The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Behavior Analytic Conceptualization and Treatment of Depression:
Traditional Models and Recent Advances
Jonathan W. Kanter
University of Wisconsin-Milwaukee
Glenn M. Callaghan
San Jose State University
Sara J. Landes, Andrew M. Busch, and Keri R. Brown
University of Wisconsin-Milwaukee
In this article, we briefly consider the phenomenon of depression from a behavior analytic perspective. Then, we
describe the history of behavior analytic conceptualizations and treatments for depression with an emphasis on how
these conceptualizations and treatments may have failed due to a lack of adherence to two basic behavior analytic
principles: (I) Idiographic, functional assessment, and (II) In-vivo application of interventions. Finally, we discuss
more two recent conceptualizations —Behavioral Activation by Martell, Addis & Jacobson (2001) and Functional
Analytic Psychotherapy by Kohlenberg & Tsai (1991)—that we see as improvements over earlier models in terms of
basic principles and may hold promise for the future.
Keywords: depression; Functional Analytic Psychotherapy; Behavior Analytic Conceptualization
Behavior analysis purports to provide a scientific philosophy and methodology that should
maximize our ability to understand (predict) and change (control) behavior (Skinner, 1953). It is the only
system of psychology that was built from the ground up to change behavior. Other systems, such as
psychoanalysis and cognitive theory, were derived first and foremost as explanations of behavior that
were then applied to change behavior. As such, behavior analysis should hold an advantage in the
behavior change arena. Of course, this is ultimately an empirical matter, and empirical evidence suggests
such an advantage is held in several clinical fields, notably developmental disabilities and autism.
Despite great advances, however, the field has yet to offer a satisfying conceptualization of the
most common presenting problem in the adult outpatient population (Kessler et al., 1994)—depression.
Likewise, behavior analysis has only recently, and tentatively, demonstrated that it can develop treatment
interventions for depression that improve on and outperform those developed by our non-behavioral
colleagues. In this article, we will briefly consider the phenomenon of depression from a behavior
analytic perspective. Then, we will describe the history of behavior analytic conceptualizations and
treatments for depression with an emphasis on how these conceptualizations and treatments may have
failed due to a lack of adherence to two basic behavior analytic principles. Finally, we discuss more two
recent conceptualizations, Behavioral Activation by Martell, Addis & Jacobson (2001) and Functional
Analytic Psychotherapy by Kohlenberg & Tsai (1991). These treatments are best described as
reformulations and reinventions of original material and basic principles rather than as thoroughly new
conceptualizations. These new treatments represent a radical, radical behaviorism, returning radical
behaviorism to its roots after efforts to abandon them failed, and are part of a third wave of behavior
therapy (Naugle & O’Donohue, 1998; Hayes, in press).
The Phenomenon of Depression
Depression is a strange and unwieldy beast to behavior analysts for several reasons. First,
depression evidences substantial heterogeneity of etiology, time course (e.g., depression may appear
episodically or chronically), and functional impairment. The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR; American Psychiatric Association, 2000) attempts to address the complexity by
proposing an increasing number of diagnostic categories of depressive disorders or problems involving
sad or irritable affect, in addition to Major Depressive Disorder and Dysthymic Disorder. This solution
seems to only add to the complexity rather than reduce it. In Appendix B of DSM-IV-TR, the authors
255
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
have proposed seventeen disorders for further study. Six of these new diagnostic categories
(approximately 35%) deal with disorders of mood. Four of those six have several criteria that overlap
with those of Major Depressive Disorder, differing only in the duration or number of symptoms necessary
to meet criteria. A review of these subcategories of depression suggests that they may indeed be distinct
disorders with different etiologies and corresponding treatment implications. Behavior analysis, in
contrast, holds that the current organization of depressive disorders is largely arbitrary because diagnostic
categories are descriptive of symptomatology and not based on underlying causal processes (Pennington,
2002). However, behavior analysis has yet to offer an account of depression that satisfactorily addresses
its complexity.
Second, clients experience depression largely as an array of private behaviors that, because they
are harder to identify and control than public behaviors, complicates functional analysis (Moore, 1980).
DSM-IV-TR lists anhedonia (decrease in or complete lack of positive affect) and depressed mood
(increase in negative affect) as the hallmark symptoms of Major Depression, and describes the remaining
criteria in terms of cognitive (guilt, worthlessness, and hopelessness; poor memory and concentration;
poor decision making; suicide ideation), behavioral (psychomotor retardation or agitation) and somatic
(changes in appetite and sleep; decreased energy and fatigue) subsystems. By emphasizing hallmark
affective symptoms followed by multiple disordered subsystems, DSM-IV-TR (and its earlier versions)
describes a heterogeneous, affect-dominated phenomenon, which indeed characterizes the presentations
of those claiming to be “depressed” (Buchwald & Rudick-Davis, 1993). This description of depression,
couched in terms that fit the experiential qualities of the phenomenon, immediately challenges behavior
analysts because the criteria do not functionally describe behavior. For example, only three of the nine
criteria for Major Depression are public behaviors: changes in eating patterns, changes in sleeping
patterns, and psychomotor retardation or agitation (restlessness). Thus, a behavioral account of depression
conflicts with the diagnostic category of depression from the start.
Two Basic Behavior Analytic Principles
The core and guiding belief of behavior analysis is that operant behavior can be changed by
altering available reinforcers, applying punishers, changing stimulus conditions, shifting establishing
operations, and, of course, modifying the response itself. In order to activate these mechanisms of change,
behavior analysts generally apply two basic principles that guide their behavior as therapists: (I)
Idiographic, functional assessment, and (II) In-vivo application of interventions. However, when
discussing the history of behavior analytic approaches to depression, and Lewinsohn’s (1974) approach
specifically, a case will be made that these conceptualizations did not adhere to these principles. Although
great gains have been made, we are at a point in the development of behavioral treatments for depression
where adherence to and application of these principles remains difficult. The difficulty may be due to the
complexity of depressive phenomena, which has stymied behavior analysts, especially in the translation
of behavior analytic conceptualizations into treatments. The result has been the infusion of non-behavioral
conceptualizations, research methods, and treatment techniques into the original models, and the
simultaneous abandonment of basic principles and practices. These two principles require a brief review
here in order to facilitate the ensuing discussion.
Principle I: Idi ographic, Functional Assessment
The first governing principle of clinical behavior analysis is that treatment interventions are to be
determined by a functional analysis of the contingencies that control each targeted response class (see for
example, Haynes & O’Brien, 1990). These analyses determine the variables which function to evoke,
maintain, and strengthen the response class, and help to define the response class in terms of such
functions, regardless of the topography of specific responses. These analyses are conducted for all
256
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
behaviors relevant to the client, where relevance is determined by both the therapist and the client or
his/her caregivers. The behaviors targeted for intervention are also determined by the specific conditions
that bring a client in for therapy. For example, if a client is in crisis, those behaviors that are likely to
cause the client more distress or even self-harm will be targeted first. The identified variables
(discriminative stimuli, responses, and reinforcers) will be unique to the personal history or ontogenic
evolution of that particular client. By necessity, then, a functional analysis is highly individualized, or in
more typical behavioral analytic terminology, idiographic.
An idiographic, functional analysis is designed to capture the specific variables that control the
behavior of this particular client, at this time, under these conditions. The corresponding interventions
chosen for the client are based on these idiographic assessments. Once variables are identified that are
alterable and manipulable (e.g., Hawkins, 1986; Haynes & O’Brien, 1990), the therapist will choose
whatever technology is available to impact the behavior. These interventions are chosen based on an
established empirical literature (when available), the need for an immediate impact on the behavior, and
the ability or willingness of the client to engage in the change strategy. Any intervention that a priori
assumes that clients will benefit from it based on either a diagnosis (e.g., depression) or a belief that all
clients can benefit from one strategy (e.g., cognitive therapy) misses the point of conducting an
idiographic analysis and risks failure. This does not mean that when a client’s problems have been
functionally analyzed interventions borrowed from other systems (such as those in cognitive therapy)
would not be useful. A true functional analysis may point toward such interventions. Provided these are
conceptualized within a behavioral framework (e.g., cognitions are addressed as modifiable verbal
behaviors), they do not represent a paradigm shift or philosophically inconsistent eclecticism. Indeed, a
behavior therapist who conducts a functional analysis and is open to examining the broad array of tools
available for any intervention that best fits each client will maximize efficiency and efficacy in his/her
treatments.
