Metacognitive beliefs about rumination in recurrent major depression

1 6 0 P a p a g e o r g i o u & Wells

Margo, A., Hemsley, D. R., & Slade, E D. ( 1981 ). The effects of varying auditory input on schizophrenic hallucinations. British Journal of Psychiatry, 139, 122-127.

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Morrison, A. E (1998). A cognitive analysis of auditol 7 hallucinations: Are voices to schizophrenia what bodily sensations are to panic? Behavioural and Cognitive Psychotherapy, 26, 289-302.

Morrison, A. E, & Haddock, G. (1997a). Cognitive factors in source monitoring and auditory hallucinations. Psychologdcal Medicine, 27, 669-679.

Morrison, A. P., & Haddock, G. (1997b). Self-focused attention in schizophrenic patients and normal subjects: A comparative stud): Personality and Individual Differences, 23, 937- 941.

Morrison, A. P., Haddock, G., & Tarrier, N. (1995). Intrusive thoughts and auditory hallucinations: A cognitive approach. Behaviourat and Cognitive Psychotherapy, 23, 265-280.

Morrison, A. P., Renton, J., Williams, S., & Dunn, H. (1999). An effec~ tiveness study of cognitive therapy for psychosis: Preliminary findings. Paper presented at 3rd International Conference on Psychologi- cal Treatments for Schizophrenia, Oxford, UK.

Morrison, A. P., Wells, A., & Nothard, S. (2000). Cognitive factors in predisposition to auditory and visual hallucinations. British Journal of Clinical Psychology, 39, 67-78.

Nelson, H. E., Thrasher, S., & Barnes, T. R. E. (1991). Practical ways of alleviating auditol T hallucinations. British Medical Journal, 302, 307.

Padesky, C. (1993). Schema as self-prejudice. International Cognitive Therapy Newsletteg, 5/6, 16-17.

Padesky, C. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherap); 1,267-278.

Pose),, T. B., & Losch, M. E. (1983). AuditoD, hallucinations of hearing voices in 375 normal subjects. Daagination, Cognition and Personal itv, 2, 99-113.

Romme, M. A.J., Honig, A., Noorthorn, E. O., & Escher, A. D. M. A. C. (1992). Coping with hearing voices: An emancipatory approach. British Journal of Psychiatry, 161, 99-103.

Salkovskis, E M. (1991). The importance of behaviour in the mainte- nance of anxiet T and panic: A cognitive account. Behavioural Psy- chotherapy, 19, 6-19.

Slade, E D., & Bentall, R. E (1988). Sensory deception: A scientific analysis of hallucination. London: Croom Helm.

Strauss, J. s. (1969). Hallucinations and delusions as points on con- tinua flmctions. Archives of General Psychiatry, 21, 581-586.

Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273-280.

Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Hillsdale, NJ: Laurence Erlbaurn.

Wells, A., White,J, & Carter, K. (1997). Attention training: Effects on anxiety, and beliets in panic and social phobia. Clinical Psychology and Po'chotherapy, 4, 226-232.

Address correspondence to Dr. Tony Morrison, Department of Clinical Psycholog T Mental Health Services of Salford, Prestwich Hospital, Bu~' New Road, Manchester, England M25 3BL; e-mail: tmorrison@psycholog): mhss-tr.nwest.nhs.uk.

Received: September l, 1999 Accepted: November 5, 1999

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Metacognitive Beliefs About Rumination in Recurrent Major Depression

C o s t a s P a p a g e o r g i o u , University o f Manchester a n d North Manchester N H S Trust A d r i a n W e l l s , University o f Manchester

Wells and Matthezos (1994, 1996) proposed that perseverative negative thinking, such as depressive rumination and anxious worry, is supported by metacognitive beliefs concerning the functions and consequences of these styles of thinking. However, to date no studies have investigated metacognitive beliefs about rumination. This study examined the presence and content of metacognitive beliefs about rumination in patients with recurrent major depression. To achieve this aim, a semistructured interview was conducted with each patient. The results showed that all patients held positive and negative beliefs about rumination. Positive beliefs appear to reflect themes concerning rumination as a coping strategy. Negative beliefs seem to reflect themes concerning uncontroUability and harm, and interpersonal and social consequences of rumination. The conceptual and clinical implications of the results are discussed.

