appendb 88-150 December 12, 1989
Professional readers, both researchers and practising therapists, will wish to compare the theory and methods offered here--which I call Self-Comparisons Analysis--with the cognitive therapies of Beck and of Ellis, behavioral therapy, the Inter- personal Therapy of Klerman and Weissman, Seligman's prescriptions about the sense of helplessness, and other views of depression. They will want to know what is new about the ideas and practices presented here. This Postscript responds to that question, and takes up some other matters of interest to the professional reader.
Before discussing differences, however, I would like to emphasize the key element in common: From Beck and Ellis I gained the central insight that particular modes of "cognitive" thinking cause people to be depressed. This implies the cardinal thereapeutic principle that people can change their modes of thinking by a combination of learning and will-power in such fashion as to overcome depression. For this I am indebted to them not only intellectually but also for my own welfare. And now to the differences and novelties.
Beck has properly claimed as an advantage of his Cognitive Therapy over previous work that "the therapy is largely dictated by the theory."13 This book offers a more comprehensive theory of depression than has been offered heretofore, theory which includes the others as elements in it. The therapeutic approaches suggested here are dictated even more clearly by the specificity of the theory given here, and more possibilities are suggested by it, than any of the previous approaches alone. Even folk wisdom nicely takes its place within Self-Comparisons Analysis, as for example the dimension-shifting common sense of counting your blessings, living one day at a time, and devoting yourself to helping others rather than rehearsing your own woes.
This section barely dips into the vast literature on depression; a thorough review would not be appropriate here, and the works mentioned below contain comprehensive review. I have merely selected some major themes for discussion.
In reading the following discussion of differences between Self-comparisons Analysis and other approaches, please notice this in particular: Beck focuses on distortion of the actual- state numerator, and loss is his central analytical concept. Ellis focuses on absolutising the bench-mark-state denominator, using ought's and must's as his central analytical concept. Self-comparisons Analysis embraces both of these approaches by pointing out that either the numerator or the denominator can be the root of a Rotten Mood Ratio, and the comparison of the two (in the context of belief that one is helpless to make changes) causes sadness and depression. Hence, Self-comparisons Analysis reconciles and integrates Beck's and Ellis's approaches, and at the same time the self-comparisons construct points to many additional points of therapeutic intervention in the depression system.
Aaron Beck's Cognitive Therapy
Beck's original version of Cognitive Therapy has the sufferer "Start by Building Self-Esteem" (title of Chapter 4 of Burns, 1980). Excellent advice, but not very systematic. Neither "self-esteem" nor "negative thought" is a precise theoretical term. Focusing on your negative self-comparisons is a better method --clearcut and systematic - for achieving the aim Beck sets. But there are also other paths to overcoming depression that are part of the overall approach given here.
Beck et. al. focus on the depressive's actual state of affairs, and her distorted perceptions of that actual state. Self-comparisons Analysis agrees that such distortions--which lead to negative self-comparisons and a rotten Mood Ratio--are (together with a sense of helplessness) a frequent cause of sadness and depression. But Beck et. al.s exclusive focus on distortion keeps them from seeing the deductively-consistent inner logic of many depressives, and accepting as valid such issues as which goals should be chosen.4 It also has focused them away from the role of helplessness in disabling the purposive activities which sufferers might otherwise undertake to change the actual state and thereby avoid the negative self- comparisons.
4In some later work, e. g. Beck et. al. (1979, p. 35) widen the concept to "patient's misinterpretations, self-defeating behavior, and dysfunctional attitudes". But the latter new elements border on the tautologous, being approximately equal to "thoughts that cause depression", and hence contain no guidance to their nature and treatment.
Beck's view of depression as "paradoxical" (1967, p. 3; 1987, p. 28) is not helpful, I believe. Underlying this view is a comparison of the depressed person to a perfectly-logical individual with full information about the present and future of the person's external and mental situation -- like the model of the perfectly-rational consumer in economics. A better model for therapeutic purposes is an individual with limited analytic capacity, only partial information, and a set of conflicting desires. Given these inescapable constraints, it is inevitable that the person's mental behavior will not take full advantage of all opportunities for personal welfare, and will proceed in a manner which is quite dysfunctional with respect to some goals. With this view of the individual, we may try to help the individual reach a higher level of satisficing (Herbert Simm's concept) as judged by the individual, but recognizing that this is done by means of trade-offs as well as improvements in thinking processes. Seen this way, there are no paradoxes.
