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Behavior Analytic Conceptualization and Treatment of Depression:

Traditional Models and Recent AdvancesJonathan 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

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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: Idiographic, 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

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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 (Kohlenberg, 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

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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

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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 response-

contingent 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.

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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

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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 cognitive-

behavioral 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

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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 training 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 cognitive-

behavioral 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).

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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-

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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,

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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 moderately-

to-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.

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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 theoretical 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 in-

session 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

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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).

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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,

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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.

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Footnotes

1Although 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).

2ACT 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