Behavioral theories of depression

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Behavioral theories of depression explain the etiology of depression based on the behavioural sciences, and they form the basis for behavioral therapies for depression.

Contents

Behavioral theories

Introduction

Depression is a significant mental illness with physiological and psychological consequences, including sluggishness, diminished interest and pleasure, and disturbances in sleep and appetite. [1] It is predicted that by the year 2030, depression will be the number one cause of disability in the United States and other high-income countries. [2]

Behavioral theories of depression emphasize the role maladaptive actions play in the onset and maintenance of depression. These theories stem from work concerning the principles of learning and conditioning from the early to mid-1900s. [3] Ivan Pavlov and B. F. Skinner are often credited with the establishment of behavioral psychology with their research on classical conditioning and operant conditioning, respectively. Collectively, their research established that certain behaviors could be learned or unlearned, and these theories have been applied in a variety of contexts, including abnormal psychology. [4] Theories specifically applied to depression emphasize the reactions individuals have to their environment and how they develop adaptive or maladaptive coping strategies. [5]

Behavioral activation

Behavioral activation (BA) is an idiographic and functional approach to depression. It argues that people with depression act in ways that maintain their depression and locates the origin of depressive episodes in the environment. [6] While BA theories do not deny biological factors that contribute to depression, they assert that it is ultimately the combination of a stressful event in an individual's life and their reaction to the event that produces a depressive episode. Individuals with depression may display socially aversive behaviors, fail to engage in enjoyable activities, ruminate on their problems, or engage in other maladaptive activities. [7] [8] According to BA theory, these behaviors most often function as avoidance mechanisms while the individual tries to cope with a stressful life event, resulting in a decrease in positive reinforcers or perceived control. [9] Rumination is particularly important in the onset of depression. There are two main coping mechanisms, rumination and distraction. Ruminators spend time focusing on the stressful event and their feelings, while distractors engage in activities that distance them from the event and their feelings. Ruminators are much more likely to become depressed than distractors. [10]

Social skills

Deficits in social skills and positive social interactions have been empirically proven to be main contributors to the maintenance of depression. Individuals with depression typically interact with others less frequently than non-depressed persons, and their actions are typically more dysfunctional. [11] [12] One theory of social skills revolves around the lack of interaction-seeking behaviors displayed by the depressed individual. This lack of interaction results in social isolation that furthers the development of a negative self-concept, loneliness, and isolation. [13] An alternative social skills theory attributes problems within interactions with the maintenance of depression. The "pro-happiness social norm" causes people to approach social interactions with the expectation of a positive exchange; however, individuals with depression typically violate these expectations. The lack of responsiveness displayed by individuals with depression becomes annoying to their interaction partners, causing the interaction partners to either avoid interactions with the depressed individual or to approach them more negatively in future interactions, generating a self-fulfilling prophecy of continued negative social interactions for both individuals. [14] The depressed individual often sends ambiguous social cues that result in a misinterpretation by their interaction partner, such as a lack of responsiveness that can be interpreted as personal aversion. This misinterpretation leads to a decrease of positive interactions, resulting in a further decreased in social interactions, facilitating the maintenance of depression. [15]

Reinforcement contingencies

Reinforcement contingencies theory asserts that depression results from a loss of adequate reward contingencies. [16] Specifically, when positive behaviors are no longer rewarded in ways that are perceived to be adequate, those behaviors occur less frequently and, eventually, become extinct. The eventual extinction of a large spectrum of behaviors reduces the behavioral repertoire of the individual, resulting in the lack of responsiveness and arousal associated with depression. The loss or ineffectiveness of reinforcement can be attributed to a variety of causes:

After the removal of reinforcers, the affected individual begins to interpret their behavior as meaningless due to the lack of obvious consequences. This interpreted lack of control in a given domain is typically generalized, developing into learned helplessness. Learned helplessness is defined as a sense of having no control over outcomes, regardless of one's actions. This may mediate the emergence of the lack of responsiveness and arousal observed in persons with depression after a perceived change in positive reinforcers. [20]

