(Lewinsohn & Atwood, 1969) Depression: A clinical-research approach

A case study. The case exemplifies the premise that depressions are initiated and
maintained by prolonged reductions of positive social reinforcements. Treatments:
improve communication in her marriage, expand social activities, and engage in
rewarding activities. The extent to which the overall improvement can be causally
attributed to the patient’s increased activity and social intercourse remains uncleal,
but the case is confirmatory with regard to the author’s assumptions.

(Lewinsohn & Shaffer, 1971) Use of home observations as an integral part

of the treatment of depression

The major assumptions underlying approach are:

1) A low rate of positive reinforcement acts as an eliciting stimulus for some

depressive behaviors such as verbal statements of dysphoria, fatigue, and
other somatic symptoms

Eliciting Stimulus
Depressive
Low rate of S R+ behaviors
(e.g., verbal statement of
dysphoria, fatigue, somatic
symptoms
Eliciting Stimulus: any stimulus, conditioned or unconditioned, that elicits a
response.

2) A low rate of positive reinforcement constitutes a sufficient explanation for

other parts of the depressive syndrome such as the low rate of activity and
verbal behavior (prolonged extinction schedule)

Low rate of SR+ Low rate of

healthy behaviors
of healthy behaviors (Prolonged Extinction)

3) The social environment provides reinforcement in the form of sympathy,

interest, and concern which strengthens and maintains depressive behaviors
Depressive
Depressive Social behaviors
behaviors Environment Maintained
(e.g., verbal statement of provide High SR+ verbal statement of
dysphoria, fatigue, somatic Sympathy, interest, dysphoria, fatigue, somatic
symptoms concern symptoms

4) A number of different environmental events (e.g., loss through death,

separation, rejection, poverty, misfortune) and organismic states and traits
(e.g., lack of social skill, ignorance) are presumed to be causally related to a
state of low positive reinforcement.

Social Skill: “the emission of behaviors which are positively reinforced by others”
Deficits of social skill is often found among people with depression.

“The main goals of treatment are to restore an adequate schedule of positive

reinforcement for the individual by changing the patient’s behavior and/or the
environment.

The study aimed to identify factors involved in the causation and maintenance of
depressive behaviors.

Social interaction patterns:

- Paucity of interactional behavior

- Lack of social reinforcement

(Lewinsohn & Libet, 1972) Pleasant events, activity schedules, and

depressions

Three groups of 10 Ss (depressed, psychiatric control, and normal control). The Ss

rated their moods and also indicated the number of “pleasant” activities engaged in
each day over a period of 30 days.

Result: a significant association between mood and pleasant activities were found.
They found a significant correlation between daily reports of mood and the number
of pleasant activities in which both depressed and nondepressed individuals
engaged.

Conclusion: there is an association between rate of positive reinforcement and

intensity of depression.

“The behavioral theory requires the onset of depression be accompanied by a

reduction in positive reinforcement, that intensity of depression covary with rate of
positive reinforcement, and that improvement be accompanied by an increase of
positive reinforcement.”

(Lewinsohn & Graf, 1973) Pleasant activities and depression

They identified 49 pleasant and 35 unpleasant mood-related events, that is these

events were shown to be significantly correlated with mood for 10% or more of the
respective samples. These events are hypothesized to be of special relevance to
depression (they are expected to be especially discriminating between depressed
and nondepressed groups) and to reinforcement and punishment (they are
expected to have high reinforcement or punishment value).
(MacPhillamy & Lewinsohn, 1974) Depression as a function of levels of
desired and obtained pleasure

“A test of the assumption that depressed individuals receive less positive

reinforcement in general than do their nondepressed peers has yet to be made”.

“Theoretically, the behavioral position on depression regards the low rate of

behavior of depressed people as both the result of their being on an extinction
schedule and as a cause of their remaining on such a schedule”.

In this article they argued that pleasant events are a major subset of all positive
reinforcements. There fore, measuring the frequency of pleasant events can be
indicators of the rate of positive reinforcement that people experience. However,
there are several limitations of this assumption:

1) Not all positive reinforcement is experienced as pleasurable (e.g., starting a

car).