Idiographic, functional analyses guide most applied behavior analytic interventions in autism and
other developmental disabilities (see for example, Hanley, Iwata, & McCord, 2003). However, clinical
behavior analysts working with and writing about adult outpatient populations (especially depressed
clients) have ignored idiographic, functional assessments and have focused on describing the diagnostic
category and then developing a treatment intervention broadly applicable for individuals with such a
diagnosis. Problems resulting from this strategy will be discussed below.
Principle II: In-vivo Application
The second governing principle in the application of behavioral interventions stipulates that
treatment interventions are most successful if reinforcement (and punishment) can be delivered contingent
on the occurrence of the target behavior, in -vivo. A well-known aspect of reinforcement is that it is most
effective when delivery is immediate (Renner, 1964). Fundamentally, in order to change a response, the
behaviorist must have an understanding of the contingencies that give rise to and support the response. If
the person conducting the intervention has direct access to those contingencies and can manipulate them
directly, then treatment should be more efficient and more effective. Again, interventions for autism and
other developmental disabilities are exemplary in this regard. In these interventions, treatment targets are
defined, functional analyses are executed to determine the controlling variables, and the targeted behavior
is systematically shaped in-vivo through application of contingent reinforcement.
Behavior analytic treatments for outpatient depression have struggled with this fundamental
principle. It is typical for a behavior analyst to assume that the behaviors of interest have occurred in the
client’s past and will likely occur again in the future but are not immediately available for modification in
session (Kohle nberg, Tsai, & Dougher, 1993). This type of analysis forfeits our ability to focus on those
variables we have direct access to altering: the in-session responses. Rather than producing behavior
257
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
change in-vivo we are reduced to talking about behavior change. As behavior therapists we can do this as
well as our non-behavioral colleagues if we so choose, but it is not our strength and it does not utilize our
principles of change. Ignoring these in-session operants was a critical mistake and will be addressed later
in this article.
History of Behavior Analytic Approaches to Depression
Early behavior analytic conceptualizations of depression were provided by Lazarus (1968),
Seligman (1974), Ferster (1973), Lewinsohn (1974) and others (e.g., Costello, 1977). Ferster’s account
remains the seminal work, although he did not propose many treatment recommendations nor did he
attempt to research his model. Instead, Lewinsohn led the way in research with his conceptualization and
treatment, resulting in his model becoming somewhat synonymous with the behavioral conceptualization
in general. Ferster’s model will be described first and then Lewinsohn’s conceptualization and treatment
will be discussed in detail.
Ferster’s Model
Ferster (1973) emphasized that two behavioral patterns characterize the repertoire of the
depressed person. First, there is a low rate of positively reinforced social behaviors, such as eye contact,
verbal communication, and eating. Second, there is a high rate of escape and avoidance behaviors, such as
complaining, requesting help, suicidal behaviors, and passivity in or avoidance of social situations. These
behaviors are controlled by increases in dysphoria, aversive interpersonal consequences, and other
aversive stimuli. Ferster noted that an absence of positively reinforced behavior may be due to the
strength and prepotency of escape and avoidance behaviors and it may be difficult to ascertain the
controlling variables in a given case. However, according to Ferster, the long-range treatment objectives
should emphasize acquisition of the missing positively-reinforced behaviors. Although escape and
avoidance behavior was a feature of Ferster’s model, its role in the conceptualization and treatment of
depression was largely overlooked until recently.
Ferster (1973) proposed several etiological factors that could account for the depressed repertoire.
Two of these factors demonstrate the influence of psychoanalytic conceptualizations prevalent at the time,
namely fixated personality development and anger-turned-inward. Ferster’s reformulations of these
processes emphasized the development of a repertoire characterized by high rates of escape and
avoidance behavior. Regarding fixated personality development, Ferster described the etiology of
depression in terms of disrupted early childhood attachment experiences. For example, consider a mother
who may not differentially reinforce her child’s food-seeking behavior, resulting in the child’s behavior
not coming under appropriate stimulus control. Instead, this history produces a repertoire characterized by
escape and avoidance behavior and emotional elicitation in response to frequent, perhaps even chronic,
deprivation. Regarding anger, Ferster suggested that anger is elicited and evoked by aversive stimuli, but
its expression is punished by others and frequently suppressed. Behavioral repertoires characterized by
frequent suppression of anger prohibit a full repertoire of appetitively -controlled behavior. Ferster’s
emphasis on aversive control and states of deprivation predicts the more recent Behavioral Activation
conceptualization of depression by Martell, Addis, & Jacobson (2001), described below.
Ferster also proposed two etiological factors that had more purely behavioral theoretical origins.
In contrast to the psychoanalytic reformulations, both of these factors focused on low rates of positively
reinforced behavior. First, he emphasized that depressive reactions, particularly the low rate of behavior
seen in depressed individuals, could result from fixed-ratio schedules that require a fixed and large
amount of activity. For example, depression may occur when one is in a stable work situation for which a
constant and unchanging amount of work activity and quality is required. Second, Ferster described how
major life transitions and other changes in the environment could result in low rates of behavior, if the
current environment no longer provides the relevant controlling stimuli. For example, the death of a loved
one or a retirement may result in a substantial loss of positive reinforcers and a subsequent reduction in
258
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
positively reinforced behavior. Ferster’s emphasis on low rates of positive reinforcement shares much in
common with Lewinsohn’s (1974) model, described next.
Lewinsohn’s Model
Lewinsohn (1974) described depression as characterized primarily by a low rate of responsecontingent positive reinforcement (RCPR). For example, Lewinsohn and Atwood (1969) reported on a
depressed woman who initiated many social interchanges with her family but her family rarely responded
to her attempts at conversation; thus her responses produced few reinforcements. According to Lewinsohn
(1974), a low rate of RCPR produces a low rate of social and other behaviors because the lack of
reinforcement effectively extinguishes the behaviors contingent on such reinforcement. In addition, the
low rate of RCPR is assumed to act as an eliciting stimulus for additional depressive behaviors, such as
dysphoria, fatigue, and other somatic symptoms. Finally, cognitive symptoms of depression such as low
self-esteem, pessimism, and feelings of guilt are assumed to be secondary elaborations of other symptoms
which have been elicited or evoked by the low rate of RCPR. In other words, the cognitive symptoms
may be inaccurate tacts or causal explanations for the observed private and public experiences of
depression. For example, “I am sick” may be evoked by somatic symptoms, “I am unlikable” may be
evoked by social isolation and poor interpersonal relations, and “I am bad” may be evoked by feelings of
guilt.
According to Lewinsohn (1974), RCPR is a function of three factors. First, RCPR is a function of
the number of events that are potentially reinforcing to the individual. The number of these events should
vary depending on the person’s history and biological (e.g., age and sex) variables. For example, going to
the state fair may be reinforcing for one individual, while a quiet dinner with a friend may be reinforcing
for another individual. Yet another individual may be reinforced by both events, providing more
opportunities for RCPR. Lewinsohn did not elaborate these variables or their treatment implications.
Second, RCPR is a function of the availability of these reinforcing events in the environment. The
main question is: Do these events actually occur in the individual’s environment with sufficient frequency
to shape, strengthen, and maintain non-depressive behavioral patterns? For example, hiking may be
reinforcing for an individual but this reinforcement may be unavailable if the individual lives in the heart
of a big city and has no car.
