An Integrated Cognitive Theory of Depression
Rehm recently summarized the state of depression studies as follows: "The important question to be asked here is, Can the various factors that have been postulated [with respect to the causation of depression] be reduced to some single factor characteristic of depressive inference? The likely candidate appears to be simply negativity about oneself." (1988, p. 168). Alloy and Abramson begin another recent article in similar fashion: "It is common knowledge that depressed people view themselves and their experiences negatively" (1988, p. 223).
The present article argues that, typically, Rehm's summary(1) is correct but insufficient. It is incomplete in omitting the role of a sense of helplessness, which I shall argue is a vital auxiliary to the central mechanism. Even more fundamental, the summary's term and concept "negativity" are crucially imprecise; they do not specify what this paper argues is the key intellectual mechanism responsible for the pain in depression. A theory will be offered which substitutes the concept of negative self-comparisons for negativity, a substitution for which major theoretical and therapeutic benefits are claimed.
Beck has properly claimed as an advantage of his Cognitive Therapy over previous work 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 article offers a more comprehensive theory of depression which includes the theories of Beck, Ellis, and Seligman as elements within it. The theory focuses on the key cognitive channel -- self- comparisons -- through which all the other influences flow. Specific therapeutic devices are clearly dictated by this theory, many more devices than are suggested by any of the previous approaches alone.
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, and instead, the concept "negative thoughts" has been used. That is, negative thoughts have not been discussed in a systematic fashion as comprising comparisons. Nor have theorists specified the interaction between negative self-comparisons and the sense of helplessness, which converts negative self-comparisons into sadness and depression.
An expanded theoretical view of depression which encompasses and integrates the key insights of previous theories makes possible that instead of the field being seen as a conflict of "schools," each of the "schools" may be seen as having a distinctive therapeutic method that fits the needs of different sorts of sufferers from depression. The framework of Self- Comparisons Analysis helps weigh the values of each of these methods for a particular sufferer. Though the various methods may sometimes be serviceable substitutes for each other, usually they are not simply viable alternatives for the given situation, and Self-Comparisons Analysis helps one choose among them. This should be of particular benefit to the helping professional who is responsible for referring a patient to one or another specialist for depression treatment. In practice the choice probably is usually made mainly on the basis of which "school" the referring professional is most familiar with, a practice severely criticized by recent writers (e. g. Papalos and Papalos, 1987).
For ease of exposition I shall frequently use the word "you" in referring to the subject of the theoretical analysis and therapy.
A negative self-comparison is the last link in the causal chain leading to sadness and depression. It is the "common pathway," in medical parlance. You feel sad when a) you compare your actual situation with some "benchmark" hypothetical situation, and the comparison appears negative; and b) you think you are helpless to do anything about it. This is the whole of the theory. The theory does not encompass the antecedent causes of a person having a propensity to make negative self-comparisons or to feel helpless to alter her/his life situation.
1. The "actual" state in a self-comparison is what you perceive it to be, rather than what it "really" is.2 And a person's perceptions may be systematically biased to make the comparisons negative.
2. The "benchmark" situation may be of many sorts:
- The benchmark situation may be one that you were accustomed to and liked, but which no longer exists. This is the case, for example, after the death of a loved one; the consequent grief-sadness arises from comparing the situation of bereavement with the situation of the loved one being alive.
- The benchmark situation may be something that you expected to happen but that did not materialize, for example, a pregnancy you expected to yield a child but which ended in miscarriage, or the children you expected to raise but never were able to have.
- The benchmark may be a hoped-for event, a hoped-for son after three daughters that turns out to be another daughter, or an essay that you hope will affect many people's lives for the good but that languishes unread in your bottom drawer.
- The benchmark may be something you feel you are obligated to do but are not doing, for example, supporting your aged parents.
- The benchmark may also be the achievement of a goal you aspired to and aimed at but failed to reach, for example, quitting smoking, or teaching a retarded child to read.
The expectations or demands of others may also enter into the benchmark situation. And, of course, the benchmark state may contain more than one of these overlapping elements.
3. The comparison can be written formally as:
Mood=(Perceived state of oneself) (Hypothetical benchmark state)
This ratio bears a resemblance to William James' formula for self-esteem, but it is rather different in content.
