164 Lejuez et al.

sented at the 33rd Annual Convention of the Associationfor Advance- Wells, A., & Matthews, G. (1996). Modelling cognition in emotional
ment of Behavior Therapy, Toronto, Canada. disorder: The S-REF model, Behaviour Research and Therapy, 34,
Teasdale, J. D., & Barnard, R J. (1993). Affect, cognition and change: 881-888.
Re-modelling depressive thought. Hove, UK: Lau~'ence Erlbaum Wells, A., & Papageorgiou, C. (1995). Worry and the incubation of
Associates. intrusive images followingstress. Behaviour Research and Therapy,
Wells,A. (1995). Meta-cognitionand worry: A cognitivemodel of gen- 33, 579-583.
eralized anxie~" disorder. Behavioural and CognitivePsychotherato; Wells, A., & Papageorgiou, C. (1998). Relationships between wony,
23, 301-320. obsessive-compulsivesymptomsand meta-cognitivebeliefs.Behav-
Wells, A. (1997). Cognitive therapy of anxiety disorders:A practice manual iour Researchand Therapy, 36, 899-913.
and conceptualguide. Chichester, UK: Wile},.
Wells, A. (2000). Emotional disorders and metacognition:Innovative cogni- Address correspondence to DI: Costas Papageorgiou, Division of
tive therapy. Chichester, UK: Wiley. Clinical Psychology, University of Manchester, Rawnsley Building,
Wells,A., & Carter, 1L (1999). Preliminarytests of a cognitivemodel of Manchester RoyalInfirmary,Oxford Road, Manchester M13 9WL,UK;
generalized anxie~ disorder. Behaviour Research and Therap3; 37, e-mail: cpapage751@aol.com.
585-594.
Wells,A., & Matthews, G. (1994). Attention and emotion:A clinicalper~;t~ec- Received: January 29, 2000
tire. Hove, UK: Lawrence Erlbaum Associates. Accepted: May 15, 2000

A Brief Behavioral Activation Treatment for D e p r e s s i o n

C. W. L e j u e z a n d D e r e k R. H o p k o , West Virginia University
J a m e s P. L e P a g e , West Virginia University School o f Medicine a n d West Virginia University
S a n d r a D. H o p k o a n d D a n i e l W. M c N e i l , West Virginia University

A time-limited behavioral treatment of depression is described, based upon the matching law, targeting both environmental factors
maintaining depressive behaviors and factors limiting the occurrence of more healthy behaviors. This treatment is designed to reduce
depression by way of a gradual increase in desired, healthy activity. Three case studies using this intervention are provided, with
marked improvement evidenced in each case. Although considerably more work is necessary to establish the clinical utility of this
treatment, it appears to be a parsimonious and useful approach that may help to shed light on the active ingredients of the successful
treatment of depression.

HE TREATMENT of depression is characterized by a outcome (e.g., Jacobson, Dobson, Truax, & Addis, 1996;
T wide variety of psychological a n d biological ap-
proaches (cf. Beckham & Leber, 1995). Jarrett (1995)
Murphy, Carney, Knesvich, & Wetzel, 1995).
In this article, we consider evidence for a variety of
succinctly summarizes treatment outcome studies com- change mechanisms regarding depression and, based o n
paring these disparate techniques. Eight of the 10 available these arguments, provide an activation-based treatment
outcome studies revealed that antidepressant medications for depression that follows directly from recent advance-
a n d short-term psychotherapy were equally effective in ments in basic behavior analysis. We utilize the m a t c h i n g
treating clinical depression. In terms of c o m p a r i n g the law which, similar to the law of effect, suggests that behav-
relative efficacy of psychotherapeutic treatments for de- ior is m a i n t a i n e d by its consequences. The matching law,
pression, however, the results are less clear. For example, however, further frames each instance of an individual's
although several researchers have reported that cognitive behavior in terms of choice. As a result, the consequences
therapy was superior to behavior therapy (e.g., Dobson, for any particular instance of behavior are considered in
1989; Robinson, Berman, & Neimeyer, 1990), other studies relation to consequences for all other possible instances
have d e m o n s t r a t e d that the cognitive c o m p o n e n t of of behavior. Thus, depressed behavior n o t only is consid-
cognitive-behavioral therapy does not e n h a n c e t r e a t m e n t ered in terms of its direct consequences, b u t also in terms
of the consequences for healthier, alternative behavior.
Cognitive and Behavioral Practice 8, 1 6 4 - 1 7 5 , 2001 Based on these behavioral principles, we argue that envi-
1077-7229/01/164-17551.00/0 r o n m e n t a l m a n i p u l a t i o n s e n g e n d e r i n g behavioral activa-
Copyright © 2001 by Association for Advancement of Behavior tion are a primmT c o m p o n e n t in the m a i n t e n a n c e a n d
Therapy. All rights of reproduction in any form reserved. treatment of depression.
Continuing Education Quiz located on p. 21 I. Specifically, we provide a t r e a t m e n t for depression de-
 Behavioral Activation Treatment for Depression 165