UMINATION is a t h i n k i n g style t h a t typifies d e p r e s s i o n

a n d ha s b e e n l i n k e d to t he m a i n t e n a n c e o f dep res -

sive e p i s o d e s (e.g., N o l e n - H o e k s e m a , 1991; Teasda le &

B a r n a r d , 1993) . Wells a n d M a t t h e w s (1994, 1996) have

Cognitive and Behavioral Practice 8, 160-164, 2001 1077-7229/01 / 160-16451.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All rights of reproduct ion in any form reserved.

[ ~ C o n t i n u i n g E d u c a t i o n Q u i z l o c a t e d o n p . 2 1 0 ,

a d v a n c e d a m e t a c o g n i t i v e m o d e l o f e m o t i o n a l ~ a l n e r a b i l -

ity in w h i c h pe r seve ra t ive nega t i ve t h i n k i n g , s u c h as de-

press ive r u m i n a t i o n a n d a n x i o u s worry, is s u p p o r t e d by

m e t a c o g n i t i v e be l ie fs c o n c e r n i n g t h e f u n c t i o n s a n d con-

s e q u e n c e s o f s u c h t h i n k i n g . M e t a c o g n i t i o n re fe r s to be-

liefs a n d appra i sa l s a b o u t o n e ' s t h i n k i n g a n d t he abil i ty to

m o n i t o r a n d r e g u l a t e c o g n i t i o n . R u m i n a t i v e t h i n k i n g

c a n b e v iewed as s y m p t o m a t i c o f d e p r e s s i o n , b u t may also

r e p r e s e n t a s t ra tegy i n t e n d e d to c o p e wi th d e p r e s s i o n .

Recent ly , P a p a g e o r g i o u a n d Wells (1999a, 1999b) ex-

Metacognitive Beliefs About Rumination in Depression 161

plored the process and metacognit ive dimensions of rumina t ion and worry. Similarities and differences eme rge d in a n u m b e r of dimensions. Moreover, a metacognit ive d imens ion reflecting negative appraisals of th inking was associated with depressed and anxious affect even when the overlap between depress ion and anxiety was control led. These data suppor t the idea that depressed individuals negatively appraise their own th inking processes, and this is not solely d e p e n d e n t on anxiety.

In Wells and Matthews's (1994, 1996) Self-Regulatory Executive Funct ion (S-REF) mode l of emot iona l disorders, perseverative processing is viewed as a coping strategy or a p re fe r red means of appraisal that has several negative consequences for emot iona l self-regulation. For instance, worrying following stress appears to incubate intrusive images (Wells & Papageorgiou, 1995). Active and perseverative thinking, in the form of rumina t ion or worry, is l inked to positive and negative metacognitive beliefs about these processes (Cartwright-Hatton & Wells, 1997; Wells & Carter, 1999; Wells & Papageorgiou, 1998). This concept has been deve loped in a recent metacognitive mode l and t r ea tment of genera l ized anxiety d i sorder (GAD; Wells, 1995, 1997).

To date, no studies have tested the pred ic t ion that positive and negative metacognit ive beliefs about rumination are he ld by depressed individuals. Al though several authors have previously l inked rumina t ion to the mainte- nance of depress ion (e.g., Nolen-Hoeksema, 1991; Teas- dale & Barnard, 1993), the na ture of the knowledge base responsible for the selection of rumina t ion as a coping strategy has no t been cons idered outside of the S-REF model . Therefore , in this pre l iminary study, we a imed to systematically examine the presence and con ten t of positive and negative metacognit ive beliefs about rumina t ion in depression.