Burns nicely summarizes Beck's approach (which he espouses) as follows: "The first principle of cognitive therapy is that all your moods are created by your `cognitions'" (1980, p. 11). Well said (though a bit over-stated; anger at being hit by a stray snowball is something other than cognitive). Self- comparisons Analysis makes this proposition more specific: Moods are caused by a particular type of cognition, self- comparisons, in conjunction with such general attitudes as (for example, in the case of depression) feeling helpless.
Burns says the "The second principle is that when you are feeling depressed, your thoughts are dominated by a pervasive negativity". (p. 12). Self-Comparisons Analysis also makes this proposition more specific: it replaces "negativivity" with negative self-comparisons, in conjunction with feeling helpless.
According to Burns, "The third principle is ...that the negative thoughts ...nearly always contain gross distortions" (p. 12, itals. in original). Below I argue at some length that depressed thinking is not always best characterized as distorted.
Another difference between Beck's and my point of view is that he makes the concept of loss central to his theory of depression. It is true, as he says, that "many life situations can be interpreted as a loss" (1976, p. 58), and that loss and negative self-comparisons often can be logically translated one into the other without too much conceptual strain. But many sadness-causing situations must be bent and massaged in order to be interpreted as losses; consider, for example, the tennis player who again and again seeks matches with better players and then is pained at the outcome. It seems to me that most situations can be interpreted more naturally and more fruitfully as negative self-comparisons. Furthermore, this concept points more clearly to a variety of ways that one's thinking can change to overcome depression than does the more limited concept of loss.
It also is relevant that the concept of comparison is fundamental in perception and in the production of new thoughts. It therefore is more likely to link up logically with other branches of theory (see discussion below of decision-making theory) than is a less basic concept. Hence this more basic concept would seem preferable on the grounds of potential fruitfulness.
Albert Ellis's Rational-Emotive Therapy
Ellis operates primarily upon the benchmark state, urging that the depressive not consider goals and "ought" states as strongly binding "must"s. He teaches people not to "musturbate" - - that is, to free oneself of unnecessary must's and ought's. Again this is fine advice which helps a depressive adjust his/her benchmark state, and the person's relationship to it, in such fashion that one makes fewer and less-painful negative self- comparisons. Coming to recognize that I did not have to accept the particular goals and standards that I had previously accepted was the first of the key events in my own victory over depression. But as with Beck's (and below, Seligman's) therapeutic advice, Ellis's focuses on only one aspect of the depression structure. As a system, therefore, his doctrine therefore restricts the options available to the therapist and patient, omitting some other avenues which may be just what a particular person needs.
Klerman, Weissman, et. al. focus on the neg-comps that flow from interactions between the depressive and others as a result of conflict and criticism. There can be no doubt that bad relationships with other people damage a person's actual inter- personal situation and and exacerbate other difficulties in the person's life. And it therefore is undeniable that teaching a person better ways of relating to others will improve a person's real situation and therefore the person's state of mind. But the fact that people living alone often suffer depression makes clear that not all depression flows from inter-personal relationships, and therefore to focus only on inter-personal relationships to the exclusion of other cognitive and behavioral elements is too limited.
Seligman focuses on ways to reduce the helplessness that almost all depression sufferers report, an element which combines with neg-comps to produce sadness. And he expresses what other writers say less explicitly about their own core ideas, that the theoretical element he concentrates on is the main issue in depression. Talking about the many kinds of depression classified by another writer, he says: "I will suggest that, at the core, there is something unitary that all these depressions share" (p. 78).
