Skip to main content

Advertisement

SpringerLink
Log in

Avoidance and processing as predictors of symptom change and positive growth in an integrative therapy for depression

  • Published:
International Journal of Behavioral Medicine Aims and scope Submit manuscript

Abstract

Depression is a leading cause of disability worldwide and can worsen the course of a variety of medical illnesses. There is a clear need to develop more potent treatments for this debilitating disorder and prevent its return. We are developing a promising psychotherapy that integrates components of current, empirically supported therapies for depression and also teaches healthy lifestyle and emotion regulation habits to promote psychological health. In the 1st open trial, growth curve analyses revealed a significant linear decrease in symptoms of depression in a sample of 29 clients who completed the therapy. Participants wrote essays about their depression each week, and the content was analyzed using a new coding system of change processes. Hierarchical linear modeling (HLM) revealed that peak levels of processing in the essays were associated with more improvement in depression and with the expression of more hope and of both negative and positive views of the self, presumably as clients explored their depressive views of self. Peak levels of avoidance were associated with less improvement in depression and with more hopelessness and negative views of the self. These preliminary results suggest possible targets of change that can facilitate symptom reduction and perhaps also promote psychological health.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Angus, L., Levitt, H., & Hardtke, K. (1999). The Narrative Processes Coding System: Research applications and implications for psychotherapy practice. Journal of Clinical Psychology, 55, 1255–1270.

    Article  PubMed  Google Scholar 

  • Antoni, M. H. (2003). Stress management intervention for women with breast cancer. Washington, DC: American Psychological Association.

    Google Scholar 

  • Baumeister, R. F. (1991). Suffering and unhappiness. Meanings of life (pp. 232–268). New York: Guilford.

    Google Scholar 

  • Beck, A. T., Freeman, A., Davis, D. D., & Associates. (2004). Cognitive therapy of personality disorders. New York: Guilford.

    Google Scholar 

  • Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Wiley.

    Google Scholar 

  • Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.

    Google Scholar 

  • Beevers, C. G., Wenzlaff, R. M., Hayes, A. M., & Scott, W. D. (1999). Depression and the ironic effects of thought suppression: Therapeutic strategies for improving mental control. Clinical Psychology: Science and Practice, 6, 133–148.

    Article  Google Scholar 

  • Bolger, N., Davis, A., & Rafaeli, E. (2003). Diary methods: Capturing life as it is lived. Annual Review of Psychology, 54, 579–616.

    Article  PubMed  Google Scholar 

  • Borkovec, T. D. (2002). Life in the future versus life in the present. Clinical Psychology: Science and Practice, 9, 76–80.

    Article  Google Scholar 

  • Bostwick, J. M., & Pankratz, V. S. (2000). Affective disorders and suicide risk: A reexamination. American Journal of Psychiatry, 157, 1925–1932.

    Article  PubMed  Google Scholar 

  • Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103, 670–686.

    Article  PubMed  Google Scholar 

  • Brewin, C. R., Reynolds, M., & Tata, P. (1999). Autobiographical memory processes and the course of depression. Journal of Abnormal Psychology, 108, 511–517.

    Article  PubMed  Google Scholar 

  • Carney, R. M., & Freedland, K. E. (2003). Depression, mortality, and medical morbidity in patients with coronary heart disease Biological Psychiatry, 54, 241–247.

    Article  PubMed  Google Scholar 

  • Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716.

    Article  PubMed  Google Scholar 

  • Cicchetti, D., Ackerman, B. P., & Izard, C. E. (1995). Emotions and emotion regulation in developmental psychopathology. Development and Psychopathology, 7, 1–10.

    Article  Google Scholar 

  • Davidson, R. J. ( 2000). Affective style, psychopathology, and resilience: Brain mechanisms and plasticity. American Psychologist, 55, 1196–1214.

    Article  PubMed  Google Scholar 

  • Evans, D. L., & Charney, D. S. ( 2003). Mood disorders and medical illness: A major public health problem. Biological Psychiatry, 54, 177–180

    Article  PubMed  Google Scholar 

  • Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., & Belluardo, P. (1998). Prevention of recurrent depression with cognitive behavioral therapy. Archives of General Psychiatry, 55, 816–820.

    Article  PubMed  Google Scholar 

  • First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). User’s guide for the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P), (Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.

    Google Scholar 

  • Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.

    Article  PubMed  Google Scholar 

  • Frank, E., Prien, R. F., Jarrett, R. B., Keller, M. B., Kupfer, D. J., Lavori, P. W., Rush, A. J., & Weissman, M. M. (1991). Conceptualization and rationale for consensus definitions of terms in major depressive disorder—remission, recovery, relapse, and recurrence. Archives of General Psychiatry, 48, 851–855.

