Cited by 176Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychological Treatments and AssessmentsChild and Adolescent Psychosocial and Emotional Development

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Behavioral theory of depression: Reinforcement as a mediating variable between avoidance and depression

Carvalho, John P., Hopko, Derek R.·2011·Journal of Behavior Therapy and Experimental Psychiatry

DOI 10.1016/j.jbtep.2010.10.001

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Abstract

Behavioral theory posits that certain environmental changes and avoidant behaviors inhibit individuals from experiencing environmental reward and reinforcement and subsequently leads to the development and maintenance of depressive symptoms. Using self-report and behavioral (daily diary) indices of environmental reward as proxy measures for positive reinforcement, this investigation examined whether environmental reward mediated the relationship between avoidance and depression. When controlling for anxiety, both indices of environmental reward significantly mediated the relationships of depression with cognitive, behavioral and total avoidance. Post-hoc mediation analyses were conducted to examine potential gender differences. Self-reported environmental reward significantly mediated the relationship between avoidance and depression across both genders. Among females, however, daily diary-measured reward only mediated the relation between cognitive avoidance and depression. In males daily diary reward was a mediator with all three forms of avoidance and depression. This investigation provides initial support for reinforcement as a significant mediator between avoidance and depression and further highlights the relevance of avoidance and reinforcement in behavioral conceptualizations of depression.