Lewinsohn derived several treatment strategies from this second factor. Assuming that
reinforcing events could be identified by asking clients to rate how “comfortable or good” they felt when
certain “pleasant events” occurred, Lewinsohn emphasized that treatment should teach the client to
monitor and record the occurrence of pleasant and unpleasant events using a daily activity chart. In
addition, the therapist assists the client in identifying sources of positive reinforcement that may not be
occurring. Once relevant pleasant activities are defined and identified, the therapist assists the client in
scheduling more positive reinforcement by increasing participation in activities that the client has rated or
experienced as pleasant.
The third factor influencing RCPR is the instrumental behavior of the individual. A key feature of
Lewinsohn’s (1974) model is that a major source of depression-relevant RCPR is the individual’s social
environment. Thus, the final factor that influences rates of RCPR is whether or not the individual has in
his/her repertoire the instrumental behavior necessary to obtain positive reinforcement from others. For
example, spending time with friends may be reinforcing to an individual, and friends may be potentially
available, but the individual does not possess the social skills necessary to acquire and maintain such
friendships. Working from the assumption that depressed individuals lack these requisite social skills,
Lewinsohn’s early treatment approach emphasized building these repertoires through social skills
training.
259
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Behavioral Treatment for Depression
Lewinsohn’s treatment was groundbreaking in its emphasis on the importance of reinforcement
contingencies in the treatment of depression. However, it was limited in terms of the basic behavior
analytic principles described above. Unlike Ferster’s (1973) multivariate approach, Lewinsohn (1974)
presented a univariate behavioral model of depression that focused on behaviors extinguished by
reductions in response-contingent positive reinforcement (RCPR) and paid less attention to behaviors
initiated by increases in negative reinforcement. This relegated to the theoretical backseat a large set of
potentially important, controlling variables (negative reinforcers, aversive discriminative stimuli, and
deprivation-establishing operations), and resulted in less attention to the heterogeneous nature of
depression. Behavior analysis rejects use of univariate models of diagnostic categories as they tend to
inhibit functional assessment. For example, the diagnostic criteria of decreased appetite for one client may
be a product of loss of collateral positive social reinforcers, for another client it may function as an
avoidance of aversive social situations, for another client it may be respondently elicited by other events,
and for another client it may be controlled by several of these variables. The controlling variables in a
particular case can only be understood through an individualized behavioral assessment. Ferster’s (1973)
conceptualization of depression allowed for this idiographic approach but Lewinsohn’s did not.
With a smaller set of hypothesized controlling variables to assess, Lewinsohn still had trouble
adequately incorporating functional assessment into the treatment. Although early treatment attempts
included in–home functional assessments to determine controlling variables before designing treatment
interventions (Lewinsohn & Atwood, 1969; Lewinsohn & Shaffer, 1971; Lewinsohn & Shaw, 1969),
when Lewinsohn outlined his theory in full in 1974, it included no such emphasis. This theory largely
neglected Principle I. Based on the univariate model described above, treatment focused on pleasant
activity scheduling to address problems with the availability of RCPR in the environment and social skills
training to address problems with the instrumental behavior of the individual in obtaining RCPR. These
problems were assumed, not assessed. The role of escape and avoidance behaviors, or any other
idiographic factors, in the etiology and maintenance of depression were not assessed. A therapist using
Lewinsohn’s conceptualization would not conduct a functional analysis because the conceptualization
already provided the analysis as well as the subsequent interventions. This therapist is likely to not
identify, mis-identify, or identify only a subset of the relevant controlling variables for a client. Choice of
interventions in turn will be limited and interventions chosen may only apply to a subset of the depressed
client’s problems, if any.
Lewinsohn’s theory also largely neglected Principle II, with some early exceptions. As described
above, the main hurdle to overcome in this regard was the assumption that outpatient office visits would
not evoke or elicit the relevant behavior. Lewinsohn’s early treatment attempted to observe and assess the
depressed individual in his/her home environment and to teach the client and significant others how to
apply operant principles themselves (Lewinsohn & Atwood, 1969; Lewinsohn & Shaffer, 1971;
Lewinsohn & Shaw, 1969). This in-home effort was abandoned as impractical in favor of a group
treatment approach through which the client could be shaped in session into new patterns of interpersonal
behavior (Lewinsohn, Weinstein, & Alper, 1970). However, this group approach was appropriate for
social skills training but not pleasant activities scheduling, which instead emphasized a didactic approach
(e.g., Turner, Ward, & Turner, 1979). When applied individually, social skills training was unable to
retain an emphasis on in-vivo shaping of behavior (e.g., Zeiss, Lewinsohn, & Muñoz, 1979).
Research on Lewinsohn’s treatment approaches was mixed at best (reviewed in Blaney, 1981). Of
social skills training for depression, Blaney wrote “…one can hardly do more than express amazement at
the diversity of outcomes” (p. 14). Regarding pleasant activities scheduling, Blaney wrote: “By way of
summarizing the findings, it should be obvious that the pleasant activities prescription for depression—
client to increase pleasant activities, client does so, client is rewarded, client’s depression lifts—is not at
260
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
all the normative finding in these studies. Indeed, one would be tempted to announce its funeral were it
not for the fact that it was supported in one major study…” (p. 19). Despite the fact that Lewinsohn’s
model emphasized both components, the studies reviewed by Blaney (all conducted in the 1970’s)
isolated either Pleasant Activities Scheduling or Social Skills Training as stand-alone interventions. These
studies, as a group, suggested these interventions were not as effective as hoped. However, other studies
that combined these or similar interventions with other behavioral interventions fared better, leading
Blaney to conclude: “There is a preponderance of studies indicating that multifaceted behavioral
approaches are effective, even that they are more effective than other credible treatments” (p. 24). The
best study of this type was conducted by McLean and Hakstian (1979). The behavior therapy condition in
that study focused on communication skills, behavioral activation, social interactions, assertiveness,
decision making and problem solving, and cognitive self-control strategies.
McLean and Hakstian’s (1979) inclusion of cognitive strategies foretold the future. In response to
several factors, including the research reviewed by Blaney (1981), his own study that showed no
enhanced effectiveness of his behavioral treatment compared to cognitive treatment (Zeiss, Lewinsohn, &
Muñoz, 1979), and his own study that showed that the frequency of pleasant or unpleasant events does
not predict the later occurrence of depression (Lewinsohn & Hoberman, 1982), Lewinsohn himself
abandoned his behavioral theory in favor of an integrative theory that combined behavioral and cognitive
factors (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985). Likewise, he modified his treatment into
“Coping with Depression,” a group treatment that includes relaxation training, pleasant activities
monitoring and scheduling, social skills training, and cognitive restructuring (Lewinsohn, Antonuccio,
Breckenridge, & Teri, 1984; Lewinsohn, Muñoz, Youngren, & Zeiss, 1986).
The turn away from purely behavioral models of depression and idiographic assessment occurred
during the so called “cognitive revolution” (Mahoney, 1984) of the 1970’s. New mainstream
conceptualizations of depression that emphasized the primacy of the cognitive subsystem dominated,
subsuming or distorting earlier behavioral conceptualizations. During this period, many behavior analysts,
rather than trying to reformulate their conceptualizations of depression in line with increasing awareness
of the complexity of the phenomenon, largely abandoned behavior analysis in favor of cognitivebehavioral models (Kohlenberg, Bolling, Kanter, & Parker, 2002; O’Donohue, 1998). In addition to
Lewinsohn, Lazarus and Seligman were among the revolution’s notable CBT converts. For example, in
1968, Lazarus claimed that “depression may be regarded as a function of inadequate or insufficient
reinforcers” (p. 84); in his later conceptualization (1976) he suggested using purely cognitive techniques
such as elimination of irrational self-talk and thought blocking. Likewise, while Seligman’s original
animal experiments on learned helplessness were behavioral in method and interpretation (e.g., Overmier
& Seligman, 1967), over time Seligman’s formulation of learned helplessness as a model of human
depression grew increasingly cognitive (Abramson, Teasdale, & Seligman, 1978; Seligman, 1975). By the
1980’s, cognitive-mediational models dominated the treatment of depression literature and Cognitive
Therapy (CT) for depression (Beck, Rush, Shaw & Emery, 1979) became the most well-researched and
highly-regarded of all psychotherapeutic treatments (DeRubeis & Crits-Christoph, 1998).
