Scandinavian Journal of Psychology, 2016, 57, 73–82 DOI: 10.1111/sjop.

12233

Personality and Social Psychology

A learning theory account of depression
€ 1 FREDRIK FOLKE2,3 and JONATHAN W. KANTER4
JONAS RAMNERO,
1
Department of Psychology, Stockholm University, Stockholm, Sweden
2
Department of Neuroscience, Psychiatry, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
3
Center for Clinical Research, Dalarna, Sweden
4
Department of Psychology, University of Washington, Seattle, USA

Ramner€o, J., Folke, F. & Kanter, J. W. (2016). A learning theory account of depression. Scandinavian Journal of Psychology, 57, 73–82.

Learning theory provides a foundation for understanding and deriving treatment principles for impacting a spectrum of functional processes relevant to the
construct of depression. While behavioral interventions have been commonplace in the cognitive behavioral tradition, most often conceptualized within a
cognitive theoretical framework, recent years have seen renewed interest in more purely behavioral models. These modern learning theory accounts of
depression focus on the interchange between behavior and the environment, mainly in terms of lack of reinforcement, extinction of instrumental behavior,
and excesses of aversive control, and include a conceptualization of relevant cognitive and emotional variables. These positions, drawn from extensive
basic and applied research, cohere with biological theories on reduced reward learning and reward responsiveness and views of depression as a
heterogeneous, complex set of disorders. Treatment techniques based on learning theory, often labeled Behavioral Activation (BA) focus on activating the
individual in directions that increase contact with potential reinforcers, as defined ideographically with the client. BA is considered an empirically well-
established treatment that generalizes well across diverse contexts and populations. The learning theory account is discussed in terms of being a
parsimonious model and ground for treatments highly suitable for large scale dissemination.
Key words: Depression, learning theory, behavioral principles, behavior activation.
Jonas Ramner€o, Department of Psychology, Stockholm University, S106 91 Stockholm, Sweden. Tel: +468163944; e-mail: [email protected]

INTRODUCTION by Beck et al. (1979) and transformed into instrumental aids in

the primary service of cognitive change. Interest in purely
The World Health Organization (WHO, 2014) identifies behavioral approaches waned at that time, but since the turn of
depression as the leading cause of disability worldwide, affecting the millennia we have witnessed a resurgence of interest in
more than 350 million individuals. As used by the WHO and treatments more aligned with a purely behavioral, or learning
the medical community, the term depression refers to multiple theory view (Dimidjian, Barrera Jr., Martell, Mu~ noz &
disorders with heterogeneous clinical presentations, all of which Lewinsohn, 2011). Along with the development of more
share the common element of depressed mood that is extended in sophisticated behavioral theoretical views of language and
severity and duration. Likewise, a diversity of theoretical models cognition (Hayes, Barnes-Holmes & Roche, 2001), this has
to account for the disorder and related treatments has been spurred interest in revisiting behavioral theoretical models and in
proposed in psychology. Among the most prominent are cognitive conceptualizing interventions from a more purely behavioral point
(Beck, Rush, Shaw & Emery, 1979), behavioral (Martell, Addis of view.
& Jacobson, 2001) and psychodynamic (Busch, Rudden &
Shapiro, 2007). But no theoretical model has gained general
acceptance as an over-arching theoretical framework for DEPRESSION AND LEARNING
depression. It is rather a number of theoretical formulations, each
covering different aspects of the clinical phenomena that are A behavioral phenomena
associated with the disorder. This remains the case even if we A defining feature of learning theory conceptualizations is that
focus on a sub-division such as the models used in cognitive they do not focus on internal events, such as mood or cognition,
behavioral therapies or even those more clearly defined as as explanations of behavior. Instead they focus on describing an
behavior therapies. individual’s behavior, which could include cognitive activity
Within the cognitive-behavioral tradition, learning theory (seen as private behavior), in terms of the context in which the
accounts have been far less influential on our understanding of behavior takes place. Furthermore, while typical medical usage of
mood disorders than other disorders, particularly anxiety disorders the term depression may give the impression of a technical term
(e.g., Mineka & Zinbarg, 2006). In the depression field, treatment with an essential composition, the behavioral view sees the term
techniques associated with learning theory accounts of depression, as loose and metaphorical rather than technical (Kanter, Busch,
developed in the 1960s and 1970s, came to be seen as lacking Weeks & Landes, 2008). In other words, no assumption that
sophistication, particularly with respect to cognition and cognitive depression represents a biologically distinct syndrome with a
phenomena (Blaney, 1977; Dobson & Block, 1988). As the distinct biological composition is made. This is not to say that
cognitive revolution took hold, behavioral techniques were biology is irrelevant. Rather, this view of depression as an
assimilated into the extremely popular cognitive model put forth umbrella term for a heterogeneous set of related conditions, each

