Psychologica] Review Copyright 1989 by the American Psychologica] Association, Inc.

1989, Vol. 96, No. 4,576-607 Q033-295X/g9/$00.75

Psychotherapy of Depression: A Self-Confirmation Model

John D. W. Andrews
University of California, San Diego

The concepts of self-confirmation, interpersonal diagnosis, and prototype construction are used
to integrate research and clinical findings concerning depression. The person is conceptualized as
sustaining his or her self-concept through a feedback loop that provides both interpersonal and intra-
psychic confirmation. The personality styles specified in interpersonal diagnosis are viewed as proto-
types that characterize the self-confirmation strategies used by different sorts of individuals. It is
argued that various theories of depression reflect distinct segments of the depressive self-confirma-
tion feedback cycle, and hence the stages of that cycle provide a systematic basis for deriving proto-
type features at both descriptive and causal levels. Various interventions are targeted toward different
links in the self-confirmation cycle, and all effective interventions can lead, in different ways, to
^channeling the cycle as a whole. For this reason, combinations of interventions will often be partic-
ularly valuable. The therapeutic relationship also helps to redirect the depressive client's self-con-
firmation patterns and should be coordinated with target-specific interventions in order to attain
maximum therapeutic impact.

The aim of this article is to conceptualize the depressive syn-
drome by using a theoretical framework that integrates three
elements: the self-confirmation model of personality (Andrews,
1977, in press; Swann, 1983, 1985, 1987), the interpersonal di-
agnosis system (Carson, 1969,1982;Kiesler, 1983;Leary, 1957;
McLemore & Benjamin, 1979), and the prototype model of di-
agnostic classification (Cantor & Genaro, 1986; L. Horowitz,
Wright, Lowenstein, & Farad, 1981). After outlining this frame-
work, I will synthesize various theoretical accounts of depres-
sive functioning, delineate a causal prototype of depression, and
apply these ideas to the psychotherapy process.
The state of the art concerning research on depression is cur-
rently quite fragmented. Many theorists have proposed testable
models of the mechanisms assumed to bring about depressive
mood, and these models are usually not connected to overarch-
ing theoretical systems; rather, each uses a few key predictive
variables drawn from research on cognition and social behavior.
Most such models would benefit from a more comprehensive
perspective. Many proposed accounts present one variable as
"the" causal factor; and on the face of it, this seems too narrow.
Should assumptions about depressive functioning really be re-
stricted to negative attributions alone, or to helplessness expec-
tancies, or to lack of social skill? Such thinking seems likely to
lead to oversimplification. The same critique applies to argu-
ments that attempt to reduce one theory to another—argu-
ments that the key process proposed by one theory is "nothing
but" an epiphenomenon of the true causal factor hypothesized
by some other model.
These concerns have been raised by a number of reviewers. A
good example of this trend is Craighead's (1980) article, "Away
From a Unitary Model of Depression." The need for a more
complex approach, Craighead suggested, applies both to the
Correspondence concerning this article should be addressed to John
D. W. Andrews, University of California, San Diego, Psychological and
Counseling Services, B-004, La Jolla, California 92093.
theories themselves and to the therapeutic interventions derived
from them. Similar points have been made by several contribu-
tors to Rehm's (1981) volume on depression, by Segal and Shaw
(1986), and by the participants in a recent symposium on de-
pressive subtypes (L. Horowitz, Blatt, Pilkonis, & Robins,
1987). Accordingly, the approach taken in the present article is
to introduce an integrative conceptual framework and then to
examine various theoretical accounts and bodies of data con-
cerning depression as to their fit with this framework.
Conceptual Framework
Self-Confirmation Model
The idea of the self as the center of personal consistency or
stability is a key element in many personality theories, such as
those of Lecky (1945), Sullivan (1953), and Rogers (1965). An
important extension of these views is the proposition that
people continually reconfirm their self-concepts through cur-
rent social interaction. An early version of this account was pre-
sented by Secord and Backman (1961). Simitar ideas have been
applied to psychotherapy by Wachtel (1977) and by Carson
(1982), who wrote of "an unbroken causal loop between social
perception, behavioral enactment, and environmental reac-
tion" (p. 66). Also related are formulations that view cognitive
dissonance as largely reflecting a need to reduce incongruence
between self-perceptions and other cognitions (Markus & Za-
jonc, 1985; Rosenberg, 1968;Snyder&Ickes, 1985).
In recent years, many studies relevant to the self-confirma-
tion model have appeared. Much of this evidence has been mar-
shaled by Felker( 1974), Rosenberg (1979), Swann (1983,1985,
1987), and myself (Andrews, 1977, in press). The latter two
publications have presented a conceptualization of the self-con-
firmation system in the form of a cyclical feedback loop. The
stages in this cycle, to be discussed later in this article, provide
a framework for classifying most of the pertinent research stud-
ies, which now number in the hundreds.
A major thrust of this research is to show that the self-system

576
 PSYCHOTHERAPY OF DEPRESSION
Responses
. '
Figure 1. The self-confirmation feedback loop.
has boundary-maintaining properties. Faced with self-incon-
gruent feedback, the individual will find ways to counteract,
avoid, overlook, or discount such disconcerting information
and thereby sustain a self-consistent feedback environment.
Thus, the appearance of fixity or stability in the self-concept
is the product of an ongoing, though not usually conscious or
deliberate, effort at self-confirmation. Continuity is accom-
plished by a series of self-fulfilling prophecies that support the
person's initial expectations about self and experience. This for-
mulation is particularly relevant to psychotherapy because it is
centrally concerned with processes affecting change and resis-
tance to change.
Figure 1 characterizes the self-confirmation process in more
detail as a feedback loop with multiple stages (Andrews, 1977,
1988c, in press). The person expresses his or her self-concept
by selectively interacting with the environment and selectively
assimilating feedback from it. At each stage in this loop, the
individual channels action and experience in ways that are con-
gruent with, and confirmatory of, the self-concept. These stages
will be described and illustrated with sample findings from the
research literature.
The cycle begins with a self-concept (Stage I on the diagram),
consisting of generalized self-conceptions concerning one's feel-
ings, attitudes, capacities, styles of behavior, and so on—who
one is on the whole and who one is not (Rogers, 1965). And the
577
individual attempts to maintain congruence among these self-
views. For example, Pyszczynski and Greenberg (1985, 1986)
found that depressed subjects were low in self-esteem and pre-
ferred self-focused attention (via a mirror) following task fail-
ure, whereas nondepressed individuals preferred self-focus fol-
lowing success; in this way, each type of person selectively di-
rected attention to the aspect of self that was consistent with
initial self-esteem level. Also, Monson and Hesley (1982) found
that self-attributions served to sustain self-concept. Subjects
used internal attributions to account for self-perceptions that
were consistent with their self-images and situational attribu-
tions to account for self-inconsistent perceptions.
One's needs (Stage Ha) and expectations (Stage lib) regarding
specific people and situations tend to be consistent with, and to
help sustain, one's generalized self-images. First, where needs
are concerned, Dengerink and Myers (1977) found that after
failure, depressed men became less aggressive in response to
provocation, whereas nondepressed subjects became more ag-
gressive. The authors reasoned that failure would be self-con-
firming for low self-esteem depressive subjects, but that nonde-
pressive subjects would need to react with anger in order to re-
affirm their self-confidence. With respect to expectations,
McFarlin and Blascovich (1981) found that subjects' predic-
tions of future performance following task success or failure
were consistent with chronic self-esteem level. They also found
578 JOHN D. W. ANDREWS
that high self-esteem subjects in the failure condition predicted
significantly higher levels of future performance than did high
self-esteem subjects in the success condition. McFarlin and
Blascovich concluded that this elevated expectation would help
to restore self-esteem following the threat posed by the failure.
Behavior (Stage III), in turn, has a confirmatory relation with
the self-image of the one who initiates an action and with the
feelings and expectations that underlie that self-image. To test
this connection, Swann and Hill (1982) provided subjects with
serf-confirming and self-discrepant feedback (supposedly from
the experimental partner) and then arranged for one half of
each group to interact again with that partner. The discrepant-
feedback subjects tried harder to change the partner's impres-
sion and also behaved more "in character," that is, more con-
gruently with their prior self-descriptions than did subjects who
were exposed to congruent feedback. Moreover, those subjects
who had the opportunity to interact again with the partner, and
hence to reconfirm their identities in action, changed their self-
ratings less than those who lacked that opportunity.
In addition to meeting the needs of the initiator, behavior is
an interpersonal message, a set of cues from which others form
an image (Stage IV) of the person with whom they are dealing.
This image will significantly overlap the person's own self-pic-
ture (Kiesler, 1983). Thus, Swann and Ely (1984) studied inter-
actions in which "perceivers" were induced to see "targets" in
ways opposite to the latter's own self-conceptions. They found,
as predicted, that in this conflict of expectations the targets
"won" by bringing perceivers to see them in a manner consis-
tent with their (the targets') self-views. As a result of such im-
pressions, the responses of others (Stage V) will, on the whole,
tend to confirm one's expectations about oneself (Leary, 1957).
This effect is further reinforced by the tendency to selectively
associate with others who do provide self-confirmation and to
avoid those who might challenge our ideas about ourselves
(Snyder, 1981). For example, Broxton (1963) found that among
college roommates, friends usually held mutually confirming
views of each other, and that when this congruence was not pres-
ent there was a greater likelihood that one party would change
roommates. This finding involves a combination of Stage III
(selective interaction) and Stage V (self-confirming interper-
sonal response). How such friendship patterns can affect self-
confirmation was shown by Swann and Predmore (1985). They
found that following self-discrepant feedback, subjects who dis-
cussed the feedback with friends who saw them as they saw
themselves manifested the least self-image change and were the
most resistant to future discontinuing information.
Of course, the match between a person's self-image and the
other's reaction is not perfect. The other, in turn, will have his or
her own interactive patterns, and may present a discontinuing
response. As is shown by the last sector of Figure 1, we have
ways to deal with the dissonance and tension that can arise in
such exchanges in order to keep our self-definitions intact. First,
there is selective perception (Stage VI). We generally filter out
social feedback that is not self-confirming and pay particular
attention to that which supports our self-systems (Kiesler,
1982). Moreover, when we are unable to avoid perceiving such
cues, it is still possible to reinterpret them, relabel them, or deny
responsibility for them in some way (Stage Vila). As Felker
(1974) noted, the self-concept serves as an inner filter, as per-
ceptions pass through the filter, they are given meanings that
reflect the view the person has of himself or herself. These mean-
ings are the result of selective interpretation.
A study by D. Hamilton (1969) demonstrated a form of
chaining among these perceptual and interpretive self-confir-
mation strategies. He provided subjects with self-discrepant
feedback, supposedly based on a personality test. Some subjects
underrecalled the dissonant items. Others reinterpreted the sit-
uation by either discrediting the test or disparaging the skills of
the supposed test interpreter. Still others were "conformers":
They changed their self-ratings in response to the feedback.
And, as in the Swann and Hill (1982) study, it was primarily
when no self-reconfirmation strategy was used that such change
occurred.
Finally, the emotional impact (Stage Vllb) of an experience is
often significantly determined by the person's self-image. Self-
confirming selective perception and interpretation shape the
meaning of the event, and the individual's affective response
generally reflects that meaning,1 thus further reinforcing his or
her concept of self. For example, Conn and Crowne (1964) ar-
ranged for subjects to be confronted with hostile provocation by
an experimental confederate. Individuals high in self-perceived
need for approval (a characteristic that is incongruent with hos-
tility) reacted with less anger and were more ingratiating than
under nonprovocation conditions, whereas other subjects
showed the reverse pattern. Thus, the approval-oriented sub-
jects intensified their "agreeable" style of self-expression when
they were faced with a stimulus that might evoke self-inconsis-
tently hostile emotions.
A further implication is shown by the interior dotted line of
Figure 1. We maintain continuity not only by engaging in real-
world interactions, but also by engaging in intrapersonal or
symbolic interactions with internalized others (Stryker, 1985)
or internal objects (M. Horowitz, 1979) that are the legacy of
important early interactions such as parent-child relationships.
The communications of these internalized others, when self-at-
tributed, form part of what Meichenbaum (1977) referred to
as "a (cognitive) self-communication system, a dialogue with
oneself that comes to influence behavior" (p. 212). This internal
dialogue or self-talk1 plays a role in an inner self-confirmation
1
In recent years a controversy has arisen concerning the interdepen-
dence or independence of the cognitive and affective systems, fueled by
Zajonc's (1980) argument in favor of the separate-systems view. The
position taken here is that affect is at least partly a response to the world
as it is perceived and interpreted, as is stressed by Beck (1976), Ellis
(1962), and other cognitive theorists. For a rejoinder to Zajonc that dis-
cusses the evidence for cognitive-affective linkages and the role of infor-
mation processing in affective response, see also Lazarus (1982). Per-
haps most pertinent here is Bandura's (1978) statement that "in the
social learning view, thought, affect, and action operate as reciprocally
interacting factors rather than as loosely linked components or as con-
joint events" (p. 257). A similar assumption is built into the self-con-
firmation model.
2
The implication of a parallel between the idea of self-talk as used by
cognitive therapists and the psychoanalytic concept of internal object
may be questioned by some readers. Certainly, the two ideas stem from
different frameworks and are clothed in different languages; yet a close
parallel to Meichenbaum's (1977) statement is to be found in the psy-
choanalyst Schafer's (1972) discussion of intemalization, in which he
critiques what he calls pseudospalial metaphors—such as incorporation
or introjeaion—that are commonly used in psychoanalytic theorizing.
 PSYCHOTHERAPY OF DEPRESSION
cycle that continues to operate even when the person is alone or
in a new environment. Thus, if one expresses one's self-concept
via a certain action (Stage III), one can adopt an intemalized-
other stance (mirroring Stages IV and V) toward one's own be-
havior and give oneself internal feedback; and one can even, in
turn, reject or reinterpret (Stages VI and Vila) that feedback as
if it were an external stimulus.
Recent research has experimentally distinguished between
internal and external self-presentation. Baumeister (1982)
noted evidence for self-presentational factors in studies of such
patterns as reactance and self-serving bias and concluded that
"the two main self-presentational motives are to please the au-
dience and to construct (create, maintain, and modify) one's
public self congruent to one's ideal" (p. 3). One type of evidence
cited by Baumeister as demonstrating internal self-confirma-
tion is the audience-transfer effect, in which an experience (usu-
ally involving self-image damage) leads the individual to coun-
teractive behavior in the absence of the people who produced
or witnessed the initial event. Because influencing the original
audience is not possible, the aim must be to reestablish one's
generalized self-image, across audiences, as perceived by the
only person present in both contexts: oneself.
A chain of causal influence is implicit in the self-confirma-
tion feedback cycle. As the arrows in Figure 1 show, there is a
continuous loop of time-sequenced stages such that each stage
leads to the next in order. Thus, the self-concept is generally
expressed in behavior via the mediation of situation-specific
needs and expectancies. Internal processes (self-perceptions,
needs, expectancies) only influence other people via the me-
dium of overt (verbal and nonverbal) behavior. Cues from oth-
ers' behavior and the nonsocial environment usually affect us
by being perceived and by being interpreted in some fashion,
however rudimentary. Finally, one's emotional response to a
stimulus is dependent on how that stimulus is perceived and
interpreted.
In short, the process outlined in Figure 1 constitutes a self-
perceived self-fulfilling prophecy. The term self-perceived is in-
cluded because it is the feedback actually assimilated by the
person that counts. He or she may succeed in inducing others
to fulfill expectations (via Stages Ila-IIb-III), but Stages VI-
Vlla-V lib enable him or her to maintain the self-fulfilling expe-
rience even when the environment is unaccommodating.3 The
overall result is that people develop an "idiosyncratically
skewed version of social reality that verifies, validates, and sus-
tains their self-conceptions" (Swann & Read, 1981, p. 352).
With respect to depression specifically, there is considerable evi-
dence to show that this principle holds even for those such as
He warned of the danger of reification inherent in such terminology and
wrote that "after all, why do we have to add anything about localization
once we have said that a child now reminds himself to do things when
before it was his mother who did so; or that he imagines his father's
visage in his father's absence; or that he thinks of himself as looking
after himself?" (p. 434). This formulation is, I suggest, quite similar to
Meichenbaum's notion of self-instruction, and in both frameworks,
also, the source of such processes lies in interaction with adult caretak-
ers. Thus, Meichenbaum stressed that cognitive development involves
a progressive movement from instruction by others, through a phase of
conscious vocal self-instruction, toward more automatic intrapersonal
or subvocal self-talk that parallels Schafer's examples.
579
depressive individuals, whose self-views are derogatory and
cause them considerable distress (Shrauger, 1975; Swann,
1987). Thus, through engaging in the activities described by the
self-confirmation model, we maintain a complete negative feed-
back cycle (Carver & Scheier, 1981), and we define much of our
experience of the world in the process.
Although the greatest emphasis is here placed on the need for
self-concept confirmation, it should be emphasized that be-
cause the self-concept is embedded in a closed feedback loop,
the tendency to maintain consistency among the stages of that
loop adds powerfully to the stability of personality. Thus, al-
though the person's striving to maintain self-continuity is a cen-
tral factor, functional modalities such as expressive behavior
patterns or attributional styles are also stable structures in their
own right, and hence each stage makes its independent and dis-
tinctive contribution to perpetuating the cycle. The choice of
a starting point in portraying the functioning of the cycle is,
therefore, to some extent an arbitrary one (Carson, 1982).
Moreover, the individual's self-concept not only contributes to
shaping other stage-specific modalities, but is also affected by
them; as a result, the self-concept can at times be changed by
introducing novelty at one or more of the other stages.
Research bearing on this point has shown how influencing
various personality systems can alter self-perceptions—at least
in the short run. For example, we may arrange interaction that
stimulates self-dissonant behavior, which is then assimilated
into the individual's self-concept (Haemmerlie & Montgomery,
1982). One can also alter self-perceptions by arranging for the
subject to be treated as if he or she possessed certain characteris-
tics (Fazio, Effrein, & Falender, 1981). Fostering selective self-
attention and self-presentation influences subsequent self-
esteem ratings (Gergen & Gibbs, 1966; Jones, Rhodewalt,
Berglas, & Skelton, 1981). And feedback about personal charac-
teristics often affects the individual's self-perceptions (Shrauger,
1975). Providing performance feedback can lead the subject to
attend selectively to his or her positive or negative characteris-
tics (Mischel, Ebbesen, & Zeiss, 1973, 1976). Similarly, when
primed with a failure experience, subjects tend to process nega-
tive information about the self more deeply and fully than under
success conditions (Ingram, 1984a). Experimentally induced
emotion can influence selective awareness of self (Wright &
Mischel, 1982). And prearranged selective self-comparison
with others affects self-esteem (Morse & Gergen, 1970). Finally,
the assimilation of self-dissonant perceptions of one's behavior
and affect is potentiated by conditions that foster self-attribu-
tion (Jones et al., 1981; Rhodewalt & Agustsdottir, 1986).
We should be cautious, however, about generalizing the afore-
mentioned findings to situations, such as psychotherapy, in
which enduring change is sought. There is little evidence that
these alterations of self-concept last beyond the time span of a
laboratory experiment (Shrauger, 1975), and the self-confirma-
tion hypothesis suggests that people may eventually respond to
such influences with a self-reconfirming "rebound." Evidence
for such a two-stage reaction was provided by Swann and Hill
3
It should be added that exceptions to this sequencing may occur in
certain areas. Expectations (Stage lib) can influence how strongly needs
(Ha) are felt, and reactive feelings (Stage Vllb) can affect the nature
of selective interpretation (Stage Vila). It is for this reason that these
processes are given an a/b designation in Figure 1.
580 JOHN D. W. ANDREWS
(1982) in a study cited earlier. When given a second opportunity
to interact with the partner who was the supposed source of self-
discrepant feedback, subjects used that opportunity to reaffirm
their identities, thereby minimizing self-concept change.
The processes influencing self-concept stability and change
as postulated by the self-confirmation model have implications
for personality assessment and psychotherapy. Because the indi-
vidual's self-definitions, both adaptive and maladaptive, are
sustained by a person-environment feedback loop, we can as-
sess a client's difficulties by portraying his or her self-confirma-
tion strategies at each point in that loop. This information can
be used as a basis for planning therapy. We can promote self-
awareness by sharing our impressions with the client, and
change can then be initiated by helping him or her to interrupt
or rechannel the self-confirming feedback cycle. Just as each
stage of the cycle is a source of self-stability, so it also provides
a leverage point at which change can be introduced (Andrews,
1977, 1988c, 1989b). The therapist's interventions can be tar-
geted toward particular effects and can be characterized in
terms of which stage or stages of the cycle they influence most
directly. Because each stage is distinctive, where and how we
intervene makes a difference, and various interventions may ap-
pear quite dissimilar because they take on the form of the stage
toward which they are directed. At the same time, interventions
that are very different in initial impact may produce overlap-
ping outcomes in the long run because they have the common
ultimate aim of redirecting the entire cycle of which each stage
is a part. This commonality in diversity is the basis for the inte-
grative model presented here.
In order to minimize self-confirmatory rebounds of the type
found by Swann and Hill (1982), it is often valuable to use tar-
get-specific interventions in combination. This is because the
confirmation cycle tends to operate as a single self-consistent
system in its resistance to change. One manifestation of this
system property is that there can be intersubstitutability of self-
reconfirmation processes. When one means of reducing self-
dissonance is used, other means may not be needed, as in Ham-
ilton's (1969) study described earlier. And conversely, when
dissonance is introduced at one stage, a reconfirmation tactic
involving a different point in the feedback cycle may be used by
the individual who is motivated to prevent change, as in the
Swann and Hill (1982) study. These are common phenomena
throughout the research literature (for a review, see chap. 2 of
Andrews, in press). Accordingly, it is desirable to orchestrate
interventions in order to impact the confirmation cycle at mul-
tiple points and to prevent the client from counteracting thera-
peutic influence by a redoubling of his or her self-confirmation
endeavors. As Secord and Backman (1961) suggested, "the ad-
vantage of a systematic theory providing an exhaustive classifi-
cation of the various forms of reducing incongruity is that it
allows the therapist to anticipate various ways in which the indi-
vidual may fail to change" (p. 31). The self-confirmation model
is proposed here as a classification system of this kind.
Self-Confirmation and Interpersonal Diagnosis
The self-confirmation system meshes well with the interper-
sonal diagnosis model of personality initially developed by
Leary (1957). This model has been applied to psychotherapy by
Carson (1969), updated by Kiesler (1983, 1986), McLemore
and Benjamin (1979), and Wiggins (1982), and used as a vehicle
for psychotherapy integration by Andrews (1989a). The con-
gruence between the two frameworks stems from the fact that
each personality style denoted by interpersonal diagnosis is or-
ganized around a characteristic interpersonal reflex, one that
tends to "train" others to treat the person as he or she is used
to being treated. According to Leary (1957), people behave in
ways that "invite reciprocal interpersonal responses from the
'other' person in the interaction that lead to a repetition of the
original reflex" (p. 123). These responses are confirming for the
initiator and, hence, contribute to the sort of self-fulfilling
prophecy delineated in Figure 1.
The interpersonal system is built around the orthogonal axes
of hostility-friendliness and dominance-submission (see the in-
terpersonal circle diagram in Figure 2). Each pole of these two
dimensions corresponds to a distinctive personality style. In ad-
dition, combinations of the basic dimensions produce four
other types: friendly-dominant, friendly-submissive, hostile-
dominant, and hostile-submissive. In this way the typology
yields a total of eight personality styles, as is denoted by the
boxed labels (hostile-dominant, etc.) at the outer edge of the
interpersonal circle diagram.4 Moreover, the system specifies
self-confirmingly complementary interactions among these
personality patterns. Dominance and submission complement
each other, whereas hostility and friendliness are their own com-
plements; thus, dominant behavior "pulls" submissiveness, and
vice versa, whereas friendliness elicits reciprocal friendliness,
and hostility provokes counterhostility in return. The subtypes
partake of both dimensions. Thus, friendly dominance (nurtur-
ance) draws friendly submissiveness (dependence) because they
are similar (complementary) on the friendliness-hostility axis
and opposite (also complementary) on the dominance-submis-
sion axis. A parallel interlocking occurs between hostile-domi-
nant (punitive or superior) and hostile-submissive (guilty or re-
bellious) interactional styles. These interlocking patterns are
shown in Figure 3. Each pair of arrows linked by a line desig-
nates a complementary pair of styles.
4
Readers who are familiar with interpersonal theory will be aware
that several revisions and variations of the interpersonal circle itself and
of related measuring instruments have appeared since the original
model was published. Most of these formulations have been proposed
to correct conceptual or empirical flaws in the earlier versions (for a
review, see Wiggins, 1982). These newer approaches, in turn, have both
strengths and limitations. I have elected to use Leary's original interper-
sonal circle diagram for several reasons. This model was coordinated
with standard diagnostic categories in Leary's (1957) volume, in a dis-
cussion that carries considerable evocativeness and clinical depth. More
recently, this version of the circle was used by McLemore and Benjamin
(1979) as one basis for their reexamination and updating of interper-
sonal diagnosis. Supplementing the diagram with octant labels that cor-
respond to permutations of the dominance and submission axes, as is
done in Figure 2, provides a conceptual symmetry that is compatible
with Kiesler's (1983) "1982 Interpersonal Circle." Kiesler's work inte-
grates several earlier models and revises certain sectors of the circle that
have presented conceptual and empirical difficulties, particularly the
friendly-dominant and hostile-submissive sectors; but the submissive
sector—which is most pertinent to the present article—is not signifi-
cantly altered in the revision. In short, given the current status of theo-
retical development in this area, the version of the interpersonal circle
portrayed in Figure 2 seems a productive basis for the present discus-
sion.
 PSYCHOTHERAPY OF DEPRESSION 581