signed to gradually increase targeted healthy behavior by social treatment for depression, what are the factors
way of increasing the value of reinforcers for such behav- maintaining such behavior? Several models of reinforce-
ior, while devaluing reinforcers for depressed behavior. ment have been posited to address this question. Accord-
Within this model, increased activity is perceived as a nec- ing to Lewinsohn (Lewinsohn, 1974; Lewinsohn & Got-
essary precursor in the reduction of both overt and covert lib, 1995; Lewinsohn, Munoz, Youngren, & Zeiss, 1986),
depressed behavior. Furthermore, we attempt to show the primary cause of depression involves insufficient lev-
how such a concentration differs from previous cognitive els of positive reinforcement for healthy behavior, which
behavioral treatments and may provide a time- and cost- often occurs due to (a) nega-
effective treatment for depression. tive environmental changes
resulting in an overall de- Increased activity
crease in available reinforce- is p e r c e i v e d a s a
Mechanisms of Change: Theoretical Perspectives
ment, (b) inaccessibility of re-
necessary
Perspectives regarding the mechanisms of change in inforcers, and (c) a decrease
the treatment of depression vary across theories; cogni- in value of potential reinforc- p r e c u r s o r in t h e
tive theorists propose it is the modification of dysfunc- ers due to the interference ef- reduction of
tional thoughts (e.g., Beck, Rush, Shaw, & Emory, 1979), fects of other variables (see
depressed
whereas interpersonal psychotherapists suggest the ac- Barlow, Chorpita, & Turovsky,
quisition of interpersonal skills is the critical element 1996, for a discussion of the thoughts and
(Klerman, Weissman, Rounsaville, & Chevron, 1984). interaction of depression and f e e l i n g s , in fact,
From the behavioral perspective provided here, overt ac- anxiety). Various therapies have
several researchers
tivation is the primary mechanism of change. In cases in successfully used positive rein-
which the environmental contingencies support healthy forcement, both within the con- have demonstrated
behavior, activation is necessary for the individual to con- text of therapy (Kohlenberg & that cognitive
tact these potentially positive contingencies. For exam- Tsai, 1994) and through the
changes are just
ple, enjoyable social interactions (i.e., initial overt behav- manipulation of naturalistic en-
ior) may increase the likelihood of future initiation of vironmental contingencies. a s likely u s i n g
social activity as well as positive thoughts and feelings re- This approach is used to in- environment-based
garding one's self-esteem and adequacy in social situa- crease healthy behaviors and
manipulations
tions (i.e., resulting healthy overt and covert behavior). improve mood, thus overcom-
Although cognitions are not targeted directly, covert ing the obstacles discussed by as compared to
changes produced through activation also effectively may Lewinsohn. direct cognitive
be associated with further behavior change (Hollon, As one method of identify-
interventions.
DeRubeis, & Evans, 1987). Nevertheless, initial instances ing potential positive reinforc-
of activation are considered as the primary change mech- ers, McPhillamy and Lewinsohn
anism because they are hypothesized as a necessary pre- (1971) developed the Pleasant Events Schedule. Using
cursor to the resulting covert changes. this instrument, the therapist and patient identify activi-
In cases in which the environmental circumstances ties most highly associated with positive affect and work
surrounding the individual are not conducive to healthy toward increasing the frequency of these activities. In a re-
behavior, environmental manipulations most often are lated approach, Rehm's Self-Management Therapy (Fuchs
necessary before activation can produce positive conse- & Rehm, 1977; Rehm, 1977) assumes that depression, in
quences. For example, if an individual is constantly belit- part, results from inattention to positive events. Early in
tled by an abusive and uncompassionate spouse, attempts treatment, patients are taught to self-monitor and record
by that individual to engage in more outgoing behavior positive events and thoughts, which are compared to
and have more positive thoughts may be fruitless. Fur- daily mood to demonstrate the relation between positive
thermore, constructing a healthier environment (e.g., events and emotion. Therapists then focus on increasing
through marital therapy or by prompting the identified the number of positive events the patient encounters to
patient to have more time with friends) may be more nec- improve the patient's mood and feeling of self-control.
essary for depressed individuals as they have been shown To provide reinforcement-based treatment in a group set-
to more accurately identify and interpret negative life cir- ting, Antonuccio (1998) adapted the coping-with-depres-
cumstances and situations than nondepressed individu- sion course (CWD; Lewinsohn, Antonuccio, Brecken-
als (Haaga & Beck, 1995; Kapci & Cramer, 1998). Once ridge, & Teri, 1984), an empirically supported (e.g.,
these environmental manipulations are enacted, activa- Cuijpers, 1998), highly structured manual-based treat-
tion effectively can be instituted. ment that focuses on increasing the number, range, and
If activation is the essential component in the psycho- quality of satisfying activities.
166 Lejuez et al.

Cognitive theorists also acknowledge the importance 1979). Further, it has been found that the benefits of cog-
of exposing patients to positive events. For example, Beck nitive-behavior therapy most often occur in the initial ses-
and colleagues (A. T. Beck et al., 1979; J. T. Beck, 1995) sions of treatment, a period in which behavioral interven-
have incorporated positive events through the use of tions often are more prominent (Beckham & Leber, 1995;
scheduled activities. In this approach, therapist and pa- Hollon, Shelton, & Davis, 1993; Otto, Pava, & Sprich-
tient plan the patient's day on an hourly basis, with the Buckminster, 1996).
objective of undermining the inactMty associated with Particularly supportive of behavioral interventions in
depression. Developed within the planned days are goal- the treatment of depression are the results ofJacobson et
oriented tasks. Therapists often use graded-task hierar- al. (1996). In this investigation, 150 clinically depressed
chies that break goals down into smaller and progres- patients were assigned to either the behavioral activation
sively more difficult targets. The patient works through c o m p o n e n t of a cognitive treatment (BA), a c o m b i n e d
the hierarchy until the final goal is achieved. behavioral activation and skills training approach to
Positive reinforcement for depressed behavior also modify automatic thoughts (AT), or the full cognitive
can play a role in the development and maintenance of treatment including BA and AT. Results indicated that
depression. Coyne's interpersonal theory of depression the BA and AT approaches were just as effective as the
(Coyne, 1976) hypothesizes that depressed individuals complete cognitive therapy at both termination of treat-
behave in a way that elicits support from others in their m e n t and at 6-month follow-up. Moreover, the BA ap-
social system. Initially, the depressed person will receive proach and full cognitive treatment were reported as be-
the social support desired by behaving in a depressed way ing equally effective in altering cognitive behaviors such
(e.g., sad facial gestures, crying, discussing failure). As
as negative thinking and dysfunctional attributional
the depressed person persists in efforts to gain support
styles.
and reassurance, howevm, those in the social system be-
Given that both cognitive and more recent behavioral
gin to withdraw, which may result in even more intense
treatments for depression include a broad range of possi-
efforts to gain social support.
bly superfluous components, the remainder of this arti-
In contrast to depressive behaviors maintained through
cle will outline the underlying principles and implementa-
positive reinforcement, the relation of negative reinforce-
tion of a parsimonious treatment for depression targeting
m e n t to depressed behavior has received comparably less
specific mechanisms of change. Although many other
attention. Investigations that have examined this relation
treatments include some form of the interventions en-
have focused on interpersonal interactions, demonstrating
that depressed behavior may function to reduce negative compassed in our proposed treatment, we have at-
reactions of other individuals such as family members. tempted to provide these interventions in a clear and
For example, it has been demonstrated that depressed considerably more concise manner, uncomplicated by in-
behavior can immediately, though temporarib; reduce terventions that focus on other mechanisms of change.
aggressive behavior from nondepressed spouses (Biglan Specificalb; we target the contextual factors that affect
et al., 1986; Hops et al., 1987). behavioi; using the matching law as a guiding principle.
To supplement traditional behavioral interventions, As opposed to a global attempt to indiscriminately
more recent behavioral treatments have incorporated increase positive events in the individual's life, the goal
cognitive strategies, including direct attempts to manipu- of this treatment is to gradually increase the frequency of
late covert p h e n o m e n a such as reinforcing positive targeted healthy behavior through increasing the relative
thoughts and punishing negative thoughts (Lewinsohn value of such behavior. Three case studies using this
et al., 1986; Lewinsohn, Hoberman, Teri, & Hautzinger, behavioral-activation treatment for depression (BATD)
1985). The inclusion of cognitive components in behav- will be provided, along with suggestions for other poten-
ioral treatments (e.g., Lewinsohn et al., 1986; Lewinsohn, tial applications of BATD.
Clarke, Hops, & Andrews, 1990; Lewinsohn & Gotlib,
1995) likely has occurred because (a) behavioral inter-
Applicability of the Matching Law to Depression
ventions are thought to be insufficient for a comprehen-
sive treatment of depression and (b) the absence of di- According to behavioral principles, factors such as the
rect cognitive manipulations are regarded as limitations absence of reinforcers for nondepressed behavior and
of behavioral interventions. Nevertheless, little empirical the reinforcement-degrading influence of other variables
evidence supports the necessity of this integration. In (e.g., decreased pleasure from activities in response to
fact, researchers have demonstrated that cognitive changes the death of a family member) may lead to the increased
are just as likely using environment-based manipulations frequency of depressed behavior (e.g., staying in bed, cry-
as c o m p a r e d to direct cognitive interventions (Simons, ing). That is, although depressed behavior may produce
Garfield, & Murphy, 1984; Zeiss, Lewinsohn, & Munoz, little reinforcement, such behavior frequently may occur
 Behavioral Activation Treatment for Depression 167