If the numerator in the Mood Ratio is low compared to the denominator--a state of affairs which I'll call a Rotten Ratio-- your mood will be bad. If on the contrary the numerator is high compared to the denominator--a state which I'll call a Rosy Ratio--your mood will be good. If the ratio is Rotten and you feel helpless to change it, you will feel sad. Eventually you will be depressed if a Rotten Ratio and a helpless attitude continue to dominate your thinking.
The comparison you make at a given moment may concern any one of many possible personal characteristics-- occupational success, personal relationships, state of health, or morality, for just a few examples. Or you may compare yourself on several different characteristics from time to time. If the bulk of self-comparison thoughts are negative over a sustained period of time, and you feel helpless to change them, you will be depressed.
Only this framework makes sense of such cases as the person who is poor in the world's goods but nevertheless is happy, and the person who "has everything" but is miserable; not only do their actual situations affect their feelings, but also the benchmark comparisons they set up for themselves.
The sense of loss, which often is associated with the onset of depression, also can be seen as a negative self-comparison -- a comparison between the way things were before the loss, and the way they are after the loss. A person who never had a fortune does not experience the loss of a fortune in a stock market crash and therefore cannot suffer grief and depression from losing it. Losses that are irreversible, such as the death of a loved one, are particularly saddening because you are helpless to do anything about the comparison. But the concept of comparisons is a more fundamental logical element in thought processes than is loss, and therefore it is a more powerful engine of analysis and treatment.
The key element for understanding and dealing with depression, then, is the negative comparison between one's actual state and one's benchmark hypothetical situation, together with the attitude of helplessness as well as the conditions that lead a person to make such comparisons frequently and acutely.
Hints of the self-comparison concept are common in the literature. For example, Beck remarks that "the repeated recognition of a gap between what a person expects and what he receives from an important interpersonal relationship, from his career, or from other activities, may topple him into a depression" (Beck, 1976, p. 108) and "The tendency to compare oneself with others further lowers self-esteem" (p. 113). But Beck does not center his analysis on the self-comparisons. The systematic development of this idea which constitutes the new approach offered here.
Self-comparison is the link between cognition and emotion -- that is, between what you think and what you feel. A hoary old joke illuminates 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. To illustrate with a light touch, let us explore the cognitive and emotional possibilities for 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.
You might think: No, I probably can't improve the situation. But maybe these incredible efforts I'm making will get me out of this. In that case, you are likely to feel anxiety mixed with depression.
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 pleasant and 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.
Why Do Negative Self-Comparisons Cause A Bad Mood?
Now let us consider why negative self-comparisons produce a bad mood.
There are grounds for belief in a biological connection between negative self-comparisons and physically-induced pain. Psychological trauma such as a loss of a loved one induces some of the same bodily changes as does the pain from a migraine headache, say. When people refer to the death of a loved one as "painful", they are speaking about a biological reality and not just a metaphor. It is reasonable that more ordinary "losses" -- of status, income, career, and of a mother's attention or smile in the case of a child -- have the same sorts of effects, even if milder. And children learn that they lose love when they are bad, unsuccessful, and clumsy, as compared to when they are good, successful, and graceful. Hence negative self-comparisons indicating that one is "bad" in some way are likely to be coupled with the biological connections to loss and pain. It also seems reasonable that the human's need for love is connected to the infant's need for food and being nursed and held by its mother, the loss of which must be felt in the body (Bowlby, 1969; 1980).3
Indeed, there is a statistical link between the death of a parent and the propensity to be depressed, in both animals and humans. And much careful laboratory work shows that separation of adults and their young produces the signs of depression in dogs and monkeys (Scott and Senay, 1973). Hence lack of love hurts, just as lack of food makes one hungry.
Furthermore, there apparently are chemical differences between depressed and undepressed persons. Similar chemical effects are found in animals which have learned that they are helpless to avoid painful shocks (Seligman, 1975, pp. 68, 69, 91, 92). Taken as a whole, then, the evidence suggests that negative self-comparisons, together with a sense of helplessness, produce chemical effects linked to painful bodily sensations, all of which results in a sad mood.
A physically-caused pain may seem more "objective" than a negative self-comparison because the jab of a pin, say, is an absolute objective fact, and does not depend upon a relative comparison to cause a painful perception of it4. The bridge is that negative self-comparisons are connected to pain through learning during one's entire lifetime. You learn to be hurt by a lost job or an examination failure; a person who has never seen an exam or a modern occupational society could not be caused pain by those events. Learned knowledge of this sort always is relative, a matter of comparisons, rather than involving only one absolute physical stimulus.