4>7 X^C^
// #>SJ®£^

' o,l«sZf>-Zf 7*<S**HG

<%^N^/co,uA"<«5i''v

—-l
/ Submissive \

Figure 2. The interpersonal circle. (From Interpersonal Diagnosis of Personality (p. 65] by T. Leary,
1957, New York: Ronald. Copyright 1957 by Ronald Press. Adapted by permission.)

The self-confirmation cycle model adds complexity and de-
tail to this characterization by specifying the substages (see Fig-
ure 1) by which such self-confirming processes occur. Each self-
fulfilling interaction involves interpersonal needs, expectancies,
behavior, the impressions and responses of others, and selective
perceptions, interpretations, and reactive emotions that con-
tribute to shaping the relationship. Where the self-images of
both parties are complementary—as when a self-perceived
dominant individual and a self-perceived submissive person in-
teract, for example—the resulting relational system will be the
most stable and will provide the greatest degree of self-confir-
mation for both parties.
Disturbed individuals are described in terms of how they use
interpersonal reflexes to draw others into self-confirming but
self-defeating interactions. The more rigid and unvarying such
patterns are, the more disturbed the individual is assumed to
be. The eight interpersonal categories of Figure 2 are linked to
varieties of psychopathology as discussed by Leary and CoSey
(1955) and McLemore and Benjamin (1979). Psychiatric diag-
noses generally refer to a combination of interpersonal behavior
and the symptom complexes that are coordinated with that be-
havior, and the symptom itself tends to express the same mes-
sage as the personality style per se.
Where psychotherapy is concerned, it is important to remem-
ber that the client will endeavor to sustain his or her self-concept
by eliciting social reciprocity within the therapeutic relation-
ship as well as in outside life. Thus, there will be a confirmation
cycle enacted between therapist and client that functions in ac-
582 JOHN D. W. ANDREWS

(Gill, 1982). Furthermore, both sorts of change influences are

most effective when initiated within a climate of empathy and
acceptance as stressed by the client-centered approach (Patter-
son, 1984; Rogers, 1965) because this climate reduces the inten-
sity of the client's need for self-consistency. These considera-
tions will be applied to psychotherapy of depression in the con-
cluding section of this article.

Diagnostic Prototype

The self-confirmation feedback loop framework and the in-

terpersonal diagnosis system are congruent with the prototype
model of diagnostic classification (L. Horowitz, Wright, et al.,
1981; L. Horowitz, Post, French, Wallis, & Siegelman, 1981).
This approach deals with the unreliability, fuzziness, and dubi-
ous predictive utility of traditional diagnostic systems by draw-
ing on findings about human classification processes in other
realms, such as person perception. Instead of expecting a syn-
drome to exhibit a small set of necessary, sufficient, and con-
Figure 3. Complementary (confirming) links between personality styles. stant defining features—which implies that an individual either
is or is not an instance of a given category—the prototype ap-
proach identifies a larger cluster of correlated but not universal
cord with the interpersonal reflex model. The therapist must be qualities. The prototype is an "ideal" type, a personality that
prepared to initiate anticomplementary behavior (Kiesler, possesses all of these qualities, and any actual person can be
1983), thus providing an antidote (Benjamin, 1982) to the cli- assessed in terms of how many characteristics he or she shares
ent's maladaptive interpersonal style. For each style, anticom- with the prototype. This degree-of-match criterion replaces the
plementary behavior is behavior that will elicit responses dia- in-or-out distinction used in classical diagnosis. Thus, the pro-
metrically opposite to (i.e., across the interpersonal circle from) totype model has its own logical structure that can be further
that style. This behavior introduces interpersonal novelty and refined, rather than being viewed as a flawed attempt at the nec-
thus stimulates self-concept change. For example, hostile sub- essary-and-sufficient system of classification.
missiveness is anticomplementary for dependence (friendly The interpersonal diagnosis framework provides a systematic
submissiveness) because the complementary response to hostile inventory of prototypes, in that each prototype corresponds to
submissiveness is hostile dominance, and the latter behavior is one of the eight basic personality styles built into the interper-
directly opposite to the friendly-submissive style. Anticomple- sonal circle (Figure 2). In addition, the self-confirmation pro-
mentary pairings are diagrammed in Figure 4. Several studies cesses incorporated in the feedback loop model of Figure 1 pro-
(Andrews, 1973, 1983; Brokaw, 1983; Dietzel & Abeles, 1975) vide a template for systematically deriving prototype features.
have shown that therapy is most effective when an optimal de- That is, a person who matches the complete prototype will en-
gree of anticomplementarity is introduced into the therapist-
client relationship. Often this involves a gradual transition from
an early "hooking" stage—during which the client's interper-
sonal messages are reciprocated by the therapist in order to es-
tablish an initial basis for relatedness—toward a phase of in-
creasingly anticomplementary interaction (Benjamin, 1987;
Cashdan, 1982).
The therapist-client relationship also provides a context for
the target-specific interventions discussed previously, because
each intervention has both form and content. When making an
intervention, the therapist is usually talking about some aspect
of the client's life and is also talking about it in a particular
manner. In self-confirmation theory, the form and content levels
are linked by their converging implications for self-definition.
Intervention content influences the client's self-confirmation
tactics, and how an intervention is expressed implies a defini-
tion of the relationship. This definition, in turn, conveys a cer-
tain image of the client that is therapeutically important be-
cause it influences the client's own self-perceptions. This for-
mulation enables us to integrate therapeutic approaches, such
as the cognitive-behavioral, that focus primarily on the effects
of targeted interventions (Lazarus, 1981), and those, such as Figure 4. Anticomplementary (disconfirming) links
the psychoanalytic, that deal primarily with transference factors between personality styles.
 PSYCHOTHERAPY OF DEPRESSION
gage in characteristic self-confirmation tactics at each of the
nine confirmation cycle stages. Other individuals may, of
course, match the prototype to varying degrees. The approach
used here will be to derive from current theorizing and research
a prototype of the depressive personality based on self-image,
interpersonal style, and self-confirmation strategies, and to use
the resulting portrayal to integrate various accounts of the syn-
drome.
Theoretical Synthesis
The three theoretical elements previously discussed comple-
ment one another in such a way as to establish a system in which
each element remedies certain incompletenesses found in the
others. Thus, the interpersonal diagnosis model, as portrayed in
Figure 2, provides a systematic array of personality types and
incorporates the idea of self-fulfilling prophecy, yet is somewhat
static. The self-confirmation feedback cycle of Figure 1 supple-
ments this limitation by specifying the processes through which
individuals with different personality styles interact in self-ful-
filling ways. Reciprocally, the self-confirmation view of social
interaction lacks a systematic enumeration of the types of iden-
tities that are confirmed, a lack that is filled by the interpersonal
typology. Moreover, both of these formulations stand in need of
an account of how personality characterizations are con-
structed by clinicians and lay individuals, and the prototype
model, derived from research in cognitive psychology, offers an
account of this kind. At the same time, the inventories of proto-
type features identified in such studies as those of L. Horowitz,
Wright, et al. (1981) are largely inductive and would be en-
hanced by a framework that specifies the range of prototype
features and how they are interrelated. The self-confirmation
feedback loop model, with its multiple interlocking stages of
personality functioning, provides such a framework. In addi-
tion, as will be discussed later in analyzing prototypes of depres-
sion, this framework proves to encompass most of the prototype
features identified by empirical research. Finally, the selection
of personality prototypes for study, such as loneliness or depres-
sion (L. Horowitz, French, Lapid, & Weckler, 1982), would be
facilitated by a typology that specifies which prototypes are sa-
lient in human construct systems and represented in various
sorts of psychopathology. The interpersonal diagnosis system
serves this function.
In sum, the interpersonal self-confirmation model defines a
set of personality prototypes and social identities that embody
variations along key dimensions of social interaction—domi-
nance-submission and friendliness-hostility—as specified by
the interpersonal diagnosis system (Figure 2). These styles inter-
lock in complementary ways that generate self-fulfilling prophe-
cies through an interactive cycle of linked stages (Figure 1). By
using the categories defined by these stages, we can derive a sys-
tematic prototype of any given personality style. This portrayal
is particularly relevant to psychotherapy because it highlights
the leverage points at which stability is perpetuated and at
which change can be introduced. By intervening to rechannel
the feedback cycle that is enacted in the client's life experiences
and in the therapeutic relationship, we can facilitate the client's
efforts to redefine his or her self-image.
This theoretical model, although it is introduced here for the
purpose of systematizing research and clinical experience re-
583
garding depression, is a general one, applicable to any personal-
ity style. It is particularly directed toward elaborating the eight
personality prototypes defined by interpersonal diagnosis.
Thus, other studies have applied this model to understanding
the prototype of the friendly or overconventional individual,
which is defined in clinical terms as hysterical or histrionic per-
sonality (Andrews, 1984; Andrews & Moore, in press), the
friendly-submissive or dependent prototype, characterized by
anxiety or phobic symptoms or both (Andrews, 1966, 1987),
and the hostile-dominant or narcissistic personality (Andrews,
1988b). In addition, the self-confirmation model has been pro-
posed as a paradigm for psychotherapy integration (Andrews,
1988c, 1989b). This content analysis study defines the interven-
tions favored by different therapeutic schools in terms of the
feedback loop stages and demonstrates how they can be system-
atically combined and orchestrated.
Models of Depression Viewed in Terms of
Self-Confirmation Theory
An examination of the complex literature on depression
shows that most of the explanatory constructs used to account
for this syndrome fit within the categories of the self-confirma-
tion cycle. Moreover, when combined, they interlock and com-
plement one another so as to "cover the map" of the feedback
loop quite completely. This pattern is shown in Figure 5, which
indicates how the confirmation cycle can be useful in integrat-
ing theories of depression and the therapeutic methods to which
they lead. This hypothesis will be explored in detail in the over-
view that follows.
This overview will summarize various current theories of de-
pression and link them with the pertinent confirmation cycle
stages, discussing briefly at each point the supporting research
data. Because a complete research review is beyond the scope
of the present discussion,5 other reviews will be drawn upon,
and particular attention will be given to findings that bear on
various causal hypotheses concerning depression. The latter ap-
proach is taken for two reasons. First, as noted previously, many
theories hypothesize that a particular factor, such as cognitive
distortion or poor social skill, is the source of affective depres-
sion. This is what we might call the strong form of a theory, as
contrasted with the weak form, which simply states that a given
factor is descriptively associated with depressed mood (Blaney,
1977; Coyne &Gotlib, 1983). Most theories are stated in strong
form, yet the majority of evidence, which involves correlational
patterns, bears only on the weak form; causal research is there-
5
For a fuller review of research literature on depression organized
within the self-confirmation framework, the reader is referred to chap.
$ of Andrews (in press). Also, because it will not be feasible to add
methodological qualifications at every point, certain difficulties that run
through the literature should be mentioned at the start. These include
the use of different criteria and definitions of depression from study
to study, lack of attention to subtypes, the limited generalizability of
analogue studies involving college student subjects and impersonal ex-
perimental tasks, the lack of nondepressed disturbed control groups,
and the paucity of longitudinal etiological studies. These flaws are
pointed out by many reviewers, including Blaney (1977,1986), Brewin
(1985), Coyne and Gotlib (1983), Craighead (1980), Heiby (1979),
Johnson and Magaro (198 7), and Peterson and SeUgman (1984).
584 JOHN D. W. ANDREWS

