I've never had any "real" mental health problems, but sometimes I feel stressed or guilty or whatever, like everyone, and who doesn’t want to feel more good more often? So a couple months ago I read Feeling Great: The Revolutionary New Treatment for Depression and Anxiety by David Burns (published 2020) on audiobook. I was really glad I did!

I can't comment on how it compares to other psychotherapy books. It's the first one I've ever read, and I kinda came upon it randomly—an acquaintance recommended David Burns's podcast, so I listened to a couple random episodes, and I found them intriguing but confusingly out-of-context, so instead I bought his book which was much better.

But for what it's worth, David Burns's older 1980 book, Feeling Good, is super famous and popular, and apparently there are studies that say that giving people a copy of Feeling Good is as effective as antidepressants, with effects that persist for years (ref). (More discussion on wikipedia.) Also, I just saw that Scott Alexander suggested Feeling Great for people with depression. So of all the psychotherapy books to randomly stumble across, I think I got a pretty legit one!!

I'm not going to talk about everything in the book in this review; I just want to flag a few parts that were highlights for me.

I also couldn't resist throwing in some speculations on the neuroscience of depression at the bottom.

“Classic CBT” stuff

David Burns is, I gather, something of a leader in Cognitive-Behavioral Therapy (CBT). What is CBT? My vague pop-culture stereotyped impression of CBT has been something like:

• The patient says “I’m a terrible person and everyone hates me”.
• Then the therapist and patient have a discussion to try to tease out (1) whether that’s actually true (very often it’s not), (2) even if it is true, whether it’s a good reason to feel miserable, as opposed to, y’know, self-acceptance, trying to solve the problem, etc., (3) given 1 and 2, what are good strategies to actually stop feeling miserable, including what to think about, what to visualize, what to do, etc.

I haven’t read David Burns’s more famous older book Feeling Good, but my vague impression is that it’s largely about that kind of stuff, and in particular, that it’s full of lots of different techniques for questioning and countering negative thoughts and feelings.

This new book reprises and (he says) somewhat improves on that material. I found that part somewhat but not terribly helpful to me personally, mainly because I do that part instinctively, at least to some extent. I'm a very analytical guy, I think I'm pretty well aware of which of my negative thoughts are literally true and which ones aren't, and several of his suggested techniques were things I’ve been doing naturally since forever (although others were new to me). I may still refer back to that part of the book at some point, but the best part for me was something else…

The big new thing: "Magic Button, Positive Reframing, Magic Dial"

Compared to previous work (like Feeling Good), Burns adds a big new thing, which he says makes a huge difference in getting through to his patients who used to remain stuck no matter how many negative-thought-countering techniques he would throw at them. He says that he can now reliably have his patients walk out of their very first extended (~2-hour) therapy sessions feeling dramatically happier, maybe even dancing-on-the-sidewalk happy, even if they’ve spent the previous 20 years suffering treatment-resistant depression and anxiety. That’s a pretty bold claim, but I guess I'm inclined to believe it, because apparently he does exactly that all the time in front of live audiences, and you can even listen to numerous live sessions of that type on his podcast. Sure, maybe he only broadcasts the best sessions, or maybe he's lying, whatever, I don't really know, I'm just inclined to believe him right now. I think the peer-reviewed studies using this new technique are still underway.

So what’s this big new thing? He has a shtick that he goes through every time. I’ll just excerpt it.

Example "Magic Button, Positive Reframing, Magic Dial" shtick:

Next I asked Maria the miracle cure question: If a miracle happened in today’s session, what miracle would she be hoping for? She said she wanted her negative thoughts and feelings to disappear so she could enjoy her baby daughter and her role as a new mother without feeling miserable all the time.

I asked her to imagine that we had a magic button and that if she pushed it, all of her negative thoughts and feelings would instantly disappear, with no effort at all, and she’d immediately feel joyous, even euphoric. Would she push the button?

Maria said she’d definitely push the button. Almost everyone says that!

