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LIBRAR Y
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11-1-

This is to certify that the

. ,‘n.
the51s entltled

A Comparative Study of Short-Term Treatments
For Depression

presented by

Barbara Fleming

has been accepted towards fulfillment
of the requirements for

_Mas_ter____degree in m
of Arts

(3“. \ g A
[72% cut Quart—“r W.

Major professor

[hue August 6, 1979

 

    
   

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Mas—— ' r-

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m ‘4 _

A COMPARATIVE STUDY OF SHORT-TERM TREATMENTS
FOR DEPRESSION

By

Barbara Fleming

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Psychology

1979

 

 

 

 

 

ABSTRACT

A COMPARATIVE STUDY OF SHORT-TERM TREATMENTS
FOR DEPRESSION

By

Barbara Fleming

This study compared three approaches to the short-term
group treatment of depression and examined the influence
of a subject variable, cognitive complexity, on the effective-
ness of these treatments.

Depression control workshops were conducted in each
of three conditions: cognitive, behavioral and nondirective.
Thirty-five moderately depressed community residents
participated in the eight-session groups, led by graduate
student group leaders. Subjects in all three conditions
showed significantly decreased depressive symptomatology as
measured by general, cognitive and self-report behavioral
measures of depression. These decreases in depression
were maintained at a six-week follow-up period. There were
no significant differences among the treatment conditions
on most of the dependent measures and no significant
differences between subjects with high and low levels of
cognitive complexity. The implications of the finding that
three seemingly different interventions conducted by
relatively inexperienced leaders could all lead to signi-

ficant alleviation of depression were discussed.

To my parents, Bob and Iris Fleming,
for their love and faith in me

ii

 

 

u

n-
‘\

.r-l

‘h

n
-‘a
5 3‘

‘v

 

ACKNOWLEDGMENTS

I would like to express my deepest appreciation to
Dr. Dozier Thornton, my thesis committee chairman, for his
support and guidance, and most of all, his patience and
confidence in me. By so competently filling the over-
lapping roles of research chairman, advisor, psychotherapy
supervisor and teacher, he has contributed immeasurably
to my success and enjoyment in completing this study, as
well as to my professional development as a whole.

I would also like to thank my committee members,

Dr. Robert Zucker and Dr. Gordon Williams, for offering
helpful advice and suggestions while also allowing me the
freedom to grow by working independently.

In addition, my thanks go to all the group leaders
and the group members who invested so much of their time,
energy and enthusiasm to make this study possible.

Finally, I very warmly thank Jim Pretzer for his
emotional support as well as his help in demystifying the
MSU computer system. I greatly appreciate his being there
to offer me assistance in so many ways throughout the

course of this study.

iii

TABLE OF CONTENTS

LIST OF TABLES
STATEMENT OF THE PROBLEM .
RELATED LITERATURE .

Cognitive Therapy in General
Changing Irrational Belief Systems

Improving Problem-Solving Ability and.

Coping Skills . .

Changing Faulty Thinking Styles
Cognitive Approach to Depression
Behavioral Approach to Depression .
Conclusions . .

HYPOTHESES AND PREDICTIONS
METHOD .

Subjects

Screening Measures .
Psychological Screening Inventory
Beck Depression Inventory
The D- 30 Scale .

Dependent Measures .
Dysfunctional Attitude Scale
Irrational Beliefs Test
Pleasant Events Schedule .
Verbal Behavioral Measure

Cognitive Complexity Scale

Group Leaders

Treatment . . .
Cognitive Workshop .
Behavioral Workshop
Nondirective Workshop

RESULTS

Treatment Effects

Time Effects .

Cognitive Complexity Effects
Additional Analyses .

iv

Page

vi

100
109
112
114

DISCUSSION .
APPENDICES
A. Sample Media Announcement Used to
Recruit Subjects
B. Standardized Telephone Interview
C. Research Consent Form .
D. Psychological Screening Inventory .
E. Beck Depression Inventory .
F. The D—3O Scale
G. Dysfunctional Attitude Scale
H. Irrational Beliefs Test
I. Pleasant Events Schedule
J. Cognitive Complexity Scale
K. Post-test and Follow-up Questionnaires
L. Cognitive Treatment Manual for
Depression .
M. Behavioral Self-control Manual
Nondirective Manual
0. General Instructions for All Groups

REFERENCE NOTES

REFERENCES .

Page
120

134
136
142
144
148
152
155
161
166
171
174

179
192
210
274
276
279

Table

10.

11.

LIST OF TABLES

Page
Demographic Characteristics of Subjects . . . 97
Pre-assessment Scores of Subjects According
to Groups . . . . . . . . . . . . . . . . . . 98
Main Effects of Treatment Conditions . . . . 101

A Priori Contrasts Among Treatment Conditions
at Post-test . . . . . . . . . . . . . . . . 104

A Priori Contrasts Among Treatment Conditions
at Follow-up . . . . . . . . . . . . . . . . 106

Main Effects of Time Factor for all Treatment
Conditions Combined . . . . . . . . . . . . . 110

Planned Comparisons of Depression Scores at
the Three Testing Periods for all Treatment
Conditions Combined . . . . . . . . . . . . . 111

Main Effects of Cognitive Complexity Level
for all Treatment Conditions Combined . . . . 113

Differences Among Treatment Conditions on
Answers to Post-test Questionnaire . . . . . 115

Differences Among Treatment Conditions on
Answers to Follow-up Questionnaire . . . . . 117

Comparisons Among Treatment Conditions for

Post-test and Follow-up Questions that
Showed Significant Differences . . . . . . . ll9

vi

STATEMENT OF THE PROBLEM

Little attention has been paid to specific client
variables that might influence the effectiveness of cogni-
tive therapy, although some of the initial research on
cognitive therapy for depression has involved clinic popu-
lations as well as student populations. One client variable
that could effect the ability to benefit from cognitive
therapy would be the client's level of cognitive complexity.
The concept of cognitive complexity has developed from
Kelly's theory of personal constructs (1955) and Werner's
developmental theory (1957). Cognitive complexity has been
defined as "the relative differentiation of a person's
system of dimensions for construing behavior" and as "the
capacity to construe social behavior in a multidimensional
way" (Bieri, Atkins, Briar, Leaman, Miller & Tripodi, 1975,
p. 185). A cognitively complex person is seen as having a
more differentiated system for perceiving other's behavior
than does a less cognitively complex individual. Cognitive
complexity has been described as part of a developmental
process, where there is an increased differentiation of one's
social environment and an increased variety of behavior as
one's cognitive structures develop. Thus, while the child's

early conceptions may be global, diffuse and somewhat

2
unrelated, with development these cognitions become more
discrete. Also with development, these concepts are inte-
grated into hierarchically organized systems, with complex
patterns of relationship becoming established between con-
cepts, and certain concepts becoming superordinate to others.
This increase in development in differentiation and hierarchic
integration is thought to be found not only in development
from childhood to adulthood, but also in the gradual develop-
ment of totally new knowledge in a mature individual.

A number of empirical studies (summarized in Bieri,

1975 and Crockett, 1965) have indicated that cognitive
complexity may be related to information-processing in
social and clinical judgement. The empirical evidence from
several of these studies seems to suggest that individuals
high in cognitive complexity are more likely than those low
in cognitive complexity to use both favorable and unfavor-
able constructs in their descriptions of pe0p1e and to
entertain the possibility of unbalanced interpersonal
relationships. There is also some evidence that cognitively
complex people are better able to reconcile potentially
conflicting themes in descriptions of other peOple than
less cognitively complex pe0ple.

Cognitive therapy may, in fact, be most ideally suited V
for use with clients who have reached a high level of
development of cognitive complexity, since so much of the
emphasis in cognitive therapy is on learning to make fine
discriminations between adaptive and maladaptive thought

patterns and moving away from dichotomous thinking. On

3

the other hand, a person at a lower level of cognitive
complexity might have more difficulty making the distinc-
tions necessary in cognitive therapy and may more effec-
tively be treated with behavior therapy. The purpose of
this thesis, therefore, will be to test whether Beck's
cognitive approach is equally effective with subjects at
high and low levels of cognitive complexity, and to com-.
pare it with a self-control behavioral as well as a non- 1
directive approach to the short-term treatment of depres-

sion.

RELATED LITERATURE

Cognitive Therapy in General

In every area of psychology, cognitive factors are
suddenly gaining recognition. The current popularity of
cognitive perspectives is so pervasive that it has been
termed the "cognitive revolution" (Dember, 1974; Mahoney,
1977; Weimer & Palermo, 1973). This is especially true in
the area of clinical psychology, where new cognitive
theories and therapies are springing up at a rapid pace
and seem to be flourishing. The list of recent books and
articles on cognitive approaches to therapy is too long

to enumerate here, and a new journal entitled Cognitive

 

Therapy and Research started in January of 1977. Cog-
nitive therapies have been used to treat every disorder
from schizophrenia to stuttering, anxiety to anger,
impulsivity to depression, and paranoia to unassertiveness.
As Dember (1974) stated, "psychology has gone cognitive"
(p. 161).

Interest in thoughts and cognitions is certainly
nothing new. Cognitive theorists are especially fond of
quoting the ancient philosophers on the subject of
cognitions. For example, Buddha, before 480 A.D., said
"All that we are is a result of our thoughts, it is founded

on our thoughts; made up of our thoughts". In the first

4

5
century A.D., the stoic philosopher Epictetus said "Men
are disturbed not by things, but by the views which they
take of them" (both cited in Ullmann & Krasner, 1975,
p. 238). The current upsurge of interest in cognitive
variables, however, seems to be a reaction against the
relative neglect of cognitive variables in early behavior-
ism. Psychology is said to have "lost its mind" with the
advent of Watsonian behaviorism in the mid 1900's (Dember,
1974). Early behaviorists were eager to dissociate
themselves from psychodynamic traditions and "insight"
therapies with their highly speculative and untestable
theories of internal dynamics. Behaviorists were also
trying to develop an orientation which had what they
considered to be a firm scientific basis. In pursuit of
these goals, however, they tended to reject data and
concepts derived from man's internal experience.
Psychological constructs were reduced to behavioral obser-
vations, and man's private world was not considered to be
a useful area of inquiry. Mahoney (1974) calls this era
of almost religious avoidance of inferred variables
"the Cognitive Inquisition" (p. 3). Most early behavior‘u~
modifiers restricted their studies to discrete and
clearly observable behavior. Skinner himself actually
speculated at length about covert phenomena (1953),
although his cautions about these phenomena seem to have
been misinterpreted as a warning to avoid the study of

covert responses entirely.

6

Since Homme's classic paper on "coverants, the
operants of the mind" (1965) and Bandura's summary of the
literature pointing toward cognitive-symbolic mediation
(1969), the study of cognitive phenomena has gradually
become accepted as a scientifically legitimate enterprise.
Especially within the past few years, research in this
area has mushroomed and many ambitious attempts are being
made to identify and control significant mediating
behaviors. Excellent reviews of the literature on cogni-
tive mediation in general can be found elsewhere (Johnson &
Elson, Note 1; Mahoney, 1974). This paper will focus more
specifically on the research and practice of cognitive
therapy.

Without necessarily denying the effectiveness of
clinical procedures derived strictly from classical and
instrumental conditioning, behavior therapists seem to be
starting to recognize some of the inadequacies of such
limited techniques in dealing with complex clinical cases
(Goldfried & Goldfried, 1975; Lazarus, 1971). In fact,
it seems rather doubtful that many behavior therapists
behave exactly according to their specified techniques
(Goldfried & Davison, 1976). For example, when Brown
(1967) observed Wolpe treating patients with systematic
desensitization, he found that this presumably strict
S-R behavior therapist advised patients to "speak up for
your rights" and told the patients what to say and how to

say it. So it seems likely that cognitive variables have

7
played an important part in behavior therapy all along,
but that now clinical researchers are more willing to
acknowledge and study that dimension explicitly.

Cognitive therapy has been broadly defined as "any
technique whose major mode of action is the modification
of faulty patterns of thinking" and more narrowly defined
as "a set of operations focused on a patient's cognitions
(verbal or pictoral) and on the premises, assumptions, and
attitudes underlying these cognitions" (Beck, 1970,

p. 187). One of the problems involved in discussing the
effectiveness of cognitive therapy has been pointed out
by Meichenbaum (1977). Given the present state of cogni-
tive therapies and the vague definitions used, it does
not make sense to subsume them all under a single term or
to impose the "uniformity myth" (Kieslar, 1966) by
assuming that cognitive therapies are somehow all equiva-
lent. Most of the investigations of "cognitive therapy"
use different types of therapy techniques and some of the
techniques used share little more than the fact that they
have been referred to as "cognitive".

The distinction between cognitive and behavioral
therapies has also not been clearly defined. Many cogni-
tive therapy packages have included behavioral techniques,
and vice versa. In cases where behavioral methods are
used to modify cognitions, the decision seems rather
arbitrary as to whether to call it a cognitive or
behavioral technique. The trend in psychology seems tot

be moving towards a cognitive-behavioral integration

8
(Bergin, 1970; Mahoney, 1977; Taylor & Marshall, 1977) and
several treatment packages are currently referred to as
"cognitive-behavioral therapy". Bergin (1970) concludes ’8
that "there may be highly specific interventions which
have a behavioral or cognitive focus, but these are
always embedded in a multi-dimensional context or multiple
consequences". While researchers in the field are still
evaluating the relative effectiveness of the various com-
ponents of these treatment packages, however, some general
classification of "cognitive" and "behavioral" techniques
would appear to be useful. At least for the purposes
of this paper, the cognitive-behavioral dimension will be
viewed as a continuum from a relative emphasis on modi-
fying cognitions and the assumptions and attitudes under-
lying them to, at the other extreme, a relative emphasis
on modifying overt physical behaviors. Thus, even if a
therapy package includes both cognitive and behavioral
components, it will be discussed in this paper according
to what appears to be its emphasis in terms of both
theory and techniques. Since often in the past, any
therapy that dealt with cognitions at all was classified
as a cognitive therapy, the classifications in this paper
may differ from those in other studies.

In order to clarify the distinctions between cogni-
tive therapies near the extreme cognitive end of the
continuum, Meichenbaum (1977) has divided cognitive
therapies into three categories: those that attempt to

change irrational belief systems, those that work towards

9
developing problem-solving ability and coping skills, and
those that try to alter faulty thinking styles. This
distinction is also somewhat of an oversimplification,
since in fact many therapies involve a combination of
different categories of cognitive techniques as well as
combinations of cognitive and behavioral techniques;
however, this classification can be useful in clarifying
the differences in relative emphasis of these cognitive

approaches.

Changing Irrational Belief Systems

 

The cognitive therapy that has the longest history
and has received the most popular attention in recent
years is Albert Ellis' rational-emotive therapy (RET).

RET is based on the premise that much, if not all, emotional
suffering is due to the irrational ways people construe
the world and to the assumptions they make. These assump-
tions can lead to self-defeating internal dialogues or
self-statements that have a negative effect on emotions
and behavior. According to Ellis (1958), "for all
practical purposes, the sentences that human beings keep
telling themselves 33; or become their thoughts and
emotions" (p. 36). Since thoughts and emotions are seen
as significantly overlapping in many respects, disordered
emotions can be changed by changing one's thinking. Ellis
holds that certain core irrational ideas, which have been
clinically observed, are at the root of most emotional

disturbance. These have been summarized as follows:

10.

11.

10

The idea that it is a dire necessity for

an adult human being to be loved or approved
by virtually every significant other person
in his community.

The idea that one should be thoroughly
competent, adequate, and achieving in all
possible respects if one is to consider
oneself worthwhile.

The idea that certain people are bad,
wicked, or villainous and that they should
be severely blamed and punished for their
villainy.

The idea that it is awful and catastrophic
when things are not the way one would very
much like them to be.

The idea that human unhappiness is exter-
nally caused and that people have little
or no ability to control their sorrows and
disturbances.

That idea that if something is or may be
dangerous or fearsome one should be
terribly concerned about it and keep
dwelling on the possibility of its occurring.

The idea that it is easier to avoid than to
face certain life difficulties and self-
responsibilities.

The idea that one should be dependent on
others and needs someone stronger than
oneself on whom to rely.

The idea that one's past history is an all-
important determiner of one's present
behavior and that because something once
strongly affected one's life, it should
indefinitely have a similar effect.

The idea that one should become quite upset
over other people's problems and distur-
bances.

The idea that there is invariably a right,
precise, and perfect solution to human
problems and that it is catastrophic if
this perfect solution is not found.

(Ellis, 1962, pp. 61-88)

11

Like the stoic school of philosophy from two thousand
years ago, RET asserts that there are virtually no
legitimate reasons for human beings to make themselves
terribly upset, hysterical, or emotionally disturbed.
Once clients can be taught to challenge the irrational
ideas which lead to their emotional problems and to
replace them.with scientifically testable hypotheses
about themselves and the world, they will be less likely
to get into further emotional difficulties.

The task of the therapist in RET is to determine
the precipitating external events that upset the client,
to determine the specific thought patterns and under-
lying beliefs that give rise to the negative emotions,
and then to assist the client in altering these beliefs
and thought patterns (Meichenbaum, 1977). Ellis (1971)
symbolizes his therapeutic process as an A-B-C-D-E
sequence. A refers to an objective experiential event
(also called an Activating event). B represents the
Beliefs and self-statements that follow the event. C then
symbolizes the negative emotional Consequences generated
by these thoughts. Emotionally upsetting consequences
do not follow directly from any actual activating event,
but rather, follow from non-empirical, irrational beliefs
about the event. In RET, the therapist teaches the clients
how to challenge, question and Dispute (at point D) these
irrational beliefs. If the clients persist at challenging
these beliefs, they will achieve a new cognitive Effect

(point E) that is more rational and less emotionally

12
disturbing. For example, if a man fails at a job
(point A), he might tell himself (at point B) "How awful
it is for me to fail! I must be a thoroughly worthless
person for failingl". This would lead to the consequences
(point C) of feeling depressed and worthless. However,
if he disputes (point D) his irrational beliefs, he may
get to the point (E) where he can say to himself "It was
inconvenient that I failed, and I would rather succeed,
but that doesn't make me a worthless person. I'm
merely a person who has failed at this one particular job".
Feelings and emotions will certainly still exist, and the
client may feel sad, disappointed or annoyed that he
failed; but hopefully the self—defeating and inappropriate
emotions (such as guilt, depression, anxiety, worthless-
ness or rage) that lead to emotional disturbance can be
avoided.

Ellis' own therapy style, and the one that he recom-
mends, is quite forcefully didactic. Ellis explains this
as follows:

More often than not, his (the client's)
illogical thinking will be so ingrained from
constant self-repetitions, and will be so
inculcated in motor pathways (or habit patterns)
by the time he comes for therapy, that simply
showing him, even by direct interpretation, that
he is illogical will not greatly help.

The therapist, therefore, must keep pounding
away, time and time again, at the illogical
ideas which underlie the client's fears.

The rational therapist, then is a frank propa-
gandist who believes wholeheartedly in a most
rigorous application of the rules of logic,

of straight thinking and of scientific method

to everyday life, and who ruthlessly uncovers
every vestige of irrational thinking in the

13

client's experience and energetically urges
him into more rational channels.

(Ellis, 1958, p. 45)

Ellis also advocates the use of various supplementary,

behavioral techniques to also help change the client's

ideas. Mahoney (1974) sees RET as involving at least

the following active components:

1.

didactic persuasion toward a belief system
that emphasizes the role of irrational
thoughts in subjective distress and defi-
cient performance; a value system is also
communicated--its main premise being that
of non-contingent self—acceptance
irrespective of performance competencies.

training in the discrimination and system-
atic observation of self-statements.

training in the logical and empirical
evaluation of self-statements.

graduated performance assignments.

immediate and often candid social feedback
on a) actual performance progress, b) stan-
dard setting, and c) the logical and
adaptive nature of private monologues
(logical inferences, self-evaluations, etc.).

explicit instructions and selective rein-
forcement for the therapeutic alteration
of self-statements.

extensive therapist modeling of prescribed
mediation styles (via self-disclosure,
role-playing, etc.).

(pp. 182-183)

Some therapists who agree with the basic premises of

RET therapy argue that the forcefulness and bluntness

of Ellis' approach may be overpowering and intimidating

(Rimm & Masters, 1974) or may backfire if the client feels

he's being coerced into changing his beliefs or behavior

l4

(Goldfried, Decenteco & Weinberg, 1974). The procedure
called ”systematic rational restructuring" is based on
premises similar to RET, but differs in its methods of
teaching clients to label situations more rationally
(Goldfried & Davison, 1976; Goldfried et a1., 1974;
Goldfried & Goldfried, 1975). Rather than verbally
attacking client's irrational beliefs and cajoling them
into thinking more logically, in systematic rational
restructuring the therapist attempts to get clients to
gradually agree to the underlying rationale by having them
offer their own arguments against their irrational assump-
tions. Then clients participate in a series of practice
sessions aimed at systematically modifying their internal
sentences. Systematic rational restructuring is placedv/I
into a learning framework as a self-control technique,
where the ultimate objective is to provide individuals
with the skills necessary for them to regulate their own
behavior. The goal is for emotional upset to eventually
provide the signal for the individual to rationally re-
evaluate the reason for that upset. RET and systematic
rational restructuring share the same theoretical basis,
and have been grouped together under the more general term
"cognitive restructuring", but they are examples of
different procedural means toward effecting the modifica-
tion of maladaptive cognitive behaviors.

Ellis has been practicing and writing about RET for
at least 20 years, but only recently has his work been

considered a legitimate subject for scientific

 

15
investigation. His work had previously been classified
along with several pOpularized strategies for personal
self-improvement which appealed to the general public,
but were forbidden territory to "respectable” scientists.
For example, Bain (1928) and Dale Carnegie (1948)
suggested strategies of thought control to improve personal
adjustment, and Norman Vincent Peale (1960) described the
"power of positive thinking". There are, however, numerous
contrasts between the global and often unrealistic sugges-
tions popularized in these and other best-sellers, and the
individualized and specific techniques of RET. Such
”miracle cures" are likely to be insensitive to situational
conditions and to ignore the importance of working through
graduated performance tasks. Most importantly, the pro-
ponents of RET are moving towards empirical verification
and improvement of their techniques, rather than using
unsubstantiated and unbridled claims in order to sell
more books.

The substantial body of evidence that symbolic events
play a significant role in behavioral disorders (as
reviewed in Mahoney, 1974) provides indirect support for
the theory behind RET. Velten (1968) was one of the firstl'
researchers to test the hypothesis that the interpreta-
tions people place on events determine their affective
responses to the events. He had students read either
Elation, Depression or Neutral self-statements both
silently and aloud. After reading these statements, the

subjects showed significant differences on four behavioral

16
measures and a mood checklist. Velten concludes that his
results support the claims of Ellis, and he even suggests
the use of statement-reading as a type of therapy.

More recent studies have extended Velten's work to
consider the influence of cognitive mediation on behaviors
that are thought to specifically reflect the state of
depression (Hale & Strickland, 1976; Strickland, Hale &
Anderson, 1975). They found that subjects who read
Depression self-statements reported significantly more
depression, anxiety and hostility than subjects who read
Elation self-statements. Also, subjects who read
Depression statements were less expansive on a graphic
constriction-expansion measure, preferred less social and
active activities, wrote more slowly and did worse on a
digit symbol task than those who read Elation statements.
These results seem to provide some implicit support for a
cognitive mediation theory of depression, since the
response of the subjects in the Depression condition is
somewhat similar to the withdrawal and psychomotor retard-
ation reported by clinically depressed people.

A study by May and Johnson (1973) tested the
hypothesis that the amount of autonomic activity would be
greatest to stressful thoughts, less to neutral thoughts
and the least to relaxing thoughts. The results in this
study, as in many physiological studies, were not consis-
tent over all the measures of autonomic activity used.
Although the results for measures of skin conductance and

GSR were not clear, there were significant results in

17

the predicted direction for measures of heart rate,
respiration rate and respiration amplitude. Thus, at
least according to these three measures, internally
elicited stimuli did seem to provoke physiological stress.

Other researchers have more directly tested hypotheses
about RET. Rimm and Litvak (1969) presented subjects with
sentence triads that fit into Ellis' model of emotional

self-arousal. For example:

A) Observed event People don't notice me
emough.
B) Inference Maybe there is something
unattractive about me.
C) Self-evaluative How terrible!
conclusion

The results showed that this type of negative sentence
triad induced substantial physiological arousal as
measured by respiration rate and depth. There were, how-
ever, no differences in emotional responsiveness to each
of the three sentences, as would be predicted by RET
theory. A replication of this study done by Russell and
Brandsma (1974) further complicates the matter. They
found that GSR measures significantly differentiated
groups reading negative sentence dyads from groups
reading neutral dyads, but respiration rate and depth
measures did not. Also, differences in response to
sentence A and sentence B occurred only when the sentence
dyads were of low personal relevance to the subject, but
not when the sentences seemed to be highly relevant to

their concerns. As they stand, these two studies support

18
the basic concept of symbolic self-arousal, but do not
directly support Ellis' A-B-C theory of self-arousal
per se.

A study by Goldfried and Sobocinski (1975) supported
Ellis' assumption that people who maintain certain
irrational beliefs tend to become more easily upset than
people who do not hold as many irrational beliefs. The
authors found that scores on paper-and-pencil measures of
social anxiety, test anxiety and speech anxiety all
correlated positively with a measure of the tendency to
think irrationally. When exposed to tape recorded scenes
of ambiguous interpersonal events, subjects who strongly
believed that they should expect approval and love from
everyone displayed significantly more anxiety and hostility
than people who were rated lowest in that belief.

The primary focus of research in this area has been on
documenting the effectiveness of RET and other, similar
cognitive restructuring approaches in the treatment of
various behavioral disorders. A number of successful
case studies have been reported by Ellis (1962, 1971)

and throughout the journal entitled Rational Living.

 

Other researchers have also reported on their successful
use of cognitive restructuring techniques. For example,
reports have been made on the use of these techniques
with cases of paranoid schizophrenia (Shapiro &
Ravenette, 1959; Watts, Powell & Austin, 1973); anxiety
proneness (Beck, 1970; Goldfried et al., 1974; Weissberg,
1975), marital problems (McClellan & Stieper, 1973), and

19
depression (Shapiro, Neufield & Post, 1962). Ellis (1957)
used his own case records over a period of several years
to compare psychoanalysis with RET. Ellis treated his
clients with psychoanalysis for many years before this
theoretical model developed and he began to use RET.
He reports a much higher success rate with RET, but the
possible bias from temporal and sampling errors as well
as his own knowledge of the "experimental conditions"
makes these results difficult to interpret.

Some controlled studies have also tested the effective-
ness of cognitive restructuring. Analogue studies have
shown these techniques to be effective in reducing anxiety
from the threat of shock (Burkhead, 1970) and in increasing
the number of positive self-references used in an initial
interview (Baker, 1966). The analogue nature of these
studies does, however, place some limits on the general-
izability of these findings to clinical situations.

Controlled studies have been conducted to investigate
the effects of cognitive restructuring on several types of
anxiety: interpersonal anxiety (DiLoreto, 1971; Kanter,
1975), test anxiety (Holroyd, 1975; Maes & Heimann, Note 2;
Montgomery, 1971), speech anxiety (Jarmon, 1972; Karst
& Trexler, 1970; Trexler & Karst, 1972), and specific
phobias (Dolgan, 1968; D'Zurilla, Wilson & Nelson, 1973).
Similar studies have also been done on treatments of
unassertive clients (Wolfe, 1975) and clients who stutter

(Moleski & T031, 1976).

20

Although the evidence from the case studies as well
as these controlled studies of cognitive restructuring
suggests a certain optimism about the future potential
of these clinical techniques, their methodological
limitations need to also be considered. The results of
one of these studies (Montgomery, 1971) were only weakly
positive and not at all consistent across measures, while
Jarmon (1972) found that only the RET bibliotherapy
(and Egg the live, group RET) was effective in reducing
speech anxiety. Some studies used only self-report
outcome measures (DiLoreto, 1971; Montgomery, 1971) while
other studies included behavioral measures but only
obtained significant results on the subjective measures
(D'Zurilla et al., 1973; Karst & Trexler, 1970; Trexler
& Karst, 1972). Conversely, Maes and Heimann (Note 2)
showed a significant reduction in physiological arousal
with the use of RET, but not a significant reduction in
subjective distress. Several studies used the principal
investigator as a therapist for all the conditions creating
the potential problem of experimenter bias (D'Zurilla et
al., 1973; Karst & Trexler, 1970; Montgomery, 1971;
Trexler & Karst, 1972). Most of the studies did not do
any follow-up, and one of the studies that did have a
follow-up period (Jarmon, 1972) found that the positive
results were not maintained. Also, over half of the
studies discussed here used only college student popula-
tions who had mild levels of disorder, so that the

effectiveness of cognitive restructuring has been most

21
strongly demonstrated on "YAVIS" clients: young, attrac-
tive, verbal, intelligent and successful (Schofield,
1964). The methodological limitations and the inconsis—
tent findings of some of these studies suggest that much
further research will be necessary to firmly establish
the clinical efficacy of cognitive restructuring approaches
to therapy. The evidence that has been collected thus
far, and the wide range of problems to which they have
been applied, do however seem to augur a promising future

for cognitive restructuring therapies.

Improving Problem-Solving Ability and Coping Skills

Unlike Ellis' approach which focuses on the presence
of maladaptive and irrational beliefs, advocates of the
problem-solving approach focus on the absence of adaptive
cognitive problem-solving skills in clinical populations
(Meichenbaum, 1977). D'Zurilla and Goldfried (1971)
define problem-solving as "a behavioral process, whether
overt or cognitive in nature, which a) makes available a
variety of potentially effective response alternatives
for dealing with the problematic situation and b) in-
creases the probability of selecting the most effective
response from among these various alternatives" (p. 108).
Adolescent and adult psychiatric patients have been demon-
strated to have obvious problem-solving deficits, especially
a lack of means-ends thinking (Platt & Spivack, 1972a,
1972b; Shure & Spivack, 1972; Shure, Spivack & Jaeger,

1971). Therefore, it has been hypothesized that teaching

22

clients more effective cognitive problem-solving skills
will have therapeutic value (D'Zurilla & Goldfried, 1971;
Goldfried & Goldfried, 1975; Spivack, Platt & Shure,
1976). A number of recent studies have illustrated the
use of problem-solving training approaches with various
clinical populations. For example, this approach has
been used in short-term outpatient therapy (McGuire &
Sifneos, 1970), with hospitalized psychiatric patients
(Coche & Flick, 1975), ex-drug addicts (Copeman, 1973),
high school students with interpersonal anxiety (Christen-
sen, 1974), female alcoholics (Spivack et al., 1976), and
with disruptive children (Spivack & Shure, 1974).

D'Zurilla and Goldfried (1971) outline a typical
training program in problem-solving where the goals are
reached in progressive steps. At the beginning of the
program, the therapist demonstrates the 5 main stages of

problem-solving: 1) general orientation or set" to
recognize when a problem exists 2) detailed problem
definition and formulation 3) generation of many alter-
natives 4) decision-making and 5) verification and evalua-
tion in terms of the personal, social, short and long-term
consequences of the alternatives. First the therapist
models these stages by verbalizing the appropriate thought
sequences, and then the client gradually takes on a more
active role. Eventually, the therapist serves only to

guide and encourage the client, to evaluate in vivo appli-

cation, and to reinforce successive approximations.

23

The problem-solving approach can be seen as a broad
social competence training model, or a form of self-
control training, which can be applied in different ways
to various populations (Meichenbaum, 1977). In contrast
to the problem-solving approach which teaches the client
to stand back and systematically analyze problem situa-
tions, the coping skills approach focuses on teaching
clients what to actively do when confronted by acute
stressful situations. This model views the client's
cognitions as cognitive skills that can be used in con-
fronting stressful situations.

One example of a coping-skills training package is
Meichenbaum's self-instructional training. Meichenbaum
emphasizes the importance of private, covert self-statements
in problem-solving as well as neurosis. According to
Meichenbaum and Cameron (1974), "a large population of
clients, who generally fall under the rubric of 'neurotic'
seem to emit a variety of maladaptive, anxiety-engendering
self-statements. The goal of intervention. . .is to make
the neurotic patients aware of the self-statements that
mediate maladaptive behaviors and to train them to produce
incompatible self-statements and behaviors" (p. 271).

The following components of Meichenbaum's self-instructional
training have been outlined by Mahoney (1974):
l. didactic presentation and guided self-
discovery of the role of self-statements in

subjective distress and performance inade-
quacies.

24
2. training in the fundamentals of problem
solving (e.g., problem definition, antici-
pation of consequences).

3. training in the discrimination and system-
atic observation of self-statements.

4. graduated performance assignments.

5. explicit suggestions and self-reinforcement
for the modification of self-statements
along the lines of "coping" adaptation and
performance-relevant attentional focusing.

6. structured modeling of both overt and
cognitive skills.

7. modeling and encouragement of positive
self-evaluation (self-reinforcement).

8. depending on the treatment package employed,
relaxation training combined with the use
of coping imagery in a modified desensiti-
zation procedure.

(pp. 190-191)

There are many striking similarities between this coping-
skills treatment and Ellis' rational-emotive therapy.
The main distinction between them seems to center around
the relative emphasis on formal logical analysis.
Whereas Ellis predominantly uses Socratic dialogue and
logical self-examination to change irrational belief
systems, Meichenbaum.emphasizes the use of graduated
tasks, cognitive modeling, directed mediational training
and self-reinforcement to change the dysfunctional self-
statements.

The empirical evidence for the effectiveness of
self-instructional training seems promising. Controlled

studies of this treatment package have been done on

several different populations: schizophrenics (Meichenbaum

25
& Cameron, 1973), impulsive children (Meichenbaum &
Goodman, 1971), depressed clients (Gioe, 1975; Morris,
Note 3), test—anxious students (Meichenbaum, 1972;
Sarason, 1973; Wine, 1970), speech-anxious students
(Meichenbaum, Gilmore & Fedoravicus, 1971; Norman, 1975),
students with fear of snakes (Meichenbaum, 1971),
students with dating problems (Glass, Gottman.& Shmurak,
1976), smokers (Steffy, Meichenbaum & Best, 1970),
clients with anger control problems (Novaco, 1975), the
elderly (Labouvie—Vief & Gonda, 1976), and children who
are afraid of the dark (Kanfer, Karoly & Newman, 1975).
These studies are subject to many of the same limitations
as the cognitive restructuring studies discussed earlier.
Labouvie-Vief and Gonda (1976) found very weak and incon-
sistent results, while Norman (1975) got significant
results on only the self-report, but not the behavioral,
measures. Several studies had possible bias from the
principal investigator leading all the treatment condi-
tions, few studies had a follow-up period, and the majority
of the studies used only students with mild behavioral
problems as subjects. Self-instructional training, along
with RET, still needs a great deal more research to
establish its clinical efficacy.

Another coping skills training package, which draws
heavily from Meichenbaum's self-instructional training,
is called stress-inoculation training (described in
Meichenbaum, 1977). This package includes 1) a discussion

of stress reactions (with emphasis on labeling, attribution,

26
and arousal-inducing self-statements) 2) relaxation
training (presented as an active, coping skill)
3) instructed practice in the emission of coping self-
statements (cognitive self-monitoring, preparation for
stress, self-reinforcement) and 4) supervised practice
in utilizing the coping skills in an actual, stressful
situation. The major difference between stress inocula-
tion training and self-instructional training is the
presence of supervised practice in an actual stress
situation. A study by Meichenbaum and Cameron (cited in
Mahoney, 1974) found stress inoculation training to be
dramatically more effective than self-instructional
training in the treatment of phobias. The authors con-
clude the self-instructional training alone may effect
only mild and temporary benefits which quickly dissipate
in the presence of actual stress, and that relevant
performance opportunities may be necessary to effect
permanent therapeutic results.

Other types of coping skills training have emphasized
the act of maintaining an anxiety-arousing image and
learning to actively "relax it away" (Goldfried, 1973;
Richardson & Suinn, 1973; Suinn & Richardson, 1971). The
current data on these approaches is still so meager that

no conclusions can yet be drawn about their effectiveness.

Changing Faulty Thinking Styles

 

Beck (1976) posits that the common psychological

disorders center around certain aberrations in thinking.

27
According to his theory, patients show faulty or dis-
ordered thinking in circumscribed areas of experience
and this disordered thinking is the primary cause of
mental disorders. In these specific areas, patients have
a reduced ability to make fine discriminations, so they
tend to make global, undifferentiated judgements and
distortions (Beck, 1970). Part of the task of cognitive
therapy lies in helping patients to recognize the distor-
tions in their thought patterns and to make the appro-
priate corrections.

Beck's cognitive model of psychopathology (Beck,
1970) divides the total cognitive organization into two
parts: primitive systems of relatively crude cognitive
structures (corresponding to Freud's notions of primary
process) and more mature systems of refined and elastic
structures (corresponding to Freud's secondary process).
The primitive schemas are absolute rather than relative,
dichotomous rather than graduated, global rather than
discriminative. Many of the primitive concepts may be
idiosyncratic and unrealistic, but under normal conditions
they are tested, authenticated and rejected by higher
centers. When the cognitive organization is dislocated
in neurotic states, however, these idiosyncratic ideas
become hyperactive and tend to supercede the more realistic
conceptualizations. The particular form of the psycholog-
ical disorder is related to the content of the predominant,

perseverating verbal cognitions or fantasies.

28
Beck has distinguished among the common neurotic
disorders on the basis of the differences in the content

of ideation:

 

Disorder Idiosyncratic Ideational Content

Depression Devaluation of domain

Hypomania Inflated evaluation of domain

Anxiety Neurosis Danger to domain

Phobia Danger connected with specific,
avoidable situations

Paranoid State Unjustified intrusion on domain

Hysteria Concept of motor or sensory
abnormality

Obsession Warning or doubting

Compulsion Self-command to perform specific

act to ward off danger
(Beck, 1976, p. 84)

One of the main cognitive techniques consists of
training the client to recognize his own "automatic :'/
thoughts". These are defined as idiosyncratic thoughts
that seem to emerge automatically and extremely rapidly
prior to the experience of emotion. These cognitions are
also described by Ellis as "things that you tell yourself"
(1962). In Beck's model, ”automatic thoughts" intervene
between events and one's emotional reaction to them.

When these thoughts are a distorted appraisal of the event,
the affect will tend to be inappropriate or extreme. These
"automatic thoughts" seem to be relatively autonomous and

involuntary in that clients make no effort to initiate

them and they can be difficult to "turn off". In addition,

29
clients seem to accept these thoughts as plausible or
reasonable even if they would sound far-fetched to other
people or to the clients themselves on another occasion.

Once clients learn to identify their automatic
thoughts, they may still have problems examining these
ideas objectively since these thoughts can be extremely
salient. "Distancing" is Beck's term for the process of
gaining objectivity towards these cognitions. Since
neurotic individuals tend to accept the validity of these
thoughts automatically, it is necessary to train them to
distinguish between their thoughts and external reality.
Only once clients can distance themselves from their
thoughts can they apply the rules of logic and empirical
evidence to correcting their cognitive distortions.

Since the client's distorted thought processes may be
deeply ingrained, the client may need to go through
several steps in order to correct them: 1) becoming aware
of the thoughts 2) recognizing what thoughts are awry
3) substituting accurate for inaccurate judgements and
4) receiving feedback as to the usefulness of these
changes (Beck, 1976). It often can be helpful for the
client to learn to specify the type of cognitive distor-
tions involved in the maladaptive cognitions in order to
better understand how affective experiences and maladap-
tive behaviors are a result of thinking processes which
can be changed and controlled. Some of the most common

distortions are listed by Beck (1967) as arbitrary

30
inference, overgeneralization, magnification and minimi-
zation, cognitive deficiency and dichotomous reasoning.

Arbitrary inference is the process of drawing a con-
clusion when the factual evidence is lacking or contrary
to the conclusion. Such misconceptions are especially
likely to occur when the cues are ambiguous, as is often
the case in interpersonal relationships. Intrinsic to
this type of thinking is the failure to consider more
plausible and probable alternative explanations. This
type of distortion often takes the form of personaliza-
tion (or self-reference), the tendency to make egocentric
interpretations of events. For example, neurotic clients
may overestimate the degree to which events are related
to them and become overly absorbed in the personal
meanings of events. Another type of personalization
occurs when clients have a tendency to compare themselves
with other people.

Overgeneralization is the process of making an
unjustified general conclusion on the basis of a single
incident. Thus, one incidence of failure can be taken as
a sign of total incompetence and worthlessness.

Magnification (termed "catastrophizing" by Ellis,
1962) is the process of exaggerating the meaning or
significance of an event. This type of error in evalua-
tion is demonstrated by the tendency to make extreme
judgements or to anticipate intensely negative outcomes

to everything. The parallel process of minimization

31
occurs when an individual grossly underestimates his
own performance, achievement or ability.

Cognitive deficiency is the process of disregarding
an important aspect of a life situation. Clients who
use this distortion tend to ignore, or simply not to
utilize, information which derives from their own
experience. These clients act as though they have a
defect in their systems of expectations, and constantly
engage in behavior which they later realize is self-
defeating.

Dichotomous reasoning (also called "bipolar thinking")
is the tendency to make overly simplified and rigid
judgements of events as either good or bad, right or wrong,
black or white. This thinking in extremes may be confined
only to situations which involve particularly sensitive
areas. The basic premises underlying this type of
thinking are generally couched in absolute terms such as
"always” or "never".

Beck's cognitive therapy involves helping clients
to evaluate their attributions and performances more
realistically. Graded tasks, homework assignments and
activity lists provide the behavioral data around which
to examine the client's thinking style. Although treat-
ment is generally tailored to fit each individual, Beck's
therapy follows a basic pattern. The clients learn to
recognize and monitor their cognitions as well as to

test and validate the relationships between cognition

32
and affect. Both semantic and behavioral techniques are
used to challenge the validity of negative cognitions and
misconceptions. Once the clients recognize their cogni-
tive distortions, the belief systems behind their dis-
tortions are then challenged. The clients do their own
data collection so that they can review their behavior
within the context of their daily lives and their
distortions, as well as alternative interpretations, become
more apparent.

The effectiveness of Beck's cognitive therapy has so
far been systematically studied only in the treatment of
depression. The initial results are encouraging but not
yet definitive, and the specific techniques have not yet
been expanded into the treatment of other types of dis-
orders. Controlled studies which have specifically used
Beck's cognitive treatment of depression have been
conducted by Shaw (1977), Taylor and Marshall (1977),
Schmickley (1976) and Rush, Beck, Kovacs and Hollon
(1977). Other researchers have isolated specific aspects
of Beck's treatment package for study, such as training
in the positive anticipation of future activities
(Anton, 1974; Anton, Dunbar & Friedman, 1976). These
studies will be presented in more detail after a brief

introduction to the cognitive theory of depression.

Cognitive Approach to Depression

 

The clinical phenomena known today as depression has

been recognized for at least 3,000 years. The depressions

33
of Job and Saul are detailed in the Old Testament, and
Hippocrates made the first clinical description of
"melancholia" (Friedman and Katz, 1974). Depression's
long history has led Beck to conclude that "there are
few psychiatric syndromes whose clinical descriptions
are so constant through successive eras of history"
(1967, p. 5).

The National Institute of Mental Health recently
found that the clinical condition of depression is on
the increase and is beginning to rival schizophrenia as
the nation's number one mental health problem (1973).
They estimate that 10% of the general population will
have a significant depressive episode at some time in
their lives, and that more than 80% of reported suicides
can be traced to a precipitating depressive episode.
Clearly a public health problem of this magnitude merits
much attention from clinical scientists today.

In spite of its long history, most of the important
issues concerning the definition, etiology and treatment
of depression remain unresolved. The term "depression”
is often poorly defined, being used variously to describe
normal reactions to life events, abnormal mood states,
symptoms, symptom syndromes, disease processes, and even
a series of disease processes (Lewinsohn, 1974). There
is still much heated debate over the distinctions between
neurotic and psychotic depression, endogenous and reactive

depression, retarded and agitated depression, unipolar

34
and bipolar depression, and so on. Although hundreds of
investigations have been conducted, the conflicting
evidence has thus far done little to clarify these
distinctions. An extensive review of the literature
related to these controversies is not within the scope
of this paper, but may be found in volumes by Beck (1967)
and Becker (1974).

The most commonly used classification of depressed
individuals has been the distinction between psychotic and
neurotic depression. The concept of depression as
utilized in this paper most closely corresponds to the
descriptions of neurotic depression. In the second edi-
tion of the American Psychiatric Association's diagnostic
manual (1968), depressive neurosis is described as follows:

This disorder is manifested by an excessive
reaction of depression due to an internal
conflict or to an identifiable event such as
the loss of a love object or cherished
possession. It is to be distinguished from
involutional melancholia and manic-depressive

illness. Reactive depressions or depressive
reactions are to be classified here.