because the healthy alternatives (e.g., visiting friends, divorcing one's spouse) may be disturbing yet tolerable
completing responsibilities) provide even less immediate to one individual, whereas it may lead to a depressive epi-
reinforcement. Furthermore, depressed behavior may be sode for another individual. Although it is not our pur-
maintained as a function of immediate positive reinforce- pose to summarize the role of such variables in a behav-
ment provided by concerned friends and family mem- ioral account of depression, it should be acknowledged
bers, as potential reinforcers for nondepressed behavior that these factors might affect the relative value of stimuli
are either absent, delayed, or ineffective (cf. Lewinsohn, and their functioning as reinforcers or punishers. In the
Youngren, & Grosscup, 1979). Additionally, and less of a following section, we provide the matching law as a com-
focus in previous behavioral theories of depression, de- prehensive framework to both understand and treat
pressed behavior also may produce a high level of nega- depression.
tive reinforcement, resulting in a decrease in responsi-
bilities or avoidance of undesirable situations (e.g.,
The M a t c h i n g Law a s a Basis for Treatment
encountering environmental situations reminding one
of a deceased loved one). Thus, the frequency of de- To reduce depressed behavior, treatment should focus
pressed behavior can be reduced by decreasing the posi- on increasing reinforcers for nondepressed behavior.
tive and negative reinforcement for depressed behavior, Based on the matching law, depression persists because
in addition to increasing the reinforcement available for (a) the reinforcement avail-
other types of behavior. able for nondepressed behav-
The above analysis is based upon the matching law. ior is low or nonexistent or (b) The matching law
When applied to depression, the matching law suggests depressed behavior produces
suggests that
that the relative frequency of depressed behavior, com- a relatively high rate of rein-
pared to nondepressed behavior (i.e., all other types of forcement. Because biological depression persists
behavior), is proportional to the relative value of rein- and other contextual factors b e c a u s e (a) t h e
forcement obtained for depressed behavior compared to may influence the occurrence
reinforcement
nondepressed behavior (see Herrnstein, 1970; McDow- of depressed behavior and the
ell, 1982). Value is defined as the interaction of several factors maintaining it, the ini- available for
parameters of reinforcement, including frequency, mag- tial stages of treatment should nondepressed
nitude, duration, immediacy, and certainty. In other therefore begin with assessing
b e h a v i o r is l o w o r
words, if the value of reinforcers for depressed behavior the function of depressed be-
is increased, the relative value of reinforcers for nonde- havior. That is, is depressed nonexistent and/or
pressed behavior must decrease. Consequently, the likeli- behavior maintained by (a) an (b) d e p r e s s e d
hood of future depressed behavior will increase, while absence of reinforcement for
behavior produces
the likelihood of future nondepressed behavior will de- nondepressed behavior, (b)
crease. Conversely, if the value of reinforcers for depressed reinforcement for depressed a relatively
behavior is less than for nondepressed behavior, the behavior, or (c) some combi- higher rate of
probability of nondepressed behavior will increase. In nation of both? Additionally,
reinforcement than
both cases, the shift in relative reinforcement frequency what are the particular con-
will be correlated with the shift in relative preference. For texts in which stimuli do and nondepressed
example, if reinforcement is obtained for nondepressed do not serve as reinforcers of behavior.
behavior at half the frequency of reinforcement for de- depressed and nondepressed
pressed behavior, nondepressed behavior should occur behavior? Furthermore, is the
half as often. Although the descriptions provided by the problem cyclically recurrent, and are there historical an-
matching law are consistent with what might be deter- tecedents contributing to current behavior patterns?
mined using common sense or clinical intuition, the con- Once the stimuli that play a role in the maintenance of
tribution of the matching law is that it adds an experi- depression are determined, treatment should focus on
mentally tested level of precision not otherwise available. eliminating or decreasing reinforcers for depressed be-
A matching law analysis focuses upon current relative havior (e.g., attention contingent upon reports of depres-
rates of reinforcement, but it also should be mentioned sion), with the ultimate goal being to increase the ratio of
that this analysis is amenable to the incorporation of a va- nondepressed to depressed behavior.
riety of other variables that play a prominent role in other According to the matching law, depressed behavior
conceptualizations of depression (e.g., historical and bio- occurs at a high rate not only when there is an absence of
logical factors). For example, the interaction of one's at- reinforcement for nondepressed behavior, but also when
tributional style and experiences must be considered reinforcement for nondepressed behavior is delayed. In
when examining why a similar environmental event (e.g., such cases, this delay to reinforcement often reduces the
168 Lejuez et al.

