At the end of the day before you go to bed, write down what you actually did each hour and rate each activity for Mastery and Pleasure. Then make out a new schedule for the following day. This simple procedure may be the first step toward a sense of self-respect and genuine self-reliance.

The Antiprocrastination Sheet. In Figure 5 3 is a form I

-

have found effective in breaking the habit of procrastination.

You may be avoiding a particular activity because you predict it will be too difficult and unrewarding. Using the Antiprocrastination Sheet, you can train yourself to test these negative predictions. Each day write down in the appropriate column one or more tasks you have been putting off. If the task requires substantial time and effort, it is best to break it down into a series of small steps so that each one can be completed in fifteen minutes or less. Now write down in the next column how difficult you predict each step of the task will be, using a 0-to-100 percent scale. If you imagine the task will be easy, you can write down a low estimate such as 10 to 20 percent; for harder tasks, use 80 to 90 percent. In the next column, write down your prediction of how satisfying and rewarding it will be to complete each phase of the task, again using the percentage system. Once you've recorded these predictions, go ahead and complete the first step of the task. After you've completed each step, take note of how difficult it actually turned out to be, as well as the amount of pleasure you gained from doing it. Record this information in the last two columns, again using the percentage system.

Figure 5-3 shows how a college professor used this form to overcome several months of putting off writing a letter applying for a teaching position opening up at another university. As you can see, he anticipated that writing the letter would be difficult and unrewarding. After he recorded his pessimistic predictions, he became curious to outline the letter 90

Figure 5-3. A professor procrastinated for several months in writing a letter because he imagined it would be difficult and unrewarding. He decided to break the task down into small steps and to predict on a 040-100 percent scale how difficult and rewarding each step would be (see the appropriate columns). After completing each step, he wrote down how difficult and rewarding it actually was. He was amazed to see how off-base his negative expectations really were.

The Antiprocrastination Sheet

(Write down the predicted difficulty and satisfaction before you attempt the task. Write down the actual difficulty and satisfaction after you have completed each step.)

Predicted

Predicted

Actual

Actual

v:3

1.

Activity (Break each task

Difficulty

Satisfaction

Difficulty

Satisfaction

Date

down into small steps)

(0-100%)

(0-100%)

(0-100%)

(0-100%)

6/10/76

1. Outline letter.

90

10

10

60

2. Write rough draft.

90

10

10

75

3. Type up final draft.

75

10

5

80

4. Address the envelope and

50

5

0

95

mail the letter.

David D. Burns, M.D.

and prepare a rough draft to see if it would be as tedious and unrewarding as he thought. He found to his great surprise that it turned out to be easy and satisfying, and he felt sufficiently motivated that he went on to complete the letter. He recorded this data in the last two columns. The information gained from this experiment so greatly astonished him that he used the Antiprocrastination Sheet in many other areas in his life. Consequently, his productivity and self-confidence underwent a dramatic increase, and his depression disappeared.

Daily Record of Dysfunctional Thoughts. This record, introduced in Chapter 4, can be used to great advantage when you are overwhelmed by the urge to do nothing. Simply write down the thoughts that run through your mind when you think about a particular task. This will immediately show you what your problem is. Then write down appropriate rational responses that show these thoughts are unrealistic. This will help you mobilize enough energy to take that first difficult step. Once you've done that, you will gain momentum and be on your way.

An example of this approach is indicated in Figure 5-4.

Annette is an attractive, young single woman who owns and operates a successful boutique (she is Patient A, described on page 76). She does well during the week because of all the bustle at her store. On weekends she tends to hide away in bed unless she has social activities lined up. The moment she gets into bed, she becomes despondent, yet claims it is beyond her control to get out of bed. As Annette recorded her automatic thoughts one Sunday evening (Figure 5-4), it became obvious what her problems were: She was waiting around until she felt the desire, interest, and energy to do something; she was assuming that there was no point in doing anything since she was alone; and she was persecuting and insulting herself because of her inactivity.

When she talked back to her thoughts, she reported that the clouds lifted just a bit so that she was able to get up, take a shower, and get dressed. She then felt even better and arranged to meet a friend for dinner and a movie. As she predicted in the Rational Responses column, the more she did, the better she felt.

If you decide to use this method, be sure you actually write down upsetting thoughts. If you try to figure them out in 92

Figure 5-4. Daily Record of Dysfunctional Thoughts.

Date

Situation

Emotions

Automatic Thoughts

Rational Responses

Outcome

7/15/79 I stayed in bed all day Depressed I have no desire to do That's because I'm doing

Felt some relief

Sunday—slept off and Exhausted anything.

nothing. Remember motiva-

and decided to

on—no desire or en- Guilty

tion follows action!

get up and take

ergy to get up or do

Self-hatred

a shower at least.

anything productive.

Lonely

I don't have the energy I can get out of bed; I'm not to get out of bed.

crippled.

I'm a failure as a

I do succeed at things when I

person.

want to. Doing nothing makes

me depressed and bored, but it

doesn't mean I'm "a failure

as a person" because there is

no such thingl

I have no real interests. I do have interests, but not when I'm doing nothing. If I

get started at something, I'll

probably get more interested.

I'm self-centered be-

I do care about other things

cause I don't care about

when I'm feeling really good.

anything that's going on

It's natural to be less inter-

around me.

ested when you're depressed.

Automatic Thoughts

Rational Responses

(continued)

(continued)

Most people are out en-

So what does that have to do

joying themselves.

with me? I'm free to do any-

thing I want to.

I don't enjoy anything. I enjoy things when I feel good. If I do something I'll

probably enjoy it once I get

started, even though it doesn't

seem that way when I'm lying

in bed.

I'll never have a normal

I have no proof of that; I'm

energy level.

working on it now and seeing

some results. When I feel

good. I'm full of energy. When

I get involved in things, I get

more energetic.

I don't want to talk to

So don't! No one's forcing me

anyone or see anyone.

to talk. So, decide to do some-

thing on my own. At least I

can get out of bed and start

doing things.

FEELING GOOD

your head, you will in all probability get nowhere because the thoughts that stymie you are slippery and complex. When you try to talk back to them, they'll come at you even harder from all angles with such speed that you won't even know what hit you. But when you write them down, they become exposed to the light of reason. This way you can reflect on them, pinpoint the distortions, and come up with some helpful answers.

The Pleasure-Predicting Sheet. One of Annette's self-defeating attitudes is her assumption that there is no point in doing anything productive if she is alone. Because of this belief, she does nothing and feels miserable, which just confirms her attitude that it's terrible to be alone.

Solution: Test your belief that there is no point in doing anything by using the Pleasure-Predicting Sheet shown in Figure 5-5, page 96. Over a period of weeks, schedule a number of activities that contain a potential for personal growth or satisfaction. Do some of them by yourself and some with others. Record who you did each activity with in the appropriate column, and predict how satisfying each will be—be-tween 0 and 100 percent. Then go and do them. In the Actual Satisfaction column, write down how enjoyable each activity really turned out to be. You may be surprised to learn that things you do on your own are more gratifying than you thought.

Make sure that the things you do by yourself are of equal quality as those you do with others so that your comparisons will be valid. If you choose to eat a TV dinner alone, for example, don't compare it with the fancy French restaurant dinner you share with a friend!

Figure 5-5 shows the activities of a young man who learned that his girl friend (who lived 200 miles away) had a new boyfriend and didn't want to see him. Instead of moping in self-pity, he became involved with life. You will notice in the last column that the satisfaction levels he experienced by himself ranged from 60 to 90 percent, while those with other people ranged from 30 to 90 percent. This knowledge strengthened his self-reliance because he realized that he wasn't condemned to misery because he lost his girl, and that he didn't need to depend on others to enjoy himself.

You can use the Pleasure-Predicting Sheet to test a number 95

Figure 5-5. The Pleasure-Predicting Sheet.

Activity for Satisfaction.

Who Did You Do This

Predicted Satisfaction

Actual Satisfaction

(Sense of Achievement

With? (If Alone,

Date

(0-100%). (Write This (0-100%). (Record This

or Pleasure.)

Specify Self.)

Before the Activity.)

After the Activity.)

8/2/79

Reading (1 hour)

self

50%

60%

8/3/79

Dinner + bar w/13en

Ben

80%

90%

8/4/79

Susan's party

self

80%

85%

8/5/79

N.Y.C. and Aunt Helen

parents and grandma

40%

30%

8/5/79

Nancy's house

Nancy and JoeIle

75%

65%

8/6/79

Dinner at Nancy's

12 people

60%

80%

8/6/79

Luci's party

Luci + 5 people

70%

70%

8/7/79

Jogging

self

60%

90%

8/8/79

Theater

Luci

80%

70%

8/9/79

Harry's

Harry, Jack, Ben and Jim

60%

85%

8/10/79

Jogging

self

70%

80%

8/10/79

Phillies game

Dad

50%

70%

8/11/79

Dinner

Susan and Ben

70%

70%

8/12/79

Art museum

self

60%

70%

8/12/79

Peabody's

Fred

80%

85%

8/13/79

Jogging

self

70%

80%

FEELING GOOD

of assumptions you might make that lead to procrastination.

These include:

1. I can't enjoy anything when I'm alone.

2. There's no point in doing anything because I failed at something important to me (e.g., I didn't get the job or promotion I had my heart set on).

3. Since I'm not rich, successful, or famous, I can't really enjoy things to the hilt.

4. I can't enjoy things unless I'm the center of attention.

5. Things won't be particularly satisfying unless I can do them perfectly (or successfully).

6. I wouldn't feel very fulfilled if I did just a part of my work. I've got to get it all done today.

All of these attitudes will produce a round of self-fulfilling prophecies if you don't put them to the test. If, however, you check them out using the Pleasure-Predicting Sheet, you may be amazed to learn that life can offer you enormous fulfillment. Help yourself!

A question that commonly comes up about the PleasurePredicting Sheet is: "Suppose I do schedule a number of activities, and I find out they are just as unpleasant as I had anticipated?" This might happen. If so, try noting your negative thoughts and write them down, answering them with the Daily Record of Dysfunctional Thoughts. For example, suppose you go to a restaurant on your own and feel tense. You might be thinking, "These people probably think I'm a loser because I'm here all alone."

How would you answer this? You might remind yourself that other people's thoughts do not affect your mood one iota. I have demonstrated this to patients by telling them I will think two thoughts about them for fifteen seconds each.

One thought will be extremely positive, and the other will be intensely negative and insulting. They are to tell me how each of my thoughts affects them. I close my eyes and think, "

Jack here is a fine person and I like him." Then I think, "

Jack is the worst person in Pennsylvania." Since Jack doesn't know which thought is which, they have no effect on him!

Does that brief experiment strike you as trivial? It's not—

because only your thoughts can ever affect you. For example, if you are in a restaurant feeling miserable because you are 97

David D. Burns, M.D.

alone, you really have no idea what people are thinking. It's your thoughts and only yours that are making you feel terrible; you're the only person in the world who can effectively persecute yourself. Why do you label yourself a "loser" because you're in a restaurant alone? Would you be so cruel to someone else? Stop insulting yourself like that! Talk back to that automatic thought with a rational response: "Going to a restaurant alone doesn't make me a loser. I have just as much right to be here as anyone else. If someone doesn't like it, so what? As long as I respect myself, I don't need to be concerned with others' opinions."

How to Get off Your "But"—the But Rebuttal. Your

"but" may represent the greatest obstacle to effective action.

The moment you think of doing something productive, you give yourself excuses hi the form of buts. For example, "I could go out and jog today, BUT . . ."

1. I'm really too tired to;

2. I'm just too lazy;

3. I'm not particularly in the mood, etc.

Here's another example. "I could cut down on my smoking, BUT .. ."

1. I don't have that kind of self-discipline;

2. I don't really feel like going cold turkey, and cutting down gradually would be slow torture;

3. I've been too nervous lately.

If you really want to motivate yourself, you'll have to learn how to get off your but. One way to do this is with the "

But-Rebuttal Method" shown in Figure 5-6. Suppose it's Saturday and you've scheduled mowing the lawn. You've procrastinated for three weeks, and it looks like a jungle. You tell yourself, "I really should, BUT I'm just not hi the mood."

Record this in the But column. Now fight back by writing a But Rubuttal: "I'll feel more like it once I get started. When I'm done, I'll feel terrific." Your next impulse will probably be to dream up a new objection: "BUT it's so long it will take forever." Now fight back with a new rebuttal, as shown in Figure 5-6, and continue this process until you've run out of excuses.

98

FEELING GOOD

Figure 5-6. The But-Rebuttal Method. The zigzag arrows trace your thinking pattern as you debate the issue in your mind.

But Column

But Rebuttal

I really should mow the lawn, but I'll feel more like it once I get I'm just not in the mood.

started. When rm done rn feel

terrific.

But now it's so long it would tak

It won't take that much extra time

forever.

with the power mower. I can al-

ways do a part of it now.

But I'm too tired.

So just do some of it and rest.

I'd rather rest now or watch TV.

I can, but I won't feel very good about it knowing this chore is

hanging over my head.

But rm just too lazy to do it today.

That can't be true—I've done it on

numerous occasions in the past.

Learn to Endorse Yourself Do you frequently convince yourself that what you do doesn't count? If you have this bad habit, you will naturally feel that you never do anything worthwhile. It won't make any difference if you are a Nobel laureate or a gardener—life will seem empty because your sour attitude will take the joy out of all your endeavors and defeat you before you even begin. No wonder you feel unmotivated!

To reverse this destructive tendency, si good first step would be to pinpoint the self-downing thoughts that cause you to feel this way in the first place. Talk back to these thoughts and replace them with ones that are more objective and self-endorsing. Some examples of this are shown in Figure 5-7. Once you get the knack of it, practice consciously endorsing yourself all day long for the things you do even if they seem trivial. You may not feel a pleasant emotional lift in the beginning, but keep practicing even if it seems mechanical. After a few days you will begin to experience some mood lift, and you will feel more pride about what you're doing.

You may object, "Why should I have to pat myself on the back for everything I do? My family, friends, and business

99

David D. Burns, M.D.

Figure 5-7.

Self-Downing Statement

Self-Endorsing Statement

Anybody could wash these dishes.

If it's a routine, boring job, I deserve extra credit for doing it.

There was no point in washing these That's just the point. They'll be dishes. They just get dirty again.

clean when we need them.

I could have done a better job Nothing in the universe is perfect, straightening up.

but I did make the room look a hell

of a lot better.

It was just luck the way my speech

It wasn't a matter of luck. I pre-

turned out.

pared well and delivered my talk

effectively. I did a darn good job.

I waxed the car, but it still doesn't The car looks a heck of a lot better look as good as my neighbor's new than it did. I'll enjoy driving it car.

around.

associates should be more appreciative of me." There are several problems here. In the first place, even if people are overlooking your efforts, you are guilty of the same crime if you also neglect yourself, and pouting won't improve the situation.

Even when someone does stroke you, you can't absorb the praise unless you decide to believe and therefore validate what is being said. How many genuine compliments fall on your deaf ears because you mentally discredit them? When you do this, other people feel frustrated because you don't respond positively to what they are saying. Naturally, they give up trying to combat your self-downing habit. Ultimately, only what you think about what you do will affect your mood.

It can be helpful simply to make a written or mental list of the things you do each day. Then give yourself a mental credit for each of them, however small. This will help you focus on what you have done instead of what you haven't gotten around to doing. It may sound simplistic, but it works!

TIC-TOC Technique. If you are procrastinating about getting down to a specific task, take note of the way you are thinking about it. These TICs, or Task-Interfering Cognitions, will lose much of their power over you if you simply write

100

FEELING GOOD

them down and substitute more adaptive TOCs, or Task-Oriented Cognitions, using the double-column technique. A number of examples are shown hi Figure 5-8. When you record your TIC-TOCs, be sure to pinpoint the distortion hi the TIC

that defeats you. You may find, for example, that your worst enemy is all-or-nothing thinking or disqualifying the positive, or you may be in the bad habit of making arbitrary negative predictions. Once you become aware of the type of distortion Figure S-8. The TIC-TOC Technique. In the left-hand column, record the thoughts that inhibit your motivation for a specific task. In the right-hand column, pinpoint the distortions and substitute more objective, productive attitudes.

TIC:

TOCs

(Task-interfering Cognitions)

(Task-oriented Cognitions)

Housewife:

Overgeneraiization; all-or-nothing

Fit never be able to get the garage thinking.

cleaned out. The junk's been piling Just do a little bit and get started.

up for years.

There's no reason I have to do it all

today.

Bank Clerk?

Disqualifying the positive.

My work isn't very important or ex-

It may seem routine to me, but !es citing.

quite important to the people who

use the bank. When I'm not de.

pressed, it can be very enjoyable.

Many people do routine work but

this doesn't make them unimportant

human beings. Maybe I could do

something more exciting in my free

time.

Student:

All-or-nothing thinking.

Writing this term paper is pointless.

Just do a routine job. It doesn't have The subject is boring.

to be a masterpiece. I might learn something, and it will make me feel

better to get it done.

Secretary:

Fortune teller error.

ni probably flub typing this and I don't have to type perfectly. I can make a bunch of typos. Then my correct the errors. If he's overly boss will yell at me.

critical, I can disarm him, or tell

him rd do better if he were more

supportive and less demanding.

101

David D. Burns, M.D.

Figure S-8. Continued.

Politician:

Fortune teller error; labeling.

If I lose this race for governor, I'll It's not shameful to lose a politic---I be a laughing stock.

contest. A lot of people respect r

for trying and taking an honest-sta.:J

on some important issues Unto:-

tunately, the best man often doeset

win, but I can believe in mysel

whether or not I come out on top.

Insurance Salesman:

Mind reading.

What's the point in calling this guy I have no way of knowing. Give it a back? He didn't sound interested.

try. At least he asked me to cal

back. Some people will be interested

and I have to sift the chaff from the

wheat. I can feel productive even

when someone turns me down. I'D

sell one policy on the average fat

every five people who turn me down,

so it's to my advantage to get as

many turndowns as possible! The

more turndowns, the more sales!

Shy Single Man:

Fortune teller error; overgeneraliza-

If I call up an attractive girl, she'll lion.

just dump on me, so what's the They can't all turn me down, and it's point? IT just wait around until not shameful to try. I can learn some girl makes it real obvious that from any rejection I've got to start she likes me. Then I won't have to practicing to improve my style, so take a risk.

take the big plunge/ It wok courage

to jump off the high dive the first

time, but I did it and survived I can

do this too!

Author:

All-or-nothing thinking,

This chapter has to be great. But I

Just prepare an adequate draft. I

don't feel very creative.

can improve ft later.

Athlete:

Disqualifying the positive; all-or-

I can't discipline myself. I have no nothing thinking.

self-controL I'll never get in shape. I must have self-control because I've done well Just work out for a

while and call it quits if I get ex-

hausted.

102

FEELING GOOD

that most commonly thwarts you, you will be able to correct it. Your procrastination and time-wasting will give way to action and creativity.

You can also apply this principle to mental images and daydreams as well as to thoughts. When you avoid a task, you probably automatically fantasize about it in a negative, defeatist fashion. This creates unnecessary tension and apprehension, which impairs your performance and increases the likelihood that your dreaded fear will actually come true.

For example, if you have to give a speech to a group of associates, you may fret and worry for weeks ahead of time because in your mind's eye you see yourself forgetting what you have to say or reacting defensively to a pushy question from the audience. By the time you give the speech, you have effectively programmed yourself to behave just this way, and you're such a nervous wreck it turns out just as badly as you had imagined!

If you dare to give it a try, here's a solution: For ten minutes every night before you go to sleep, practice fantasiz-ing that you deliver the speech in a positive way. Imagine that you appear confident, that you present your material in an energetic manner, and that you handle all questions from the audience warmly and capably. You may be surprised that this simple exercise can go a long way to improving how you feel about what you do. Obviously there is no guarantee things will always come out exactly as you imagine, but there's no doubt that your expectations and mood will profoundly influence what actually does happen.

Little Steps for Little Feet. A simple and obvious self-activation method involves learning to break any proposed task down into its tiny component parts. This will combat your tendency to overwhelm yourself by dwelling on all the things you have to do.

Suppose your job involves attending lots of meetings, but you find it difficult to concentrate due to anxiety, depression, or daydreaming. You can't concentrate effectively because you think, "I don't understand this as I should. Gosh, this is boring. I'd really prefer to be making love or fishing right now."

Here's how you can beat the boredom, defeat the distraction, and increase your ability to concentrate: Break the task 103

David D. Burns, M.D.

down into its smallest component parts! For example, decide to listen for only three minutes, and then take a one-minute break to daydream intensively. At the end of this mental vacation, listen for another three minutes, and do not entertain any distrac ting thoughts for this brief period. Then give yourself another one minute break to daydream.

This technique will enable you to maintain a more effective level of overall concentration Giving yourself permission to dwell on distracting thoughts for short periods will diminish their power over you. After a while, they will seem ludicrous.

An extremely useful way to divide a task into manageable units is througl- time limitation Decide how much time you will devote to a particular task, and then stop at the end of the allotted time and go on to something more enjoyable, whether or not you're finished. As simple as this sounds, it can work wonders. For example, the wife of a political VIP

spent year harboring resentment toward her husband for his successful. glamorous life She felt her life consisted of an oppressive load of child-rearing and housecleaning Bet ause she was compulsive she never felt she had enough time to complete her dreary chores. Life was a treadmill She was straddled by depression. and had been unsuccessfully treated by a long string of famous therapists for over a decade as she looked in vain for the elusive key to personal happiness.

After consulting twice with one of my colleagues (Dr.

Aaron T Beck), she experienced a rapid mood swing out of her depression (his therapeutic wizardry never ceases to astonish me). How did he perform this seeming miracle? Easy.

He suggested to her that her depression was due in part to the fact that she wasn't pursuing goals that were meaningful to her because she didn't believe in herself. Instead of acknowledging and confronting her fear of taking risks, she blamed her lack of direction on her husband and complained about all the undone housework.

The first step was to decide how much time she felt she wanted to spend on the housework each day; she was to spend no more than this amount even if the house wasn't perfect, and she was to budget the rest of the day to pursue activities that interested her. She decided that one hour of housework would be fair, and enrolled in a graduate program so she could develop her own career. This gave her a feeling 104

FEELING GOOD

of liberation. Like magic, the depression vanished along with the anger she harbored toward her husband.

I don't want to give you the idea that depression is usually so easy to eliminate Even in the above case this patient will probably have to fight off a number of depressive recurrences.

She may at time fall back temporarily into the same trap of trying to do too much, blaming others and feeling overwhelmed Then she will have to apply the same solution again. The important thing is she has found a method that works for her.

The same approach might work for you. Do you tend to bite off bigger pieces than you can comfortably chew? Dare to put modest time limits on what you do! Have the courage to walk away from an unfinished task' You may be amazed that you will experience a substantial increase in your productivity and mood, and your procrastination may become a thing of the past.

Mothation Without Coercion. A possible source of your procrastination is an inappropriate system for self-motivation.

You may inadvertently undermine what you attempt by flagellating yourself with so many "oughts," "shoulds," and "

musts" that you end up drained of any desire to get moving.

You are defeating yourself by the way you kill yourself to get moving' Dr. Albert Ellis describes this mental trap as "

musterbation."

Reformulate the way you tell yourself to do things by eliminating those coercive words from your vocabulary. An alternative to pushing yourself to get up in the morning would be to say, "It will make me feel better to get out of bed, even though it will be hard at first. Although I'm not obliged to, I might end up being glad I did. If, on the other hand, I'm really benefiting from the rest and relaxation. I may as well go ahead and enjoy it!" If you translate shoulds into wants, you will be treating yourself with a sense of respect This will produce a feeling of freedom of choice and personal dignity.

You will find that a reward system works better and lasts longer than a whip. Ask yourself, "What do I want to do?

What course of action would be to my best advantage?" I think you will find that this way of looking at things will enhance your motivation.

If you still have the desire to lie in bed, mope, and feel 105

David D. Burns, M.D.

doubtful that getting up is really what you want to do, make a list of the advantages and disadvantages of staying in bed for another day. For example, an accountant who was far behind in his work around tax time found it hard to get up each day. His customers began to complain about the undone work, and in order to avoid these embarrasing confrontations, he lay in bed for weeks trying to escape, not even answering the phone. Many customers fired him, and his business began to fail.

His mistake was in telling himself, "I know I should go to work but I don't want to. And I don't have to either! So I won't!" Essentially, the word "should" created the illusion that the only reason for him to get out of bed was to please a bunch of angry, demanding customers. This was so unpleasant that he resisted. The absurdity of what he was doing to himself became apparent when he made a list of the advantages and disadvantages of staying in bed (Figure 5-9, opposite page). After preparing this list, he realized it was to his advantage to get out of bed. As he subsequently became more involved with his work, his mood rapidly improved in spite of the fact that he had lost many accounts during the period of inactivity.

Disarming Technique. Your sense of paralysis will be intensified if your family and friends are in the habit of pushing and cajoling you. Their nagging should statements reinforce the insulting thoughts already echoing through your head. Why is their pushy approach doomed to failure? It's a basic law of physics that for every action there's an equal and opposite reaction. Any time you feel shoved, whether by someone's hand actually on your chest or by someone trying to boss you around, you will naturally tighten up and resist so as to maintain your equilibrium and balance. You will attempt to exert your self-control and preserve your dignity by refusing to do the thing that you are being pushed to do. The paradox is that you often end up hurting yourself.

It can be very confusing when someone obnoxiously insists you do something that actually would be to your advantage.

This puts you in a "can't win" situation because if you refuse to do what the person tells you, you end up defeating yourself just in order to spite him or her. In contrast, if you do what the person tells you to do, you feel had. Because you 106

FEELING GOOD

Figure 5-9.

Advantages of Lying in Bed

Disadvantages of Lying in Bed

1. It's easy.

1. While it seems easy, it gets

awfully boring and painful after

a while. It's actually not so easy

to do nothing and to lie here

moping and criticizing myself

hour after hour.

2. I won't have to do anything or 2. I won't be obliged to do anything f a c e m y p r o b l e m s . i f I g e t o u t o f b e d e i t h e r , b u t i t might feel better. If I avoid my

problems they won't go away,

they'll just get worse, and I won't

have the satisfaction of trying

to solve them. The short-term

discomfort of facing up to things

is probably less depressing than

the endless anguish of staying in

bed.

3. I can sleep and escape.

3. Ican't

slep forever, and Irealy

don't need any more sleep sinco

I have been sleeping nearly six-

teen hours a day. I will probably

feel less fatigued if I get up and

get my arms and legs moving

rather than lie around in bed

like a cripple waiting for my

arms and legs to rotl

gave in to those pushy demands, you get the feeling the individual controlled you, and this robs you of self-respect. No one likes to be coerced.

For example, Mary is a woman in her late teens who was referred to us by her parents after many years of depression.

Mary was a real "hibernator," and had the capacity to sit alone in her room watching TV soap operas for months at a time. This was due in part to her irrational belief that she looked "peculiar," and that people would stare at her if she went out in public, and also by her feeling of being coerced by her domineering mother. Mary admitted that doing things 107

David D. Burns, M.D.

might help her feel better, but this would mean giving in to her mother who kept telling her to get off her duff and do something. The harder Mom pushed, the more stubbornly Mary resisted.

It is an unfortunate fact of human nature that it can be extremely difficult to do something when you sense you are being forced into it. Fortunately, it's very easy to learn how to handle people who nag and harangue you and try to run your life. Suppose you are Mary, and after thinking things over, you decide you would be better off if you got involved in doing a number of things. You've just made this decision when your mother comes into your bedroom and announces, "

Don't you lie around any longer! Your life is going down the drain. Get moving! Get involved in things the way the other girls your age do!" At that moment, in spite of the fact that you already have decided to do just that, you develop a tremendous aversion to it!

The disarming technique is an assertive method that will solve this problem for you (other applications of this verbal maneuver will be described in the next chapter). The essence of the disarming technique is to agree with your mother, but to do so in a way that you remind her you are agreeing with her based on your own decision, and not because she was telling you what to do. So, you might answer this way: "Yes, Mom, I just thought the situation over myself and decided it would be to my advantage to get moving on things. Because of my own decision, I'm going to do it." Now you can start doing things and not feel had. Or if you wish to put more of a barb in your comments, you can always say, "Yes, Mom, I have in fact decided to get out of bed in spite of the fact that you've been telling me to!"

Visualize Success. A powerful self-motivation method involves making a list of the advantages of a productive action you've been avoiding because it requires more self-discipline than you have been able to muster. Such a list will train you to look at the positive consequences of doing it. It's only human to go after what you want. Furthermore, clubbing yourself into effective action doesn't usually work nearly as well as a fat, fresh carrot.

Suppose, for example, you want to quit smoking. You may be reminding yourself about cancer and all the other dangers 108

FEELING GOOD

of smoking. These fear tactics make you so nervous that you immediately reach for another cigarette; they don't work.

Here's a three-step method that does work.

The first step is to make a list of all the positive consequences that will result when you become a nonsmoker. List as many as you can think of, including:

1. Improved health.

2. I'll respect myself.

3. I'll have greater self-discipline. With my new self-confidence, I may be able to do a whole lot of other things I've been putting off.

4. I will be able to run and dance actively, and still feel good about my body. I'll have lots of stamina and extra energy.

5. My lungs and heart will become strong. My blood pressure will go down.

6. My breath will be fresh.

7. I'll have extra spending money.

8. I'll live longer.

9. The air around me will be clean.

10. I'll be able to tell people that I've become a nonsmoker.

Once you have prepared the list, you're ready for the second step. Every night before you go to sleep, fantasize you are in your favorite spot—walking through the woods in the mountains, on a crisp autumn day, or maybe lying on a quiet beach near a crystal-blue ocean, with the sun warming your skin. Whatever fantasy you choose, visualize every enjoyable detail as vividly as possible, and let your body relax and let go. Allow every muscle to unwind. Let the tension flow out of your arms and legs and leave your body. Notice how your muscles begin to feel limp and loose. Notice how peaceful you feel. Now you are ready for the third step.

Fantasize that you are still in that scene, and you have become a nonsmoker. Go through your list of benefits and repeat each one to yourself in the following way: "Now I have improved health and I like it. I can run along the beach, and I want this. The air around me is clean and fresh, and I feel good about myself. I respect myself. Now I have greater

109

David D. Burns, M.D.

self-discipline, and I can take on other challenges if I want to. I have extra spending money," etc.

This method of habit management through the power of positive suggestion works amazingly well. It enabled me and many of my patients to quit smoking after a single treatment session. You can do it easily, and you'll find it's well worth your efforts. It can be used for self-improvement in losing weight, lawn mowing, getting up on time in the morning, adhering to a jogging routine, or for any other habit you'd like to modify.

Count What Counts. A three-year-old boy named Stevie stood by the edge of the children's pool, afraid to jump in.

His mother sat hi the water in front of him, urging him to take the leap. He held back; she cajoled. The power struggle went on for thirty minutes. Finally, he jumped. The water felt fine. It wasn't so difficult, and there was actually nothing to fear. But his mother's efforts backfired. The unfortunate message imprinted on Stevie's mind was, "I have to be pushed before I can do anything risky. I don't have the gumption to jump in on my own like the other kids." His mother and father got the same idea; they began to think, "

Left to his own devices, Stevie would never dare go into the water at all. If he isn't constantly pushed, he'll do nothing by himself. Raising him is going to be a long, hard struggle."

Sure enough, as Stevie grew up, the drama was repeated over and over. He had to be persuaded and pushed to go to school, to join the baseball team, to go to parties, and so on.

He rarely initiated any action on his own. By the time he was referred to me at age twenty-one, he was chronically depressed, living with his parents, and not doing much with his life. He was still waiting around for people to tell him what to do and how to do it. But by now his parents were fed up trying to motivate him.

After each therapy session, he would leave the office charged with my enthusiasm to follow through on whatever self-help assignment we had discussed. For example, one week he decided to smile or say hello to three people he didn't know as a small first step in breaking his isolation. But the next week he would come into my office with a drooping head and a sheepish look that let me know he had "forgot-ten" to say hello to anyone. Another week, his assignment 110

FEELING GOOD

was to read a three-page article I had written for a singles magazine on how an unmarried man learned to overcome his loneliness. Steve came back the next week and said he had lost the manuscript before having a chance to read it. Each week as he left, he would feel a great surge of eagerness to help himself, but by the time he was in the elevator, he would "

know" in his heart of hearts that the week's assignment, however simple, would just be too hard to do!

What was Stevie's problem? The explanation goes back to that day at the swimming pool. He still carries in his mind the powerfully imprinted idea that "I really can't do anything on my own. I'm the kind of guy who's got to be pushed." Because it never occurred to him to challenge this belief, it continued to function as a self-fulfilling prophecy, and he had over fifteen years of procrastination to back up his belief that he "really was" like that.

What was the solution? First Stevie had to become aware of the two mental errors that were the key to his problem: mental filter and labeling. His mind was dominated by thoughts about the various things he put off doing, and he ignored the hundreds of things he did each week that did not involve his being pushed by someone else.

"All of that is well and good," Stevie said after we discussed this. "You seem to have explained my problem, and I think that's correct. But how can I change the situation?"

The solution turned out to be simpler than he anticipated. I suggested he obtain a wrist counter (as discussed in the last chapter), so that each day he could count the things he did on his own without prodding or encouragement from anyone.

At the end of the day he was to write down the total number of clicks he scored and keep a daily log.

Over a several-week period, he began to notice that his daily score increased. Every time he clicked the counter, he reminded himself that he was in control of his life, and in this way he trained himself to notice what he did do. Stevie began to feel increased self-confidence, and to view himself as a more capable human being.

Does it sound simple? It is! Will it work for you? You probably don't think so. But why not put it to the test? If you have a negative reaction and are convinced the wrist counter won't work for you, why not evaluate your pessimistic preclic-David D. Burns, M.D.

tion with an experiment? Learn to count what counts; you may be surprised at the results!

Test Your "Can'ts." An important key to successful self-activation involves learning to adopt a scientific attitude toward the self-defeating predictions you make about your performance and abilities. If you put these pessimistic thoughts to the test, you can discover what the truth is.

One common self-defeating thought pattern when you are depressed or procrastinating is to "can't" yourself every time you think of something productive to do. Perhaps this stems from your fear of being blamed for your do-nothingism. You try to save face by creating the illusion that you are just too inadequate and incompetent to do a single thing. The problem with defending your lethargy in this manner is that you may really start believing what you are telling yourself! If you say, "I can't," over and over often enough it becomes like a hypnotic suggestion, and after a while you become genuinely convinced you really are a paralytic invalid who can't do anything. Typical "can't" thoughts include: "I can't cook,"

"I can't function," "I can't work," "I can't concentrate," "I can't read," "I can't get out of bed," and "I can't clean my apartment."

Not only do such thoughts defeat you, they will sour your relationships with those you love because they will see all your "I can't" statements as annoying whining. They won't perceive that it really looks and seems impossible for you to do anything. They will nag you, and set up frustrating power struggles with you.

An extremely successful cognitive technique involves testing your negative predictions with actual experiments. Suppose, for example, you've been telling yourself: "I'm so upset I can't concentrate well enough to read anything at all."

As a way of testing this hypothesis, sit down with today's newspaper and read one sentence, and then see if you can summarize the sentence out loud. You might then predict—"But I could never read and understand a whole paragraph." Again—put this to the test. Read a paragraph and summarize. Many severe, chronic depressions have been cracked open with this powerful method.

The "Can't Lose" System. You may feel hesitant to put your "can'ts" to the test because you don't want to run the 112

FEELING GOOD

risk of failure. If you don't run any risks, at least you can maintain the secret belief that you're basically a terrific person who's decided for the time being not to get involved. Behind your aloofness and lack of commitment lurks a powerful sense of inadequacy and the fear of failure.

The "Can't Lose" System will help you combat this fear.

Make a list of the negative consequences you might have to deal with if you took a risk and actually did fail. Then expose the distortions in your fears, and show how you could cope productively even if you did experience a disappointment.

The venture that you have been avoiding may involve a financial, personal, or scholastic risk. Remember that even if you do fail, some good can come from it. After all, this is how you learned how to walk. You didn't just jump up from your crib one day and waltz gracefully across the room. You stumbled and fell on your face and got up and tried again.

At what age are you suddenly expected to know everything and never make any more mistakes? If you can love and respect yourself in failure, worlds of adventure and new experiences will open up before you, and your fears will vanish. An example of a written "Can't Lose" System is shown in Figure 5-10.

Don't Put the Cart Before the Horse!

I'll bet you still may not know for sure where motivation comes from. What, in your opinion, comes first—motivation or action?

If you said motivation, you made an excellent, logical choice. Unfortunately, you're wrong. Motivation does not come first, action does! You have to prime the pump. Then you will begin to get motivated, and the fluids will flow spontaneously.

Individuals who procrastinate frequently confuse motivation and action. You foolishly wait until you feel in the mood to do something. Since you don't feel like doing it, you automatically put it off.

Your error is your belief that motivation comes first, and then leads to activation and success. But it is usually the 113

David D. Burns, M.D.

Figure 5-10. The "Can't Lose" System. A housewife used this technique to overcome her fear of applying for a part-time job.

Negative Consequences of

Positive Thoughts and

Being Turned Down for a lob

Coping Strategies

1. This means I'll never get a job.

1. Overgeneralization. This is un-

likely. I can test this by applying

for a series of other jobs and put-

ting my best foot forward to see

what happens..

2. My husband will look down on 2. Fortune teller error. Ask hint.

me.

Maybe he will be sympathetic.

Point out to him I'm doing my

3. But what if he's not sympathetic? 3. best and that his rejecting atti-He might say this shows I belong

tude doesn't help. Tell him that

in the kitchen and don't have

I am disappointed, but that I

what it takes.

credit myself for trying.

4. But We're nearly broke. We need

4. We've survived so fat and haven't

the money.

missed a single meal

5. If I don't get a job, I won't be

S. I can get some clothes later on.

able to afford some decent new

We'll have to learn to get along

school clothes for the kids.

with what we have for a while.

They'll look scraggly.

Happiness doesn't come from

clothes but from our self-respect.

6. A lot of my friends have. jobs.

6. They're not all employed, and

They'll see I can't cut the mus-

even my friends who do have

tard in the business world.

jobs can probably remember a

time when they were out of work.

They haven't done anything so

far to indicate they look down

on me.

other way around; action must come first, and the motivation comes later on.

Take this chapter, for example. The first draft of this chapter was overwritten, clumsy, and stale. It was so long and boring that a true procrastinator would never even have the fortitude to read it. The task of revising it seemed to me like trying to go swimming with concrete shoes. When the day I had scheduled for revising it came—I had to push myself to 114

FEELING GOOD

sit down and get started. My motivation was about 1 percent, and my urge to avoid the task was 99 percent. What a hide-ous chore!

After I got involved in the task, I became highly motivated, and the job seems easy now. Writing became fun after all! It works like this:

First:

Action

Second:

Motivation .4-/

Third:

More Actionl

If you are a procrastinator, you probably aren't aware of this. So you lie around hi bed waiting for inspiration to strike. When someone suggests you do something, you whine,

"I don't feel like it." Well, who said you were supposed to feel like it? If you wait until you're "hi the mood," you may wait forever!

The following table will help you review the various active-tion techniques and select what's most helpful to you.

115

Table S-1. Synopsis of Self-Activation Methods

Target Symptoms

Self-Activation Techniques

Purpose of the Method

1. You feel disorganized. You have

1. Daily Activity Schedule

1. Plan things one hour at a time

nothing to do. You get lonely and

and record the amount of mastery

bored on weekends.

and pleasure. Virtually any ac-

tivity will make you feel better

than lying in bed and will under-

cut your sense of inadequacy.

2. You procrastinate because tasks

2. The Antiprocrastination Sheet

2. You put your negative predictions

aseem too difficult and unrewarding.

to the test.

3. You feel overwhelmed by the urge

to do nothing.

3. Daily Record of Dysfunctional

3. You expose the illogical thoughts

Thoughts

that paralyze you. You learn that

motivation follows action, not vice

versa.

4. You feel there's no point in doing

4. Pleasure-Predicting Sheet

4. Schedule activities with the poten-

anything when you're alone.

tial for personal growth or satis-

faction, and predict how rewarding

they will be. Compare the actual

satisfaction you experience when

you are alone and when you are

with others.

Table 5-1. Continued.

5. You give yourself excuses for

5. But-Rebuttal

S. You get off your "but" by combat-avoiding things.

ting your "buts" with realistic rebuttals.

6. You have the idea that whatever

6. Self-Endorsement

6. Write down the self-downing

you do isn't worth much.

thoughts and talk back to them.

Look for distorted thought pat-

terns, such as "all-or-nothing

thinking." Make a list of things

you do accomplish each day.

,.., 7. Yon think about a task in a self-

i-.

7. TIC-TOC Technique

7. You substitute task-oriented cog-

N

defeating manner.

nitions (TOGS) for task-interfer-

ing cognitions (TICS).

8. You feel overwhelmed by the mag-

8. Little Steps for Little Feet

8. Break the task down into its tiny

component parts, and do these one

nitude of everything you have to

step at a time.

do.

9. a. You eliminate "shoulds," "

9. You feel guilty, oppressed, obliged,

9. Motivation Without Coercion

musts," and "oughts" when

and duty-bound.

you give yourself instructions.

b. You list the advantages and dis-

advantages of any activity so

you can begin to think in terms

of what you want to do rather than what you nut do.

Table

Continued,

10. Someone else nags and harangues

10. Disarming Technique

10. You assertively agree with them

you. You feel pressured and re-

and remind them that you are

sentful, so you refuse to do any-

capable of doing your own think.

thing at alL

11. You have difficulty modifying a

11. Visualize Success

11. You maim a fist of the positive

habit such as smoking.

benefits of having changed the

habit. You visualize these after inf.

during a state of deep relaxation.

I-. 12. You feel unable to do anything on 12. Count What CounfS

12. You count the things you do each

07,

your

own

in

t

a

ve

bcause

you

day on your own initiative, using a

see yourself as "a procrastinator?

wrist counter. This helps you over-

come your bad habit of constantly

dwelling en your inadequacies.

13. You feel inadequate and incom-

13. Test Your Can'ft

13. You set up an experiment in which

petent because you say, "I can't."

you challenge and disprove your

negative predictions.

14. Write down any negative conse-

14. You are afraid to fail, so you risk

14. "Can't Lose" System quences of failure and develop a

nothing.

coping strategy ahead of time.

CHAPTER 6

Verbal Judo:

Learn to Talk Back

When You're Under the Fire

of Criticism

You are learning that the cause of your sense of worthlessness is your ongoing self-criticism. This takes the form of an upsetting internal conversation hi which you constantly harangue and persecute yourself in a harsh, unrealistic manner.

Frequently your inner criticism will be triggered by someone else's sharp remark. You may dread criticism simply because you have never learned effective techniques for handling it.

Because it is relatively easy to do, I want to emphasize the importance of mastering the art of handling verbal abuse and disapproval nondefensively and without a loss of self-esteem.

Many depressive episodes are set in motion by external criticism. Even psychiatrists, who are supposedly professional abuse-takers, can react adversely to criticism. A psychiatric resident called Art received negative feedback intended to be helpful from his supervisor. A patient had complained that several comments Art made during a therapy session were abrasive. The resident reacted with a wave of panic and depression when he heard this, due to his thought, "Oh God!

The truth is out about me. Even my patients can see what a worthless, insensitive person I am. They'll probably kick me out of the residency program and drum me out of the state."

Why is criticism so hurtful to some people, while others can remain unperturbed hi the face of the most abusive attack? In this chapter you will learn the secrets of people who face disapproval fearlessly, and you will be shown specific, concrete steps to overcome and eliminate your own exquisite

119

David D. Burns, M.D.

vulnerability to criticism. As you read the following sections, keep this in mind: Overcoming your fear of criticism will require a moderate amount of practice. But it is not difficult to develop and master this skill, and the positive impact on your self-esteem will be tremendous.

Before I show you the way out of the trap of crumbling inwardly when criticized, let me show you why criticism is more upsetting to some poeple than to others. In the first place, you must realize that it is not other people, or the critical comments they make, that upset you. To repeat, there has never been a single time in your life when the critical comments of some other person upset you—even to a small extent. No matter how vicious, heartless, or cruel these comments may be, they have no power to disturb you or to create even a little bit of discomfort.

After reading that paragraph you may get the impression that I am cracking up, mistaken, highly unrealistic, or some combination thereof. But I assure you I am not when I say: Only one person in this world has the power to put you down—and you are that person, no one else!

Here's how it works. When another person criticizes you, certain negative thoughts are automatically triggered hi your head. Your emotional reaction will be created by these thoughts and not by what the other person says. The thoughts which upset you will invariably contain the same types of mental errors described in Chapter 3; overgeneralization, allor-nothing thinking, the mental filter, labeling, etc.

For example, let's take a look at Art's thoughts. His panic was the result of his catastrophic interpretation: "This criti-ism shows how worthless I am." What mental errors is he making? In the first place, Art is jumping to conclusions when he arbitrarily concludes the patient's criticism is valid and reasonable. This may or may not be the case. Furthermore, he is exaggerating the importance of whatever he actually said to the patient that may have been undiplomatic (

magnification), and he is assuming he could do nothing to correct any errors in his behavior (the fortune teller error).

He unrealistically predicted he would be rejected and ruined professionally because he would repeat endlessly whatever error he made with this one patient (overgeneralization). He focused exclusively on his error (the mental filter) and over-120

FEELING GOOD

looked his numerous other therapeutic successes (disqualifying or overlooking the positive). He identified with his erroneous behavior and concluded he was a "worthless and insensitive human being" (labeling).

The first step in overcoming your fear of criticism concerns your own mental processes: Learn to identify the negative thoughts you have when you are being criticized. It will be most helpful to write them down using the double-column technique described in the two previous chapters. This will enable you to analyze your thoughts and recognize where your thinking is illogical or wrong. Finally, write down rational responses that are more reasonable and less upsetting.

An excerpt from Art's written homework using the double-column technique is included (Figure 6-1). As he learned to think about the situation in a more realistic man-Figure 6-1. Excerpt from Art's written homework, using the double-column technique. He initially experienced a wave of panic when he received critical feedback from his supervisor about the way he handled a difficult patient. After writing down his negative thoughts, he realized they were quite unrealistic. Consequently, he felt substantial relief.

Automatic Thoughts

Rational Responses

(SELF-cRatosas)

(SELF-DEFENSE)

1. Oh, God! The truth is out about 1. Just because one patient comme. Even the patients can see

plains it doesn't mean that I am

what a worthless, insensitive in-

a "worthless, insensitive individ-

dividual I am.

ual." The majority of my pa-

tients do, in fact, like me.

Making a mistake doesn't

reveal my "true essence."

Everyone is entitled to make

mistakes.

2. They'll probably kick me out of 2.*This is silly and rests on several the residency program. erroneous assumptions: (a) all I do is bad things; (b) I have

no capacity to grow. Since (a)

and (b) are absurd, it is

extremely

unlikely

my

position here is threatened. I

have on many occasions

received praise from my

supervisor.

121

David D. Burns, M.D.

ner, he stopped wasting mental and emotional effort in catastrophizing, and was able to channel his energy into creative, goal-oriented problem solving. After evaluating precisely what he had said that was offensive or hurtful, he was able to take steps to modify his clinical style with patients so as to minimize future similar mistakes. As a result, he learned from the situation, and his clinical skills and maturity increased. This gave his self-confidence a boost and helped him overcome his fear of being imperfect.

To put it succinctly, if people criticize you the comments they make will be right or wrong. If the comments are wrong, there is really nothing for you to be upset about.

Think about that for a minute! Many patients have come to me in tears, angry and upset because a loved one made a critical comment to them that was thoughtless and inaccurate.

Such a reaction is unnecessary. Why should you be disturbed if someone else makes the mistake of criticizing you in an unjust manner? That's the other guy's error, not yours. Why upset yourself? Did you expect that other people would be perfect? On the other hand, if the criticism is accurate, there is still no reason for you to feel overwhelmed. You're not expected to be perfect. Just acknowledge your error and take whatever steps you can to correct it. It sounds simple (and it is!), but it may take some effort to transform this insight into an emotional reality.

Of course, you may fear criticism because you feel you need the love and approval of other people in order to be worthwhile and happy. The problem with this point of view is that you'll have to devote all your energies to trying to please people, and you won't have much left for creative, productive living. Paradoxically, many people may find you less interesting and desirable than your more self-assured friends.

Thus far, what I have told you is a review of the cognitive techniques introduced in the previous chapter. The crux of the matter is that only your thoughts can upset you and if you learn to think more realistically, you will feel less upset.

Right now, write down the negative thoughts that ordinarily go through your head when someone criticizes you. Then identify the distortions and substitute more objective rational responses. This will help you feel less angry and threatened.

Now I would like to teach you some simple verbal tech-122

FEELING GOOD

niques which may have considerable practical relevance.

What can you say when someone is attacking you? How can you handle these difficult situations in a way that will enhance your sense of mastery and self-confidence?

Step One—Empathy. When someone is criticizing or attacking you, his (or her) motives may be to help you or to hurt you. What the critic says may be right or wrong, or somewhere in between. But it is not wise to focus on these issues initially. Instead, ask the person a series of specific questions designed to find out exactly what he or she means. Try to avoid being judgmental or defensive as you ask the questions. Constantly ask for more and more specific information.

Attempt to see the world through the critic's eyes. If the person attacks you with vague, insulting labels, ask him or her to be more specific and to point out exactly what it is about you the person dislikes. This initial maneuver can itself go a long way to getting the critic off your back, and will help transform an attack-defense interaction into one of collaboration and mutual respect.

I often illustrate how to do this in a therapy session by role-playing an imaginary situation with the patient so that I can model this particular skill. I'll show you how to role-play; it's a useful skill to develop. In the dialogue that follows, I want you to imagine you are an angry critic. Say the most brutal and upsetting thing to me you can think of. What you say can be true, false, or partly both. I will respond to each of your assaults with the empathy technique.

YOU (playing the role of angry critic): Dr. Burns, you're a no-good shit.

DAVID: What about me is shitty?

YOU: Everything you say and do. You're insensitive, self-centered, and incompetent.

DAVID: Let's take each of these. I want you to try to be specific. Apparently I've done or said a number of things that upset you. Just what did I say that sounded insensitive? What gave you the impression I was self-centered?

What did I do that seemed incompetent?

YOU: When I called to change my appointment the other day, you sounded rushed and irritable, as if you were in a big hurry and didn't give a damn about me.

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DAVID: Okay, I came across in a rushed, uncaring way on the phone. What else have I done that irritated you?

You: You always seem to hurry me out at the end of the session—just like this was a big production line to make money.

DAVID: Okay, you feel I've been too rushed during sessions as well. I may have given you the impression I'm more interested in your money than in you. What else have I done? Can you think of other ways I might have goofed up or offended you?

What I am doing is simple. By asking you specific questions I minimize the possibility that you will reject me completely. You—and I—become aware of some specific concrete problems that we can deal with. Furthermore, I am giving you your day in court by listening to you so as to understand the situation as you see it. This tends to defuse any anger and hostility and introduces a problem-solving orientation in the place of blame casting or debate. Remember the first rule—even if you feel the criticism is totally unjust, respond with empathy by asking specific questions. Find out precisely what your critic means. If the person is very hot under the collar, he or she may be hurling labels at you, perhaps even obscenities. Nevertheless, ask for more information. What do those words mean? Why does the person call you a "no-good shit"? How did you offend this individual? What did you do? When did you do it? How often have you done it? What else does the person dislike about you? Find out what your action means to him or her. Try to see the world through your critic's eyes. This approach will frequently calm the roaring lion and lay the groundwork for a more sensible discussion.

Step Two—Disarming the Critic. If someone is shooting at you, you have three choices: You can stand and shoot back—this usually leads to warfare and mutual destruction; you can run away or try to dodge the bullets—this often results in humiliation and a loss of self-esteem; or you can stay put and skillfully disarm your opponent. I have found that this third solution is by far the most satisfying. When you take the wind out of the other person's sails, you end up 124

FEELING GOOD

the winner, and your opponent more often than not will also feel like a winner.

How is this accomplished? It's simple: Whether your critic is right or wrong, initially find some way to agree with him or her. Let me illustrate the easiest situation first. Let's assume the critic is primarily correct. In the previous example when you angrily accused me of sounding rushed and indifferent on several occasions, I might go on to say: "You're absolutely right. I was rushed when you called, and I probably did sound impersonal. Other people have also pointed this out to me at times. I want to emphasize that I didn't intend to hurt your feelings. You're also right that we have been rushed during several of our sessions. You might recall that sessions can be any length you like, as long as we decide this ahead of time so that the scheduling can be appropriately adjusted.

Perhaps you'd like to schedule sessions that are fifteen or thirty minutes longer, and see if that's more comfortable."

Now, suppose the person who's attacking you is making criticisms you feel are unfair and not valid. What if it would be unrealistic for you to change? How can you agree with someone when you feel certain that what is being said is utter nonsense? It's easy—you can agree in principle with the criticism, or you can find some grain of truth in the statement and agree with that, or you can acknowledge that the person's upset is understandable because it is based on how he or she views the situation. I can best illustrate this by continuing the role-playing; you attack me, but this time say things that are primarily false. According to the rules of the game, I must (1) find some way to agree with whatever you say; (2) avoid sarcasm or defensiveness; (3) always speak the truth.

Your statements can be as bizarre and as ruthless as you like, and I guarantee I will stick by these rules! Let's go!

YOU (continuing to play the role of angry critic) : Dr.

Bums, you're a shit.

DAVID: I feel that way at times. I often goof up at things.

YOU: This cognitive therapy is no damn good!

DAVID: There's certainly plenty of room for improvement.

YOU: And you're stupid.

DAVID: There are lots of people who are brighter than I am. I'm sure not the smartest person in the world.

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YOU: You have no real feelings for your patients. Your approach to therapy is superficial and gimmicky.

DAVID: I'm not always as warm and open as I'd like to be.

Some of my methods might seem gimmicky at first.

YOU: You're not a real psychiatrist. This book is pure trash. You're not trustworthy or competent to manage my case.

DAVID: I'm terribly sorry I seem incompetent to you. It must be quite disturbing to you. You seem to find it difficult to trust me, and you are genuinely skeptical about whether we can work together effectively. You're absolutely right—we can't work together successfully unless we have a sense of mutual respect and teamwork.

By this time (or sooner) the angry critic will usually lose steam. Because I do not fight back but instead find a way to agree with my opponent, the person quickly seems to run out of ammunition, having been successfully disarmed. You might think of this as winning by avoiding battle. As the critic begins to calm down, he or she will be in a better mood to communicate.

Once I have demonstrated these first two steps to a patient in my office, I usually propose we reverse roles to give the patient the chance to master the method. Let's do this. I will criticize and attack you, and you will practice the empathy and make up your own answers. Then see how closely they are accurate or nonsensical. To make the following dialogue a more useful exercise, cover up the responses called "You" and make up your own answers. Then see how closely they correspond with what I have written. Remember to ask questions using the empathy method and find valid ways to agree with me using the disarming technique.

DAVID (playing the role of angry critic): You're not here to get better. You're just looking for sympathy.

YOU (playing the role of the one under attack): What gives you the impression I'm just looking for sympathy?

DAVID: You don't do anything to help yourself between sessions. All you want to do is come here and complain.

YOU: It's true that I haven't been doing some of the writ-126

FEELING GOOD

ten homework you suggested. Do you feel I shouldn't complain during sessions?

DAVID: You can do whatever you want. Just admit you don't give a damn.

You: You mean you think I don't want to get better, or what?

DAVID: You're no good! You're just a piece of garbage!

YOU: I've been feeling that way for years! Do you have some ideas about what I can do to feel differently?

DAVID: I give up. You win.

YOU: You're right. I did win!

I strongly suggest you practice this with a! friend. The role-playing format will help you master the necessary skills needed when a real situation arises. If there is no one you feel comfortable with who could role-play with you effectively, a good alternative would be to write out imaginary dialogues between you and a hostile critic, similar to the ones you've been reading. After each harangue write down how you might answer using the empathy and disarming technique. It may seem difficult at first, but I think you'll catch on quite readily. It's really quite easy once you get the gist of it. You will notice you have a profound, almost irresistible tendency to defend yourself when you are unjustly accused.

This is a MAJOR mistake! If you give in to this tendency, you will find that the intensity of your opponent's attack increases! You will paradoxically be adding bullets to that person's arsenal every time you defend yourself. For example, you be the critic again, and this time I'll defend myself against your absurd accusations. You'll see how quickly our interaction will escalate to full-scale warfare.

you (in the role of critic again) : Dr. Burns, you don't care about your patients.

DAVID (responding in a defensive manner) : That's untrue and unfair. You don't know what you're talking about!

My patients respect all the hard work I put in.

you: Well, here's one who doesn't! Good-bye! (You exit, having decided to fire me. My defensiveness leads to a total loss.)

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In contrast, if I respond with empathy and disarm your hostility, more often than not you will feel I am listening to you and respecting you. As a result you lose your ardor to do battle and quiet down. This paves the way for step three—

feedback and negotiation.

You may find initially that in spite of your determination to apply these techniques, when a real situation arises in which you are criticized, you will be caught up by your emotions and your old behavior patterns. You may find yourself sulking, arguing, defending yourself vehemently, etc. This is understandable. You're not expected to learn it all overnight, and you don't have to win every battle. It is important, however, to analyze your mistakes afterward so that you can review how you might have handled the situation differently along the lines suggested. It can be immensely helpful to find a friend to role-play the difficult situation with you afterward so that you can practice a variety of responses until you have mastered an approach you are comfortable with.

Step Three—Feedback and Negotiation. Once you have listened to your critic, using the empathy method, and disarmed him by finding some way to agree with him, you will then be in a position to explain your position and emotions tactfully but assertively, and to negotiate any real differences.

Let's assume that the critic is just plain wrong. How can you express this in a nondestructive manner? This is simple: You can express your point of view objectively with an acknowledgment you might be wrong. Make the conflict one based on fact rather than personality or pride. Avoid direct-ing destructive labels at your critic. Remember, his error does not make him stupid, worthless, or inferior.

For example, a patient recently claimed that I sent a bill for a session for which she had already paid. She assaulted me with "Why don't you get your bookkeeping straight!"

Knowing she was in error, I responded, "My records may indeed be wrong. I seem to recall that you forgot your check-book that day, but I might be confused on this point. I hope you'll allow for the possibility that you or I will make errors at times. Then we can be more relaxed with each other. Why not see if you have a canceled check? That way we can find out the truth and make appropriate adjustments."

In this case my nonpolarizing response allowed her to save 128

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face and avoided a confrontation in which her self-respect was at risk. Although it turned out she was wrong, she later expressed relief that I acknowledged I do make mistakes.

This helped her feel better about me, as she was afraid I would be as perfectionistic and demanding with her as she was with herself.

Sometimes you and the critic will differ not on a matter of fact but of taste. Once again, you will be a winner if you present your point of view with diplomacy. For example, I have found that no matter how I dress, some patients respond favorably and some negatively. I feel most comfortable in a suit and tie, or in a sports coat and tie. Suppose a patient criticizes me because my clothes are too formal and this is ir-itating because it makes me appear to be part of the "Es-tablishment." After eliciting further specific information about other things this person might dislike about me, I could then respond, "I can certainly agree with you that suits are a bit formal. You would be more comfortable with me if I dressed more casually. I'm sure you'll understand that after dressing in a variety of ways, I have found that a nice suit or sports coat is most acceptable to the majority of the people I work with, and that's why I've decided to stick with this style of dressing. I'm hopeful you won't let this interfere with our continued work together."

You have a number of options when you negotiate with the critic. If he or she continues to harangue you, making the same point again and again, you can simply repeat your assertive response politely but firmly over and over until the person tires out. For example, if my critic continued to insist I stop wearing suits, I might continue to say each time, "I understand your point entirely, and there is some truth to it.

Nevertheless, I've decided to stick with more formal attire at this time."

Sometimes the solution will be in between. In this case negotiation and compromise are indicated. You may have to settle for part of what you want. But if you have conscien-tiously applied the empathy and disarming techniques first, you will probably get more of what you want.

