I've never had any "real" mental health problems, but sometimes I feel stressed or guilty or whatever, like everyone, and who doesn’t want to feel more good more often? So a couple months ago I read Feeling Great: The Revolutionary New Treatment for Depression and Anxiety by David Burns (published 2020) on audiobook. I was really glad I did!
I can't comment on how it compares to other psychotherapy books. It's the first one I've ever read, and I kinda came upon it randomly—an acquaintance recommended David Burns's podcast, so I listened to a couple random episodes, and I found them intriguing but confusingly out-of-context, so instead I bought his book which was much better.
But for what it's worth, David Burns's older 1980 book, Feeling Good, is super famous and popular, and apparently there are studies that say that giving people a copy of Feeling Good is as effective as antidepressants, with effects that persist for years (ref). (More discussion on wikipedia.) Also, I just saw that Scott Alexander suggested Feeling Great for people with depression. So of all the psychotherapy books to randomly stumble across, I think I got a pretty legit one!!
I'm not going to talk about everything in the book in this review; I just want to flag a few parts that were highlights for me.
I also couldn't resist throwing in some speculations on the neuroscience of depression at the bottom.
David Burns is, I gather, something of a leader in Cognitive-Behavioral Therapy (CBT). What is CBT? My vague pop-culture stereotyped impression of CBT has been something like:
I haven’t read David Burns’s more famous older book Feeling Good, but my vague impression is that it’s largely about that kind of stuff, and in particular, that it’s full of lots of different techniques for questioning and countering negative thoughts and feelings.
This new book reprises and (he says) somewhat improves on that material. I found that part somewhat but not terribly helpful to me personally, mainly because I do that part instinctively, at least to some extent. I'm a very analytical guy, I think I'm pretty well aware of which of my negative thoughts are literally true and which ones aren't, and several of his suggested techniques were things I’ve been doing naturally since forever (although others were new to me). I may still refer back to that part of the book at some point, but the best part for me was something else…
Compared to previous work (like Feeling Good), Burns adds a big new thing, which he says makes a huge difference in getting through to his patients who used to remain stuck no matter how many negative-thought-countering techniques he would throw at them. He says that he can now reliably have his patients walk out of their very first extended (~2-hour) therapy sessions feeling dramatically happier, maybe even dancing-on-the-sidewalk happy, even if they’ve spent the previous 20 years suffering treatment-resistant depression and anxiety. That’s a pretty bold claim, but I guess I'm inclined to believe it, because apparently he does exactly that all the time in front of live audiences, and you can even listen to numerous live sessions of that type on his podcast. Sure, maybe he only broadcasts the best sessions, or maybe he's lying, whatever, I don't really know, I'm just inclined to believe him right now. I think the peer-reviewed studies using this new technique are still underway.
So what’s this big new thing? He has a shtick that he goes through every time. I’ll just excerpt it.
Example "Magic Button, Positive Reframing, Magic Dial" shtick:
Next I asked Maria the miracle cure question: If a miracle happened in today’s session, what miracle would she be hoping for? She said she wanted her negative thoughts and feelings to disappear so she could enjoy her baby daughter and her role as a new mother without feeling miserable all the time.I asked her to imagine that we had a magic button and that if she pushed it, all of her negative thoughts and feelings would instantly disappear, with no effort at all, and she’d immediately feel joyous, even euphoric. Would she push the button?Maria said she’d definitely push the button. Almost everyone says that!I told Maria that I didn’t have a magic button, but I did have some awesome tools, and I predicted that if we used them, she’d probably feel a whole lot better by the end of the session and might even feel joyful. But I told her I wasn’t so sure it would be a good idea to use those tools.She was surprised and asked why not. I explained that although her negative thoughts and feelings were certainly creating a lot of pain for her, I suspected there might be some real advantages, or benefits, of thinking and feeling the way she did. I added that her negative thoughts and feelings might also be an expression of her most beautiful and awesome qualities, and that maybe we should take a look at that before we went about trying to change things.I suggested we could ask the following questions about each negative thought or feeling before she made any decision about pressing the magic button:1. What are some benefits, or advantages, of this negative thought or feeling? How might it be helping you and your baby?2. What does this negative thought or feeling show about you and your core values that’s positive and awesome?