I. Self-Concept

Low self-esteem (Psychoanalytic model—

Bibring, Gaylin)

Negative self-focus (Cybernetic model—

Pyszczynski & Greenberg)

Negative self-schemata (Self-worth contin-

gency model-Kuiper & Olinger)

Vllb. Reactive Emotions Ha. Motivations

Self-reward deficit (Self-regulation model— Motivational deficit (Motivational model—

Hehm) Layne)

Unmanageable anxiety (Conditioning model- Inhibited/internalized aggression (Psycho-

Wolpe) analytic model—Abraham)

Vila. Interpretations lib. Expectations

Negative interpretive style (Cognitive model- Helplessness expectancy (Learned helpless-

Beck) ness model—Seligman)

Internal, stable, global attributions for failure Pessimism (Cognitive model—Beck)

(Revised learned helplessness model— Low expectancy of reward (Motivational
Abramson, Seligman, & Teasdale) model—Layne)

VI. Perceptions Internalized Others III. Behaviors

Negatively toned information systems (Self- Punitive, rejecting introject (Object-relations Social skill deficit (Operant learning model -
referenced memory model—Kuiper et a/.) model—Blatt) Coslello. Ferster, Lazarus, lewinsohn)

Focus on negative experience (Cognitive

model—Beck)

V. Others' Responses IV. Others' Impressions

Elicitation of rejection and false reassurance Induction of dysphoha and aversion in others
from others (Interpersonal model—Coyne, (Interpersonal model—Coyne, Leary)
Leary)

Figure 5. The self-confirmation feedback loop in depressive personality.