M e t h o d

Participants In o r d e r to investigate metacognit ive beliefs in depres-

sion, we e lec ted to restrict the sample to individuals with recur ren t major depress ion without concur ren t Axis I disorders. In total, 75 individuals who had been consecu- tively refer red for psychological t r ea tment of depress ion were screened. Four teen pat ients (7 women, 7 men) met DSM-1V (American Psychiatric Association, 1994) cri teria for r ecur ren t major depressive d i sorder (MDD) and d id not mee t cri teria for concur ren t Axis I disorders. Diag- noses were made following adminis t ra t ion of the Struc- tu red Clinical Interview for DSM-IV Axis I D i so rde r s - Pa t ien t Edi t ion (SCID-I /P; First, Spitzer, Gibbon , & Williams, 1997). Table 1 shows pat ients ' characteristics, inc luding age, dura t ion of cur ren t episode, and n u m b e r of r ecu r ren t episodes. None of the pat ients had received

Table I Demographic and Clinical Characteristics

of Patients (N = 14)

Variable M SD Range

Age (years) 38.5 9.9 22 to 55 Duration of current MDE (months) 11.5 5.4 3 to 20 Number of recurrent MDEs 3.6 1.3 2 to 6 BDI 31.7 8.9 21 to 50 BAI 17.2 4.6 9 to 24

Note. MDE = Major Depressive Episode; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory.

previous psychological treatments for depression. All of the patients had been stabilized on ant idepressant medica- tion for at least 3 months pr ior to part icipating in the study.

Measures In o rde r to assess the severity of depressive symptoms,

pat ients were asked to comple te the Beck Depress ion In- ventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). In addi t ion, since anxious symptoms are com- monly found in MDD, the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) was admin i s te red to assess the level of anxiety. Table 1 shows pat ients ' mean BDI and BAI scores. These scores indicate that pa t ients ' severity of depressive and anxious symptoms fell within the severe and mild- to-moderate range, respectively.

Procedure Following assessment and diagnost ic screening, a br ie f

semis t ructured interview was conduc ted with each patient. The interview was based on a metacogni t ive profil- ing interview developed by Wells and Matthews (1994) in o rde r to de te rmine cognitive and metacognit ive processes dur ing "on-line" negative emotional experiences. For purposes of this study, only a specific sec- t ion of the metacognit ive pro- filing interview was ext rac ted and used. This section is conce rned with el ici t ing metacognitive beliefs about negative self-processing.

At the beg inn ing of the interview, pat ients were asked to "think about the most recen t t ime in which you felt par t icular ly depressed and you were ruminat ing." Since two pat ients were uncer ta in about the mean ing of ruminating, they were provided with alternative words in an a t t empt to assist t hem with the task. The words dwelling and brooding proved to be

R u m i n a t i o n c a n b e

v i e w e d a s

s y m p t o m a t i c o f

d e p r e s s i o n , b u t

m a y a l s o r e p r e s e n t

a s t r a t e g y

i n t e n d e d t o c o p e

w i t h d e p r e s s i o n .

162 Papageorgiou & Wells

helpful in facili tating comprehens ion . It should be no ted that we avoided the term worry so as to reduce possible confounds with anxious thinking.

Having ident i f ied a specific occasion, patients were asked, "Thinking about that t ime, I ' d like to ask you some quest ions about your ruminat ing." Patients were then asked a n u m b e r of p robe questions to examine the pres-

Modifications of positive and negative metacognit ive beliefs about rumination may be beneficial in the treatment of depression.

ence and conten t of metacognitive beliefs about rumination. Initially, pat ients were asked quest ions a imed at ex- p lor ing the presence of positive beliefs. They were asked, "Were there any advantages of ruminat ing?" If pat ients re- por ted positive beliefs about ruminat ion , they were then asked, "What were the advantages of ruminat ing?" and "Would there be any disadvantages of giving up ruminating?" Similarly, patients were

asked p robe quest ions in t ended to de te rmine the presence of negative beliefs about ruminat ion: "Were there any disadvantages of ruminat ing?" If negative beliefs were indicated, the conten t of these beliefs was el ici ted by ask- ing, "What were the disadvantages of ruminat ing?" and "Would there be any advantages of giving up ruminating?" On comple t ion of the interview, all patients were appropr ia te ly debr iefed.