Cognitive Versus Behavior Therapy for Depression
Ironically, the current resurgence in interest in behavior therapy for depression can largely be
credited to Aaron Beck, the founder of CT (Beck, Rush, Shaw, & Emery, 1979). He included several
behavioral interventions in his treatment package and, as will be described below, this allowed Jacobson
and colleagues (1996) to establish these behavioral interventions again as a worthy stand-alone treatment
package.
Cognitive Therapy’s (Beck et al., 1979) behavioral interventions are embedded in a staunchly
cognitive conceptualization. The cognitive therapist is encouraged to use behavioral strategies, especially
261
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
early in treatment and for severely depressed individuals, to target passivity. The task is to identify
behavior problems and activate the client in his/her natural environment with daily activity monitoring
and scheduling as well as graded behavioral homework assignments. The specific content of the
interventions is strikingly similar to Lewinsohn’s (although the manual notably lacks references to
Lewinsohn’s earlier work). However, Beck and colleagues clearly stated that the overarching function of
these behavioral interventions was cognitive change: “The term behavioral techniques may suggest that
the immediate therapeutic attention is solely on the patient’s overt behavior…[but] the ultimate aim of
these techniques in cognitive therapy is to produce change in the negative attitudes so that the patient’s
performance will continue to improve” (p. 118). Social skills trainin g and problem solving interventions
also are encouraged throughout treatment as appropriate.
Jacobson and colleagues (1996) wrestled the behavioral interventions back from CT through a
rigorous component analysis study. In this study, CT was broken into three additive components. The first
component (BA I) prescribed behavioral interventions for the full course of treatment and proscribed any
attempts at cognitive modification. The second component prescribed behavioral interventions and
attempts to identify, monitor, challenge and modify automatic thoughts but proscribed work on
underlying assumptions. The third component allowed behavioral interventions, work on automatic
thoughts, and work on underlying assumptions and thus represented the full and complete CT package.
Jacobson and colleagues reasoned that if BA I was as effective in treating depression as were the other
components, this could be taken as evidence that cognitive theory and interventions were unnecessary in
the treatment of depression.
Jacobson and colleagues (1996) found no evidence that the complete treatment produced better
outcomes, despite a large sample, excellent adherence and competence by therapists in all conditions, and
a clear bias by the study therapists favoring CT. Also, CT was no more effective than BA I in preventing
relapse at a 2-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998).
Evidence that a behavioral intervention for depression performs as well as a cognitive
intervention is an important but small victory. Ideally, the techniques of behavior analysis should result in
improved outcomes over those based on theories not developed exclusively to predict and control
behavior (Skinner, 1953). In addition, while CT and BA I performed roughly equivalently in the Jacobson
study, neither performed particularly well. In the BA I condition, approximately 50% of treatment
completers were classified as recovered (Jacobson et al., 1996), and approximately 50% of these
responders were still depression-free two years later (Gortner et al., 1998). In other words, one in four
clients who completed BA I were depression-free two years later. When clients who started treatment but
dropped out during treatment were included in the analysis, only 20% (11/56) of clients who started
treatment were depression-free two years later. These poor results are not unique to the Jacobson study
but are typical for empirically supported treatments for depression (Westen & Morrison, 2001). Improved
treatments for depression are still needed, and the field of behavior analysis is primed to contribute.
It may be the case that BA I’s lack of superiority over Cognitive Therapy and other cognitivebehavioral approaches may be due to the failure to successfully incorporate either Principle I (idiographic,
functional assessment) or Principle II (in-vivo application) into the treatment approach. It may be said that
BA I was a behavioral treatment but not a behavior analytic treatment. The interventions were simply
lifted, intact, from the CT manual (Beck et al., 1979) which ignored functional assessment and paid sparse
attention to in-vivo shaping of behavior. Instead, all clients were instructed to identify, monitor, and
schedule pleasant activities regardless of any established functional relationship between such activities
and depressive behaviors (Principle I). In addition, no attempt was made by the therapists to shape or
contingently respond to targeted client behavior (Principle II).
262
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Modern Behavior Analytic Treatments for Depression
No behavior analytic treatment for depression currently exists that accomplishes full adherence to
Principle I and II. However, two recent treatments offer advancements over earlier models. Each will be
described separately.
Modern Behavioral Activation for Depression
After the success of the 1996 component analysis, Jacobson and colleagues began developing a
full behavioral activation treatment package, which we will refer to as BA II. The basic principles and
interventions of BA II will not be described here. The interested reader is referred to Martell, Addis, and
Jacobson (2001) for the treatment manual and Jacobson, Martell, and Dimidjian (2001) for an overview.
Briefly, BA II uses many of the same treatment techniques as BA I, but while BA I was a component of
Cognitive Therapy defined in large part by what could not be done (i.e., the proscription of cognitive
interventions), BA II was developed as a stand-alone, functional analytic treatment, based on Ferster’s
(1973) theory and the philosophy of functional contextualism. The change to a more functional treatment
is evidenced by this comparison between BA I and BA II by the authors (Martell, Addis, & Jacobson,
2001):
BA [II] is not about simple maneuvers that increase positive activity in a person’s life. It is
about trying to discover, through a functional analysis, what contingencies are maintaining
the depression, and teaching the client about the functional aspects of behavior. (p. 62)
Thus, BA II addresses Principle I (functional assessment) and represents an important advance in the
behavioral treatment of depression. Specifically, therapists conduct functional assessments in terms of a
simple Antecedents-Behavior-Consequences model. However, the emphasis is on teaching clients to
conduct their own functional analyses, and little guidance is given to therapists on how to conduct
functional analyses themselves.
The re-examination of Ferster’s theory also led to a re-emphasis of the role of aversive
controlling stimuli and escape and avoidance behavior in depression. BA II therapists use functional
analysis to discern specific exemplars of a generalized response class of avoidance that are conceptualized
as producing the low rate of response-contingent positive reinforcement. In this sense, BA II can be
distinguished from BA I simply because it replaced one univariate model of the diagnostic category of
depression (low rate of response-contingent positive reinforcement) with another (high rate of negative
reinforcement that results in a low rate of response-contingent positive reinforcement). As described
above, this limits the range of variables to be functionally assessed. Ferster did not emphasize such a
univariate view; instead, he suggested that the relationship between negatively and positively reinforced
behaviors was variable and difficult, but important, to assess.
Another limitation of BA II in terms of Principle I is that controlling variables are not directly
assessed. Instead, the therapist relies on client self-reports and activity charts to generate hypotheses about
controlling variables and contingencies that prevail in clients’ daily lives. Therapists encourage clients to
use the activity chart to record the activities they engage in during each day and to rate their moods
(specifically, their experiences of “mastery” and “pleasure”) during the activities. As in Lewinsohn’s
treatment, the mastery and pleasure ratings are assumed to be markers for the occurrence of
reinforcement. In addition, therapists acquire information about prevailing contingencies through standard
clinical interviewing techniques. Behavior analysts are skeptical about such self-reports, as client verbal
behavior is a function of complex histories (Naugle & O’Donohue, 1998). What clients do and what they
say about what they do are different responses maintained by different consequences (Branch &
Hackenberg, 1998). BA II does not address this complexity of verbal behavior and largely accepts self-
263
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
reports as veridical. For example, a BA II therapist “continually questions the consequences of the client’s
behavior, and he or she accepts without judgment behaviors that the client describes as useful or mood
enhancing [italics added]…” (Martell, Addis, & Jacobson, 2001, p. 63).
The failings of BA II on Principle I in part are a product of the challenges inherent in functional
assessment of the depressed adult outpatient. The assumption that the controlling variables are not
observable during the office visit creates much of the problem. This assumption renders obsolete any
attempt at true functional analysis to demonstrate an empirical relationship between discriminative
stimuli, responses and consequences before intervening. If we cannot observe the controlling variables
during the session we will not have sufficient environmental control to conduct the analysis. Nor will we
have the ability to determine in a pure scientific sense that the intervention we conducted was the sole
cause of a behavior change.