fore essential in order to test these theories fully. Second, causal
findings are important to the confirmation cycle model, which
posits links of influence among cycle stages. To address these
issues, the minority of studies involving causal sequences will
be examined in terms of the theoretical system that has been
set forth.
The discussion begins with the depressive individual's self-
concept and then moves counterclockwise around the feedback
cycle. The reason for this ordering is related to the fact that in
many formulations, the phenomena covered by a particular
stage of the cycle are accounted for by the processes of the pre-
ceding stage. Thus, the counterclockwise approach highlights
how the proposed causal connections are related to the assump-
tions of the self-confirmation model.
Stage I: Self-Concept
Theoretical accounts. In applying self-confirmation concepts
to the depressive syndrome, I first ask, What i s the characteristic
depressive identity image (Stage I)? This pattern corresponds to
what Leary (1957) calls the self-effacing personality, which is
located at the submissive pole of the interpersonal circle. Here
is Leary's description:
The symptomatic, clinical aspects of the overtly self-effacing per-
sonality are easily described. The outstanding symptom is depres-
sion. These people are overtly anxious and unhappy. They exhibit
guilt and self-depreciation. Doubt, rumination, and obsessive un-
certainty are emphasized. Associated with this is an immobilized
passivity, (p. 286)
The typical presenting messages of the depressive individual,
Leary suggested, involve such self-characterizations as " 'I have
done wrong,' 'I am unworthy,' and 'I am inferior"" (p. 286).
The loss or lowering of self-esteem is also a central theme in
psychoanalytic theories of depression. Freud (1917/1959)
wrote that the depressed individual "reproaches himself, vilifies
himself, and expects to be cast out and chastised. He abases
himself before everyone and commiserates his own relatives for
 PSYCHOTHERAPY OF DEPRESSION
being connected with someone so unworthy" (p. 155). Abra-
ham (1948) noted similarly that depressive individuals tend to
imagine an inborn defect in themselves. These ideas have been
carried forward by other psychoanalytic writers, including
Bibring (1953), Fenichel (1945), Gaylin (1968), Jacobson
(1953), and Rado (1928). And Arieti and Bemporad (1978)
aptly expressed the tortuous convolutions of self-regard that de-
pressive thinking can generate: "The patient often realizes. . .
that he tends to underestimate himself. It is his duty to undersell
h i m s e l f . . . . He [also] tends to blame himself for underestimat-
ing himself and giving himself no chance to develop his own
talents and potential abilities" (p. 139).
Gaylin (1968) traced the shift in psychoanalytic theorizing
from the early emphasis on object-loss toward an increasing
concern with deficient self-esteem. Thus, according to Freud's
early formulation, depression involves a real or imagined lost
love object that is introjected into the ego.
The sadistic part of the ego then attacks the object, now fused with
the receptive part of the ego, for having left it. Consciously this is
perceived as 'a conflict between one part of the ego and its self-
criticizing faculty1. . . . This results in a deflation of the self-es-
teem, self-accusation, and need for self-punishment. (Gaylin, 1968,
P. 9)
This account was altered by the development of the tripartite
model of personality structure; it then became less necessary to
invoke the idea that depression involves punishing an abandon-
ing other because "every individual contains within him an in-
corporated parent—in the structure of the super-ego. The in-
strument for self-punishment is already available without the
need for introjecting the lost love" (Gaylin, 1968, p. 12).
This notion of the superego punishing the ego is roughly
equivalent to the idea that the depressive individual's inner con-
firmatory dialogues involve a self-effacing, guilty self-role
whose complement is an internalized punisher and critic. A
similar idea is central to Blatt's (1974) account of introjective
depression, which stresses the role of harshly critical internal
objects, derived from early parent-child relationships, in gener-
ating self-perceptions of worthlessness, guilt, and failure. More-
over, this intrapsychic confirmation cycle parallels the interper-
sonal cycle, described by Leary (1957), between the self-effacing
depressive and his or her hostile-dominant partners (see the dis-
cussion of Stages III-IV-V ahead).
A concluding step in psychoanalytic theorizing was described
by Gaylin (1968) as follows:
We begin to see an enlargement of the role of self-esteem and its
movement from the periphery to a more central position in the
writings of Rado and Fenichel. Nonetheless, it is still seen as effect
rather than cause. Bibring took the final position of reversing the
roles and stating that diminished self-esteem is the cause of depres-
sion, (p. 388)
This means that "only when a loved object is invested with our
self-esteem does its loss produce a depression. What we are
mourning is our lost self-esteem, the love object merely being
symbolic of it" (Gaylin, 1968, p. 17).
A quite different model that also stresses self-esteem was pre-
sented by Pyszczynski and Greenberg (1987), who used the con-
cept of self-focusing to account for the depressive individual's
low self-esteem and also to derive other depressive features.
Their formulation is based on the cybernetic model of Carver
585
and Scheier (1981), which views self-focus as part of a self-regu-
latory feedback cycle somewhat similar to the confirmation cy-
cle. The individual compares actual experience against the ref-
erence values implicit in certain self-expectancies, and dys-
phoric affect results when this discrepancy is too large.
Pyszczynski and Greenberg have built on the psychoanalytic
idea that depression involves the loss of a person or goal that
has served as the basis for security and self-worth, and have also
stressed that
Depression occurs to the extent that the individual who experi-
ences such loss fails to disengage the cycle and continues to self-
focus in the absence of any way to regain what was lost. Essentially,
the individual becomes stuck in a self-regulatory cycle in which
successful discrepancy reduction is impossible, (p. 127)
The resulting negative self-focus has several consequences. It
increases the internality of the person's attributions for the loss,
which may spread to include self-blame for other negative out-
comes. There may gradually evolve a depressive self-focusing
style, in which self-focus is high following negative outcomes
but minimal following positive outcomes. Expectancies, which
are formed on the basis of (negative) self-focus, will become
more pessimistic; and this, in turn, will weaken the incentives
needed for motivated, effective performance. In this way,
learned helplessness (see Stage lib ahead), social ineffectiveness
(Stage III ahead), and a negative cognitive style (Stage Vila
ahead) are viewed by Pyszczynski and Greenberg (1987) as
originating in negative self-focus. Then,
Asa result of this spiral of events, the depression may deepen to the
point at which the emerging negative self-image begins to provide
benefits that motivate the individual to work to maintain it. The
initial benefit of a negative self-image may be that it provides relief
from the effortful manoeuvers necessary to maintain a positive self-
image. The negative self-image may also take on value because it
appears to provide a simple, parsimonious explanation for the per-
son's negative experiences.. . .Finally, it provides a relatively safe,
unassailable perspective from which to deal with the world, (p. 128)
This model, as well as somewhat similar formulations by Hy-
land (1987) and Lewinsohn, Hoberman, Teri, and Hautzinger
(1985), shares with self-confirmation theory the idea that a
feedback cycle in which self-perceptions occupy a central place
is critical for understanding personality. However, the latter also
stresses the role of self-concept maintenance as a primary
causal factor rather than as a consequence of other processes,
as well as the importance of a self-effacing depressive personal-
ity style that provides a precondition for both negative self-focus
and the overattachment to a single source of self-esteem.
Finally, Kuiper and Olinger (1986) have proposed a self-worth
contingency model of depression, according to which the clini-
cally depressed individual has a strongly consolidated, negative
self-schema that incorporates the "contractual contingency"
that one's self-worth depends on the approval of others. Individ-
uals who hold this expectancy and whose self-schemata are bi-
ased toward recognition of negative content are vulnerable to
depression and tend to become depressed when they fail to elicit
the approval they need in order to feel good about themselves.
Moreover, a cycle of depressogenic events often develops from
this situation. Thus,
The individual's negative view of self, and his/her perceived failure
to meet self-esteem contingencies, leads to self-rejection. This pro-
586 JOHN D. W. ANDREWS
duces a negativistic, self-critical presentation style that enhances
the possibility that others will reject the vulnerable depressed indi-
vidual. In turn, this rejection from others makes it extremely
difficult for the vulnerable individual to fulfill her/his dysfunc-
tional self-esteem contingencies, thus maintaining a state of de-
pression, (p. 136)
In terms of the confirmation cycle, the depressive self-schema
(Stage I) generates interpersonal expectancies (Stage lib) involv-
ing approval and rejection, as well as a self-blaming or unasser-
tive self-presentation style (Stage III) that may stimulate actual
social rejection (Stage V); and the latter leads, in turn, to further
self-derogation.
With respect to therapy, Kuiper and Olinger (1986) placed
the greatest emphasis on cognitive factors: "The self-worth con-
tingency model suggests that interventions be directed toward
the modification or elimination of dysfunctional attitudes.. . .
of particular importance would be therapeutic approaches
which focus on replacing dysfunctional self-worth contingenc-
ies with more adaptive cognitions and standards" (p. 137). In
addition, however, the perspective advanced in the present arti-
cle suggests that interventions designed to influence processes
at all nine stages of person-environment interaction can be
helpful in redirecting the depressive vicious spiral.
Research findings. Research data generally confirm, at a cor-
relational level, the poor self-esteem of depressives. Thus,
Coyne and Gotlib (1983), in their review, concluded that "de-
pressed patients and students tend to evaluate their perfor-
mances and themselves more negatively than do nondepressed
persons" (p. 479). The same conclusion is reached in a more
recent critique by Segal and Shaw (1986).
There are also studies showing short-term causal relation-
ships that affect self-esteem. Blaney (1977) argued that many
helplessness inductions designed to test learned helplessness
theory (e.g., Miller & Seligman, 1975) actually involve failure,
and he interpreted such research as showing a causal relation-
ship among failure, lowered self-esteem, and depressive func-
tioning. Pyszczynski and Greenberg (1985, 1986) supported a
related assumption by showing that depressive individuals en-
gage in self-focusing following failure, thus intensifying their
low self-esteem. A followup study (Greenberg & Pyszczynski,
1986) produced similar results. Correspondingly, Gibbons et al.
(1985) found a causal connection between self-focus and nega-
tive affect among depressive individuals; and Strack, Blaney,
Ganellen, and Coyne (1985) showed that reducing self-focus
diminished the performance deficits of their depressed subjects.
In short, then, processes within the self-system affect self-es-
teem (Stage 1), mood state (Stage Vllb), and behavioral perfor-
mance (Stage IH).
Stage Vllb: Reactive Affects
Theoretical accounts. The reactive affects of sadness, disap-
pointment, and self-hate are closely linked with the depressive
individual's low self-esteem. As the defining characteristic of
the "affective disorder" of depression, they are more typically
looked on as needing explanation than as sources of explana-
tion in themselves. Some theories do, however, identify certain
reactive emotions as the cause of other depressive features.
Thus, Rehm's (1977) self-regulation model of depression in-
cludes the variable of low self-reinforcement: the depressive in-
dividual's weakened capacity to provide positive emotional ex-
periences for himself or herself. In this sense, the lack of self-
reinforcement is being used to account for the dejected mood
and low self-esteem of the depressed person. In self-confirma-
tional terms, self-reinforcement—which is a mixture of serf-
evaluation (Stage Vila) and self-reward (Stage Vllb)—is viewed
as causally affecting Stage Vllb and Stage I. In addition, because
of its emphasis on ^/^reinforcement, Rehm's model points to
the role of internalized confirmation cycles in the maintenance
of depressive mood. And, despite wide differences in terminol-
ogy, this formulation is not incompatible with the psychoana-
lytic idea that the depressive individual is characterized by a
harsh superego that punishes and does not reward.
Wolpe (1979) espoused a quite different affect-centered the-
ory of depression, one that reflects his reciprocal inhibition
model of neurosis and therapy. He argued on the basis of certain
animal studies that depression results from severe and pro-
longed anxiety produced by conditioning, cognitions, interper-
sonal helplessness, or bereavement. Wolpe also critiqued the
learned helplessness model; helplessness expectancies, he ar-
gued, actually stem from conditioning processes. In this way,
his proposal is a formulation that reduces all depressive phe-
nomena to a single causal factor. To date it has generated little
research with depressed human subjects, although Wolpe did
present some supporting case material.
Research findings. A number of studies have dealt with
Rehm's (1977) self-regulation of self-reward theory. According
to Heiby (1979) and Coyne and Gotlib (1983), most pertinent
studies do show a relation between low self-reinforcement and
depression, but because they are correlational in method it is
not possible to determine causality. Often, too, it is difficult to
decide whether low self-reinforcement is due to self-punish-
ment tendencies per se (Stages Vila-Vllb) or to the depressive
individual's actual poor performance (Stage III). Studies by
Gotlib (1982), Roth and Rehm (1980), and Wollert and Buch-
wald (1979) show an overlap between these variables.
One series of studies (Heiby, 1981, 1983a, 1983b) has shown
a short-term causal relationship between self-reinforcement
and depressed mood. Heiby (1981) first replicated the finding,
discussed earlier, that low frequencies of self-reinforcement are
correlated with depression. Then (1983b) she compared how
high and low self-reinforcers responded to different levels of ex-
ternal reinforcement for task performance. Those who were in-
frequent self-reinforcers to begin with showed a greater increase
in depressed mood following a decrease in environmental rein-
forcement. A similar pattern was found in another study
(Heiby, 1983a) of retrospective self-reports: "Persons who en-
gaged in a relatively low frequency of self-reinforcements and
who reported a major reduction in environmentally controlled
reinforcement were more likely to become depressed than per-
sons in the other conditions" (p. 430). This finding suggests a
causal sequence that fits into the confirmation cycle. Environ-
mental cues are processed through the individual's system of
self-evaluation and self-reward (Stages Vila-Vllb), and this
leads, in turn, to different types of affective response (Stage
Vllb). An additional causal link was reported by Rosenbaum
and Ben-Ari (1985), who found that only individuals having low
capacity for self-regulation responded to a helplessness induc-
tion with reduced performance and negative self-evaluation.
 PSYCHOTHERAPY OF DEPRESSION
Thus, it may be that low self-reinforcement also intensifies self-
criticism (Stage I) and behavioral apathy (Stage III).
Stage Vila: Selective Interpretation
Theoretical accounts. Another contribution to current theo-
rizing about depression is Beck's cognitive model (Beck, 1976;
Beck, Rush, Shaw, & Emery, 1979). Beck argued that depressive
individuals are characterized by a primary triad of negative
cognitive patterns or schemata; depression is "primarily a result
of the tendency to view the self, the future, and the world in an
unrealistically negative manner" (Sacco & Beck, 1985, p. 4).
The depressive individual sustains these views through cogni-
tive distortions such as selective abstraction, arbitrary infer-
ence, and overgeneralization; thus, in terms of the self-confir-
mation model, the individual's information-processing modes
(Stage Vila) were used by Beck to account for reactive affect
(Stage Vllb), the content of the self-image (Stage I), and behav-
ior (Stage III).
The learned helplessness model of Seligman (1975) is primar-
ily an expectancy theory and will be taken up under that head-
ing (Stage lib). However, the revised learned helplessness model
(Abramson, Seligman, & Teasdale. 1978; Peterson & Seligman,
1984) includes attributions and, hence, is also relevant to Stage
Vila. According to this account, the depressive individual is one
who makes internal, global, and stable attributions for negative
outcomes, thereby reinforcing his or her sense of inadequacy
and helplessness. Peterson and Seligman (1984) stated that "in-
temality of causal beliefs affects self-esteem loss following bad
events. . . . Stability of causal beliefs affects the chronicity of
helplessness and depression following bad events.. . . Finally,
globality of causal beliefs influences the pervasiveness of deficits
following bad events" (p. 348).
An extension of the attribution model was proposed by Ja-
noff-Bulman (1979). She called attention to the paradox that
depressive individuals seem to take exaggerated responsibility
for their failures, yet also feel helpless. To resolve this contradic-
tion, she drew a distinction between characterological and be-
havioral self-blame, according to which only the former leads
to depression. If one sees one's failures as the result of fixed,
characterological qualities, such as badness or stupidity, one
can feel both blameworthy and helpless. By contrast, modifiable
behaviors, such as errors or poor judgments, are less irrevocably
attached to the self and are more under the individual's control.
In such instances, one can attribute failure to oneself and yet
not confirm an identity involving helplessness, dysphoria, or
lowered self-esteem.
Research findings. The attribution hypothesis, relevant to
Beck's model as well as to the revised learned helplessness the-
ory, is one of the more thoroughly researched aspects of depres-
sive cognition. Most descriptive studies have correlated various
paper-and-pencil measures of attributions, such as the Attribu-
tional Styles Questionnaire (Seligman, Abramson, Semmel, &
von Baeyer, 1979), with measures of depression, such as the
Beck Depression Inventory (Beck, Ward, Mendelson, Modi, &
Erbaugh, 1961). The results have been mixed, and different re-
viewers have drawn different conclusions. Abramson and Mar-
tin (1981) have written of "consistent and robust differences"
(p. 134), but Coyne and Gotlib (1983) have concluded that sup-
port for the attribution hypothesis is quite weak. Still more re-
587
cently, reviews by Brewin (1985), Peterson and Seligman
(1984), and Segal and Shaw (1986) were again positive; and
Sweeney, Anderson, and Bailey (1986), in a meta-analysis cover-
ing 104 studies, found support for the conclusion that internal,
stable, and global attributions for failure are used by depressive
individuals, whereas such individuals tend to attribute positive
outcomes externally.
The causal role of attributional style (Stage Vila) as a vulner-
ability factor for depression (Stage Vllb) has been the subject of
considerable recent research. The pertinent body of literature
has been reviewed by Brewin (1985) and by Peterson and Selig-
man (1984), who used somewhat different classification
schemes but reached overlapping conclusions. Brewin distin-
guished between the vulnerability and recovery/coping models;
the former hypothesizes that internal, global, and stable attribu-
tions for failure produce depression, whereas the latter predicts
that the reverse of this explanatory style is an asset in enabling
people to resist or recover from depression. By contrast, Peter-
son and Seligman were simply concerned with noting whether
the attributional style precedes and predicts differences in de-
pressive mood; no distinction between vulnerability and recov-
ery/coping was made in their discussion.
Regardless of which classificatory scheme is used, the picture
of recent findings is reasonably encouraging with respect to the
relatively long-term (measured in months and years) predictive
value of attributional style. Studies by Nolen-Hocksema, Gir-
gus, and Seligman (1986) and Seligman et al. (1984) found that
depressogenic explanatory style among children predicted de-
pressive symptoms 6 months later. Similar results were reported
with college students by Colin, Sweeney, and Shaeffer (1981),
Metalsky, Abramson, Seligman, Semmel, and Peterson (1982),
and Metalsky, Halberstadt, and Abramson (1987); among pris-
oners by Peterson, Nutter, and Seligman (1982; as cited by Pe-
terson and Seligman, 1984); with depressed patients by Firth
and Brewin (1982); with pregnant women by Cutrona (1983)
and O'Hara, Rehm, and Campbell (1982); among cancer pa-
tients by Timko and Janoff-Bulman (1983); and in a psycho-
therapy case study by Peterson, Luborsky, and Seligman (1983).
Negative predictive findings have been reported, however, in
prospective studies by Cochran and Hammen (1985), Manly,
McMahon, Bradley, and Davidson (1982), O'Hara, Neunaber,
and Zekoski (1984), and Peterson, Schwartz, and Seligman
(1981).
With respect to the recovery/coping model, Brewin (1985)
cited studies showing that nondepressive attributional styles
predicted better spontaneous remission of depression (Cutrona,
1983; Colin et al., 1981; Hammen, Krantz, & Cochran, 1981;
Lewinsohn, Steinmetz, Larson, & Franklin, 1981; Seligman et
al., 1984) and response to medication (Firth & Brewin, 1982).
Although Brewin was more cautious concerning the vulnerabil-
ity hypothesis than were Peterson and Seligman (1984), a num-
ber of studies that he considered to represent coping patterns
also seem interpretable as supporting the vulnerability account
(e.g., Colin et al., 1981; Hammen et al., 1981; Seligman et al.,
1984). Hence, his differences with Peterson and Seligman's con-
clusions may be more a matter of labeling than of substance.
Several experimental/causal studies are relevant to the attri-
bution model. Kammer (1983) found that depressed female
students reported the familiar pattern of attributing a hypothet-
ical academic failure to global, stable, and internal factors.
588 JOHN D. W. ANDREWS
However, when provided with a checklist of 32 possible expla-
nations, depressed subjects shifted their attributions to a less
depressogenic pattern. Moreover, this intervention had the
"therapeutic effect" of reducing the generalization of failure ex-
pectancies to new situations. This finding suggests a short-term
causal connection between attributions (Stage Vila) and future
expectancies (Stage lib). Miller and Norman (1981) provided
clinically depressed inpatients with positive feedback, and then
introduced experimental manipulations designed to induce at-
tribution to one of four types of causes: internal-general, inter-
nal-specific, external-general, and external-specific. The treat-
ment involving internal and general attributions for success
produced the greatest reduction in depressed mood, suggesting
a causal relationship between Stages Vila and VHb. Alloy, Pe-
terson, Abramson, and Seligman (1984) found that global as
opposed to specific attributions led to greater performance
deficits (Stage III) on dissimilar tasks following a helplessness
experience; and Pasahow (1980) found, similarly, that inducing
global explanations in some subjects led to greater generaliza-
tion of performance deficits. Also, McFarland and Ross (1982)
showed that subjects instilled with internal attributions for poor
scores on a social accuracy test demonstrated lowered self-es-
teem (Stage 1). Finally, Anderson (1983) measured naturally oc-
curring explanatory styles (characterological or behavioral) and
also introduced a parallel attributional induction. He found
that subjects holding characterological attributions (whether
spontaneously or by virtue of experimental manipulation) re-
ported lower expectations of success (Stage lib) in persuading
others to give blood, displayed lower motivation (Stage Ila), and
performed less successfully (Stage III). Taken in combination,
these studies show that internal, global, and negative attribu-
tional patterns (Stage Vila) can produce dysphoria (Stage
Vllb), lowered self-esteem (Stage I), weakened motivation
(Stage Ila), diminished expectancies of success (Stage lib), and
performance decrements (Stage III).
A complication concerning causality is suggested by the find-
ings of E. Hamilton and Abramson (1983), and Persons and
Rao (1981), who found that attributional pattern varied con-
currently with depressive mood; this calls into question the as-
sumption that attributional style is a stable characteristic that
determines mood fluctuations in response to life events. To han-
dle this issue, Riskind and Rholes (1984) and Hammen and
Marks (1983) have proposed that depressive individuals possess
latent negative self-schemata that are usually not cognitively ac-
cessible (and hence not measurable), but are primed by negative
life events. Also, Peterson and Seligman (1984) suggested the
possibility of reciprocal influences, stating that explanatory
style "should be treated as a dependent variable that can be
modified by life events, as well as an independent variable that
modifies future events" (p. 370). From the self-confirmation
perspective, such simultaneity is quite understandable; various
confirmation strategies may arise or disappear concurrently as
the depressive cycle waxes or wanes. Rather than assuming that
any single element—such as attributional style—causes the en-
tire cycle, the self-confirmation model views each aspect as part
of a complex interactive system. For example, depressogenic
attributions could lead to lowered self-esteem (Stage I), intensi-
fied expectations of rejection (Stage lib), and self-abnegating,
interpersonal behavior (Stage III), and this sequence, in turn,
could generate social feedback that would reinforce the original
attributional pattern.
Stage VI: Selective Perception and Recall
Theoretical accounts. It has been suggested that information
processing and memory access in depression stem from and
serve to reinforce the individual's self-concept. This idea is, of
course, part of Beck's (1976) cognitive model, and it is also cen-
tral to the work of Kuiper, MacDonald, and Derry (1983),
which grew out of research on the role of self-referenced sche-
mata in the encoding of information. Their theory suggests that
information networks linked to the self provide the best mem-
ory access and that depressive individuals possess negatively
toned networks that are associated with low self-esteem. Thus,
they argued, the memory-processing system (Stage VI) of the
depressive person will retrieve predominantly negative experi-
ences, thereby generating dysphoric affect (Stage Vllb).
Ingram (1984b), building on this work and on other informa-
tion-processing models, proposed a more general account of de-
pressive cognition. He drew on four concepts: network theories,
affect nodes, depth of processing, and cognitive capacity. Incor-
porated into cognitive networks are emotion nodes that, when
activated, excite other elements associated with the emotion.
When a network is extensive and complex, information is
highly elaborated and central in the individual's awareness. As
a consequence, there will be greater depth of processing. In ad-
dition, when elaboration is extensive, a greater part of the per-
son's cognitive capacity is occupied, leaving less capacity for
other types of cognitions. Ingram assumed that depressive indi-
viduals possess extensive negative networks and that, as a result,
negative information will be most elaborated and will occupy
the greater proportion of cognitive capacity. Reactive depres-
sion is triggered by events covered by the "broadly conceived
notion of loss" (p. 453), and is then maintained by the cognitive
mechanisms previously described. When a depression-causing