In many cases you will be just plain wrong, and the critic will be right. In such a situation your critic's respect for you will probably increase by an orbital jump if you assertively 129

David D. Burns, M.D.

agree with the criticism, thank the person for providing you with the information, and apologize for any hurt you might have caused. It sounds like old-fashioned common sense (and it is), but it can be amazingly effective.

By now you may be saying, "But don't I have a right to defend myself when someone criticizes me? Why should I always have to empathize with the other person? After all, he may be the ninny, not I. Isn't it human just to get angry and blow your stack? Why should I always have to smooth things out?"

Well, there is considerable truth in what you say. You do have the right to defend yourself vigorously from criticism and to get angry at anyone you choose whenever you like.

And you are right on target when you point out that it is often your critic, and not you, whose thinking is fouled up.

And there is more than a grain of truth behind the slogan "

Better mad than sad." After all, if you're going to conclude that someone is "no damn good," why not let it be the other fellow? And furthermore, sometimes it does feel so much better to be mad at the other person.

Many psychotherapists would agree with you on this point.

Freud felt that depression was "anger turned inward." In other words he believed depressed individuals direct their rage against themselves. In keeping with this view, many therapists urge their patients to get in touch with their anger and to express it more frequently to others. They might even say that some of the methods described in this section amount to a repressive cop-out.

This is a false issue. The crucial point is not whether or not you express your feelings, but the manner in which you do it. If your message is "I'm angry because you're criticizing me and you're no damn good," you will poison your relationship with that person. If you defend yourself from negative feedback in a defensive and vengeful way, you will reduce the prospect for productive interaction in the future. Thus, while your angry outburst momentarily feels good, you may defeat yourself in the long run by burning your bridges. You have polarized the situation prematurely and unnecessarily, and eliminated your chance to learn what the critic was trying to convey. And what is worse, you may experience a de-130

FEELING GOOD

pressive backlash and punish yourself inordinately for your burst of temper.

Antiheckler Technique. A specialized application of the techniques discussed in this chapter might be particularly helpful for those of you who are involved in lecturing or teaching. I developed the "antiheckler technique" when I began lecturing to university and professional groups on current depression research. Although my lectures are usually well received, I occasionally find there is a single heckler in the audience. The heckler's comments usually have several characteristics: (1) They are intensely critical, but seem inaccurate or irrelevant to the material presented; (2) they often come from a person who is not well accepted or regarded among his or her local peers; and (3) they are expressed in a haranguing, abusive style.

I therefore had to develop an antiheckler technique which I could use to silence such a person in an inoffensive manner so that the rest of the audience could have an equal opportunity to ask questions. I find that the following method is highly effective: (1) I immediately thank the person for his or her comments; (2) acknowledge that the points brought up are indeed important; and (3) I emphasize that there is a need for more knowledge about the points raised, and I encourage my critic to pursue meaningful research and investigation of the topic. Finally, I invite the heckler to share his or her views with me further after the close of the session.

Although no verbal technique is guaranteed to bring a particular result, I have rarely failed to achieve a favorable effect when using this upbeat approach. In fact, these heckling individuals have frequently approached me after the lecture to compliment and thank me for my kind comments. It is sometimes the heckler who turns out to be most demonstrative and appreciative of my lecture!

Summary. The various cognitive and verbal principles for coping with criticism are summarized in the accompanying diagram (see Figure 6-2, page 132). As a general rule, when someone insults you, you will immediately go down one of three pathways—the sad route, the mad route, or the glad route. Whichever option you choose will be a total experience, and will involve your thinking, your feelings, your behavior, and even the way your body functions.

131

Iboss says, "You've been doing sloppy I

work and goofing off lately."

"1'm No Good" Response

"You're No Good" Response

Self-Esteem Response

Thought:

Thought:

Thought:

"I'm always goofing

"That stupid SOB is

"Here's a chance to

up. I'm worthless."

on my back again!"

learn something."

Behavior:

Behavior:

Feeling:

Behavior:

Isolation,

Obscenities and

You inquire,

Angry,

ti

frustrated

moping,

accusations are

"What ways have

N

giving up.

hurled.

I been goofing

, off?"

OUTCOME: You lie in bed, avoid

OUTCOME: You are fired on the

OUTCOME: The problem is defined,

work, and put yourself down. You sink

spot. You fume for days, constantly

and a solution is proposed. You

deeper into the quicksand of depres-

telling yourself the world is no damn

experience self-esteem and mood

sion. You are put on probation at work.

good. You learned nothing and

elevation. Your boss is satisfied with

poisoned your relationship with your

how you handled his complaint.

boss.

Figure 6-2. The three ways that you might react to criticism. Depending on how you think about the situation, you will feel sad, mad, or glad. Your behavior and the outcome will also be greatly influenced by your mental set FEELING GOOD

Most people with a tendency to depression choose the sad route. You automatically conclude the critic is right. Without any systematic investigation, you jump to the conclusion that you were in the wrong and made a mistake. You then magnify the importance of the criticism with a series of thinking errors. You might overgeneralize and wrongly conclude that you whole life consists of nothing but a string of errors. Or you might label yourself a "total goof-up." And because of your perfectionistic expectation that you are supposed to be flawless, you will probably feel convinced that your (

presumed) error indicates you are worthless. As a result of these mental errors, you will experience depression and a loss of self-esteem. Your verbal responses will be ineffectual and passive, characterized by avoidance and withdrawal.

In contrast, you may choose the mad route. You will defend yourself from the horrors of being imperfect by trying to convince the critic that he or she is a monster. You will stubbornly refuse to admit any error because according to your perfectionistic standards, this would be tantamount to admitting you are a worthless worm. So you hurl accusations back on the assumption that the best defense is a good of-fense. Your heart beats rapidly, and hormones pour into your bloodstream as you prepare for battle. Every muscle tightens and your jaws are clenched. You may feel a temporary exhilaration as you tell your critic off in self-righteous indignation.

You'll show him what a no-good piece of crap he is! Unfortunately, he doesn't agree, and in the long run your outburst is self-defeating because you've poisoned the relationship.

The third option requires that you either have self-esteem or at least act as if you did. It is based on the premise that you are a worthwhile human being and have no need to be perfect. When you are criticized, your initial response is investigative. Does the criticism contain a grain of truth? Just what did you do that was objectionable? Did you in fact goof up?Having defined the problem by asking a series of nonjudg-mental questions, you are in a position to propose a solution.

If a compromise is indicated, you can negotiate. If you were clearly in the wrong, you can admit it. If the critic was mistaken, you can point this out in a tactful manner. But 133

David D. Burns, M.D.

whether your behavior was right or wrong, you will know that you are right as a human being, because you have finally perceived that your self-esteem was never at issue in the first place.

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CHAPTER 7

Feeling Angry? What's Your IQ

What's your IQ? I'm not interested in knowing how smart you are because your intelligence has little, if anything, to do with your capacity for happiness. What I want to know is what your Irritability Quotient is. This refers to the amount of anger and annoyance you tend to absorb and harbor in your daily life. If you have a particularly high IQ, it puts you at a great disadvantage because you overreact to frustrations and disappointments by creating feelings of resentment that blacken your disposition and make your life a joyless hassle.

Here's how to measure your IQ. Read the list of twenty-five potentially upsetting situations described below. In the space provided after each incident, estimate the degree it would ordinarily anger or provoke you, using this simple rat-.

ing scale:

0—You would feel very little or no annoyance.

1—You would feel a little irritated.

2—You would feel moderately upset.

3—You would feel quite angry.

4—You would feel very angry.

Mark your answer after each question as in this example: You are driving to pick up a friend at the airport, and you are forced to wait for a long freight train.

2

The individual who answered this question estimated his reaction as a two because he would feel moderately irritated, but this would quickly pass as soon as the train was gone. As you describe how you would ordinarily react to each of the following provocations, make your best general estimate even 135

David D. Burns, M.D.

though many potentially important details are omitted (such as what kind of day you were having, who was involved in the situation, etc.).

NOVACO ANGER SCALE*

1. You unpack an appliance you have just bought, plug it in, and discover that it doesn't work

2. Being overcharged by a repairman who has you over a barrel

3. Being singled out for correction, when the actions of others go unnoticed.

4. Getting your car stuck in the mud or snow

5. You are talking to someone and they don't answer you

6. Someone pretends to be something they are

not.

7. While you are struggling to carry four cups of coffee to your table at a cafeteria, someone bumps into you, spilling the coffee.

8. You have hung up your clothes, but someone knocks them to the floor and fails to pick them up.

9. You are hounded by a salesperson from the moment that you walk into a store

10. You have made arrangements to go somewhere with a person who backs off at the last minute and leaves you hanging.

11. Being joked about or teased

12. Your car is stalled at a traffic light, and the guy behind you keeps blowing his horn.

13. You accidentally make the wrong kind of turn in a parking lot. As you get out of your car someone yells at you, "Where did you learn to drive?"

14. Someone makes a mistake and blames it on you.

15. You are trying to concentrate, but a person near you is tapping their foot.

* This scale was developed by Dr. Raymond W. Novaco of the Program in Social Ecology at the University of California, Irvine, and part of it is reproduced here with his permission The full scale contains eighty items.

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16. You lend someone an important book or tool, and they fail to return it.

17. You have had a busy day, and the person you live with starts to complain about how you forgot to do something that you agreed to do

18. You are trying to discuss something important with your mate or partner who isn't giving you a chance to express your feelings

19. You are in a discussion with someone who persists in arguing about a topic they know very little

about

20. Someone sticks his or her nose into an argument between you and someone else

21. You need to get somewhere quickly, but the car in front of you is going 25 mph in a 40 mph zone, and you can't pass.

22. Stepping on a gob of chewing gum.

23. Being mocked by a small group of people as you pass them

24. In a hurry to get somewhere, you tear a good pair of slacks on a sharp object.

25. You use your last dime to make a phone call, but you are disconnected before you finish dialing and the dime is lost.

Now that you have completed the Anger Inventory, you are in a position to calculate your IQ, your Irritability Quotient. Make sure that you have not skipped any items. Add up your score for each of the twenty-five incidents. The lowest possible total score on the test would be zero. This would mean you put down a zero on each item. This indicates you are either a liar or a guru! The highest score would be a hundred. This would mean you recorded a four on each of the twenty-five items, and you're constantly at or beyond the boiling point.

You can now interpret your total score according to the following scale:

0-45: The amount of anger and annoyance you generally experience is remarkably low. Only a few

percent of the population will score this low on the test. You are one of the select few!

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David D. Burns, M.D.

46-55: You are substantially more peaceful than the average person.

56-75: You respond to life's annoyances with an average amount of anger.

76-85: You frequently react in an angry way to life's many annoyances. You are substantially more irritable than the average person.

86-100: You are a true anger champion, and you are

plagued by frequent intense furious reactions

that do not quickly disappear, You probably harbor negative feelings long after the initial insult has passed. You may have the reputation

of a firecracker or a hothead among people you

know. You may experience frequent tension

headaches and elevated blood pressure. Your anger may often get out of control and lead to

impulsive hostile outbursts which at times get

you into trouble. Only a few percent of the adult population react as intensely as you do,

Now that you know how much anger you have, let's see what you can do about it. Traditionally psychotherapists (and

the general public) have conceptualized two primary ways to deal with anger: (a) anger turned "inward"; or (b) anger turned "outward." The former solution is felt to be the "sick"

one—you internalize your aggression and absorb resentment like a sponge. Ultimately it corrodes you and leads to guilt and depression. Early psychoanalysts such as Freud felt that internalized anger was the cause of depression. Unfortunately, there is no convincing evidence in support of this notion.

The second solution is said to be the "healthy" one—you express your anger, and as you ventilate your feelings, you presumably feel better. The problem with this simplistic approach is that it doesn't work very well. If you go around ventilating all your anger, people will soon regard you as loony. And at the same time you aren't learning how to deal with people in society without getting angry.

The cognitive solution transcends both of these. You have a third option: Stop creating your anger. You don't have to

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choose between holding it in or letting it out because it won't exist.

In this chapter I provide guidelines to help you assess the pros and cons of experiencing anger in a variety of situations so you can decide when anger is and isn't in your best self-interest. If you choose, you can develop control over your feelings; you will gradually cease to be plagued by excessive irritability and frustration that sour your life for no good reason.

Just Who Is Making You Angry?

"People!

Shit!

I'm fed up with them!

I need a vacation from people."

The woman who recorded this thought at 2:00 A.M.

couldn't sleep. How could the dogs and noisy neighbors in her apartment building be so thoughtless? Like her, I'll bet you're convinced it's other people's stupid, self-centered actions that make you angry.

It's natural to believe that external events upset you. When you're mad at someone, you automatically make them the cause of all your bad feelings. You say, "You're annoying me! You're getting on my nerves." When you think like this, you're actually fooling yourself because other people really cannot make you angry. Yes—you heard me right. A pushy teenager might crowd in front of you in line at the movie theater. A con artist might sell you a fake ancient coin at an antique shop. A "friend" might screw you out of your share of a profitable business deal. Your boyfriend might always show up late for dates in spite of his knowing how important promptness is to you. No matter how outrageous or unfair others might appear to you, they do not, never did, and never will upset you. The bitter truth is that you're the one who's creating every last ounce of the outrage you experience.

Does that sound like heresy or stupidity to you? If you think I'm contradicting the obvious, you may feel like burning this book or throwing it down in disgust. If so, I dare you to read on, because—

Anger, like all emotions, is created by your cognitions. The 139

David D. Burns, M.D.

relationship between your thoughts and your anger is shown in Figure 7-1. As you will note, before you can feel irritated by any event you must first become aware of what is occurring and come to your own interpretation of it. Your feelings result from the meaning you give to the event, not from the event itself.

For example, suppose that after a hectic day you put your two-year-old child to sleep in his crib for the night. You close his bedroom door and sit down to relax and watch television.

Twenty minutes later he suddenly opens the door to his room and walks out giggling. You might react to this in a variety of ways, depending on the meaning you attach to it. If you feel irritated, you're probably thinking, "Damn it! He's always a bother. Why can't he stay in bed and behave like he should? He never gives me a minute's rest!" On the other hand, you could be delighted to see him pop out of his room because you're thinking, "Great! He just crawled out of his crib on his own for the first time. He's growing up and get-Figure 7.-1. It is not negative events but your perceptions and thoughts about these events that create your emotional response.

EXTERNAL EVENTS: (not

INTERNAL EVENTS: (within

within your control)

your control)

The actions of other people.

Thoughts

"It's unfair!"

`That damn jerk!"

"I won't stand for it!"

Behaviors

Emotions

You tell the other guy off or with-

Anger, frustration, fear, guilt.

draw icily. You scheme to re-

taliate so as to even the score.

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FEELING GOOD

ting more independent." The event is the same in both cases.

Your emotional reaction is determined entirely by the way you are thinking about the situation.

I'll bet I know what you're thinking now: "That example with the baby is not applicable. When 1 get angry there's a justifiable provocation. There's plenty of genuine unfairness and cruelty in this world. There's no valid way I can think about all the crap I have to put up with each day without getting uptight. Do you want to perform a lobotomy and turn me into an unfeeling zombie? NO THANKS!"

You are certainly right that plenty of genuinely negative events do go on every day, but your feelings about them are still created by the interpretations you place on them. Take a careful look at these interpretations because anger can be a two-edged sword. The consequences of an impulsive outburst will frequently defeat you in the long run. Even if you are being genuinely wronged, it may not be to your advantage to feel angry about it. The pain and suffering you inflict on yourself by feeling outraged may far exceed the impact of the original insult. As a woman who runs a restaurant put it, "

Sure—I have the right to fly off the handle. The other day I realized the chefs forgot to order ham again even though I had specifically reminded them, so I exploded and threw a cauldron of hot soup across the kitchen floor in disgust. Two minutes later I knew I'd acted like the biggest asshole in the world, but I didn't want to admit it, so I had to spend all my energy for the next forty-eight hours trying to convince myself I had the right to make a jackass of myself in front of twenty employees! It wasn't worth it!"

In many cases your anger is created by subtle cognitive distortions. As with depression, many of your perceptions are twisted, one-sided, or just plain wrong. As you learn to replace these distorted thoughts with others that are more realistic and functional, you will feel less irritable and gain greater self-control.

What kinds of distortion occur most often when you are angry? One of the greatest offenders is labeling. When you describe the person you're mad at as "a jerk" or "a bum" or

"a piece of shit," you see him in a totally negative way. You could call this extreme form of overgeneralization "globaliz-ing" or "monsterizing." Someone may in fact have betrayed 141

David D. Burns, M.D.

your trust, and it is absolutely right to resent what that person did. In contrast, when you label someone, you create the impression that he or she has a bad essence. You are direct-ing your anger toward what that person "is."

When you write people off this way, you catalog in your mind's eye every single thing about them you don't like (the mental filter) and ignore or discount their good points (

disqualifying the positive). This is how you set up a false target for your anger. In reality, every human being is a complex mix of positive, negative, and neutral attributes.

Labeling is a distorted thinking process that causes you to feel inappropriately indignant and morally superior. It's destructive to build your self-image this way: Your labeling will inevitably give way to your need to blame the other person. Your thirst for retaliation intensifies the conflict and brings out similar attitudes and feelings in the person you're mad at. Labeling inevitably functions as a self-fulfilling prophecy. You polarize the other person and bring about a state of interpersonal warfare.

What's the battle really all about? Often you're involved in a defense of your self-esteem. The other person may have threatened you by insulting or criticizing you, or by not loving or liking you, or by not agreeing with your ideas. Consequently, you may perceive yourself in a duel of honor to the death. The problem with this is that the other person is not a totally worthless shit, no matter how much you insist! And, furthermore, you cannot enhance your own esteem by denigrating someone else even if it does feel good temporarily.

Ultimately only your own negative, distorted thoughts can take away your self-respect, as pointed out in Chapter 4.

There is one and only one person in this world who has the power to threaten your self-esteem—and that is you. Your sense of worth can go down only if you put yourself down.

The real solution is to put an end to your absurd inner harangue.

Another distortion characteristic of anger-generating thoughts is mind reading—you invent motives that explains to your satisfaction why the other person did what he or she did. These hypotheses are frequently erroneous because they will not describe the actual thoughts and perceptions that mo-142

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tivated the other person. Due to your indignation, it may not occur to you to check out what you are saying to yourself.

Common explanations you might offer for the other person's objectionable behavior would be "He has a mean streak"; "She's unfair"; "He's just like that"; "She's stupid"; "

They're bad kids"; and so forth. The problem with these so-called explanations is that they are just additional labels that don't really provide any valid information. In fact, they are downright misleading.

Here's an example: Joan got hot under the collar when her husband told her he'd prefer to watch the Sunday football game on TV rather than go with her to a concert. She felt miffed because she told herself, "He doesn't love me! He always has to get his own way! It's unfair!"

The problem with Joan's interpretation is that it is not valid. He does love her, he doesn't always get his way, and he isn't intentionally being "unfair." On this particular Sunday the Dallas Cowboys are locking spurs with the Pittsburgh Steelers, and he really wants to see that game! There's no way he's going to want to get dressed and go to a concert.

When Joan thinks about her husband's motivations in such an illogical fashion, she creates two problems for the price of one. She has to put up with the self-created illusion that she's unloved in addition to missing out on his company at the concert.

The third form of distortion that leads to anger is magnification. If you exaggerate the importance of the negative event, the intensity and duration of your emotional reaction may get blown up out of all proportion. For example, if you are waiting for a late bus and you have an important appointment, you might tell yourself, "I can't take this!" Isn't that a slight exaggeration? Since you are taking it, you can take it, so why tell yourself you can't? The inconvenience of waiting for the bus is bad enough without creating additional discomfort and self-pity in this way. Do you really want to fume like that?

Inappropriate should and shouldn't statements represent the fourth type of distortion that feeds your anger. When you find that some people's actions are not to your liking, you tell yourself they "shouldn't" have done what they did, or they "

should have" done something they failed to do. For exam-143

David D. Burns, M.D.

ple, suppose you register at a hotel and discover they lost the record of your reservation, and now there are no rooms available. You furiously insist, "This shouldn't have happened!

Those stupid goddam clerks!"

Does the actual deprivation cause your anger? No. The deprivation can only create a sense of loss, disappointment, or inconvenience. Before you can feel anger, you must necessarily make the interpretation you are entitled to get what you want in this situation. Consequently, you see the goof-up on your reservation as an injustice. This perception leads to your feeling angry.

So what's wrong with that? When you say the clerks shouldn't have made a mistake, you are creating unnecessary frustration for yourself. It's unfortunate your reservation was lost, but it's highly unlikely anyone intended to treat you unjustly, or that the clerks are especially stupid. But they did make an error. When you insist on perfection from others, you will simply make yourself miserable and become immobilized. Here's the rub: Your anger probably won't cause a room to appear magically, and the inconvenience of going to another hotel will be far less than the misery you inflict on yourself by brooding for hours or days about the lost reservation.

Irrational should statements rest on your assumption that you are entitled to instant gratification at all times. So on those occasions when you don't get what you want, you go into panic or rage because of your attitude that unless you get X, you will either die or be tragically deprived of joy forever (X can represent love, affection, status, respect, promptness, perfection, niceness, etc.). This insistence that your wants be gratified at all times is the basis for much self-defeating anger. People who are anger-prone often formulate their desires in moralistic terms such as this: If I'm nice to someone, they should be appreciative.

Other people have free will, and often think and act in ways that aren't to your liking. All of your insistence that they must fall in line with your desires and wishes will not produce this result. The opposite is more often true. Your attempts to coerce and manipulate people with angry demands most often will alienate and polarize them and make them much less likely to want to please you. This is because other 144

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people don't like being controlled or dominated any more than you do. Your anger will simply limit the creative possibilities for problem solving.

The perception of unfairness or injustice is the ultimate cause of most, if not all, anger. In fact, we could define anger as the emotion which corresponds in a one-to-one manner to your belief that you are being treated unfairly.

Now we come to a truth you may see either as a bitter pill or an enlightening revelation. There is no such thing as a universally accepted concept of fairness and justice. There is an undeniable relativity of fairness, just as Einstein showed the relativity of time and space. Einstein postulated—and it has since been experimentally validated—there is no "absolute time" that is standard throughout the universe. Time can appear to "speed up" and "slow down," and is relative to the frame of reference of the observer. Similarly, "absolute fairness" does not exist. "Fairness" is relative to the observer, and what is fair to one person can appear quite unfair to another. Even social rules and moral strictures which are accepted within one culture can vary substantially in another.

You can protest that this is not the case and insist that your own personal moral system is universal, but it just ain't so!

Here's proof: When a lion devours a sheep, is this unfair?

From the point of view of the sheep, it is unfair; he's being viciously and intentionally murdered with no provocation.

From the point of view of the lion, it is fair. He's hungry, and this is the daily bread he feels entitled to. Who is "

right"? There is no ultimate or universal answer to this question because there's no "absolute fairness" floating around to resolve the issue. In fact, fairness is simply a perceptual interpretation, an abstraction, a self-created concept. How about when you eat a hamburger? Is this "unfair"? To you, it's not.

From the point of view of the cow, it certainly is (or was)!

Who's "right"? There is no ultimate "true" answer.

In spite of the fact that "absolute fairness" does not exist, personal and social moral codes are important and useful. I am not recommending anarchy. I am saying that moral statements and judgments about fairness are stipulations, not objective facts. Social moral systems, such as the Ten Commandments, are essentially sets of rules that groups decide to abide by. One basis for such systems is the en-

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David D. Burns, M.D.

lightened self-interest of each member of the group. If you fail to act in a manner that takes into account the feelings and interests of others you are likely to end up less happy because sooner or later they will retaliate when they notice you are taking advantage of them.

A system which defines "fairness" varies in its generality depending on how many people accept it. When a rule of behavior is unique to one person, other people may see it as ec-centric. An example of this would be my patient who washes her hands ritualistically over fifty times a day to "set things right" and to avoid extreme feelings of guilt and anxiety.

When a rule is nearly universally accepted it becomes part of a general moral code and may become a part of the body of law. The prohibition against murder is an example.

Nevertheless, no amount of general acceptance can make such systems "absolute" or "ultimately valid" for everyone under all circumstances.

Much everyday anger results when we confuse our own personal wants with general moral codes. When you get mad at someone and you claim that they are acting "unfairly,"

more often than not what is really going on is that they are acting "fairly" relative to a set of standards and a frame of reference that differs from yours. Your assumption that they are "being unfair" implies that your way of looking at things is universally accepted. For this to be the case, everyone would have to be the same. But we aren't. We all think differently. When you overlook this and blame the other person for being "unfair" you are unnecessarily polarizing the interaction because the other person will feel insulted and defensive.

Then the two of you will argue fruitlessly about who is "

right." The whole dispute is based on the illusion of "absolute fairness."

Because of your relativity of fairness, there is a logical fallacy that is inherent in your anger. Although you feel convinced the other guy is acting unfairly, you must realize he is only acting unfairly relative to your value system. But he is operating from his value system, not yours. More often than not, his objectionable action will seem quite fair and reasonable to him. Therefore, from his point of view—which is his only possible basis for action—what he does is "fair." Do you want people to act fairly? Then you should want him to act 146

FEELING GOOD

as he does even though you dislike what he does, since he is acting fairly within his system! You can work to try to convince him to change his attitudes and ultimately modify his standards and his actions, and in the meantime you can take steps to make certain you won't suffer as a result of what he does. But when you tell yourself, "He's acting unfairly," you are fooling yourself and you are chasing a mirage!

Does this mean that all anger is inappropriate and that the concepts of "fairness" and "morality" are useless because they are relative? Some popular writers do give this impression. Dr. Wayne Dyer writes:

We are conditioned to look for justice in life and when it doesn't appear, we tend to feel anger, anxiety or frustration. Actually, it would be equally productive to search for the fountain of youth, or some such myth.

Justice does not exist. It never has, and it never will.

The world is simply not put together that way. Robins eat worms. That's not fair to the worms. . . . You have only to look at nature to realize there is no justice in the world. Tornadoes, floods, tidal waves, droughts are all unfair.*

This position represents the opposite extreme, and is an example of all-or-nothing thinking. It's like saying—throw your watches and clocks away because Einstein showed that absolute time does not exist. The concepts of time and fairness are socially useful even though they do not exist in an absolute sense.

In addition to this contention that the concept of fairness is an illusion, Dr. Dyer seems to suggest that anger is useless: You may accept anger as a part of your life, but do you realize it serves no utilitarian purpose? . . . You do not have to possess it, and it serves no purpose that has anything to do with being a happy, fulfilled person. . . .

The irony of anger is that it never works in changing others.. • •t

* Dr. Wayne W. Dyer, Your Erroneous Zones (New York: Avon Books, 1977), p. 173.

t Ibid., pp. 218-220.

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David D. Burns, M.D.

Again, his arguments seem to be based on cognitive distortion. To say anger serves no purpose is just more all-or-nothing thinking, and to say it never works is an overgeneralization. Actually, anger can be adaptive and productive in certain situations. So the real question is not "Should I or should I not feel anger?" but rather "Where will I draw the line?"

The following two guidelines will help you to determine when your anger is productive and when it is not. These two criteria can help you synthesize what you are learning and to evolve a meaningful personal philosophy about anger: 1. Is my anger directed toward someone who has knowingly, intentionally, and unnecessarily acted in a hurtful manner?

2. Is my anger useful? Does it help me achieve a desired goal or does it simply defeat me?

Example: you are playing basketball, and a fellow on the other team elbows you in the stomach intentionally so as to upset you and get you off your game. You may be able to channel your anger productively so you will play harder and win. So far your anger is adaptive.* Once the game is over, you may no longer want that anger. Now it's maladaptive.*

Suppose your three-year-old son runs mindlessly into the street and risks his life. In this case he is not intentionally inflicting harm. Nevertheless, the angry mode in which you express yourself may be adaptive. The emotional arousal in your voice conveys a message of alarm and importance that might not come across if you were to deal with him in a calm, totally objective manner. In both these examples, you chose to be angry, and the magnitude and expression of the emotion were under your control. The adaptive and positive effetcs of your anger differentiate it from hostility, which is impulsive and uncontrolled and leads to aggression.

Suppose you are enraged about some senseless violence you read about in the paper. Here the act seems clearly hurtful and immoral. Nevertheless, your anger may not be adaptive if—as is usually the case—there is nothing you plan to do

* Adaptive means useful and self-enhancing; maladaptive means useless and self-destructive.

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about it. If, in contrast, you choose to help the victims or begin a campaign to fight crime in some way, your anger might again be adaptive.

Keeping these two criteria in mind, let me give you a series of methods you can use to reduce your anger in those situations where it is not in your best interest.

Develop the Desire. Anger can be the most difficult emotion to modify, because when you get mad you will be like a furious bulldog, and persuading you to stop sinking your teeth into the other person's leg can be extremely tough. You won't really want to rid yourself of those feelings because you will be consumed by the desire for revenge. After all, because anger is caused by what you perceive to be unfair, it is a moral emotion, and you will be extremely hesitant to let go of that righteous feeling. You will have the nearly irresistible urge to defend and justify your anger with religious zeal. Overcoming this will require an act of great willpower. So why bother?

The first step: Use the double-column technique to make a list of the advantages and disadvantages of feeling angry and acting in a retaliatory manner. Consider both the short- and long-term consequences of your anger. Then review the list and ask yourself which are greater, the costs or the benefits?

This will help you determine if your resentment is really in your best self-interest. Since most of us ultimately want what's best for us, this can pave the way for a more peaceful and productive attitude.

Here's how it works. Sue is a thirty-one-year-old woman with two daughters from a previous marriage. Her husband, John, is a hard-working lawyer with one teenage daughter from his prior marriage. Because John's time is very limited, Sue often feels deprived and resentful. She told me she felt he wasn't giving her a fair shake in the marriage because he was not giving her enough of his time and attention. She listed the advantages and disadvantages of her irritablity in Figure 7-2.

She also made a list of the positive consequences that might result from eliminating her anger: (1) People will like me better. They will want to be near me; (2) I will be more predictable; (3) I will be in better control of my emotions; (4) I will be more relaxed; (5) I will be more comfortable 149

Figure 7-2. The Anger Cost-Benefit Analysis.

Advantages of My Anger

Disadvantages of My Anger

1. It feels good.

1. I will be souring my relationship

with John even more.

2. John will understand that I

2. He will want to reject me.

strongly disapprove of him.

3. I have the right to blow my stack 3. I will often feel guilty and down on myself aftcr I blow my stack.

if I want to.

He will probably retaliate against

4. He'll know I'm not a doormat. 4. me and get angry right back, since he doesn't like being taken advantage of either.

3. I'll show him I won't stand for

5. My anger inhibits both of us

being taken advantage of.

from correcting the problem that

caused the anger in the first

place. It prevents resolution and

sidetracks us from dealing with

the issues.

4. Even though I don't get what I

want, I can at least have the sat-

6. One minute I'm up, one minute I'

m down. My irritability makes

isfaction of getting revenge. I can

John and the people around me

make him squirm and feel hurt

never know what to expect. I get

like I do. Then he'll have to shape

labeled as moody and cranky and

up.

spoiled and immature. They see

me as a childish brat.

7. I might make neurotics out of my

kids. As they grow up, they may

resent my explosions and see me

as someone to stay away from

rather than to go to for help.

8. John may leave me if he gets

enough of my nagging and bitch-

ing.

9. The unpleasant feelings I create

make me feel miserable. Life be-

comes a sour and bitter experience, and I miss out on the joy

and creativity I used to prize so

highly.

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with myself; (6) I will be viewed as a positive, nonjudgmen-tal, practical person; (7) I will behave more often as an adult than as a child who has to get what it wants; (8) I will influence people more effectively, and I'll get more of what I want through assertive, calm, rational negotiation than through tantrums and demands; and (9) my kids, husband, and parents will respect me more. As a result of this assessment, Sue told me she was convinced that the price of her anger substantially exceeded the benefits.

It is crucial that you perform this same type of analysis as a first step in coping with your anger. After you list the advantages and disadvantages of your anger, give yourself the same test. Mk yourself, if the upsetting situation that provokes me doesn't change immediately, would I be willing to cope with it instead of getting angry? If you can answer yes, then you are clearly motivated to change. You will probably succeed in gaining greater inner peace and self-esteem, and you will increase your effectiveness in life. This choice is up to you.

Cool Those Hot Thoughts. Once you've decided to cool down, an invaluable method that can help you is to write down the various "hot thoughts" that are going through your mind when you are upset. Then substitute less upsetting, more objective "cool thoughts," using the double-column method (Figure 7-3). Listen for those "hot thoughts" with your "third ear" so as to time in to the antagonistic statements that go through your head. Record this private dialogue without any censorship. I'm sure you'll notice all kinds of highly colorful language and vengeful fantasies—write them all down. Then substitute "cool thoughts" that are more objective and less inflammatory. This will help you feel less aroused and overwhelmed.

Sue used this technique to deal with the frustration she felt when John's daughter, Sandy, acted manipulative and wrapped John around her finger. Sue kept telling him to be more assertive with Sandy and less of a soft touch, but he often reacted negatively to her suggestions. He felt Sue was nagging and making demands to get her way. This made him want to spend even less time with her, which contributed to a vicious cycle.

Sue wrote down the "hot thoughts" that made her feel jeal-151

David D. Burns, M.D.

ous and guilty (see Figure 7-3). As she substituted "cool thoughts," she felt better, and this served as an antidote to her urge to try to control John. Although she still felt he was wrong in letting Sandy manipulate him, she decided he had the "right" to be "wrong." Consequently, Sue pushed Figure 7-3. Sue wrote down her "Hot Thoughts" when her husband acted like a soft touch in response to his teenage daughter's selfish manipulations. When she substituted less upsetting "Cool Thoughts," her jealousy and resentment diminished.

Hot Thoughts

Cool Thoughts

1. How dare he not listen to me!

1.

Easi

ly

He'

not

bl

gd

to

everything my way. Besides he is

listening, but he's being defensive

because I'm acting so pushy.

2. Sandy lies. She says she's work- 2. It's her nature to lie and to be ing, but she's not. Then she ex-lazy and to use people when it

pects John's help.

comes to work in school. She

hates work. That's her problem.

3. John doesn't have much free time 3. So what. I like being alone. I'm and if he spends it helping her,

capable of taking care of my

I will have to be alone and take

kids by myself. I'm not helpless.

care of my kids by myself.

I can do it. Maybe he'll want to

be with me more if I learn not to get angry all the time.

4. Sandy's taking time away from 4. That's true. But I'm a big girl. I m e .

c a n t o l e r a t e s o m e t i m e a l o n e . I wouldn't be so upset if he were

working with my kids.

5. John's a schmuck. Sandy uses 5. He's a big boy. If he wants to people.

help her he can. Stay out of it.

It's not my business.

6. I can't stand it!

6. Ican. It's only temporary. rve

stood worse.

7. I'm a baby brat. I deserve to feel 7. I'm entitled to be immature at guilty,

times. I'm not perfect and I don't

need to be. It's not necessary to

feel guilty. This won't help.

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John less, and he began to feel less pressured. Their relationship improved and ripened in a climate of mutual freedom and respect. Simply talking back to her "hot thoughts" was, of course, not the only ingredient that led to a successful second marriage for Sue and John. but it was a necessary and gigantic first step without which both of them could have easily ended up stalemated again!

You can also use the more elaborate chart, the "Daily Record of Dysfunctional Thoughts," to deal with your anger (see Figure 7-4, page 154). You can describe the provocative situation and assess how angry you feel before and after you do the exercise. Figure 7-4 shows how a young woman coped with her frustration when she was dealt with tersely by a prospective employer over the telephone. She reported that pinpointing her "hot thoughts" and putting the lie to them helped her nip an emotional explosion in the bud. This prevented the fretting and fuming that normally would have soured her entire day. She told me, "Before I did the exercise I thought my enemy was the man on the other end of the phone. But I learned that / was treating myself ten times worse than he was. Once I recognized this, it was relatively easy to substitute cooler thoughts, and I surprised myself by feeling a whole lot better right away!"

Imagining Techniques. Those negative "hot thoughts" that go through your mind when you are angry represent the script of a private movie (usually X-rated) that you project onto your mind. Have you ever noticed the picture on the screen? The images, daydreams, and fantasies of revenge and violence can be quite colorful indeed!

You may not be aware of these mental pictures unless you look for them. Let me illustrate. Suppose I ask you to visualize a red apple in a brown basket right now. You can do this with your eyes open or closed. There! Do you see it now?

That's what I'm referring to. Most of us have these visual images all day long. They are a part of normal consciousness, the pictorial illustrations of our thoughts. For example, memories sometimes occur to us as mental pictures. Conjure up an image now of some vivid past event—your high-school graduation, your first kiss (do you still remember it?), a long hike, etc. Do you see it now?

These images can affect you strongly, and their influence 153

Figure 7 4.

-

Daily Record of Dysfunctional Thoughts.

Provocative Situation

Emotions

Hot Thoughts .

Cool Thoughts

Outcome

Called ad in paper for part- Anger

I. That jerk! Who the hell' 1. Why am I getting so excited? Anger time medical transcriptionist. hatred

does he think he is! I have

I didn't like the tone of his hatred voice

Ad said—needs "some experi- frustration m ore th eticiugh experi•

anyway. So he didn't frustration allow

ence." First, the man wouldn't 98%

ence.

me to really explain my 15% experience. I

even tell me what kind of com-

know I'm good.

pany it was. Then he turned

So it's not my fault I didn't

me down for job 'cause he

get the job—it's his. Besides,

didn't think I had enough ex-

would I want to work for

perience!

someone like that?

2. That was the best ad In the

2. Fm blowing things out of pro.

paper, and I lost it.

portion. There are many other

jobs I can get.

3. My parents will kill me,

3. Of course they won't At least

Fm trying.

4. rm going to cry.

4. Now isn't that ridiculous? Why

should someone make me cry?

This Isn't worth crying over.

I know my worth—that's

what counts.

FEELING GOOD

can be positively or negatively arousing, just like erotic dreams or nightmares. The exhilarating effect of a positive image can be intense. For instance, on your way to an amusement park you might have an image of that first daz-zling descent down the roller coaster, and you may experience the excited rush in your belly. The daydream actually creates the pleasurable anticipation. Similarly, negative images play a powerful role in your level of emotional arousal. Visualize right now someone whom you've gotten good and mad at sometime in your life. What images come to mind? Do you imagine punching them in the nose or tossing them into a vat of boiling oil?

These daydreams actually keep your anger alive long after the initial insult has occurred. Your sense of rage may eat away at you for hours, days, months, or even years after the irritating event has long since passed. Your fantasies help keep the pain alive. Every time you fantasize about the occurrence you shoot new doses of arousal into your system.

You become like a cow chewing on poison cud.

And who is creating this anger? You are because you chose to put those images in your mind! For all you know, the person you are mad at lives in Timbuktu, or maybe isn't even alive anymore, so he or she could hardly be the culprit! You are the director and producer of the film now, and, what's worse, you're the only one in the audience. Who has to watch and experience all the arousal? YOU DO! You're the one who's subjected to a continual teeth clenching, a tightening of back muscles, and an outpouring of adrenal hormones into the bloodstream. You're the one whose blood pressure is going up. IN A NUTSHELL: You're making yourself hurt. Do you want to keep this up?

If not, you will want to do something to reduce the anger-generating images that you are projecting onto your mind.

One helpful technique is to transform them in a creative way so they become less upsetting. Humor represents one powerful tool you can use. For example, instead of imagining wringing the neck of the person you are furious with, fantasize that he is walking around in diapers in a crowded department store. Visualize all the details: the potbelly, the diaper pins, the hairy legs. Now what's happening to your anger? Is that a broad smile spreading across your face?

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David D. Burns, M.D.

A second method involves thought stoppage. As you notice the images crossing your mind each day, remind yourself that you have the right to turn the projector off. Think about something else. Find someone and engage him or her in conversation. Read a good book. Bake bread. Go jogging. When you don't reward the anger images with your arousal, they will recur less and less often. Instead of dwelling on them, think about an upcoming event that excites you, or switch to an erotic fantasy. If the upsetting memory is persistent, engage in vigorous physical exercise such as push-ups, rapid jogging, or swimming. These have the additional benefit of rechanneling your potentially hurtful arousal in a highly beneficial way.

Rewrite the Rules. You may frustrate and upset yourself needlessly because you have an unrealistic rule about personal relationships that causes you to be let down all the time. The key to Sue's anger was her belief she was entitled to John's love because of her rule "If I'm a good and faithful wife, I deserve to be loved."

As a result of this innocent-sounding assumption, Sue experienced a constant sense of danger in her marriage because anytime John wasn't giving her an appropriate helping of love and attention, she would experience it as a confirmation of her inadequacy. She would then manipulate and demand attention and respect in a constant battle to defend herself against a loss of self-esteem. Intimacy with him became like slipping slowly toward the edge of an icy cliff. No wonder she was desperately grabbing onto John, and no wonder she would explode when she sensed his indifference—didn't he realize her life was at stake?

In addition to the intense unpleasantness that her "love"

rule created, it didn't work well in the long run. For a while Sue's manipulations did, in fact, get her some of the attention she craved. After all, she could intimidate John with her emotional explosions, she could punish him with her icy withdrawal, and she could manipulate him by arousing his guilt.

But the price Sue pays is that the love she receives isn't—and can't—be given freely and spontaneously. He will feel exhausted, trapped, and controlled. The resentment he's been storing up will press for release. When he stops buying into her belief that he has to give in to her demands, his 156

FEELING GOOD

desire for freedom will overpower him, and he will explode.

The destructive effects of what passes for love never cease to amaze me!

If your relationships are characterized by this cyclic tension and tyranny, you may be better off rewriting the rules. If you adopt a more realistic attitude, you can end your frustration. It's much easier than trying to change the world. Sue decided to revise her "love" rule in the following way: "If I behave in a positive manner toward John, he will respond in a loving way a good bit of the time. I can still respect myself and function effectively when he doesn't." This formulation of her expectations was more realistic and didn't put her moods and self-esteem at the mercy of her husband.

The rules that get you into interpersonal difficulty often won't appear to be malignant. On the contrary, they often seem highly moral and humanistic. I recently treated a woman named Margaret who had the notion that "marriages should be fifty-fifty. Each partner should do for the other equally." She applied this rule to all human relationships. "If I do nice things for people, they should reciprocate."

So what's wrong with that? It certainly sounds "reason-able" and "fair." It's kind of a spin-off from the Golden Rule. Here's what's wrong with it: It's an undeniable fact that human relationships, including marriages, are rarely spontaneously "reciprocal" because people are different. Reciprocity is a transient and inherently unstable ideal that can only be approximated through continued effort. This involves mutual consensus, communication, compromise, and growth.

It requires negotiation and hard work.

Margaret's problem was that she didn't recognize this. She lived in a fairytale world where reciprocity existed as an assumed reality. She went around always doing good things for her husband and others and then waited for their reciprocity. Unfortunately, these unilateral contracts fell apart because other people usually weren't aware that she expected to be repaid.

For example, a local charity organization advertised for a salaried assistant director to start in several months. Margaret was quite interested in this position and submitted her application. She then gave large amounts of her time doing volunteer work for the organization and assumed that the other 157

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employees would "reciprocate" by liking and respecting her, and that the director would "reciprocate" by giving her the job. In reality, the other employees did not respond to her warmly. Perhaps they sensed and resented her attempt to control them with her "niceness" and virtue. When the director chose another candidate for the position, she hit the roof and felt bitter and disillusioned because her "reciprocity" rule had been violated!

Since her rule caused her so much trouble and disappointment she opted to rewrite it, and to view reciprocity not as a given but as a goal she could work toward by pursuing her own self-interest. At the same time she relinquished her demand that others read her mind and respond as she wanted.

Paradoxically, as she learned to expect less, she got more!

If you have a "should" or "shouldn't" rule that has been causing you disappointment and frustration, rewrite it in more realistic terms. A number of examples to help you do this are shown in Figure 7-5. You will notice that the substitution of one word—"it would be nice if" in place of "

should"--can be a useful first step.

Learn to Expect Craziness. As the anger in Sue's relationship with John cooled down, they became closer and more loving. However, John's daughter, Sandy, responded to his increased intimacy by even greater manipulations. She began to lie, borrowed money without returning it; she sneaked into Sue's bedroom, went through drawers, and stole Sue's personal items; she left the kitchen messy, etc. All these actions effectively got Sue's goat because she told herself, "Sandy shouldn't act so sneaky. She's crazy! It's unfair!" Sue's sense of frustration was the product of two necessary ingredients: 1. Sandy's obnoxious behavior;

2. Sue's expectation that she should act in a more mature way.

Since the evidence suggested that Sandy wasn't about to change, Sue had only one alternative: She could discard her unrealistic expectation that Sandy behave in an adult, lady-like fashion! She decided to write the following memo to herself entitled:

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Why Sandy Should Act Obnoxiously

It is Sandy's nature to be manipulative because she believes that she's entitled to love and attention. She believes that getting love and attention is a matter of life and death. She thinks she needs to be the center of attention in order to survive. Therefore, she will see any lack of love as unfair and a great danger to her sense of self-esteem.

Figure 7-5. Revising "Should Rules."

Self-Defeating Should Rule

Revised Version

I. If I'm nice to someone, they 1. It would be nice if people were should be appreciative.

always appreciative, but this isn't

realistic. They will often be ap-

preciative, but sometimes they

won't be.

2. Strangers should treat me cour-

2. Most strangers will treat me

teously.

courteously if I don't act like I

have a chip on my shoulder. Oc-

casionally some sourpuss will act

obnoxious. Why let this bother

me? Life is too short to waste

time concentrating on negative

details.

3. If I work hard for something, I 3.

This is ridiculous. I have no

guarantee I'll always be success-

should get it.

ful in everything. I'm not perfect

and I don't have to be.

4. If someone treats me unfairly, I 4. All human beings have the right should get mad because I have

to get mad whether or not they're

the right to get mad and because it treated unfairly. The real issue is makes me more human.

—is it to my advantage to get

mad? Do I want to feel angry?

What are the costs and benefits?

5. People shouldn't treat me in 5. Hogwash. Everyone doesn't live ways I wouldn't treat them.

by my rules, so why expect they

will? People will often treat me

as well as I treat them, but not

always.

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David D. Burns, M.D.

Because she feels she has to manipulate in order to get attention, she should act in a manipulative way. Therefore, I can expect and predict that she will continue to act this way until she changes. Since it is unlikely that she will change in the near future, I can expect her to continue to behave this way for a period of time. Therefore, I will have no reason to feel frustrated or surprised because she will be acting the way she should act.

Furthermore, I want all humans including Sandy to act in a manner that they believe to be fair. Sandy feels she's entitled to more attention. Since her obnoxious behavior is based on her sense of entitlement. I can remind myself that what she does is fair from her point of view.

Finally, I want my moods to be under my control, not hers. Do I want to make myself feel upset and angry at her

"fair, obnoxious" behavior? No! Therefore, I can begin to change the way I react to her:

1. I can thank her for stealing since this is what she "

should" do!

2. I can laugh to myself about her manipulations since they are childish.

3. I can choose not to be angry unless it is my decision to use the anger to accomplish a specific goal.

4. If I feel a loss of self-esteem due to Sandy's manipulations, I can ask myself, Do I want to give a child such power over me?

What is the desired effect of such a memorandum? Sandy's provocative actions are probably knowingly malicious. Sandy consciously targets Sue because of the resentment and helpless frustration she feels. When Sue gets upset, she paradoxically gives Sandy exactly what she wants! She can greatly reduce her frustration as she changes her expectations.

Enlightened Manipulation. You may fear that you will be a pushover if you change your expectations and give up your anger. You might sense that other people would take advantage of you. This apprehension reflects your sense of inadequacy as well as the fact that you probably have not been trained in more enlightened methods of going after what you want. You probably believe that if you didn't make demands on people you'd end up empty-handed.

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So what's the alternative? Well, as a starting point let's review the work of Dr. Mark K. Goldstein, a psychologist who has done some brilliant and creative clinical research on the behavioral conditioning of husbands by wives. In his work with neglected and angry wives, he became aware of the self-defeating methods they used to get what they wanted from their husbands. He asked himself: What have we learned in the laboratory about the most effective scientific methods for influencing all living organisms, including bac-teria, plants, and rats? Can we apply these principles to way-ward and sometimes brutal husbands?

The answer to these questions was straightforward—reward the desired behavior instead of punishing the undesired behavior. Punishment causes aversion and resentment and brings about alienation and avoidance. Most of the deprived and abandoned wives he treated were misguidedly trying to punish their husbands into doing what they wanted. By switching them to a reward model in which the desired behavior got copious attention, he observed some dramatic turnabouts.

The wives Dr. Goldstein treated were not unique. They were ensnarled in the ordinary marital conflicts that most of us confront. These women had a long history of giving their spouses attention either indiscriminately or, in some cases, primarily in response to undesirable behavior. A major shift had to occur in order for them to elicit the kind of response they desired from their husbands but were not getting. By keeping meticulous scientific records of their interactions with their husbands, the women were able to achieve control over how they responded.

Here's how it worked for one of Dr. Goldstein's patients.

After years of fighting, wife X reported she lost her husband.

He abandoned her and moved in with his girl friend. His primary interactions with wife X had centered around abuse and indifference. It appeared on the surface as if he didn't care much about her. Nevertheless, he did call her occasionally, indicating he might have some interest in her. She had the choice of cultivating this attention or crushing it further by continued inappropriate responses.

Wife X defined her goals. She would experiment to see if she could in fact get her husband back. The first milestone 161

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would be to determine if she could effectively increase his rate of contact with her. She measured meticulously the frequency and duration of his every telephone call and visit home, recording this information on a piece of graph paper taped to the refrigerator door. She carefully assessed the crucial relationship between her behavior (the stimulus) and the frequency of his contacts (the response).

She initiated no contacts with him at all on her own, but instead responded positively and affectionately to his calls.

Her strategy was straightforward. Rather than noticing and reacting to all the things about him that she didn't like, she began to reinforce systematically those that she did like. The rewards she used were all the things that turned him on—

praise, food, sex, affection, etc.

She began by responding to his rare calls in an upbeat, positive, complimentary manner. She flattered and encouraged him. She avoided any criticism, argument, demands, or hostility, and found a way to agree with everything he said, using the disarming technique described in Chapter 7. Initially she terminated all these calls after five to ten minutes to ensure the likelihood the conversations would not deteriorate into an argument or become boring to him. This guaranteed that her feedback would be pleasant to him, and that his response to it would not be suppressed or eliminated.

After she did this a few times, she noticed her husband began to call more and more frequently because the calls were positive, rewarding experiences for him. She noted this increased rate of telephoning on her graph paper just as a scientist observes and documents the actions of an experimental rat. As his phone calls increased, she began to feel encouraged, and some of her irritation and resentment melted away.

One day he appeared at the house and according to her plan, she announced, "I'm so happy you dropped by because I just happen to have a fresh, fancy imported Cuban cigar in the freezer for you. It's the expensive type you really like." She actually had a whole box of them waiting so she was able to repeat this each time he visited—regardless of why or when he came. She noticed the frequency of his visits substantially increased.

In a similar manner, she continued to "shape" his behavior using rewards rather than coercion. She realized how success-162

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ful she had been when her husband decided to leave his girl friend and asked if he could move back in with her.

Am I saying that is the only way to relate and to influence people? No—that would be absurd. It's just a pleasant spice, not the whole banquet or even the main course. But it's a frequently overlooked delicacy that few appetites can resist.

There's no guarantee it will work—some situations may be irreversible, and you can't always get what you want.

At any rate, try the upbeat reward system. You may be pleasantly surprised at the remarkable effectiveness of your secret strategy. In addition to motivating the people you care about to want to be around you, it will improve your mood because you learn to notice and focus on the positive things that others do rather than dwell on their negatives.

"Should" Reduction. Because many of the thoughts which generate your anger involve moralistic "should" statements, it will help you to master some "should" removal methods. One way is to make a list, using the double-column method, of all the reasons why you believe the other person "shouldn't"

have acted as he did. Then challenge these reasons until you can see why they are unrealistic and don't actually make good sense, as in Figure 7-6.

Example: Suppose the carpenter on your new house did a sloppy job on the kitchen cabinets. The doors are poorly aligned and don't close properly. You feel irate because you see this as "unfair." After all, you paid full union wages, so you feel entitled to excellent workmanship from a top crafts-man. You fume as you tell yourself, "The lazy bastard should take some pride in his work. What's the world coming to?"

You list the following reasons and rebuttals:

The rationale for eliminating your "should" statement is simple: It's not true that you are entitled to get what you want just because you want it. You'll have to negotiate. Call the carpenter, complain, and insist the job be corrected. But don't double your trouble by making yourself excessively hot and bothered. The carpenter probably wasn't trying to hurt you, and your anger might simply polarize him and put him on the defensive. After all, half of all the carpenters (and psychiatrists, secretaries, writers, and dentists, etc.) throughout human history have been below average. Do you believe that? It's true by definition because "average" is defined as 163

David D. Burns, M.D.

Figure 7-6.

Reasons He Should Have Taken

More Pride in His Work

Rebuttals

He gets paid the same wage

1. Because I paid top dollar.

1. whether or not he takes extra

pride in his work.

2. Because it's only decent to do a 2. He probably felt he did an adequate job. And the paneling he

good job.

did actually looks quite decent.

3. Because he should make sure he 3. Why should he?

gets it done right.

4. Because I would if I were a car- 4. But he's not me—he's not trying penter.

to meet my standards.

5. Because he should care more 5. . There's no reason for him to care about his product.

more. Some carpenters care a lot

about their work, and for others it'

s just a job.

5. So why must / get the one who 6.. All the people who worked on does sloppy work?

your house didn't do sloppy

work. You can't expect to get

100 percent top-notch people.

That would just be unrealistic.

the halfway point! It's ludicrous to fume and complain that this particular carpenter's average talent is "unfair," or that he "should" be other than he is.

Negotiating Strategies. At this point you may be bristling because you are thinking, "Well! That's a fine kettle of fish!

Dr. Burns seems to be telling me I can find happiness by believing that lazy, incompetent carpenters should do mediocre work. After all, it's their nature, the good doctor claims!

What weak-spined hogwash! I'm not going to be stripped of my human dignity and let people walk all over me and get away with second-rate crappy work I'm paying a fortune for."

Cool down! Nobody's asking you to let the carpenter pull the wool over your eyes. If you want to exert your influence in an effective way instead of moping angrily and creating in-

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ner turmoil, a calm, firm, assertive approach will usually be the most successful. Moralistic "shoulding," in contrast, will simply aggravate you and polarize him, and cause him to feel defensive and to counterattack. Remember—fighting is a form of intimacy. Do you really want to be so intimate with this carpenter? Wouldn't you prefer to get what you want instead?

As you stop consuming your energy in anger, you can focus your efforts on getting what you want. The following negotiating principles can work effectively in such a situation: 1. Instead of telling him off, compliment him on what he did right. It's an undeniable fact of human nature that few people can resist flattery even if it's blatantly insincere. However, since you can find something good about him or his work, you can make your compliment honest. Then mention the problem with the cupboard doors tactfully, and calmly explain why you want him to come back and correct the alignment.

2. Disarm him if he argues by finding a way to agree with him regardless of how absurd his statements are. This will shut him up and take the wind out of his sails. Then immediately-

3. Clarify your point of view again calmly and firmly.

Repeat the above three techniques over and over in vary-ing combinations until the carpenter finally gives in or an acceptable compromise is reached. Use ultimatums and intimidating threats only as a last resort, and make sure you are ready and willing to follow through when you do. As a general principle, use diplomacy in expressing your dissatisfaction with his work. Avoid labeling him in an insulting way or implying he is bad, evil, malignant, etc. If you decide to tell him about your negative feelings, do so objectively without magnification or an excess of inflammatory language. For example, "I resent shoddy work when I feel you have the ability to do a good professional job" is far preferable to "

You mother —4 Your—work is an outrage."

In the following dialogue I will identify each of these techniques.

YOU: I was pleased with how some of the work came out, and I'm hopeful I'll be able to tell other people I was 165

David D. Burns, M.D.

happy with the whole job. The paneling was especially well done. I'm a little concerned about the kitchen cabinets, however. (Compliment)

CARPENTER: What seems to be the trouble?

YoU: The doors aren't lined up, and many of the handles are on crooked.

CARPENTER: Well, that's about the best I can do on those kinds of cabinets. They're mass-produced, and they just aren't made the best.

YOU: Well, that's true. They aren't as well made as a more expensive type might be. (Disarming technique) Nevertheless, they aren't acceptable this way, and I'd appreciate it if you'd do something to make them more

presentable. (Clarification; tact)

CARPENTER: You'll have to talk to the manufacturer or the builder. There's nothing I can do about it.

YoU: I can understand your frustration, (Disarming technique) but it's your responsibility to complete these cabinets to our satisfaction. They're simply not acceptable,.

They look shoddy, and they don't close properly. I know it's an inconvenience, but my position is that the job can't be considered complete and the bill won't be paid until you've corrected it. (Ultimatum) I can see from your other work that you have the skill to make them look right in spite of the extra time it will take. That way we'll be completely satisfied with your work, and we can give you a good recommendation. (Compliment) Try these negotiating techniques when you are at logger-heads with someone. I think you'll find they work more effectively than blowing your stack, and you'll feel better because you'll usually end up getting more of what you want.

Accurate Empathy. Empathy is the ultimate anger antidote. It's the highest form of magic described in this book, and its spectacular effects are firmly entrenched in reality. No trick mirrors are needed.

Let's define the word. By empathy, I do not mean the capacity to feel the same way someone else feels. This is sympathy. Sympathy is highly touted but is, in my opinion, somewhat overrated. By empathy, I do not mean acting in a 166

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tender, understanding manner. This is support. Support is also highly valued and overrated.

So what is empathy? Empathy is the ability to comprehend with accuracy the precise thoughts and motivations of other people in such a way that they would say, "Yes, that is exactly where I'm coming from!" When you have this extraordinary knowledge, you will understand and accept without anger why others act as they do even though their actions might not be to your liking.

Remember, it is actually your thoughts that create your anger and not the other person's behavior. The amazing thing is that the moment you grasp why the other person is acting that way, this knowledge tends to put the lie to your anger-producing thoughts.

You might ask, If it's so easy to eliminate anger through empathy, why do people get so damn mad at each other every day? The answer is that empathy is difficult to acquire.

As humans we are trapped in our own perceptions, and we react automatically to the meanings we attach to what people do. Getting inside the other person's skull requires hard work, and most people don't even know how to do this. Do you? You will learn how in the next few pages.

Let's start with an example. A businessman recently sought help because of his frequent episodes of angry outbursts and abusive behavior. When his family or employees didn't do what he wanted, he'd bite their heads off. He usually succeeded in intimidating people, and he enjoyed dominating and humiliating them. But he sensed that his impulsive explosions ultimately caused problems for him because of his reputation as a sadistic hothead.

He described a dinner party he attended where the waiter forgot to fill his wineglass. He felt a surge of rage due to his thought, "The waiter thinks I'm unimportant. Who the hell does he think he is anyway? I'd like to wring the mother—'s neck."

I used the empathy method to demonstrate to him how illogical and unrealistic his angry thoughts were. I suggested that we do some role-playing. He was to play the waiter, and I would act the part of a friend. He was to try to answer my questions as truthfully as possible. The following dialogue evolved:

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DAVID (playing the role of the waiter's friend): I noticed that you didn't fill the wineglass of that businessman there.

PATIENT (playing the role of waiter): Oh, I see that I didn't fill his glass.

DAVID: Why didn't you fill his glass? Do you think he is an unimportant person?

PATIENT (after a pause): Well, no, it wasn't that. I actually don't know much about him.

DAVID: But didn't you decide that he was an unimportant person and refuse to give him any wine because of that?

PATIENT (laughing): No, that isn't why I didn't give him any wine.

DAVID: Then why didn't you give him wine?

PATIENT (after thinking): Well, I was daydreaming about my date for tonight. Furthermore, I was looking at that pretty girl across the table. I was distracted by her low-cut dress, and I just overlooked his wineglass.

This role-playing episode created great relief for the patient because by placing himself in the waiter's shoes he was able to see how unrealistic his interpretation had been. His cognitive distortion was jumping to conclusions (mind reading).