Resu l t s

All pat ients readily ident i f ied a recent occasion when they felt depressed and were ruminat ing. Of the 14 occa- sions identif ied, 5 had occur red on the day of the interview, 6 on the day before, and 3 on the previous 2 days pr io r to the interview.

All of the patients r epor ted advantages (i.e., positive beliefs) and disadvantages (i.e., negative beliefs) of ruminating. Table 2 shows the conten t of each pat ient 's metacognitive beliefs. The advantages o f rumina t ion appea r to reflect themes concern ing rumina t ion as a coping strategy. The disadvantages of rumina t ion seem to reflect themes conce rn ing uncontrol labi l i ty and harm, and in- te rpersonal and social consequences of ruminat ion. Po- tential conflicts appea r to exist between the advantages and disadvantages of ruminat ion .

D i s c u s s i o n

This study provides p re l iminmy evidence suppor t ing the assertion that individuals with recur ren t MDD hold positive and negative beliefs about depressive rumination. The presence of these beliefs is consistent with Wells

and Matthews's (1994, 1996) S-REF model . This mode l accounts for ruminat ive th inking in terms of the activa- t ion of positive and negative metacognit ive beliefs about perseverative negative th inking (i.e., rumina t ion) . If individuals with positive beliefs exper ience depressed mood, they are liable to activate rumina t ion as a coping strategy in o rde r to regulate mood. However, rumina t ion is likely to consist of little informat ion that can modify negative affective exper ience. Moreover, once negative beliefs are activated in these individuals, a sense of hopelessness may be intensif ied as the p r e d o m i n a n t (ruminative) coping strategy is unde rmined . Thus, positive or negative beliefs or their in teract ion may cont r ibute to depression.

Positive and negative beliefs about repetit ive negative th inking have previously been l inked to the process of worrying, and are a central feature of a cognitive mode l of GAD (Wells, 1995, 1997). It seems that depressed patients have positive and negative beliefs about rumination that may be similar to the beliefs that pat ients with GAD hold about worry. GAD and MDD may share under- lying metacogni t ions, which may explain the substantial comorbidity, that exists between these disorders. While these disorders may be dif ferent ia ted in terms of the content of thought and dysfunctional at t i tudes (Beck, 1967, 1976), which are outside of the metacognit ive domain , this level may not be the "central engine" responsible for perseverative (ruminative) th inking styles. Accord ing to the S-REF model , metacognit ive beliefs are an impor t an t vulnerabil i ty factor for maladapt ive th inking styles.

From a therapeut ic perspective, modif icat ions of positive and negative beliefs about worry a n d / o r rumina t ion should be beneficial in the t rea tment of emot iona l disorders (Wells, 1997, 2000; Wells & Matthews, 1994, 1996). While this study has focused on beliefs expressed in a propos i t ional or declarative form, in the S-REF mode l such representa t ions are tied to plans or p rocedura l knowledge that de te rmines the style of thinking. There- fore, t r ea tment requires the in te r rupt ion of perseverative th inking processes and the deve lopmen t of executive control of processing that can be channe led into the ac- quisit ion of new thinking styles for deal ing with threat.

Clearly, this study is pre l iminary in nature. The sample consisted of patients with recurrent MDD. Thus, the beliefs about rumina t ion of pat ients with single MDD remain to be established. The interview was retrospective, hence patients ' responses may merely reflect rat ionalizat ions for ruminative symptoms of depress ion and not truly reflect stable beliefs that cont r ibute to ruminat ion. Finally, for- real measures of metacogni t ive beliefs were not used in this study. Future studies could use the Meta-Cognit ions Ques t ionnai re (Cartwright-Hatton & Wells, 1997) or a specific measure of beliefs about ruminat ion . We are cur- rently developing a psychometr ic measure des igned to assess metacognit ive beliefs about depressive ruminat ion .