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Background
Management of emotional distress following a myocardial infarction: a qualitative content analysis
Liljeroos, T., Humphries, S., Puthoopparambil, S. J., Norlund, F., & Olsson, E. M. G. (2023) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2022.2135591 · Cited by 15
“According to Lewinsohns’ model, depression starts with a disruption in the normal behavioural pattern leading to a change in contingent positive reinforcement (Carvalho & Hopko, 2011; Lewinsohn, 1986).”
Background
A Feasibility Study of Behavioral Activation for Major Depressive Disorder in a Community Mental Health Setting
Crits-Christoph, P. F., Goldstein, E., KING, C. A., Jordan, M., Thompson, D., Fisher, J., & Gibbons, M. B. C. (2020) · Behavior Therapy · doi:10.1016/j.beth.2020.01.008 · Cited by 16
Preliminary Assessment of the Behavioral Activation Model in Japanese Undergraduate Students
Takagaki, K., Okajima, I., Nakajima, S., Ishikawa, S., Kunisato, Y., Kanai, Y., & Sakano, Y. (2013) · Psychological Reports · doi:10.2466/02.15.21.pr0.112.1.47-59 · Cited by 14
Wanting and liking in dysphoria: Cardiovascular and facial EMG responses during incentive processing
Franzén, J., & Brinkmann, K. (2016) · Biological Psychology · doi:10.1016/j.biopsycho.2016.07.018 · Cited by 14
“Individual are asked to identify a problematic behavior and to find an alternative behavior, which would be more adaptive in the given situation (Carvalho & Hopko, 2011).”
Background
Behavioral Activation Treatments for Depression
Quigley, L., & Dobson, K. S. (2017) · Elsevier eBooks · doi:10.1016/b978-0-12-803457-6.00012-x · Cited by 14
Activation, Avoidance, and Response-Contingent Positive Reinforcement Predict Subjective Wellbeing
Gill, C. C., Kane, R. T., & Mazzucchelli, T. G. (2017) · Journal of Happiness Studies · doi:10.1007/s10902-017-9949-8 · Cited by 17
Maladaptive Emotional Schemas and Emotional Functioning: Evaluation of an Integrated Model Across Two Independent Samples
Edwards, E. R., Liu, Y., Ruiz, D., Brosowsky, N. P., & Wupperman, P. (2020) · Journal of Rational-Emotive & Cognitive-Behavior Therapy · doi:10.1007/s10942-020-00379-8 · Cited by 16
Behavioral Activation
Kanter, J. W., & Puspitasari, A. J. (2012) · Wiley eBooks · doi:10.1002/9781118470886.ch9 · Cited by 15
Chapter 7. Cognitive-Behavioral Theories
Leahy, R. L., Clark, D. A., & Dozois, D. J. A. (2022) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615375233.gg07 · Cited by 13
Validation and Psychometric Properties of the French Versions of the Environmental Reward Observation Scale and of the Reward Probability Index
Wagener, A., & Blairy, S. (2015) · Psychologica Belgica · doi:10.5334/pb.bg · Cited by 11
“…author: Aurélie Wagener ψ depression, there has also been an increased interest in the notion of environmental rewards, which is fundamental in the behavioural approach of depression (Carvalho & Hopko, 2011; Correia, Carey & Borsari, 2002; Hopko, Armento, Cantu, Chambers & Lejuez, 2003).”
Background
Identifying Mechanisms of Change
Riley, A. R., & Gaynor, S. T. (2014) · Behavior Modification · doi:10.1177/0145445514530756 · Cited by 12
Two subtypes of compulsive sexual behavior disorder
Golder, S., Markert, C., Psarros, R., Discher, J. P., Walter, B., & Stark, R. M. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1248900 · Cited by 10
Cognitive risk, coping‐oriented substance use, and increased avoidance tendencies among depressed outpatients: A prospective investigation
Heggeness, L. F., Bean, C. A. L., Kalmbach, D. A., & Ciesla, J. A. (2020) · Journal of Clinical Psychology · doi:10.1002/jclp.22978 · Cited by 12
“In particular, depressed individuals tend to rely on passive or avoidance‐oriented coping strategies when faced with environmental stressors (Carvalho & Hopko, 2011; Grant et al., 2013; Holahan, Moos, Holahan, Brennan, & Schutte, 2005).”
Background
A Psychometric Evaluation of the Cognitive-Behavioral Avoidance Scale in Women with Major Depressive Disorder
Ottenbreit, N. D., Dobson, K. S., & Quigley, L. (2014) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-014-9416-3 · Cited by 10
Neural reward response to substance-free activity images in opiate use disorder patients with depressive symptoms
Yi, J. Y., Dichter, G. S., Reese, E. D., Bell, R. P., Bartuska, A. D., Stein, J. R., & Daughters, S. B. (2019) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2019.01.047 · Cited by 11
“Individuals with depression demonstrate decreased pleasure from rewarding stimuli and in turn, reduced engagement in values-congruent activities, the avoidance of which contributes to the maintenance of depressive symptomology (Carvalho and Hopko, 2011; Lewinsohn, 1974; Martell et al., 2001).”
Background
Aberrant reward learning, but not negative reinforcement learning, is related to depressive symptoms: an attentional perspective
Hertz‐Palmor, N., Rozenblit, D., Lavi, S., Zeltser, J., Kviatek, Y., & Lazarov, A. (2023) · Psychological Medicine · doi:10.1017/s0033291723002519 · Cited by 9