experience occurs, activation spreads through the individual's
loss-associated network, whose contents then come into con-
scious awareness. Ingram stated that because the affect node of
depressive mood is so central, "as activation cycles through the
network, it is eventually fed back . . . to the depression node,
causing it to remain activated. Phenomenologically, it may seem
to the individual that negative memories keep coming back,
again and again, thus maintaining depressive feelings" (p. 455).
Research findings. With respect to selective perception, little
research has been reported; however, Beck (1984) described two
unpublished studies that showed that depressed individuals are
particularly prone to recognize negative words and scenes,
whereas nondepressed individuals have a positive bias. Also,
Sharp and Tennen (1983) found that depressed subjects selec-
tively emphasized negative attributional cues in accounting for
failure. Similar findings were reported by Dunbar and Lishman
(1984) and Powell and Helmsley (1984).
Concerning recall of negative information in depression, the
evidence is much more substantial; consistently, depressed sub-
jects remember negatively toned material more readily than
positively toned material (see reviews by Blaney, 1986; Coyne
& Gotlib, 1983; Craighead, 1980; Johnson & Magaro, 1987;
and Segal & Shaw, 1986). Also, as noted in a review by Kuiper
et al. (1983), depressed individuals show the self-referenced
 PSYCHOTHERAPY OF DEPRESSION
memory access effect chiefly when negative self-references are
involved. Still other researchers have examined the recall of
success and failure feedback among depressed individuals. In
their review of this literature, Coyne and Gotlib (1983)—al-
though noting various methodological, theoretical, and inter-
pretive problems—stated that "depressed persons, relative to
nondepressed persons, are more negative in their recall of feed-
back given on laboratory tasks" (p. 495). More recent conclu-
sions by Blaney (1986) and Segal and Shaw (1986) are similar.
Where causality is concerned, Blaney (1977) argued that
studies using various mood-induction techniques provide evi-
dence of a (short-term) causal relationship between selectively
focused attention and depressed affect. The best known of these
techniques was devised by Velten (1968). Subjects are asked to
read sad statements, to view sad films, or to think of sad events,
with a consequent deepening of negative emotion. Thus, it may
be that depressed persons make themselves unhappy (Stage
Vllb) by engaging spontaneously in the attentional selectivity
(Stage VI) that the subjects in these studies used under experi-
mental direction. According to Blaney (1986), most studies
such as those also show that this dysphoria generates retrieval of
negative memories, a finding that demonstrates linkages among
selective attention, mood, and selective recall. Of course, it still
remains for these causal connections to be demonstrated di-
rectly with depressed individuals. Blaney (1986) noted that this
hypothesis is questionable because the effects of mood manipu-
lations are ordinarily quite brief, and he suggested that attribu-
tional style or the use of self-control strategies may determine
the outcome. It may be, as well, that negatively toned cognitive
networks of the sort discussed by Ingram (1984b) perpetuate
the effects of what would otherwise be transient dysphoric
moods. In addition, the self-confirmation model proposes a
multistage cycle of depression-intensifying events.
A related issue concerns what interpretation should be placed
on data showing that depressed persons have a chronically nega-
tive recall bias. This pattern may stem from underlying negative
self-schemata, as is assumed by Kuiper et al. (1983) and other
researchers; however, as Segal (1988) noted, it may also be ac-
counted for by the effects of current depressed affect, as found
in the mood-induction studies discussed in the review by Bla-
ney (1986) cited earlier. In examining this literature, Segal con-
cluded that most research has not provided a basis for distin-
guishing between these two accounts.
Two studies have addressed this problem by measuring the
interference of depressive word content with color naming in a
variant of the Stroop test and by assessing subjects under vari-
ous mood conditions (Gotlib & McCann, 1984; Williams &
Nulty, 1986). The last authors concluded that "interference in
color naming of negative material reflects stable biases in con-
struct accessibility in depression-prone individuals rather than
transient mood disturbance" (p. 485), and the findings of Got-
lib and McCann were similar. A related conclusion was drawn
by Strohmer, Moilanen, and Barry (1988), who found that de-
pression-related, as opposed to elation-related personal hypoth-
eses were selectively confirmed not only by currently depressed
subjects but also by those identified on the basis of a self-report
instrument as cognitively depression-vulnerable. Again, this
suggests the presence of a cognitive structure that potentiates
the processing of depression-producing information. In addi-
tion, the role of the self-concept as a schema that determines
589
selective information retrieval was suggested by Blaney (1986);
he noted that the findings he reviewed "are rather consistent
in suggesting that mood-congruence effects (on memory) are
obtainable only under self-reference set" (p. 231). Finally, the
influence of the self-concept on selective social information
seeking was also noted by Swann, Krull, and Pelham (1987),
who showed that low self-esteem, but not temporarily induced
dysphoric mood, led to a preference for questions that probed
for negative feedback about self. On the other hand, however,
some studies (Clark & Teasdale, 1982; Slife, Miura, Thompson,
& Shapiro, 1984) have found that negative recall among de-
pressed persons varies with dysphoria level; and these findings
are given additional support by the previously cited conclusion
that attributional patterns can be influenced by affective state
(E. Hamilton &Abramson, 1983; Persons & Rao, 1981).
The results of Kuiper, Olinger, Macdonald, and Shaw (1985)
point to the importance of both mood and cognitive structure
in memory access. They found that affectively depressed per-
sons showed mood-congruence effects only if they also mani-
fested a depressive attributional style, suggesting the presence
of a cognitive structure. At the same time, that style did not, in
and of itself, lead to negative memory bias. This may indicate
that a combination of negative mood state (Stage Vllb) and cog-
nitive vulnerability (Stage Vila) are necessary to produce
strong memory-bias effects. Such an account was proposed by
Johnson and Magaro (1987), who concluded from their litera-
ture review that "mood, independent of diagnosis, may be con-
sidered to act as a switching device that activates or deactivates
schemata" (p. 37).
Finally, a causal link of a different sort was reported by
Mitchell and Madigan (1984). These researchers used Velten's
(1968) technique to induce various moods in college students
and then measured interpersonal problem-solving effectiveness.
As compared with the elated and neutral groups, depressed-
mood subjects generated significantly more irrelevant and in-
effective solutions as well as failures to produce a response. The
authors suggested that "deficiencies in social skills like interper-
sonal problem solving not only may be factors in the onset of
depression but may be exacerbated by the disorder itself (p.
283). Here again, one can see causal interactions among differ-
ent elements of the depressive cycle. Selective attention (Stage
VI) produces dysphorica affect (Stage Vllb), which, in turn,
leads to reduced problem-solving effectiveness (Stage lib).
Stages III-IV- V: Interpersonal Behavior and Response
Theoretical accounts. According to interpersonal theories,
what is distinctive about the depressive individual is the type of
social environment he or she sets up in dealing with others.
Leary (1957) identified depression with the self-effacing person-
ality type, and wrote that
self-effacement pulls depreciation and patronizing superiority
from others.. . .if a person acts in a glum, guilty, withdrawn, and
weak manner [Stage HI], he will tend to train others to look down
on him and to view him with varying amounts of contempt [Stage
IV]. (p. 284)
Through this interpersonal reflex, the depressed individual in-
duces others to respond (Stage V) in hostile-dominant ways that
complement and confirm his or her self-abasement (Stage I). As
noted in connection with Stage I, in this formulation the actual
590 JOHN D. W. ANDREWS
reactions elicited by the depressed person are quite similar to
the self-punitive internal interactions postulated by psychoana-
lytic writers such as Blatt (1974).
Coyne (1976b) has developed an interpersonal model of de-
pression that overlaps at several points with that of Leary
(1957). He stressed the pull for support from significant others,
as well as the guilt and resentment generated by the depressive
person's attempts to shift the interactive burden to the other
party. The resulting negative emotion, combined with growing
impatience when reassurance seems to produce little effect, of-
ten leads to the very rejection the depressed person had been so
anxious to avoid in the first place. This formulation has been
offered as an alternative to the cognitive view of depression.
Whereas the latter treats cognitions as primarily a function of
the cognizer's information-processing structures, the former
stresses the role of the stimulus: actual feedback from other peo-
ple. Thus, Strack and Coyne (1983), in summarizing one inter-
personal study, posed the issue this way:
In a 15-minute conversation, depressed persons induced hostility,
depression, and anxiety in others and got rejected. Their guesses
that they were not accepted were not a matter of cognitive distor-
tion, as current models of depression (Beck, 1974) would suggest,
but were consistent with the response of others, (p. 803)
Here again, as we follow the feedback loop in reverse order,
we find proposals to account for a given process in terms of
the preceding stage(s) of the cycle. Previously, negatively biased
cognitive processes (Stages VI and Vila) were assumed to ac-
count for dysphoric affect and low self-esteem; and now an aver-
sive interpersonal pull and the resultant social feedback (Stages
HI-IV-V) are being suggested by Strack and Coyne (1983) as
the explanation for (veridically) negative cognitions. Here, as
well, one can see theorists assuming implicitly or explicitly that
the aim is to find the single variable from which all other depres-
sive characteristics can be derived.
A related interpersonal portrayal was offered by Arieti and
Bemporad (1978), who wrote from a psychodynamic perspec-
tive. They stressed the depressive individual's lack of autonomy
and self-direction and asserted that this sort of individual typi-
cally looks to a dominant other or a dominant goal as the major
source of gratification, self-direction, and self-esteem. This idea
is similar to the self-worth contingency model of Kuiper and
Olinger (1986), discussed earlier. According to Arieti and Bem-
porad, such patterns typically begin in childhood, when the po-
tentially depressed individual learns that nurturance and ap-
proval must be won by being dutiful, striving, and compliant.
Subsequent dominant others fulfill an interpersonal role similar
to that of parents, and in some instances the success demanded
by the parents becomes in and of itself the condition for self-
worth. Disappointment in these crucial relationships or en-
deavors often triggers the depressive reaction, a conclusion doc-
umented by Oatley and Bolton (1985). This interlocking of
dominant and submissive styles, with the depressive playing the
submissive and self-effacing role, is what we would expect on
the basis of Leary's (1957) interpersonal complementarity for-
mulation; and it is also consistent with the assumption of self-
perpetuating interaction that is central to the self-confirmation
model.
Other psychodynamic theories of depression are more intra-
psychically oriented and focus on internalized interactions that
mirror the complementarity hypothesis. Slipp (1976) empha-
sized the role of double-binding parental messages: "The child
was encouraged to achieve, yet when he did succeed it was taken
for granted, and he was emotionally rewarded only when he
failed" (p. 397). As a result, the individual has internalized both
a good-self-approving-parent dyad and a bad-self-critical-par-
ent dyad. Then, in turn,
The depressive evolves an oppositional form of symbiosis as a com-
promise solution to this double bind. By partial compliance to both
succeed and rail messages, he does not risk abandonment by either
parent, yet by rebelling sufficiently against these injunctives, he
preserves some autonomy. (Slipp, 1976, p. 398)
Again, we see the depressed individual's role as one who is
trapped by his or her own neediness and oppressed by dominant
others—both internal and external. Blatt (1974) wrote in a sim-
ilar vein of introjective depression, in which the internal objects
of the depressed person generate and sustain self-perceptions of
worthlessness, guilt, and failure. Blatt also distinguished be-
tween introjective and anaclitic depression. The former centers
around self-blame, whereas the latter involves fear of abandon-
ment and the struggle to maintain contact with significant oth-
ers. This distinction and other formulations of depressive sub-
types will be explored further following the review of theoretical
models.
Poor interpersonal functioning—seen as an incapacity to
elicit positive reinforcement—is a central ingredient in behav-
ioristic theories of depression. This assumption is reflected in
the formulations of Costello (1972), Ferster (1966,1973), Laza-
rus (1968), and Lewinsohn (1974, 1976). As Eastman (1976)
pointed out, each of these models stresses different ways in
which reinforcement loss may generate a depressive process.
These include reduction of reinforcement, reduced frequency
of reinforcement, loss of reinforcible behavior, loss of reinforcer
effectiveness, and aversive control. As adjustive, reward-produc-
ing behaviors decrease, depressive behaviors become more
prevalent and are often rewarded by social attention. Although
the lack of positive reinforcement may initially be due to an
external event (such as loss of a relationship), it is the degree of
interpersonal capability the person brings to the experience—
his or her level of skill in obtaining social reinforcements—that
determines how the event will be handled and whether depres-
sion will develop.
On first examination, it seems straightforward enough to ex-
plain the depressed person's negative social impact in terms of
such skill deficits. That is, Stages IV-V in the cycle are to be
accounted for by Stage III. There are, however, several complex-
ities involved. To begin with, the data showing that depressed
individuals engage in fewer pleasant or reinforcing activities can
also be accounted for in other ways. This variable is generally
measured by the individual's self-report, and as Blaney (1977)
and Heiby (1979) have pointed out, these findings could also be
the result of negative recall bias. Thus, data relevant to one stage
of the confirmation cycle (Stage III, reinforcement-producing
social behavior) may be explained by a process located at an-
other stage (Stage VI, selective attention and recall). It may also
be the case, of course, that both a lack of reward-producing
behavior and an information-processing bias—as found, for ex-
ample, by Roth and Rehm (1980)—contribute to depressive re-
 PSYCHOTHERAPY OF DEPRESSION
actions in a progressively intensifying sequence. This idea is
built into the feedback loop model.
Second, there is a subtle but important difference between
the behavioristic notion of lack of social skill and Leary's (1957)
interpersonal reflex concept. The latter assumed that the de-
pressed person is not unskillful, but is instead extremely effec-
tive at engineering a particular kind of response (hostile domi-
nance) from other people. Even though such reactions may also
make the person unhappy in many instances, he or she operates
verbally and nonverbally in ways that establish this sort of pre-
dictable social environment. A somewhat similar assumption
was made by Coyne (1976b), but not by Lewinsohn (1974) and
other reinforcement theorists.
This distinction implies different concepts of reward as well.
Lewinsohn (1974) assumed that pleasant events such as positive
social responses are rewarding to everyone, whereas the inter-
personal reflex model views as a reward any response that will
strengthen the individual's tendency to act in accustomed ways
(Brokaw & McLemore, 1983). Thus, hostile dominance would
be reinforcing for depressed individuals and would lead to fur-
ther self-effacing behavior, whereas positive "rewards" could
even be perceived as self-dissonant. Like self-confirmation the-
ory, Leary's (1957) model assumes that the depressed person
provokes rejection or disparagement because he or she feels de-
prived of a familiar social identity when he or she does not expe-
rience such responses. From this perspective, rewarding social
interaction is not likely to produce change until the depressed
client has come to grips with the self-demeaning confirmation
patterns he or she has previously established.
Moreover, as Strack and Coyne (1983) pointed out, most
studies of interpersonal skill are based on interactive mea-
sures—for example, the amount of eye contact or number of
positive statements. They noted that these measures depend
partly on how the second party behaves; thus, eye contact can
occur only if both individuals seek it. Because, as Coyne's
(1976a) research shows, depressed persons are able to turn off
others quite quickly, their low scores on interpersonal skill mea-
sures may be due partly to the other person's withdrawal. In
this sense, poor interpersonal skill, as operationally denned by
behavioral researchers, may also reflect skill at inducing inter-
personal avoidance. It is, thus, a mixture of Stages III, IV, and
V, rather than being a purely behavioral (Stage III) phenome-
non. The confirmation cycle, with its multiple stages, provides
a context for understanding this conceptualization.
Finally, a cognitive prototype held by others that shapes their
impressions and responses (Stages IV-V) may contribute to
maintaining the depressive pattern in still another way. Cane
and Gotlib (1985) pointed out that many lay individuals hold a
prototype of depression that includes such elements as with-
drawal, self-blame, dependence, and sadness (see L. Horowitz,
Wright, et al., 1981). Cane and Ootlib went on to suggest that
when a person notices one or a few prototype features in an-
other, he or she may invoke the full prototype and hence assume
the existence of other features that are not necessarily present.
This amounts to creating a stereotype of the depressed person,
one that has a certain independence once invoked. Such an im-
pression can then function as a self-fulfilling prophecy. The de-
pressed individual, finding himself or herself treated as more of
a global depressive than is actually the case, may behave in ac-
591
cord with this expectation, thereby intensifying the depresso-
genic cycle still further.
Research findings. Coyne's (1976b) interpersonal formula-
tion, which stresses the realistic aversive impact of the depressed
individual's behavior, has generated considerable research. In
his original study, Coyne (1976a) found that during a brief tele-
phone conversation, depressed women created a negative effect
on "target" strangers. After interaction with depressive, as con-
trasted with control, subjects, the targets rated themselves as
more depressed, anxious, and hostile, and were less willing to
engage in further interaction. These findings have both descrip-
tive and causal implications. They identify an association be-
tween depression and certain modes of social behavior, and they
also demonstrate the influence of such behavior (Stage III) on
the response of others (Stages IV-V).
A number of studies have produced support for this hypothe-
sis of the depressive's problematic social impact. However, the
nature of this influence varies from study to study. Some re-
searchers, like Coyne, found dysphoric affect in the target (Got-
lib & Beatty, 1985; Hammen & Peters, 1978; Howes, Hokan-
son, & Loewenstein, 1985; Robbins, Strack, & Coyne, 1979;
Strack & Coyne, 1983; Winer, Bonner, Blaney, & Murray,
1981). Others emphasized rejection of further interaction (Bos-
well & Murray, 1981; Wierzbicki, 1980; Yarkin, Harvey, &
Bloxom, 1981). And an ambivalent reaction has been identified
by Howes and Hokanson (1979), Sacco, Milana, and Dunn
(1985), and Stephens, Hokanson, and Welker (1987). The first
of these studies found that depressive, as contrasted with con-
trol, subjects elicited more direct support, but also more pun-
ishing and insulting remarks and fewer positive and neutral con-
versation-maintaining responses. In the second study, depressed
subjects' requests for help "elicited significantly more anger and
social rejection but equal amounts of concern and willingness
to help" (Sacco et al., 1985, p. 1728). And the third study
showed that depressive subjects received more conversational
advice and support, but were more likely to be rejected on a
postinteraction questionnaire.
Other studies have not found distinctive reactions on the part
of others, but do report poor social skills among depressed sub-
jects (Gotlib & Robinson, 1982; \oungren & Lewinsohn,
1980). It seems likely that the various factors noted are all as-
pects of a broad social process and that each element would
contribute to the depressive's overall interpersonal impact. Fu-
ture research may clarify the conditions under which each com-
ponent is most apt to become salient. Also, there is little direct
evidence that depressed persons, on receiving negative re-
sponses from others (Stage V), become still more dysphoric
(Stage VHb); this hypothesis remains to be tested.
Two studies by Sacco and Hokanson (1978, 1982) explored
the potential of the interpersonal model in accounting for self-
reinforcement phenomena of the sort postulated by Rehm
(1977). These researchers introduced a public versus private
distinction, involving the presence or absence of the experi-
menter during the task, and found the characteristic depressive
low level of self-reward only in the public condition. They sug-
gested that "depressed persons display reduced levels of self-
rewarding behaviors in the presence of others as a tactic for
managing interpersonal stress" (Sacco & Hokanson, 1982, p.
383). This conclusion accounts for a phenomenon associated
with Stage Vllb (self-reinforcement) in terms of Stages III-IV
592 JOHN D. W. ANDREWS
(interpersonal self-presentation). Related findings are reported
by Swann et al. (1987), who examined the social impact of se-
lective information seeking. The tendency of depressed subjects
to use questions that probed for negative evaluation from others
was associated with derogation and rejection by those others.
Concerning the depressive person's insufficient skill at elicit-
ing social reinforcement, there is a sizable body of correlational
evidence (see reviews by Blaney, 1977; Craighead, 1980; and
Heiby, 1979). Depressed individuals are less socially or inter-
personally skillful in general than are nondepressed persons.
Compared with nondepressed individuals, they elicit less posi-
tive reinforcement and their moods are significantly correlated
with the number of reinforcing events they engage in. They fo-
cus conversation on themselves and their problems, exhibit a
lower rate of speech during verbal interchanges, use more am-
biguous nonverbal communications, and show more depressive
facial expressions and hand movements.
Studies attempting to show that behavioral deficits (Stage III)
cause depression (Stage Vllb) have had more mixed results.
Lewinsohn, Biglan, and Zeiss (1976) found no relation between
social effectiveness and depression measured after a 2-month
lag. On the other hand, Sanchez and Lewinsohn (1980) did find
a negative association between assertive behavior and dysphoric
mood measured on the following day. Two studies that exam-
ined relationships between engaging in pleasant activities on a
given day and mood on the following day produced null findings
(Lewinsohn & Graf, 1973; Lewinsohn & Libet, 1972). And
Hammen and Glass (1975) found no relation between an in-
struction to increase pleasant activities and later depression
scores.
Stage lib: Expectations
Theoretical accounts. As noted earlier, the original learned
helplessness model (Seligman, 1974, 1975) is built around an
expectancy construct. The key expectation is that the probabil-
ity of a particular consequence, if one makes a response, will
equal the probability of the consequence if there is no response.
In plain terms, no matter what you do, it will not make any
difference. Particularly when aversive consequences are in-
volved, this results in learned helplessness (Stage lib)—from
which the depressive symptoms of passivity (Stage III), negative
cognitive set (Stage Vila), lack of capacity for satisfaction (Stage
Vllb), and dysphoria (Stage Vllb) are assumed to follow. In this
sense, learned helplessness theory is also a single-factor explan-
atory model.
Hollon and Garber (1980) presented a more elaborate expec-
tancy account that overlaps with the learned helplessness con-
struct at many points. They stressed that expectations (Stage
lib) are the key element in a cognitive cycle that also involves
lack of motivation (Stages Ha and lib) and behavioral passivity
(Stage III). Moreover, expectations of future events are often
derived from attributions (Stage Vila) made by the individual
concerning previous experiences. This formulation is some-
what similar to the self-confirmation model in that it deals with
multiple interrelated processes. At the same time, however, it
still emphasizes a single, fundamental causative mechanism;
thus, Hollon and Garber stated that "negative expectations
about the future produce much of the depressive symptomatol-
ogy, and therefore, the cognitive-expectancy model of interven-
tion suggests that the major focus of the process and procedure
of therapy should be on expectations" (p. 182). By contrast, the
self-confirmation approach suggests multiple points of inter-
vention, each of which is viewed as providing an opportunity to
interrupt the depressive vicious cycle.
Research findings. Many researchers have tested the hypoth-
esis that depressed subjects expect to be personally helpless in
task situations. Noting the similarity of the learned helplessness
formulation to the locus of control construct, Blaney (1977) re-
viewed a number of studies correlating the two measures and
concluded that "on balance the data on the association between
measures of depression and pencil-and-paper measures of con-
trol are consistent with Seligman's model of depression" (p.
209). On the other hand, Coyne and Gotlib (1983) pointed out
mixed results from experimental studies.
Another type of study involves measuring how subjects ad-
just their expectancies based on feedback about initial perfor-
mance. It is predicted from learned helplessness theory that de-
pressed subjects will differ from the nondepressed only on skill
tasks and will not differ on chance tasks. The argument is that
if depressed persons view all tasks as based on chance (in the
sense that they perceive no response-outcome relationship),
they will treat the feedback on skill tasks as if it were as irrele-
vant to their expectations as would be the case under chance
conditions. This hypothesis, which involves the association be-
tween two features (depression and an expectancy pattern), will
thus produce descriptive rather than causal evidence. Blaney
(1977) and Heiby (1979) considered the aggregate of findings
in this area generally supportive of learned helplessness theory.
However, Coyne and Gotlib (1983) noted that later research
failed to support the prediction.
A number of studies have tested the short-term causal hy-
pothesis that subjects who experience response-outcome inde-
pendence—often after having been asked to work on unsolvable
problems—will begin to feel depressed. Heiby (1979) con-
cluded that this experimental manipulation has rarely been
shown to produce affective symptoms of depression (Stage
Vllb) in normal individuals. However, a later study by Raps,
Reinhard, and Seligman (1980) used a helplessness induction
with depressed and nondepressed subjects and found that this
led to both depressed affect (Stage Vllb) and poorer perfor-
mance (Stage III); "therapy," in the form of Velten's (1968)
mood induction procedure, reversed both effects. Heiby added
that helplessness inductions do generally lead to performance