Next I asked Maria the miracle cure question: If a miracle happened in today’s session, what miracle would she be hoping for? She said she wanted her negative thoughts and feelings to disappear so she could enjoy her baby daughter and her role as a new mother without feeling miserable all the time.
I asked her to imagine that we had a magic button and that if she pushed it, all of her negative thoughts and feelings would instantly disappear, with no effort at all, and she’d immediately feel joyous, even euphoric. Would she push the button?
Maria said she’d definitely push the button. Almost everyone says that!
I told Maria that I didn’t have a magic button, but I did have some awesome tools, and I predicted that if we used them, she’d probably feel a whole lot better by the end of the session and might even feel joyful. But I told her I wasn’t so sure it would be a good idea to use those tools.
She was surprised and asked why not. I explained that although her negative thoughts and feelings were certainly creating a lot of pain for her, I suspected there might be some real advantages, or benefits, of thinking and feeling the way she did. I added that her negative thoughts and feelings might also be an expression of her most beautiful and awesome qualities, and that maybe we should take a look at that before we went about trying to change things.
I suggested we could ask the following questions about each negative thought or feeling before she made any decision about pressing the magic button:
1. What are some benefits, or advantages, of this negative thought or feeling? How might it be helping you and your baby?
2. What does this negative thought or feeling show about you and your core values that’s positive and awesome?
…And now they go through the “positive reframing” part. I’ll get back to that below. After that, here's the rest of the shtick…
Once we’d listed all the positives we could think of, I asked Maria if she felt the list was realistic. She said the list was absolutely realistic but very surprising since she’d never thought there could be anything positive about how she was thinking and feeling. She’d been thinking that her depression and anxiety meant there was something wrong with her and not that there might be something right with her.I asked Maria if she still wanted to press the magic button since all of these positives would go down the drain along with her negative thoughts and feelings. Maria insisted that she still wanted to feel better because her suffering was almost unbearable.Now she had a dilemma. She wanted to feel better, but she also didn’t want to give up all the fabulous things on our list of positives. As her therapist, I also wasn’t trying to sell her on the idea of change. Instead, I was doing the opposite. I was trying to persuade her that all of her negative thoughts and feelings showed what was really great about her and that she shouldn’t give them up.To help her resolve this dilemma, I asked Maria to imagine that we had a magic dial instead of a magic button and that she could dial down each negative feeling to a more manageable level that would allow her to keep all the benefits of that feeling without feeling so much intense pain. That way, she could feel better without losing all the beautiful things we’d listed about her.What would she dial each feeling down to, starting with depression? How sad and depressed would she want to feel at the end of our session? What might be an appropriate level of depression given all the horrible things she’d been going through? She said 15% would be plenty of depression, so she recorded this as a goal in the second column of her Daily Mood Journal, as you can see. She also decided to dial her anxiety down from 80% to 20%, so on and so forth.
Once we’d listed all the positives we could think of, I asked Maria if she felt the list was realistic. She said the list was absolutely realistic but very surprising since she’d never thought there could be anything positive about how she was thinking and feeling. She’d been thinking that her depression and anxiety meant there was something wrong with her and not that there might be something right with her.
I asked Maria if she still wanted to press the magic button since all of these positives would go down the drain along with her negative thoughts and feelings. Maria insisted that she still wanted to feel better because her suffering was almost unbearable.
Now she had a dilemma. She wanted to feel better, but she also didn’t want to give up all the fabulous things on our list of positives. As her therapist, I also wasn’t trying to sell her on the idea of change. Instead, I was doing the opposite. I was trying to persuade her that all of her negative thoughts and feelings showed what was really great about her and that she shouldn’t give them up.