(p . 40)
Neurotic depressives seem to comprise a somewhat hetero-
geneous group, defined more in terms of the absence of
psychotic features than on the presence of specific
neurotic features. Beck (1967) recommends that in
distinguishing between neurotic and psychotic depression,
”the best guide is to designate as psychotic depressive
all cases that show definite signs of psychosis, such

as loss of reality, delusions and hallucinations" (p. 84).

35
Recent studies have in fact shown neurotic depression
to be weak as a diagnostic entity, and two recent investi-
gations using cluster analysis have failed to obtain a
neurotic cluster of patients (Everitt, Gourlay & Kendell,
1971; Pilowsky, Levine & Boulton, 1969). The neurotic-
psychotic distinction does, however, seem to be useful in
predicting treatment response. Paykel (1972) found that
neurotic depressives were more likely to show a poor
response to tricyclic antidepressants than were psychotic
depressives. Also, a negative relationship has been
reported between neurotic depressive features and response
to electroconvulsive therapy (Kiloh & Garside, 1963;
Mendels, 1965a, 1965b, 1965c, 1967).

The search for the causes of depression has also not
yet been conclusive. According to Beck (1974b), "At one
time, this strange affliction was ascribed to demons that
allegedly took possession of the victim. Theories advanced
since then have not yet provided a more durable solution
to the problem of depression" (p. 4). Theories of a
physiological cause of depression date back to the belief
of ancient Greeks that depression was a result of
excessive black bile in the body fluids (Lewinsohn, 1974)
and can be found in present times in advanced biochemical
and physiological research. Pharmacological treatments
of depression have had a parallel development from the
ancient story of Penelope taking a drug to dull her grief
in Homer's Odyssey to the modern use of such antidepressant

drugs as tricyclics and monoamine oxidase inhibitors

36
(Beck, 1967). Electroconvulsive therapy is also used by
some proponents of the theory that depression has a
physiological etiology.

Other theorists propose that internal psychological
mechanisms are responsible for depression. Psychoanalytic
theorists suggest that depression follows the loss of a
real or fantasized love object with whom the person had
identified so narcissistically that they could not
differentiate the external loss from a loss within their
own ego. This is experienced as a loss of self-esteem
which, along with internalized hostility, results in
depression (Freud, 1917). The corresponding treatment
would be psychoanalysis, to help the person work through
these unconscious dynamics. There have been many other
psychological theories with many corresponding therapeutic
interventions too numerous to discuss here; extensive
reviews of these approaches appear in volumes by Beck
(1967), Becker (1974), and Friedman and Katz (1974).

The lack of consensus among researchers about the
definition and etiology of depression has led to a corres-
ponding lack of agreement about appropriate methods for
assessing depression. Self-report depression scales are
the assessment methods which have thus far received the
most empirical support. Many self-administered depression
scales have been described in the literature, but few of
these scales assess similar symptoms of depression,

and most of these measures have had limited use and are

37
supported by relatively little psychometric data
(Rehm, 1976). Some interviewer rating scales have also
been developed; but they rely on self-report almost as
much as the self-administered depression scales do, except
that with these measures an interviewer is used to make
the final rating. The direct assessment of overt
depressive behavior, both verbal and motor, has only
recently been attempted and much more research will be
needed before the reliability and validity of such
measures will be fully established. At present, however,
there is no generally accepted or well standardized means
for assessing depression.

In his classic work on depression, Beck (1967)
maintains that the only thing investigators of depression
have consistently agreed upon is its symptomatology.

As long as so many key issues remain unresolved, therefore,
the most useful definitions of depression seem to involve
descriptions in terms of its clinical manifestations. For
example, Beck (1974a) divided the signs and symptoms
characterizing depressed individuals into four separate
categories:

Emotional: Sadness or apathy; crying spells,

dislike; loss of gratification; loss of feelings
of affection; loss of sense of humor.

 

Cognitive: Negative self-concept; negative
expectations; exaggerated view of problems;
attribution of blame to self.

 

Motivational: Increased dependency; loss of
motivation; avoidance, indecisiveness; su1cidal
wishes.

 

38

Physical and Vegetative: Loss of appetite;
sleep disturbance; fatigability; loss of
sexual interest.

 

(p. 62)

Another method of describing the manifestations of
depression has been through factor analysis. For example,
Grinker, Miller, Sabshin, Nunn and Nunnally (1961) used
factor analysis to combine factors involving descriptions
of the feelings and concerns of 96 depressed patients
with factors derived from behavioral observations of these
same patients. This resulted in four factor patterns
describing depression as follows:

a. Feelings: dismal, hopeless, loss of self-
esteem, slight guilt feelings.

Behavior: isolated, withdrawn, apathetic,
speech and thinking slowed, with
some cognitive disturbances.

b. Feelings: hopeless with low self-esteem,
considerable guilt feelings,
high anxiety.

Behavior: agitation and clinging demands
for attention.

c. Feelings: abandonment and loss of love.

Be av1or

agitated, demanding, hypochon-
driacal.

d' T's-$2933.32 fiifi:‘§a£§?ei§§i3?SSéoififiiiiié.
One of the most recent and complete descriptions
of depression appears in the latest revision of the
Diagnostic and Statistical Manual, Third Edition (A.P.A.,

1979). The diagnostic criteria for Depressive Episode are

listed there as follows:

39

Dysphoric mood or loss of interest or pleasure
in all or almost all usual activities and past-
times. The dysphoric mood is characterized by
symptoms such as the following: depressed, sad,
blue, hopeless, low, down in the dumps, irri-
table, worried. The disturbance must be prom-
inent and relatively persistent but not
necessarily the most dominant symptom. It does
not include momentary shifts from one dysphoric
mood to another dysphoric mood, e.g., anxiety
to depression to anger, such as are seen in
states of acute psychotic turmoil.

The illness has had a duration of at least two
weeks during which, for most of the time, at
least four of the following symptoms have per-
sisted and have been present to a significant
degree:

(1) Poor appetite or significant weight loss
(when not dieting) or increased appetite
or significant weight gain.

(2) Insomnia or hypersomnia.
(3) Loss of energy, fatigability, or tiredness.

(4) Psychomotor agitation or retardation (but
not mere subjective feelings of restless-
ness or being slowed down).

(5) Loss of interest or pleasure in usual
activities, or decrease in sexual drive
(do not include if limited to a period
when delusional or hallucinating).

(6) Feelings of self-reproach or excessive or
inappropriate guilt (either may be delusional).

(7) Complaints or evidence of diminished ability
to think or concentrate such as slowed
thinking, or indecisiveness (do not in-
clude if associated with obvious formal
thought disorder).

(8) Suicidal ideation or wishes to be dead,
or any suicide attempt.

Not superimposed on either Schizophrenia, Schizo-
phreniform Disorder, or a Paranoid Disorder.

None of the following predominate the clinical
picture for more than three months after the
onset of the Depressive Episode:

40

(l) Preoccupation with a mood-incongruent
delusion or hallucination.

(2) Marked formal thought disorder.
(3) Bizarre or grossly disorganized behavior.

(American Psychiatric Association,
1979, PP. 35-36)

The common cognitive manifestations of depression
include such phenomena as low self-esteem, pessimism,
guilt and helplessness. Although depression has most
traditionally been considered an affective disorder which
happens to have cognitive consequences, Beck views these v/’
cognitions as the cause of depression and classified
depression as primarily a thought disorder (1976). The
depressed person shows specific cognitive distortions
which Beck terms "the cognitive triad". This triad in-
cludes a negative view of the self, of the outside world,
and of the future. Depressed people view themselves as
”losers" who are inadequate, undesirable and worthless.
They see their interactions with their environment as
depriving, defeating, and overdemanding, and they fully
expect their failures and rejections to continue on far
into the future. As a result of these negative beliefs,
these people feel depressed and withdraw, becoming passive,
self-critical and guilty.

Beck describes the development of depression as a
chain reaction that begins with an experience connoting
loss to individuals (1976). This loss could be a single,
obvious event or a long series of subtle deprivations; but

in either case, the individuals feel they have lost

41
something that is essential for their happiness. If they
then interpret everything in terms of a negative "cognitive
triad", these negative evaluations may lead to the many
emotional, motivational, behavioral and vegetative phen-
omena of depression (Beck, 1967). Such "secondary"
symptoms of depression serve to reinforce their initial
beliefs and activate a downward spiral such that the
depression becomes progressively worse.

Beck states that

I have followed a number of people subject
to recurrent depressions over long periods
of time and have noticed that before the onset
of a new depressive episode they begin to show
distortions in the way they interpret matters
. .In a number of cases I have been able to
arrest the onset of depression by pointing
out to the person how he is beginning to misin-
terpret reality.

(1974b, p. 26)

Although Beck's cognitive theory of depression is
largely derived from clinical data, many elements have
also been substantiated by correlational and experimental
studies. In two studies of the manifest content of
patient's dreams, the dreams of depressed psychiatric
patients showed a higher proportion of dreams with nega- “V
tive outcomes (termed "masochism") than the dreams of a
matched group of nondepressed psychiatric patients
(Beck & Hurvich, 1959; Beck & Ward, 1961). The typical
dreams of depressed patients portrayed the dreamer as a
"loser", suffering some type of deprivation. In an

analysis of the verbatim reports of 81 depressed and

nondepressed patients in psychotherapy, a preponderence

42
of the following verbal themes distinguished the depressed
from nondepressed patients: low self-regard, ideas of
deprivation, self-criticism and self-blame, overwhelming
problems and duties, self-commands and injunctions, and
escapist and suicidal wishes (Beck, 1963). These
depressive cognitions also seemed to be automatic, invol-
untary, plausible and persevering to the patients.

A series of correlational studies found significant
relationships between the depth of depression and the
degree of pessimism and negative self-evaluation (Beck,
1972). After recovery from depression, there was a
remarkable improvement in the outlook and self-appraisals
of the patients. Also, the high correlations between
measures of the negative view of the future and the
negative view of the self support the concept of the
"cognitive triad". When depressed patients' low concepts
of their capabilities were modified by allowing them to
succeed on a card-sorting task, they did indeed increase
their optimism and improved their performance on a second
task (Loeb, Beck & Diggory, 1971). Objectively, the
depressed patients did perform at least as well as non-
depressed patients on both these tasks.

That severely depressed people have a distorted
negative self-image has also been demonstrated by Friedman
(1964). Well matched depressed and normal subjects were
tested on 33 cognitive, perceptual and psychomotor tests.
The depressed subjects performed more poorly than the

normals on only 4% of the test scores, while they rated

43
themselves more negatively on 82% of the Clyde Mood Scale
items. Friedman concludes that "the actual ability and
performance during severe depression is not consistent with
the patient's unrealistically low image of himself" (p. 237).

A more recent study by Weintraub, Segal and Beck
(1974) substantiates the relationship between depressed
mood and negative cognitive content in normal males. A
group of 30 student volunteers completed the Depression
Adjective Checklist (Lubin, 1965) and a story completion
task at two-week intervals over a two-month period. As
hypothesized, depression as an affective state was closely
related to expectations of discomfort and failure as well
as to negative perceptions of interpersonal relationships
and the self. In addition, the negative cognitions were
more stable and enduring than the negative affect, sugges-
ting that the cognitive component is strongly activated
in depressed mood and may even trigger it.

All three of the cognitive approaches to therapy
described above have been used for the treatment of
depression, although most of the research has centered on
the changing of faulty thinking styles in depression.

The successful use of specific RET techniques to treat
depression has been reported in several case studies
(Ellis, 1962; Hauck, 1971), but has not been studied
systematically as of yet. In a study of the use of self-
instructional training to alleviate depression, Morris
(Note 3) compared self-instructional training to a

traditional insight-oriented therapy and a no-treatment

f 44

Vlcontrol group. Morris found that after six lk-hour
self-instructional training sessions, subjects reported
themselves to be less depressed, less anxious, higher in
self-esteem and more satisfied with their social inter-
actions than either of the other two groups, and these
differences were maintained at a 3-week follow-up period.
There was no reliable evidence that the insight therapy
was any more effective than the no-treatment control in
this study. Although this self-instructional training did
focus on the discrimination and modification of self-
statements, Morris also explicitly incorporated the
techniques of Ellis and Beck into this coping skills
package.

Another type of coping skills program was studied
by Gioe (1975). He used what he called cognitive modifi-
cation to change the negative cognitive triad of depressed
students into more positive views of themselves, their
worlds and their futures. He saw this as a preparation
for the acceptance of positive feedback from other people,
which was then provided in the form of a 4-hour group
interaction session designed to give positive reinforce-
ment for intrapersonal and interpersonal skills and
abilities. The actual cognitive modification used was a
simplified self-instructional training conducted over
five 30-minute sessions on consecutive days. Students
were taught relaxation training and then they were pre-

sented with positive self-statements as they imagined

pleasant scenes. This "cognitive modification" was

45
compared with the positive group experience alone, a
combination of the two treatments, and a no-treatment
control group. Gioe (1975) predicted that both components
of the treatment would be necessary to produce a therapeutic
effect. As predicted, the students in the combination
treatment had significantly reduced Beck Depression
Inventory scores and used more words to describe their

positive qualities than students in each of the three

”other groups. The author acknowledges the limited general-

izability of this study, since the students were only very
mildly depressed to begin with, and the treatments were
not powerful enough to effect their self-concepts as
measured by the Tennessee Self-Concept Scale.

Most of the systematic studies of the effects of
cognitive therapy on depression have been based on Beck's
cognitive model and emphasize the faulty thinking styles
of depressed clients. Taylor and Marshall (1977) compared
cognitive therapy with behavioral therapy, a combination
of the two strategies, and a no-treatment control group.
All treatments were administered individually in six 40-
minute sessions by the author. In the cognitive therapy
condition, subjects were taught to identity the cognitions
that intervened between events and emotions, and to sub-
stitute more constructive self-statements for the original
negative cognitions. They were also instructed to read
positive self-statements 3 or 4 times per day before a
high probability behavior, in accordance with the

Premack principle (Premack, 1959). In the behavioral

46

therapy condition, the subjects were taught to identify

the behavioral situations in which they became depressed,
and to develop alternative behavior patterns designed to
give them more positive reinforcement. These alternative
behaviors were taught by modeling and role-playing. In
addition, subjects were encouraged to increase the range

of their positive enjoyable activities. The results showed
that all three treatment groups improved significantly more

than waiting list controls on all measures of depression,

annd there were no differences between either the cognitive

or the behavioral treatment when used alone. The combined

"group, however, was significantly more effective than the

average of either of its components alone in reducing
depression as measured by the Beck Depression Inventory
(BDI), Dempsey's D-30 Scale (Dempsey, 1964), and a Self-
Esteem and a Self-Acceptance variant of Kelly's Reper-
tory Grid (Kelly, 1955). All results were maintained at a
5-week follow-up period. The conclusions from this study
are somewhat limited by the fact that only quite mildly
depressed college students were used as subjects, there
was no placebo control condition, and all assessments were
of a self-report nature. Experimenter bias was also
possibly introduced since the senior author conducted all
treatments himself and was clearly aware of the specific
hypotheses of the study.

A similar comparative study was conducted by Shaw
(1977). This study added a nondirective treatment group

to the groups used by Taylor and Marshall. In this study,

 

47

all treatments were conducted in groups over eight 2—hour
sessions by the author. The cognitive modification
group showed the most significant changes in EDI and the
Hamilton Rating Scale of Depression (Hamilton, 1960). The
other two treatment groups had lower depression scores
than the waiting list controls, but not as low as the
cognitive modification group. At a one-month follow-up,
the BDI scores of the cognitive modification group in-
creased slightly, but the scores of the behavior modifica-
tion group remained stable. This study is also limited
by its use of a mildly depressed college student population,
only self-report measures, and the one author conducting
all the treatment sessions.

Schmickley (1976) studied 11 depressed females from
a community mental health center and used four different
therapists to avoid some of the possible bias problems.
He also designed an Outpatient Depressive Behavior Rating
Scale which was filled out daily by each subject and two
significant others. Unfortunately, this behavioral
measure proved to be quite unreliable, so it did not add
much to the results of the study. Rather than having a
control group, Schmickley used an intensive case study
design with a multiple baseline and each subject serving
as her own contro1. The cognitive treatment was administered
individually over four l-hour sessions. Although Schmickley
concluded that the cognitive therapy had demonstrated its

effectiveness, his hypotheses were actually only weakly

 

 

48
supported by varying proportions of subject data, and the
results are quite inconsistent and unclear.

Beck's own research group at the University of
Pennsylvania has also been conducting studies of his
cognitive therapy. A study by Rush, Beck, Kovacs and Hollon
(1977) compared Beck's cognitive therapy to a generally
accepted standard treatment of depression, tricyclic
pharmacotherapy. Tricyclic antidepressants have been
'"found to be superior to placebo, marital therapy (Friedman,
1975), social casework treatment (Klerman, DiMascio,
Weissman, Prusoff & Paykel, 1974), and brief supportive
therapy or psychodynamic group therapy (Covi, Lipman,
Derogatis, Smith & Pattison, 1974). Thus Rush et al.
(1977) were using the best available treatment for the
acute symptoms of depression as a standard for comparison.
Their cognitive therapy consisted of a maximum of 20
individual sessions over a 12-week period, while the
pharmacotherapy consisted of a maximum of 12 sessions
over a lZ-week period. Eighteen therapists participated
in the study, and none of the principal investigators
conducted any of the treatments. The subjects were
community outpatients, with more serious depressive his-
tories than most of the subjects in the studies discussed
above. The results showed that both treatment groups made
significant decreases in depressive symptomatology. Cog-
nitive therapy resulted in significantly greater improve-
ment than pharmacotherapy on the BDI, the Hamilton Rating

Scale for Depression, and the Raskin Scale (Raskin, 1970).

 

49
In addition, the dropout rate was significantly higher
with pharmacotherapy than with cognitive therapy. A
3-month and a 6-month follow-up indicated that treatment
gains were maintained over time.

Other studies show support for the effectiveness of
one isolated component of Beck's treatment program in
combination with one behavioral technique. "Anticipation
training" is designed to modify the negative expectations
which may limit the amount of positive reinforcement
perceived as resulting from an activity (Anton, 1974;
Anton, Dunbar, & Friedman, 1976). This training program
”involves teaching clients to plan six pleasant activities
and to actively practice anticipating their positive
aspects. Subjects receiving this training for six
sessions significantly decreased their reported feelings
of depression and increased their reported pleasantness
of activities as compared to a self-observation group and
a no-treatment control. The authors recommend anticipa-
i/tion procedures as a first step in the treatment of

depression, to be followed by more specific interventions
tailored to the client's specific needs.

The work of Fuchs and Rehm (1977) on a self-control
treatment of depression illustrates the difficulty involved
in trying to make absolute distinctions between "cognitive"
and "behavioral" therapies. Their treatment package has
been classified elsewhere as a cognitive therapy
(Meichenbaum, 1977) because of its emphasis on the concept

of self-control, even though the primary focus of

50
treatment is on modifying overt behaviors. The distinction
in relative focus may be clarified if we compare the self-
control technique of Goldfried, Decenteco and Weinberg
(1974) called systematic rational restructuring with the
self-control treatment of Fuchs and Rehm. Both treatments
emphasize the active ways in which the client can work to
'“control his problems. Systematic rational restructuring
is considered a cognitive technique because the client
learns how to use anxiety as a signal to rationally
reevaluate the reasons for being upset, whereas Fuchs and
Rehm's treatment is considered a behavioral therapy because
the client learns to arrange his activities and reinforce-

ments such that they are more rewarding to him.

Behavioral Approach to Depression

 

Since cognitive therapies are so closely and com-
plexly related to behavioral therapies, no discussion of
the cognitive therapy of depression would be complete
without at least a brief discussion of the behavioral
approach to depression. Charles Ferster first laid the
groundwork for a systematic behavioral theory of depression
when he emphasized the importance of both a topographic
and functional analysis of pathology. He recognized that
"whether a man who moves and acts slowly is 'depressed'
or merely moving slowly is not easily or reliably deter-
mined by observing his behavior alone. The relation of
his behavior to events in the past or present environment

is a critical element in the description" (Ferster, 1965,

51
p. 9). Ferster later expanded his ideas into a full
functional analysis of depression (1973). In this analysis,
he pointed out that "the common denominator among depres-
sed persons is the decreased frequency of many different
kinds of positively reinforced activity" (p. 861).
Lazarus (1968) and Jackson (1972) conceptualized depression
similarly, as a consequence of inadequate reinforcement
or behavior that has become ineffective at securing rein-
forcement. Since behavior is a product of so many
psychological processes, a single cause of depression
cannot be expected. Rather, it is important to understand
all the processes that could reduce a person's positively
reinforced behavior, and several such processes are outlined
by Ferster (1973). One common cycle results when people
lose a major source of positive reinforcement such as
through the loss of a loved one. People may than receive
immediate reinforcement for depressive behaviors from
their sympathetic friends. If they do not find alternate
means of reinforcement, this depressive behavior may be
maintained as the only source of reinforcement they have
left.

Lewinsohn and his associates (1974) have developed
and tested an extensive behavioral theory of depression.
This theory is based on the assumption that a low rate of
response-contingent positive reinforcement (which
Lewinsohn terms "resconposre") acts as an eliciting
stimulus for some depressive behaviors (e.g., dysphoria,

fatigue) and is a sufficient explanation for other aspects

52
of depression (such as low behavior rate). The total amount
of resconposre received by an individual is seen as a
function of 1) the number of events which are potentially
reinforcing for the individual, 2) the availability of
reinforcement in the environment and 3) the extent to which
behaviors are emitted by the individual which will elicit
'reinforcement from the environment. Whereas cognitive
theorists assign primary causal significance to cognitive
distortions, behavior theorists see these as being second-
ary elaborations of dysphoria, a consequence of low
resconposre.

Several studies have been completed thus far which
seem to support Lewinsohn's behavioral theory of depres-
sion. Lewinsohn and Libet (1972) found a significant
association between mood and the number of pleasant
activities engaged in by depressed subjects, psychiatric
controls and normal controls (with no differences between
the groups). MacPhillamy and Lewinsohn (1974) found that
depressed subjects had significantly lower levels of
reported pleasure, general activity level and perceived
potential for reinforcement than normals or nondepressed
psychiatric controls. Another study (Libet & Lewinsohn,
:“l973) found that depressed individuals emit interpersonal v/
behaviors at about half the rate of nondepressed controls,
and that they also elicit fewer behaviors from other people
than do controls. Lewinsohn, Lobitz and Wilson (1973)

discovered that aversive stimuli elicit a greater

autonomic response in depressed subjects than in either

53
psychiatric or normal controls, which would predict
greater avoidance and hence lower resconposre on the part
of depressed individuals in social situations. In an
analogue study, Wener and Rehm (1975) found that different
rates of reinforcement led to differences in depressive
affect, self-confidence ratings and latency of responding.

Although case studies of the use of behavioral
techniques in treating depression have been reported,
few methodologically sound, systematic studies with appro-
priate control groups and follow-up data have yet been
conducted. Two of the studies discussed above compared
behavioral treatments to cognitive treatment (Shaw,

1977; Taylor & Marshall, 1977). In both studies, the
behavior therapy was more effective than the control
groups, although Shaw found it to be significantly less
effective than the cognitive therapy.

Another promising behavioral approach to depression ;
is the self-control behavior therapy program developed at
the University of Pittsburgh (Fuchs & Rehm, 1977; Rehm,
Fuchs, Roth, Kornblith & Romano, Note 4). Many of the
critical symptoms of depression are seen as constituting,
or resulting from, impairment in the three processes of
self-control: self-monitoring, self-evaluation, and self-
reinforcement (Kanfer, 1971). The therapy program, there-
fore, consists of training in each of these three processes:
self-monotoring of daily pleasant activities and mood,
self-evaluation by means of specific behavioral goals and

sub-goals for increasing pleasant activities, and

54

self-reinforcement for successfully achieving these sub-
goals. A study of 36 depressed women volunteers from the
community compared this 6-session self-control program
to a nonspecific therapy and waiting list control (Fuchs
& Rehm, 1977). The self-control treatment led to more
therapeutic change as measured by self-reports of
depression, a behavioral measure of activity level, and
general psychopathology level on the MMPI. A 6-week
follow-up showed general maintenance of this improvement,
with the differences between conditions dissipating some-
what due to follow-up improvement in the non-specific
condition.

A later study using a similar subject population
(Rehm et al., Note 4) compared the same self-control
behavior therapy to a behavioral social skills training
program. While the self-control group improved more on
the measures of self-control, and the social skills group
improved more on measures of social skill, the self-
control group improved more on self-report of depression
and observer ratings of overall depression, negative self-
references, and negative references to others. The lack
of a control group makes the results more difficult to
interpret; but taken together, the results of these two
investigations seem to be a good start towards demonstra-
ting the effectiveness of this self-control behavioral
therapy of depression.

Most recently, Rehm, Kornblith, O'Hara, Lamparski,

Romano and Volkin (Note 5) conducted a study which

55

investigated the importance of each element of their
treatment package to the overall treatment effects. Using
45 subjects from the same type of subject population, they
compared five experimental conditions: 1) the full self-
control program including training in self-monitoring,
self-evaluation and self-reinforcement 2) self-monitoring
plus self-evaluation 3) self monitoring plus self-
reinforcement 4) self-monitoring only and 5) waiting list
control. Each of the experimental conditions were more
effective than the waiting list control group in reducing
depression as measured by several self-report as well as
interview ratings. Thus, in this one study, training
in self-monitoring alone seemed as effective as training
that includes components of self-evaluation and/or self-
reinforcement. No follow-up data was included in this
report, however, so it remains unclear as to how the
various components of this treatment package might contri-
bute to the maintenance of reduced depression over time.

In a study by McLean, Ogston and Grauer (1973) a
behavioral treatment of depression was administered to
depressed clients and their spouses. Treatment included
training in social learning principles, immediate feedback
as to the perception of the verbal interactions between
the client and the spouse, and training in the construction
and use of reciprocal behavioral contracts. As compared
to clients in more traditional therapies, the clients in

this behavioral treatment showed more improvement after

 

56
eight sessions on both self—report and behavioral measures
of depression.

A very simple behavioral technique was investigated
by Shipley and Fazio (1973). Clients were taught to
confine their expressions of unhappiness to a designated
period when they would be neither reinforced or punished
by others. After only three sessions, the behavioral
group showed significant improvement on the MMPI as
compared to an interest support group and a waiting list
control. No follow-up period was used, so it cannot yet
be determined whether the results of such a seemingly
mild intervention would be maintained over time.

In a study by Hammen and Glass (1975), it was found
that having depressed students simply increase their
pleasant activities did not improve their mood or reduce
their depression. Lewinsohn, in his critique of that
study (1975), points out several differences between his
techniques and those of Hammen and Glass which could
explain their lack of results. For example, Hammen and
Glass used only students who appeared to be depressed on
questionnaires but did not necessarily even present
depression as a problem for themselves, and they used
their own definition of "pleasant" rather than that of
each individual subject. Lewinsohn did, however, conclude
that "the prediction that an increase in pleasant activity
level will produce a reduction in depression level

probably should be restricted to individuals (a) in whom

57
there is a significant association between activity level
and mood. . .and (b) whose baseline pleasant-activity
level is low" (1975, p. 730). Hopefully it will eventually
be possible, with enough research, to predict more
specifically which types of clients can benefit most from

which therapeutic techniques.

Conclusions

 

Since the research in the area of cognitive-behavioral
treatments of depression has thus far focused on demon-
lstrating the effectiveness of several large, complex
treatment packages, one of the next steps necessary would
be to define and isolate those components of the package
which are responsible for the resulting change. Each
of the treatment packages discussed above consists of
several fairly well-defined components which all may or
may not be relevant to therapeutic improvement. According
to Mahoney (1974), "In the development or unprecedented
application of therapeutic procedure, a pragmatic rule
'of thumb is: First show an effect, then isolate its cause”
(p. 198). Now that cognitive therapies have given at
least some initial indication of their effectiveness in
treating depression, there is a need for much more‘
specificity. This would include comparing the usefulness
of different components within a single treatment package,'
comparing different types of cognitive therapies, v5

comparing different cognitive and behavioral techniques,

58
and so on. As Paul (1969) points out, the most useful
research questions are not the broad, general questions
like "Is cognitive therapy effective?" or "Does behavior
therapy work?". The ultimate goal of therapy research is
to find out, as exactly as possible, "what treatment, by
whom, is most effective for this individual with that
specific problem, under which set of circumstances"
(p. 162). Speaking of the need in this field for specifi-
city, Bergin maintains that "there are few assertions in
recent literature more widely believed or more persuasively
argued than this one" (1969, p. 113).

One concern about cognitive therapy has been that its
emphasis on thoughts and beliefs will limit its usefulness
for certain types of clients. In an early discussion of
RET, Ellis (1958) states that

Many clients are not bright enough to follow
a rigorously rational analysis. For another
thing, some individuals are so emotionally
aberrated by the time they come for help
that they are, at least temporarily, in no
position to comprehend and follow logical
procedures. Still other clients are too

old and inflexible; too young and impres-
sionable; too philosophically prejudiced
against logic and reason; too organically or
biophysically deficient; or too something

else to accept, at least at the start of
therapy, rational analysis.

(p. 49)
McLean (1976) also questions the generalizability of cog-
nitive therapy in terms of whether concrete thinkers can
be successful in cognitive modification. He points out

that depressed clients often have poor concentration,

a restricted attention span, agitation and response

59
retardation which could effect the feasibility of cognitive
approaches to the treatment of severe depressions.
Beck, Rush and Kovacs, in their cognitive-behavioral
treatment manual (Note 6) state that their techniques have
been successful with both "endogenous" and "reactive"
depressions, but realistically conclude that ”like other
treatments for depression, itzis unlikely that this treat-
ment strategy alone will prove useful for all depressed
patients" (p. i). One of the goals of this paper is to
begin to clarify what some of those limits on cognitive
therapy may be.

One subject variable which would seem to have
relevance to the effectiveness of cognitive therapy is
cognitive complexity. The term "cognitive complexity”
has been defined and conceptualized in a vast number of
ways. For the purposes of this study, cognitive complexity
will be defined as the distinctiveness of the elements
which constitute one's cognitive system (Scott, 1963b) or,
conversely, the degree of relatedness of attribute
dimensions within a cognitive domain (Condon, Note 11).

An interpersonal cognitive system would be considered
relatively complex if it contains many interpersonal
constructs which are hierarchically integrated to a high
degree (Crockett, 1965). The number of dimensions that
one employs to make meaning out of a set of stimuli is
one component of complexity, but the relatedness of these

dimensions is also crucial to an understanding of complexity.

60
An example, provided by Condon (Note 11) may clarify these
two components of complexity. Two people (A & B) may both
be able to discriminate among people on each of three
attributes (helpfulness, responsibility and friendliness).
If for A each attribute is a relatively independent
dimension of judgment (such that people who are helpful
may or may not be responsible and may or may not be
friendly) while for B, these three attributes are com-
pletely related (people who are helpful are also responsible
and friendly), person A would be defined as more cogni-
tively complex than person B.

I One aspect of the research on cognitive complexity
which seems especially pertinent to a discussion of
cognitive therapy involves dichotomous thinking. Campbell
(1960, cited in Bieri, 1961) found that subjects who were
rated as low in cognitive complexity were more likely to
separate people into two groups on the basis of a good-bad
dichotomy than those rated high in cognitive complexity.
Also, the cognitively "simple" subjects more often saw
social relationships among associates as balanced, with a
mutuality of liking or disliking involved, than the more
"complex" subjects. In a completely different content
area, Scott (1963a) found that subjects with low cognitive
complexity grouped nations significantly more often into
a dichotomy of positive vs. negative, while subjects with
high cognitive complexity included both liked and disliked
nations in more differentiated categories. In addition,

Supnick (cited in Crockett, 1965) found that the less

61
cognitively complex individuals gave significantly more
univalent descriptions of people than more cognitively
complex subjects.

One of the major objectivescxfcognitive therapy is to
alter clients ' tendencies to view themselves and their futures
in a totally negative way. The goal of the treatment is to
help clients learn to make realistic discriminations between
specific environmental events and behaviors (e.g., "I did
poorly on a quiz") and their judgments of their own self
worth (e.g., "I must be a rotten, stupid person"). .Although
most depressed people may have difficulties differentiating
clearly when it comes to their own personal attributes,
highly cognitively complex people who are at least capable
of identifying complicated patterns of positive and nega-
tive attributes in other people may find it easier to learn
to make similar discriminations when it comes to their own
self-image. On the other hand, people with low cognitive
complexity who may use only dichotomous reasoning in all
aspects of their lives may find it more difficult to make
these changes, since they would be changing not only their
way of looking at themselves, but their ways of construing
the entire world.

This study will attempt to examine the subject variable
of cognitive complexity as it relates to the ability to
benefit from short-term treatment of depression by comparing
the effectiveness of cognitive, behavioralanuinondirective
depression workshops for subjects with both high and low

levels of cognitive complexity.

HYPOTHESES AND PREDICTIONS

Each of the three types of cognitive therapy dis-
cussed in this paper has demonstrated at least some initial
effectiveness in treating different types of psychological
disorder. With mildly to moderately depressed clients,
Beck's cognitive therapy has been studied in attempts to
alleviate the depressions of both student and clinic
populations. Beck has concluded that "by pinpointing
the patient's specific cognitions and demonstrating their
invalidity through behavioral or cognitive techniques,
the psychotherapist can achieve a rapid improvement in the
symptoms of depression" (1974b, p. 19). Considering the
range of clients who have already been treated with some
success in cognitive therapy, it is hypothesized that, for
people of both high and low levels of cognitive com-
plexity, cognitive therapy is more effective in reducing
depression than more traditional, nondirective therapy.

Prediction 1: Subjects in the cognitive groups
will Show a significantly greater reduction on
all the measures of depression after treatment

than subjects in the nondirective control
groups.

 

Researchers have also made a start towards demon-
strating the effectiveness of behavioral therapies in the
treatment of depression. Both student and clinical pop-

ulations have been treated using behavioral approaches

62

63

with some success, and even quite simple behavioral
techniques seem to help improve the symptoms of depression.
Therefore, it is hypothesized that behavioral self-control
therapy will also be more effective in treating depressed
clients than is nondirective therapy, regardless of
cognitive complexity level.

Prediction 2: Subjects in the behavioral self-

control groups will show a significantly

greater reduction on all the measures of depres-

sion after treatment than subjects in the non-
directive control groups.

 

Level of cognitive complexity may influence the
ability to integrate the information taught in cognitive
therapy with previous concepts of the self and to learn
further discriminations in cognitive processes. Therefore,
it is hypothesized that cognitive therapy is more effec-
tive in the treatment of depressed clients with high
cognitive complexity than those with low cognitive com-
plexity while behavioral self-control therapy is more
effective in treating depressed clients with low cognitive
complexity than with high cognitive complexity.

Prediction 3: Highly cognitively complex sub-
jects will show a significantly greater
reduction in overall depression (as measured
by the BDI and the D-30 Scale) after being in
a cognitive group than subjects with low cog-
nitive complexity. On the other hand, subjects
with low cognitive complexity will improve
significantly more after being in a behavioral

self-control group than subjects with high
cognitive complexity.

 

Since cognitive and behavioral self-control therapy
each emphasize different modalities of behavior change,

they may both be effective therapeutic strategies in the

64
modification of depression, although working via different
routes. Behavioral self-controltherapy, with its
emphasis on changing overt behavior, is hypothesized
to be especially effective in modifying the behavioral
components of depression. On the other hand, since
cognitive therapy emphasizes the modification of cognitive
behavior, it is hypothesized that cognitive therapy is most
effective in reducing the cognitive components of depres-

sion.

Prediction 4: Subjects in the behavioral self-
contrOl groups will improve significantly more
on the behavioral measures of depression than
subjects in the cognitive groups. Subjects in
the cognitive groups will, however, improve
significantly more on the cognitive measures

of depression than subjects in the behavioral
self-control groups.

According to Beck (1976), "Since each of the com-
ponents of depression (emotional, motivational, cognitive,
behavioral and physiological) contribute to other com-
ponents, it might be anticipated that improvement in any
one problem area (e.g., cognitive) would lead to improve-
ment in other areas (e.g., behavioral) and would finally
spread to include the entire syndrome of depression"

(p. 265). It is therefore hypothesized that over time the

modality-specific improvements will generalize to effect

improvement in other components of depression as well.
Prediction 5: At the 6-week follow-up point,
the pattern of changes in overall depression
will be maintained as predicted above; however,
the behavioral self-control groups will show
increased improvement on the cognitive measures
and the cognitive groups will show increased

improvement on the behavioral measures of
depression.

METHOD

Subjects

Volunteer subjects were recruited from the local

community through announcements in the mass media stating

that short-term workshops were being offered to help

people cope with depression (Appendix A). To qualify

for selection, subjects were required to meet each of the

following criteria:

1.

\lChUI-D

Self-reported depression of at least 3 weeks
duration.

Willingness to participate in a treatment and
research program.

No current involvement in any other psychological
treatment program for depression.

At least 18 years of age.
A Beck Depression Inventory score 1 l7.
D-30 score 1 l4.

Psychiatric Screening Inventory Alienation score
< 70 and Defensiveness scores less than 70
but greater than 30.

Clinical judgment based on the test results and
at least two telephone interviews (Appendix B)
that depression is the major presenting problem
and that no obvious psychotic symptoms (e.g.,
hallucinations, delusions) are present which
might warrant hospitalization or extreme suicide
risk. People whose depressions were associated
with schizophrenia, organic brain disease,
alcoholism, or drug addictions were not included
in this study.

Subjects fulfilling these criteria would most closely fit

65

66
the category "major depressive disorder" according to
the American Psychiatric Association's Diagnostic and
Statistical Manual, Third Edition (1979).

Ideally, each subject who fit the screening criteria
would be randomly assigned to a treatment condition, and
groups in all three conditions would begin and run simul-
taneously. In order to minimize the delay between the
subject's response to the media announcements and the
actual start of the workshop, however, it was necessary
to assign each group of subjects to a treatment condition
rather than to assign individuals to treatments. Thus, as
soon as sufficient subjects had been screened to form
one workshop, that group of subjects was randomly assigned
to one of the three treatment conditions and that work-
shop was started. This way, one group could begin every
two weeks rather than having all subjects wait six weeks
until there were sufficient subjects to begin all con-
ditions. All screening procedures and interviews were
conducted blind to the subjects' experimental condition,
since subjects were not assigned to a condition until
after the screening was completed.

A total of six workshops were conducted throughout
the 9-month course of this study, two in each of the
three experimental conditions (cognitive, behavioral self-
control and nondirective). Since a committment was made
to the subjects that their workshop would begin within

two weeks of screening, the groups were of unequal size.

67
Forty subjects qualified according to the screening criteria
and were assigned to groups as follows: 15 subjects in the
cognitive condition (in groups of 8 and 7), 14 subjects
in the behavioral self-control condition (in groups of 7
each), and 11 in the nondirective condition (in groups of
7 and 4). Three workshops (one in each condition) were
run at 2-week intervals during the summer months and three
workshops (one in each condition) were run at 2-week
intervals during the winter months. The workshops were
run during the summer and winter months due to the availa-
bility of group leaders at those times.

Written informed consent (Appendix C) was obtained
from each subject before the beginning of the screening
process. At the conclusion of each workshop, subjects
were offered referrals to local agencies if they were

interested in further psychological treatment.

Screening Measures

 

Psychological Screening Inventory

 

The Psychological Screening Inventory (PSI) was
designed by Lanyon (1978) as a brief mental health screening
device, to be useful in detecting those peOple who would
most need further psychological attention (Appendix D).

The goal of the PSI is to enable users to make specific
decisions and predictions that improve over the predictions
made without using the test. The PSI consists of 130
personal statements to be answered true or false with

items worded at grade school level. The PSI form.takes

68

approximately 15 minutes to complete. The entire PSI
contains five scales, but only the two scales used in
subject selection for this study will be discussed here:
the Alienation Scale (A1) and the Defensiveness Scale (De).

The A1 scale was designed to measure the similarity
of the subject to hospitalized psychiatric patients, in
order to identify people who may need to be examined
further for the possibility that they may require inpatient
psychiatric treatment. According to Lanyon, high Al scores
are associated with the same characteristics as high
scores on the MMPI scales most related to serious psycho-
pathology (Sc, F, Pa, and Ma). He describes high A1
scorers as "having an unsatisfactory emotional life,
being suspicious, sensitive and anxious, feeling unaccep-
table and alienated, denying normal expression of affect,
and perceiving themselves as not responsible for, or in
control of, their own lives" (Lanyon, 1978, p. 9). The
validity of the A1 scale was tested in several ways.
Mean A1 scores were calculated for 38 different subject
groups, and psychiatric patient groups consistently scored
close to two standard deviations above the normative mean.
Al scores were correlated with scales from other tests,
and the highest average correlations (at approximately .5)
were shown between the Al scale and the Sc, F and Pa
scales of the MMPI. The A1 scale was also used to dis-
criminate psychiatric inpatients from normals with a

hit-and-miss accuracy of approximately 80%. A highly

69

significant association was found between scores on the
A1 scale and the six MMPI "psychotic signs" delineated
by Meehl (1946) and Peterson (1954). Finally, the mean
MMPI profiles of subjects with high Al scores indicated
more tendency for high Al scorers to show psychotic,
rather than neurotic, disturbances.

The reliability of the Al scale was assessed in
terms of internal consistency (.62) and test-retest
reliability (.66 & .73 in two different samples).
Although these reliability coefficients are not high,
Lanyon (1978) states that they compare favorably with
reliability coefficients for the MMPI.

For use as a screening device in this study, a cut-
off score of 70 was used, since Lanyon suggests that
scores of 70 or more indicate the desirability of more
thorough psychological examination. To minimize the
possibility of subjects with psychotic disturbances which
require more intensive intervention being admitted into
the depression workshops, subjects with Al scores above
70 were not selected for this study and were referred
elsewhere for psychological treatment.

The Defensiveness (DE) Scale of the PSI was designed
to assess the subjects' test-taking attitude. A score of
70 or more is seen by Lanyon (1978) as fairly definite
evidence of "faking good" and a score of 30 or less
indicates the probability of "faking bad". Lanyon found
that when using a specific cut-off score in the A1 scale,

use of the De scale could improve the accuracy of the

70
discriminations made. Thus, in order to minimize the
probability that a subject was deliberately distorting
his or her responses in either direction, which would
invalidate the use of the A1 scale cut-off scores, sub-
jects were selected for this study only if their De score

was less than 70 and more than 30.

Beck Depression Inventory

 

The Beck Depression Inventory (BDI, Appendix E) has
been considered to be "probably the best developed and
most widely used self-report depression measure" (Becker,
1974, p. 25). The BDI was developed as a measure of the
level of depression in a client, not as a means of dis-
tinguishing between standard diagnostic categories (Beck,
Ward, Mendelson, Mock and Erbaugh, 1961). The scale consists
of 21 categories covering the various psychological,
physiological and behavioral manifestations of depression.
Each category contains a set of graded self-evaluative
statements that are rated from 0 (neutral) to 3 (maximum
severity). Analysis of BDI scores done on several large
psychiatric samples indicate good reliability and validity
for the measure (Beck, 1972; Beck & Beamesderfer, 1974;
Beck et al., 1961; Metcalfe & Goldman, 1965). The BDI
showed high reliability in terms of internal consistency
and stability: split-half Spearman-Brown corrected
Pearson r = .93, all items were significantly related to
total score at the p < .001 level per item, and highly

significant test-retest correlations were found.

71
Inter-rater reliabilities were also quite good. The
validity data for the BDI is encouraging as well.
Correlations between diagnostician's ratings and BDI
scores were found to be .67, and comparable findings have
been obtained in several different areas of the United
States as well as in 5 countries outside of the U.S.
Correlations of the BDI with symptom check-lists, the
MMPI D-scale and the Hamilton Rating Scale for Depression
range from .66 to .75 (Beck, 1972). Beck and his colleagues
(1961) also report that the inventory is sensitive to
changes in the severity of depression over time. In
terms of construct validity, the BDI has been success-
fully used as the criterion measure of several simple
hypotheses about depression. BDI scores have been found
to be unrelated to race, age and intelligence, but females
and the less well-educated do tend to obtain higher scores
(Beck & Beamesderfer, 1974). One important advantage of
the BDI over other measures of depression is its apparent
ability to discriminate depression from anxiety
(Beck, 1972).

In this thesis, a BDI score 1 17 was used as the
cutting off score for clinical neurotic depression (as
suggested by Beck and cited in Schmickley, 1976).

