88-148 bhapter3 January 20, 1990
When you are depressed you feel sad; this is the basic fact about the condition called "depression." The feeling of sadness is accompanied by the thought "I'm worthless." An attitude of "I'm helpless" is a precursor of the sadness, and the belief "I ought to be different than I am" usually helps keep the person locked into sadness. Our first task, then, is to understand sadness--to learn what causes sadness, what relieves sadness, and what prevents sadness.
Attempts to distinguish `normal' from `abnormal' sadness have not proven useful. Apparently there is but a single sort of sad feeling; the pain is the same whether it follows upon the loss of a friend (a "normal" event) or, say, the keenly-felt loss of an honor which it was not reasonable for you to expect but which you had nevertheless set your heart on. This makes sense when we notice that one does not distinguish between the pain from a finger that got cut in an accident, and the pain of a self-inflicted cut on the finger. The contexts are very different, however, in the cases of the two sorts of loss mentioned above, and it is those contexts that distinguish between the depressed person and the person who suffers from a "normal" sadness.
We must know, then: Why does one person respond to a particular negative event in his/her life with short-lived sadness after which normal cheerful life reappears, whereas another responds to a similar event with persistent depression? And why does a trivial or almost nonexistent blemish in life trigger sadness in some people and not in others?
The answer in brief is as follows: Some people acquire from their personal histories: 1) a tendency to make frequent negative self-comparisons, and therefore a tendency to have a Rotten Mood Ratio; 2) a tendency to think one is helpless to change the events that enter into the Rotten Ratio; and 3) a tendency to insist that one's life should be better than it is.
Concerning the first of these elements, the tendency to make frequent negative self-comparisons: This does not mean quite the same as "thinking poorly of yourself" or "having low self- esteem." The differences will be explained later.
There are many possible interacting elements in the development of a propensity to make neg-comps (negative self- comparisons), conceivably including a genetic element, and the elements differ from person to person. Understanding this mechanism is a necessary forerunner to designing the appropriate cure as discussed in Part III. The neg-comp is the last link in the causal chain leading to sadness and depression, the "common pathway", in medical parlance. If we can remove or alter this link, we can relieve depression.
To repeat, the central element in your sadness and depression, and the key to your cure, is as follows: 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 analysis may seem obvious to you after you reflect on it, and many great philosophers have touched on it. But this key idea has had little place in the psychological literature on depression, though the negative self-comparison is the key to understanding and treating depression.
The element of "negative thoughts" has been mentioned by just about every writer on depression through the ages, as has been the more specific set of negative thoughts that make up low self-evaluation. And controlled laboratory experiments have recently shown that depressed people remember fewer instances of being rewarded for successful performance than do non-depressed subjects, and remember more instances of being punished for unsuccessful performance. Depressed subjects also reward themselves less frequently when told to decide which responses were successful and which were not1.
Negative thoughts have not, however, been previously discussed in a systematic fashion as comprising comparison, as every evaluation is by nature a comparison. Nor has the interaction between the neg-comps and the sense of helplessness, which converts neg-comps into sadness and depression, been described elsewhere as it is here. It is the conceptualization of the negative thoughts as negative self-comparisons which opens up the wide variety of theoretical and curative approaches discussed here.
After you grasp this idea, you see its traces in many places. For example, notice the casual mention of self- comparisons in these remarks of Beck 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"2, and "The tendency to compare oneself with others further lowers self-esteem"3. But Beck does not center his analysis on the self-comparisons. It is the systematic development of this idea which provides the new thrust in Self- comparisons Analysis as offered here.
The State of Your Life As You Perceive It to Be
Your "actual" state is what you perceive it to be, of course, rather than what it "really" is. 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 your 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.
The Benchmark to Which You Compare Yourself
The "benchmark" situation to which you compare your actual situation may be of many sorts:
a) 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 benchmark situation of the loved one being alive.
b) 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 ends in miscarriage, or the children you expected to raise but never were able to have.
c) 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.
d) The benchmark may be something you feel you are obligated to do but are not doing, for example, supporting your aged parents.
e) 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 with which you negatively compare your actual situation. And, of course, the benchmark state may contain more than one of these overlapping elements.
The best proof that sadness is caused by the unfavorable comparison of actual and benchmark situations is self-inspection of your thoughts. If you observe in your thinking, when you are sad, such a negative self-comparison along with a sense of helplessness about changing the situation, -- whether the sadness is part of a general depression or not--this should convince you of the key role of negative self-comparisons in causing depression.
Only the concept of negative self-comparisons makes sense of a person being bereft of life's good things yet happy anyway, or having everything a person could want but being miserable nevertheless.
The author of Ecclesiastes -- traditionally considered to be King Solomon -- tells us how useless and helpless he felt despite all his riches:
So I hated life, because the work that is wrought under the sun was grievous unto me; for all is [in vain] and a striving after wind (2-17, my language in brackets).