M e t a c o g n i t i v e Be l ie f s A b o u t R u m i n a t i o n in D e p r e s s i o n 163

Table 2 Metacogn i t ive Beliefs Abou t t he A d v a n t a g e s and Di sadvan tages of Dep re s s ive Ruminat ion for Each Patient

Metacognitive Beliefs

Patient Advantages of Depressive Ruminat ion Disadvantages of Depressive Ruminat ion

1 I need to ruminate about my problems to find answers about Rumina t ing is uncont ro l l ab le /makes me feel more depressed. the causes of my depression. If I d idn ' t rumina te about my Everyone would desert me if they knew how m u c h I feelings of depression, I wouldn ' t be able to u n d e r s t a n d / rumina te about myself. W h e n I ruminate , I can ' t do control them. anything else.

2 Rumina t ing about my feelings of depression helps me to cope Rumina t ing lowers my m o o d / m a k e s me feel physically ill/ with t hem/ recogn ize the triggers for my depress ion /ge t the means that I 'm out of control. I'll end up alone ifI cont inue bad things out of my system, to ruminate .

3 If I d idn ' t rumina te about my feelings of depression, they People will reject me if I ruminate . It isn' t normal to ruminate . would take over m e / n e v e r end. People who rumina te are weak.

4 I need to rumina te about the pas t / t he bad things that have It's impossible no t to rumina te about the bad things that have h a p p e n e d in the past to prevent future mis takes /make happened in the past. Rumina t ing makes me feel very low/ sense of them. can be destructive.

5 Rumina t ing about nay feelings helps me to unders tand what Rumina t ing about p r o b l e m s / t h e way I feel, is uncon t ro l l ab le / went wrong in the pas t /what starts my depression, depressing.

6 Rumina t ing about the pas t /depress ion shows that I 'm a caring It's uncon t ro l l ab le /damaging when I rumina te about my pe r son /he l p s me to unde r s t and past failures. If I d idn ' t problems. rumina te about my negative mood, I wouldn ' t be able to control it.

7 Ruminat ing about the past means that I ca re /he lps me to work out how things could have been done better.

8 If I d idn ' t rumina te about my feelings, I wouldn ' t be able to control t h e m / I could end up h a r m i n g myself.

9 If I d idn ' t ruminate about my feelings of dep res s ion /bad things that occurred in the past, I would make similar kinds of mistakes in the future. Ruminat ing about my problems helps me to find answers to them.

10 If I rumina te about my past / feel ings of depression, I could avoid making the same mistakes aga in / f ind answers to my problems.

11 Rumina t ing about my problems helps me to concentrate on what 's t roubl ing me the mos t / s t op them from gett ing worse /search for good solutions to my depression. I need to rumina te about nay feelings in order to control them.

12 Rumina t ing about the past helps me to sort ou t what went w r o n g / h o w things could improve.

13 I need to rumina te about my problems of depression so that I can unde r s t and them be t t e r / f ind the reasons for the way I fee l /overcome my depression.

14 Rmnina t ing about the bad things that h a p p e n e d to me in the pas t /my depression is a sign that I 'm a good pe r son /he lp s me to look for solutions to my problems.

Rumina t ing makes me feel seriously depressed /unhea l thy .

Rumina t ing about my depression could make me kill myself. ! can ' t stop myself f rom ruminat ing.

It's very depress ing /uncont ro l lab le to rumina te about my fee l ings /problems. I could become a complete loser, if I cont inue to ruminate .

I can ' t stop myself f rom ruminat ing. It's abnormal to ruminate . Only weak people ruminate .

Nobody wants to be with people who rumina te all the time. Rumina t ing means that I 'm a bad p e r s o n / m a k e s me feel down.

W h e n I rumina te about my problems, I can ' t do anything else. Rumina t ing will turn me into a failure.

It's b a d / h a r m f u l to rumina te about my problems/fee l ings . Rumina t ion makes me feel very low.

Rumina t ing makes me feel physically i l l /means that I've no control. I can ' t prevent myself f rom ruminat ing.

R e f e r e n c e s

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper and Row.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. NewYork: International Universities Press.

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties.Journal of Consulting and Clinical Psychology, 56, 893-897.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measur ing depression. Archives of General Psychiatry, 4, 561-571.

Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and

intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279-296.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams,J. B. W. (1997). Struc- tured Clinical Interview far DSM-IV Axis I Disorders-Patient Edition (SCID-I/P, Version 2.0, 4 /97 revision). Biometrics Research Department, New York State Psychiatric Institute, New York.

