BEHAVIORALACTIVATIONTREATMENTFORDEPRESSION.docx

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

10

BEHAVIORAL ACTIVATION TREATMENT FOR DEPRESSION

Christopher R. Martell

Over the past 10 years there has been a resurgence of interest in behavioral treatments for depression

that were originally proposed in the early 1970s with the theoretical formulations of C. B. Ferster (1973,

1981) and the applied work of Peter Lewinsohn and colleagues (Lewinsohn, 1974; Lewinsohn, Biglan, &

Zeiss, 1976; Lewinsohn & Graf, 1973). The basic idea of the behavioral theory of depression was that

individuals become depressed when there is an imbalance of punishment to positive reinforcement in

their lives. According to Ferster (1981), when an individual responds primarily to deprivation and the

removal of an aversive, deprived state, he or she develops behaviors that function primarily as

avoidance behaviors and there is little access to positive reinforcement built into the behavioral

repertoire of the individual. Treatment for depression would, therefore, consist of a process that would

increase the individual's access to positive reinforcers.

Following the analysis of Ferster, Lewinsohn and colleagues focused on increasing pleasant events and

pleasurable activities in order to treat depression (Lewinsohn & Graf, 1973). These researchers

developed the use of activity logs and activity scheduling to help depressed patients increase positive

activities that would combat their lethargy and bring them into contact with positive reinforcers. During

this same time, cognitive therapy for depression was also being formulated (Beck, 1976) and utilized the

activity scheduling elements of Lewinsohn's approach but focused on changing the negative content of

depressed patients' beliefs. Cognitive therapy was studied extensively and empirically validated as a

treatment for depression, and the field of behavior therapy took on a distinctively cognitive profile

throughout much of the 1980s and 1990s. The idea of increasing pleasant events alone, without

cognitive interventions, was questioned (Hammen & Glass, 1975), and cognitive behavior therapy was

seen as a psychosocial treatment of choice for depression.

A recent meta-analysis (Ekers, Richards, & Gilbody, 2007) suggests that behavioral treatments are

efficacious for treating depression. A component analysis of cognitive therapy for depression (Jacobson

et al., 1996) demonstrated that depressed participants treated with behavioral activation alone

improved as well as those subjects treated with a full cognitive therapy treatment. Their results were

maintained at follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998). The results of the component

analysis study opened the door for a larger study of the treatment of depression, which compared

cognitive therapy, behavioral activation, paroxetine, and pill placebo (Dimidjian, Hollon, Dobson, et al.,

2006). For moderately to severely depressed clients, behavioral activation performed as well as

antidepressant medication and outperformed cognitive therapy in the acute treatment. Both behavioral

activation and cognitive therapy were efficacious in the prevention of relapse (Dobson, Hollon,

Dimidjian, et al., in press).

Behavioral activation is a structured, behavior analytic approach that borrows heavily from earlier

behavioral formulations of depression (Jacobson, Martell, & Dimidjian, 2001; Martell, Addis, & Jacobson,

2001). Through functional analyses, client behavior is understood according to its setting and

consequences rather than the particular form it takes. The emphasis is, indeed, on the function of a

behavior rather than the form and the treatment is not just about getting depressed clients to be more

active. For example, while chatting with a friend on the phone may formally appear to be a positive

behavior for a depressed individual, one must understand the contexts and consequences prior to

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

coming to such a conclusion. If chatting with the friend serves to keep the individual from working on a

project that is overdue, thus making her or him more depressed, it functions as avoidance and has

negative consequences. The treatment is theory driven rather than protocol driven with a focus on

targeting avoidance behavior as a primary treatment goal with depressed clients.

