A Critique of the Book Feeling Good :
In the book Feeling Good, David Burns MD - the author – outlines certain cognitive techniques an individual suffering from depression could use in combating the disorder. He begins the book by briefly describing the pertinence and the prevalence of depression. The author captures the audience's attention in the first paragraph - In fact depression is so widespread it is considered the common cold of psychiatric disturbances. Burns (1992) continues to suggest that the difference between the common cold and depression lies in the fact that depression is lethal. Irwing and Barbara Serason (1996) suggest that at least 90 percent of all suicide victims suffer from a diagnosable psychiatric disorder at the time of their death.
Irwing and Barbara Serason (1996) also state that one of the risk factors in committing suicide is the presence of mood disorder. Silverman (1993) states that suicide among young people 15 to 19 years of age has increased by 30 percent from the years 1980 to 1990.
In my opinion David Burns brings up a valid issue in addressing the pertinence of depression as it pertains to peoples tendencies of committing a suicide; other academics have agreed with the same findings.
However these academics have not specifically stated that depression is the only risk factor of committing a suicide. They did not even suggest that depression is the highest weighted risk factor in committing a suicide. The impression the reader gets after reading the introductory paragraph of the Feeling Good book is that severe depression will inevitably result in suicide unless it is cured. Implying that if a person has a depressive disorder, it will lead to a suicide can be dangerous and counterproductive for a person who already feels hopeless. This may reaffirm their belief of hopelessness and the inevitability of the disorder.
Once the first paragraph is passed the author indicates that there is hope in curing depression, giving the reader an encouragement to continue with the book.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), mood disorders are classified into two broad categories - bipolar and unipolar depressive disorders. The book Feeling Good only talks about the unipolar depressive disorders, thus, I will only concentrate on that one category. Unipolar mood disorders are classified under axis I of the DSM-IV. Unipolar depressive disorders are further classified into two categories: dysthymic, and major depressive disorder. Even though both of the disorders are mood disorders they have some fundamental differences and similarities. According to DSM-IV people experiencing major depression must have depressed moods and/or diminished interest for at least two weeks, for most of the day and for most days than not. They must also experience four additional symptoms, such as weigh loss or gain, insomnia or hypersomnia, psychomotor retardation or agitation, feelings of worthlessness, feelings of hopelessness, low self-esteem, difficulty concentrating, or suicidal thoughts. This is an acute and usually recurrent disorder. Around 50 percent of people who experience one major depressive episode will experience another in the course of their life.
Dysthymic disorder is similar to major depressive disorder in that people experiencing the disorder go through periods of depressed moods.
However, intensity, and duration of such moods are one among many differences between the two disorders. Dysthymic disorder is a chronic disorder lasting, on average, five years. In order to be diagnosed with the disorder one has to feel depressed for most of the day, most days than not for at least two years. The person experiencing this disorder also has to have two of the symptoms mentioned in the section that described major depressive disorder. Due to its chronic nature, dysthymic disorder is sometimes difficult to distinguish from a personality disorder.
Feeling Good does not clearly identify the categories of unipolar disorders. It groups them together into one category called depression. The danger of this is in the reader's perception of what condition they may have. For example, a person who is expressing a major depressive episode and is incapacitated may not have the energy or concentration to employ some of the cognitive techniques outlined in this book. This person may however benefit more from of an Electroconvulsive treatment (ECT) which is not outlined in this book. The readers are not informed of all the options they have to treat the disorder they are experiencing.
Rush and Weissemburger (1994) suggest that ECT is very effective in treatment of the major depressive disorders. Research indicates that in 80 to 90 percent of patients experiencing a major depressive episode, ECT is effective. However this treatment is shown not to be effective in treatment of milder forms of depressive disorders such as dysthymia.
David Burns' neglect to classify the two separate disorders into distinct categories does not allow him to identify ECT as a successful option in treating major depression.
