Cognitive Therapy and Research, Vol. 7, No. 1, 1983, pp.

99-106

Self-Modification of Depression via

Cognitive-Behavioral Intervention Strategies:
A Time Series Analysis I
Scott B. Hamilton 2 and David A . Waldman
Colorado State University

A 20-year-oM student enrolled in an undergraduate adjustment course

implemented a self-modification program oriented toward the reduc-
tion o f a 4-year history o f moderate to severe depression. Following an
initial baseline period, separate interventions were aimed at reducing
depressive ruminatory activity by (a) reinforcing the gradual completion o f
academic tasks that had been serving as primary sources o f negativistic
thinking, and (b) reducing maladaptive rumination directly via the
implementation o f a cognitive-behavioral intervention package consisting
o f rational restructuring, covert self-reinforcement, and covert modeling.
Results, analyzed by time series analysis, indicated a significant decline
in frequency and intensity o f self-monitored depressive thoughts only
during the cognitive-behavioral intervention. Moreover, treatment effects
were maintained at 6-month follow-up, with self-report data being cor-
roborated by independent peer evaluation. Limitations and potential
implications o f the present single-subject experiment are discussed.

Training in self-management has recently been incorporated into under-

graduate psychology courses where students learn experientially by con-
ducting personally relevant self-modification projects (see Hamilton, 1980;
Menges & Dobroski, 1977). Despite the significant change produced in a
variety of self-designated target behaviors (e.g., studying, exercise, weight),

1This work has been submitted as a case study.

2Address all correspondence to Scott B. Hamilton, Department of Psychology, Colorado
State University, Fort Collins, Colorado 80523.

99
01.17-5916/83/0200-0099503.00/0 cod1983PlenumPublishingCorporation
100 Hamilton and Waldman

affective disorders have rarely been selected as targets for student-im-

plemented self-change efforts. Moreover, in the one available case study
where depression was treated via self-modification procedures (Tharp,
Watson, & Kaya, 1974), the severity of the disorder was not specified,
no outcome or follow-up data were presented, and ongoing consultation
was provided for each of the four women treated. The purpose of the
present investigation was therefore to more clearly demonstrate the
independent application of student-implemented self-control procedures in
a case of moderate to severe depression.

CASE STUDY

Subject

The subject, A1, was a 20-year old student enrolled in a 3-hour

"Psychological Principles of Human Relations" course. The first half of
this undergraduate course was oriented toward behavioral self-control
principles, which provided a basic framework for student-implemented
self-modification projects (see Hamilton, 1980, 1981, for a description
of course format). Although 73 students conducted self-modification
projects, Al's project was selected for more intensive evaluation due to the
apparent severity and chronicity of the affective disturbance.
More specifically, in his written proposal, Al reported a 4-year
history of noncyclical, chronic depression associated with severe family
stress, parental divorce, and continual exposure to maternal criticism.
Although attempts were made to alter his emotional state through personal
effort and group therapy, A1 continued to engage in frequent self-criticism
and depressive rumination. Al's prebaseline functional analysis revealed
prolonged periods of negativistic thinking oriented toward such concerns
as insufficient studying, poor grades, inadequate time scheduling, and lack
of career goals. Although infrequent in occurrence, such monothematic
ruminations would last up to 4 hours, with the intensity of the resulting
depression being exacerbated by cognitive distortion and overgeneraliza-
tion (e.g., "I'm stupid, and a total failure because my grades are bad").
In light of other self-reported symptoms (e.g., dysphoric mood, loss of
interest and motivation, fatigue, extreme guilt, concentration difficulties,
insomnia, social withdrawal, irritability), Al's affective disturbance was
viewed as most clearly representing a major depressive disorder according
to the Diagnostic and Statistical Manual III (DSM-III; American Psy-
chiatric Association, 1980).
Self-Modification of Depression 101