An additional challenge is that target behaviors are complex and heterogeneous both within and
between clients. This diversity of problem behaviors suggests that the client responses are determined by
multiple, interacting, and complex variables. It is unlikely that behavioral therapists would be able to
conduct an assessment that exclusively and exhaustively identifies all controlling variables or specifies a
completely accurate causal model for depression for any one client.
The point here is not to concede defeat that idiographic analyses are too difficult, but to say that
any level of individualized behavioral assessments would be more helpful than resigning to the
application of treatments based on topographically defined responses without attempting to understand
the functional nature of a specific client’s problems. Functional analyses need not rely solely on
experimental manipulations. Skinner (1953) suggested that clinical case material and clinical interviews
are also appropriate to determine the relevant history and guide the choice of interventions, and a
behavior analytic treatment for depression undoubtedly should start with such a proxy functional
assessment. Behaviorists typically are pragmatic in their approach, and a complete and exhaustive
analysis is not necessary for one to begin an intervention. In this sense, BA II is an improvement over BA
I, because it includes a limited assessment of controlling variables related to avoidance repertoires based
on client self-reports and activity charts. BA I, in contrast, offered only an idiographic assessment of
“pleasant events” as proxy variables for positive reinforcers. BA II’s expansion of functional assessment
should produce a more flexible and effective treatment.
Like BA I (and most modern cognitive-behavioral psychotherapies), treatment interventions in
BA II rely primarily on in-session verbal instructions for the client to engage in new behaviors outside of
session. Thus, there is little-to-no application of Principle II. Much of what occurs in a BA II treatment
session concerns discussions about what has occurred out of session in the time since the therapist and
client last interacted. The therapist provides suggestions about interventions to try, encourages the client
to do so, and the client typically reports back at the next session about what worked or that the client did
not do the assigned tasks. This is a necessary part of any intervention in that the goal of psychotherapy is
to get the behavior to occur outside of the context of the session. However, in this situation the behavioral
therapist only has direct access to the contingencies controlling the verbal behavior of the client reporting
what occurred. Technically, then, the therapist can directly modify only those verbal report behaviors by
the client. The therapist does not have access to the contingencies of, for example, the interaction the
client had with his/her mother when she withdrew and isolated following an argument. While the therapist
can praise or otherwise reinforce the client for talking, the therapist cannot directly manipulate a situation
that has already occurred. Thus, BA II holds an advantage over BA I on Principle I but not on Principle II.
While BA I and BA II have not been compared directly, both have been compared to CT in
randomized trials. While the original component analysis of CT (Jacobson et al., 1996; Gortner et al.,
1998) was described above, a recently completed randomized clinical trial compared BA II, CT,
264
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Paroxetine (Paxil) and a medication placebo in a large sample. All treatments performed well for mildly
depressed clients but BA II performed surprisingly well for the traditionally difficult-to-treat moderatelyto-severely depressed clients, outperforming CT and performing equivalently to Paroxetine (Dimidjian et
al., 2004). In addition, Paroxetine evidenced a very large drop-out rate and problems with relapse and
recurrence when the medication was discontinued (Dobson et al., 2004), so BA II appears to be the
superior treatment when all is considered.
Functional Analytic Psychotherapy
Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991), which has recently been
applied to the treatment of depression (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002; see also
Bolling, Kohlenberg, & Parker, 1999) represents a direct application of Principles I and II, the latter more
so than any other behavior analytic treatment to date. FAP provides a set of treatment recommendations
based on Skinnerian functional analyses (e.g., Skinner, 1953, 1957, 1969) of complex clinical phenomena
that are directly relevant to depression, including emotions, memories, cognitions, and an understanding
of the self. These analyses are largely theoretical rather than empirical but nonetheless provide the FAP
therapist with a consistent behavioral conceptualization for working with these issues. Unlike earlier
behavioral treatments for depression, FAP assumes that clinically -relevant target behaviors can be
observed and modified during the outpatient office visit. This assumption recontextualizes the office visit
from one characterized mainly by verbal behavior about target behaviors to one during which target
behaviors can be directly assessed (Principle I) and modified (Principle II). This article will not describe
FAP principles and procedures in detail; rather it will focus on the application of Principle I and II in
FAP. The interested reader is referred to Kohlenberg and Tsai (1991) for the full description and Follette,
Naugle, and Callaghan (1996); Kohlenberg, Hayes, and Tsai (1993); and Kohlenberg and Tsai (1995) for
overviews of the treatment.
FAP and Principle I. While the original FAP text (Kohlenberg & Tsai, 1991) and other writings
by these authors have focused more on the application of Principle II than Princip le I in FAP, Callaghan
and colleagues (Callaghan, 2001b; Callaghan, Summers, & Weidman, 2003) have developed specific
procedures for the application of Principle I. They designed the Functional Idiographic Assessment
Template (FIAT) to functionally assess and specify general classes of target behavior often seen in FAP
(Callaghan, 2001b; Callaghan, Summers, & Weidman, 2003). The FIAT uses a consistent language for
targeted behaviors organized into five functional domains: identification and assertion of the client’s
needs and values; identifying and responding to feedback (and providing feedback to others);
identification and responding to conflict in interpersonal interactions; identifying opportunities to and
effectively disclosing information with others; and identifying, specifying, experiencing, and expressing
emotions.
The FIAT system examines discriminative stimulus conditions and other variables related to
contextual control of the client’s behavior. It also creates a language to consistently specify different
aspects of the targeted response class that should be adapted to lead to more successful, pro-social
responding. For example, through functional analysis the therapist may determine that the client has
difficulties with interpersonal interactions (lack of access to social reinforcers) because he/she is unable to
identify situations in which to disclose or cannot identify the appropriate people with whom to do so. This
would be a problem of discriminative stimulus control. The FIAT also may identify problems with the
response itself. For example, the client may have a problem with modifying the amount of information
that is disclosed in one setting, serving to interpersonally distance the person to whom he/she is talking. In
addition, the FIAT may highlight problems with consequential control. For example, a client’s repertoire
may be dominated by a response class of escaping or avoiding his/her own emotional experiences.
265
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
The FIAT helps structure a behavioral interview and gives a common language to very complex
intra- and interpersonal behaviors. By creating a structure and format to the idiographic, functional
assessment, the FIAT adheres to Principle I of behavioral interventions and helps guide the analytic
portion of FAP. This analysis in turn should clarify and focus the interventions. For example, if the client
has difficulties discriminating when to disclose, the therapist can shape this skill during the therapy hour.
If the client tends to disclose a great deal of content so quickly that it becomes aversive to others, the
therapist can shape this repertoire. If the client is unable to tolerate his/her own aversive emotional
experiences or will not express those, the therapist can target in-vivo emotional acceptance, as well. As in
traditional behavioral assessment, the functional analysis dictates the intervention for FAP.
As with BA I and BA II, functional assessment with the FIAT is limited by boundaries of the
larger theoretic al conceptualization. In other words, FAP focuses on interpersonal problems so assessment
with the FIAT may miss variables functionally related to other domains of behavior important to
depression. In addition, although the FIAT does guide the therapist in the assessment of in-vivo behavior,
the focus remains on the description of contingencies that occur outside the session. However, other FAP
guidelines, described next, focus the therapist on viewing the assessment results as hypotheses and
identifying instances of the hypothesized operants as they occur in session. Functional assessment is an
ongoing and evolving process in FAP. In this way, direct observation of in-vivo behavior plays a large
role in FAP functional assessment.