decrements (Stage III), which have sometimes been interpreted
as behavioral "depression." However, as she pointed out, there
is no evidence linking such deficits directly to the behavioral
retardation seen in many depressed individuals.
A causal link between helplessness and depression has been
shown in several studies that involved "therapeutic" reversal
of depressed mood when helplessness was counteracted. Thus,
Klein and Seligman (1976) found that when depressed subjects
were presented with solvable problems, both self-reported sad-
ness (Stage Vllb) and performance deficits (Stage III) decreased
significantly. However, Miller and Seligman (1976) found oppo-
site results. Also, positive findings were obtained in two natural-
istic studies of retirement home residents who became less de-
pressed when they were given greater control over their lives and
social contacts (Langer & Rodin, 1976; Schulz, 1976).
 PSYCHOTHERAPY OF DEPRESSION
Stage Ha: Motivation
Theoretical accounts. A motivational formulation that
bridges the connection between expectancies and incentives was
offered by Layne (1980) and Layne, Merry, Christian, and Ginn
(1982). These authors reviewed a number of studies that sup-
ported the assumption that "depression is primarily a motiva-
tional deficit; motivation consists of the organism's expectancy
of an outcome multiplied by the organism's valuation of that
outcome. Therefore, depression is primarily a deficit in the per-
son's expectancies and values" (Layne et al., 1982, p. 259). This
model thus involves a close intertwining of Stages Ha and lib in
the confirmation cycle. Layne (1980) incorporated elements of
Beck's (1974) and Seligman's (1974) theories into the expec-
tancy aspect of the model and cited Costello's (1972) and Lew-
insohn's (1974) reinforcement theories to support the notion of
impaired reward values. In one sense, then, this is an integrative
formulation; yet at the same time, it, too, emphasized a single
causal factor: the "primary" motivational deficit.
Early psychoanalytic accounts of the depressed subject's mo-
tivations stressed oral dependency and aggression turned
against the self (Abraham, 1948). Arieti and Bemporad (1978)
presented a cognitive-interpersonal version of this idea that
traced the depressed person's handling of hostility to his or her
self-concept within the context of a dominant-submissive dyad.
Arieti and Bemporad wrote that
The depressive does not overtly display anger because he automati-
cally structures his view of himself and others so that anger is not
produced.. . . depressives idealize the dominant other and so im-
plicitly trust the other's judgment that they see no reason for resent-
ment and anger. If they fail to obtain the other's acceptance, it is
because they have not tried hard enough to be worthy, and not
because the other is stingy or unjust. They feel they have only them-
selves to blame and thus have no cause to become angry, (p. 177)
This statement completes the feedback loop, inasmuch as the
depressed person's lack of anger and assertiveness (Stage Ila) is
here accounted for in terms of a "wrong and blameworthy" im-
age of self (Stage I).
Research findings. Some correlational evidence supports
Layne's (1980) view that depression is a motivational deficit in-
volving both expectations and capacities for satisfaction. Layne
et al. (1982) found that depressed subjects, as compared with
normal and psychiatric control subjects, would undervalue
both rewards and punishments and would expect to earn fewer
rewards. And Layne, Lefton, Walters, and Merry (1983) found
evidence for this hypothesis under both public and private con-
ditions, supporting their argument that an expectancy process
(Stage lib) rather than a self-presentational strategy (Stages III-
IV) is involved. This differs from the finding of Sacco and Ho-
kanson (1978, 1982) that depressed persons are only reluctant
to reward themselves under public conditions.
One study also confirmed the hypothesis that the depressed
individual's lack of self-esteem is related to the handling of an-
ger. Dengerink and Meyers (1977), in a study described earlier
to illustrate the self-confirmation model, found that following
task failure, depressed men were less aggressive in response to
provocation than under neutral conditions, whereas nonde-
pressed men showed the reverse pattern. This suggests that fail-
ure feedback (Stage V) was confirming for the depressed sub-
jects and that because this feedback reinforced their low self-
593
esteem (Stage I), they accepted the aggression against them
(Stage V) as self-congruent and felt no need to (Stage Ila) "get
their own back" via extrapunitiveness.
Overview and Implications
Self-Confirmation Model as an Integrative Template
It can be seen from the foregoing account that a number of
theories claim to hold the explanatory key to depressive func-
tioning and argue that phenomena made central in other theo-
ries are in fact secondary or noncausal processes. Moreover, as
various theorists pursue this reductionistic path, they often ex-
plain a given process in the confirmation cycle by invoking an-
other that is upstream from it in the feedback loop. Thus, low
self-esteem and dysphoria are explained by negative self-focus
(Pyszczynski & Greenberg, 1987), self-punishment patterns
(Rehm, 1977), cognitive distortions (Beck, 1976), and negative
memory structures (Ingram, 1984 and Kuiper et al., 1983).
Negative cognitions are seen as due to the accurate perception
of a rejecting interpersonal environment (Coyne, 1976b). The
individual sets up interpersonal disappointment through lack
of social skill (Lewinsohn, 1974), an all-too-effective skill in
provoking rejection (Coyne, 1976b; Leary, 1957), an overreli-
ance on external self-worth contingencies (Kuiper & Olinger,
1986), or the investment of too much interpersonal meaning in
one dominant other (Arieti & Bemporad, 1978). Apparent lack
of interpersonal skill is, in turn, viewed as partly reflecting the
tendency of other people to withdraw from the depressed person
(Coyne, 1976b). And this latter reaction may sometimes stem
from the other's disposition to stereotype depressed people on
the basis of a previously held prototype (Cane & Gotlib, 1985).
Those who focus on expectancies argue that depressed individ-
uals do not learn or use social skills because of a belief in re-
sponse-outcome independence (Seligman, 1975), hopelessness
(Beck, 1976), or a low expectancy of reward (Layne, 1980).
These expectancies are linked with motivational deficits
(Layne), subjugation to the power of dominant others (Arieti &
Bemporad (1978), and inhibition of anger (Arieti & Bemp-
orad). And motivational deficits are, in turn, rooted in a self-
conception of personal helplessness (Seligman, 1975) or low
self-esteem (Beck, 1976). Finally, deficient self-esteem (Bibring,
1953, and Gaylin, 1968), punitive internal objects (Blatt, 1974;
Slipp, 1976), negative self-focus (Pyszczynski & Greenberg,
1987), or self-worth contingency schemata (Kuiper & Olinger,
1986) can also be seen as producing the entire array of depres-
sive manifestations.
This "dog-chasing-its-tail" circularity is a problem only if
one is seeking the cause of depression. In fact, the very diversity
of explanatory accounts—each with its supporting evidence—
calls into question the endeavor to derive all depressive charac-
teristics from any one factor. As Coyne and Holroyd (1982)
noted, "events seldom occur only once, but persist, overlap, and
recur with maddening complexity, [and therefore] a circular
causal model is often more appropriate than a linear one that
artificially abstracts events from the intricate sequences in
which they occur" (p. 114). Such complexity is actually an asset
from the perspective of self-confirmation theory, which is con-
cerned with precisely this type of cyclical phenomenon. More-
over, the causal influences invoked by most depression models
594 JOHN D. W. ANDREWS
occur between adjacent stages of the confirmation cycle, and
their combined operation is closely isomorphic with the com-
plete feedback-loop system (see Figure 5). Evidently, the causal
links assumed by various theorists are consistent with those
built into the self-confirmation model, and this strengthens still
further the case for incorporating them into a single framework.
This perspective implies that it is the progressive intensification
occurring at each succeeding stage that causes personality dis-
turbances such as depression to be so tenaciously entrenched.
Subtypes of Depression
If the interpersonal self-confirmation model is to be used
comprehensively as an integrative framework, the issue of sub-
types of depression must be addressed. As the preceding over-
view indicates, it is rare for theoretical accounts to deal with
this issue. Most distinctions among subtypes, including the bi-
polarity or unipolarity of the person's functioning, the endoge-
nous versus reactive origin of the state, and the psychotic or
neurotic degree of depression, are usually not included as fac-
tors in these models. Moreover, this same unconcern with sub-
classification is generally reflected in the choice of research pop-
ulations, which include mildly depressed college students, preg-
nant women, and depressed inpatients, to name only a few. The
sources of data are so varied that one must adopt a broad-brush
approach in order to synthesize either causal theories or re-
search findings.
The primary exception to this generalization concerns the
distinction between a self-blaming and a dependent form of de-
pression. This is similar to Arieti and Bemporad's (1978) con-
trast between enslavement to a dominant goal and dependence
on a dominant other, and to Blatt's (1974) discussion ofintro-
jective and anaclitic depression. Blatt, Quinlan, Chevron, and
McDonald (1982) have noted parallels to this distinction in the
writings of Beck (1967), Freud (1917/1959), and Seligman
(1975); and Beck (1983) has recently reemphasized this theme.
Moreover, the contributors to a recent symposium (L. Horo-
witz, Blatt, et al., 1987) have proposed that these differences
reflect a major subclustering of depressive psychosocial fea-
tures.
The characteristics of the self-blaming subtype include guilt,
self-dislike, hopelessness, irritability, rejection of help, and lack
of enjoyment. The dependent depressed individual seeks help
and reassurance and is afnliative, anxious, and overtly sad. This
dichotomy parallels the finding that when depressed individu-
als—particularly those who do not respond well to therapy—
manifest DSM-IH (Diagnostic and Statistical Manual of Men-
tal Disorders, 3rd ed.; American Psychiatric Association, 1980)
personality disorders, these are most commonly of either the
avoidant or the dependent type (E. Frank, Kupfer, Jacob, & Jar-
ren, 1987; Shea, Glass, Pilkonis, Watkins, & Docherty, 1987).
Also, Hammen, Marks, Mayol, and deMayo (1985) have docu-
mented the predictive value of this distinction by showing that
depressed subjects with self-critical schemata are most affected
by negative achievement events, whereas those with depen-
dency schemata generally become depressed in response to in-
terpersonal stress.
These patterns can be understood more fully in terms of in-
terpersonal diagnosis. Although Leary's (1957) account of de-
pression stresses a hostile-submissive/hostile-dominant inter-
action (that is, guilt pulls contempt), an examination of the in-
terpersonal circle (Figure 2) suggests that this characterization
is too narrow, fitting well only with the H segment of the circle.
By contrast, the portrait corresponding to the entire self-effac-
ing/masochistic or submissive octant (segments H and I) in-
cludes elements of compliance as well as guilt. Thus, the differ-
ence between these segments matches closely with the self-
blame versus dependence distinction, in that the characteristics
of the self-blaming depressed individual fall consistently into
the H sector, whereas the dependent depressed individual is de-
scribed best by the I sector (see L. Horowitz, Rosenberg, Baer,
Ureno, & Villasenor, 1987). In these terms, for the distancing,
self-blaming person, criticism will be self-confirming, whereas
for the dependent subtype, reassurance will be the basis for in-
terpersonal reciprocity. Also, because these two personality
styles are adjacent on the interpersonal circle, they can be
viewed as forming the halves of the global depressive prototype
defined by the submissive (H-I) octant. This conclusion is sup-
ported by the finding of Blatt et al. (1982) that subjects who
were both self-critical and dependent were the most consistently
identified as depressed.
Critique: Causal Theories and Research Findings
The foregoing review shows that a significant discrepancy ex-
ists in the field of research and theorizing on depression. Most
theories are presented as primary causal accounts of the phe-
nomenon, yet the bulk of available evidence, including the data
generated to test those theories, is correlational in nature.
Short-term causal hypotheses are addressed in a much smaller
number of studies. Still fewer deal directly with clinically rele-
vant etiological factors, and comparative developmental re-
search is nonexistent. Many findings are discussed as if they
provided strong support for a particular causal theory, but this
is frequently not the case. In fact, it is striking that such a sizable
investigative effort has taken us so little beyond the descriptive
level. In essence, what has been accomplished by correlational
research is to elaborate the descriptive prototype of depression.
For example, the DSM-III (American Psychiatric Association,
1980) cites depressed affect, incapacity for enjoyment, low ac-
tivity level, self-blame, and a tendency to search the environ-
ment for proof of unworthiness—all characteristics that emerge
from the body of research data concerning depressed subjects.
Moreover, the very fact that most of the predictions made by
current theories have been given some support militates against
viewing any one theory as primary. Taken in combination, these
findings suggest that a complex, multifaceted account is needed
to understand the depressive pattern. It is proposed here that
the interpersonal self-confirmation model provides such an ac-
count.
Because the signposts pointing toward a multifactor formula-
tion are so clear, it is also striking that few studies have explored
the covariation or intercorrelation among the variables empha-
sized by different theories. This state of affairs undoubtedly re-
flects the fact that most studies have been designed by propo-
nents of a single theory, specifically to test that theory. The re-
sult is an important gap, one that was mentioned some years
ago by both Blaney (1977) and Heiby (1979) and is still present
today (Segal & Shaw, 1986). What patterning exists is simply
not known, and this also makes purportedly causal studies even
 PSYCHOTHERAPY OF DEPRESSION
more questionable. If, for example, one measures one variable
(such as attributional style) but not other variables (such as self-
esteem or interpersonal behavior) that may be correlated with
it, one has no way of knowing which of these covarying factors
is truly causal. This ambiguity will remain even when positive
temporal-causal findings are obtained with respect to a given
variable, because other correlated variables may in fact be oper-
ating but are unrecognized.
Proposals for Future Research
This analysis of the current situation suggests that there is
more to be gained by combining theories and by investigating
the interrelationships and interactions of multiple factors, than
can be gained in narrow single-process studies. Instead of at-
tempting to show that one or another feature predicts affective
depression, investigators should be identifying the empirical
correlations among prototype features and then studying indi-
viduals who show varying degrees of match with the prototype.
Then variations in the expression of prototype features across
time, prediction of the emergence of affective reactions, and
other questions could be studied both cross-sectionally and
longitudinally. The most clear-cut results would be expected
with subjects whose match with the multifeature depressive
prototype is particularly close; such individuals would be the
most solidly entrenched in a depressive style of functioning, in-
asmuch as each characteristic would reinforce and deepen the
self-effacing identity. This standard could be used across set-
tings to provide a common method of identifying depressed
subjects, thus helping to systematize the current profusion of
criteria and operational definitions of depressive characteris-
tics. We would probably find, also, that there are subtypes of
depression that manifest particular clusterings of features. For
example, some depressed persons may frequently engage in re-
jection-evoking interpersonal behavior and perceive that rejec-
tion quite accurately, as suggested by Strack and Coyne (1983),
whereas others may maintain positive self-presentations while
negatively construing the responses they elicit, as stressed by
Beck (1976).
Establishing patterns of association among prototype fea-
tures would also set the stage for expanding our knowledge of
the causal connections among those features. By forming and
testing hypotheses concerning such connections, investigators
may eventually be able to delineate the interlocking cycle of de-
pressive characteristics with more precision. Some studies al-
ready point in this direction. For example, Roth and Rehm
(1980) found that depressed individuals not only demonstrated
poor social skills (Stage III) but selectively overlooked (Stage
VI) manifestations of the skills they did possess when reviewing
videotapes of their own interactions. Sacco and Hokanson
(1978, 1982) explored the function of self-reward (Stage Vllb)
as a self-presentation strategy (Stages III-IV). Gotlib and Beatty
(1985) and Stephens et al. (1987) assessed whether different at-
tributional patterns (Stage Vila), involving self-blame versus
other-blame, would result in different interpersonal responses
when communicated to other people (Stages III-IV-V). And
Swann et al. (1987) showed that negatively biased information-
seeking strategies (Stages lib-Ill) were associated with social
rejection (Stages IV-V). The confirmation cycle provides a sys-
tematic framework for exploring interrelations of this sort.
595
Finally, the self-confirmation assumption itself provides an
additional avenue for research. It is hypothesized that individu-
als' characteristics are not merely static qualities but are in the
service of establishing and protecting a definition of self. Ac-
cordingly, when that definition is challenged, the person is ex-
pected to intensify his or her expression of various self-defining
modes of functioning. The studies by Greenberg and Pyszczyn-
ski (1986) and Pyszczynski and Greenberg (1985, 1986) cited
earlier demonstrate this effect. When low self-esteem, depressed
subjects are given success feedback, they are more apt to avoid
self-focused attention than under failure conditions. This re-
sponse has the effect of diminishing the self-disconfirming
effects of the feedback. Such responses have been identified by
many studies at all points in the feedback cycle (for a review,
see chap. 2 of Andrews, in press); yet, little systematic work of
this kind has been conducted with disturbed populations. Such
studies could be carried out by providing self-disconfirmation
and then measuring the subject's self-reconfirmation endeavors,
as in Swann's (1987) research. We would predict that following
success or other positive feedback, depressive individuals will
intensify their apathy, their helplessness expectancies, their self-
abnegating interpersonal behavior, their negative perceptual se-
lectivity and attributional tendencies, and their dysphoria. The
feedback cycle systematizes these self-confirmation strategies,
thus serving as an inventory of dependent variables. Exploring
such strategies at all points in the cycle should provide a clearer
picture of how depressive persons sustain their low self-esteem.
To study these processes would require a greatly expanded
measurement system. As Hammen (1981), Liberman (1981),
and Rehm and Kornblith (1979) have noted, most standard in-
struments tap depressive mood and cognition only. We would
need, in addition, ways to measure all of the elements included
in the confirmation cycle. For this purpose, the research litera-
ture reviewed earlier should prove useful, in that we can draw
on various research procedures to operationally define each
prototype feature. In the following sections, steps are taken to-
ward such a multifaceted approach by developing both descrip-
tive and causally based depressive prototypes derived from the
theoretical and empirical overview presented earlier.
Research-Based Depressive Prototypes
As discussed earlier, the prototype approach involves estab-
lishing an "ideal" portrait or standard against which any indi-
vidual can be assessed. The self-confirmation model provides a
systematic, theory-based means of deriving prototype features,
in that the complete prototype will describe a person who en-
gages in self-confirmation efforts at each cycle stage. Other indi-
viduals may use certain self-confirmation tactics predomi-
nantly and others only minimally, thus leading to subprototypes
with differing characteristics. Yet they all share the tendency to
confirm a particular image of self; in the case of depressed per-
sons, this involves an identity centered on helplessness and self-
negation as defined by the interpersonal diagnosis system. The
sections that follow explore the prototype of depression in both
descriptive and causal terms and show how it is related to the
assumptions built into the self-confirmation model. Here, for
the sake of manageability, only the global prototype corre-
sponding to the submissive (H-I) octant of the interpersonal
circle will be examined. The self-blaming and dependent sub-
596 JOHN D. W. ANDREWS
types, which cannot be distinguished in much of the research
reviewed earlier, are combined in this portrayal.
Descriptive Prototype of Depression
As noted earlier, the traditional descriptive characteristics of
depression—as reflected, for example, in the DSM-III por-
trayal—match quite well with the research-based features iden-
tified here; common elements include depressed affect, incapac-
ity for enjoyment, low activity level, self-blame, and a tendency
to search the environment for proof of unworthiness. There is
also considerable overlap between descriptive research findings
and the results of two inductive studies of the prototypes typi-
cally held regarding depressed persons (L. Horowitz, Post, et
al., 1981;L. Horowitz, Wright, etal., 1981). The firststudy sam-
pled experienced clinicians, and the second assessed undergrad-
uates' opinions. In both studies, the methodology was similar:
Subjects were asked to list the main features of depression, and
those responses were analyzed to yield a set of most frequently
nominated features as well as clusterings of features within the
overall pattern. The results of these two studies are also quite
similar, and the prototypes generated are largely compatible
with the DSM-III criteria and with the major characteristics
identified in the foregoing research review. They include fea-
tures denoting low self-esteem, lack of motivation, hopeless-
ness, helplessness, expectations of failure and rejection, unas-
sertiveness, low activity level, self-isolation, a sense of unlovabil-
ity, negative self-attributions, and feelings of sadness, self-pity,
and loneliness. These prototype categories are also generally
congruent with the feedback-loop "mapping" of depression the-
ories presented in Figure 5. Finally, the depressive prototype
corresponds to the submissive pole of the interpersonal circle,
and the typical relationship patterns involved exemplify the in-
terlocking cycle of dominance-submission relationships pre-
dicted by the interpersonal model (Figure 2).
Dynamic/Causal Prototype of Depression
It is important, of course, to go further—to make causal and
not merely descriptive statements. As was shown in the over-
view section, the research literature does offer a limited but sig-
nificant number of conclusions about short-term causal pat-
terns; and when these are taken in combination, they help us to
piece together a preliminary model of such influences. The re-
sult is what can be called a dynamic prototype, a set of personal-
ity processes that characterize depressive individuals and are
both descriptively and causally interrelated.
Table 1 shows the theoretically causal links that have received
some empirical validation, as discussed in the foregoing over-
view of conceptual models and supporting research. Almost all
of these are short-term effects that have been found to occur
during the time span of a laboratory experiment. The only ex-
ception to this generalization involves attributional style, which
has been shown to have long-term predictive value. These find-
ings show that there are many interconnections among proto-
type elements. Equally significant is the fact that many of these
relationships involve prototype features that are adjacent or
nearly adjacent in the confirmation cycle. This suggests that the
dynamic prototype features may be causally linked to one an-
other in the loop pattern portrayed by Figures 1 and 5 and helps
to support the causal model proposed by self-confirmation the-
ory. In this way, the cycle provides more than a set of categories
for classifying theories and data concerning depression; it also
gives us a framework for integrating the relevant causal linkages
into a portrait of the depressive self-confirmation system.
To summarize the elements of the depressive causal proto-
type portrayed in Table 1: Self-perceptions of inadequacy, self-
focus following failure, and self-worth contingency schemata
generate pessimistic expectancies for self as well as negative
affect following failure or disappointment. Helplessness expec-
tancies often produce lowered motivation and effort. Poor skills
for obtaining interpersonal reinforcement, a tendency to probe
for negative feedback, and behavior that elicits disparagement
or insincere support can lead to social isolation. This impact is
intensified by the depressive individual's tendency to focus on
negative environmental cues and to emphasize their implica-
tions for his or her shortcomings in the form of global, internal,
and stable attributions, and also by an incapacity to provide
self-reinforcement in the absence of external reward. These fac-
tors magnify environmental stresses and disappointments,
thereby intensifying dysphoria, low self-esteem, apathy, failure
expectancies, and unassertiveness. Dysphoric mood also ap-
pears to stem from negative self-schemata and to produce in-
effective problem-solving, retrieval of negative memories, and
the use of negative attributions. The resulting feedback loop of
interconnected stages perpetuates the depressed person's way of
life, because the selective patterning manifested at each stage
builds on and magnifies the self-confirmational bias(es) already
present at the previous stage(s). This generates a progressive in-
tensification of the individual's self-confirming experience of
the world, thus making it extremely difficult for corrective feed-
back to get through. Using the confirmation cycle model to
guide such corrective intervention is the topic of the following
section.
Implications for Psychotherapy
In this section I examine therapeutic counterstrategies in re-
sponse to the self-confirmation endeavors of the depressive indi-
vidual. Here the interpersonal self-confirmation model helps to
define change goals and points of leverage. As defined by inter-
personal diagnosis, the personality style of the depressed per-
son—like that of any other disturbed individual—is limited to
a few expressive social behaviors that are often manifested in
extreme and rigid ways. An important therapeutic goal is to
help the client develop a broader and more flexible repertoire
of interpersonal styles that will enable him or her to meet vari-
ous needs and adapt to various social settings (Kiesler, 1983).
Moreover, because this rigidity is sustained by the interlocking
of prototype features in the form of a self-confirming feedback
loop, each stage of that loop provides a leverage point at which
the client can be helped to function in new ways. And when
several leverage points are targeted for intervention, the oppor-
tunity to rechannel the depressive confirmation cycle as a whole
is enhanced.
This approach can be used in two contexts. The first of these
is the client's life outside the therapeutic relationship, which
is often the content of therapist-client conversation. Here the
therapist may introduce interventions that correspond to the
theoretically defined causal mechanisms reviewed earlier in or-
 PSYCHOTHERAPY OF DEPRESSION 597