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74 J. Ramner€o et al. Scand J Psychol 57 (2016)

of which may have a distinct pathology, is consistent with Cantu, Chambers & Lejuez, 2003; Hopko & Mullane, 2008;
directions in the neurobiology of depression as well, where Lewinsohn & Amenson, 1978).
researchers have struggled to find evidence for universal In the early models of depression, special emphasis was put on
biological processes that account for large proportions of variance social reinforcement and the observation that depressed persons
in depressed patient populations (e.g., Mayberg, 2007). tended to withdraw from social interactions (Lewinsohn, 1974).
Thus, a behavioral account of depression needs to be grounded Since there was some evidence that assertion training could be an
in a behavioral description of the phenomena that we subsume effective treatment (Sanchez, Lewinsohn & Larson, 1980), it was
under the label depression and seeks to understand the variety hypothesized that social skill deficits were at times responsible for
of antecedent circumstances that occasion use of the term. reduced social reinforcement, thereby contributing to depression.
Etymologically the word depression stems from depress, to However, the negative correlation found between social skills and
press down (http://www.oxforddictionaries.com/definition/english/ depression could be interpreted that what appears to be skill
depression), and this may delineate a relevant starting point in deficits may at times be treated as a consequence, rather than a
understanding what the heterogeneous usages of the term may cause, of depression (Kanter, Cautilli, Busch & Baruch, 2011).
have in common – how a vital part of the individuals’ adaptive Although there are theoretical and biological differences
behavioral repertoire may be experienced as “pressed down” by between the concepts of reward and reinforcement (White, 1989),
life and circumstance. This usually begins with a description of there is significant overlap and the idea of deficient response-
behavioral deficits (e.g., Lewinsohn, Biglan & Zeiss, 1976; contingent positive reinforcement is consistent with biological
Martell, Dimidjian & Herman-Dunn, 2010): lack of activity, lack literature that stresses impaired reward learning and reward
of initiative, lack of pleasurable activities and slowed or lack of responsiveness as defining features of depression (Dichter, Felder,
thinking and problem solving, for example. It should be noted Petty, Bizzell, Ernst & Smoski, 2009). While the behavioral view
that the descriptive features of the diagnosis also to a large extent focuses on environmental reductions in reinforcement frequency,
rest upon verbal reports of private events, such as perceived the biological view focuses on biological changes in reward
hopelessness, fatigue, suicidal ideation and difficulty in making responsiveness. In either case, the outcome – that the individual
decisions. One can expect behavioral excesses when it comes to experiences less reward and reinforcement – is the same, leading
activities such as resting, spending time in isolation, complaining biological researchers to predict that behavioral therapy
and ruminating over one’s condition. These behavioral patterns of approaches focused on improving contact with environmental
depressed individuals are not seen as qualitatively different from reinforcement will resolve brain deficits related to reward
those of his or her non-depressed counterparts. The difference is responsiveness (Dichter et al., 2009).
only one of relative frequency with regards to the total behavioral Depressed patients, especially those showing marked
repertoire (Ferster, 1973). Thus, an excess in ruminating and a anhedonia, have been found less apt to adapt their behavior
deficit in active problem solving acquires clinical status, only as a function of rewards in the surrounding environments. In
when related to the total behavior of an individual. Neither experimental studies, dysfunction in reward learning has been
of these behaviors are in themselves pathological independent of found not only to predict persistence in depression, but also to be
the context in which they occur. For the learning theorist, the task normalized by treatment (Vrieze, Pizzagalli, Demyttenaere et al.,
is to explain the functional properties of these behaviors that 2013). Further, depressed patients have shown significantly
become maladaptive, and the environmental circumstances that reduced reward responsiveness and also impairment in integrating
give rise to these behavioral phenomena. reinforcement over time. This indicates that depression is
Within a learning theory account, a preliminary differentiation characterized by impairment in the modulation of behavior as a
could be made between three major categories of environmental function of reinforcement history (Pizzagalli, Iosifescu, Hallett,
events that could be suspected to give rise to the pressing down Ratner & Fava, 2009). It also gives an indication of a way how
of a person’s behavior, or his or her depression: (i) the absence of anhedonia is associated with learning processes in depression.
potential reinforcers/rewards; (ii) the withdrawal of reinforcers/ The notions of environmental reinforcement and biological
rewards, resulting in extinction of instrumental behavior, and; reward responsiveness have been linked in a study by Bogdan
(iii) uncontrollable aversive, punishing events (Huston, de Souza and Pizzagalli (2006) who found that acute stress (a response
Silva, Komorowski, Schulz & Topic, 2013). to stressful environments) reduces reward responsiveness,
particularly in individuals with anhedonic symptoms. Since stress
is one of the strongest risk factors for depression, the hypothesis
Lack of reinforcement of a stress-induced hedonic deficit is a promising candidate
In one of the first learning theory accounts of depression, mechanism linking stressful experiences to depression, via
Lewinsohn (1974) posited insufficient response-contingent deficient accessing of reinforcing events.
positive reinforcement as a central feature of clinical depression.
This could be due either to reduced access to potentially
reinforcing events following changes in the environment, or due Helplessness and aversive control
to a person’s limited ability to gain access to such reinforcers. Experimental animal models of depression have tended to focus
These hypotheses have gained correlational support from studies on paradigms such as chronic stress and learned helplessness
where self-reported low mood was related to fewer positive to induce depression-like behavior (Diener, 2013). The idea of
events, decreased access to environmental reward, and more learned helplessness is that exposure to inescapable aversive
limited abilities to obtain reinforcement (e.g., Hopko, Armento, events leads to extinction of escape behavior that otherwise would