He automatically concluded the waiter was being unfair, which made him feel he had to retaliate to maintain his self-pride. Once he acquired some empathy, he was able to see that his righteous indignation was caused entirely and exclusively by his own distorted thoughts and not the waiter's actions. It is often extremely difficult for angry-prone individuals to accept this at first because they have a nearly irresistible urge to blame others and to retaliate. How about you? Does the idea that many of your angry thoughts are invalid seem abhorrent and unacceptable?

The empathy technique can also be quite useful when the other person's actions appear more obviously and intentionally hurtful. A twenty-eight-year-old woman named Melissa sought counseling around the time she was separating from her husband, Howard. Five years earlier Melissa discovered that Howard was having an affair with Ann, an attractive secretary who worked in his building. This revelation was a heavy blow to Melissa, but to make matters even worse, 168

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Howard was hesitant to make a clean break with Ann, and so the affair dragged on for eight additional months. The humiliation and rage Melissa felt during this period was a major factor that led to her ultimate decision to leave him. Her thoughts ran along these lines: (1) He had no right to act like that. (2) He was self-centered. (3) It was unfair. (4) He was a bad, rotten person. (5) I must have failed.

In the course of a therapy session, I asked Melissa to play Howard's role, and then I cross-examined her to see if she could explain precisely why he had had the affair with Ann and acted as he did. She reported that as the role-playing evolved, she suddenly saw where Howard had been coming from, and at that moment her anger toward him completely vanished. After the session she wrote a description of the dramatic disappearance of the anger she had harbored for years:

After Howard's affair with Ann presumably ended, he insisted on continuing to see her and was still very much bound up with her. This was painful to me. It made me feel that Howard really didn't respect me and considered himself more important than I was. I felt that if he really did love me he wouldn't put me through this. How could he continue to see Ann when he knew how miserable it made me feel? I felt really angry at Howard and down on myself. When I tried the empathy approach and played the role of Howard, I saw the "whole." I suddenly saw things differently. When I imagined I was Howard, I could see where he was coming from. Putting myself in his place, I saw the problem of loving Melissa my wife, as well as Ann my lover. It dawned on me that Howard was really trapped in a "can't-win" system created by his thoughts and feelings. He loved me but was desperately attracted to Ann. As much as he wanted to he couldn't stop seeing her. He felt very guilty and couldn't stop himself. He felt he would lose if he left Ann, and he would lose if he left me. He was unwilling and unable to come to terms with either form of loss, and it was his indecisiveness rather than any inadequacy on my part which caused him to be slow in making up his mind.

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The experience was a revelation for me. I really saw what had happened for the first time. I knew Howard had not done anything deliberately to hurt me, but had been incapable of doing anything other than what he did. I felt good being able to see and understand this.

I told Howard when I spoke to him next. We both felt a lot better about this. I also got a really good feeling from the experience with the empathy technique. It was very exciting. More real than what I had seen before.

The key to Melissa's anger was her fear of losing self-esteem. Although Howard had indeed acted in a genuinely negative manner, it was the meaning she attached to the experience that caused her sense of grief and rage. She assumed that as a "good wife" she was entitled to a "good marriage." This is the logic that got her into emotional trouble: Premise: If I am a good and adequate wife, my husband is bound to love me and be faithful to me.

Observation: My husband is not acting in a loving, faithful way.

Conclusion: Therefore, either I am not a good and adequate wife, or else Howard is a bad, immoral person because he is breaking my "rule."

Thus, Melissa's anger represented a feeble attempt to save the day because within her system of assumptions, this was actually the only alternative to suffering a loss of self-esteem.

The only problems with her solution were (a) she wasn't really convinced he was "no good"; (b) she didn't really want to write him off since she loved him; and (c) her chronic sour anger didn't feel good, it didn't look good, and it drove him farther away.

Her premise that he would love her as long as she was good was a fairy tale she had never thought to question. The empathy method transformed her thinking in a highly beneficial way by allowing her to relinquish the grandiosity inherent in her premise. His misbehavior was caused by his distorted cognitions, not her inadequacy. Thus, he was responsible for the jam he was in, not she!

This sudden insight struck her like a lightning bolt. The moment she saw the world through his eyes, her anger van-170

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ished. She became a much smaller person in the sense that she no longer saw herself as responsible for the actions of her husband and the people around her. But at the same time she experienced a sudden increase in self-esteem.

In the next session I decided to put her new insight to the acid test. I confronted her with the negative thoughts that had originally upset her to see if she could answer them effectively:

DAVID: Howard could have stopped seeing her sooner. He made a fool out of you.

MELISSA: No—he couldn't stop because he was trapped.

He felt a tremendous obsession, and he was attracted to Ann.

DAVID: But then he should've gone off with her and broken up with you so he could stop torturing you. That would've been the only decent thing to do!

MELISSA: He felt he couldn't break off with me either because he loved me and was committed to me and to our children.

DAVID: But that was unfair, to keep you dangling so long.

MELISSA: He didn't mean to be unfair. It just happened.

DAVID: It just happened! What Pollyanna nonsense! The fact is, he shouldn't have gotten into such a situation in the first place.

MELISSA: But that's where he was at. Ann represented excitement, and he felt bored and overwhelmed by life at the time. Eventually one day he just couldn't resist her flirting any more. He took one small step over the line in a moment of weakness, and then the affair was off and running.

DAVID: Well, you are less of a person because he wasn't faithful to you. This makes you inferior.

MELISSA: It has nothing to do with being less of a person. I don't have to get what I want all the time to be worthwhile.

DAVID: But he never would have sought excitement else-where if you were an adequate wife. You're undesirable and unlovable. You're second-rate, and that's why your husband had an affair.

MELISSA: The fact is, he ultimately chose me over Ann, 171

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but that doesn't make me any better than Ann, does it?

Similarly, the fact that he chose to deal with his problems by escaping doesn't mean that I'm unlovable or less desirable.

I could see that Melissa was clearly unruffled by my vigorous attempts to get her goat, and this proved she had transcended this painful period of her life. She traded in her anger for joy and self-esteem. Empathy was the key that freed her from being trapped in hostility, self-doubt, and despair.

Putting It All Together: Cognitive Rehearsal. When you get angry, you may feel you react too rapidly to be able to sit down and assess the situation objectively and apply the various techniques described in this chapter. This is one of the characteristics of anger. Unlike depression, which tends to be steady and chronic, anger is much more eruptive and episodic. By the time you are aware you are upset you may already feel out of control.

"Cognitive rehearsal" is an effective method for solving this problem and for synthesizing and using the tools you have learned thus far. This technique will help you learn to overcome your anger ahead of time without actually experiencing the situation. Then when the real thing happens, you'll be prepared to handle it.

Begin by listing an "anger hierarchy" of the situations that most commonly trigger you off and rank these from +1 (the least upsetting) to +10 (the most infuriating), as shown in Figure 7-7. The provocations should be ones that you'd like to handle more effectively because your anger is maladaptive and undesirable.

Start with the first item on the hierarchy list that is the least upsetting to you, and fantasize as vividly as you can that you are in that situation. Then verbalize your "hot thoughts"

and write them down. In the example given in Figure 7-7, you're feeling annoyed because you're telling yourself, "The goddamn mother—ing waiters don't know what the —

they're doing! Why don't the lazy bastards get off their butts and move? Who the hell do they think they are? Am I supposed to starve to death before they'll give me a menu and a glass of water?"

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Figure 7-7. The Anger Hierarchy.

+I -I sit in a restaurant for fifteen minutes, and the waiter doesn't come.

+2-I call a friend who doesn't return the call.

+3-A client cancels an appointment at the last minute without explanation.

+4-A client fails to show up for an appointment without informing me.

+5-Someone criticizes me nastily.

+6-An obnoxious group of juveniles crowd in front of me in line at a theater.

+7-I read in the paper about senseless violence, such as rape.

+8-A customer refuses to pay a bill for goods I've delivered and skips town so that I can't collect.

+9-Local delinquents repeatedly knock down my mailbox in the middle of the night over a several-month period. There's nothing I can do to catch them or stop them.

+10-I see a television report that someone—presumably a group of teenagers—have broken into the zoo at night, and stoned a number of small birds and animals to death and mutilated others.

Next fantasize flying off the handle, telling off the maitre d', and storming out and slamming the restaurant door. Now record how upset you feel between 0 and 100 percent.

Then go through the same mental scenario, but substitute more appropriate "cool thoughts" and fantasize that you feel relaxed and unperturbed; imagine that you handle the situation tactfully, assertively, and effectively. For example, you might tell yourself, "The waiters don't seem to be noticing me. Perhaps they're busy and overlooked the fact that I haven't gotten a menu yet. No point in getting hot under the collar about this."

Then instruct yourself to approach the headwaiter and explain the situation assertively, following these principles: Point out tactfully that you've been waiting; if he explains they are busy, disarm him by agreeing with him; compliment him on the good business they are doing; and repeat your request for better service in a firm but friendly way. Finally, 173

David D. Burns, M.D.

imagine that he responds by sending a waiter who apologizes and gives you top-notch VIP service. You feel good and enjoy the meal.

Now practice going through this version of the scenario each night until you have mastered it and can fantasize handling the situation effectively and calmly in this manner. This cognitive rehearsal will enable you to program yourself to respond in a more assertive and relaxed way when the actual situation confronts you again.

You might have one objection to this procedure: You may feel it is unrealistic to fantasize a positive outcome in the restaurant since there is no guarantee the staff will in reality respond in a friendly way and give you what you want. The answer to this objection is simple. There's no guarantee they'll respond abrasively either, but if you expect a negative response, you'll enhance the probability of getting one because your anger will have an enormous capacity to act as a self-fulfilling prophecy. In contrast, if you expect and fantasize a positive outcome and apply an upbeat approach, it will be much more likely to occur.

You can, of course, also prepare for a negative outcome in a similar way, using the cognitive rehearsal method.

Imagine you do approach the waiter, and he acts snotty and superior and gives you poor service. Now record your hot thoughts, then substitute cool thoughts and develop a new coping strategy as you did before.

You can continue to work your way up your hierarchy list in this way until you have learned to think, feel, and act more peacefully and effectively in the majority of the provocative situations you encounter. Your approach to these situations will have to be flexible, and different coping techniques may be required for the different types of provocations listed.

Empathy might be the answer in one situation; verbal assertiveness could be the key to another, and changing your expectations might be the most useful approach to a third.

It will be crucial not to evaluate your progress in your anger-reduction program in an all-or-nothing way because emotional growth takes some time, especially when it comes to anger. If you ordinarily react to a particular provocation with 99 percent anger and then find you become 70 percent upset next time, you could view this as a successful first try. Now 174

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keep working at it, using your cognitive rehearsal method, and see if you can reduce it to 50 percent and then to 30

percent. Eventually you will make it vanish altogether, or at least you will have brought it down to an acceptable, irreduc-ible minimum.

Remember that the wisdom of friends and associates can be a potential gold mine you can utilize when you're stuck.

They may see clearly in any area where you have a blind spot. Ask them how they think and behave in a particular situation that makes you feel frustrated, helpless, and enraged.

What would they tell themselves? What would they actually do? You can learn a surprising amount rapidly if you are willing to ask.

Ten Things You Should Know

About Your Anger

1. The events of this world don't make you angry. Your "

hot thoughts" create your anger. Even when a genuinely negative event occurs, it is the meaning you attach to it that determines your emotional response.

The idea that you are responsible for your anger is ultimately to your advantage because it gives you the opportunity to achieve control and make a free choice about how you want to feel. If it weren't for this, you would be helpless to control your emotions; they would be irreversibly bound up with every external event of this world, most of which are ultimately out of your control.

2. Most of the time your anger will not help you. It will immobilize you, and you will become frozen in your hostility to no productive purpose. You will feel better if you place your emphasis on the active search for creative solutions.

What can you do to correct the difficulty or at least reduce the chance that you'll get burned in the same way in the future? This attitude will eliminate to a certain extent the helplessness and frustration that eat you up when you feel you can't deal with a situation effectively.

If no solution is possible because the provocation is totally beyond your control, you will only make yourself miserable with your resentment, so why not get rid of it? It's difficult if 175

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not impossible to feel anger and joy simultaneously. If you think your angry feelings are especially precious and important, then think about one of the happiest moments of your life. Now ask yourself, How many minutes of that period of peace or jubilation would I be willing to trade in for feeling frustration and irritation instead?

3. The thoughts that generate anger more often than not will contain distortions. Correcting these distortions will reduce your anger.

4. Ultimately your anger is caused by your belief that someone is acting unfairly or some event is unjust. The intensity of the anger will increase in proportion to the severity of the maliciousness perceived and if the act is seen as intentional.

5. If you learn to see the world through other people's eyes, you will often be surprised to realize their actions are not unfair from their point of view. The unfairness in these, cases turns out to be an illusion that exists only in your mind?

If you are willing to let go of the unrealistic notion that your concepts of truth, justice, and fairness are shared by everyone, much of your resentment and frustration will vanish.

6. Other people usually do not feel they deserve your punishment. Therefore, your retaliation is unlikely to help you achieve any positive goals in your interactions with them.

Your rage will often just cause further deterioration and polarization, and will function as a self-fulfilling prophecy. Even if you temporarily get what you want, any short-term gains from such hostile manipulation will often be more than coun-terbalanced by a long-term resentment and retaliation from the people you are coercing. No one likes to be controlled or forced. This is why a positive reward system works better.

7. A great deal of your anger involves your defense against loss of self-esteem when people criticize you, disagree with you, or fail to behave as you want them to. Such anger is always inappropriate because only your own negative distorted thoughts can cause you to lose self-esteem. When you blame the other guy for your feelings of worthlessness, you are always fooling yourself.

8. Frustration results from unmet expectations. Since the event that disappointed you was a part of "reality," it was "

realistic." Thus, your frustration always results from your 176

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unrealistic expectation. You have the right to try to influence reality to bring it more in line with your expectations, but this is not always practical, especially when these expectations represent ideals that don't correspond to everyone else's concept of human nature. The simplest solution would be to change your expectations. For example, some unrealistic expectations that lead to frustration include:

a. If I want something (love, happiness, a promotion, etc.), I deserve it.

b. If I work hard at something, I should be successful.

c. Other people should try to measure up to my standards and believe in my concept of "fairness."

d. I should be able to solve any problems quickly and easily.

e. If I'm a good wife, my husband is bound to love me.

f. People should think and act the way I do.

g. If I'm nice to someone, they should reciprocate.

9. It is just childish pouting to insist you have the right to be angry. Of course you do! Anger is legally permitted in the United States. The crucial issue is—is it to your advantage to feel angry? Will you or the world really benefit from your rage?

10. You rarely need your anger in order to be human. It is not true that you will be an unfeeling robot without it. In fact, when you rid yourself of that sour irritability, you will feel greater zest, joy, peace, and productivity. You will experience liberation and enlightenment.

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CHAPTER 8

Ways of Defeating Guilt

No book on depression would be complete without a chapter on guilt. What is the function of guilt? Writers, spirtual leaders, psychologists, and philosophers have grappled forever with this question. What is the basis of guilt? Does it evolve from the concept of "original sin"? Or from Oedipal incestuous fantasies and the other taboos that Freud postulated? Is it a realistic and helpful component of human experience? Or is it a "useless emotion" that mankind would be better off without, as suggested by some recent pop psychology writers?

When the mathematics of calculus was developed, scientists found they could readily solve complex problems of motion and acceleration that were extremely difficult to handle using older methods. The cognitive theory has similarly provided us with a kind of "emotional calculus" that makes certain thorny philosophical and psychological questions much easier to resolve.

Let's see what we can learn from a cognitive approach.

Guilt is the emotion you will experience when you have the following thoughts:

1. I have done something I shouldn't have (or I have failed to do something that I should have) because my actions fall short of my moral standards and violate my concept of fairness.

2. This "bad behavior" shows that I am a bad person (or that I have an evil streak, or a tainted character, or a rotten core, etc.).

This concept of the "badness" of self is central to guilt. In its absence, your hurtful action might lead to a healthy feeling of remorse but not guilt. Remorse stems from the un-178

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distorted awareness that you have willfully and unnecessarily acted in a hurtful manner toward yourself or another person that violates your personal ethical standards. Remorse differs from guilt because there is no implication your transgression indicates you are inherently bad, evil, or immoral. To put it in a nutshell, remorse or regret are aimed at behavior, whereas guilt is targeted toward the "self."

If in addition to your guilt you feel depression, shame, or anxiety, you are probably making one of the following assumptions:

1. Because of my "bad behavior," I am inferior or worthless (this interpretation leads to depression).

2. If others found out what I did, they would look down on me (this cognition leads to shame).

3. I'm in danger of retaliation or punishment (this thought provokes anxiety).

The simplest way to assess whether the feelings created by such thoughts are useful or destructive is to determine if they contain any of the ten cognitive distortions described in Chapter 3. To the extent that these thinking errors are present, your guilt, anxiety, depression, or shame certainly cannot be valid or realistic. I suspect you will find that a great many of your negative feelings are in fact based on such thinking errors.

The first potential distortion when you are feeling guilty is your assumption you have done something wrong. This may or may not actually be the case. Is the behavior you condemn in yourself in reality so terrible, immoral, or wrong? Or are you magnifying things out of proportion? A charming medical technologist recently brought me a sealed envelope containing a piece of paper on which she had written something about herself which was so terrible she couldn't bear to say it out loud. As she trembling handed the envelope to me, she made me promise not to read it out loud or laugh at her. The message inside was—"I pick my nose and eat it!" The apprehension and horror on her face in contrast to the triviality of what she had written struck me as so funny I lost all professional composure and burst into laughter. Fortunately, she too broke into a belly laugh and expressed a sense of relief.

Am I claiming that you never behave badly? No. That 179

David D. Burns, M.D.

position would be extreme and unrealistic. I am simply insisting that to the extent your perception of goofing up is unrealistically magnified, your anguish and self-persecution are inappropriate and unnecessary.

A second key distortion that leads to guilt is when you label yourself a "bad person" because of what you did. This is actually the kind of superstitious destructive thinking that led to the medieval witch hunts! You may have engaged in a bad, angry, hurtful action, but it is counterproductive to label yourself a "bad" or "rotten" person because your energy gets channeled into rumination and self-persecution instead of creative problem-solving strategies.

Another common guilt-provoking distortion is personalization. You inappropriately assume responsiblity for an event you did not cause. Suppose you offer a constructive criticism to your boyfriend, who reacts in a defensive and hurt manner. You may blame yourself for his emotional upset and arbitrarily conclude that your comment was inappropriate. In fact, his negative thoughts upset him, not your comment.

Furthermore, these thoughts are probably distorted. He might be thinking that your criticism means he's no good and conclude that you don't respect him. Now—did you put that illogical thought into his head? Obviously not. He did it, so you can't assume responsiblity for his reaction.

Because cognitive therapy asserts that only your thoughts create your feelings, you might come to the nihilistic belief that you cannot hurt anybody no matter what you do, and hence you have license to do anything. After all, why not run out on your family, cheat on your wife, and screw your partner financially? If they're upset, it's their problem because it's their thoughts, right?

Wrong! Here we come again to the importance of the concept of cognitive distortion. To the extent that a person's emotional upset is caused by his distorted thoughts, then you can say he is responsible for his suffering. If you blame yourself for that individual's pain, it is a personalization error. In contrast, if a person's suffering is caused by valid, undistorted thoughts, then the suffering is real and may in fact have an external cause. For example, you might kick me in the stomach, and I could have the thoughts, "I've been kicked! It hurts! — —I" In this case the responsibility for my pain 180

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rests with you, and your perception that you have hurt me is not distorted in any way. Your remorse and my discomfort are real and valid.

Inappropriate "should" statements represent the "final common pathway" to your guilt. Irrational should statements imply you are expected to be perfect, all-knowing, or all-powerful. Perfectionistic shoulds include rules for living that defeat you by creating impossible expectations and rigid-ity. One example of this would be, "I should be happy at all times." The consequence of this rule is that you will feel like a failure every time you are upset. Since it is obviously unrealistic for any human being to achieve the goal of perpetual happiness, the rule is self-defeating and irresponsible.

A should statement that is based on the premise you are all-knowing assumes you have all the knowledge in the universe and that you can predict the future with absolute certainty. For example, you might think, "I shouldn't have gone to the beach this weekend because I was coming down with the flu. What a jerk I aml Now I'm so sick I'll be in bed for a week." Berating yourself this way is unrealistic because you didn't know for certain that going to the beach would make you so ill. If you had known this, you would have acted differently. Being human, you made a decision, and your hunch turned out to be wrong.

Should statements based on the premise you are all-powerful assume that, like God, you are omnipotent and have the ability to control yourself and other people so as to achieve each and every goal. You miss your tennis serve and wince, exclaiming, "I shouldn't have missed that serve!" Why shouldn't you? Is your tennis so superb that you can't possibly miss a serve?

It is clear that these three categories of should statements create an inappropriate sense of guilt because they do not represent sensible moral standards.

In addition to distortion, several other criteria can be helpful in distinguishing abnormal guilt from a healthy sense of remorse or regret. These include the intensity, duration, and consequences of your negative emotion. Let's use these criteria to evaluate the incapacitating guilt of a married fifty-two-year-old grammar-school teacher named Janice. Janice had been severely depressed for many years. Her problem 181

David D. Burns, M.D.

was that she continually obsessed about two episodes of shoplifting that had occurred when she was fifteen. Although she had led a scrupulously honest life since that time, she could not shake the memory of those two incidents. Guilt-provoking thoughts constantly plagued her: "I'm a thief. I'm a liar. I'm no good. I'm a fake." The agony of her guilt was so enormous that every night she prayed that God would let her die in her sleep. Every morning when she woke up still alive, she was bitterly disappointed and told herself, "I'm such a bad person even God doesn't want me." In frustration she finally loaded her husband's pistol, aimed it at her heart, and pulled the trigger. The gun misfired and did not go off.

She had not cocked it properly. She felt the ultimate defeat: She couldn't even kill herself! She put the gun down and wept in despair.

Janice's guilt is inappropriate not only because of the obvious distortions, but also because of the intensity, duration, and consequences of what she was feeling and telling herself.

What she feels cannot be described as a healthy remorse or regret about the actual shoplifting, but an irresponsible degradation of her self-esteem that blinds her to living in the here and now, and is far out of proportion to any actual transgression. The consequences of her guilt created the ultimate irony—her belief that she was a bad person caused her to attempt to murder herself, a most destructive and pointless act.

The Guilt Cycle

Even if your guilt is unhealthy and based on distortion, once you begin to feel guilty, you may become trapped in an illusion that makes the guilt appear valid. Such illusions can be powerful and convincing. You reason:

1. I feel guilty and worthy of condemnation. This means I'

ve been bad.

2. Since I'm bad, I deserve to suffer.

Thus, your guilt convinces you of your badness and leads to further guilt. This cognitive-emotional connection locks your thoughts and feelings into each other. You end up trapped in a circular system which I call the "guilt cycle."

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Emotional reasoning fuels this cycle. You automatically assume that because you're feeling guilty, you must have fallen short in some way and that you deserve to suffer. You reason, "I feel bad, therefore I must be bad." This is irrational because your self-loathing does not necessarily prove that you did anything wrong. Your guilt just reflects the fact that you believe you behaved badly. This might be the case, but it often is not. For example, children are frequently punished inappropriately when parents are feeling tired and irritable and misinterpret their behavior. Under these conditions, the poor child's guilt obviously does not prove he or she did anything wrong.

Your self-punishing behavior patterns intensify the guilt cycle. Your guilt-provoking thoughts lead to unproductive actions that reinforce your belief in your badness. For example, a guilt-prone neurologist was trying to prepare for her medical-board certification examination. She had difficulty studying for the test, and felt guilty about the fact that she wasn't studying. So she wasted time each night watching television while the following thoughts raced through her mind: "I shouldn't be watching TV. I should be preparing for my boards. I'm lazy. I don't deserve to be a doctor. I'm too self-centered. I ought to be punished." These thoughts made her feel intensely guilty. She then reasoned, "This guilt proves what a lazy no-good person I am." Thus, her self-punishing thoughts and her guilty feelings reinforced each other.

Like many guilt-prone people, she had the idea that if she punished herself enough she would eventually get moving.

Unfortunately, quite the opposite was true. Her guilt simply drained her energy and reinforced her belief that she was lazy and inadequate. The only actions that resulted from her self-loathing were the nightly compulsive trips to the refrigerator to "pig out" on ice cream or peanut butter.

The vicious cycle that she trapped herself in is shown in Figure 8-1. Her negative thoughts, feelings, and behaviors all interacted in the creation of the self-defeating, cruel illusion that she was "bad" and uncontrollable.

The Irresponsibility of Guilt. If you have actually done something inappropriate or hurtful, does it follow that you deserve to suffer? If you feel the answer to this question is yes, then ask yourself, "How long must I suffer? One day? A 183

David D. Burns, M.D.

Figure 8-1. A neurologist's self-critical thoughts caused her to feel so guilty that she had difficulty preparing for her certification examination.

Her procrastination strengthened her conviction that she was bad and deserved punishment. This further undermined her motivation to solve the problem.

Thoughts:

I shouldn't be watching TV. I'm

lazy and no good. I'm a self-

indulgent pig.

-

,

,

Emotions:

Behavior

Guilt

Procrastination

Anxiety

Binge-eating

Self-loathing

year? For the rest of my life?" What sentence will you choose to impose on yourself? Are you willing to stop suffering and making yourself miserable when your sentence has expired?

This would at least be a responsible way to punish yourself because it would be time-limited. But what is the point of abusing yourself with guilt in the first place? If you did make a mistake and act in a hurtful way, your guilt won't reverse your blunder in some magical manner. It won't speed your learning processes so as to reduce the chance you'll make the same mistake in the future. Other people won't love and respect you more because you are feeling guilty and putting yourself down in this manner. Nor will your guilt lead to productive living. So what's the point?

Many people ask, "But how could I behave morally and control my impulses if I don't feel guilt?" This is the probation-officer approach to living. Apparently you view yourself as so willful and uncontrollable that you must constantly castigate yourself in order to keep from going wild.

Certainly, if your behavior has a needlessly hurtful impact on others, a small amount of painful remorse will add to your awareness more effectively than a sterile recognition of your goof-up with no emotional arousal. But it certainly never 184

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helped anyone to view himself as a bad person. More often than not, the belief that you are bad contributes to the "bad"

behavior.

Change and learning occur most readily when you (a) recognize that an error has occurred and (b) develop a strategy for correcting the problem. An attitude of self-love and relaxation facilitates this, whereas guilt often interferes.

For example, occasionally patients criticize me for making a sharp comment that rubs them the wrong way.

This criticism usually only hurts my feelings and arouses my guilt if it contains a grain of truth. To the extent that I feel guilty and label myself as "bad," I tend to react defensively. I have the urge to either deny or justify my error, or to counterattack because that feeling of being a "bad person"

is so odious. This makes it much more difficult for me to admit and correct the error. If, in contrast, I do not harangue myself or experience any loss of self-respect, it is easy to admit my mistake. Then I can readily correct the problem and learn from it. The less guilt I have, the more effectively I can do this.

Thus, what is called for when you do goof up is a process of recognition, learning, and change. Does guilt help you with any of these? I don't believe it does. Rather than facilitating your recognition of your error, guilt engages you in a cover-up operation. You want to close your ears to any criticism.

You can't bear to be in the wrong because it feels so terrible.

This is why guilt is counterproductive.

You may protest, "How can I know I've done something wrong if I don't feel guilty? Wouldn't I just indulge in a blind rampage of uncontrolled, destructive selfishness if it weren't for my guilt?"

Anything is possible, but I honestly doubt this would happen. You can replace your guilt with a more enlightened basis for moral behavior—empathy. Empathy is the ability to visualize the consequences, good and bad, of your behavior.

Empathy is the capacity to conceptualize the impact of what you do on yourself and on the other person, and to feel appropriate and genuine sorrow and regret without labeling yourself as inherently bad. Empathy gives you the necessary mental and emotional climate to guide your behavior in a 185

David D. Burns, M.D.

moral and self-enhancing manner in the absence of the whip of guilt.

Using these criteria, you can now readily determine whether your feelings represent a normal and healthy sense of remorse or a self-defeating, distorted sense of guilt. Ask yourself

1. Did I consciously and willfully do something "bad," "

unfair," or needlessly hurtful that I shouldn't have? Or am I irrationally expecting myself to be perfect, all-knowing, or all-powerful?

2. Am I labeling myself a bad or tainted person because of this action? Do my thoughts contain other cognitive distortions, such as magnification, overgeneralization, etc.?

3. Am I feeling a realistic regret or remorse, which results from an empathic awareness of the negative impact of my action? Are the intensity and duration of my painful emotional response appropriate to what I actually did?

4. Am I learning from my error and developing a strategy for change, or am I moping and ruminating nonproduc-tively or even punishing myself in a destructive manner?

Now, let's review some methods that will allow you to rid yourself of inappropriate guilty feelings and maximize your self-respect.

1. Daily Record of Dysfunctional Thoughts. In earlier chapters you were introduced to a Daily Record of Dysfunctional Thoughts for overcoming low self-esteem and inadequacy. This method works handsomely for a variety of unwanted emotions, including guilt. Record the activating event that leads to your guilt in the column labeled "Situa-tion." You may write, "I spoke sharply to an associate," or "

Instead of contributing ten dollars, I threw my alumni fund-raising appeal in the wastebasket." Then "tune in" to that tyrannical loudspeaker in your head and identify the accusations that create your guilt. Finally, identify the distortions and write down more objective thoughts. This leads to relief.

An example of this is demonstrated in Figure 8-2. Shirley was a high-strung young woman who decided to move to New York to pursue her acting career. After she and her mother had spent a long and tiring day looking for apart-ments, they took a train back to Philadelphia. After boarding, 186

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they discovered they had mistakenly taken a train without food service or a lounge car. Shirley's mother began to complain about the lack of cocktail service, and Shirley felt flooded with guilt and self-criticism. As she recorded and talked back to her guilt-provoking thoughts, she felt substantial relief. She told me that by overcoming her guilt, she avoided the temper tantrum she would normally have thrown in such a frustrating situation (see Figure 8-2, page 188).

2. Should Removal Techniques. Here are some methods for reducing all those irrational "should" statements you've been hitting yourself with. The first is to ask yourself, "Who says I should? Where is it written that I should?" The point of this is to make you aware that you are being critical of yourself unnecessarily. Since you are ultimately making your own rules, once you decide that a rule is not useful you can revise it or get rid of it. Suppose you are telling yourself that you should be able to make your spouse happy all the time.

If your experience teaches you that this is neither realistic nor helpful, you can rewrite the rule to make it more valid. You might say, "I can make my spouse happy some of the time, but I certainly can't at all times. Ultimately, happiness is up to him or her. And I'm not perfect any more than he or she is. Therefore, I will not anticipate that what I do will always be appreciated."

In deciding about the usefulness of a particular rule, it can be helpful to ask yourself, "What are the advantages and disadvantages of having that rule for myself?" "How will it help me believe I should always be able to make my spouse happy, and what will the price be for believing this?" You can assess the costs and benefits, using the double-column method shown in Figure 8-3.

Another simple but effective way to rid yourself of should statements involves substituting other words for "should,"

using the double-column technique. The terms "It would be nice if' or "I wish I could" work well, and often sound more realistic and less upsetting. For example, instead of saying, "I should be able to make my wife happy," you could substitute

"It would be nice if I could make my wife happy now because she seems upset. I can ask what she's upset about and see if there might be a way I could help." Or instead of "I shouldn't have eaten the ice cream," you can say, "It would 187

Figure 8-2.

Situation

Emotions Guilt-provoking Thoughts

Cognitive Distortions

Rational Responses

Outcome

My mother is Extreme

1. Gee, Mom walked all

1. Personalization;

1. I feel bad for Mom— Substantial

very tired and

guilt;

over New York with me•

mental filter;

but the train ride is relief

due to her lack frustration;

today, and now she can't

should statement.

only 11/2 hours. I

of understand- anger;

even get a drink because

thought I explained

ing of the train self-pity

I really didn't e.tplain

everything. I guess we

schedule, we

the schedule properly. I

all make mistakes

take a train

should have explained

sometimes.

without corn-

that "no food" did not

,-..

co forts.

mean snacks.

co

2. Emotional

2. I am more upset than

2. Now I feel terrible—I'm

reasoning.

Mom. What's done is

so selfish.

done—don't cry over

spilt milk.

3. Why do I always foul up

3. 0 vergeneralization;

3. I don't foul up every-

everything?

personalization.

thing. It's not my fault

she misunderstood.

4. She's so good to me, and I'

4. Labeling; all-or-

4. One incident does not

m a louse.

nothing thinking.

make a louse.

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Figure 8-3. The advantages and disadvantages of believing "I should be able to make my wife happy all the time."

Advantages

Disadvantages

1. When she is happy, I will feel I'm 1. When she's unhappy, I'll feel doing what I'm supposed to.

guilty and I'll blame myself.

2. I'll work very hard to be a good 2. She'll be able to manipulate me h u s b a n d . w i t h m y g u i l t . A n y t i m e s h e w a n t s her way she can act unhappy,

and then I'll feel so bad I'll have

to back down.

3. Since she is unhappy a good bit of the time, I'll often feel like a failure. Since her unhappiness

often has nothing to do with me,

this will be a waste of energy.

4. I'll end up feeling resentful that I'm paradoxically giving her so much power over my moods!

have been better if I hadn't eaten the ice cream, but it's not the end of the world that I did."

Another anti-should method involves showing yourself that a should statement doesn't fit reality. For example, when you say, "I shouldn't have done X," you assume (1) it is a fact that you shouldn't have, and (2) it is going to help you to say this. The "reality method" reveals—to your surprise—that the truth is usually just the opposite: (1) In point of fact, you should have done what you did; and (b) it is going to hurt you to say you shouldn't have.

Incredulous? Let me demonstrate. Assume you've been trying to diet and you ate some ice cream. So you have the thought, "I shouldn't have eaten this ice cream." In our dialogue I want you to argue that it's really true that you shouldn't have eaten the ice cream, and I will try to put the lie to your arguments. The following is modeled after an as conversation, which I hope you find as delightful and helpful as I did:

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David D. Burns, M.D.

DAVID: I understand you're on a diet, and you ate some ice cream. I believe you should have eaten the ice cream.

YoU: Oh, no. That's impossible. I shouldn't have eaten it because I'm on a diet. You see, I'm trying to lose weight.

DAVID: Well, I believe you should have eaten the ice cream.

YOU: Burns, are you dense? I shouldn't have because I'm trying to lose weight. That's what I'm trying to tell you.

How can I lose weight if I'm eating ice cream?

DAVID: But in point of fact you did eat it.

YOU: Yeah. That's the problem. I shouldn't have done that. Now do you see the light?

DAVID: And apparently you're claiming that "things should have been different" than they were. But things were the way they were. And things usually are the way they are for a good reason. Why do you think you did what you did? What's the reason you ate the ice cream?

YoU: Well, I was upset and I was nervous and I'm basically a pig.

DAVID: Okay, you were upset and you were nervous. Have you had a pattern in your life of eating when you've been upset and nervous?

YOU: Yeah. Right. I've never had any self-control.

DAVID: So, wouldn't it be natural to expect then that last week when you were nervous you would do what you have habitually done?

YOU: Yeah.

DAVID: So, wouldn't it be sensible therefore to conclude that you should have done that because you had a very long-standing habit of doing it?

YOU: I feel like you're telling me that I should just keep eating ice cream and end up like a fat pig or something.

DAVID: Most of my clients aren't as difficult as your At any rate, I'm not telling you to act like a pig, and I'm not recommending you continue this bad habit of eating when you're upset. What I'm saying is that you're giving yourself two problems for the price of one. One is that you did in fact break your diet. If you're going to lose weight, this will slow you down. And the second problem 190

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is that you're being hard on yourself about having done that. The second headache you don't need.

YOU: So you're saying that because I have a habit of eating when I'm nervous it's predictable that until I learn some methods for changing the habit, I'll continue to do it.

DAVID: I wish I'd said it that well myself!

You: Therefore, I should have eaten the ice cream because I haven't changed the habit yet. As long as the habit continues, I will and should keep overeating when I'm nervous. I see what you mean. I feel a whole lot better, doctor, except for one thing. How can I learn to stop doing this? How can I develop some strategies for modifying my behavior in a more productive way?

DAVID: You can motivate yourself with a whip or a carrot.

When you tell yourself, "I should do this" or "I shouldn't do that" all day long, you get bogged down with a shouldy approach to life. And you already know what you end up with—emotional constipation. If you'd rather get things moving instead, I suggest you try to motivate yourself through rewards rather than punishment. You might find that these work more effectively.

In my case I used the "Dots and doughnuts" diet. Mason Dots (a gum candy) and glazed doughnuts are two of my favorite sweets. I found that the most difficult time to control my eating was in the evening when I was studying or watching TV. I'd have an urge to eat ice cream. So, I told myself that if I controlled this urge, I could reward myself with a big, fresh, glazed doughnut in the morning and a box of Mason Dots in the evening. Then I'd concentrate on how good they'd taste, and this helped me forget the ice cream.

Incidentally, I also had the rule that if I did goof up and eat the ice cream, I could still have the Dots and the doughnut as a reward for trying or as a commiseration for slipping back. Either way it helped me, and I lost over fifty pounds this way.

I also made up the following syllogism:

(A) Human beings on diets goof up from time to time.

(B) I'm a human being.

(C) Therefore, I should goof up from time to time.

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This helped me greatly too, and it enabled me to binge on weekends and feel good about it. I usually lost more during the week than I gained on weekends; so, overall I lost weight and enjoyed myself. Every time I goofed up in my diet I didn't allow myself to criticize the lapse or feel guilty. I began to think about it as the "Binge-on-whatever-you-want-whenever-you-want-to-without-guilt-and-enjoy-it diet," and it was so much fun it was a mild disappointment when I finally achieved my aimed-for weight. I actually lost over ten more pounds at that point because the diet was so enjoyable. I believe that the proper attitude and feelings are the key. With them you can move mountains—even mountains of flesh.

The major thing that holds you back when you're trying to change a bad habit like eating, smoking, or drinking too much is your belief you are out of control. The cause of this lack of control is those should statements. They defeat you.

Suppose, for example, you are trying to avoid eating ice cream. There you are watching TV, saying, "Oh, I really should study and I shouldn't eat any ice cream." Now ask yourself, "How do I feel when I say these things to myself?

" I think you know the answer: You feel guilty and nervous.

Then what do you do? You go and eat! That is the point.

The reason you're eating is that you're telling yourself you shouldn't! Then you try to bury your guilt and anxiety under more piles of food.

Another simple should removal technique involves your wrist counter. Once you become convinced that the shoulds are not to your advantage, you can count them. Every time you make a should statement, click the counter. If you do this, be sure to set up a reward system based on the daily total. The more shoulds you spot this way, the greater the reward you deserve. Over a period of several weeks, your daily total of should statements will begin to go down, and you'll notice you're feeling less guilty.

Another should removal technique zeroes in on the fact that you don't really trust yourself. You may believe that without all these should statements you would just turn wild and go on a rampage of destruction or murder, or even ice-cream eating. A way to evaluate this is to ask yourself if there was any period in your life when you were particularly happy and felt reasonably fulfilled, productive, and under control.

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Think it over for a moment before you read on, and make sure you have a mental picture of this time. Now ask yourself, "During that period in my life, was I whipping myself with a lot of should statements?" I believe your answer will be no. Now tell me—were you doing all these wild, terrible things then? I think you'll realize you were "should-free" and under control. This is proof that you can lead a productive, happy life without all those shoulds.

You can test this hypothesis with an experiment in the next couple of weeks. Try reducing your should statements using these various techniques, and then see what happens to your mood and self-control. I think you'll be pleased.

Another method that you can fall back on is the obsessional-filibuster technique described in Chapter 4. Schedule two minutes three times a day to recite all your should statements and self-persecutions out loud: "I should have gone to the market before it closed," and "I shouldn't have picked my nose at the country club," and "I'm such a rotten bum," etc.

Just rattle off all the most abusive self-criticisms you can think of. It might be especially helpful to write them down or dictate them into a tape recorder. Then read them later out loud, or listen to the tape I think this will help you see how ludicrous these statements are. Try to limit your shoulds to these scheduled periods so you won't be bothered by them at other times.

Another technique to combat should statements involves getting in touch with the limits of your knowledge. When I was growing up, I often heard people say, "Learn to accept your limits and you'll become a happier person," but no one ever bothered to explain what this meant or how to go about doing it. Furthermore, it always sounded like a bit of a put-down, as if they were saying, "Learn what a second-rate dud you actually are."

In reality, it's not as bad as all that. Suppose you frequently look into the past and mope about your mistakes.

For example, as you review the financial section of the paper, you tell yourself, "I shouldn't have bought that stock. It's gone down two points." As a way out of this trap, ask yourself, "Now, at the time I bought the stock, did I know it was going to go down in value?" I suspect you'll say no. Now ask,

"If I'd known it was going down, would I have bought it?"

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Again you'll answer no. So what you're really saying is that if you'd known this at the time, you'd have acted differently. To do this you would have to be able to predict the future with absolute certainty. Can you predict the future with absolute certainty? Again your answer must be no. You have two options: You can either decide to accept yourself as an imperfect human being with limited knowledge and realize that you will at times make mistakes, or you can hate yourself for it. Another effective way to combat shoulds is to ask, "Why should I?" Then you can challenge the evidence you come up with so as to expose the faulty logic. In this way you can reduce your should statement to the level of absurdity. Suppose, for example, you hire someone to do some work for you. It could be lawn work, or a painting job, or anything.

When he submits his bill, it seems higher than you understood it would be, but he gives you some fast talk, so you give in and end up paying his price. You feel taken advantage of. You begin to berate yourself for not acting more firmly. Let's do some role-playing, and you can pretend that you're the poor sucker who paid too much.

YOU: Yesterday I should have told that guy that his bill was too high.

DAVID: You should have told him that he gave you a lower estimate?

YOU: Yeah. I should have been more assertive.

DAVID: Why should you have? I agree that it would have been to your advantage to speak up for yourself. You can work on developing your assertive skills so that in the future you'll do better in situations like that. But the point is: Why should you have been more effective yesterday?

YOU: Well, because I'm always letting people take advantage of me.

DAVID: Okay, let's think about your line of reasoning. "Be-cause I'm always letting people take advantage of me, I should have been more assertive yesterday." Now—what is the rational response to this? Is there anything about your statement that seems a little bit illogical? Is there anything fishy about your reasoning?

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you: Mmmm . . . let me think. Well, in the first place, it's not exactly true that I'm always letting people take advantage of me. That would be an overgeneralization. I sometimes do get my way. In fact, I can be quite demanding at times. Furthermore, if it were true that I was always getting taken advantage of in certain situations, then it would follow that I should have behaved exactly as I did since this is my habit. Until I've mastered some new ways to deal with people, I'll probably continue to have this problem.

DAVID: Great. I couldn't have put it better. I see you've been absorbing what I've been telling you about should statements! I hope all my readers are as smart and attentive as you are! Are there any other reasons you think you should have behaved differently?

YOU: Uh, well, let me see. How about: I should have been more assertive because I wouldn't have had to pay more than I owed?

DAVID: Okay. Now what's the rational response to that?

What is illogical about that argument?

YOU: Well, since I'm human I won't always do the right thing.

DAVID: Exactly. In fact, the following syllogism may help you. First premise: All human beings make mistakes, like sometimes paying too much. Do you agree with me so far?

You: Yes.

DAvID: And what are you?

YOU: A human being.

DAVID: And what follows?

YOU: I should make mistakes.

DAvID: Right.

That should be enough should removal techniques for you.

Oops! I just did it myself! Let me say—it would be nice if you found those methods helpful. I think you'll find that by reducing this mental tyranny, you'll feel better because you won't be berating yourself. Instead of feeling guilty, you can use your energy to make necessary changes and enhance your self-control and productivity.

3. Learn to Stick to Your Guns. One of the big disad-195

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vantages of being guilt-prone is that others can and will use this guilt to manipulate you. If you feel obligated to please everyone, your family and friends will be able to coerce you effectively into doing many things that may not be in your best self-interest. To cite a trivial example, how many social invitations have you halfheartedly accepted so as not to hurt someone's feelings? In this case the price you pay for saying yes when you really would have preferred to say no is not great. You only end up wasting one evening. And there is a payoff. You will avoid feeling guilty, and you can fantasize that you are an especially nice person. Furthermore, if you try to decline the invitation, the disappointed host may say. "

But we are expecting you. Do you mean you are going to let the old gang down? Aw, come on." And then what would you say? How would you feel?

Your obsession with pleasing others becomes more tragic when your decisions become so dominated by guilt that you end up trapped and miserable. The irony is that, more often than not, the consequences of letting someone manipulate you with guilt end up being destructive not only to you but to the other person. Although your guilt-motivated actions are often based on your idealism the inevitable effects of giving in turn out to be quite the opposite.

For example, Margaret was a happily married twenty-seven-year-old woman whose obese brother, a gambler.

tended to take advantage of her in a variety of ways. He borrowed money when he ran short and often forgot to repay it.

When he was in town (often for several months at a time) he assumed it was his right to eat dinner with her family every night, to drink up the liquor, and to use her new car whenever he wanted. She rationalized giving in to his demands by saying: "If I asked him for a favor or needed his help, he'd do the same for me. After all, a loving brother and sister should help each other out. And besides, if I tried to say nc to him he'd explode and I might lose him. Then I'd feel like 1

did something wrong."

At the same time, she was able to see the negative consequences of continually giving in: 1) She was supporting his dependent, self-defeating life-style and gambling addiction; 2 1

She felt trapped and taken advantage of; 3) The basis of the relationship was not love but blackmail—she was constantly 196

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having to say yes to his demands to avoid the tyranny of his temper and her own sense of guilt.

Margaret and I did some role-playing so she could learn to say no and stick to her guns in a tactful but firm manner. I played Margaret's role, and she pretended to be her brother: BROTHER (played by Margaret) : Are you using the car tonight?

MARGARET (played by me) : I'm not planning to now.

BROTHER: Do you mind if I borrow it later?

MARGARET: I'd prefer that you don't.

BROTHER: Why not? You're not going to use it. It'll just be sitting there.

MARGARET: Do you feel I'm obliged to loan it to you?

BROTHER: Well, I'd do the same for you if I had a car and you needed it.

MARGARET: I'm glad you feel that way. Although I'm not planning to use the car, I'd like to have it available in case I decide to go somewhere later on.

BROTHER: But you're not planning to use it! Haven't we been brought up to help each other?

MARGARET: Yes we have. Do you think that means I always have to say yes to you? We both do a great deal for each other. You have made a lot of use of my car and from now on I'd feel more comfortable if you'd begin to arrange your own transportation.

BROTHER: I'm just planning to use it for an hour so I'll get it back in case you need it. It's very important and it's only a half mile away, so I won't wear your car out, don't worry.

MARGARET: It sounds like it is something important to you.

Perhaps you can arrange some other transportation.

Could you walk that distance?

BROTHER: Oh, that's fine! If that's how you feel, don't come to me for any favors!

MARGARET: It sounds like you're pretty mad because I'm not doing what you want. Do you feel I'm always

obliged to say yes?

BROTHER: You and your philosophy! Shove it! I refuse to listen to any more of this hogwash! (Begins to storm off).

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MARGARET: Let's not talk about it any further then. Maybe in a couple of days you'll feel more like talking about. I think we do need to talk things over.

After this dialogue we reversed roles so that Margaret could practice being more assertive. When I played her brother's role, I gave her as tough a time as I could, and she learned how to handle me. This practice boosted her courage.

She felt it was helpful to keep certain principles in mind when standing up to her brother's manipulations. These were: (1) She could remind him it was her right not to say yes to all his demands. (2) She could find a grain of truth in his arguments (the disarming technique) so as to take the wind out of his sails, but she could then come back to her position that love did not mean always giving in. (3) She was to adopt a strong, decisive and uncompromising position as tactfully as possible. (4) She was not to buy into his role as a weak, inadequate little boy who couldn't stand on his own feet. (5) She was not to respond to his anger by getting angry herself, because this would reinforce his belief he was a victim who was being unjustly deprived by a cruel, selfish witch. (6) She had to risk the possibility he would temporarily withdraw and thwart her by refusing to talk to her or to consider her point of view. When he did this, she was to let him storm off but she could let him know there were some things she wanted to talk over with him later on when he was more in the mood to communicate.

When Margaret did confront him she found he was not nearly as tough a customer as she imagined. He actually seemed relieved and began to act more adult when she put some limits on the relationship.

If you choose to apply this technique, you will have to be determined to stick to your guns because the other guy (or gal) may try to bluff you into believing that you're mortally wounding them by not giving in to their requests. Remember that the hurt you inflict in the long run by not following your best self-interest is usually far greater.

Practicing ahead of time is the key to success. A friend will usually be happy to role-play with you and provide some useful feedback. If such a person is not available to you, or you feel too shy to ask, write out an imaginary dialogue of

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the type illustrated. This will go a long way to firing up the appropriate circuits in your brain so you'll have the necessary courage and skill to say no diplomatically but forcefully and make it stick when the time actually comes!

4. Antiwhiner Technique. This is one of the most surprising, delightfully effective methods in this book. It works like a charm in situations where someone—usually a loved one—makes you feel frustrated, guilty, and helpless through whining, complaining, and nagging. The typical pattern works like this: The whiner complains to you about something or someone. You feel the sincere desire to be helpful, so you make a suggestion. The person immediately squashes your suggestion and complains again. You feel tense and inadequate, so you try harder and make another suggestion.

You get the same response. Anytime you try to break loose from the conversation, the other person implies he or she is being abandoned, and you are flooded with guilt.

Shiba lived with her mother while she completed graduate school. Shiba loved her mother, but found her constant harangues about her divorce, the lack of money, etc., so intolerable she sought treatment. I taught her the antiwhiner method the first session, as follows: Regardless of what her mother said, Shiba was to find some way to agree (the disarming technique), and then instead of offering advice, she was to say something genuinely complimentary. Shiba initially found this approach astonishing and rather bizarre because it differed radically from her usual approach. In the following dialogue, I asked Shiba to play the role of Mother while I played her role so I could demonstrate this technique: slum (as her mother) : Do you know that during the divorce proceedings it came out that your Dad sold his share in the business, and I was the last person to know about it?

DAVID (as Shiba): That's absolutely correct. You didn't hear about it until the divorce proceedings. You really deserve better.

slum: I don't know what we're going to do for money.

How am I going to put your brothers through college?

DAVID: That is a problem. We are short on money.

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SHIBA: It was just like your father to pull something like this. His head isn't screwed on straight.

DAVID: He never was too good at budgeting. You've always been much better at that.

SHIBA: He's a louse! Here we are on the verge of poverty.

What if I get sick? We'll end up in the poorhouse!

DAVID: You're right! It's no fun at all to live in the poorhouse. I agree with you completely.

Shiba reported that in her role as Mother she found it was

"no fun" to complain because I kept agreeing with her. We did a role-reversal so she could master the technique.

In fact, it is your urge to help complainers that maintains the monotonous interaction. Paradoxically, when you agree with their pessimistic whining, they quickly run out of steam.

Perhaps an explanation will make this seem less puzzling.

When people whine and complain, they are usually feeling irritated, overwhelmed, and insecure. When you try to help them, this sounds to them like criticism because it implies they aren't handling things properly. In contrast, when you agree with them and add a compliment, they feel endorsed, and they then usually relax and quiet down.

5. Moorey Moaner Method. A useful modification of this technique was proposed by Stirling Moorey, a brilliant British medical student who studied with our group in Philadelphia and sat in with me during therapy sessions during the summer of 1979. He worked with a chronically severely depressed fifty-two-year-old sculptor named Harriet with a heart of gold. Harriet's problem was her friends would often bend her ear with gossip and personal problems. She found these problems upsetting because of her excessive capacity for empathy.

Because she wouldn't know how to help her friends, she felt trapped and resentful until she learned the "Moorey Moaner Method." Stirling simply instructed her to find a way to agree with what the person was saying, and then to distract the moaner by finding something positive in the complaint and to comment on it. Here are several examples:

1. MOANER: Oh, what in the world can I ever do about my daughter? I'm afraid she's been smoking pot again.

RESPONSE: There sure is a lot of pot going around 200

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these days. Is your daughter still doing that outstanding art work? I heard she recently got an important award.

2. MOANER: My boss didn't give me my raise, and my last raise was nearly a year ago. I've been here for twenty years, and I think I deserve better.

RESPONSE: You certainly do have seniority here and you've made tremendous contributions. Tell me, what was it like when you first started working twenty years ago? I'll bet things were a lot different then.

3. MOANER: My husband never seems to have enough time at home. Every night he's out with that darned bowling league.

RESPONSE: Weren't you also doing some bowling recently? I heard you got some pretty high scores yourself!

Harriet mastered the Moorey Moaner Method quickly and reported a dramatic change in her mood and outlook because it gave her a simple, effective way to handle a problem that had been very real and overwhelming. When she returned for the next session, her depression—which had crippled her for over a decade—had lifted and was entirely gone. She was bubbling and joyous, and heaped well-deserved praise on Stirling's head. If you have a similar problem with your mother, mother-in-law, or friends, try Stirling's method.

Like Harriet, you'll soon be smiling!

6. Developing Perspective." One of the commonest distortions that leads to a sense of guilt is personalization—the misguided notion that you are ultimately responsible for other people's feelings and actions or for naturally occurring events. An obvious example would be your sense of guilt when it rained unexpectedly on the day of a large picnic you had organized to honor the retiring president of your club. In this case you could probably shake your absurd reaction off without a great deal of effort because you clearly cannot control the weather.

Guilt becomes much more difficult to overcome when someone suffers substantial pain and discomfort and insists it results from their personal interaction with you. In such cases it can be helpful to clarify the extent to which you can realis-201

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tically assume responsibility. Where does your responsibility end and the other person's begin? The technical name for this is "disattribution," but you might call it putting things into perspective.

Here's how it works. Jed was a mildly depressed college student whose twin brother, Ted, was so seriously depressed he dropped out of school and began to live like a recluse with his parents. Jed felt guilty about his brother's depression.

Why? Jed told me he had always been more outgoing and hardworking than his brother. Consequently, from early childhood he always made better grades and had more friends than Ted. Jed reasoned that the social and academic success he enjoyed caused his brother to feel inferior and left out. Consequently, Jed concluded that he was the cause of Ted's depression.

He then carried this line of reasoning to its illogical extreme and hypothesized that by feeling depressed himself, he might help Ted stop feeling depressed and inferior through some type of reverse (or perverse) psychology. When he went home for the holidays, Jed avoided the usual social activities, minimized his academic success, and emphasized how blue he was feeling. Jed made sure he gave his brother the loud and clear message that he too was down and out.

Jed took his plan so seriously that he was quite hesitant to apply the mood-control techniques I was trying to teach him.

In fact, he was downright resistant at first because he felt guilty about getting better and feared his recovery might have a devastating impact on Ted.

Like most personalization errors, Jed's painful illusion that he was at fault for his brother's depression contained enough half-truths to sound persuasive. After all, his brother probably had felt inferior and inadequate since early childhood and undoubtedly did harbor some jealous resentment of Jed's success and happiness. But the crucial questions were: Did it follow that Jed caused his brother's depression, and could Jed effectively reverse the situation by making himself miserable?

In order to help him assess his role in a more objective way, I suggested Jed use the triple-column technique (Figure 8-4). As a result of the exercise, he was able to see that his guilty thoughts were self-defeating and illogical. He reasoned that Ted's depression and sense of inferiority were ultimately 202

Figaro 8-4.

Automatic Thoughts

Cognitive Distortion

Rational Responses

I. I am part of the cause for Ted's depres-1. Jumping to conclusions 1. I myself am not the cause of Ted's de-sion due to our relationship since early

(mind reading);

pression. It is Ted's illogical thoughts and

childhood. I have always worked harder

personalization

attitudes that are causing his depression.

and been more successful.

The only responsibility that I can take is

that of being part of the environment that

Ted is interpreting in a negative, distorted

manner.

2. I feel it would upset Ted if I told him /

2. Jumping to conclusiong (

2. It might cheer Ted up and give him some

was having a good time at school while he

fortune teller error)

hope if he knows I'm feeling better and

is home alone doing nothing.

having a good time. It probably only de-

presses Ted more if I act as miserable as N

he does because this takes away his

hope.

too

3. If Ted is sitting around doing nothing, it 5. Personalization

is my responsibility to correct the situa-

3. I can encourage him to do things, but I

tion.

cannot force him. Ultimately this is his

4. I will be doing something for him by not 6. Jumping to conclusions (

responsibility.

doing anything for myself. In fact, it will

mind reading)

4. My actions are totally independent of his

help him if I am depressed.

actions. There is no reason to think that

my depression will be helpful to him. He

has even told me he doesn't want me to

be dragged down. If he sees that I am

improving, this might actually encourage

him. I can possibly be a good role model

for him by showing him that I can be

happy. I can't eliminate his sense of in-

adequacy by botching up my life.

David D. Burns, M.D.

caused by Ted's distorted thinking and not by his own happiness or success. For Jed to try to correct this by making himself miserable was as illogical as trying to put out a fire with gasoline. As Jed grasped this, his guilt and depression rapidly lifted, and he was soon back to normal functioning.

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PART III

"Realistic" Depressions

CHAPTER 9

Sadness Is Not Depression

"Dr. Burns, you seem to be claiming that distorted thinking is the only cause of depression. But what if my problems are real?" This is one of the most frequent questions I encounter during lectures and workshops on cognitive therapy. Many patients raise it at the start of treatment, and list a number of "

realistic" problems which they are convinced cause "realistic depressions." The most common are:

bankruptcy or poverty;

old age (some people also view infancy, childhood, ado-lescense, young adulthood and mid-life as periods of inevitable crisis);

permanent physical disability;

terminal illness;

the tragic loss of a loved one.

I'm sure you could add to the list. However, none of the above can lead to a "realistic depression." There is, in fact, no such thing! The real question here is how to draw the line between desirable and undesirable negative feelings. What is the difference between "healthy sadness" and depression?

The distinction is simple. Sadness is a normal emotion created by realistic perceptions that describe a negative event involving loss or disappointment in an undistorted way. Depression is an illness that always results from thoughts that are distorted in some way. For example, when a loved one dies, you validly think, "I lost him (or her), and I will miss the companionship and love we shared." The feelings such a thought creates are tender, realistic, and desirable. Your emotions will enhance your humanity and add depth to the meaning of life. In this way you gain from your loss.

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In contrast, you might tell yourself, "I'll never again be happy because he (or she) died. It's unfair!" These thoughts will trigger in you feelings of self-pity and hopelessness. Because these emotions are based entirely on distortion, they will defeat you.

Either depression or sadness can develop after a loss or a failure in your efforts to reach a goal of great personal importance. Sadness comes, however, without distortion. It involves a flow of feeling and therefore has a time limit. It never involves a lessening of your self-esteem. Depression is frozen—it tends to persist or recur indefinitely, and always involves loss of self-esteem.

When a depression clearly appears after an obvious stress, such as ill health, the death of a loved one, or a business reversal, it is sometimes called a "reactive depression." At times it can be more difficult to identify the stressful event that triggered the episode. Those depressions are often called "

endogenous" because the symptoms seem to be generated entirely out of thin air. In both cases, however, the cause of the depression is identical—your distorted, negative thoughts.

It has no adaptive or positive function whatsoever, and represents one of the worst forms of suffering. Its only redeeming value is the growth you experience when you recover from it.

My point is this: When a genuinely negative event occurs, your emotions will be created exclusively by your thoughts and perceptions. Your feelings will result from the meaning you attach to what happens. A substantial portion of your suffering will be due to the distortions in your thoughts.

When you eliminate these distortions, you will find that coping with the "real problem" will become less painful.

Let's see how this works. One clearly realistic problem involves serious illness, such as a malignancy. It is unfortunate that the family and friends of the afflicted person are often so convinced that it is normal for the patient to feel depressed, they fail to inquire about the cause of the depression, which more often than not turns out to be completely reversible. In fact, some of the easiest depressions to resolve are those found in people facing probable death. Do you know why?