“While encouraging a specific behavior with rewards (i.e. positive reinforcement) is clearly relevant to anhedonia and depression (Carvalho & Hopko, 2011; Manos, Kanter, & Busch, 2010), the same behavior can be also strengthened by the removal of an aversive or negative stimulus for performing the…”
Psychometric Properties and Factor Structure of the French Version of the Behavioral Activation for Depression Scale (BADS) in Non-Clinical Adults
Krings, A., Bortolon, C., Yazbek, H., & Blairy, S. (2021) · Psychologica Belgica · doi:10.5334/pb.542 · Cited by 11
“Studies have revealed that a low level of RCPR in depressed patients is related to decreased involvement in pleasurable and reinforcing activities and a withdrawal from professional or social activities (Carvalho & Hopko, 2011; Hopko, Lejuez, Ruggiero, & Eifert, 2003).”
Background
Avoidance in Anxiety and Depression: Adaptation of the Cognitive-Behavioral Avoidance Scale in a Spanish Sample
Barajas, S., Palud, L. G., & Ros, L. (2017) · The Spanish Journal of Psychology · doi:10.1017/sjp.2017.16 · Cited by 9
“For example, Ottenbreit and Dobson (2004) found a correlation of .48, Moulds et al. (2007) of .62 and Carvalho and Hopko (2011) of .75 between Total-CBAS and BDI-II.”
BackgroundInfluential
Co-designing behavioural activation for depression for autistic adolescents: A case series
Mohamed, Z., Russell, A., Palmer, M. L., Simonoff, E. A., & Hollocks, M. J. (2024) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045241229583 · Cited by 9
“This predicts that reductions in engagement with activities that generate positive reinforcement results in a reduction is positive affect, lower motivation and ultimately in a depressed mood (Carvalho & Hopko., 2011).”
Background
Understanding the individual's transition from acute to chronic disabling pain: Opportunities for improved care
Linton, S. J., & Nicholas, M. K. (2025) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2025.101989 · Cited by 10
Therapeutic factors and mechanisms of change in music therapy for people with late-life depression: A scoping review
van Essen, K., Akse, M., Pelgrim, T. C., Prick, A.-E. J. C., & Aalbers, S. (2025) · The Arts in Psychotherapy · doi:10.1016/j.aip.2025.102289 · Cited by 9
Negative Bias or Positive Deficiency, or Both? The Relationship Between Individual Authenticity and Depression Among Preschool Teachers: The Sequential Mediation Effects of Mindfulness and Self-Alienation
Pan, B., Fan, S., Song, Z., & Li, Y. (2023) · Psychology Research and Behavior Management · doi:10.2147/prbm.s393191 · Cited by 9
“In behavioral theory, the reinforcement of an individual’s experience of the environment will be inhibited by changes in the external environment and avoidance behavior, resulting in the deepening of depression emotions.(51) When an individual’s level of mindfulness increases, he will maintain a more accepting attitud…”
Background
Health correlates of experiential and behavioral avoidance among trauma-exposed veterans
Schwartz, E. K. C., Palmisano, A. N., Petrakis, I. L., Pietrzak, R. H., & Sofuoglu, M. (2024) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2024.06.014 · Cited by 8
Punishment sensitivity and risk taking in depressed mood
Kim, D., Lam, J. C., Kutz, A. M., & Yoon, K. L. (2021) · Motivation and Emotion · doi:10.1007/s11031-020-09860-4 · Cited by 8
Dysfunctional Metacognitive Beliefs, Experiential Avoidance,and Behavioral Inhibition System in Depressive Disorder
Baykan, H., & Can, M. Ş. (2023) · ALPHA PSYCHIATRY · doi:10.5152/alphapsychiatry.2023.231144 · Cited by 7
“The median (minimum–maximum) AAQ-II scores were 9 (7-35) points in the control group and 30 (9-46) points in the depressed patients (P < .”
BackgroundInfluential
Anxiety Symptoms Predict Subsequent Depressive Symptoms in Neurodivergent Youth: A 10-Year Longitudinal Study
Orm, S., Wood, J. J., Fossum, I. N., Adams, K., Andersen, P. N., Fjermestad, K. W., Øie, M. G., & Skogli, E. W. (2025) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-025-01292-3 · Cited by 8
“In line with behavioral theory, avoidance behaviors may prevent youth from experiencing environmentally-mediated social and non-social positive reinforcement, which subsequently can lead to depressive symptoms (Carvalho & Hopko, 2011).”
Schematherapie für chronische Depressionen
Renner, F., Arntz, A. R., Leeuw, I., & Huibers, M. J. H. (2014) · Verhaltenstherapie · doi:10.1159/000365472 · Cited by 7
Acceptance of chronic pain in depressed patients with HIV: correlations with activity, functioning, and emotional distress
Moitra, E., Stein, M. D., Busch, A. M., Pinkston, M. M., Abrantes, A. M., Baker, J. V., Weisberg, R. B., Anderson, B. J., & Uebelacker, L. A. (2021) · AIDS Care · doi:10.1080/09540121.2021.1981819 · Cited by 8
“Avoidance of depressive symptoms might take similar forms, such as staying in bed or at home all day, which also can exacerbate symptoms over time due to the reinforcing effects of this coping approach (Carvalho & Hopko, 2011).”
Background
Síntomas de Depresión en Hombres
Pérez, C. E. L., Castro, W. P., & Rodríguez, M. G. (2017) · Universitas Psychologica · doi:10.11144/javeriana.upsy16-4.sdeh · Cited by 7