WHO MIGHT BENEFIT FROM THIS TECHNIQUE

Behavioral activation (BA) is currently a treatment for depression and has undergone evaluation in that

arena. A small pilot study has suggested that BA may be useful in the treatment of veterans with

posttraumatic stress disorder (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, et al., 2006). The BA

focus on avoidance places it in the realm of other exposure-based treatments that have been used for

the treatment of anxiety and other disorders. However, no data are yet available to demonstrate the

utility of the approach in these areas. Participants in Jacobson's lab met criteria for major depressive

disorder and were screened out only if there was presence of a thought disorder or active substance or

chemical dependence. No other comorbid disorders were excluded. Therefore, the participant pool on

which the treatment was tested had at least an Axis I major depressive disorder, but could have had

comorbid Axis I or Axis II disorders (other than psychosis or substance dependence).

CONTRAINDICATIONS OF THE TREATMENT

Understanding the possible contraindications of this treatment requires clinical hypothesis rather than

hard data. The treatment does not seem to be contraindicated for most people suffering from major

depression. Although it is a context-based, nonpharmachological treatment that encourages clients to

look outward at their life context rather than at hypothesized internal defects, it has even been used

with clients who maintain a need for psychotropic medication (implying a flaw in the machine). We

would caution clinicians, however, from using this technique with depressed individuals who may be

involved in a domestic violence situation, where activating may expose them to greater harm from an

abusive partner. Clinicians should be cautious not to encourage a client to engage in behavior that could

result in any such harmful interpersonal interaction.

OTHER DECISIONS IN DECIDING WHETHER TO USE BEHAVIORAL ACTIVATION

The data suggest that BA alone, without evaluation of the content of clients' thinking, works well in the

treatment of a major depressive episode. However, outside of the research setting, there is no

prohibition against using cognitive restructuring although recent investigations into methods for treating

client rumination (see, e.g., Watkins, Scott, Wingrove, Rimes, Bathurst, Steiner, et al., 2007) are more

consistent with the behavioral formulation. Some clients maintain strong beliefs that their thinking is

the problem. We would recommend that, rather than arguing with a client, therapists incorporate the

very behavioral aspects of BA with a cognitive conceptualization. The two treatments are

complementary and provide a bridge for some clients (and therapists). For example, the context and

consequences of clients' thinking (where and when it occurs, and what effect it has on how the client

feels and what he or she does next) can be incorporated into BA without focusing on the content.

HOW DOES THE TECHNIQUE WORK?

At this time, we can only make assumptions about the factors that make BA work. Primarily, the

therapist takes the role of a coach, encouraging clients to become active even when they feel as if they

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

cannot possibly complete tasks or get any pleasure from life. Because BA works to help clients establish

a regular routine, it breaks the destructive process of routine disruption that often accompanies

depression (Ehlers, Frank, & Kupfer, 1988). Activity in BA means getting engaged rather than just doing

something for the sake of being busy or living under a Calvinist work ethic.

STEP-BY-STEP PROCEDURES

The treatment is based on the theory, described earlier, that depression often results from changes in a

vulnerable individual's life that decrease the person's access to positive reinforcement. Basically, the

treatment consists of strategies that increase activity and block avoidance so that the client can come in

contact with natural reinforcers in his or her environment. In order to do this in a manner that is

idiographic and not merely applying broad classes of pleasant activities that may or may not actually be

reinforcing, the therapist needs to do a good functional analysis.

Conducting a Functional Analysis

Whereas the laboratory provides much control over conditions that can lead to accurate understanding

of contingencies at work in the behavior of organisms under study, the clinical setting does not provide

the same level of control. When we speak of functional analysis we are speaking of the best hypotheses

that the therapist and client can develop about the antecedents, behaviors, and consequences that form

elements of the client's repertoire contributing to depression. In BA we are interested in the function of

the behavior and not the form of the behavior. Therefore, we are less concerned with what popular

opinion may be about a certain behavior (e.g., people may think that going for a run early in the

morning is a good and healthy thing to do) that with the function of a particular behavior for particular

person (e.g., the runner may actually be out early in the morning because she does not want to remain

at home to have a discussion with her partner about having neglected to pay an expensive bill).

Functional analysis is the heart of BA, and it will be conducted throughout the treatment. The first step,

however, is to develop general case conceptualization from a behavior analytic perspective.