These courageous individuals are often "supercopers" who haven't made misery their life-style. They are usually willing 208

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to help themselves in any way they can. This attitude rarely fails to transform apparently irreversible and "real" difficulties into opportunities for personal growth. This is why I find the concept of "realistic depressions" so personally abhorrent.

The attitude that depression is necessary strikes me as destructive, inhuman, and victimizing Let's get down to some specifics, and you can judge for yourself.

Loss of Life. Naomi was in her mid-forties when she received a report from her doctor that a "spot" had appeared on her chest X ray. She was a firm believer that going to doctors was a way of asking for trouble, so she procrastinated many months in checking this report out. When she did, her worst suspicions were validated. A painful needle biopsy confirmed the presence of malignant cells, and subsequent lung removal indicated that a spread of the cancer had already occurred.

This news hit Naomi and her family like a hand grenade.

As the months wore on, she became increasingly despondent over her weakened state. Why? It was not so much the physical discomfort from the disease process or the chemotherapy, although these were genuinely uncomfortable, but the fact that she was sufficiently weak that she had to give up the daily activities that had meant a great deal to her sense of identity and pride. She could no longer work around the house (now her husband had to do most of the chores), and she had to give up her two part-time jobs, one of which was volunteer reading for the blind.

You might insist, "Naomi's problems are real. Her misery is not caused by distortion. It's caused by the situation."

But was her depression so inevitable? I asked Naomi why her lack of activity was so upsetting. I explained the concept of "automatic thoughts," and she wrote down the following negative cognitions: (1) I'm not contributing to society; (2) I'

m not accomplishing in my own personal realm; (3) I'm not able to participate in active fun; and (4) I am a drain and drag on my husband. The emotions associated with these thoughts were: anger, sadness, frustration, and guilt.

When I saw what she had written down, my heart leaped for joy! These thoughts were no different from the thoughts of physically healthy depressed patients I see every day in my practice. Naomi's depression was not caused by her malig-209

David D. Burns, M.D.

nancy, but the malignant attitude that caused her to measure her sense of worth by the amount she produced! Because she had always equated her personal worth with her achievements, the cancer meant—"You're over the hill! You're ready for the refuse heap!" This gave me a way to intervene!

I suggested that she made a graph of her personal "worth"

from the moment of birth to the moment of death (see Figure 9-1, opposite page). She saw her worth as a constant, estimating it at 85 percent on an imaginary scale from 0 to 100

percent. I also asked her to estimate her productivity over the same period on a similar scale. She drew a curve with low productivity in infancy, increasing to a maximum plateau in adulthood, and finally decreasing again later in life (see Figure 9-1). So far, so good. Then two things suddenly dawned on her. First, while her illness had reduced her productivity, she still contributed to herself and her family in numerous small but nevertheless important and precious ways. Only all-or-nothing thinking could make her think her contributions were a zero. Second, and much more important, she realized her personal worth was constant and steady; it was a given that was unrelated to her achievements. This meant that her human worth did not have to be earned, and she was every bit as precious in her weakened state. A smile spread across her face, and her depression melted in that moment. It was a real pleasure for me to witness and participate in this small miracle. It did not eliminate the tumor, but it did restore her missing self-esteem, and that made all the difference in the way she felt.

Naomi was not a patient, but someone I spoke with while vacationing in my home state of California during the winter of 1976. I received a letter from her soon after which I share with you here:

David—

An incredibly belated, but really important "P.S." to my last letter to you. To wit: the simple little "graphs" you did of productivity as opposed to self-worth or self-esteem or whatever we shall call it: It has been especially sustaining to me, a plus which I dose out liberally! It really turned me into a psychologist without having to go 210

100— SELF-ESTEEM—WORTH AS A HUMAN BEING

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Figure 9-1. Naomi's worth and work graphs. In the upper figure Naomi plotted her human "worth" from the time of her birth to the time of her death. She estimated this at 85 percent. In the lower figure she plotted her estimated productivity and achievement over the course of her life. Her productivity began low in childhood, reached a plateau in adulthood, and would ultimately fall to zero at the time of death. This graph helped her comprehend that her "worth" and "achievement" were unrelated and had no correlation with each other.

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for my Ph.D. I find that it works with lots of things that badger and bother people. I've tried these ideas out on some of my friends. Stephanie is treated like a piece of furniture by a chit of a secretary one-third her age; Sue is put down constantly by her 14 year old twins; Becky's husband has just walked out; Ilga Brown is being made to feel like an interloper by her boy friend's 17 year old son, etc. To them all I say "Yes, but your personal worth is a CONSTANT, and all the garbage the world heaps on you doesn't touch it!" Of course in many cases I realize its an over-simplification and cannot be an ano-dyne for all things, but boy is it helpful and useful!

Again, thank you, sir!

As ever,

Naomi

She died in pain but with dignity six months later.

Loss of Limb. Physical handicaps represent a second category of problems felt to be "realistic." The afflicted individual—or the family members—automatically assume that the limitations imposed by old age or by a physical disability, such as an amputation or blindness, necessarily imply a decreased capacity for happiness. Friends tend to offer understanding and sympathy, thinking this represents a humane and "realistic" response. The case can be quite the opposite, however. The emotional suffering may be caused by twisted thinking rather than by a twisted body. In such a situation, a sympathetic response can have the undesirable effect of reinforcing self-pity as well as feeding into the attitude that the handicapped individual is doomed to less joy and satisfaction than others. In contrast, when the afflicted individual or family members learn to correct the distortions in their thinking, a full and gratifying emotional life can frequently result.

For example, Fran is a thirty-five-year-old married mother of two, who began to experience symptoms of depression around the time her husband's right leg became irreversibly paralyzed because of a spinal injury. For six years she sought relief from her intensifying sense of despair, and received a variety of treatments in and out of hospitals, including an-212

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tidepressant drugs as well as electroshock therapy. Nothing helped. She was in a severe depression when she came to me, and she felt her problems were insoluble.

In tears she described the frustration she experienced in trying to cope with her husband's decreased mobility: Every time I see other couples doing things we can't do tears come to my eyes. I look at couples taking walks, jumping in the swimming pool or the ocean, riding bikes together, and it just hurts. Things like that would be pretty tough for me and John to do. They take it for granted just like we used to. Now it would be so good and wonderful if we could do it. But you know, and I know, and John knows—we can't.

At first, I too had the feeling Fran's problem was realistic.

After all, they couldn't do many things that most of us can do. And the same could be said of old people, as well as those who are blind or deaf or who have had a limb amputated.

In fact, when you think of it, we all have limitations. So perhaps we should all be miserable . . . ? As I puzzled over this, Fran's distortion suddenly came to my mind. Do you know what it is? Look at the list on page 40 right now and see if you can pick it out . . . that's right, the distortion that led to Fran's needless misery was the mental filter. Fran was picking out and dwelling on each and every activity that was unavailable to her. At the same time the many things she and John could or might do together did not enter her conscious mind. No wonder she felt life was empty and dreary.

The solution turned out to be surprisingly simple. I proposed the following to Fran: "Suppose at home between sessions you were to make a list of all the things that you and John can do together. Rather than focus on things you can't do, learn to focus on the ones you can do. I, for example, would love to go to the moon, but I don't happen to be an astronaut, so it's not likely I'll ever get the opportunity. Now, if I focused on the fact that in my profession and at my age it is extremely unlikely I could ever get to the moon, I could make myself very upset. On the other hand, there are many things I can do, and if I focus on these, then I won't feel dis-213

David D. Burns, M.D.

appointed. Now, what would be some things you and John can do as a couple?"

FRAN: Well, we enjoy each other's company still. We go out to dinner, and we're buddies.

DAVID: Okay. What else?

FRAN: We go for rides together, we play cards. Movies, Bingo. He's teaching me how to drive . ..

DAVID: You see, in less than thirty seconds you've already listed six things you can do together. Suppose I gave you between now and next session to continue the list. How many items do you think you could come up with?

FRAN: Quite a lot of them. I could come up with things we've never thought of, maybe something unusual like skydiving.

DAVID: Right. You might even come up with some more adventurous ideas. Keep in mind that you and John might in fact be able to do many things you are assuming you can't do. For example, you told me you can't go to the beach. You mentioned how much you'd like to go swimming Could you go to a beach that's a little more secluded so you wouldn't have to feel quite so self-conscious? If I were on a beach and you and John were there, his physical disability wouldn't make one darn bit of difference to me. In fact, I recently visited a fine beach on the North Shore of Lake Tahoe in California with my wife and her family. As we were swimming, we suddenly happened upon a cove that had a nude beach, and here were all these -young people with no clothes on. Of course, I didn't actually look at any of them, I want you to understand! But in spite of this I did happen to notice that one young man had his right leg missing from the knee down, and he was there having fun with the rest of them. So I'm not absolutely convinced that just because someone is crippled or missing a limb they can't go to the beach and have fun. What do you think?

Some people might scoff at the idea that such a "difficult and real" problem could be so easily resolved, or that an intractable depression like Fran's could turn around in response to such a simple intervention. She did in fact report a com-214

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plete disappearance of her uncomfortable feelings and said she felt the best she had in years at the end of the session. In order to maintain such improvement, she will obviously need to make a consistent effort to change her thinking patterns over a period of time so she can overcome her bad habit of spinning an intricate mental web and getting trapped in it.

Loss of lob. Most people find the threat of a career reversal or the loss of livelihood a potentially incapacitating emotional blow because of the widespread assumption in Western culture that individual worth and one's capacity for happiness are directly linked with professional success. Given this value system, it seems obvious and realistic to anticipate that emotional depression would be inevitably linked with financial loss, career failure, or bankruptcy.

If this is how you feel, I think you would be interested in knowing Hal. Hal is a personable forty-five-year-old father of three, who worked for seventeen years with his wife's father in a successful merchandising firm. Three years before he was referred to me for treatment, Hal and his father-in-law had a series of disputes about the management of the firm. Hal resigned in a moment of anger, thus giving up his interests in the company. For the next three years, he bounced around from job to job, but had difficulty finding satisfactory employment. He didn't seem to be able to succeed at anything and began to view himself as a failure. His wife started working full time to make ends meet, and this added to Hal's sense of humiliation because he had always prided himself on being the breadwinner. As the months and years rolled on, his financial situation worsened, and he experienced increasing depression as his self-esteem bottomed out.

When I first met Hal, he had been attempting to work for three months as a trainee in commercial real-estate sales. He had rented several buildings, but had not yet finalized a sale.

Because he was working on a strict commission basis, his income during this break-in period was quite low. He was plagued by depression and procrastination. He would at times stay at home in bed all day, thinking to himself, "What's the use? I'm just a loser. There's no point in going to work. It's less painful to stay in bed."

Hal volunteered to permit the psychiatric residents in our training program at the University of Pennsylvania to observe 215

David D. Burns, M.D.

one of our psychotherapy sessions through a one-way mirror.

During this session, Hal described a conversation in the locker room of his club. A well-to-do friend had informed Hal of his interest in the purchase of a particular building.

You might think he would have jumped for joy on learning this, since the commission from such a sale would have given his career, confidence, and bank account a much needed boost. Instead of pursuing the contact, Hal procrastinated several weeks. Why? Because of his thought, "It's too complicated to sell a commercial property. I've never done this before. Anyway, he'll probably back out at the last minute.

That would mean I couldn't make it in this business. It would mean I was a failure."

Afterward, I reviewed the session with the residents. I wanted to know what they thought about Hal's pessimistic, self-defeating attitudes. They felt that Hal did in fact have a good aptitude for sales work, and that he was being unrealistically hard on himself. I used this as ammunition during the next session. Hal admitted that he was more critical of himself than he would ever be toward anyone else. For example, if one of his associates lost a big sale, he'd simply say, "It's not the end of the world; keep plugging." But if it happened to him he'd say, "I'm a loser." Essentially, Hal admitted he was operating on a "double standard"—tolerant and supportive toward other people but harsh, critical, and punitive toward himself. You may have the same tendency. Hal initially defended his double standard by arguing it would be helpful to him:

HAL: Well, first of all, the responsibility and interest that I have in the other person is not the same as the responsibility that I have for myself.

DAVID: Okay. Tell me more.

HAL: If they don't succeed, it's not going to be bread off my table, or create any negative feelings within my family unit. So the only reason I'm interested in them is because it's nice to have everybody succeed, but there ...

DAVID: Wait—wait—wait! You're interested in them be cause it's nice to have them succeed?

HAL: Yeah. I said . ..

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DAVID: The standard you apply to them is one that you think would help them succeed?

HAL: Right.

DAVID: And is the standard you apply to yourself the one that will help you succeed? How do you feel when you say, "One missed sale means I'm a failure"?

HAL: Discouraged.

HAvm: Is this helpful?

HAL: Well, it hasn't produced positive results, so apparently it's not helpful.

DAVID: And is it realistic to say "One missed sale and I'm a failure"?

HAL: Not really.

DAVID: So why are you using this all-or-nothing standard on yourself? Why would you apply helpful and realistic standards to these other people who you don't care so much about and self-defeating, hurtful standards to yourself who you do care something about?

Hal was beginning to grasp that it wasn't helping him to live by a double standard. He judged himself by harsh rules that he would never apply to anyone else. He initially defended this tendency—as many demanding perfectionists will—

by claiming it would help him in some way to be so much harder on himself than on others. However, he then quickly owned up to the fact that his personal standards were actually unrealistic and self-defeating because if he did try to sell the building and didn't succeed, he would view it as a catastrophe. His bad habit of all-or-nothing thinking was the key to the fear that paralyzed him and kept him from trying.

Consequently, he spent most of his time in bed, moping.

Hal asked for some specific guidelines concerning things he might do to rid himself of his perfectionistic double standards so that he could judge all individuals, including himself, by one objective set of standards. I proposed that as a first step, Hal might use the automatic-thought, rational-response technique. For example, if he were sitting at home procrastinating about work, he might be thinking, "If I don't go to work early and stay all day and get caught up on all my work, there's no point in even trying. I might as well lie in bed."

After writing this down, he would substitute a rational re-217

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sponse, "This is just all-or-nothing thinking, and it's baloney.

Even going to work for a half day could be an important step and might make me feel better."

Hal agreed to write down a number of upsetting thoughts before the next therapy session at those times he felt worthless and down on himself. (See Figure 9-2, below.) Two Figure 9-2.

Hal's homcwork for recording and challenging his self-critical thoughts. He wrote down the Rational Responses during the therapy session (see text).

Negative Thoughts

Rational Responses

(SELF-CRITICISM)

(SELF-DEFENSE)

1. I am lazy.

1. I have worked hard much of my

life.

2. I enjoy being ill.

2. It's not fun.

3. I am inadequate. I am a failure.

3. I've had some degree of success.

We've had a good home. We've

reared three outstanding children.

People admire and respect me.

I have involved myself in com-

munity activity.

4. This lying around doing nothing 4. I am experiencing symptoms of represents the real me.

an illness. It's not the "real me."

6. I could have done more.

5. At least, I did more than most people. It's meaningless and

pointless to say, "I could have

done more" because anyone

could say this.

days later he received a layoff notice from his employer, and he came to the next session highly convinced his self-criticaT

thoughts were absolutely valid and realistic. He'd been unable to come up with a single rational response. The notice implied that his failure to show up at work necessitated his release from his job. During the session, we discussed how he could learn to talk back to his critical voice.

DAVID: Okay, now let's see if we can write down some answers to your negative thoughts in the Rational Response 218

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column. Can you think of any answer based on what we talked about last session? Consider your statement "I am inadequate." Would this in any way result from your all-or-nothing thinking and perfectionistic standards?

The answer might be clearer to you if we do a role-reversal. It's sometimes easier to speak objectively about someone else. Suppose I came to you with your story and told you that I was employed by my wife's father.

Three years ago we had a fight. I felt I was being taken advantage of. I walked out. I've kinda been feeling blue ever since that time, and I've been tossing around from job to job. Now I've been fired from a job that was purely on a commission basis, and that's really a double defeat for me. In the first place, they didn't pay me anything, and then in the second place, they didn't even figure I was worth that much, so they fired me. I've concluded that I'm inadequate—an inadequate human being. What would you say to me?

HAL: Well, I . . . assuming that you'd gotten up to that point, say the first forty years or more of your life, you obviously were doing something.

DAVID: Okay, write that down in the Rational Response column. Make a list of all the good, adequate things you did for the first forty years of your life. You've earned money, you've raised children who were successful, etc., etc.

HAL: Okay. I can write down that I've had some success.

We've had a good home. We've reared three outstanding children. People admire and respect me, and I have involved myself in community activities.

DAVID: Okay, now those are all the things you've done.

How do you reconcile this with your belief that you are inadequate?

HAL: Well, I could have done more.

DAVID: Great! I was certain you'd figure out a clever way to disqualify your good points. Now write that down as another negative thought: "I could have done more."

Beautiful!

HAL: Okay, I've written it down as number five.

DAVID: Okay, now what's the answer to that one?

(long silence)

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DAVID: What is it? What's the distortion in that thought?

HAL: You're a tricky bugger!

DAVID: What is the answer?

HAL: At least I did more than most people.

DAVID: Right, and what percent do you believe that?

HAL: That I believe one hundred percent.

DAVID: Great! Put it down in the Rational Response column. Now, let's go back to this "I could have done more." Suppose you were Howard Hughes sitting up in his tower, with all those millions and billions. What could you say to yourself to make yourself unhappy?

HAL: Well, I'm trying to think.

DAVID: Just read what you wrote down on the paper.

HAL: Oh. "I could have done more."

DAVID: You can always say that, can't you?

HAL: Yeah.

DAVID: And that's why a lot of people who have won fame and fortune are unhappy. It's just an example of perfectionistic standards. You can go on and on and on, and no matter how much achievement you experience, you can always say, "I could have done more." This is an arbitrary way of punishing yourself. Do you agree or not?

HAL: Well, yeah. I can see that. It takes more than one element really to be happy. Because if it was money, then every millionaire and billionaire would be euphoric.

But there are more circumstances that involve being happy or satisfied with yourself than making money.

That's not the drive that paralyzes me. I've never had a drive to go after money.

DAVID: What were your drives? Did you have a drive to raise a family?

HAL: That was very important to me. Very important. And I participated in the rearing of the children.

DAVID: And what would you do in raising your children?

HAL: Well, I would work with them, teach them, play with them.

DAVID: And how did they come out?

HAL: I think they're great!

DAVID: Now, you were writing down, "I'm inadequate. I'm a failure." How can you reconcile this with the fact that your aim was to raise three children and you did it?

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HAL: Again, I guess I wasn't taking that into account.

DAVID: So how can you call yourself a failure?

HAL: I have not functioned as a wage earner . . . as an effective money-maker for several years.

DAVID: Is it realistic to call yourself a "failure" based on that? Here's a man who has had a depression for three years, and he finds it difficult to go to work, and now it's realistic to call him a failure? People with depressions are failures?

HAL: Well, if I knew more of what caused depression, I would be better able to make a value judgment.

DAVID: Well, we're not going to know the ultimate cause of depression for some time yet. But our understanding is that the immediate cause of depression is punitive, hurtful statements that you hit yourself with. Why this happens more to some people than others we don't know.

The biochemical and genetic influences have not yet been worked out. Your upbringing undoubtedly contributed, and we can deal with that in another session if you like.

HAL: Since there is no final proof yet of the ultimate cause of depression, can't we think of that in terms of a failure in itself? I mean, we don't know where it's coming from

. . . It must be something wrong with me that caused it . . . some way that I have failed myself that causes the depression.

DAVID: What evidence do you have for that?

HAL: I don't. It's just a possibility.

DAvm: Okay. But to make an assumption as punishing as that . . . anything is a possibility. But there is no evidence for that. When patients get over depressions, then they become just as productive as they ever were. Seems to me that if their problem was that they were failures, when they got over the depression they would still be failures. I've had college professors and corporate presidents who have come to me. They were just sitting and staring at the wall, but it was because of their depression. When they got over the depression, they started giving conferences and managing their businesses like before. So how can you possibly say that depression is due to the fact that they are failures? Seems to me that 221

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it's more the other way around—that the failure is due to the depression.

HAL: I can't answer that.

DAVID: It's arbitrary to say that you're a failure. You have had a depression, and people with depression don't do as much as when they are undepressed.

HAL: Then I'm a successful depressive.

DAVID: Right! Right! And part of being a successful depressive means to get better. So I hope that's what we're doing now. Imagine that you had pneumonia for the past six months. You wouldn't have earned any dough.

You could also say, "This makes me a failure." Would that be realistic?

HAL: I don't see how I could claim that. Because I certainly wouldn't have willfully created the pneumonia.

DAVID: Okay, can you apply the same logic to your depression?

HAL: Yeah, I can see it. I don't honestly feel that my depression was willfully induced either.

DAVID: Of course it wasn't. Did you want to bring this on?

HAL: Oh boy, no!

DAVID: Did you consciously do anything to bring it on?

HAL: Not that I know of.

DAVID: And if we knew what was causing depression, then we could put the finger someplace. Since we don't know, isn't it silly to blame Hal for his own depression? What we do know is that depressed people get this negative view of themselves. And they feel and behave in accord with this negative vision of everything. You didn't bring that on purposely or choose to be incapacitated. And when you get over that vision and when you have switched back to a nondepressed way of looking at things, you are going to be just as productive or more so than you've ever been, if you're typical of other patients that I've worked with. You see what I mean?

HAL: Yeah, I can see.

It was a relief for Hal to realize that although he had been financially unsuccessful for several years, it was nonsensical to label himself as "a failure." This negative self-image and his sense of paralysis resulted from his all-or-nothing think-222

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ing. His sense of worthlessness was based on his tendency to focus only on the negatives in his life (the mental filter) and to overlook the many areas where he had experienced success (

discounting the positive). He was able to see that he was aggravating himself unnecessarily by saying, "I could have done more," and he realized that financial value is not the same as human worth. Finally, Hal was able to admit that the symptoms he was experiencing—lethargy and procrastination—

were simply manifestations of a temporary disease process and not indications of his "true self." It was absurd for him to think his depression was just punishment for some personal inadequacy, any more than pneumonia would be.

At the end of the session, the Beck Depression Inventory test indicated that Hal had experienced a 50 percent improvement. In the weeks that followed, he continued to help himself, using the double-column technique. As he trained himself to talk back to his upsetting thoughts, he was able to reduce the distortions in his harsh way of evaluating himself, and his mood continued to improve.

Hal left the real-estate business and opened a paperback bookstore. He was able to break even; but in spite of considerable personal effort, he was unable to show enough profit to justify continuing beyond the first year's trial period. Thus, the marks of external success had not changed appreciably during this time. In spite of this, Hal managed to avoid significant depression and maintained his self-esteem. The day he decided to "throw in the towel" on the bookstore, he was still below the zero point financially, but his self-respect did not suffer. He wrote the following brief essay which he decided to read each morning while he was looking for a new job:

Why Am I Not Worthless?

As long as I have something to contribute to the well-being of myself and others, I am not worthless.

As long as what I do can have a positive effect, I am not worthless.

As long as my being alive makes a difference to even one person, I am not worthless (and this one person can be me if necessary).

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If giving love, understanding, companionship, encouragement, sociability, counsel, solace means anything, I am not worthless.

If I can respect my opinions, my intelligence, I am not worthless. If others also respect me, that is a bonus. If I have self-respect and dignity, I am not worthless. If helping to contribute to the livelihood of my employees'

families is a plus, I am not worthless.

If I do my best to help my customers and vendors through my productivity and creativity, I am not worthless.

If my presence in this milieu does makes a difference to others, I am not worthless.

I am not worthless. I am eminently worthwhile!

Loss of a Loved One. One of the most severely depressed patients I treated early in my career was Kay, a thirty-one-year-old pediatrician whose younger brother had committed suicide in a grisly way outside her apartment six weeks earlier. What was particularly painful for Kay was that she held herself responsible for his suicide, and the arguments she proposed in support of this point of view were quite convincing.

Kay felt she was confronted by an excruciating problem that was entirely realistic and insoluble. She felt that she too deserved to die and was actively suicidal at the time of referral.A frequent problem that plagues the family and friends of an individual who successfully commits suicide is the sense of guilt. There is a tendency to torture yourself with such thoughts as, "Why didn't I prevent this? Why was I so stupid?" Even psychotherapists and counselors are not immune to such reactions and may castigate themselves: "It's really my fault. If only I had talked to him differently in that last session. Why didn't I pin him down on whether or not he was suicidal? I should have intervened more forcefully. I murdered him!" What adds to the tragedy and irony is that in the vast majority of instances, the suicide occurs because of the victim's distorted belief that he has some insoluble problem which, viewed from a more objective perspective, would seem much less overwhelming and certainly not worth suicide.

Kay's self-criticism was all the more intense because she felt that she had gotten a better break in life than her 224

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brother, and so she had gone out of her way to try to compensate for this by providing emotional and finanical support for him during his long bout with depression. She arranged for his psychotherapy, helped pay for it, and even got him an apartment near hers so that he could call her whenever he was very down.

Her brother was a physiology student in Philadephia. On the day of his suicide, he called Kay to ask about the effects of carbon monoxide on the blood for a talk he was to give in class. Because Kay is a blood specialist, she thought the question was innocent and gave him the information without thinking. She didn't talk to him very long because she was preparing a major lecture to deliver the following morning at the hospital where she worked. He used her information to make his fourth and final attempt outside her apartment window while she was preparing her lecture. Kay held herself responsible for his death.

She was understandably miserable, given the tragic situation she confronted. During the first few therapy sessions she outlined why she blamed herself and why she was convinced that she would be better off dead: "I had assumed the responsibility for my brother's life. I failed, so I feel I am responsible for his death. It proves that I did not adequately support him as I should have. I should have known that he was in an acute situation, and I failed to intervene. In retrospect, it's obvious that he was getting suicidal again. He'd had three prior serious suicide attempts. If I had just asked him when he called me, I could have saved his life. I was angry with him on many occasions during the month before he died, and in all honesty he could be a burden and a frustration at times.

At one time I remember feeling annoyed and saying to myself that perhaps he would be better off dead. I feel terrible guilt for this. Maybe I wanted him to die! I know that I let him down, and so I feel that I deserve to die."

Kay was convinced that her guilt and agony were appropriate and valid. Being a highly moral person with a strict Catholic upbringing, she felt that punishment and suffering were expected of her. I knew there was something fishy about her line of reasoning, but I couldn't quite penetrate her illogic for several sessions because she was bright and persuasive and made a convincing case against herself. I almost began to 225

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buy her belief that her emotional pain was "realistic." Then, the key that I hoped might free her from her mental prison suddenly dawned on me. The error she was making was number ten discussed in Chapter 3—personalization.

At the fifth therapy session, I used this insight to challenge the misconceptions in Kay's point of view. First of all, I emphasized that if she were responsible for her brother's death, she would have had to be the cause of it. Since the cause of suicide is not known, even by experts, there was no reason to conclude that she was the cause.

I told her that if we had to guess the cause of his suicide, it would be his erroneous conviction that he was hopeless and worthless and that his life was not worth living. Since she did not control his thinking, she could not be responsible for the illogical assumptions that caused him to end his life. They were his errors, not hers. Thus, in assuming responsibility for his mood and actions, she was doing so for something that was not within her domain of control. The most that anyone could or would expect of her was to try to be a helping agent, as she had been within the limits of her ability.

I emphasized that it was unfortunate she did not have the knowledge necessary to prevent his death. If it had dawned on her that he was about to make a suicide attempt, she would have intervened in whatever manner possible. However, since she did not have this knowledge, it was not possible for her to intervene. Therefore, in blaming herself for his death she was illogically assuming that she could predict the future with absolute certainty, and that she had all the knowledge in the universe at her disposal. Since both these expectations were highly unrealistic, there was no reason for her to despise herself. I pointed out that even professional therapists are not infallible in their knowledge of human nature, and are frequently fooled by suicidal patients in spite of their presumed expertise.

For all these reasons, it was a major error to hold herself responsible for his behavior because she was not ultimately in control of him. I emphasized that she was responsible for her own life and well-being. At this point it dawned on her that she was acting irresponsibly, not because she "let him down"

but because she was allowing herself to become depressed and was contemplating her own suicide. The responsible thing 226

FEELING GOOD

to do was to refuse to feel any guilt and to end the depression, and then to pursue a life of happiness and satisfaction. This would be acting in a responsible manner.

This discussion was followed by a rapid improvement in her mood. Kay attributed this to a profound change in her attitude. She realized we had exposed the misconceptions that made her want to kill herself. She then elected to remain in therapy for a period of time in order to work on enhancing the quality of her own life, and to dispel the chronic sense of oppression that had plagued her for many years prior to her brother's suicide.

Sadness Without Suffering. The question then arises, What is the nature of "healthy sadness" when it is not at all con-taminated by distortion? Or to put it another way—does sadness really need to involve suffering?

While I cannot claim to know the definitive answer to this question, I would like to share an experience which occurred when I was an insecure medical student, and I was on my clinical rounds on the urology service in the hospital at Stanford University Medical Center in California. I was assigned to an elderly man who recently had had a tumor successfully removed from his kidney. The staff anticipated his rapid discharge from the hospital, but his liver function suddenly began to deterioriate, and it was discovered that the tumor had metastasized to his liver. This sad complication was untreatable, and his health began to fail rapidly over several days. As his liver function worsened, he slowly began to get groggier, slipping toward an unconscious state. His wife, aware of the seriousness of the situation, came and sat by his side night and day for over forty-eight hours. When she was tired, her head would fall on his bed, but she never left his side. At times she would stroke his head and tell him. "You're my man and I love you." Because he was placed on the critical list, the members of his large family, including children, grandchildren, and great-grandchildren, began to arrive at the hospital from various parts of California.

In the evening the resident in charge asked me to stay with the patient and attend the case. As I entered the room, I realized that he was slipping into a coma. There were eight or ten relatives there, some of them very old and others very young. Although they were vaguely aware of the seriousness 227

David D. Burns, M.D.

of his condition, they had not been informed of just how grave the imminent situation was. One of his sons, sensing the old gentleman was nearing the end, asked me if I would be willing to remove the catheter which was draining his blad-der. I realized the removal of the catheter would indicate to the family that he was dying, so I went to ask the nursing staff if this would be appropriate to do. The nursing staff told me that it would because he was indeed dying. After they showed me how to remove a catheter, I went back to the patient and did this while the family waited. Once I was done, they realized that a certain support had been removed, and the son said, "Thank you. I know it was uncomfortable for him, and he would have appreciated this." Then the son turned to me as if to confirm the meaning of the sign and asked, "Doctor, what is his condition? What can we expect?"

I felt a sudden surge of grief. I had felt close to this gentle, courteous man because he reminded me of my own grandfa-ther, and I realized that tears were running down my cheeks.

I had to make a decision either to stand there and let the family see my tears as I spoke with them or to leave and try to hide my feelings. I chose to stay and said with considerable emotion, "He is a beautiful man. He can still hear you, although he is nearly in a coma, and it is time to be close to him and say good-bye to him tonight." I then left the room and wept. The family members also cried and sat on the bed, while they talked to him and said good-bye. Within the next hour his coma deepened until he lost consciousness and died.

Although his death was profoundly sad for the family and for me, there was a tenderness and a beauty to the experience that I will never forget. The sense of loss and the weeping reminded me—"You can love. You can care." This made the grief an elevating experience that was entirely devoid of pain or suffering for me. Since then, I have had a number of experiences that brought me to tears in this same way. For me the grief represents an elevation, an experience of the highest magnitude.

Because I was a medical student, I was concerned that my behavior might be seen as inappropriate by the staff. The chairman of the department later took me aside and informed me that the patient's family had asked him to extend their appreciation to me for being available to them and for 228

FEELING GOOD

helping make the occasion of his passing intimate and beautiful. He told me that he too had always felt strongly toward this particular individual, and showed me a painting of a horse the elderly man had done which was hanging on his wall.

The episode involved a letting go, a feeling of closure, and a sense of good-bye. This was in no way frightening or terrible; but in fact, it was peaceful and warm, and added a sense of richness to my experience of life.

229

PART IV

Prevention and

11

Personal Growth

CHAPTER 10

The Cause of It All

When your depression has vanished, it's a temptation to enjoy yourself and relax. Certainly you're entitled. Toward the end of therapy, many patients tell me they feel the best they've ever felt in their lives. It sometimes seems that the more hopeless and severe and intractable the depression seemed, the more extraordinary and delicious the taste of happiness and self-esteem once it is over. As you begin to feel better, your pessimistic thinking pattern will recede as dramatically and predictably as the melting of winter's snow when spring arrives. You may even wonder how in the world you came to believe such unrealistic thoughts in the first place. This profound transformation of the human spirit never ceases to amaze me. Over and over I have the opportunity to observe this magical metamorphosis in my daily practice.

Because your change in outlook can be so dramatic, you may feel convinced that your blues have vanished forever.

But there is an invisible residue of the mood disorder that remains. If this is not corrected and eliminated, you will be vulnerable to attacks of depression in the future.

There are several differences between feeling better and getting better. Feeling better simply indicates that the painful symptoms have temporarily disappeared. Getting better implies:

1. Understanding why you got depressed.

2. Knowing why and how you got better. This involves a mastery of the particular self-help techniques that worked specifically for you so that you can reapply them and make them work again whenever you choose.

3. Acquiring self-confidence and self-esteem. Self-confidence is based on the knowledge that you have a good chance of being reasonably successful in personal rela-233

David D. Burns, M.D.

tionships and in your career. Self-esteem is the capacity to experience maximal self-love and joy whether or not you are successful at any point in your life.

4. Locating the deeper causes of your depression.

Parts I, II, and III of this book were designed to help you achieve the first two goals. The next several chapters will help you with the third and fourth goals.

Although your distorted negative thoughts will be substantially reduced or entirely eliminated after you have recovered from a bout of depression, there are certain "silent assumptions" that probably still lurk in your mind. These silent assumptions explain in large part why you became depressed in the first place and can help you predict when you might again be vulnerable. And they contain therefore the key to relapse prevention.

Just what is a silent assumption? A silent assumption is an equation with which you define your personal worth. It represents your value system, your personal philosophy, the stuff on which you base your self-esteem. Examples: (1) "If someone criticizes me, I feel miserable because this automatically means there is something wrong with me." (2) "To be a truly fulfilled human being, I must be loved. If I am alone, I am bound to be lonely and miserable." (3) "My worth as a human being is proportional to what I've achieved." (4) "If I don't perform (or feel or act) perfectly, I have failed." As you will learn, these illogical assumptions can be utterly self-defeating. They create a vulnerability that predisposes you to uncomfortable mood swings. They represent your psychological Achilles' heel.

In the next several chapters you will learn to identify aid evaluate your own silent assumptions. You might find that an addiction to approval, love, achievement, or perfection forms the basis of your mood swings. As you learn to expose and challenge your own self-defeating belief system, you will lay the foundation for a personal philosophy that is valid and self-enhancing. You will be on the road to joy and emotional enlightenment.

In order to unearth the origins of your mood swings, most psychiatrists, as well as the general public, assume that a long and painfully slow (several years) therapeutic process is 234

FEELING GOOD

necessary, after which most patients would find it difficult to explain the cause of their depression. One of the greatest contributions of cognitive therapy has been to circumvent this.

In this chapter you will learn two different ways to identify silent assumptions. The first is a startlingly effective method called the "vertical-arrow technique," which allows you to probe your inner psyche.

The vertical-arrow technique is actually a spin-off of the double-column method introduced in Chapter 4, in which you learned how to write down your upsetting automatic thoughts in the left-hand column and substitute more objective rational responses. This method helps you feel better because you deprogram the distortions in your thinking patterns. A brief example is shown in Figure 10-1. It was written by Art, the Figure 10-1.

Automatic Thoughts

Rational Responses

1. Dr. B said the patient found

1. Mind reading; mental filter;

my comment abrasive. He --,

labeling.

probably thinks Fm a lousy

Just because Dr. B pointed out

therapist.

my error it doesn't follow ha

thinks rm a "lousy therapist."

I'd have to ask him to sea

what he really thinks, but on

many occasions he has praised

me and said I had outstanding

talent

psychiatric resident described in Chapter 7, who became upset after his supervisor tried to offer a constructive criticism.

Putting the lie to his upsetting thoughts reduced Art's feelings of guilt and anxiety, but he wanted to know how and why he made such an illogical interpretation in the first place.

Perhaps you've also begun to ask yourself—is there a pattern

inherent in my negative thoughts? Is there some psychic kink that exists on a deeper level of my mind?

Art used the vertical-arrow technique to answer these questions. First, he drew a short downward arrow directly beneath

his automatic thought (see Figure 10-2, page 236). This downward arrow is a form of shorthand which tells Art to

235

Figure 10-2. Exposing the silent assumption(s) that give rise to your automatic thoughts with the use of the vertical-arrow method. The downward arrow is a form of shorthand for the following questions: "If that thought were true, why would it upset me? What would it mean to me?"

The question represented by each downward arrow in the example .appears in quotation marks next to the arrow. This is what you might ask yourself if you had written down the automatic thought. This process leads to a chain of automatic thoughts that will reveal the root cause of the problem.

Automatic Thoughts

Rational Responses

1. Dr. B. probably things I'm a -,

lousy therapist.

♦

"If he did think this,

why would it be upset-

ting to me?"

2. That would mean I was a lousy -, therapist because he's an expert.

♦

"Suppose I was a lousy

therapist, what would

this mean to me?"

3. That would mean I was a total -,

failure. It would mean I was no

good.

.1, "Suppose I was no good.

Why would this be a

problem? What would

it mean to me?"

4. Then the word would spread

and everyone would find out

what a bad person I was. Then

no one would respect me. I'd

get drummed out of the medical

society, and I'd have to move to

another state.

.1, "And what would that

mean?"

5. It would mean I was worthless.

I'd feel so miserable I'd want

to die.

236

FEELING GOOD

ask himself, "If this automatic thought were actually true, what would it mean to me? Why would it be upsetting to me?" Then Art wrote down the next automatic thought that immediately came to mind. As you can see, he wrote, "If Dr. B. thinks I'm a lousy therapist, it would mean I was a lousy therapist because Dr. B. is an expert." Next Art drew a second downward arrow beneath this thought and repeated the same process so as to generate yet another automatic thought, as shown in Figure 10-2. Every time he came up with a new automatic thought, he immediately drew a vertical arrow beneath it and asked himself, "If that were true, why would it upset me?" As he did this over and over, he was able to generate a chain of automatic thoughts, which led to the silent assumptions that gave rise to his problems. The downward-arrow method is analogous to peeling successive layers of skin off an onion to expose the ones beneath. It is actually quite simple and straightforward, as you will see in Figure 10-2.

You will notice that the vertical-arrow technique is the opposite of the usual strategy you use when recording your automatic thoughts. Ordinarily you substitute a rational response that shows why your automatic thought is distorted and invalid (Figure 10-1). This helps you change your thinking patterns in the here and now so that you can think about life more objectively and feel better. In the vertical-arrow method you imagine instead that your distorted automatic thought is absolutely valid, and you look for the grain of truth in it. This enables you to penetrate the core of your problems.

Now review Art's chain of automatic thoughts in Figure 10-2 and ask yourself—what are the silent assumptions that predispose him to anxiety, guilt, and depression? There are several:

1. If someone criticizes me, they're bound to be correct.

2. My worth is determined by my achievement.

3. One mistake and the whole is ruined. If I'm not successful at all times, I'm a total zero.

4. Others won't tolerate my imperfection. I have to be perfect to get people to respect and like me. When I goof up, I'll encounter fierce disapproval and be punished.

237

Figure 10-3. After eliciting his chain of automatic thoughts, using the downward-arrow method, Art identified the cognitive distortions and substituted more objective responses.

Automatic Thoughts

Rational Responses

I. Dr. B. probably thinks I'm a

1. Just because Dr. B. pointed out

lousy therapist.

my error it doesn't follow he

♦

"If he did think this,

thinks I'm a -"lousy therapist."

why would it be. upset-

I'd have to ask him to see what

he really thinks, but on many

ting to me?

occasions he has praised me and

said I had outstanding talent.

2. That would mean I was a lousy 2. An expert can only point out

therapist because he's an

my specific strengths and weak-

expert.

nesses as a therapist. Any time

♦

"Suppose I was a lousy

anyone labels me as "lousy"

therapist, what would

they are simply making a global,

this mean to me?"

destructive,

useless

statement. I have had a lot of

success with most of my

patients, so it can't be true I'm

"lousy" no matter who says it.

3. Overgeneralization. Even if I

3. That would mean I was a total

were relatively unskilled and

failure. It would mean I was no

ineffective as a therapist, it

good.

wouldn't mean I was "a total

♦

"Suppose I was no good.

failure" or "no good." 'I have

Why would this be a

many other interests, strengths,

problem? What would

and desirable qualities that

aren't related to my career.

it mean to me?"

4. This is absurd. If I made a mis-

4. Then the word would spread

take, I can correct it. "The

and everyone would find out

word" isn't going to spread

What a bad person I was. Then

around the state like wildfire

no one would respect me. I'd

just because I made an error:

get drummed out of the medical

What are they going to do, pub-

society, and I'd have to move to

lish a headline in the news-

another state.

paper: "NOTED PSYCHIA-

♦

"And what would that

TRIST MAKES MISTAKE!"?

mean?"

5. Even if everyone in the wor:d

5. It would mean I was worthless.

238

FEELING GOOD

Figure 10-3. Continued.

Automatic Thoughts

Rational Responses

I'd feel so miserable I'd want

disapproves of me or criticizes

to die.

me, it can't make me worthless

because I'm not worthless. If

I'm not worthless, I must be

quite worthwhile. So, what is

there to fed miserable about?

5. This disapproval will mean I am a bad, worthless person.

Once you have generated your own chain of automatic thoughts and clarified your silent assumptions, it is crucial to pinpoint the distortions and substitute rational responses as you usually do (see Figure 10-3, page 238).

The beauty of the downward-arrow method is that it is in-ductive and Socratic: Through a process of thoughtful questioning, you discover on your own the beliefs that defeat you.

You unearth the origin of your problems by repeating the following questions over and over: "If that negative thought were true, what would it mean to me? Why would it upset me?" Without introducing some therapist's subjective bias or personal beliefs or theoretical leanings, you can objectively and systematically go right to the root of your problems. This circumvents a difficulty that has plagued the history of psychiatry. Therapists from all schools of thought have been no-torious for interpreting patients' experiences in terms of preconceived notions that may have little or no experimental validation. If you don't "buy" your therapist's explanation of the origin of your problems, this is likely to be interpreted as `

resistance" to the "truth." In this subtle way, your troubles eet forced into your therapist's mold regardless of what you say. Imagine the bewildering array of explanations for suffer-ine that you would hear if you went to a religious counselor (

spiritual factors), a psychiatrist in a Communist country (

the social-political-economic environment), a Freudian analyst (internalized anger), a behavior therapist (a low rate of positive reinforcement), a drug-oriented psychiatrist (genetic factors and brain-chemistry imbalance), a family therapist (

disturbed interpersonal relationships), etc.!

239

David D. Burns, M.D.

A word of caution when you apply the vertical-arrow method. You will short-circuit the process if you write down thoughts that contain descriptions of your emotional reactions. Instead, write down the negative thoughts that cause your emotional reactions. Here's an example of the wrong way to do it:

First Automatic Thought: My boyfriend didn't call me this weekend as he promised he would.

"Why is that upsetting to me? What does

it mean to me?"

Second Automatic Thought: Oh, it's awful and terrible because I can't stand it.

This is useless. We already know you feel awful and terrible. The question is—what thoughts automatically crossed your mind that caused you to feel so upset? What would it mean to you if he had neglected you?

Here's the correct way to do it;

1. My boyfriend didn't call me this weekend as he promised he would.

•

"Why would that be upsetting

to me? What does it mean to

me?'

2. That means he's neglecting me. That means he really doesn't love me.

•

"And suppose that were true.

What would that mean to

me?"

3. That would mean there's something wrong with me.

Otherwise he'd be more attentive.

•

"And suppose that was true.

What would that mean to

me?"

4. That would mean I was going to be rejected.

•

"And if I were in fact rejected,

what then? What would that

mean to me?"

5. That would mean I was unlovable and I would always be rejected.

"And if that happened, why

would it upset me?"

240

FEELING GOOD

6. That would mean I'd end up alone and miserable.

Thus, by pursuing the meaning rather than your feelings, your silent assumptions became obvious: (1) If I'm not loved I'm not worthwhile; and (2) I'm bound to be miserable if I'

m alone.

This is not to say your feelings aren't important. The whole point is to deliver the real McCoy—valid emotional transformation.

The Dysfunctional Attitude Scale (DAS). Because of the crucial importance of eliciting the silent assumptions that give rise to your mood swings, a second, simpler method for eliciting them called the "Dysfunctional Attitude Scale" (DAS) has been developed by a member of our group, Dr. Arlene Weissman. She has compiled a list of one hundred self-defeating attitudes that commonly occur in individuals predisposed to emotional disorders. Her research has indicated that while negative automatic thoughts are reduced dramatically between episodes of depression, a self-defeating belief system remains more or less constant during episodes of depression and remission. Dr. Weissman's studies confirm the concept that your silent assumptions represent a predisposition to emotional turbulence that you carry with you at all times.

Although a complete presentation of the lengthy Dysfunctional Attitude Scale would be beyond the scope of this book, I have selected a number of the more common attitudes and have added several others which will be useful. As you fill out the questionnaire, indicate how much you agree or disagree with each attitude. When you are finished, an answer key will let you score your answers and generate a profile of your personal value systems. This will show your areas of psychological strength and vulnerability.

Answering the test is quite simple. After each of the thirty-five attitudes, put a check in the column that represents your estimate of how you think most of the time. Be sure to choose only one answer for each attitude. Because we are all different, there is no "right" or "wrong" answer to any statement. To decide whether a given attitude is typical of your own philosophy, recall how you look at things most of the dine.

241

David D. Burns, M.D.

EXAMPLE:

Disagree

Agree

Agree

Disagree

Very

Strongly Slightly

Neutral

Slightly

Much

35. People

who

have

the marks of success

(good looks, social

status,

wealth,

o r

fame)

are

bound

to be happier than

those who do not.

In this example the checkmark in the Agree Slightly column indicates that the statement is somewhat typical of the attitudes of the person completing the inventory. Now go ahead.

The Dysfunctional Attitude Scale *

Disagree

Very

Agree

Agree

Disagree

Much

Strongly Slightly

Neutral

Slightly

1. Criticism will obvi-

ously upset the per-

son who receives the

criticism.

2. It is best to give up

my own interests in

order to please other

people.

• Copyright 1978, Arlene Weissman.

242

Disagree

Agree

Agree

Disagree Very

Strongly Slightly Neutral Slightly Much

3. I need othcr people's

approval in order to

be happy.

4. If someone impor-

tant to mc expects

me to do something,

then I really should

do it.

5. My value as a person

depends greatly on

what others think of

me.

6. I cannot find happi-

ness

without being

loved

by

another

person.

7. If others dislike you,

you arc bound to be

less happy.

8. If people whom I

care about

reject

me, it means there

is something wrong

with mc.

9. If a person I love

does not love me, it

means I am unlov-

able.

10. Being isolated from

others is bound

to

lead to unhappiness.

11. If I am to be

a

worthwhile person, I

must be truly out-

standing in at least

one major respect.

243

Disagree

Agree

Agree

Disagree

Very

Strongly Slightly Neutral Slightly Much

12. I must be a useful,

productive,

creative

person

or life

has

no purpose.

13. Peoplewhohave

good ideas are more

worthy

than

those

who do not.

14. If I do not do as well

as other people,

it

means I am inferior.

15. If I fail at my work,

then I am a failure

as a person.

16. If you

cannot do

something well, there

is little point in do-

ing it at all.

17. It is shameful for a

person to display his

weaknesses.

18. A person should try

to be the

best

at

everything he under-

takes. -

19. I should be upset if

I make a mistake.

20. If I don't set

the

highest standards for

myself, I am likely

to end up a second-

rate person.

21. If I strongly believe

I deserve something,

I have reason to ex-

pect that I should

get ft.

244

Disagree

Agree

Agree

Disagree Very

Strongly Slightly Neutral Slightly Much

22. It is necessary to be-

come frustrated if

you find obstacles

to getting what you

want.

23. ItI put other peo-

ple's needs before

my own, they should

Help me when I

need something from

them.

24. If I am a good hus-

band (or wife), then

my spouse is bound

to love me.

25. If I do nice things

for someone, I can

anticipate that they

will respect me and

treat me just as well

as I treat them.

25. I should assume re-

sponsibility for how

people feel and be-

have if they are

close to me.

27. If

I criticize

the

way someone does

something and they

become angry or de-

pressed, this means

I have upset them.

23. To be a good, worth-

while, moral person,

I must try to help

everyone who needs

it

._..

245

g t 1

, .

Agree

Agree

Disagree'

Strongl Slightly Neutral Slightly

y

29. If a child is having

emotional or behav-

ioral &faculties, this

shows that the child's

parents have failed

in some important

respect

30. I should be able to

please everybody.

31. I cannot expect to

control how I feel

when something bad

baPPa•

32. There is no point in

trying to change up-

setting emotions be-

cause they are a

valid and inevitable

part of daily living.

33. My moods are pri-

marily created by

factors

that

are

largely beyond my

control, such as the

past, or body chem-

istry, or. hormone cy-

cles, or biorhythms,

or chance, or fate.

34. My

happiness

is

largely dependent on

what happens to me.

35. People who have

the marks of success

(good looks, social

status,

wealth, or

fame)

are

bound

to be happier than

those who do not.

246

FEELING GOOD

Now that you have completed the DAS, you can score it in the following way. Score your answer to each of the thirty-five attitudes according to this key:

Agree

Agree

Disagree

Disagree

Strongly

Slightly

Neutral

Slightly

Very Much

—2

—1

0

+1

+2

Now add up your score on the first five attitudes. These measure your tendency to measure your worth in terms of the opinions of others and the amount of approval or criticism you receive. Suppose your scores on these five items were +2; +1; —1; +2; 0. Then your total score for these five questions would be +4.

Proceed in this way to add up your score for items 1

through 5, 6 through 10, 11 through 15, 16 through 20, 21

through 25, 26 through 30, and 31 through 35, and record these as illustrated in the following example:

SCORING EXAMPLE:

Value System

Attitudes

Individual Scores

Total Scores

L Approval

1 through 5

+2,+1,-1,+2,0

+4

IL Love

6 through 10 —2,-1,-2,-2,0

—7

II/. Achievement 11 through 15 +1,+1,0,0,-2

0

IV. Perfectionism 16 through 20 +2,+2,+1,+1,+1

+7

V. Entitlement 21 through 25 +1,+1,-1,+1,0

+2

VL Omnipotence 26 through 30 —2,-1,0,-1,+1

—3

TU. Autonomy

31 through 35 —2,-2,-1,-2,-2

—9

247

David D. Burns, M.D.

RECORD YOUR ACTUAL SCORES HERE:

Value System

Attitudes

Individual Scores

Total Scores

I. Approval

1 through 5

II. Love

6 through 10

III. Achievement

11 through 15

IV. Perfectionism

16 through 20

V. Entitlement

21 through 25

VL Omnipotence 26 through 30

V1L Autonomy

31 through 35

Each cluster of five items from the scale measures one of seven value systems. Your total score for each cluster of five items can range from +10 to —10. Now plot your total scores on each of the seven variables so as to develop your "

personal-philosophy profile" as follows:

248

FEELING GOOD

SCORING EXAMPLE:

4.

e

41).

• e

<;).

e

.‹z.& ,,,-

+ 1 0 —

,.0 ,040 ,.<,>

4,.,,' ,0>

0,,..> ko

— — — - - _

_ ..... _ ...... ..

0.6.0

7.1

4

.

8 - - _ - -

. 2

:.'r., ol

—.

....MD

•••1

M..0

dim.

t " % + 6 - - - , -

-

• -

......

A

-2

-

:-.

•

-6-

0.10

■•••■

••■■•

•■•••

•••■■

•■•■

—

-

8

■•••■•

.10

-

I.

II.

III.

IV.

V.

VL

VII.

249

V•

V

iP

0

V"

David D. Burns, M.D.

As you can see, a positive score represents an area where you are psychologically strong. A negative score represents an area where you're emotionally vulnerable.

This individual has strengths in the areas of approval, perfectionism, and entitlement. His vulnerabilities lie in the areas of love, omnipotence, and autonomy. The meanings of these concepts will be described. First, plot your own personal-philosophy profile here.

4

.$540

■il•

0

ci) A

.1-

+10

--.....

+ 8

-

+ 6

+ 4 _

+ 2 _

0

2 _

—4— .

—6—.

0

—

— 8 —

—10 —

L

IL

La.

IV.

V.

VL

VII.

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Interpreting Your DAS Scores

I, Approval. The first five attitudes on the DAS test probe your tendency to measure your self-esteem based on how people react to you and what they think of you. A positive score between zero and ten indicates you are independent, with a healthy sense of your own worth even when confronted with criticism and disapproval. A negative score between

rero and minus ten indicates you are excessively dependent because you evaluate yourself through other people's eyes. If someone insults you or puts you down, you automatically tend to look down on yourself. Since your emotional well-being is exquisitely sensitive to what you imagine people think of you, you can be easily manipulated, and you are vulnerable to anxiety and depression when others criticize you or are angry with you.

IL Love. The second five attitudes on the test assess your tendency to base your worth on whether or not you are ioved. A positive score indicates you see love as desirable, but you have a wide range of other interests you also find gratifying and fulfilling. Hence, love is not a requirement for your happiness or self-esteem. People are likely to find you attractive because you radiate a healthy sense of self-love and are interested in many aspects of living.

A negative score indicates you are a "love junkie." You see love as a "need" without which you cannot survive, much less be happy. The closer your score is to minus ten, the more dependent on love you are. You tend to adopt inferior, put-down roles in relationships with people you care about for fear of alienating them. The result of this, more often than not, is that they lose respect for you and consider you a burden because of your attitude that without their love you would collapse. As you sense that people drift away from you, you become gripped by a painful, terrifying withdrawal syndrome. You realize you may not be able to "shoot up"

with your daily dose of affection and attention. You then become consumed by the driving compulsion to "get love." Like Most junkies, you may even resort to coercive, manipulative behavior to get your "stuff." Ironically, your needy, greedy 251

David D. Burns, M.D.

love addiction drives many people away, thus intensifying your loneliness.

///. Achievement. Your score on attitudes 11 through 15

will help you measure a different type of addiction. A negative score indicates you are a workaholic. You have a constricted sense of your own humanity, and you see yourself as a commodity in the marketplace. The more negative your score, the more your sense of self-worth and your capacity for joy are dependent on your productivity. If you go on vacation, if your business slumps, if you retire or become ill and inactive, you will be in danger of an emotional crash.

Economic and emotional depressions will seem identical to you. A positive score, in contrast, indicates that you enjoy creativity and productivity, but do not see them as an exclusive or necessary road to self-esteem and satisfaction.

M. Perfectionism. Items 16 through 20 measure your tendency to perfectionism. A negative score indicates you are hooked on searching for the Holy Grail. You demand perfection in yourself—mistakes are taboo, failure is worse than death, and even negative emotions are a disaster. You're supposed to look, feel, think, and behave superbly at all times.

You sense that being less than spectacular means burning in the flames of hell. Although you drive yourself at an intense pace, your satisfactions are meager. Once you do achieve a goal, another more distant goal instantly replaces it, so you never experience the reward of getting to the top of the mountain. Eventually you begin to wonder why the promised payoff from all your effort never seems to materialize. Your life becomes a joyless, tedious treadmill. You are living with unrealistic, impossible personal standards, and you need to reevaluate them. Your problem does not lie in your performance, but in the yardstick you use to measure it. If you bring your expectations in line with reality, you will be regularly pleased and rewarded instead of frustrated.

A positive score suggests you have the capacity to set meaningful, flexible, appropriate standards. You get great satisfaction from processes and experiences, and you are not exclusively fixated on outcomes. You don't have to be outstanding at everything, and you don't always have to "try your best." You don't fear mistakes, but you see them as golden opportunities to learn and to endorse your humanity.

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Paradoxically, you are likely to be much more productive than your perfectionistic associates because you do not become compulsively preoccupied with detail and correctness.

Your life is like a flowing river or a geyser compared with your rigid perfectionistic friends who appear more like icy glaciers.

V. Entitlement. Attitudes 21 through 25 measure your sense of "entitlement." A negative score indicates that you feel "entitled" to things—success, love, happiness, etc. You expect and demand that your wants be met by other people and by the universe at large because of your inherent good-ness or hard work. When this does not happen—as is often the case—you are locked into one of two reactions. Either you feel depressed and inadequate or you become irate. Thus, you consume enormous amounts of energy being frustrated, sad, and mad. Much of the time you see life as a sour, rotten experience. You complain loudly and often, but you do little to solve problems. After all, you're entitled to have them solved, so why should you have to put out any effort? As a result of your bitter, demanding attitudes, you invariably get far less of what you want from life.

A positive score suggests you don't feel automatically entitled to things, so you negotiate for what you want and often get it. Because of your awareness that other people are unique and different, you realize there is no inherent reason why things should always go your way. You experience a negative outcome as a disappointment but not a tragedy because you are a percentage player, and you don't expect perfect reciprocity or "justice" at all times. You are patient and persistent, and you have a high frustration tolerance. As a result, you often end up ahead of the pack.

VI. Omnipotence. Attitudes 26 through 30 measure your tendency to see yourself as the center of your personal universe and to hold yourself responsible for much of what goes on around you. A negative score indicates you often make the personalization error discussed in Chapters 3 and 6. You blame yourself inappropriately for the negative actions and attitudes of others who are not really under your controL

Consequently, you are plagued by guilt and self-condemna-tion. Paradoxically, the attitude that you should be omnipo-253

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tent and all-powerful cripples you and leaves you anxious and ineffectual.

A positive score, in contrast, indicates you know the joy that comes from accepting that you are not the center of the universe. Since you are not in control of other adults, you are not ultimately responsible for them but only for yourself.

This attitude does not isolate you from others. Quite the opposite is true. You relate to people effectively as a friendly collaborator, and you are not threatened when they disagree with your ideas or fail to follow your advice. Because your attitude gives people a sense of freedom and dignity, you paradoxically become a human magnet. Others often want to be close to you because you have relinquished any attempt to control them. People frequently listen to and respect your ideas because you do not polarize them with an angry insistence they must agree with you. As you give up your drive for power, people repay you by making you a person of influence.

Your relationships with your children and friends and associates are characterized by mutuality instead of dependency.

Because you don't try to dominate people, they admire, love, and respect you.

VII. Autonomy. Items 31 through 35 measure your autonomy. This refers to your ability to find happiness within yourself. A positive score indicates that all your moods are ultimately the children of your thoughts and attitudes. You assume responsibility for your feelings because you recognize they are ultimately created by you. This sounds as if you might be lonely and isolated because you realize that all meaning and feelings are created only in your head. Paradoxically, however, this vision of autonomy frees you from the petty confines of your mind and delivers the world to you with a full measure of all the satisfaction, mystery, and excitement that it can offer.

A negative score suggests you are still trapped in the belief that your potential for joy and self-esteem comes from the outside. This puts you at a great disadvantage because everything outside is ultimately beyond your control. Your moods end up the victim of external factors. Do you want this? If not, you can eventually free yourself from this attitude as surely as a snake sheds its skin, but you will have to work at it with the various methods outlined in this book. When it's 254

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finally your turn to experience the transformation to autonomy and personal responsibility, you will be amazed—or awestruck—or pleased—or delightfully overwhelmed. It's well worth a major personal commitment.

In the following chapters a number of these attitudes and value systems will be examined in detail. As you study each one, ask yourself: (1) Is it to my advantage to maintain this particular belief? (2) Is this belief really true and valid? (3) What specific steps can I take that will allow me to rid myself of attitudes that are self-defeating and unrealistic, and substitute others that are more objective and more self-enhancing?

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CHAPTER 11

The Approval Addiction

Let's consider your belief that it would be terrible if someone disapproved of you. Why does disapproval pose such a threat? Perhaps your reasoning goes like this: "If one person disapproves of me, it means that everyone would disapprove of me. It would mean there was something wrong with me."