I told Maria that I didn’t have a magic button, but I did have some awesome tools, and I predicted that if we used them, she’d probably feel a whole lot better by the end of the session and might even feel joyful. But I told her I wasn’t so sure it would be a good idea to use those tools.

She was surprised and asked why not. I explained that although her negative thoughts and feelings were certainly creating a lot of pain for her, I suspected there might be some real advantages, or benefits, of thinking and feeling the way she did. I added that her negative thoughts and feelings might also be an expression of her most beautiful and awesome qualities, and that maybe we should take a look at that before we went about trying to change things.

I suggested we could ask the following questions about each negative thought or feeling before she made any decision about pressing the magic button:

1. What are some benefits, or advantages, of this negative thought or feeling? How might it be helping you and your baby?

2. What does this negative thought or feeling show about you and your core values that’s positive and awesome?

…And now they go through the “positive reframing” part. I’ll get back to that below. After that, here's the rest of the shtick…

Once we’d listed all the positives we could think of, I asked Maria if she felt the list was realistic. She said the list was absolutely realistic but very surprising since she’d never thought there could be anything positive about how she was thinking and feeling. She’d been thinking that her depression and anxiety meant there was something wrong with her and not that there might be something right with her.

I asked Maria if she still wanted to press the magic button since all of these positives would go down the drain along with her negative thoughts and feelings. Maria insisted that she still wanted to feel better because her suffering was almost unbearable.

Now she had a dilemma. She wanted to feel better, but she also didn’t want to give up all the fabulous things on our list of positives. As her therapist, I also wasn’t trying to sell her on the idea of change. Instead, I was doing the opposite. I was trying to persuade her that all of her negative thoughts and feelings showed what was really great about her and that she shouldn’t give them up.

To help her resolve this dilemma, I asked Maria to imagine that we had a magic dial instead of a magic button and that she could dial down each negative feeling to a more manageable level that would allow her to keep all the benefits of that feeling without feeling so much intense pain. That way, she could feel better without losing all the beautiful things we’d listed about her.

What would she dial each feeling down to, starting with depression? How sad and depressed would she want to feel at the end of our session? What might be an appropriate level of depression given all the horrible things she’d been going through? She said 15% would be plenty of depression, so she recorded this as a goal in the second column of her Daily Mood Journal, as you can see. She also decided to dial her anxiety down from 80% to 20%, so on and so forth.

…So then after that “magic button, positive reframing, magic dial” shtick we get to the “classic CBT” stuff, where he goes through his many techniques to counter negative thoughts.

I cut the "positive reframing" part out of the middle of the excerpt above. How does that work? He actually goes through lots of examples of "positive reframing" throughout the book. It’s pretty easy once you get the hang of it. In fact, since reading the book I’ve done it myself, sporadically. For example:

My typical inner monologue before reading the book:

1. Negative thought: I spend too much money.
2. “Classic CBT”-ish self-talk: I don't spend too much money and/or shouldn't feel bad about it because of (long list of well-rehearsed perfectly-sensible reasons).

My typical inner monologue after reading the book:

1. Negative thought: I spend too much money.
2. Positive reframing: This thought has a lot of benefits for me, and it also illustrates beautiful and awesome aspects of me and my core values, for the following reasons: (1) It motivates me to remain aware about my finances, (2) and it protects me from making bad financial decisions, (3) and it demonstrates that I’m prudent, (4) and conscientious, (5) and humble, (6) and responsible, (7) and frugal, etc. etc.
3. Magic dial: OK so it’s good that I feel that way, and I want to keep feeling that way, I just don’t want to feel that way quite so strongly and often, maybe I want to dial it down from 80% to 20%, and the 20% would still be plenty high enough to keep reaping those benefits.
4. “Classic CBT”-ish self-talk: I don't spend too much money and/or shouldn't feel bad about it because of (long list of well-rehearsed perfectly-sensible reasons).

The final step is the same in both cases, but my experience is that without those extra two steps in the middle, the final step doesn't sink in nearly as well. Like I would believe it on an intellectual level but still feel bad. The new system is definitely an improvement. Really, it still feels slightly magical.