Measures

A1 oriented his self-monitoring toward the frequency of negative

thoughts and the negative affect resulting from such cognitions. Each
thematic rumination was counted as one negative thought (despite dura-
tion), and the highest intensity of depression reached was judged via a 7-
point scale (0 = depression absent, 6 -- extreme depression). Moreover,
following submission of his written proposal, A1 was contacted by mail
and asked to participate in additional assessment procedures. Reliability
enhancement instructions (i.e., consequence clarification, cuing) were in-
cluded as a means of increasing self-report accuracy (see Hamilton,
1981). A1 agreed to participate and completed the following inventories:
the Multiple Affect Adjective Check List (MAACL; Zuckerman & Lubin,
1965), the Visual Analogue Scale (VAS; Aitken, 1969), and the Beck
Depression Inventory (BDI; Beck, 1978). Additionally, Al allowed us to
contact his roommate, who agreed to confidentially complete the VAS
and MAACL, which were modified slightly to serve as peer rating
instruments (i.e., external measures of Al's depression).

Self-Modification Procedure

Baseline. A1 recorded the frequency and intensity of negative thoughts

during an 18-day baseline period.
Behavioral Intervention. Since negative rumination appeared to be a
major antecedent of depressive affect, A1 attempted to intervene directly
by eliminating apparent sources of ruminatory activity. A contingency
program was therefore instituted whereby points were earned for securing
career information, meeting daily study goals, maintaining a datebook,
and following through with all appointments and deadlines. A token menu
of 20 reinforcing activities allowed A1 to exchange points for a broad
array of reinforcers.
Cognitive Behavioral Intervention. Following the 14-day behavioral
intervention, A1 dropped the contingency program and, instead, oriented
his efforts toward maladaptive cognitions. More specifically, a behavioral
contract was formed where by A1 agreed to (a) immediately engage in
rational restructuring at the onset of negative rumination by recording
the instigating event, the intensity of negative feelings, his depression-
inducing cognitions, and his rational re-evaluation of the original situation;
(b) implement a daily covert self-reinforcement strategy by which he
would review written, positive statements about himself while engaging
in pleasant activities; and (c) initiate a covert modeling procedure during
 102 Hamilton and Waidman

prespecified daily periods in which he would relax, and imagine himself

engaging in a stressful situation and either coping successfully or "coolly
working out the problem" after the worst possible outcome had occurred.
The cognitive-behavioral intervention lasted 70 days. On the basis of Al's
self-report, there appeared to be no differential expectations associated
with the behavioral and cognitive-behavioral interventions at the point
of treatment implementation.
Follow-Up. Six months following project termination, A1 recorded
the daily frequency and intensity of depressive thoughts during a 14-day
period. Inventories were also readministered to both A1 and his room-
mate.

RESULTS

The self-monitored frequency (F) and intensity (I) of negative

thoughts are presented in Figure 1. Self-monitored data were subjected to
time series analysis, including autocorrelation procedures to identify the
appropriate model (i.e., A R I M A [0, 0, 1]), and least-squares analysis
t tests to evaluate treatment effects. Only t values associated with the most
appropriate first-order moving averages coefficient are reported (see Glass,
Willson, & Gottman, 1975).
Results indicated a nonsignificant change in level between base-
line (MF -- 3.22; MI = 3.21) and behavioral intervention (MF = 2.57;
MI = 3.93) for both frequency, t(30) = 1.75, p > .05, and intensity of
negative thoughts, t(30) = - 1.44, p > . 10. However, a significant decline
in level did occur for frequency during cognitive-behavioral intervention
(MF = .89) as compared with both baseline, t(86) = 7.48, p < .001, and
behavioral intervention periods, t(82) = 4.48, p < .001. Similarly, a sig-
nificant decline in level occurred for intensity during cognitive-behavioral in-
tervention (MI = .18) as compared with both baseline, t(86) = 25.13,
p < .001, and behavioral intervention periods, t(82) = 14.40, p <
.001. Moreover, a nonsignificant change in level between the cognitive-be-
havioral intervention and follow-up (MF = .79; MI = .09) for both frequency,
t(82) = .23, p > .80, and intensity, t(82) = .88, p > .20, provided statistical
support for the maintenance of treatment effects.
Scores from the VAS, MAACL, and BDI (see Table I) not only
support the initial severity and subsequent decline in depressive affect
but provide external validation of Al's self-report for both targeted and
nontargeted problem areas.