There are several questions that the therapist needs to ask about the depressive episode that the client

is experiencing. First, the therapist should understand the client's history and gather information about

significant life events, positive or negative, that influence the client's current life context. To do this, the

therapist simply need ask the client to recount such events, with questions like "What is your family

like? What kinds of things have been good in your life? What has hurt you or has been distressing?" It is

also important, second, to understand how the client behavior during a depressive episode is different

from his behavior at other times. Asking the client "What is your life like when you are not depressed?

Are there things that you are not doing now that you typically do when you are not de pressed? What

do you hope to accomplish in you life? Are you taking steps toward accomplishing, these things?" can

help to gather a picture of what problems the client may be experiencing.

Gathering this information helps the therapist to develop a case conceptualization of the client's

depression. We express the case conceptualization in terms of the life events that may have contributed

to the depression by making the client's life less rewarding, and we then look at how the client has tried

to cope with the symptoms of depression. Often the client's attempts at coping become problems in

themselves, and we refer to these as secondary problem behaviors. For example, the runner mentioned

earlier might be coping with feelings of hopelessness and inadequacy by engaging in a fervent exercise

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

program the enables her to avoid dealing with issues with her significant other. We would call her

exercise regime a secondary problem. Even though we know exercise is good for depressed people in

general, with this particular client we would want to help her to address her issues with her partner and

then institute exercise that is not avoidance.

Day-by-Day Analysis

Since its earliest conception by Lewinsohn and others, BA has made ample use of activity charts to help

therapists understand the level of a client's activity and to schedule pleasant events. We continue to rely

heavily on activity charts in our work. We use activity charts for several reasons. The therapist can use

an activity chart to understand the following:

• The client's current level of activity

• Restriction of the client's affect

• Connections between the client's activity and mood

• Mastery and pleasure ratings

• How to help the client monitor avoidance behaviors

• Guided activity

• Steps the client is taking toward stated life goals

It does not matter what type of activity chart a therapist chooses to use with his or her clients. All that is

important is that the chart include all the hours in the day and provide room enough for the client to

record what he or she did and felt, and the intensity of the feeling, in each hour block.

Techniques for Dealing with Client Avoidance

We find it most important that clients continually be vigilant of their avoidance behaviors. It is also a

basic tenet in BA that clients can choose to engage in activities that will possibly help them to feel

better, or they can choose to continue to avoid and possibly remain depressed. Although we never tell

clients that they are choosing to be depressed, we do indeed suggest to clients that choices made about

specific behaviors can lead to certain consequences.

While not required in the treatment, three acronyms illustrate the concept of avoidance to clients and

help them to be aware of their patterns and to modify behaviors. Using these acronyms simplifies the

explanation of complex ideas. The first is the acronym ACTION, which stands for the following:

Assess my behavior: Is my current behavior avoidant? How does this behavior serve me?

Choose whether to activate myself and engage in behaviors that could help my depression in the long

run, or to continue to avoid this experience.

Try the behavior that I've chosen.

Integrate any new activity into a regular routine, remembering that trying a new behavior only once is

unlikely to lead to significant change.

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

Observe the outcome of the behavior: Does it affect mood, or does it improve a life situation?

Never give up. Counteracting depression and avoidance takes continued work and tenacity in the face of

frequent disappointments.

The second acronym we use is TRAP, which stands for trigger, or some happening or event; response,

usually the client's emotional response to the trigger; and avoidance pattern, which is the typical

avoidance response to the trigger. Once the client has identified a TRAP, we use the third acronym to

help him or her get back on TRAC (trigger, response, alternative coping). The strategies of using activity

charts and helping clients to recognize avoidance patterns and modify their behavior make up the bulk

of BA treatment.