The sense of loss--which is often associated with the onset of depression--is a negative comparison between the way things were and the way they are now. The American poet John Greenleaf Whittier (in Maud Muller) caught the nature of loss as a comparison in these lines: "For of all sad words of tongue or pen, the saddest are these: It might have been!" Whittier makes it clear that sadness arises not just because of what actually happened, but also because of the counterfactual benchmark which "might have been."
Notice how, when we suffer from what we call "regret," we harp on the counterfactual benchmark--how an inch more to the side would have won the game which would have put the team into the playoffs which would have led to a championship, how but for one horse's nail the war was lost, how--if not for the slaughter by the Germans in World War II, or the Turks in World War I--the Jews and Armenians would be so much more numerous and their cultures would be strengthened, and so on.
The basis for understanding and dealing with depression, then, is the negative comparison between your actual and hypothetical benchmark situations that produces a bad mood, together with the conditions that lead you to make such comparisons frequently and acutely, and combined with the helpless feeling that makes the bad mood into a sad rather than angry mood; this is the set of circumstances constituting the deep and continued sadness that we call depression.
Why Do Negative Self-Comparisons Cause a Bad Mood?
But why do negative self-comparisons and a Rotten Ratio produce a bad mood?There is 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 to the biological connections to loss and pain. It also makes sense 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.4
Indeed, research cited later shows 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 monkeys5. Hence lack of love hurts and makes one sad, just as lack of food makes one hungry.
Research shows chemical differences between depressed and undepressed persons. Similar chemical effects are found in animals which have learned that they are helpless to avoid painful shocks6. 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 for you to have a painful perception of it7. The bridge is that neg-comps are connected to pain through learning during your entire lifetime. You learn to be sad about a lost job or an examination failure; a person who has never seen an exam or a modern occupational society could not be made sad by those events. Learned knowledge of this sort always is relative, a matter of comparisons, rather than involving only one absolute physical stimulus.
All this represents 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 relearn 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; relearning 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.
The Nature of Comparisons
Comparison and evaluation of the present state of affairs relative to other states of affairs is fundamental in all planning and businesslike thinking. The relevant cost in a business decision is the "opportunity cost"-- that is, the cost of what else you might do rather instead of the opportunity being considered. Comparison is also part of judgments in all other endeavors. As the book's front note says: "Life is hard". But compared to what?
Indeed, comparison-making is central to all our information processing, scientific as well as personal:
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.8
A classic remark illuminates the centrality of comparisons in understanding the world: A fish would be the last to discover the nature of water.
Just about every evaluation you make 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.
The psychologist Helson put it this way: "[A]ll judgments (not only judgments of magnitude) are relative." Without a standard of comparison, you cannot make judgments.8.1 [Harry Helson, Adaptation-Level Theory (New York: Harper and Row, 1964), p. 126]
An example of how one cannot communicate factual knowledge without making comparisons is my attempt in the Epilogue to describe to you the depth of my depression. It is only by comparing it to something else that you might understand from your own experience--time in jail, or having a tooth pulled--that I can give you any reasonable idea of how my depression felt. And communicating factual knowledge to oneself is not basically different from communicating with others; without comparisons you cannot communicate to yourself the information (true or false) that leads to sadness and eventually to depression.
Now the difference between this view of depression and that of traditional Freudian psychotherapy is clear: Traditional psychotherapists, from Freud on, believe that negative self- comparisons (or rather, what they call "low self-esteem") and sadness both are symptoms of the underlying causes, rather than the negative self-comparisons causing the sadness; their view is shown in Figure 1. Therefore, traditional psychotherapists believe that one cannot affect depression by directly altering the kinds of thoughts that are in one's consciousness, that is, by removing negative self-comparisons. Additionally,they believe that you are not likely to cure yourself or ameliorate your depression in any simple direct way by altering the contents of your thoughts and ways of thinking, because they believe that unconscious mental elements influence behavior. Rather, they believe that you can only remove the depression by reworking the events and memories in your early life that led you to have a propensity to be depressed.
In direct contrast is the cognitive viewpoint of this book as shown in Figure 2. Negative self-comparisons operate between the underlying causes and the pain, which (in the presence of a sense of being helpless) cause sadness. Therefore, if one can remove or reduce the negative self-comparisons, one can then cure or reduce the depression.***
Note: The rest of this chapter is rather technical, and intended mainly for professionals. Laypersons may well skip to the next chapter. Professionals will find additional technical discussion in the Postscript for the Professional Reader at the end of the book.
Freud pointed in the right direction when he talked about people avoiding pain and seeking pleasure. Nor was this purely a tautology in which what people chose to do is simply called pleasurable; painful events can be connected to chemical events within the body, as discussed in Chapter 2. This idea is helpful here because it helps us understand the relationship of a variety of mental illnesses to negative self-comparisons and the pain they cause.
Some of the possible responses to neg-comps and the consequent pain are as follows:
1) One can sometimes avoid pain by changing the real circumstances involved in the neg-comp; this is what the "normal", active, undepressed person does, and what the normal rat does who has not previously been subjected to shocks that it cannot escape9. The absence of such purposive activity with respect to neg-comps because of a sense of helplessness to improve the situation is a crucial characteristic of sufferers from depression.