This implies therapeutic opportunity: It is because the causes of sadness and depression are largely learned that we can hope to remove the pain of depression by managing our minds properly. This is why we can conquer psychologically-induced pain with mental management more easily than we can banish the sensation of pain from arthritis or from freezing feet. With respect to a stimulus that we have learned to experience as painful--lack of professional success, for example--we can re- learn a new meaning for it. That is, we can change the frame of reference, for example, by altering the comparison states that we choose as benchmarks. But it is impossible (except perhaps for a yogi) to change the frame of reference for physical pain so as to remove the pain, though one can certainly reduce the pain by quieting the mind with breathing techniques and other relaxation devices, and by teaching ourselves to take a detached view of the discomfort and pain.
To put the matter in different words: Pain and sadness which are associated with mental events can be prevented because the meaning of the mental events was originally learned; re- learning can remove the pain. But the impact of physically- caused painful events depends much less on learning, and hence re-learning has less capacity to reduce or remove the pain.
Comparison and evaluation of the present state of affairs relative to other states of affairs is fundamental in all information processing, planning, and judgmental thinking. When someone said that life is hard, Voltaire is said to have answered, "Compared to what?" An observation attributed to China illuminates the centrality of comparisons in understanding the world: A fish would be the last to discover the nature of water.
Basic to scientific evidence (and to all knowledge-diagnostic processes including the retina of the eye) is the process of comparison of recording differences, or of contrast. Any appearance of absolute knowledge, or intrinsic knowledge about singular isolated objects, is found to be illusory upon analysis. Securing scientific evidence involves making at least one comparison. (Campbell and Stanley, 1963, p. 6)
Every evaluation boils down to a comparison. "I'm tall" must be with reference to some group of people; a Japanese who would say "I'm tall" in Japan might not say that in the U. S. If you say "I'm good at tennis", the hearer will ask, "Whom do you play with, and whom do you beat?" in order to understand what you mean. Similarly, "I never do anything right" , or "I'm a terrible mother" is hardly meaningful without some standard of comparison.
Helson put it this way: "[A]ll judgments (not only judgments of magnitude) are relative" (1964, p. 126). That is, without a standard of comparison, you cannot make judgments.
Other Related States
Other states of mind which are reactions to the psychological pain of negative self-comparisons5 fit well with this view of depression, as illustrated in the saleswoman joke earlier. Spelling out the analyses further:
1) The person suffering from anxiety compares an anticipated and feared outcome with a benchmark counterfactual; anxiety differs from depression in its uncertainty about the outcome, and perhaps also about the extent to which the person feels helpless to control the outcome.6 People who are mainly depressed often suffer from anxiety, too, just as people who suffer from anxiety also have symptoms of depression from time to time (Klerman, 1988, p. 66). This is explained by the fact that a person who is "down" reflects on a variety of negative self- comparisons, some of which focus on the past and present whereas others focus on the future; those negative self-comparisons pertaining to the future are not only uncertain in nature but may sometimes be altered, which accounts for the state of arousal that characterizes anxiety in contrast to the sadness that characterizes depression.
Beck (1987, p. 13) differentiates the two conditions by saying that "In depression the patient takes his interpretation and predictions as facts. In anxiety they are simply possibilities". I add that in depression an interpretation or prediction -- the negative self-comparison -- may be taken as fact, whereas in anxiety the "fact" is not assured but is only a possibility, because of the depressed person's feeling of helplessness to change the situation.
2) In mania the comparison between actual and benchmark states seems to be very large and positive, and often the person believes that she or he is able to control the situation rather than being helpless. This state is especially exciting because the manic person is not accustomed to positive comparisons. Mania is like the wildly-excited reaction of a poor child who has never before been to a circus. In the face of an anticipated or actual positive comparison, a person who is not accustomed to making positive comparisons about his life tends to exaggerate its size and tends to be more emotional about it than are people who are accustomed to comparing themselves positively.
3) Dread refers to future events just as does anxiety, but in a state of dread the event is expected for sure, rather than being uncertain as is the case in anxiety. One is anxious about whether one will miss the meeting, but one dreads the moment when one finally gets there and has to perform an unpleasant task.