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Scand J Psychol 57 (2016) A learning theory account of depression 75

be expected in the face of aversive stimulation (Seligman, 1974). attempts to avoid the experience per se (Hayes, Wilson, Gifford,
While the core of instrumental or operant learning is that subjects Follette & Strosahl, 1996).
learn that their behavior controls reinforcement, learned
helplessness proposes that subjects learn that their behavior
cannot control reinforcement (Diener, 2013). This mimics clinical Emotional reactions
phenomena observed in depression. Thus far, we have focused on models that analyze how a vital
In empirical studies of humans, a significant association part of the individual’s adaptive behavioral repertoire is “pressed
between depression and adverse life experiences has been found, down” or depressed. But the etymological roots of depression
regardless of whether these experiences occur early in life or in point to another feature that is pressed down: the mood. The
adulthood (Kessler, 1997). While discrete stressful life events, like affective state associated with depression is its primary diagnostic
bereavement and adverse uncontrollable conditions, can be related feature, often a central reason for clients to seek treatment
to depression, empirical studies have generally favored chronic, (Dougher & Hackbert, 1994), and the basis for the characterization
rather than acute, stress factors as a predictor of depression of depression as a mood disorder. From a behavioral perspective,
(McGonagle & Kessler, 1990). Daily hassles have an effect on when a lack of positive reinforcement is generalized or persistent,
mood and chronic conditions like low socioeconomic status, it frequently results in emotional reactions that we label sadness or
sustained medical disability, and prolonged marital conflict, and despair. Technically, insufficient reinforcement, extinction, and
especially the interaction between chronic and acute stressors, punishment function as unconditioned stimuli that increase the
constitute risk factors for depression (Mazure, 1998). likelihood of eliciting responses labeled sadness, frustration, anger
Aversive events may, apart from eliciting direct emotional and the like. These respondent functions could be regarded as
responses, also function as punishers and thereby suppress unconditioned responses, analogues to the emotional reactions
behavior. Further, when aversive consequences follow behavior, observed in laboratory animals placed on extinction or exposed to
escape and avoidance behavior may increase in the future. Such punishment (Dougher & Hackbert, 1994). Lewinsohn (1974)
behavior is said to be under aversive control (Catania, 2013). characterized the core affective experience of depression as an
Ferster (1973), in one of the earliest learning theory accounts of elicited by-product of losses of or reductions in positive
depression, emphasized the role of aversive control, escape and reinforcement. As stated above, this behavioral view is consistent
avoidance behavior, and especially the passive response to with biological approaches that focus on reward responsiveness as
aversive stimuli in the surrounding environment. For example, a core feature of anhedonia.
Ferster (1973, p. 859) suggested, “In the face of silence for It is well accepted that experiences of loss of reinforcement
example, the depressed person will prompt someone else to speak or operant extinction often result in a number of behavioral
rather than initiate some activity that is important to himself.” The and emotional consequences in humans, such as frustration,
depressed person, rather than taking direct action to alter an aggression, sadness or anger, crying, agitation and reduced
aversive situation, instead takes indirect action, such as happiness (Huston et al., 2013). Huston et al. (2013) posited an
complaining or withdrawing, which does nothing to improve animal model of extinction-induced depression, and found various
the situation. behaviors emitted during the extinction trials that responded to
While aversive control and a pre-dominance of negatively treatment with antidepressant drugs. The behavioral marker for
reinforced behavior (i.e., escape and avoidance) may in principle extinction of escape was immobility. During extinction after
be distinguished from deficits in response-contingent positively positive reinforcement, among the important indices for
reinforced behavior, under actual circumstances the repertoires extinction-induced depression were the withdrawal from the
are intertwined. Avoidance of aversive stimuli results in former site of reward and biting behavior. Avoidance behavior
distancing individuals from contact with the circumstances and biting may model aspects of human depressive behavior,
that potentially could lead to environmental reward and which may include withdrawal or avoidance as well as
reinforcement, and this cycle may maintain and exacerbate the aggressive-like behaviors.
depressive state. In fact, the behavioral view suggests that With regards to respondent conditioning, there is some
avoidance of aversive stimuli in itself is not pathological and evidence that depression in humans is associated with deficits
only becomes problematic when it leads to reductions in positive in appetitive conditioning, resulting in the failure to form or
reinforcement (Martell et al., 2001). In line with this, Carvalho maintain positive associations between appetitive unconditioned
and Hopko (2011) found that reductions in self-reported envi- stimuli and neutral stimuli (Martin-Soelch, Linthicum & Ernst,
ronmental reward mediated the relationship between avoidance 2007). This process may pose another link to understanding
and depression. anhedonia, but generally behavioral models have tended to favor
From a respondent conditioning perspective, aversive stimulation treating the core affective experiences of depression as respondent
also may produce conditioned fear (Catania, 2013); thus, the well- byproducts of operant interactions. This stands in sharp contrast
established comorbidity of anxiety and depressive disorders may be to modern learning accounts of anxiety disorders (e.g., Mineka &
seen as a function of the degree to which aversive stimulation Zinbarg, 2006; Neudeck & Wittchen, 2012), where respondent
produces both conditioned fear and anxious avoidance that result conditioning serves as a dominating theoretical basis. But there is
in a loss of positive reinforcement (Jacobson & Newman, 2014). a difference with anxiety disorders, in that the core fear response
Contemporary behavioral models suggest that, in addition to is seen as central to the symptom list, and the other symptoms
attempts to avoid the situations that evoke aversive reactions, a have obvious relations to it (Barlow, 2004), but with depression
central feature across different areas of psychopathology lies in the the core respondent reactions such as sadness or anhedonia do not