If these thoughts apply to you, your moods will shoot up every time you are being stroked. You reason, "I got some positive feedback so I can feel good about myself."

Why is this illogical? Because you are overlooking the fact that it is only your thoughts and beliefs which have the power to elevate your spirits. Another person's approval has no ability to affect your mood unless you believe what he or she says is valid. But if you believe the compliment is earned, it is your belief which makes you feel good. You must validate external approval before you experience mood elevation. This validation represents your personal self-approval.

Suppose you were visiting the psychiatric ward of a hospital. A confused, hallucinating patient approaches you and says, "You are wonderful. I had a vision from God. He told me the thirteenth person to walk through the door would be the Special Messenger. You are the thirteenth, so I know you are God's Chosen One, the Prince of Peace, the Holy of Holies. Let me kiss your shoe." Would this extreme approval elevate your mood? You'd probably feel nervous and uncomfortable. That's because you don't believe what the patient is saying is valid. You discredit the comments. It is only your beliefs about yourself that can affect the way you feel. Others can say or think whatever they want about you, good or bad.

but only your thoughts will influence your emotions.

The price you pay for your addiction to praise will be an 256

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extreme vulnerability to the opinions of others. Lice any addict, you will find you must continue to feed your habit with approval in order to avoid withdrawal pangs. The moment someone who is important to you expresses disapproval, you will crash painfully, just like the junkie who can no longer get his "stuff." Others will be able to use this vulnerability to manipulate you. You will have to give in to their demands more often than you want to because you fear they might reject or look down on you. You set yourself up for emotional blackmail.

You may come to see that your addiction to approval is not to your advantage, but still believe that other people really do have the right to judge not only the merit of what you do and say but also your worth as a human being. Imagine that you made a second visit to the psychiatric hospital ward.

This time a different hallucinating patient approaches you and says, "You're wearing a red shirt. This shows you are the Devil! You are evil!" Would you feel bad because of this criticism and disapproval? Of course not. Why would these disapproving words not upset you? It's simple—because you don't believe the statements are true. You must "buy into"

the other person's criticism—and believe that you are in fact so good—in order to feel bad about yourself.

Did it ever occur to you that if someone disapproves of rou, it might be his or her problem? Disapproval often reflects other people's irrational beliefs. To take an extreme example, Hitler's hateful doctrine that Jews were inferior did not reflect anything about the inner worth of the people he intended to destroy.

There will, of course, be many occasions when disapproval will result from an actual error on your part. Does it follow that you are a worthless, no-good person? Obviously not. The other person's negative reaction can only be directed toward a specific thing you did, not at your worth. A human being cannot do wrong things all the time!

Let's look at the other side of the coin. Many well-known criminals have had bands of fervent admirers regardless of how repulsive and abhorrent their crimes. Consider Charles Manson He promoted sadism and murder, yet was regarded as a messiah by his numerous followers, who seemed to do whatever he suggested. I want to make it abundantly clear 257

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that I am not advocating atrocious behavior, nor am I an admirer of Charles Manson. But ask yourself these questions: If Charles Manson did not end up totally rejected for what he did or said, what have you ever done that was so terrible that you will be rejected by everyone? And do you still believe in the equation: approval = worth? After all, Charles Manson enjoyed the intense adulation of his "family." Did the approval he received make him an especially worthy person?

This is obvious nonsense.

It's a fact that approval feels good. There's nothing wrong with that; it's natural and healthy. It is also a fact that disapproval and rejection usually taste bitter and unpleasant. This is human and understandable. But you are swimming in deep, turbulent waters if you continue to believe that approval and disapproval are the proper and ultimate yardsticks with which to measure your worth.

Did you ever criticize someone? Did you ever disagree with a friend's opinion? Did you ever scold a child because of his or her behavior? Did you ever snap at a loved one when you were feeling irritable? Did you ever choose not to associate with someone whose behavior was distasteful to you?

Then ask yourself—when you disagreed, or criticized, or disapproved—were you making the ultimate moral judgment that the other person was a totally worthless, no-good human being? Do you have the power to make such sweeping judgments about other people? Or were you simply expressing the fact that you held a different point of view and were upset with what the other person did or said?

For example, in the heat of anger you may have blurted out to your spouse, "You're no damn good!" But when the flame cools down a day or two later, didn't you admit to yourself that you were exaggerating the extent of his or her "

badness"? Sure, your loved one may have many faults, bu: isn't it absurd to think your outburst of disapproval or criticism makes him or her totally and forever worthless? If you admit your disapproval does not contain enough moral atomic power to devastate the meaning and value of another person's life, why give their disapproval the power to wipe out your sense of self-worth? What makes them so special'

When you tremble in terror because someone dislikes you you magnify the wisdom and knowledge that person possesse,, 258

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and you have simultaneously sold yourself short as being unable to make sound judgments about yourself. Of course, someone might point out a flaw in your behavior or an error in your thinking. I hope they will because you can learn this way. After all, we're all imperfect, and others have the right to tell us about it from time to time. But are you obliged to make yourself miserable and hate yourself every time someone flies off the handle or puts you down?

The Origin of the Problem. Where did you get this approval addiction in the first place? We can only speculate that the answer may lie in your interactions with people who were important to you when you were a child. You may have had a parent who was unduly critical when you misbehaved, or who was irritable even at times when you weren't doing anything particularly wrong. Your mother may have snapped, "

You're bad for doing that!" or your father may have blurted out, "You're always goofing up. You'll never learn."

As a small child you probably saw your parents as gods.

They taught you how to speak and tie your shoes, and most of what they told you was valid. If Daddy said, "You will be killed if you walk out into traffic," this was literally true. Like most children, you might have assumed that nearly everything your parents said was true. So when you heard "You're no good" and "You'll never learn," you literally believed it and this hurt badly. You were too young to be able to reason, Daddy is exaggerating and overgeneralizing." And you didn't have the emotional maturity to see that Daddy was irritable and tired that day, or perhaps had been drinking and wanted to be left alone. You couldn't determine whether his outburst was his problem or yours. And if you were old enough to suggest he was being unreasonable, your attempts to put things into a sane perspective may have been rapidly deprogrammed and discouraged with a swift smack on the behind.

No wonder you developed the bad habit of automatically looking down on yourself every time someone disapproved of you. It wasn't your fault that you picked up this tendency as a child, and you can't be blamed for growing up with this blind spot. But it is your responsibility as an adult to think the issue through realistically, and to take specific steps to outgrow this particular vulnerability.

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Just how does this fear of disapproval predispose you to anxiety and depression? John is an unmarried, soft-spoken fifty-two-year-old architect who lives in fear of criticism. He was referred for treatment because of a severe recurring depression, which had not diminished in spite of several years of therapy. One day when he was feeling particularly good about himself, he approached his boss enthusiastically with some new ideas about an important project. The boss snapped, "Later, John. Can't you see I'm busy!" John's self-esteem collapsed instantly. He dragged himself back to his office, drowning in despair and self-hatred, telling himself he was no good. "How could I have been so thoughtless?" he asked himself.

As John shared this episode with me, I asked him the simple and obvious questions, "Who was the one who was acting goofy—you or your boss? Were you actually behaving in an inappropriate manner, or was your boss acting irritable and unpleasant?" After a moment's reflection, he was able to identify the true culprit. The possibility that the boss was acting obnoxiously had not occurred to him because of his automatic habit of blaming himself. He felt relief when he suddenly realized he had absolutely nothing to be ashamed of in how he had acted. His boss, who was aloof, was probably under pressure himself and off the mark that day.

John then raised the question, "Why am I always struggling so hard for approval? Why do I fall apart like this?" He then remembered an event that occurred when he was twelve.

His only sibling, a younger brother, had tragically died after a long bout with leukemia. After the funeral he overheard his mother and grandmother talking in the bedroom. His mother was weeping bitterly and said, "Now I've got nothing to live for." His grandmother responded, "Shush. Johnny is just down the hall! He might hear you!"

As John shared this with me, he began to weep. He had heard these comments, and they meant to him, "This proves I'm not worth much. My brother was the important one. My mother doesn't really love me." He never let on that he had been listening, and through the years he tried to push the memory out of his mind by telling himself, "It really isn't important whether or not she loves me anyway." But he struggled intensely to please his mother with his achievements 260

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and his career in a desperate bid to win her approval. In his heart he didn't believe he had any true worth, and perceived himself as inferior and unlovable. He tried to compensate for his missing self-esteem by earning other people's admiration and approval. His life was like a constant effort to inflate a balloon with a hole in it.

After recalling this incident, John was able to see the irrationality of his reaction to the comments he had overheard in the hall. His mother's bitterness, and the emptiness she felt, were a natural part of the grieving process that any parent goes through when a child dies. Her comments had nothing to do with John, but only with her temporary depression and despair.

Putting this memory into a new perspective helped John see how illogical and self-defeating it was to link his worth to the opinions of others. Perhaps you too are beginning to see that your belief in the importance of external approval is highly unrealistic. Ultimately you, and only you, can make yourself consistently happy. No one else can. Now, let's review some simple steps that you can take to put these principles into practice so you can transform your desire for self-esteem and self-respect into an emotional reality.

The Path to Independence and SelfRespect

-

Cost-Benefit Analysis. The first step in overcoming your belief in any of the self-defeating assumptions from the DAS

test is to perform a cost-benefit analysis. Ask yourself, what are the advantages and disadvantages of telling myself that disapproval makes me less worthwhile? After listing all the ways this attitude hurts you and helps you, you will be in a position to make an enlightened decision to develop a health-ier value system.

For example, a thirty-three-year-old married woman named Susan found she was overly involved with church and community activities because she was a responsible and capable worker and was frequently selected for various committees. She felt enormously pleased every time she was chosen for a new job and she feared saying no to any request because that would mean risking someone's disapproval. Because 261

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she was terrified about letting people down, she became more and more addicted to the cycle of giving up her own interests and desires in order to please others.

The DAS test and the "Vertical Arrow Technique"

described in the previous chapter revealed one of her silent assumptions to be: "I must always do what people expect me to do." She seemed reluctant to give up this belief, so she performed a cost-benefit analysis (Figure 11-1). Because the disadvantages of her approval addiction greatly outweighed the advantages, she became much more open to changing her personal philosophy. Try this simple technique with regard to one of your self-defeating assumptions about disapproval. It can be an important first step to personal growth.

Rewrite the Assumption. If, based on your cost-benefit analysis, you see that your fear of disapproval hurts you more than it helps, the second step is to rewrite your silent assumption so that it becomes more realistic and more self-enhancing (you can do this with any of the 35 attitudes on the DAS test that represent areas of psychological vulnerability for you). In the above example, Susan decided to revise her belief as follows: "It can be enjoyable to have someone approve of me, but I don't need approval in order to be a worthwhile person or to respect myself. Disapproval can be uncomfortable, but it doesn't mean I'm less of a person."

The Self-Respect Blueprint. As a third step it might help you to write a brief essay entitled "Why It Is Irrational and Unnecessary to Live in Fear of Disapproval or Criticism."

This can be your personal blueprint for achieving greater self-reliance and autonomy. Prepare a list of all the reasons why disapproval is unpleasant but not fatal. A few have already been mentioned in this chapter, and you might review them before you begin to write. In your essay include only what seems convincing and helpful to you. Make sure you believe each argument you write down so your new sense of independence will be realistic. Don't rationalize! For example, the statement, "If someone disapproves of me, I don't need to get upset because they're really not the kind of pe--son I'd care to have as a friend," won't work because it's a distortion. You are trying to preserve your self-esteem by writing the other person off as no good. Stick with what yo.: know to be the truth.

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Figure 11-1. The Cost-Benefit Method for EValuating "Silent Assumptions."

ASSUMPTION: "I must always do what people expect me to do."

Advantages of

Disadvantages of

Believing This

Believing This

L If I'm able to meet people's ex- 1. I sometimes compromise and end pectations, I can feel I'm in con-up doing things that are not in

trol. This feels good.

my best interest that I don't

really want to do.

2. When I please people I will feel 2. This assumption keeps me from s e c u r e a n d s a f e . t e s t i n g r e l a t i o n s h i p s — / n e v e r know if I could be accepted just

for me. Thus, I always have to

earn love and the right to be

close to people by doing what

people want me to do. I become

like a slave.

3. I can avoid a lot of guilt and con- 3. It gives people too much power fusion. I don't have to think

over me—they can coerce me

things out, since all I have to do

with the threat of disapproval.

is what others want me to.

4 I don't have to worry about peo- 4. It makes it hard for me to know pie being upset with me or look-what I really want I'm not used

isg down on mo.

to setting priorities for myself

and making independent deci-

sions.

S. I can avoid conflict and I don't 5. When people do disapprove of have to be assertive and speak

me, as is inevitable at times, then

op for myself.

I conclude rye done something

to displease them, and I experi-

ence severe guilt and depression.

This puts my moods under the

control of other people instead

of myself.

6. What other people want me to do

may not always be what's best

for me, since they often have

their own interests at heart. Their

expectations for me may not al-

ways be realistic and valid.

7. I end up seeing other people as

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Figure 11-1. Continued.

Advantages of

Disadvantages of

Believing This

Believing This

so weak and fragile that they are

dependent on me and would be

hurt and miserable if I let them

down.

8. Because I fear taking risks and

having someone upset with me,

my life becomes static. I don't

feel motivated to change, to grow

or to do things differently so as

to enhance my range of experi-

ences.

As new ideas come to you, add them to your list. Read it over every morning for several weeks. This might be a first step in helping you trim other people's negative opinions and comments about you down to life-size.

Here are a few ideas that have worked well for a lot of people. You might use some of them in your own essay.

1. Remember that when someone reacts negatively to you, it may be his or her irrational thinking that is at the heart of the disapproval.

2. If the criticism is valid, this need not destroy you. You can pinpoint your error and take steps to correct it.

You can learn from your mistakes, and you don't have to be ashamed of them. if you are human, then you

should and must make mistakes at times.

3. If you have goofed up, it does not follow that you are a BORN LOSER. It is impossible to be wrong all the time or even most of the time. Think about the thousands of things you have done right in your life! Furthermore, you can change and grow.

4. Other people cannot judge your worth as a human being, only the validity or merit of specific things you do or say.

5. Everyone will judge you differently no matter how well you do or how badly you might behave. Disapproval

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cannot spread like wildfire, and one rejection cannot lead to a never-ending series of rejections. So even if worse comes to worst and you do get rejected by someone, you can't end up totally alone.

6. Disapproval and criticism are usually uncomfortable, but the discomfort will pass. Stop moping. Get involved in an activity you've enjoyed in the past even though you feel certain it's absolutely pointless to start.

7. Criticism and disapproval can upset you only to the extent that you "buy into" the accusations being brought against you.

8. Disapproval is rarely permanent. It doesn't follow that your relationship with the person who disapproves of you will necessarily end just because you are being criticized. Arguments are a part of living, and in the majority of cases you can come to a common understanding later on.

9. If you are criticizing someone else, it doesn't make that person totally bad. Why give another individual the power and right to judge you? We're all just human beings, not Supreme Court justices. Don't magnify other people until they are larger than life.

Can you come up with some additional ideas? Think about this topic over the next few days. Jot your ideas down on a piece of paper. Develop your own philosophy about disapproval. You'll be surprised to find how much this can help you change your perspective and enhance your sense of independence.

Verbal Techniques. In addition to learning to think differently about disapproval, it can be a lot of help to learn to behave differently toward individuals who express disapproval.

As a first step, review the assertive methods such as the disarming technique presented in Chapter 6. Now we will discuss some additional approaches to help you build your skills in coping with disapproval.

First of all, if you fear someone's disapproval, have you ever thought of asking the person if he or she, in fact, does look down on you? You might be pleasantly surprised to learn that the disapproval existed only in your head. Although it requires some courage, the payoff can be tremendous.

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Remember Art, the psychiatrist described in Chapter 6, who was receiving training at the University of Pennsylvania?

Art had no suspicion that a particular patient of his might be suicidal. The patient had no history or symptoms of depression, but felt hopelessly trapped in an intolerable marriage. Art received a call one morning that his patient had been found dead with a bullet hole through his head. Although the suspicion of homicide was raised, the probable cause of death was suicide. Art had never lost a patient in this way. His reaction included sadness, because of his fondness for this particular patient, and anxiety, for fear that his supervisor and peers would disapprove of him and look down on him for his "mistake" and lack of foresight. After discussing the death with his supervisor, he asked frankly, "

Do you feel I have let you down?" His supervisor's response conveyed a sense of warmth and empathy, not rejection. Art was relieved when his supervisor told him that he too had experienced a similar disappointment in the past. He emphasized that this was an opportunity for Art to learn to cope with one of the professional hazards of being a psychiatrist.

By discussing the case and refusing to give in to his fear of disapproval, Art learned that he had made an "error"—he had overlooked the fact that a feeling of "hopelessness" can lead to suicide in individuals who are not clinically depressed.

But he also learned that others did not demand perfection of him, and that he wasn't expected to guarantee a successful outcome for any patient.

Suppose it had not turned out so well and his supervisor or peers had condemned him for being thoughtless or incompetent. What then? The worst possible outcome would have been rejection. Let's talk about some strategies for coping with the worst conceivable eventuality.

Rejection Is Never Your Fault! Aside from bodily injury or a destruction of your assets, the greatest pain a person can try to inflict on you is through rejection. This threat is the source of your fear when you are being "put down."

There are several types of rejection. The most common and obvious is called "adolescent rejection," although it is not limited to the adolescent age-group. Suppose you have a ro-mantic interest in someone you are dating or have met, and it turns out you're not his or her cup of tea. Perhaps it's your

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looks, race, religion, or personality style that are the problem.

Or maybe you are too tall, short, fat, thin, old, young, smart, dull, aggressive, passive, etc. Since you don't fit that person's mental image of an ideal mate closely enough, he or she re-buffs your advances and gives you the cold shoulder.

Is this your fault? Obviously not! The individual is simply turning you down because of subjective preferences and tastes. One person may like apple pie better than cherry pie.

Does this mean that cherry pie is inherently undesirable? Ro-mantic interests are almost infinitely variable. If you are one of those toothpaste-commercial types who is blessed with what our culture defines as "good looks" and an appealing personality, it will be much easier for you to attract potential dates and mates. But you will learn this mutual attraction is a far cry from developing a loving permanent relationship, and even the beautiful and handsome types will have to cope with rejection sometimes. No one can turn on each and every person they meet.

If you are only average or below average in appearance and personality, you will have to work harder initially to attract people, and you may have to cope with more frequent turndowns. You will have to develop your social skills and master some powerful secrets of making people feel attracted to you. These are: (1) Don't sell yourself short by looking down on yourself. Refuse to persecute yourself. Boost your self-esteem to the hilt with the methods outlined in Chapter 4. If you love yourself, people will respond to this sense of joy you radiate and want to be close to you. (2) Express genuine compliments to people. Instead of waiting around nervously to find out if they will like you or reject you, like them first and let them know about it. (3) Show an interest in other people by learning about what turns them on. Get them to talk about what excites them most, and respond to their comments in an upbeat manner.

If you persevere along these lines, you will eventually discover there are people who find you attractive, and you in turn will discover you have a great capacity for happiness.

Adolescent rejection is an uncomfortable nuisance, but it's not the end of the world and it's not your fault.

"Ah hal" you retort. "But how about the situation where a lot of people reject you because you turn them off with your 267

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abrasive mannerisms? Suppose you're conceited and self-centered. Certainly that's your fault, isn't it?" This is a second type of rejection, which I call "angry rejection." Again, I think you will see that it's not your fault if you are angrily rejected because of a personal fault.

In the first place, other people aren't obliged to reject you just because they find things about you they don't lice—they have other options. They can be assertive and point out what they don't lice about your behavior, or they can learn not to let it bother them so much. Of course, they have the right to avoid and reject you if they want, and they are free to choose any friends they prefer. But this doesn't mean that you are an inherently "bad" human being, and it is definitely not the case that everyone will react to you in the same negative way. You will experience a spontaneous chemistry with some people, whereas you will tend to clash with others. This is no one's fault, it's just a fact of life.

If you have a personality quirk that alienates more people than you would like—such as being excessively critical or losing your temper frequently—it would definitely be to your advantage to modify your style. But it's ridiculous to blame yourself if someone rejects you based on this imperfection.

We're all imperfect, and your tendency to fault yourself—or to "buy into" the hostility that someone else directs at you—

is self-defeating and pointless.

The third type of rejection is "manipulative rejection." In this case the other person uses the threat of withdrawal or rejection to manipulate you in some way. Unhappy spouses, and even frustrated psychotherapists, sometimes resort to this ploy to coerce you into changing. The formula goes lice this: "

Either you do such and such or we're all through!" This is a highly irrational and usually self-defeating way of trying to influence people. Such manipulative rejection is simply a cul-turally taught coping pattern, and it is usually ineffective. It rarely leads to an enhanced relationship because it generates tension and resentment. What it really indicates is a low frustration tolerance and poor interpersonal skills on the part of the individual making the threat. It certainly isn't your fault that they do this, and it usually isn't to your advantage to let yourself be manipulated this way.

So much for the theoretical aspects. Now, what can you 268

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say and do when you are actually getting rejected? One effective way to learn is to use role-playing. To make the dialogue more entertaining and challenging, I will play the role of the rejector and confront you with the worst things about you I can think of. Since I'm acting caustic and insulting, begin by asking if I am in fact rejecting you because of the way I've been treating you lately:

YOU: Dr. Burns, I notice you've been acting somewhat cool and distant. You seem to be avoiding me. When I try to talk to you, you either ignore me or snap at me. I wonder if you're upset with me or if you've had thoughts of rejecting me.

Comment: You don't accuse me initially of rejecting you.

That would put me on the defensive. Furthermore, I might not be rejecting you—I might be upset about the fact that nobody's buying my book, so I'm just generally irritable. Just for practice, let's assume the worst—that I am trying to dump you.

DAVID: I'm glad we got it out in the open. I have in fact decided to reject you.

YOU: Why? Apparently I've been turning you off a lot.

DAVID: You're a no-good piece of rot.

YOU: I can see you're upset with me. Just what have I been doing wrong?

Comment: You avoid defending yourself. Since you know you are not a "piece of rot," there's no point in insisting to me that you're not. It will just fire me up more, and our dialogue will quickly deteriorate into a shouting match. (This "‘

empathy method" was presented in detail in Chapter 6.) DAVID: Everything about you stinks.

YOU: Can you be specific? Did I forget to use deodorant?

Are you upset by the way I talk, something I've said lately, my clothes, or what?

Comment: Again, you resist getting sucked into an argument. By urging me to pinpoint what I dislike about you, you are forcing me to fire my best shot and say something meaningful or end up looking like an ass.

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DAVID: Well, you hurt my feelings when you put me down the other day. You don't give a damn about me. I'm just a "thing" to you, not a human being.

Comment: This is a common criticism. It tips you off that the rejector basically cares for you, but feels deprived and fears losing you. The rejector decides to lash out at you to protect his shaky self-esteem. The rejector might also say you're too stupid, too fat, too selfish, etc. Whatever the nature of the criticism, your strategy is now twofold: (a) Find some grain of truth in the criticism and let the rejector know you agree in part (see the "disarming technique,"

Chapter 6); (b) apologize or offer to try to correct any actual error you actually did make (see "feedback and negotiation," Chapter 6).

YOU: I'm really sorry I said something that rubbed you the wrong way. What was it?

DAVID: You told me I was a no-good jerk. So I've had it with you—this is the end.

YOU: I can see that was a thoughtless, hurtful comment I made. What other things have I said that hurt your feelings? Was that all? Or have I done this many times?

Go ahead and say all the bad things you think about me.

DAVID: You're unpredictable. You can be sweet as sugar, and then all of a sudden you're cutting me to shreds with your sharp tongue. When you get mad, you turn into a foul-mouthed pig. I can't stand you, and I can't see how anyone else puts up with you. You're arrogant and cocky, and don't give a damn about anyone but yourself. You're a selfish snot, and it's time you woke up and learned the hard way. I'm sorry I've got to be the one to put you down, but it's the only way you're going to learn. You have no real feelings for anyone but yourself, and we're through for good!.

You: Well, I can see there are numerous problems in our relationship we've never looked at, and it sounds like I'

ve really been missing the boat. I can see that I have been acting irritable and thoughtless. I can see how unpleasant I've been and how uncomfortable it's been for you. Tell me more about this side of me.

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Comment: You then continue to extract negative comments from the rejector. Avoid being defensive and continue to find some grain of truth in what the rejector says. After you have elicited all the criticisms and agreed with whatever was true about them, you are ready to fire the sharpest arrow straight into the rejector's balloon. Point out that you have acknowledged your imperfections and that you are willing to try to correct your errors. Then ask the rejector why he is rejecting you. This maneuver will help you see why rejection is never your fault! You are responsible for your errors, and you will assume responsibility for trying to correct them. But if someone rejects you for your imperfections, that's their goofiness, not yours! Here's how this works.

You: I can see I've done and said a number of things you don't like. I'm certainly willing to try to correct these problems to the greatest extent possible. I can't promise miracles, but if we work at it together, I see no reason why things can't improve. Just by talking this way, our communications are already better. So why are you going to reject me?

DAVID: Because you infuriate me.

You: Well, sometimes differences come up between people, but I don't see that this has to destroy our relationship.

Are you rejecting me because you feel infuriated or what?

DAvm: You're a no-good bum, and I refuse to talk to you again.

You: I'm sorry you feel that way. I'd much prefer to continue our friendship in spite of these hurt feelings. Do we need to break off entirely? Maybe this discussion was just what we needed to understand each other better. I don't really know why you've decided to reject me. Can you tell me why?

DAVID: Oh, no! I'm not being tricked by you. You goofed up once too often, and that's it! No second chances!

Good-bye!

Comment: Now whose goofy behavior is this? Yours or the one who is rejecting you? Whose fault is it that the rejection occurs? After all, you offer to try to correct your errors and to improve the relationship through frank communica-271

David D. Burns, M.D.

tion and compromise. So how can you be blamed for the rejection? Obviously you can't.

Using the above approach may not prevent all actual rejections, but you will enhance the probability of a positive outcome sooner or later.

Recovering from Disapproval or Rejection. You actually have been disapproved of or rejected in spite of your efforts to improve the relationship with the other person. How can you most quickly overcome the emotional upset you understandably feel? First, you must realize that life goes on, so this particular disappointment need not impair the quality of your happiness forever. Following the rejection or disapproval it will be your thoughts which are doing the emotional damage, and if you fight these thoughts and stubbornly refuse to give in to distorted self-abuse, the upset will pass.

One method which might be quite helpful is one that has aided people who experience prolonged grief reactions following the loss of a loved one. If the bereaved individual schedules periods each day to allow themselves to be flooded by the painful memories and thoughts of the deceased loved one, this can accelerate and complete the grieving process. If you do this when you are alone, it will be most helpful. Sympathy from another person often backfires; some studies have reported that it prolongs the painful period of mourning.

You can use this "grieving" method to cope with rejection or disapproval. Schedule one or more periods of time each day—five to ten minutes are probably enough—to think all the sad, angry, and despairing thoughts you want. If you feel sad, cry. If you feel mad, pound a pillow. Keep flooding yourself with painful memories and thoughts for the full time period you have set aside. Bitch, moan and complain nonstop! When your scheduled sad period is over, STOP IT and carry on with life until your next scheduled cry session. In the meantime, if you have negative thoughts, write them down, pinpoint the distortions, and substitute rational responses as outlined in previous chapters. You may find this will help you gain partial control over your disappointment and hasten your return to full self-esteem more quickly than you anticipated.

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Turning on the "Inner Light"

The key to emotional enlightenment is the knowledge that only your thoughts can affect your moods. If you are an approval addict, you are in the bad habit of flicking your inner switch only when someone else shines their light on you first.

And you mistakenly confuse their approval with your own self-approval because the two occur almost simultaneously.

You mistakenly conclude that the other person has made you feel good! The fact that you do at times enjoy praise and compliments proves that you know how to approve of yourself! But if you are an approval addict, you have developed the self-defeating habit of endorsing yourself only when someone you respect approves of you first.

Here's a simple way to break that habit. Obtain the wrist counter described in earlier chapters and wear it for at least two or three weeks. Every day try to notice positive things about yourself—things you do well whether or not you get an external reward. Each time you do something you approve of, click the counter. For example, if you smile warmly at an associate one morning, click whether he scowls or smiles back. If you make that phone call you were putting off—

click the counter! You can "endorse" yourself for big or trivial things. You can even click it if you remember positive things you did in the past. For example, you might recall the day you got your driver's license or your first job. Click the counter whether or not you have a positive emotional arousal. Initially you may have to force yourself to notice good things about yourself, and it may seem mechanical. Persist anyway because after several days I think you will notice that the inner light is beginning to glow--dimly at first and then more brightly. Every night look at the digits on the counter and record the total number of personal endorsements on your daily log. After two or three weeks, I suspect you will begin to learn the art of self-respect, and you will feel much better about yourself. This simple procedure can be a big first step toward achieving independence and self-approval. It sounds easy—and it is. It's surprisingly powerful, and the rewards will be well worth the small amount of time and effort involved.

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CHAPTER 12

The Love Addiction

The "silent assumption" which often goes hand in hand with the fear of disapproval is "I cannot be a truly happy and fulfilled human being unless I am loved by a member of the opposite sex. True love is necessary for ultimate happiness."

The demand or need for love before you can feel happy is called "dependency." Dependency means that you are unable to assume responsibility for your emotional life.

The Disadvantages of Being a Love Junkie. Is being loved an absolute necessity or a desirable option?

Roberta is a thirty-three-year-old single woman who moped around her apartment evenings and weekends because she told herself, "It's a couple's world. Without a man I am nothing." She came to my office attractively groomed, but her comments were bitter. She was brimming with resentment because she was sure that being loved was as crucial as the ox-ygen she breathed. However, she was so needy and greedy that this tended to drive people away.

I suggested that she start by preparing a list of the advantages and disadvantages of believing that "without a man (

or woman) I am nothing." The disadvantages on Roberta's list were clear-cut: "(1) This belief makes me despondent since I have no lover. (2) Furthermore, it takes away any incentive I might have to do things and go places. (3) It makes me feel lazy. (4) It brings on a sense of self-pity. (5) It robs me of self-pride and confidence, and makes me envi-ous of others and bitter. (6) Finally, it brings on self-destructive feelings and a terrible fear of being alone."

Then she listed what she thought were the advantages of believing that being loved was an absolute necessity for happiness: "(1) This belief will bring me a companion, love, and security. (2) It will give purpose to my life and a reason to 274

FEELING GOOD

live. (3) It will give me events to look forward to." These advantages reflected Roberta's belief that telling herself she couldn't live without a man would somehow bring a companion into her life.

Were these advantages real or imaginary? Although Roberta had believed for many years that she couldn't exist without a man, this attitude still hadn't brought a desirable mate. She admitted that making men so totally important in her life was not the magic charm that would bring one to her doorstep.

She acknowledged that clinging and dependent individuals often demand so much attention from other people and appear so needy that they have great difficulty not only initially attracting people of the opposite sex but also maintaining an ongoing relationship. Roberta was able to grasp the idea that people who have found happiness within themselves are usually the most desirable to members of the opposite sex and become like magnets because they are at peace and generate a sense of joy. Ironically, it is usually the dependent woman, the "manaholic," who ends up alone.

This really isn't so surprising. If you take the position you "

need" someone else for a sense of worth, you broadcast the following: "Take me! I have no inherent worth! I can't stand myself!" No wonder there are so few buyers! Of course, your unstated demand does not endear people to you either: "

Since you're obliged to love me, you're rotten shit if you don't."

You may cling to your dependency because of the erroneous notion that if you do achieve independence, others will see you as a rejecting person and you will end up alone. If this is your fear, you are equating dependency with warmth.

Nothing could be farther from the truth. If you are lonely and dependent, your anger and resentment stem from the fact that you feel deprived of the love you believe you are entitled to receive from others. This attitude drives you farther into isolation. If you are more independent, you are not obliged to be alone—you simply have the capacity to feel happy when you are alone. The more independent you are, the more secure you will be in your feelings. Furthermore, your moods will not go up and down at someone else's mercy. After all, the amount of love that someone can feel for you is often quite unpredictable. They may not appreciate 275

David D. Burns, M.D.

everything about you, and they may not act in an affectionate way all the time. If you are willing to learn to love yourself, you will have a far more dependable and continuous source of self-esteem.

The first step is to find out if you want independence. All of us have a much greater chance of achieving our goals if we understand what they are. It helped Roberta to realize that her dependency was condemning her to an empty existence. If you are still clinging to the notion that it is desirable to be "dependent," list the advantages, using the double-column technique. Spell out how you benefit if you let love determine your personal worth. Then in order to assess the situation objectively, write down the counterarguments, or rational responses, in the right-hand column You may learn that the advantages of your love addiction are partially or totally illusory. Figure 12-1 shows how a woman with a problem similar to Roberta's assessed these issues. This written exercise motivated her to look within herself for what she had been seeking in others, and enabled her to see that her dependency was the real enemy because it incapacitated her.

Perceiving the Difference Between Loneliness and Being Alone. As you read the previous section you may have concluded that it would be to your advantage if you could learn to regulate your moods and find happiness within yourself.

This would give you the capacity to feel as alive when you are alone as when you are with someone you love. But you may be thinking, "That all sounds well and good, Dr. Burns, but it is not realistic. The truth is that it is undeniably emotionally inferior to be alone. All my life I have known that love and happiness are identical, and all my friends agree.

You can philosophize until you're blue in the face. But when it comes down to the bottom line, love is where it's at and being alone is a curse!"

In fact, many people are convinced that love makes the world go around. You see this message in ads, you hear it in popular songs, you read it in poems.

You can however convincingly disprove your assumption that love is necessary before you can experience happiness.

Let's take a hard look at the equation, alone = lonely.

Consider, first, that we get many of life's basic satisfactions by ourselves. For example, when you climb a mountain, pick 276

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Figure 12-1. An Analysis of the Presumed "Advantages" of Being a '

Love Junkie."

Advantages of Being Dependent

on Love to Be Happy

Rational Responses

L Someone will take care of me 1. This is also true of independent w h e n I a m h u r t . p e o p l e . I f I a m i n a n a u t o a c c i -

dent, they will take: me to an

emergency room. The doctors

will care for me whether I am a

dependent or independent per-

son. It is nonsense that only de-

pendent people get help whep

they are hurt.

2. But if I am dependent, I won't 2. But as a dependent person, I will have to make decisions. have much less control over my life. It is unreliable to depend on

other people to make decisions

for me. For example, do I want

someone else to tell me what to

wear today or what to eat for

dinner? They might not choose

the thing that is my first choice.

IL But as an independent person, I 3. So pay the consequences—you might make the wrong decision.

can learn from your mistakes if

Then I'd have to pay the conse-

you are independent. No one can

quences.

be perfect, and there arc no guar-

antees of absolute certainty in

life. The uncertainty can be part

of the spice of life. It's how I

cope—not whether I am right all

the time—that forms the basis

of self-respect. And besides, I

will be able to take the credit

when things work out well.

I. But if / am a dependent person, 4. Independent people can also I won't have to think. I can just

choose not to think if they want

277

Figure 12-1. Continued.

Advantages of Being Dependent

on Love to Be Happy

Rational Responses

react to things.

to. There is no rule that says that

only dependent people have the

right to stop thinking.

S. But if I am dependent, I will be 5. Candy gets nauseating after a

gratified. It will be like eating

while. The person I choose to de-

candy. It feels good to have

pend on may not be willing to

someone to care for me and to

love and stroke me, and take care

lean on.

of me forever. He may get tired

of it after a while. And if he with-

draws from me either through

anger or resentment, I will then

feel miserable because I'll have

nothing else to rely on. They will

be able to manipulate me if I am

dependent, just like a slave or

robot.

6. But if I am a dependent person,

6. As an independent person, I can

I will be loved. Without love I

learn to love myself and this may

couldn't live.

make me even more desirable to

others, and if I can learn to love

myself, I can always be loved.

My dependency in the past has

driven others away from me more

frequently than it has attracted

people to me. Babies can't sur-

vive without love and support,

but I won't die without love.

7. But some men are looking for

7. There's some truth to this, but

dependent women.

relationships which are based on

dependency frequently fall apart

and culminate in divorce because

you are asking the other person

to give you something which

they are not in the position to

give; namely, self-esteem and

self-respect. Only I can make

myself happy, and if I rely on

someone else to do this for me,

I am likely to be bitterly disap-

pointed in the end.

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a flower, read a book, or eat a hot fudge sundae, you do not require someone else's company for these experiences to be enjoyable. A physician can enjoy the satisfaction of treating a patient whether or not he and the patient are involved in a meaningful personal relationship. When writing a book, an author is generally by himself or herself. As most students know, you do most of your learning when you are alone. The list of pleasures and satisfactions that you can enjoy when alone is endless.

This indicates that many sources of gratification are acces-sible to you whether or not you are with someone else. Can you add to that list? What are some pleasures that you can have alone? Do you ever listen to good music on your stereo?

Do you enjoy gardening? Jogging? Carpentry? Hiking? A lonely bank teller named Janet, who was recently separated from her husband, enrolled in a creative dancing class and found (to her surprise) that she could derive enormous pleasure from practicing by herself at home. As she became caught up in the rhythm of the movements, she felt at peace with herself in spite of the fact that she had no one to love.

Perhaps you are thinking now, "Oh, Dr. Burns, is that your point? Well, it's trivial! Of course, I can experience temporary moments of mediocre distraction by doing things when I'm alone. This might take the edge off the blues, but those things are just some crumbs from the table that might keep me from starving totally. I want the banquet, the real thing! Love! True and complete happiness!"

That was exactly what Janet told me before she enrolled in the dancing class. Because she assumed it was miserable to be alone, it hadn't occurred to her to do enjoyable things and care for herself during the separation from her husband. She had been living according to a double standard whereby if she was with her husband, she would go to great lengths to plan pleasurable activities, but when she was alone, she would simply mope and do very little. This pattern obviously functioned as a self-fulfilling prophecy, and she did in fact find it unpleasant to be alone. Why? Simply because she failed to treat herself in a caring way. It had never occurred to her to challenge her lifelong assumption that all her activities would be unsatisfactory unless she had someone to share them with.

On another occasion, instead of heating a TV dinner after 279

David D. Burns, M.D.

work, Janet decided to plan a special meal, just as if she were going to entertain a man she cared a lot about. She carefully prepared her dinner and set the table with candles. She began with a glass of fine wine. After dinner she read a good book and listened to her favorite music. To her amazement, she found the evening a total pleasure. The next day, which was Saturday, Janet decided to go to the art museum alone. She was surprised to discover that she got more enjoyment out of this excursion alone than she had in the past when dragging her reluctant and disinterested husband along.

As a result of adopting an active, compassionate attitude toward herself, Janet discovered for the first time in her life that she could not only make it on her own but could really enjoy herself.

As is so often the case, she began to generate an infectious joy of living that caused many individuals to feel attracted to her, and she began to date. In the meantime her husband began to get disillusioned with his girl friend and wanted his wife back. He noticed Janet was happy as a lark without him, and at this point the tables began to turn. After Janet told him she no longer wanted him back, he suffered a severe depression. She ultimately established a very satisfying relation.

ship with another man and remarried. The key to her success was simple—as a first step, she proved that she could develop a relationship with herself. After this, the rest was easy.

The PleasurePredicting Method

-

I don't expect you to rely on my word on this topic, or even on the reports of others like Janet who have learnei how to experience the joys of self-reliance Instead, I propose you perform a series of experiments, just as Janet did, to test out your belief that "being alone is a curse." If you are willing to do this, you can arrive at the truth in an objective.

scientific manner.

To help you, I have developed the "Pleasure-Predicting Sheet" shown in Figure 12-2. This form is divided into a series of columns in which you predict and record the actual amount of satisfaction you derive from various work and recreational activities you engage in when alone, as well as from those you share with other people. In the first column, 280

FEELING GOOD

record the date of each experiment. In the second column, write down several activities that you plan to do as a part of that day's experiments. I suggest that you carry out a series of forty or fifty experiments over a two- to three-week period.

Choose activities that would ordinarily give you a sense of accomplishment or pleasure, or which have the potential for learning or personal growth. In the third column, record who you do the activity with. If you do it alone, write "self' in this column. (This word will remind you that you are never really alone, since you are always with yourself!) In the fourth column, predict the satisfaction you think you will derive from this activity, estimating it on a scale of between 0

and 100 percent. The higher the number, the greater the anticipated satisfaction. Fill in the fourth column before you do each planned activity, not after!

Once you have filled in the columns, proceed with the activities. Once they are completed, record the actual satisfaction in the last column, using the same 0- to 100-percent rating system.

After you have performed a series of such experiments, you will be able to interpret the data you have collected. You can learn many things. First, by comparing the predicted satisfaction (column four) with the actual satisfaction (column five), you will be able to find out how accurate your predictions are. You may find that you typically underestimate the amount of satisfaction you anticipate experiencing, especially when doing things alone. You might also be surprised to learn that activities with others are not always as satisfying as anticipated. In fact, you may even find that there are many times when it was more enjoyable to be alone, and you might discover that the highest ratings you received when you were alone were equal to or higher than those for activities involving others. It can be helpful to compare the amount of satisfaction you derived from work activities versus pleasurable activities. This information can help you achieve an optimal balance between work and fun as you continue to plan your activities.

Questions are probably now crossing your mind, "

Suppose I do something and it isn't as satisfying as I predicted? Or suppose I make a low prediction and it really comes out that

281

Figure 12-2. The Pleasure-Predicting Sheet.

Activity for Satisfaction

Who Did You Do

Predicted Satisfaction

Actual Satisfaction

(Sense of Achievement

This With? (If Alone, (0-100%) (Write This (0-100%) (Record This

Date

or Pleasure)

Specify Self)

Before the Activity)

After the Activity)

8/18/77 Visit arts and crafts center

self

20%

65%

8/19/77 Go to rock concert

self

15%

75%

8/26/77 Movie

Sharon

85%

80%

8/30/77 Party

Many invited guests

60%

75%

9/2/77 Read novel

self

75%

85%

9/6/77 Jogging

self

60%

80%

9/9/77 Go shopping for blouse at boutique

self

50%

85%

9/10/77 Go to market

mother

40%

30% (argument)

9/10/77 Walk to the park

Sharon

60%

70%

9/14/77 Date

Bill

95%

80%

9/15/77 Study for exam

self

70%

65%

9/16/77 Go for driving test

mother

40%

95% (passed test!)

9/16/77 Ride bicycle to ice cream store

self

80%

95%

FEELING GOOD

way?" In this case try to pinpoint the automatic negative thoughts that dampen the experience for you. Then talk back to these thoughts. For example, a lonely sixty-five-year-old woman whose children were all grown and married decided to enroll in an evening course. All the other students were of college freshman age. She felt tense the first week of classes because of her thought, "They probably think I'm an old bag with no right to be here." When she reminded herself she had no idea what the other students thought of her, she felt some relief. After talking to another student, she found out that some of them admired her gumption. She then felt much better, and her satisfaction levels began to climb.

Now let's see how the Pleasure-Predicting Sheet can be used to overcome dependency. Joanie was a fifteen-year-old high-school student who had suffered from a chronic depression for several years after her parents moved to a new town. She had difficulty making friends in the new high school, and believed, as many teenage girls do, that she had to have a boyfriend and be a member of the "in crowd" before she could be happy. She spent nearly all her free time at home alone, studying and feeling sorry for herself. She resisted and resented the suggestion she start going out and doing things because she claimed there would simply be no point in doing them alone. Until a circle of friends magically dropped into her lap, she seemed determined to sit and brood.

I persuaded Joanie to use the Pleasure-Predicting Sheet.

Figure 12-2 shows that Joanie scheduled a variety of activities, such as visiting an arts and crafts center on a Saturday, going to a rock concert, etc. Because she did them alone, she anticipated they would be unrewarding, as indicated by her low predictions in column four. She was surprised to find she actually did have a reasonably good time. As this pattern tended to repeat itself, she began to realize that she was predicting things in an unrealistic negative way. As she did more and more on her own, her mood began to improve. She still wanted friends, but no longer felt condemned to misery when she was alone. Because she proved she could make it on her own, her self-confidence went up. She then became more assertive with her peers, and invited several people to a party. This helped her develop a network of friends, and she 283

David D. Burns, M.D.

found that boys as well as girls in her high-school class were interested in her. Joanie continued to use the Pleasure-Predicting Sheet to evaluate the levels of satisfaction she experienced in dates and activities with her new friends. She was surprised to find that they were comparable to the enjoyment levels she experienced in doing things alone.

There is a difference between wanting and needing something. Oxygen is a need, but love is a want. I repeat: LOVE

IS NOT AN ADULT HUMAN NEED! It's okay to want a loving relationship with another human being. There is nothing wrong with that. It is a delicious pleasure to be involved in a good relationship with someone you love. But you do not need that external approval, love, or attention in order to survive or to experience maximal levels of happiness.

Attitude Modification. Just as love, companionship, and marriage are not necessary for happiness and self-esteem, they are not sufficient either. The proof of this is the millions of men and women who are married and miserable. If love were the antidote to depression, then I would soon be out of business because the vast majority of the suicidal individuals I treat are in fact loved very dearly by their spouses, children, parents, and friends. Love is not an effective antidepressant. Like tranquilizers, alcohol, and sleeping pills, it often makes the symptoms worse.

In addition to restructuring your activities more creatively, challenge the upsetting negative thoughts that flow through your mind when you are alone.

This was helpful to Maria, a lovely thirty-year-old single woman, who found that when she did activities on her own, she sometimes soured the experience unnecessarily by telling herself, "Being alone is a curse." In order to combat the feelings of self-pity and resentment this thought created, she wrote a list of counterarguments (see Figure 12-3, opposite page). She reported this was very helpful in breaking the cycle of loneliness and depression.

Over a year after terminating my work with her I sent her an early draft of this chapter, and she wrote back: "Last night I read very thoroughly the chapter ... It proves that it is not being alone that is so bad or so good, but rather how one thinks regarding that or any other condition of being.

Thoughts are so powerful! They can make or break you,

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right? . . . It is almost funny, but now I am almost afraid to have a man.' I do rather well, maybe better, without one . . . Dave, did you ever think you would hear this from me?"

Figure 12-3. "Being alone is a curse." Counterarguments: The advantages of being alone.

L Being alone gives a person the opportunity to explore what she or he really thinks, feels, and knows.

2 Being alone gives the person a chance to try all sorts of new things that might be harder to try if one had ties to a housemate, spouse, etc.

3. Being alone forces you to develop your personal strengths.

4. Being alone enables you to put aside excuses for taking responsibility for yourself.

S. Being a woman alone is better than being a woman with an unsuitable male mate. The same applies to a man.

6. Being a woman alone can be an opportunity to develop into a full human being and not be an appendage to a man.

7. Being a woman alone can be helpful in making you more understanding of the problems women in different situations face. This can help you learn to be more supportive of other women and can enable you to develop more meaningful relations with them. The same could also apply to men and their understanding of various male problems.

8. Being a woman alone can show a woman that even if she later lived with a man, she need not be constantly afraid of his leaving her or dying. She knows that she can live alone and has the potential for happiness within herself; thus, the relationship can be one of mutual enhancement rather than one of mutual dependency and demandingness.

The double-column technique can be especially useful in helping you overcome the negative thinking pattern that makes you fear standing on your own two feet. For example, a divorced woman with one child contemplated suicide because her lover—a married man—had broken off with her.

She had an intensely negative self-image, and didn't believe that she would ever be capable of sustaining an ongoing relationship. She was sure she would always end up a reject and 285

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a loner. She wrote in her journal the following thoughts as she contemplated a suicide attempt:

The empty place in the bed next to me silently mocks me. I am alone—alone—my greatest fear, my most dreaded fate, a reality. I am a woman alone and in my mind that means I am nothing. The logic I am operating on goes something like this:

1. If I were desirable and attractive there would be a man beside me now.

2. There is no man beside me.

3. Therefore I am undesirable and unattractive.

4. Therefore there is no point in living.

She went on to ask herself in her journal, "Why do I need a man? A man would solve all my problems. He would take care of me. He would give my life direction and most importantly he would provide me with a reason to get out of bed each morning when all I now want to do is put my head under the covers and sink into oblivion."

She then utilized the double-column technique as a way of challenging the upsetting thoughts in her mind. She labeled the left-hand column "Accusations of My Dependent Self,"

and labeled the right-hand column "Counterarguments of My Independent Self." She then carried out a dialogue with herself to determine what the truth of the matter really was (see Figure 12-4, opposite page).

After doing the written exercise, she decided to read it over each morning in order to develop the motivation to get out of bed. She wrote the following outcome in her personal diary: I learned to see that there is a big difference between wanting and needing. I want a man but I no longer feel that I must have a man to survive. By maintaining a more realistic inner dialogue with myself and by looking at my own strengths, by listing and reading and reading again the things that I have obtained on my own, I slowly am beginning to develop a sense of confidence in my ability to handle what might come. I find that I am taking better care of myself. I am treating myself as I would have treated a beloved friend in the past with kindness and compassion, with a tolerance for flaws and 286

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an appreciation of assets. Now I can view a difficult situation not as a pestilence especially contrived to plague me but as an opportunity to practice the skills I am learning, to challenge my negative thoughts, to reaffirm my strengths and to enhance my confidence in my ability to deal with life.

Figure 12-4.

Accusations of My

Counterarguments of My

Dependent Self

Independent Self

L I necd a man.

1. Why do you need a Irian?

Have you been coping so far in

2. Because I can't cope on my own. 2. life?

3. Okay. But I'm lonely.

3. Yes, but you have a child and

you do have friends, and you

have enjoyed being with them

very much.

4 Yes, but they don't count.

4. They don't count because you

dismiss them.

S. But people will •think no man

5. People will think what they want

wants me.

to think. What is important is

what you think. Only your

thoughts and beliefs can affect

your moods.

IL I think I am nothing without a 6. What did you accomplish having man.

a man that you couldn't accom-

plish on your own?

7. Actually nothing. Everything im- 7.

Then why do you need a man?

portant I've done on my own.

L I guess I don't need a man. I just

8. It's fine to want things. They just

want one.

can't become so important that

life loses its meaning without

them.

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CHAPTER 13

Your Work Is Not Your Worth

A third silent assumption that leads to anxiety and depression is "My worth as a human being is proportional to what I have achieved in my life." This attitude is at the core of Western culture and the Protestant work ethic. It sounds innocent enough. In fact, it is self-defeating, grossly inaccurate, and malignant.

Ned, the physician described in earlier chapters, called me at home one recent Sunday evening. He had been feeling panicky all weekend. His upset was triggered by plans to attend the twentieth reunion of his college class (he graduated from an Ivy League college). He had been invited to give the keynote address to the alumni. Why was Ned in such a state of apprehension? He was concerned that he might meet up with some classmate at his reunion who had achieved more than he had. He explained why this was so threatening: "It would mean I was a failure."

Ned's exaggerated preoccupation with his achievements is particularly common among men. While women are not immune to career concerns, they are more likely to be depressed after the loss of love or approval. Men, in contrast, are especially vulnerable to concerns about career failure because they've been programmed from childhood to base their worth on their accomplishments.

The first step in changing any personal value is to determine if it works more to your advantage or disadvantage. Deciding that it will not really help you to measure your worth by what you produce is the crucial first step in changing your philosophy. Let's begin with a pragmatic approach, a cost-benefit analysis.

Clearly, there can be some advantage to equating your 288

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self-esteem with your accomplishments. In the first place, you can say "I'm okay" and feel good about yourself when you have achieved something. For example, if you win a golf game, you can pat yourself on the back and feel a little smug and superior to your partner because he missed his putt on the last hole. When you go jogging with a friend and he runs out of breath before you do, you can puff up with pride and tell yourself, "He's a good guy for sure, but I'm just a little

betterl" When you make a big sale at work, you can say, "I'm producing today. I'm doing a good job. My boss will be pleased and I can respect myself." Essentially, your work ethic allows you to feel you've earned personal worth and the right to feel happy.

This belief system may make you especially motivated to produce. You might put extra effort into your career because you're convinced this will give you extra worthiness units, and you will therefore see yourself as a more desirable per son. You can avoid the horrors of being "just average." In a nutshell, you may work harder to win, and when you win you may like yourself better.

Let's look at the other side of the coin. What are the disadvantages of your philosophy of "worth equals achievement"?

Fffst, if your business or career is going well, you may become so preoccupied with it that you may inadvertently cut yourself off from other potential sources of satisfaction and enjoyment as you slave away from early morning to late night. As you become more and more of a workaholic, you Xll feel excessively driven to produce because if you fail to keep up the pace, you will experience a severe withdrawal characterized by inner emptiness and despair. In the absence of achievement, you'll feel worthless and bored because you'll have no other basis for self-respect and fulfillment.

Suppose as a result of illness, business reversal, retirement, or some other factor beyond your control, you find you are unable to produce at the same high level for a period of time.

Now you may pay the price of a severe depression, triggered by the conviction that because you are less productive it means you are no good. You'll feel like a tin can that's been used and is now ready for the trash. Your lack of self-esteem might even culminate in a suicide attempt, the ultimate pay-

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ment for measuring your worth exclusively by the standards of the marketplace. Do you want this? Do you need this?

There may be other prices to pay. If your family suffers from your neglect, a certain resentment may build up. For a long time they may hold it in, but sooner or later you'll get the bill. Your wife has been having an affair and is talking about divorce. Your fourteen-year-old son has been arrested for burglary. When you try to talk with him, he snubs you: "

Where've you been all these years, Dad?" Even if these unfortunate developments do not happen to you, you will still have one great disadvantage—the lack of true self-esteem.

I have recently begun treating a very successful businessman. He claims to be one of the top money earners in the world in his profession. Yet he is victimized by episodic states of fear and anxiety. What if he should fall off the pinnacle?

What if he had to give up his Rolls-Royce Silver Cloud and drive a Chevrolet instead? That would be unbearable! Could he survive? Could he still love himself? He doesn't know if he could find happiness without the glamour or glory. His nerves are constantly on edge because he can't answer these questions. What would your answer be? Would you still respect and love yourself if you experienced a substantial failure?

As with any addiction, you find that greater and greater doses of your "upper" will be needed in order to become "

high." This tolerance phenomenon occurs with heroin, "

speed" (amphetamines), alcohol, and sleeping pills. It also happens with riches, fame, and success. Why? Perhaps because you automatically set your expectations higher and higher once you have achieved a particular level. The excitement quickly wears off. Why doesn't the aura last? Why do you keep needing more and more? The answer is obvious: Success does not guarantee happiness. The two are not identical and are not causally related. So you end up chasing a mirage. Since your thoughts are the true key to your moods and not success, the thrill of victory fades quickly. The old achievements soon become old hat—you begin to feel sadly bored and empty as you stare at your trophy case.

If you do not get the message that happiness does not reliably and necessarily follow from success, you may work even harder to try to recapture the feeling you once had from being on top. This is the basis for your addiction to work.

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Many individuals seek guidance or therapy because of the disillusionment that begins to dawn on them in their middle or later years. Eventually these questions may confront you as well: What's my life all about? What's the meaning of it all? You may believe your success makes you worthwhile, but the promised payoff seems elusive, just beyond your grasp.

As you read the above paragraphs, you may suspect that the disadvantages of being a success junkie outweigh the advantages. But you may still believe it is basically true that people who are superachievers are more worthwhile—the big shots seem "special" in some way. You may be convinced that true happiness, as well as the respect of others, comes primarily from achievement. But is this really the case?

In the first place, consider the fact that most human beings are not great achievers, yet most people are happy and well respected. In fact, one could say that the majority of the people in the United States are loved and happy, yet by definition most of them are pretty much average. Thus, it cannot be the case that happiness and love come only through great achievement. Depression, like the plague, is no respecter of status and strikes those who live in fancy neighborhoods as often—if not more frequently—as it does those of average or below-average means. Clearly, happiness and great achievement have no necessary connection.

Does Work = Worth?

Okay, let's assume you've decided that it's not to your advantage to link your work and your worth, and you also admit that achievement will not reliably bring you love, respect, or happiness. You may still feel convinced that on some level, people who achieve a lot are somehow better than others.

Let's take a hard look at this notion.

First, would you say that everybody who achieves is particularly worthwhile just because of their achievement? Adolf Hitler was clearly a great achiever at the height of his career.

Would you say that made him particularly worthwhile? Obviously not. Of course, Hitler would have insisted he was a great human being because he was a successful leader and because he equated his worth and achievements. In fact, he was probably convinced that he and his fellow Nazis were su-291

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permen because they were achieving so much. Would you agree with them?

Perhaps you can think of a neighbor or someone you don't like very much who does achieve a lot and yet seems overly grasping and aggressive. Now, is that person especially worthwhile in your opinion just because he or she is an achiever?

In contrast, perhaps you know someone you care for or respect who is not a particularly great achiever. Would you say that person is still worthwhile? If you answer yes, then ask yourself—if they can be worthwhile without great achievement, then why can't I be?

Here's a second method. If you insist your worth is determined by your achievement, you are creating a self-esteem equation: worth = achievement. What is the basis for making this equation? What objective proof do you have that it is valid? Could you experimentally measure people's worth as well as their achievement so as to find out if they were in fact equal? What units would you use to measure it? The whole idea is nonsense.

You can't prove the equation because it is just a stipulation, a value system. You're defining worth as achievement and achievement as worth. Why define them as each other?

Why not say worth is worth and achievement is achievement?

Worth and achievement are different words with different meanings

In spite of the above arguments, you may still be convinced that people who achieve more are better in some way.

If so, I'm going to hit you now with a most powerful method which, like dynamite, can shatter this attitude even when it appears to be etched in granite.

First, I would like you to play the role of Sonia (or Bob), an old friend from high-school days. You have a family and teach school. I have pursued a more ambitious career. In the dialogue you will assume that human worth is determined by achievement, and I will push the implications of this to their obvious, logical, and obnoxious conclusion. Are you ready? I hope so because you're about to be assaulted in a most unpleasant way by a belief you apparently still cherish.

DAVID: Sonia (or Bob), how are you doing?

YOU (playing the role of my old friend) : Just fine, David.

How are you?

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DAVID: Oh, great. I haven't seen you since high school.

What's been happening?

YOU: Oh, well, I got married, and I'm teaching at Parks High School and I have a little family at home. Things are great.

. DAVID: Well, gee. I'm sorry to hear that. I turned out a lot better than you.

YOU: How's that? Come again?

DAVID: I went to graduate school and I got my Ph.D. and I have become quite successful in business. I'm earning a lot of money. In fact, Pm one of the wealthier people in town now. I've achieved a great deal. More than you by a long shot. I don't mean to insult you or anything, but I guess that means I'm a lot better person than you, huh?

YOU: Well, gee, Dave, I'm not sure what to say. I thought I was a rather happy person before I started to talk to you.

DAVID: I can understand that. You're at a loss for words, but you might as well face facts. I've got what it takes, and you don't. I'm glad you're happy, though. Mediocre, average people are entitled to a little happiness too. After all, I certainly don't begrudge you a few crumbs from the banquet table. But it's just too bad you couldn't have done more with your life.

YOU: Dave, you seem to have changed. You were such a nice person in high school. I get the feeling you don't like me anymore.

DAVID: Oh, no! We can still be friends as long as you admit you're an inferior, second-rate person. I just want to remind you to look up to me from now on, and I want you to realize that I'll look down on you because I'm more worthwhile. This follows from the assumption that we have—worth equals achievement. Remember that attitude you cherish? I've achieved more, so I'm worth more.

YOU: Well, I sure hope I don't run into you soon again, Dave. It's not been such a pleasure talking to you.

That dialogue cools most people off very quickly because it illustrates how the inferior-superior system follows logically from equating your worth with your achievement. Actually, 293

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many people do feel inferior. The role-playing can help you see how ludicrous the assumption is. In the above dialogue, who was acting jerky? The happy housewife/schoolteacher or the arrogant businessman trying to make a case that he was better than other people? I hope this imaginary conversation will help you see clearly how screwball the whole system is.