I agree that the sense of helplessness is centrally involved in all depressions. But Seligman leaves the impression that helplessness is the only invariable element, which I believe is not the case; negative self-comparisons are at least as omni- present. His therepeutic focus on reducing the sense of helplessness points him away from adaptations of other parts of the system. (This may follow from his experimental work with animals, which do not have the capacity to make such adjustments in perceptions, judgments, goals, values, and so on, which are central to human depression and which people can and do alter. That is, people disturb themselves, as Ellis puts it, whereas animals do not.)
Self-comparisons Analysis and the procedure it implies include learning not to feel helpless. But this approach focuses on the helpless attitude in conjunction with the neg-comps that are the direct cause of the sadness of depression, rather than only on the helpless attitude, as Seligman does. Again, Self- comparisons Analysis reconciles and integrates another important element of depression into an over-arching theory.
Viktor Frankl's Logotherapy offers two modes of help. One mode is a philosophical attempt to help a person find meaning in his or her life which will give the person a reason to live, and to live with the pain of sadness and depression; this has much in common with Values Treatment as discussed in Chapter 18, and is discussed there. Another mode is the tactic Frankl calls "paradoxical intention". The therapist offers the patient a radically different perspective on the patient's situation, either the numerator or the denominator of the Mood Ratio, using absurdity and humor; this is discussed in Chapter 10. Frankl has successfully trained others in the use of his techniques, and he reviews studies showing success. Both patients and therapists can surely find his tools useful in a variety of thought contexts.
Substitutions and Combinations of Methods
Even a simple procedure like that of Coue' could achieve good results with some sufferers by operating on just one aspect of the process in an uncomplicated fashion. Such a single view of a depressive's thinking is just the opposite of the complex view of the process in my explanatory diagram in Appendix A, which looks like spaghetti. But complexity offers opportunities for many kinds of interventions and adjustments that are obscured from the sufferer and from the therapist by a focus on a single procedure.
Self-comparisons Analysis makes clear that many sorts of influences, perhaps in combination with each other, can produce persistent sadness. From this it follows that many sorts of interventions may be of help to a depression sufferer. That is, different causes--and there are many different causes--call for different therapeutic interventions. Furthermore, there may be several sorts of intervention that can help any particular depression.
In short, different strokes for different folks. In contrast, however, each of the various schools of psychological therapy--psychoanalytic, behavioral, religious, and so on--does its own thing no matter what the cause of the person's depression, on the implicit assumption that all depressions are caused in the same way. Furthermore, each school of thought insists that its way is the only true therapy despite the wise remark of Greist and Jefferson quoted earlier that because "depression is almost certainly caused by different factors, there is no single best treatment for depression" (1984, p. 72). As a practical matter, the depression sufferer faces a baffling disarray of treatments, and the choice is too often made simply on the basis of chance.
Self-comparisons Analysis points a depression sufferer toward the most promising tactic to banish the particular person's depression. It focuses first on understanding why a person makes negative self-comparisons. Then it develops ways of preventing the neg-comps, rather than focusing on merely understanding and reliving the past, or on simply changing contemporary habits. With this understanding one can choose how best to fight the depression and achieve happiness.
A key difference between Self-comparisons Analysis and both Beck's and Ellis's cognitive therapy is their belief that depression is always the result of "disabled or "irrational" thinking. Self-comparisons Analysis differs from Beck and Ellis in not considering depressive thinking as irrational by definition.
In my view, everyone's thinking is bent and twisted, especially in matters that affect one personally. Everyone's perception is biased in various ways; it is never unbiased, not just in psychologically-charged issues but in all kinds of cognitive thinking and judgments in business, science, politics, and everyday life. The question is not who sees the matter "correctly" and who does not, but in what fashion the thinking of each person is inclined away from what might be a "true" view.
Let's agree that unsound thinking either causes or is involved in many cases of depression, and improving one's thinking can therefore help fight against depression in those cases. But as I see it, this is not an appropriate or "rational" treatment for all cases of depression.
Underlying cognitive therapy is the value (belief) that it is silly and childish and irrational to be depressed, that depression is proof-positive that one is not thinking rationally.