Nolen-Hoeksema, S. (1991 ). Responses to depression and their effects on the duration of depressive episodes.Journal of AbnormalPsychol- ogy, 100, 569-582.

Papageorgiou, C., & Wells, A. (1999a). Process and metacognitive dimensions of depressive and anxious thoughts and relationships with emotional intensity. Clinical Psychology and Psychotherapy, 6, 156-162.

Papageorgiou, C., & Wells, A. (1999b, November). Dimensions of depressive rumination and anxious worry: A comparative study. Paper pre-

164 Lejuez et al.

sented at the 33rd Annual Convention of the Association for Advance- ment of Behavior Therapy, Toronto, Canada.

Teasdale, J. D., & Barnard, R J. (1993). Affect, cognition and change: Re-modelling depressive thought. Hove, UK: Lau~'ence Erlbaum Associates.

Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxie~" disorder. Behavioural and Cognitive Psychotherato; 23, 301-320.

Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wile},.

Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. Chichester, UK: Wiley.

Wells, A., & Carter, 1L (1999). Preliminary tests of a cognitive model of generalized anxie~ disorder. Behaviour Research and Therap3; 37, 585-594.

Wells, A., & Matthews, G. (1994). Attention and emotion: A clinicalper~;t~ec- tire. Hove, UK: Lawrence Erlbaum Associates.

Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model, Behaviour Research and Therapy, 34, 881-888.

Wells, A., & Papageorgiou, C. (1995). Worry and the incubation of intrusive images following stress. Behaviour Research and Therapy, 33, 579-583.

Wells, A., & Papageorgiou, C. (1998). Relationships between wony, obsessive-compulsive symptoms and meta-cognitive beliefs. Behav- iour Research and Therapy, 36, 899-913.

Address correspondence to DI: Costas Papageorgiou, Division of Clinical Psychology, University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; e-mail: cpapage751 @aol.com.

Received: January 29, 2000 Accepted: May 15, 2000

A Brief Behavioral Activation Treatment for Depress ion

C. W. Le juez a n d D e r e k R. H o p k o , West Virginia University

J a m e s P. LePage , 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. McNei 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.

T HE TREATMENT of depression is characterized by a wide variety of psychological and biological ap-

proaches (cf. Beckham & Leber, 1995). Jarrett (1995) succinctly summarizes t reatment outcome studies comparing these disparate techniques. Eight of the 10 available outcome studies revealed that antidepressant medications and short-term psychotherapy were equally effective in treating clinical depression. In terms of comparing the relative efficacy of psychotherapeutic treatments for depression, however, the results are less clear. For example, al though several researchers have reported that cognitive therapy was superior to behavior therapy (e.g., Dobson, 1989; Robinson, Berman, & Neimeyer, 1990), other studies have demonstra ted that the cognitive componen t of cognitive-behavioral therapy does not enhance t reatment

Cognitive and Behavioral Practice 8, 164-175 , 2001 1077-7229/01/164-17551.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

Continuing Education Quiz located on p. 21 I.

outcome (e.g., Jacobson, Dobson, Truax, & Addis, 1996; Murphy, Carney, Knesvich, & Wetzel, 1995).

In this article, we consider evidence for a variety of change mechanisms regarding depression and, based on these arguments, provide an activation-based t reatment for depression that follows directly from recent advance- ments in basic behavior analysis. We utilize the matching law which, similar to the law of effect, suggests that behavior is main ta ined by its consequences. The matching law, however, further frames each instance of an individual 's behavior in terms of choice. As a result, the consequences for any particular instance of behavior are considered in relation to consequences for all other possible instances of behavior. Thus, depressed behavior not only is considered in terms of its direct consequences, but also in terms of the consequences for healthier, alternative behavior. Based on these behavioral principles, we argue that envi- ronmenta l manipulat ions engender ing behavioral activation are a primm T c ompone n t in the main tenance and t reatment of depression.

Specifically, we provide a t reatment for depression de-

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Metacognitive beliefs about rumination in recurrent major depression