Conceptualized as a contextual treatment, BA focuses on helping clients to change behavior in such a

way as to bring them into contact with positive reinforcers in their natural environment. There is much

less emphasis on skills training than in other behavioral therapies. The model in BA is that therapists

may conduct skills training, but they are not required to. Whether to conduct skills training such as

problem-solving training will depend on the behavioral analysis of each client. In clinical outcome trials

of BA, therapists have used problem-solving training or assertiveness training, but they have done so in

a fashion that anchors the training in the context of the client's life. In other words, even in skills

training, the BA therapist tries not to teach a broad class of skills that can be applied by following rules;

rather, the therapist debriefs specific incidents in the client's life and helps the client understand how he

or she might have changed an outcome by behaving differently. In some cases the client may be

planning a particular encounter, and the therapist would discuss options for achieving particular

outcomes.

FINAL CONSIDERATIONS

The therapeutic stance in BA is always collaborative. The therapist serves as a coach for the client. When

the therapist is trying to help a client develop a new skill, the therapist takes the position that his or her

suggestions are hypotheses to be tested rather than prescriptions from an authority figure. Behavioral

activation therapists are working within a model that is quite different from a medical model. Clients are

seen as individuals whose lives have somehow gone awry rather than as patients with some defect or

flaw that must be modified. The therapist works to help the client understand the areas of his or her life

that are not working and to make adjustments in behavior to enhance the workable aspects of life.

In the treatment outcome studies conducted on BA to date from Jacobson's laboratory, the therapy has

consisted of a 16-week protocol, with clients allowed up to 24 therapy sessions. Many clients begin to

show improvement in depression scores within the first 10 sessions. However, there are no clear data to

suggest an optimal length of treatment. Researchers in a different setting, conducting BA that primarily

focused on activity scheduling, had successful results with a 10-session protocol (Lejuez, Hopko, LePage,

Hopko, & McNeil, 2001). This would suggest that the treatment may be successful over a shorter time

period.

Further Reading

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression:

Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255-270.

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

New York: W. W. Norton.

References

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: New American Library.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006).

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute

treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658-670.

Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling, K. B., Kohlenberg, R. J., Gallop, R., et al. (in press).

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the

prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology.

Ekers, D., Richards, D., & Gilbody, S. (2007, October). A meta-analysis of randomized trials of behavioural

treatment of depression. Psychological Medicine, 1(13) (forthcoming article, e-publication at

http://journals.cambridge.org).

Ferster, C. B. (1973). A functional analysis of depression. American Psychologist, 28, 857-870.

Ferster, C. B. (1981). A functional analysis of behavior therapy. In L. P. Rehm (Ed.), Behavior therapy for

depression: Present status and future directions (pp. 181-196). New York: Academic Press.

Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral treatment for

depression: Relapse prevention. Journal of Consulting and Clinical Psychology, 66(2), 377-384.

Hammen, C. L., & Glass, D. R. (1975). Depression, activity, and evaluation of reinforcement. Journal of

Abnormal Psychology, 54(6), 718-721.

Jacobson, N. S., Dobson, K., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A

component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical

Psychology, 64(2), 295-304.

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression:

Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255-270.

Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P., Michael, S., Reed, R., et al. (2006). A pilot study of

behavioral activation for veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 19,

387-391.

Lejuez, C. W., Hopko, D. R., LePage, J. P., Hopko, S. D., & McNeil, D. W. (2001). A brief behavioral

activation treatment for depression. Cognitive and Behavioral Practice, 8, 164-175.

From O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive

behavior therapy. Wiley.

Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. M. Friedman & M. M. Katz (Eds.),

The psychology of depression: Contemporary theory and research (pp. 157-185). New York: John Wiley &

Sons.

Lewinsohn, P. M., Biglan, A., & Zeiss, A. S. (1976). Behavioral treatment of depression. In P. O. Davidson

(Ed.), The behavioral management of anxiety, depression and pain (pp. 91-146). New York:

Brunner/Mazel.

Lewinsohn, P. M., & Graf, M. (1973). Pleasant activities and depression. Journal of Consulting and

Clinical Psychology, 41, 261-268.

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

New York: W. W. Norton.

Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., et al. (2007). Rumination-focused

cognitive behaviour therapy for residual depression: A case series. Behavior Research and Therapy, 45,

2144-2154.