This also is compatiblewith the results of a study by
Fahy (1974) who found that the mean BDI score of depressed

patients seen in general practice was 17.4.

72
The D-3O Scale

 

The MMPI Depression Scale (Hatheway and McKinley,
1956) is one of the oldest and most traditional self-
report depression measures. This is a 60-item scale
that is based on 49 items which discriminate hospitalized
manic-depressive patients in their depressed phase from
normals, and 11 items discriminating manic-depressives
from other psychiatric patients. Although this scale seems
to show consistent validity as an index of client change
(Bergin, 1971), it has been said to do reasonably well in
predicting differences between nosological groups but
poorly in predicting individual differences within
groups (Becker, 1974). Thus, similar scores on this scale
can reflect quite different depressive states both quan-
titatively and qualitatively.

In one attempt to overcome this lack of dimension-
ality, Dempsey (1964) designed a 30-item modification of
the original MMPI Depression Scale which he calls the
D-30 Scale (Appendix F). He selected 30 of the original
60 items by contextual analysis such that the items
related consistently in the same direction to the major
underlying dimension within normal and abnormal samples of
both sexes. Despite the fact that the number of items was
cut in half, the D-30 Scale showed improved reliability
over the original scale using both split-half (r = .88)
and test-retest (r = .92) reliabilities. The cut-off

score used in the selection of subjects for this study

73
was a score of 14 on the D-30 scale, which corresponds

to a T-score of 70 on the MMPI Depression Scale

Dependent Measures

 

In addition to the screening procedures, subjects
were tested three times: before the start of the workshop,
at the end of the workshop, and at a six-week follow-up
point. The dependent measures include two measures of
over all depression (the Beck Depression Inventory and the
D-30 Scale, which were also used in the screening process),
two self-report behavioral measures (the Pleasant Events
Schedule and the Verbal Behavioral Measure), and two
cognitive measures (the Dysfunctional Attitude Scale

and the Irrational Beliefs Test).

Dysfunctional Attitude Scale

 

The Dysfunctional Attitude Scale (DAS) is a measure
recently developed by Weissman "to measure the extent to
which persons hold beliefs which predispose them to
depression" (Note 7). According to Beck's model of
psychotherapy (1976), depressed individuals would hold
more dysfunctional and distorted attitudes than non-
depressed people, so that the goal of his cognitive therapy
is to change these dysfunctional attitudes and hence
alleviate depression. Thus, the DA8 would seem to be an
especially appropriate measure of the success of cognitive

therapy.

74

The DAS consists of two parallel forms, each having
40 statements which are rated on a 7-point modified Likert
scale, rating from Totally Agree to Totally Disagree
(Appendix G). The total DAS score for each person is
simply the sum of the scores for each for the 40 state-
ments. The items of the scale were derived clinically,
and statements were selected which seemed to most
accurately describe the attitudes underlying the cognitive
distortions of Beck's cognitive model of depression. Both
forms of the DAS were validated in a sample of 355 normal
college students. The internal consistency ranged from
.89 to .92, while test-retest reliability over an 8-week
period was .84. Weissman also found a significant
relationship between the salience of a person's dysfunc-
tional attitudes (as measured by the DAS) and the intensity
of depression (as measured by the Beck Depression Inven-
tory and the Depression Scale of the Profile of Mood States).
In addition, dysfunctional attitudes were found to be more
persistent over time than depressed affect. The relation-
ship of age, sex, race and educational level to scores
on the DAS was studied; and although both sex and educa-
tional level were significantly related to the DAS, these
significant differences were small, accounting for only
4% of the variance. Weissman has shown that the DAS
discriminates among normals at varying levels of depression,
but further research is needed to determine whether the DAS
can also be useful in discriminating among various psychia-

tric groups.

75
Irrational Beliefs Test

The Irrational Beliefs Test (IBT) is an instrument
constructed by Jones (1968) to measure irrational beliefs
within the framework of Ellis. Although it would be
most appropriate as a measure of the effectiveness of
Ellis' rational-emotive therapy, the theories behind RET
and Beck's cognitive therapy are closely enough related so
that the IBT is also an appropriate outcome measure of
Beck's cognitive therapy. This test is being used in
addition to the DAS as a measure of attitudes that might
predispose people to depression.

The IBT consists of 100 items measuring the relative
presence or absence of 10 irrational beliefs in separate
scales (Appendix H). The cross validation sample included
178 college students, 72 state mental hospital patients
and 177 normal adult volunteers. Construct validities
were found to range from .561 to .824 with a mean of .699.
Homogeneity reliability coefficients ranged from .662 to
.801 with a mean of .737, based on inter-correlations of
item scores and scale scores. Test-retest reliabilities
were .921 for a full scale and from .675 to .872 for
individual scales. Eight of the ten IBT scales correlated
highly with admitted psychiatric symptomatology, and the
differences between IBT scores of a normal adult sample
and a mental hospital sample were highly significant for
eight of the scale scores. Age was not found to be

significantly related to irrational beliefs, but there

76
were significant sex differences specific to scales, and
education level had a negative functional relationship to
IBT scores which involved most scales. It was concluded
that the IBT was "sufficiently reliable and valid as a
measure of irrational beliefs for use in both research and

specific clinical needs” (Jones, 1968).

Pleasant Events Schedule

The Pleasant Events Schedule (MacPhillamy &
Lewinsohn, Note 8) is an assessment device for the measure-
ment of positive reinforcers in adults. The Reinforcement
Survey Schedule (Cautela & Kastenbaum, 1967) was the
first such assessment device, but it is best suited to
the assessment of potential reinforcers which are available
to therapists or teachers in the clinic or classroom.
The Pleasant Events Schedule (PES), however, was designed
primarily for use in assessing events which occur in a
person's natural environment. The original PES consists
of 320 items which are rated both with regard to their
frequency and their subjective enjoyability over the
preceding 30 days. The items were selected empirically
from items generated by people of diverse ages, educational
and social backgrounds in an attempt to avoid restricting
items to those which might have obvious stereotyped
pleasurable associations. The intrascale homogeneities
were found to be consistently over .96 using coefficient
alpha (Chronback, 1951). The test-retest reliability

was not quite so strong. For all items together, the

77
percent agreement was 76% and Pearson r was .53 for
frequency ratings, while for enjoyability ratings the
percent agreement was 69% and Pearson r was .55. Several
different types of validity have also been examined, with
promising, if not conclusive, results. On the whole, the
PES scales seem to possess "reasonable degrees of factorial
stability, item homogeneity, stability over time, statis-
tical independence, convergent and discriminant validity
with alternative concurrent measures of the same variables,
predictive validity, and the ability to discriminate in
the predicted direction between groups of pe0ple having
differing psychological characteristics" (MacPhillamy &
Lewinsohn, Note 8, p. 33).

Scores on the Pleasant Events Schedule have been
found to discriminate significantly between depressed
people and both normal individuals and people with
psychological problems other than depression (MacPhillamy &
Lewinsohn, 1974). Lewinsohn and his colleagues (Lewin-
sohn & Graf, 1973; Lewinsohn & Libet, 1972) have also
demonstrated that depressed mood correlates with activity.
Since behavioral theory posits that depression is a result
of a low rate of response-contingent positive reinforce-
ment (Lewinsohn, 1974), measures of pleasant activities
have been used as outcome measures of self-reported
behavior change in studies of therapy with depressed
clients (Anton, 1974; Anton et al., 1976; Fuchs & Rehm,
1977; Rehm.et al., Note 4 and Note 5).

78

The 49-item version used in this study (Appendix I)
was made up of the items which best correlated with
depression (Lewinsohn & Graf, 1973). This same version
was also used by Ruchs & Rehm (1977) and Rehm et a1.
(Note 4 and Note 5) in their research on depressed clients.
Subjects were given two separate scores on the PES: PESA
is the rating of the frequency of pleasant events, while

PESB is the rating of the enjoyability of these events.

Verbal Behavioral Measure

 

In order to measure overt behavior associated with
depression, a behavioral measure similar to that used
successfully by Rehm et a1. (Note 4) was also included
in this study. At each testing session, each client
was individually asked to say something about his or her
current functioning. These statements were audio-taped
so that several undergraduate raters who were blind to
conditions could later rate each speech on a 5-point
scale of Overall Depression and count the number of sen-
tences containing positive self-references, negative
self-references, positive other-references, and negative
other-references. In order to adjust for the actual
number of sentences spoken, the rate of negative self-
references and negative other-references was calculated.
Thus, the Verbal Behavioral Measure (VBM) includes an
Overall Depression Rating, a Negative Self-Reference Rate

and a Negative Other-Reference Rate.

79
Cognitive Complexity Scale

The many different conceptualizations of cognitive
complexity have led to as many different measures of the
concept. The tendency for each research team to develop
their own measures and use only these measures in their
research has led to a lack of clarity about the possible
unity of the concept and the empirical relationship
between these measures. Vannoy (1965) tried to find the
commonality among the many conceptions of cognitive
complexity by administering 20 different measures to 113
male undergraduate subjects. Some of these measures had
been explicitly designed to measure cognitive complexity,
while other measures were included which Vannoy merely
thought might reflect such a variable. His failure to
find a large first factor on which most of these measures
were substantially loaded led him to conclude that
"no such predisposition (as cognitive complexity) exists
or none of the instruments included in the test battery
is a valid measure of it" (p. 387). In his clever cri-
tique of Vannoy's study, Condon (Note 11) compares
Vannoy's procedures to trying to find a needle in a hay-
stack and concludes that "following Vannoy's logic to its
absurd extreme, one would deny the existence of the needle
due to its lack of commonality with the surrounding hay!”
(p. 11).

Only three of the measures included in Vannoy's

study are similar to the concept of cognitive complexity

as used in the present study. When Condon (Note 11)

80
reanalyzed Vannoy's data using only these three measures,
the factor analysis yielded a first factor which accounted
for 56% of the total variance. While this procedure is
not wholly legitimate statistically, it does suggest that
some common element may exist among these measures.
Thus, rather than abandon the concept of cognitive com-
plexity as invalid, further research might prove more
useful by discriminating among the various definitions of
cognitive complexity and trying to find empirical relation-
ships among measures which are at least ostensibly
measuring the same concept.

The cognitive complexity scale used in this study
consisted of judgments of 20 personal acquaintances on
each of 20 7-point semantic differential scales
(Appendix J). Osgood's semantic differential scales have
been widely used to assess individuals' cognitive space.
Osgood and his colleagues stress that the semantic
differential is not any one particular test with stan-
dard concepts and standard scales; rather, it is a general
method which is to be adapted to the specific research
problem for which it is used (Osgood, Suci & Tannenbaum,
1957). In this adaptation of the semantic differential,
role descriptions of 20 people were provided to subjects
and they were instructed to list the 20 different
adquaintances who best fit the descriptions. Each
acquaintance was then rated on each of 20 attribute scales.

The results were then factor analyzed for each subject

81
individually, and the cognitive complexity score was
calculated as the number of dimensions that accommodated
75% of the variance, a technique suggested by Thompson
(Note 12).

This measure is most similar to measures used pre-
viously by Ware (1958, cited in Osgood, 1962) and Condon
(Note 11). Ware had subjects rate 31 simple but varied
concepts on 20 semantic differential scales, and used
the percentage of variance extracted by the first factor
as his measure of ”dimensionality". Condon (Note 11) had
subjects rate 28 personal acquaintances on the same
semantic differential scales used in the present thesis,
labeling the average absolute interattribute correlation
as his measure of "dimensional complexity". On this
measure, Condon found internal consistency as measured
by Chronbach's alpha to be .93. The similarily of the
concepts behind these three measures is clear, but the
slight variations in techniques of measurement leave com-
parisons among these measures somewhat confusing and
difficult.

In addition to the screening measures and dependent
measures, subjects were asked to fill out brief question-
naires at the post-test and follow-up periods, rating their
opinions of the workshop and their group leader (Appen-

dix K).

82

Group Leaders

 

The group leaders used in this study were six first-
year graduate students in a clinical psychology doctoral
program. Each group leader led a group in the condition
which, according to their self-report, seemed closest to
his or her own personal orientation towards psychological
treatment. Throughout the study, the group leaders
remained blind to the specific hypotheses of the study.
Leaders were informed that the study was designed to
look at subject variables which effected individual
subjects' success in the different workshops, and that in
general subjects were expected to improve in all three
conditions.

Prior to participating, all group leaders were
provided with a manual appropriate to their experimental
condition, a session-by-session workshop outline, and a
required reading list. Training consisted of two separate
two-hour sessions for leaders in each condition, where
a summary of the appropriate intervention mode was
presented and questions about the manuals and readings
were discussed.

In the cognitive condition, leaders used the
cognitive modification manual and session-by-session
treatment outline as used by Shaw (1977, Appendix L).
Relevant readings included the individual treatment manual

used by Beck and his colleagues (Beck et al., Note 6).

83

The manual and session-by-session outline used for
the behavioral self-control condition was the self-control
therapy manual used in studies by Fuchs and Rehm (1977)
and Rehm et a1. (Note 4). The only significant change
made in the manual was to expand the program from a
6-session to an 8-session workshop, in order to keep the
actual amount of time spent in the workshop consistent
across conditions (Appendix M). The group leaders had

all previously read Bandura's Principles of Behavior

 

Modification (1969) and in addition were assigned to read

 

the first six chapters in Mahoney and Thoresen's Self-

Control: Power to the Person (1974).

 

The manual used for the nondirective workshops was
made up of exerpts from the manual used by the Drug
Education Center (Hughes, 1977), the Listening Ear Crisis
Center (Thornton, Note 9) and the Adolescent Diversion
Project (Kantrowitz, Note 10). This manual focuses on
teaching the skills seen as "necessary and sufficient"
conditions for therapeutic change in nondirective
approaches: accurate empathy, unconditional positive
regard, and genuineness (Appendix N). In addition,
relevant readings which specifically discuss nondirective
treatment in groups were assigned, including articles by
Hobbs (1951) and by Dickenson (1967).

Once each workshop had started, twice weekly super-
vision sessions were held separately for leaders in each

experimental condition.

84
Treatment

The treatment programs, described as Depression Control
Workshops, were conducted in six groups, each consisting
of four to eight group members and a group leader.
Sessions were held twice a week for approximately two
hours per session, and each entire workshop lasted four
weeks. Sessions were tape-recorded, and blind under-
graduate raters rated random samples of the tapes to see
whether they could identify which treatment was being used.
This was done as a check to see that the different treat-
ment conditions did indeed differ from each other and
follow the appropriate treatment model.

All workshops started out with the same general
introductions to the Depression Control Workshops
(Appendix 0). After this introduction and any general
questions, the workshops varied according to the different

therapeutic conditions.

Cognitive Workshpp

 

Session 1. After the standard introduction, a

 

specific rationale for the cognitive approach was presented.
The history and current status of each client's symptoms
were then explored in an attempt to delineate the major
maladaptive sequences in the client's life. The group
leader concentrated on the specific events leading up to

a depressive episode and the member's response to these

events. The leader then tried to develop hypotheses

85
about the member's idiosyncratic response patterns and
some of his or her basic attitudes and beliefs.

Session 2. The leader helped each group member to

 

delineate the maladaptive cognitions and self-verbalizations
which occurred in response to various events. This was

done by discussing those specific events which were followed
by feelings of sadness or depression. These events were
discussed in terms of the chain of environmental stimuli +
cognitions + affect. The first homework assignment was

for the members to write down the thoughts that occurred
immediately before any feelings of sadness or depression
until the next session.

Session 3. The homework assignment was discussed,

 

and the leader pointed out the close connections between
the thoughts and feelings of depression. The leader
helped the members to categorize their cognitions in terms
of the major themes and distortions involved. Methods

of challenging the validity of these thoughts (such as

separating "ideas from "facts" and checking out assump-
tions) were introduced, and alternatives to these mis-
conceptions were discussed. Homework involved the "double
column technique": Members wrote down their depressogenic
thoughts on the left side of a sheet of paper, and wrote
more realistic answers to these cognitions on the right

side.

Session 4. Homework was discussed and the objective

 

discussion of cognitions was encouraged. The leader

86
provided feedback about the members' attempts to correct
their depressive thoughts. In addition, members were
encouraged to discuss and become more aware of the non-
depressing situations and activities in which they were
successful or which they enjoyed. They also were asked to
record positive statements about themselves and to repeat
these positive thoughts in order to invalidate any negative,
depressive thoughts. If a member had trouble recording
positive statements about himself, the leader and other
group members reflected good points honestly seen in the
person and encouraged them to add to the list of positive
thoughts themselves as the workshop went on.

Session 5. Homework was discussed_and the leader

 

continued to teach members to evaluate the validity of their
cognitions. Once a cognition was established as invalid,
the member was taught to neutralize it by verbalizing the
reasons why the thought was erroneous, each and every time
it occurred. The leader guided the group members through
the logical steps of reasoning, and verbally modeled this
behavior. The group also examined alternative explanations
and ways of conceptualizing and solving problems, so that
members learned to consider alternatives to depressive
cognitions and then to evaluate each alternative. The
homework assignment was to be repeated again, and any
problems doing the homework were discussed.

Session 6. Homework was discussed and an attempt was

 

made to begin clarifying the assumptions and attitudes which

87
were behind the individual's cognitions. These assumptions
center on the members' views of their worlds, themselves
and their futures. These chronic attitudes were inferred
from.examining recurrent themes in members' cognitions
and the way they responded to different situations.
Further information was obtained by probing members about
their reasoning, values and beliefs in a safe, noncondemnatory
atmosphere. The leader worked to maintain this safe atmos-
phere within the group, and to ensure that other group
members did not interfere with the emotional behavior which
accompanied exploration of these core assumptions. The
homework assignment was continued.

Session 7. Homework was discussed and basic assump-

 

tions were examined in an objective manner. The same
strategies which were used to modify depressive cognitions
were then used to modify basic assumptions, but this was

a slower, more difficult process. It was stressed in

the session that these changes might not happen quickly,
but group members were encouraged to challenge these
assumptions and to examine alternatives often. They were
also asked to observe the positive consequences of these
attitude changes. The therapist actively helped the
members to explore their assumptions in a safe atmosphere,
without telling the clients how to run their lives and
taking responsibility away from them. For homework,
members were asked to record any changes which were taking

place in their attitudes.

88

Session 8. Homework was discussed and an attempt was

 

made to integrate assumptions and their effects. Future
plans of the members were discussed and the importance of
continuing to use the skills learned in this workshop
beyond the end of training was stressed. The members were
asked for feedback on the effectiveness of the training,
and feelings about termination were discussed. Referral
sources were identified for members who were interested in

further treatment.

Behavioral Workshop

 

Session 1. After the standard introduction, a brief

 

discussion and summary of the types of problems being
brought to the group took place. A specific rationale

for behavioral therapy was presented in colloquial language,
and members were taught a basic behavioral framework.
Emphasis was placed on how moods are a result of one's
behavior, and how rewards tend to increase the frequency of
the rewarded behavior and lack of rewards or punishment
tend to decrease the frequency of that behavior. The
importance of learning to control one's own behavior through
self-monitoring, self-evaluation and self-reward was
stressed. An overview of the entire treatment program was
presented.

Session 2. This session focused on a didactic pre-

 

sentation and discussion of the importance of accurate self-
monitoring. Positive activities were pinpointed as target

behaviors, and the importance of increasing the frequency

89
of positive activities was stressed. Members were given
a Positive Activities List as a guide in learning to dis-
criminate positive activities, but the variety of individual
differences was also discussed. The homework assignment
was for each group member to record a one-line description
of each of their day's positive activities. In addition,
they were asked to rate their mood on a 10-point scale
after each event was logged. Members were also given a
graph on which to record their daily average mood and total
number of positive activities. The assignment was dis-
cussed in detail and any questions were answered.

Session 3. A general check-in procedure was followed

 

at the beginning of this session and each subsequent
session. In this session, about 20 minutes were spent on
group discussion of the homework, and 10 to 15 minutes

were spent on each individual's log. Specific examples
from the homework were tied to the basic principles of
self-monitoring, and all appropriate uses of the homework
were reinforced verbally by the therapist. The guidelines
for successful self-monitoring were reviewed and discussed.
The assignment for the next session was for each member

to continue the previous assignment. In addition, they
were asked to choose a few classes of positive activities that
were especially significant or difficult to them and to
concentrate on increasing the frequency of those activities.
Strategies for increasing the rate of positive behaviors

were discussed.

90

Session 4. After a brief check-in period, the self-

 

evaluation phase began. The importance of setting
realistic and obtainable goals in evaluating oneself
accurately was stressed. To facilitate learning realistic
self-evaluation, members selected specific goals using
their logs to identify desirable but low-frequency classes
of behavior that they wanted to increase. They developed
specific behavioral criteria or sub-goals that were
discrete, attainable, overt and immediately discernable in
terms of their own behavior. The therapist gave examples
of goals and sub-goals, and the group discussed and made
suggestions about the goals and sub-goals of each indivi-
dual. The homework assignment was to plan and write about
three sub-goals for each class of behavior they had
committed themselves to work on (hierarchically arranged).
In addition to the usual monitoring and graphing, the
members were asked to record each engagement in a sub-
goal behavior and were encouraged to deliberately engage
in sub-goal behavior.

Session 5. After a long check-in period, members

 

were taught to judge their own ongoing behaviors by
comparing them to their own, pre-set sub-goals. A point
system made the sub-goals more explicit. From 1 to 5
points were assigned by the member to each sub-goal on
the basis of the subjective importance and/or difficulty
of the behavior. Ways of shaping particularly difficult

or important activities were described, and the guidelines

91
for successful self-evaluation were reviewed and dis-
cussed. For homework, members were asked to record
their point values of accomplished behaviors and to maxi-
mize their total number of points.

Session 6. In this session, the self-reinforcement

 

phase began. After the check-in period, members were
taught the general principles of reinforcement, and espe-
cially of self-reinforcement. Clients constructed
"reward menus” of highly pleasant and freely available
rewards, and were encouraged to start off with generously
low prices. The homework assignment was to continue

the self-monitoring and self-evaluation procedures, as
well as to self-administer rewards from the menu as points
were earned. The importance of following strict contin-
gencies of reinforcement was stressed.

Session 7. After a long check-in period, the guide-

 

lines for successful self-reinforcement were reviewed and
discussed. The group leader reinforced high self-evaluation,
increased positive behaviors, the following of self-
reinforcement schedules, and any self-reinforcing state-
ment made (such as statements of self-confidence, self-
esteem, etc.). The complete homework assignment of self-
monitoring, self-evaluation and self-reinforcement was
continued.

Session 8. This session started with a long check-in

 

period where an attempt was made to integrate the three

phases of the training program. Future plans of the

92
members were discussed, and the importance of continuing
to use the skills learned in this workshop beyond the end
of training was stressed. The clients were asked for
feedback on the effectiveness of training, and feelings
about termination were discussed. Referral sources were
identified for members who were interested in further

treatment .

Nondirective Workshop

 

The nondirective condition was not divided into session-
by-session outline, since in nondirective approaches the
same general procedures are followed throughout the
treatment program. Session 1 did include the standard
introduction. Then a specific rationale for nondirective
treatment was presented. From that point on, all the
sessions followed the same general format. Discussion
centered on depression, its manifestations and current
life events. The group leader attempted to provide the
three essential ingredients of nondirective therapy:
accurate empathy, unconditional positive regard, and
genuineness. Accurate empathy involved both the leader's
sensitivity to current feelings and the ability to com-
municate this understanding to the group members.
Genuineness involved responding in an authentic and sincere
manner. This does not mean that the leaders always dis-
closed their total self to the group, but that whatever
the leaders did reveal was a real aspect of themselves.

unconditional positive regard involved accepting the

93
members as people, separate from any evaluations of their
behavior or thoughts. At its highest level, this meant
nonpossessively caring for all the members as individuals
who are allowed to have their own feelings, experiences,
and behaviors.

Several specific techniques were used to facilitate
the nondirective workshop. The leader identified the
members' feelings as accurately and specifically as
possible and conveyed this understanding to the members.
In addition, the leader clarified the statements made by
group members by reflecting the feelings and paraphrasing
the content of the statements. Confrontation of discrep-
ancies was also used in the workshop. Confrontation is
defined as "the halting of any on-going interaction for the
purpose of assessing its intentions, consequences, or
possible alternatives" (Kantrowitz, Note 10, p. 40).
Confrontations may be initiated through feedback to the
members about how their behavior is effecting the leader,
self-disclosure by the leader, or by direct questioning.
These basic techniques were used throughout all workshop
sessions. The leader did not attempt to structure the
content of the sessions nor provide a specific conceptual-
ization of the central factors involved in maintaining
depression. In addition, the leader did not offer
suggestions or coping strategies to the members, but
attempted to facilitate their autonomy, trusting that
the members would find their own resources for ultimately

finding and carrying out a solution to their problems.

94

The goal of nondirective group treatment is to
achieve "group treatment" and not just individual treat-
ment within the group. The members themselves took on
some of the role of the leader. To encourage this, the
leader delayed slightly before responding to a member in
the hopes that some other group member would respond in
a manner that facilitated further self-exploration. If,
however, some important feeling went unrecognized or if
group members denied the feelings of a member, the leader
stepped in to maintain a dependable atmosphere of
acceptance and understanding within the group.

In the final session, the members were asked for
feedback on the effectiveness of the workshop, and their
feelings about termination were discussed. Referral
sources were identified for members who were interested in

further treatment.

RESULTS

Of the 40 subjects who originally qualified and were
admitted to the study, 5 did not complete the study. Two
subjects (one in the cognitive and one in the behavioral
self-control condition) dropped out after one workshop
session, one subject (in the nondirective condition)
dropped out after the second workshop session, one subject
(in the cognitive condition) dropped out after three sessions
and one subject (in the nondirective condition) attended
only the first, second and sixth sessions. The dropout
rate did not differ significantly among experimental
conditions x2(2) = .694. T-tests were used to compare
this group of drop-outs to the group of subjects who
completed the workshOps. These tests indicate that the
non-completers did not differ significantly from the
completers on demographic characteristics or pre-test
scores. Therefore, all the following analyses and dis-
cussions are based on the data from the 35 subjects who
completed the study.

The final subject population included 13 subjects in
the cognitive condition (seen in groups of 7 and 6),

13 subjects in the behavioral self-control condition
(seen in groups of 7 and 6), and 9 subjects in the non-

directive condition (seen in groups of 5 and 4). This

95

96
sample includes 27 females and 8 males, with ages ranging
from 19 to 68 years. The demographic characteristics
of the subjects are summarized in Table 1.

Scores on the pre-test measures are presented in
Table 2. For the Verbal Behavioral Measure, only the
measures of Overall Depression and Rate of Negative
Self-References are included in the analysis. So few
references were made to others during the taping of this
measure, that it was decided to eliminate Rate of Negative
Other-References from the analysis. Two undergraduate
raters (who were blind to conditions) independently
rated each of the tape-recorded speeches in random order.
Ratings were made of Overall Depression (on a S-point
scale), number of positive self-references and number of
negative self-references. Inter-rater reliability,
calculated using Pearson correlations, was .725 for the
Overall Depression Rating, .88 for number of positive
self-references, and .92 for negative self-references.
The ratings for the two raters were averaged, and the
Negative Self-Reference rate was calculated as the number
of negative self—references divided by the sum of both
positive and negative self-references.

One-way analyses of variance were performed on all
the pre-test data to verify that the conditions were
actually equated by the random assignment procedure. For
all of the variables except one, there were no significant

differences among conditions. There were, however,

97
Table 1

Demographic Characteristics of Subjects

 

 

 

 

 

 

 

 

Behavioral
Cognitive Self-control Nondirective
Condition Condition Condition
Variable (N = 13) (N = 13) (N = 9)
Sex
_—Female 8 10 ' 9
Male 5 3 0
Mean Age in Years 40.7 38.7 34.3
Highest Level of
Education Completed
High School
graduate 3 4 2
Some additional
education 4 3 2
B.A., 3.8. 2 6 3
Education beyond
B.A., 3.8. 4 O 2
Occupation
Professional and
Semi-professional 5 4 4
Clerical, Sales
Skilled Workers 3 5 l
Homemakers 2 3 2
Student 0 l 2
Retired or
Unemployed 3 O 0
Ethnic Group
Caucasian 12 12 8
Black 0 O 1
Hispanic 1 l 0
Marital Status
Never Married 3 2 2
Married 7 5 3
Divorced, Separated
Widowed 2 6 4
Remarried l 0 0
Previous Therapy
Yes 9 10 4
None 4 3 S

98

Table 2

Pre-Assessment Scores of Subjects

According to Groups

 

 

 

 

 

 

 

 

 

 

Cognitive Behavioral Nondirective Signifi-
Condition Condition Condition F cance of

Measure (N = 13) (N = 13) (N = Ratio

Beck Depression Inventory
Mean 23.46 24.15 26.44 .74 .48
S.D. 6.60 5.32 5.08

D-30 Scale
Mean 19.77 20.77 22.22 1.37 .27
S.D. 3.56 2.98 3.80

Dysfunctional Attitude Scale
Mean 129.85 150.85 183.22 5.95 .006*
S.D. 31.58 40.39 33.95

Irrational Beliefs Test
Mean 311.54 325.77 332.22 1.90 .16
S.D. 26.87 27.65 21.09

Pleasant Events Schedule - Question A
Mean 102.31 102.92 98.00 .40 .67
S.D. 14.16 13.08 12.81

Pleasant Events Schedule - Question B
Mean 109.61 120.85 117.77 1.59 .22
S.D. 19.54 15.60 12.11

Verbal Behavioral Measure - Negative Self-Reference Rate
Mean .63 69 .68 .41 .67
S.D. .15 20 .18

Verbal Behavioral Measure - Overall Depression
Mean 4.00 4.15 3.87 .26 .77
S.D. .84 90 .92

Cognitive Complexity
Mean 3.69 3.54 3.55
S.D. .85 1.27 .88 .08 .92

*Statistically significant

99
significant differences among conditions on the Dysfunc-
tional Attitude Scale (DAS), {(2,32) = 5.95, p = .006.
T-test comparisons show that at pre-test, subjects in the
nondirective condition scored significantly higher on the
DAS than subjects in the cognitive condition, 5(20) =
-3.78, E = .001.

One-way analyses of variance were also performed for
the individual group data to determine whether the data
for both groups within each condition could be pooled for
the analysis. The analysis of variance for group data
was consistent with the analyses for data by conditions,
with the only significant difference among groups being
on the DAS, {(5,29) = 2.76, p = .037. Thus, for all the
remaining analyses, the data for the 2 groups within each
treatment condition has been pooled.

The major analysis of this study was a 3 x 3
(treatment x time) analysis of variance for repeated
measures with a nested design (subjects nested within
treatments). This analysis was designed to analyze the
differences among the experimental groups as well as to
analyze the differences among the three testing periods
(pre-test, post-test and 6 week follow-up). In addition
to these comparisons, a comparison was planned between
the average of the means of the two more structured
treatment conditions (the cognitive and the behavioral
self-control conditions) and the mean for the unstructured

nondirective condition to test for a general effect of an

100

active, structured treatment program for depression.
Finally, a 3 x 2 (treatment x cognitive complexity level)
analysis of variance was used to determine whether cog-
nitive complexity level influenced the effectiveness of
the three treatment conditions.

To simplify the presentation of the data, the tables
will include data pertinent only to main effects. Inter-
actions between factors will be discussed separately when

they are significant.

Treatment Effects

 

The data concerning the effect of treatment condition
upon the various measures of depression are presented
in Table 3. The analysis of variance showed that, with
data for all three testing times combined, there was a
significant treatment effect for the DAS, {(2.32) =
3.58, p|= .04. It has previously been noted, however,
that the DAS was the one measure on which the treatment
conditions had not been equated by the randomization
process. A priori contrasts (Tables 4 & 5) do, in fact,
indicate that none of the comparisons at post-test or
follow-up show significant differences among the treat-
ment conditions. Thus, it does seem that the significant
treatment effect on DAS is accounted for by the pre-test
differences, and not by any differential treatment

effects after the workshops started.

101

 

 

 

 

 

 

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103

Two of the behavioral measures, the VBM Negative Self-
Reference Rate and the VBM Overall Depression Rating, show
significant differences among treatment conditions at post-
testing, {(2,31) = 4.554, p,= .0185, and F(2,31) = 3.81,

p = .0332, respectively. Planned comparisons (Tables 4 and
5) indicate that at post-test subjects in the behavioral
self-control condition had significantly lower Negative
Self-Reference Rates than subjects in either the nondirec-
tive or the cognitive conditions. Also, the comparison
between the two more structured conditions combined and the
unstructured nondirective condition shows that, directly
after the workshop ended, subjects in the structured
conditions as a whole had significantly lower Negative
Self-Reference Rates than subjects in the nondirective
condition, E(31) = -2.115, p_= .043. These differences
were not maintained at follow-up, as shown in Table 5.

At post-testing, the VBM Overall Depression Rating was
significantly lower for the behavioral condition than for the
nondirective condition, 5(31) = 2.747, p.= .010. Also,
when combined, the subjects in both structured conditions
showed significantly lower Overall Depression Ratings than
the nondirective condition, 2(31) = -2.3l6, p.= .027.

Here again, however, neither of these differences was
maintained at the 6-week follow-up period.

Although none of the other measures of depression
showed differences among the treatment conditions that
were significant at the .05 alpha level, there were some

strong trends that are worth mentioning here. At

104

 

 

 

 

 

 

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106

 

 

 

 

 

 

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< cowumond n madwonom muco>m uammmmam
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ooo. Rm ooo.- HmHoH>mnmm-m>HHHawoo
mom. No omo.H m>HHumuHocoz-HmuoH>onmm
«RH. Rm Hoo.H- m>HuomHHoaoz-m>HoHsmoo
umoH mmofiaom HocowumuHH
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Hoo. Rm «Ho.- HmuoH>momo-m>HHHawoo
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oHo. No Roo.- m>HuumHHocoz-m>Huchoo
mHoom om-o
moo. mm oNH.- m>HuomHHoaoz-RHmu0H>mnmm + m>HHchooo
moo. Rm HRH. HmHoH>momm-m>HuHamou
coo. Rm HmH. m>HuomuHoaoz-HmuoH>mnmm
HRm. Rm Rmo.- m>HuomHHoaoz-m>HuHawoo
zp0uao>aH zoommoumoa moon
huwawnmnOHm Eooooum mo osHm>nH whammoz
Hamuum moouwoa

anuzoaaom um maofluflocou quSuoouH

m wanna

waoa< mummuucoo Huoflum <

107

oNo. Rm omo. m>HHumHHocoz-RHmHoH>mnmm + m>Hochooo

 

 

 

 

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ooo. mm ooo.- m>HuomHHocoz-HmH0H>momo
amo. No MRo. m>moomHHoaoz-m>HuHawoo
cowmmoumoa Hamno>o u ousmooz Hmuow>m£om amnuo>
aom. Rm mmo.- m>HHomHHoaoz-RHmHoH>msmm + m>HuHawooo
oHa. Rm moH.- HmHoH>momm-m>HuHawoo
mom. No oHo.- m>HHomuHocoz HmHoH>mnmm
mom. Rm omo.- m>HuomHHoaoz-m>HuHcmoo
oumm oocouomom mamm o>flumwoz u whammoz Hmuow>m£om Hmnhm>
«om. Rm ooH. m>HuomHHoaoz-RHouoH>momm + m>HuHawooo
oOH. No ooo.H- HmHoH>momm-m>Huchoo
com. Rm mwm.- m>HuomHHocoz-HmHoH>mnmm
ooo. Rm oRo.- m>HoomHHocoz-m>Huchoo
m cowumond n oasoofiom muco>m odomomam
Nowawnmnoum Bowooum mo oDHo>IH whammoz
meunm moouwoo

R.ucooo o mHome

108

post-testing, subjects in the behavioral condition show
less depression than subjects in the nondirective con-
dition as measured by the BDI (p = .071), the D-30 Scale
(3 = .062), and the PES-Question A (p = .065). In
addition, subjects in the cognitive condition have lower
scores at post-test on the DAS than those in the non-
directive condition (2 = .085). These differences tend
towards significance. At follow-up, however, none of these
differences are maintained.

Analyses of group data can often be misleading, and
discussions of statistical significance which pertain
only to the consistency of between-group differences may
have little or no bearing on the issue of clinical
relevance. In addition to the above analyses, therefore,
it would seem appropriate to compare the numbers of sub-
jects in the various conditions who scored in the non-
depressed range of the BDI (less than 11 according to Beck,
1972) at post-test as compared to pre-test. Before the
beginning of the workshops, all subjects scored in the
clinically depressed range of the BDI (greater than 17).
At post-test, however, 61% of the subjects in the behavioral
condition, 54% of the subjects in the cognitive condition,
and 22% of the subjects in the nondirective condition had
moved into the nondepressed range of the BDI. Fisher's
exact probability test of change from pre-test to post-
test showed that this change in the number of nondepressed

subjects was highly significant for the behavioral condition

109
(p = .0008) and for the cognitive condition (p.= .0002),
but not significant for the nondirective condition
(2 = .23). This same pattern was maintained at follow-up,
with significant pre-test to follow-up changes being shown
by the behavioral condition (2 = .0002) and the cognitive
condition (2 = .020) but not for the nondirective condition

(p = .10).

Time Effects

 

There were strongly significant time effects across
all three conditions on most of the measures of depression
(Table 6). In fact, the only measure of depression that
did ng£_show a highly significant time effect was Question B
of the Pleasant Events Schedule. Thus, on these general,
cognitive, and behavioral measures of depression there
were significant differences among scores at the pre-test,
post-test and follow-up periods. Planned t-test comparisons
(summarized in Table 7) show that, for all three treatment
conditions combined, subjects had significantly lower
depression scores after taking part in the depression
workshops than they had shown before the workshop. These
measures also showed significantly lower depression scores
at follow-up than at the pre-test, substantiating that
these lower depression scores were maintained at follow-up.
There were no significant differences between any of the
depression scores at post-test and follow-up periods.

No significant interactions were found between the

treatment and time factors.

110

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rmooo. qm.~m oo.m om.~ HN.¢ cooz
scammmumoa HHmuo>o u oHSmmoz Hmuow>m£om Hmnuo>

mm. om. mRH. .n.m

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oumm monouomom maom o>wumwoz u onsmmoz Honow>o£om Hmnum>

m¢.wa wm.om mn.oa .n.m

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m aowumoso n oasmonom muao>m ucmmmoam

mm.oH mm.ma ma.ma .n.m

«mooo. Hw.oH m¢.NHH mN.NHH NNHHOH coo:
< cowumoso n oHDooSUm muco>m ucmmmoam

wo.mm NH.om «m.o~ .n.m

smooo. m¢.RH «n.0mm o¢.qmm «H.~Nm coo:
umoH mmoflaom HmaoflumHHH

ma.um mm.om on.o¢ .Q.m

smooo. mm.NH Rm.omH ¢H.RNH Rm.HmH coo:
mamom ovsufluu< HmsoauUCDMmma

o~.o om.o oq.m .n.m

kmooo. RH.om mo.¢H mw.mH RR.ON amoz
oamom omun

ow.m om.w ¢R.m .Q.m

smooo. Hm.No Rm.HH «m.HH m¢.¢m coo:
NHOHao>cH coflmmoumon xoom
m mo ofiumm NUIBoHHom umouuumom umouuoum whammoz

mocmowmwcwflm m

UGCfiQEOU mCOHUHUGOU UCQEUQMHH HHm .HOM .HOUUmh QEHH. MO muomwwm SHNZ

o oHan

111
Table 7
Planned Comparisons of Depression Scores at the

Three Testing Periods for all Treatment
Conditions Combined

 

 

 

 

 

 

 

 

Degree 2-tai1

Measure T-value of Freedom Probability
Beck Depression Inventory

Pre-Post 10.08 34 .001*

Pre-Follow-up 9.48 34 .001*

Post-Follow-up .12 34 .903
D-30 Scale

Pre-Post 6.20 34 .001*

Pre-Follow-up 6.54 34 .001*

Post-Follow-up -.17 34 .868
Dysfunctional Attitude Scale

Pre-Post 44.12 34 .001*

Pre-Follow-up 3.37 34 .002*

Post-Follow-up -.92 34 .364
Irrational Beliefs Test

Pre-Post 44.69 34 .001*

Pre-Follow—up 4.36 34 .001*

Post-Follow-up -.68 34 .500
Pleasant Events Schedule - Question A

Pre-Post -45517 34 .001*

Pre-Follow-up -4.37 34 .001*

Post-Follow-up -.17 34 .868
Verbal Behavioral Measure - Negative Self Reference Rate

Pre-Post i10l04 32 .00i*

Pre-Follow-up 6.51 33 .001*

Post-Follow-up -1.20 33 .238
Verbal Behavioral Measure - Overall Depression

Pre-Post 9.36 32 .001*

Pre-Follow-up 6.61 33 .001*

Post-Follow-up -.77 33 .448

*Statistically significant

112

Cognitive Complexity Effects

 

Subjects were divided into two groups according to their
scores on the Cognitive Complexity Scale: subjects with
complexity scores less than or equal to 3 were considered
to be in the Low Complexity group and subjects with
scores greater than or equal to 4 were placed in the High
Complexity groups. A 3 x 2 (Treatment by Cognitive
Complexity level) analysis of variance was conducted to
determine whether level of cognitive complexity, as
measured by this Cognitive Complexity Scale, influenced
the effectiveness of the three treatment conditions. The
data concerning effects of cognitive complexity are
summarized in Table 8.

A significant complexity effect was found on the DAS,
{(1,29) = 4.05, p = .054. Planned t-test comparisons show
that at post-testing, subjects with high levels of cognitive
complexity have significantly higher DAS scores than
subjects with lower levels of cognitive complexity,

5(33) = -2.09, p = .044. There are also trends in a similar
direction at pre-test, £(33) = -l.79, p = .082, and at
follow-up, £(33) = -1.81, p = .080.

Of particular interest were any interactions between
cognitive complexity level and treatment«conditions, since
such interactions would indicate that cognitive complexity
differentially influenced the effectiveness of the three
treatment conditions. There were no significant interac-

tions between complexity level and workshOp condition on

113

mQHOUm Emma 0U .Hmwmh mCEDHOU mmmfiu CH mNHHUCmm

 

omo. oNR. Ro.m o~.m :onmmHama HHmHm>o
u whammoz Hmpow>mnom Hmnno>
RHo. ooo. HoHo. oRNo. moms mocmumomm onm m>HHmwoz
u ouamwmz Houow>mnom Hmnuo>
oHN. Hoo.H RR.mHH oo.HNH m coHummso
u manomzom muco>m ucmmmmam
mom. Nmm.H oo.oOH mo.OHH < coHummso
a oasoonom muco>m ucmmooam
Rom. ooo.H oo.HHm oo.mm~ Home mmmHHmm HchHumuuH
ooo. Hoo.o mH.ooH mN.o~H mHmum monuHuu< HchHooasomRa
moo. moo. Ha.oH mo.oH QHmoo om-a
Rmo. RNN. oo.oH oo.oH Ruoocm>cH cOHmmmuama Homo
m oHHmm RoH u zo HRH u zv mummmmz
mo mocmo m mxuwxoaaaoo mmuwonmEou
-HoHame m>Huchoo m>HHHawoo
anm 30H

conwnsou mSOHuHUcoo uCoEumeH Ham How Ho>oq mowonQEoo o>fluacwou mo muoommm Cam:

w maan

114
any of the measures of depression. There was, however,
such a significant interaction for ratings on the post-test
question of "would you recommend this type of workshop
for a close friend with depression?" {(2,22) = 4.78,
p = .019. When comparisons were made for each condition
separately, it was found that this difference resulted from
the fact that in the nondirective condition, subjects
with high levels of cognitive complexity rated their
workshop significantly more positively than subjects with

low levels of complexity, 2(7) = -4.08, p = .005.

Additional Analyses

 

One way analysis of variance was used to test for
differences among treatment conditions on subject's post-
test and follow-up ratings of the workshop and their group
leader. Questions were rated on a 7-point scale, with 7
being the most positive answer possible. These results
are presented in Table 9 and Table 10. Significant dif-
ferences were found between treatments on each of the
following questions:

At post-test -

1) To what degree has this workshop been helpful to

you in coping with depression?

2) To what degree has this workshop been helpful to

you in other areas, besides depression?

3) To what degree has your depression been reduced

as a result of this workshop?

115

Table 9

Differences Among Treatment Conditions on
Answers to Post-test Questionnaire

Cognitive Behavioral Nondirective
Condition Condition Condition F Signifi-
Question (N = 13) (N = 13), (N = 9) Ratio cance of F

1) To what degree has this workshop been helpful to you
in coping with depression?

5.00 6.20 3.83 4.48 .022*

2) To what degree has this workshop been helpful to you in
other areas, besides depression?