To help her resolve this dilemma, I asked Maria to imagine that we had a magic dial instead of a magic button and that she could dial down each negative feeling to a more manageable level that would allow her to keep all the benefits of that feeling without feeling so much intense pain. That way, she could feel better without losing all the beautiful things we’d listed about her.
What would she dial each feeling down to, starting with depression? How sad and depressed would she want to feel at the end of our session? What might be an appropriate level of depression given all the horrible things she’d been going through? She said 15% would be plenty of depression, so she recorded this as a goal in the second column of her Daily Mood Journal, as you can see. She also decided to dial her anxiety down from 80% to 20%, so on and so forth.
…So then after that “magic button, positive reframing, magic dial” shtick we get to the “classic CBT” stuff, where he goes through his many techniques to counter negative thoughts.
I cut the "positive reframing" part out of the middle of the excerpt above. How does that work? He actually goes through lots of examples of "positive reframing" throughout the book. It’s pretty easy once you get the hang of it. In fact, since reading the book I’ve done it myself, sporadically. For example:
My typical inner monologue before reading the book:
My typical inner monologue after reading the book:
The final step is the same in both cases, but my experience is that without those extra two steps in the middle, the final step doesn't sink in nearly as well. Like I would believe it on an intellectual level but still feel bad. The new system is definitely an improvement. Really, it still feels slightly magical.
The same pattern has been working well for my various other periodically-recurring stupid negative thoughts, like "I shouldn't have said that mildly-embarrassing thing when chatting with my friend three weeks ago", or “I should be doing better at my job”, or “I'm recklessly hastening the apocalypse”, or whatever. (Yeah I know, First-World Problems…) In all cases I find that coming up with the "positive reframing" list is pretty easy, once I actually try. But maybe it helps that I read the book, with its tons of examples of positive-reframing a wide variety of types of negative thoughts.
So that’s the main practical thing I got out of the book.
Another thing in the book that I found interesting was that the author is super into exposure therapy, and moreover he makes exposure therapy sound a lot less complicated and delicate than I had previously believed.
He also makes it sound more broadly applicable than I had thought. My pop-culture impression is that exposure therapy is that it's a treatment for stereotypical "phobias" like fear-of-spiders and fear-of-heights. But he also applies it to various other kinds of anxiety, and OCD. He even advocates a version of exposure therapy for stressful thoughts!!
I won’t say any details about exposure therapy because I don’t want to describe it wrong, but I can definitely imagine trying that in the future, for certain types of unusually stressful thoughts.
Having read the book, I’m now much more inclined to believe a somewhat-more-cognitive theory of depression sorta along the lines of “Depression is what happens when every possible thought you can think and plan you can make is judged by the plan-assessing part of your brain as unacceptably terrible, and this dynamic remains true for an extended period.” For example, take the stereotypical person with OCD. Their thoughts might be dominated by the following dynamic:
Basically there is no thought they can think, and no plan they can entertain, that isn’t rated as “that’s a terrible thought, if you think it then you’re doomed, DOOMED!” by the plan-assessing part of their brain. I’m now inclined to think that this is the core dynamic of depression and anxiety, and every other symptom is closely related to that dynamic, and every risk factor feeds into this dynamic.
I guess I should write a separate post spelling out the details, but you can basically get the gist of it as follows:
That’s not a carefully-researched confident opinion, it’s just an idea I'm playing around with right now.
There's a wonderful book "How to talk so kids will listen & listen so kids will talk", which teaches that if you want your crying&shouting child to actually solve some problem/change behavior/listen to your advice at all, you must realize that there are actually two different personas in them (say: the reptile part of the brain and the neocortex) and you have to first address the first one before you can even start talking with the other: so for example when a child is having a tantrum, what you see is perhaps more like a frightened lizard, than a reasonable person you can persuade, so first you have to calm it down. And the trick to disarm this emotional alert is to actually acknowledge the message it tries to send you - usually by paraphrasing the emotional content ("Oh, I see you have a terrible day, you are angry that we have to finish playing...") [which is even more important in case of children which don't know how to verbalize the emotional state as they lack the words/introspection skills]. There are subtleties to it, like for example: you don't have to copy/inhabit the same emotional state (you don't have to be angry that the play is over yourself) but you need to match the tone and choice of words to the emotion you talk about so that the child believes you are really treating it seriously, not just impassionately describe/condescending/mocking it. So "I see you are angry" delivered in too robotic tone and poker face can backfire and restart the tantrum, but said with harsher tone and grim face can work much better - obviously this is much easier if you simply truly mean it and honestly try to convey that you accept the feelings of your child. It's much more difficult when you are yourself struggling to learn empathy/figure out how to talk about emotions/etc. So I guess it's more natural for some people than others.