4) Apathy occurs when the person responds to the pain of negative self-comparisons by giving up goals in order that there no longer be a negative self-comparison. But when this happens the joy and the spice go out of life. This may still be thought of as depression, and if so, it is a circumstance when depression occurs without sadness -- the only such circumstance that I know of.
Bowlby observed in children aged 15 to 30 months of age who were separated from their mothers a pattern that fits with the relationships between types of responses to negative self- comparison outlined here. Bowlby labels the phases "Protest, Despair, and Detachment". First the child "seeks to recapture [his mother] by the full exercise of his limited resources. He will often cry loudly, shake his cot, throw himself about...All his behavior suggests strong expectation that she will return" (Bowlby, 1969, Vol. 1, p. 27). Then, "During the phase of despair...his behaviour suggests increasing hopelessness. The active physical movements diminish or come to an end...He is withdrawn and inactive, makes no demands on people in the environment, and appears to be in a state of deep mourning" (p. 27). Last, in the phase of detachment, "there is a striking absence of the behaviour characteristic of the strong attachment normal at this age...he may seem hardly to know [his mother]...he may remain remote and apathetic...He seems to have lost all interest in her" (p. 28). So the child eventually removes the painful negative self-comparisons by removing the source of the pain from his thought.
5) Various positive feelings arise when the person is hopeful about improving the situation-- that is, when the person contemplates changing the negative comparison into a more positive comparison.
People we call "normal" find ways to deal with losses and the consequent negative self-comparisons and pain in ways that keep them from prolonged sadness. Anger is a frequent response which can be useful, partly because the anger-caused adrenaline produces a rush of good feeling. Perhaps any person will eventually be depressed if subjected to many very painful experiences, even if the person does not have a special propensity for depression; consider Job. And paraplegic accident victims judge themselves to be less happy than do normal uninjured people (Brickman, Coates, and Bulman, 1977). On the other hand, Beck asserts that survivors of painful experiences such as concentration camps are no more subject to later depression than are other persons (Gallagher, 1986, p. 8).
Requited youthful romantic love fits nicely into this framework. A youth in love constantly has in mind two deliciously positive elements -- that he or she "possesses" the wonderful beloved (just the opposite of loss), and that messages from the beloved say that the youth is wonderful, the most desired person in the world. In the unromantic terms of the mood ratio this translates into numerators of the perceived actual self being very positive relative to a range of benchmark denominators that the youth compares him/herself to at that moment. And the love being returned -- indeed the greatest of successes -- makes the youth feel full of competence and power because the most desirable of all states -- having the love of the beloved -- is not only possible but is actually being realized. So there is a Rosy Ratio and just the opposite of helplessness and hopeless. No wonder it feels so good.
It makes sense, too, that unrequited love feels so bad. The person is then in the position of being denied the most desirable state of affairs imaginable, and believing her/himself incapable of bringing about that state of affairs. And when one is rejected by the lover, one loses that most desirable state of affairs which formerly obtained. The comparison then is between the actuality of being without the beloved's love and the former state of having it. No wonder it is so painful to believe that it really is over and nothing one can do can bring back the love.
Therapeutic Implications of Self-Comparisons Analysis
Now we may consider how one's mental apparatus may be manipulated so as to prevent the flow of negative self- comparisons which the person feels helpless to improve. 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 call for different therapeutic interventions. Furthermore, there may be several sorts of intervention that can help any particular depression.
The possibilities include: changing the numerator in the Mood Ratio; changing the denominator; changing the dimensions upon which one compares oneself; making no comparisons at all; reducing one's sense of helplessness about changing the situation; and using one or more of one's most cherished values as an engine to propel the person out of depression. Sometimes a powerful way to break a logjam in one's thinking is to get rid of some "oughts" and "musts", and recognize that it is not necessary to make the negative comparisons that have been causing the sadness. Each of these modes of intervention includes a wide variety of specific tactics, of course, and each is briefly described in Appendix A to this paper. (The appendix is not intended for publication with this paper because of the limitations of space, but will be made available upon request. Longer descriptions are given in book form; Pashute, 1990).
In contrast, each of the contemporary "schools", as Beck (dustjacket of Klerman et. al., 1986.) and Klerman et. al. (1986, p. 5) call them, addresses one particular part of the depression system. 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" (pp. 4, 5). Any "school" is therefore likely to achieve best results with people whose depression derives most sharply from the element in the cognitive system which that school focuses upon, but is likely to do less well with people whose problem is mainly with some other element in the system.