l i k e l i h o o d o f the long-term o c c u r r e n c e of the behavior cisely the type of rich clinical i n f o r m a t i o n that behavior
a n d the eventual reinforcers. For example, starting an ex- therapists often are accused o f ignoring. Thus the devel-
ercise p r o g r a m provides little immediate reinforcement, o p m e n t a n d m a i n t e n a n c e of a positive t h e r a p e u t i c rela-
perhaps leading to a decrease or t e r m i n a t i o n of exercise tionship is vital to the success o f BATD, as it is otherwise
behavior. T h e e x t e n d e d o c c u r r e n c e o f such behavior, unlikely that a patient will p u t forth the effort necessary
however, often p r o d u c e s reinforcers such as i m p r o v e d for the effective c o m p l e t i o n of this program. Further-
health, positive appraisals o f one's a p p e a r a n c e , a n d in- more, the therapy sessions that follow should include
creased social contact. Conse- time for patients to interact with the therapist to express
quently, other reinforcers, such general life concerns, reevaluate hierarchy items, a n d
The d e v e l o p m e n t as praise or a small reward provide feedback r e g a r d i n g the p r o g r a m .
and maintenance (e.g., o p p o r t u n i t i e s for the
patient to access enjoyed ac-
of a positive Assessment of Factors Maintaining
tivities) for each instance of
therapeutic Depressive Behavior
exercise, may be necessary to
As the therapeutic relationship is developed, a thor-
relationship is vital increase the likelihood of fu-
ough functional analysis of the patient's depressive symp-
ture exercise. For reasons dis-
to the success of toms should be conducted. Because d e p r e s s e d patients
cussed previously, effective
BATD, as it is are at elevated risk for suicide attempts a n d d e a t h by sui-
contrived reinforcers differ
cide, suicidal ideation must be carefully assessed, a n d rel-
otherwise unlikely a m o n g individuals and, de-
evant interventions utilized if necessary (Clark, 1995).
p e n d i n g u p o n the individual
that a patient will Additionally, the patient should be e d u c a t e d r e g a r d i n g
a n d the context, have in-
put forth the effort responsibilities for the successful i m p l e m e n t a t i o n of this
c l u d e d social activities (e.g.,
treatment, a n d a c o m m i t m e n t to change should be ob-
necessary for the Bakel, Blampied, & Haye, 1983;
tained. As patient activity is an integral part o f this treat-
Brannon & Nelson, 1987;
effective ment, medical problems a n d psychosocial factors such as fi-
Hersen, Bellack, & H i m m e l -
c o m p l e t i o n of this nancial constraints a n d seasonal changes (e.g., n u m b e r
hoch, 1980), m o n e y (Hughes,
of daylight hours) also should be carefully assessed.
program. Pleasants, & Pickens, 1985),
Early sessions o f BATD should involve a special focus
therapy session time (see Rehm
on the individual needs o f the patient. As a first step in the
& Kaslow, 1984), and tokens
actual i m p l e m e n t a t i o n o f the p r o g r a m , the d e p r e s s e d be-
(e.g., Hersen, EisleI; Alford, & Argras, 1973; L i p p m a n &
haviors in which the patient regularly engages must be iden-
Motta, 1994). As continued healthy behavior begins to pro-
tified. Next, the positive and negative r e i n f o r c e m e n t a n d /
duce the more naturally occurring reinforcers (e.g., im-
o r p u n i s h m e n t o f d e p r e s s e d behaviors is e x a m i n e d . For
proved health or appearance), these contrived reinforcers
example, the patient may list that staying in b e d for several
can be laded out and eventually eliminated (Ferster, 1967).
days often p r o d u c e s otherwise unavailable attention from
her spouse and reduction of household duties. AS suggested
BATD by the m a t c h i n g law, failure to r e d u c e r e i n f o r c e m e n t for
highly reinforced d e p r e s s e d behavior may limit the likeli-
BATD utilizes reinforcers such as positive therapist-
h o o d that even increasing the r e i n f o r c e m e n t for o t h e r
delivered f e e d b a c k to e n g e n d e r healthy behavior. This
behavior will be sufficient for behavior change. If particu-
t r e a t m e n t is d e s i g n e d to gradually increase healthy be-
lar behaviors are identified, the patient is asked to endorse
havior by way o f a general increase in desired, healthy ac-
a contract for individuals who provide the counterproduc-
tivity a n d s u b s e q u e n t decrease in both overt a n d covert
tive reinforcement. With the acceptance o f this contract,
d e p r e s s e d behavior. A l t h o u g h this t r e a t m e n t p r o t o c o l is
individuals agree to refrain from reinforcing d e p r e s s e d
b o t h highly o r g a n i z e d a n d goal directed, its successful
behavior, or at least r e d u c i n g such r e i n f o r c e m e n t to an
i m p l e m e n t a t i o n c a n n o t occur without an initial focus on
a g r e e d - u p o n level. T h e p a t i e n t is asked to r e p o r t in-
d e v e l o p i n g a t h e r a p e u t i c relationship (Schaap, Bennun,
stances in which the contract is m a i n t a i n e d a n d broken.
Schinder, & H o o g d u i n , 1993; Wilson & Evans, 1977). Es-
pecially for patients who are e x p e r i e n c i n g debilitating
levels o f depression, a relationship based on trust a n d Assessment of Current Activity Level
compassion can provide the necessary motivation for be- O n c e efforts have b e e n m a d e to r e d u c e reinforce-
havior change. D e v e l o p m e n t of such a relationship re- m e n t for d e p r e s s e d behavior, a systematic a p p r o a c h for
quires that the i m p l e m e n t a t i o n o f the p r o g r a m does n o t increasing r e i n f o r c e m e n t for healthy behavior is begun.
p r e c e d e the patient's o p p o r t u n i t y to express a n d de- Similar to Beck's cognitive t r e a t m e n t for depression, the
scribe his o r h e r e x p e r i e n c e of depression, which is pre- first h o m e w o r k assignment for this p o r t i o n of t r e a t m e n t
 Behavioral Activation Treatment for Depression 169

involves self-monitoring of already occurring daily activi- C o n s t r u c t i o n o f the Activity Hierarchy