2) Not all pleasure events are indicators of positive reinforcement. Sometime

avoidance behaviors that are the function of negative reinforcement can be
experienced as pleasurable in the short term.

The Pleasant Event Schedule measures two responses for each item:

1) The frequency of occurrence of the events during the past month on a 3-point
scale

2) Subjective enjoyability on a 3-point scale

Results:

• “The prediction derived from cognitive theory of higher desired reward scores
for the depressed subjects was clearly not supported”.

• The results are consistent with behavioral position of depression.

• Depressed individuals have relatively low levels of reported pleasure, general

activity level, and perceived potential for reinforcement.

• “The high degree of similarity between the psychiatric control and normal
control groups suggests that the observed effects are specific to depression.”

• Related to the “range hypothesis”, depressed people engage in a more

restricted range of activities.
Conclusions:

• Depressed people have lower activity level than nondepressed

• “It has been suggested (Costello, 1972) that depressed people suffer not
from a lack of positive reinforcement per se but from a decrease in the
reinforcement potential of their usual rewards. The results of this study
suggest that this decrease does occur, but again it is probably not the sole
source of depressive behaviors”.  This finding does not really fit our
model because merely experiencing an increase in positive reinforcement
may not result in decreased depressed mood or lower depressive symptoms.

• “It is more reasonable to conclude that the depressed individual has a

reduced input of positive reinforcement due to a lower activity level,
decreases in the effectiveness of the availability reinforcers, and a restricted
range of activities.”  Does it mean that depressed clients should be
encouraged to do a larger range of activities to increase the chance to
contact a more variety of positive reinforcers?

• “Finally, it must be stressed that while the behavioral hypothesis is a causal

one, the evidence presented here is not capable of demonstrating causality”
 So they did acknowledge this limitation. And they added that in order to do
a naturally occurring experiment to determine causality, longitudinal study
with highly expensive procedure is required.

This study showed that depressed persons engage in fewer pleasant

activities and rate the pleasantness of activities lower than do
nondepressed individuals.

Suggested treatment implication:

“… the client is trained to observe and record his activities and is assisted in
increasing the frequency of those behaviors which are likely to bring positive
reinforcement.”

(Kazdin, 1974) Reactive self-monitoring: The effects of response

desirability, goal setting, and feedback

Self monitoring can be reactive. For instance monitoring depressed behavior may
directly results in the reduction of these behaviors. Why? According to Kanfer, “self-
monitoring enables the individual to discriminate the occurrence of the response to
a greater extent than do vague self reports and casual observations. If his
performance departs from the standard, self-regulatory processes (e.g., self-
reinforcement and self-punishment) are triggered.
“There are a number of interesting and perplexing features of self-monitoring
(Kazdin, 1974):

1) The reactive effects of self-monitoring are elusive. A number of carefully

designed investigations across diverse behaviors have shown no effect of
self-monitoring (Berecs, 1972; Hall, 1972; Mahoney, Moura, & Wade, 1973;
McNamara, 1972; Stollac, 1967).

2) When self-monitoring does result in behavior change, the effects sometimes

attenuate with time (Broden et al., 1971; Fixsen, Phillips, & Wolf, 1972;
Mahoney, 1974; Stuart, 1971).

3) Change resulting from self-monitoring does not depend upon accurate or

reliable recording on the part of the client (Broden et al., 1971; Fixsen et al.,
1972; Herbert & Baer, 1972)

4) Coversely, highly reliable monitoring of one’s own behavior does not ensure
behavior change (Powell & Azrin, 1968).

5) Several reports sometimes cited as support for the efficacy of self monitoring
have been confounded with other procedures (e.g., reinforcement,
punishment, punishment, nonspecific treatment effects, therapeutic
instruction, and suggestion) that in themselves could account for behavior
change (Bayer, 1972; McFall & Hammen, 1971; Rehm & Marston, 1968;
Rutner & Bugle, 1969; Thomas et al., 1971).