The author however discusses some alternative options in the treatment of depression. He describes one study that was done at the University of Pennsylvania school of Medicine. Doctors John Rush and Aaron Beck and some other specialists were involved in the study which compared the effectiveness of cognitive therapy and pharmacological treatment of depression. Individuals suffering from major depression were randomly assigned to two groups. One group received individual cognitive psychotherapy while the other group was treated with a tricyclic antidepressant drug called Tofralin. Both groups were treated for twelve weeks before the symptoms were re-evaluated. The results showed that cognitive therapy was superior to the pharmacological treatment in almost all of the conditions measured (number of people recovered completely, number of people who recovered considerably but still experiencing borderline to mild depression, number of people who did not substantially improve, number of people who dropped out of treatment). The empirical findings indicated that fifteen out of nineteen people who were treated with the cognitive therapy completely recovered. Only five out of twenty five people treated with antidepressants completely recovered. The only category where pharmacological treatment was superior was the category that measures the number of people who recovered considerably but are still experiencing border line to mild depression. Only two individuals recovered partially under the cognitive treatment, where 7 people recovered partially under the pharmacological treatment.
Similar research was done in 1992 by the National Institute of Mental Health (NIMH), NIMH did not find significant difference between the two therapies immediately after the treatments. They however did find in a 24 month follow up study that patients who were treated with cognitive therapy were much less likely to have the disorder return than the patients who were treated with antidepressants.
Even though cognitive therapy seemed to have been superior in both studies, the findings from the two studies were not corroborative. The study David Burns describes in order to support cognitive therapy indicated that significantly more patients recovered in cognitive therapy than in pharmacological therapy immediately after the twelve week treatment. NIMH study found no significant difference between the two treatments immediately following the therapy. The reasons the two studies came up with different results may be numerous. It is impossible to conclude which one of the two studies is more valid. However both studies have experimentally demonstrated that cognitive therapy is a superior form of treatment whether immediately following the therapy or after 24 month follow up period.
In order to make a stronger point about the superiority of cognitive therapy, David Burns could have offered at least one more experiment that corroborated the results. In addition the methodology of the experiment he illustrated has some obvious flaws. The group sizes of the two compared conditions (Cognitive therapy and Pharmacological therapy) were not equal. The cognitive therapy group had 19 individuals where the drug therapy group had 25 individuals. In calculating the significant difference between the two group means, using the t-test would require the groups to be of equal sizes. Therefore, due to the group size inequality, the results may have been interpreted more liberally than if the group sizes were the same. On the other hand having a smaller degree of freedom in the cognitive therapy group required a greater t score in order to infer significance. As a result it is difficult to conclude whether the methodology of the experiment had anything to do with the significance of the results. However, if the study is to be replicated, it would be beneficial to keep the sample sizes the same. This would make the study stronger, and results more interpretable.
The author of this book has been greatly influenced by the theories and studies of Aaron Beck MD. Specifically, the author has based the theoretical part of the book on Beck's cognitive distortion model. This model postulates that depression is best described as a cognitive triad of negative thoughts (Saranson & Saranson 1996). Beck suggests that a person who is depressed focuses on negative thoughts, interprets situations in a negative way, and is pessimistic and hopeless about the future. In other words people who are depressed might blame themselves for their actions in the past and continue to believe that the future is just as gloomy. Beck also believes that any misfortune that happens to a depressed person is internalized and attributed to their own character.
These internal and stable interpretations of negative events leaves the person feeling hopeless and in turn depressed. On the other hand, according to Beck's theory, any positive events in the depressed person life are externalized or considered to be lucky. In a sense, such people may feel that only bad things happen to them and that if anything good does happen it is due to a circumstance that is beyond their control. However, people who are not depressed tend to do the opposite. They blame the situation for anything bad in their life and accept full responsibility for the positive aspects of their life. Beck describes the above as the attribution model of depression. David Burns summarizes this theory in a way that is very easy to follow and conceptualize. He identifies the process that is going on in the depressed person/s mind as the process of cognitive distortions. He identifies the ten most common cognitive distortions. Most of them are self-explanatory therefore I will name all of them and only elaborate on some. The first cognitive distortion mentioned is All or Nothing Thinking, a tendency to evaluate personal qualities in black or white categories. Second is Overgeneralization. Third is a Mental Filter which is a way of picking out a negative part of a situation and thus assuming that the situation as a whole is negative. Forth is Disqualifying the Positive. Fifth is Jumping to Conclusions. Sixth is Magnification and Minimization which is the way a depressed person magnifies the bad elements of their life and minimizes the good. The seventh cognitive distortion mentioned in the book is Emotional Reasoning which is interpreting emotions as proof of how bad the situation is ( i.e., I feel stupid, therefore I am stupid). Eight is Should Statements. Ninth is Labeling and Mislabeling, a way of creating a negative self-image based on the errors of the person's errors. The last cognitive distortion David Burns mentions is Personalization which is assuming responsibility for negative events even though there is no basis for doing so.