A computer-based avatar task designed to assess behavioral inhibition extends to behavioral avoidance but not cognitive avoidance
Allen, M. T. (2018) · PeerJ · doi:10.7717/peerj.5330 · Cited by 9
Major Depressive Disorder' Definition, Etiology and Epidemiology: A Review -
Çelik, F. H., & Hocaoğlu, Ç. (2016) · DergiPark (Istanbul University) · Cited by 7
Behavioral activation for depression delivered by drug and alcohol treatment workers: A pilot randomized controlled trial
Pott, S. L., Kellett, S., Green, S. A., Daughters, S. B., & Delgadillo, J. (2022) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2022.108769 · Cited by 7
Novel Perspectives on Adversity Exposure, Stress Responding, and Academic Retention Among First- and Continuing-Generation Students
Fletcher, A. C., Jensen, M. R., & Vrshek‐Schallhorn, S. (2022) · Emerging Adulthood · doi:10.1177/21676968221089087 · Cited by 18
“A number of studies have supported that both anxiety (Ottenbreit & Dobson, 2004) and depression (Carvalho & Hopko, 2011) are strongly correlated with behavioral avoidance, so strongly in fact, that reducing avoidance is seen as a key feature of many evidence-based cognitive behavioral interventions…”
Background
A translational approach to the functional analysis of language in psychotherapy
Ortega, J. V., & Parga, M. X. F. (2014) · International Journal of Clinical and Health Psychology · doi:10.1016/j.ijchp.2014.10.001 · Cited by 6
“This nterpretation is consistent with the mediating role of reinorcement on depression (e.g., Carvalho & Hopko, 2011).”
Result
Media Multitasking and Mental Health
Cheever, N. A., Peviani, K., & Rosen, L. D. (2018) · Technology and Adolescent Mental Health · doi:10.1007/978-3-319-69638-6_8 · Cited by 10
“It is today that counts, and today everything is fine”: coping strategies utilized by parents of children treated for cancer who seek psychological support - a qualitative study
Lundgren, J., Reuther, C., Farrand, P. A., Lutvica, N., Thiblin, E., von Essén, L., & Woodford, J. (2025) · BMC Psychology · doi:10.1186/s40359-025-02860-4 · Cited by 5
“The finding parents use avoidant coping strategies further supports the use of behavioral activation and worry management as techniques designed to reduce behavioral and experiential avoidance, which are maintaining factors in depression and GAD [80, 81].”
The Management of Cancer and Depression in People With Intellectual Disabilities
Carneiro, L. S. R. D. S. F., Ćwirynkało, K., Vaičekauskaitė, R., Doğan, S., Kowalczyk, O., & WELLS, J. S. G. (2023) · Advances in psychology, mental health, and behavioral studies (APMHBS) book series · doi:10.4018/978-1-6684-6040-5.ch002 · Cited by 5
The Role of Social Adjustment in a Collegiate Behavioral Activation Program
Felton, J. W., Triemstra, J. D., Reynolds, E. K., Hale, N., Magidson, J. F., & Lejuez, C. W. (2021) · Behavior Modification · doi:10.1177/01454455211047606 · Cited by 5
“Further, youth with lower levels of social adjustment may find it more difficult to seek out and engage in rewarding activities, increasing social withdrawal and contributing to the negative reinforcement cycle of depression (e.g., Carvalho & Hopko, 2011).”
Background
Lockdown in Chinese university dormitories: Significant increase in negative feelings and time perception distortion
Wang, J., Wang, C., Gu, X., & Sun, Y. (2022) · Psychology in the Schools · doi:10.1002/pits.22833 · Cited by 5
“According to behavioral theories of depression (Carvalho & Hopko, 2011), a reduction in pleasurable activities can increase depressive and anxious emotions (Fegert et al., 2020).”
Method
The contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in pediatric inflammatory bowel disease
Edwards, C. S., Baudino, M. N., Roberts, C. M., Basile, N. L., Dattilo, T. M., Gamwell, K. L., Jacobs, N. J., Edwards, D. S., Tung, J., Parker, C. V., et al. (2023) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1002/jpn3.12056 · Cited by 4

Authors: Carvalho, J. P., & Hopko, D. R.
Affiliations: University of Tennessee at Knoxville (US)
Venue: Journal of Behavior Therapy and Experimental Psychiatry
Publisher: Elsevier BV
Published: 2011-06
Volume: 42
Issue: 2
Pages: 154-162
ISSN: 0005-7916 (ISSN-L)
DOI: 10.1016/j.jbtep.2010.10.001
OpenAlex: W2159243388
Cited by: 176
References: 91
Citations by year: 2026: 10 · 2025: 15 · 2024: 14 · 2023: 15 · 2022: 17 · 2021: 13 · 2020: 15 · 2019: 8 · 2018: 5 · 2017: 13 · 2016: 9 · 2015: 9 · 2014: 14 · 2013: 8 · 2012: 7
FWCI: 7.49
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Journal of Behavior Therapy and Experimental Psychiatry (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords: depression, avoidance, reinforcement, environmental reward, mediation, cognitive avoidance, behavioral avoidance, gender differences, anxiety, daily diary
MeSH terms: Adolescent, Depressive Disorder, Female, Humans, Male, Surveys and Questionnaires, Reinforcement, Psychology, Young Adult

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Behavioral theory of depression: Reinforcement as a mediating variable between avoidance and depression

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