nEHavioa TnEnavy (1972) ~ 298-307

Treatment of Depression by Self-Reinforcement

BARRY JACKSON t Dalhousie University

The processes of self-evaluation and self-reinforcement are discussed and related to maladaptive behaviors and behavior change. A procedure for treating low frequency behaviors is described and illustrated by treatment of a case of depression. The patient is active in all phases of the treatment from selecting and monitoring behaviors and reinforcers to administering the reinforcement contingent upon completing self-prescribed tasks.

There is little doubt that much of our behavior is regulated by its consequences but the bulk of the experimental evidence has been con- cerned primarily with consequences emanating from the person's social environment. Once control of the independent variables of which the behavior is a function is obtained, emission of the behavior itself will be controlled. With the exception of institutions such as penitentaries and mental hospitals, it is difficult to gain control over a person's environment in the sense of regulating the presentation of reinforcers and discriminative stimuli. Settings such as the home or the classroom have been successfully programmed for response-reinforcement con- tingencies (e.g., Guerney, 1969) with a variety of problematic behaviors. However, with many children and adults it is not possible to harness the environmental sources of reinforcement that could have regulatory potency. The person who has few friends or people available who are behaviorally equipped to cooperate might be unamenable to a treatment program of differential social reinforcement. For example, an individual released from a mental hospital after years of institutionalization would probably have few potential suppliers of positive reinforcement, or a person who is relatively unresponsive to social reinforcements because of low dependency habits. In cases such as these the administration of positive reinforcement to either establish or maintain behaviors may have come from the person himself.

Recently, considerable interest has been shown in self-reinforcement, the essence of which is the administration of reinforcing events to one-

1 Requests for reprints should be sent to Barry Jackson, Psychological Services, Dalhousie University, Halifax, Nova Scotia.

298 © 1972 by Academic Press, Inc.

CASE REPORTS 299

self contingent upon performing a preestablished response, in the absence of direct social influence. For summaries of the research in this area see Bandura (1969), Franks (1969) and Kanfer and Phillips (1970). Basically, four components of a self-reinforcement system may be identified, although not always explicitly, by the individual. In the first place the person establishes standards for what he considers to be an acceptable performance. Since this is often difficult because of inadequate reference points, the person may use socially defined norms or the performance of others as guidelines. When a person lacks objective criteria for evaluating his performance, social comparisons are likely to be used (Festinger, 1954; Diggory, 1966). Second, the person performs the task and appraises his performance relative to the standards he pre- viously set. Lastly, the person administers a positive or aversive conse- quence to or withholds a positive stimulus from himself. Responses to be strengthened or the actual reinforcer to be employed do not have to be tangible. Homme (1965) has outlined how coverants may be con- trolled through manipulating reinforcing events based on Premack's principle (Premack, 1965).

It is assumed that, while reinforcers a person may allot to himself are continuously available, he reinforces himself only when his performance reaches specified criteria. For each response the activity is not interrupted to assess performance or to administer a reinforcer. Rather, what likely happens is that the person continually monitors his performance and subjects only those responses to evaluation that deviate or mismatch a predefined band of expectations or a confirming interval (Birney, Burdick & Teevan, 1969). Birney et al. describe the confirming interval as representing an area of adaptation such that performances that fall lead to feelings of success if above, or failure if below. They hypothesize that "for the general population the more important the ability the nar- rower the confirming interval" (Birney et al., p. 124) thereby increasing the likelihood of success or failure judgments.

Bandura and Perloff (1967) have shown that, for children between 7 and 10 years, self monitored reinforcement systems are as effective as externally imposed ones in maintaining an effortful response. Similar results with college freshmen in a study skills program were found in that self-administered reinforcement was as effective as external rein- forcement in promoting efficient study behaviors and both reinforcement conditions were equally superior to two control conditions (Jackson & Van Zoost, 1971).

One aspect of the self-reinforcement sequence is the individual's own appraisal of his performance which, in itself, is frequently a focal be- havior for psychotherapeutic attention. Through a host of conversational

300 CASE REPORTS

maneuvers, the counsellor often attempts to alter the person's evaluation of himself on the assumption that a positive change in such self-related attitudes will lead to enhanced adjustment.

Kanfer and Marston (1963) demonstrated that positive self-evaluation is amenable to manipulation and that success contingent upon positive self-evaluation increases the frequency of the latter. Working with male adolescent retardates in residence, Brodsky, Lepage, Quiring and Zeller (1970) found that contingent reinforcement increased the accuracy of self-evaluative responses based primarily on a decrement of positive self-evaluations for incorrect responses.