4.42 6.30 4.67 4.09 .029*

3) To what degree has your depression been reduced as a
result of this workshop?

4.25 5.80 3.83 3.57 .043*

4) To what degree do you feel better able to c0pe with
future depressions as a result of this workshop?

4.83 6.00 4.33 2.72 .085
5) Was this type of workshop appropriate for you?

5.17 6.20 4.33 2.26 .126

6) Would you recommend this type of workshop to a close friend
with depression?

5.75 6.80 5.33 3.92 .033*
7) How likable did you find your group leader?

6.42 6.30 5.83 .80 .460
8) How competent did you find your group leader?

5.75 5.90 4.17 2.54 .099
9) Do you plan to seek further treatment for depression?

3.5 3.7 3.67 .039 .962

116

Table 9 (cont.)

Cognitive Behavioral Nondirectixe
Condition Condition Condition F Signifi-
Question (N = l3)i (N = 13) (N = 9) Ratio cance of F

 

10) Do you plan to seek further treatment in areas other
than depression?

3.92 3.10 3.83 .713 .500

aEntries in these columns refer to the mean rating on a
7-point scale, with 7 being the most positive possible
response.

*Statistically significant.

117

Table 10

Differences Among Treatment Conditions on
Answers to Follow-up Questionnaire

Cognitive Behavioral Nondirectiye
Condition Condition Condition F Signifi-
Question (N = 13) (N = 13) (N = 9) Ratio cance of F

 

1) To what degree has this workshop been helpful to you
in coping with depression?

4.67 6.00 4.00 2.03 .152

2) To what degree has this workshop been helpful to you
in other areas, besides depression?

3.92 6.30 3.83 7.10 .003*

3) To what degree has your depression been reduced as a
result of this workshop?

4.33 5.20 4.0 .822 .451

4) To what degree do you feel better able to cope with
future depressions as a result of this workshop?

4.58 5.50 4.0 1.30 .290

3Entries in these columns refer to the mean rating on a
7-point scale, with 7 being the most positive possible
response.

*Statistically significant.

118
4) Would you recommend this workshop to a close
friend with depression?
At follow-up -
1) To what degree has this workshop been helpful
to you, in other areas, besides depression?
T-test comparisons (summarized in Table 11) show that for
each of these questions, subjects in the behavioral self-
control condition answered significantly more positively
than subjects in either the cognitive or the nondirective
conditions.

A procedure suggested by Shaw (1977) was used to
evaluate whether the treatment protocols had been adhered
to and the treatment conditions could be discriminated
from each other. Three lO-minute sections were selected
from the tapes of each treatment session at random. Two
undergraduate raters were trained to identify the crucial
components of each type of workshop and then independently
rated these sections of the tapes in random order, trying
to determine which type of program was being conducted.
These raters showed 100% agreement on their ratings. The
chi-square test showed that a significantly greater
number of sessions were correctly identified than would

be expected by chance, x2(l) = 106.87, p < .001.

119

Table 11

Comparisons Among Treatment Conditions for

Post-test and Follow-up Questions that showed

Significant Differences

 

 

2-tail
Question T-value Df Probability
Post-test
1) To what degree has this workshop been helpful to you

in coping with depression?

Cognitive-Nondirective 1.26 20 a .222
Behavioral-Nondirective -3.55 11.278 .005*
Cognitive-Behavioral -2.30 18.18 .034*

 

2) To what degree has this workshop been helpful to you
in other areas, besides depression?
Cognitive-Nondirective -.18 20 .856
Behavioral-Nondirective -3.33 20 .003*
Cognitive-Behavioral -3.30 18.648 .004*

3) To what degree has your depression been reduced as a
result of this workshop?

Cognitive—Nondirective .36 20 .720
Behavioral-Nondirective -3.25 20 .004*
Cognitive-Behavioral -2.42 24 .023*

4) Would you recommend this workshop to a close friend

with depression?
Cognitive—Nondirective .52 20 .608
Behavioral-Nondirective ~3.06 10.96: .011*
Cognitive-Behavioral -2.75 17.65 .013*
Follow-up
1) To what degree has this workshop been helpful to you

in other areas, besides depression?

Cognitive-Nondirective -.53 20 .600
Behavioral-Nondirective -2.39 19 .027*
Cognitive-Behavioral -3.25 23 .003*

aSeparate variance estimates were necessitated rather than
pooled variance estimates, since the Bartlett test showed
that the variances were not homogenous.

*Statistically significant.

DISCUSSION

This study was designed to compare three different
types of short-term treatment for depression and to examine
how the subject variable of cognitive complexity might be
related to the effectiveness of each of these workshops.
After participation in either the cognitive, behavioral
or nondirective workshop, subjects in this study showed a
significant decrease in depressive symptomatology, as
measured by general, cognitive, and behavioral measures of
depression. This decrease in reported depression was
consistently maintained at the end of a six-week follow-
up period.

While all three depression control workshops led to a
decrease in depression, most of the specific hypotheses of
this study were not confirmed. No significant differences
were found between the cognitive and the nondirective
conditions on any of the measures of depression, so even
though changes in the number of subjects in the nondepressed
range on the BDI were significant for the cognitive con-
dition and not for the nondirective condition, Prediction 1
was not supported in this study.

Prediction 2 was given only mild support by this study.
Rather than showing a greater reduction on all the measures

of depression, the behavioral condition showed greater

120

121
improvement than either the nondirective or cognitive
conditions on only one of the depression measures. 0n the
Verbal Behavioral Measure, the one measure that did not
rely solely on self-report, subjects in the behavioral
condition did make significantly fewer negative self-references
and sounded signficantly less depressed on a tape-recording
at post-test than subjects in the other two conditions.
None of the other measures of depression showed differences
among the treatment groups that are statistically signifi-
cant, although changes in the number of subjects in the
non-depressed range on the BDI were highly significant for
the behavioral condition but not for the nondirective condi-
tion. In addition, subjects rated their behavioral workshop
significantly more positively than subjects in either the
cognitive or the nondirective workshops.

Concerning the specifically cognitive and behavioral
measures of depression, only part of Prediction 4 was
supported. Subjects in the behavioral condition did improve
significantly more than those in the cognitive condition
on one behavioral measure, but subjects in the cognitive
condition did not improve significantly more on any of the
cognitive measures of depression than those in the behav-
ioral condition.

The results of this study showed substantially
weaker treatment differences than the previous studies of
cognitive and behavioral self-control therapy which were

discussed earlier. In exploring some of the variables which

122
might account for these differences, comparisons will be
drawn between this study and the other studies which have
used similar treatment models, including research done by
Beck et a1. (1977), Fuchs and Rehm (1977), Shaw (1977) and
Taylor and Marshall (1977).

Whenever one is comparing treatments based on models
designed by other researchers, one major issue to explore
in drawing conclusions is how representative the treat-
ments were of the original treatment models. One impor-
tant factor that relates to this issue is the lack of
clinical experience of the group leaders in this study.
Using relatively inexperienced group leaders, this study
constituted a rather stringent test of the hypotheses,
and it could be argued that the treatments were not given
a fair chance since the group leaders were not experienced
enough to follow the models to their full advantage.
Although all the other studies listed above also used
graduate student therapists, the group leaders used in this
study were only in their first year of clinical training
and had not previously had any formal, supervised clinical
experience. This factor could have been crucial in
weakening the differences among experimental conditions.
The relative lack of experience of the leaders, however, .w’
makes it especially impressive that subjects in all three
conditions did show significant reductions in depression.

Having had raters listen to random sections of the

workshop tapes and judge which type of group was being

123
conducted does at least serve as a check that the workshops
were recognizably different and followed the basic format
intended for each condition. The behavioral approach used
was not intended to represent behavioral treatments of
depression as a whole, but was specifically designed to
follow the self-control program developed by Rehm and his
colleagues (Fuchs and Rehm, 1977; Rehm et al., Notes 4 and
5). The cognitive workshops conducted were not expected to
represent each of the three different types of cognitive
therapy discussed above, but were modeled after Beck's
particular approach to cognitive therapy, as outlined by
Shaw (1977). One factor of possible importance is that
the behavioral self-control program had originally been
designed to be conducted in groups, while Beck's cognitive
therapy program was designed to be used with individual
clients. In this study, where all the workshops were
conducted in groups, the behavioral self-control condition
seemed to be somewhat more successful in reducing depres-
sion than the cognitive condition. While some studies have
tested Beck's approaches with groups (Shaw, 1977; Taylor
and Marshall, 1977), it is notable that those studies have
used only undergraduate student populations. The studies
done on clinical populations by Beck and his colleagues
(1977) have used an individual approach. Thus, it may well
be that, with an older, non-student population such as used
in this study, Beck's cognitive approach is more effective

when conducted individually than in groups.

124

Another variable that could have been related to the
lack of consistent differences among the treatment condi-
tions in this study is the difference between the "placebo"
condition of this study and the previous studies. The
only other studies which have examined similar treatment
models which included some type of attention control
condition were the studies by Shaw (1977) and by Fuchs and
Rehm (1977). In both of these previous studies, bias
due to the therapists' knowledge of the hypotheses of the
study could have effected the results. Shaw (1977)
conducted all of the groups himself, so he was clearly
not blind to the hypotheses of his study. The two thera-
pists in Fuchs and Rehm's study (1977) were presented with
readings and a detailed manual for the self-control
condition, but no equivalent formal preparation for the
nonspecific condition, so it was most likely clear to them
which condition was expected to lead to greater improvement.
Even when an earnest attempt is made to minimize experimenter
bias and lead each group with equal enthusiasm, one's
expectancies that one group will be more effective than the
other are likely to have some effect on how the group is
conducted.

In the present study, the group leaders remained
blind to the specific hypotheses of the study throughout
the workshop period. The study was presented to the leaders
as research into the subject variables affecting how much

clients benefited from each of the workshops, rather than

125
a comparison of the effectiveness of the three different
types of workshop. The expectancy was set that all three
workshop conditions would be effective, but that certain
types of clients might benefit more from one workshop than
another. Given that subject variables were actually a
major facet of this study and that the principal investiga-
tor was known to use components of all three conditions in
her own clinical work, it seemed quite plausible that all
three conditions would be expected to succeed. Thus, each
condition was treated equally seriously as a treatment
group, with a treatment manual, readings, and equal amounts
of training and supervision. Some experimenter bias was
still possible since the principal investigator supervised
all the group leaders herself, yet she too was more
focused on the subject variables and did expect all condi—
tions to show significant reduction of depression.

This careful attempt to minimize bias against the
nondirective condition may have resulted in a more effec-
tive nondirective condition than most attention control
groups. When the results for the nondirective conditions
are compared across studies, it does seem possible that this
is part of what accounts for the different treatment effects
between the current study and the Shaw (1977) study, since
the nondirective condition in this study did show a greater
rate of improvement than the similar condition in Shaw's
study. This cannot account completely for the lack of

strong treatment differences in this study, however, since

126
the nonspecific group in the study by Fuchs and Rehm (1977)
did show improvements similar to the nonspecific group in
this study, yet their self-control condition still showed
significantly greater reductions in depression.

Although multiple group leaders were included in this
study to minimize experimenter bias, having only two group
leaders in each condition meant that there were not enough
leaders to insure that specific leader variables were
randomized across conditions. In fact, the limited supply
of available group leaders and the attempt to assign leaders
to groups that they preferred and could lead with enthu-
siasm led to the sex of group leaders not being balanced
across conditions. Leaders for both cognitive groups were
female, while all the leaders in the other conditions were
male. In addition, the sizes of the groups were different
across conditions, with the nondirective groups containing
4 to 5 members while groups in the other two conditions had
6 to 7 members. Thus, the groups differed on several
dimensions and it remains unclear as to how these differ-
ences might have affected the results. Ideally, future
research in this area would use a large sample of group
leaders, equal numbers of members in each group, and a
balance of sexes of both members and group leaders across
conditions so that the groups and conditions would be more
clearly comparable.

As with any research, the generalizability of the
findings in this study is limited by the specific character-

istics of the subjects. Although this study did not use

127
the undergraduate subject population so typical of
psychological studies, the use of advertising in the mass
media to recruit subjects (as also used by Fuchs and Rehm,
1977) differentiates this study from those using true
clinical populations. The scores of subjects on the
screening measures and data from the interviews do indicate
that these subjects showed moderate levels of depression
and would be appropriate clients at an outpatient clinical
setting. In fact, 23 of the 35 subjects had been involved
in outpatient therapy within the past few years, a fact
supporting the similarity between these subjects and an
outpatient clinical population.

The specific criteria for selection to this study also
limits the generalizability of these findings. The subjects
in this study showed moderate levels of depression compar—
able to the other studies done in this area, but none of
the subjects had obviously psychotic symptoms, serious
intent to commit suicide, or depressions associated with
schizophrenia, organic brain disorder, alcoholism or drug
addictions. One subject variable distinguishing subjects
in this study from those in previous studies testing similar
models of treatment is that subjects in this study tended
to be older, with a mean age of 38 years. It could be that
older depressed clients are somewhat less amenable to
change through short-term structured workshops than younger
clients with similar levels of depression, and that this

was related to the weaker treatment effects in this study.

128

Another issue worth consideration in any treatment
outcome research is whether the outcome measures adequately
measure improvement in the phenomenon under investigation.
This study, as well as most outcome studies examining
treatments for depression, relies heavily on self-report
measures of depression. Good, reliable behavioral measures
of depression have not yet been developed but are badly
needed to supplement the data from self-report measures.
It is noteworthy that the one behavioral measure in this
study, the Verbal Behavioral Measure (VBM), proved to be
the only measure that was sensitive to differences among
the treatment conditions. The VBM did not show patterns
that were radically different from those of the self-report
measures, but these patterns of differences among treatment
conditions were more strongly and clearly exemplified by
this behavioral measure than by the self-report measures.
The VBM is based on the behavioral measure used by Rehm
and his colleagues in their research (Fuchs and Rehm,
1977; Rehm et al., Notes 4 and 5) and both these measures
are new enough that their psychometric properties have
not yet been thoroughly investigated. The sensitivity of
the VBM to the treatment effects in this study does
indicate some promise for this measure, so further
research to examine its psychometric characteristics seems
to clearly be in order.

The results of this study with regard to cognitive

complexity do not confirm Prediction 3. In fact, contrary

129
to expectation, subjects with high levels of cognitive
complexity scored higher on the Dysfunctional Attitude
Scale (DAS) than subjects with low cognitive complexity,
especially at the time of the post-testing. Subjects
at both levels of complexity showed significantly reduced
DAS scores from pre-test to post-test, but subjects with
high cognitive complexity had started with higher DAS
scores and maintained the difference across the three time
periods. The variable of cognitive complexity has not been
previously investigated in relation to depression, but
these data suggest that there may be a complex relationship
between cognitive complexity and depression. For example,
one hypothesis that might explain this data is that when
people who are high in cognitive complexity become depressed,
they manifest the cognitive component of depression most
strongly, giving them more pronounced dysfunctional
attitudes than people with low cognitive complexity, who
may manifest depression somewhat differently.

Besides the possibility of a complex relationship
between depression and cognitive complexity, deficiencies
in the concept or measurement of cognitive complexity
itself could be responsible for the disappointing results
of this aspect of the study. The definition and measures
of cognitive complexity are still the subject of so much
controversy among researchers that it could be argued that
cognitive complexity is related to the success of indivi-

duals in different types of short-term workshops, but

130

simply not as defined or measured in this study. More
cooperation among researchers in this area, empirical
findings comparing and contrasting various measures and
definitions of cognitive complexity, and further research
to clarify the relationship between cognitive complexity
and depression will all be needed before the variable of
cognitive complexity is likely to be a useful predictor of
the effectiveness of different treatments for depression.

At the end of the relatively brief 6-week period,
the few significant differences among treatment conditions
which had existed at post-test were no longer present,
and there was no significant improvement on any of the
depression measures from the post-test to the follow-up
period. Therefore, Prediction 5 was not confirmed in this
study. This finding is consistent with the results of
previous studies in this area, which suggests that the
treatment approaches being compared may show no real
differences which last over even brief periods of time.
In particular, the two other studies that included non-
specific control groups (Shaw, 1977 and Fuchs and Rehm,
1977) found that many of the significant differences between
conditions at post-test became only non-significant trends
at the end of brief follow-up periods. It is important to
note that it is the differences between the treatment
conditions that show a tendency to disappear over brief
periods of time, not the overall reductions of the

subjects' depression.

131

What is especially striking in this study is that,
despite the lack of experience of the group leaders,
subjects in all the conditions improved markedly in their
depressive symptomatology, and these improvements were
consistently maintained after a 6-week follow-up period.
A waiting list control group was not included in this study
due to the practical and ethical problems involved in
deliberately withholding assistance from a group of
depressed people. Without this type of control group,
it could be argued that the depression was simply following
its natural course and that none of the workshops had
anything to do with the high rate of symptomatic improve-
ment. To conclusively answer this argument, it would
be necessary to replicate this study, including a waiting
list control group as one of the conditions. In other
studies using similar subject populations which did
include a waiting list control group, however, subjects in
the control groups did not show significant decreases
in depression from pre-test to post-test. Although this
support is admittedly indirect, it does seem unlikely that
the pronounced improvements shown in all three conditions
of this study were merely spontaneous and unrelated to
participation in the depression control workshops.

The marked improvement of subjects in all three con-
ditions of this study is especially interesting in light
of the recent finding by Rehm et a1. (Note 5) that each

component of their self-control treatment package was

132
effective in reducing depression when used separately as
well as when combined with other elements of the package.
Thus, a treatment as simple as self-monitoring alone proved
to be significantly more effective in reducing depression
than that of a waiting list control group and equally as
effective as approaches combining all three components of
the self-control program. Given that such relatively simple
interventions used by relatively inexperienced therapists
and group leaders can result in reductions in depression
that are highly significant both statistically and clin-
ically, it seems clear that further research into the use
of short-term approaches to the treatment of depression is
warranted. Longer follow-up studies are definitely needed
to determine whether these reductions in depression are
stable or temporary, and such studies are currently in
progress by Beck as well as by Rehm (Note 13). While it
is clear that further research is needed to overcome the
limitations of this study and to isolate the mechanisms
resulting in change from even simple interventions, this
study does demonstrate potential for the use of inexper-
ienced group leaders, and perhaps even paraprofessionals,

to help ameliorate the increasing problem of depression.

APPENDICES

133

APPENDIX A

SAMPLE MEDIA ANNOUNCEMENT USED TO RECRUIT SUBJECTS

134

APPENDIX A
SAMPLE MEDIA ANNOUNCEMENT USED
TO RECRUIT SUBJECTS
Depression Control Workshops

We will conduct Depression Control workshops at
the MSU Psychological Clinic throughout the winter of
1979 to help people cope with depression. Each group will
consist of six to eight members and a group leader, and
will meet two evenings per week for four weeks. The groups
will be led by graduate students in clinical or counseling
psychology at Michigan State University, and the program
will be supervised by Dr. Dozier Thornton. The groups
will be free of charge to people who complete some research
questionnaires.

This is not group therapy, but a workshop where
people can work together to try to find ways to overcome
depression. Separate workshops will be starting on
January 15, January 29, and February 12. Interested indi-
viduals should call Barbara Fleming at the MSU Psycholo-
gical Clinic at (517) 355-9564.

135

APPENDIX B

STANDARDIZED TELEPHONE INTERVIEW

136

APPENDIX B
STRUCTURED TELEPHONE INTERVIEW

Hello, I'm Barbara Fleming from the MSU Psycholo-
gical Clinic. I understand that you are interested in
more information about the Depression Control Workshops.
I'll just briefly describe the groups and if you decide
you're interested, we can discuss it in more detail, okay?

The workshops will meet two evenings per week for
four weeks, making the complete workshop a total of eight
sessions. Each group consists of four to eight group
members and a group leader who is a graduate student in
clinical psychology at Michigan State University. The
purpose of the group is to help each member better cope
with his or her depression. The groups are for people who
feel that they have a problem.with depression in their own
lives, and there is a screening process designed to
ensure that the people in each group will have similar
enough concerns so that they are likely to work well
together. There isru>charge for the group in terms of
money, but since these groups are part of a research
project we do ask that you pay for the group by filling

out a series of research forms at three different points

137

138

in time: before the workshop begins, at the end of the
workshop, and six weeks after the workshop has ended. Do
you have any questions?

(If subjects asked for more details about what
would actually go on in the groups, they were told that
several different leaders would be running different
groups, and each leader had a different style of running
groups as well as different techniques that they felt were
useful in helping people cope with depression. The one
thing that all the groups have in common is that the mem-
bers are all encouraged to actively work together to explore
ways of coping with depression.)

If you think you might be interested in partici-
pating in this workshop, the first step would be to spend
some time talking with me over the telephone about your-
self and what depression is like for you, so that we can
both get a better idea as to whether this workshop might
be helpful to you. If, at the end of our discussion, we
both decide that this workshop does seem appropriate for
you, we would schedule a time for you to come in and
complete the screening forms and the first set of research
questionnaires. I will then call and let you know within
24 hours of the screening session whether it seems that
this would be an appropriate workshop for you. If not, I

will be glad to talk with you about what I have learned

139

through the interview and screening process, and I will

do my best to help you find resources in the community
that will better suit your needs. The screening process
is not designed to determine whether you are "good enough"
or "depressed enough" for the workshops; rather, we are
trying to form groups of people who are most likely to
benefit from the workshop.

Would you like to take some time now to discuss
this further, or would you prefer that we set up another
time to talk?

First of all, I'd like to get some factual infor-
mation (age, marital status, occupation, level of educa-
tion, current or previous therapy, etc.).

The word "depression" is used in many different
ways. What exactly is depression like for you and how
does it affect your life?

(An open-ended discussion of the person's experi-
ence of depression follows. Information is gathered about
how depression affects each of the areas listed below.
Each area is discussed within the context of a conversation
and areas not mentioned spontaneously by the subject are
introduced into the discussion by the interviewer.)

Areas informally covered within the interview:

1. Loss of interest or pleasure--How does

depression affect your interest or enjoyment
of family, friends, work, hobbies and interests,

sex? Are you withdrawing from or avoiding
people or activities?

140

2. Self-image--How do you currently feel
about yourself? What are your good points, bad
points? How do you see yourself in comparison
to other people?

3. Worry and guilt--How much do you worry?
What do you worry about? What do you feel guilty
about, blame yourself for? Do you deserve to
be punished?

4. Future orientation--How do you view your
future? What plans, goals do you have?

5. Sleep-~How does depression affect your
sleep? Trouble falling asleep, waking early,
restless sleep, sleeping too much? How many
hours of sleep do you get per day?

6. Appetite--How does depression affect
your appetite? Eating less or more than usual?
Losing or gaining weight? How much?

7. Fatigue--Have less energy than ususal?
Feel too tired to do things? Physical slowness
of movement or speech?

8. Agitation--More restless, tense than
usual? Speeding up of movement or speech? More
irritable than usual?

9. Suicide--Have you thought about harming
or killing yourself? Made plans? How would
you do it? Any attempts? Are you considering
suicide now?

10. Functioning--How does depression affect
your ability to do your job, housework? Trouble
making decisions? Concentrating?

11. Alcohol and drug use--How does depres-
sion affect your drinking and drug use? How
much and often do you drink? What drugs do you
use, how much and often? Do you consider your
drinking or drug use to be a problem?

12. Health--How is your physical health?
Have you had a check-up within the past year?
What were the results? Are you worried about
your health? What medications are you on?

141

What medical problems have you had in the past?
What hospitalizations have you had? If psychi-
atric, what diagnosis?

13. Strange or unusual experiences--Is there
anything unusual about the way things look,
sound, smell? Do you feel that things are unreal?
Have you ever felt that you were outside your
body?

14. Time frame of depression-~How long has
this been a problem? How often do you feel
depressed? Ups and downs? Fluctuations related
to time of day, seasons?

15. Precipitants of depression--Can you
generally tell what you are depressed about?
What generally leads to depression? What seems
to lead to feeling better?

16. What else should I know that would help
me to understand what depression is like for you?

APPENDIX C

RESEARCH CONSENT FORM

142

APPENDIX C

Research Consent Form

 

l. I have freely consented to take part in a
scientific study being conducted by Barbara Fleming under
the supervision of Dr. Dozier Thornton, Professor in the
Department of Psychology.

2. The study has been explained to me and I
understand the explanation that has been given and what
my participation will involve. More specifically, parti-
cipation involves attending and sharing in eight workshop
sessions, led by graduate students in clinical psychology
at MSU, and completing research questionnaires at the
beginning and end of the workshop and at a six-week
follow-up period.

3. I understand that I am free to discontinue my
participation in the study at any time without penalty.

4. I understand that the workshop sessions will
be audio-taped, and the tapes will be used for research
purposes only. I understand thatllmay withdraw my per-
mission for use of these tapes at any time.

5. I understand that the tapes and the results
of this study will be treated in strict confidence and
that I will remain anonymous. The tapes will be kept for
no more than five years from the date noted below; and as
soon as the tapes are no longer useful for research pur-
poses, they will be erased or destroyed. Within these
restrictions, results of the study will be made available
to me at my request.

6. I understand that my participation in the study
does not guarantee any beneficial results to me.

7. I understand that, at my request, I can receive
additional explanation of the study after my participation
is completed.

 

 

Signed Dated,

143

APPENDIX D

PSYCHOLOGICAL SCREENING INVENTORY

144

place a

place a

 

APPENDIX D

Psychiatric Screening Inventory

 

If a statement tends to be TRUE for you, F T
check in the column headed T: that is /

If a statement tends to be FALSE for you, F T
check in the column headed F: that is

Please try to answer all questions.

I enjoy classical music.

I am usually happy.

Being a TV announcer would be fun.
I am happy just being alone.
Shooting is a good sport.

At times I lose all my drive.

I guess I am not very efficient.

I have never broken a major law.

I do not worry about going insane.

\OCDVCthIDUJNH

10. Things are always frightening me.

11. Sometimes I don't quite know what to say.
12. I forget things more quickly nowadays.
13. People usually understand me.

14. I think carefully about all my actions.
15. I think there is something wrong with my memory.
16. I am active in clubs.

17. I don't get sick very often.

18. It is fun to bet.

19. I am rarely at a loss for words.
20. When I sleep I toss and turn.

21. I guess I know some pretty undesirable types.
22. I do not like to gamble.

23. I often find it hard to concentrate.

24. I have sometimes drunk too much.

25. I am sensitive to the needs of others.

26. I would like to be more outgoing.

27. I break more laws than many people.

28. My friends were always welcome at home.
29. Adults should not shout and yell so much.
30. As a child I occasionally stole things.
31. All people tell "white lies."

32. I am pretty healthy for my age.

33. My thoughts are sometimes unusual.

145

 

146

I enjoy the theater.

I take all my responsibilities seriously.
High speeds thrill me.

I am.tempted to sleep too much.

I do not curse.

Most people are honest with themselves.

I do not like to perform for others.

My health is no problem for me.

Sometimes I am no good for anything at all.
Strange voices have spoken to me.

I would not like to be an actor.

I have sometimes sat about when I should have
been working.

I'm afraid I broke a few rules at school.
Warm relationships are difficult for me.

At times I am a little shy.

I frequently feel nauseated.

My childhood home was happy.

I have sometimes been temp ted to hit people .
I was always well behaved in school.

I sometimes get all steamed up.

My appetite is very healthy.

I am extremely persistent.

I am often tired during the day.

My school teachers had some problems with me.
Odd things have happened to me in my lifetime.
I do not like to sit and daydream.

Few people win arguments with me.

I am easily distracted from a task.

I rarely wake up tired.

People should look after themselves first.
Sometimes I am tempted to break something.
I have been tempted to leave home.

I have no trouble controlling my urges.

I am rather a loud-mouth at times.

Most people are looking for sympathy.

I am a fairly conservative person.

Much of my life is uninteresting.

Some people really wish me harm.

My parents like (or liked) my friends.

I have little confidence in myself.

I seldom feel frightened.

People think I am pretty calm.

Drug addiction is very undesirable.

I feel isolated from other people.

It is very hard to embarrass me.

I have a lot of energy.

I never act without thinking.

The world has always seemed pretty real.

I have avoided people I did not wish to speak to.

 

124.
125.
126.
127.

128.
129.
130.

147

People tend to watch me.
The world is full of odd things.
I like to obey the law.
I have never had a strange mental attack.
I always do my work thoroughly.
People generally like to help others.
I would make a good leader.
I sometimes feel I am in a world alone.
My troubles are not all my fault.
I enjoy talking in front of groups.
I find it hard to start a conversation.
I don't like to rush about.
When I get nervous my hands tremble.
People stop talking when I approach.
Being a racing driver would be fun.
Life treats me badly.
I have rarely been punished.
My failures are largely due to myself.
I would like to be really important.
I stay away from trouble.
Sometimes I hear noises inside my head.
I rarely stumble or trip when I walk.
Many people do not know how sensitive I am.
If I don t like somebody, I say so.
My life is definitely worthwhile.
I think carefully about most things I do.
I rarely feel anxious in my stomach.
People think I am more immature than I am.
At times I feel worn out for no special reason.
We should obey every law.
Some of my relatives have done strange things.
I am painstaking and thorough.
I rarely or never get headaches.
My parents are (or were) too conservative.
I am usually the one to open a conversation.
People often embarrass me.
It is very easy for me to make friends.
Sometimes the police use unfair tricks.
Occasionally I feel dizzy or light-headed.
At school I was never easy to manage.
I am extremely talkative.
Some people simply have too much energy.
I feel that people keep secrets from me.
I like to let others start a oonversation.
I can usually judge what effect I will have
on others.
My strength often seems to drain away from me.
Sometimes I wish I could control myself better.
I have a soft voice.
--by Richard I. Lanyon, Ph.D.

APPENDIX E

BECK DEPRESSION INVENTORY

148

PLEASE NOTE:

Capyrighted materials in this document
have not been filmed at the request of
the author. They are available for
consultation, however, in the author's
university library.

These consist of pages:

#21?- U73

 

 

 

 

 

UHiIii/leirtrsgyfilms
International

300 N. ZEEB RD, ANN ARBOR, Ml 48106 l'3l3) 761-4700

APPENDIX E

Beck Depression Inventory

 

On this questionnaire are groups of statements.

Please read each group of statements carefully. Then pick
out the one statement in each group which best describes
the way you have been feeling the PAST WEEK, INCLUDING

TODAY!

 

Circle the number beside the statement you picked.

If several statements in the group seem to apply equally
well, circle each one. Be sure to read all the statements
in each group before making your Ehoice.

 

 

1.

ri-Io

”NO-‘0

WNHO

WNHO

do not feel sad.

feel sad.

am sad all the time and I can't snap out of it.
am so sad or unhappy that I can't stand it.

am not particuarly discouraged about the future.
feel discouraged about the future.

feel I have nothing to look forward to.

feel that the future is hopeless and that things
cannot improve.

HHHH HHHH

I do not feel like a failure.

I feel I have failed more than the average person.

As I look back on my life, all I can see is a lot
of failures.

I feel I am a complete failure as a person.

I get as much satisfaction out of things as I used
to.

I don't enjoy things the way I used to.

I don't get real satisfaction out of anything any-
more.

I am dissatisfied or bored with everything.

don't feel particularly guilty.

feel guilty a good part of the time.
feel quite guilty most of the time.
feel guilty all of the time.

don't feel I am being punished.
feel I may be punished.

expect to be punished.

feel I am being punished.

HHHH HHHH

149

10.

ll.

12.

13.

14.

15.

wN HO (plot-Io wNv-ao

whit-0o

150

I don't feel disappointed in myself.
I am disappointed in myself.

I am disgusted with myself.

hate myself.

don't feel I am any worse than anybody else.
am critical of myself for my weaknesses or mistakes.
blame myself all the time for my faults.

blame myself for everything bad that happens.

don't have any thoughts of killing myself.

have thoughts of killing myself, but I would not
carry them out.

I would like to kill myself.

I would kill myself if I had the chance.

HH HHHH H

I don't cry anymore than usual.

I cry more now than I used to.

I cry all the time now.

I used to be able to cry, but now I can't cry even
though I want to.

I am no more irritated now than I ever am.

I get annoyed or irritated more easily than I used
to.

I feel irritaed all the time now.

I don't get irritated at all by the things that
used to irritate me.

I have not lost interest in other people.

I am less interested in other people than I used
to be.

I have lost most of my interest in other people.

I have lost all of my interest in other people.

I make decisions about as well as I ever could.

I put off making decisions more than I used to.

I have greater difficulty in making decisions than
before.

I can't make decisions at all anymore.

I don't feel I look any worse than I used to.

I am.worried that I am looking old or unattractive.

I feel that there are permanent changes in my
appearance that make me look unattractive.

I believe that I look ugly.

I can work about as well as before.

It takes an extra effort to get started at doing
something.

I have to push myself very hard to do anything.

I can't do any work at all.

l6.

17.

18.

19.

20.

21.

wNHo (DNHO tor-no

wNi-‘O

H

M

NH

(.0

151

I can sleep as well as usual.

I don't sleep as well as I used to.

I wake up one to two hours earlier than usual and
find it hard to get back to sleep.

I wake up several hours earlier than I used to and
cannot get back to sleep.

I don't get more tired than usual.

I get tired more easily than I used to.
I get tired from doing almost anything.
I am too tired to do anything.

My appetite is no worse than usual.

My appetite is not as good as it used to be.
My appetite is much worse now.

I have no appetite at all anymore.

I haven't lost much weight, if any lately.
I have lost more than five pounds.

I have lost more than 10 pounds.

I have lost more than 15 pounds.

I

am purposely trying to lose weight by eating
less. Yes No

 

I am no more worried about my health than usual.

I am worried about physical problems such as aches
and pains; or upset stomach; or constipation.

I am very worried about physical problems and it's
hard to thing of much else.

I am so worried about my physical problems, that I
cannot think about anything else.

I have not noticed any recent change in my interest
in sex.

I am less interested in sex than I used to be.

I am much less interested in sex now.

I have lost interest in sex completely.

Copyright 1972 by Aaron T. Beck, M.D. Reproduction without
author's express written consent is forbidden. Additional
copies and/or permission to use this scale may be obtained
from Center for Cognitive Therapy, Room 602, 133 South 36th
Street, Philadelphia, Pa. 19104.

APPENDIX F

THE D-30 SCALE

152

APPENDIX F

The D30 Scale

This scale consists of numbered statements. Read
each statement and decide whether it is true as applied to
you or false as applied to you.

 

If a statement is TRUE or MOSTLY TRUE, as applied
to you, write TRUE in the space provided. If a statement
is FALSE or NOT USUALLY TRUE, as applied to you, write
FALSE in thespace provided. If a statement does not apply
to you or if it is something that you don't know about,
make no mark on the sheet.

Remember to give YOUR OWN opinion of yourself. 29
not leave any blank spaces ifpyou can avoid it.

1. My dzily life is full of things that keep me inter-
este .

2. I am about as able to work as I ever was.

3. I find it hard to keep my mind on a task or job.

4. At times I feel like smashing things.

5. I have had periods of days, weeks, or months when I
couldn't take care of things because I couldn't
"get going."

6. My sleep is fitful and disturbed.

7. I prefer to pass by school friends, or people I know
but have not seen for a long time, unless they speak
to me first.

___8. I am a good mixer.

___9. I wish I could be as happy as others seem to be.
___10. I am certainly lacking in self-confidence.
___11. I usually feel that life is worthwhile.

‘___12. I don't seem to care what happens to me.

___13. I am happy most of the time.

_14. I seem to be about as capable and smart as most

others around me.

15. I (k) not worry about catching diseases.

16. Criticism or scolding hurts me terribly.

17. I certainly feel useless at times.

18. Most nights I go to sleep without thoughts or ideas
bothering me.

19. During the past few years I have been well most of
the time.

153

154

20. I cry easily.
21. I cannot understand what I read as well as I used to.
22. I have never felt better in my life than I do now.
23. My memory seems to be all right.

24. I am afraid of losing my mind.
_25. I feel weak all over much of the time.
___26. I enjoy many different kinds of play and recreation.
___27. I brood a great deal.

28. I believe I am no more nervous than most others.
___29. I have difficulty in starting to do things.

30. I work under a great deal of tension.

From: Dempsey, P. A. A unidimensional depression scale
for the MMPI. Journal of Consulting Psychology. 1964, 28,
364-370.

APPENDIX C

DYSFUNCTIONAL ATTITUDE SCALE

155

APPENDIX G

Dysfunctional Attitude Scale

This Inventory lists different attitudes or beliefs
which people sometimes hold. Reach EACH statement care-
fully and decide how much you agree or disagree with the
statement .

For each of the attitudes, show your answer by
placing a checkmark (/) under the column that BEST DESCRIBES
HOW YOU THINK. Be sure to choose only one answer for each
attitude. Because people are different, there is no right
answer or wrong answer to these statements.

To decide whether a given attitude is typical of
your way of looking at things, simply keep in mind what
you are like MOST OF THE TIME.

 

Example:
' ml . ' 111'-
: . w. ulwtu m
[Emmomdflwmgfloim
'Atublgndfib g ‘fifl E14”:
'<mm mmEyomwd<o
ATTITUDES , U: ‘<LD< ‘ <
.HUUinDI we
jo<<m<hum mr—lmmom
{—4 ; m' Q‘Z‘HAHMHH
‘ >lm amo> Q

l"

 

1. Most people are okay once you
get to know them.

'\

 

Look at the example above. To show how much a
sentence describes your attitude, you can check any point
from totally agree to totally disagree. In the above
example, the checkmark at "agree slightly" indicates that
this statement is somewhat typical of the attitudes held
by the person completing the inventory.

Remember that your answer should describe the way
you think MOST OF THE TIME.

HOW TURN THE PAGE AND BEGIN

 

From: Weissman, A.N. The Dysfunctional Attitude Scale:
A Validation Study. Unpublished doctoral dissertation,
University of Pennsylvania, 1978.

156

157

 

H a..." .__..———_.

 

AGREE SLIGHTLY

NEUTRAL

o“ _m-MH ... M

DISAGREE SLIGHTLY

‘

DISAGREE VERY MUCH

 

 

TOTALLY DISAGREE

 

EJ

m .
g a
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of the time. a";
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1. You can be a happy person without
going out of your way in order to '
please other people. '

l

-.----1}..H.. -

 

2. I have to impress new acquaintances
with my charm, intelligence, or
wit or they won't like me.

 

3. If I put other people's needs
before my own, they should help me
when I want them to do something
for me.

 

4. It is shameful for a person to
display his weaknesses.

 

5. People will like me even if I am
not successful. '

 

6. People who have the marks of suc-
cess (good looks, fame, wealth)
are bound to be happier than
people who do not.

 

7. I should try to impress other
people if I want them to like me.

 

8. If a person I love does not love
me, it means I am unloveable.

 

9. I ought to be able to solve my
problems quickly and without a
great deal of effort.

 

10. If a person is indifferent to me,
it means he does not like me.

 

11. I should be able to please every-
body.

12. Others can care for me even if
they know all my weaknesses.

13. If people whom I care about do
not care for me, it is awful.

 

158

 

 

 

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son who receives the criticism.

 

15.

My life is wasted unless I am a
success.

__R- ..4

 

16.

People should prepare for the
worst or they will be disap-
pointed.

 

17.

I must be a useful, productive,
creative person or life has no
purpose. .

 

18.

A person should think less of him-
self if other people do not accept
him.

 

19.

I do not need other people's
approval for me to be happy.

 

20.

I can enjoy myself even when
others do not like me.

 

21.

My value as a person depends

greatly on what others think of me.

 

22.

If I make a foolish statement, it
means I am a foolish person.

 

23.

If a person has to be alone for a
long period of time, it follows
that he has to feel lonely.

 

24.

25.

A person should be able to con-
trol what happens to him.

If a person is not a success, then
his life is meaningless.

 

159

 

 

 

 

 

 

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26. A person doesn't need to be well ' i

liked in order to be happy. i

 

 

 

 

 

 

 

 

 

 

to chance; if I do badly, it is

27. If someone performs a selfish act, 1
this means he is a selfish person. '

28. I should always have complete con- ,
trol over my feelings. '

29. I should be happy all the time.

30. If people consider me unattractive
it need not upset me.

31. Whenever I take a chance or risk
I am only looking for trouble.

32. A person cannot change his emo-
tional reactions even if he knows
they are harmful to him.

33. I may be able to influence other
people's behavior but I cannot .
control it. g

m

34. People will reject you if they g
know your weaknesses. g

35. People should be criticized for '
their mistakes. I

36. One should look for a practical é
solution to problems rather than =
a perfect solution. g

37. If I do well, it is probably due i

I

probably my own fault.

 

160

 

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38.

39.

40.

The way to get people to like you
is to impress them with your per-

sonality.

Turning to someone else for advice
or help is an admission of weak-
nesses.

A person should do well at every-
thing he undertakes.

APPENDIX H

IRRATIONAL BELIEFS TEST

161

APPENDIX H

Irrational Beliefs Test

 

This is an inventory of the way you believe and
feel about various things. There are a number of state-
ments with which you will tend to agree or disagree. You
will be given an answer sheet with spaces to circle one
of five possible answerstx>each item. For each statement,
you should mark your answer sheet as follows, according to
your own reaction to the item:

Circle D if you STRONGLY DISAGREE

Circle d if you MODERATELY DISAGREE

Circle n if you NEITHER AGREE NOR DISAGREE
Circle a if you MODERATELY AGREE

Circle A if you STRONGLY AGREE

It is not necessaryix1think over any item.very
long. Mark your answer quickly and go on to the next
statement.

Be sure to mark how you actually feel about the
statement, not how you think you should feel.

Try to avoid the neutral or ”n" response as much
as possible. Select this answer only if you really cannot
decide whether you tend to agree or disagree with a state-
ment.

It is important to me that others approve of me.

I hate to fail at anything.

People who do wrong deserve what they get.

I usually accept what happens philosophically.

If a person wants to, he can be happy under almost any
circumstances.

I have a fear of some things that often bothers me.
I usually put off important decisions.

Everyone needs someone he can depend on for help and
advice.

"A zebra cannot change his stripes."

There is a right way to do everything.

00 oowox U‘IJ-‘UONH

H

162

163

I like the respect of others, but I don't have to
have it.

I avoid things I cannot do well.

Too many evil persons escape the pUnishment they
deserve.

Frustrations don't upset me.

People are disturbed not by situations but by the
view they take of them.

I feel little anxiety over unexpected dangers

or future events.

I try to go ahead and get irksome tasks behind me
when they come up.

I try to consult an authority on important decisions.
It is almost impossible to overcome the influences
of the past.

There is no perfect solution to anything.

I want everyone to like me.

I don't mind competing in activities where others are
better than I.

Those who do wrong deserve to be blamed.

Things should be different from the way they are.

I cause my own moods.

I often can't get my mind off some concern.

I avoid facing my problems.

People need a source of strength outside themselves.
Just because something once strongly affects your
life doesn't mean it need do so in the future.

There is seldom an easy way out of life's difficulties.

I can like myself even when many others don't.

I like to succeed at something but I don't feel I
have to.

Immorality should be strongly punished.

I often get disturbed over situations I don't like.
People who are miserable have usually made themselves
that way.

If I can't keep something from happening, I don't
worry about it.

I usually make decisions as promptly as I can.
There are certain pe0ple that I depend on greatly.
People overvalue the influence of the past.

Some problems will always be with us.

If others dislike me, that's their problem, not mine.
It is highly important to me to be successful in
everything I do.

I seldom blame people for their wrong doings.

I usually accept things the way they are, even if I
don't like them.

A person won't stay angry or blue long unless he keeps
himself that way.

164

I can't stand to take chances.

Life is too short to spend it doing unpleasant tasks.
I like to stand on my own two feet.

If I had different experiences I could be more like
I want to be.

Every problem has a correct solution.

I find it hard to go against what others think.

I enjoy activities for their own sake, no matter how
good I am at them.

The fear of punishment helps people be good.

If things annoy me, I just ignore them.

Ehe more problems a person has, the less happy he will
e.

I am seldom anxious over the future.

I seldom put things off.

I am the only one who can really understand and face

my problems.

I seldom think of past experiences as affecting me

now.

We live in a world of chance and probability.

Although I like approval, it's not a real need for
me.

It bothers me when others are better than I am at
something.

Everyone is basically good.

I do what I can to get what I want and then don't
worry about it.

Nothing is upsetting in itself--only in the way you
interpret it.

I worry a lot about certain things in the future.
It is difficult for me to do unpleasant chores.

I dislike for others to make my decisions for me.
We are slaves to our personal histories.

There is seldom.an ideal solution to anything.

I often worry about how much people approve of and
accept me.

It upsets me to make mistakes.

It's unfair that "the rain falls on both the just and
the unjust."

I am fairly easygoing about life.

MoEe people should face up to the unpleasantness of
li e.