ties. Possible examples might be brushing one's teeth ev- Following the identification of suitable activities, the
ery day or getting out of bed before 2 P.M. three times a therapist and patient construct an activity log that is hier-
week. Daily monitoring logs establish, h o u r by hour, how archically arranged. That is, activities are ranked accord-
the patient is utilizing his or her time (see Figure 1). ing to their perceived difficulty, with Level 1 activities the
Daily monitoring logs are useful in obtaining a baseline easiest and Level 5 the most difficult. Typically, a list of 15
activity level within the first few sessions, and serve as an activities is compiled with 3 activities in each level. For
educational instrument whereby individuals can examine each activity, the patient and therapist collaboratively de-
their lack of activity and potential desired nondepressed termine what the final goal will be in terms of both fre-
activities. quency and duration per week. Patients are e n c o u r a g e d
During the next phase of BATD, patients are given to make these decisions, thereby taking responsibility for
feedback regarding their activity level and are provided achieving goals and therapeutic gains. Usually prior to
with therapist acknowledgment of the completed home- the end of this second session, patients select the n u m b e r
work assignment. As the treatment is reliant on patient of times in the following week that they can engage in
completion of homework assignments, patients should each of the activities from the first category. These goals
be informed that the success of this program is contin- are recorded on the behavior checkout, similar to the
gent u p o n their compliance with such requests. Aided by form provided by Lewinsohn et al. (1986), that the pa-
the therapist, patients identify current activities, the fre- tient takes h o m e (see Figure 2). Additionally, these goals
quency and duration of these activities, and other poten- also are recorded on a master log that stays in the posses-
tial activities that might be of interest. As suggested by sion o f the therapist (see Figure 3 for a completed log).
Lewinsohn and colleagues, the Pleasant Events Schedule As each activity is introduced into treatment, weekly goals
(PES; McPhillamy & Lewinsohn, 1971) is useful for iden- initially will be lower than the final goal. For example, if
tifying relevant activities. the patient's final goal for a Level 1 activity such as wak-

Hourby Hour DailyMonitoringLog

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday

7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11

Fi~qlre 1. A blank daily monitorinS log to establish a patient's baseline activity level.
170 Lejuez e t al.

Behavior Checkout

Activity Monday Tuesday Wednesday Thursday Friday Saturday Sunday

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Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Y N G Y N G Y N G Y N G Y N G Y N G Y N G

Figure 2. A behavior checkout, based on Lewinsohn et al. (1986), used to establish patient activity goals and monitor
the completion of these goals.

Activity Log

Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Activity (final goal) Goal Do Goal Do Goal Do Goal Do Goal Do Goal Do Goal Do Goal Do Goal Do

Go to Work (5) 5 S 5 5 5 5 M M M M M M M M M M M M

Wake up I pm (7) 6 7 7 7 7 7 M M M M M M M M M M M M

Play with dog (7) 5 7 7 7 7 7 M M M M M M M M M M M M

Make dinner (3) 2 2 2 3 3 3 3 3 3 3 M M M M M M

Wash dishes (6) 3 2 3 3 4 3 4 4 5 5 6 5 5 5 6 6

Clean bedroom (2) g 0 2 1 2 2 2 2 2 2 M M M M

Exercise 15 rain (5) 2 I 2 3 3 3 3 2 3 2 3 3 4 4

Wake up 11 am (6) 3 4 3 5 5 4 6 6 6 6 6 6

Go to sleep 2 am (5) 2 2 2 3 3 3 4 4 5 4 5 5

Visit friends ( I ) I 1 I 1 1 1 M M M M

Friends visit her (1) 1 1 l 1 I 1 M M M M

Exercise 30 rain (4) 1 1 2 [ 2 2 3 2 3 3

Wake up 10 am (5) 2 2 3 4 4 4 5 5

Go to sleep 1 am (3) l 2 2 3 3 3 3 3

Karate classes ( 1)

Figure 3. Log of w e e k l y activity for Mary that spans the second-to-last w e e k of treatment. Bold numbers represent
achieved weekly goals and bold Ms represent mastered activities (i.e., 3 consecutive weeks of achieved weekly goals that
are equal with the patient's final goal for that activity).
 Behavioral Activation Treatment for Depression 171