Crucially, only when you calm down this part of the brain which was overwhelmed by emotions, you can move forward to reason with the child and explain anything/exchange arguments/plan solution etc. And often this second stage is not even needed, as the child will be able to fix the problem themselves once they're calmed down. OTOH if you start to reason with the child too early, while it's still nervous, it will not lead anywhere except escalating the conflict. In some sense: there's no one to answer your call, until you answer theirs.
I'm saying all this, because I've found these techniques surprisingly helpful in other contexts, like talking to my grown up family members. In some sense an analogue of this is useful in the Internet debates too: you first should be able to paraphrase the stance of your opponent and demonstrate you understand where they're coming from, before you say even a word of critique or argumentation - otherwise they'll immediately label you as outsider who doesn't know a shit and is not worth listening to.And your post made me realize, that the technique from the book you describe is somewhat like this, if you look through "subagents model of the brain" perspective: there is a part of you which is having emotional crisis, and it's terrified by some problem it needs to solve, but this part is not ready to listen for solution/change, as long as it's in the busy loop waiting for an ACK packet confirming someone got the S.O.S. signal. So you first need to emphatically talk with this part, describe what it feels, acknowledge its good intentions etc. and only then you can move on to actually persuade/negotiate/change anything. This also reminds me a bit the Focusing technique - where the analogue to the child which doesn't know how to name their own emotions, so is stuck in demonstrating them until you guess the keyword for them seems even better. This all starts to look to me as communication problems, not unlike communication problems between people, but within various parts of the brain.
I do like the "How To Talk" book and definitely use those techniques on my kids ("Oh, you're very upset, you're sad that we ran out of red peppers..." --me 20 minutes ago) though I haven't successfully started the habit of using it on adults. (Last time I tried I was accused of being condescending, guess I haven't quite gotten it down yet.) "Nonviolent Communication" and other sources hit that theme too.
…But I don't think that's quite it. That would be "positive reframing" without "magic dial". It's not just about acknowledging that the negative thought exists to address certain needs, it's about making sure that those needs continue to be addressed. "Magic dial" is one easy way to do so—if the negative thought addresses a set of needs, then fine, keep thinking the negative thought, and think it often enough to address those needs, and no more often than that. But the other part is, by calling out the needs to awareness, and thinking about how they can be addressed, you might come up with other solutions that don't involve thinking the negative thought.
I also have difficulties in applying this techniques on adults, of the "Me mad?No shit Sherlock!" kind. I'm not fluent with it yet, but what I've observed is that the more sincere I am, and the more my tone matches the tone of the other person, the better the results. I think this explains big chunk of "don't use that tone of voice on me!" responses I've got in my life, which I used to find strange [as I personally pay much more attention to the content of the text/speech, not the tone/style/form], but recently I've realized that this can be quite a rational response from someone who reads the cues from both content AND form, and seeing a mismatch, decides which of the two is easier to forge, and which one is the "real" message [perhaps based on their experience, in which controlling emotions is more difficult].
Also, I agree that the "paraphrase the emotions" only maps to the "positive reframing" part. In my eyes the analogy extended also beyond this single step into the pattern of using this discharge step as a necessary step to use some other rationally obvious thing, which you really think should work on its own in theory (like the “Classic CBT”-ish self-talk), but in practice you need to prepare the ground for it.