Conclusions:

• “Self-monitoring led to behavior change. The direction of the change was

determined by the valence of the behavior. For a given valence, the self
monitoring group tended to show greater change. When behavior was not
given a valence (positive or negative), self-monitoring led to only a weak and
unreliable change in the target pronouns. Thus, the valence appeared to be
an important ingredient in influencing the direction and magnitude of
behavior change”.

• “Performance standard and monitoring affected behavior. Individuals who

received a performance standard responded with significantly more target
pronouns than those who did not receive a standard. The performance
standard influence both self-monitoring and other-monitoring subjects but did
not affect no-monitoring subjects. Being monitored by someone else was
shown to be equally reactive as self-monitoring”.

• “setting a performance standard and providing response feedback

contributed to self-monitoring. Subjects who observed the record of their self-
monitored responses performed the target response more frequently than
those who did not receive feedback.”
(Hammen & Glass, 1975) Depression, activity, and evaluation of
reinforcement

Aim of the study: “to investigate the causal relation between mood and level of
reinforcement. An effort was made to learn what mood change might occur if
depressed subjects increased their levels of participation in reinforcing activities. If
the emphasis on environmental consequences is accurate, depressed subjects who
are induced to increase their levels of participation should show decreased
depression.”

“Contrary to an operant hypothesis of depression, increases in positive activity did

not alleviate depressed mood the results were replicated in a second study, which
also demonstrated that the subjects who engaged in more of the reinforcing
activities actually rated the events less positively than subjects in groups that did
not increase their activity levels. The findings are compatible with a cognitive
behavior modification perspective on depression which emphasizes individuals’
evaluations of events as a determinant of the complex relations between and
depression.”  while it may be possible that individuals evaluations of events as
the determinant, it may also be possible that only increasing pleasurable activities
is not enough. While increased in pleasurable activities may mean increased
contact with positive reinforcement, it may also be a function of negative
reinforcement (resulting in pleasurable activities as avoidance behaviors).
Therefore it may be important to not only focus on pleasurable activities but to take
into account the context of depression (e.g., choosing not only pleasurable
activities but activities that are guided by values, which will increase the chance to
contact more meaningful positive reinforcement). The assessment was conducted
also within 1 week. Is this enough time?

Based on Lewinsohn and Libet (1972) and Lewinsohn and Graf (1973) “a moderate
positive correlation between mood and activity was found for certain groups of
subjects. A major difficulty occurs with interpretation of the data, however, because
direction causality is unclear from the correlational analysis. Although it is doubtless
true that some instances of depression result from and directly covary with
reduction in positive reinforcement, the observe may also occur: In some cases,
depressed mood may be the antecedent of reduced participation in pleasurable
activites.”

Critique to behaviorism: behavior analysis tend to everemphasize the

importance of the environmental consequences at the expense of subjects’
perceptions and evaluations of the consequences.

Findings:
 • “As intended, the increase activities group performed significantly more daily
pleasurable activities than the other two experimental groups. However, the
mood results do not support the operant hypothesis of depression. It appears
that inducing depressed subjects to increase participation in pleasurable
activities did not alleviate their dysphoria.”

• “On the Depression Adjective Check List, the increase-activities group

actually felt less good than the self-monitoring control group which
presumably did not increase reinforcing activities (borderline statistical
significance)”.

(Fuchs & Rehm, 1977) A self-control behavior therapy program for

depression

“Kanfer (1971) has proposed a closed-loop learning model of self-control, defined as

the maintenance of responses in the absence of immediate external reinforcement.
Whether used to resist temptation (as in dieting) or to endure (as in studying), the
person exercising self-control skills tries to alter an externally determined pattern of
present behavior in order to achieve future reinforcers that he expects will be
ultimately forthcoming if his reponses meet preset criteria (Kanfer & Karoly, 1972).

“Many of the critical symptoms observed in depression may constitute, or result

from, impairments in the three processes involved in self-control: self-monitoring,
self-evaluation, and self-reinforcement (Kanfer, 1971).”