ing up by n o o n is 7 days/week, the goal for the first week treatment; an Axis II diagnosis was not given and no med-
could be three times. As weeks progress, weekly goals are ical conditions were reported. Mary also had experienced
increased until the final goal is regularly achieved. two previous major depressive episodes, each of which
persisted for approximately 12 months (i.e., at ages 18
Charting Weekly Activity Using the Behavior Checkout and 25). In addition to her history of depression, Mary was
After the h o m e w o r k has been agreed upon, the pa- treated for panic disorder 2 years prior, which was as-
tient is given instructions on how to complete the behav- sessed as "in full remission" at the initiation of BATD.
ior checkout. O n each day of the following week (prefer- Mary's primary complaints included general anhedonia,
ably at a specified time), the patient is instructed to circle hypersomnia, depressed mood, frequent bouts of crying,
the Y (i.e., yes) for each activity that was engaged in dur- and suicidal ideation. Mary
ing the day. Similarly, if an activity was not performed had not been prescribed any
during the day, an N (i.e., no) is circled. Circling the let- psychotropic medications. The goal of
ters is important for two reasons. First, progress toward At initiation of therapy, Mary treatment is not
weekly goals is monitored. Second, circling the letters scored a 21 on the Beck De-
serves as a conditioned reinforcer through pairing with pression Inventory (BDI; Beck, perfection (i.e.,
reinforcers (i.e., praise) for completing activities. Fur- Ward, Mendelson, Mock, & Er- completing every
thermore, to serve as an additional, and possibly more sa- baugh, 1961). Mary reported activity every
lient conditioned reinforcer, patients are instructed to that her nursing occupation
circle the G (i.e., goal) on each day once the goal is met, required her to work 5 to 6 day), but setting
regardless of whether the activity was engaged in on the nights per week and that she and meeting
days following goal attainment. This strategy provides pa- had little desire to engage in reasonable goals.
tients with additional conditioned reinforcers and signi- other activities. U p o n examin-
fies that the goal is not perfection (i.e., completing every ing her daily activities (i.e.,
activity every day), but instead setting and meeting rea- t h r o u g h the daily monitoring log), the determination
sonable goals. was made that the value of reinforcement for more
healthy activities outside of work was low. For example, al-
Assessing Progress and Treatment Modification though Mary perceived time with her husband as a sa-
At the start of each therapy session, the therapist ex- lient reinforcer (i.e., high magnitude), conflicting work
amines the patient's behavior checkout and verbally rein- schedules prevented frequent contact. Given these time
forces weekly goal attainment. The following week's goals constraints, positive interactions with her husband were
are adjusted based on the patient's reported difficulty. typically brief (i.e., short duration) and highly unpredict-
For example, if difficulties (e.g., lack of finances interfer- able (i.e., uncertain). As depressed behavior likely pro-
ing with engagement in a particular activity) are encoun- duced more valuable rewards than the more healthy al-
tered, the therapist and patient work to resolve the prob- ternatives in Mary's repertoire, it is not surprising that
lem. For each target activity, if the weekly goal was depressed behavior occurred m o r e frequently. For exam-
achieved, the goal is increased for the following assess- ple, Mary was sleeping a m i n i m u m of 10 hours a day,
ment period. Goals are evaluated and increased until the which provided immediate benefits such as avoidance of
assessment period goal is consistent with the patient's negative environmental stimuli and depressive cogni-
long-term goals (i.e., final goals). Once the final goal is tions. Moreover, on those rare occasions that Mary did
achieved for 3 consecutive weeks, the activity is considered arise early, she was unable to identify positive behaviors
to be "mastered" and no longer monitored. The rationale that could compete with depressive ruminations. Further,
of mastery is to increase generalization of increased activity she stopped engaging in almost all proactive activity at
once therapy is terminated. At the conclusion of each home, including recreational activities (e.g., exercising)
session, the patient and therapist determine which new and household responsibilities (e.g., cleaning clothes
activities will be monitored for the coming week. and washing dishes). It further was determined that her
husband's responses to her depression may have contrib-
uted to the maintenance of her inactivity. For example,
The A p p l i c a t i o n o f BATD t o Clinical O u t p a t i e n t s
he would complete any household responsibilities left
Case Study 1 u n d o n e , and rarely questioned Mary about her limited
The effectiveness of BATD was examined with a 35- activity. Additionally, he provided no benefits to Mary
year-old married Caucasian woman, Mary, who was highly (e.g., increased attention) contingent u p o n healthy be-
verbal, had earned a college degree, and was employed as havior. To address these concerns, Mary's husband
a nurse. Mary was diagnosed with major depressive disor- signed a contract stating that although he would no
der, recurrent, which had begun about 2 months prior to longer complete Mary's responsibilities, he would assist
111 Lejuez et al.

h e r if she m a d e efforts to engage in activity a n d c o m p l e t e h e r ill m o t h e r p r o v i d e d i m m e d i a t e avoidance o f per-

tasks. Additionally, he a g r e e d to a t t e n d m o r e closely to, ceived negative c o n s e q u e n c e s of c o n f r o n t i n g h e r boss
a n d provide positive consequences for, Mary's healthier a n d the guilt associated with "neglecting" h e r mother.
behaviors such as c o m p l e t i n g h o u s e h o l d tasks, exercis- C o n s i d e r i n g the lengthy hours devoted to work a n d care
ing, a n d visiting friends. taking, access to r e i n f o r c e m e n t for m o r e desirable behav-
Figure 3 lists Mary's goals a n d h e r progress t h r o u g h iors was limited. In addition, J u n e was u n c e r t a i n as to
treatment. In general, h e r lower-level goals consisted o f w h e t h e r the initiation o f social interactions would be re-
h o u s e h o l d responsibilities, whereas h e r higher-level goals ceived well by others. Finally, the delayed benefits o f
focused on social interactions a n d the a t t a i n m e n t of a healthy activities (e.g., exercise) a p p e a r e d to limit their
h e a l t h i e r lifestyle. frequency.
Mary was c o m p l i a n t a n d responsive to the overall J u n e ' s activity hierarchy b e g a n with relatively easy
structure o f BATD a n d r e p o r t e d b e i n g pleased with its goals, including the c o m p l e t i o n o f h o u s e h o l d chores.
goal-oriented focus t h r o u g h o u t treatment. At termina- H i g h e r level goals i n c l u d e d m o r e strenuous exercise,
tion of treatment, consisting of five 1-hour sessions fol- m o r e social time with friends a n d family, a n d improving
lowed by five half-hour sessions, Mary had progressed h e r occupational circumstances.
t h r o u g h Level 4 o f the hierarchy, was typically m e e t i n g J u n e was e a g e r to begin BATD a n d c o m p l i e d with the
h e r weekly goals for each activity, and her BDI score de- p r o t o c o l throughout. In the course of therapy, which
creased to 6. A l t h o u g h a structured a t t e m p t to alter neg- consisted o f 12 o n e - h o u r sessions, J u n e ' s activity level in-
ative cognitions was not utilized, Mary did r e p o r t a con- creased until she had met criteria for all Level 2 and 3 ac-
siderable decrease in negative thoughts by the final tivities, as well as most Level 4 activities. For example, she
session; these changes o c c u r r e d in the absence o f any di- regularly washed h e r dishes 3 times p e r week (Level 2);
rect attempts to alter h e r cognitions. Further, Mary re- she began to walk a r o u n d h e r n e i g h b o r h o o d on a daily
p o r t e d feeling "more positive" a b o u t the m a i n t e n a n c e of basis, losing 20 p o u n d s over the 12-week p e r i o d (Level
h e r m o o d following t e r m i n a t i o n of the p r o g r a m . 3); a n d she spent 2 hours p e r week interacting with h e r
sister outside h e r h o m e (Level 4). Potentially influenced
Case Study 2 by lower-level h o m e w o r k assignments d e s i g n e d to in-
A second case d e m o n s t r a t i n g the effectiveness o f crease assertive behaviors, J u n e also c o m p l e t e d the Level
BATD involved J u n e , a 29-year-old divorced Caucasian 5 goal o f quitting h e r j o b . She o b t a i n e d a new j o b with
woman, who e a r n e d a high school d e g r e e a n d h a d b e e n regular hours, health benefits, a n d paid vacation. Over-
e m p l o y e d as an office m a n a g e r for 11 years. J u n e was di- all, she a p p e a r e d to be m o r e i n d e p e n d e n t a n d assertive.
a g n o s e d with major depressive disorder, recurrent; an J u n e ' s BDI-II score was a 4 at the t e r m i n a t i o n o f therapy
Axis II diagnosis was n o t given a n d a medical c o n d i t i o n a n d a 7 at 3-month follow up. A l t h o u g h J u n e ' s antide-
was not r e p o r t e d . J u n e h a d a history o f depression and pressant m e d i c a t i o n may have c o n t r i b u t e d to h e r im-
suicidal ideation b e g i n n i n g at age 15. During h e r present provement, m e d i c a t i o n was d i s c o n t i n u e d 10 weeks into
episode o f major depression, J u n e was e x p e r i e n c i n g in- therapy, with no noticeable d e t r i m e n t a l effects.
somnia, had an increased appetite (she had gained 15
p o u n d s in the previous 2 m o n t h s ) , was fatigued, a n d ex- Case Study 3
hibited general a n h e d o n i a . She was p r e s c r i b e d the selec- In the final case study, BATD was used to treat Beth, a
tive s e r o t o n i n reuptake i n h i b i t o r Paxil (20 mg once p e r 44-year-old m a r r i e d Caucasian female with a high school
day), which she h a d b e e n taking for 9 weeks p r i o r to d e g r e e who was u n e m p l o y e d at the onset o f treatment.
BATD. A l t h o u g h J u n e h a d c o m p l i e d with h e r m e d i c a t i o n Beth was d i a g n o s e d with m a j o r depression, r e c u r r e n t
regimen, she r e p o r t e d no benefits o f m e d i c a t i o n at the (principal diagnosis), anxiety d i s o r d e r NOS, a n d pain
onset o f BATD. d i s o r d e r (chronic) associated with both psychological
At the initial session,June scored a 26 on the Beck De- factors a n d a general medical c o n d i t i o n (i.e., arthritis,
pression I n v e n t o r y - I I (BDI-II; Beck, Steer, & Brown, r h e u m a t o i d ) ; an Axis II diagnosis was n o t given. Beth's
1996). J u n e ' s self-monitoring o f daily activities indicated previous depressive episode, the d u r a t i o n o f which was
that despite regular a t t e n d a n c e at work, she d i d n o t en- a p p r o x i m a t e l y 1.5 years, o c c u r r e d d u r i n g h e r "mid-30s."
gage in o t h e r desirable activities such as exercising, Beth r e p o r t e d an overall d e p r e s s e d m o o d that i n c l u d e d
housework, a n d social activities.June stated that she h a d f r e q u e n t crying spells, r e d u c e d appetite, insomnia, leth-
low self-esteem a n d often was n o t very assertive when argy, a n d occasional suicidal ideation. Beth h a d n o t b e e n
others (e.g., family a n d coworkers) asked favors o f her. p r e s c r i b e d any psychotropic medications, d u e in large
Frequently she worked overtime without pay, a n d did n o t part to h e r discomfort with the p r o p o s i t i o n o f taking
feel c o m f o r t a b l e asking for vacation time. J u n e ' s long medications.
work hours a n d e n g a g e m e n t in strenuous care-taking for Prior to b e g i n n i n g BATD, Beth scored a 42 on the
 Behavioral Activation Treatment for Depression 173