If you like, we can do a role-reversal to put the icing on the cake. This time you play the role of the very successful person, and I want you to try to put me down as sadistically as you can. You can pretend to be the editor of Cosmopolitan magazine, Helen Gurley Brown.* I went to high school with you; I'm just an average high-school teacher now, and it's your job to argue that you're better than I am.

YOU (playing the role of Helen Gurley Brown): Dave, how have you been? It's been a long time.

DAVID (playing the role of a high school teacher): Well, fine. I have a little family, and I'm teaching high school here. I'm a physical education teacher and really enjoying life. I understand you've made it big.

YOU: Yeah. Well, I really have been kind of lucky. I'm editor of Cosmopolitan now. Perhaps you heard.

DAVID: Of course I have. I've seen you on TV on the talk shows plenty of times. I hear you make a huge income, and you even have your own agent.

YOU: Life's been good. Yeah. It's really been terrific.

DAVID: Now there's just one thing I heard about you that I really didn't understand. You were talking to a friend of ours, and you were saying how you're so much better than I am now that you've made it big, whereas my career is just average. What did you mean by that?

YOU: Well, Dave, I mean, just think about all the things I'

ve accomplished in my life. Here I am influencing millions, and whoever heard of Dave Burns in Philadelphia?

I'm hobnobbing with the stars, and you're bouncing a basketball around in the court with a bunch of kids.

Don't get me wrong. You're certainly a fine, sincere, average person. It's just that you never made it, so you might as well face facts!

* This is a purely imaginary dialogue having no bearing on the real Helen Gurley Brown.

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DAVID: You've made a great impact, and you're a woman of influence and fame. I respect that a lot, and it sounds quite rewarding and exciting. But please forgive me if I'm dense. I just don't understand how that makes you a better person. How does that make me inferior to you or make you more worthwhile? With my little local mind, I must be missing something obvious.

YOU: Face it, you just sit around and interact with no particular purpose or destiny. I have charisma. I'm a mover and shaker. That gives me a bit of an edge, wouldn't you say?

DAvm: Well, I don't interact to no purpose, but my purposes may seem modest in comparison with yours. I teach phys ed, and I coach the local football games and that kind of thing. Your orbit is certainly big and fancy in comparison with mine. But I don't understand how that makes you a better person than I am, or how it follows that I'm inferior to you.

YOU: I'm just more highly developed and more elaborate. I think about more important things. I go on the lecture circuit, and people flock to hear me by the thousands.

Famous authors work for me. Who do you lecture to?

The local PTA?

DAVID: Certainly in achievement, money, and influence you're way ahead of me. You've done very well. You were very bright to begin with, and you've worked very hard. You're a big success now. But how does that make you more worthwhile than I am. You must forgive me, but I still don't grasp your logic.

YOu: I'm more interesting. It's like an amoeba versus a highly developed biological structure. Amoebas are kind of boring after a while. I mean your life must be like an amoeba's. You're just bumbling around aimlessly. I'm a more interesting, dynamic, desirable person; you're second-rate. You're the burnt toast; I'm the caviar. Your life is a bore. I don't see how I can say it more clearly.

DAVID: My life isn't as boring as you might think. Take a close look at it. I'd be surprised to hear what you have to say here because I can't find anything boring about my life. What I do is exciting and vital to me. The people I teach are every bit as important to me as the 295

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glamorous movie stars you interact with. But even if it were true that my life was more tedious and routine and less interesting than yours, how would that make you a better person or more worthwhile?

YOU: Well, I suppose it just really boils down to the fact that if you have an amoeba existence, then you can only judge it on the basis of your amoeba mentality. I can judge your situation, but you can't judge mine.

DAVID: What is the basis for your judgment? You can call me an amoeba, but I don't know what that means. You seem to be reduced to name-calling. All it means is that apparently my life is not especially interesting to you.

Certainly rm not nearly as successful or glamorous, but how does that make you a better or more worthwhile person?

YOU: I'm almost starting to give up.

DAVID: Don't give up here. Press on. Perhaps you are a better person!

YOU: Well, certainly society values me more. That's what makes me better.

DAVID: It makes you more highly valued by society. That's undolibtedly the case. I mean Johnny Carson hasn't contacted me for any appearances recently.

You: I've noticed that.

DAVID: But how does being more highly valued by society make you a more worthwhile person?

YOU: I'm earning a huge salary. I'm worth millions. Just how much are you worth, Mr. Schoolteacher?

DAVID: You clearly have more financial worth. But how does that make you a more worthwhile human being?

How does commercial success make you a better person?

YOU: Dave, if you're not going to worship me, rm not going to talk to you.

DAVID: Well, I don't see how that would make me less worthwhile either. Unless you have the idea that you're going to go around deciding who's worthwhile based on who worships you!

YOU: Of course I do!

DAVID: Does that go along with being editor of Cosmopolitan? If so, please tell me how you make these decisions.

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If I'm not worthwhile, I'd definitely like to know why so that I can give up feeling good and considering myself equal to other people.

YOU: Well, it must be that your orbit is rather small and dreary. While I'm on my Lear jet to Paris, you're in a crowded school bus going to Sheboygan.

DAVID: My orbit may be small, but it's very gratifying. I enjoy the teaching. I enjoy the kids. I like to see them develop. I like to see them learn. At times they make mistakes, and I have to let them know. There's a lot of real love and humanity that goes on there. A lot of drama. What about that seems dreary to you?

YOU: Well, there's not as much to learn. No real challenge.

It seems to me that in a world as small as yours you learn just about everything there is to learn, and then you just repeat things over and over.

DAVID: Your work presents quite a challenge as it turns out. How could I know everything there is to know about even one student? They all seem complex and exciting to me. I don't think I have anybody figured out completely. Do you? Working with even one student is a complex challenge to all my abilities. Having so many young people to work with is a challenge beyond what I could ask for. I don't understand what you mean when you say my world is small and boring and everything is figured out.

YOU: Well, it just seems to me that you are unlikely to run into many people in your world who are going to develop as highly as I have.

DAVID: I don't know. Some of my students have high IQ's and may develop the same way you did, and some of them are mentally subnormal and will only develop to a modest level. Most are average and each one is fascinating to me. What did you mean when you said they were boring? Why is it that only the great achievers are interesting to you?

YOU: I give in! Uncle!

I hope you did in fact "give in" when you played the role of the successful snob. The method I used to thwart your claim you were better than I was quite simple. Whenever you 297

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claimed you were a better or more worthy person because of some specific quality such as intelligence, influence, status, or whatever, I immediately agreed with you that you are better in that particular quality (or set of qualities) and then I asked you—"But how does that make you a better (or more worthwhile person?" This question cannot be answered. It will take the wind out of the sails of any system of values that sets some people up as being superior to others.

The technical name for this method is "operationalization."

In it you must spell out just what quality makes anyone more or less worthwhile than anyone else. You can't do it!

Of course, other people would rarely think or say such insulting things to you as were said in the dialogues. The real put-down goes on in your head. You are the one who's telling yourself your lack of status, or achievement, or popularity, or love, etc., makes you less worthwhile and desirable; so you're the one who's going to have to put an end to the persecution.

You can do this in the following way: Carry on a similar dialogue with yourself. Your imaginary opponent, who we'll name the Persecutor, will try to argue that you are inherently inferior or less worthwhile because of some imperfection or lack. You simply assertively agree with the grain of truth in his criticism, but raise the question of how it follows that you are less worthwhile. Here are several examples:

1. Persecutor: You're not a very good lover. Sometimes you don't even get a firm erection. This means you're less of a man and an inferior person.

You: It certainly shows that I'm nervous about sex and not a particularly skilled or confident lover. But how does this make me less of a man or less of a person?

Since only a man can feel nervous about an erection, this would seem to be an especially "manly" experience; doing it well makes you more of a man! Furthermore, there's a great deal more to being a man than just having sex.

2. Persecutor: You're not as hardworking or as successful as most of your friends. You're lazy and no good.

You: This means I'm less ambitious and

hardworking. I may even be less talented, but how does it follow that I'm "lazy and no good"?

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3. Persecutor: You're not worth much because you're not outstanding in anything.

You: I agree that I don't hold a single world cham-pionship. I'm not even second best at anything. In fact, at most things I'm pretty much average. How does it follow that I'm not worth much?

4. Persecutor: You're not popular, you don't even have many close friends. and no one cares about you much.

You have no family and not even any casual lovers. So you're a loser. You're an inadequate person. There's obviously something wrong with you. You're worthless.

You: It's true I have no lover at this time, and there are just a few friends I feel close to. How many do I need to be an "adequate person"? Four? Eleven? If I'm not popular it may be that I'm relatively unskilled socially, and I may have to work harder at this. But how does it follow that I'm a "loser"? Why am I worthless?

I suggest you try out the method illustrated above. Write down the worst persecutory insults you can level at yourself and then answer them. It may be hard at first, but eventually the truth will dawn on you—you can be imperfect or unsuccessful or unloved by others, but not one iota less worthwhile.

Four Paths to SelfEsteem

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You might ask, "How can I attain self-esteem if my worth doesn't come from my success or from love or approval? If you peel all these criteria away one by one and expose them as invalid bases for personal worth, it seems there will be nothing left. Just what is it that I have to do?" Here are four valid paths to self-esteem. Choose the one that seems most useful to you.

The first path is both pragmatic and philosophical. Essentially, you must acknowledge that human "worth" is just an abstraction; it doesn't exist. Hence, there is actually no such thing as human worth. Therefore, you cannot have it or fail to have it, and it cannot be measured. Worth is not a "thing,"

it is just a global concept. It is so generalized it has no concrete practical meaning. Nor is it a useful and enhancing 299

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concept. It is simply self-defeating. It doesn't do you any good. It only causes suffering and misery. So rid yourself immediately of any claim to being "worthy," and you'll never have to measure up again or fear being "worthless."

Realize that "worthy" and "worthless" are just empty concepts when applied to a human being. Like the concept of your "true self," your "personal worth" is just meaningless hot air. Dump your "worth" in the garbage can! (You can put your "true self' in there too, if you like.) You'll find you've got nothing to lose! Then you can focus on living in the here and now instead. What problems do you face in life?

How will you deal with them? That's where the action is, not in the elusive mirage of "worth."

You may be afraid to give up your "self' or your "worth."

What are you afraid of? What terrible thing will happen?

Nothing! The following imaginary dialogue may make this clearer. Let's assume that I am worthless. I want you to rub it in and try to make me feel upset.

YOU: Burns, you're worthless!

DAVID: Of course I'm worthless. I fully agree. I realize that there is nothing about me that makes me "worthy."

Love, approval, and achievement can't give me any "

worth," so I'll accept the fact that I have none! Should this be a problem for me? Is something bad going to happen now?

YOU: Well, you must be miserable. You're just "no good."

DAVID: Assuming I am "no good," so what? What specifically do I have to be miserable about? Does being

"worthless" put me at a disadvantage in some way?

You: Well, how can you respect yourself? How could anyone? You're just a scum!

DAVID: You may think I'm a scum, but I do respect myself, and so do lots of other people. I see no valid reason not to respect myself. You may not respect me, but I don't see that as a problem.

You: But worthless people can't be happy or have any fun.

You're supposed to be depressed and despicable. My panel of experts met and determined that you're a total zero.

DAVID: So, call the papers and let them know. I can see 300

FEELING GOOD

the headline: "Philadelphia Physician Found to Be Worthless." If I'm really that bad off, it's reassuring because now I have nothing to lose. I can live my life fearlessly. Furthermore, I am happy and I am having fun, so being a "total zero" can't be bad. My motto is"

Wortbless is Wonderful!" In fact, I'm thinking of having a T-shirt made up like that. Perhaps I'm missing out on something, though. Apparently you're worthwhile, whereas I'm not. What good does this "worth" do you?

Does it make you better than people like me, or what?

The question may occur to you—"If I gave up my belief that success adds to my personal worth, then what would be the point in doing anything?" If you stay in bed all day, the probability that you will bump into something or someone that will make your day a little brighter is very small. Furthermore, there can be enormous satisfactions from daily living that are totally independent of any concept of personal worth. For example, as I am writing this I feel very turned on, but it isn't due to my belief that I am particularly "worth-while" because I'm writing it. The exhilaration comes from the creative process, pulling ideas together, editing, watching clumsy sentences sharpen up, and wondering how you will react when you read this. This process is an exciting adventure. Involvement, commitment, and taking a risk can be quite stimulating. This is an adequate payoff, to my way of thinking.

You might also wonder—"What is the purpose and meaning of life without a concept of worth?" It's simple. Rather than grasp for "worth," aim for satisfaction, pleasure, learning, mastery, personal growth and communication with others every day of your life. Set realistic goals for yourself and work toward them. 1 think you will find this so abundantly gratifying you'll forget all about "worth," which in the last analysis has no more buying power than fool's gold.

"But I'm a humanistic or spiritual person," you might argue. "I've always been taught that all human beings have worth, and I just don't want to give up this concept." Very well, if you want to look at it that way, I'll agree with you, and this brings us to the second path to self-esteem. Acknowledge that everyone has one "unit of worth" from the 301

David D. Burns, M.D.

time they are born until the time they die. As an infant you may achieve very little, and yet you are still precious and worthwhile. And when you are old or ill, relaxed or asleep, or just doing "nothing," you still have "worth." Your "unit of worth" can't be measured and can never change, and it is the same for everyone. During your lifetime, you can enhance your happiness and satisfaction through productive living, or you can act in a destructive manner and make yourself miserable. But your "unit of worth" is always there, along with your potential for self-esteem and joy. Since you can't measure it or change it, there is no point in dealing with it or being concerned about it. Leave that up to God.

Paradoxically, this solution comes down to the same bottom line as the previous solution. It becomes pointless and irresponsible to deal with your "worth," so you might as well focus on living life productively instead! What problems do you confront today? How will you go about solving them?

Questions such as these are meaningful and useful, whereas rumination about your personal "worth" just causes you to spin your wheels.

Here is the third path to self-esteem: Recognize that there is only one way you can lose a sense of self-worth—by persecuting yourself with unreasonable, illogical negative thoughts.

Self-esteem can be defined as the state that exists when you are not arbitrarily haranguing and abusing yourself but choose to fight back against those automatic thoughts with meaningful rational responses. When you do this effectively, you will experience a natural sense of jubilation and self-en-dorsement. Essentially, you don't have to get the river flowing, you just have to avoid damming it.

Since only distortion can rob you of self-esteem, this means that nothing in "reality" can take away your sense of worth.

As evidence for this, many individuals under conditions of extreme and realistic deprivation do not experience a loss of self-esteem. Indeed, some individuals who were imprisoned by the Nazis during World War II refused to belittle themselves or buy into the persecutions of their captors. They reported an actual enhancement of self-esteem in spite of the miseries they were subjected to, and in some cases described experiences of spiritual awakening.

Here is the fourth solution: Self-esteem can be viewed as 302

FEELING GOOD

your decision to treat yourself like a beloved friend. Imagine that some VIP you respect came unexpectedly to visit you one day. How might you treat that person? You would wear your best clothes and offer your finest wine and food, and you would do everything you could to make him feel comfortable and pleased with his visit. You would be sure to let him know how highly you valued him, and how honored you were that he chose to spend some time with you. Now—why not treat yourself like that? Do it all the time if you can! After all, in the final analysis, no matter how impressed you are with your favorite VIP, you are more important to you than he is. So why not treat yourself at least as well? Would you insult and harangue such a guest with vicious, distorted put-downs?

Would you peck away at his weaknesses and imperfections?

Then why do this to yourself? Your self-torment becomes pretty silly when you look at it this way.

Do you have to earn the right to treat yourself in this loving, caring way? No, this attitude of self-esteem will be an assertion that you make, based on a full awareness and acceptance of your strengths and imperfections. You will fully acknowledge your positive attributes without false humility or a sense of superiority, and will freely admit to all your errors and inadequacies without any sense of inferiority or self-depreciation whatever. This attitude embodies the essence of self-love and self-respect. It does not have to be earned, and it cannot be earned in any way.

Escape from the Achievement Trap

You might be thinking, "All that philosophizing about achievement and self-worth is well and good. After all, Dr.

Burns has a good career and a book on the market, so it's easy for him to tell me to forget about achievement. It sounds about as genuine as a rich man trying to explain to a beggar that money isn't important. The raw fact is, I still feel bad about myself when I do poorly, and I believe that life would be a whole lot more exciting and meaningful if I had more success. The truly happy people are the big shots, the executives. I'm only average. I've never done anything really outstanding, so I'm bound to be less happy and satisfied. If this isn't right, then prove it to met Show me what I can do 303

David D. Burns, M.D.

to change the way I feel, and only then will I be a true believer."

Lt's review several steps you might take to liberate yourself from the trap of feeling you must perform in an outstanding manner in order to earn your right to feel worthwhile and happy.

Remember to talk back. The first useful method is to keep practicing the habit of talking back to those negative, distorted thoughts which cause you to feel inadequate. This will help you realize that the problem is not your actual performance, but the critical way in which you put yourself down. As you learn to evaluate what you do realistically, you will experience increased satisfaction and self-acceptance.

Here's how it worked for Len, a young man pursuing a career playing the guitar in rock bands. He sought treatment because he felt like a "second-rate" musician. From the time he was young, he was convinced he had to be a "genius" in order to be appreciated. He was easily hurt by criticism, and often made himself miserable by comparing himself with better-known musicians. He would feel deflated when he told himself, "I'm a nobody in comparison with X." He was certain that his friends and fans also viewed him as a mediocre person, and he concluded that he could never receive his fair share of the good things in life: praise, admiration, love, etc.

Len utilized the double-column technique to expose the nonsense and illogic in what he was saying to himself (Figure 13-1). This helped him see that it was not a lack of musical talent that was the cause of his problems, but his unrealistic thinking patterns. As he began to correct this distorted thinking, his self-confidence improved. He described the effect of this: "Writing down my thoughts and answering them helped me to see how hard I was being on myself, and it gave me a sense there was something I could do to change. Instead of sitting there getting bombed by what I was telling myself, I suddenly had some antiaircraft artillery to fight back with."

Tune in to what turns you on. One assumption which might be driving you to constant preoccupation with achievement is the idea that true happiness comes only through success in your career. This is unrealistic because the majority of life's satisfactions do not require great achievement at all. It takes no special talent to enjoy an average walk 304

FEELING GOOD

through the woods on an autumn day. You don't have to be "

outstanding" to relish the affectionate hug of your young son. You can enjoy a good game of volley ball tremendously even though you're just an average player. What are some of life's pleasures that have turned you on? Music? Hiking?

Swimming? Food? Travel? Conversation? Reading? Learning?

Sports? Sex? You don't have to be famous or a top performer to enjoy these to the hilt. Here's how you can turn up the volume so that this kind of music comes in loud and clear.

Josh is a fifty-eight-year-old man with a history of destructive, manic mood swings as well as incapacitating depressions.

When he was a child, Josh's parents emphasized over and over that his career was destined to be extraordinary, so he always felt he had to be number one. He eventually did make an exceptional contribution in his chosen field, electrical en-gineering. He won numerous awards, was appointed to presidential commissions, and was credited with many patents. However, as his cyclic mood disorder became increasingly severe, Josh began to have "high" episodes. During these periods, his judgment became grossly impaired and his behavior was so bizarre and disruptive that he had to be hospitalized on several occasions. Sadly, he came down off one high to learn he had lost his family as well as his prestigious career. His wife had filed for divorce, and he had been forced into an early retirement by the company he worked for. Twenty years of achievement went down the drain.

In the years that followed, Josh was treated with lithium and developed a modest consulting business. Eventually he was referred to me for treatment because he still experienced uncomfortable mood swings, especially depression, in spite of the lithium.

The crux of his depression was clear-cut. He was discouraged about his life because his career no longer measured up in terms of the money and prestige he had experienced in the past. While he had enjoyed the role of charismatic "charger"

as a young man, he was now approaching sixty and felt alone and "over the hill." Because he still believed the only way to true happiness and personal worth was through superlative, creative achievements, he felt certain that his constricted career and modest life-style made him second-rate.

Since he was still a good scientist at heart, Josh decided to 305

David D. Burns, M.D.

Figure 13-1. Len's homework form for recording and answering his upsetting thoughts about being "the greatest."

Automatic Thoughts

Rational Responses

1. If I'm not "the greatest," it means 1. (All-or-nothing thinking.) Wheth-I won't get any attention from

er or not I'm "the greatest,"

people.

people will listen to me, they

will see me perform, and many

will respond positively to my

music.

2. But everybody doesn't like the 2. This is true of all musicians, even

kind of musk I play.

Beethoven or Bob Dylan. No mu-

sician can please everybody.

Quite a few people do respond

to my musk. If I enjoy my music,

then that should be enough.

3. But how can I enjoy my music if

3. By playing music that turns me

I know I'm not "the greatest"?

on, just as I always have! Be-

sides, there's no such thing as "

the world's greatest musician."

So stop trying to be it!

4. But if I were more famous and 4. How many fans and how many

talented, then I'd have more fans.

girl friends do I need before I'll

How can I be happy on the side-

be happy?

lines when the big-name per-

formers with charisma are in the

spotlight?

S. But I feel that no girl could S. Other people are loved who are really love me until I become a

just "average" in their work.

big-name talent.

Do I really have to be a big shot

before someone will love me?

Many of the guys I know get

plenty of dates and they're not

so unusual.

test his hypothesis that his life was destined to be mediocre by using the Pleasure-Predicting Sheet (described in previous chapters). Each day he agreed to schedule various activities that might give him a sense of pleasure, satisfaction, or personal growth. These activities could be related to his consult-

306

Figure 13-2. The Pleasure-Predicting Sheet.

Who Did You Do

Predicted Satisfaction

Actual Satisfaction

Activity for Pleasure

This With? (If Alone, (0-100%). (Record This (0-100%). (Record This

Date

or Satisfaction

Specify Self.)

Before the Activity.)

After the Activity.)

4/18/78 Work on consulting project

self

70%

75%

4/19/78 Take long walk before breakfast

self

40%

85%

4/19/78 Prepare written report

self

50%

50%

4/19/78 Make a "missionary call" on a po-self

60%

40% (no new business)

tential customer

4/20/78 Roller-skating

girl friend

50%

99%I

David D. Burns, M.D.

ing business as well as hobbies and recreational pursuits.

Before each activity he was to write down his prediction of how enjoyable it would be and mark it between 0 percent (

no satisfaction at all) and 99 percent (the maximum enjoyment a human being can experience).

After filling out these forms for several days, Josh was surprised to find that life had just as much potential for joy and satisfaction as it ever had (see Figure 13-2). His discovery that work was at times quite rewarding and that numerous other activities could be just as enjoyable, if not more so, was a revelation to him. He was amazed one Saturday night when he went roller-skating with his girl friend. As they moved to the music, Josh found he began to tune into the beat and the melody, and as he became absorbed in the rhythm, he experienced a great sense of exhilaration. The data he collected on the Pleasure-Predicting Sheet indicated he didn't need a trip to Stockholm to receive the Nobel Prize to experience the ultimate in satisfaction—he didn't have to go any farther than the skating rink! His experiment proved that life was still filled with abundant opportunities for pleasure and fulfillment if he would enlarge his mental focus from a microscopic fixation on work and open himself up to the broad range of rich experiences that living can offer.

I am not arguing that success and achievement are undesirable. That would be unrealistic. Being productive and doing well can be enormously satisfying and enjoyable. However, it is neither necessary nor sufficient to be a great achiever in order to be maximally happy. You don't have to earn love or respect on the treadmill, and you don't have to be number one before you can feel fulfilled and know the meaning of inner peace and self-esteem. Now doesn't that make good sense?

308

CHAPTER 14

Dare to Be Average!—

Ways to Overcome Perfectionism

I dare you to try to be "average." Does the prospect seem blah and boring? Very well—I dare you to try it for just one day. Will you accept the challenge? If you agree, I predict two things will happen. First, you won't be particularly successful at being "average." Second, in spite of this you will receive substantial satisfaction from what you do. More than usual. And if you try to keep this "averageness" up, I suspect your satisfaction will magnify and turn to joy. That's what this chapter is all about—learning to defeat perfectionism and enjoy the spoils of pure joy.

Think of it this way—there are two doors to enlightenment. One is marked "Perfection," and the other is marked "

Average." The "Perfection" door is ornate, fancy, and seductive. It tempts you. You want very much to go through.

The "Average" door seems drab and plain. Ugh! Who wants it? So you try to go through the "Perfection" door and always discover a brick wall on the other side. As you insist on trying to break through, you only end up with a sore nose and a headache. On the other side of the "Average" door, in contrast, there's a magic garden. But it may never have occurred to you to open this door to take a look!

You don't believe me? I didn't think so, and you don't have to. I want you to maintain your skepticism! It's healthy—

but at the same time I dare you to check me out. Prove me wrong! Put my claim to the test. Walk through that "Average" door just one day in your life. You may end up amazed!

Let me explain why. "Perfection" is man's ultimate illusion. It simply doesn't exist in the universe. There is no per-309

David D. Burns, M.D.

fection. It's really the world's greatest con game; it promises riches and delivers misery. The harder you strive for perfection, the worse your disappointment will become because it's only an abstraction, a concept that doesn't fit reality. Everything can be improved if you look at it closely and critically enough—every person, every idea, every work of art, every experience, everything. So if you are a perfectionist, you are guaranteed to be a loser in whatever you do.

"Averageness" is another kind of illusion, but it's a benign deception, a useful construct. It's like a slot machine that pays a dollar fifty for every dollar you put in. It makes you rich—on all levels.

If you're willing to explore this bizarre-sounding hypothesis, let's begin. But beware—don't let yourself become too average because you may not be used to so much euphoria.

After all, a lion can eat only so much meat after the kill!

Do you remember Jennifer, the perfectionistic writer-student mentioned in Chapter 4? She complained that friends and psychotherapists kept telling her to stop being such a perfectionist, but no one ever bothered to tell her how to go about doing this. This chapter is dedicated to Jennifer. She's not the only one who feels in a quandry about this. At my lectures and workshops, psychotherapists have often asked me to prepare a how-to-do-it manual that illustrates the fifteen techniques I have developed for overcoming perfectionism Well—here's the manual. These methods work. You have nothing to fear or lose because the effects are not irreversible.

1. The best place to begin your fight against perfectionism is with your motivation for maintaining this approach.

Make a list of the advantages and disadvantages of being perfectionistic. You may be surprised to learn that it is not actually to your advantage. Once you understand that it does not in fact help you in any way, you'll be much more likely to give it up.

Jennifer's list is shown in Figure 14-1. She concluded that her perfectionism was clearly not to her advantage. Now make your list. After you have completed it, read on.

2. Using your list of the advantages and disadvantages of perfectionism, you might want to do some experiments to test some of your assumptions about the advantages. Like many people, you may believe "Without my perfectionism I'd be 310

FEELING GOOD

Figure 14-1. Jennifer's list of advantages and disadvantages of perfectionism. She concluded, "Clearly the disadvantages outweigh the one possible advantage."

Advantages of Perfectionism

Disadvantages

1. It can produce fine work. I'll try 1. It makes me so "tight" and ner-hard to come up with an creep- vous I can't produce fine work.

tional result.

2. I become afraid and unwilling to

risk the mistakes necessary to

come up with a fine product.

3. It makes me very critical of my-

self. I can't enjoy life because I

can't admit my successes or alow

myself to revel in them.

4. I can't ever relax because I'll al-

ways be able to find something

somewhere that Isn't perfect, and then I'll get self-critical.

5. Since I can never be perfect, T11

always be depressed.

6. It makes me intolerant of others.

I end up without many Mends

because people don't appreciate

being criticized. I find so many

faults in people I lose my ca-

pacity to feel warm and to like

them.

7. Another disadvantage is that my

perfectionism keeps me from try-

ing new things and making dis-

coveries. Tm so afraid of making

mistakes that I don't do much at

all besides the same familiar

things Tm good at. The result is

that it narrows my world and

makes me bored and restless be-

cause I have no new challenges.

311

David D. Burns, M.D.

nothing. I couldn't perform effectively." I'll bet you never put this hypothesis to the test because your belief in your inadequacy is such an automatic habit it has never even occurred to you to question it. Did you ever think that maybe you've been as successful as you are in spite of your perfectionism and not because of it! Here's an experiment that will allow you to come to the truth of the matter. Try altering your standards in various activities so you can see how your performance responds to high standards, middle standards, and low standards. The results may surprise you. I've done this with my writing, my psychotherapy with patients, and my jogging. And in all cases I have been pleasantly shocked to discover that by lowering my standards not only do I feel better about what I do but I tend to do it more effectively.

For example, I began jogging in January 1979 for the first time in my life. I live in a very hilly region, and initially I couldn't run more than two or three hundred yards without having to stop and walk because there are hills in all directions from my driveway. Each day I nade it my aim to run a little less far than the day before. The effect of this was that I could always accomplish my goal easily. Then I would feel so good it would spur me on farther—and every step was gravy, more than I had aimed for. Over a period of months I built up to the point at which I could run seven miles over a steep terrain at a fairly rapid pace. I have never abandoned my basic principles—to try to accomplish less than the day before. Because of this rule I never feel frustrated or disappointed in my running There have been many days when due to sickness or fatigue, I actually didn't run far or fast.

Today, for example, I could only run a quarter mile because I had a cold and my lungs said NO FARTHER! So I told myself, "This is as far as I was supposed to go." I felt good because I achieved my goal.

Try this. Choose any activity, and instead of aiming for 100 percent, try for 80 percent, 60 percent, or 40 percent.

Then see how much you enjoy the activity and how productive you become. Dare to aim at being average! It takes courage, but you may amaze yourself!

3. If you are a compulsive perfectionist you may believe that without aiming for perfection you couldn't enjoy life to the maximum or find true happiness. You can put this notion 312

FEELING GOOD

to the test by using the Antiperfectionism Sheet (Figure 14-2). Record the actual amount of satisfaction you get from a wide range of activities, such as brushing your teeth, eating an apple, walking in the woods, mowing the lawn, sun-bathing, writing a report for work, etc. Now estimate how

perfectly you did each activity between 0 and 100 percent, as well as marking how satisfying each was between 0 and 100

percent. This will help you break the illusory connection between perfection and satisfaction.

Here's how it works. In Chapter 4 I referred to a physician who was convinced he had to be perfect at all times. No matter how much he accomplished he would always raise his standards slightly higher, and then he'd feel miserable. I told Figure 14-2. The Antiperfectionism Sheet.

Record How Effectively Record How

Satisfying You Did This Between This Was

Between Activity

0% and 100%

0% and 100%

Fa broken pipe in

20% (I took a long 99% (I actually did ill) kitchen

time and made a lot of

mistakes.)

Cove lecture to 'medi- 98% (I got a standing SO% (I usually get a al school class

ovation.)

standing ovation—I

wasn't particularly

thrilled with my per.

formance.)

Play tennis afte•work

60% (I lost the match 95% (Really felt good.

but played okay.)

Enjoyed the game and

the exercise.)

Edit draft of my latest 75% (I stuck with it 15% (I kept tellitig paper for one hour

and corrected many er- myself it wasn't the de-

rors, and smoothed out Pave paper and felt the sentences.)

quite frustrated.)

Talk to student about 50% (I didn't do any- 90% (He really seemed his career optioas

thing special. I just to appreciate our talk, listened to him and of- so I felt turned on.) fered a few obvious

suggestions.)

313

David D. Burns, M.D.

him he was the Philadelphia all-or-nothing thinking champion! He agreed but protested he didn't know how to change. I persuaded him to do some research on his moods and accomplishments, using the Antiperfectionism Sheet. One weekend he did some plumbing at home because a pipe broke and flooded the kitchen. He was a novice plumber, but did manage to fix the leak and clean up the mess. On the sheet he recorded this as 99 percent satisfaction (see Figure 14-2). Since it was the first time he'd ever tried to fix a pipe, he recorded his expertise as only 20 percent. He got the job done, but it was time-consuming and required considerable guidance from a neighbor. In contrast, he received low degrees of satisfaction from some activities he did an outstanding job on.

This experience with the Antiperfectionism Sheet persuaded him that he did not have to be perfect at something to enjoy it, and, furthermore, that striving for perfection and performing exceptionally did not guarantee happiness, but indeed tended to be associated more frequently with less satisfaction. He concluded he could either give up his compulsive drive for perfection and settle for joyous living and high productivity, or make his happiness of secondary importance and constantly push for greatness, and settle for emotional anguish and modest productivity. Which would you choose?

Try out the Antiperfectionism Sheet and put yourself to the test.

4. Let's assume that you've decided to give up your perfectionism at least on a trial basis just to see what happens.

However, you have the lingering notion that you really could be perfect in at least some areas if you tried hard enough, and that when you achieve this, something magical will happen. Let's take a hard look at whether this goal is realistic.

Does a model of perfection ever really fit reality? Is there anything you have personally encountered that is so perfect it could not be improved?

To test this, look around you right now and see how things could be improved. For example, take someone's clothing, a flower arrangement, the color and clarity of a television picture, the quality of a singer's voice, the effectiveness of this chapter, anything at all. I believe you can always find some way in which something could be improved. When I first did 314

FEELING GOOD

this exercise, I was riding on a train. Most things, such as the dirty, rusty old tracks, were so obviously imperfect I could easily find many ways to improve them. Then I came to a problem area. A young black man had his hair in one of those fuzzy naturals. It looked perfectly smooth and sculp-tured, and I couldn't think of any way it could possibly be improved. I began to panic and saw my whole antiperfection-ist philosophy going down the drain! Then I suddenly noticed some spots of gray on his head. I felt instant relief! His hair was imperfect after all! As I looked more closely, I noticed a few hairs that were too long and out of place. The closer I examined the young man, the more uneven hairs I could see—hundreds in fact! This helped convince me that any standard of perfection just doesn't fit reality. So why not give it up? You are guaranteed to be a sure loser if you maintain a standard for evaluating your performance that you can't ever meet. Why persecute yourself any longer?

5. Another method for overcoming perfectionism involves a confrontation with fear. You may not be aware that fear always lurks behind perfectionism. Fear is the fuel that drives your compulsion to polish things to the ultimate. If you choose to give up your perfectionism, you may initially have to confront this fear. Are you willing? There is, after all, a payoff in perfectionism—it protects you. It may protect you from risking criticism, failure, or disapproval. If you decide to start doing things less perfectly, at first you may feel as shaky as if a big California earthquake were about to hit.

If you don't appreciate the powerful role that fear plays in maintaining perfectionistic habits, the exacting behavior patterns of perfectionistic people can seem incomprehensible or infuriating. There is, for example, a bizarre illness known as `

compulsive slowness," in which the victim becomes so totally bound up with getting things "just right" that simple everyday tasks can become totally consuming. An attorney with this brutal disorder became preoccupied with how his hair looked. For hours each day he would stand before a mirror with a comb and scissors trying to make adjustments. He became so involved in this, he had to cut back on his legal practice so he could have more and more time to work on his hair. Each day his hair got shorter and shorter because of all his furious clipping. Eventually it was only an eighth of an 315

David D. Burns, M.D.

inch long all over his head. Then he became preoccupied with balancing the hairline along his forehead, and started shaving it to get it "just right." Each day the hairline receded farther and farther until eventually he had shaved his head totally bald! Then he felt a sense of relief and let it all grow back again, hoping it would come in "even." After the hair grew back, he would start clipping it again, and the whole cycle would be repeated. This ludicrous routine went on for years and left him a substantially disabled person.

His case may seem extreme but cannot be considered severe. Far worse forms of the disorder exist. Although the victims' strange habits may seem absurd, the effects are tragic. Like alcoholics, these individuals may sacrifice career and family to their miserable compulsions. You too may be paying heavily for your perfectionism.

What motivates these exacting, overcontrolled individuals?

Are they insane? Usually not. What traps them in the senseless drive for perfection is fear. The moment they try to stop what they are doing, they are gripped by a powerful uneasiness that rapidly escalates to raw terror. This drives them back to their compulsive ritual in a pathetic attempt to find relief. Getting them to give up their perfectionistic malignancy is like trying to persuade a man hanging by his fingers from the edge of a cliff to let go.

You may have noticed compulsive tendencies in yourself to a much less severe degree. Have you ever pushed relentlessly to look for an important item like a pencil or a key you mis-placed when you knew it was best to forget about it and wait for it to show up? You do this because it's tough to stop. The moment you try, you become uneasy and nervous. You feel somehow "not right" without the lost item, as if the whole meaning of your life were in the balance!

One method of confronting and conquering this fear is called "response prevention." The basic principle is simple and obvious. You refuse to give in to the perfectionistic habit, and you allow yourself to become flooded with fear and discomfort. Stubbornly stick it out and do not give in no matter how upset you become. Hang in there and allow your upset to reach its maximum. After a period of time the compulsion will begin to diminish until it disappears completely.

At this point—which might require as much as several hours 316

FEELING GOOD

or as little as ten to fifteen minutes—you have won! You've defeated your compulsive habit.

Let's take a simple example. Suppose you are in the habit of double-checking the house or car locks several times. Certainly it's okay to check things once, but more often than that is redundant and pointless. Drive your car to a parking lot, lock the doors, and walk away. Now—refuse to check them!

You will feel uneasy. You'll try to persuade yourself to go back and "just make sure." DON'T. Instead, record your degree of anxiety every minute on the "Response-Prevention Form" (see Figure 14-3,) until the anxiety has vanished.

At this point, you win. Often, one such exposure is sufficient to break a habit permanently, or you may need numerous exposures as well as a booster shot from time to time.

Many bad habits lend themselves to this format, including various "checking rituals" (checking to see if the stove is turned off or if the mail has fallen into the mailbox, etc.), Ilgure 14-3. The Response-Prevention Form. Record the degree of waxiety and any automatic thoughts every one or two minutes until you ket completely mined. The following experiment was performed by someone who wanted to end a bad habit of compulsively checking door locks.

Percent of Anxiety

Tune

or Uneasiness

Automatic Thoughts

4:00

80%

What if someone steals the car?

4:02

95%

This is ridiculous. Why not just go and

make sure the car is okay?

4:04

95%

Someone may be in it right now. / can't

stand thisl

4:06

80%

4:08

70%

4:10

50%

4:12

20%

This is boring. The car will probably be

okay.

4:14

5%

4:16

0%

.Hey—I Vitt

317

David D. Burns, M.D.

cleaning rituals (compulsive hand-washing or excessive housecleaning), and others. If you are ready and willing to break free of these tendencies, I think you'll find the response-prevention technique quite helpful.

6. You may be asking yourself about the origin of the crazy fear that drives you to compulsive perfectionizing. You can use the vertical-arrow method described in Chapter 10 to expose the silent assumption that causes your rigid, tense approach to living. Fred is a college student who was so preoccupied with getting a term paper "just right" that he dropped out of college to work on it for an entire year to avoid the horrors of turning in a product he wasn't entirely satisfied with. Fred finally enrolled in college again when he felt ready to turn the paper in, but sought treatment for his perfectionism because he realized it might take too long to complete college this way!

He had his confrontation with fear when he was required to turn in another term paper at the end of his first semester back in school. This time the professor gave him the ultimatum of either turning it in by six P.M. on the due date, or getting docked one full grade for every day it was late. Since Fred had an adequate draft of the paper, he realized it wouldn't be wise for him to try to polish it and revise it, so he reluctantly turned it in at 4:55, knowing that there were a number of uncorrected typographical errors as well as some sections he wasn't entirely satisfied with. The moment he turned it in, his anxiety began to mount. Minute by minute it increased, and soon Fred was gripped by such a severe panic attack that he called me at home late in the evening. He was convinced that something terrible was about to happen to him because he had turned in an imperfect paper.

I suggested he use the vertical-arrow method to pinpoint just what he was so afraid of. His first automatic thought was, "I didn't do an excellent job on the paper." He wrote this down (see Figure 14-4, opposite page), and then asked himself, "If that were true, why would it be a problem for me?" This question generated the upsetting thought lurking behind it, as demonstrated in Figure 14-4. Fred wrote down the next thought that came to mind, and continued to use the downward-arrow technique to reveal his fears at a deeper and deeper level. He continued peeling the layers off the 318

iSgstre 14-4. Fred used the vertical-arrow method to uncover the origin at his fears about turning in an "imperfect" paper for a class. This helped '

same some of the terror he was experiencing. The question next to each vertical arrow represents what Fred asked himself in order to uncover the alcxt automatic thought at a deeper level. By unpeeling the onion in this way, he was able to expose the silent assumptions which represented the origin and root of his perfectionism (see text).

Automatic Thoughts

Rational Responses

1. I didn't do an excellent job on 1. All-or-nothing thinking.

The

the paper.

paper is pretty good even though

4, "If that were true, why

would it be a problem

it's not perfect.

for me?"

2. The professor will notice all the

2. Mental filter. He probably will

typos and the weak sections.

notice typos, but he'll read the

4. "And why would that be

whole paper. There are some

a problem?"

fairly good sections.

3. He'll feel that I didn't care

3. Mind reading. I don't know

about it.

that he will think this. If he

4. "Suppose he does. What there',

did, it wouldn't be the end of

the world. A lot of students

don't care about their papers.

Besides I do care about it, so if he thought this he'd be

wrong.

4. I'll be letting him dOwn.

4, "It that were true and

4. All-or-nothing thinking; for-

he did feel that way, why

tune teller error. I can't please

would it be upsetting to

everyone all the time. He's

me?"

liked most of my work. If he

does feel disappointed in this

paper he can survive.

5. I'll get a D or an F on the paper.

4, "Suppose I did—what

5. Emotional reasoning; fortune

then?"

teller error. I feel this way be-

cause I'm upset. But I can't

predict the future. I might

get a B or a C, but a D or an F

6, That would ruin •my academic

isn't very likely.

record.

6. All-or-nothing thinking; fortune

♦ "And then what would

teller error. Other people goof

happen?"

up at times, and it doesn't seem

to ruin their lives. Why can't I

goof up at times?

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David D. Burns, M.D.

Figure 14-4. Continued.

Automatic Responses

Rational Responses

7. That would mean I wasn't the 7. Should statement. Who ever

kind of student I was supposed

laid down the rule I was "sup-

to be.

posed" to be a certain way at

4, "Why would that be up-

all times? Who said I was pre-

setting to me?"

destined and morally obliged to

live up to some particular

standard?

8. People will be angry with me.

8. The fortune teller error. If

rube a failure.

someone is angry with me, it's

♦ "And suppose they were

their problem. I can't be pleas-

angry and I was a fail-

ing people all the time—it's too

ure? Why would that be

exhausting. It makes my life a

so terrible?"

tens; constricted, rigid mess.

Maybe I'd do better to set my

own standards and risk some-

one's anger. If I fail at the

paper, it certainly doesn't make

me "A FAILURE."

9. Then I would be ostracized and

9. The fortune teller error. Every-

alone.

one won't ostracize me!

4. "And then what?"

10. If rm alone, I'm bound to be

10. Disqualifying positive data.

miserable.

Some of my happiest times have

been when I'm alone. My "

misery" has nothing to do with

being alone, but comes from

the fear of disapproval and

from persecuting myself for

not living up to perfectionistic

standards.

onion in this way until the deepest origin of his panic and perfectionism was uncovered. This required only a few minutes.

His silent assumption then became obvious: (1) One mistake and my career will be ruined. (2) Others demand perfection and success from me, and will ostracize me if I fall short.

Once he wrote down his upsetting automatic thoughts, he

320

FEELING GOOD

was in a position to pinpoint his thinking errors. Three distortions appeared most often—all-or-nothing thinking, mind reading, and the fortune teller error. These distortions had trapped him in a rigid, coercive, perfectionistic, approval-seeking approach to life. Substituting rational responses helped him recognize how unrealistic his fears were and took the edge off his panic.

Fred was skeptical, however, because he wasn't entirely convinced a catastrophe was not about to strike. He needed some actual evidence to be convinced. Since he'd been keeping the elephants away by blowing the trumpet all his life, he couldn't be absolutely sure a stampede wouldn't occur once he decided to set the trumpet down.

Two days later Fred got the needed evidence: He picked up his paper, and there was an A— at the top. The typographical errors had been corrected by the professor, who wrote a thoughtful note at the end that contained substantial praise along with some helpful suggestions.

If you are going to let go of your perfectionism, then you may also have to expose yourself to a certain amount of initial unpleasantness just as Fred did. This can be your golden opportunity to learn about the origin of your fears, using the vertical-arrow technique. Rather than run from your fear, sit still and confront the bogeyman! Ask yourself, "What am I afraid of?" "What's the worst that could happen?" Then write down your automatic thoughts as Fred did, and call their bluff. It will be frightening, but if you tough it out and en-dure the discomfort, you will conquer your fears because they are ultimately based on illusions. The exhilaration you experience when you make this transformation from worrier to warrior can be the start of a more confident assertive approach to living.

The thought may have occurred to you—but suppose Fred did end up with a B, C, D, or an F? What then? In reality, this usually doesn't happen because in your perfectionism, you are in the habit of leaving yourself such an excessively wide margin of safety that you can usually relax your efforts considerably without a measurable reduction in the quality of the actual performance. However, failures can and do occur in life, and none of us is totally immune. It can be useful to prepare ahead of time for this possibility so that you can ben-321

David D. Burns, M.D.

efit from the experience. You can do this if you set things up in a "can't lose" fashion.

How can you benefit from an actual failure? It's simple!

You remind yourself that your life won't be destroyed. Getting a B, in fact, is one of the best things that can happen to you if you are a straight A student because it will force you to confront and accept your humanness. This will lead to personal growth. The real tragedy occurs when a student is so bright and compulsive that he or she successfully wards off any chance of failure through overwhelming personal effort, and ends up graduating with a perfect straight A average.

The paradox in this situation is that success has a dangerous effect of turning these students into cripples or slaves whose lives become obsessively rigid attempts to ward off the fear of being less than perfect. Their careers are rich in achievement but frequently impoverished in joy.

7. Another method for overcoming perfectionism involves developing a process orientation. This means you focus on processes rather than outcomes as a basis for evaluating things. When I first opened my practice, I had the feeling I had to do outstanding work with each patient every session. I thought my patients and peers expected this of me, and so I worked my tail off all day long. When a patient indicated he benefited from a session, I'd tell myself I was successful and I'd feel on top of the world. In contrast, when a patient gave me the runaround or responded negatively to that day's session, I'd feel miserable and tell myself I had failed.

I got tired of the roller-coaster effect and reviewed the problem with my colleague, Dr. Beck. His comments were extremely helpful, so I'll pass them on to you. He suggested I imagine I had a job driving a car to City Hall each day.

Some days I'd hit mostly green lights and I'd make fast time.

Other days I'd hit a lot of red lights and traffic jams, and the trip would take much longer. My driving skill would be the same each day, so why not feel equally satisfied with the job I did?

He proposed I could facilitate this new way of looking at things by refusing to try to do an excellent job with any patient. Instead, I could aim for a good, consistent effort at 322

FEELING GOOD

each session regardless of how the patient responded, and in this way I could guarantee 100 percent success forever.

How could you set up process goals as a student? You could make it your aim to (1) attend lectures; (2) pay attention and take notes; (3) ask appropriate questions; (4) study each course between classes a certain amount each day; (5) review class study notes every two or three weeks. All these processes are within your control, so you can guarantee success. In contrast, your final grade is not under your control. It depends on how the professor feels that day, how well the other students did, where he sets the curve, etc.

How could you set up process goals if you were applying for a job? You could (1) dress in a confident, appealing manner; (2) have your résumé edited by a knowledgeable friend and typed professionally; (3) give the prospective employer one or more compliments during the interview; (4) express an interest in the company and encourage the interviewer to talk about himself; (5) when the prospective employer tells you about his work, say something positive, using an upbeat approach; (6) if the interviewer makes a critical or negative comment about you, immediately agree, using the disarming technique introduced in Chapter 6.

For example, in my negotiations with a prospective publisher about this book, I noticed the editor expressed a number of negative reactions in addition to a few positive ones. I found the use of the disarming technique worked extremely well in keeping the waters flowing nonturbulently during potentially difficult discussions. For example,

EDITOR x: One of my concerns, Dr. Burns, involves the emphasis on symptomatic improvement in the here and now. Aren't you overlooking the causes and origins of depression?

(In the first draft of this book, I had written several chapters on the silent assumptions that give rise to depression, but apparently the editor was not adequately impressed with this material or had not read it. I had the option of counterattacking in a defensive manner—which would have only polarized the editor and made her feel defensive. Instead, I chose to disarm her in the following way.)

323

David D. Burns, M.D.

DAVID: That's an excellent suggestion, and you're absolutely right. I can see you've been doing your homework on the manuscript, and I appreciate hearing about your ideas. The readers obviously would want to learn more about why they get depressed. This might help them avoid future depressions. What would you think about expanding the section on silent assumptions and introducing it with a new chapter we could call "Getting Down to Root Causes"?

EDITOR: That sounds great!

DAVID: What other negative reactions do you have to the book? I'd like to learn as much as I can from you.

I then continued to find a way to agree with each criticism and to praise Editor X for each and every suggestion. This was not insincere because I was a greenhorn in popular writing, and Editor X was a very talented, well-established individual who was in a position to give me some much-needed guidance. My negotiating style made it clear to her that I respected her, and let her know that we would be able to have a productive working relationship.

Suppose instead that I had been fixed on the outcome rather than on the negotiating process when the editor interviewed me. I would have been tense and preoccupied with only one thing—would she or would she not make an offer for the book? Then I would have seen her every criticism as a danger, and the whole interpersonal process would have fallen into unpleasant focus.

Thus, when you are applying for work, do not make it your aim to get the job! Especially if you want the job! The outcome depends on numerous factors that are ultimately out of your control, including the number of applicants, their qualifications, who knows the boss's daughter, etc. In fact, you would do better to try to get as many rejections as possible for the following reason: Suppose on the average it takes about ten to fifteen interviews for each acceptable job offer you receive in your profession (a typical batting average for people I know who have been recently looking for work).

This means you've got to go out and get those nine to fourteen rejections over with in order to get the job you want! So each morning say, "I'll try to get as many rejections as pos-324

FEELING GOOD

sable today." And each time you do get rejected you can say,

"I was successfully rejected. This brings me one important step closer to my goal."

8. Another way to overcome perfectionism involves assuming responsibility for your life by setting strict time limits on all your activities for one week. This will help you change your perspective so you can focus on the flow of life and enjoy it.

If you are a perfectionist, you are probably a real procrastinator because you insist on doing things so thoroughly. The secret to happiness is to set modest goals to accomplish them.

If you want misery, then by all means cling to your perfectionism and procrastination. If you would like to change, then as you schedule your day in the morning, decide on the amount of time you will budget on each activity. Quit at the end of the time you have set aside whether or not you have completed it, and go onto the next project. If you play the pi-ano and tend to play for many hours or not at all, decide instead to play only an hour a day. I think you'll enhance your satisfaction and output substantially this way.

9. I'll bet you're afraid of making mistakes! What's so terrible about making mistakes? Will the world come to an end if you're wrong? Show me a man who can't stand to be wrong, and I'll show you a man who is afraid to take risks and has given up the capacity for growth. A particularly powerful method for defeating perfectionism involves learning to make mistakes.

Here's how you can do this. Write an essay in which you spell out why it is both irrational and self-defeating to try to be perfect or to fear making mistakes. The following was written by Jennifer, the student mentioned earlier: Why It's Great to Be Able to Make Mistakes

1. I fear making mistakes because I see everything in abso-lutist, perfectionistic terms—one mistake and the whole is ruined. This is erroneous. A small mistake certainly doesn't ruin an otherwise fine whole.

2. It's good to make mistakes because then we learn—in fact, we won't learn unless we make mistakes. No one can avoid making mistakes—and since it's going to hap-325

David D. Burns, M.D.

pen in any case, we may as well accept it and learn from it.

3. Recognizing our mistakes helps us to adjust our behavior so that we can get results we're more pleased with—so we might say that mistakes ultimately operate to make us happier and make things better.

4. If we fear making mistakes, we become paralyzed—

we're afraid to do or try anything, since we might (in fact, probably will) make some mistakes. If we restrict our activities so that we won't make mistakes, then we are really defeating ourselves. The more we try and the more mistakes we make, the faster we'll learn and the happier we'll be ultimately.

5. Most people aren't going to be mad at us or dislike us because we make mistakes—they all make mistakes, and most people feel uncomfortable around "perfect"

people.

6. We don't die if we make mistakes.

Although such an essay does not guarantee that you will change, it can help get you started in the right direction. Jennifer reported an enormous improvement the week after she wrote the essay. She found it useful in her studies to focus on learning rather than obsessing constantly about whether or not she was great. As a result, her anxiety decreased and her ability to get things done increased. This relaxed, confident mood persisted through the final examination period at the end of the first semester—a time of extreme anxiety for the majority of her classmates. As she explained, "I realized I didn't have to be perfect. I'm going to make my share of mistakes. So what? I can learn from my mistakes, so there's nothing to worry about." And she was right!

Write a memo to yourself along these lines. Remind yourself that the world won't come to an end if you make a mistake, and point out the potential benefits. Then read the memo every morning for two weeks. I think this will go a long way toward helping you join the human race!

10. In your perfectionism you are undoubtedly great at focusing on all the ways you fall short. You have the bad habit of picking out the things you haven't done and ignoring those you have. You spend your life cataloging every mistake and 326

FEELING GOOD

shortcoming. No wonder you feel inadequate! Is somebody forcing you to do this? Do you like feeling that way?

Here's a simple method of reversing this absurd and painful tendency. Use your wrist counter to click off the things you do right each day. See how many points you can ac-cumulate. This may sound so unsophisticated that you are convinced it couldn't help you. If so, experiment with it for two weeks. I predict you'll discover that you will begin to focus more on the positives in your life and will consequently feel better about yourself. It sounds simplistic because it is But who cares, if it works?

11. Another helpful method involves exposing the absurdity in the all-or-nothing thinking that gives rise to your perfectionism. Look around you and ask yourself how many things in the world can be broken down into all-or-nothing categories. Are the walls around you totally clean? Or do they have at least some dirt? Am I totally effective with all of my writing? Or partially effective? Certainly every single paragraph of this book isn't polished to perfection and breathtak-ingly helpful. Do you know anyone who is totally calm and confident all the time? Is your favorite movie star perfectly beautiful?

Once you recognize that all-or-nothing thinking doesn't fit reality very often, then look out for your all-or-nothing thoughts throughout the day and when you notice one, talk back to it and shoot it down. You'll feel better. Some examples of how a number of different individuals combat all-or-nothing thoughts appear in Figure 14-5.

12. The next method to combat perfectionism involves personal disclosure. If you feel nervous or inadequate in a situation, then share it with people. Point out the things you feel you've done inadequately instead of covering them up.

Ask people for suggestions on how to improve, and if they're going to reject you for being imperfect, let them do it and get it over with. If in doubt as to where you stand, ask if they think less of you when you make a mistake.

If you do this, you must of course be prepared to handle the possibility that people will look down on you because of your imperfections. This actually happened to me during a teaching session I was conducting for a group of therapists. I pointed out an error I felt I had made in reacting angrily to a 327

Figure 14-5. How to replace all-or-nothing thoughts with others that are morc in tune with reality. These examples were contributed by a variety of individuals.

All-or-nothing Thinking

Realistic Thoughts

1. What a lousy day!

I. A couple of bad things have

happened, but everything hasn't

been a disaster.

2. This meal I cooked really turned 2. It's not the best meal I ever out terrible.

cooked, but it's okay.

3. I'm too old.

3. Too old for what? Too old to

have fun? No. Too old for occa-

sional sex? No. Too old to enjoy

friends? No. Too old to love or

be loved? No. Too old to enjoy

music? No. Too old to do some

productive work? No. So what

am I "too old" for? It really has no meaning!

4. Nobody loves me.

4. Nonsense. I have many friends

and family. I may not get as

much love as I want when I want it, but I can work on this.

5. I'm a failure.

S. I've succeeded at some things

and failed at others, just like

everybody.

6. My career is over the hill.

6. I can't do as much as when I was younger, but I can still work and

produce and create, so why not

enjoy it?

7. My lecture was a flop!

7. It wasn't the best lecture I ever

gave. In fact, it was below my

average. But I did get some

points across, and I can work to

improve my next lectures. Re-

member—half my lectures will be,

below my average, and half will

be above!

8. My boyfriend doesn't like me!

8. He doesn't like me enough for

what? He may not want to marry

me, but he takes me out on

dates, so he must like me par-

tially.

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FEELING GOOD

afficult, manipulative patient. I then asked if any of the therapists present thought less of me after hearing about my foible. I was taken aback when one replied in the affirmative, and the following conversation took place:

THERAPIST (in the audience): I have two thoughts. One thought is a positive one. I appreciate your taking that risk to point out your error in front of the group because I would have been scared to do it I think it takes great courage on your part to do this. But I have to admit I'm ambivalent about you now. Now I know that you do make mistakes, which is realistic, but . . . I feel disappointed in you. In all honesty, I do.

DAVID: Well, I knew how to handle the patient, but I was so overcome with my anger that I just got caught up in the moment and retaliated. I was overly abrupt in the way I reacted to her. I admit I handled it quite poorly.

THERAPIST: I guess in the context that you see so many patients each week for so many years, if you make one blunder like that it's definitely not earthshattering. It's not going to kill her or anything. But I do feel let down, I have to admit.

DAVID: But it isn't just one rare error. I believe that all therapists make many blunders every single day. Either obvious ones or subtle ones. At least I do. How will you come to terms with that? It seems you're quite disappointed in me because I didn't handle that patient effectively.

THERAPIST: Well, I am. I thought you had a sufficiently wide behavioral repertoire that you could easily handle nearly anything a patient said to you.

DAVID: Well, that's untrue. I sometimes come up with very helpful things to say in difficult situations, but sometimes I'm not as effective as I'd like to be. I still have a lot to learn. Now with that knowledge, do you think less of me?

THERAPIST: Yeah. I really do. I have to say that. Because now I see that there's a reasonably easy kind of conflict that can upset you. You were unable to handle it without showing your vulnerabilities.

DAVID: That's true. At least that time I didn't handle it 329

David D. Burns, M.D.

well. It's an area where I need to focus my efforts and grow as a therapist.

THERAPIST: Well, it shows that at least in that case, and I assume in others, that you don't handle things as well as I thought you did.

DAVID: I think that's correct. But the question is, why do you think less of me because I am imperfect? Why are you looking down on me? Does it make me less a person to you?

THERAPIST: You're exaggerating the whole thing now, and I don't feel that you are necessarily of less value as a human or anything like that. But on the other hand, I think you're not as good as a therapist as I thought you were.

DAVID: That's true. Do you think less of me because of that?

THERAPIST: As a therapist?

DAVID: As a therapist or as a person. Do you think less of me?

THERAPIST: Yes, I suppose I do.

DAVID: Why?

THERAPIST: Well, I don't know how to say this. I think "

therapist" is the primary role that I know you in. I'm disappointed to find you're so imperfect. I had a higher expectation of you. But perhaps you're better in other areas of your life.

DAVID: I hate to disappoint you, but you'll discover that in many other aspects of my life I'm even more imperfect.

So if you're looking down on me as a therapist, I presume you'll look down on me more as a person.

THERAPIST: Well, I do think less of you as a person. I think that's an accurate description of how I'm feeling about you.

DAVID: Why do you think less of me because I don't measure up to your standard of perfection? I'm a human and not a robot.

THERAPIST: Pm not sure I understand that question. I judge people in terms of their performance. You goofed up, so you have to face the fact I'll judge you negatively. It's tough, but it's reality. I thought you should perform better because you're our preceptor and our 330

FEELING GOOD

teacher. I expected more of you. Now it sounds like I could have handled that patient better than you did!

DAVID: Well, I think you could have done better than I did with that patient that day, and this is an area where I think I can learn from you. But why do you look down on me for this? If you get disappointed and lose respect each time you notice I've made a mistake, pretty soon you'll be totally miserable, and you'll have no respect for me at all because I've been making errors every day since I was born. Do you want all that discomfort? If you want to continue and enjoy our friendship, and I hope you will, you'll just have to accept the fact that I'm not perfect. Maybe you'd be willing to look for mistakes I make and point them out to me so I can learn from you while I'm teaching you. When I stop making mistakes, I'll lose much of my capacity to grow. Recognizing and correcting my errors and learning from them is one of my greatest assets. And if you can accept my humanity and imperfection, maybe you can also accept your own. Maybe you'll want to feel that it's okay for you to make mistakes too.