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76 J. Ramner€o et al. Scand J Psychol 57 (2016)

have sufficient explanatory power in and of themselves with depressive symptoms who were provided with inaccurate
respect to the chronicity, severity, and associated symptoms of instructions for how to succeed at an experimental task showed
clinical depression (discussed in more detail in Kanter et al., evidence of persistent rule-following and failed to adapt their
2008). behavior to the actual contingencies, leading to less success with
the experimental tasks. Participants with low levels of depressive
symptoms also demonstrated problematic rule-following at first
Reinforcement of depressive behavior but, unlike their depressed counterparts, they successfully adapted
In addition to understanding how non-depressed behavior is their behavior to the actual contingencies with repeated exposure
reduced in depression, it is also possible to understand how to the contingencies.
depressive behavior, at least initially, may be positively reinforced One particular behavior of interest is the internal verbal
by the social environment (Lejuez, Hopko & Hopko, 2001). behavior of rumination, spending long periods of time rehashing
Verbal behaviors associated with depressed affect, such as and analyzing problems, which seems to be a key process in
complaining and expressing negative affect, may initially be depression (Nolen-Hoeksema, Wisco & Lyubomirsky, 2008).
maintained through positive and negative reinforcement, when Ruminative response style predicts the onset, length, and severity
the individual’s environment responds to these behaviors with of depressive episodes. While rumination correlates with a
genuine support and concern and assistance (Lewinsohn & number of negative thinking processes (like hopelessness) that
Gotlieb, 1995). Complaining may be met with listening and predict depression, it appears to have a unique relationship to
sometimes the listener adapts to these complaints. Negativity can depression over and above these other variables and may mediate
be met with efforts to make the person see things in a more the relationship between depression and negative thinking styles.
positive light. Expressing weariness is often met with reassurance Experimental studies have shown that in persons with dysphoric
and significant others may take over responsibilities. In fact, mood, rumination leads to several behavioral consequences which
depressed statements have been found to have interpersonal may exacerbate depression, such as increased negatively biased
influence as they lower the probability of aggressive responses thoughts (Lyubomirsky & Nolen-Hoeksema, 1995), increased
from both spouses and children (Biglan, Rothlind, Hops & access to negative memories (Lyubomirsky, Caldwell & Nolen-
Sherman, 1989; Hops, Biglan, Sherman, Arthur, Friedman & Hoeksema, 1998), deficits in problem solving (Lyubomirsky &
Osteen, 1987). In the long run, however, if these behaviors come Nolen-Hoeksema, 1995), and inhibition of instrumental behavior
to dominate the total repertoire, the listeners may fatigue and burn (Lyubomirsky & Nolen-Hoeksema, 1993). People who are prone
out. Thus, depressive behavior may ultimately lead to aversive to rumination also appear to behave in ways that are
social consequences in the form of negative responses from counterproductive in relationships to other people. A study of
significant others ultimately increasing rejection and thereby bereaved adults, for example, found that increased rumination was
exacerbating conditions that lead to depressed mood (Coyne, associated with seeking social support after the loss, but also with
1976). reports of more social friction and with receiving less emotional
support from others (Nolen-Hoeksema & Davis, 1999).
Rumination is seen as a behavioral phenomenon within a
Language and rules learning theory account (Martell et al., 2001), specifically as a
Despite considerable behavioral theory on the topic (e.g., Skinner, verbal process that is triggered by stressful or aversive events and
1957), early behavioral models suffered due to the perception that results in the transformation of the meanings (functions) of those
they could not address cognitive phenomena (Dobson & Block, events (Kanter et al., 2008). As rumination is associated with
1988). Over the last 40 years, however, the behavioral theory withdrawal and inactivity, it may be negatively reinforced because
of language and cognition has progressed and transformed it reduces exposure to the aversive environment (Martell et al.,
considerably, due to new advances in theory and research 2001). But there may also be another reinforcement contingency
(Dymond & Roche, 2013; Hayes et al., 2001). At the heart of at hand when considering rumination. Ruminating implies
these changes is the notion of rule-governed behavior: a sustained processing of negative emotional material, but the
functional property of language is that one can tell someone what individuals may perceive that this verbal activity provides
to do (provide rules) and their behavior can be governed by these justification for the inactivity and inability to act. Rumination
descriptions of reinforcement contingencies rather than by the may be reinforced by the certainty it produces (Nolen-Hoeksema
actual contingencies (Hayes, Brownstein, Haas & Greenway, et al., 2008). An important feature of verbal behavior is that
1986). Such rule-governed behavior can expedite the learning correspondence between different parts of the relational network,
process, in that it may be much quicker to follow a rule than to known as verbal coherence, will function as a powerful reinforcer
learn the actual contingencies through experience with them. But of the activity (Roche, Barnes-Holmes, Barnes-Holmes, Stewart
rule-governance also can invoke a certain amount of insensitivity & O’Hora, 2002). In other words, it is reinforcing when things
to the actual contingencies when the contingencies differ from “makes sense.”
what is described by the instructions (Catania, 2013). This may While engaged in a ruminative process, the individual may be
have implications for depression, to the extent that depressed less sensitive to the actual contingencies that triggered the
individuals, prone to rumination and negative thinking (discussed process. This will have the further effect of reducing the
below), may be more likely to display these insensitivities individual’s contact with other potentially rewarding and
to contingencies. For example, McAuliffe, Hughes, and reinforcing events and impairing the individual’s ability to
Barnes-Holmes (2014) found that persons with high levels of actively cope with the events that actually could be resolved with