More broadly, each of the various basic approaches to human nature -- psychoanalytic, behavioral, religious, and so on-- intervenes in its characteristic manner no matter what the cause of the person's depression, on the implicit assumption that all depressions are caused in the same way. Furthermore, practitioners of each viewpoint often insist that its way is the only true therapy even though, because "depression is almost certainly caused by different factors, there is no single best treatment for depression" (Greist and Jefferson, 1984, p. 72). As a practical matter, the depression sufferer faces a baffling array of potential treatments, and the choice is too often made simply on the basis of what is readily at hand.
Self-comparisons Analysis points a depression sufferer toward the most promising tactic to banish the particular person's depression. It first inquires why a person makes negative self-comparisons. Then in that light it develops ways of preventing the negative self-comparisons, rather than focusing on merely understanding and reliving the past, or on simply changing contemporary habits.
Differences From Previous Theories
Before discussing differences, the fundamental similarity must be stressed. From Beck and Ellis comes the central insight that particular modes of "cognitive" thinking cause people to be depressed. This implies the cardinal therapeutic principle that people can change their modes of thinking by a combination of learning and will-power in such fashion as to overcome depression.
This section barely dips into the vast literature on depression theory; a thorough review would not be appropriate here, and several recent works contain comprehensive reviews and bibliographies (e. g. Alloy, 1988; Dobson, 1988). I shall focus only on some major themes for comparison.
The key point is this: Beck focuses on distortion of the actual-state numerator; 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. Seligman argues that removing the sense of helplessness will alleviate the depression. Self-comparisons Analysis embraces Beck's and Ellis's 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. And it integrates Seligman's principle by noting that the pain of negative self- comparison becomes sadness and eventually depression in the context of belief that one is helpless to make changes. Hence, Self-comparisons Analysis reconciles and integrates Beck's and Ellis's and Seligman's approaches. At the same time the self- comparisons construct points to many additional points of therapeutic intervention in the depression system.
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). This is certainly excellent advice, but it lacks system and is vague. In contrast, focusing on your negative self-comparisons is a clear-cut and systematic method of achieving this aim.
Beck and his followers 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 an exclusive focus on distortion obscures the deductively-consistent inner logic of many depressives, and denies validity to such issues as which life goals should be chosen by the sufferer.7 The emphasis on distortion also has pointed away from the role of helplessness in hindering the purposive activities which sufferers might otherwise undertake to change the actual state and thereby avoid the negative self-comparisons.
Beck's view of depression as "paradoxical" (1967, p. 3; 1987, p. 28) is not helpful, I believe. Underlying that 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. A better model for therapeutic purposes is an individual with limited analytic capacity, partial information, and conflicting desires. Given these inescapable constraints, it is inevitable that the person's thinking 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. Following on this view, we may try to help the individual reach a higher level of satisficing (Herbert Simon'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.8
Another difference between Beck's and the present point of view is that Beck 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 greatly twisted 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, a process that can be interpreted as loss only with great contortions. 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 than does the more limited concept of loss to a variety of ways that one's thinking can change to overcome depression.
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 (such as decision-making theory) than is a less basic concept. Hence this more basic concept would seem preferable on the grounds of potential theoretical fruitfulness.
Ellis's Rational-Emotive Therapy
Ellis focuses primarily upon the benchmark state, urging that the depressive not consider goals and oughts as binding upon them. He teaches people not to "musturbate" -- that is, to get rid of unnecessary must's and ought's.
Ellis's therapy helps the person adjust the benchmark state in such fashion that the person makes fewer and less-painful negative self-comparisons. But like Beck, Ellis focuses on a single aspect of the depression structure. His doctrine therefore restricts the options available to the therapist and sufferer, omitting some other avenues which may serve a particular person's needs.
Seligman's Learned Helplessness
Seligman focuses on the helplessness that most depression sufferers report, and which combines with negative self- comparisons to produce sadness. 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" (1975, p. 78), i. e. the sense of helplessness. And he gives the impression that helplessness is the only invariable element. This emphasis seems to point him away from therapy that intervenes at other points within the depression system. (This may follow from his experimental work with animals, which do not have the capacity to make adjustments in perceptions, judgments, goals, values, and so on, such as are central to human depression and which people can and do alter. That is, people disturb themselves, as Ellis puts it, whereas animals apparently do not.)