2) One can deal with the pain by getting angry, which tends to make you forget about the pain -- until after the rage subsides. Anger can also be useful in changing the circumstances. Anger arises in a situation where the person has not lost hope but feels frustrated in attempting to remove the source of the pain.
3) You can lie to yourself about the existing circumstances. Distortion of reality can avoid the pain of a neg-comp. But this can lead toward schizophrenia and paranoia.10 A schizophrenic may fantasize that his actual state is different than it really is, and while believing that the fantasy is true the painful neg- comp is not in the person's mind. The irony of such distortion of reality to avoid the pain of a neg-comp is that the neg-comp itself may contain a distortion of reality; making the neg-comp more realistic would avoid the need for schizophrenic distortion of reality.11
4) Still another possible outcome is that the person assumes that he or she is helpless to do anything about it, and this produces sadness and eventually depression.
Other states of mind which are reactions to the psychological pain of neg-comps fit well with this view of depression.12
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.13 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 time14. This is explained by the fact that a person who is "down" reflects on a variety of neg-comps, some of which focus on the past and present whereas others focus on the future; those neg-comps pertaining to the future are not only uncertain, but may sometimes be altered, which accounts for the state of arousal that characterizes anxiety, in contrast to the sadness that characterizes depression.
Beck15 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 it is not assured but is only a possibility, because of the depressed person's feeling of helplessness to change the situation.
2) Mania is the state in which the comparison between actual and benchmark states seems to be very large and positive, and often it is a state in which the person believes that she or he is able to control the situation. It is especially exciting because the person is not accustomed to positive comparisons. Mania is like the wildly-excited reaction of a poor kid who has never before been to a professional basketball game. 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 be more emotional about it than 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 in anxiety. One is anxious about whether one will miss the plane, 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 neg-comps by giving up goals, so that there is no longer a neg- comp. 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.
The English psychiatrist John Bowlby observed a pattern in children aged 15 to 30 months of age who were separated from their mothers that fits with the relationships between types of responses to neg-comps 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."16
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."17
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"18 So the child eventually removes the painful neg-comps by removing the source of the pain from his thought.
5) Various positive feelings arise when the person is hopeful about improving the situation--changing the neg-comp into a more positive comparison -- and is actively striving to do so.
People we call "normal" find ways to deal with losses and the consequent neg-comps and pain in ways that keep them from prolonged sadness. Anger is a frequent response, and 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.19 On the other hand, consider this exchange reported between Walter Mondale, who ran for president of the United States in 1984, and George McGovern, who ran in 1972: Mondale: " George, when does it stop hurting?" McGovern, "When it does, I'll let you know." But despite their painful experiences, neither McGovern nor Mondale seems to have fallen into prolonged depression because of the loss. And Beck asserts that survivors of painful experiences such as concentration camps are no more subject to later depression than are other persons.20
This book confines itself to depression, leaving these other topics for treatment elsewhere.
Let's close this chapter on an upbeat topic, love. 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, which often figures in depression) and that messages from the beloved say that in the eyes of the beloved he or she 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 relatve 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!
And of course it makes sense that unrequited love feels so bad. The youth is then in the position of not having the most desirable state of affairs one can imagine, and believing her/himeself 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 the lover formerly had. The comparison 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.
The basis for understanding and dealing with depressionis the negative comparison between your actual and hypothetical benchmark situations that produces a bad mood, together with the conditions that lead you to make such comparisons frequently and acutely, and combined with the helpless feeling that makes the bad mood into a sad rather than angry mood; this is the set of circumstances constituting the deep and continued sadness that we call depression.
Negative self-comparisons and a Rotten Ratio produce a bad mood because there is 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 to the biological connections to loss and pain.
Because the causes of sadness and depression are largely learned, we can remove the pain of depression by managing our minds properly. With respect to a stimulus that we have learned to experience as painful--lack of professional success, for example--we can relearn 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.
Traditional psychotherapists, from Freud on, believe that negative self-comparisons (or rather, what they call "low self- esteem") and sadness both are symptoms of the underlying causes, rather than the negative self-comparisons causing the sadness. Therefore, traditional psychotherapists believe that one cannot affect depression by directly altering the kinds of thoughts that are in one's consciousness, that is, by removing negative self- comparisons. Additionally,they believe that you are not likely to cure yourself or ameliorate your depression in any simple direct way by altering the contents of your thoughts and ways of thinking, because they believe that unconscious mental elements influence behavior. Rather, they believe that you can only remove the depression by reworking the events and memories in your early life that led you to have a propensity to be depressed.
In direct contrast is the cognitive viewpoint. Negative self-comparisons operate between the underlying causes and the pain, which (in the presence of a sense of being helpless) cause sadness. Therefore, if one can remove or reduce the negative self-comparisons, one can then cure or reduce the depression.