    PubMed  Google Scholar 

  • Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226.

    Article  PubMed  Google Scholar 

  • Gilboa-Schechtman, E., & Foa, E. B. (2001). Patterns of recovery from trauma: The use of intraindividual analysis. Journal of Abnormal Psychology, 11, 392–400.

    Article  Google Scholar 

  • Gotlib, I. H., & Hammen, C. L. (2002). Handbook of depression. New York: Guilford.

    Google Scholar 

  • Greenberg, L. S. (2002a). Integrating an emotion-focused approach to treatment in psychotherapy integration. Journal of Psychotherapy Integration, 12, 154–189.

    Article  Google Scholar 

  • Greenberg, L. S. (2002b). Emotion-focused therapy: Coaching clients to work through feelings. Washington, DC: American Psychological Association.

    Google Scholar 

  • Greenberg, L. S., Elliott, R., & Foerster, F. (1990). Essential process in the psychotherapeutic treatment of depression. In D. McCann & N. Endler (Eds.), Depression: Development in theory, research, and practice (pp. 157–185). Toronto, Canada: Thompson.

    Google Scholar 

  • Greenberg, L. S., & Paivio, S. (1997). Working with emotion. New York: Guilford.

    Google Scholar 

  • Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy: Affect, cognition, and the process of change. New York: Guilford.

    Google Scholar 

  • Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2, 271–299.

    Article  Google Scholar 

  • Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology, 39, 281–291.

    Article  PubMed  Google Scholar 

  • Hamilton, M. (1960). Development of a rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56–62.

    Article  PubMed  Google Scholar 

  • Hayes, A. M., Castonguay, L. G., & Goldfried, M. R. (1996). The effectiveness of targeting the vulnerability factors of depression in cognitive therapy. Journal of Consulting and Clinical Psychology, 64, 623–627.

    Article  PubMed  Google Scholar 

  • Hayes, A. M., & Feldman, G. (2004). Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy. Clinical Psychology: Science and Practice, 11, 255–262.

    Article  Google Scholar 

  • Hayes, A. M, Feldman, G. C., & Goldfried, M. R. (in press). From insight to processing: Two measures of therapeutic change. In L. G. Castonguay & C. Hill Eds., Insight and change in psychotherapy . 00-00. Washington, DC: American Psychological Association.

  • Hayes, A. M., & Harris, M. S. (2000). The development of an integrative treatment for depression. In S. Johnson, A. M. Hayes, T. Field, N. Schneiderman, & P. McCabe (Eds.), Stress, coping, and depression (pp. 291–306). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

    Google Scholar 

  • Hayes, A. M., & Strauss, J. L. (1998). Dynamic systems theory as a paradigm for the study of change in psychotherapy: An application to cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 66, 939–947.

    Article  PubMed  Google Scholar 

  • Hayes, S. C., Wilson, K. W., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Emotional avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.

    Article  PubMed  Google Scholar 

  • Hollon, S. D., Muñoz, R. F., Barlow, D. H., Beardslee, W. R., Bell, C. C., Bernal, G., Clarke, G. N., Franciosi, L., Kazdin, A. E., Kohn, L., Linehan, M. M., Markowitz, J. C., Miklowitz, D. J., Persons, J. B., Niederehe, G., & Sommers, D. (2002). Psychosocial intervention development for the prevention and treatment of depression: Promoting innovation and increasing access. Biological Psychiatry, 52, 610–630.

    Article  PubMed  Google Scholar 

  • Hollon, S. D., Thase, M. E., & Markowitz, J. C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest, 3, 39–77.

    Article  Google Scholar 

  • Hunt, M. G. (1998). The only way out is through: Emotional processing and recovery after a depressing life event. Behaviour Research and Therapy, 36, 361–384.

    Article  PubMed  Google Scholar 

  • Ironson, G., Antoni, M., Schneiderman, N., Chesney, M., O’Cleirigh, C., Balbin, E., Greenwood, D., Lutgendorf, S., LaPerriere, A., Klimas, N., & Fletcher, M. A. (2002). Coping: Interventions for optimal disease management in HIV. In M. Chesney & M. Antoni (Eds.), Innovative approaches to health psychology: Prevention and treatment lessons from AIDS (pp. 167–196). Washington, DC: American Psychological Association.

    Google Scholar 

  • Joynt, K. E., Whellan, D. J., & O’Connor, C. M. (2003). Depression and cardiovascular disease: Mechanisms of interaction. Biological Psychiatry, 54, 248–261.