Sometimes I can't get a fear off my mind.

A life of ease is seldom very rewarding.

I find it easy to seek advice.

Once something strongly affects your life, it always
will.

It is better to look for a practical solution than
a perfect one. '

100.

165

I have considerable concern with what people are
feeling about me.

I often become quite annoyed over little tings.

I usually give someone who has wronged me a second
chance.

I dislike responsibility.

There is never any reason to remain sorrowful for
very long.

I hardly ever think of such things as death or atomic
war.

People are happiest when they have challenges and
problems to overcome.

I dislike having to depend on others.

People never change basically.

I feel I must handle things in the right way.

It is annoying but not upsetting to be criticized.
I'm not afraid to do things which I cannot do well.
No one is evil, even though his deeds may be.

I seldom become upset over the mistakes of others.
Man makes his own hell within himself.

I often find myself planning what I would do in
different dangerous situations.

If something is necessary, I do it even if it is
unpleasant.

I've learned not to expect someone else to be very
concerned about my welfare.

I don't look upon the past with any regrets.

There isru>such thing as an ideal set of circumstances.

From: Jones, K.G. A factored measure of Ellis' irrational
belief system, with personality and maladjustment corre-
lates. Doctoral dissertaiton, Texas Technological College,
1968. Dissertation Abstracts International, 1969, 29,
4379-4380B.

APPENDIX I

PLEASANT EVENTS SCHEDULE

166

APPENDIX 1

Pleasant Events Schedule

 

This schedule is designed to find out about the
things you have enjoyed during the past month. The
schedule contains a list of events or activities which
people sometimes enjoy. You will be asked to go over the
list twice, the first time rating each event on how many
times it has happened in the past month and the second
time rating each eventcnihow pleasant it has been for you.
There are no right or wrong answers.

Please rate every event. Work quickly; there are
many items and you will not be asked to make fine distinc-
tions on your ratings. Please make your ratings on the
answer sheets provided. Use the answer sheet labeled "A"
to answer Question A; use the sheet labeled "B" to answer
Question B.

Directions--Question A

 

On the following pages you will find a list of
activities, events, and experiences. HOW OFTEN HAVE THESE
EVENTS HAPPENED IN YOUR LIFE IN THE PAST MONTH? Please
answer this question by rating each item on the following
scale:

1. This has pg; happened in the past 30 days.

2. This has happened a few times (1 to 6) in the

past 30 days.

3. This has happened often (7 or more) in the

past 30 days.

Place your rating for each item on answer sheet
labeled "A." Here is an example: an item might be "Being
in the country." Suppose you have been in the country
three times during the past 30 days. Then you would mark
a "2" on the answer sheet next to item number 1.

Important: Some items will list more than one
event; for these items, mark how often you have done gny_
of the listed events. For example: "Doing art work
(painting, sculpture, drawing, movie-making, etc.)." You
should rate the item on how often you have done guy form
of art work in the past month.

 

167

 

 

168

Since this list contains events that might happen

to a wide variety of people, you may find that many of the
events have not happened to you in the past 30 days. It
i5tunzexpected that anyone will have done all of these
things in one month.

\OmVChUl-PUJNH

Laughing

Being relaxed

Being with happy people

Eating good meals

Thinking about something goodixxthe future
Having people show interest in what you have said
Thinking about people I like

Seeing beautiful scenery

Breathing clean air

Being with friends

Having peace and quiet

Being noticed as sexually attractive
Kissing

Watching people

Having a frank and open conversation
Sitting in the sun

Wearing clean clothes

Having spare time

Doing a project in my own way

Sleeping soundly at night

Listening to music

Having sexual relations with a partner of the opposite
sex

Smiling at people

Being told I am loved

Reading stories,novels, poems or plays.
Planning or organizing something

Going to a restaurant

Expressing my love to someone

Petting, necking

Being with someone I love

Seeing good things happen to my family or friends
Complimenting or praising someone

Having coffee, tea, a Coke, etc., with friends
Meeting someone new of the same sex

Driving skillfully

Saying something clearly

Being with animals

Being popular at a gathering

Having a lively talk

Feeling the presence of the Lord in my life
Planning trips or vacations

169

42. Listening to the radio

43. Learning to do something new

44. Seeing old friends

45. Watching wild animals

46. Doing a job well

47. Being asked for my help or advice

48. Amusing people

49. Being complimented or told I have done well

Directions--Question B

 

Now please go over the list once again. This time
the question is: HOW PLEASANT, ENJOYABLE, OR REWARDING
WAS EACH EVENT DURING THE PAST MONTH? Please answer this
question by rating each event on the following scale.

1. This was not pleasant (Use this rating for
events whiEh were either neutral or unpleasant.)

2. This was somewhat pleasant. (Use this rating
for events which were mildly or moderately
pleasant.)

3. This was ver pleasant. (Use this rating for
events whic were strongly or extremely plea-
sant.)

Important: If an event has happened to you more
than once in the past month, try to rate roughly how
pleasant it was on the averagg. If an event has not
happened toyyou duripg the past month, then rate it
according to how muEh you think it would have been. When
an item lists more than one event, rate it on the events
you have actually done (if you haven't done any of the
events in such an item, give it the average rating of the
events in that item which you would like to have done.)

 

 

Place your rating for each event on the answer
sheets labeled "B." Here is an example: An item might
be "Being in the country." Suppose that each time you
were in the country in the past 30 days you enjoyed it a
great deal. Then you would rate this event "3," since it
was "very pleasant."

The list of items may have some events which you
would not enjoy. The list was made for a wide variety of
people, and it is not expected that one person would enjoy
all of them.

Now go back to the list of events, start with item
1, and go through the entire list rating each event on rou hl
how pleasant it was (or would have been) during the paSt 3%
days. Please be sure that you rate each item.

170

From: MacPhillamy, D. J. and Lewinsohn, P. M.
Manual for the Pleasant Events Schedule, unpublished manu-
script, 1976.

APPENDIX J

COGNITIVE COMPLEXITY SCALE

171

\OmVGLfi-L‘ WNH

APPENDIX J

Cognitive Complexity Scale: Role Descriptions

 

Yourself
The person you know whom you would most like to be like
The person you've met recently whom you would most
like to get to know
Your closest friend (same sex)
The most successful person you know personally
The person you most like to socialize with
Someone you kow personally whom you admire
The person you most dislike of the same sex
The person with whom you would most like to share your
intimate thoughts and feelings
Your closest friend (opposite sex)
Someone you know personally for whom you feel sorry
The person you least like to socialize with
The person you've met recently whom you would least
like to get to know
The person you most dislike of the opposite sex
{hfi person you know whom you would least like to be

i e
The least successful person you know personally
The person with whom you would most like to work on a
project that is important to you
The person you know who most depends on you
The person with whom you would least like to share
your intimate thoughts and feelings
The person with whom you would least like to work on
a project that is important to you.

Cognitive Complexity Scale: Bi-Polar
IPersonaIityrAttributes

 

l. considerate inconsiderate
*2. intelligent unintelligent
3. wise foolish
*4 perceptive ‘ unperceptive
5. openminded closeminded
*6. interesting uninteresting
7. warm cold
8. confident not confident
*9. creative not creative
10. skillful not skillful

172

*ll.
*12.
13.
*14.
15.
16.
*17.
18.
*19.
*20.

hardworking
responsible
beautiful
friendly
competent
sociable
trustworthy
independent
dependable
clever

173

lazy
irresponsible
ugly
unfriendly
incompetent
unsociable
untrustworthy
dependent
undependable
not clever

*These scales were reversed to reduce the possibility of
scale checking biases.

APPENDIX K

POST-TEST AND FOLLOW-UP QUESTIONNAIRES

174

APPENDIX K

Gromp Member Post-Workshop Questionnaire

 

To what degree has this workshop been helpful to you
in c0ping with depression?

Not Helpful / / / / / / Very Helpful

 

To what degree has this workshop been helpful to you
in other areas, besides depression?

Not Helpful / / / / / / Very Helpful

 

To what degree has your depression been reduced as a
result of this workshop?

None / / / / / / Very Much

 

To what degree do you feel better able to cope with
future depressions as a result of this workshop?

None / / / / / / Very Much
Was the workshop of appropriate length to be helpful
to you?
Too Short / / / / / / Too Long
a. If length was inappropriate, how many sessions
would you estimate to have been more appropriate?
sessions

Was this type of workshop appropriate for you?
Inappropriate / / / / / / Very Appropriate

 

Would you recommend this type of workshop to a close
friend in depression?

Strongly Advise Strongly
Against It / / L L / / Recommend It

What is your opinion of your group leader?
Very Unlikable / / / / / / Very Likable
Very Competent / / / (prip / Very Incompetent

175

176

9. Do you plan to seek further treatement for depression?
Definitely Not / / / / / / Definitely w111

10. Do you plan to seek further treatment in areas other
than depression?

Definitely Will / / / / / / Definitely Not

11. Any further comments you wish to make:

 

 

 

 

 

177

Group Member Follow-Up Questionnaire

 

Togwhat degree has this workshop been helpful to you in
coping with depression?

Not Helpful / / / / / / Very Helpful

 

To what degree has this workshop been helpful to you
in other areas, besides depression?

Not Helpful / l / _1. / / Very Helpful
To what degree has your depression been reduced as a
result of this workshop?
None / / / L. / / Very Much
To what degree do you feel better able to cope with
future depressions as a result of this workshop?
None / / / / / / Very Much

 

Have you sought further treatment for depression?
Yes No (circle one)
a. If no, do you plan to seek further treatment for
depression?
Definitely Not / / / I / L, Definitely Will

 

Have you actually become involved in further treatment
for depression?

Yes No (circle one)

a. If yes, what type of treatment are you receiving?

 

b. Where are you receiving treatment? By whom?

 

Have you sought further treatment in areas other than
depression?

Yes No (circle one)
a. If no, do you plan to seek further treatment in
areas other than depression?
Definitely Will / / / / / / Definitely Not

 

178

Have you actually become involved in further treatmentix:
areas other than depression?

Yes No (circle one)

a. If yes, what type of treatment are you receiving?

 

b. Where are you receiving treatment? By whom?

 

Any further comments you wish to make:

 

 

 

 

 

APPENDIX L

COGNITIVE TREATMENT MANUAL FOR DEPRESSION

179

APPENDIX L
COGNITIVE TREATMENT MANUAL FOR DEPRESSION

Protocol for Cpgnitive Thergpy of Dgpression

 

Brian F. Shaw

University of Western Ontario

Objective and Rationale

 

The major objective for this therapy will be to alter
the idiosyncratic, maladaptive ideation of depressed
patients. According to the cognitive paradigm of depres-
sion, a depressed person systematically misconstrues his
experiences so that he views himself and his future in a
negative way. It is important to distinguish between
normal and abnormal reactions. A depressed individual's
reactions to environmental events is based on a faulty
interpretation of the stimuli and therefore, neutral or
even favourable events result in a negative conclusion.
The patient's faulty assumptive system results in his
negative conceptualizations of experiences and these
negative concepts are thought to contribute to the other
symptoms of depresSion such as the lack of adaptive
behaviour, the affective state and the physiological mani-
festations. As a result, a depressive cycle is esta-
blished in which the negative thinking, the unpleasant
affect, the physical symptoms and the self-defeating, mal-
adaptive behaviour reinforce each other.

The ultimate goal of this cognitive therapy is to
modify the patient's faulty assumptive system thereby
reducing the probability that the individual will respond
to stressful stimuli in a depressive manner in the future.
A more immediate aim of therapy, to alter the individual's
current depression, is also attainable using cognitive
therapy. By concentrating on specific depressive symptoms,
the cognitive therapist attempts to help patients recognize
faulty or irrational thinking and to make the appropriate
corrections. In doing so he may concentrate on cognitive,
behavioural or affective phenomena. This doesn't imply,

180

181

in the case of a behavioural focus, that the therapist's
interventions are based on conditioning theory. Rather,
the cognitive components are examined and if needed, modi-
fications in those components are attempted. Examples of
this strategy will be presented later. The general
strategy used to counteract the depression, then, is to
use techniques that will enable the patient to interpret
his experiences in a positive and rational way.

Treatment

 

While flexibility is normally the rule with this
and most treatments, the goalscfifresearch require that the
outlined procedures are followed as closely as possible.
It is most important that the therapist remain with this
specific treatment for only then can the effects of treat-
ment be systematically studied. The therapist should be
as warm, interested and helpful as he would be in any
helping relationship. The main difference between this
approach and the more traditional methods is that with
cognitive therapy the therapist guides and directs the
course and content of treatment. Also, like behaviour
therapy, cognitive therapy does not require that the
patient obtain insight into the origin of the symptoms
and thus, a minimum of therapy time is spent on intro-
spection and little or none is spent searching for etio-
logical factors. Since the diagnosis of depression will
have been determined prior to the therapist's contact with
the patient, focus on the treatment will begin with the
first session.

As noted previously, cognitive therapy utilizes a
number of techniques whose major mode of action is the
modification of faulty patterns of thinking. A basic
session by session outline was provided in Table 2 of the
main text.

There are six major procedures involved in the use
of cognitive therapy:

(1) Presentation of general and specific
rationale of treatment

(2) Exploration of history and current
status of symptoms.

(3) Exploration of depressive cognitions.

(4) Examination, evaluation and modifi-
cation of these cognitions.

(5) Identification of underlying assumptions.

(6) Examination, evaluation and modifi-
cation of basic premises and assumptions.

182

Specific Procedures

 

1. Presentation of general and specific treatment ration-
ale.

It is important that each patient understand and
accept the treatment process. A brief explanation of the
theory and course of treatment should be presented and
clarified if questions arise. It should be made clear
that in depression the thoughts of individuals are very
important. If any patient has trouble understanding,
explanations should be rephrased in language that he can
understand. Questions from.more sophisticated subjects
should be dealt with openly to allay any doubts they might
have; e.g., "We have found that patients receiving this
treatment do not require drugs." The patients should also
be informed of a telephone contact that will be available
24 hours a day to handle emergency problems.

The general instructions (on a separate page)
should be presented initially. These instructions are
designed to control for the initial expectancies of patients
in all groups as well as giving patients a general outline
of treatment.

The following specific rationale for the cognitive
therapy should be a sufficient introduction.

The symptoms that you are experiencing (a
review of the symptoms may be included here)
are all related to the way that you interpret
and think about situations in your life. Because
we are all individuals, the way that we react
to events in our lives may be quite different.
On the other hand, individuals who feel depressed
often react in a similar way to many of their
problems. As a result of your past experiences
with people and situations you have learned to
react in a particular manner. For example, say
I asked you to outline in detail everything
that I have said to you in the last five minutes;
some people might react by thinking, "I can't
do that," others might think "Why does he want
me to do that?" and still others might think,
”He's got to be kidding!" Each person reacts
in his or her own particular way.

 

Initially in our session we are going to
look at some of the difficulties or problems
that you are having and hopefully, how to

183

resolve these difficulties. It will be important

for us to find out how you reacted to specific
situations in your life and what effect these
reactions have on your feelings. By looking carefully
at your reactions we will have a better idea of how

to best help you. we will then be able to examine
alternative ways of coping with stresses, specifically
those which could be used to prevent future depres-
Sions.

We've used this treatment with many depressed
individuals with excellent results. Most of
the procedures will become clearer after we
get into them. Do you have any questions before
we continue?

2. Exploration of history and current status of symptoms.

This phase is an extremely important one. In
exploring the patient's relevant life history the therapist
attempts to identify major sequences in the patient's
life. The therapist should develop hypotheses about the
patient's style and idiosyncratic response patterns to
important life experiences. The therapist should also
attempt to reconstruct with the patient the stages in the
development of his depression. The information concerning
the patient's specific concepts and attitudes which
should become evident will be utilized throughout the
treatment. Recall that the cognitive paradigm of depres-
sion assumes that depression is precipitated when a stress-
ful situation (or stressful situations) interacts with a
particular cognitive structure (i.e. negative self image,
negative view of world and/or negative view of future).
Following the reasoning that many individuals would not
have become depressed if they had been in the same situ-
ation as the depressed person, the therapist should
attempt to delineate the salient features of the stressors
and of the patient's response. The stressors are not
under the patient's control but the response pattern is.
It is the cognitive structure, therefore, that requires
modification. On reviewing the development of the depres-
sion, the therapist should begin to ascertain what cogni-
tive structure changes would be of the most benefit to the
patient. This strategy also requires that the patient
concentrate on specific problems rather than symptoms,
thereby increasing his/her objectivity and understanding
of the depression.

184

When the stages of development of the depression
are better understood the therapist should have some idea
of the assumptions, attitudes, beliefs, values etc. that
the patient has. While the major objective of the therapy
is to make some alteration in the patient's cognitive
structure it is difficult at this stage for most patients
to examine these cognitive components productively. For
this reason, the therapist at this point should concen-
trate on specific events in the client's current life and
his/her response to these events. The goal here is to
intervene in the depressive cycle and alter the patient's
depressive cognitions. These cognitions are obviously
reflections of the patients more elaborate assumptions,
attitudes, etc.

3. Exploration of depressive cognitions.

These depressive cognitions have been referred to
as "self-statements" and "things that the patient tells
himself" (Ellis, 1962) as well as "automatic thoughts"
(Beck, 1967). These thoughts reflect the distortions that
occur in the depressed state and may range from.a mild
distortion to a complete misinterpretation. The thoughts
may be triggered by environmental stimuli or may occur
spontaneously but in depression they lead to an unpleasant
affect. For example, Beck (1967) reported that one patient
felt sad every time he made a mistake. After exploring
the thoughts which occurred after he made a mistake he
reported thinking "I'm a dope" or "I never do anything
right." This procedure, therefore, serves to make
patients aware that self-verbalizations do occur and more
importantly, effect the affective state of the patient.
Patients should be instructed to record the thoughts which
lead to unpleasant affect, thereby completing the chain;
environmental stimuli + cognition + affect.

4. Examination, evaluation and modification of the depres-
sive cognitions.

The depressed cognitions are closely related to
affective and behavioural phenomena of depression. A
decrease in adaptive behaviour often results in thoughts
such as, "I won t be able to do it," or "If I do this I
will only feel worse" invade the patient's phenomenological
field. To this point, therapy has been structured to
facilitate the patient's awareness that depressive cogni-
tions occur and effect his depression. As the patient
becomes more adept at recognizing the wording of his
depressive cognitions he can view them.more objectively.
Beck (1970) referred to "distancing" as the process of

185

gaining objectivity towards the cognitions. The therapist
should assist the patient in categorizing his cognitions,
generally by defining the major themes such as self-blame,
inferiority or deprivation. It is important to emphasize
that of the innumerable ways in which he can interpret his
life experiences he tends to perseverate in a few stereo-
typed interpretations or explanations. Also, the defining
characteristic of these interpretations is that they are
negative, self-defeating and irrational.

After the patient learns to recognize the idiosyn-
cratic content and other characteristics of the cognitions,
the therapist should begin to train him to evaluate the
validity and accuracy of the cognitions. A number of
techniques may be useful in the evaluation and modification
of these cognitions.

(l) Distinguishing "ideas" from "facts." It is
important to indicate to patients that thoughts are not
equivalent to external reality, and no matter how convincing
they seem, they should not be accepted unless validated
by some objective procedure. The goal here is to help the
patient shift from.a deductive analysis of experiences (by
far the most common in depression) to more inductive
procedures. The basic therapeutic doctrine is as follows:
simply because the patient thinks something does not neces-
sarily mean that it s true.

(2) Checking observations. The validation of
the patient's interpretations and judgments depends on
checking the accuracy and completeness of the initial
environmental observations. In many instances, fallacious
thinking is involved in the cognitive responses of depressed
persons. The following are three common categories of
cognitive distortion.

(a) Arbitrary inference refers to the process
of drawing a conclusion when evidence is lacking or is
actually contrary to the conclusion. For example, a
depressed woman, who was kept waiting for a few minutes by
the therapist thought, "He has deliberately left in order
to avoid seeing me."

(b) Overgeneralization refers to the process
of making an unjustified generalization on the basis of a
single incident. An example is the patient who thinks,
"I never succeed at anything," when he has a single iso-
lated failure.

186

(c) Magnification refers to the propensity
to exaggerate the meaning or significance of a particular
event. Ellis (1962) used the term "catastrophizing" to
refer to this kind of response. Many examples of this
type of distortion involve persons exaggerating the inten-
sity or significance of stressful events.

The therapist should utilize these categories of
distorted responding in the examination and evaluation of
the patient's cognitions. By following this strategy
the patient will become more aware of the distortions and
with training, will be able to respond to the thoughts in
a more appropriate manner. As homework, patients should
be introduced to the "double column technique" (Beck, 1976).
The patient should continue to write down his/her depres-
sogenic thoughts on the left hand side of a piece of paper.
0n the right side he/she should write down the realistic
answers to these cognitions. For example:

Unreasonable Reasonable

 

I never succeed. This isn't true, my past
record doesn't support such
a claim. (Overgeneralization)

I am weak, for any criticism This is an opportunity to

seems to trip this irra- fight these thoughts and
tional thought. get them under control once
and for all.

The patient's record of thoughts and responses should be
closely monitored by the therapist. It should provide

data for discussions and feedback from the therapist. Once
the particular cognition is established as invalid, it
should be neutralized by the patient (or initially, the
therapist) by stating precisely why it is inaccurate,
inappropriate or invalid. By verbalizing the reasons

that the thought was erroneous every time it occurs, the
patient will be abletx>reduce the intensity and frequency
of the thought as well as the accompanying affect.

(3) Examining alternative explanations. A third
strategy that can be used to break up the patient's nega-
tive cognitive set, is to show him the alternative ways
of conceptualizing and solving problems. That is, the
patient is trained to consider the alternatives to the
depressive cognitions and then to evaluate these alter-
natives. For example, the thought, "Robert has not called.
He doesn't love me, should be weighed against, "He loves
me. He is just very busy and thinks that I am improving
and therefore isn't worrying and calling all the time.”

187

(4) Building on positives. The phenomenological
field of the depressed patient is constantly flooded with
negative depressogenic cognitions. The three procedures
just discussed are utilized by the therapist to alter these
depressive cognitions. In addition, it is often useful
to replace these negative thoughts with positive ones for,
as shown by Velten (1968) positive thoughts may lead to
pleasurable affect. Two techniques may be used with
respect to this strategy, with the goals of increasing the
patient's awareness of situations in which they are
successful and of increasing positive self-verbalizations.

The first technique requires that the patient agree
that activity is better than inactivity (i.e., he feels
better when active). The main argument here is that the
patient has more depressing thoughts when he/she is in-
active. The patient is asked to keep a record of the
activities which result in pleasurable affect. These
activities will vary with the individual. By keeping this
record the patient will have more objective data to
counter negative thoughts (i.e., "I do succeed in some
tasks; yesterday I fixed the toaster."). The second tech-
nique involves having the patient record positive state-
ments about himself. This process may be a difficult one
for the patient at first and the therapist may have to
reflect honestly good points he sees in the patient. As
therapy progresses, however, the patient should be encour-
aged to add to the list. The patient is then asked to
repeat the positive thoughts immediately after he/she
invalidates and neutralizes any negative, depressive
thoughts. In summary, the patient is informed that "people
who are depressed have trouble seeing themselves and their
environment as they really are," but this can be corrected
with accurate record keeping and objective interpretations.

5. Identification of underlying assumptions.

The procedures to be described here are directed
towards the patient's assumptions of his world, himself
and his future. An individual's concepts are drawn from
his experiences, from the attitudes and opinions communi-
cated to him by others, and from his identifications.
Related to these concepts is the way the individual sets
goals, assesses and modifies his behaviour and explains
the occurrences in his life. These assumptions or concepts
also underlie the criticisms, punitiveness and blame that
the patient directs towards himself.

The objective of this section of treatment is to
identify the chronic attitudes and assumptions. The con-
tent of the chronic attitudes may be inferred from.the

188

examination of the recurrent themes in the patient's cog-
nitive responses to specific situations. The therapist
should have been developing hypotheses about these atti-
tudes from the initial session. Further information about
the patient's basic premises and assumptions may be obtained
by asking him either what he bases a particular conclusion
on, or his reasons for a specific judgment. An inquiry

into his values and beliefs will yield additional data.

Beck (1976) suggested a number of attitudes that
predispose people to excessive sadness or depression.
Examples are:

(a) In order to be happy, I have to be
successful in whatever I undertake.

(b) To be happy, I must be accepted by all
people at all times.

(c) If I make a mistake, it means that I'm
inept.

(d) I can't live without love.

(e) If somebody disagrees with me, it means
that he doesn't like me.

(f) My value as a person depends on what
others think of me.

6. Examination, evaluation and modification of basic
premises and assumptions.

Following the identification of the patient's mala-
daptive assumptions, the therapist's objective is to modify
or attenuate them on the basis that they partly determine
the content of the individual's cognitions. It follows
that a modification or attenuation of these assumptions
will alter the way he organizes and interprets specific
experiences, as well as how he sets his goals and goes
about achieving them. Also, since the predominance of
deductive (as opposed to inductive) thinking is an impor-
tant determinant of the cognitive distortions in depression,
any correction of the invalid major premises will tend to
reduce the erroneous conclusions.

The strategies involved in modifying basic assump-
tions are similar to those used in the modification of the
depressive cognitions. Once the assumptions are identified
they can be examined and evaluated as to their validity.
Changing these assumptions and attitudes is a more diffi—
cult task. Sometimes the patient can see the fallacy of
his basic assumptions and may acknowledge their irration-
ality in the office. Nevertheless, change requires more

189

than acknowledgement. The patient should be encouraged
to challenge the assumptions by stating the reasons that
they are invalid.

It should be stressed that the changes should not
be expected to happen quickly. The maladaptive attitudes,
like all of a person's attitudes, most often have developed
over a long period of time. The patient will have to exa-
mine and utilize alternatives, as well as experience the
consequences of such attitude changes, many times in and
out of the therapist's office before changes are struc-
turalized, i.e. before they become permanent formations
in the cognitive structure.

Efran (Note 14) made some important comments regarding
a specific set of assumptions that are particularly rele-
vant to depression, namely, self-criticisms. He suggested
that basically the patient would like to be able to say
comfortably, with full attention, and without evasion, in
what way he is displeased with himself. It is the thera-
pist's job to help him do this by making it "safe" for the
patient. To do this the therapist must guard against
emitting cues that he intends to be condemnatory or act
superior with regard to what the patient has to say.
Efran (Note 14) noted that an emphasis on "problem solving"
is usually detrimental, as is any feeling by the therapist
that he should be responsible for telling the client how
he can better run his life. The cognitive therapist, when
dealing with assumptive systems, doesn't activel tell the
patient what to do. Rather, the therapist is active in
setting the situation so that the patient can oEjectively
examine his assumptions. Thus any evaluative or modifi-
cation procedures should notbe initiated until the assump-
tions have been clearly identified and examined. This is
extremely important, for the therapist who challenges the
patient's initial attempts at defining his beliefs, atti-
tudes, etc. will probably give the patient an "unsafe"
message. Also, recall that the overall objective is for
the patient to feel (have) mastery of his world, and
therefore, the patient, not the therapist should be
responsible for how hg runs his life.

190

A Session by Session Outline of the Treatment Procedures:

Cognitive Modification

 

 

 

 

OBJECTIVE METHOD (TECHNIQUE)
WEEK 1 Introduction - GENERAL AND TREAT- A. Goals and rationale
MINT SPECIFIC
SESSION I --Review events leading to depres-
Delineate major maladaptive pat- sive episode.
terns and sequences in patient's --Review history of past depressions.
current life. --If possible. therapist should '
attempt to ascertain the features
Emphasis that depression should not of patient's responding (i.e.,
be viewed in terms of specific selective responding to specific
problems and not in terms of types of experiences).
symptoms.
WEEK 1 Delineate maladaptive cognitions A. Discuss specific events which occur
occurring in response to environ- and which are followed by feelings
SESSION 2 mental stimuli--patients should of sadness or other depressive
be aware of self-verbalizations. symptomsc-investigate the cognitive
component in the chain, stimuli +
cognition + affect.

8. Introduce homework--patients should
be instructe to write depressogenic
thoughts down.

WEEK 2 Awareness that thoughts (negative) A. Discussion of homework-- oint out
do occur and result in feelings what is invalid about thinking
SESSION 3 of sadness. etc. (e.g. "I never succeed"). This
statement is an overreaction.
Introduce methods of dealing with Allow patient to challenge thought
thoughts--challenging their if he/she is capable.
validity.

8. Correct misconceptions, provide
alternatives.

Homework: continue to record thoughts

an try to record realistic replies to

EhEse cognitions.

WEEK 2 Continue to focus on maladaptive A. Promote objective discussion of
cognitions and methods of dealing cognitions--provide feedback about
SESSION 6 with them. Establish invalidity attempts to correct thoughts.
of thoughts.
8. In addition to recording maladap-

 

Increase patient awareness of non-

depressive situations and responses
which occur in their lives--neutra-
lize pessimism.

 

tive thoughts patients should
record (situations/activities) in
which they were successful or which
they enjoyed. Also list their
positive features--CONTINUE THROUGH-
OUT TRT.

 

191

 

 

 

 

OBJECTIVE METHOD (TECHNIQUE)
WEEK 3 Ascertain patient's response to A. These assignments should be con-
homework assignment--discuss prob- tinued as they provide a method for
SESSION 5 lems related to homework. looking objectively at experiences
and self.
Continue to train patients to eval-
uate validity and accuracy of 8. Provide alternative ways of looking
cognitions. atsituations,solving them. etc.
Once cognitions established as C. Therapist guides patient through
invalid train patient to neutra- logical steps of reasoning.
lize them by verbalizing why.
e.g. THOUGHT: "I won't be able
Check on homework--problems, to do it.
difficulties. RESPONSE: "This isn't true.
I've done it many times before. I may
be alittle slower when I'm depressed
but I know what to do and if I do things
ste -by-step there's no reason why I
can t do it."
WEEK 3 Begin to clarify assumptions and A. Chronic attitudes may be inferred
attitudes which underlie indivi- from the patient's responses to
SESSION 6 dual's cognitions. (Notice dif- particular situations--information
ferenoebetweendealing with speci- should also be obtained by ques-
fic cognitions versus dealing tioning patient on his reasoning,
with patients' assumptions.) values, beliefs. etc.
e.g. "In order to be happy I have
to be successful.”
"My value as a person depends
on what others think of me."
E. Provide atmosphere of "safety" by
DEE responding in a condemnatory
or superior manner. This is
particularly important if patient
is dealing with self-criticism.
*Core assumptions may be accompanied by
emotional behaviour. etc. This beha-
viour should mpg be interfered with.
WEEK 4 Examine the assumptions of patients A. Using similar methods as with the
in objective manner. specific cognitions investigate
SESSION 7 invalid logic-oexplore alternative
assumptions--discuss effects major
changes in attitude may have.
Homework: patients should record
changes which have taken place in
their attitudes. etc.
WEEK 4 Final session integrating assump-
tions and effects.
SESSION 8

 

Discuss future plans of patients
feedback re: treatment effective-
ness.

 

 

APPENDIX M

BEHAVIORAL SELF-CONTROL MANUAL

192

APPENDIX M

Behavioral Self-Control Manual

 

Brian F. Shaw

University of Western Ontario

Treatment

 

While flexibility is normally the rule with this
and most treatments, the goalscufresearch require that the
outlined procedures are followed as closely as possible.
It is most important that the therapist remain with this
specific treatment for only then can the effects of treat-
ment be systematically studied. The therapist should be
as warm, interested and helpful as he would be in any
helping relationship. The main difference between this
approach and the more traditional methods is that with
behaviour therapy the therapist guides and directs the
course and content of treatment. Also, like cognitive
therapy, behaviour does not require that the patient
obtain insight into the origin of the symptoms and thus,

a minimum of therapy time is spent on introspection and
little or none is spent searching for etiological factors.
Since the diagnosis of depression will have been deter-
mined prior to the therapist's contact with the patient,
focus on the treatment will begin with the first session.

Presentation of General and
Specific Treatment Ratihnale

 

It is very important that each patient understand
and accept the treatment process. A brief explanation of
the theory and course of treatment should be presented and
clarified if questions arise. It should be made clear that
in depression the behaviours of individuals are very
important. If any patient has trouble understanding,
explanations should be rephrased in language that he can
understand. Questions from more sophisticated subjects
should be dealt with openly to allay any doubts they might
have; e.g., "We have found that patients receiving this
treatment do not require drugs." The patients should also
be informed of a telephone contact that will be available
24 hours a day to handle emergency problems.

193

194

The general instructions (on a separate page)
should be presented initially. These instructions are
designed to control for the initial expectancies of
patients in all groups as well as giving patients a gen-
eral outline of the workshop.

It is important to do a great deal of "structuring"
in the treatment of depressed individuals so that there
is a clear mutual understanding of expectations, goals,
time commitments and other conditions.

The following specific rationale for the behavioural
therapy should be a sufficient introduction.

"The symptoms that you are experiencing (a review
of symptoms may be included here) are all related to the
interaction between you and your environment (i.e.,
family, friends, job, hobbies). Because we are all indi-
viduals our daily activities are probably quite different.
On the other hand, individuals who feel depressed often
do not engage in behaviours which might decrease their
depression."

"Initially in our sessions we are going to look
at some of the difficulties or problems that you are
having and hopefully how to resolve these difficulties.
We hope to find out as much information as we can about
you and your behaviour so that we can sit down and arrive
at some mutually acceptable treatment goals. The workshop
will then focus on achieving our goals."

"These workshops have been used with many depressed
individuals with excellent results. Most of the proce-
dures will become clearer after we get into them. Do you
have any questions before we continue?"

195

Self-Control Therapy Manual
Lynn P. Rehm

University of Pittsburgh

SESSION 1: Establish rapport, give rationale.

A.

Introductions

 

1. Confidentiality
2. Self—introductions
Rationale

 

Give clients a basic behavioral framework. Answer
questions and lead discussion on the following issues.
Involve clients by asking them to give examples of
each point from their own lives.

1. Mood is a result of behavior--how you feel depends
on what you d6. Depression follows when actions
fail to obtain desired outcomes/satisfactions.

2. Reward--define in terms of subjective values/
pleasurable outcomes. Mention individual differ-
ences in goals as natural.

3. Types of rewards
a. Comment on variety.

b. Stress social/symbolic as commonly highly
important to human beings, and give examples.

c. Define positive reinforcement as any event/
result that can be gained by own actions and
which is rewarding.

d. Define contingent as an "if and only if" con-
dition (positive reinforcement contingent on
own action/behaviors).

e. Stress important role of positive reinforce-
ment in human behavior (increases, maintains,
shapes instrumental responding) and feelings
(depression ensues when reinforcements are
lost or delayed). People behave for contin-
gent rewards.

 

4. Role of self-reinforcement

a. Necessary to Bridge the gap when external
reinforcements are not immediately forthcoming
but behavior must endure to gain ultimate
rewards: absence of external controls requires
self-control.

196

b. Self-control is a process composed of several
behaviors, skill in which is necessary to
enable one to judge, adjust, and keep going
one's behaviors aimed at earning external
reinforcements ultimately.

c. Situations requiring skillful self-control
very frequent in our culture, and normal part
of adult human functioning.

d. Consequences of failure to apply self-control
effectively in absence of external controls
are extinction (behaviors gradually cease--
passivity, inactivity, etc.) and depression.

e. Questions concerning willpower should be
answered in terms of self-control behaviors,
which need to be learned and applied.

Three aspects of self-control: introduce the

terms selfimonitoring (SM), self-evaluation (SE),

self-reward (SR) and draw parallel between influ-
encing another person's behavior and directing
own actions.

 

Overview

Outline program procedure, structuring experience for

clients so that they can easily follow the programs
Give the following points of information:

1.

Goal is to learn more effective SM, SE, SR behav-

iors so that these self-control (SC) skills can

be used by each client to modify their own depres-

sive patterns of behavior.

Accumulative, sequential, 8-session training

programs-focus will be on SM for two weeks, SE for

two weeks, and SR for two weeks.

Pgocedure within each two-week phase will consist

o :

a. Explanation of principles and directions on
”how-to-do-it" (specification of new behaviors).

b. Learning by doing-—daily systematic practice
(homework) in real life of skills being taught.

c. Feedback--in sessions, discussions will revolve
around clients' reports of real-life experi-
ences and around planning how to be better the
next week.

SESSION 2

A.

Introduction to SM

 

Orient clients towards positive activities as target

behaviors. Pass out Positive Activities Survey--

clients' forms and have group read directions and skim
items. Answer questions and lead discussion covering
the issues below; involve clients by asking for examples
from their own lives.

197

1. Positive activities--define as those direct, active,
ihstrumental'behaViors that have a high proba-
bility of ultimately being rewarded and rewarding
(i.e., they usually result in pleasant outcomes
in time, though not necessarily immediately or
always). These are the behaviors that are
desirable and gratifying.

2. Necessity to increase frequency of positive acti-
vities--to overcome depression, clients must deli-
Berately seek out opportunities to engage in these
positive behaviors.

3. Individual differences--discuss differences in
what is vdlued/desired as an outcome and personal
responsibility to choose goals. Stress PAS as
list of suggestions only--each client must choose
which items are most important for her/him and aim
at increasing those significant behaviors.

Instructions for SM

Give directions for homework and instigate use of SM

skills in real life.

1. Pass out SM logs and instruct clients in their use.
Lead discussion on the following points:

a. Record as soon after vou make a positive
response as is possible. Keep materials
conveniently at hand (e.g., in purse, pocket)
and bring them (PAS, log, etc.) to sessions.

b. Three guidelines for monitoring:

(1) Look at your own behaviors, not at out-
comes or external events.

(2) Monitor positive acts, not failures or
negative behaviors.

(3) Monitor every positive response--any step
in the right direction counts and needs
to be recorded when you are trying to
shape up a particular target class of
behaviors.

c. Log each positive activity engaged in; describe
briefl in terms of one of the PAS items (note
item #) in the column for that day.

d. Record subsequent mood right after positive
activity: rate mood from O (miserable) to 10
(euphoric) and enter rating in column provided
for that day. Ignore the last column (points)
for now. End of day summary--compute and
record average mood for day. End of week
summary (last page of log)--record total # of
positive activities for week; compute and
record average daily mood.

2. Pass out Self-Graphing forms and instruct in use.
Clients should plot day's number of positive acti-
vities and average mood at end of each day (ignore
points).

 

 

198

 

C. Close Session

Repeat directions and remind clients of next meeting.

Have clients write these down on their PAS forms.

1. Three guidelines for SM-dmonitor own behaviors,
monitor positive (not negative) and focus on steps
(components) of specific target behaviors that
need to be increased/improved.

2. Record as soon after each behavior as feasible.
Keep materials with you, compute average mood at
end of each day and graph day's # of positive
activities and average mood. Just before next
session, compute and record total # of positive
activities and average daily mood for the week.

3. Stress importance of following directions so as
to learn by objectivity and modifying own behavior.

4. Remind clients of next meeting date and place and
to bring PAS and filled-in log and graph forms
with them.

5. End session warmly.

SESSION 3

Review of SM: Reinforce accurate SM and instigate planning
of increased engagement in positive activities. Prmmpt
clients to reiterate and internalize the points made last
week, and to help each other as a cohesive group.

A.

Check-in

Follow the procedure outlined at the end of this manual.

Allot about 20 minutes to group discussion, and about

10-15 minutes to each individual's log (total of

approximately 1% hours). Emphasize the three rules

for SM by translating clients' reports of their exper-

iences during the week back into these basic principles:

1. Monitor own behaviors, not external events.

2. Monitor positive responses--those that are direct
and active efforts to achieve desired outcomes.

3. Focus on specific target behaviors--not global
categories, personality traits, overgeneralizations,
or descriptive labels.

Instructions for next week

1. Continue monitoring, recording and graphing positive
activities and mood as before, aiming to increase
overall total frequency of positive behavior.

2. Choose a few classes of positive activities that
are particularly significant or difficult for you
personally and concentrate on increasing your fre-
quency of engaging in those priority goals.

199

3. Strategies for increasing rate of positive behaviors

(prompt clients to use any and all of these).

a. Increase # of times you do each activity.

b. Increase amount of time you spend on each
activity.

c. Increase variety (# of different positive
activities) by trying some new ones (concen-
trate on priority goals)--deliberately seeking
out opportunities to engage in those areas.

4. Close session reminding clients of next meeting
date and place, and to bring their forms with them"

SESSION 4

Didactic instruction in SE criteria-setting behavior.

A.

Check-in

Follow the procedure at the end of this manual. Allott

about 15 minutes to group discussion, and about five

minutestx>each individual's log (total of about 45

'minutes). Reinforce SM behaviors and increasing of

positive activities.

Introduction to SE

Orient clients towards getting appropriate subgoals

for evaluation of their own behavior. Involve clients

in discussion and prompt examples around the following

issues:

1. Depressed people often set goals too high (perfec-
tionism), too far out into the future, or too much
in terms of ultimate outcomes rather than required
behaviors. Stress that inappropriate goals do not
permit one to use feedback of own ongoing behaviors
to guide oneself, and thus result in giving up in
despair or being over- dependent on other people's
judgments and values.

2. Setting realistic SE subgoals or criteria for com-
ponents ofiown behavior:

a. Necessity of choosing own subgoals yourself.

b. Defining them in terms of own behaviors that
you are trying to modify or maintain--set sub-
goals in terms of what you have to do next
(not in terms of what you want to gain) so as
to move towards your chosen goal.

c. P1anning--think about what you need to do to
get the rewards you want.

d. Evaluate your ongoing behaviors (not your whole
self) by comparing them.to your pre- -set sub-
goals/criteria--adjust your actions accordingly,
as necessary to meet and/or surpass your
planned criteria.

 

 

200

e. Avoid overgeneralization in evaluating your-
selves (stress this point and give examples).
It is illogical and depressing to draw sweep-
ing conclusions about your whole self and
worth--compare specific, observable behavior
to its respective pre-set criteria subgoal
only and draw conclusions only about the
behavior and what further needs to be done.

C. Instructions for SE subgoal setting:

Train clients in effective behaviors for setting cri-

teria for SE.

1. Two guidelines for SE subgoal setting--

a. Plan specific subgoals, or steps towards
achieving main goals-—these are your intentions,
or behavioral resolutions for yourself.

b. Define subgoals in terms of components or
stages of positive behavior--set targets for
behaviors. Set behavioral subgoals in as
observable, immediate, attainable terms as
possible--such that you can absolutely know
whether and when you have achieved them and/or
what more you must do to succeed at obtaining
satisfactions.

2. Modeling of subgoal setting-~direct clients to
refer to their own copies of PAS to follow along.
a. Read example subgoals for the first 3-5 items,

using therapists' copy of PAS (briefly discuss
and answer questions as you do so).

b. Prompt clients to contribute suggestions on
the next few items while you continue to give
example subgoals. Reinforce active partici-
pation.

c. Require group members to set apprOpriate sub-
goals on next few items-~reinforce good sug-
gestions and give feedback but do not model
further. Continue discussing subgoals for PAS
items, having clients suggest them and write
down ones they feel they can use, for as long
as there is time.

D. Directions for following week:

1. Instruct clients to plan and write in about three
subgoals of their own choosing for each PAS item
they have committed themselves to work on (i.e.,
their self-chosen priority goals or target behav-
iors). Suggest that these subgoals be arranged
hierarchically according to difficulty or order
in which they must be enacted.

2. Direct clients to continue monitoring and graphing
as before, but now to record each engagement in a
subgoal/component behavior. They should briefly

201

describe what they did, note what PAS item it is
a subgoal of, and rate their subsequent mood.

3. Instigate increased rate of engaging in positive
activities by encouraging clients to deliberately
engage in subgoal behaviors.

SESSION 5

Review of SE subgoal setting and continuation of SE training.

A.

Check-in
Follow the routine procedure, allowing a total of about
60-75 minutes for this.

1.

3.

Focus on choosing and defining of subgoals--ask
each client to state which PAS items they have
singled out to work on and what subgoals they have
set for them.

Reinforce efforts to clearly delineate and specify
component behaviors; also reinforce efforts to
increase positive activities by engaging in subgoal
behaviors.

Emphasize observable, immediate, attainable cri-
teria for subgoals.

Continuation of SE training

 

Teach clients to judge their own ongoing behavior by
comparing them to their own, pre-set subgoals.
1.

Introduce the symbol of points. Instruct clients
to assign from 1 to 5 points to each positive
subgoal behavior they set; grading should be based
on the subjective importance and/or difficulty of
the behavior (more points should be awarded for
more significant or difficult activities).
Instructions for logging--tell clients to continue
monitoring and recording behaviors as they did
last week, and additionally to write down (in the
column provided) the # of points they award theme
selves for each logged behavior. They are to
evaluate their own behavior right after they do
it, by comparing it to its respective pre-set
subgoal, and record the "grade" or # of points,
they assign it.