The generalization of self-evaluative statements has been investigated by Aiken and Parker (1965) who rewarded and punished subjects for positive and negative self-evaluations respectively on a sentence com- pletion type of task and found an increase in positive self-evaluations. The generalizations were to a situation immediately following acquisition trials and were related only to verbal behavior. The generalization of self-acceptance statements from a verbal conditioning situation to a written questionnaire was demonstrated by Coons and MacEachern (1967). The relationship between self-evaluation and subsequent self- reinforcement has been studied by Kanfer and Duerfeldt (1967) who showed that self-evaluation and self-reinforcement are discrete operations, and predictions about a person's probability of reinforcing himself cannot be made accurately from knowing how he evaluates his performance. Thus, encouraging a person to appraise his productions favorably does not mean that there will occur a corresponding change in self-reinforcing behaviors.

From the foregoing it would appear that both the frequency and accuracy of self-evahiations may be increased and generalized to another verbal task. Changes brought about in self-evaluation, however, do not necessarily alter self-reinforcement patterns and each operation may be bound to separate stimulus conditions.

Despite the accelerated interest in self-reinforcement little attention has been directed at using this information to deal with maladaptive behaviors. Some exceptions to this have been the theorizing of Bandura (1968), Marston (1965a, 1969) and Ullmann and Krasner (1969) and the applications by Rehm and Marston (1968), Kanfer (1967) and Cautela (1970).

Rehm and Marston (1968) treated males who experienced anxiety in heterosexual situations by encouraging them to reinforce themselves positively with approval for interacting with females in progressively more demanding social encounters. Controls comprised subjects assigned to a "basically non-directive therapy technique" and no-therapy condi-

CASE REPORTS 301

tions. Greatest improvement was shown in the self-reinforcement group on self-report measures and in a simulated social interaction situation. Gains were extant at a seven to nine month follow-up. Kanfer (1967) reports using self-reinforcement whereby the patient's social interactions are taped and self-evaluative responses are evoked and followed by reinforcement from the therapist. Marston (1969) presents an approach for helping students with unrealistically high criteria for positive self- reinforcement by having a teacher suggest more attainable goals with explicit rewards upon achieving the goals.

Marston (1964) and Bandura (1968) have conceptualized certain behavior disorders in terms of deviant self-reinforcement systems. As an example, the depressed, dejected person may be viewed as possessing low criteria for negative self-reinforcement or conversely, high criteria for positive self-reinforcement (Marston, 1964). Comparing the per- formance of 20 high and 20 low depressed subjects Loeb, Beck, Diggory and Tuthill (1967) found that highly depressed subjects evaluated their performances poorly while actually it was comparable to that of low depressed subjects.

Recently, case studies have been presented whereby depressive be- haviors have been dealt with through applying principles of learning (Burgess, 1968; Lazarus, 1968; Lewinsohn & Shaw, 1969; Lewinsohn, Shaffer & Libet, 1969) and a summary of behavior modification tech- niques for treating depression has been provided by Seitz (1970). In line with an hypothesis proposed by Ferster (1965), it would seem that, in many cases of depression, the person's behavior has become in- creasingly ineffective in securing positive reinforcers from his environ- ment often because of alterations in reinforcement schedules or changes in significant discriminative stimuli under which behaviors were typically emitted. One characteristic of many depressed people is a vulnerability based on limited sources of social interaction that provide positive rein- forcers. Lewinsohn et al. (1969) have suggested that the depressed person is more dependent upon social reinforcement than the nonde- pressed person.

Rosenberry, Weiss and Lewinsohn (1969) found that depressed under- graduates were less adept and less predictable in their dispensing of positive social reinforcers than nondepressed students although there was no difference between the groups in frequency of reinforcement. From the finding of Marston (1965) of a relation between self-reinforee- ment and the reinforcement of another person, one might wonder whether the depressed person's less effective social reinforcement pat- tern might parallel an ineffective self-reinforcement system.