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Scand J Psychol 57 (2016) A learning theory account of depression 77

better contact with the situation. Such consequences may be the (AM) and other related assessment strategies. Most, if not all, BA
common denominator in depressogenic learning processes (Kanter treatments provide clients with some kind of AM chart for writing
et al., 2008; Martell et al., 2001; Nolen-Hoeksema et al., 2008). down behaviors and moods on a regular basis. The case
conceptualization is shared with the client and serves as the
foundation for a behavior change plan.
LEARNING THEORY BASED TREATMENT The actual steps towards change are accomplished using
activity scheduling (AS) procedures. Scheduling of activities is
Behavioral activation probably what most people associate with BA, and rightfully so
Treatment techniques associated with the above theoretical and since it is the most frequent component across behavioral
empirical observations were first put into clinical practice by treatments for depression (Kanter et al., 2010). Activities are
Lewinsohn and colleagues, who in the 1960s and 1970s scheduled to be completed between sessions and the purpose is
developed, empirically evaluated and refined a set of relatively to initiate behaviour that may increase contact with potential
straightforward behavioral techniques, primarily activity reinforcers. Although earlier behavioral treatments emphasized
scheduling and social skills training (Lewinsohn, Biglan & Zeiss, scheduling activities that were pleasant, most current versions
1976; Lewinsohn, Mu~noz, Youngren & Zeiss, 1978; Zeiss, encourage therapists to derive a more functionally diverse set
Lewinsohn & Mu~noz, 1979). However, as discussed above, these of target behaviors from the case conceptualization. Target
behavioral interventions came to be deemphasized with the behaviors usually concern issues in the clients’ lives related to
increasing popularity of Cognitive Therapy (CT) in the 1980s, increasing positive reinforcement for healthy behavior, decreasing
which subsumed them into the cognitive model (i.e., Beck et al., positive reinforcement for depressed behavior, decreasing
1979). Interest in behavioral treatments was revitalized when negatively reinforced avoidance behaviors, and other issues as
Jacobson, Dobson, Truax et al. (1996) dismantled CT into its discussed above. BATD (Lejuez et al., 2001, 2011) also included
components and did not find any differences between the procedures for deriving activities to schedule from the clients’
behavioral components without cognitive restructuring and the values, and Martell et al. (2001, 2010) included techniques to
full-scale cognitive treatment. Previous to the Jacobson study, address avoidance, rumination and emotional reactions more
behavioral treatment techniques fell under the umbrella term directly. In Martell et al. (2010), clients are taught how to
behavior therapy, but Jacobson and colleagues labeled the identify and understand the functions of avoidance, how to
behavioral intervention in their study Behavioral Activation (BA), replace avoidance with alternative coping strategies and to act
and, in the years following this study, the number of behavior according to a goal-oriented plan instead of acting according to
therapy studies for depression using this term increased rapidly emotional dispositions in the moment. AS procedures are
(Dimidjian et al., 2011). typically engaged in a graded fashion in order to increase the
Many variants of BA have been developed and evaluated over likelihood of success and to address patient proneness to
the years, but the two most widely used and empirically evaluated avoidance. Clients may be encouraged to construct an activity
protocols to date have been the ones developed by Martell and hierarchy with increasingly more difficult tasks (Lejuez et al.,
colleagues (Martell et al., 2001; Martell, Dimidjian & Herman- 2001, 2011) and to break down assignments in smaller steps.
Dunn, 2010) and Behavioral Activation for Depression Treatment AS is also often accompanied with problem solving procedures
(BATD; Lejuez, Hopko & Hopko, 2001; Lejuez, Hopko, Acierno, (Martell et al., 2001, 2010). Typically, BA ends with an
Daughters & Pagoto, 2011). emphasis on building skills and activities into daily routines and
generalizing them across contexts along with traditional relapse
prevention strategies.
Treatment structure and components While AS and AM are hallmarks of behavioral treatments for
There are many shared elements across different behavioral depression, other components have been included to different
treatments for depression, both among earlier versions and degrees in different protocols to supplement AS procedures,
contemporary ones (Kanter, Manos, Bowe, Baruch, Busch & especially if AS is not initially successful (Kanter, Busch & Rush,
Rusch, 2010; Martell, 2013). All variants share common origins 2009). Social skills training (SST) is a component that follows
in learning theory accounts of depression, emphasize the logically from Lewinsohn’s (1974) assertion that skills deficits
importance of behavior change, and stress the importance of may prevent clients from contacting reinforcers that are
applying clinical strategies ideographically based on a case potentially available in the environment. Some protocols have
formulation. Furthermore, these treatments typically follow an applied SST as a standard and highly structured component
explicit structure, both within sessions and over the course of (Lewinsohn et al., 1978) whereas others have allowed therapists
therapy, and they are usually time-limited. However, there are also to assess the need for SST on an idiographic basis and have
some differences concerning structure, emphasis and components. provided less formalized instructions for therapists (e.g., Martell
The typical behavior therapy for depression starts, like any et al., 2010). When non-depressed and active behavior is not
other therapy within this tradition, by orienting the client to reinforced, or even punished by the client’s environment,
treatment through a brief rationale and basic therapy information. contingency management (CM) has been applied in different
The therapist collaborates with the client to obtain knowledge ways in many behavioral protocols. CM procedures have included
regarding both behavioral problems and potential treatment goals, self-rewards for achieving goals (e.g., Lejuez et al., 2001) and
in order to build a case conceptualization. This is accomplished behavioral contracts with significant others (Lejuez et al., 2011;
through a clinical interview and by initiating activity monitoring Martell et al., 2010).

