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Behavioral Activation for Depression
By Lynn Mollick
Behavioral Activation (BA) is a lot more than getting depressed patients busy doing things. BA is radical behaviorism — an empirically-supported, third wave treatment. It attributes depressed behavior — e.g. crying, ruminating, lying in bed, feeling pessimistic or ill — to individuals' interaction with their environment, or "context."" It does not view depression as a chemical imbalance or as a dysfunction of thinking or relationships.
This chart illustrates the BA view of how depression develops. The process begins with negative life events — a failure, a change, or the loss of a significant relationship. Negative life events result in fewer opportunities to experience mastery or pleasure (reinforcement.) Without reinforcement, previously reinforced "normal" behavior decreases, and inactivity, depressed emotions, and depressed cognitions increase. These depressed behaviors, emotions, and cognitions lead to additional negative life events, still fewer experiences of mastery and pleasure, and further behavioral inactivity and depressed emotions and cognitions.
According to BA, three person-environment experiences predispose an individual to depression:
Clinicians should identify these three processes in the patient's life history and explain these processes and the chart below to patients. This demonstrates understanding of the patient's problem, increases patient motivation for BA, and helps to develop a good therapeutic relationship.
The BA therapist's job is to help the patient develop a new repertoire of behavior that is naturally reinforced by experiences of mastery and pleasure. In BA, this means helping patients achieve their most treasured life goals.
Are you surprised to discover that a hard-nosed, almost mechanical approach like BA is so explicitly idealistic? I was. But whether you are surprised or not, BA is much more than a quick-fix, get-busy-for-the-sake-of-being-busy gimmick.
Hoping that you are now intrigued, let me describe BA in practice. Several general concepts direct the therapist:
BA's flagship technique is the Activity Chart. For every hour of every day, patients should record: what they were doing, who they were doing it with, what they were feeling, and the intensity of the feeling (1-10). Therapists usually need to shape patients to complete the Activity Chart.
The Activity Chart helps patients understand the relationships among situations, activities, behaviors, and mood. The Activity Chart teaches patients to do their ABCs, to observe the antecedents, behaviors, and consequences of their own behavior.
of Cognitions, Behaviors, and Emotions,
and Ignores the Content of Cognitions.
In BA patients learn two acronyms that facilitate their treatment:
In spite of emphasizing action, the BA therapist is empathic with the difficulty of changing entrenched behavior patterns. BA explicitly offers patients the option not to activate.
When patients are seriously depressed or suicidal, and immediate relief is required, the BA therapist may suggest escape and avoidance strategies such as: distraction from unpleasant experiences, limited contact with unpleasant people, and "behavior stopping" (like "thought stopping" — snapping a rubber band on the wrist or yelling "stop.") Since these techniques are avoidances that are inconsistent with core BA principles, they should be used sparingly.
Martell & Addis (Depression in Context, 2001, New York: W. W. Norton) recognize that BA sometimes leads to other forms of therapy such as problem-solving therapy or couple therapy. They also accept that in clinical practice, but not research, BA therapists may make cognitive interventions if they seem warranted.
Martell & Addis provide many clinical vignettes that illustrate how to do BA. I very much enjoyed reading the patient's side of the therapy transcripts and trying to figure out how the BA therapist would respond. It was a challenge to set aside my cognitive ways. Depression in Context reminded me of radical behaviorism's elegance and power. I recommend this book highly.
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