APPENDIX

BACKGROUND INFORMATION FOR RESEARCHERS AND PRACTITIONERS

The book uses "you" language to address the depression sufferer. And some general readers will find interesting the information in the appendices. But the book also is aimed at psychotherapeutic professionals, both researchers and practitioners, with an additional message: the contains a new theoretical understanding of depression, which implies new ways of confronting depression.

The fundamental idea of modern psychological therapy for depression is that individuals can change their thinking processes in ways that will eliminate the patterns which cause the depression. The layperson may consider this to be plain common sense. But when seen in light of the older Freudian view, this common-sense foundation is revolutionary. And though the fundamental assumption is "only" common sense, the scientific structure constructed upon it is not at all obvious. Building upon this foundation, various researchers have focused on different aspects of the thinking processes which are commonly faulty among depressives. And they have shown how altering the defective thinking can improve people's moods.

This book develops a broader framework that encompasses all the major insights of earlier writers. Within that framework, it focuses on the key cognitive channel -- self-comparisons -- through which all the other influences flow. Philosophers have understood for centuries that the comparisons one makes affect one's feelings. But this element has not previously been explored or integrated into scientific understanding of the thinking of depressives, or exploited as the central pressure-point for therapy. Instead, the concept "negative thoughts" has been used.

Appendix B continues the theoretical discussion with an analysis of how this approach to depression fits with, and broadly encompasses, the other modern cognitive psychological approaches to depression. The remainder of this Appendix A adds some theoretical underpinning to discussions in early chapters. It also briefly discusses how this approach, along with cognitive therapy in general, has been moving toward the use of concepts found in philosophy and other social sciences, some by borrowing but even more by independent invention. In this way, cognitive therapy moves toward what may eventually be the the first application of integrated social science.

In brief, Self-Comparisons Analysis does the following: 1) It presents a theoretical framework which identifies and focuses on the common pathway through which all depression-causing lines of thought must pass. This framework combines and integrates other valid approaches, subsuming all of them as valuable but partial. All of the many variations of depressions that modern psychiatry now recognizes as heterogenous but related forms of the same illness can be subsumed under the theory except those that have a purely biological origin, if there are such. 2) It sharpens each of the other viewpoints by converting, the rather vague notion of "negative thinking"1 to a precise formulation of a self-comparison and a negative Mood Ratio with two specific parts, an assumed actual state of affairs and a hypothetical benchmark state of affairs. This idea opens up a wide variety of novel interventions. 3) It offers a new line of attack upon stubborn depressions, called here Values Treatment, which leads the patient to make a committed choice to give up depression in order to attain more important deeply-held values.

The American Psychiatric Association's publication Depression and Its Treatment by John H. Greist and James W. Jefferson (Washington: Am. Psychiatric Press, 1984) may be taken as canonical: "Depressed thinking often takes the form of negative thoughts about one's self, the present and the future"

Beck has properly claimed as an advantage of his Cognitive Therapy that "the therapy is largely dictated by the theory" rather than being simply ad hoc. (1976, p. 312). Beck also notes that "Currently, there is no generally accepted theory within the cognitive-clinical perspective." This book offers a more comprehensive theory of depression than do the others, and includes the others as elements in it. Furthermore, the therapeutic approaches suggested here are dictated even more clearly by the more specific theory given here, and more possibilities are suggested by it, than any of the previous approaches alone.

Each of the contemporary "schools", as Beck (On dustjacket of Klerman et. al., 1986.) and Klerman et. al. (1986, p. 5) call them, addresses one particular part of the depression system and, therefore, depending upon the "theoretical orientation and training of the psychotherapist, a variety of responses and recommendations would be likely...there is no consensus as to how best [to] regard the causes, prevention, and treatment of mental illnesses" (Klerman et. al., 1986, pp. 4,5). Any "school" is therefore likely to achieve best results with people whose depression derives most sharply from the point in the cognitive system that that school focuses upon, but less well with people whose problem is mainly at some other point in the system. (Of course the depression sufferer may have a defective mechanism that spreads into several aspects of the system, and therefore therapy at any one point can benefit the system as a whole, but that is beside the point here).

