In a special after-school class seventy-five of the mildly depressed students learned to challenge the thinking patterns associated with depression, to become more adept at making friends, to get along better with their parents, and to engage in more social activities they found pleasant. By the end of the eight-week program, 55 percent of the students had recovered from their mild depression, while only about a quarter of equally depressed students who were not in the program had begun to pull out of their depression. A year later a quarter of those in the comparison group had gone on to fall into a major depression, as opposed to only 14 percent of students in the depression-prevention program. Though they lasted just eight sessions, the classes seemed to have cut the risk of depression in half.36
Similarly promising findings came from a special once-a-week class given to ten-to thirteen-year-old youngsters at odds with their parents and showing some signs of depression. In after-school sessions they learned some basic emotional skills, including handling disagreements, thinking before acting, and, perhaps most important, challenging the pessimistic beliefs associated with depression—for example, resolving to study harder after doing poorly on an exam instead of thinking, "I'm just not smart enough."
"What a child learns in these classes is that moods like anxiety, sadness, and anger don't just descend on you without your having any control over them, but that you can change the way you feel by what you think," points out psychologist Martin Seligman, one of the developers of the twelve-week program. Because disputing the depressing thoughts vanquishes the gathering mood of gloom, Seligman added, "it's an instant reinforcer that becomes a habit."
Again the special sessions lowered depression rates by one half—and did so as long as two years later. A year after the classes ended, just 8 percent of those who participated scored at a moderate-to-severe level on a test of depression, versus 29 percent of children in a comparison group. And after two years, about 20 percent of those in the course were showing some signs of at least mild depression, compared to 44 percent of those in the comparison group.
Learning these emotional skills at the cusp of adolescence may be especially helpful. Seligman observes, "These kids seem to be better at handling the routine teenage agonies of rejection. They seem to have learned this at a crucial window for risk of depression, just as they enter the teen years. And the lesson seems to persist and grow a bit stronger over the course of the years after they learn it, suggesting the kids are actually using it in their day-to-day lives."
Other experts on childhood depression applaud the new programs. "If you want to make a real difference for psychiatric illness like depression, you have to do something before the kids get sick in the first place," Kovacs commented. "The real solution is a psychological inoculation."
EATING DISORDERS
During my days as a graduate student in clinical psychology in the late 1960s, I knew two women who suffered from eating disorders, though I realized this only after many years had passed. One was a brilliant graduate student in mathematics at Harvard, a friend from my undergraduate days; the other was on the staff at M.I.T. The mathematician, though skeletally thin, simply could not bring herself to eat; food, she said, repulsed her. The librarian had an ample figure and was given to bingeing on ice cream, Sara Lee carrot cake, and other desserts; then—as she once confided with some embarrassment—she would secretly go off to the bathroom and make herself vomit. Today the mathematician would be diagnosed with anorexia nervosa, the librarian with bulimia.
In those years there were no such labels. Clinicians were just beginning to comment on the problem; Hilda Bruch, the pioneer in this movement, published her seminal article on eating disorders in 1969.37 Bruch, puzzled by women who were starving themselves to death, proposed that one of the several underlying causes lay in an inability to label and respond appropriately to bodily urges—notably, of course, hunger. Since then the clinical literature on eating disorders has mushroomed, with a multitude of hypotheses about the causes, ranging from ever-younger girls feeling compelled to compete with unattainably high standards of female beauty, to intrusive mothers who enmesh their daughters in a controlling web of guilt and blame.
Most of these hypotheses suffered from one great drawback: they were extrapolations from observations made during therapy. Far more desirable, from a scientific viewpoint, are studies of large groups of people over a period of several years, to see who among them eventually comes down with the problem. That kind of study allows a clean comparison that can tell, for example, if having controlling parents predisposes a girl to eating disorders. Beyond that, it can identify the cluster of conditions that leads to the problem, and distinguish them from conditions that might seem to be a cause, but which actually are found as often in people without the problem as in those who come for treatment.
When just such a study was done with more than nine hundred girls in the seventh through tenth grades, emotional deficits—particularly a failure to tell distressing feelings from one another and to control them—were found to be key among the factors leading to eating disorders.38 Even by tenth grade, there were sixty-one girls in this affluent, suburban Minneapolis high school who already had serious symptoms of anorexia or bulimia. The greater the problem, the more the girls reacted to setbacks, difficulties, and minor annoyances with intense negative feelings that they could not soothe, and the less their awareness of what, exactly, they were feeling. When these two emotional tendencies were coupled with being highly dissatisfied with their body, then the outcome was anorexia or bulimia. Overly controlling parents were found not to play a prime role in causing eating disorders. (As Bruch herself had warned, theories based on hindsight were unlikely to be accurate; for example, parents can easily become intensely controlling in response to their daughter's eating disorder, out of desperation to help her.) Also judged irrelevant were such popular explanations as fear of sexuality, early onset of puberty, and low self-esteem.
Instead, the causal chain this prospective study revealed began with the effects on young girls of growing up in a society preoccupied with unnatural thinness as a sign of female beauty. Well in advance of adolescence, girls are already self-conscious about their weight. One six-year-old, for example, broke into tears when her mother asked her to go for a swim, saying she'd look fat in a swimsuit. In fact, says her pediatrician, who tells the story, her weight was normal for her height.39 In one study of 271 young teenagers, half the girls thought they were too fat, even though the vast majority of them were normal in weight. But the Minneapolis study showed that an obsession with being overweight is not in and of itself sufficient to explain why some girls go on to develop eating disorders.
Some obese people are unable to tell the difference between being scared, angry, and hungry, and so lump all those feelings together as signifying hunger, which leads them to overeat whenever they feel upset.40 Something similar seems to be happening in these girls. Gloria Leon, the University of Minnesota psychologist who did the study of young girls and eating disorders, observed that these girls "have poor awareness of their feelings and body signals; that was the strongest single predictor that they would go on to develop an eating disorder within the next two years. Most children learn to distinguish among their sensations, to tell if they're feeling bored, angry, depressed, or hungry—it's a basic part of emotional learning. But these girls have trouble distinguishing among their most basic feelings. They may have a problem with their boyfriend, and not be sure whether they're angry, or anxious, or depressed—they just experience a diffuse emotional storm that they do not know how to deal with effectively. Instead they learn to make themselves feel better by eating; that can become a strongly entrenched emotional habit."