Inspired by his mentor, Dr. Aaron T. Beck, the father of cognitive therapy and a leading researcher in psychopathology, Dr. David D. Burns authored his seminal book on cognitive behavior therapy (CBT) in 1980 . A revised edition was authored in 2000. Cognitive behavioral therapy, abbreviated CBT, is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of psychological disorders notably depression, and that associated symptoms and distress can be reduced by teaching new information-processing skills and coping mechanisms. The diagram below shows the relation of thoughts emotions or feelings, and behaviors. The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT' tenet that a person’s core beliefs can be summed up in three categories: self, others, future.
This problem-focused and action-oriented mode of therapy which has been most notably used to treat depression, focuses the therapist in finding and practicing effective strategies to address identified goals to decrease symptoms of the disorder. It differs from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors and then formulates a diagnosis.
Written in 7 parts in the original edition, the book Feeling Good, is a must read for patients and health providers. The book starts by asserting that mildly and moderately affected older adults with depression self-assessed by the Beck Depression Inventory (BDI), and who participated in CBT by simply reading of the book, Feeling Good, a study method called bibliotherapy, did better than depressed subject controls who did not read the book.
Part I, entitled, Theory and Research, introduces readers to the concept of CBT.
Chapter 1: CBT is premised on the view that moods are created by your cognitions or thoughts. There are three assumptions therein: 1) you feel the way you do right now because of the thoughts you are thinking; 2) when you are feeling depressed your thoughts are dominated by the pervasive negativity; and 3) negative thoughts contain gross distortions.
Chapter 2: A deeper understanding of one’s moods can be reached by classifying an individual’s cognitive distortions into one of 10 types. They include: 1) all-or-nothing thinking that refers to the tendency to evaluate personal qualities in stark terms; 2) overgeneralization that suggests bad things will happen over and over again; 3) mental filtering that picks out and dwells on a negative detail in any situation; 4) disqualifying positive experiences in rejecting positive experiences by insisting that they don’t count; 5) jumping to conclusions especially in making a negative interpretation of a situation; 6) magnification or catastrophizing events out of proportion; 7) faulty emotional reasoning that translates negative feelings into a prophesized reality; 8) overuse of should statements to self-motivate; 9) labelling and mislabeling events, especially ones that color a negative self-image based on errors of assumption; and 10) personalization, in which an individual assumes responsibility for a negative event when there is little or no basis for doing so.
Chapter 3: One or more of these 10 cognitive distortions account for the disturbed mood. Ergo, you feel the way your think.
Part II, entitled, Practical Applications, respectively deals with building self-esteem, beating procrastination, talking back to criticism, preventing anger, and defeating guilt.
Chapter 4: Individuals with impaired thought processing will have self-esteem issues, wherein a trivial mistake or an imperfection may be magnified into an overwhelming symbol of personal defeat. Overcoming a sense of worthlessness is accomplished by targeting negative thoughts, writing each of them down, and equating them to the list of 10 cognitive distortions. By substituting a rationale statement of self-defense, it is possible to recognize self-defeating thoughts as they arise, understand each as a thought distortion, and talk back to them, disarming the internal critic that dwells in your mind.
Chapter 5: Procrastination, like self-esteem, in another destructive aspect of depression. It leads to lethargy by accumulating self-defeating painful thoughts the unpleasant consequences of which make your problems seem all the worse, and leads to one or more negative mindsets: hopelessness, helplessness, overwhelming emotions, jumping to conclusions, self-labeling, undervaluing of rewards, perfectionism, fears of failure and success, disapproval, resentment, and a low frustration tolerance. Among the many available, self-activation technique that effectively deal with procrastination, a Daily Activity Schedule, Anti-Procrastination Sheet, or a Daily Record of Dysfunction Thoughts, will provide eventual relief. The method of But-Rebuttals, using zigzag arrows to trace your thinking pattern as you debate an issue in your mind; and the TIC-TOC technique that places task-interfering cognitions (TIC) in the left-hand column and task-oriented cognitions (TOC) in the right hand column, will both lead to immediate relief of procrastination by changing thought distortions. Getting involved in a task (action) and becoming highly motivated, leads to more action and thus alleviation of procrastination.
Chapter 6: So called, verbal judo, or learning to talk back to criticism, may seem like a dreaded task if you have never learned a technique that does so. Overcoming self-criticism and the remarks of others are both important because it acknowledges the axiom that only one person in this world has the power to put you down, and you are that person. Effectively dealing with an external critic involves two simple steps that include empathy and disarming by finding common ground with your critic. You might think of this as winning by avoiding battle, but as the critic calms down, he or she will be in a better mood to communicate effectively with you. Coping with critics can lead to a variety of responses that either tear down or build up self-esteem, such as: “I’m no good”, “You’re no good retaliation” or “Here’s a chance to learn something”, depending upon how you feel about the situation, respectively sad, mad or glad. Thus, your behavior and outcome will be greatly influenced by your mental state.
Chapter 7: An irritability quotient (IQ), is a useful measure that can be ascertained by a simple rating scale. By using the technique of Cognitive Rehearsal, and listing the situations least to most upsetting, it is possible to rehearse and extinguish detrimental thought responses and resulting maladaptive behaviors.