BDI-II. During the initial intake assessment, it was deter- sion of behavioral interventions that directly influence
mined that Beth's depression was related to restrictions environmental variables, which in turn p r o d u c e both
imposed by both her medical condition and anxiety, in overt and covert changes in behavior. As such, we pro-
addition to apprehension regarding activities such as pose BATD, a treatment for depression following from
driving and being alone in the dark. For Beth, depressed recent advancements in basic behavior analysis, which di-
behavior allowed her to avoid many responsibilities such rectly targets the environ-
as driving and household chores (e.g., taking out the gar- ment-behavior relations re-
bage, feeding the dog), and this response pattern had lated to both activity, as well as Although BATD
persisted for an extended duration (i.e., 1 year). Observ- thoughts and feelings. Al- m a y be m o s t
ing that Beth was behaving in a depressed m a n n e r (e.g., though BATD may be most
lethargic movements, crying), her husband would invari- clearly applicable to individu-
clearly applicable
ably offer to drive her various places and perform most of als with low levels of activity, it to individuals with
her household responsibilities. Although he perceived also may be used for individu- low levels of
these behaviors as being supportive, we conceptualized als who are engaging in high
these efforts as negatively reinforcing Beth's depressive levels of undesirable activity.
activity, it also
behavior, thereby increasing its value. Consequently, dur- O u r goal in proposing may be used for
ing the second therapy session, Beth's husband contracted BATD is to provide clinicians individuals w h o
to cease carrying out these tasks and to consciously work with powerful behavioral in-
toward reducing attention to comments regarding the terventions in a simple and
are e n g a g i n g in
experience of depression and pain. parsimonious package. We do high levels of
Beth's activity hierarchy focused on lower-level goals not, however, suggest that undesirable
such as increasing pleasurable activities that she could BATD is an entirely new treat-
perform despite her arthritis (e.g., mild exercise, relax- ment. In fact, there have been activity.
ation, bingo, shopping) and increasing her frequency of several attempts, as discussed
driving to facilitate more autonomy. Higher-level goals in- previously, to provide activation-based interventions
cluded increasing her exposure to darkness, reducing within a behavioral framework. Unlike BATD, however,
her avoidance behavior, and increasing the frequency these other treatment packages also included a host of
and duration of social contacts with family and friends. other direct interventions that may be difficult for thera-
Although somewhat tentative at the onset of therapy, pists to learn and greatly increase the a m o u n t of therapy
possibly due to her c o m o r b i d anxiety concerns, Beth's time n e e d e d to treat depression. In addition to issues re-
reported compliance and satisfaction with the program garding the patient's time and financial investment in
was high within the first few weeks of implementation. therapy, emphasis on the efficiency of treatment may be
T h r o u g h o u t treatment, consisting o f nine 1-hour ses- especially useful to clinicians given increasing demands
sions, Beth had reached many o f her final goals, includ- to provide effective, time-limited therapy.
ing driving to the mall (Level 2), completing a variety of O n e a r g u m e n t that may be levied against BATD is that
household chores on a regular basis (Level 3), and it does not focus u p o n aspects of depression such as emo-
spending lengthy periods of time outside during the tion and destructive cognitions. Although the interven-
evening (Level 4). Beth reported that she was crying less, tions of BATD are focused on behavioral activation,
had more energy, and no longer experienced suicidal cognitive and emotional processes are not ignored.
thoughts. Moreover, by the end of therapy, her BDI-II Although not directly targeted for change, such pro-
score had decreased to 16. Interestingly, Beth's increased cesses may be assessed across sessions as an index of treat-
a u t o n o m y and decreased reliance on her husband led to m e n t success. In addition, we do not deny the potential
an improvement in their relationship. moderating effects of resulting covert changes; we merely
assert that activation should be the direct target for
change in a cycle that may lead to the long-term remis-
Summary and Conclusions
sion of depression.
Considerable debate has occurred regarding the ac- We acknowledge that some may be u n c o n v i n c e d that
tive mechanisms of change underlying the treatment o f BATD alone is sufficient for the successful treatment o f
depression. Although direct attempts to address the emo- depression. In such cases, the structure and simplicity
tional and cognitive concerns o f the patient might make o f BATD may make it an ideal c o m p o n e n t for engender-
intuitive sense, outcome data suggest that the behavioral ing behavioral activation within b r o a d e r traditional
c o m p o n e n t of treatment may be of primary importance. treatments primarily focusing on cognitive variables or
Based u p o n these findings, we suggest that some of the m o r e process-oriented variables. Consequently, unre-
success of cognitive treatments may be due to their inclu- solved theoretical debates do n o t preclude the use o f
174 Lejuez et al.