Table 1
Causal-Process Prototype of Depression

Confirmation cycle
stages Causal links

I-IIb Self-perceptions of inadequacy lead to specific expectancies of negative outcomes or failure where the self (but not others
or the world in general) is concerned.
I-III Under self-focus conditions, depressive individuals show greater performance deficits than under external-focus
conditions.
I-VI-VIIb The self-schema influences selective perception and memory access, in that depressive persons tend to focus on and to
recall negative words and experiences, thus producing dysphoria.
I-VIIb Self-focus following failure produces or intensifies negative affect and depressed mood.
Ila-llb Low motivation is a consequence of low expectancies of success and/or high helplessness expectancies.
lib-Ill Expectancies of helplessness and negative outcomes lead to low rates of behavioral response, poor performance, and
nonuse of available interpersonal skills.
Ilb-III-IV-V Negatively biased information-seeking strategies, when communicated interpersonally, lead to negative impressions and
rejection on the part of other people.
Ilb-VIIb Induction of helplessness expectancies may produce dysphoria, and the reversal of those expectancies can alleviate
depression.
III-IV Poor interpersonal skills for obtaining social reinforcement (or good skills at provoking rejection and other negative
III-V reactions) generate impatience, insincerely offered support, punishment, and rejection from other people.
V-VIla-VlIb-I-III Low environmental reinforcement or failure feedback is responded to by low self-reinforcers (depressive persons) with
lack of self-reward, dysphoria, lowered self-esteem, and reduced performance.
V-I-Vllb Failure feedback that may lower self-esteem leads to inhibition of aggressive reactions to others.
VI-VHb The depressive tendency to selectively notice and remember negative information produces dysphoric mood.
VI-I The depressive tendency to selectively focus on failure experiences leads to lowered self-esteem.
VHa-VIIb Internal and global attribution of failure leads to dysphoric mood following disappointments and other stressful or
negative situations.
Vila-lib Internal and global attribution of failure intensifies helplessness or failure expectancies, which are generalized to a wide
range of future situations.
VIIa-IH Internal and global attribution of failure leads to performance deficits and generalization of such deficits to dissimilar as
well as similar tasks.
VIIb-Hb Negative affect influences how the individual plans and anticipates events, lowering the quality of interpersonal problem-
solving.
Vllb-VI Induction of dysphoric mood leads to retrieval of a higher proportion of negative memories.