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Many BA protocols have emphasized the importance of Parling & Ghaderi, 2015), negative symptoms in psychosis
targeting cognitive processes in treatment (e.g., Martell et al., (Mairs, Lovell, Campbell & Keeley 2011) and trans-diagnostic
2010). The specific approaches employed have varied over the populations (e.g., Chen, Liu, Rapee & Pillay, 2013; Chu,
years and across different treatment manuals (Kanter et al., 2010). Colognori, Weissman & Bannon, 2009). Furthermore, BA has
Earlier versions of BA prescribed strategies for directly targeting been studied in diverse settings including inpatient psychiatry
the frequency of negative thoughts, for example through (Folke, Hursti, Tungstr€
om, S€ oderberg, Ekselius & Kanter, 2014;
modelling positive self-talk (McLean & Hakstian, 1979) or Folke, Hursti, Tungstr€
om et al., 2015; Gollan, Hoxha, Hanson,
thought-stopping (Lewinsohn et al., 1976). Current versions of Perkins, Slade & Roberts, 2014; Hopko, Lejuez, LePage, Hopko &
BA emphasize the importance of targeting rumination, which is McNeil, 2003) and residential substance abuse treatment
described as a particularly problematic internal behavior that can (Magidson, Gorka, MacPherson et al., 2011). The treatment
undermine activation and function as avoidance behavior (Martell format has also been varied using group therapy (Porter, Spates &
et al., 2010). Instead of focusing on the content of thoughts Smitham, 2004) and internet or smartphone treatment (Carlbring,
therapists are advised to attend to the process of ruminative H€agglund, Luthstr€om et al., 2013; Hoa Ly, Tr€ uschel, Jarl et al.,
thinking, that is, when and where it occurs, what it is triggered 2014). BA has also been adapted for different ethnic groups
by, and what consequences maintain it. Martell et al. (2010) (Collado, Castillo, Maero, Lejuez & MacPherson, 2014; Kanter,
suggest that therapists can target rumination in a number of ways, Santiago-Rivera, Santos et al., 2015; Moradveisi, Huibers, Renner,
for example by discussing the negative consequences it may have Arasteh & Arntz, 2013) and age groups (e.g., Chu et al., 2009;
on mood or goal attainment. Also, therapists can introduce Snarski, Scogin, DiNapoli, Presnell, McAlpine & Marcinak, 2011).
problem solving as an alternative approach to deal with the
situation that triggered rumination. Furthermore, therapists can
assist clients in re-directing their attention towards sensory CONCLUSION
experiences, the task at hand, or some distracting task instead As was stated above, over the years the term behavior therapy for
of attending to ruminative thoughts. Taken together, instead of depression has been increasingly abandoned in favor of the term
attempting to modify thought content per se in BA, clients are BA. While use of this term is understandable given the body of
trained to become aware of rumination and its’ functions, and to empirical research that has followed and built on the titular study
engage in alternative behaviors. (Jacobson et al., 1996), it is also somewhat unfortunate as it may
lead people to unjustly believe that BA is something different
from behavior therapy or that it is merely a single technique (e.g.,
Treatment efficacy scheduling of pleasant events). We hope the current paper clarifies
Over 30 randomized trials of BA have been conducted since that BA stands at the front of a diverse, rich and sophisticated