Self-regulation

Self-regulation is a sub-category of reinforcement contingency theories. Self-regulation theories emphasize the role of self-implemented reinforcers and environment-dependent reinforcers. These self-implemented reinforcers may explain why some individuals who experience an external loss develop depression and others do not. Self-regulation begins with a self-evaluation in which the person recalls past performances and monitors their actions, followed by a reward or punishment. Individuals with depression may have unrealistic expectations for themselves, resulting in extreme self-punishment, or alternatively, may not engage in self-regulatory behaviors, depending completely on external sources of reinforcement. [21] In either circumstance, the individual limits their experiences of positive enforcers, leading to a preoccupancy with negative feelings and depression. [22]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is based on the assumption that depression has its roots in negative thought patterns that then result in negative behavior patterns. Aaron Beck is cited as the first to develop this cognitive-behavioral approach, focusing on the here and now rather than predisposing factors. Beck's theories are based on his cognitive triad: a negative view of self, the world, and the future. Individuals with depression have unwarranted negative views of themselves and the world and, consequently, have overly negative expectations for the future. These negative expectations result in aversive behaviors; however, the behaviors are only a symptom of the original cognitive misconceptions. [23]

Personality

Personality is defined as consistent patterns of thoughts, feelings, and behaviors. [24] Beck revised his original cognitive-behavioral theory to include predisposing personality types, which have been expanded upon by other cognitive-behavioral therapists. [25] Silvano Arieti and Jules Bemporad link these consistent patterns of thought and behavior with the development of depression. They define two personality types that are vulnerable to the development of depression: dominant other and dominant goal. Dominant others value the input of others and rely heavily on others for their self-esteem. When individuals with this personality type fail to meet the expectations of those others, they become vulnerable to the development of depression. Alternatively, individuals with the dominant goal personality value personal achievement and success. These individuals become vulnerable to depression when they realize that they cannot or have not reached their goals. [26] More generally, depression has been linked to differences in attributional styles and affect. Negative affect, the tendency to react negatively and to be overly sensitive to negative stimuli, predisposes individuals to depression. Conversely, positive affect, the tendency to react positively and to maintain high energy levels and high amounts of positive emotion, may serve as a buffer against depression. Additionally, the tendency to make negative internal attributions predisposes individuals to the development of hopelessness and depression. The opposite effect is seen for those who make positive internal attributions. [27]

Social psychological social environment theory of depression

According to social psychologist Wendy Treynor, depression happens when one is trapped in a social setting that rejects the self, on a long-term basis (where one is devalued continually), and this rejection is internalized into self-rejection, winning one rejection from both the self and group— social rejection and self-rejection, respectively. This chronic conflict seems inescapable, and depression sets in. Stated differently, according to Treynor, the cause of depression is as follows: One's state of harmony is disrupted when faced with external conflict (social rejection) for failing to measure up to a group’s standard(s). Over time, this social rejection is internalized into self-rejection, where one experiences rejection from both the group and the self. Therefore, the rejection seems inescapable and depression sets in. In this framework, depression is conceptualized as being the result of long-term conflict (internal and external), where this conflict corresponds to self-rejection and social rejection, respectively, or the dual needs for self-esteem (self-acceptance) and belonging (social acceptance) being unmet, on a long-term basis. The solution to depression offered, therefore, is to end the conflict (get these needs met): Navigate oneself into an unconditionally accepting social environment, so one can internalize this social acceptance into self-acceptance, winning one peace both internally and externally (through self-acceptance and social acceptance—self-esteem and belonging, respectively), ending the conflict, and the depression.

But what if one cannot find an unconditionally accepting group to navigate oneself into? If one cannot find such a group, the solution the framework offers is to make the context in which one generally finds oneself the self (however, the self must be in meditative solitude—alone and at peace, not lonely and ruminating—as stated, a state commonly achieved through the practice of meditation). The framework suggests that a lack of self-acceptance lies at the root of depression and that one can heal their own depression if they (a) keep an alert eye to their own emotional state (i.e., identify feelings of shame or depression) and (b) upon identification, take reparative action: undergo a context shift and immerse oneself in a new group that is unconditionally accepting (accepts the self, as it is)—whether that group is one that exists apart from the self or simply is the self [in meditative solitude]. Over time, the unconditional acceptance experienced in this setting will be internalized, allowing one to achieve self-acceptance, eradicating conflict, eliminating one’s depression. [28]

Helplessness and hopelessness theories of depression

In 1848, George Washington Burnap wrote that the "grand essentials to happiness" were "something to do, something to love and something to hope for." [29]

In 1958, Fritz Heider (with the help of Beatrice Wright) wrote "The Psychology of Interpersonal Relations", which pioneered attribution theory. [30] This theory explains the importance of how someone consciously attributes the causes of events in their life.