FAP and Principle II. The application of interventions in FAP stems directly from Principle II,
and in this area FAP represents a true breakthrough in clinical behavior analysis for adult outpatients. It is
the first behavior analytic treatment to fully explore the possibility of in-vivo application of interventions
for this population. Ferster (1981) offered a succinct analysis of psychotherapy in terms of Principle II
that presaged the FAP analysis:
It is in the immediate interaction between patient and therapist that there is objective data
about the patient’s repertoire, and the therapist, as a trained observer, is in a position to
differentially reinforce accurate observation. In therapy, even though they may be talking
about events, the patient can learn to observe his or her own behavior, the therapist’s, and
the way they influence each other. The events of the therapy itself, therefore, are as crucial
determinants of the patient’s behavior as the events talked about. (p. 192)
Likewise, FAP assumes that the psychotherapeutic situation is a social environment with the
potential to evoke and change actual instances of the client’s problematic behavior in-vivo (Kohlenberg &
Tsai, 1991). Problem behaviors will occur during the therapy session due to formal similarities between
qualities of the therapist, the therapy, and the therapy setting and qualities of the outside environments
that set the occasion for the problem behaviors. The therapist’s goal in FAP is to watch for and evoke insession instances of the targeted operants and differentially reinforce more effective client responding
(see also Callaghan, Naugle, & Follette, 1996). Therapists seek to shape more effective client behaviors
following the identification of ineffective responding. This requires that the therapist keep the client’s
highly individualized functional assessment in mind each session. It also requires that the therapist be able
to respond to any improvements clients make in a way that will be reinforcing of that client behavior.
Additional FAP strategies target the generalization of in-vivo improvements to daily life.
Key to the in-vivo application of treatment techniques in FAP is the distinction between natural
and arbitrary reinforcement as discussed by Ferster (1967, 1972). FAP therapists are discouraged in the
application of arbitrary reinforcement to shape target behaviors and are encouraged to provide natural
reinforcers, including showing caring, telling the client how the therapist feels about him/her in the
moment, and non-verbal displays of interpersonal connection. This dictum necessitates a view of the
therapeutic relationship as a genuine, real interpersonal relationship in which therapists amplify their
266
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
private reactions to provide natural feedback to clients contingent on the occurrence of targeted behavior
(Follette, Naugle, & Callaghan, 1996). In this way, the direct application of Principle II to adult outpatient
psychotherapy transforms behavior therapy into something that may appear to be, to one conducting a
topographical rather than functional analysis, an exemplar of a humanistic or even psychoanalytic
approach. FAP remains behavioral, though, in its use of behaviorally defined mechanisms of change and
its consistent focus on an idiographic, functional analysis and in-vivo application of behavior change
strategies.
FAP and Cognitive Therapy for Depression. Together with an idiographic, functional assessment
and the application of behavior change strategies in-vivo, FAP is an exemplary behavioral treatment. It
offers solutions to problems in the application of basic behavior analytic principles that stymied behavior
analysts for many years. Theoretically it should produce a more efficient and effective treatment. Several
single-case reports on FAP have been published (Callaghan, Summers, & Weidman, 2003; Gaynor &
Lawrence, in press; Kohlenberg & Tsai, 1994; Paul, Marx, & Orsillo, 1999; see also Cordova & Koerner,
1993; Vandenberghe, Ferro, & da Cruz, 2004). However, a convincing empirical case for the benefits of
FAP has yet to be made (Corrigan, 2001).
Recently FAP was used to improve the efficacy of CT for depression (Beck et al., 1979) in an
open trial (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002). This study attempted to train experienced
cognitive therapists in the methods of FAP, resulting in a treatment called FAP -Enhanced Cognitive
Therapy (FECT). The basic premise of the study was that an infusion of basic behavior analytic principles
into CT for depression would enhance outcomes. FECT modified CT in the several ways to address
weaknesses of CT in terms of Principle I and II. First, therapists were encouraged to begin treatment with
behavioral activation strategies as per the standard CT protocol. Unlike standard CT, however, therapists
did not automatically progress to cognitive interventions but did so only after assessment indicated such a
progression might be useful. Therapists were taught an expanded conceptualization of depression that
included the possibility that thinking and feeling could be functionally related in a way that suggested
cognitive interventions would be appropriate (see Kohlenberg & Tsai, 1991; Kohlenberg, Tsai, &
Kohlenberg, 1996; Kohlenberg et al., in press, for a discussion of how cognition is treated as behavior in
FECT), but the conceptualization also included additional behavioral possibilities. This expansion of the
CT treatment rationale resulted in a more flexible, behavioral conceptualization and a larger set of
intervention options. Neither the FIAT nor additional functional assessment strategies were used in
FECT. Thus, while FECT represents a weaker form of treatment than FAP in terms of Principle I, it
represents an improved treatment over CT by those same criteria.
On the other hand, Principle II was heavily stressed in FECT. Therapists were taught the basic
FAP approach of identifying, evoking, and differentially reinforcing clinically-relevant behaviors in
session. This resulted in a more intense focus on interpersonal problems and the occurrence of these
problems in the context of the client-therapist relationship. In particular, therapists were instructed in the
in-vivo application of cognitive modification strategies.
Results were encouraging (Kohlenberg et al., 2002). Both CT and FECT performed well (60% of
CT clients and 79% of FECT clients responded to treatment). In addition, as predicted by FECT’s
increased focus on interpersonal relationships and the therapeutic relationship in particular, FECT clients
showed large improvements on measures of interpersonal functioning while CT clients showed no
improvements. Also, the in-vivo application of cognitive modification strategies predicted improved
client depression and social avoidance outcomes. New, unpublished analyses also suggest that sessions
with increased emphasis on in-vivo behavior were rated by clients as more helpful, and clients were also
more likely to report improvements in outside relationships after these sessions (Kanter, Schildcrout, &
Kohlenberg, 2004).
267
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Conclusion
In this paper we outlined two essential operating principles for behavior analytic treatments,
idiographic, functional assessment to determine interventions and in-vivo application of such
interventions. We then emphasized the difficulty maintaining adherence to these principles when faced
with the clinical presentation of depression, a complex and multi-faceted behavioral disorder that does not
lend itself to easy measurement as an operant. We closely examined the behavioral conceptualizations of
Ferster (1973) and Lewinsohn (1974) and traced the history of Lewinsohn’s behavioral treatment for
depression. Lewinsohn’s treatment evolved from Pleasant Activities Scheduling into a form of Behavioral
Activation (BA I) that was a component of Cognitive Therapy (Beck et al., 1979) and then into the
contemporary Behavioral Activation (BA II) by Martell, Addis, & Jacobson (2001).1 In a recent large
randomized clinical trial, BA II showed great promise as a treatment for adult depression (Dimidjian et
al., 2004; Dobson et al., 2004) and mainstream cognitive-behavior therapy undoubtedly will take notice.
Although the methodology of the BA II study was not behavior analytic, behavior analysts should also
take notice. This is an important time for clinical behavior analysts to claim BA II as their own, lest we
witness the gains made again become subsumed by mainstream forces.
When critically viewing BA II, it is clear that it is an improvement over earlier versions in terms
of adherence to basic principles but still lacking in several ways. BA II attempts to resurrect functional
analysis by teaching therapists the simple Antecedents-Behavior-Consequences model. However, the
assessment is limited by a univariate model that emphasizes escape and avoidance repertoires over other
possibilities. It also is limited by a strategy that encourages teaching the client to conduct his/her own
analyses but does not stipulate or encourage the in -vivo observation of target behaviors by the therapist.
In addition, BA II to a large extent neglects Principle II, the in-vivo application of behavior change
strategies.
We suggest that FAP better utilizes these essential principles, creating interventions that keep us
closer to our core assumptions. FAP provides a template for idiographic functional assessment, a set of
behavioral analyses of complex, clinical phenomena relevant to depression, and a clear set of guidelines
for the delivery of in-vivo interventions. An exemplar of basic behavior analytic principles, FAP may
more efficiently produce long-lasting clinical changes than other non-behavioral, or less behavioral,
treatments. While FAP may be theoretically rich and paradigmatically satisfying, the largest study of FAP
to date, that of FECT for depression (Kohlenberg et al., 2002), was not a randomized trial. Also, FECT
focused on improving the practice of existing cognitive therapists, and thus the treatment may not be as
appealing to clinical behavior analysts. FAP in its original form awaits robust empirical evaluation,
several single case investigations notwithstanding. Indeed, FAP may be more difficult in practice than in
theory, as the emphasis on in-vivo observation and shaping with natural reinforcement places large
demands on the therapist.