Lewinsohn and colleagues’ early work in the 1970s, with the tradition of behavioral therapeutic methods, with a distinctive
number of studies increasing notably during the last two decades therapeutic style for assessment and intervention and a theoretical
(Dimidjian et al., 2011) since the publication of the dismantling groundwork rooted in learning theory: the empirical study of
study by Jacobson et al. (1996). Four meta-analyses of these basic learning processes.
studies conclude that BA is effective in comparison to other From the start, behavior therapy differed from other theoretical
psychological treatments (Cuijpers, van Straten & Warmerdam, approaches to psychological treatments in claiming the conviction
2007; Ekers, Richards & Gilbody, 2008; Mazzucchelli, Kane & to use experimentally verified principles in applied clinical
Rees, 2009) and pharmacological treatments (Ekers, Webster Van settings (Dougher & Hayes, 1999). We stated earlier that the
Straten, Cuijpers, Richards & Gilbody, 2014), and that BA is an learning theory account has had less influence on mainstream
empirically well-established treatment, according to APA Division theoretical conceptions of depression, but this should not be
12 criteria (Mazzucchelli et al., 2009). attributed to a deficient basis in basic principles. On the contrary,
The largest randomized trial of BA to date compared BA with we would assert that behavioral treatment of depression represents
CT and pharmacotherapy (Dimidjian et al., 2006). In this trial all a clinical field that parallels the work done on exposure treatments
treatments performed well with the mildly depressed participants in anxiety disorders (e.g., Neudeck & Wittchen, 2012), where a
but BA performed as well as pharmacotherapy and better than CT solid foundation of empirically verified principles of learning
with the more severely depressed participants. A two-year follow- provided the basis for the development of clinical strategies.
up showed that BA results appear to be lasting, with sustained Recent theoretical and empirical developments within the
remission rates equivalent to long-term medication and superior behavioral tradition have increased our understanding of basic
to discontinued medication (Dobson, Hollon, Dimidjian et al., behavioral processes within language and cognition (Dymond &
2008). Roche, 2013; Hayes et al., 2001). Earlier learning theory
These promising results have spurred researchers to test BA approaches also continue to be relevant (Ferster, 1973). These
outside typical adult outpatient settings. It has been applied to approaches consider language and cognition similar in kind to
treat depression in people with different medical conditions (e.g., other behavioral phenomena, that is, treated as behavior described
Hopko, Armento, Robertson et al., 2011; Pagoto, Bodenlos, in relation to the context where it occurs. For example, rumination
Schneider, Olendzki, Spates & Ma, 2008) and comorbid may be treated as a cognitive phenomenon that produces
psychiatric disorders (e.g., Gros, Price, Strachan, Yuen, Milanak cognitive content, but the behavior of ruminating may also be
& Acierno, 2012). BA has also been extended to other psychiatric considered a relevant target regardless of content (Martell et al.,
disorders beyond depression such as eating disorders (Alfonsson, 2001; Nolen-Hoeksema et al., 2008). As a behavior, it is an event