Instruct clients to total and compute average
number of points each day, and to compute daily
average points at the end of the week.

Particularly difficult or important activities need
to be shaped(learnedby successive approximations or

 

trial and success).
Do this by:

202

Breaking down subgoals into more basic components
or steps, such that the first few are readily
achievable. Arrange these components in sequence
of steps, according to difficulty or order in
which they must be enacted (hierarchy).

When these component behaviors are carried out,
they should be assigned more points (graded
generously)--every step in the right direction
counts and must be evaluated generously ‘when you
are first starting.

Each time you do one of these significant activi-
ties, deliberately form a sentence in your mind,
praising your progress or achievement--e.g., "That
was right," or "That's good, I'm getting there."
Stress that this sort of normal positive SE is the
aim of the point system exercise and that clients
should deliberately practice self-encouragement

as much as possible to establish good habits.

Review of the threeyguidelines for SE
Encourage note-taking.

1.

Plan subgoals (preset behavioral criteria) for
achieving desired outcomes through your own posi-
tive acts.

Set subgoals realistically--in observable, imme-
diate, attainable terms. Define subgoals in terms
of steps of own behavior.

Evaluate own ongoing behaviors independently, by
comparing them to their respective pre-set subgoals.
Adjust actions and efforts.

Directions for week:

 

l.

Prompt clients to maximize their total # of points
by using any and all of the following strategies.
Do each positive activity more often.

Do more different positive activities.

Set more reasonable, achievable subgoals.

Work at a few higher, more significant, or

more difficult subgoals and grade these gener-

ously.

e. Break down new or significant behaviors into
components so that you can get started at doing
these.

Stress that more points can be earned by doing

positive activities that are personally more signi-

ficant or difficult, but clients should not neglect
to accumulate points in easier ways too, when they
are tired, discouraged or have little time, since
it is the total amount of positive activity that
counts.

CLO 0‘93

203

SESSION 6

Didactic instruction in principles of SR and establishing
effective SR schedules.

A.

Check-in

FoIIow the routine, allowing about 45 minutes. Have

each client state what their priority goals were for

the week, what subgoals they set for these, and what

points were awarded for meeting the criteria on signi-

ficant activities. Focus on total # of points. Rein-

force high SE and setting of behavioral criteria that

are observable, attainable, immediate. Stress evalu-

ation of own ongoing behaviors by comparing them to

their respective preset criteria.

Introduction to SR

Orient clients towards shaping and maintaining their

own positive behavior by contingent administration of

SR. Discuss the following issues:

1. SR is the basis of motiviation--makes efforts more
enjoyable. Depressives fail to SR+, excessively

 

2. Contingent rewards shape, maintain, and increase
preceding behavior. Stress that reinforcement of
positive acts and extinction ofnegative (rather
than punishment) has been shown to be the most
effective way to learn, and produces self-confi-
dence/self-esteem.and positive mood/feelings. Dis-
courage self-punishment.

3. "Lock up" rewards-~administer them.contingently,
only when you meet or surpass your criteria for
behavior (subgoals). Comment on the loss of
reinforcer effectiveness if rewards are freely
taken noncontingently and how this is squandering
your resources. Encourage group to discuss this
point fully and to commit themselves to self-
administer rewards contingently only.

4. Maximum effects occur when rewards come immediately
after target behavior. Stress importance of eval-
uating own behavior (points, self-approving covert
sentences) as it occurs and to make a mental note
at least, if you can't immediately log it and
reward it. Points bridge time gap, but must be
backed up.

5. Types of rewards-~any freely available reinforcer
can be used for SR—-covert or overt, tangible or
nontangible; opportunity to engage in some highly
pleasing activity is often a good reward. Stress
immediate availability, pleasure, and precise

204

specification (quantitative description) of rewards.
Use tangible rewards and observable activities
when first learning, to establish habits of covert
SR+.

C. Reward Menus

Establishing SR+ schedules.

1. Instruct clients to make a list on the back of their
PAS of several rewards that are highly pleasant
and freely available. Suggest that some of their
easier positive activities may already be so satis-
fying that the chance to do them can serve to
reinforce more challenging positive behaviors.
Answer questions as clients work on lists--prompt
explicitness and quantitative specification of
rewards.

2. Instruct clients to decide how many points they
will require of themselves to earn (trade-in) each
reward. They should write down the # of points
they promise themselves to earn before partaking
of that reward, next to each reward. When com-
pleted, each client should have a reward menu with
rewards listed on the left and their "prices" in
# of points on the right.

3. Encourage generosity of SR, no hoarding of points,
and contingent SR only (no "credit"). Point out
missing points can always be earned by doing an
easy positive activity subgoal before rewarding
yourself.

D. Review the three SR guidelines

Encourage notetaking.

l. Reward positive behaviors, rather than berating
self for failures.

2. Reward each positive response (whenever behavior
meets or surpasses a subgoal) contingently, and
as immediately as possible (use points and covert
sentences to bridge delays).

3. Be generous with rewards at first (low "prices"--
fade or thin them out--up demands on self) after
new positive behavior is well established--i.e.,
is frequent, easy, and pleasant.

E. Directions for week

Continue monitoring subgoal behaviors and assigning

points but be sure to trade-in points for rewards (back

up the points with reinforcement) as soon as you've
accumulated the contracted amount. Stress importance
of following reward menus closely.

 

 

SESSION 7

Review of SR

205

A. Check-in
Follow the routine procedure, allowing about one hour

for it.
1. Focus on SR principles, reviewing the three guide-
lines:

a. Reward positive behaviors--ignore mistakes.
Rewards should be freely available, hedonic,
immediate.

b. Reinforce each step in the right direction with
a contingent reward (use points and covert
sentences to bridge delays).

c. Be generous with rewards when you are first
starting--set prices low enough to assure
frequent self-reward.

2. Reinforce high SE and increased positive behaviors.
Especially reinforce clients' efforts to follow
their SR schedules and SR statements (expressions
of self-confidence, self-esteem, positive affect,
etc.).

B. Directions for week
Continue homeworkifrom.last session

 

SESSION 8: Integration of all phases.

A. Check-in

Eollow the routine procedure, allowing about one hour

or it.

1. Review the guidelines for SM, SE and SR.

2. Reinforce clients for all three phases of program:
SM, SE and SR.

B. Instructions for final week

Prompt clients to continue using self-control behaviors,

especially covert SR+, beyond the end of training and

at any time in future, as necessary.

1. Point out that the complete chain of SC behavior
(SM, SE, SR) has only just been learned and should
be practiced for at least several weeks to obtain
full benefits. Offer to supply extra logs for
all interested clients at the last session.

2. Instruct clients to continue logging, assigning
points, and trading them in for rewards according
to their menus for the next week. Clients are
to bring their final week's completed logs to the
post-test session.

C. Termination

Ask each client in turn to express their positive and

negative feelings about her experiences with the group

and the program. State your own feelings about ending
and lead discussion about termination feelings.

 

206

Encourage clients to continue working on their prob-
lems and induce expectancy of continued progress after
termination. Allow group to make social plans, if
they wish. Remind them of follow-up testing.

D. Close
CIose by reminding group of date and place for post-
testing and to bring their last logs with them.

207

Check-in Procedure

General Tactic. Review by taking client reports of
specific experiences over the last week and translating
them into basic principles.

A. Group as a whole

Ask how things went over the week with the program.

1.
2.

Check for technical difficulties--reexplain mech-
anics where necesary.

Ask clients what they found out, or what happened
as a result of following the program. Reinforce
all reports of efforts to apply self-control and
to increase positive activities.

Encourage group cohesiveness-~prompt clients to
help each other and to offer suggestions on how
to handle difficulties.

B. Individual logs

 

Review each client's in turn.

1.
2.
3.

Check log (name, completed summary data) and
collect. Give client new log for next week.

Check graph--comment on relationship between rate
of positive activities and mood, if possible.

Ask client to summarize highlights: What did she/
he set out to do (priority goals) over the week,

and what success did she have.

Reinforce (attention, empathy, praise) increases

in frequency of positive behaviors, mood ratings,
and/or points. Involve rest of group in reinforcing
client. Have client tell how she/he achieved
improvements. Encourage her/him to teach others

by sharing ideas she/he found useful and helpful.
Ask her/him about plans for next week.

Prompt planning to apply SC skills to solve prob-
lems and improve if client's frequency of positive
responding, mood, or points are low and/or she makes
depressive complaints. Prompt others to model and
support specific problem solving in this client.

208

Positive Activities Survey--Directions

Attached is a list of suggested postiive activities,
to help you in getting started. Positive activities are
those that you can expect will usually result in pleasant,
satisfying, or rewarding outcomes in time. They are direct
actions on your surroundings (people and/or object) to
achieve what you desire, or what would give you pleasure.

In order to feel better, you will need to work towards
increasing your frequency of engaging in these direct,
active, positive behaviors.

There are individual differences in what is desired,
considered pleasant, or valued as an outcome. No one is
expected to find all of the suggested activities worthwhile.
Neither is this list of suggestions comprehensive. You
are encouraged to add your own items as you discover them
and to select your own goals and priorities. For the
present, try not to focus on activities that result in
unwanted or unpleasant consequences for you. Concentrate
on those activities that would lead to consequences you
personally value or that you have previously enjoyed.

Objective self-observation is critically essential
in changing your behavior pattern and resultant moods.
Throughout this program you will be keeping daily logs of
what positive activities you do, and how you feel immedi-
ately afterwards. You should monitor every positive acti-
vity you engage in, no matter how small. As immediately
after your positive action as possible, record what you
did (briefly describe the class of positive activities it
comes under) and then rate your subsequent mood. Rate
your mood on a scale from: 0 - worst or most miserable
feelings you have ever experienced,to 10 - best or most
elated feelings you have ever experienced. A rating of
5 would indicate a neutral feeling experience--neither
particularly joyous nor particularly unpleasant for you.

209

Positive Activities

Trying to make new friends .

Arranging to be with happy and/or interesting peOple.
Expressing yourself to another person in an open way.
Getting another person interested in you.

Cooperating with other people.

Getting involved in new circles of people (e.g., spec-
ial interest group, social organization, community
service, social or political movement, academic or
professional group).

7. Initiating social interactions.

8. Arranging to go out (e.g., to a concert or show, exhi-
bit, restaurant or bar, dance, party or other social
affair).

9. Doing a favorite or new hobby, project or physical
activity.

10, Learning something new or figuring something out (e.g.,
puzzle, new skill, intellectual or personal problem).

11. Going on a trip (e.g., to the park, beach, or country,
zoo or fair, downtown for shopping, sightseeing or
exploring an area, etc.).

12. Caring for your self.

13. Making yourself attractive.

l4. Actively enjoying beautiful weather.

15. Getting a good meal.

16. Physically contacting another person.

17 . Looking at attractive scenery.

18. Deliberately thinking about something good (e.g.,
physical pleasure, social event, personal achievement).

19. Making time for yourself.

20. Other pleasurable activity (please describe).

O‘U‘IbLONH

APPENDIX N

NONDIRECTIVE MANUAL

210

APPENDIX N

Nondirective Manual

 

Treatment

 

While flexibility is normally the rule with this
and most treatments, the goals of research require that
the outlined procedures are followed as closely as possible.
It is most important that the therapist remain with this
specific treatment for only then can the effects of treat-
ment be systematically studied. The therapist should be
as warm, interested and helpful as he would be in any
helping relationship. Since the diagnosis of de ression
will have been determined prior to the therapist 3 contact
with the patient, focus on the treatment will begin with
the first session.

Presentation of General and
Specific Treatment Rationale

 

It is very important that each patient understand
and accept the treatment process. A brief explanation of
the theory and course of treatment should be presented and
clarified if questions arise. It should be made clear that,
in depression, discussing the feelings of individuals is
very important. If any client has trouble understanding,
explanations should be rephrased in language that she/he
can understand. Questions from more sophisticated sub-
jects should be dealt with openly to allay any doubts they
might have; e.g., "We have found that patients receiving
this treatment do not require drugs." The patients should
also be informed of a telephone contact that will be avail-
able 24 hours a day to handle emergency problems.

The general instructions (on a separate page)
should be presented initially. Those instructions are
designed to control for the initial expectancies of sub-
jects in all groups as well as giving subjects a general
outline of the workshop.

The following specific rationale for the nondir—
ective workshop should be a sufficient introduction:

211

212

"The symptoms that you are experiencing (a review
of symptoms may be included here) are all related to the
ways you deal with your feelings. Because we are all indi-
viduals, the ways that we deal with our feelings may be
quite different. On the other hand, most of us do not
even recognize, let alone accept, many of our own impor-
tant feelings.

"Initially in our sessions we are going to look
at some of the difficulties or problems that you are having
and hopefully how to resolve these difficulties. By
gaining awareness of the feelings, values and beliefs that
are relevant to your problems, we will be better able to
assist you in solving your own problems in a way that
satisfies you.

"These workshops have been used with many depressed
individuals with excellent results. Most of the procedures
will become clearer after we get into them. Do you have
any questions before we continue?"

Compiled from:

Hughes, R. DEC, Inc. Listenin Skills Manual.
East Lansing, Michigan: DEC, Inc., 19 7.

Thornton, D.W. (Ed.). ListeningyEar Manual,
Unpublished manuscript, 1974.

Kantrowitz, R. (Ed.). A relationship manual for
nonprofesgionals working with delinquents. Unpublished
manuscript, Michigan State University, 1977.

213

The Helping Relationship and
The Helping Process

Physically, the helping relationship consists of
a speaker, who presents a problem. and a listener, who
uses certain skills to engage the speaker in the helping
process. As we see it, there are also some crucial affec-
tive and attitudinal elements of the helping relationship.
These are warmth, genuineness, and res ect toward the
speaker on the part of the listener, and the listener's
belief that, if he demonstrates these affective elements
while engaging the speaker in the helping process, the
speaker can and will take the risk to solve his own prob-
lems, and learn to know himself better. Carl Rogers and
others who have developed "client-centered therapy" have
repeatedly shown that to the extent that listeners demon—
strate these affective and attitudinal elements in the
helping process, their speakers are helped, and that trust
develops, both between the speaker and listener, and
within the speaker himself.

There are three stages of the helping process, as
we see it:

(1) Accurately labelling feelings and the sources
of the feelings that the speaker is discussing. This is
called empathic listening and respondimg. This stage, in
particular, builds trust anti is the foundation for Stages
2 and 3.

 

(2) Helping the speaker explore his thoughts and
values that are related to the problem, and integrating
these with his feelings. This is called Values and Atti-
tudes Clarification.

 

 

(3) Helping the speaker develop and act on a
behavioral plan to solve the problem; what to do and how
to do it. This is, simply, ProblemrSoIving.

 

At base, then, the helping process is a series of inter-
actions wherein the speaker gains awareness of those feelings,
beliefs, and values that are relevant to the development
and implementation of a plan to resolve his problem. The
ultimate goal of the process is for the speaker to solve
his problem in a way that satisfies him, and at the same
time, to learn to solve other problems by the same (or a
similar) process. The listener acts as a helper in facil-
itating the speaker's self-exploration and the resolution
of the problem by his use of empathy, values clarification
and problem-solving.

214

We will be giving you a set of skills to learn and
practice so that you will be able to help a speaker in any
stage of the helping process in which he needs assistance.
Once you have mastered these skills, you will be ready to
do crisis work, and will be able to be helpful to clients
who ask you for assistance.

Introduction to Empathy

In this first stage of the helping process, your
central task will be to respond to the feelings you hear
the speaker expressingixxa way that lets the speaker know
you accept and understand those feelings. When you do
this, you are making an empathic response; you are feeding
back, or reflecting, the feelings the speaker is having.
We believe that by responding empathically, a listener can
aid a speaker in getting all of the information he will
need to deal more effectively with his problem.

Because of previous learnings (with society, parents,
friends), many of us find it uncomfortable and/or difficult
to experience, label, or talk about our feelings. We are
supposed to: "be rational;" "be cool, calm, and collected;"
"keep a stiff upper lip." Our feelings are supposedly
what get us into trouble; everything would supposedly be
fine if we would just keep our heads and ignore our guts.

So, people ask us to talk about what ha ened (thus, making
a situation response), or, they tell us what we should do
(or shouldihave done), giving us solution responses.

 

But feelings are as important as our "rational"
thoughts: they serve as barometers, telling us (or trying
to!) what we do or don't want, expect, like, believe, and
value in our world. Feelings don t cause problems; they
exist with problems. Psychosomatic medicine has shown that
unexpressed, ignored, or denied feelings can mess us up,
sooner or later, with things like headaches, ulcers, and
other physical ailments. We all know that unexpressed
feelings can lead to bad moods, nervousness, or "flying
off the handle." So, it definitely appears that feelings
need to be dealt with, especially when a person is having
a problem that he has feelings about. They need to be
talked about, owned, and integrated into a person's aware-
ness of himself and his problem.

Empathic responses to a person's statements about
his problem help him to constructively deal with his
feelings and his problem in that:

215

(1) They encourage the speaker to discuss and
explore his feelings.

 

(2) They give the speaker permisSion to have,
own, and discuss his feelings.

 

(3) They build trust between the speaker and the
listener, which enables the speaker to explore himself
more completely.

(4) They place final responsibility for dealing
with the problem on the speaker; he basically leads the
interaction and comes to his own conclusions about his
problem.

Thus, empathic responses begin to counteract many of the
"anti-feeling" messages that most of us have learned. In
doing this, they help a speaker learn more about himself,
and increase the chances that he will be satisfied with
and carry through the resolution to his problem.

Feelings

' When a speaker is talking about a problem she is
experiencing, she will often talk about three things
related to the problem: The situation, her symptoms, and

her feelings.

The situation, or storyline, is what has happened
to the speaker. It‘s what she did, or they did, or she
said, or they said. It is the series of events that have
occurred which are part of the speaker's prohlem.

The s toms the speaker describes are the h sio-
logical responses that the speaker has had to the situation
3 e is in. She laughs, she cries, she has a knot in her

stomach. The symptoms a speaker describes will often give
you a clue to what she is feeling.

 

 

 

Feelings are the emotional or affective labels that
we put on our p ysiological responses to a given situation.
Examples of feelings are happy, sad, mad, scared.

When you listen to a speaker discussing a personal
problem, we would like you to focus on her feelin 3, since
these are what are often at the base of a speaker's concern.
Different people will respond to identical situations with
different symptoms; some people will label the same symptoms
with different feeling labels. It is the feeling that the

216

speaker has that to a large extent personalizes her exper-
ience of a given situation. Becoming more aware of her
reactions and feelings in a situation will give a spddker
‘more information with which to know herself, and upon which
to base her own actions in this, and in future, situation(s).

Owning of Feelings

 

When someone "owns" his feelings, he recognizes
them, labels them, and takes responsibility for them. He
basically says, "This iS‘m feeling about this situation."
Speakers differ in their a ilities to own and communicate
their feelings as they experience them. To distinguish
between experiencing and owning a feeling, consider the
person, who with reddened face, tight jaw, frown, and
pounding fist, yells, "I AM NOT ANGRY!!!" He experiences
all of the symptoms of anger, yet does not label--own--his
feeling. Or, consider the woman who, crying softly, says,
"That was arotten thing for her to do." It is obvious that
she is feeling sad, or hurt, or both, but she hasn't said,
"I feel sad." She hasn't owned her feeling.

It is our bias that feelings are important to deal
with when a person is having a problem. Thus, it seems
"better" when a erson can own his feelings when he wants
than when he can t. In the next section of the training
program, we will talk about ways to help a speaker own his
feelings. Now, we want you to simply identify whether or
not this owning is occurring, and, if so, to what extent.

To fully own his feeling, a speaker:

(1) Expresses his feeling here and now.

(2) Expresses the full intensity of the feeling.

(3) Recognizes that it is his feeling; that no
one or nothing made hifi—feel the feeling; that
the feeling is his response to another person,
situation, or thihg.

(4) Labels the source of the feeling (the situation
or event that stimulates the feeling).

Can you think of other aspects of owning feelings?
Ways of not owning feelings include:

(1) Talking about situations as though the feeling
attached is so "obvious" that it need not be
mentioned or labelled. '

(2) Talking about feelings as they were in the
past, or how they may be in the future.

217

(3) Using "minimizers:" "kind of," "sort of,"
"a little bit," "maybe," to diminish the
feelings intensity.

(4) Talking in a philosophical manner about feelings
"people" have.

(5) Using vague feeling words.

It is important that a listener identify if and
how well a speaker owns his feelings for a couple of
reasons. First, it helps the listener attend to feelings
and respond to them. Second, it gives the listener good
information about how the speaker deals with his feelings
(vaguely? intellectually? specifically?), which then lets
the listener know how much time he will have to spend
working with the speaker to get his feelings out and inte-
grated, before moving on to values and problemrsolving.

We would like you to practice identifying statements
in which feelings are owned, and evaluating how clearl or
full they are owned. To give you all a common reference
p01nt in your practicing, we've devised a scale that places
owning of feelings on a continuum, and spells out three
distinct levels of owning feelings. At Level One, feelings
are owned the least, at Level Three, they're owned the
most. Please read and discuss the Owning of Feelings
Scale with your group.

Ownings of Feelings Scale

 

LEVEL ONE: --Speaker denies having feelings.

--If speaker states feelings, they are seen as
coming from outside himself, and as being
somehow forced on him. He denies or disowns
responsibility for his feelings.

--Speaker talks in an abstract or philosophical
manner about his personal feelings.

LEVEL TWO: --Speaker usually owns his feelings in past or
future terms; here and now feelings, when
expressed, are talked about in a general
‘manner, with little intensity.

--Speaker uses minimizers when talking about
past feelings, or owning present feelings.

--Speaker sometimes identifies the source of
his feelings, and takes minimal responsibil-
ity for the feelings, often using the phrase,
"He/she/it made me feel

 

218

LEVEL THREE: --Speaker clearly owns, identifies, and takes
responsibility for his here and now
feelings, and expresses them with emotion.

--Speaker owns the intensity of his feelings.
--Speaker clearly identifies the source of
his feelings.

Labeling and Responding to Feelings

The purpose of this section is to develop your
skills in responding to feelings. In a previous section,
you learned to discriminate between feelings, situations,
and symptoms. In this section, we would like you to
specifically label feelings, and make empathic responses
to the speaker, using those labeled feelings to do so.

Specific labeling of feelings occurs when a speaker
or listener talks ahout feelihgs using words that are
precise and clear descriptions of feelings. What do we
mean by "precise" and "clear?" Answer: feeling words
that leave no doubt about what the feeling is.

Some examples of unclear, vague, abstract feeling
words, along with some possible precise meanings are:

"blah" could mean: apathetic, listless, bored
"bummed" could mean: depressed, sad, angry, disap-

pointed
"hassled" could mean: nervous, pressured, angry,
preoccupied

"uptight" could mean: threatened, angry, irritated
"upset" could mean: sad, angry
"down" could mean: depressed, sad, ashamed, guilty

Other vague words like "good," "bad," "up," etc.,
present the same kinds of confusing messages. Thus, using
vague words like these to describe feelings can result in
confusion for both the speaker and the listener, since
neither can be sure what the other means by the words.
Therefore, avoid using vague feeling words; especially,
avoid "lingo" or jargon that can have any one of a number
of meanings depending upon the speaker's age, peer group,
or hometown region.

Specific labeling of feelings also involves accur-
ately talking about the intensity of the expressed feelings.
Differences in intensity can be expressed in a couple of
ways:

 

219

(1) By using different feeling words of the same
family. For example, to express different degress/inten-
sities of ANGRY:

--annoyed --disgusted
--irritated —-furious
--enraged

Other feelings like happy, sad, and scared, have a family
of related words that differ in their intensity.

 

(2) By choosing to use modifiers. For instance,
"You feel. "

slightly very
somewhat extremely
quite
" .pleasedl" Different modifiers with the same feeling

word can specifically label feelings' intensities.

CAUTION! Be EXTREMELY careful NOT to use
minimizers like ”a little," or "a bit," or the modifiers
"kind of” and "sort of." Many of us use these modifiers
because we learned that strong feelings (especially strong
"negative" feelings) are not admissable or permitted;
saying we're "a little bit" angry supposedly makes the
anger more acceptable. In the helping relationship, however,
‘minimizers decrease your potency as a helper, and convey
to the speaker that it isn't OK to own feelings intensely.
Furthermore, how much is "kind of?" Is your "kind of" the
same as another person's? In summary, avoid the use of
these modifiers. If you are sure that the speaker only
feels "a little" whatever, use a different minimizer to
reduce the intensity. If you aren't sure, don't use a
minimzer at all.

Undercurrents. Sometimes the speaker will appear
to be having another feeling besides the one she is talking
about, the one she states. Let's look at an example:

 

Speaker: I didn't get asked to the dance by my boyfriend.
That makes me angry.

Listener: I hear you being really angry, but it also looks
like you're hurt.

While the speaker states she is angry, her tears
convey that she is sad or hurt. The listener picked up on
this, and responded to both the anger and the hurt. The
hurt is an undercurrent. Undercurrents are feelings that
the speaker may be experiencing, But that she has not yet
labeled or owned. Ways of picking up on this kind of
feeling include:

 

220

(l) watching non-verbal behavior and labeling
the feelings the speaker shows you but doesn't talk
about;

(2) imagining yourself in the speaker's shoes
and labeling what you think she might be feeling;

(3) using your understanding of "human nature"
to label what you suspect she might be feeling, given
the situation she describes.

CAUTIONlll. Labeling undercurrents is not to be confused
with telling the speaker how she should—feel. Telling the
speaker how she should feel is not helpful, and it will
stop her from eproring her feeIihgs with and trusting you
as quickly as your walking out of the room. Labeling
undercurrents only brings out feelings that the speaker
already a ears to be experiencing, or has hinted at, but
hasn't herseIf labeled.

 

Responding to stated and undercurrent feelings.
Once you can accurately label the feelings a speaker is
expressing, you can go on to responding to the speaker's
feelings.

Responding to feelings is different than responding
in the way most of us are used to responding to a person
sharing a concern with us: with solution responses,
situation responses, or with sympathetic responses.

 

 

Solution responses are listener statements that
tell the speaker fihat the listener thinks the speaker
should do to solve her problem. These are not helpful to
the speaker most of the time; they take the focus off of
the speaker, and place her in one-down position to the
listener (since the listener apparently knows what's best
for the speaker).

 

Situation responses are listener statements that
respond to what hasihappéned to or around the speaker.
They increase the amount of storyline and decrease the
amount of feelings the speaker will discuss.

Sympathetic responses are of the "That's too bad,"
or "You poor thing," varieties. They place the speaker in
a one-down position again, and don't do much for developing
the speaker's resources for dealing with her feelings.

 

Responses to feelings (or, gmpathic responses)
reflect, or mirror, the feelings you hear the speaker
expressing, using the same or similar specific feeling words
she used, in a declarative statement (n2£_in a question).

 

221

This is simply another form of feedback: Telling
the speaker what feelings you hear her expressing to you.
Empathic responses, given in a warm, caring, and acceptant
manner, let the speaker hear and focus on (sometimes for
the first time) what she has been saying, and tell her that
it's okay for her to continue expressing her feelings.

Again, when you respond empathically to a speaker,
you respond to the stated or undercurrent feelings, using
the same or similar words she used (or, with undercurrents,
implied). These are the types of responses we are asking
you to make in this training program.

How to Make an Empathic Response. We offer these
suggestions to give you a framework for responding to
feelings. Hopefully, they will help you develop your
empathic skills more quickly than if they were not here.
You will probably feel awkward using them at first, but
you will become more comfortable with them as you practice
your skills.

(1) Empathic openers. Empathic openers are ways
to tell the speaker that what you are about to say is
your impression of what she's been saying. They add ten-
tativeness to your responses, thereby leaving the speaker
some room to disagree with you. Some empathic openers you
could use are:

 

"You seem to be feeling
"It sounds like you feel
"I hear you saying you feel
"I get the impression you feel

 

 

 

(2) Keep your responses SHORTII Mince your words.
One sentence is idealiat this point.

 

(3) In any one response, respond to only one
feeling. Later, we'll talk about responding to conflicting
feelings and making summaries; then, we'll ask you to
respondtxrmore than one feeling. If the speaker talks
about more than one feeling, choose the last one mentioned,
93 the one that sounds predominant to you.

We have another scale for you to use to evaluate
your group members' (and your own!) empathic responses.
Please read over the scale.

222

Responding to Feelings Scale

 

LEVEL ONE--Listener responds to facts and information,
situation, or storyline.
--Listener does not respond to speaker's stated
feelings.
--Listener rejects and/or denies speaker's feelings
by judging, ridiculing, putting them down,
giving advice, or coming up with quick solutions.

LEVEL TWO-~Listener responds to the stated feelings of the
speaker, mirroring the feelings in the same or
similar specific feeling words.

--Listener is accepting of the speaker's feelings:
s/he does not deny, ridicule, or otherwise
reject the speaker's feelings.

--Listener's non-verbal behavior is attentive to
the speaker.

LEVEL THREE

--Listener responds to speaker's stated feelings,
and goes on to label undercurrents that are
implicit (though not actually stated) in the
speaker's statements.

--Listener emphasizes the intensity of the
speaker's feelings by using tone of voice,
gestures, and words which accent feelings.

Specific Labeling of Feelings with Sources

The purpose of this section is to help you polish
your skills in responding to feelings. We would like you
to continue to respondtfoeelings very specifically. We
would also like you to start connecting the specific
feelings with their respective sourcesixtsome of your
empathic responses.

Specific labeling of feelings with sources occurs
when a listener briefly summarizes the eventcn:situation
that has stimulated a feeling in the speaker, along with
reflecting the feeling itself. It's talking about both the
feeling and "where the feeling is coming from" in specific
terms. This can be extremely helpful to a speaker when
he is having a number of different feelings about a number
of facets of his concern. In that type of situation, it
is easy for both the speaker and the listener to be (or
become!) confused. Specifically labeling feelings with
their sources and reflecting these to the speaker can clarify
the speaker's feelings for both him and you.

223

As With labeling feelings specifically, there are
clear and vague ways to label sources. Let's look at some
examples of unspecific versus specific summaries of sources.

Speaker: I think I'm pregnant. I'm really worried about
what my parents will think.

Specific Response: You sound frightened about how your
parents might react ifyou'repregnant.

 

Unspecific Response: You sound worried about that.

 

"How your parents might react" is specific. It
spells out the situation the feeling "frightened" is
coming from.

"That" is vague and unclear, in that it doesn't
clarify what the speaker is worried about. It doesn't
tell the speaker that you've been listening.

Another example:

Speaker: My parents have been fighting and it really hurts
me to watch it.

Specific Response: You feel hurt when your parents fight.

Unspecific Response: You feel hurt when you see people
fight.

This response trades specific people for people-in—general.

The same thing can be done with situations. Both should

be avoided.

 

Finally:

Speaker: My sister broke my favorite record last night!
I was so mad at her I could've hit her!!!"

Specific Response: You felt really angry because she
broke your favorite record.

 

Unspecific Response: You felt mad because she did that.

So, in general, try to avoid vague source summaries
like "that," "when that happened," or "when people. . "
They don't help clarify a speaker's thoughts and feelings
as well as more specific source statements like the ones
above.

224

How to Respond to Feelings with Sources. As before,
there are a couple ofi"formulas" you can use to get
started.

"You feel because

"When ' , you feel/felt ' ."

 

As you become more adept at labeling feelings with sources,
you can develop more natural-sounding ways of responding.
Remember to keep your source summaries brief, so that your
responses stay short.

When to Respond to Feelings and Sources. During
this training program we will he asking you to respond to
feelings with their sources in the majority of your
responses. When you are actually listening to a client,
you will probably wish to reduce the number of feelings-
with-sources responses you make; since they can result in
overly-long responses. For now, we want you to become
skilled enough to be able to make these responses easily
and effectively. This is your practice time for developing
this skill. Later, we will discuss how and when you might
choose to respond to feelings with or without sources; for
now, please respond with sources as often as you can.

Please read over the following scale. As with the
other scales, we would like on to learn to respond at a
Level Two on this, the Speci ic Labeling of Feelings With
Sources Scale. Once you have read and become familiar with
the scale, go on to use the tape, as before.

Labeling of Feelings with Sources Scale

LEVEL ONE--Listener does not label speaker's feelings and/
or sources of the feelings.
--Listener moves the speaker away from.the feelings
and sources which are most important to him.
--Listener does not match the appropriate feelings
to the appropriate sources.
LEVEL TWO-~Listener responds to speaker's stated feelings
and sources by:
using abstract and general terms;
using the same or similar words that the

 

The examples in this section are taken from Trainin
Manual for COunseling_Skills. Washington, D.C. National
Drug Abuse Training Center, 1973, p. 24, 37, and 38.

 

225

speaker used;
matching the appropriate feelings to the
appropriate sources.

LEVEL THREE-~Listener labels specific feelings and speci-
fic sources for those feelings.
--Listener focuses on those feelings he sees
as most important to the speaker's concern.
--Listener reflects undercurrent feelings and
sources.

Responding to Conflicts in Speaker Feelings

A person is in conflict when she has one or more
pairs of opposing or incompatible feelings about a person,
action, or situation. For example, a man starting to date
one woman steadily may feel excited and afraid about
getting involved in this new relationship. Similarly, a
woman graduating from college may feel happy to be finished
with school, and sad to be leaving the familiar security
of the lifestyle she has known for four years.

Ambivalence--the experience of having opposing or
incompatible feelings about something--is unpleasant for
many of us. We feel uncomfortable, unsure, confused; we
have a hard time knowing who we are, what we feel, or what
we want to do about our continually changing feelings.

An important part of the helping process is sorting
out a speaker s conflict in her feelings. Until a person
knows and understands all of the feelings that are in
conflict, she cannot move towards resolving the conflict
in a satisfactory way--one which takes all of her feelings
into account.

Later in this training program. we will teach you
a specific model for helping a person decide upon a course
of action for dealing with her ambivalence, or conflict;
at this point, the skill we would like you to master
involves recognizin the ambivalence a speaker is expressing,
and responding to that ambivalence by accurately labeling
the feelings that are in conflict.

 

 

 

The first three examples in this section are taken
from.Traininnganua1 for Counseling Skills. Washington,
D.C.: National Drug Abuse Training Center, 1973.

226

Let's consider three speakers, each discussing a
personal conflict.

Speaker: I love my boyfriend and I really care about him,
but it's just too confining living with him. Our
relationship is not helping me grow as a person.
I want to leave, but it's hard to give him.up.

The feelings that are in conflict here are caring
and love versus feeling confined and stagnant. Later,
she wiIl probably decide between wanting to leave and
wanting to stay, but right now she needs to clarify the
feelings that lead to wanting to stay or to go.

Let's look at another example:

Speaker: I want to quit my job, because I can't stand
working for that S.O.B. any longer. I need to
get out, but there's no place to go. I've
looked around for jobs, but this town's dry. It
gets me down to look for a job.

Here, the feelings in conflict are feeling frustrated with
his job and feeling depressed and hopEless ahout finding

a new job. Again, later, this man will decide whether or

not he will actually quit his job; but right now, he needs
to have the feelings that lead to his choice clarified.

In the next example, you label the feelings that
are in conflict.

Speaker: I want to go with you all on the trip since it
would be great to get away and relax, but I just
can't stand Joe. He just irritates the hell out
of me. I don't know what to tell you.

The feelings in conflict are:

versus

 

 

Later, what might this person need to decide once he
clarifies his feelings?

Throughout these examples, we have talked about
the speaker's need to make a decision, at a later time in
the helping process, about what she wants to do. This was
done to separate out the feelings from the "wants" and/or
action plans the speaker expressed. It is important to
resist the urge to label conflicts in terms of simply
wanting versus n25 wanting something, doing versus npp

 

227

doing something, or feeling versus not feeling something
about the same situation. For example:

Speaker: I don't know whether to leave school or not.
I‘m not doing that well. But to go away from
here, and leave my friends, is pretty scary.

Listener: It sounds like you're pretty confused about
whether or not to leave school.

This response is true, and accurate, and the speaker will
probably go on to discuss his concern more fully. How-
ever, it does not add to the speaker's understanding of
the conflict. It doesn't really clarify his feelings. A
response that would be more likelyix>do so might be:

Listener: It sounds like on the one hand, you feel
unsuccessful in school, but on the other hand,
you're afraid to leave its familiarity.

Responding to the feelings that areixiconflict, along with
their sources, will facilitate the speaker's self-explor-
ation, and give him.more information to work with in
problem-solving.

In summary, ambivalence causes psychological
discomfort. The first step in dealing with this discomfort
is to label the feelings that are involved in the conflict,
along with each feeling's source. This will bring the
conflict into focus, and clarify it. Then, using her
'more complete awareness of her feelings, the speaker can
go on to consider alternative ways of acting to reduce or
eliminate the discomfort.

As inthe_preceding sections, there is a scale with
which we can evaluate responses to conflicts in speakers'
feelings. Please read over and discuss this scale with
your group.

Responding to Conflicts in Speaker's Feelings

LEVEL ONE--Listener does not respond to the conflicts in
the speaker's feelings, but rather, responds
to the situation.

--Listener points out conflicts in the speaker's
feelings in a judgmental way.

LEVEL TWO--Listener recognizes and reflects the conflicting
feelings the speaker expresses.

228

--Listener labels the conflict in speaker's
feelings in terms of "wanting/not wanting"
or "feeling/not feeling" something.

--Listener accurately points out the conflicts
in a speaker's feelings in a non-judgmental
'way.

LEVEL THREE--Listener responds to conflicting feelings
that were actually stated by the speakers,
and goes on to point out undercurrent
feelings the speaker appears to be having.

--Listener responds to feeling conflicts by
using examples from experiences the speaker
has described.

 

Owning of Listener Feelings

We've stressed the importance of being non-judg-
mental, non-possesively caring, and otherwise non-directive
in respondingto your speaker. ‘Most of the time, this
will probably not be too difficult for you as you use the
skills you've learned. Sometimes, however, you may have
a reaction to the speaker that impedes your ability to
respond to her/him.inaihelpful way. The purpose of this
section is to give you some guidelines for and practice
in dealing with those kinds of reactions in a manner that
continues to help your speaker.

Listener roadblocks are those situations that you
come up agaihst in which you have difficulty listening
and/or responding empathically because of the im act that
the speaker is having on you. Some examples 0 roa blocks
are:

feeling unable to formulate a response

feeling confused about what the speaker is trying
to tell. you

feeling defensive when you respond

feeling very sympathetic toward the speaker

The root of a roadblock is a feelin you are experiencing.
The first step in moving a roathocE is to own your feeling
internally.

 

 

Let's look at an example:

Speaker: I really don't think my parents love me. They
always put me down when I try to talk with them.

Listener: They must love you!

229

(That was a defensive response, I wonder what's
going on with me? I know! Whenever anyone talks
about their parents, I think about mine and that
HURTS.)

Because the listener wasn't paying attention to
his own feelings, he responded defensively. By being
more aware of his feelings and labeling them for himself,
his response could have been like this:

Speaker: I really don't think my parents love me. They
always put me down when I try to talk with them.

Listener: (There are knots in my stomach, I wonder why?
Ah ha! My parents do that too and it hurts me.)
It sounds like it hurts you a lot when your
parents don't listen to you.

Here, the listener paid attention to and labeled
his own feelings, decided that his emotional response to
the situation the speaker was describing was probably
similar to her own feeling response and used his labeled
feeling as an undercurrent feeling label in responding to
the s eaker. In this case, not only did the listener own
his feeIing, but he was able to mpg that in helping the
speaker deal with n25 feelings.

In summary, when you have a feeling reaction to
what your speaker is discussing, own the feeling, label
it, and decide if he probably is experiencing this as an
undercurrent. If so, try labeling the feeling as an under-
current when you respond to the speaker.

If you think that your feeling reaction is basic-
ally personal and idiosyncratic, you can put your feeling
aside and go on to listen and respond to what the speaker
is saying he is feeling, rather than using your feeling
reaction in responding.

Another type of listener roadblock occurs when a
speaker says something that confuses you. For example:

 

Speaker: I can't seemtxaget out of this depression. Well,
it's not a depression because. . .anyway, going
to school and working at the same time.
never get to have, uh, well, I guess sometimes
I do okay. It's just that I want to get
away. . .no, not get away, just rest. Maybe I
could quit school.

The moral of this story is: own your confusion and ask
for clarification!

230

Finally, there is a class of roadblocks that can
be pretty tricky to deal with. These roadblocks occur
when you have a reaction to something the speaker is
saying or doing here and now, and that reaction is getting
in your way.

Speaker: I want you to give me some answer right now!
That's why I came here.

Listener: (I feel like I'm getting a lot of pressure to
solve the speaker's problem.) I'm feeling a
lot of pressure from you to find some quick
answers. I guess I want to check that out with
you because it seemstx>be getting in the way of
your working on your problem.

By labeling the feeling "pressured" and discussing the
speaker's here and now impact on her, the listener was
able to go on to share her reaction and put the focus
back onto the speaker for finding answers to his problems.

A variation of this kind of roadblock occurs when
you suspect that the listener has the same impact on
other people in his life that he is having on you. In
this situation, you can own your reaction, and ask the
speaker to examine his style of interacting with you and/
or others which may contribute to his concerns.

Speaker: (Loudly) I guess that my parents really hurt
me a lot when they tell me they don't like the
way I live!

Listener: I hear the pain coming from.your parents, but I
also hear that you're plenty mad at them, too.

Speaker: (Softly) No, I'm not angry, I just feel like
my parents really hurt me a lot and I can't do
anything. You know, they just keep putting me
down.

Listener: It sounds like you feel pretty helpless.

Speaker: (Crying) Sure. I mean, hOW’WOUId you feel if
your parents didn't love you? I just hurt all
the time.

Listener: I'm feeling like I really want to protect you
now because you seem so helpless. I wonder if
that's the way you relate to other people?

231

Finally, a listener roadblock that often occurs
when we're just starting to respond empathically is
expecting ourselves to be perfect, and being overly crit-
ical of any mistakes we make. Give yourself room to be
less-than-perfect; recognize your mistakes without being
harshly judgmental of yourself as a listener. When you
make a mistake as a listener, the speaker will usually
try to help you out by clarifying what she said or meant.
You will get another chance to label the feeling or con-
flict accurately!

Now, we are going to give you some practice in
owning your feelings as a listener. Close your eyes and
listen to each of the speakers on the tape your trainers
will play. Pretend that each speaker is talking directly
to you: that you said something to them, and this is
their immediate responsetx>you. Then, own your feelings,
using the "Owning of Feelings Scale" as a guide. The
following questions may help you to own your feelings:

What did the speaker say?

What did s/he feel toward me?

What are my symptoms?

What feeling labels would I put on these symptoms?
What's the source of my feeling?

Once you've owned your feeling, decide what you
would say to the speaker. Some questions to consider in
formulating your response are:

Will it help our interaction if I own my feelings?

Can I own my feelings and put the focus back on the
speaker?

Is the speaker trying to manipulate me?

Do I think it would be valuable for the speaker, or
me, to discuss the impact s/he is having on me?

Discuss your feelings, and your responses to the
speaker, with your group.

232

Is Help Helpful?

by
Jack R. Gibb

People in the service profession often see them-
selves as primarily engaged in the job of helping others.
Helping becomes both the personal style of life and a
core activity that gives meaning and purpose to the life
of the professional. The youth worker, the camp director,
the counselor, the consultant, the therapist, the teacher,
the lawyer--each is a helper.

Helping is a central social process. The den
mother, the committee chairman, the parent, the personal
friend, the board member, the dance sponsor-~each is a
helper.

Help, however, is not always helpful. The reci-
pient of the proffered help may not see it as useful. The
offering may not lead to greater satisfaction or to better
performance. Even less often does the helping process
‘meet a more rigorous criterion--1ead to continued growth
on the part of the participants.

To begin with, a person may have varied motivations
for offering help. He may wish to improve performance of
a subordinate, reduce his own guilt, obtain gratitude,
make someone happy, or give meaning to his own life. He
may wish to demonstrate his superior skill or knowledge,
induce indebtedness, control others, establish dependency,
punish others, or simply meet a job prescription. These
conscious or partially conscious motivations are so inter-
mingled in any act of help that it is impossible for either
the helper or the recipient to sort them out.

Depending upon his own needs and upon the way he
sees the motives of the helper, the recipient will have
varied reactions. He may feel helpless and dependent, or
jealous of the helper who has the strength or resources
to be in the helper role. He may feel indebted, or
pressured to conform to the perceived demands or beliefs
of the helper.