In 1972, Martin Seligman’s learned helplessness theory of depression posited that if someone finds that their actions don't appear to help resolve their problems, they learn they are helpless, and this will cause them to become depressed. [31] However, others found that this theory didn't account for different people in similarly helpless situations having differing levels of depression. [32]

In 1974, Aaron T. Beck, Arlene Weissman, David Lester and Larry Trexler published a "hopelessness scale". [33]

In 1976, Beck released Beck's cognitive triad. [34] This triad posits the importance of "automatic, spontaneous and seemingly uncontrollable negative thoughts" about the self, the world/environment, and the future. [35]

In 1978, Lyn Yvonne Abramson, Seligman and John D. Teasdale reformulated Seligman's 1972 work, using Heider's attribution theory. They proposed that people differed in how they classified negative experiences on three scales, from internal to external, stable to unstable, and from global to specific. They believed that people who were more likely to attribute negative events to internal, stable, and global causes were more likely to become depressed than those attributed things to causes at the other ends of the scales. [36]

In 1979, Beck, Augustus John Rush, Brian Shaw and Gary Emery published the book "Cognitive therapy of depression", [37] which had the cognitive triad as a major underpinning concept. This mode of therapy became a major part of Cognitive Behavioral Therapy in the 1980s, which became the standard non-pharmaceutical treatment for depression.

In 1988, Beck's "hopelessness scale" of 1974 was redeveloped into the first edition of the Beck Hopelessness Scale. [38] This soon became the standard measure of hopelessness, though it was less used than the long existing Beck Depression Inventory.

In 1988 and 1989, Abramson, Gerald Metalsky, Lauren Alloy and Shirley Hartlage revised Abramson's 1978 work, and named the results the "hopelessness theory of depression". They believed that "hopelessness depression" was a subtype of depression, and that it was not inclusive of all depression. [39] [40]

In 1992, Donna Rose and Abramson published a paper emphasising the importance of childhood experiences on setting someone's positions on the internal, stable, and global attributional scales. [41]

In 2002, John Abela and Sabina Sarin found that if someone was at the far depressive end of any of the three attributional scales, they would likely become depressed. There was no anti-depressive benefit from being higher on the other two. They called this the "weakest link hypothesis." [42]

In 2006, Catherine Panzarella, Alloy and Wayne Whitehouse published an "Expanded Hopelessness Theory of Depression". This expanded on the 1989 theory, noting the importance of social support in an individual's defence against depression. In particular, "adaptive inferential feedback" was deemed to be especially important. This is feedback given to someone that defines the cause of a negative event as external, unstable and specific - the kind of thinking that leads away from depression. [43]

Behavioral therapies

Behavior therapy, also known as behavior modification, is a sub-category of psychotherapy. The emphasis is placed on observable, measurable behavior and the alteration of maladaptive behaviors via rewards and punishment. [44] Behavior therapies for depression first emerged in the mid-1960s with Saslow's positive group reinforcement, which focused on increasing social skills. Three alternative therapies emerged over the next 4 years: Lewinsohn's social learning theory, Patterson's anti-depression milieu, and Lazarus' behavioral deprivation. Social learning theory focused on identifying and avoiding behaviors that increased depressive thoughts. Anti-depression milieu encouraged catharsis to overcome depression. Behavioral deprivation therapy denied patients any stimulus for an extended period of time, positing that any future stimulus would elicit positive feelings. Though none of these therapies are practiced in their original form, they formed the basis for all behavioral therapies in use today. [45] Behavioral therapy has been shown to be as effective as cognitive therapy and antidepressants in the treatment of depression. The benefits of behavioral therapy have also been shown to persist after the end of therapy. [46]

Behavioral activation therapy

Behavioral activation therapy emphasizes the role of the individual in creating treatment goals and engaging with their environment in a way that facilitates positive reinforcement. Treatment is typically intended to be brief, intense, and specific to the goals of the individual. [47] Goals are specific and measurable, focusing on single avoidance behaviors. Patients keep activity logs to monitor the feelings associated with different activities and therapists assign graded homework to help patients accomplish their goals. Patients are encouraged to participate in activities that they find pleasurable and to avoid activities that generate feelings of depression. [48] Engaging in more diverse and positively reinforcing activities will, over time, rebuild the individual's behavioral repertoire, providing more variability in their responses and actions. This variability has been linked to a decrease in depressive symptoms and to a typical behavioral profile. [49] The ultimate goal is to engage the individual in a wide range of stable and meaningful reinforcers, consequently alleviating depressive symptoms. [50]