The same pattern has been working well for my various other periodically-recurring stupid negative thoughts, like "I shouldn't have said that mildly-embarrassing thing when chatting with my friend three weeks ago", or “I should be doing better at my job”, or “I'm recklessly hastening the apocalypse”, or whatever. (Yeah I know, First-World Problems…) In all cases I find that coming up with the "positive reframing" list is pretty easy, once I actually try. But maybe it helps that I read the book, with its tons of examples of positive-reframing a wide variety of types of negative thoughts.

So that’s the main practical thing I got out of the book.

Exposure therapy

Another thing in the book that I found interesting was that the author is super into exposure therapy, and moreover he makes exposure therapy sound a lot less complicated and delicate than I had previously believed.

He also makes it sound more broadly applicable than I had thought. My pop-culture impression is that exposure therapy is that it's a treatment for stereotypical "phobias" like fear-of-spiders and fear-of-heights. But he also applies it to various other kinds of anxiety, and OCD. He even advocates a version of exposure therapy for stressful thoughts!!

I won’t say any details about exposure therapy because I don’t want to describe it wrong, but I can definitely imagine trying that in the future, for certain types of unusually stressful thoughts.

Speculative neuroscience tangent: What causes depression?

(UPDATE 2024: For my current opinion on depression in the brain, see my Valence series, particularly Post 5: “Valence Disorders” in Mental Health & Personality. And see also §3.3.5 for how anxiety fits in.)

Having read the book, I’m now much more inclined to believe a somewhat-more-cognitive theory of depression sorta along the lines of “Depression is what happens when every possible thought you can think and plan you can make is judged by the plan-assessing part of your brain as unacceptably terrible, and this dynamic remains true for an extended period.” For example, take the stereotypical person with OCD. Their thoughts might be dominated by the following dynamic:

• If this thought involves an immediate plan to wash my hands again, then it’s contributing to how OCD is ruining my life and relationships.
• If this thought does not involve an immediate plan to wash my hands again, then I will get sick and die.

Basically there is no thought they can think, and no plan they can entertain, that isn’t rated as “that’s a terrible thought, if you think it then you’re doomed, DOOMED!” by the plan-assessing part of their brain. I’m now inclined to think that this is the core dynamic of depression and anxiety, and every other symptom is closely related to that dynamic, and every risk factor feeds into this dynamic.

I guess I should write a separate post spelling out the details, but you can basically get the gist of it as follows:

• Start with my post Big Picture Of Phasic Dopamine, which basically says: There's a high-level "thought-emitting" part of your brain (dorsolateral prefrontal cortex etc.), and there's a "thought-assessing" part of your brain (medial prefrontal cortex, hypothalamus, brainstem, etc.) If the thought-emitting part of your brain thinks a thought that is judged really bad by the thought-assessing part of the brain, it induces a phasic dopamine pause. Not only does that dopamine pause cause that particular thought to be immediately suppressed, but it also gradually teaches the thought-emitting part of your brain that, in the future, it shouldn't ever think that thought again. And if every possible thought is in the category of "really bad and deserving of a dopamine pause", well, then the thought-emitting part of your brain is just going to gradually become less and less likely to strongly activate any thought at all.
  • (More specifically, if you believe my post, I'm thinking mainly of the dopamine-in-the-striatum learning algorithm, and more specifically the parts of the striatum that get what I called Success-In-Life reward signals. So I'm thinking something like: (1) part of the dorsal striatum gets trained to prevent any strong activity in the dorsolateral prefrontal cortex, and (2) the lateral septum gets trained to prevent any strong activity in the hippocampus. Maybe other things too.)
• …Then that dovetails with my very old post Predictive Coding & Depression, which argues (following many others) that most depression symptoms look like not having any strong top-down messages whatsoever coming from the high-level-thinking centers of the brain.

That’s not a carefully-researched confident opinion, it’s just an idea I'm playing around with right now.