“It is hypothesized that depressed person set unrealistic, perfectionistic, global

standars for themselves, making attainment improbable.”

“Depressed persons may be characterized by relatively low rates of self-reward and

relatively high rates of self-punishment.”

Self-control therapy:

1. Session 1

- Self-control rationale

- Positive Activities Surveys

2. Session 2

- Identifying activities that had high personal significance but low frequency

3. Session 3
 - Self-evaluation rationale

4. Session 4

5. Session 5

- Self-reinforcement

- Presenting general principles of reinforcement, including issues of immediacy

versus delay, types of reinforcement, and the importance of contingency.

- “reward menus”: immediate and freely available rewards.

6. Session 6

(Lewinsohn & Amenson, 1978) Some relations between pleasant and

unpleasant mood-related events and depression

“Glaser (1971) defines reinforcer as “an event, stimulus, or state of affairs that
changes subsequent behavior when it temporally follows an instance of that
behavior”.

“The frequency ratings are assumed to reflect the rate at which the events occurred
during the past month. The enjoyabilitity (aversiveness) ratings are assumed to
reflect the potential reinforcing (punishing) impact of the events for the individual.”

“The sum of the products of the frequency and impact ratings for all the events is
assumed to provide an approximate measure of response-contingent positive
reinforcement (punishment) experienced by the individual during the past month.
The mean pleasantness (aversiveness) of each item (averaged across individuals) is
assumed to reflect something about the reinforcing (punishing) impact of the
events in the population at large.”

Another way that had been attempted to measure reinforcement is to correlate the
frequency of activities with mood.

“Events that are correlated with mood for a substantial (10% or more) proportion of
the population (mood-related events) are assumed to represent events that have
reinforcing or punishing properties in the population at large.”
“The assumption is that events that are followed by good feeling have positive
reinforcing impact, whereas events that are followed by dysphoria have punishing
impact.”

“Thorndike (1935) postulated that responses that are accompanied, or closely

followed, by satisfaction are more likely to reoccur, whereas those that are
accompanied, or closely followed, by discomfort are less likely to occur.”

The work of Olds and Milner (1954) suggested a link between pleasure and positive
reinforcement.

Conclusions:

- “The proportion of the population for whom a PES item correlated with mood
was strongly related to its mean enjoyability rating.”

- “The fact that the mood-related pleasant events were also rated as highly
enjoyable suggests that these events constitute an especially potent set of
reinforcers. In contrast, the non-mood-related pleasant events were given low
enjoyability ratings.”

(Kessler, 1997) The effects of stressful life events on depression

Some studies have looked at the short term effects of stress on depression.
Usually they compared aggregated stressful life event scales between persons who
did and did not report the recent onset of an episode of major depression. The
comparisons have generally been retrospective, in which the participants completed
surveys about previous stressful life events after depression symptoms are
experienced. Common findings:

1) There is a consistently documented association between exposure to

stressful life events and subsequent onset of episodes of major depression.

2) However, the magnitude of this association varies across studies.

3) There is consistent evidence for a dose-response relationship between

stressful events and depression, with severe events more strongly associated
with depression than nonsevere events.

4) Stressful life events are highly prevalent in these studies. Although the
majority of depressed
(Carvalho & Hopko, in press) Behavioral theory of depression –
reinforcement as a mediating variable between avoidance and depression

Lower
Environmental
reinforcement
Changes Avoidant
↓
(Death, divorce, behaviors
Depressive
retirement, etc) +
symptoms
=

This model is slightly different from our model:

- Does not really talk about the fact that environmental change can lead to
decreased positive reinforcement for healthy behaviors. As a result
decreased activation of healthy behavior is not included in the model.

- Only considers positive and negative reinforcement of avoidant behaviors.

- As a result lower reinforcement is seen as a function of only increased in

avoidant behaviors but NOT of a decrease in healthy behaviors (at least in
the model).

Aim of the study: to investigate whether environmental reward mediated the

relationship between avoidance and depression.