This kind of dialogue transcends the possibility you will feel put down. Asserting your right to make mistakes will paradoxically make you a greater human being. If the other person feels disappointed, the fault is really his for having set up the unrealistic expectation you are more than human. If you don't buy into that foolish expectation, you won't have to become angry or defensive when you do goof up—nor will you have to feel any sense of shame or embarrassment. The choice is clear-cut: You can either try to be perfect and end up miserable, or you can aim to be human and imperfect and feel enhanced. Which do you choose?

13. The next method is to focus mentally on a time in your life when you were really happy. What image comes to mind? For me the image is of climbing down into Havasupai Canyon one summer vacation when I was a college student.

This canyon is an isolated part of the Grand Canyon, and you have to hike in to it or arrange for horses. I went with a friend. Havasupai, an Indian word meaning "blue-green water people," is the name of a turquoise river that bubbles 331

David D. Burns, M.D.

out of the desert floor and turns the narrow canyon into a lush paradise many miles long. Ultimately, the Havasupai River empties into the Colorado River. There are a numt-r of waterfalls several hundred feet high, and at the bottom cf each, a green chemical in the water precipitates out an:: makes the river's bottom and edges smooth and polished, jus like a turquoise swimming pool. Cottonwood trees and Jim-sonweed with purple flowers like trumpets line the river abundance. The Indians who live there are easygoing an_

friendly. It is a blissful memory. Perhaps you have a similar happy memory. Now ask yourself—what was perfect abo:: that experience? In my case, nothing! There were no toilet facilities, and we slept in sleeping bags outdoors. I didn't hike perfectly or swim perfectly, and nothing was perfect. There was no electricity available in most of the village because cf.

its remoteness, and the only available food in the store was canned beans and fruit cocktail—no meat or vegetables.

the food tasted darn good after a day of hiking and swimming. So who needs perfection?

How can you use such a happy memory? When you are having a presumably pleasurable experience—eating out, tal,:-ing a trip, going to a movie, etc.—you may unnecessarily sour the experience by making an inventory of all the ways falls short and telling yourself you can't possibly enjoy it. Btr.

this is hogwash—it's your expectation that upsets you. Suppose the motel bed is too lumpy and you paid fifty-six dollars for the room. You called the front desk, and they have nc other beds or rooms available. Tough! Now you can double your trouble by demanding perfection, or you can conjure LT

your "happy, imperfect" memory. Remember the time ye-.1

camped out and slept on the ground and loved it? So you can certainly enjoy yourself in this motel room if you choose'

Again, it's up to you.

.14. Another method for overcoming perfectionism is the "

greed technique." This is based on the simple fact that MOK of us try to be perfect so we can get ahead in life. It may nct have occurred to you that you might end up much more successful if your standards were lower. For example, when !

started my academic career, I spent over two years writirr the first research paper I published. It was an excellent preci-uct, and I'm still quite proud of it. But I noticed that in the 332

FEELING GOOD

same time period, many of my peers who were of equal intelligence wrote and published numerous papers. So I asked myself—am I better off with one publication that contains ninety-eight "units of excellence," or ten papers that are each worth only eighty units of excellence"? In the latter case, I would actually end up with 800 "excellence units," and I would be way ahead of the game. This realization was a strong personal persuader, and I decided to lower my standards a bit. My productivity then became dramatically enhanced, as well as my levels of satisfaction.

How can this work for you? Suppose you have a task and you notice you're moving slowly. You may find that you've already reached the point of diminishing returns, and you'd do better by moving on to the next task. I'm not advocating that you slough off, but you may find that you as well as others will be equally if not more pleased with many good, solid performances than with one stress-producing masterpiece.

15. Here's the last approach. It involves simple logic.

Premise one: All human beings make mistakes. Do you agree?

Okay, now tell me: What are you? A human being, you say?

Okay. Now, what follows? Of course—you will and should

make mistakes! Now tell yourself this every time you persecute yourself because you made an error. Just say, "I was

supposed to make that mistake because I'm human!" or "

How human of me to have made that mistake."

In addition, ask yourself, "What can I learn from my mistake? Is there some good that could come from this?" As an experiment, think about some error you've made and write down everything you learned from it. Some of the best things can be learned only through making mistakes and learning from them. After all, this is how you learned to talk and walk and do just about everything. Would you be willing to give up that kind of growth? You may even go so far as to say your imperfections and goof-ups are some of your greatest assets. Cherish them! Never give up your capacity for being wrong because then you lose the ability to move forward. In fact, just think what it would be like if you were

perfect. There'd be nothing to learn, no way to improve, and life would be completely void of challenge and the satisfaction that comes from mastering something that takes effort. It would be like going to kindergarten for the rest of your life.

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You'd know all the answers and win every game. Every project would be a guaranteed success because you would do everything correctly. People's conversations would offer you nothing because you'd already know it all. And most important, nobody could love or relate to you. It would be impossible to feel any love for someone who was flawless and knew it all. Doesn't that sound lonely, boring, and miserable? Are you so sure you still want perfection?

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PART V

Defeating Hopelessness

and Suicide

CHAPTER 15

The Ultimate Victory:

Choosing to Live

Dr. Aaron T. Beck reported in a recent study that suicidal wishes were present in approximately one-third of individuals with a mild case of depression, and in nearly three-quarters of people who were severely depressed.* It has been estimated that as many as 5 percent of depressed patients do actually die as a result of suicide. This is approximately twenty-five times the suicide rate within the general population. In fact, when a person with a depressive illness dies, the chances are one in six that suicide was the cause of death.

No age group or social or professional class is exempt from suicide; think of the famous people you know of who have killed themselves. Particularly shocking and grotesque—but by no means rare—is suicide among the very young. In a study of seventh- and eighth-grade students in a suburban Philadelphia parochial school, nearly one third of the youngsters were significantly depressed and had suicidal thoughts. Even infants who undergo maternal separation can develop a depressive syndrome in which failure to thrive and even self-imposed death from starvation can result.

Before you get overwhelmed, let me emphasize the positive side of the coin. First, suicide is unnecessary, and the impulse can be rapidly overcome and eliminated with cognitive techniques. In our study, suicidal urges were reduced substantially in patients treated with cognitive therapy or with antidepressant drugs. The improved outlook on life occurred within the first week or two of treatment in many cognitively treated patients. The current intensive emphasis on the prevention of depressive episodes in individuals prone to mood swings should also result in a long-term reduction in suicidal impulses.

Why do depressed individuals so frequently think of suicide, and what can be done to prevent these impulses? You will understand this if you examine the thinking of people

* Beck, Aaron T. Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1972, pp. 30-31.

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who are actively suicidal. A pervasive, pessimistic vision dominates their thoughts. Life seems to be nothing but a hellish nightmare. As they look into the past, all they can remember are moments of depression and suffering.

When you feel down in the dumps, you may also feel so low at times that you get the feeling you were never really happy and never will be. If a friend or relative points out to you that, except for such periods of depression, you were quite happy, you may conclude they're mistaken or only trying to cheer you up. This is because while you are depressed you actually distort your memories of the past. You just can't conjure up any memories of periods of satisfaction or joy, so you erroneously conclude they did not exist. Thus, you mistakenly conclude that you always have been and always will be miserable. If someone insists that you have been happy, you may respond as a young patient recently did in my office, "

Well, that period of time doesn't count. Happiness is an illusion of some kind. The real me is depressed and inadequate. I was just fooling myself if I thought I was happy."

No matter how badly you feel, it would be bearable if you had the conviction that things would eventually improve. The critical decision to commit suicide results from your illogical conviction that your mood can't improve. You feel certain that the future holds only more pain and turmoil! Like some depressed patients, you may be able to support your pessimistic prediction with a wealth of data which seems to you to be overwhelmingly convincing.

A depressed forty-nine-year-old stockbroker recently told me, "Doctor, I have already been treated by six psychiatrists over a ten-year-period. I have had shock treatments and all types of antidepressants, tranquilizers, and other drugs. But in spite of it all, this depression won't let up for one minute. I have spent over eighty thousand dollars trying to get well.

Now I am emotionally and financially depleted. Every doctor has said to me, 'You'll beat this thing. Keep your chin up.'

But now I realize it wasn't true. They were all lying to me. I'

m a fighter, so I fought hard. You'd better realize when you are defeated. I've got to admit I'd be better off dead."

Research studies have shown that your unrealistic sense of hopelessness is one of the most crucial factors in the development of a serious suicidal wish. Because of your twisted 338

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thinking, you see yourself in a trap from which there seems to be no escape. You jump to the conclusion that your problems are insoluble. Because your suffering feels unbearable and appears unending, you may erroneously conclude that suicide is your only way of escape.

If you have had such thoughts in the past, or if you are seriously thinking this way at present, let me state the message of this chapter loud and clear:

You Are Wrong in Your Belief That Suicide Is the Only Solution or the Best Solution to Your Problem.

Let me repeat that. You Are Wrong! When you think that you are trapped and hopeless, your thinking is illogical, distorted, and skewed. No matter how thoroughly you have convinced yourself, and even if you get other people to agree with you, you are just plain mistaken in your belief that it is ever advisable to commit suicide because of depressive illness.

This is not the most rational solution to your misery. I will explain this position and help point the way out of the suicide trap.

Assessing Your Suicidal Impulses

Although suicidal thoughts are common even in individuals who are not depressed, the occurrence of a suicidal impulse if you are depressed is always to be regarded as a dangerous symptom. It is important for you to know how to pinpoint those suicidal impulses which are the most threatening. In the Beck Depression Inventory in Chapter 2, question nine refers to your suicidal thoughts and impulses. If you have checked a one, two, or three on this question, suicidal fantasies are present, and it is important to evaluate their seriousness and to intervene if necessary (see page 20).

The most serious error you could make with regard to your suicidal impulses is to be overly inhibited in talking them over with a counselor. Many people are afraid to talk about suicidal fantasies and urges for fear of disapproval or because they believe that even talking about them will bring on a suicide attempt. This point of view is unwarranted. You are more likely to feel a great sense of relief in discussing 339

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suicidal thoughts with a professional therapist, and consequently you have a much better chance of defusing them.

If you do have suicidal thoughts, ask yourself if you are taking such thoughts seriously. Are there times when you wish you were dead? If the answer is yes, is your death wish active or passive? A passive death wish exists if you would prefer to be dead, but you are unwilling to take active steps to bring this about. One young man confessed to me, "Doctor, every night when I go to bed I pray to God to let me wake up with cancer. Then I could die in peace, and my family would understand."

An active death wish is more dangerous. If you are seriously planning an actual suicide attempt, then it's important to know the following: Have you thought about a method?

What is your method? Have you made plans? What specific preparations have you made? As a general rule, the more concrete and well-formulated your plans are, the more likely you may actually make a suicide attempt. The time to seek professional help is now!

Have you ever made a suicide attempt in the past? If so, you should view any suicidal impulse as a danger signal to seek help immediately. For many people these previous attempts seem to be "warm-ups," in which they flirt with suicide but have not mastered the particular method they have selected. The fact that an individual has made this attempt unsuccessfully on several occasions in the past indicates an increased risk of success in the future. It is a dangerous myth that unsuccessful suicide attempts are simply gestures or attention-getting devices and are therefore not to be taken seriously. Current thinking suggests that all suicidal thoughts or actions are to be taken seriously. It can be highly misleading to view suicidal thoughts and actions as a "plea for help."

Many suicidal patients want help least of all because they are 100 percent convinced they are hopeless and beyond help.

Because of this illogical belief, what they really want is death.

Your degree of hopelessness is of the greatest importance in assessing whether or not you are at risk for making an active suicide attempt at any time. This one factor seems more closely linked with actual suicide attempts than any other.

You must ask yourself, "Do I believe that I have absolutely no chance of getting better? Do I feel that I have exhausted 340

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all treatment possibilities and that nothing could possibly help? Do I feel convinced beyond all doubt that my suffering is unbearable and could never come to an end?" If you answer yes to these questions, then your degree of hopelessness is high, and professional treatment is indicated now! I would like to emphasize that hopelessness is as much a symptom of depression as a cough is a symptom of pneumonia. The feeling of hopelessness does not in fact prove that you are hopeless, any more than a cough proves you are doomed to succumb to pneumonia. It just proves that you are suffering from an illness, in this case, depression. This sense of hopelessness is not a reason to make a suicide attempt, but gives you a clear signal to seek competent treatment. So, if you feel hopeless, seek help! Do not consider suicide for one more minute!

The last important factor concerns deterrents. Ask yourself, "Is there anything that is preventing me from committing suicide? Would I hold back because of my family, friends, or religious beliefs?" If you have no deterrents, the possibility is greater that you would consider an actual suicide attempt.

SUMMARY: If you are suicidal, it is of great importance for you to evaluate these impulses in a matter-of-fact manner, using your common sense. The following factors put you in a high-risk group:

1. If you are severely depressed and feel hopeless; 2. If you have a past history of suicide attempts; 3. If you have made concrete plans and preparations for suicide; and

4. If no deterrents are holding you back.

If one or more of these factors apply to you, then it is vital to get professional intervention and treatment immediately.

While I firmly believe that the attitude of self-help is important for all people with depression, you clearly must seek professional guidance right away.

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The Illogic of Suicide

Do you think depressed people have the "right" to commit suicide? Some misguided "humanists" and novice therapists are unduly concerned with this issue. If you are counseling or trying to help a chronically depressed individual who is hopeless and threatening self-destruction, you may ask yourself, "Should I intervene aggressively, or should I let him go ahead? What are his rights as a human being in this regard?

Am I responsible for preventing this attempt, or should I tell him to go ahead and exercise his freedom of choice?"

I regard this as an absurd and cruel issue that misses the point entirely. The real question is not whether a depressed individual has the right to commit suicide, but whether he is realistic in his thoughts when he is considering it. When I talk to a suicidal person, I try to find out why he is feeling that way. I might ask, "What is your motive for wanting to kill yourself? What problem in your life is so terrible that there is no solution?" Then I would help that person expose the illogical thinking that lurks behind the suicidal impulse as quickly as possible. When you begin to think more realistically, your sense of hopelessness and the desire to end your life will fade away and you will have the urge to live. Thus, I recommend joy rather than death to suicidal individuals, and I try to show them how to achieve it as fast as possible! Let's see how this can be done.

Holly was a nineteen-year-old woman who was referred to me for treatment by a child psychoanalyst in New York City.

He had treated her unsuccessfully with analytic therapy for many years since the onset of a severe unremitting depression in her early teens. Other doctors had also been unable to help her. Her depression originated during a period of family turbulence that led to her parents' separation and divorce.

Holly's chronic blue mood was punctuated by numerous wrist-slashing episodes. She said that when periods of frustration and hopelessness would build up, she would be overcome by the urge to rip into her flesh and would experience relief only when she saw the blood flowing across her skin. When I first met Holly, I noticed a mass of white scar tissue across her wrists that attested to this behavior. In addition to these 342

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episodes of self-mutilation, which were not suicide attempts, she had tried to kill herself on a number of occasions.

In spite of all the treatment she had received, her depression would not let up. At times it became so severe that she had to be hospitalized. Holly had been confined to a closed ward of a New York hospital for several months at the time she was referred to me. The referring doctor recommended a minimum of three years of additional continuous hospitalization, and appeared to agree with Holly that her prognosis for substantial improvement, at least in the near future, was poor.

Ironically, she was bright, articulate, and personable. She had done well in high school, in spite of being unable to go to classes during the times she was confined to hospitals. She had to take some courses with the help of tutors. Like a number of adolescent patients, Holly's dream was to become a mental-health professional, but she had been told by her previous therapist that this was unrealistic because of the nature of her own explosive, intractable emotional problems. This opinion was just one more crushing blow for Holly.

After graduation from high school, she spent the majority of her time in inpatient mental-hospital facilities because she was considered too ill and uncontrollable for outpatient therapy. In a desperate attempt to find help, her father contacted the University of Pennsylvania because he had read about our work in depression. He requested a consultation to determine whether any promising treatment alternatives existed for his daughter.

After speaking to me by phone, Holly's father obtained custody of her and drove to Philadelphia so that I could talk to her and review the possibilities for treatment. When I met them, their personalities contrasted with my expectations. He proved to be a relaxed, mild-mannered individual; she was strikingly attractive, pleasant, and cooperative.

I administered several psychological tests to Holly. The Beck Depression Inventory indicated severe depression, and other tests confirmed a high degree of hopelessness and serious suicidal intent. Holly put it to me bluntly, "I want to kill myself." The family history indicated that several relatives had attempted suicide—two of them successfully. When I asked Holly why she wanted to kill herself, she told me that 343

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she was a lazy human being. She explained that because she was lazy, she was worthless and so deserved to die.

I wanted to find out if she would react favorably to cognitive therapy, so I used a technique that I hoped would capture her attention. I proposed we do some role-playing, and she was to imagine that two attorneys were arguing her case in court. Her father, by the way, happened to be an attorney who specialized in medical malpractice suits! Because I was a novice therapist at the time, this intensified my own anxious, insecure feelings about tackling such a tough case. I told Holly to play the role of the prosecutor, and she was to try to convince the jury that she deserved a death sentence. I told her I would play the role of the defense attorney, and that I would challenge the validity of every accusation she made. I told her that this way we could review her reasons for living and her reasons for dying, and see where the truth lay: HOLLY: For this individual, suicide would be an escape from life.

DAVID: That argument could apply to anyone in the world.

By itself, it is not a convincing reason to die.

HOLLY: The prosecutor replies that the patient's life is so miserable, she cannot stand it one minute longer.

DAVID: She has been able to stand it up until now, so maybe she can stand it a while longer. She was not always miserable in the past, and there is no proof that she will always be miserable in the future.

HOLLY: The prosecutor points out that her life is a burden to her family.

DAVID: The defense emphasizes that suicide will not solve this problem, since her death by suicide may prove to be an even more crushing blow to her family.

HOLLY: But she is self-centered and lazy and worthless, and deserves to die!

DAVID: What percentage of the population is lazy?

HOLLY: Probably twenty percent . . . no, I'd say only ten percent.

DAVID: That means twenty million Americans are lazy. The defense points out that they don't have to die for this, so there is no reason the patient should be singled out for 344

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death. Do you think laziness and apathy are symptoms of depression?

HOLLY: Probably.

DAVID: The defense points out that individuals in our culture are not sentenced to death for the symptoms of illness, whether it be pneumonia, depression, or any other disease. Furthermore, the laziness may disappear when the depression goes away.

Holly appeared to be involved in this repartee and amused by it. After a series of such accusations and defenses, she conceded that there was no convincing reason she should have to die, and that any reasonable jury would have to rule in favor of the defense. What was more important was that Holly was learning to challenge and answer her negative thoughts about herself. This process brought her partial but immediate emotional relief, the first she had experienced in many years. At the end of the consultation session, she said to me, "This is the best that I have felt in as long as I can remember. But now the negative thought crosses my mind, This new therapy may not prove to be as good as it seems.' "

In response to this she felt a sudden surge of depression again. I assured her, "Holly, the defense attorney points out that this is no real problem. If the therapy isn't as good as it seems to be, you'll find out in a few weeks, and you'll still have the alternative of a long-term hospitalization. You'll have lost nothing. Furthermore, the therapy may be partially as good as it seems, or conceivably even better. Perhaps you would be willing to give it a try." In response to this proposal, she decided to come to Philadelphia for treatment.

Holly's urge to commit suicide was simply the result of cognitive distortions. She confused the symptoms of her illness, such as lethargy and loss of interest in life, with her true identity and labeled herself as a "lazy person." Because Holly equated her worth as a human being with her achievement, she concluded she was worthless and deserved to die.

She jumped to the conclusion that she could never recover, and that her family would be better off without her. She magnified her discomfort by saying, "I can't stand it." Her sense of hopelessness was the result of the fortune-telling error—

she illogically jumped to the conclusion that she could not 345

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improve. When Holly saw that she was simply trapping herself with unrealistic thoughts, she felt a sudden relief. In order to maintain such improvement, Holly had to learn to correct her negative thinking on an ongoing basis and that took hard work! She wasn't going to give in that easily!

Following our initial consultation, Holly was transferred to a hospital in Philadelphia, where I visited her twice a week to initiate cognitive therapy. She had a stormy course in the hospital with dramatic mood swings, but was able to be discharged after a five-week period, and I persuaded her to enroll as a part-time summer-school student. For a while her moods continued to oscillate like a yo-yo, but she showed an overall improvement. At times Holly would report feeling very good for several days. This constituted a real breakthrough, since these were the first happy periods she had experienced since the age of thirteen. Then she would suddenly relapse into a severe depressive state. At these times she would again become actively suicidal, and would try her best to convince me that life was not worth living. Like many adolescents, she seemed to carry a grudge against all mankind, and insisted there was no point in living any longer.

In addition to feeling negative about her own sense of worth, Holly had developed an intensely negative and disillusioned view of the entire world. Not only did she see herself as trapped by an endless, untreatable depression, but like many of today's adolescents, she had adopted a personal theory of nihilism. This is the most extreme form of pessimism.

Nihilism is the belief that there is no truth or meaning to anything, and that all of life involves suffering and agony. To a nihilist like Holly, the world offers nothing but misery. She had become convinced that the very essence of every person and object in the universe was evil and horrible. Her depression was thus the experience of hell on earth. Holly en-visioned death as the only possible surcease, and she longed for death. She constantly complained and harangued cyni-cally about the cruelties and miseries of living. She insisted that life was totally unbearable at all times, and that all human beings were totally lacking in redeeming qualities.

The task of getting such an intelligent and persistent young woman to see and admit how distorted her thinking was provided a real challenge to this therapist! The following lengthy 346

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dialogue illustrates her intensely negative attitudes as well as my struggles to help her penetrate the illogic in her thinking: HOLLY: Life is not worth living because there is more bad than good in the world.

DAVID: Suppose I was the depressed patient and you were my therapist and I told you that, what would you say?

(I used this maneuver with Holly because I knew her goal hi life was to be a therapist. I figured she'd say something reasonable and upbeat, but she outfoxed me in her next statement.)

HOLLY: I'd say that I can't argue with you!

DAVID: So, if I were your depressed patient and told you that life is not worth living, you'd advise me to jump out the window?

HOLLY (laughing): Yes. When I think about it, that's the best thing to do. If you think about all the bad things that are going on in the world, the right thing to do is to get really upset about them and be depressed.

DAVID: And what are the advantages to that? Does that help you correct the bad things in the world or what?

HOLLY: No. But you can't correct them.

DAVID: You can't correct all the bad things in the world, or you can't correct some of them?

HOLLY: You can't correct anything of importance. I guess you can correct small things. You can't really make a dent in the badness of this universe.

DAVID: Now, at the end of each day if I said that to myself when I went home, I could really become upset. In other words, I could either think about the people that I did help during the day and feel good, or I could think of

all the thousands of people that I will never get a chance to see and work with, and I could feel hopeless and helpless. That would incapacitate me, and I don't think that it is to my advantage to be incapacitated. Is it to your advantage to be incapacitated?

HOLLY: Not really. Well, I don't know.

DAVID: You like being incapacitated?

HOLLY: No. Not unless I were completely incapacitated.

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DAVID: What would that be like?

HOLLY: I would be dead, and I think I would be better of being that way.

DAVID: Do you think being dead is enjoyable?

HOLLY: Well, I don't even know what it's like. I suppose is might be horrible to be dead and to experience nothinz.

Who knows?

DAVID: So it might be horrible, or it might be nothing. Now the closest thing to nothing is when you are being anes-thetized. Is that enjoyable?

HOLLY: It's not enjoyable, but it's not unenjoyable either.

DAVID: I'm glad you admit that it's not enjoyable. An'

you're right, there's really nothing enjoyable about nothing. But there are some things enjoyable about life.

(At this point I thought I had really made a mark. But agai^-

in her adolescent insistence that things were no good, she continued to outmaneuver me and contradict everything I said. Her contrariness made my work with her challenging and more than a bit frustrating at times.)

HOLLY: But you see, there are so few things that are enjoyable about life, and there is so much other stuff that you have to go through to get those few enjoyable things that it seems to me it just doesn't weigh out.

DAVID: How do you feel when you're feeling good? Do you feel that it doesn't weigh out then, or do you just feel this way when you're feeling bad?

HOLLY: It all depends on what I want to focus on, right?

The only way I get myself not to be depressed is if I don't think about all the lousy things in this universe that make me depressed. Right? So when I am feeling good, that means I'm focusing on the good things. But all the bad things are still there. Since there is so much more bad than good, it is dishonest and phony to look only at the good and feel good or feel happy, and that's why suicide is the best thing to do.

DAVID: Well, there are two kinds of bad things in this uni•

verse. One is the pseudo-bad. This is the unreal bad that we create as a figment of our imagination by the way we think about things.

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HOLLY (interrupting): Well, when I read the newspapers, I see rapes and murders. That seems to me to be the real bad.

DAVID: Right. That's what I call the real bad. But let's look at the pseudo-bad first.

}roux: Like what? What do you mean by pseudo-bad?

DAVID: Well, take your statement that life is no good. That statement is an inaccurate exaggeration. As you pointed out, life has its good elements, its bad elements, and its neutral elements. So the statement that life is no good or that everything is hopeless is just exaggerated and unrealistic. This is what I mean by the pseudo-bad. On the other hand, there are the real problems in life. It's true that people do get murdered and that people do get cancer, but in my experience these unpleasant things can be coped with. In fact, in your life you will probably make the decision to commit yourself to some aspect of the world's problems where you think you can make a contribution to a solution. But even there, the meaningful approach involves interaction with the problem in a positive way rather than getting overwhelmed by it and sitting back and moping.

HOLLY: Well, see, that's what I do. I just get immediately overwhelmed with the bad things I encounter, and then I feel like I ought to kill myself.

DAVID: Right. Well, it might be nice if there were a universe where there were no problems and no suffering, but then there would be no opportunity for people to grow or solve these problems either. One of these days you'll probably take one of the problems in the world, and contributing to its solution will become a source of satisfaction to you.

HOLLY: Well, that's not fair to use problems in that way.

DAVID: Why don't you test it out? I wouldn't want you to believe anything that I say unless you test it out for yourself and find out if it's true. The way to test it out is to begin getting involved in things, to go to classes, do your work, and establish relationships with people.

HOLLY: That's what I am beginning to do.

DAVID: Well, you can see how it works out over a period of time, and you may find that going to summer school and 349

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making a contribution to this world, and meeting with friends and getting involved with activities, and doing your work and getting adequate grades, and experiencing a sense of achievement and pleasure in doing what you can—all of this might not be satisfying to you, and you might conclude, "Hey, depression was better than this." And "I don't like being happy." You might say, "

Hey, I don't like being involved in life." If that's true, you can always go back to being depressed and hopeless.

I'm not going to take anything away from you. But don't knock happiness until you've tried it. Check it out.

See what life is like when you get involved and make an effort. Then we'll see where the chips fall at that time.

Holly again experienced a substantial emotional relief as she realized, at least in part, that her intense conviction that the world was no good and life was not worth living was simply the result of her illogical way of looking at things. She was making the mistake of focusing only on negatives (the mental filter) and arbitrarily insisting that the positive things in the world didn't count (disqualifying the positive). Consequently, she got the impression that everything was negative and that life was not worth living. As she learned to correct this error in her thinking, she began to experience some improvement. Although she continued to have a number of ups and downs, the frequency and severity of her mood swings diminished with time. She was so successful in her summer-school work that she was accepted in the fall as a full-time student at a top Ivy League college. Although she made many pessimistic predictions that she would flunk out because she didn't have the brains to make it in academics, to her great surprise she did outstandingly well in her classes. As she learned to transform her intense negativity into productive activity, she became a top-notch student.

Holly and I had a parting of the ways after less than a year of weekly sessions. In the middle of an argument, she fled from the office, slammed the door, and vowed never to return. Maybe she didn't know any other way to say good-bye. I believe she felt she was ready to try and make it on her own. Perhaps she finally got tired of trying to batter me down; after all, I was just as stubborn as she was! She called 350

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me recently to let me know how things turned out. Although she still struggles with her moods at times, she is now a senior and at the top of her class. Her dream of going to graduate school to pursue a professional career appears to be a certainty. God bless you, Holly!

Holly's thinking represents many of the mental traps that can lead to a suicidal impulse. Nearly all suicidal patients have in common an illogical sense of hopelessness and the conviction they are facing an insoluble dilemma. Once you expose the distortions in your thinking, you will experience considerable emotional relief. This can give you a basis for hope and can help you avert a dangerous suicide attempt. In addition, the emotional relief can give you some breathing room so you can continue to make more substantive changes in your life.

You may find it difficult to identify with a turbulent adolescent like Holly, so let's take a brief look at another more common cause for suicidal thoughts and attempts—the sense of disillusionment and despair that sometimes hits us in middle age or in our senior years. As you review the past, you may conclude that your life hasn't really amounted to much in comparison with the starry-eyed expectations of your youth. This has been called the mid-life crisis—that stage in which you review what you have actually done with your life compared with your hopes and plans. If you cannot resolve this crisis successfully, you may experience such intense bitterness and such profound disappointment that you may attempt suicide. Once again, the problem turns out to have little, if anything, to do with reality. Instead, your turmoil is based on twisted thinking

Louise was a married woman in her fifties who had emi-grated from Europe to the United States during World War II. Her family brought her to my office one day after she had been discharged from an intensive care unit, where she had been treated for an almost successful and totally unexpected suicide attempt. The family was unaware she had been experiencing serious depression, so her sudden suicide attempt was a complete surprise. As I spoke with Louise, she told me bitterly that her life had not measured up. She had never experienced the joy and fulfillment that she dreamed of as a girl:

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she complained of a sense of inadequacy and was convinced she was a failure as a human being. She told me that she had accomplished nothing worthwhile and concluded her life was not worth living.

Because I felt a rapid intervention was necessary in order to prevent a second suicide attempt, I used cognitive techniques to demonstrate to her as fast as possible the illogic of what she was saying to herself. I first asked her to give me a list of things she had accomplished in life as a way of testing her belief that she hadn't succeeded at anything worthwhile.

LOUISE: Well, I helped my family escape from the Nazi terrorism and relocate in this country during World War II. In addition, I learned to speak many languages flu-ently—five of them—when I was growing up. When we came to the United States, I worked at an unpleasant job so that enough money would be available for my family. My husband and I raised a fine young son, who went on to college and is now a highly successful businessman. I'm a good cook; and in addition to perhaps being a good mother, my grandchildren seem to think I'm a good grandmother. These would be the things which I feel I have accomplished during my life.

DAVID: In light of all these accomplishments, how can you tell me you have accomplished nothing?

LOUISE: You see, everyone in my family spoke five languages. Getting out of Europe was just a matter of survival. My job was ordinary and required no special talent. It is a mother's duty to raise her family, and any good housewife should learn to cook. Because these are all the things I was supposed to do, or that anyone could have done, they are not real accomplishments. They are just ordinary, and this is why I have decided to commit suicide. My life is not worthwhile.

I realized that Louise was upsetting herself unnecessarily by saying, "It doesn't count" with regard to anything good about herself. This common cognitive distortion, called "

disqualifying the positive," was her main enemy. Louise focused only on her inadequacies or errors, and insisted that her successes weren't worth anything. If you discount your 352

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achievements in this way, you will create the mental illusion that you are a worthless zero.

In order to demonstrate her mental error in a dramatic fashion, I proposed that Louise and I do some role-playing. I told her that I would play the role of a depressed psychiatrist, and she was to be my therapist, who would try to find out why I have been feeling so depressed.

Louisa (as therapist): Why is it you feel depressed, Dr. Burns?

DAVID (as depressed psychiatrist): Well, I realize that I've accomplished nothing with my life.

Louisa: So you feel you've accomplished nothing? But that doesn't make sense. You must have accomplished something. For example, you care for many sick depressed patients, and I understand you publish articles about your research and give lectures. It sounds like you have accomplished a great deal at such a young age.

DAVID: No. None of those things count. You see, it is every doctor's obligation to care for his patients. So that doesn't count. I'm just doing what I'm supposed to do.

Furthermore, it is my duty at the university to do research and publish the results. So these are not real accomplishments. All the faculty members do this, and my research is not very important, at any rate. My ideas are just ordinary. My life is basically a failure.

Louisa (laughing at herself—no longer being the therapist): I can see that I have been criticizing myself like that for the past ten years.

DAVID (as therapist again): Now, how does it feel when you continually say to yourself, "It doesn't count" whenever you think about the things you have accomplished?

Louisa: I feel depressed when I say this to myself.

DAVID: And how much sense does it make to think of the things that you haven't done that you might have liked to do, and to overlook the things that you have done which turned out well and were the result of substantial effort and determination?

LinnsE: It doesn't make any sense at all.

As a result of this intervention, Louise was able to see she

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had been arbitrarily upsetting herself by saying over and over, "What I have done isn't good enough." When she recognized how arbitrary it was to do this to herself, she experienced immediate emotional relief, and her urge to commit suicide disappeared. Louise realized that no matter how much she had accomplished in her life, if she wanted to upset herself she would always be able to look back and say, "It wasn't enough." This indicated to her that her problem was not realistic but simply a mental trap she had fallen into. The role-reversal seemed to evoke a sense of amusement and laughter in her. This stimulation of her sense of humor appeared to help her recognize the absurdity of her self-criticism, and she achieved a much needed sense of compassion for herself.

Let's review why your conviction that you are "hopeless" is both irrational and self-defeating. First, remember that depressive illness is usually, if not always, self-limiting, and in most cases eventually disappears even without treatment. The purpose of treatment is to speed the recovery process. Many effective methods of drug therapy and psychotherapy now exist, and others are being rapidly developed. Medical science is in a constant state of evolution. We are currently experiencing a renaissance in our approaches to depressive illness. Because we cannot predict yet with complete certainty which psychological intervention or medication will be most helpful for a particular patient, a number of techniques must sometimes be applied until the right key to the locked-up potential for happiness is found. Although this does require patience and hard work, it is crucial to keep in mind that nonresponse to one or even to several techniques does not indicate that all methods will fail. In fact, the opposite is more often true. For example, recent drug research has shown that patients who do not respond to one antidepressant medication often have a better than average chance of responding to another. This means if you fail to respond to one of the agents, your chances for improvement when you are given another may actually be enhanced. When you consider that there are large numbers of effective antidepressants, psychotherapeutic interventions, and self-help techniques, the probability for eventual recovery becomes tremendously high.

When you are depressed, you may have a tendency to con-354

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fuse feeling with facts. Your feelings of hopelessness and total despair are just symptoms of depressive illness, not facts.

If you think you are hopeless, you will naturally feel this way. Your feelings only trace the illogical pattern of your thinking. Only an expert, who has treated hundreds of depressed individuals, would be in a position to give a meaningful prognosis for recovery. Your suicidal urge merely indicates the need for treatment. Thus, your conviction that you are "hopeless" nearly always proves you are not. Therapy, not suicide, is indicated. Although generalizations can be misleading, I let the following rule of thumb guide me: Patients who feel hopeless never actually are hopeless.

The conviction of hopelessness is one of the most curious aspects of depressive illness. In fact, the degree of hopelessness experienced by seriously depressed patients who have an excellent prognosis is usually greater than in terminal malignancy patients with a poor prognosis. It is of great importance to expose the illogic that lurks behind your hopelessness as soon as possible in order to prevent an actual suicide attempt. You may feel convinced that you have an insoluble problem in your life. You may feel that you are caught in a trap from which there is no exit. This may lead to extreme frustration and even to the urge to kill yourself as the only escape. However, when I confront a depressed patient with respect to precisely what kind of trap he or she is in, and I zero in on the person's "insoluble problem," I invariably find that the patient is deluded. In this situation, you are like an evil magician, and you create a hellish illusion with mental magic. Your suicidal thoughts are illogical, distorted, and erroneous. Your twisted thoughts and faulty assumptions, not reality, create your suffering. When you learn to look behind the mirrors, you will see that you are fooling yourself, and your suicidal urge will disappear.

It would be naive to say that depressed and suicidal individuals never have "real" problems. We all have real problem, including finances, interpersonal relationships, health, etc. But such difficulties can nearly always be coped with in a reasonable manner without suicide. In fact, meeting such challenges can be a source of mood elevation and personal growth. Furthermore, as pointed out in Chapter 9, real prob-355

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lems can never depress you even to a small extent. Only distorted thoughts can rob you of valid hopes or self-esteem. I have never seen a "real" problem in a depressed patient which was so "totally insoluble" that suicide was indicated.

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PART VI

Coping with the

Stresses and Strains

of Daily Living

CHAPTER 16

How I Practice What I Preach

'Physician, heal thyself."—Lnke 4:23

A recent study of stress has indicated that one of the world's most demanding jobs—in terms of the emotional tension and the incidence of heart attacks—is that of an air-traffic controller in an airport tower. The work involves precision, and the traffic controller must be constantly alert—a blunder could result in tragedy. I wonder however if that job is more taxing than mine. After all, the pilots are cooperative and intend to take off or land safely. But the ships I guide are sometimes on an intentional crash course.

Here's what happened during one thirty-minute period last Thursday morning. At 10:25 I received the mail, and skimmed a long, rambling, angry letter from a patient named Felix just prior to the beginning of my 10:30 session. Felix announced his plans to carry out a "blood bath," in which he would murder three doctors, including two psychiatrists who had treated him in the past! In his letter Felix stated, "

I'm just waiting until I get enough energy to drive to the store and purchase the pistol and the bullets." I was unable to reach Felix by phone, so I began my 10:30 session with Harry. Harry was emaciated and looked like a concentration camp victim. He was unwilling to eat because of a delusion that his bowels had "closed off," and he had lost seventy pounds. As I was discussing the unwelcome option of hospitalizing Harry for forced tube feeding to prevent his death from starvation, I received an emergency telephone call from a patient named Jerome, which interrupted the session. Jerome informed me he had placed a noose around his neck and was seriously considering hanging himself before his wife

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came home from work. He announced his unwillingness to continue outpatient treatment and insisted that hospitalization would be pointless.

I straightened out these three emergencies by the end of the day, and went home to unwind. At just about bedtime I received a call from a new referral—a well-known woman VIP referred by another patient of mine. She indicated she'd been depressed for several months, and that earlier in the evening she'd been standing in front of a mirror practicing slitting her throat with a razor blade. She explained she was calling me only to pacify the friend who referred her to me, but was unwilling to schedule an appointment because she was convinced her case was "hopeless."

Every day is not as nerve-racking as that ones But at times it does seem like I'm living in a pressure cooker. This gives me a wealth of opportunities to learn to cope with intense uncertainty, worry, frustration, irritation, disappointment, and guilt. It affords me the chance to put my cognitive techniques to work on myself and see firsthand if they're actually effective. There are many sublime and joyous moments too.

If you have ever gone to a psychotherapist or counselor, the chances are that the therapist did nearly all the listening and expected you to do most of the talking. This is because many therapists are trained to be relatively passive and nondirective—a kind of "human mirror" who simply reflects what you are saying.* This one-way style of communication may have seemed unproductive and frustrating to you. You may have wondered—"What is my psychiatrist really like?

What kinds of feelings does he have? How does he deal with them? What pressures does he feel in dealing with me or with other patients?"

Many patients have asked me directly, "Dr. Burns, do you actually practice what you preach?" The fact is, I often do pull out a sheet of paper on the train ride home in the evening, and draw a line down the center from top to bottom so I can utilize the double-column technique to cope with any nagging emotional hangovers from the day. If you are curi-

*Some of the newer forms of psychiatric treatment, such as cognitive therapy, allow for a natural fifty-fifty dialogue between the client and therapist, who work together as equal members of a team.

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ous to take a look behind the scenes, I'll be glad to share some of my self-help homework with you. This is your chance to sit back and listen while the psychiatrist does the talking! At the same time, you can get an idea of how the cognitive techniques you have mastered to overcome clinical depression can be applied to all sorts of daily frustrations and tensions that are an inevitable part of living for all of us.

Coping With Hostility:

The Man Who Fired Twenty Doctors

One high-pressure situation I often face involves dealing with angry, demanding, unreasonable individuals. I suspect I have treated a few of the East Coast's top anger champions.

These people often take their resentment out on the people who care the most about them, and sometimes this includes me.

Hank was an angry young man. He had fired twenty doctors before he was referred to me. Hank complained of episodic back pain, and was convinced he suffered from some severe medical disorder. Because no evidence for any physical abnormality had ever surfaced, in spite of lengthy, elaborate medical evaluations, numerous physicians told him that his aches and pains were in all likelihood the result of emotional tension, much like a headache. Hank had difficulty accepting this, and he felt his doctors were writing him off and just didn't give a damn about him. Over and over he'd explode in a fury, fire his doctor, and seek out someone new. Finally, he consented to see a psychiatrist. He resented this referral, and after making no progress for about a year, he fired his psychiatrist and sought treatment at our Mood Clinic.

Hank was quite depressed, and I began to train him in cognitive techniques. At night when his back pain flared up, Hank would work himself up into a frustrated rage and impulsively call me at home (he had persuaded me to give him my home number so he wouldn't have to go through the answering service). He would begin by swearing and accusing me of misdiagnosing his illness. He's insist he had a medical, not a psychiatric problem. Then he'd deliver some unreasonable demand in the form of an ultimatum: "Dr. Burns, either

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you arrange for me to get shock treatments tomorrow or go out and commit suicide tonight." It was usually difficult, if not impossible, for me to comply with most of his demands.

For example, I don't give shock treatments, and furthermore I didn't feel this type of treatment was indicated for Hank.

When I would try to explain this diplomatically, he would explode and threaten some impulsive destructive action.

During our psychotherapy sessions Hank had the habit of pointing out each of my imperfections (which are real enough). He'd often storm around the office, pound on the furniture, heaping insults and abuse on me. What used to get me in particular was Hank's accusation that I didn't care about him. He said that all I cared about was money and maintaining a high therapy success rate. This put me in a dilemma, because there was a grain of truth in his criticisms—he was often several months behind in making pay-ments for his therapy, and I was concerned that he might drop out of treatment prematurely and end up even more disillusioned. Furthermore, I was eager to add him to my list of successfully treated individuals. Because there was some truth in Hank's haranguing attacks, I felt guilty and defensive when he would zero in on me. He, of course, would sense this, and consequently the volume of his criticism would increase.

I sought some guidance from my associates at the Mood Clinic as to how I might handle Hank's outbursts and my own feelings of frustration more effectively. The advice I received from Dr. Beck was especially useful. First, he emphasized that I was "unusually fortunate" because Hank was giving me a golden opportunity to learn to cope with criticism and anger effectively. This came as a complete surprise to me; I hadn't realized what good fortune I had. In addition to urging me to use cognitive techniques to reduce and eliminate my own sense of irritation, Dr. Beck proposed I try out an unusual strategy for interacting with Hank when he was in an angry mood. The essence of this method was: (1) Don't turn Hank off by defending yourself. Instead, do the opposite—urge him to say all the worst things he can say about you. (2) Try to find a grain of truth in all his criticisms and then agree with him. (3) After this, point out any areas of disagreement in a straightforward, tactful, nonargumentative

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manner. (4) Emphasize the importance of sticking together, in spite of these occasional disagreements. I could remind Hank that frustration and fighting might slow down our therapy at times, but this need not destroy the relationship or prevent our work from ultimately becoming fruitful.

I applied this strategy the next time Hank started storming around the office screaming at me. Just as I had planned, I urged Hank to keep it up and say all the worst things he could think of about me. The result was immediate and dramatic. Within a few moments, all the wind went out of his sails—all his vengeance seemed to melt away. He began communicating sensibly and calmly, and sat down. In fact, when I agreed with some of his criticisms, he suddenly began to defend me and say some nice things about me! I was so impressed with this result that I began using the same approach with other angry, explosive individuals, and I actually did begin to enjoy his hostile outbursts because I had an effective way to handle them.

I also used the double-column technique for recording and talking back to my automatic thoughts after one of Hank's midnight calls (see Figure 16-1, page 364). As my associates suggested, I tried to see the world through Hank's eyes in order to gain a certain degree of empathy. This was a specific antidote that in part dissolved my own frustration and anger, and I felt much less defensive and upset. It helped me to see his outbursts more as a defense of his own self-esteem than as an attack on me, and I was able to comprehend his feelings of futility and desperation. I reminded myself that much of the time he was damn hard working and cooperative, and how foolish it was for me to demand he be totally cooperative at all times. As I began to feel more calm and confident in my work with Hank, our relationship continually improved.

Eventually, Hank's depression and pain subsided, and he terminated his work with me. I hadn't seen him for many months when I received a message from my answering service that Hank wanted me to call him. I suddenly felt apprehensive; memories of his turbulent tirades flooded my mind, and my stomach muscles tensed up. With some hesitation and mixed feelings, I dialed his number. It was a sunny Saturday afternoon, and I'd been looking forward to a much needed 363

David D. Burns, M.D.

Figure 16-4. Coping with Hostility.

Automatic Thoughts

Rational Responses

1. I've put more energy into work- 1. Stop complaining. You sound ing with Hank than nearly any-like Hank! He's frightened and

one, and this is what I get—

frustrated, and he's trapped in

abuse!

his resentment. Just because you

work hard for someone, it doesn't

necessarily follow that they'll

feel appreciative. Maybe he will some day.

2. Why doesn't he trust me about 2. Because he's in a panic, he's exhis diagnosis and treatment?

tremely uncomfortable and in

pain, and he hasn't yet gotten

any substantial results. He'll be-

lieve you once he starts getting

well.

3. But in the meantime, he should 3. Do you expect him to show re-at least treat me with respect!

spect all the time or part of the

time? In general, he exerts tre-

mendous effort in his self-help

program and does treat you with

respect. He's determined to get

well—if you don't expect perfec-

tion, you won't have to feel frus-

trated.

4. But is it fair for him to call me 4. Talk it over with him when so often at home at night? And

you're both feeling more relaxed.

does he have to be so abusive?

Suggest that he supplement his

individual therapy by joining a

self-help group in which the vari-

ous patients call each other for

moral support. This will make it

easier for him to cut down on

calls to you. But for now, re-

member that he doesn't plan

these emergencies, and they are

very terrifying and real to him.

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rest after an especially taxing week. Hank answered the phone: "Dr. Burns, this is Hank. Do you remember me?

There's something I've been meaning to tell you for some time . ." He paused, and I braced for the impending explosion. "I've been essentially free of pain and depression since we finished up a year ago. I went off disability and I've gotten a job. I'm also the leader of a self-help group in my own hometown."

This wasn't the Hank I remembered! I felt a wave of relief and delight as he went on to explain, "But that's not why I'm calling. What I want to say to you is .. ." There was another moment of silence--"I'm grateful for your efforts, and I now know you were right all along. There was nothing dreadfully wrong with me, I was just upsetting myself with my irrational thinking. I just couldn't admit it until I knew for sure. Now, I feel lice a whole man, and I had to call you up and let you know where I stood . . . It was hard for me to do this, and I'm sorry it took so long for me to get around to telling you."

Thank you, Hank! I want you to know that some tears of joy and pride in you come to my eyes as I write this. It was worth the anguish we both went through a hundred times over!

Coping With Ingratitude:

The Woman Who Couldn't Say Thank You

Did you ever go out of your way to do a favor for someone only to have the person respond to your efforts with indifference or nastiness? People shouldn't be so unappreciative, right? If you tell yourself this, you will probably stew for days as you mull the incident over and over. The more inflammatory your thoughts and fantasies become, the more disturbed and angry you will feel.

Let me tell you about Susan. After high-school graduation, Susan sought treatment for a recurrent depression. She was very skeptical that I could help her and continually reminded me that she was hopeless. She had been in a hysterical state for several weeks because she couldn't decide which of two colleges to attend. She acted as though the world would come 365

David D. Burns, M.D.

to an end if she didn't make the "right" decision, and yet the choice was simply not clear-cut. Her insistence on eliminating all uncertainty was bound to cause her endless frustration because it simply couldn't be done.

She cried and sobbed excessively. She was insulting and abusive to her boyfriend and her family. One day she called me on the phone, pleading for help. She just had to make up her mind. She rejected every suggestion I made, and angrily demanded I come up with some better approach. She kept insisting, "Since I can't make this decision, it proves your cognitive therapy won't work for me. Your methods are no damn good. I'll never be able to decide, and I can't get better." Because she was so upset, I arranged my afternoon schedule so that I could have an emergency consultation with a colleague. He offered several outstanding suggestions; I called her right back and gave her some tips on how to resolve her indeciveness. She was then able to come to a satisfactory decision within fifteen minutes, and felt an instan-taneous wave of relief.

When she came in for her next regularly scheduled session, she reported she had been feeling relaxed since our talk, and had finalized the arrangements to attend the college that she chose. I anticipated waves of gratitude because of my strenu-ous efforts on her behalf, and I asked her if she was still convinced that cognitive techniques would be ineffective for her. She reported, "Yes, indeed! This just proves my point.

My back was up against the wall, and I had to make a decision. The fact that I'm feeling good now doesn't count because it can't last. This stupid therapy can't help me. I'll be depressed for the rest of my life." My thought: "My God!

How illogical can you get? I could turn mud into gold, and she wouldn't even notice!" My blood was boiling, so I decided to use the double-column technique later that day to try and calm my troubled and insulted spirits (see Figure 16-2, opposite page).

After writing down my automatic thoughts, I was able to pinpoint the irrational assumption that caused me to get upset over her ingratitude. It was, "If I do something to help someone, they are duty-bound to feel grateful and reward me for it." It would be nice if things worked like this, but it's simply not the case. No one has a moral or legal obligation to credit 366

FEELING GOOD

me for my cleverness or praise my good efforts on their behalf. So why expect it or demand it? I decided to tune in to reality and adopt a more realistic attitude: "If I do something to help someone, the chances are the person will be apprecia-Figure 16-2. Coping with Ingratitude.

Automatic Thoughts

Rational Responses

1. How can such a brilliant girl be

1. Easily! Her illogical thinking is

so illogical?

the cause of her depression. If

she didn't continually focus on

negatives and disqualify positives,

she wouldn't be depressed so

often. Its your job to train her in

how to get over this.

2. But I can't. She's determined to

2. She doesn't have to give you any

beat me down. She won't give

satisfaction. Only you can do

me an ounce of satisfaction.

this. Don't you recall that only

your thoughts affect your moods?

Why not credit yourself for what

you did? Don't wait around for

her. You just learned some ex-

citing things about how to guide

people in making decisions.

Doesn't that count?

3. But she should admit I helped

3. Why "should" she? That's a fairy herl She should be grateful!

tale. If she could she probably

would, but she can't yet. In time

she'll come around, but she'll

have to reverse an ingrained pat-

tern of illogical thinking that's

been dominating her mind for

over a decade. She may be afraid

to admit she's getting help so she won't end up disillusioned again.

Or she might be afraid you'll say,

"I told you so." Be like Sherlock

Holmes and gee if you can figure

out this puzzle. It's pointless to

demand that she be different

from the way she is.

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tive, and that will feel good. But every now and then, someone will not respond the way I want. If the response is unreasonable, this is a reflection on that person, not me, so why get upset over it?" This attitude has made life much sweeter for me, and overall I have been blessed with as much gratitude from patients as I could desire. Incidentally, Susan gave me a call just the other day. She'd done well at college and was about to graduate. Her father had been depressed, and she wanted a referral to a good cognitive therapist!

Maybe that was her way of saying thank you!

Coping With Uncertainty and Helplessness:

The Woman Who Decided to Commit Suicide

On my way to the office on Monday, I always wonder what the week will hold in store. One Monday morning I was in for an abrupt shock. As I unlocked the office, I found some papers had been slipped under the door over the weekend—a twenty-page letter from a patient named Annie. Annie had been referred to me several months earlier on her twentieth birthday, after having received eight years of completely successful treatment from several therapists for a horrible, grotesque mood disorder. From age twelve on, Annie's life had deteriorated into a nightmarish pattern of depression and self-mutilation. She loved to slash her arms to shreds with sharp objects, one time requiring 200 stitches. She also made a number of nearly successful suicide attempts.

I tensed as I picked up her note. Annie had recently expressed a deep sense of despair. In addition to depression, she suffered from a severe eating disorder, and the previous week had engaged in a bizarre three-day spree of compulsive, uncontrollable binge-eating. Going from restaurant to restaurant, she would stuff herself for hours nonstop. Then she'd vomit it all up and eat some more. In her note she described herself as a "human garbage disposal," and explained that she was beyond hope. She indicated that she had decided to give up trying because she realized she was basically "a nothing."

Without reading further, I called her apartment. Her roommates told me that she had packed up and "left town" for three days without giving any indication of where or why.

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Alarms sounded in my head! This is exactly what she had done on her last several suicide attempts prior to treatment—she'd drive to a motel, sign in under an assumed name, and overdose. I continued to read her letter. In it she stated, "I'm drained, I'm like a burnt-out light bulb. You can pipe electricity into it, but it just won't light up. I'm sorry but I guess it's just too late. I'm not going to feel false hope any longer . . . During the last few moments I do not feel particularly sad. Once every so often I try to grasp onto life, hoping to clench my hands around something, anything—but I keep grasping nothing, empty."

It sounded like a bona fide suicide note, although no ex-plicit intention was announced. I suddenly became submerged by a massive uncertainty and helplessness—she had disappeared and left no traces. I felt angry and anxious. Because I could do nothing for her, I decided to write down the automatic thoughts that flowed through my mind. I hoped some rational responses would help me cope with the intense uncertainty I was facing (see Figure 16-3, page 370).

After recording my thoughts, I decided to call my associate, Dr. Beck, for a consultation. He agreed that I should assume she was alive unless it was proved otherwise. He suggested that if she were found dead, I could then learn to cope with one of the professional hazards of working with depression. If she was alive, as we assumed, he emphasized the importance of persisting with treatment until her depression finally broke.

The effect of this conversation and the written exercise was magnificent. I realized I was under no obligation to assume "

the worst," and that it was my right to choose not to make myself miserable over her possible suicide attempt. I decided I couldn't take on responsibility for her actions, only for mine, and that I had done well with her and would stubbornly continue to do so until she and I had finally defeated her depression and tasted victory.

My anxiety and anger disappeared completely, and I felt relaxed and peaceful until I received the news by telephone on Wednesday morning. She had been found unconscious in a motel room fifty miles from Philadelphia. This was her eighth suicide attempt, but she was alive and complaining as usual in the Intensive Care Unit of an outlying hospital. She 369

David D. Burns, M.D.

Figure 16-3. Coping with Uncertainty.

Automatic Thoughts

Rational Responses

1. She's probably made a suicidc at 1. There's no proof she's dead. Why t e m p t — a n d s u c c e e d e d . n o t a s s u m e s h e ' s a l i v e u n t i l proven otherwise? Thcn you

won't have to worry and obsess

in thc meantime.

2. If she's dead, it means I killed 2. No, you're not a killer. You're her.

trying to help.

3. If I'd donc something different 3. You're not a fortunc teller—you last week, 1 could have prevented

can't predict the futurc. You do

this. It's my fault.

thc best you can based on what

you know—draw the line there

and respect yourself on this basis.

4. This shouldn't have happened— 4. Whatever happened did happen.

I t r i e d s o h a r d . J u s t b e c a u s e y o u m a k e m a x i m a l efforts, there's no guarantee about

the results. You can't control

her, only your efforts.

5. This means my approach is sec 5. Your approach is one of the o n d - r a t e . f i n e s t e v e r d e v e l o p e d , a n d y o u apply yourself with great effort

and commitment, and get out-

standing results. You are not

second-rate.

6. Her parents will .be angry with 6. Thcy may and they may not.

me.

They know how you've knocked

yourself out for her.

7. Dr. Beck and my associates will 7. Extremely unlikely. Well all be be angry with me—they'll know

disappointed to lose a patient

Fm incompetent, and they'll look

we've gone to such extreme

down on me.

lengths to help, but your peers

won't feel you've let them down.

If you're at all concerned, call

theml Practice what you preach,

Burns.

8. I'll feel miserable and guilty until 8. You'll only feel miserable if you I find out what happened. I'm ex-make a negative assumption.

pected to feel that way.

Odds are (a) she's alive and (b)

she'll get better. Assume this and

you'll feel goodl You have no

obligation to feel bad—you have

the right to refuse to get upset.

FEELING GOOD

would survive, but would require plastic surgery to replace the skin over her elbows and ankles because of sores which had developed during the long period of unconsciousness. I arranged for her transfer to the University of Pennsylvania, where she would be back in my relentless, cognitive clutches again!

When I spoke with her, she was enormously bitter and hopeless. The next couple of months of therapy were especially turbulent. But the depression finally began to lift in her eleventh month, and exactly one year to the day of her referral, her twenty-first birthday, the symptoms of depression disappeared.

The Payofl: My joy was enormous. Women must have this feeling when they first see their child after delivery—all the discomfort of pregnancy and the pain of delivery are forgot-ten. It's the celebration of life—quite a heady experience. I find that the more chronic and severe the depression, the more intense the therapeutic struggle becomes. But when the patient and I at last discover the combination that unlocks the door to their inner peace, the riches inside far exceed any effort or frustration that occurred along the way.

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PART VII

The Chemistry

of Mood

CHAPTER 17

The Consumer's Guide

to Antidepressant Drug Therapy

The Search for "Black Bile"

Throughout the ages, men have searched for the causes of depression. Even in ancient times there was some suspicion that blue moods were due, at least in part, to an imbalance in body chemistry. Hippocrates (460-355 B.c.) thought that "

black bile" was the culprit. In recent years scientists have spearheaded an intensive search for the elusive black bile.

They are frying to pinpoint the abnormalities in brain chemistry that cause depression. There are hints about the answer, but in spite of increasingly sophisticated research tools, the definitive solution is still just beyond our grasp. Sooner or later, neurochemists may provide us with frightening technology that will allow us to regulate our moods at will. This will represent one of the most extraordinary and philosophically confusing developments in human history. For the immediate future the goals are much more modest. We are aiming for increased precision in diagnosing depressive illnesses and the development of more humane and effective treatment methods.

What is the basis for believing that there may be a chemical component in depression? First, the physical (somatic) symptoms of depression support the notion that organic change is involved in at least some depressions. These changes in body function include, among others, agitation (

increased nervous activity such as pacing or hand-wringing), or retardation (motionless apathy—you feel like a ton of bricks and do nothing). You also may experience a "diurnal"

variation in mood (this refers to the worsening of symptoms 375

David D. Burns, M.D.

in the morning in some depressions), changed sleep patterns (

insomnia is the most common), constipation, abnormalities in appetite (usually decreased, sometimes increased), an impaired concentration ability, and a decreased interest in sex.

A second argument for a physiologic cause for depression is that at least some forms of mood disorders run in families, suggesting a role for genetic factors. If there is an inherited abnormality that predisposes some individuals to depression, it is likely to be in the form of a disturbance in body chemistry, as is the case with so many genetic diseases.

The modern era of research on the chemistry of mood disorders began several decades ago, when it was hypothesized that depression might result from decreased levels of certain brain substances known technically as "amines."*

What are amines? They are chemical transmitters which nerves use to send messages to each other. Amines are the brain's biochemical "mailmen," particularly concentrated in the limbic system, a primitive brain region which appears to be involved in mood regulation.

Discoveries resulting from several types of research have been consistent with this amine theory. The findings can be simplified as follows:

I. Some (but not all) drugs used in the treatment of high blood pressure appear to bring on attacks of depression in individuals predisposed to mood disorders. These drugs have a tendency to deplete the brain of the amine chemical messengers. The lowered amine levels may trigger the depressed mood.

2. Drugs which raise the brain levels of these amines cause increased activity and alertness in laboratory animals.

Conversely, drugs which block or reduce the activity of the brain amines cause sedation and lethargy in these animals While such increased or decreased activity In animals obviously does not constitute an adequate model for the possible physiologic cause of human elation or depression, it is true that changed activity and alertness levels are seen in human mood disorders. Thus, these laboratory observations are consistent with the amine theory.

* The amines currently implicated in mood disorders include nore-pinephrine, dopamine, and serotonin.