    Article  PubMed  Google Scholar 

  • Judd, L. L., Akiskal, H. S., Maser, J. D., Zeller, P. H., Endicott, J., Coryell, W., Paulus, M. P., Kunovac, J. L., Leon, A. C., Mueller, T. I., Rice, J. A., & Keller, M. B. (1998). A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Archives of General Psychiatry, 55, 694–700.

    Article  PubMed  Google Scholar 

  • Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216–226.

    Article  PubMed  Google Scholar 

  • Kaufmann, P. G. (2003), Depression in cardiovascular disease: Can the risk be reduced? Biological Psychiatry, 54, 187–190.

    Article  PubMed  Google Scholar 

  • Kiecolt-Glaser, J. K., McGuire, L, Robles, T. F., & Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83–107.

    Article  PubMed  Google Scholar 

  • Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986). The Experiencing Scales. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook. (pp. 21–71). New York: Guilford.

    Google Scholar 

  • Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books

    Google Scholar 

  • Kumar, S. M., Feldman, G. C., & Hayes, A. M. (2004). Change in mindfulness in an integrative therapy for depression. Manuscript submitted for publication.

  • Leserman, J. (2003). HIV disease progression: Depression, stress, and possible mechanisms Biological Psychiatry, 54, 295–306.

    Article  PubMed  Google Scholar 

  • Lewinsohn, P. M., Hoberman, H. M., & Clarke, G. N. (1989). The “Coping with Depression” course: Review and future directions. Canadian Journal of Behavioral Science, 21, 470–493.

    Article  Google Scholar 

  • Linley, P. A., & Joseph, S. (2004). Positive change following trauma andadversity: Areview. Journal of Traumatic Stress, 17, 11–21.

    Article  PubMed  Google Scholar 

  • Lyubomirsky, S., & Nolen-Hoeksema, S. (1993). Self-perpetuating properties of dysphoric rumination. Journal of Personality and Social Psychology, 65, 339–349.

    Article  PubMed  Google Scholar 

  • Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton.

    Google Scholar 

  • Martin, L. T., & Tesser, A. (1996). Some ruminative thoughts. In R. S. Wyer (Ed.), Ruminative thoughts (pp. 1–47). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

    Google Scholar 

  • McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system for psychotherapy (CBASP). New York: Guilford.

    Google Scholar 

  • Miller, I. W., Bishop, S. B., Norman, W. H., & Maddever, H. (1985). Modified Hamilton Rating Scale for Depression: Reliability and validity. Psychiatry Research, 14, 131–142.

    Article  PubMed  Google Scholar 

  • Murray, C. J. L., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet, 349, 1436–1442.

    Article  PubMed  Google Scholar 

  • ba]Musselman, D. L., Betan, E., Larsen, H., & Phillips, L. S. (2003). Relationship of depression to diabetes types 1 and 2: Epidemiology, biology, and treatment. Biological Psychiatry, 54, 317–329.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  • Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511.

    Article  PubMed  Google Scholar 

  • Nolen-Hoeksema, S. & Davis, C. G. (2004). Theoretical and methodological issues in the assessment and interpretation of posttraumatic growth. Psychological Inquiry, 15, 60–64.

    Google Scholar 

  • O’Cleirigh, C., Ironson, G., Antoni, M., Fletcher, M. A., McGuffey, L., Balbin, E., Schneiderman, N., & Solomon, G. (2003). Emotional expression and depth processing of trauma and their relation to long-term survival in patient with HIV/AIDS. Journal of Psychosomatic Research, 54, 225–235.

    Article  PubMed  Google Scholar 

  • Ottenbreit, N. D., & Dobson, K. S. (2004). Avoidance and depression: The construction of the cognitive-behavioral avoidance scale. Behaviour Research and Therapy, 42, 293–313.

    Article  PubMed  Google Scholar 

  • Pennebaker, J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162–166.

    Article  Google Scholar 

  • Pennebaker, J. W., & Francis, M. E. (1996). Cognitive, emotional, and language processes in disclosure. Cognition and Emotion, 10, 601–626.

    Article  Google Scholar 

  • Pennebaker, J. W., & Seagal, J. D. (1999). Forming a story: The health benefits of narrative. Journal of Clinical Psychology, 55, 1243–1254.

    Article  PubMed  Google Scholar 

  • Pos, A. E., Greenberg, L. S, Goldman, R. N., & Korman, L. M. (2003). Emotional processing during experiential treatment of depression. Journal of Consulting & Clinical Psychology, 71, 1007–1016.

    Article  Google Scholar 

  • Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). Thousand Oaks, CA: Sage.