der to target particular aspects of the client's functioning. Sec-
ond, the therapeutic relationship can serve as a new arena for
revising the client's self-confirmational endeavors as therapy
progresses. The therapist may introduce anticomplementarity
into this interaction in order to redirect the client's self-con-
firmation patterns and provide opportunities for new forms of
experience and relatedness,
Target-Specific Interventions
Effects of interventions on targeted processes. The self-con-
firmation framework suggests how therapeutic interventions
can be targeted toward defined outcomes and orchestrated for
maximum effectiveness (Andrews, 1988c, 1989b, in press).
With respect to depression specifically, the feedback-loop model
serves to systematize and organize many of the methods found
in the therapeutic literature. It is shown later how certain inter-
ventions used in cognitive-behavioral work can be matched to
particular stages of the cycle,6 and suggestions are also made as
to how combinations of interventions can be used to rechannel
the depressive circular process delineated in Figure 5.
At Stage I, many therapists redirect self-talk and self-reward
to improve client self-esteem (e.g., Jackson, 1972; Mahoney,
1971). Mahoney provided positive self-statements for his client,
who gradually learned to use them as rewards and to generate
them for himself. The self-reward elements in these cases are
also pertinent to reactive emotion (Stage Vllb), and some thera-
pists focus on this stage by encouraging clients to expand their
pleasant activities, especially as an antidote to depressive rumi-
nations (e.g., Anton, Dunbar, & Friedman, 1976; Tharp, Wat-
son, & Kaya, 1974). Another approach to reshaping reactive
emotion involves cases in which there is both depression and
anxiety. For example, Wanderer (1972) used desensitization to
counteract phobia-related depression.
Cognitive therapies are focused on Stages Vila and VI, en-
couraging clients to replace their negative attributional and at-
tentional patterns with more self-valuing cognitions (e.g., Rush,
Khatami, & Beck, 1975; Schmickley, 1976). Other approaches
deal primarily with Stages IV and V, working to alter the inter-
personal feedback given to the client. In this sphere, therapists
often act as reinforcers of adaptive behavior and discourage de-
pressive talk, or enlist the client's significant others for this pur-
pose (e.g., Burgess, 1969; Johansson, Lewinsohn, & Hippo,
1969; Lewinsohn, 1976; Liberman & Raskin, 1971). The cli-
ent's social behavior (Stage III) is also a direct focus of interven-
tion. Typical programs involve practicing assertion and anger
expression, as well as communication skills such as making eye
contact and eliciting social rewards (e.g., Lazarus, 1968; Shipley
& Fazio, 1973; Wells, Hersen, Bellak, & Himmelhoch, 1977).
The short-term interpersonal psychotherapy method (Weiss-
6
As with the theoretical overview, this discussion begins with Stage 1
and moves counterclockwise around the cycle.
598 JOHN D. W. ANDREWS
man, Klerman, Rounsaville, Chevron, & Neu, 1982) is focused
on present interpersonal difficulties, such as role disputes and
role transitions, and thus involves Stages III-IV-V.
Cognitive therapists often work with helplessness expectanc-
ies (Stage lib) in depression. For example, Glass (1978) helped
clients both to identify areas in which helplessness was experi-
enced and to generate alternative behaviors for anticipating and
dealing with it. Problem-solving training works with the client's
expectancies in a somewhat similar way (e.g., Caple & Blech-
man, 1976). Finally, motivation-oriented therapies help clients
to reestablish the reward values (Stage Ha) that are often lacking
in depression. Lazarus (1968) and Sammons (1974) used
guided fantasy for this purpose, and Sammons incorporated the
positive fantasy thus generated into an in vivo exercise, called
systematic resensitization, that leads to renewed seeking of re-
inforcement.
There is considerable evidence that the interventions de-
scribed previously are effective, although various reviewers
(Biglan & Dow, 1981; Blaney, 1981; Emmelkamp, 1986; Hol-
lon, 1981; Hollon & Beck, 1986; Rehm & Kornblith, 1979)
differed somewhat in their conclusions. It has been generally
agreed that cognitive, self-control, and social/marital skills
training programs are quite impactful. Affectively based inter-
ventions such as deserialization may be effective with clients
whose symptoms show a mixture of anxiety and depression, but
not with other groups. Pleasant activities prescriptions were not
supported in the studies reviewed by Blaney, but were consid-
ered useful by Biglan and Dow and by Emmelkamp. Purely
behavioral approaches were considered dubious by Hollon but
valuable by Blaney and Emmelkamp.
There is also evidence for target-specific effects. Biglan and
Dow (1981) commented that
It does appear that each component "gives you what you pay for"
in the sense that it is most likely to affect the behavior for which it
is targeted. Pleasant activities interventions increase pleasant activ-
ities, though they may not affect mood or other aspects of depres-
sion. Cognitive-verbal modification may produce changes in co-
vert and overt verbal behavior (including questionnaire measures)
but they may not affect dysphoria or physiological symptoms. So-
cial interventions affect social behavior, though they may not affect
cognitive events or other activities, (pp. 115-116)
Most convincing in this regard are studies that show such tar-
geting effects when two or more methods are compared in terms
of correspondingly specific outcome criteria. Representative
studies of depression showing such effects with respect to behav-
ior, mood, and self-reward are reported by Bellack, Hersen, and
Himmelhoch (1983) and Rehm, Fuchs, Kornblith, and Ro-
mano (1979).7
Psychoanalytic therapists do not usually emphasize target-
specific interventions of the sort discussed earlier, as these ap-
proaches run counter to the explanatory model and interven-
tive style of psychoanalysis. Certain psychodynamic writers on
depression have, however, advocated the use of interventions
that are specifically targeted and have a strong cognitive-behav-
ioral flavor (Arieti & Bemporad, 1978; Levine, 1968). For ex-
ample, Levine suggested leading the client toward new topics
in order to interrupt his or her "broken record" of self-critical
complaints, analyzing the childhood sources of hopelessness
and inadequacy, encouraging assertiveness toward overdomi-
nant relationship partners and the development of more mutual
relationships, reattributing difficulties from "hidden internal
sources" to more manageable situational and interactional fac-
tors, and encouraging clients to reestablish rewarding social
patterns that had been abandoned. Most of these interventions
can be identified as directed toward specific stages of the con-
firmation cycle.
Combinations of target-specific interventions. If each inter-
vention principally affects the targeted process, then combina-
tions of interventions will often be needed, especially for more
complex depressive problems. Such a multifaceted perspective
has, ironically, been more commonly assumed among therapists
than it has in the basic research that supposedly underlies inter-
vention. Several reviewers have concluded that combined cogni-
tive-behavioral methods are the most effective (Blaney, 1981;
Hollon, 1981; Liberman, 1981), and a number of integrative
proposals have been advanced. Liberman (1981), for example,
suggested reestablishing rewarding activities, developing social
skills, and revising cognitions, commenting that this approach
"satisfies the proponents of each of the major theoretical
schools within the behavioral camp, since it draws component
techniques from each of them" (p. 239). In this way, the thera-
pist is enabled to tailor therapy to the needs of each client and
to engage the client in therapeutic decision making. Similar sug-
gestions concerning the combining of interventions have been
offered by other writers on depression, including Craighead
(1980), Lazarus (1981), McCullough (1984), McLean (1976),
Rehm (1977), and Wolpe (1979).
7
In contrast to the target-specificity assumption, it is often argued
that research has found no demonstrable outcome difference between
techniques, and that nonspecific factors such as the therapist-client re-
lationship must therefore account for therapeutic impact (J. Frank,
1973, 1979; Garfield, 1981; Luborsky, Singer, & Luborsky, 1975;
Strupp, 1973). Although the studies on which this conclusion is based
are valuable in some contexts, they essentially beg the question of
whether specific targeting effects exist because they involve assessing
which approach is superior in terms of some global measure of well-
being or improvement. This research strategy eliminates from the out-
set the possibility of finding relationships between specific techniques
and correspondingly defined specific outcomes. When we do examine
such method-outcome linkages, differential effects emerge in a number
of problem areas. For example, the meta-analyses performed by Sha-
piro and Shapiro (1982) and Smith, Glass, and Miller (1980) are often
cited as supporting the equivalence of therapies view. Yet the effect sizes
reported in both studies vary dramatically when we consider how each
method fared in different areas. Many techniques are two to four times
as effective with some types of problems as they are with others, and
most techniques have certain foci of effectiveness in which they outper-
form other methods by a similar order of magnitude. In addition, most
studies that compare two or more methods on contrasting outcome
measures show that the measure reflecting the greatest change corre-
sponds to the technique used. Andrews (in press-a, chap. 3) reviewed
more than 30 such comparative studies and found that about three
fourths of them showed technique-specific outcomes. This conclusion
does not, of couree, deny that relationship effects may also be therapeu-
tically important, even when targeted interventions are used. Indeed, it
seems likely that with depressed clients, as has been found in several
studies of desensitization with phobias (e.g., Rabavilas, Boulogouris, &
Ferissaki, 1979), the therapeutic relationship potentiates the effect of
the target-specific technique. Research of this kind remains to be con-
ducted with depressed clients, but a later section of the present article
suggests how relationship factors may influence the depressed individu-
al's response to therapy.
 PSYCHOTHERAPY OF DEPRESSION
A case that exemplifies the combined use of target-specific
interventions was reported by O'Brien (1978). It involved a
man who had developed acute reactive depression with psy-
chotic manifestations following a job demotion near the end of
his career. O'Brien stated that "a behavioral analysis under-
scored the complex interrelationships of the variables involved
in maintaining and eliciting depressive behavior" (p. 259). Ac-
cordingly, the client was taught a relaxation exercise, and hospi-
tal staff were instructed to reinforce coping and ignore sick role
behavior. Later, upon the client's discharge, an in vivo desensiti-
zation program and an activity schedule were set up to counter-
act his loss of environmental reinforcement. In addition, family
members were trained to reward and model coping behavior.
This combination of interventions helped restore the client to
his prior level of functioning.
The combining of methods takes on additional importance
when it is considered in the context of the depressive self-con-
firmation system because the feedback-loop model helps to in-
tegrate the use of multiple target-specific interventions. If one
views various aspects of depressive functioning as parts of an
interactive cycle, then it makes sense to identify how that cycle
operates in a particular case and to orchestrate diverse interven-
tions toward the overarching goal of rechanneling the entire
feedback loop.
A complexity that arises in carrying out this approach stems
from the fact that there are two opposing forces at work within
the self-confirmation cycle. On one hand, there are causal links
among cycle stages (and among the interventions associated
with those stages), and hence an intervention introduced at one
stage may influence others as the individual strives to maintain
consistency among different aspects of his or her experience.
One consequence of these interrelationships is that there can
be a ripple of change that spreads throughout the client's self-
confirmation system and facilitates the restructuring of that
system.
On the other hand, however, the various stage-related self-
confirmation patterns have a measure of independence, and are
also intersubstitutable so that one pattern may be invoked by
the client to counteract a change introduced at another stage.
For either or both of these reasons, the effect of a single-target
intervention used alone may be diluted by the consistency-
maintaining inertia of the cyclical system as a whole. In such
situations, it is often important to select and sequence interven-
tions in ways that prevent the change-perpetuating ripple from
fading out. For example, altering self-worth contingency expec-
tations (Stage lib) does not guarantee that the client will go on
to revise the expressive behaviors (Stage III) that have pre-
viously reflected those expectations, and it may be necessary
to introduce behavioral retraining in order to carry the change
process forward. Similarly, new assertive behavior (Stage III)
may not be recognized (Stage IV) and may be discouraged
(Stage V) by significant others who have an investment in the
client's prior interpersonal patterns, and relationship interven-
tion may then be needed. Also, as Goldfried and Robins (1982)
pointed out, increased behavioral effectiveness (Stage III) may
not lead to enhanced self-efficacy expectations (Stages I-IIb) if
the effects of that behavior are attributed by the client (Stage
Vila) in such a way as to deny him or her credit for the outcome.
In such situations, cognitive followup work is often valuable.
Finally, even if successes are acknowledged by the client (Stages
599
VI-Vila), they may have minimal impact if he or she continues
to use a negative self-focusing style (Stage I) that renders those
successes shadowy and peripheral. Self-focus retraining would
seem to be a useful therapeutic tool in this context. A psycho-
therapy case study that illustrates how the self-confirmation
model can be used to orchestrate multiple interventions in these
ways is presented in Andrews (1988a).
In sum, the causal self-confirmation prototype of depression
(Figure 5 and Table 1) provides a perspective on the employ-
ment of target-specific interventive methods. Multiple interven-
tions are needed to influence various depressive features sepa-
rately and in combination. They also enable the therapist to
maintain the momentum of change from one cycle stage to the
next and help to prevent the client from counteracting change
introduced at one stage by initiating reconfirmation tactics at
other stages. These effects are enhanced when a diagnostic por-
trait derived from the cycle-model prototype is shared with the
client. This information can be used as the starting point for
planning therapy collaboratively, and on this basis clients may
at times select or devise their own assignments (Andrews, in
press; McCullough, 1984). By seeing how he or she creates a
self-confirming environment via the feedback cycle, the client
will increasingly assume responsibility for the identity and way
of life that emerges from it. This provides the leverage the client
needs to redefine his or her concept of self by initiating change
experiments at various stages, thereby rechannelling the cycle
as a whole.
Therapeutic Relationship
As discussed previously, the depressive individual tends to es-
tablish dominant-submissive dyads with other people, and he
or she will endeavor to draw the therapist into a similar pattern.
In crude terms, the depressive interpersonal equation states that
weakness evokes strength and submissiveness pulls dominance
(Leary, 1957). Horowitz and Vitkus (1986) provided data con-
firming this assumption, and concluded
We see a vicious circle develop in which both participants are
doomed by their own methods. The depressed person, by openly
displaying discomfort, makes an inadvertent bid for [the other] to
take charge; and [the other], by trying to chetr, support, or coerce
[the depressive] into improvement, elicits more submissive behav-
ior, thereby sustaining [his or her] depression, (p. 456)
The therapist, although he or she will be pulled to engage in this
cycle, must gradually introduce anticomplementary responses
that will produce change in the client's self-confirmation pat-
terns. As Horowitz and Vitkus noted, this corrective relation-
ship is needed "in order to avoid interactions that sustain the
very distress that the work of therapy is supposed to reduce"
(p. 466).
Complementary interactions of this sort are generally in-
volved in the transference patterns emphasized in psychoanaly-
sis. Moreover, many psychodynamic writers (e.g., Jacobson,
1968; Lorand, 1968) have noted that the classical "blank
screen" analytic technique must be modified with depressed cli-
ents; it is generally recommended that to counteract the client's
self-critical negativity, the therapist should adopt an active, sup-
portive, and visibly involved role. Lorand, for example, urged
that therapists honor the client's inarticulate plea to "show me
600 JOHN D. W. ANDREWS
emotion, that I may know I make a difference to you" (p. 336).
This provides an effective antidote to the depressive's self-effac-
ing tendencies.
The most thorough examination of these themes was pro-
vided by Arieti and Bemporad (1978), whose model is quite
explicitly interpersonal and who also described how the thera-
pist must shift his or her role during the course of therapy. As
mentioned earlier, these authors stressed the importance to the
depressive individual of a dominant other who provides security
and reassurance at the price of severely restricting his or her
autonomy. Arieti and Bemporad discussed how this issue can
arise during the beginning stages of the therapeutic relationship
by noting the following paradox:
We have seen how often the difficulty of the depressed patient stems
from his dependence on a dominant other. And now we would en-
courage him to substitute for the dominant other a dominant third
(the therapist); in other words, we would not encourage him to as-
sume an independent role. (p. 215)
They went on to point out the risks of initial anticomplemen-
tarity:
The first meaningful rapport with the patient must be made only
through the mechanisms that the illness puts at our disposal.. . .
[otherwise] treatment would be immediately experienced by the
patient as dangerous and would therefore be rejected before mean-
ingful therapeutic relatedness had been established, (p. 215)
This injunction corresponds to the initial or "hooking" phase
of therapy discussed by interpersonal theorists such as Cashdan
(1982), during which the therapist reciprocates the client's in-
terpersonal reflexes as a way of establishing a relationship that
will serve as the basis for later work.
Arieti and Bemporad (1978) also discussed how the therapist
can gradually alter this role and begin to evoke new behavior
from the client as the therapeutic alliance grows strong and
trustworthy. In the middle, more anticomplementary phase of
therapy, the therapist ceases being a dominant third and be-
comes a significant third:
Whereas the dominant other was experienced as a rigid and static
person, the significant third will change rapidly and will appear
eventually as a person who shares life experiences without aiming
to control and dominate. He may indicate alternative possibilities
but he does not demand their implementation, (p. 216)
This change is furthered by interpreting the role of the domi-
nant-other relationship, both within therapy and in the client's
outside life; and in addition, the therapist, by being honest
about his or her own limitations, can prevent the depressed per-
son from casting him or her as an overidealized dominant other.
This results in the replacement of a dominant-submissive com-
plementarity with a more equal and flexible relationship, a
transition that corresponds to the anticomplementary "strip-
ping" of old interpersonal patterns discussed by Cashdan
(1982). Arieti and Bemporad noted that because of the psycho-
social disruptions involved, this process often entails consider-
able struggle and resistance on the part of the client. In terms
of the model proposed here, this reaction is viewed as stemming
partly from the tendency to resist self-concept disconfirmation
by maintaining consistency among the elements of the person-
environment interactive cycle.
In successful therapy, this reaction subsides as the depressive
client learns new interpersonal behavior in response to the ther-
apist's flexibility and becomes increasingly ready to function in
ways that will establish a more confident, self-affirming identity
that is independent of external reassurance. To accomplish this
goal, Arieti and Bemporad (1978) recommended using target-
specific strategies that reflect all aspects of the confirmation cy-
cle. Among these interventions are pointing out the client's in-
creasing competence, helping the client to value his or her own
wants and needs, counteracting helplessness expectations, en-
couraging active, satisfaction-producing behavior, fostering be-
havioral experiments in personal relationships (especially those
involving assertiveness vis a vis the dominant other), and chal-
lenging depressogenic interpretations of events.
Multilevel Model of Therapeutic Influence
As the foregoing discussion suggests, maximum therapeutic
benefit will be attained when both the form and content of ther-
apeutic intervention have impact on the depressed individual's
self-abnegating identity and the self-connrmational style that
sustains it. Where form is concerned, the therapist should intro-
duce progressively greater degrees of anticomplementarity into
the interaction, thereby shifting the relationship toward greater
empowerment of the client. And intervention content is best
targeted toward discussion of how the client can alter various
depressogenic self-confirmation patterns to accomplish the
same end. Because relationship form and intervention content
converge to influence the confirmation cycle enacted by the cli-
ent, this approach provides the opportunity to integrate the
transference elements made central in psychoanalytic theory
with the targeted interventions stressed by cognitive-behavioral
models. It is also important to avoid situations in which the
form and content levels interfere with one another, and to or-
chestrate both levels of influence consistently within a context
of therapeutic acceptance and empathy.
An example of such multilevel impact is described in An-
drews (1988a). The client, on hearing an explanation of how his
internal, stable, and global attributions for failure were perpetu-
ating his depression, became increasingly upset and exclaimed:
"Even when I'm wrong, I'm wrong!" This statement meant that
not only did the client make his original mistake, which was
bad enough; in addition, he made a second mistake in how he
thought about the first one. The client insisted that he did not
feel resentful toward the therapist, who was, he thought, quite
right in criticizing his faulty attributional processes. The target-
specific cognitive intervention had thus become entangled in a
complementarity pattern that cast the client in a submissive,
invalidated role in relation to the "all-knowing" therapist. It
was only after this depressogenic pattern of relatedness had
been discussed openly, thus providing the client with an oppor-
tunity to regain his autonomy, that he could make productive
use of the cognitive intervention on its own terms.
Conclusion
The theoretical framework presented here helps to organize
the picture of depressive personality in several ways. It provides
a theoretically grounded category system, derived from the in-
terpersonal circle model (Figure 2), within which to locate the
traditional syndrome portrait. This adds coherence to the de-
 PSYCHOTHERAPY OF DEPRESSION
pressive personality prototype based on a self-effacing personal
style, and to the subtypology reflecting self-blaming versus de-
pendent depressive patterns. The framework also organizes the
features that emerge from recent studies of depressive proto-
types by deriving such features systematically from the stages of
the confirmation cycle (Figure 1). The result is a causal/process
account of how the depressive individual sustains his or her self-
conception (Table 1). In these terms, various current theories
of depression appear as ways to account for the entire prototype
on the basis of particular features (Figure 5). Although substan-
tial evidence demonstrates the role of these features at a descrip-
tive level, this evidence does not—contrary to some interpre-
tations—validate any of the exclusive-causality notions that
have been advanced. Indeed, most short-term causality studies
suggest that various prototype elements influence each other in
multiple, complex ways. These findings are generally congruent
with the causal links derived by applying the self-confirmation
feedback loop to depressive personality. This supports a self-
confirmation view of depression, structured around the self-
effacing pole of the interpersonal circle as a key identity nucleus.
From this perspective, conceptualizations that propose to iden-
tify the causal element in depression can be seen as ways to
punctuate the endless feedback loop so that a particular process
appears as the originating stimulus. It is more productive, in-
stead, to view the situation as involving interpenetrating causes
or reciprocal determinism, a state of affairs in which each stage
of the cycle contributes its influence to maintaining a stable
and self-consistent interaction pattern. An additional benefit of
applying the interpersonal circle model is that depression can
be viewed in systematic relation to other syndromes, rather than
being conceptualized in relative isolation, as is the case with
most of the theories examined here.
Psychotherapy is usefully viewed in these terms. There is evi-
dence for the efficacy of many target-specific therapeutic tech-
niques, leading an increasing number of writers to propose that
they be used in combination to deal with particular problem
patterns and subtypes of depression. The self-confirmation
model provides a taxonomy of these methods, suggests ways of
orchestrating them toward the goal of redirecting the depressive
vicious cycle, and offers an integrative cross-syndrome perspec-
tive on therapeutic impact. Within this framework, interventive
methods can be most fully understood by being viewed in terms
of relationship form as well as intervention content. Through
the vehicle of the therapeutic interaction, the depressive client's
tendency to confirm a submissive/self-effacing identity can be
challenged as he or she is accepted by the therapist and encour-
aged to enact a more autonomous and assertive role. Target-
specific methods are apt to be most useful when introduced in
this context, because then both the form and content of thera-
peutic intervention will facilitate the client's efforts to revise his
or her self-confirming dealings with the world.
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Received May 13, 1988
Revision received November 21, 1988
Accepted November 29, 1988 •

Beutler, Levin, Tesser, and Miller Appointed

New Editors, 1991-1996

The Publications and Communications Board of the American Psychological Association an-
nounces the appointments of Larry E. Beutler, University of Arizona; Joel R. Levin, University
of Wisconsin; Abraham Tesser, University of Georgia; and Norman Miller, University of South-
ern California, as editors of the Journal of Consulting and Clinical Psychology, the Journal
of Educational Psychology, the Attitudes and Social Cognition section and the Interpersonal
Relations and Group Processes section of the Journal of Personality and Social Psychology,
respectively. As of January 1,1990, manuscripts should be directed as follows:

• For Consulting and Clinical send manuscripts to Larry E. Beutler, Journal of Consulting and
Clinical Psychology, Department of Psychiatry, University of Arizona, College of Medicine,
Tucson, Arizona 85724.

• For Educational send manuscripts to Joel R. Levin, Department of Educational Psychology,

University of Wisconsin, 1025 West Johnson Street, Madison, Wisconsin 53706.

• For JPSP: Attitudes send manuscripts to Abraham Tesser, Institute for Behavioral Research,
University of Georgia, 548 Boyd Graduate Studies, D. W. Brooks Drive, Athens, Georgia
30602.

• For JPSP: Interpersonal send manuscripts to Norman Miller, Department of Psychology,

Seeley G. Mudd Building, University of Southern California, University Park, Los Angeles,
California 90089.

Manuscript submission patterns make the precise date of completion of 1990 volumes uncer-
tain. Current editors will receive and consider manuscripts until December 1989. Should any
1990 volume be completed before that date, manuscripts will be redirected to the newly ap-
pointed editor-elect for consideration in the 1991 volume.