Indeed there seems to be no analog of "Magical dial" in the "How to talk.." approach. There are some fragments of the book though which teach how to extract the goals/needs/fears of the child and then help them construct a solution which achieves those goals/needs, but this is more like a part of the analog of "classic CPT-ish self talk"-step I think. (In particular I don't recall the book saying things like "do the same stuff just less intensively", so yeah, this part is new and interesting). For example today I told my son, that "So you get mad each time we come to pick you up from your friend right in the moment when you've finally figured out some cool way to play with each other, and this is mega-frustrating, I know. Sure, one way to handle this would be to find yet another way to express anger which doesn't hurt mommy, say punch a pillow, stump, or tear paper, BUT I think that your feeling of being mad is actually trying to tell you something important: that you like your friend very much, like spending time with him, like playing, and hate to be surprised by abruptly having to stop. I don't think we should expect you to feel this each time over and over again each day we pick you up, and try to somehow manage this - how about instead we give you a handwatch, teach you how time works, and let you know in advance when we gonna pick you up? That should eliminate the root cause, not just the effect.".
Thanks to whoever upvoted my comment recently bringing it again to my attention via notification system - rereading my comment after 2 years, I feel really sorry for myself that despite writing the sentence
And your post made me realize, that the technique from the book you describe is somewhat like this, if you look through "subagents model of the brain" perspective: there is a part of you which is having emotional crisis, and it's terrified by some problem it needs to solve, but this part is not ready to listen for solution/change, as long as it's in the busy loop waiting for an ACK packet confirming someone got the S.O.S. signal.
I did not really understand what it means and how to implement it and how huge impact on my life it will have once finally executed. Only recently I took part in a Lowen's therapy, in which by performing some body movements typical for aggression I've finally established connection between the part which was angry and the part which could listen about it.
Hi Steven, I like both your review of the book and your interesting speculation on the neuroscience. Here's the PDF of a book written by a neuroscientist, Dr. Mark Noble, on the neuroscience behind this approach of doing cognitive behaviour therapy, if you're interested. Your review of this book was done so well that I didn't have to review it again, but could just link to it, and then riff on what I found particularly interesting for my own review of this same book.
I've been applying this method of mindfulness + positive reframing (somewhat unaware that I was using it) for my bipolar disorder for the last year. It's unbelievably effective. Paired with a six-week ketamine therapy, my depressive symptoms have almost completely disappeared, and my mania is far more manageable and stable. I'm not on medication, and a combination of imaginative, behavioral, and cognitive techniques like this have worked remarkably well for the past 6 months. This has been more successful and longer-lasting than any other therapy I've tried. The book Bipolar Breakthrough also has more specific advice for managing bipolar disorder, and the author uses a similar approach as Burns in Feeling Great. Further, I don't just think positive reframing is useful or helpful therapeutically. Yes, it is, but it's also true. These disorders are genuinely adaptive and valuable - or have been in our evolutionary history - and there are good reasons for most 'psychopathological' responses. Often, seeing and experiencing the value of a 'mental illness' just requires some relatively minor adjustments, either from you or from your social context. Someone already mentioned Good Reasons for Bad Feelings, and it contains some great argument for this view. But what really convinced me of the adaptive value of mental disorders was Giudice's Evolutionary Psychopathology - see Book Review: Evolutionary Psychopathology | Slate Star Codex. The thought-emitting and thought-assessing parts of the brain that you mention here might correlate to the generative and evaluative processes involved in creativity? See The Sparks of Generative Creativity in Mental Disorders. This also suggests a potential continuum of mental disorders, between 'generative' disorders that involve over-activation of thought-emitting systems (bipolar mania, ADHD, Tourette's, schizophrenia) and 'evaluative' disorders that involve over-activation of thought-assessing systems (depression, anxiety, possibly autism). This might map onto the continuum that psychiatric research has arrived on, between approach-based (generative) and avoidance-based (evaluative) psychopathologies (cf. Baas et al 2016, Mad Genius Revisited). I think the predictive theory of depression is promising, but it may not explain all forms of depression - I suspect the disorder is far more heterogenous than indicated by the DSM-V major depressive disorder construct.