DISCUSSION

Results of the present case study provide preliminary evidence con-

cerning the efficacy of self-modification procedures in the treatment of
Self-Modification of Depression 103

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104 Hamilton and Waldman

Table I. Pretreatment and Follow-Up Scores from the

Visual Analogue Scale (VAS), Multiple Affect Adjective
Checklist (MAACL), and Beck Depression Inventory
(BDI)"
MAACL
Assessment period VAS Anx Hos Dep BDI
Subject
Pretreatment 69 16 22 35 26
Follow-up 14 4 3 7 1
Roommate
Pretreatment 73 15 18 32 m

Follow-up 19 7 8 15
"Anx = Anxiety, Hos = Hostility, Dep = Depression.

moderate to severe depression. The current findings extend those previously

reported by Tharp et al. (1974) in that (a) the level of depression was
assessed via standardized instruments, (b) intervention strategies were
designed and administered independently of direct therapist contact, (c)
multiple change criteria were employed, (d) a 6-month follow-up was con-
ducted, (e) self-report data were corroborated by independent peer evalua-
tion, and (f) time series analysis was used in evaluating therapeutic change.
Although these results support the potential applicability of instructionally
based self-control procedures in the provision of cost-effective services
to students with more severe behavior problems, implications must be
tempered by the limitations imposed on all single-subject investigations
and the more specific restrictions involved when A-B type designs are
employed. Moreover, due to the length of intervention and follow-up
periods, natural remission of depressive symptomatology cannot be ruled
out.
Although sequential confounding does not allow for unambiguous
comparisons to be made between the two intervention procedures, it would
appear that the cognitive intervention package provided a valuable change-
instigating function either alone or in sequential combination with the con-
tingency-management program. Indeed, the sequential nature of inter-
vention may have been particularly important in the present case in view
of the subject's anecdotal report that the behavioral intervention served
to eliminate previous sources of depressive rumination (i.e., insufficient
studying, lack of career goals, etc.) but that n e w ruminative themes (e.g.,
physical appearance, heterosexual interaction) began to replace previous
themes during the 2-week behavioral intervention period. It is also in-
teresting to note that cognitive strategies appeared to precipitate a more
dramatic change in intensity than in frequency of negative thoughts.
Self-Modification of Depression 105

Such effects are consistent with cognitive change theory (Beck, 1976) in
that cognitive interventions are aimed at reducing the intensity of negative
affect through the rapid identification and reinterpretation of cognitive
errors. In the present case, the prompt short-circuiting of initial irrational
thoughts may have been especially important in preventing the exac-
erbation of depressive affect through prolonged negative rumination.
In any event, instructionally based training in self-control would
appear to have important implications for the provision of mental health
services to students who might not otherwise seek direct therapeutic contact.
However, future research using more rigorous single-subject or between-
groups designs will be necessary to further validate the therapeutic potential
of such instructionally based programs.

REFERENCES

Aitken, R. C. B. Measurement of feelings using visual analogue scales. Proceedings of the

Royal Society of Medicine, 1969, 62, 989-993.
American Psychiatric Association. Diagnostic and statistical manual 111. Washington, D.C.:
Author, 1980.
Beck, A. T. Cognitive therapy and emotional disorders. New York: International Univer-
sities Press, 1976.
Beck, A. T. Depression inventory. Philadelphia: Center for Cognitive Therapy, 1978.
Glass, G. V., Willson, V. L., & Gottman, J. M. Design and analysis of time-series
experiments. Bourder: Colorado Associated University Press, 1975.
Hamilton, S. B. Instructionally based training in self-control: Behavior-specific and
generalized outcomes resulting from student-implemented self-modification projects.
Teaching of Psychology, 1980, 7, 140-145.
Hamilton, S. B. Increasing the accuracy of self-recording in instructionally based self-
control programs. Behavioral Counseling Quarterly, 1981, 1, 136-147.
Menges, R. J., & Dobroski, B. J. Behavioral self-modification in instructional settings: A
review. Teaching of Psychology, 1977, 4, 168-173.
Tharp, R. G., Watson, D., & Kaya, J. Self-modification of depression. Journal of Con-
sulting and Clinical Psychology, 1974, 42, 624.
Zuckerman, M., & Lubin, B. Multiple affect adjective checklist. San Diego: Educational
and Industrial Testing Service, 1965.