Self-comparisons Analysis and the procedure it implies include having the sufferer learn not to feel helpless. But this approach focuses on the helpless attitude in conjunction with the negative self-comparisons 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.
Klerman, Weissman, and colleagues focus on the negative self-comparisons that flow from interactions between the depressive and others as a result of conflict and criticism. Bad relationships with other people surely damage a person's actual inter-personal situation and exacerbate other difficulties in the person's life. Therefore it is undeniable that teaching a person better ways of relating to others can improve a person's actual 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. Therefore, to focus only on inter-personal relationships to the exclusion of other cognitive and behavioral elements is too limited.
Viktor Frankl's Logotherapy offers two modes of help to sufferers from depression. He offers philosophical argument to help find meaning in the person's life which will provide a reason to live and to accept the pain of sadness and depression; the use of values in Self-comparisons Analysis has much in common with this tactic. Another mode is the tactic Frankl calls "paradoxical intention". The therapist offers the patient a radically different perspective on the patient's situation with respect to either the numerator or the denominator of the Mood Ratio, using absurdity and humor. Again Self-comparisons Analysis encompasses this mode of intervention.
Some Other Technical Issues That Self-Comparisons Analysis Illuminates
1. It was noted earlier that the concept of negative self- comparisons pulls together into a single coherent theory not only depression but normal responses to negative self-comparisons, angry responses to negative self-comparisons, dread, anxiety, mania, phobias, apathy, and other troubling mental states. (The brief discussion here is no more than a suggestion about the direction a full-scale analysis might take, of course. And it might extend to schizophrenia and paranoia in this limited context.) Recently, perhaps partly a result of DSM-III (APA, 1980) and DSM-III-R (APA, 1987), the relationships among the various ailments -- anxiety with depression, schizophrenia with depression, and so on -- has generated considerable interest among students of the field. The ability of Self-comparisons Analysis to relate 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; 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, or other types of depression. This course 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 types "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 common pathway of negative self-comparisons in combination with a sense of helplessness, which is the focus of Self-Comparisons Analysis. This element both distinguishes depression from other syndromes and constitutes the key 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 such techniques as "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 (1902/1958), makes a great deal of such "second births".
The nature of this sort of process -- which evokes such terms as "release" or "letting go" or "surrender to God" -- may hinge on the sense of "permission" that Ellis makes much of. The person comes to feel free of the musts and oughts 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.
Summary and Conclusions
Self-comparisons Analysis does the following: 1) 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 heterogeneous 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) Sharpens each of the other viewpoints by converting the too-vague notion of "negative thinking" to a precise formulation of a self-comparison and a negative Mood Ratio with two specific parts -- a perceived actual state of affairs, and a hypothetical benchmark state of affairs. This framework opens up a wide variety of novel interventions. 3) Offers a new line of attack upon stubborn depressions by leading the sufferer to make a committed choice to give up depression in order to attain important deeply-held values.
The "actual" state is the state that "you" perceive yourself to be in; a depressive may bias perceptions so as to systematically produce negative comparisons. The benchmark situation may be the state you think you ought to be in, or the state you formerly were in, or the state you expected or hoped to be in, or the state you aspire to achieve, or the state someone else told you you must achieve. This comparison between actual and hypothetical states makes you feel bad if the state in which you think you are in is less positive than the state you compare yourself to. And the bad mood will become a sad mood rather than an angry or determined mood if you also feel helpless to improve your actual state of affairs or to change your benchmark.
The analysis and approach offered here fit with other varieties of cognitive therapy as follows:
1) Beck's original version of Cognitive Therapy has the patient "build self-esteem" and avoid "negative thoughts". But neither "self-esteem" nor "negative thought" is a precise theoretical term. Focusing on one's negative self-comparisons is a clear-cut and systematic method for achieving the goal Beck sets. But there are also other paths to overcoming depression that are part of the overall approach given here.
2) Seligman's "learned optimism" focuses upon ways to overcome learned helplessness. The analytic procedure suggested here includes learning not to feel helpless, but the present approach focuses on the helpless attitude in conjunction with the negative self-comparisons that are the direct cause of the sadness of depression.
3) Ellis teaches people not to "musterbate" -- that is, to free oneself of unnecessary musts and oughts. This tactic helps a depressive adjust his/her benchmark state, and the person's relationship to it, in such fashion that fewer and less-painful negative self-comparisons are made. But as with Beck's and Seligman's therapeutic advice, Ellis's focuses on only one aspect of the depression structure. As a system, it therefore restricts the available options, omitting some other avenues which may be just what a particular person needs.