We have all noticed that in certain cases the
recipient of the help becomes more helpless and dependent,
less able to make his own decision or initiate his own

233

actions, less self-sufficient, more apathetic and passive,
less willing to take risks, more concerned about propriety
and conformity, and less creative and venturesome. We

have also seen circumstances in which, following help,
recipients become more creative, less dependent upon
helpers, more willing to make risk decisions, more highly
motivatedtxntackle tough problems, less concerned about
conformity, and more effective at working independently

or inter-dependently. Help may or may not lead to personal
growth and organizational health.

Under certain conditions both the giver and the
receiver grow and develop. In general people tend to grow
when there is reciprocal dependence--interdependence,
joint determination of goals, real communication in depth,
and reciprocal trust. To the degree that these conditions
are absent, people fail to grow.

From the standpoint of the organization, help must
meet two criteria: the job or program must be done more
effectively, and the individual members must grow and
develop. These two criteria tend to merge. The program
and the organization are effective only as the participants
grow. The same conditions that lead to organizational
health lead to personal growth. The following table
presents a theory of the helping relationship. Seven
parallel sets of orientations are presented. One set of
conditions maximize help and a parallel set of conditions
minimize help.

TABLE l--The Helping Relationship

 

 

 

Orientations that help Orientations that hinder
l. Reciprocal trust (EOnfi- l. Distrust (féar, puni-
dence, warmth, acceptance) tiveness, defensiveness)
2. Cooperative learning (in- 2. Teaching (training, ad-
quiry, exploration, quest) vice giving, indoctrin-
ating)
3. Mutual growth (becoming, 3. Evaluating (fixing, cor-
actualizing, fulfilling) recting, providing a
remedy)
4. Reciprocal openness (spon- 4. Strategy (planning for
taneity, candor, honesty) ‘maneuvering, gamemahdhip)
5. Shared problem solving 5. Modeling (demonstration,
(defining, producing alter- information giving,
natives, testing) guiding)
6. Autonomy (freedom, inter- 6. Coaching (molding,
dependency, equality) steering, controlling)
7. Experimentation (play, 7. Patterning (standard,

innovation, provisional. try) static, fixed)

234

Reciprocal Trust. People accept help from those
they trust. When the relationship is one of acceptance
and trust, offers of help are appreciated, listened to,
seen as potentially helpful, and often acted upon. The
receiver accepts help from one whose perceived motives
are congenial to him. He tends to reject offers from
people whose offering is seen as a guise for attempts to
control, punish, correct, or gain power. "Help" is most
helpful when given in an atmosphere in which people have
reciprocal feelings of confidence, warmth, and acceptance.
When one feels that his worth as a person is valued he is
able to place himself in psychological readiness to
receive aid.

Distrust. When people fear and distrust each
other, even weII-intended help is resisted, resented, or
seen as unhelpful. Offers of help are sometimes given
in service of motivations that are unacceptable to the
receiver. That is, one offers help in order to place the
other person in a dependent position, elicit expressions
of gratitude, assert one's superiority, or punish him.

In distrust the recipient's guard is up. He is likely to
project his distrusts into the helper and to resist or
resent the help.

One often gives help to camouflage or assuage
his desiretx>change another person--change his character,
habits, or misconceptions. The desire to change another
person is essentially hostile. At a deep level, one who
genuinely accepts another person does not wish to change
him. A person who is accepted is allowed to be, to become,
determine his own goals and follow them at his own pace.
The person who genuinely wishes to help offers the help
that the recipient wishes. Genuine help is not foisted
upon the receiver. Neither the punisher nor the child
really believes that the punishment is given "for the
good of the child." Punishment or censure may be given
with a conscious desire to help but usually is accompanied
by a deep component of retaliation, or by a desire to hurt,
control, or assert superiority. The giver often speaks
of his act as "helpful" in order to rationalize to himself
and to the receiver acts that are done for other motiva-
tions.

Coqperative learning. People are helpful to each
other when they are engaged in a cooperative quest for
learning. The learning atmosphere is one of joint inquiry
and exploration. Needs for help and impulses to give help
arise out of the demands of the common cooperative task.

235

Help is thus reciprocal. The helper and helpee roles are
interchangeable. Each participant has the intent to learn
and feels he can learn from the partners and from.the
common task. The boss and the subordinate, the teacher
and the student, the professional worker and the youth--
all are most helpful when each member of the pair sees

the relationship as a quest with potential learning for
each. An effective project team is guided by the task

and not by the teacher. It is motivated by the shared
potential for learning.

Teachin . When one participant in a project sets
out to teach, train, advise, persuade, or indoctrinate the
other members or is seen as wanting to do so, the learning
of each member is reduced. People cannot be taught.
People must learn. People cannot be trained. They grow
and develop. The most deeply helpful relationship is one
of common inquiry and quest, a relationship between co-
learners and co-managers in which each is equally depend-
ent upon the other for significant help and in which each
sees and accepts this relationship.

Mutual Growth. The most permanent and significant
help occurs in a relationship in which both members are
continually growing, becoming and seeking fulfillment.

Each member participates in a mutual assessment of progress,
accepts this reality of growth, and participates in a way
that will maximize the growth of both participants. In a
fundamental sense one can only help himself. The helper
can only participate with another in an effort to create

a climate in which growth can occur.

 

Evaluatin . Growth is often hindered when one
member of the heIping team sets out to appraise or remedy
the defects in the other member. Help is most effective
when it is seen as a force moving toward growth rather
than as an effort to remove gaps, remedy defects or bring
another person up to a standard criterion. The limits of
growth of any person are extremely difficult to foresee
or to assess. The potential for growth is consistently
underestimated by both participants in helping relation-
ships.

Reciprocal openness. One of the essential condi-
tions for effective human learning is the opportunity for
feedback of knowledge of progress. Feedback is essential
in acquiring skills, knowledge, and attitudes. In the
areas where professional help is most commonly sought or
given, the essential progress in learning and growth is

 

236

blocked most often by the failure to obtain adequate data
on people's feelings and perceptions of each other. In
order to do effective work, one must know how others feel
and how they see things. In the usual situations in which
professional helpers find themselves, there are many
pressures which camouflage or distort the relevant data
necessary for efficient work and best learning. Many
factors reduce the availability of the relevant data;
differential status, differential perceived power, and
fears that one can hurt or be hurt.

Strate . When some part of the helping process
is close or unavailable to all participants, people are
likely to become anxious, resentful, or resistant. Neither
participant in the helping process can "use" the other for
his own needs. The helping process is most effective when
one plans with another, not for another. One is not helped
when he is maneuvered into some action which he does not
understand. Gamesmanship and gimmicks are antithetical
to the helping process.

Shared Problem Solving. The productive helping
relationships focus upon the problem to be solved. Problem
solving involves a joint determination of the problem,
continual redefinition of the problem as successive
insights are gained, joint focus upon possible alternative
solutions, joint exploration of the data, and continual
reality testing of the alternatives. The expertness and
resources of each person are shared. The aspect of the
behavior about which help is given is seen as a shared
problem--not as a defect to be remedied or as something
to be solved by the helper as consultant.

Modelin . A common image of the helping relation-
ship is one where the helper offers a model for the advisee
to follow. The expert gives a demonstration of how the
recipient may solve his problems. The problem is defined
by the expert. Diagnosis is made by the expert. The
expert is challenged to offer additional alternatives to
the solution of the problem.and perhaps even to test the
solutions. The process in uni-directional. The limita—
tions of modeling are many. Dependency is increased. The
pupil seldom gives better than the model. The worker tries
to conform to the image of the supervisor. Growth is
limited.

Autonom . The ideal relationship for helping is
an inter epen ent one in which each person sees the other
as both helper and recipient in an exchange among equals.

237

It is essential that each participant preserve his freedom
and maintain his autonomous responsibility for guiding
himself toward his own learnings, growth, and problem
solving. The helper must work himself out of the helping
job. The supervisor, youth worker, and counselor must
become decreasingly necessary to the people being helped.
Psychological weaning, however painful to both helper and
recipient, must continue if help is to be truly helpful.

Coachin . The coach molds, steers, or controls
the behavior of the recipient, much as a tennis coach or
physical education director molds the behavior of the
athlete or skill-directed recipient of help. This is
another uni-directional process in which the coach is
assumed to have special diagnostic and observational powers
which he applies in a skilled way to the behavior of the
recipient, who puts himself in the hands of the coach.

The recipient of help is encouraged to maintain respectful
dependency upon the coach, to not challenge his coaching
or expertness, to put implicit trust in his abilities and
powers, and to receive from the coach motivational or
inspirational guidance. Both coach and pupil suffer under
this pattern. Each may gain in skill. Neither grows as

a person.

Experimentation. Tentativeness and innovative
experimentation are characteristic of the most productive
helping relationship. There is a sense of play, excite-
ment, and fun in the common exploratory quest for new
solutions to continually changing problems. The helping
process is viewed as a series of provisional trials. Each
participant joins in the game and adds to the general
excitement. Errors can be made--and are perhaps expected.
Help is a search. Finding creative solutions to newly
defined problems is a game--full of zest and intrinsic
drives that keep the game going.

 

Patterning. Help is lbmited when the process is
seen as an attempt on the part of one person to help
another meet a prescribed standard, come up to a criterion,
or reach a goal specified in advance. Helping is a crea-
Eive synthesis of growth and a continual search for new

orms.

 

"Help" is not always helpful--but it can be. Both
the helper and the recipient can grow and learn when help
is given in a relationship of trust, joint inquiry,
openness, and interdependence. Growth-centered helping
processes leadtx>healthy groups and effective organizations.

238

Communication
Some general aspects of communication are:

1. You can't communicate. You are always sending out
messages.
2. Message sent is not necessarily message received.
3. Communication is a complex process. There are
three main aspects of communication:
a. The content. What the words are.
b. Process. How the words were said.
c. Context. Where and to whom the words are said.

Eight Communication Hang-Ups
These hang-ups result in communication break-downs:

l. Incongruence between levels of communication.

a. Verbal-nonverbal. Saying one thing with your words
and another with your tone of voice and body.

b. A statement made in the form of a question: "Don't
you really think that you're being unreasonable
about this?"

c. A statement in the form of a joke. Not really
saying what you mean but giving a dig in the form
of a joke.

2. Vague and unclear communication.

a. A shift in time, place: "I don't like that," but
saying, "we don't like that." A shift back to
something that happened before when dealing with
something that is going on between two persons now.

b. Vague statements like "you know how I feel." "I've
told you about that."

3. Not giving feedback.
a. What I hear you saying is this. . .is that what
you are saying?
b. You are coming across to me like this.

4. Not acknowledging that a message has been sent.
"I see that you want to say something but can't get
to it right now."
"I'll come back to it."
"I hear you."

5. Not distinguishing between fact and opinion; almost
nothing about interpersonal relationships is a fact.
"Why are you so unreasonable?"

"Why are you so insensitive?"

239

Not owning your feelings, thoughts and behaviors.
This results in the "blame game." If you just share
how you feel (think) so that the other person can
then deal with whether he really wants you to feel
(think) that way. For example, say "I am beginning
to feel bad," rather than "you make me feel bad,"

which results in the blame game. "You make me angry."
"You are getting me upset." "It is your fault that
I act this way." "You make me do that."

Disqualification of another's thoughts, feelings,
beliefs or behavior which really is a way of saying
you do not count as a person because I can pretend
that you do not exist. "How can anyone belong to that
political party?" Ignoring that another person is
trying to get your attention to ask for something.
"You)really don't hate me” (disqualification of feel—
ings .

Not checking out assumptions.

a. Assuming why another person is acting a certain
way-~ggt checking it out--and then acting on it.

b. Assuming how another feels without really finding
out.

240

Summagy of Basic Communication Skills
*For Improving Integpersonal
Relationships

1. PARAPHRASE: Letting the speaker know what meaning
his remark conveys to you.

Exam les: "Do you mean. . .(this)?" "Is this.
(statement). . .an accurate understanding of your
idea?" "Would this be an example of your point?.
(then stating a specific example)."

2. BEHAVIOR DESCRIPTION: Describing specific, observable
actions of others as contrasted with stating inferences,
accusations or generalizations about their motives,
personality or character traits.

Exam 1e: "Jim and Harry have done nearly all the
talking and the rest of us said very little," NOT
"Jim and Harry just have to have the spotlight on
them all the time."

3. DESCRIPTION OF FEELINGS: Identifying feelings by (a)
name, (b) simile, or (c) action urge.

Describing your own feelings.

Example: "I feel embarrassed." (naming)

"I'm very fond of you." (naming)

"I feel like a tiny frog in a huge pond.”
(simile)

"I'd like to hug you and hug you." (action
urge)

Perception check: Describing what you perceive the
other is feeling in order to check whether you do
understand what he feels.

Examples: "You look like you felt hurt by my comment.
Did you?"
"I get the impression you'd like to change
the subject. Is that accurate?"
"You seem to be feeling more at home now."

To Understand the Other as a Person

--Check to make sure you understand his ideas, infor-
mation and suggestions as he intended them” (skill:
paraphrase)

241

--Check to make sure you accurately understand what
he feels. (skill: perception check)

To Help Others Understand You as a Person

 

--Describe what others did that affects you personally
or as a group member. (skill: behavior description)

 

--Let others know clearly what you are feeling. (skill:
description of your own feelings)

--John Wallen

242

Paraphrase

 

A Basic Communication Skill for Improving
Interpersonal Relationships

The Problem

 

Tell somebody your phone number and he will usually
repeat it to make sure he heard it correctly. However, if
you make a complicated statement most people will express
agreement or disagreement without trying to insure that
they are responding to what you intended. Most people
seem to assume that what they understand from a statement
is what the other intended.

How do you check to make sure that you understand
another person's ideas, information, or suggestions as he
intended them? How do you know that his remark means the
same to you as it does to him?

Of course, you can get the other erson to clarify his
remark, by asking, "What do you mean?‘ or "Tell me more,"
or by saying, "I don't understand." However, after he has
elaborated you still face the same question: "Am I
understanding his idea as he intended it to be understood?"
Your feeling of certainty is no evidence that you do in
fact understand (see "On Misunderstanding").

The Skill

 

If you state in your own way what his remark conveys
to you, the other can begintx>determine whether his message
is coming through as he intended. Then if he thinks you
misunderstand, he can speak directly to the specific
misunderstanding you have revealed. I will use the term
"paraphrase" for anypmeans of showing the other person
what his idea or suggestion means to you.

 

 

Paraphrasing, then, is any way of revealing your under-
standing of the other person's comment in order to test
your understanding.

An additional benefit of paraphrasing is that it lets
the other know that you are interested in him. It is
evidence that you do want to understand what he means.

243

If you can satisfy the other that you really do
understand his point, he will probably be more willing to
attempt to understand your views.

Paraphrasing, thus, is crucial in attempting to
bridge the interpersonal gap. (a) It increases the accuracy
of communication, and thus the degree of mutual or shared
understanding. (b) The act of paraphrasing itself conveys
feeling—-your interest in the other, your concern to see
how he views things.

Learning to Paraphrase

People sometimes think of paraphrasing as merely
putting the other person's ideas in another way. They try
to say the same thing with different words. Such word-
swapping may merely result in the illusion of mutual under-
standing as in the following example.

Sarah: Jim should never have become a teacher.
Fred: You mean teaching isn't the right job for him?
Sarah: Exactly! Teaching is not the right job for Jim.

Instead of trying to re-word Sarah's statement Fred
might have asked himself, "What does Sarah's statement mean
to me?" In that case the interchange might have sounded
like this.

Sarah: Jim should never have become a teacher.

Fred: You mean he is too harsh on the children? Maybe
even cruel?

Sarah: Oh, no. I meant that he has such expensive tastes
that he can't ever earn enough as a teacher.

Fred: Oh, I see. You think he should have gone into a
field that would have insured him a higher standard
of living.

Sarah: Exactly! Teaching is not the right job for Jim.

Effective paraphrasing is not a trick or a verbal
gimmick. It comes from an attitude, a desire to know what
the other means. And to satisfy this desire whether it
matches the meaning he intended to convey.

If the other's statement was general, it may
convey something specific to you.

Larry: I think this is a very poor textbook.

You: Do you mean it has too many inaccuracies?

Larry: No, the text is accurate, but the book comes apart
too easily.

244

Possibly the other's comment suggests an eXample

to you.

Laura: This text has too many omissions; we shouldn't
adopt it.

You: Do you mean, for example, that it contains nothing
about the Negro's role in the development of
America?

Laura: Yes, that's one example. It also lacks any discus-
sion of the development of the arts in America.

If the speaker's comment was very specific, it
may convey a more general idea to you.

 

Ralph: Do you have 25 pencils I can borrow for my class?

You: Do you just want something for them to write with?
I have about 15 ball point pens and 10 or 11 pen-
cils.

Ralph: Anything that will write will do.

Sometimes the other's idea will suggest its inverse
or opposite to you.

Stanley: I think the Teacher's Union acts so irresponsibly
because the administration has ignored them.so
long.

You: Do you mean that the T.U. would be less militant
now if the administration had consulted with them
in the past?

Stanley: Certainly. I think the T.U. is being forced to
more and more desperate measures.

To develop your skill in understanding others, try
different ways of (a) conve ing your interest in under-
standing what they mean, (b revealing what the other's
statements mean to you. Find out what kinds of responses
are helpful ways of paraphrasing for you.

The next time someone is angry with you or is criti-
cizing you, try to paraphrase until you can demonstrate
that you understand what he is trying to convey as he
intends it. What effect does this have on your feelings
and on his?

--John L. Wallen

245

Behavior DescriptiOn

 

A Basic Communication Skill for Improving
Interpersonal Relationships

The Problem

 

If you and another person are to improve the way
you get along together, you must be able to convey what
each does that affects the other. This is not easy. Must
of us do not describe behavior clearly enough for others
to know what actions we have in mind. Instead, we usually
state what we infer about his motivations, attitudes and
personality traits; often we are not even aware we are
inferring rather than describing. Because we are so used
to inferring we may not even know what the other did that
led to our inferences.

The skill of behavior description, then, depends
upon accurate observation which, in turn, depends upon
being aware of when you are describing and of when you are
inferring.

The Skill

 

A statement must pass two tests to be a behavior
description.

1. A behavior description reports specific, observable
actions rather than inferences or generalizations
ahout the person's motives, feelings, attitudes or
personality traits. It states what was observed. It
does not infer about why.

 

 

 

Behavior Descriptions Inferences
Fran walked out of the meet- Fran was annoyed.
ing 30 minutes before it was Fran had an appointment
finished. elsewhere.

Bob's eyes filled with tears. Bob had a cold.
Bob felt sorry for himself.

Becky did not say anything Becky did not hear Bill.
when Bill asked her a ques- Becky resented Bill's
tion. question.

Becky was embarrassed.

246

2. A behavior description is non-evaluative:

it does not

say or imply what happened was good or had, right or

wrong.

Evaluative statements (such as name calling,

accusations, judgments) usually express what the
speaker is feeling and convey little about what behav-

ior he observed.

Behavior Descriptions

 

Jim talked more than others
on this topic. Several times
he out others off before they
finished.

"Bob, you've taken the oppo-
site of most statements
Harry has made today."

Fran walked out of the
meeting 30 minutes before
it was finished.

"Sam, you cut in before I
finished."

Evaluative Statements

 

Jim is rude.
Jim wants to hog the center
of attention.

"Bob, you're just trying to
show Harry up."

Fran is irresponsible.
Fran doesn't care about
others.

"Sam, you deliberately
didn't let me finish.‘

The word "deliberately" implies that Sam knowingly and

intentionally cut you off.

All anybody can observe is

that he did cut in before you had finished.

As an example of the difference a behavior description
may make, let's suppose you tell me I am.rude (a general-
ized trait) or that I don't care about your feelings (an

inference about my motivation).

Because I am not trying

to be rude and because I feel I do care about your
feelings, I don't know what the basis is for your negative

evaluation of me.
a shared understanding.

We certainly have not moved closer to
However, if you point out that

several times in the past few minutes I have interrupted
you and have overridden you before you could finish what
you were saying, I get a clearer picture of what actions

of mine were affecting you.

Several members of his group had told Ben that he was

too arrogant.
judgment.

Ben was confused and puzzled by this
He was confused because he didn't know what to
do about it; he didn't know what it referred to.

He‘was

puzzled because he didn't feel arrogant or scornful of

the others.
and unsure of himself.

In fact, he admitted he really felt nervous
Finally, Joe said that Ben often

laughed explosively after Ben made a comment that seemed

247

to have no humorous aspects. Others immediately agreed
this was the behavior that led them to perceive Ben as
looking down on them and, therefore, arrogant. Ben said
he had not been aware of this.

The pattern, thus, was as follows. When he made a
statement of which he was somewhat unsure, Ben felt

insecure. . . .Ben's feelings of insecurity expressed

themselves in an explosive laugh after he made the state-
ment. . . .the other person perceived Ben as laughing at
him. . .the other person felt put down and humilitated.. .

the other's feeling of humiliation was expressed in the
accusation that Ben was arrogant. Note that Ben had no
awareness of his own behavior (the laugh) which was being
‘misread until Joe accurately described what Ben was doing.
Ben could then see that his laugh was a way of attempting
to c0pe with his own feelings of insecurity.

To develop skill in describing behavior you must
sharpen your observation of what actually did occur. You
must force yourself to pay attention to what is observable
and to hold inferences in abeyance. As you practice this
you may find that many of your conclusions about others
are based less on observable evidence than on your own
feelings of affection, insecurity, irritation, jealousy,
or fear. For example, accusations that attribute undesir-
able motives to another are usually expressions of the
speaker's negative feelings toward the other.

--John L. Wallen

248

Description of Feelings

A Basic Communication Skill for Improving
Interpersonal Relationships

The Problem

To communicate your own feelings accurately or
to understand those of others is difficult.

First, expressions of emotion take many different
forms. Feelings can express themselves in bodily changes,
in action, and in words (see attached diagram).

Second, any specific expression of feeling may
come from very different feelings. A blush, for example,
may indicate that the person is feeling pleased, but it
may also indicate that he feels annoyed, or embarrassed,
or uneasy.

Likewise, a specific feeling does not always get
expressed in the same way. For example, a child's feeling
of affection for his teacher may lead him to blush when
she walks around the room, to tell her "you're nice," to
bring his pet turtle to show* her, etc.,--different forms
of expression for the child's feeling of affection.

Communication of feelings, thus, is often inaccur-
ate or even misleading. What looks like an expression of
anger, for example, often turns out to result from hurt
feelings or from.fear.

A further obstacle to the accurate communication
of feelings is that your perception of what another is
feeling is based on so many different kinds of information.
When somebody speaks, you notice more than just the words
he says. You note his gestures, voice tone, posture,
facial expression, etc. In addition you are aware of the
immediate present situation--the context in which the
interaction is occurring. You are aware of whether some-
body is watching, for example. And so you make assumptions
about how the situation influences what the other is
feeling. Beyond all of this you also have expectations
based on your past experiences with the other.

You make inferences from all of this information-—
his words, nonverbal cues, the situational context, your
expectations of the other. These inferences are influenced
by your own current emotional state. What you perceive

249

the other to be feeling, then, often depends upon what

you are feeling (e.g., to be afraid of or wishing for)

than upon the other person's actions or words. For example,
if you are feeling guilty about something, you may perceive
others as angry with you. If you are feeling depressed

and discouraged about yourself, others may seem to be
expressing disapproval of you.

And so--communicating your own and understanding
the feelings of others isaulextremely difficult task.
And yet, if you wish others to respond to you as a person,
you must help them understand how you feel. Likewise, if
you are concerned about the other as a person and about
your relationship with him, you must try to understand his
emotional reactions.

The Skill

 

Although we usually try to describe our ideas
clearly and accurately, we often do not try to describe
our feelings clearly. Feelings get expressed in many
different ways, but we do not usually attempt to identify
the feeling itself.

 

One way to describe a feeling is to identify or
name it. "I feel angry." "I feel embarrassed." "I feel
comfortable with you." However, we do not have enough
names or labels to emcompass the broad range of human
emotions, and so we invent other ways to describe our
feelings, such as the use of similes. "I feel like a tiny
frog in a huge pond." A girl whose friendly overture had
just been rebuffed said, "I feel like I have just had an
arm amputated."

A third way to describe a feeling is to report
what kind of action the feeling urges you to do. "I feel
like hugging and hugging you." "I'd like to slap you."
"I wish I could walk off and leave you."

In addition, many figures of speech serve as
descriptions of feeling. "I just swallowed a bushel of
spring sunshine."

Describing Your Own Feelings

You try to make clear what feelings you are exper-
iencing by identifying them. The statement must (a) refer
to "I," "me," or "my," and (b) specify some kind of feeling
by name, simile, action urge or other figure of speech.

250

The following examples show the relation between
two kinds of expressions of feeling: (a) those that
describe what the speaker is feeling, and (b) those that
do not. Notice that expressions of feeling which describe
the speaker's emotional state are more precise, less capa-
ble of misinterpretation, and thus, convey more accurately
what feelings are affecting the speaker.

 

 

 

 

 

Expressing feeling by des- Expressing feeling without
cribing your emotional describing your emotional
state state

”I feel embarrassed." Blushing and saying nothing.

"I feel pleased."
"I feel annoyed."

"I feel angry!" Suddenly becoming silent
"I'm worried about this." in the midst of conversa-
"I feel hurt by what you tion.

said."

"I enjoy her sense of humor." "She's a wonderful person."
"I respect her abilities and

competence."

"I love her but I feel I
shouldn't say so."

"I hurt too much to hear "Shut up!!!"
any more."

"I feel angry with myself."

"I'm angry with you.‘

Where emotional states express themselves simultan-
eously in words, in actions, through physiological changes,
a person may convey contradictory messages about what he
is feeling. For example, his actions (a smile or laugh)
may contradict his words (that he is angry). The clearest
emotional communication occurs when the speaker's descrip-
tion of what he is feeling matches and, thus, amplifies
what is being conveyed by his actions and other nonverbal
expressions of feeling.

The aim in describing your own feelings is to
start a dialogue that will improve your relationship with
the other. After all, others need to know how you feel if
they are to take your feelings into account. Negative
feelings are indicator signals that something may be going
wrong in a relationship with another person. To ignore
negative feelings is like ignoring a warning light that
indicates that an electrical circuit is overloaded. '

251

Negative feelings are a signal that the two of you need
to check for misunderstanding and faulty communications.

After discussing how each of you sees the situation
in your relationship, you may discover that your feelings
resulted from false perceptions of the situation and of
his motives. In this case, your feelings would probably
change. However, the other may discover that his actions
are arousing feeling in you that he wasn't aware of--
feelings that others beside you might experience in response
to his behavior--and he may change.

In short, describing your feelings should not be
an effort to coerce the other into changing so that you
won't feel as you do. Rather you report your inner state
as just one more piece of information that is necessary
if the two of you are to understand and improve your rela-
tionship.

Perception Check

You describe what you perceive to be the other's
inner state in order to check whether you do understand
what he feels. That is, you test to see whether you have
decoded his expressions of feeling accurately. You trans-
form his expressions of feeling into a tentative descrip-
tion of hi§'feeling. A good perception check conveys
this message, "I want to understand your feelings-—is this
(making a description of his feelings) the way you feel?"

 

 

Examples: "I get the impression you are angry with me.
Are you?" (NOT: "Why are you so angry with
me?" This is mind reading, not perception
check.)

"Am I right that you feel disappointed that
nobody commented on your suggestion?"

"I'm.not sure whether your expression means
that my comment hurt your feelings, irritated
you, or confused you.‘

Note that a perception check (a) describes the
other's feelings, and (b) does not express disapproval or
aprpoval. It merely conveys, "This is how I understand
your feelings. Am.I accurate?"

--John Wallen

252

Emotions as Problems

The way we deal with emotion is the most frequent
source of difficulty in our relations with others. Although
each of us continually experience feelings about others
and about himself, most of us have not yet learned to
accept when others express strong feelings; in addition,
most of us do not even recognize, much less accept many of
our own feelings.

We know, intellectually, that it is natural to have
feelings. We know that the capacity to feel is as much a
part of being a person as is the capacity to think and
reason. We are aware of incompleteness in the one who
seems only to think about life and does not seem to feel--
to care about, enjoy, be angered and hurt by what goes on
around him. We know all this, and yet we feel that
feelings are disruptive, the source of obstacles and prob-
lems in living and working with others.

It is not the feelings that are the source of
difficulty in our relations with others but the way we
deal with them, our failure to use them.

Because of our negative attitude toward emotions,
because of our fear of and discomfort with our feelings we
spend much effort trying, in one way or another, to deny
or ignore them” Look around you and observe how you and
others deal with feelings. Make your own observations and
see if they support or contradict the point that our usual
response is some variation of "don't feel that way."

To the person expressing disappointment, discour-
agement, or depression we say things like, "Cheer up!"
"Don't let it get you down." "There's no use crying over
spilt milkfl' "Things will get better." In short, "Don't
feel that way." To the sorrowing or hurting person we
advise, "Don't cry. Put your mind on something pleasant."
We tell the angry person, "Simmer down. There's no point
in getting angry. Let's be objective." To the person
expressing joy and satisfaction in something he has done
we caution, "Better watch out. Pride goeth before a fall."
In various group meetings we counsel each other, "Let's
keep our feelings out of this. Let's be rational."

 

 

Another sign of the difficulty we all experience
with feelings is that the more distant and remote the
feelings, the more comfortably we discuss them. Try to
pay attention to yourself and others when talking about

253

feelings and ask, "How distant are these feelings?" I
predict that you will find relatively few discussions of
feelings that someone is having "right now" in comparison
with a number of discussions about feelings they had in
the past toward somebody else. Do you find that you talk
more easily about feelings you had in the past than about
feelings you have right now? Do you find that you talk
more easily about feelings toward somebody else than about
your feelings toward persons who are present? As you
observe yourself and others discussing feelings, see
ghesher the following scale roughly represents what you
in .

Feelings are spontaneous reponses to factors over
which we have little direct control. To control the
arousal of our feelings, we attempt to arrange the envir-
onment so that it will evoke the feelings we desire and
not those we wish to avoid. Much of the interaction between
persons can be viewed as an effort by eachtx>control which
feelings will be aroused. That is, I try to get you to
act in ways that will elicit feelings in me that I desire
and not those I dislike. You, in turn, attempt to get me
to act in ways that will have a similar effect on your
feelings. Each of us, thus, tries to control the rela-
tionship (and the other's behavior) as a way of controlling
his own feelings.

Others seem to have more control over what we feel
that we ourselves have. People usually say, "You made me

angry," rather than, "I've become angry." One popular
song declared, "You made me love you. I didn't want to do
it." Maybe our discomfort with our own feelings springs

from a belief (a recognition?) that to feel something
toward another is to surrender some of our control of self
to him. Certainly, if we believe that the other "made"

us angry or "made' us love him, he has some control over
us.

Paradoxically, however, if we hold the other
responsible for our anger, we probably expect that he
should stop his annoying behavior because we feel angry.
Our anger, then, is not just a felt inner state, but is
felt as a claim against the other. Likewise, if we feel
that the other "made"1uslove him, we will probably expect
him to return our affection. Note your own tendency when
somebody expresses affection for you to feel that you
should reciprocate, a "you're-nice-too" effect.

I believe much of our discomfort with our own and
others' feelings arises because interpersonal feelings

 

254

precipitate a struggle for control between persons. Which
of us Will succeed in defining what our relationship is

to be? Which of us will yield and thus give up some of
his own identity? Do I have control over you because I
can make you angry? Do you have control over me because
you get angry or hurt when I act in a certain way? You
and I must come to some shared understanding of the meaning
of your feelings of anger, of my feelings of being hurt,
of your feelings of affection, of my feelings of inade-
quacy around you. Are the feelings each of us has about
the other really claims on the other, obligations to be
and act in a certain way? Or are our feelings phenomena
to be accepted and then understood. Your anger may tell
us something about you and about me, if we can understand
it.

To interact with another is to risk having feelings
aroused by him.and to risk arousing feelings in him. You
and he cannot turn on and turn off your feelings toward
each other merely by wishing or deciding to. Unless you
avoid each other totally and forever, you must each share
some of yourself with the other. To feel something
toward another-~whether anger, disgust, fear, interest,
enjoyment--is to become related, interdependent, with the
other. Most of us seem to feel that to be interdependent
with another is to lose some of our control over our own
life. Feelings, thus, seem to threaten our voluntary,
planful control over our own affairs.

FREEING

255

The Interpersonal Effect of
Various Responses

EFFECTS increase other's autonomy as a person;

they increase one's sense of equality:

l.

BINDING

Increasing your understanding of the other as a
person and conveying your understanding to him.

Active attentive listening: Responsive listening,
not just silence.

Paraphrasing: Testing to insure that the message
you got was the one he sent.

Perception check: Showing your desire to relate
to him and understand him as a person by checking
out your perception of his inner state. Showing
acceptance of feelings.

Seeking information to help you understand him:
Questions directly relevant to what he has said,
not ones that introduce new tOpics.

Offering information relevant to the other's con-
cerns: But letting him use it or not without
pressing him.

 

 

 

 

Helping the other to understand you as a person.

Sharing information that has influenced your feelings
and viewpoints.

Directly reportinggyour own feelings,

Offering new alternatives: Action proposals offered
as hypotheses to be tested, not as solutions you
already know to be best.

 

 

EFFECTS diminish other's autonomy:

Changing the subject without explanation: For
example, to avoid encountering the other's
feelings.

Explaining the other, interpreting his behavior:
"You do that because your mother always.

This binds him to past behavior and may be seen
as an effort to get him to change.

Advice and persuasion: "What you should do is.. .."

Vigorous agreement: Binds him to present position--
limits his changing his mind.

Expectations: Binds to past--"You never did this

efore. What's wrong?‘ Or cues him.to future

 

 

 

256

action--"I'm sure you will. . . ." "I know you
can do it."

Denying his feelings: ”You don't reall mean that!"
"You have no reason to feel that way!‘ General-
izations like "everybody has problems like that."

Approval on personal grounds: Praising the other
fhr thinking, feeling, or acting in ways you
prefer; that is, praising him for conforming to
your standards.

Disapproval on aersonal 'rounds: Blaming or cen-
suring the other for t inking, acting, or feeling
in ways you do not want him.to. Imputing unworthy
motives to him,

Commandstorders: Telling the other what to do.
Includes, "Tell me what to do!"

Emotional Obligations: Control through arousing
feelings of shame and inferiority. "How can
you do this to me when I have done so much for
you?"

 

 

 

THE EFFECT OF ANY RESPONSE DEPENDS UPON THE DEGREE OF TRUST
IN THE RELATIONSHIP. The less trust, the less freeing
effect from.any response. The more trust, the less binding
effect from any response.

--John Wallen

257

By learning the skill of behaViOral description
we can be more accurate in communicating with another about
the quality of the relationship. Once we are clear about
the behavior, we can tell the other person how this
behavior is affecting us. This is called feedback.

 

Feedback can have a number of helpful effects.
It can:

1. Reinforce--feedback may confirm behavior by
encouraging its repetition. "You really helped then when
you clarified."

2. Correct--feedback may help bring behavior in
line with intention. "It would have helped me more if
you had stood up to talk."

3. Identify--feedback may help identify persons
and their relationship. "Joe, I thought we were enemies,
but we're not, are we?"

As well, there are a number of criteria for
helpful feedback:

1. Intended to Help--It takes into account the
needs of both the receiver and giver of feedback. Feed-
back can be destructive when it serves only our own needs
and failstxaconsider the needs of the person on the
receiving end.

2. Trust--A trusted non-threatening source who
gives feedback directly and with feeling helps to make
feedback more palatable. "Daddy, you're getting too fat"
from your three-year-old daughter is more acceptable than
from a forever-carping wife.

3. Descriptive--It is descriptive rather than
evaluative. By describing one's own reaction, it leaves
the individual free to use or not as he sees fit. By
avoiding evaluative language, it reduces the need for the
individual to react defensively, i.e., "Ralph, I want to
be sure to hear you. Could you raise your voice a bit,
please?" This gives a different feel from the statement,
"Henry, you talk too low." The latter sounds condemning
and puts all the responsibility on Henry. The former
shares the situation between Henry and the speaker, and
contains a complimentary rather than accusative note.

4. Specific--It is specific rather than general.
To be told that one is "dominating" will probably not be

258

as useful as to be told that "just now when we were deciding
the issue I felt forced to accept your arguments or face
attack from you."

5. Timely and Recent--It is well-timed. In
general, feedback is most useful when offered at the
earliest opportunity after the given behavior (depending,
of course, on the person's readinesstx>hear it, support
available from others, etc.).

 

6. Not an Overload--Don't give too much feedback
at the same time.

7. Usable--It is directed toward behavior which
the receiver can do something about. Frustration is only
increased when a person is reminded of some short-coming
over which he has no control.

8. Requested--It is solicited, rather than imposed.
Feedback is most acceptable when the receiver himself has
formulated the question which those observing him.can
answer.

When you have reached the point in your relation-
ship where it is possible to give serious feedback, it means
that you are relating at a deeper, more mature level with
your youth.

Confrontation

 

In addition to being aware of and communicating
the impact of your youth's behavior on you, you will also
want to be aware of the impact of the behavior on the
youth himself/herself, especially in terms of whether
these behaviors help bring about the youth's desired goals.
When there are discrepancies between what a youth says
he/she wants to accomplish and.what he/she is actually
feeling, doing, thinking, etc., you will want to use a
skill called confrontation.

Confrontation is defined as the halting of any
ongoing interaction for the purpose of assessing its
intentions, consequences, or possible alternatives. It is
an invitation to the youth to engage in self-examination,
to explore his/her behavior, especially the discrepancies
in his/her life.

The act of confronting is a learned behavior. The
more practice one has, the more comfortable one will be

259

when confronting. In order to confront another person you
‘must accept that you have the right to stop an interaction,
that you have the right to interrupt. For this reason
confronting is an assertive behavior.

Given that confronting is an assertive behavior,
it is important to acknowledge the rights of the other
people involved in the confrontation. If a person confronts
nonassertively or assumes that the person being confronted
can't accept a direct and appropriate confrontation, this
will result in a padded confrontation. If a person con-
fronts aggressively, he7she will accept his/her personal
rights and ignore the other person's rights. This will
result in a punitive confrontation.

Confrontation is generally not helpful for
learning when received as condemnation. It is far more
helpful within the confrontation to conclude the possibility
that the confronter's interpretation of behavior might be
badly distorted.

Possible Ways of Initiating a Confrontation of Discrepancies

1. Feedback: It is possible to stop an ongoing
interaction By giving an individual feedback about the
interaction. While giving the feedback it is important
to remember the criteria for appropriate feedback.

(a) behavior oriented—-something that can be
changed.

(b) specific--the shorter the statement, the
easier it is to hear

(c) timely--it helps if the behavior is fresh
in both individuals"mind

In order to facilitate the confrontation, it may be helpful
to add.more criterion to the feedback model.

(d) consequences--telling the person you're
confronting what you will or won't do if they continue
certain behavior(s) allows for a more complete exploration
of the behavior(s). Sharing the different perceived con-
sequences of the behavior leads to exploring values behind
the behavior and the confrontation. When sharing the
consequences of a behavior, it is important to speak for
yourself. You can't be sure how the behavior will affect
others, therefore own what you say.

260

2. Self-disclosure: Confronting in an interaction
by telling how you feel about that interaction may facili-
tate the exploration of certain behavior(s). Self-disclo-
sure is similar to the "consequence" stage of feedback.
However, when giving feedback a cause and effect statement
regarding the behavior is presented. When self-disclosing
you need not know the cause and effect relationship. You
can label your feeling about the behavior(s) and then by
exploring the behavior a cause and effect relationship
may be established.

 

3. uestionin : Questioning an interaction may
stop it to a ow or urther exploration. Questioning is
an effective way to explore the assumptions, contradictions
and values behind certain behavior(s). Appropriate
questioning is not for the purpose of having an individual
defend his/her behavior. Recognize an individual's
personal rights when confronting by questioning.

Following Up,a Confrontation

 

After a behavior displayed during an interaction .
has been confronted (by giving feedback, self-disclosing,
or questioning). the next step in completing the confron-
tation is to explore intentions, consequences, and alter-
natives associated with the behavior. During this time
it is important to use communication skills. Empathy,
feedback, questioning, self-disclosure, and paraphrasing
may all be helpful to complete the confrontation. Possible
areas to explore about a behavior:

(a) values--behind the behavior and the confron-
tations

(b) assumptions--what assumptions are behind the
behavior?

(c) feelings--what feelings are associated with
the behavior?

(d) history--when does a person usually display
the behavior?

When exploring the confronted behavior, it may be possible
that one or both of the people involved may not feel
resolved. This is something that has to be accepted. It
may take awhile to resolve a confrontation.

Thus, confrontation of discrepancies is an impor-
tant part of your relationship because it is a useful way
of teaching your youth to be aware of his/her behaviors
and the consequences that result. Yet, it might be one

261

 

of the scariest things that you do. It involves a lot of
risk-taking--risking that your youth might become an ry,
feel hurt, etc. Yet, because giving feedback and con ronting
discrepancies makes your relationship an especially mean-
ingful and effective learning situation, the risk you

might have to take seems worthwhile. He/she may be doing
destructive or contradictory behaviors that he/she is not
aware of. Your honesty and sensitivity to your youth,

your ability to give and receive feedback and be confronting
are essential components of the model we are developing.
This model involves the development of a helping relation-
ship that is geared toward aiding the youth to solve his/
her prpblems and in taking final responsibility for himself/
hersel .

262

Typical Gaffes and FauxPas COmmon Among
Beginning Counselor Trainees in Their
Alarming Attempts to be Helpful and
othssistance to the Diverse
Victims of Their Art, Being
a Taxonomy which Categorizes,
IdentifiesLand
Isolates ThEm

 

 

 

Richard S. Dunlop
University of Missouri

Counselors in training make many errors as they
attempt to learn appropriate verbal responses to facili-
tate the helping relationship. These errors appear typi-
cally to involve a confusion of verbal aspects of coun-
seling with techniques appropriate to conversational,
teaching, or inquisitorial relationships in which people
may also engage. Sometimes a misapplication of counseling
theory comes out all wrong, and not infrequently the
trainees own personality or authority needs get in the way.
The following taxonomy of response errors has proven itself
helpful in pointing up to counselor candidates the sorts
of mistakes they are making, and seems to be useful in
improving the student counselor's verbal behavior in his
interactions with clientele.

CATEGORY I: THE EMPATHIC TRAP RESPONSE

 

Form A. The Sharer. The Counselor is compelled to share,
andforgets who is in focus.

 

Couns: Gee, you really have a problem. I had a
second cousin who had a problem just like yours,
and.

g;
Couns: I know just how you feel, because this
happened to me, and .

Form B. The Conversationalist. The Counselor does not
understand the differences between counseling and
conversation.

 

Client: I just bought a new dress at Knapp's store.
Couns: Oh? I saw some very attractive skirts there.
Client: You can usually get good bargains.

CATEGORY

Form A.

Form B.

CATEGORY

Form A.

Form B.

263

Couns: But their jewelry department is awful.
Client: I know. Junk.
Couns: What do you think of Macy's?

II: THE NON-DIRECTIVE OBSESSIVE RESPONSE

General Type. The counselor has only one technique
at his command.

 

Client: I feel awfully warm, can't you open the
window?
Couns: You feel warm.

or
Client: Can you tell me how to find the restroom?
Couns: You want to find the restroom.

Perseveratinngarrot Type. The counselor confuses
reflectihn and repitition.

 

Client: I'm sorry I'm a little late today, but
it's so beautiful outside that I stopped to look
at the flowers, and the birds, and the trees,

and the bushes.

Couns: You're sorry you're a little late today,
but it's so beautiful outside that you stopped

to look at the flowers, and the birds, and the
trees, and the bushes.

III: THE INQUISITORIAL RESPONSE

True or False Type. The counselor demands a

"yes" or no response.

 

Couns: Do you like school?
93
Couns: You're not going to fail again, are you?

Loaded Option Type. The counselor tells his
client how to respond.

 

Couns: Don't you think you ought to get a good
education so that you can amount to something?
You're not really going to marry that clod!

g

Couns: Why are you talking about your mother like
this? Everyone loves his mother, don't you love
yours?

Form C.

Form D.

Form E.

a
Couns:

264

A big guy like you shouldn't be having

trouble in gym, should he?

Multiple-Choice Type.

The counselor delimits

response options available to his client.

Couns:
bad?

2:.
Couns:

How did you feel?

Did you feel good or

How do you feel when your father hits you?

Do you hate him or don't you feel anything?

Declaration of War Type.

The counselor challenges

 

his client to defénd himself.

Couns:
9.1;
Couns:

Der Gestapointerrogationisch Type.

Why do you feel this way?

Where'd you ever get an idea like that?

The counselor

 

wears jack boots and walks funny.

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Have a seat. Name?
Jones. John Jones.
Address?

Hm? Oh, I live in the dorm.
Your problem?