Along with Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999)2 and
several other treatments, BA II and FAP are part of a third wave of behavior therapy, characterized by a
focus on principles, broad applicability, contextualistic philosophy, and targeting the problems of the
adult, outpatient population that have befuddled earlier behavior analysts (Hayes, in press; Naugle &
O’Donohue, 1998). BA II and FAP in particular provide clinical behavior analysts with a larger, more
fundamentally behavior-analytic set of tools with which to engage the depressed client than previously
available. Nonetheless, the problem of depression continues to present a major challenge to the field.
Although results are promising, there is much work to be done in improving these treatments in terms of
basic behavior analytic principles, such as integrating more application of Principle I into FECT and more
application of Principle II into BA II, and in other ways, such as developing functional treatments not
based on diagnostic categories at all (e.g., Follette, Naugle, & Linnerooth, 1999; Hayes, Wilson, Gifford,
268
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Follette, & Strosahl, 1996; Koerner, Kohlenberg, & Parker, 1996). These efforts should not be academic
exercises aimed toward the attainment of behavioral ideological purity. Rather, it is the hope that
treatments invigorated by these principles will be more powerful and more efficient, thereby helping
therapists and ultimately benefiting clients.
References
Abramson, L. Y., Teasdale, J. D., & Seligman, M. E. (1978). Expectancy changes in depression and
Schizophrenia. Journal of Abnormal Psychology, 87(1), 102-109.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (text
revision). Washington, DC: Author.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York:
Guilford Press.
Blaney, P. H. (1981). The effectiveness of cognitive and behavioral therapies. In L. P. Rehm (Ed.),
Behavior Therapy for Depression: Present Status and Future Directions (pp. 1-32). New York:
Academic Press.
Bolling, M. Y., Kohlenberg, R. J., & Parker, C. R. (2000). Behavior analysis and depression. In M. J.
Dougher (Ed.), Clinical behavior analysis (pp. 127-152). Reno, NV: Context Press.
Branch, M. N., & Hackenberg, T. D. (1998). Humans are animals, too: Connecting animal research to
human behavior and cognition. In W. T. O’Donohue (Ed.), Learning and BehaviorTtherapy (pp.
15-35). Needham Heights, MA: Allyn & Bacon.
Buchwald, A. M., & Rudick-Davis, D. (1993). The symptoms of Major Depression. Journal of Abnormal
Psychology, 102(2), 197-205.
Callaghan, G. M. (2001a). Demonstrating clinical effectiveness for individual practitioners and clinics.
Professional Psychology: Research & Practice, 32(3), 289-297.
Callaghan, G. M. (2001b). The Functional Idiographic Assessment Template: The FIAT System.
Unpublished manual, San Jose State University.
Callaghan, G. M., Naugle, A. E., & Follette, W. C. (1996). Useful constructions of the client-therapist
relationship. Psychotherapy: Theory, Research, Practice, Training, 33(3), 381-390.
Callaghan, G. M., Summers, C. J., & Weidman, M. (2003). The treatment of Histrionic and Narcissistic
Personality Disorder behaviors: A single-subject demonstration of clinical improvement using
Functional Analytic Psychotherapy. Journal of Contemporary Psychotherapy, 33(4), 321-339.
Cordova, J. V., & Koerner, K. (1993). Persuasion criteria in research and practice: Gathering more
meaningful psychotherapy data. The Behavior Analyst, 16, 317-330.
Corrigan, P. W. (2001). Gettin g ahead of the data: A threat to some behavior therapies. the Behavior
Therapist, 24(9), 189-193.
Costello, C. G. (1977). Adaptive function of depression. Canada’s Mental Health, 25(4), 20-21.
269
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological
treatments for adult mental disorders. Journal of Consulting & Clinical Psychology, 66(1), 37-52.
Dimidjian, S. A., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M., &
Dunner, D. L. (2004, May). Methods and acute-phase outcomes. In S. D. Hollon (Chair),
Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Treatment of
Major Depression. Symposium conducted at the annual meeting of the American Psychiatric
Association, New York, NY.
Dobson, K. S., Hollon, S. D., Dimidjian, S. A., Schmaling, K. B., Kohlenberg, R. J., Rizvi, S., & Dunner,
D. L. (2004, May). Prevention of relapse. In S. D. Hollon (Chair), Behavioral Activation,
Cognitive Therapy, and Antidepressant Medication in the Treatment of Major Depression.
Symposium conducted at the annual meeting of the American Psychiatric Association, New
York, NY.
Ferster, C. B. (1967). Arbitrary and natural reinforcement. The Psychological Record, 17(3), 341-347.
Ferster, C. B. (1972). An experimental analysis of clinical phenomena. The Psychological Record, 22(1),
1-16.
Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28(10), 857-870.
Ferster, C. B. (1981). A functional analysis of behavior therapy. In L. P. Rehm (Ed.), Behavior therapy
for depression: Present status and future directions (pp. 181-196). New York: Academic Press.
Follette, W. C., Naugle, A. E., & Callaghan, G. M. (1996). A radical behavioral understanding of the
therapeutic relationship in effecting change. Behavior Therapy, 27(4), 623-641.
Follette, W. C., Naugle, A. E., & Linnerooth, P. J. (2000). Functional alternatives to traditional
assessment and diagnosis. In M. J. Dougher (Ed.), Clinical behavior analysis (pp. 99-126). Reno,
NV: Context Press.
Gaynor, S. T., & Lawrence, P. S. (in press). Complementing CBT with learning through in vivo
experience (LIVE): Conceptual analysis, treatment description, and feasibility study. Behavioural
and Cognitive Psychotherapy.
Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral treatment for
depression: Relapse prevention. Journal of Consulting and Clinical Psychology, 66(2), 377-384.
Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior: A review.
Journal of Applied Behavior Analysis, 36(2), 147-185.
Hawkins, R. P. (1986). Selection of target behaviors. In R. O. Nelson & S. C. Hayes (Eds.), Conceptual
foundations of behavioral assessment (pp. 329-385). New York: Guilford Press.
Hayes, S. C. (in press). ACT, RFT, and the third wave of behavior therapy. Behavior Therapy.
Hayes, S. C., Strosahl, K. D. & Wilson, K. G. (1999). Acceptance and commitment therapy: An
experiential approach to behavior change. New York: Guilford Press.
270
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Emotional avoidance
and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal
of Consulting and Clinical Psychology, 64, 1152-1168.
Haynes, S. N., & O’Brien, W. H. (1990). Functional analysis in behavior therapy. Clinical Psychology
Review, 10(6), 649-668.
Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., & Eifert, G. H. (2003). Contemporary behavioral activation
treatments for depression: Procedures, principles, and progress. Clinical Psychology Review, 23,
699-717.
Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression:
Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255-270.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E., &
Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression.
Journal of Consulting & Clinical Psychology, 64(2), 295-304.
Kanter, J. K., Schildcrout, J. S., & Kohlenberg, R. J. (2004). The frequency and benefits of a focus on the
client-therapist relationship in Cognitive Therapy for depression. Manuscript submitted for
publication.
Kazdin, A. E. (1993). Evaluation in clinical practice: Clinically sensitive and systematic methods of
treatment delivery. Behavior Therapy, 24, 11-45.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., et al. (1994).
Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States.
Archives of General Psychiatry, 51, 8-19.
Koerner, K., Kohlenberg, R. J., & Parker, C. R. (1996). Diagnosis of personality disorder: A radical
behavioral alternative. Journal of Consulting & Clinical Psychology, 64(6), 1169-1176.
Kohlenberg, R. J., Bolling, M. Y., Kanter, J. W., & Parker, C. R. (2002). Clinical behavior analysis:
Where it went wrong, how it was made good again, and why its future is so bright. The Behavior
Analyst Today, 3(3), 248-254. Available at http://www.behavior-analystonline.org/NEWBAT/Frameless%20BAT/BATissues.html
Kohlenberg, R. J., Hayes, S. C., & Tsai, M. (1993). Radical behavioral psychotherapy: Two
contemporary examples. Clinical Psychology Review, 13(6), 579-592.