This paper reports the treatment of a case of depression to illustrate

~0~ CASE REPORTS

how self-reinforcement patterns may be changed. Although ill many psychotherapies a goal is often changing concomitants of self-rein- forcement behavior (self-concept, self-esteem, etc.) through condition- ing of verbal behaviors, self-reinforcement modification is seldom an enunciated objective and approached directly. In the following case a more propitious self-reward system was the target behavior. The form of treatment to be outlined may be classified as instigation therapy (Kanfer & Phillips, 1969) or programmed psychotherapy (Salzinger, 1969) whereby the locus of treatment control is the patient himself. Thus, the patient is active in the observation, design and execution of be- haviors and in this case serves as the primary source of reinforcement. Needless to say, reinforcers are provided by the person's social environ- ment but these are not deliberately manipulated. Basically, the procedure involves having the patient monitor a problematic behavior, select a reinforcer and a final target behavior, set goals defined in performance terms and arrange for the administration of the reinforcer contingent upon a favourable performance assessment. Goals or standards are established such that the probability of attaining these is maximal.

CASE ILLUSTRATION

History

L. M. is a 22-year-old housewife married for two years to a derical worker. During the last two years she has seen a number of therapists because of feelings of de- pression, worthlessness, inactivity, and frequent self-denigratory statements. Previous therapeutic attempts had tried to increase understanding of "WHY" she was de- pressed and to get her doing things, and although this would reduce some depres- sion, she reported that invariably it returned. Raised as an only child, she would receive countless lectures and negative comparisons by her mother with other children her age, the predominant theme being her deficient love and respect toward her mother. She perceived her father as being somewhat benign but he would not defend her from her mother's tirades. Her academic achievement was consistently above average and culminated in her obtaining a B.A. in Sociology with a "B'" average. According to her husband's accounts she was a meticulous housekeeper and an excellent cook but nevertheless had an alacrity to criticize her performance around the house. When asked to evaluate her achievement, "ob- jectively" she realized that she did a number of things comparable to or better than her peers.

It was patent that L. M. was extremely harsh with herself to the point of restricting herself from pleasurable experiences. Her activities were carried out in a quasimechanical manner with an apparent unfavorable distortion to feedback in terms of considerable sensitivity only to unacceptable performances. When questioned about rewarding experiences she gave herself, she was quick to reply that this definitely contradicted her upbringing; thus, self-managed consequences were pre- dominately aversive or, if ever positive, seemed to be random. Generally, the only positive reinforcement she received came from her surroundings, this being infrequent and neutralized by self-devaluating statements. It turned out that, over time, compliments became a discriminative stimulus for self-criticism.

CASE REPORTS 308

Procedure

It was decided to select a task that she performed frequently and considered important and to elaborate a self-reinforcement pattern for it. While reviewing her activities she enumerated relating to people, housekeeping, reading, talking to her husband, watching television and drawing. When asked to assess them in terms of frequency and their importance to her she chose housekeeping as the first behavior to monitor and she was given three records to keep daily, assessing them at about the same time each evening (between 9-10 PM). She was instructed to record the total amount of time per day spent on washing and drying dishes, and dusting. Second, she was asked to rate her depression according to her own criteria on a 10-point scale, 10 being very depressed. She was to record the number of rewards she gave herself throughout the day for housekeeping. A reward was defined as "praising yourself, doing something you like, or feeling contented as a consequence for doing housework."

Baseline data for these three measures were kept for 10 days and are presented in Fig. 1.

During the second interview the role of positive self-reinforcement was explained in detail to her, especially in maintaining behaviors for which positive social rein- foreement is available only intermittently. She was asked to take each chore separately and define what she wanted to accomplish in terms of the task and the amount of time estimated to complete it in much the same way that instructional objectives are formulated.

At first it was necessary for the therapist to lower the goals that L. M. had set for herself thus increasing the probability of her attaining success. To provide later reference, each goal was written down specifying the performance before

10--

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I SELF-RATED DEPRESSION 87- \\v/A\',I'/ i 110 POINT SCALE) k\

\

6--

5 -- \\ 5 5

3 - ~/ \\\\ 2-- POSITIVE SELF-REINFORCEMENT / - - - -~\ I - (FREQUENCY PER DAY) / \ _

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' ' " ' ' " 'ol 2'o'1 I 2 4 6 8 BASELINE DAYS SR + MANIPULATION

+ DENOTES INTERVIEW WITH THERAPIST

FIG. I DALLY RECORDS OF DEPRESSION AND FREQUENCY

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2 MONTH FOLLOW-UP

FIc. 1. Daily records of depression and frequency of positive self-reinforcement (Sn+).

804 CASE REPORTS

starting the task. When she had completed the task, she was told to assess what she had done in light of what she had set out to do. If she judged that she had matched or surpassed her goals she was told to do something positive or pleasant immediately, such as compliment herself, have a cigarette or telephone an interesting friend. To concretize these operations at first, she was given a box of poker chips and told to take as many as she thought she deserved up to 10 and then record the number she took. The inclusion of the chips was to promote her dispensing consequences to her performance. During the interview the process was modeled by the therapist and then rehearsed by L. M. until she had it mastered.