Heretofore, the choice among therapies had to be made mainly on competing merits. Self-comparisons Analysis provides an integrated framework which directs attention to those aspects of a sufferer's thought which are most amenable to intervention, and it then suggests an intellectual strategy appropriate for those particular therapeutic opportunities. The various therapeutic methods thereby become complements rather than competitors.
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1 The American Psychiatric Association's publication Depression and Its Treatment by John H. Greist and James W. Jefferson statement is similar and may be taken as canonical: "Depressed thinking often takes the form of negative thoughts about one's self, the present and the future" (1984, p. 2, italics in original). "Negative thinking" is also where the concept with which cognitive therapy of depression began, in the work of Beck and Ellis.
2 If you think you have failed an examination, even though you will later learn you passed it, then your perceived actual state is that you have failed the test. Of course there are many facets of your actual life that you can choose to focus upon, and the choice is very important. The accuracy of your assessment is important, too. But the actual state of your life usually is not the controlling element in depression. How you perceive yourself is not completely dictated by the actual state of affairs. Rather, you have considerable discretion as to how to perceive and assess the state of your life.
3 This view, though phrased as learning theory, is consistent with the psychoanalytic view: "At the bottom of the melancholiac's profound dread of impoverishment, there is really the dread of starvation...drinking at the mother's breast remains the radiant image of unremitting, forgiving love: (Rado in Gaylin, 1968, p. 80).
4 Please notice that this statement in no way denies that biological factors may be implicated in a depression. But biological factors, to the extent that they are operative, are underlying predisposing factors of the same order as a person's psychological history, rather than contemporary triggering causes.
5 Gaylin (1979) provides rich and thought-provoking descriptions of the feelings connected with these and other states of mind. But he does not distinguish between pain and the other states he calls "feelings," which I find confusing (see e.g. p. 7). Gaylin mentions in passing that he has found very little in print about feelings, which he classifies as an "aspect of emotions" (p. 10).
6 As Beck et. al. (1987) put it, based on patient responses to a study of "automatic thoughts" using a questioner, "anxiety cognitions...embody a greater degree of uncertainty and an orientation toward the future, whereas depressive cognitions are either oriented toward the past or reflect a more absolute negative attitude toward the future."
Freud asserted that "when the mother-figure is believed to be temporarily absent the response is one of anxiety, when she appears to be permanently absent it is one of pain and mourning." Bowlby in Gaylin, The Meaning of Despair (New York: Science House, 1968) p. 271.
7 In 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.
8 Burns nicely summarizes Beck's approach as follows: "The first principle of cognitive therapy is that all your moods are created by your 'cognitions'" (1980, p. 11). 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 "negativity" 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.
The name of the author on the enclosed paper is a pseudonym for a writer who is well-known in another field but does not ordinarily work in the field of cognitive therapy. The author asked me to send a copy to you (and to some others in the field) in hopes that you will give him/her some criticism on it. He/she feels that it would be fairer to the paper and to him/herself that you read it without knowing the author's identity. Your comments would be particularly valuable because of the author writes from outside your field.
In advance, thank you for your time and thought to an unknown colleague.
(see p. 16 of paper)
Indeed, a solid body of research in recent years suggests that depressives are more accurate in their assessments of the facts concerning their lives than are non-depressives, who tend to have an optimistic bias. This raises interesting philosophical questions about the virtue of such propositions as "Know thyself", and "The unexamined life is not worth living", but we need not pursue them here.
2.1See Alloy and Abramson (1988) for a review of the data. If you make no self-comparisons, you will feel no sadness; that's the point of this chapter in a nutshell. A recent body of research0.1 confirms that this is so. There is much evidence that increased attention to yourself, in contrast to increased attention to the people, objects, and events around you, is generally associated with more signs of depressed feeling.
0.1This body of research is reviewed by Musson and Alloy (1988). Wicklund and Duval (1971, cited by Musson and Alloy) first directed attention to this idea.
Staff, H. (2008, December 1). An Integrated Cognitive Theory of Depression, HealthyPlace. Retrieved on 2023, September 26 from https://www.healthyplace.com/depression/articles/an-integrated-cognitive-theory-of-depression