Sorry if this is dumb, but you put mania on the thought-emitting side … why can't mania look like the thought-assessing system just saying "Hell yeah that thought is friggin awesome!!!!" all the time?
Apologies for the late response! Well, you could say that. But I wouldn't consider a constant "hell yeah this thought is amazing!!" evaluative. After all, there isn't really an evaluation of the content of the thought - just a generic affirmation. The main point is that the kind of critical assessment involved in evaluative thinking is under-activated in mania, and over-activated in depression. These are distinct cognitive and neural systems that are somewhat competitive with each other.
Hmm, OK, I guess your model is that every thought coming from the thought-emitting system is treated as a "good idea" by default, and then the point of the thought-assessing systems is to find problems with them. (You can correct me if I'm wrong.) Whereas my model is that there's no such thing as a default because the thought-assessing systems assess every thought no matter what, and judge it as good or bad or neutral.
That said, within what I'm calling the thought-assessing systems, especially within the brainstem, there are presumably little pockets that do specialized processing involved in negative-valence things like panicking and other little pockets that do specialized processing involved in positive-valence things like relaxing. For example, the lateral habenula is involved in the detailed mechanics of setting up dopamine pauses (= judgments that a thought is bad), or something like that, so obviously the lateral habenula is over-active in depression when all your thoughts are bad. But I would think of "lateral habenula under-activity" as probably not usually a root cause of depression but more like a symptom. I currently think that things the amygdala and ventral striatum and medial prefrontal cortex and hypothalamus and brainstem are all involved in finding both good and bad aspects of thoughts. (Well, I'm not 100% sure about the amygdala.) If you have an idea of "distinct neural systems" for finding good and bad aspects of thoughts, I'd be curious what specific neural systems you would assign to each, or if you have a reference that might have that breakdown. I would be really interested to see that.
(Sorry if I'm misunderstanding.)
Regarding the podcasts, I agree that they are somewhat confusing and seem out of context, unless you listen to a substantial amount of them. I discovered the podcast before Feeling Great came out, and while the book is great, I think the podcast has helped me more on the "gut level" as it really drives the point home. I can definitely recommend listening to the live sessions in addition to reading the book - I've put together a list of some of the best episodes here.
Your brief example of positive reframing reminded me of Randolph Nesse's Good Reasons for Bad Feelings: Insights from the Frontier of Evolutionary Psychiatry (which I heard about through the wise Peter Hase).
Where the upsides you described above were quite particular (e.g. "my parsimony protects me from bad financial decisions and demonstrates that I'm prudent"), Nesse discusses upsides of negative emotion from an evolutionary perspective. These evolutionary upsides are in some respects personal and particular like the above (e.g. "my relationship anxiety shows I care about my partner and is trying to tell me that they have not signalled their commitment satisfactorily") but also have a suprapersonal or naturalistic dimension (e.g. "my relationship anxiety is an evolved, intelligent, healthy response to my social circumstances... it makes sense!").
Nesse encourages positive reframing throughout the book, but it's sometimes unclear how important he thinks the uniquely-evolutionary perspective is for patient outcomes vs positive reframing à la Burns. I find it hard to make empirical guesses about this in the absence of data, but I wouldn't be surprised if thinking about evolution is unnecessary and Burns' method is sufficient. Perhaps others who've read Nesse's book will be able to clarify his thesis/claims more than my memory will allow. In any case, some people may enjoy the books together, particularly among this crowd.
I do recommend both of Nesse's books (the other is Why We Get Sick, co-authored with the great George C. Williams). Thanks to Steve for sharing! Look forward to reading Burns.
There's a 16 week Zoom book club coming up for Burns' book about TEAM-CBT, facilitated by a TEAM-CBT trainer, in case anyone is interested (starts Sep 8th 2021): https://www.feelinggreattherapycenter.com/book-club(I just signed up)