I had a date with this girl. .
When was that? When was the date with
the girl?

Friday or Saturday. Saturday, I think.
I never had a date before. .

Don' t you like girls?

I feel.

It's no use.

Hm? Sure, but I never felt.
'M-hmu You never felt a girl.
No! No! I felt comfortable, I.

 

How old are you?
Nineteen last month.
a birthday card.
Then actually you're a little over nine-
teen, aren' t you?

Well, about a month over. I need help.. .
Where is your home? Don't you have a
father? What's wrong with your mother?
Why is your shoe untied?

No one ever sent me

Tell me what you did to the girl.

Form F.

CATEGORY

Form A.

Form B.

265

Client: Please, can't you turn off that light?
It's in my eyes.

Couns: The girl. Tell me about it. Come on,
tell me your sordid little story. I'm
here to help you.

Focus on Minutae Type. The counselor has strong
needs to gather data.

 

Client: (Sniffing) I'm.going to have to get an
abortion.

Couns: I didn't get the spelling of your last
name. Would you repeat that, please?

Client: Fox. F-O—X. Like the furry little animal
(weeping) in the woods, with its c-c-cubs.
(Weeps copiously) My friend, June, had
an abortion. (Bawling)

Couns: (Writing) F-O-X. June Fox.

Client: No, I'm Mary Fox. June is my friend. She
damn near died. (Cries heavily)

Couns: How old are you?

Client: Hm? Twenty-two. I've already made the
arrangements with that terrible little
man and his ghastly nurse, but I just
don't know if it's right. (Nearly hyster-
ical)

Couns: And June?.

Client: (Wailing) Huh?

Couns: HOW'Old is June?

IV: THE SAFETY DODGE RESPONSE

 

General Type. The counselor is frightened by his
client's material, and withdraws to high ground.

 

Couns: So your homosexual problem really bothers
you. What kind of grades did you make
last year?

or

Couns: . . .and you're very concerned about your
relationshipship with God. well, lots of
people are. Are you interested in athle-
tics?

Diversionary Trap Type. The counselor responds
to inappropriate material.

Client: Ever since Mother died I've been pretty
depressed. I just don't think it's any use. What

Form C.

Form D.

Form E.

266

point is there in going on? And.my sister
feels awful, too.
Couns: Your sister is upset.

22

Client: When my fiance and I broke up I was so
angry and distraught that I went out and
raced my car through the streets and
screamed and screamed. I wrecked the car,
and Daddy was furious.

Couns: Your father has a nasty temper.

Estranged Type. The counselor is a fool.

Client: Mother and Dad were fighting, and he was
pounding on her and knocking her down,
so I beat hell out of him and went out
and had a steak.

Couns: How do you like your steak cooked?

Aborted Reflection Type. The counselor wants,

properly, to communicate his understanding, but
is afraid to stick his neck out. So he uses a

question mark when a period is indicated.

Client: I'm going to run away from home.
Couns: You're going to run away from home?
Client: I'm going somewhere else to live.
Couns: You're going somewhere else to live?
Client: No one loves me.

Couns: No one loves you?

Client: I'm all alone.

Couns: You're all alone?

Client: Lonely.

Couns: Lonely?

Missing the Concealed-Inference Ploy. The coun-
selor d6esn't know whath going on.

Client: We have no money at all; my husband's an
awful drunk and he spends the welfare
check on beer and wine. My daughter's a
prostitute, and my son's on dope. I can't
go home to my folks because Ma throws
knives around, and Pa chases me through
the house. My brothers are in jail. My
sister's a lesbian. The cops are always
coming around and the windows are broken
out and the roof leaks and they've cut
off the gas and lights. But I'm really

Form F.

Form G.

267

a very lucky person and I don't have no

right to complain. I' m.actually very,

very happy. I really am. Really.
Couns: Life is a bowl of cherries.

The "Aw Shucks" Type. The counselor lacks confi-
dence in his profession and in his skills.

 

Client: I get nervous before tests.
Couns: Oh, dear. You'd better see your physician
about that. I'm only a counselor.

a

Client: I‘m having a problem with my mother.
Couns: I should caution you that I'm not a real
psychologist, and.

2E

Client: I'm wondering if I should quit going to
church.

Couns: It's best that you consult your spiritual
advisor about that.

Reassurance Type. The counselor insists that his

 

client Be strong.

Couns: Hell, everyone' 3 had that problem. Don't
let a little thing like that bother you.
Stop crying.

 

CATEGORY V: THE BUFFALO STAMPEDE The counselor is not

 

only incompetent hut rude.

Client: I'm not sure if I should stay in school.

Couns: You're thinking you should do something
else.

Client: Yes, that's right, I. .

Couns: You might stay in school, or you might.

Client: I could.

Couns: . . .drop out and do something else, like.

Client: I. .

Couns: . .get a job or grow a beard, or join
the circus.

Client: . . .I

Couns: . .or draw welfare or something, but

you' re feeling guilty because everyone
tells you to finish school.
Client: No, I.
Couns: . . .but you.

CATEGORY VI:

CATEOGRY

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

C

268

I.

. .don' t really want to stay in school.
M-hm.
And you're about to say, "The hell with
it, " but you really can't. .

Hm. I.

So that's the problem as you see it.
M-hm.

Don't interrupt. I notice that you inter-
rupt a good deal. I'm.trying to under-
stand your problem so that I can help you.

THE LEAPFROG INTERPRETATION RESPONSE. The

ounselor gets far, fér ahead of his client

and shows off his psychological know-how.

Client:

Couns:

25
Client:

Couns:

VII:

Client:

Couns:
Client:

Couns:

Client:

Couns:

I was up late last night studying, and
I'm pretty tired this morning.

I make you uncomfortable, and you're
excusing this by blaming your masochistic
study pattern.

I wish my Dad.would lose some weight.
You're suffering typical penis envy, com-
plicated by Oedipal conflict and castra-
tion anxiety.

THE INVERTED RELATIONSHIP RESPONSE. The
counselor allows his own interests or needs
to dominate the interview or influence it
significantly.

I divorced my husband several years ago,
and now that the kids are out of college
and on their own I need to find something
to occupy my time. I thought perhaps I
could. .

Tell me about your husband.

Fred? Oh, I 'm,well rid of him. Better
all around. But you see, I had an art
major, and I thought perhaps I could.
You feel the divorce was best for every-
one.

That's ancient history. What would I
have to do to get licensed as a teacher
in this state?

Fred is unimportant to you.

 

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

22

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

Couns:

Client:

CATEOGRY VIII:

Client:

Couns:

52:.

Client:

Couns:

THE DEFENSIVE RESPONSE.

269

Also, I need to know if I'd be better

in an elementary school or at senior high.
You've just about forgotten your husband.
I suppose I'd have to get a master's
degree, but am.I too old to learn?

Your divorce is very painful to you and
you resist talking about it.

I could go to school full time.

How do you see yourself as a woman, having
lost your husband, and all?

What?

I've been majoring in Psychology, but

those mazes are getting to me.

M'hm.

I've thought about changing to counseling.
People, you know.

You prefer people to pigeons.

Yeah. Fewer feathers.

Psych's a pretty rough course, isn't it?
They have their own language.

Tough to learn?

Oh, I don't know. Pretty tough. "Rein-
forcement schedule," "Rorschach," "biomodal
distributions," funny words like that.

What are the profs like?

They mumble a lot. You thinking of changing
to psych?

I don't know.
getting to me.
M-hm.

Do you think I could make it in psych?
You're concerned about your inadequacy.

These damn people are

The counselor is

 

protective of himselff

Why won't you school people let me wear
a beard?

Surely you don't blame me; that's the
fault of those unfeeling administrators.

That's an awful tie you're wearing.

I happen to like this tie very much.
been my favorite tie for twenty years.
Lots of people like nudes on their ties.

It's

 

 

270

CATEGORY IX: THE FRIENDLY ADVISOR RESPONSE. The counse-
lor has lots of good’advice to offer.

Client: I'm really having trouble in history.

Couns: You should get to class on time, and pay
attention, and take good notes, and ask
intelligent questions.

23

Client: Tom keeps making passes at me.
Couns: Slap the S.O.B.

 

271

The Problemasolving Process
or

How to Keep the Mountain from.Falling
Down on You

William C. Hinds

The last part of the helping relationship deals
with problemrsolving. It is during this final step that
the listener can take a more active role, assuming the
relationship is firm.and the speaker feels he can trust
the listener. The listener can begin to point out the
places where the speaker's feelings, values and attitudes,
and behavior may or may not fit together. The listener
can begin to encourage the s eaker to do some risk-taking
(trying new ways of behaving) and can offer alternatives
to ways the speaker has tried to deal with his problems
in the past. The listener can also begin to share more of
his own feelings and thoughts with the speaker. More infor-
mation can be offered, and helpful questions can be asked.

CAUTION: The listener can take a more active
part in the problem-solving process. However, his role is
still NOT to try to solve the problem for the speaker.
Advice giving takes away from.giving the speaker a chance
to solve his problem.for himself.

In the problem-solving process, we are asking you
to learn the steps to finding solutions. There will be no
scales to follow. Instead, think of these steps as a series
of questions the speaker must consider before he can solve
his problem.

First, are six steps related to clearly identifying
the speaker's problem.(or, find out what part of the moun-
tain is coming down on you).

1. The listener helps the speaker try to find out
exactly what the problem.is (the situation, the people
involved, the events surrounding the problem), when it
happens, how it happens (how the speaker behaves when his
problem.c3hfronts him), and how often it happens.

2. The listener helps the speaker focus on his
final problemrsolving goal (how the situation will be
changed once the problem is solved; how the behavior of
the speaker and the people around him.will be changed).

272

3. The listener helps the speaker identify the
‘ways he avoids solving the problem (how he blames others
for his troubles, how he puts off doing anything about it,
what he tells himself so he won't have to work at solving
his problem).

4. The listener helps the speaker understand the
prices he pays for doing nothing about solving the problems

5. The listener helps the speaker tune in on how
the speaker feels about trying to solve the problem.

6. The listener helps the speaker tune in on the
rewards he gets for not solving his problem.

Second, the speaker and listener explore the
speaker's alternatives (or, how many different ways are
there to stop that big rock from coming down on you?).

7. The listener helps the speaker identify alter-
native ways he can solve the problem.

 

 

8. The listener helps the speaker clarify the
rewards and punishments attached to each alternative.

9. The listener helps the speaker tune in on
how the speaker feels about each alternative.

We have found that just understanding the problem
and discussing ways to solve it doesn't always help the
speaker change. Hence, the next step is to encourage him
to make some initial plans which will keep him motivated
to change. In other words, making plans to change the
problem.

10. The listener helps the speaker identif the
initial change he wants to make in order that his final
goal may be reached.

11. The listener helps the speaker identif the
amount of success the speaker needs to achieve initially
to keep him going in the problem solving process.

12. The listener helps the speaker explore what
he will do should an alternative not work.

Finally, the listener helps the speaker think
through how he will test out his plans (or, rehearsing
your plans so opening night won't be a flop).

273

13. The listener helps the speaker organize the
order of activities that need to be followed to carry out
the solution to his problem,

14. The listener helps the speaker identify the
things the speaker might do to defeat the testing-out
process and thus maintain the problem,

15. The listener helps the speaker understand
what kinds of things the speaker is afraid will happen in
the testing-out process.

It is importanttx>understand that you will probably
not have to deal in depth with each of these considerations
during actual helping interactions, particularly if the
speaker has already been doing some work on his own. You
should, however, check to make sure that point has been
considered completely and appropriately by the speaker.

One of the things you'll have to watch out for
when going through the problem-solving process is knowing
when to step encouraging the speaker to change. One of
the helpffil things about this process is that the speaker
gets confronted with whether or not he really wants to
change. Many times after looking at the problem, exploring
alternatives and examining the payoffs and costs of the
problem, the speaker decides he wants to keep things as
they are. In other words, it will be even more painful
to change. We can't change people. They have to want to
change themsElves. In clarifying the problem and exploring
the alternatives, the speaker gathers more information
about his problem, and many times this is enough to carry
him through the tight spots. If the speaker decides he
can solve his problem on his own, then we must trust that
we as listeners have helped initiate change and the speaker
is ready to deal with the problem on his own. If the
speaker decides he does n35 want to solve his problem,
then at least we have cleared up the haze enough to help
the speaker know that he has made his choice on the basis
of what he is ready to do at this point in his life.

 

APPENDIX 0

GENERAL INSTRUCTIONS FOR ALL GROUPS

274

APPENDIX 0

General Instructions for All Groups

 

Everyone in this group has agreed to a contract
which requires them to participate actively in the work-
shop for a period of four weeks. In doing this, you have
actually made a contract with the members of this group
as well as with me. As you all know, the effects of this
workshop are going to be evaluated two times in the future:
at the conclusion of treatment and six weeks after treat-
'ment has ended. I want to emphasize that the purpose of
the workshop is to help each individual in the group to
overcome his or her own depression as well as to learn more
about themselves.

This type of group has been used many times to
help other depressed persons. The workshop itself is not
experimental! It is based on scientific findings and I
feel that each one of you could benefit from the workshop.
I say could because the success will depend on your active
participation (by following suggestions made in the group).
I realize that you are all eager to begin, but first I
would liketx>answer any questions about anything except
the actual workshop procedures (for example, when the
meeting times are, questions about the assessment proce-
dures, etc.).

From Brian F. Shaw, University of Western Ontario

275

REFERENCE NOTES

276

 

REFERENCE NOTES

Johnson, R. G. & Elson, S. E. The modification of
covert behavior: A survey of the literature.
Paper presented at the Annual Meeting of the
American Educational Research Association,
Chicago, 1974.

Maes, W. R. & Heimann, R. S. The comparison of three
approaches to the reduction of’test anxiety in
high school students. Unpuhlished manuscript,
Arizona State University, 1970.

 

Morris, N. E. A group self-instruction method for the
treatment of depressed outpatients. Unpublished—
dhctoraI dissertation, University of Toronto,
1975.

 

Rehm, L. P., Fuchs, C. 2., Roth, D. M., Kornblith, S. J.
& Romano, J. M. A comparison of self-control
and social skills treatments of'depression.
Unpublished manuscript, University of Pittsburgh,
1977.

Rehm, L. P., Kornblith, S. J., O'Hara, M. W.,
Lamparski, D. M., Romano, J. M. & Volkin, J. I.
An evaluation of major elements in a self-control
therapy program fOr depression. Unpublished
manuscript, University of Pittsburgh, 1978.

 

Beck, A. T., Rush, J. & Kovacs, M. Individual
treatment manual for cognitive/behavioral
psychotherepy Of_depression. Unpublishéd
manuscript, 1976.

 

Weissman, A. N. The Dysfunctional Attitude Scale:
A validation study. Unpublishéd doctoral
dissertation, University of Pennsylvania, 1978.

 

MacPhillamy, D. J. & Lewinsohn, P. M. Manual for the
Pleasant Events Schedule. Unpublished manuscript,
1976.

 

Thornton, D. W. (Ed.) Listening Ear training manual.
Unpublished manuscript, 1974.

277

 

10.

ll.

12.
l3.
14.

278

Kantrowitz, R. (Ed.) A relationship manual for non-
professionals working with delinquents.

Unpublished manuscript, Michigan State University,
1977.

 

 

Condon, J. W. Similarity of attribute structures and
facility of communication. Unpublished doctordl
dissertation, Michigan State University, 1979.

 

 

Thompson, E. Personal communication, 1978.
Rehm, L. Personal communication, 1979.

Efran, J. S. Self-criticism and psychotherapeutic
exchanges. Unpublished manuscript, 1973.

 

 

 

REFERENCES

279

 

REFERENCES

American Psychiatric Association. Diagnostic and statis-
tical manual of mental disorders (2nd Ed{y}
Washington, D. C.: Author, 1968.

 

American Psychiatric Association. Diagnostic and statis-
tical manual of mental disorders (3rd Ed., revised
drafET. Washington, D. C.: Author, 1979.

 

Anton, J. L. An experimental analysis of training the
anticipation and performance of reinforcing acti-
vities in the treatment of depression (Doctoral
Dissertation, Stanford University, 1974). Disser-
tation Abstracts International, 1975, 3;, 5804A.
(University Microfilms No. 75:6802)

 

Anton, J. L., Dunbar, J. & Friedman, L. Anticipation
training in the treatment of depression. In J. D.
Krumboltz & C. E. Thoresen (Eds.), Counseling methods.
New York: Holt, Rinehart & Winston, 1976.

Bain, J. A. Thought control in everyday life. New York:
Funk &Wagnalls, 1928.

Baker, J. N. Reason versus reinforcement in behavior
modification (Doctoral Dissertation, University of
Illinois, 1966). Dissertation Abstracts International,
%ggp, 21, 2509B. (University Microfilms No. 66-12,

Bandura, A. Principles of behavior modification. New
York: Holt,’Rinehart & Winston, 1969.

Beck, A. T. Thinking and depression. Archives of General
Psychiatry, 1963, 9, 324-333.

 

 

Beck, A. T. Depression: Clinical, experimental and
theoretical aspects. New York: Hoeber-Harper,
1967.

 

Beck, A. T. Cognitive therapy: Nature and relation to
behavior therapy. Behavior Therapy, 1970, 1,
184-200. _

 

280

 

281

Beck, A. T. Measuring depression: The depression
inventory. In T. A. Williams, M. M. Katz & J. A.
Shield (Eds.), Recent advances in the psychobiology
of the depressive illnesses. Washington, D. C.:
U. S. Government Printing Office, 1972.

 

 

Beck, A. T. Depressive neurosis. In S. Arieti & E. B.
Brody (Eds.), American handbook of psychiatry
(2nd Ed., Vol. 3). New York: Basie Books, 1974a.

 

Beck, A. T. The development of depression: A cognitive
model. In R. J. Friedman & M. M. Katz (Eds.),
The psychology of depression: Contemporary theory
and research. New York: John Wiley & Sons,
l974b.

 

 

Beck, A. T. Cognitive therapy and the emotional disorders. f/
New York: International Universities Press, 1976. V

 

Beck, A. T. & Beamesderfer, A. Assessment of depression,
the depression inventory. In P. Pichot (Ed.),
Psychological measurements in psychopharmacology and

modern pharmaco s chiatr (Vol. 7). Basel,
Switzerland: Kerger, l9;4.

Beck, A. T. & Hurvich, M. Psychological correlates of
depression. Psychosomatic Medicine, 1959, 2;,
50-55.

 

 

 

Beck, A. T. & Ward, C. H. Dreams of depressed patients:
Characteristic themes in manifest content. Archives
of General Psychiatry, 1961, 2, 462-467.

 

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., &
Erbaugh, J. An inventory for measuring depression.
Archives of General Psychiatry, 1961, 3, 561-571.

Becker, J. Depression: Theory and research. Washington,
D. C.: Winston & Sons, 1974.

 

Bergin, A. E. Self-regulation technique for impulse
control disorders. Psychotherspy: Theory; Research
and Practice, 1969, E: 113-118.

 

 

Bergin, A. E. Cognitive therapy and behavior therapy:
Foci for a multidimensional approach to treatment.
Behavior Therapy, 1970, i, 205-212.

Bergin, A. E. The evaluation of therapeutic outcome. In
A. E. Bergin & S. L. Garfield (Eds.), Handbook of
psyehotherapy and behavior change: An experimental
analysis. New York: John Wiley 8 Sons, l97l.

 

282

Bieri, J. Complexity-simplicity as a personality variable
in cognitive and preferential behavior. In D. W.
Fiske & S. Maddi (Eds.), Functions of varied
experience. Homewood, IL: Dorsey, 1961.

 

 

Bieri, J., Atkins, A. L., Briar, S., Leaman, R. L.,
Miller, H., & Tripodi, T. Clinical and social
judgment: The discrimination of behavioral informa-
tion. Huntington, NY: Krieger Publishing Co., 1975.

Brown, B. M. Cognitive aspects of Wolpe's behavior therapy.
American Journal of Psychiatry, 1967, 124, 854-859.

 

Burkhead, D. E. The reduction of negative affect in human
subjects: A laboratory investigation of Rational-
Emotive psychotherapy (Doctoral Dissertation,
Western Michigan University, 1970). Dissertation
Abstracts International, 1970, 3;, 2097A. (Univer-
sity Microfilms No. 70-21, 858)

 

Carnegie, D. How to stop worrying and start living. New
York: Simon & Sthuster, 1948.

Cautela, J. R. & Kastenbaum, R. A reinforcement survey
for use in therapy, training and research. Psycho-
logical Reports, 1967, 29, 1115-1130.

 

Christensen, C. Deve10pment and field testing of an
interpersonal‘COping skills program. Toronto:
Ohtario Institute for Studies in Education, 1974.

 

Copemann, C. Aversive counterconditioning and social
retraining: A learning theory approach to drug
rehabilitation (Doctoral Dissertation, State
University of New York at Stony Brook, 1973).
Dissertation Abstracts International, 1974, 34,
5184-5185B. (University Microfilms No. 74-8940)

 

Crockett, W. H. Cognitive complexity and impression
formation. In B. A. Maher (Ed.), Pro ress in
experimental personalitysresearch (Vol. 25. New
York: Academic Press, 1965.

 

Chronbach, L. J. Coefficient alpha and the internal
structure of tests. Psyehometrika, 1951, 19,

297-334.

 

Coche, E. & Flick, A. Problem-solving training groups for
hospitalized psychiatric patients. Journal of
Psychology, 1975, 9;, 19-29.

 

 

Covi, L., Lipman, R. S., Derogatis, L. R., Smith, J. E.
& Pattison, J. H. Drugs and group psychotherapy in
neurotic depression. American Journal of Psychiatry,
1974, igl, 191-197.

 

283

Dember, W. N. Motivation and the cognitive revolution.
American Psyehologist, 1974, 29, 161-168.

Dempsey, P. A. A unidimensional depression scale for the
MMPI. Journal of Consulting Psychology, 1964,
28, 364-370.

Dickenson, W. A. An application of learning from the
training program to group counseling. In C. B.
Truax & R. R. Carkhuff (Eds.), Toward effective
counseling and psychotherapy. Chicago: Aldine, 1967.

 

DiLoreto, A. 0. Comparative psychotherapy: An experimental
analysis. Chicago: Aldine-Atherton, 1971.

Dolgan, J. I. The efficacy of systematic desensitization
procedures and a rational therapy in the modification
of phobic behavior (Doctoral Dissertation, Ohio
State University, 1967). Dissertation Abstracts
International, 1968, 28, 3874B. (University
Microfilms N6. 68-29747.

 

D'Zurilla, T. & Goldfried, M. Problem-solving and
behavior modification. Journal of Abnormal Psycho-
logy, 1971, 18, 107-126.

D'Zurilla, T. J., Wilson, G. T. & Nelson, R. A preliminary
study of the effectiveness of graduated prolonged
exposure in the treatment of irrational fear.
Behavior Therapy, 1973, 4, 672-685.

 

Ellis, A. Outcome of employing three techniques of psycho-
therapy. Journal of Clinical Psychology, 1957,
ii, 344-350:

Ellis, A. Rational psychotherapy. Journal of General
Psychology, 1958, 59, 35-49.

 

Ellis, A. Reason and emotion inspsychotherapy. New York:
Lyle Stuart, 1962.

Ellis, A. Growth through reason. Palo Alto: Science and
Behavior Bodks, 1971.

Everitt, B. S., Gourlay, A. J. & Kendell, R. E. An attempt
at validation of traditional psychiatric syndromes
by cluster analysis. British Journal of Psychiatry,
1971, £12, 399-412.

Fahy, T. J. Depression in hospital and in general prac-
tice: A direct clinical comparison. British
Journal of Psychiatry, 1974, 124, 240-242.

 

 

284

Ferster, C. B. Classification of behavioral pathology.
In L. Krasner & L. P. Ullmann (Eds.), Research in
behavior modification. New York: Holt, Rinehart &
Winston, 1965.

Ferster, C. B. A functional analysis of depression.
American Psychologist, 1973, 22, 857-870.

 

Freud, S. (1917) Mourning and melancholia. In J. Strachey
(Ed.), The standard edition (Vol. 14). London:
Hogarth Press,ll957.

 

Friedman, A. S. Minimal effects of severe depression on
cognitive functioning. Journal of Abnormal
Psychology, 1964, p2, 237-243.

 

 

Friedman, A. S. Interaction of drug therapy with marital
therapy in depressed patients. Archives of General
Psychiatry, 1975, 22, 619-637.

 

Friedman, R. J. & Katz, M. M. The psychology of depression:
Contemporasy theory and research. New York:
JOhh Wiley 8 Sons, 1974.

Fuchs, C. Z. & Rehm, L. P. A self-control behavior therapy
program for depression. Journal of Consulting and
Clinical Psychology, 1977, 4;,206-215.

 

Gioe, V. J. Cognitive modification and positive group
experience as a treatment for depression (Doctoral
Dissertation, Temple University, 1975). Disserta-
tion Abstracts International, 1975, 36, 3039B.
(University Microfilms No. 75-28, 219?

 

Glass, C. R., Gottman, J. M. & Shmurak, S. H. Response-
acquisition and cognitive self-statement modifica-
tion approaches to dating-skills training. Journal
of Counseling Psychology, 1976, 22, 520-526.

 

Goldfried, M. R. Reduction of generalized anxiety through
a variant of systematic desensitization. In M. R.
Goldfried & M. Merbaum (Eds.), Behavior change
through self-control. New York: Holt, Rinehart &
Winston,_l973}

 

Goldfried, M. R. & Davison, G. C. Clinical behavior
therapy. New York: Holt, Rinehart & Winston, 1976.

Goldfried, M. R., Decenteco, E. T. & Weinberg, L. System-
atic rational restructuring as a self-control
technique. Behavior Therapy, 1974, 5, 247-254.

 

285

Goldfried, M. & Goldfried, A. Cognitive change methods.
In F. Kanfer & A. Goldstein (Eds.), Helping people
change. New York: Pergamon Press, I975.

Goldfried, M. R. & Sobocinski, D. Effect of irrational
beliefs on emotional arousal. Journal of Consulting
and Clinical Psycholegy, 1975, 52, 504-510.

Grinker, R. R., Miller, J., Sabshin, M., Nunn, J. &
Nunally, J. D. The phenomena of depression. New
York: Harper & Row, 1961.

Hale, W. & Strickland, B. Induction of mood states and
their effects on cognitive and social behaviors.
Journal of Consultingsand Clinical Psychology, 1976,
44, 155.

Hamilton, M. A rating scale for depression. Journal of
Neurology, Neurosurgery and Psychiatry, I960, 22,
56-61.

Hammen, C. L. & Glass, D. R. Depression, activity and
evaluation of reinforcement. Journal of Abnormal
Psychology, 1975, 25, 718-721.

 

Hatheway, S. R. & McKinley, J. C. Scale 2 (Depression).
In G. S. Welsh & W. G. Dahlstrom (Eds.), Basic
readings on the MMPI inspsychology and medicine.
Minneapolis: University ofiMinnesota Press, 1956.

Hauck, P. A. A young woman with feelings of depression.
In A. Ellis (Ed.), Growth through reason: Verbatim
cases in rational-emotive therapy. Hollywood:
Wilshire, 1971.

 

Hobbs, N. Group-centered psychotherapy. In C. R. Rogers
(Ed.), Client-centered therapy. Boston: Houghton
Mifflin,gl951.

 

Holroyd, K. A. Cognition and desensitization in the group
treatment of anxiety (Doctoral Dissertation,
University of Miami, 1975). Dissertation Abstracts
International, 1976, 36, 4689B. (University
Microfilms No. 76-470lT

 

Homme, L. E. Perspectives in psychology: XXIV. Control
of coverants, the operants of the mind. Psychological
Record, 1965, 25, 501-511.

Hughes, R. D. E. C., Inc. Listening skills manual. East
Lansing, MI: D. E. C., Inc., 1977.

Jackson, B. Treatment of depression by self-reinforcement.
Behavior Therapy, 1972, 2, 298-307.

 

286

Jarmon, D. G. Differential effectiveness of RET, biblio-
therapy and attention placebo in the treatment of
speech anxiety (Doctoral Dissertation, Southern
Illinois University, 1972). Dissertation Abstracts
International, 1973, 33, 4510B. (University
MiCrofilms No. 73-6217Y

 

Jones, R. G. A factored measure of Ellis' irrational
belief system, with personality and maladjustment
correlates (Doctoral Dissertation, Texas Techno-
logical College, 1968). Dissertation Abstracts
International, 1969, 29, 4379:4380B. (University
Microfilms No. 69-64437

 

Kanfer, F. H. The maintenance of behavior by self-generated
stimuli and reinforcement. In A. Jacobs & L. B.
Sachs (Eds.), The psychology of private events:
Perspectives on covert response systems. New York:
Academic Press, 197i.

Kanfer, F. H., Karoly, P. & Newman, W. Reduction of chil-
dren's fear of the dark by competence-related and
situational threat-related cues. Journal of
Consulting and Clinical Psychology, I975, E3,
251-258.

Kanter, N. J. A comparison of self-control desensitiza-
tion and systematic rational restructuring for the
reduction of interpersonal anxiety (Doctoral
Dissertation, State University of New York at Stony
Brook, 1975). Dissertation Abstracts International
1976, 2Q, 3611B. (University Microfilms No. 76-792)

Karst, T. O. & Trexler, L. D. Initial study using fixed-
role and rational-emotive therapy in treating public-
speaking anxiety. Journal of Consulting and Clinical
Psychology, 1970, 24,360-366.

 

Kelly, G. A. The psychology of personal constructs.
New York? Norton, 1955.

Kieslar, D. Some myths of psychotherapy research and the
search for a paradigm. Psychological Record, 1966,
65, 110-136.

Kiloh, L. G. & Garside, R. F. The independence of neurotic

depression and endogenous depression. British
Journal of Psychiatry, 1963, 109, 451-463.

Klerman, G. L., Di Mascio, A., Weissman, M. M., Prusoff,
B. & Paykel, E. Treatment of depression by drugs
and psychotherapy. American Journal of Psychiatry,
1974, 222, 186-191.

287

Labouvie-Vief, G. & Gonda, T. Cognitive strategy training

and intellectual performance in the elderly.
Journal of Gerontolqu, 1976, 52, 327-332.

 

Lanyon, R. I. Psychological screening inventory manual

 

(2nd Ed.)i Port Huron: Research Psychologists
Press, 1978.

Lazarus, A. A. Learning theory and the treatment of

depression. Behavior Research and Therspy, 1968,
6, 83-89.

 

Lazarus, A. A. Behavior therapy and beyond. New York:

 

McGraw-Hill, 1971.

Lazarus, A. A. Multimodal behavioral treatment of depres-

sion. Behavior Therapy, 1974, 5, 549-554.

 

Lewinsohn, P. M. Clinical and theoretical aspects of

depression. In K. S. Calhoun, H. E. Adams & K. M.
Mitchell (Eds.), Innovative treatment methods in
psychopathology. New York: Wiley & Sons, l9747

 

 

Lewinsohn, P. M. Engagement in pleasant activities and

depression level. Journal of Abnormal Psychology,
1975, 54, 729-731.

 

Lewinsohn, P. M. Activity schedules in the treatment of

depression. In J. D. Krumboltz and C. E. Thoresen
(Eds.), Counseling methods. New York: Holt,
Rinehart & Winston, 1976.

 

Lewinsohn, P. M. & Graf, M. Pleasant activities and

depression. Journal of Consufting and Clinical
Psychology, 1973, 41, 261-268.

 

Lewinsohn, P. M. & Libet, J. Pleasant events, activity

schedules and depression. Journal of Abnormal
Psychology, 1972, 22, 291-295.

 

 

Lewinsohn, P. M., Lobitz, C. & Wilson, S. "Sensitivity"

of depressed individuals to aversive stimuli.
Journal of Abnormal Psychology, 1973, 22, 259-263.

 

Libet, J. & Lewinsohn, P. M. The concept of social skill

with special reference to the behavior of depressed
persons. Journal of Consulting and Clinical
Psychology, 1973, 49, 304-312.

 

 

Loeb, A., Beck, A. T., & Diggory, J. Differential effects

of success and failure on depressed and nondepressed
patients. Journal of Nervous and Mental Disease,
1971, 152, l06-ll4}

 

288

Lubin, B. Adjective checklists for the measurement of
depression. Archives of General Psychiatsy, 1965,
12, 57-62.

 

MacPhillamy, D. J. & Lewinsohn, P. M. Depression as a
function of levels of desired and obtained pleasure.
Journal of Abnormal Psychology, 1974, 55, 651-657.

Mahoney, M. J. Cognition and behavior modification.
Cambridge, MA: Ballinger, 1974.

 

Mahoney, M. J. Reflections on the cognitive-learning
trend in psychotherapy. American Psychologist, 1977,
32, 5-13.

 

Mahoney, M. J. & Thoresen, C. E. Self-control: Power to
the person. Monterey, CA: Brooks/Cole, 1974.

 

 

May, J. R. & Johnson, H. J. Physiological activity to
internally elicited arousal and inhibitory thoughts.
Journal of Abnormal Psychology, 1973, 52, 239-245.

 

McClellan, T. A. & Stieper, D. R. A structured approach
to group marriage counseling. Rational Living, 1973,
8, 12-18.

 

McGuire, M. & Sifneos, P. Problem-solving in psychotherapy.
Psychiatric Quarterly, 1970, 44, 667-673.

 

McLean, P. Therapeutic decision-making in the behavioral
treatment of depression. In P. 0. Davidson (Ed.),
The behavioral management of anxiety, depression and
pain. New York: Brunner/Mazel, 1976.

 

McLean, P. D., Ogston, K. & Grauer, L. A behavioral
approach to the treatment of depression. Journal

of Behavior Therapy and Experimental Psychiatpy,
1973, 4, 323-330.

Meehl, P. E. Profile analysis of the MMPI in differential
diagnosis. Journal of Applied Psychology, 1946,
55, 517-524.

 

Meichenbaum, D. Examination of model characteristics
in reducing avoidance behavior. Journal of
Personality and Social Psychology, I97I, ll,
298-307.

Meichenbaum, D. Cognitive modification of test anxious
college students. Journal of Consulting and Clinical
Psychology, 1972, 55, 370-380.

 

Meichenbaum, D. Cognitive-behavior modification: An
integrative approach. New York: Plenum Press, 1977.

 

 

289

Meichenbaum, D. & Cameron, R. Training schizophrenics to
talk to themselves: A means of developing atten-
tional controls. Behavior Therapy, 1973, 4,
515-534.

Meichenbaum, D. & Cameron, R. The clinical potential of
modifying what clients say to themselves. In
M. J. Mahoney & C. E. Thoresen (Eds.), Self-control:
Power to the person. Monterey: Brooks Co e,

Meichenbaum, D. H., Gilmore, J. & Fedoravicus, A. Group
insight vs. group desensitization in treating
speech anxiety. Journal of Consulting and Clinical
Psychology, 1971, 55, 4l0-42l.

 

Meichenbaum, D. H. & Goodman, J. Training impulsive
children to talk to themselves: A means of develop-
ing self-control. Journal of Abnormal Psychology,
1971, 22, 115-126.

Mendels, J. Electroconvulsive therapy and depression, I.
The prognostic significance of clinical factors.
British Journal of Psychiatry, 1965a, 111, 675-681.

Mendels, J. Electroconvulsive therapy and depression, II.
Significance of endogenous and reactive syndromes.
British Journal of Psychiatry, 1965b, 111, 682-686.

Mendels, J. Electroconvulsive therapy and depression, III.
A method for prognosis. British Journal of Psychiatry,
1965c, 111, 687-690.

Mendels, J. The prediction of response to electroconvul-
sive therapy. American Journal of Psychiatry, 1967,
124, 153-159.

Metcalfe, M. & Goldman, E. Validation of an inventory
for measuring depression. British Journal of
Psychiatry, 1965, 111, 240-242.

 

Moleski, R. & Tosi, D. J. Comparative psychotherapy:
RET vs. systematic desensitization in the treatment
of stuttering. Journal of Consulting and Clinical
Psychology, 1976, 44, 3093311.

 

Montgomery, A. G. Comparison of the effectiveness of
systematic desensitization, rational-emotive
therapy, implosive therapy, and no therapy, in
reducing test anxiety in college students (Doctoral
Dissertation, Washington University, 1971).
Dissertation Abstracts International, 1972, 32,
1861A. (University Microfilms No{_7l-27, 337T

 

290

1 National Institute of Mental Health. Special report on
depression. Bethesda, MD: Author, 1973.

 

Norman, W. H. The efficacy of self-instructional training
in the treatment of speech anxiety (Doctoral
Dissertation, Pennsylvania State University, 1975).
Dissertation Abstracts International, 1976, 36,
16633. (University Microfilms No. 75-22, 704?

Novaco, R. Anger control: The development and evaluation
of an experimental treatment. Lexington, MA:
Heath & Co.,41975.

 

Osgood, C. E. Studies of the generality of affective
meaning systems. American Psychologist, 1962,
17, 10-28.

Osgood, C. E., Suci, G. J. & Tannenbaum, P. H. The measure-
ment of meaning. Urbana, IL: University of’Illinhis
Press,0l957.

 

Paul, G. L. Behavior modification research: Design and
tactics. In C. L. Franks (Ed.), Behavior therapy:
Appraisal and status. New York: McGraw-Hill,il969.

 

Paykel, E. S. Depressive typologies and response to
amitryptyline. British Journal of Psychiatry, 1972,
120, 147-156.

Peale, N. V. The power of positive thinking. Englewood
Cliffs, N.J.: Prentice-Hall, 1960.

Peterson, D. R. The diagnosis of subclinical schizo-
phrenia. Journal of Consulting Psychology, 1954,
25, 198-200:

Pilowsky, I., Levine, S. & Boulton, D. M. The classifi-
cation of depression by numerical taxonomy.
British Journal of Psychiatry, 1969, 225, 937-945.

 

Platt, J. & Spivack, G. Problem-solving thinking of
psychiatric patients. Journal of Consulting and
Clinical Psychology, 1972a, 55, 148-151.

 

Platt, J. & Spivack, G. Social competence and effective
problem-solving thinking in psychiatric patients.
Journal of Clinical Psychology, 1972b, 25, 3-5.

 

Premack, D. Toward empirical behavior laws, I. Positive
reinforcement. Psychological Review, l959,{55,
219-233.

 

291

Raskin, A. Differential response to chlorpromazine,
imipramine and placebo: A study of subgroups of
hospitalized depressed patients. Archives of
General Psychiatry, 1970, 25, 164-173.

 

 

Rehm, L. P. Assessment of depression. In M. Hersen
and A. S. Bellack (Eds.), Behavioral assessment:
A practical handbook. New York: Pergamon Press,
1976.

 

 

Richardson, F. C. & Suinn, R. M. A comparison of tradi-
tional systematic desensitization, accelerated massed
desensitization, and anxiety management training
in the treatment of mathematics anxiety. Behavior
Therapy, 1973, 4, 212-218.

Rimm, D. C. & Litvak, S. B. Self-verbalization and emo-

tional arousal. Journal of Abnormal Psychology,
1969, 24, 181-187.

 

Rimm, D. C. & Masters, J. C. Behavior therapy: Techniques
and empirical findings. New York: Academic Press,
I974.

 

Rush, A. J1, Beck, A. T., Kovacs, M. & Hollon, S. Compara-
tive efficacy of cognitive therapy and pharmaco-
therapy in the treatment of depressed outpatients.
Cognitive Therapy and Research, 1977, 2, 17-37.

Russell, P. C. & Brandsma, J. M. A theoretical and empiri-
cal integration of the rational-emotive and classical
conditioning theories. Journal of Consulting and
Clinical Psychology, 1974: 42, 389-397.

 

Sarason, I. G. Test anxiety and cognitive modeling.
Journal of Personality and Social Psychology, 1973,
28, 58-61.

Schmickley, V. G. Effects of cognitive-behavior modifica-
tion upon depressed outpatients (Doctoral Disser-
tation, Michigan State University, 1976). Disser-
tation Abstracts International, 1976, 52, 987-988B.
(University Microfilms No. 76:18, 675)

Schofield, W. Psychotherapy: The purchase of friendship.
EnglewoodiCliffs, NJ: Prentice-Hall, 1964.

Scott, W. A. Cognitive complexity and cognitive balance.
Sociometry, 1963a, 25, 66-74.

Scott, W. A. Measuring cognitive structure. In 0. J.
Harvey (Ed.), Motivation and social interaction:
Cognitive determinants. New York: Ronald Press
Chmpany, I963b.

 

292

Shapiro, M. B., Neufield, I. & Post, F. Experimental study
of depressive illness. Psychological Reports, 1962,
10, 590.

 

Shapiro, M. B. & Ravenette, E. T. A preliminary experiment
on paranoid delusions. Journal of Mental Science,
1959, 105, 295-312.

 

Shaw, B. F. Comparison of cognitive therapy and behavior
therapy in the treatment of depression. Journal
of Consultingsand Clinical Psychology, 1977, 45,
543-551.

 

Shipley, C. R. & Fazio, A. F. Pilot study of a treatment
for psychological depression. Journal of Abnormal
Psychology, 1973, 52, 372-376.

 

 

Shure, M. & Spivack, G. Means-ends thinking, adjustment
and social class among elementary school-aged
children. Journal of Consulting and Clinical
Psychology,—I972,’55, 348-353.

 

 

Shure, M., Spivack, G. & Jaeger, M. Problem-solving
thinking and adjustment among disadvantaged pre-
school children. Child Development, 1971, 42,
1791-1803.

 

Skinner, B. F. Science and human behavior. New York:
Macmillan, 1953.

 

Spivack, G., Platt, J. J. & Shure, M. B. The problem-
solving approach to adjustment. San Francisco:
Jossey-Bass,1976.

 

 

Spivack, G. & Shure, M. Social adjustment of young children:
A cognitive appranh’to sclving real-life prohlems.
San Francisco: Jossey-Bass, 1974.

 

 

Steffy, R. A., Meichenbaum, D. & Best, J. A. Aversive and
cognitive factors in the modification of smoking
behavior. Behavior Research and Therepy, 1970,

8, 115-125.

 

Strickland, B. R., Hale, W. D. & Anderson, L. K. Effect
of induced mood states on activity and self-reported
affect. Journal of Consulting and Clinical

Psychology, 1975, 45, 587}

 

 

Suinn, R. M. & Richardson, F. Anxiety management training:
A nonspecific behavior therapy program for anxiety
control. Behavior Therapy, 1971, 2, 498-510.

 

293

Taylor, F. G. & Marshall, W. L. Experimental analysis of
a cognitive-behavioral therapy for depression.
ngnitive Research and Therapy, 1977, 2, 59-72.

Trexler, L. D. & Karst, T. O. Rational-emotive therapy,
placebo and no-treatment effects on public-speaking
anxiety. Journal of Abnormal Psychology, 1972,

79, 60-67.

Ullmann, L. P. & Krasner, L. A psychological approach to
abnormal behavior. EnglewoodCC1iffs, NJ: Prentihe-
Hall, 1975.

 

Vannoy, J. S. Generality of cognitive complexity-
simplicity as a personality construct. Journal of
Personality and Social Psychology, 1965, 2, 355-596.

Velten, E. A laboratory task for induction of mood states.
Behavior Research and Therapy, 1968, 5, 473-482.

Watts, F. N., Powell, G. E. & Austin, S. V. The modifica-
tion of abnormal beliefs. British Journal of
Medical Psychology, 1973, 45; 359-363.

 

Weimer, W. B. & Palermo, D. S. Paradigms and normal
science in psychology. Science Studies, 1973, 5,

211-244.

 

Weintraub, M., Segal, R. M. & Beck, A. T. An investigation
of cognition and affect in the depressive experiences
of normal men. Journal of Consultingyend Clinical
Psychology, 1974, 42, 911.

 

Weissberg, M. Anxiety-inhibiting statements and relaxation
combined in two cases of speech anxiety. Journal
of Behavior Therapy and Experimental Psychiatry,
1975, 5, 163-164.

Wener, A. & Rehm, L. P. Depressive affect: A test of
behavioral hypotheses. Journal of Abnormal Psych-
ology, 1975, 54, 221-227.

Werner, H. Comparative psychology of mental develspment.
New York: International Universities Press, 1957.

Wine, J. D. Investigations of an attentional inter-
pretation of test anxiety (Doctoral Dissertation,
University of Waterloo, 1970). Dissertation Ab-
stracts International, 1971, 52, - B.

 

294

Wolfe, J. Short-term effects of modeling/behavior
rehearsal, modeling/behavior rehearsal-plus-
rational therapy, placebo and no treatment on
assertive behavior (Doctoral Dissertation, New
York University, 1975). Dissertation Abstracts
International, 1975, 36, 1936-1937B. (University
Microfilms No. 75-22,—937)