Chapter 8: The sense of self-badness is central to guilt. Remorse differs from guilt because it relates to undistorted awareness of a hurtful or regrettable act. Remorse or regret are aimed at external behaviors, while guilt targets the self. Guilt leads to depression, shame and anxiety. The simple solution to dealing with guilt is to assess whether the feelings created by such thoughts are useful or destructive and whether they contain any of the 10 cognitive distortions. To the extent that these thinking errors are present, then guilt, anxiety, depression or shame certainly cannot be valid or realistic consequences.
Part III, entitled, Realistic Depressions, differentiates depression from sadness.
Chapter 9: Among a list of possible realistic problems that beset an individual (bankruptcy, old age, physical disabilities, terminal illness, and loss of a loved one), none should cause frank depression. The distinction is that sadness is a normal emotion created by realistic perceptions that are appropriate to a negative event involving undistorted feelings of loss or disappointment, whereas depression results from distorted thought patterns. When depression clearly appears after an obvious stress however such as illness, death of a loved one, or a business failure, it may be termed reactive. in comparison to that which occurs with inordinately minor or absent stressors. In both cases, the cause of depression is distorted negative thoughts, without adaptive or positive function, and its only redeeming value is the growth that one experiences when recovering from it.
Part IV, is entitled, Prevention and Personal Growth.
Chapter 10: When depression has successfully vanished, it is tempting to enjoy improved thoughts and mood. Some patient relate that it’s the best that they have ever felt. It may be associated with an unbelievable transformation or even magical metamorphosis. There is a difference between feeling better and being cured. It is necessary to take stock and determine why you got depressed, how and why you got better, and unearth any valid triggers to prevent recurrences and assure full recovery. Coupled with active psychiatric care, the great contribution of CBT has been the circumvention of long and often painstaking psychoanalysis that takes years, after which most patients find it difficult to explain the cause of their depression. Notwithstanding, while negative automatic thoughts or even positive attenuated symptoms of deep depression may be dramatically reduced after CBT, the persistence of a self-defeating belief system may remain, during and in-between episodes of depression in persons predisposed to mood disorders. The Dysfunctional Attitude Scale registers one’s personal philosophy profile, demonstrating where attitudes cluster in the broad categories of approval, love, achievement, perfectionism, entitlement, omnipotence, and autonomy. The ranked responses of a given individual with a mood disturbance to attitudinal statements may be a useful predictor of ongoing or lingering emotional instability.
Part V is entitled, Defeating Hopelessness and Suicide.
Chapter 15: This chapter discusses the important topic of suicide. With reportedly one-third of mildly depressed adult patients, and up to three-quarters of severe depressed people expressing suicide wishes according to Dr. Aaron Beck up to 5% of depressed individuals overall take their lives by suicide, accounting for the inordinately high rate of suicide, and the roughly 25-fold rate of suicide in depressed patients compared to the general population. Suicide rates have been rising in nearly every state across the United States according to the latest Vital Signs report by the Centers for Disease Control and Prevention (CDC). In 2016, nearly 45,000 Americans age 10 or older died by suicide. Suicide is the 10th leading cause of death and is on the rise. Anyone who is depressed and contemplating suicide should seek professional guidance right away, especially if there is severe depression and hopelessness, past history of suicidal attempts, concrete plans and preparation underway, or a lack of obvious deterrents holding back the suicidal attempt. Depressed patients should never be accorded the right to suicide no matter the chronicity or severity of the mental illness since there are always disturbed thoughts and illogical reasoning for its contemplation. While it would be naïve to say that all depressed and suicidal individuals cannot suffer real problems justifying its contemplation, such difficulties should be dealt with in an insightful manner. As real problems rarely if ever lead to frank depression, and distorted thoughts themselves can take away valid hope and self-esteem, a person contemplating suicide should be guided back to reality by exposing the illogical thinking that lurks behind the suicidal impulse. Moreover, meeting these challenges can be a source of mood elevation and personal growth.
Researchers have recently addressed the gap in evaluating youths with self-harm presentations that constitute a high-risk group for both fatal and nonfatal suicide attempts. Safe Alternatives for Teens and Youths (SAFETY) is a cognitive-behavioral mode of individual and family treatment designed to promote safety from suicide attempts. One 2016 randomized controlled clinical trial (RCT) of youth suicide attempts, SAFETY treatment, reported a reduction of the probability of a suicide attempt to 0.33 (i.e., lengthened the suicide-free survival time) at 3-months follow-up; with treatment of approximately three youths with SAFETY correlating with the prevention of one suicide attempt. Adolescence is a period when youths’ focus shifts to peers, while brain regions in areas responsible for planning and inhibitory control are still developing. Thus, parents and other adults will play key protective roles in restricting access to dangerous methods or means of suicide, and in providing protective monitoring and support (like seatbelts) when adolescents experience intense emotional distress and suicidal urges.
*1 Burns, DD. Feeling Good. The New Mood Therapy. William Morrow and Company, New York, 1980.
*2 Burns, DD. Feeling Good. The New Mood Therapy. HaperCollins, New York, 2000.
*3 Scogin F, Jamison C, Gochneaut K. The comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting and Clinical Psychology 1989; 57:403-407.
*4 Scogin F, Jamison C, Davis N. A two-year follow-up of the effects of bibliotherapy for depressed older adults. Journal of Consulting and Clinical Psychology 1990; 58:665-667.
*5 Jamison C, Scogin F. Outcome of cognitive bibliotherapy with depressed adults. Journal of Consulting and Clinical Psychology 1995; 63:644-650.
*6 Beck At. Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1972, pp. 30-31.