Functional analysis

Functional analysis is defined as "the identification of important, controllable, causal functional relationships applicable to a specified set of target behaviors for an individual [51] " and is used for individual evaluation in behavioral activation therapy. In functional analysis, the purpose of the behavior is emphasized in relation to the individual and their environment, i.e. if the behavior is avoidant, rather than the actual topography of the action. Functional analysis is based on the evaluation of an event via the three-term contingency: antecedents, behavior, and consequences. An antecedent is an event that increases the likelihood of a given behavior, the behavior is the individual's response to the antecedent, and the consequence is the reinforcement or lack thereof. Therapists help individuals identify events that typically trigger specific behaviors and the consequences of these behaviors. Then the individual is encouraged to interrupt the three-term contingency pattern for negative consequences by either avoiding the antecedent or changing the behavior. Likewise, individuals are encouraged to seek out antecedents that result in positive reinforcement and to increase the behaviors for which they are positively reinforced. [52] [53]

Social skills training

Social skills training includes all therapies that teach adaptive interaction skills. Training may be specific to a given situation, such as a job interview, or may be more general in nature. Therapists often engage individuals in behavioral rehearsal, a process in which the client practices appropriate social skills for a given situation with the therapist. [54]

Social problem solving

In social problem solving therapy, therapists help individuals develop adaptive coping mechanisms for daily life stresses, such as confrontation and discomfort, within a social environment. Emphasis is placed on manipulating the individual's responses to social stressors, as well as ways to avoid excessively stressful social situations. There is no pre-determined set of adaptive behaviors, rather, coping mechanisms are created on an individual basis. [55]

Problem solving therapy

Problem orientation therapy (PST) is a sub-category of social problem solving therapy that focuses on changing the manner in which individuals approach social stressors. Problem orientation is an individual's generalized cognitive approach to social problems and coping. Individuals with depression typically display a negative problem orientation, the tendency to become overwhelmed by social stressors and perceive them to be unsolvable, resulting in maladaptive coping. PST emphasizes decreasing negative orientations, increasing positive orientations, enhancing problem-solving skills, and minimizing avoidant and impulsive reactions. Individuals are provided with a series of steps to manipulate their orientation and reaction: the SSTA Toolkit. Therapists instruct clients to stop, slow down, think, and act to encourage rational behavior that is influenced by cognitive processes rather than emotional reactions. The emphasis is placed on generating behavioral modifications that interrupt the individual's typical progression of negative orientation and maladaptive coping, replacing them with positive orientation and useful coping behaviors. [56]

See also

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Psychology is an academic and applied discipline involving the scientific study of human mental functions and behavior. Occasionally, in addition or opposition to employing the scientific method, it also relies on symbolic interpretation and critical analysis, although these traditions have tended to be less pronounced than in other social sciences, such as sociology. Psychologists study phenomena such as perception, cognition, emotion, personality, behavior, and interpersonal relationships. Some, especially depth psychologists, also study the unconscious mind.

Social learning is a theory of learning process social behavior which proposes that new behaviors can be acquired by observing and imitating others. It states that learning is a cognitive process that takes place in a social context and can occur purely through observation or direct instruction, even in the absence of motor reproduction or direct reinforcement. In addition to the observation of behavior, learning also occurs through the observation of rewards and punishments, a process known as vicarious reinforcement. When a particular behavior is rewarded regularly, it will most likely persist; conversely, if a particular behavior is constantly punished, it will most likely desist. The theory expands on traditional behavioral theories, in which behavior is governed solely by reinforcements, by placing emphasis on the important roles of various internal processes in the learning individual.

A cognitive distortion is an exaggerated or irrational thought pattern involved in the onset or perpetuation of psychopathological states, such as depression and anxiety.

<span class="mw-page-title-main">Perfectionism (psychology)</span> Personality trait

Perfectionism, in psychology, is a broad personality trait characterized by a person's concern with striving for flawlessness and perfection and is accompanied by critical self-evaluations and concerns regarding others' evaluations. It is best conceptualized as a multidimensional and multilayered personality characteristic, and initially some psychologists thought that there were many positive and negative aspects.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Depressive realism is the hypothesis developed by Lauren Alloy and Lyn Yvonne Abramson that depressed individuals make more realistic inferences than non-depressed individuals. Although depressed individuals are thought to have a negative cognitive bias that results in recurrent, negative automatic thoughts, maladaptive behaviors, and dysfunctional world beliefs, depressive realism argues not only that this negativity may reflect a more accurate appraisal of the world but also that non-depressed individuals' appraisals are positively biased.

Emotional reasoning is a cognitive process by which an individual concludes that their emotional reaction proves something is true, despite contrary empirical evidence. Emotional reasoning creates an 'emotional truth', which may be in direct conflict with the inverse 'perceptional truth'. It can create feelings of anxiety, fear, and apprehension in existing stressful situations, and as such, is often associated with or triggered by panic disorder or anxiety disorder. For example, even though a spouse has shown only devotion, a person using emotional reasoning might conclude, "I know my spouse is being unfaithful because I feel jealous."