Self-Comparisons Analysis provides an expanded theoretical understanding of depression which encompasses and integrates the elements pinpointed and explored by these writers and others. This means that instead of the field being seen as a conflict of "schools", each of the "schools" has a distinctive method that fits the needs of different sorts of sufferers from depression. The overall framework of Self-Comparisons Analysis helps weigh the values of each of these methods for a particular person. Though the various methods may be serviceable substitutes for each other at times, to a considerable extent they are not simply competitive alternatives for the same situations, and Self- Comparisons Analysis helps one choose. This should be of particular benefit to the physician or other professional who must make the crucial decision of referring a patient to one or another specialist for depression treatment. Heretofore, the choice had to be made mainly on competing merits, and in practice the choice probably is made mainly on the basis of which "school" the referring professional is most familiar with, which has led to considerable frustration with the field voiced by recent writers (e. g. Papalos and Papalos, 1987).

There are hazards in offering a theory which claims to comprehend and integrate others. Psychotherapists, just as do professionals in others fields, have "intense loyalties to the schools they espouse" (Wender & Klein, 1981, p. 264). And contending schools in any field are greatly attached to their controversies; to offer to remove the cause of the controversy is to be in the position of a cop in a household dispute. The one matter that contending parties always can agree upon is that an outsider has nothing to contribute. Nevertheless, I step where angels professionally trained in particular `schools' of clinical therapy would be prudent enough not to tread. And not being the member of any `school' confers an advantage: Lack of socialization into, and absence of professional connection with, any particular school of therapy promotes breadth of thought and synthetic theory.

If you work at enough different tasks you sometimes experience the eerie and then exciting sensation that you have met the same idea before in another context. And so it is with many of the ideas in cognitive therapy, especially the types of thinking characteristic of depressed persons. The distortions of thought common to depressives are much the same, though with different names, as the obstacles to sound scientific knowledge faced by researchers, the logical fallacies that have been pointed out by philosophers through the ages, the devices used by propagandists to influence audiences, the causes of bias in estimates of probabilities, and many of the sources of faulty decision-making in business and other organizations. Once you recognize the similarity in these conceptual schemes, each one illuminates the others, and the overall scheme gains in generality.

Indeed, cognitive therapy has been moving toward greater use of concepts found in philosophy and other social sciences, some by borrowing but even more by independent invention. The analysis of logical and linguistic fallacies is a prime example of the bridge with philosophy. The utilization of the theory of information processing by Bowlby (1980) is another connection. Still another example is the employment (see Burns (1980, p. 150; Beck, 1987, p. 31) of such ideas from managerial economics as cost-benefit analysis, and supply of resources, and even the term "economy" with respect to the thinking mechanism. And the time is ripe for cognitive therapy to link up with decision theory, as studied in economics, psychology, political science and other fields.2 Cognitive therapy may eventually be the the first truly integrated social science.3

2An interesting connection is the "prospect theory" of Kahnemann and Twersky (1979). They find that people's evaluations of uncertain alternatives are best described as relative rather than absolute, in contrast to tahe assumption of expected-utility theory; this they explain in terms of perception theory, which fits with the discussion of comparisons in Chapter 3. Furthermore, they find that the common reference point is to the present state of affairs. This comparison scheme would seem to have appropriate properties for maximization of one's psychic well-being, in accord with discussion in this book of the appropriate choice of a benchmark-comparison state for a Rosy Mood Ratio, whereas expected-utility theory assumes that people will maximize their monetary wealth without reference to any particular state of affairs. In turn, the analysis given in this book should illuminate prospect theory by explaining why the prospect-theory form of utility function is held by people, and it suggests that the individual's utility function should be related to the individual's score on a depression inventory. And philosophers, psychologists, and economists have joined in exploring the logic and action of such mental mechanisms as "multiple selves", which fits with the practice of cognitive therapeutic techniques. (See Elster, 1986).

3My work in related cognitive fields -- economics, research methods, philosophy, and decision-making has dealt with a wider range of concepts than are traditionally available in clinical psychology. My experience with cognitive psychology and this set of subjects goes back to my undergradate thesis on concept formation in 1952-1953, and has continued with books and articles on each of these subjects mentioned above plus some others; each part of this experience has contributed to the conceptual scheme presented here. There are other remarks on this topic in Chapter 1.

Another aspect of cognitive therapy that one meets in other contexts: The dialogues between therapist and patient that Ellis and Beck and their colleagues conduct are identical in form to the Socratic form of dialogue used especially in law schools and also elsewhere in education. The back-and-forth between student and teacher is an attempt on the part of the teacher to have the student practice clearer thinking about the subject at hand, just as is the back-and-forth between therapist and patient.