BATD, at least as a c o m p o n e n t in the treatment of clini- reinforcement and extinction. Journal of Consulting and Clinical
cal depression. Psychology, 55, 117-119.
Clark, D. C. (1995). Epidemiology, assessment, and m a n a g e m e n t of
Based u p o n the matching law, we have provided a suicide in depressed patients. In E. E. Beckham & W. R. Leber
simple set of interventions for which i m p l e m e n t a t i o n is (Eds.), Handbook of depression (2nd ed., pp. 526-538). New York:
Guilford Press.
relatively time-limited and
Coyne,J. C, (1976). Toward an interactional description of depression.
uncomplicated. At present Psychiatry, 39, 28-39.
In a d d i t i o n t o i t s we have provided a limited Cuijpers, P. (1998). A psychoeducational approach to the treatment of
depression: A meta-analysis of Lewinsohn's "Coping with Depres-
potential use as a n u m b e r of case studies to
sion" course. Behavior Therapy, 29, 521-533.
support the use of this treat- Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive thm~
comprehensive apy for depression. Journal of Consulting and Clinical Psychology, 5 7,
ment, yet many questions re-
treatment, the 414-419.
main. To e x t e n d the utility of
Ferster, C. B. (1967). Arbitrary and natural reinforcement. The Psyeho-
structure and BATD and provide a m o r e logqcal Record, 22, 1-16.
c o m p e l l i n g test of its effec- Fuchs, C. Z., & Rehm, L. E (1977). A self-control behavior therapy pro-
simplicity of BATD gram for depression. Journal of Consulting and Clinical Psychology,
tiveness, controlled trials are
45, 206-215.
m a y m a k e it a n n e e d e d to e x a m i n e its use in Haaga, D. A. E, & Beck, A. T. (1995). Perspectives on depressive real-
both inpatient and out- ism: Implications for a cognitive theory of depression. Behaviour
ideal adjunct to
Research and 77~erapy, 33, 41-48.
patient settings as well as
medication and/or Herrnstein, R.J. (1970). O n the law of effectJournal of the Experimental
within individual and group Analysis of Behavior, 13, 243-266.
other therapies treatment. Although findings Hersen, M., Bellack, A. S., & Himmelhoch,J, M. (1980), Treatment of
tmipolar depression with social skills training. Behavior Modifica-
primarily focusing from such controlled, large- tion, 4, 547-557.
scale investigations are neces- Hersen, M , Eisler, R. M., Alford, G. S., & Agras, W. S. (1973). Effects of
on cognitive and/ token economy on neurotic depression: An experimental analy-
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or more process- sis. Behavior Therapy, 4, 392-397.
statements about this treat- Hollon, S. D., DeRuheis, R.J., & Evans, M. D.(1987). Causal mediation
oriented variables. ment, BATD presently ap- of change in treatment of depression: Discriminating between
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149.
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Hops, H., Biglan, A., Sherman, L., Arthur, J , Friedman, L., & Osteen,
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ule. Eugene: University of Oregon. Additional forms that may aid in the implementation of this treatment
Murphy, G. E., Carney, R. M., Knesvich, M. A., & Wetzel, R. D. (1995). are available from the first author u p o n request.
Cognitive behavior therapy, relaxation training, a n d tricyclic anti- T h e three case studies presented here were individuals who were
depressant medication in the treatment of depression. Psychologi- treated at, or in conjunction with, the Quin Curtis Center for
cal Reports, 77, 403-420. Psychological Service, Training, and Research in the Department of
Otto, M. W., Pava,J. A., & Sprich-Buckminster, S. (1996). Treatment of Psychology, Eberly College of Arts and Sciences, West Virginia
major depression: Application and efficacy of cognitive- University. Identifying information has been changed to preserve the
behavioral therapy. In M. H. Pollack & M. W. Otto (Eds.), Challenges anonymity of these patients.
in clinical practice: Pharmacologic and psychosocial strategies (pp. 31-52 ).
We thank Jan M. Kouzes a n d J . J. McDowell for comments on an
New York: Guilford Press.
earlier draft of this manuscript.
Rehm, L. P. (1977). A self control model for depression. Behavior Ther-
apy, 8, 787-4304. C. W. Lejuez is now at the University of Maryland-College Park.
Rehm, L. E, & Kaslow, N.J. (1984). Behavioral approaches to depres- Derek R. Hopko is now at the University of Tennessee-Knoxville.
sion: Research results and clinical recommendations. In C. M. Address correspondence to C. W. Lejuez, Department of
Franks (Ed.), New developments in behavior therapy (pp. 155-229). Psychology, University of Maryland, College Park, MD 20742; e-mail:
New York: Haworth Press. lejuez@psyc.umd.edu.
Robinson, L. A., Berman, J. S., & Neimeyer, R. A. (1990). Psychother-
apy for the treatment of depression: A comprehensive review of Received: June 26, 1998
controlled outcome research. Psychological Bulletin, 108, 30-49. Accepted: October 23, 1998

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