    Google Scholar 

  • Reynolds, M., & Brewin, C. R. (1999). Intrusive memories in depression and post-traumatic stress disorder. Behaviour Research and Therapy, 37, 201–215.

    Article  PubMed  Google Scholar 

  • Riso, L. P., Miyatake, R. K., & Thase, M. E. (2002). The search for determinants of chronic depression: A review of six factors. Journal of Affective Disorders, 70, 103–116.

    Article  PubMed  Google Scholar 

  • Ryff, C. D., & Singer, B. (1998). The contours of positive human health. Psychological Inquiry, 9, 1–28.

    Article  Google Scholar 

  • Salovey, P., Rothman, A. J., Detweiler, J. B., & Steward, W. T. (2000). Emotional states and physical health. American Psychologist, 55, 110–121.

    Article  PubMed  Google Scholar 

  • Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior therapy. Clinical Psychology: Science and Practice, 7, 373–385.

    Article  Google Scholar 

  • Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guildford.

    Google Scholar 

  • Segerstrom, S. C., Stanton, A. L., Alden, L. E., & Shortridge, B. E. (2003). Multidimensional structure for repetitive thought: What’s on your mind, and how, and how much? Journal of Personality and Social Psychology, 85, 909–921.

    Article  PubMed  Google Scholar 

  • Sloan, D. M., & Marx, B. P. (2004a). A closer examination of the structured written disclosure procedure. Journal of Consulting and Clinical Psychology, 72, 165–175.

    Article  PubMed  Google Scholar 

  • Sloan, D. M., & Marx, B. P. (2004b). Taking pen to hand: Evaluating theories underlying the written disclosure paradigm. Clinical Psychology: Science and Practice, 11, 121–137.

    Article  Google Scholar 

  • Smyth, J. M., True, N., & Souto, J. (2001). Effects of writing about traumatic experiences: The necessity for narrative restructuring. Journal of Social and Clinical Psychology, 20, 161–172.

    Article  Google Scholar 

  • Spiegel, D., & Giese-Davis, J. (2003). Depression and cancer: Mechanisms and disease progression. Biological Psychiatry, 54, 269–282.

    Article  PubMed  Google Scholar 

  • Stiles, W. B., Elliott, R., Llewelyn, S. P., Firth-Cozens, J. A., Margison, F. R., Shapiro, D. A., & Hardy, G. (1990). Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy: Theory, Research, Practice, & Training, 27, 411–420.

    Article  Google Scholar 

  • Stover, E., Fenton, W., Rosenfeld, A., & Insel, T. R. (2003). Depression and comorbid mental illness: The National Institute of Mental Health perspective. Biological Psychiatry, 54, 184–186.

    Article  PubMed  Google Scholar 

  • Teasdale, J. D. (1999). Emotional processing, three modes of mind, and the prevention of relapse in depression. Behaviour Research & Therapy, 37, S53-S78.

    Article  Google Scholar 

  • Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15, 1–18.

    Article  Google Scholar 

  • Watkins, E., & Baracaia, S. (2001). Why do people ruminate in dysphoric moods? Personality and Individual Differences, 30, 723–734.

    Article  Google Scholar 

  • Weissman, M. M., Markowitz, J. C., & Klerman. G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.

    Google Scholar 

  • Wenzlaff, R. M., & Luxton, D. D. (2003). The role of thought suppression in depressive rumination, Cognitive Therapy and Research, 27, 293–308.

    Article  Google Scholar 

  • Whelton, W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic modalities. Clinical Psychology and Psychotherapy, 11, 58–71.

    Article  Google Scholar 

  • Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychology, University of Delaware, 108 Wolf Hall, 19716-2577, Newark, DE, USA

    Adele M. Hayes

  2. Department of Psychology, University of Texas at Austin, 78712, Austin, TX, USA

    Christopher G. Beevers

  3. Department of Psychology, University of Miami, 33146, FL, Coral Gables, USA

    Greg C. Feldman & Jean-Philippe Laurenceau

  4. Department of Psychiatry, Massachusetts General Hospital, 02114, Boston, MA, USA

    Carol Perlman

Authors
  1. Adele M. Hayes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher G. Beevers
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Greg C. Feldman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jean-Philippe Laurenceau
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carol Perlman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adele M. Hayes.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hayes, A.M., Beevers, C.G., Feldman, G.C. et al. Avoidance and processing as predictors of symptom change and positive growth in an integrative therapy for depression. Int. J. Behav. Med. 12, 111–122 (2005). https://doi.org/10.1207/s15327558ijbm1202_9

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1207/s15327558ijbm1202_9

Key words

Search

Navigation