Self-comparison is the link between cognition and emotion -- that is, between what you think and what you feel. This traditional joke highlights the nature of the mechanism: A salesman is a person with a shine on his shoes, a a smile on his face, and a lousy territory. So imagine yourself a saleswoman with a lousy territory.

You might first think: I'm more entitled to that territory than Charley is. You then feel anger, perhaps toward the boss who favored Charley. If your anger focuses instead on the person who has the other territory, the pattern is called envy.

But you might also think: I can, and will, work hard and sell so much much that the boss will give me a better territory. In that state of mind you simply feel a mobilization of your human resources toward attaining the object of the comparison.

Or instead you might think: There is no way that I can ever do anything that will get me a better territory, because Charley and other people sell better than I do. Or you think that lousy territories are always given to women. If so, you feel sad and worthless, the pattern of depression, because you have no hope of improving your situation.

Or you may think: I only have this lousy territory another week, after which I move to a terrific territory. Now you are shifting the comparison in your mind from a) your versus another's territory, to b) your territory now versus your territory next week. The latter comparison is not consistent with depression.

Or still another possible line of thought: No one else could put up with such a lousy territory and still make any sales at all. Now you are shifting from a) the comparison of territories, to b) the comparison of your strength with that of other people. Now you feel pride, and not depression.

Cognitive therapy dovetails with the recent broad movement toward regarding individuals as responsible for themselves rather than as being automatons of social forces. For example, this anti-authoritarian pro-freedom trend in thought appears in criminology's shift away from social causation in its view of how to reform criminals, and in economics's evidence that private property rights better motivate individuals to produce than do collective incentives. Whereas in traditional Freudian therapy the analyst is a father figure who always knows best, in cognitive therapy -- especially when carried out by oneself without a therapist -- the individual determines his or her own fate in cognitive-behavioral therapy.

1. An earlier section in this appendix discusses how the concept of negative self-comparisons pulls together into a single coherent theory not only depression but also paranoia, schizophrenia, normal responses to neg-comps, angry responses to negcomps, dread, anxiety, mania, phobias, apathy, and other troubling mental states. Recently, perhaps largely as a result of DSM-III (APA, 1980) and DSM-III-R (APA, 1987), the relationship of the various ailments -- anxiety to depression, schizophrenia to depression, and so on -- has generated considerable interest among students of the field. The ability of Self-Comparisons Analysis to relate all these mental states should make the theory more attractive to students of depression. And the distinction this theory makes between depression and anxiety fits with the recent findings of Steer et. al. (1986) that depression patients show more "sadness" on the Beck Depression Inventory than do anxiety patients, and that this characteristic and loss of libido are the only discriminating characteristics. The loss of libido fits with the part of Self- Comparisons Analysis that makes the presence of helplessness -- that is, felt incapacity -- the causal difference between the two ailments.

2. No distinctions have been made here among endogenous, reactive, neurotic, psychotic, etc. types of depression. This jibes with recent writings in the field (e. g. DSM-III, and see the review by Klerman, 1988), and also with findings that these various supposed classes "are indistinguishable on the basis of cognitive symptomatology" (Eaves and Rush, 1984, cited by Beck,1987.) But the reason for the lack of distinction is more fundamentally theoretical: All varieties of depression share the basic element of Self-Comparisons Analysis -- the common pathway of negative self-comparisons in combination with a sense of helplessness. This element both distinguishes depression from other syndromes and constitutes the key and choke point at which to begin helping the patient change his or her thinking so as to overcome depression.

3. The connection between cognitive therapy, with its emphasis on thought processes, and therapies of emotional release ranging from some aspects of psychoanalysis (including "transference") to "primal scream", merits some discussion. There is no doubt that some people have obtained relief from depression from these experiences, both in and out of psychological treatment. Alcoholics Anonymous is replete with reports of such experiences. William James, in Varieties of Religious Experience, makes a great deal of such "second births". In my own case, one quiet Saturday soon after I started to read and think hard about my depression, I decided not to go to the beach with my family and friends, and stayed alone in the quiet apartment. I felt an unusual lack of pressure to do anything, a freedom to do and be whatever I desired. After wandering around aimlessly for a bit, I lay on the bed face down and began to cry. I was racked with sobs for awhile, and then cried more quietly. And after I stopped I felt wonderful, full of peace in a way that I had not felt for a long time. And a series of thoughts began which led me to sense that my depression would soon be finished. Perhaps most important was the idea that I was not obligated to hold myself to the standards that I had attempted to meet in my work, and I was not required to compare myself with the elevated goals that had previously been before me. (The discovery of my value for my children not having a depressed father would come soon.)