There are some people who are depressed yet who are not at all irrational in their thinking--at least not in the sense that Ellis and Harper use that term. Consider the following example of Ellis's, with special attention to the last sentence:
...the case of a person who, as a child, is contin- ually criticized by his parents, who consequently feels himself loathesome and inadequate, who refuses to take chances at trying and possibly failing at difficult tasks, and who comes to hate himself more because he knows that he is evasive and cowardly. Such a person, during his childhood, would of course be seriously neurotic. But how would it be possible for him to sustain his neuro- sis if he began to think later in life, in a truly logical manner?
For if this person does begin to be consistently rational, he will quickly stop being overconcerned about what others think of him and will begin to care primarily about what he wants to do in life and what he thinks of himself. Consequently, he will stop avoiding diffi- cult tasks and, instead of blaming himself for making mistakes, he will say to himself something like: 'Now this is not the right way to do things; let me stop and figure out a better way.' Or: 'There's no doubt that I made a mistake this time; now let me see how I can benefit from making it, so that my next performance will be improved.'
This person, if he is thinking straight in the present, will not blame his defeats on external events, but will realize that he himself is causing them by his inadequate or incompetent behavior. He will not believe that it is easier to avoid than to face difficult life problems, but will see that the so-called easy way is invariably the harder and more idiotic procedure. He will not think that he needs someone greater or stronger than himself on whom to rely, but will independently buckle down to hard tasks without outside help. He will not feel, because he once defeated himself by avoiding doing things the hard way, that he must always continue to act in this self-defeating manner.
How, with this kind of logical thinking, could an originally disturbed person possibly maintain and con- tinually revivify his neurosis? He just couldn't. (Ellis, l962?, pp. 91-92.)
If the person is, say, a biologist searching for an advance in treating cancer which he has not been able to find, the cause of the "defeats" is not "inadequate or incompetent behavior," to use Ellis' terms. This is not a person who "systematically misconstrues his experiences," as Beck sees it. (l977, p. 264.) Hence, no amount of "straightening out the person's thinking" by itself is the answer. Rather, the person must decide either (a) to accept such defeats if they do occur, and change the denominator (of expected cons or hopes) or the main dimension of comparison (from success-failure to courage or lack of it), or else (b) change his work subject.
By assuming that the cognitions responsible for depression always can be shown to be logically or empirically incorrect, "distorted thinking" in Beck's terms, "irrational thinking" in Ellis', they run the risk of forcing an analysis that is appropriate for some people onto others for whom it is not appropriate, and thereby not doing well both by the cognitive point of view and some clients, too.
Ellis and Beck view the role of the therapist as helping the patient learn to think in "more rational" or "less distorted" ways. In my view, sometimes the proper role for the therapist is more like that of a sports physician or trainer in those cases where the athlete desperately wishes to continue playing. The appropriate procedure then is: a) Determine the cause of the pain. b) Decide how the pain can be mitigated, and mitigate it if possible. c) If mitigating the pain requires cessation of play, then advise the patient that there is a trade-off between playing and avoiding pain. This is like the choice that a depressed person must make between continuing to work toward a valued goal where there has been little or no success so far, and only small hope of future success, as is sometimes the case with a scientist trying to persuade the world of a new theory. The therapist may offer some devices that will at least lessen the pain while playing, however, and this can be of value. It is important that the choice to play be respected and not just treated as irrational or perverse; doing the latter can worsen the person's depression.
Self-comparisons Analysis also differs in viewing sadness as an effect of negative self-comparisons plus a sense of helplessness rather than simply loss, as does Beck; and there is a great deal of difference between the implications of these two concepts. Still another difference is the systematic step-by- step procedure suggested by the Self-comparsions Analysis, as described in earlier chapters, against which may be compared the following systematic description of Beck's procedures - (actually a description of Beck's cognitive therapy for a patient suffering from anxiety rather than depression):
The formulation of the progress of this patient can now be fitted into the therapeutic model: (1) self- observations that led directly to the ideation preceding the anxiety; (2) establishing the relation between the thoughts and anxiety attack: (3) learning to regard thoughts as hypotheses rather than facts; (4) testing the hypotheses: (5) piecing together the assumptions that underlay and generated these hypotheses; (6) demonstrat- ing that these rules composing her belief system were incorrect. (Beck, l977, p. 261.)