© 2015 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 57 (2016) A learning theory account of depression 79

that occupies time and space, and has a functional relationship however, suggests that BA may hold advantages over other
to the environment, and as such will compete with the total empirically supported psychotherapy approaches in that training
behavioral repertoire of the individual. Thus, BA focuses on may be completed within a highly restricted time-frame
the understanding the antecedents and consequences of that (Puspitasari, Kanter, Murphy, Crowe & Koerner, 2013) with
behavior, and with that understanding seeks to decrease the retained efficacy and cost effectiveness (Ekers, Godfrey, Gilbody
frequency of rumination and increase the frequency of other et al., 2011; Ekers, Richards, McMillan, Bland & Gilbody, 2011).
responses that would more likely produce contact with In addition, research indicates BA can be adapted to a diversity of
sustainable environmental reinforcers. As a matter of theory, an treatment settings and for heterogeneous populations (Dimidjian
adaptive change in this behavioral repertoire does not need to et al., 2011; Kanter et al., 2015; Moradveisi et al., 2013). This, we
eradicate certain convictions held by the person, but the believe, is a function of a straightforward, broadly applicable, and
frequency and influence of such thought content should decrease easily understandable rationale and set of techniques in BA derived
as adaptive behavioral changes occur. from basic behavioral principles with those same characteristics.
It also may be useful to acknowledge that at a more general There are many remaining issues to address in future research
level, BA is essentially verbal in nature, as were the earlier regarding a learning theory account and its’ implications for
instantiations of behavior therapy for depression. Although some behavioral treatments for depression. At the level of the basic
earlier authors distinguished the behavioral therapies from research, although there is much correlational and small-scale
“verbal” or “talk” therapies (e.g., Smith, Glass & Miller, 1980), experimental support for the model (Manos, Kanter & Busch,
this distinction seems less relevant today as the research on 2010), well-designed longitudinal studies demonstrating causal
human language and cognition, discussed above, increases its relations between environmental changes (e.g., losses of
impact and learning theory accounts come to grips with the reinforcement, increases in aversive stimulation) and behavioral
pervasiveness of human language (Hayes et al., 2001). responses that either cause or ameliorate depression are now
Furthermore, while it is the case that many of the principles that possible with current methodological and statistical strategies.
form the theory of BA were derived from experimental animal Hopefully these studies will be pursued. Experimental research
research and generalizations from non-verbal organisms to that continues to refine our understanding of the relations between
humans, it is also the case that the actual process of BA is a rule-governed/verbal behavior, non-verbal contingency-shaped
largely verbal interchange between the client and the therapist, behavior, and emotional variables (e.g., McAuliffe et al., 2014)
like other therapeutic processes derived from different theories. will also improve our understanding of depressive responses and
This process itself can be submitted to a behavioral analysis, and treatment.
it may be useful to do so (Kanter et al., 2008), but in general the At the level of treatment outcomes, there is a continued need
reinforcement contingencies targeted by BA are located outside for larger well designed randomized controlled studies in different
the therapist’s office, and the therapist’s influence on these populations and settings. The purported mechanisms of BA have
contingencies is largely mediated by the verbal interchange with been less researched than the issue of efficacy. The theoretically
the client in the therapy office and the rule-governed behavior of critical questions about whether therapy-induced activation and
the client that results from these interchanges. decreased avoidance mediate symptomatic improvement have
Even with the complex considerations of human language as a only been investigated in a few studies (Manos et al., 2010).
behavioral phenomenon in place, a learning theory account strives Some researchers have used single case designs to investigate the
for parsimony in using a limited number of concepts to temporal relations between the proposed mechanisms and
encompass a wide range of phenomena (Biglan & Hayes, 1996). outcome (Gaynor & Harris, 2008; Manos, Kanter & Lou, 2011;
Still, analytic concepts such as reinforcement contingencies, Folke et al., 2015) and others have investigated the correlation
developed to be applied at the level of clinically meaningful between client compliance with activation assignments and
human action, should cohere with and accommodate concepts outcomes (e.g., Busch, Uebelacker, Kalibatseva & Miller, 2010;
at other levels. An analysis of contingencies of learning, for Folke et al., 2014; Hershenberg, Paulson, Gros & Acierno, 2014;
example, should cohere with, but not replace, analyses at other Ryba, Lejuez & Hopko, 2014).
levels. It is therefore encouraging to see that, as predicted by Although BA is helpful for many individuals, more research in
biological theory, patients having undergone BATD who showed these areas is needed to refine our understanding of for whom and
clinical improvements also showed functional changes in neural under what conditions BA will be maximally helpful. With a
structures that mediate responses to rewards (Dichter et al., 2009). behavioral account of depression that does not exclude biological
Parsimony is also reflected in the nature of the treatment or cognitive variables, but rather offers a formulation that can
techniques (BA and BATD) and this technical parsimony may be a serve as the foundation for cross-disciplinary basic and applied
primary driver of the increasing interest in these treatments as research, continued efforts to establish such cross-disciplinary
suitable candidates for large scale dissemination across diverse collaborations will unify and benefit science, broadly defined
mental health care settings and cultural contexts. As described (Kanter, 2013). This, in turn, will benefit our clients. Our hope is
in detail above, empirical studies have indicated that BA is that the current learning theory account of depression, by focusing
as effective as gold standard psychotherapy and medication on identifying variables that are available for deliberate and direct
(Dimidjian et al., 2006; Dobson et al., 2008; Ekers et al., 2014; influence, will produce efficient, effective, and easily disseminable
Mazzuchelli et al., 2009) and perhaps particularly efficacious in interventions in the service of sustainable, non-invasive behavioral
more severe cases (Dimidjian et al., 2006; Moradveisi et al., change of a complex, biological, human being acting in a
2013). The parsimonious nature of BA (Jacobson et al., 1996), complex context.

© 2015 Scandinavian Psychological Associations and John Wiley & Sons Ltd
80 J. Ramner€o et al. Scand J Psychol 57 (2016)

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