Kohlenberg, R. J., Kanter, J. W., Bolling, M. Y., Parker, C. R., & Tsai, M. (2002). Enhancing Cognitive
Therapy for depression with Functional Analytic Psychotherapy: Treatment guidelines and
empirical findings. Cognitive and Behavioral Practice, 9, 213-229.
Kohlenberg, R. J., Kanter, J. W., Bolling, M., Wexner, R., Parker, C., & Tsai, M. (in press). Functional
Analytic Psychotherapy, Cognitive Therapy, and Acceptance. In S. C. Hayes, V. M. Follette, &
M. Linehan (Eds.), The new behavior therapies: Expanding the cognitive behavioral tradition.
New York: Guilford Press.
Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and
therapeutic relationships. New York: Plenum.
271
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Kohlenberg, R. J., & Tsai, M. (1994). Improving Cognit ive Therapy for depression with Functional
Analytic Psychotherapy: Theory and case study. Behavior Analyst, 17, 305-319.
Kohlenberg, R. J., & Tsai, M. (1995). Functional analytic psychotherapy: A behavioral approach to
intensive treatment. In W. T. O’Donohue & L. Krasner (Eds.), Theories of behavior therapy:
Exploring behavior change (pp. 637-658). Washington, DC: American Psychological
Association.
Kohlenberg, R. J., Tsai, M., & Dougher, M. J. (1993). The dimensions of clinical behavior analysis. The
Behavior Analyst, 16, 271-282.
Kohlenberg, R. J., Tsai, M., & Kohlenberg, B. S. (1996). Functional analysis in behavior therapy. In M.
Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (pp. 1-24).
Newbury Park, CA: Sage.
Lazarus, A. A. (1968). Learning theory and the treatment of depression. Behavior Research and Therapy,
6, 83-89.
Lazarus, A. A. (1976). Multimodal behavioral treatment of depression. In A. A. Lazarus (Ed.),
Multimodal behavior therapy (pp. 97-102). New York: Springer.
Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for
depression: Treatment manual. Behavior Modification, 25(2), 255-286.
Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman & M. M. Katz (Eds.),
Psychology of depression: Contemporary theory and research (pp. 157-178). Oxford, England:
John Wiley & Sons.
Lewinsohn, P. M., Antonuccio, D. O., Breckenridge, J. S., & Teri, L. (1984). The coping with depression
course. Eugene, OR: Castalia.
Lewinsohn, P. M., & Atwood, G. E. (1969). Depression: A clinical-research approach. Psychotherapy:
Theory, Research & Practice, 6(3), 166-171.
Lewinsohn, P. M., & Hoberman, H. M. (1982). Depression. In A. S. Bellack, M. Hersen, & A. E. Kazdin
(Eds.), International handbook of behavior modification and therapy (pp. 126-148). New York:
Plenum.
Lewinsohn, P. M., Hoberman, H. M., Teri, L. & Hautzinger, M. (1985). An integrative theory of
depression. In S. Reiss & R. Bootzin (Eds.), Theoretical issues in behavior therapy, (pp. 331359). New York: Academic Press.
Lewinsohn, P. M., Muñoz, R. F., Youngren, M. A., & Zeiss, M. A. (1986). Control your depression.
Englewood Cliffs, NJ: Prentice-Hall.
Lewinsohn, P. M., & Shaffer, M. (1971). Use of home observations as an integral part of the treatment of
depression: Preliminary report and case studies. Journal of Consulting & Clinical Psychology,
37(1), 87-94.
272
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Lewinsohn, P. M., & Shaw, D. A. (1969). Feedback about interpersonal behavior change: A case study in
the treatment of depression. Psychotherapy & Psychosomatics, 17(2), 82-88.
Lewinsohn, P. M., Weinstein, M. S., & Alper, T. (1970). A behavioral approach to the group treatment of
depressed persons: A methodological contribution. Journal of Clinical Psychology, 26(4), 525532.
Mahoney, M. J. (1984). Behaviorism, cognitivism, and human change process. In M. A. Reda & M. J.
Mahoney (Eds.), Cognitive psychotherapies (pp. 3-30). Cambridge, MA: Ballinger.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided
action. New York: W.W. Norton.
McLean, P. D., & Hakstian, A. R. (1979). Clinical depression: Comparative efficacy of outpatient
treatments. Journal of Consulting & Clinical Psychology, 47(5), 818-836.
Moore, J. (1980). On behaviorism and private events. The Psychological Record, 30, 459-475.
Naugle, A. E., & O’Donohue, W. (1998). The future direction of behavior therapy: Some applied
implications of contemporary learning research. In W. O’Donohue (Ed.), Learning and behavior
therapy (pp. 545-558). Needham Heights, MA: Allyn & Bacon.
O’Donohue, W. (1998). Conditioning and third-generation behavior therapy. In W. O’Donohue (Ed.),
Learning and behavior therapy (pp. 545-558). Needham Heights, MA: Allyn & Bacon.
Overmier, J. B., & Seligman, M. E. P. (1967). Effects of inescapable shock upon subsequent escape and
avoidance responding. Journal of Comparative and Physiological Psychology, 63(1), 28-33.
Paul, R. H., Marx, B. P., & Orsillo, S. M. (1999). Acceptance-based psychotherapy in the treatment of an
adjudicated exhibitionist: A case example. Behavior Therapy, 30(1), 149-162.
Pennington, B. F. (2002). The development of psychopathology: Nature and nurture. New York: Guilford
Press.
Renner, K. E. (1964). Delay of reinforcement: A historical review. Psychological Bulletin, 61(5), 341361.
Seligman, M. E. P. (1974). Depression and learned helplessness. In R. J. Friedman & M. M. Katz (Eds.).
The psychology of depression: Contemporary theory & research (pp. 83-109). Oxford, England:
John Wiley & Sons.
Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. San Francisco: W. H.
Freeman.
Skinner, B. F. (1953). Science and human behavior. Oxford, England: Macmillan.
Skinner, B. F. (1957). Verbal behavior. East Norwalk, CT: Appleton-Century-Crofts.
Skinner, B.F. (1969). Contingencies of reinforcement. New York: Appleton-Century-Crofts.
273
The Behavior Analyst Today
Volume 5, Issue Number 3 2004
Turner, R. W., Ward, M. F., & Turner, D. J. (1979). Behavioral treatment for depression: An evaluation
of therapeutic components. Journal of Clinical Psychology, 35(1), 166-175.
Vandenberghe, L., Ferro, C. L. B., & da Cruz, A. C. F. (2004). FAP -enhanced group therapy for chronic
pain. The Behavior Analyst Today, 4(4), 369-375.
Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression,
panic, and generalized anxiety disorder: An empirical examination of the status of empirically
supported therapies. Journal of Consulting & Clinical Psychology, 69(6), 875-899.
Zeiss, A. M., Lewinsohn, P. M., & Muñoz, R. F. (1979). Nonspecific improvement effects in depression
using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of
Consulting and Clinical Psychology, 47(3), 427-439.
Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of
reason-giving. The Analysis of Verbal Behavior, 4, 30-38.
Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression.
Journal of Clinical Psychology, 45(3), 436-445.
Footnotes
1
Although not the focus of this article, it should be noted that an alternate form of Behavioral
Activation has been developed by behavior analytic researchers (Hopko, Lejuez, Ruggiero, & Eifert,
2003; Lejuez, Hopko, & Hopko, 2001).
2
ACT also been applied to the treatment of depression (Zettle & Hayes, 1986; Zettle & Rains,
1989). It has not been addressed in this article because it is built on a different set of behavior analytic
principles than those presented herein, thus it would complicate the current thesis.
Address correspondence to:
Jonathan W. Kanter, Ph.D.
P.O. Box 413
Milwaukee, WI 53201
Phone: (414) 229-3834
Fax: (414) 229-5219
E-mail: jkanter@uwm.edu
274