Beginning the l l t h day, she was instructed to reinforce herself positively con- tingent upon her evaluation of her activity and was asked to continue monitoring her behaviors. The graph indicates an increase in positive self-reinforcement and a corresponding decline in the self-rated depression. A sign test reveals that the prepostmeasures for both positive self-reinforcement and depression are significantly different at the .01 level. Additionally, she spent less time doing housework which she attributed to increased efficiency plus a more easy going attitude towards it. One early outcome was a generalization of gains to other areas such as socializing. Independently she applied the procedure to behaviors associated with the role of hostess, deciding what behaviors she wanted to manifest, evaluating her per- formance and then rewarding herself. This innovation received strong approval from the therapist. Interviews were held on the 15th and 21st days, at which time her progress was reviewed and new tasks were assigned. During the fourth interview, Day 21, L. M. reported that her depression had subsided and she ceased the observing and recording but continued the self-reinforcement program. Approximately two months later she was asked to resume the monitoring of frequency of positive self-reinforcement, depression and time spent on housework as previously defined. The results are shown in Fig. 1. The positive self-reinforcement now took the form of content or satisfaction in contrast to the initial feeling of "it still isn't good enough" and the subsequent verbal approval.

DISCUSSION

A p r o c e d u r e is desc r ibed in which a depres sed person is ins t ruc ted to sel f - re inforce pos i t ive ly for task pe r fo rmance j u d g e d to equa l or exceed se l f -prescr ibed s tandards . Al though a successful ou tcome m a y be re- l a ted to this a p p r o a c h an accep t ab l e a l te rna t ive explana t ion w o u l d be tha t the posi t ive changes m i g h t arise s imply from the se l f -moni tor ing of the behaviors ( Johnson & Whi te , 1970; McFal l , 1970). W h i l e L. M. mon i to red her depress ion for 10 days wi thou t an obse rved change this wou ld not exc lude the poss ib le in te rac t ion effects of se l f -moni tor ing and se l f - re inforcement . Addi t iona l ly , i t is p laus ib le t ha t the effects of self- obse rva t ion r equ i re longer than the base l ine pe r iod to be ac tua ted .

An e l emen t of se l f - re inforcement t ra in ing tha t appea r s cr i t ical is in i t ia l ly r equ i r ing the person to admin i s te r a t ang ib le re inforcer such as points or tokens to themselves s imul taneous ly wi th a posi t ive verba l iza- tion. This s tep encourages the person to engage de l i be ra t e ly and over t ly in the act of se l f -evaluat ion and se l f - re inforcement and prov ides a means of r eco rd ing these behaviors . T ra in ing in se l f - re inforcement has been

CASE nEPOaTS 305

used successfully with problems of avoidance of social evaluation, limited self-confidence and reduced productivity. Essential to approaching these types of problems is the presentation of ordered assignments in which the likelihood of failure is minimized. Often the person sets goals that are quite inappropriate in view of his current performance and virtually sabbotages his chance of favorably assessing his performance by adopting standards that prolific peers might use or standards that he himself employed when he was functioning more effectively. A student who procrastinates at completing an essay might have the overall task sectioned into constituents each of which become evaluated and reinforced. Thus, the student might set as a goal scanning the subject area for a topic, defining the task in explicit performance objectives while choosing a topic. Deciding upon a theme, etc., may be later goals.

Inherent in any treatment program in which behaviors required for extratreatment adjustments must be established is the problem of generalization. Usually, specific steps are not built in to facilitate transfer but rather, it is assumed, to be mediated and eventuated by symbolic self-regulation. By eliminating conflicts that support maladaptive be- haviors it is often taken for granted that the individual's repertory con- tains prosocial behaviors readily available for implementation without practice. When a person takes over the function of programming his own behavior, the probability of generalization is augmented since not only the behavior itself is established but the consequences are to a large extent controlled.

In summary, a self-regulated procedure for treating low frequency behaviors has been described and illustrated by a case of depression. Although positive outcomes have followed the use of this method, a number of alternative explanations such as enhanced discriminations, effects of self-monitoring or even placebo contributions have yet to be ruled out. The promise of this procedure lays in its emphasis on in- structing the client in generalizable strategies that may be initiated, con- ducted and assessed by the person himself.

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