Once the author identified and explained the cognitive distortions, he then attempts to illustrate how they are used in everyday life which makes the book much more relevant to the reader. This is one of the crucial differences between academic writing and self-help books such as Feeling Good. The reader automatically understands the relevance of the theory and feels compelled to apply it.
The strength of the cognitive theory of depression is that it concentrates on the obvious problem at hand. The person who is depressed often does not have the energy or will to search deeper than the problem that is facing them. Therefore, this theory seems very useful especially in its ability to raise motivation in patients. Patients usually understand the thoughts and resulting feelings more clearly as a result of this approach. However the cognitive theory of depression does not break the surface of the problem. The theory does not go deep enough into the wound (in order to try to conceptualize and fix the root of the problem). The psychodynamic approach is far superior to the cognitive approach when the nature of the problem is deeply rooted and stems from the person's childhood. If the patient who is experiencing depression has an unresolved conflict inside their psyche, the depression may recur if such conflict is not addressed. Unfortunately the original idea behind the cognitive theory would not support that. Fortunately some cognitive therapists, such as Beck, have recognized the importance of this issue and have appropriately reconstructed the clinical application of the cognitive theory so that provisions for such deep-rooted problems are made.
David Burns implements the cognitive theory of depression by suggesting some simple to use self-help techniques. These techniques are similar to some of the therapeutic approaches clinicians use in cognitive therapy. For example, a clinician may try to coach the person who is depressed to identify some automatic thought that leaves them feeling depressed, and substitute it with thoughts that evaluate the situation more realistically. David Burns implements this approach in a similar way. He first identifies the importance of gaining self-esteem in order to deal with depression. Burns presents some cases where he first identifies what the patient is saying about themselves, and then challenges their statements. This shows the patient how unrealistic their negative self-evaluations are and in turn boosts their self-image from hopeless to somewhat hopeful. The second step was to help the patient overcome their sense of worthlessness. This was done in a way that the patient is encouraged to identify thoughts that lead them to feel depressed. This approach is concurrent with other cognitive therapists' approaches. The cognitive therapist reasons with the person, encouraging them to understand why these thought are distorted and finally help them to implement more realistic self-evaluatory statements. As a result, the approach of combating distorted thoughts by talking back and implementing more realistic thoughts corroborates David Burns' therapy with other cognitively oriented clinicians.
This book seems to be very effective in identifying some common thoughts and feelings depressed people might experience. As such, this book would be very appealing to people experiencing depressed moods as well as anyone who feels hopeless about their day-today life. The author describes everyday feelings and thoughts in a way that is very comprehensive. The reader is left with the encouraging impression that their feelings are common and curable. However, for a person experiencing clinical depression, this book may present a false sense of hopefulness. The reader who is in this predicament may solely rely on this book and this failing at implementing the techniques suggested by the author. The therapeutic techniques suggested are best utilized under the supervision of a clinician. The author does not encourage the person to get help beyond this book. Therefore, the therapeutic techniques illustrated in this book are left to be interpreted by the patient.
This might be dangerous if the depressed person is in a frame of mind where he or she is hanging on any breath of hope put forth. In short, the book itself may not completely accomplish its purpose; which may bring the patient back to their original state if not leave them feeling even more hopeless about their future.
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