The nature of this sort of process -- which evokes such terms as "release" or "letting go" or "surrender to God" -- may hinge on the very sort of sense of "permission" that Ellis makes so much of. The person finds that she or he is free from the must's and ought's that had made the person feel enslaved. There is truly a "release" from this emotional bondage to a particular set of benchmark-state denominators that cause a constant Rotten Mood Ratio. So here, then, is a plausible connection between emotional release and cognitive therapy, though there undoubtedly are other connections as well.

4. There is a long tradition in psychology -- of which Freud was perhaps the leading practitioner -- of using clinical psychological theories to explain non-clinical phenomena of particular interest to the writer. I, too, shall briefly indulge in this entertainment in next few sections.

It seems to me that there are related non-therapeutic phenomena that Self-Comparisons Analysis illuminates particularly well. One such is the apparently-increasing secular trend in depression, wherein increased suicide accompanies increased income5, but the of relationship over the business cycle where decreased suicide accompanies increased income.6 In the short run, people's denominators (their income) expectations do not change much, and therefore when lower income occurs they compare it unfavorably with their former income. But over the long run, expectations change along with the change in income, and as comparisons are rooted less in such unarbitrary physical matters as a full belly, and more in such arbitrary matters as social standards. No more than a sketch of the analysis can be given in this short space, but perhaps this paragraph will at least be suggestive.

5See Klerman et. al., 1985, for birth-cohort trends, and Klerman, 1986 for a survey of the evidence. Seligman (1988) offers a wide-ranging impressionistic discussion with which the analysis sketched here may be compared. data

6For evidence on this, see Barnes and Simon (1968 ).

5. The apparently-unrelated phenomenon of special- interest-lobby doomsaying rhetoric points up the generality of this conceptual scheme beyond individual therapy. Consider as an example the devices used by those who wish to prove that the United States must protect its oil industry. To that end they attempt to cause depressing thoughts with a gloomy assessment of the situation. They distort the actual facts in the numerator of the Mood Ratio by claiming that there is an increasing shortage of oil, though the key fact is that the availability of oil as measured by the key indicator of its price has been falling in the long run and also in the short run; they also point to declining production capacity in the U. S., but omit mention of increasing production capacity elsewhere in the world which can provide for U. S. consumption. They present a frightening denominator for comparison, a prospect of running out of gasoline and electricity, and the absence of an idyllic world in which people would no longer have to apply effort and resources to obtain energy supplies. They focus attention only on the dimension of oil, without mention of substitute possibilities such as coal, nuclear power, hydropower, and solar energy, or they pooh-pooh them. They also do not mention that in each successive decade energy is a relatively less important part of the economy by all economic measures. And they threaten us with the inevitability of the decline of the U. S. industry, making us feel helpless to improve our situation by developing other alternatives. The entire mechanism of neg-comps-cum-helplessness is exploited to produce depressing thoughts, which presents the palliative of government subsidies and protection for the U. S. oil industry as the only apparent alternative. This is a case study in propaganda technique. The entire world-view schema that underlies doomsaying rhetoric (see Simon, 1981) is similar to the negative bias of depressives to which Beck (1987) also has applied the term "schema".

6. A classic case of unsound thinking with respect to money and business concerns the phenomenon of sunk cost. The amount that a person pays for a good -- whether it be a house or a stock or a patent -- has no proper place in the decision about whether to sell it, or at which price it should be sold; "sunk costs are sunk" and should be disregarded. But many people are unable to disregard the sunk cost, especially when the sale might be below the purchase price because it would then apparently represent a "loss" -- the same word which has been so salient in the depression literature. The problem is the negative comparison between actual sale price and the benchmark price; the resulting sale would be painful and "depressing", and therefore often is not made even though foregoing the sale is money-losing and bad business. (This phenomenon is related to the discussion of prospect theory earlier.)

7. Political scientists theorize that social disturbances occur, not in stable periods of bad times, but after a period of improvement and then cessation of improvement. The period of improvement raises the benchmark denominator of what people expect, and their actual state of affairs seems to fall short of that. This will evoke active efforts to win change if people feel potent, or anger if their efforts are thwarted. If they come to feel helpless, people lapse into depression and lack of activity, or finally into apathy.