Explanatory style is a psychological attribute that indicates how people explain to themselves why they experience a particular event, either positive or negative.

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on behaviorism's theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems.

Self-criticism involves how an individual evaluates oneself. Self-criticism in psychology is typically studied and discussed as a negative personality trait in which a person has a disrupted self-identity. The opposite of self-criticism would be someone who has a coherent, comprehensive, and generally positive self-identity. Self-criticism is often associated with major depressive disorder. Some theorists define self-criticism as a mark of a certain type of depression, and in general people with depression tend to be more self critical than those without depression. People with depression are typically higher on self-criticism than people without depression, and even after depressive episodes they will continue to display self-critical personalities. Much of the scientific focus on self-criticism is because of its association with depression.

Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. This involves the individual working with the therapist to develop skills for testing and changing beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. A cognitive case conceptualization is developed by the cognitive therapist as a guide to understand the individual's internal reality, select appropriate interventions and identify areas of distress.

Behavioral activation (BA) is a third-generation behavior therapy for treating mood disorders. Behavioral activation primarily emphasizes engaging in positive and enjoyable activities to enhance one's mood.

Arbitrary inference is a classic tenet of cognitive therapy created by Aaron T. Beck in 1979. He defines the act of making an arbitrary inference as the process of drawing a conclusion without sufficient evidence, or without any evidence at all. In cases of depression, Beck found that individuals may be more prone to cognitive distortions, and make arbitrary inferences more often. These inferences could be general and/or in reference to the effectiveness of their medicine or treatment. Arbitrary inference is one of numerous specific cognitive distortions identified by Beck that can be commonly presented in people with anxiety, depression, and psychological impairments.

<span class="mw-page-title-main">Rumination (psychology)</span> Focused attention

Rumination is the focused attention on the symptoms of one's mental distress, and on its possible causes and consequences, as opposed to its solutions, according to the Response Styles Theory proposed by Nolen-Hoeksema in 1998.

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences — even when doing so creates harm in the long run. The process of EA is thought to be maintained through negative reinforcement — that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the avoidance behavior will persist. Importantly, the current conceptualization of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings is thought to be linked to a wide range of problems.

A cognitive vulnerability in cognitive psychology is an erroneous belief, cognitive bias, or pattern of thought that predisposes an individual to psychological problems. The vulnerability exists before the symptoms of a psychological disorder appear. After the individual encounters a stressful experience, the cognitive vulnerability shapes a maladaptive response that increases the likelihood of a psychological disorder.

Interpersonal emotion regulation is the process of changing the emotional experience of one's self or another person through social interaction. It encompasses both intrinsic emotion regulation, in which one attempts to alter their own feelings by recruiting social resources, as well as extrinsic emotion regulation, in which one deliberately attempts to alter the trajectory of other people's feelings.

Social problem-solving, in its most basic form, is defined as problem solving as it occurs in the natural environment. More specifically it refers to the cognitive-behavioral process in which one works to find adaptive ways of coping with everyday situations that are considered problematic. This process in self-directed, conscious, effortful, cogent, and focused. Adaptive social problem-solving skills are known to be effective coping skills in an array of stressful situations. Social problem-solving consists of two major processes. One of these processes is known as problem orientation. Problem orientation is defined as the schemas one holds about problems in everyday life and ones assessment of their ability to solve said problems.

References

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  41. ↑ Liu, Richard T.; Kleiman, Evan M.; Nestor, Bridget A.; Cheek, Shayna M. (1 December 2015). "The Hopelessness Theory of Depression: A Quarter Century in Review". Clinical Psychology. 22 (4): 345–365. doi:10.1111/cpsp.12125. ISSN   0969-5893. PMC   4689589 . PMID   26709338.
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  52. ↑ Lewinsohn, Petter; Libet, Julian (1972). "Pleasant events, activity schedules, and depressions". Journal of Abnormal Psychology. 79 (3): 291–295. doi:10.1037/h0033207. PMID   5033370. S2CID   6354837.
  53. ↑ O'Donohue, William (2012). Fisher, Jane. Hoboken, NJ: Wiley. pp. 18–20.
  54. ↑ Andrews, Linda (2010). Encyclopedia of Depression. Santa Barbara, CA: ABC-CLIO.
  55. ↑ O'Donohue, William; Fisher, Jane (2012). Cognitive Behavior Therapy: Core Principles for Practice. Hoboken, NJ: Wiley. pp. 159–161.
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