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3. Most drugs used in the treatment of depression do po-tentiate the activity or raise the levels of the messenger amines in the brain. For example, in a remarkable series of recent experiments in New York, a group of depressed patients received a drug that causes a buildup in brain-amine concentrations. After several weeks of treatment, the patients were clinically improved. Then they were given a second drug that depletes the brain amines. The patients all relapsed into depression within a couple of days. When the second drug was withdrawn so that the brain-amine levels were allowed to rise, the patients again recovered. These findings raise suspicions that the brain amines may indeed be the chemical "culprits" in at least some depressions, since these patients' moods seemed to cycle up and down in response to changes in brain-amine levels.

4. Studies of these amine levels and their breakdown products in the blood, urine, and spinal fluid of depressed individuals have documented the predicted deficiencies in some (

but not all) depressed patients.

As you can see, some of the data looks promising. Does this mean we have pinpointed the precise cause of depression? Not by a long shot. Our understanding of how the brain functions is highly primitive. We're still in the Model-T

era waiting for the jet age. But an important research effort has been launched and is moving forward rapidly.

Eventually it probably will lead us to the final identification of the mysterious "black bile."

How Antidepressants Affect the Brain

In this section I have reduced to simple basics our current understanding of how antidepressant drugs influence the nerves in your brain. However, if the very word "chemical"

sends your mind reeling, just skip this section and go on to the practical details of drug administration in the next section.

The brain is essentially an electrical system. The nerves, or "wires," communicate their electrical signals to each other by way of chemical messengers (see Figure 17-1, page 378).

If the nerves become depleted of these chemical messengers, 377

David D. Burns, M.D.

These are the chemical messen-

gers, which have been released

into the "synapse," or junction

region.

Electrical

Electrical

impulse

" :;1410. n

impulse

Nerve 1

-1410. •

Nerve 2

91:1410.*

The "synapse": This is the fluid-

filled junction between the two

nerves. The chemical messenger

migrates across the synapse and

attaches to the membrane of

nerve 2.

These are packets at the end of

nerve 1 which contain the

chemical messengers.

Figure 17-1. How Nerves Send Messages to Each Other. An electrical impulse travels along nerve 1 until it reaches the terminal region. Here tiny packets containing chemical messengers rupture, and the messengers spill into the synaptic region. They then migrate across the fluid-filled synapse and become attached to the membrane of nerve 2. This triggers an electrical impulse in nerve 2. The chemical messengers are then destroyed, and the waste products are excreted from the brain and ultimately appear in the urine.

Nerve 1 must constantly manufacture fresh chemical messengers to replace those that are lost. A deficiency of messengers is thought to lead to depression. Antidepressants compensate for the postulated deficiency by raising the levels of chemical messengers, or by increasing the potency of the chemical messengers in the synaptic region.

378

Table 17-1. Tricyclic Antidepressants

Agents

Other Side Effects

Sedative

(Dry mouth, constipation,

Normally Effective

Time of Day to

Effects 2

blurred vision)a

Total Daily Dose 4

Take the Medicine a

Imiprtunine

moderate

moderate

150-300 mg

pattern 1

(Tofranil, Imanate,

Presamine, Slt-Pramine,

Janbufne)

Desipramine

moderate

moderate

150-250 mg

pattern 1

(Pertofrane, Norpramln)

Amitriptyline

substantial

moderate

75-300 mg

pattern 1

th

(Mull, Endep)

Nortiiptyline (

substantial

moderate

50-150 mg

pattern 1

r-■

A1=44)

c.,4

least

moderate

10-60 mg

pattern 2

••.1

Protriptyline (

vs

VIvactil)

Dompta

least

150-300 mg

pattern 1

8

substantial

(Sinequan, AdaPin)

CThe clumilleel same is given that, and the brand names are indicated in parentheses. If your doctor uses the chemical name on the pro-the drone* can substitute • cheaper brand if you request It and If one fa mailable.

•▪ ReceeS SNOW sunset that those dram which are meetly sedative may here the greatest effect in combating armlet, and nervousness. Who gives at eight, the sedative agent, bells reduce insomnia.

ensile Me fads, if troublesome, can be minimised by a reduction in doeage. Side effects are greatest the first few days and tend to dfravpeat

•The dam emild be geed for the treatment of en episode of depression. Some patients may require and benefit from doses outside the await range. If maintenance therapy following recovery fa felt to be appropriate, two thirds of the dose taken during the acute phase of imam= arm be med.

• hem It Up to beff the mesimunt indicated dose may be taken on • enetsper.day basis at night before bedtime. This dosage pre-load deep, and atom dde effects will occur when you are asleep. If larger doses are required, the additional medicine can be given at madames in divided amounts.

Pattern 2t This medicine fa effmulating and should be taken in divided doses in the morning and at noon. If taken later in the day, the medication may interfere with Sleep.

David D. Burns, M.D.

the wiring in the brain develops faulty connections. The result will be mental and emotional static, much like the music that comes out of a radio with a loose wire in the tuner. The emotional static would correspond to depression.

Conversely, manic states—in which the patient is overwhelmed by an uncontrollable, emotional high—are thought to be due to an excessive level of activity of these chemical messengers, leading to hyperactive nerve function.

How do antidepressant drugs correct this? There are four categories of antidepressant agents in use. The widely prescribed "tricyclic" antidepressants (see Table 17-1, page 379) appear to enhance the potency of the brain's mood messengers in the synaptic junction, although they do not cause an actual increase in the levels of these substances.

A second category of antidepressant medications is known as the "M.A.O. Inhibitors," such as Parnate (tranylcyprom-ine), Marplan (isocarboxazid), and Nardil (phenelyzine).

These drugs lead to an actual elevation of the levels of amine messengers in the emotional regions of the brain. As the brain becomes loaded with extra amounts of chemical transmitters, the presumed chemical amine deficiency is corrected.

Lithium carbonate is the third type of antidepressant. The effects of lithium are more complex and less clearly understood. Lithium is similar to ordinary table salt, and is known as an "electrolyte." It smooths out destructive mood cycles in patients whose emotions swing back and forth unpredictably from uncontrollable and extreme elation to deep despair. It is not known for certain how one drug can have two opposite effects and this paradox is one of many challenging puzzles that psychiatric researchers are trying to solve. One current theory suggests that lithium stabilizes the chemical-messenger levels so that cyclic oscillations in amine concentrations are less apt to occur.

L-tryptophan is the fourth and newest type of antidepressant. It is a naturally occurring amino acid that is present in a normal diet, and is used by the brain in the synthesis of one of the chemical messengers. Thought to be vital to mood regulations, it has been subject to intensive research in the past decade. L-tryptophan is particularly fascinating because it passes rapidly from the stomach to the mood centers of the

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FEELING GOOD

brain, and thus it has been promoted as a natural antidepressant agent.

Research in the next decade will undoubtedly advance our understanding of how the brain regulates emotional states, and, it is hoped, our armamentarium of antidepressant agents will be greatly expanded and strengthened. At present, we can only say:

1. There are at least a dozen different antidepressant drugs that do work.

2. For some patients these drugs are profoundly effective, while for others the results are disappointing.

3. We can only make educated guesses about which agent will work best for which patient. Some patients may need to try several antidepressants until the one that works best is found because we do not yet have completely effective methods for determining the correct drug based on clinical characteristics or laboratory tests.

4. Blood tests for measuring levels of tricyclic antidepressants have been recently developed in research centers and are rapidly becoming clinically available. These blood tests will guide therapists in administering the proper dose of antidepressant and may substantially improve the therapeutic effectiveness and safety of the medications.

What You and Your Doctor Need to Know

About Commonly Prescribed Antidepressants

Tricyclic Compounds. The tricyclic antidepressants are the most widely prescribed compounds at this time (the word "

tricyclic" simply refers to their chemical structure, which resembles three connected rings). A list of the most generally prescribed tricyclic compounds, along with useful information about the dose range, method of administration, and side effects, is included in Table 17-1, page 379.

The most common error your doctor is likely to make is to prescribe a dose that is too low. This statement may run against your grain if you intuitively feel you should take the lowest dose possible. In the case of tricyclics, if the dose

381

David D. Burns, M.D.

prescribed is too low, they will not be completely effective. If you insist on taking a daily dose that is too low, you will be wasting your time. It simply will not help you. On the other hand, dosages above those recommended in Table 17-1 can be dangerous, and in some cases can lead to a worsening of your depression. My advice in a nutshell: Go to a physician who specializes in treatment with antidepressant drugs; follow his advice within reason; and review Table 17-1 with him if you suspect you may be taking an inappropriately large or small dose.

Another error your doctor may make is to keep you on a particular antidepressant for many months even when there is no clear-cut evidence that you have improved. This makes absolutely no sense to me, yet I have seen many severely depressed individuals who report they have been treated continuously with the same antidepressant for months or years and were not aware of any beneficial effects! In such a case it is abundantly clear that the drug has not worked. So why keep taking it? If a drug does not begin to have fairly substantial effects, as indicated by a continuing drop in the score on the BDI test (see Chapter 2) after a three- to four-week trial at an adequate dose, then it is usually appropriate to switch to another tricyclic agent.

The best way to begin taking a tricyclic medicine is to start out with a small dose and to increase the amount each day until a dose within the normal therapeutic range is achieved.

This buildup can usually be completed within one week. For example, a typical daily dose schedule for 'imipramine, the first drug listed in Table 17-1, might be:

Day one-50 mg at bedtime;

Day two-75 mg at bedtime;

Day three-100 mg at bedtime;

Day four-125 mg at bedtime;

Day five-150 mg at bedtime.

If doses larger than 150 milligrams per day are required, the additional medicine should be given in divided doses during the daytime. Doses up to 150 milligrams per day can be conveniently taken once a day at night. The antidepressant effect will last all day long, and the most bothersome side effects will occur at night, when they will be least noticed.

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The most common side effects are sleepiness, dry mouth, mild hand tremor, transient lightheadedness, and constipation.

These symptoms usually occur in the first few days and, with the exception of dry mouth, tend to diminish as you become accustomed to the drug. If you simply put up with them, they will frequently disappear spontaneously after a few days. If the effects are strong enough to make you uncomfortable, it is best to reduce the dose gradually, but do not do so abruptly. Sudden discontinuation of the medicine may result in an upset stomach and insomnia.

Side effects that suggest you are taking an excessive dose include difficulty in urination, blurred vision, confusion, severe tremor, substantial dizziness, or increased sweating. A dose reduction for such symptoms is definitely indicated.

A stool softener or laxative can help if constipation develops. Lightheadedness is most likely to occur when you stand up suddenly—this is due to blood collecting in the legs and persists for a few seconds. If you get up more carefully and slowly, or if you exercise your legs before standing (by tightening and then relaxing your leg muscles as when you run in place), this should not be a problem.

Some patients describe feeling "strange," "spaced-out," or "

unreal" during the first few days of drug administration.

Similar reactions were observed in a study in which patients received sugar pills (placebos) they thought were antidepressants. This suggests that many so-called side effects may be imaginary to a certain extent and result from fears about the medication rather than from any actual effect of the drug itself. When patients report feeling strange on the first day or two of taking an antidepressant, I usually advise them to stick with it, and in nearly all cases this uncomfortable sensation disappears completely within a few days.

The tricyclic compounds may stimulate your appetite. If you have been losing weight due to depression, this appetite boost can be beneficial. However, if you are overweight you might have to pay more attention to dietary consideration in order to avoid additional weight gain, which can be demoral-izing.

How long will it take before you can expect to feel better?

It usually requires a minimum of two or three weeks before the medicine begins to improve your mood. It is not known 383

David D. Burns, M.D.

why antidepressants have this delayed reaction (and whoever discovers the reason will probably be a good candidate for a Nobel Prize). Many patients have the impulse to discontinue their antidepressants before the three weeks have passed because they believe the medicine is not working. This is illogical and self-defeating, since it is unusual for these agents to become effective right away.

How much mood elevation should you anticipate? My own philosophy is to use the BDI test as a guide (Chapter 2).

Take the test once or twice a week during your treatment.

Your aim should be to reduce the score until it is in the range considered normal (under ten). Treatment cannot be considered completely successful if your score remains over ten. If after three to four weeks of drug treatment the BDI score has not begun to fall substantially, I would advise discontinuation of that drug. In this case your doctor is likely to recommend that you switch immediately to another tricyclic antidepressant. This makes good sense because many patients who do not respond adequately to the first agent will have a positive response to the second or third. If you still have not improved after trying several different tricyclic drugs, it might be best to switch to a completely different type of antidepressant, such as the M.A.O. Inhibitors.*

What are the chances you will respond to a particular tricyclic? Most studies have reported approximately 65 percent of depressed patients will respond to the first tricyclic antidepressant they are given. Since approximately 30 percent of those treated with a sugar pill also recover, an antidepressant will double your chances for recovery during the first month or two of treatment. If you try several agents in succession, your chances for recovery are much higher. But do not take several different drugs simultaneously!

After you have responded adequately, how long should you continue to take the medicine? You and your doctor will have to make this decision together. If this is your first depressive episode, you can probably go off the medicine, and

* If you switch from a tricyclic drug to an M.A.O. Inhibitor, it is mandatory that you be drug-free for at least ten days. Similarly, if you switch from an M.A.O. Inhibitor to a tricyclic drug, a ten-day drug-free period is also mandatory. This is because dangerous interactions between M.A.O. Inhibitors and tricyclic compounds can occur.

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you will continue to feel like your normal self. If you have had many years of unremitting depression, or if you have been prone to recurrent attacks, you might want to consider maintenance therapy for a year or more at two thirds of the dose you were on when you improved. Recent research indicates that such maintenance therapy can reduce the incidence of depressive relapses. Since doctors are becoming more and more aware of the relapsing nature of mood disorders, the use of antidepressants on a prophylactic basis is gaining a greater favor.

What should you do if at some future time the depression comes back? Should you try a new drug? No! The chances are that you will again respond to the original agent. It may be the proper biological "key" for you. So use that drug again—go with a winner! If any blood relative of yours develops a depression, this same drug might also be a good choice for them because a person's response to antidepressants, like the depression itself, appears to be influenced by genetic factors.

M.A.O. Inhibitors. These agents were the first antidepressants to receive widespread use many years ago, but then they fell into relative disuse when the newer and somewhat safer tricyclic compounds were developed. In recent years the M.A.O. Inhibitors have experienced a resurgence of popularity because they are often remarkably effective for patients who do not respond to tricyclics, especially those who have experienced so many years of depression that this miserable illness has become an unwelcome life-style. The M.A.O. Inhibitors are particularly effective in an atypical depression that is characterized by phobias and high levels of anxiety, chronic anger, hypochondriacal complaints, or impulsive self-destructive behavior. Patients with recurrent obsessive thoughts and compulsive, ritualistic, nonsensical habits (such as recurrent hand-washing or repetitive checking of door locks) also often experience relief when treated with M.A.O.

Inhibitors. These drugs require careful medical management and close teamwork with your doctor. They are well worth the effort because they can be lifesaving when other drugs have proved ineffective, and can lead to profound, beneficial mood transformations.

Like the tricyclic compounds, the M.A.O. Inhibitors re-

385

David D. Burns, M.D.

quire at least two or three weeks to become effective. Your doctor will want to obtain a medical evaluation before starting you on this type of drug. This evaluation should include a physical examination, a chest X ray, an electrocardiogram, a blood count, blood chemistry tests, and a urinalysis. The most commonly prescribed drugs are Parnate, Nardil, and Marplan. The dose ranges are given in Table 17-2. A common prescribing error is to give too big a dose too soon. Because these drugs sometimes tend to be stimulating, they can cause insomnia. In order to minimize this possibility, the entire dose can be taken once a day in the morning. The stimulating effects of the M.A.O. Inhibitors can be especially helpful to depressed individuals who often feel tired, lethargic, and unmotivated. They may provide some much needed go power.

Table 17 2.

-

Dose Ranges for M.A.O. Inhibitors

Trade Name

Chemical Name

Dose Range

Marplan

Isocarboxazid

10-30 mg per day

Nardil

Phenelyzine

15-75 mg per day

Parnate

Tranylcypromine

10-50 mg per day

The side effects are similar to those of the tricyclic drugs but are usually very mild: dry mouth, lightheadedness when standing suddenly, a delay in starting urination, or a rash. A loosening of the stool or constipation might occur. These side effects are not dangerous.

The M.A.O. Inhibitors can in rare cases produce some serious toxic effects if they are not used properly. The most dangerous is the elevation in blood pressure that may occur if you eat certain foods or take certain drugs that are forbidden (see Table 17-3, opposite page). For this reason your blood pressure must be checked by your therapist at each session, or you might want to obtain your own blood-pressure cuff and monitor it daily just to be on the safe side. The foods you must avoid contain a substance known as "tyramine," which might interfere with your brain's ability to regulate your blood pressure properly if you are taking an M.A.O. Inhibitor. If you watch your diet carefully, you should experience no adverse blood-pressure elevation.

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Table 17-3. Foods and Medications to Avoid If You Are Taking M.A.O. Inhibitors *

FOODS: Chocolate; cheese, especially strong or aged types; pickled herring; soy sauce; pods of broad beans (fava beans); canned figs; bananas or avocados; raisins; all types of liver; yeast or yeast extract; meat prepared with tenderizer; sour cream.

BEVERAGES: Wine (especially Chianti or red wines); beer or ale; alcohol. Caffeine should be used in moderation.

MEDICATIONS•: (1) tricyclic antidepressants; (2) cold tablets, decongestants, hay fever medicines; asthma inhalers; (3) stimu-lants such as UAW or amphetamines, which are occasionally prescribed for weight loss; (4) anticonvulsants. If you are taking medicines to control high blood pressure, a consultation between your psychiatrist and internist is advisable.

DANGEROUS SIDS EFFECTS: If you develop a sudden severe headache, nausea, stiff neck, dizziness, confusion, a fear of light or other unusual symptoms, obtain an emergency medical evaluation and make certain your blood pressure is not elevated. Insomnia or an extraordinary sudden euphoria is less dangerous, but also mandates immediate intervention and may require abrupt discontinuation of the medicine.

* If you have a seizure disorder, cheek with your neurologist before taking any antidepressant.

Lithium. In 1949 an Australian psychiatrist, John Cade, observed that lithium, a common salt, caused sedation in guinea pigs. He then gave this agent to a patient with manic symptoms and observed a dramatic calming effect which he then documented in other manic patients. Since that time, lithium has slowly caught on in popularity, although it is still more widely accepted and used in Europe than in the United States. It has two major uses.

1. The reversal of acute manic states;

2. The prevention of manic and depressive mood swings in individuals with the bipolar form of manic-depressive illness.

387

David D. Burns, M.D.

"Bipolar" simply means "two poles"—the patient experiences uncontrollable euphoric mood swings in addition to severe depressions. The manic phase is characterized by an extremely elevated, ecstatic mood, inappropriate degrees of self-confidence and grandiosity, constant talking, nonstop hyperactivity (rapid body movements), increased sexual activity, a decreased need for sleep, heightened irritability and aggressiveness, and self-destructive impulsive behavior such as reckless spending binges. This extraordinary disease usually develops into a chronic pattern of uncontrollable highs and lows, so a physician will frequently recommend that you continue to take lithium for the rest of your life.

If you have experienced abnormal mood elevations as well as depression, lithium should be the drug of first choice. The use of lithium in the treatment of recurrent depressions in the absence of manic mood swings is still at the research stage.

Recent findings suggest that if you have a family history of mania, you might benefit from lithium even if you have never been manic yourself.

Like the other drugs used for treating mood disorders, lithium usually requires between two and three weeks to become effective. When taken for a prolonged period of time, its clinical effectiveness seems to increase. Thus, if you take it for a period of years, it will probably help you more and more.

Lithium comes in 300-milligram dosages, and normally three to six pills per day in divided doses are required. Your physician will guide you. The dose must be carefully monitored by frequent blood testing, especially in the early phases of treatment, in order to maintain a proper blood level. If you get too much lithium in your blood, dangerous side effects can develop. In contrast, if your blood level is too low, the drug will not help you. Body size, kidney function, weather conditions, and other factors can influence your dose requirement, so the blood test should be performed on a regular basis when you are on lithium maintenance. Your blood must be drawn eight to twelve hours after your last lithium pill. The best time for the blood test is the first thing in the morning. If you forget and take your lithium pill the morning of the blood test, don't have the test! Try again another day.

Otherwise, the results will be misleading to your doctor.

Prior to treatment, the doctor will evaluate your medical 388

FEELING GOOD

condition and order a series of blood tests and a urinalysis.

Your thyroid functioning should be tested at yearly intervals while you are taking lithium, and your kidney function must be evaluated with a blood test at four-month intervals because of kidney abnormalities reported in some patients taking this agent.

The side effects of lithium are mildly uncomfortable but are usually not serious. Tiredness and fatigue might be experienced initially but will generally disappear, An upset stomach or diarrhea may occur in the first few days of treatment, but this too will usually disappear. Increased thirst, frequent urination, and a tremor of the hands are often experienced. An antitremor drug called propranalol can be given if the tremor is especially severe and troublesome, but it is my policy to avoid prescribing an additional drug if possible.

Some patients taking lithium complain of substantial weakness and fatigue. This may indicate an excessive lithium level, and a dose reduction may be indicated. Extreme sleepiness with mental confusion, a loss of coordination, or slurred speech suggests a dangerously elevated lithium level. Discontinue the drug and seek immediate medical attention if such symptoms appear.

L-tryptophan. This is the age of ecology. Scientists, like the general public, have wondered whether naturally occurring substances (such as vitamins, etc.) might play any role in the development of mood disorders or in their treatment.

In spite of the hullabaloo about "megavitamins" and other dietary fads, systematic research by top scientists around the world has shown that only one dietary substance has been consistently linked to depression. That substance is L-tryptophan.

L-tryptophan is one of the dietary building blocks that your body tissues use to manufacture proteins. Because your body cannot manufacture its own L-tryptophan, it must be ingested in the food you eat. Hence, it is called an "essential"

amino acid.

L-tryptophan is of great interest to psychiatric researchers because it is used by the brain to manufacture serotonin.

Serotonin is one of those amine transmitters that the nerves In your brain's emotional centers use to send messengers to

389

David D. Burns, M.D.

each other, If you do not have an adequate amount of L

tryptophan in your diet, brain serotonin levels fall, which may contribute to your depression.

Of particular interest are the recent findings of Drs. Ronald Fernstorm, Richard Wurtman, and others at the Massachusetts Institute of Technology (M.I.T.). They have proved that the level of serotonin in your brain is directly influenced by the amount of L-tryptophan in your diet. Thus, these scientists have at last confirmed in part what health-food people have been claiming for years—your gut partially controls your brain!

All this is very exciting, and one is tempted to propose a simple solution to clinical depression: Just add large doses of pure powdered L-tryptophan, and your brain would in turn manufacture more chemical messengers. Any presumed chemical "imbalance" should then be corrected, thus reversing your mood disorder. Sounds good! Does it work?

That's precisely what psychiatrists around the world, including our group at the University of Pennsylvania, have been trying to determine for the past several years. The results have been encouraging but inconsistent. While psychiatrists at some centers have reported moderate to marked antidepressant effects from L-tryptophan, in other studies, few if any beneficial effects were noted. Taken in the balance, the results of these studies so far seem to indicate: 1. L-tryptophan does have some antidepressant properties, but clearly only some patients will respond.

2. When it helps, the beneficial effects may be only partial.

Additional drug or psychotherapeutic treatment may be needed to eliminate the depression entirely.

3. L-tryptophan is a moderately effective and probably safe sedative which promotes restful sleep.

Where do you get L-tryptophan? Because it has been clas-sified by the Food and Drug Administration as a food additive and not as a drug, doctors in the United States are not yet allowed to prescribe L-tryptophan, although physicians in England can. If you choose to take it, you must therefore make this decision on your own. You can get it legally through health-food stores (extremely expensive), or through 390

FEELING GOOD

chemical-supply companies (less costly). If you decide to take it, be sure to get pure L-tryptophan, NOT D-L-trypto-phan The latter is less effective because it does not pass as easily into the brain.

How much should you take? The "correct" dosage has not yet been adequately determined, but research investigators have been giving depressed patients doses in the range of three to fifteen grams per day. That's a lot of L-tryptophan!

A normal diet contains about one gram. It would be wise to consult with your physician about the proper dose if you do decide to take L-tryptophan. Do not take any of it in con-junction with any other medicines, including antidepressants, unless your doctor is aware of it.

Is L-tryptophan dangerous? So far, no adverse effects have been reported in humans. In early studies when massive amounts were given to cows or rabbits, some toxic reactions were noted, but it is not felt at the present time that these findings are applicable to humans. In general, there is always some potential risk when any drug or agent is taken in large amounts—even aspirin and vitamins can kill if abused.

Unless the benefits of L-tryptophan or any other antidepressant are obvious and clear-cut, it would not be wise to continue ingesting it.

Other Drugs Your Doctor May Prescirbe. The four categories of antidepressants I have described are the only ones which in my opinion have a clear-cut indication in the treatment of depression. There are several types of drugs which you might want to avoid. Some doctors use minor tranquilizers or sedatives for nervousness and anxiety. I usually do not because they can be addictive, and the sedation they produce might make your depression worse.

Sleeping pills can be dangerous and are easily abused.

They usually begin to lose their effectiveness after only a few days of regular use, and then greater and greater doses may be required to put you to sleep. This can lead to a dangerous pattern of dependency and addiction. These pills disrupt your normal sleep pattern, and since severe insomnia is a withdrawal symptom, every time you try to give them up you will falsely conclude that you need them even more. Thus, they might greatly worsen your sleeping problem. In contrast, some of the more sedative tricyclic antidepressants (see Table 391

David D. Burns, M.D.

17-1, page 379) enhance sleep without requiring increased doses, and in my opinion represent a superior approach to treating insomnia in depressed individuals. If you feel you need a pill, taking L-tryptophan at bedtime may also be a good alternative, since it produces restful sleep and is not addictive.

How about the "pep pills," such as Ritalin and the amphetamines, which are commonly prescribed for weight loss?

It's true that in some people these drugs produce a temporary stimulation or elation (much like cocaine), but they are dangerously habit-forming. When you come down from the temporary high state, you will tend to crash and experience an even more profound sense of despair. When given chronically, the drugs can produce an aggressive, violent, paranoid reaction resembling schizophrenia. If your doctor or a friend recommends taking such pills, I suggest that you obtain a second opinion from a reliable physician pronto!

What about the so-called "major tranquilizers," such as Thorazine, Mellaril, Stelazine, Haldol, Prolixin, or Navane?

These agents are usually reserved for true schizophrenic reactions or for manic disorders. They do not play a major role in the treatment of most depressed or anxious patients. Only a minority of depressed individuals would benefit from those agents. These are people who are extremely agitated and cannot stop pacing, as well as older depressed patients who are paranoid and delusional. For most depressions the major tranquilizers may cause a worsening of the condition because of their tendency to cause sleepiness and fatigue.

The above review of drug-prescribing practices obviously represents my own approach. Your physician's ideas might differ somewhat. Psychiatry is still a blend of art and science, Perhaps some day the "art" will no longer be a prominent ingredient. If you feel uncertain about your treatment, ask your physician questions and urge him to explain his treat•

ment in simple terms you will understand. After all, you are the boss and he is your employee! It's your brain and body that are at risk, not his. As long as a rational, understandable, mutually acceptable strategy is developed for your therapy.

you will have an excellent chance of benefiting from your doctor's efforts.

Can Anyone Take an Antidepressant? Most people can, 392

FEELING GOOD

but competent medical supervision is a must. For example, special precautions are indicated if you have a history of epilepsy: heart, liver or kidney diseases; high blood pressure; or certain other disorders. For the very young and elderly, some medications should be avoided, and different dosages may be indicated. If you are taking medicines in addition to an antidepressant, special precautions are sometimes required.

Properly administered, an antidepressant is safe and may be lifesaving. But don't try to regulate it or administer it on your own; medical supervision is a must. Whether a pregnant woman should use an antidepressant requires collaboration between the psychiatrist and the obstetrician. Since fetal abnormalities might conceivably occur, the potential benefit, the severity of the depression, and the stage of pregnancy must all be taken into account. Other treatment approaches should be employed first, and an active self-help program of the type described in this book might entirely eliminate the need for any medication, thus giving optimal protection to the developing child.

Polypharmacy. The question sometimes comes up—why not use more than one psychiatric medication, thus receiving the benefits of several simultaneously? Although there are instances where certain combinations of drugs might be indicated, to take more than one antidepressant medication at a time is generally not advised. Pills that combine an antidepressant with a tranquilizer have been marketed and promoted, but clinical studies have not documented the efficacy of such preparations. In the great majority of cases, a single drug will be sufficient to accelerate your return to a normal mood. If a particular drug doesn't help, stop taking it after three or four weeks and try another. But don't complicate things by taking several medications simultaneously. Multiple drug treatment is confusing and usually unnecessary, and it can be dangerous. The exception would be a depressed patient who has received an adequate trial of several antidepressants one at a time from different chemical classes. In the absence of an adequate therapeutic response, your physician may then try combining antidepressants. An M.A.O. Inhibitor might be combined with a tricyclic or with lithium, or a tricyclic may be combined with lithium. This is an advanced form 393

David D. Burns, M.D.

of treatment for the specialist to administer, and requires careful teamwork between you and your doctor.

Integrating Cognitive and

Biochemical Theories

By this point you may be wondering why I am writing about drug treatment in a book that stresses self-help and personal growth through a modification of thinking and behavior.

It is true that we have successfully treated hundreds of severely depressed patients in our Mood Clinic with no medication whatsoever. But there are many others who have desired and received simultaneous treatment with drugs and cognitive therapy. They also did well. It may be that for certain types of depression, the addition of the proper antidepressant to help your treatment program might make you more amenable to a rational self-help program and greatly speed up the therapy. I can think of many depressed individuals who seemed to "see the light" with regard to their illogical, twisted negative thoughts more rapidly once they began taking an antidepressant. My own philosophy is: I'm in favor of any reasonably safe tool that will help you!

Our current research studies are designed to provide more information about the combination of drug treatment an:l cognitive self-help therapy. The preliminary data indicate that patients treated with cognitive therapy in addition to an antidepressant respond more favorably than those treated with an antidepressant alone. This confirms that pure "test-tube treatment" with drugs alone is not the total answer for many patients. Thus, there is a definite role for effective psychotherapy even in those individuals who benefit from drugs.

What types of depression are most likely to benefit from an antidepressant drug? Your chance of responding to an appropriate drug is enhanced:

1. If you are functionally impaired and unable to carry c,n with your day-to-day activities because of your depression.

2. If your depression is characterized by the more organiz

394

FEELING GOOD

symptoms such as insomnia, agitation, or retardation; a worsening of symptoms in the morning; and an inability to feel cheered up by positive events.

3. If your depression is severe.

4. If your depression had a reasonably clear-cut beginning, and if your symptoms are substantially different from the way you normally feel.

5. If you do not have a long history of another psychiatric disorder or hallucinations preceding your depression.

6. If you have a family history of depression.

7. If you have had a beneficial drug response in the past.

8. If you do not have a tendency to complain and to blame others.

9. If you do not have a history of an exaggerated sensitivity to drug side effects, or a history of multiple hypochondriacal complaints.

The above guidelines are of a general nature, and they are not intended to be comprehensive. Many exceptions occur, and our ability to predict a drug response ahead of time is still quite limited. We hope that the use of antidepressant drugs will become more precise and scientific in the future, just as the use of antibiotics has become.

A Cognitive Approach to Drug Therapy. Certain negative attitudes and irrational thoughts can interfere with proper drug treatment. I would like to expose several hurtful myths at this time. I believe that enlightened caution in taking any medication is well advised, but an excessively conservative attitude based on half-truths can be equally destructive.

MYTH NUMBER 1: "If I take this drug, I won't be my true self. I'll act strange and feel unusual." Nothing could be further from the truth. Although these drugs eliminate depression, they do not normally create abnormal mood elevations, and, except in very rare cases, they will not make you feel abnormal, strange, or "high." In fact, most patients report that they feel much more like themselves after they have begun to respond to an antidepressant medication.

MYTH NUMBER 2: "These drugs are extremely dangerous." Wrong. If you are receiving medical supervision and cooperate with your doctor, you will have no reason to fear 395

David D. Burns, M.D.

the drugs. Adverse reactions are rare and can usually be safely and effectively managed when you and your doctor work together as a team. The antidepressants are far safer than the depression itself. After all, the illness, if left untreated, can kill you—if you commit suicide!

M Y T H N U M B E R 3: "But the side effects will be intolerable." No, the side effects are mild and can usually be made barely noticeable by adjusting the dose properly. If in spite of this you find the medication uncomfortable, you can probably switch to another which will be equally effective with fewer side effects.

MYTH NUMBER 4: "But I'm bound to get out of control and use these drugs to commit suicide." These drugs d o have a lethal potential, but this need not be a problem if you discuss it openly with your physician. If you feel actively suicidal, it might be helpful to obtain only a few days' or one week's supply at a time. Then you will not be likely to have a lethal supply on hand. Remember that as the drug begins to work, you will feel less suicidal. You should see your therapist frequently and receive intensive therapy until any suicidal urges have passed.

M Y T H N U M B E R 5 : "I'll become hooked and addicted, lice the junkies on the street. If I ever try to go off the druz.

I'll fall apart again. I'll be stuck with a crutch forever."

Wrong again. Unlike sleeping pills, opiates, barbiturates, and minor tranquilizers, the addictive potential of antidepressants is quite low. Once the drug is working, you will n o t need tc take larger and larger doses to maintain the antidepressant ef-f e c t , and in most instances the depression will not return when you discontinue the drug. When it is time to go off the medicine, it would be advisable to do this gradually, tapering off over a week or two. This will minimize any discomfort that might occur from abruptly stopping the medicine, a n : 2

will help you nip any relapse in the bud before it becomes full-blown.

Some doctors are now advocating long-term maintenance therapy for certain patients. A prophylactic effect can ' r e achieved if you take a low dose of the antidepressant over a 396

FEELING GOOD

period of a year or more after you have recovered. That will minimize the probability of your depression returning. If you have had a significant problem with recurrences of depression over a period of years, this might be a wise step for you. At the lower doses used for maintenance, the side effects are usually negligible.

M Y T H N U M B E R 6: "I won't take any psychiatric drug because that would mean I was crazy." This thought is quite misleading. Antidepressants are given for depression, not for "

craziness." Antidepressants actually have no place in the treatment of insanity per se. Thus, if your doctor recommends an antidepressant, that would indicate he is convinced you have a mood problem and are not "crazy." However, it i s "crazy" to refuse an antidepressant on this basis because you may bring about greater misery and suffering for yourself. Paradoxically, you may feel "normal" quicker with the help of the medicine.

M Y T H N U M B E R 7 : "But other people are bound to look down on me if I take an antidepressant. They'll think I'm inferior." This fear is unrealistic. Other people will not know you're taking an antidepressant unless you tell them—there's no other way they could know. If you do tell someone, they're likely to feel relieved. If they care about you, they'll probably think m o r e of you because you're doing something to help eliminate your painful mood disorder.

Of course, it is possible that someone might question you about the advisability of taking a drug, or even criticize your decision. This will give you the golden opportunity to learn to cope with disapproval and criticism along the lines discussed in Chapter 6. Sooner or later, you're going to have to decide to believe in yourself and to stop giving in to the disabling terror that someone might or might not agree with something you do.

M Y T H N U M B E R 8 : " I t i s s h a m e f u l t o h a v e t o t a k e a p i l l .

I should be able to eliminate the depression on my own." In our research on mood disorders, we have found that most individuals c a n recover without pills if they engage in an active, structured, self-help program of the type outlined in this 397

David D. Burns, M.D.

book. However, we have also found that in some cases an antidepressant appears to provide some needed leverage that can facilitate your efforts to help yourself. In fact, some recent evidence indicates that antidepressants may actually help reduce negative thinking. Thus, these drugs could speed up your personal effort to modify your attitudes and help you change behavior patterns. Does it really make sense to mope and suffer endlessly, stubbornly insisting you must "do it on your own"? Obviously, you must do it yourself—with or without a pharmacological boost. An antidepressant may give you that little edge you need to begin to cape in a more productive manner, thus accelerating the natural healing process.

398

Suggested Reading

Beck, A. T., Rush, A. J., Shaw, B. F., and Emery, G. Cognitive Therapy of Depression. New York: Guilford Press, 1979. This book is intended for the professional counselor or therapist and lays out the actual course of treatment in a step-by-step progression.

Burns, D. D. "Nobody is Perfect." This tape describes common self-defeating thought patterns and explains how to replace them with rational thinking to help boost self-esteem, increase joy in life, and combat bad feelings such as depression, anger, anxiety and frustration. Available for $10.95 postpaid from Psychology Today cassette series, Tape #20268, Dept. A0720, P.O. Box 278, Pratt Station, Brooklyn, N.Y. 11205.

Burns, D. D. "Feeling Good About Yourself." This tape helps you identify perfectionistic tendencies and shows how they work against you. It explains how to stop setting unrealistically high standards as a means to help increase productivity, creativity and self-satisfaction. Available for $10.95 postpaid from Psychology Today cassette series, Tape #20269, Dept. A0720, P.O. Box 278, Pratt Station, Brooklyn, N.Y. 11205.

Ellis, A., and Harper, R. A. A New Guide to Rational Living. No. Hollywood: Wilshire Book Co., 1975. Published by arrangement with Prentice-Hall, Inc., Englewood Cliffs, N.J. A classic self-help book which describes the system of rational emotive psychotherapy which shows you how to solve emotional problems by modifying the thinking processes that create them.

Emery, G. A New Beginning. New York: Simon and Schuster, 1981. This book describes the principles of cognitive therapy and shows how they can be applied to the treatment of depression.

399

Index

A

Anger, 135-77

as adaptive, 148-49

A. E. Bennett Award for

cognitive therapy and, 138

Basic Psychiatric Research,

Freud on, 138

2

frustration and, 176-77

Accomplishments, self-esteem

internalized, 138

and, 288-91

irrational statements, 143-

advantages of, 288-89

45

disadvantages of, 289

labeling, 141-42

does work equal worth,

magnification, 143-44

291-98

as maladaptive, 148

Accurate empathy, 167-72

methods for reducing

Achievement

accurate empathy, 166-

DAS test score and, 251

72

worth and, 288-91

anger hierarchy, 172-73

advantages of, 288-90

cognitive rehearsal, 172—

75

disadvantages of, 289-

90

cooling hot thoughts,

does work equal worth,

151-54

291-98

developing the desire,

Achievement trap, 304-308

149-52

Action, motivation and, 114-

enlightened manipula-

15

tion, 160-63

Action, motivation and,

imaging techniques,

114-15

153-56

Active death wish, 340

learning to expect crazi-

Adapin, 379

ness, 158-60

Adaptive anger, 148-49

negotiating strategies,

Adler, Alfred, 11n

163-67

Adolescent rejection, 266-67

putting it all together,

Air-traffic controllers, 359

171-75

Alcohol, 290

rewriting the rules, 156-

All-or-nothing thinking, 31-

58

32, 40

"should" reduction,

Amine theory of depression,

163-64

377

Amine transmitters, 389

thought stoppage, 156

Amines, 376-77

mind reading, 142-43

Amitriptyline, 377

Novaco anger scale, 136-

Amphetamines, 290, 387,

38

398

as productive,147-49

403

David D. Burns, M.D.

ten things to know about,

side effects of, 383

175-77

switching to M.A.O. In-

thoughts and, 139-40

hibitors from, 384n,

Anger Cost-Benefit Analysis,

394

150

L-tryptophan,

380-81,

Anger hierarchy, 172-73

389-92

Angry rejection, 268

benefits of, 390

Anhedonia, 83

dosage prescribed, 390-

Antidepressant drug therapy,

91

9, 11-17, 354, 375-98

potential risk of, 391-92

cognitive therapy and, 12-

serotonin levels and,

18, 394-98

389-90

lithium, 26, 387-89, 393

where to obtain, 390-91

dosage prescribed, 388

Antidepressant drugs, 21,

effectiveness of, 388

354

major uses of, 386

addictive potential of,

side effects of, 389

396-97

M.A.O. Inhibitors, 378-81,

the brain and, 377-81

384, 385-86, 393

caution in prescribing, 393

dosage ranges for, 386

myths about, 394-98

foods and medications

pregnancy and, 393

to avoid when taking,

treatment of suicidal pa-

387

tients, 337-38

side effects of, 386

See also Lithium; M.A.O.

toxic effects of, 386

Inhibitors;

in treatment of atypical

Tricyclic compounds;

depression, 385

L-Tryptophan

tricyclic compounds and,

Antiheckler technique, 131

385, 386

Antiperfectionism Sheet,

myths about, 395-98

312-15

tricyclic compounds, 378,

Antiprocrastination Sheet,

379, 381-85

91-92

dosa2ge prescribed, 381- 8 Approval, 256-73

length of treatment with,

385

DAS test score and, 251

medical information on,

independence and self-re-

379

spect, 261-72

mood elevation resulting

cost-benefit analysis,

from, 384

261-62

response to, 384-85

disapproval, 266-72

recovering from disap-

404

FEELING GOOD

proval or rejection,

C

272

rejection, 266-72

Cade, John, 387

self-respect blueprint,

"Can't Lose" System, 112-13

262-64

Center for Cognitive Ther-

verbal techniques, 265-

apy, 11 n

66

Chemotherapy, 209

need for, 256-58

Coercion, 85, 105-106

origin of the problem,

Cognitive distortions, 180,

258-61

238, 345-46, 353

self-approval, 273

definitions of, 31-41

Archives of General Psychia-

of suicidal individuals,

try, 1

345-46, 353

Autonomy, DAS test score

Cognitive rehearsal, 172-75

and, 254-55

Cognitive therapy, 3-4, 54

Aventyl, 379

anger and, 138-39

Averageness, 310

antidepressant drug ther-

apy and, 13-14, 394-98

dialogue between client

B

and therapist, 360n

helplessness and, 368-71

Beck, Dr. Aaron T., 3-4, 9,

hostility and, 361-66

51, 52n, 104, 322, 337,

ingratitude and, 365-66,

362, 369

357

Beck Depression Inventory

mood-control techniques

(BDI), 20-27, 44, 63,

of, 10-11

223, 339, 343, 382, 384

origin of, 9-10

interpreting, 22-23

principles of, 11-12

Being alone

self-criticism versus self-

advantages of, 285

defense, 59-64, 65, 71,

loneliness and, 276-80

121, 218, 233

Black bile, 375, 377

treatment for depression,

Boosting self-esteem, 51-74

12-18

Brady, Dr. John Paul, 3

treatment of suicidal indi-

Brain, the

viduals, 337-38, 345-

antidepressant drugs and,

51, 352-54

377-81

uncertainty and, 368-71

the nervous system and,

Compulsive slowness, 316-17

377-78

Cooling hot thoughts, 151-

Brown, Helen Gurley, 294

52

But-Rebuttal Method, 98

Coping, 66-72

405

David D. Burns, M.D.

with criticism, 132

Dependency, 274

with helplessness, 368-71

need for love and, 274,

with hostility, 361-65

275-78, 286-87

with ingratitude, 365-66,

Depression

367

amine theory of, 376-77

with uncertainty,

antidepressant drug ther-

368-71

apy and, 13-17, 375-98

Cosmopolitan, 294

Criticism

antiheckler technique, 131

coping with, 132

the Beck Depression In-

fear of, 85

ventory (BDI), 19-27,

overcoming fear of, 119-

44, 63, 223, 339, 343,

23

382, 384

disarming the critics,

interpreting, 22-23

124-28

cognitive therapy as treat-

empathy, 123-25

ment for, 12-18

feedback, 128-31

effects of, 28

negotiation, 128-31

Freud on, 130

right criticism versus

hopelessness and, 341, 355

identifying silent assump-

wrong, 122

tions downward-arrow

method, 239

D

Dysfunctional Attitude

Scale, 241-55

Daily Activity Schedule, 87-

vertical-arrow tech-

90

nique, 235-41

Daily Record of Dysfunc-

mania and, 25-26

tional Thoughts, 63-64,

medical science's approach

90-95, 97, 154, 186-87

to, 354-55

Death wish, 340

National Institute of Men-

Defeating guilt, 186-204

tal Health on, 16

antiwhiner technique, 200

negative self-evaluation,

Daily Record of Dysfunc-

52-53

tional Thoughts, 186-87

negative thinking and,

developing perspective,

28-29, 45-46, 56

201-204

physical symptoms of, 375

learning to stick to your

prevalency of, 9

guns, 195-99

as product of mental slip-

Moorey moaner method,

page, 12

200-201

realistic, 209

"should" removal tech-

role of genetic factors in,

niques, 187-95

376

406

FEELING GOOD

sadness and, 207-208

guilt, 86

schizophrenia and, 55

hopelessness, 81-82

search for causes of,

jumping to conclusions, 82

375-76

low frustration tolerance,

self-dislike and, 51

85

sexual drive and, 56

overwhelming oneself, 78-

suicide and, 337

83

types of depression benefit-

perfectionism, 83

ing from antidepressant

resentment, 85

drugs, 395

self-activation methods,

willpower and, 75

86-118

See also Antidepressant

Antiprocrastination

drug therapy; Suicidal

Sheet, 90,91-92

individual

breaking down task into

Depression: Causes and

component parts, 103-

Treatment (Beck), 51,

105

337n.

But-Rebuttal Method, 98

Depression: Clinical, Experi-

"Can't Lose" System,

mental, & Theoretical As-

112-14

pects (Beck) 52n

counting what counts,

Desipramine, 379

110-12

Developing the desire for re-

Daily Activity Schedule,

venge, 148-51

87-90

Disapproval, 266-71

Daily Record of Dysfunc-

fear of, 85,256-58

tional Thoughts, 92-95

self-respect and, 266-71

disarming technique, 106-

recovering from, 271-

108

72

motivation without coer-

Disarming critics, 124-28

cion, 105-107

Disarming technique, 106-

Pleasure-Predicting

108

Sheet, 95-98

Disattribution, 202

testing your "can'ts,"

Disqualifying the positive,

112-13

33-.34,40

TIC-TOC Technique,

Do-nothingism, 74-118

101-103

coercion, 85

visualizing success, 108-

examples of, 76-77

10

1

fear of disapproval or crit-

self-blame, 86

icism, 85

self-labeling, 83

fear of failure, 83-84

undervaluing the rewards,

fear of success, 84-85

83

407

David D. Burns, M.D.

Dopamine, 376n

Doxepin, 379

Dyer, Dr. Wayne, 147

Dysfunctional Attitude Scale (

Facts, feelings and, 45-46

DAS), 241-55,262

Failure, fear of, 83-84

interpreting your score,

Fairness, relativity of, 145-

251-55

47

achievement, 251-52

Fear of criticism, 85

approval, 251

overcoming, 119-23

autonomy, 254-55

disarming the critic,

entitlement, 252-53

124-28

love, 251

empathy, 123-24

omnipotence, 253

feedback, 128-31

perfectionism, 252

negotiation, 128-31

scoring, 247-50

right criticism versus

Dysfunctional Thoughts,

wrong, 122

Daily Record of, 63-64,

Fear of disapproval, 85,

92-95,97,154,186-87

256-58

Fear of failure, 83-84

E

Fear of success, 84-85

Feedback, 128-31

Feelings, facts and, 45-46

Einstein, Albert, 145,147

Fernstorm, Dr. Ronald, 390

Elavil, 379

Electroconvulsive therapy

Fortune teller error, 35-36,

(ECT), 3

40

Ellis, Dr. Albert, 11n, 105

Freud, Sigmund, 52-54,130,

Emotional reasoning, 37,40,

138,178

73

Frustration, 176-77

Empathy, 123-24,185-86

accurate, 166-67

G

Empathy method, 269-70

Endep, 379

Goldstein, Dr. Mark K., 161

Endorsing yourself, 97-100

Gratification, 279-80 "

Enlightened manipulation,

Grieving" method, 272

160-64

Guilt, 86-87,178-204

Entitlement, DAS test score

cycle of, 182-83

and, 251-52

defeating, 186-204

andwhiner technique,

199-200

Daily Record of Dys-

408

FEELING GOOD

functional Thoughts,

I

186-87

developing perspective,

Illusions, 30-31

201-203

Imaging techniques, 153-56

learn to stick to your

Imanate, 379

guns, 195-99

Imipramine, 379,383

Moorey moaner meth-

Imipramine hydrochloride

od, 200-201

(Tofranil), 13,379

"should" removal tech-

Independence, 261-72

niques, 187-95

cost-benefit analysis, 261-

distortions causing, 179-

64

80

disapproval and, 266-72

inappropriate "should"

recovering from, 272

statements, 180-82

need for love and, 275-76,

irresponsibility of, 184-86

277,286-87

thoughts leading to, 178-

rejection and, 266-72

79

recovering from, 272

self-respect blueprint, 262-

65

H

verbal techniques, 265-66

Habit management, 109-10

Ingratitude, coping with,

365-66,367

Haidol, 392

Internal dialogue, 30

Happiness, success and, 290

Internalized anger, 138-39

Healthy sadness, 227

Irrational statements, 144-45

Helplessness, 82

Irritability Quotient, 135

coping with, 368-71

Heroin, 290

calculating, 137-38

High blood pressure, 376

Isocarboxazld, 380,386

Hippocrates, 375

Hitler, Adolf, 257,291

Hopelessness, 81-82

depression and, 341,355

Janitnine, 379

suicidal individuals and,

340-41,351,355-56

Jews, 257

Homey, Karen, 11

Job, loss of, 215-24

Hostility, coping with, 36165 Jumping to conclusions, 35, 40,82

Human worth scale, 211

409

David D. Burns, M.D.

L

presumed "advantages" of

being a, 277-78

Labeling, 38-39, 41, 142

Loved one, loss of, 224-27

Lazarus, Arnold, 11

Low frustration tolerance, 85

Learning to expect craziness,

158-60

M

Lethargy Cycle, 79-80

Life, loss of, 208-12

M.A.O. Inhibitors, 378-81,

malignant attitudes toward,

384, 385-86, 393

209

dosage ranges for, 386

Limb, loss of, 212-14

foods and medications to

distorted attitudes toward,

avoid when taking, 386

212-13

Lithium, 26, 380, 387-89,

side effects of, 386

393

toxic effects of, 386-87

dosage prescribed, 388

in treatment of atypical

effectiveness of, 388

depression, 385

major uses of, 387

tricyclic compounds and,

side effects of, 389

385, 386

Loneliness, being alone and,

Magnification, 37, 40, 143

376-80

Maintenance therapy, 385

Loss of job, 215-24

Maladaptive anger, 148

Loss of life, 209-12

Mania, 25-26 Manic-

malignant attitude toward,

depressive illness, bi-

209

polar form of, 387-88

Loss of limb, 212-15

Manipulative rejection, 268

distorted attitudes toward,

Manson, Charles, 257-58

212-14

Marplan, 378, 386

Loss of a loved one, 224-27

Marshall, E., 18n

Love

Massachusetts Institute of

DAS test score and, 251

Technology (M.I.T.), 390

need for, 274-87

Medical science approaches

attitude modification,

to

depressive illness,

284-87

354-55

dependency and, 274,

Megavitamins, 389

275-78, 286-87

Mellaril, 392

independence and, 275-

Mental filter, 33, 40

77, 286-87

Mid-life crisis, 351-54

Pleasure-Predicting

Mind reading, 35, 40,

Sheet, 280-84

142-43

Love junkie, analysis of the

Minimization, 37, 40

410

FEELING GOOD

Mislabeling, 38-39, 41

Negotiation, 128-31, 163-67

Monroe, Marilyn, 54

Nervous system, the brain

Mood Clinic (University of

and, 377-78

Pennsylvania), 2, 4, 10,

Neurochemistry, 375

11, 11n, 13, 361, 362, 394 Nihilism, 346

Mood swings, 234, 338, 349, Nondirective therapy, 57

387-88

Norepinephrine, 376n

Mood-control techniques of

Norpramin, 379

cognitive therapy, 11

Nortriptyline, 379

Moorey, Stirling, 200

Novaco, Dr. Raymond W.,

Moorey moaner method,

136n

200-201

Novaco anger scale, 136-38

Motivation

action and, 113-14

coercion and, 85, 105-107

0

Motivational paralysis, 79 "

Mourning and Melancholia"

Oedipal incestuous fantasies,

(Freud), 53-54

178

Musterhation, 38, 105

Omnipotence, DAS test score

and, 253-54

N

Operationalization, 298

Original sin, 178

Overcoming perfectionism,

Nardil, 380, 386

309-34

National Institute of Mental

Health, 16

absurdity of all-or-nothing

Navane, 392

thinking, 327

Need for love, 274-87

advantages and disad-

attitude modification, 284-

vantages, 310

87

Antiperfectionicrn, Sheet,

312-15

dependency and, 274, 275-

benefiting from failure,

78, 286-87

317-22

independence and, 275-

77, 286-87 Pleasure-

developing process orien-

Predicting Sheet,

tation, 322-24

280-84

focusing on happy memo-

Negative self-evaluation, 52-

ries, 331-32

53

focusing on positive side,

Negative thinking, 218

326-27

depression and, 28-29,

learning to make mistakes,

45-47, 55-56

325-26

411

David D. Burns, M.D.

learning from mistakes,

learning to make mis-

333-34

takes, 325-26

lowering one's standards,

learning from mistakes,

311-12,333

333-34

personal disclosure, 327-

lowering one's stan-

32

dards, 311,312,333

as a realistic goal, 314-15

personal disclosure,

Response-Prevention

327-32

Form, 317-18

as a realistic goal, 314-

the role of fear, 316

15 Response-

setting time limits on one's

Prevention

activities, 324-25

Form, 316-17

Overgeneralization, 32-33,

the role of fear,315-18

40

setting time limits on

Overwhelming yourself, 82

one's activities, 324-

25

Personal inadequacy, 51-52

P

Personali7atian, 39-41,180

Pertofrane, 379

Parnate, 378,386

Phenylyzine, 380,386

Passive death wish, 340

Philadelphia Veterans Ad-

Passive-aggressive type, 78

ministration Hospital, 2

Pep pills, 391-92

Physical handicaps, 212-15

Perfectionism, 83

Placebos, 383

DAS test score and, 251-

Pleasure-Predicting

Sheet,

52

95-98,280-81,307,308

overcoming, 309-34

Polypharmacy, 393-94

absurdity of all-or-noth-

Positive, the, disqualifying,

ing thinking, 327

33-34,40

advantages and disad-

Pregnancy, antidepressant

vantages, 310

drugs and, 393

Antiperfectionism Sheet,

Presanaine, 379

312-14

Prinz, Freddie, 54

benefiting from failure,

Procrastination, 37, 77-78,

318-22

81

developing process ori-

Productive anger, 147-48

entation, 322-24 Productivity scale, 211

focusing on happy Prolixin, 392

memories, 331-32

Propranalol, 389

focusing on positive

Protriptyline, 379

side, 327-28

Psychotherapy, 11,354

412

FEELING GOOD

"Psychotherapy Works, but

Revenge, developing desire

for Whom?" (Marshall),

for, 149-52

18n

Rewriting the rules, 156-58

Ritalin, 387,392

Rothko, Mark, 54

R

Rational responses (self-de-

S

fense), 218

Realistic depressions, 208

Sadness

Reasoning, emotional, 37,

depression and, 207-208

40,73

without suffering, 227-28

Reducing anger, methods of

Schizophrenia, 392

accurate empathy, 166-72

depression and, 55

anger hierarchy, 172-73

Science, 18n

cognitive rehearsal, 172-

Self-approval, 273

75

Self-blame, 86

cooling hot thoughts,

Self-criticism, 59-64, 65,71,

151-54

121,218,233

develop the desire, 149-51

Self-defeating behavior, 77-

enlightened manipulation,

79

160-63

Self-defense, 59-64, 65, 71,

imaging techniques, 153-

121,218,222

55

Self-dislike, 51

learn to expect craziness,

Self-esteem, 211,233-34

158-60

accomplishments and,

negotiating strategies, 163-

288-91

66

advantages of, 288-89

putting it all together,

disadvantages of, 289

172-75

does work equal worth,

rewrite the rules, 156-58

291-98

"should" reduction, 163

the achievement trap,

thought stoppage, 156

303-308

Rejection, 266-71

boosting, 51-74

recovering from, 271-72

four paths to, 299-303

Relativity of fairness, 145-47

Pleasure-Predicting Sheet,

Remorse, 178

305-308

Resentment, 85

specific methods for, 59-

Response prevention, 316

74

Response-Prevention Form,

Self-evaluation, negative, 52-

317

53

413

David D. Burns, M.D.

Self-labeling, 82-83

visualizing, 108-109

Self-respect, 261-72

Suicidal impulses, assessing,

blueprint for, 262-65

339-41

cost-benefit analysis, 261-

Suicidal individual

62

antidepressant drugs in

disapproval and, 266-71

treatment of, 337-38

recovering from, 271-

assessing impulses of, 339-

72

41

rejection and, 266-71

bleak outlook of, 338-39

recovering from, 271-

cognitive distortions of,

72

345-46, 353

verbal techniques, 265-66

cognitive therapy treat-

Sense of worthlessness, over-

ment of, 337-38, 345-

coming, 56-58

51, 352-54

Serotonin, 376n, 390

conviction of insoluble di-

Sexual drive, depression and,

lemmas, 351

56

degree of hopelessness of,

"Should" statements, 37-38,

340-41, 351, 355-56

40, 187-95

desire for self-mutilation,

Silent assumptions, 234

342-43

identifying

illogic of suicide, 342-51

downward-arrow tech-

mid-life crisis and, 351-54

nique, 237-41

nihilistic theory of, 346-50

Dysfunctional Attitude

Suicide, 224-29

Scale, 241-55, 261-

depression and, 337

62

illogic of, 342-52

vertical-arrow tech-

rate among general popu-

nique, 235-41

lation, 337

Sinequan, 379

unrealistic sense of hope-

Sk-Pramine, 379

lessness and, 339

Sleeping pills, 290, 391-92

youngsters and, 337

Slowness, compulsive, 315-

Superachievers, 290

17

Synapses, 378

Society of Biological Psychi-

atry, 2

Stanford University Medical

T

Center, 227

Stelazine, 392

Task-Interfering Cognitions (

Success

TICs), 101

fear of, 84-85

Task-Oriented Cognitions (

happiness and, 290

TOCs), 101

414

FEELING GOOD

Ten Commandments, 145-46

U.S. Food and Drug Admin-

Testing your "can'ts," 112-

istration, 390

13

University of California (Irv-

Thorazine, 392

ine), 136n

Thought stoppage, 156

University of Pennsylvania

TIC-1'0C Technique, 101-

School of Medicine, 2, 9,

103

10, 215, 343, 390

Tofranil (imipramine hydro-

chloride), 13, 379

V

Tranquilizers, 9, 392

Tranylcypromine, 378, 386

Vertical-arrow technique for

Tricyclic compounds, 378,

379, 381-85

identifying silent assump-

dosage prescribed, 381-82

tions, 235-41, 262

length of treatment with,

Visualizing success, 108-109

385

Vivactil, 379

medical information on,

379

W

mood elevation resulting

from, 384

Weekend/holiday blues, 89-

response to, 384-85

90

side effects of, 383-84

Weissman, Dr. Arlene, 241-

switching to M.A.O. Inhi-

46

bitors from, 384n, 393

Weissman, Dr. Myrna, 1

D-L-Tryptophan, 390-91

Willpower, depression and,

L-Tryptophan, 380-81, 389-

75

91

Work, worth and, 291-98

benefits of, 390

Workaholics, 289

dosage prescribed, 390-91

Worth

potential risk of, 391-92

achievement and, 288-91

serotonin levels and, 389-

advantages of, 288-90

90

disadvantages of, 289

where to obtain, 390

Tyramine, 386

four paths to self-worth,

303-308

U

as only a concept, 300-

302

Uncertainty, coping with,

Pleasure-Predicting Sheet,

368-71

307, 308

Undervaluing rewards, 83

work and, 291-98

415

David D. Burns, M.D.

Worthless as a concept, 300-

Y

302

Worthlessness, sense of over-

Yale University School of

coming, 56-58

Medicine, 1

Wurtman, Dr. Richard, 389

Youngsters, suicide and, 337

Your Erroneous Zones (

Dyer), 147n

416

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