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Dr. Lynn R. Mollick and Dr. Milton C. Spett - founders of leaders of the New Jersey Associaton of Cognitive Behavior Therapists

Behavioral Activation for Depression

By Lynn Mollick

Part 1 - Behavioral Activation Concepts

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:

  1. Feeling deprived, which occurs when the environment offers few rewards or when a great deal of effort is required for very little reward;
  2. A limited repertoire of effective behavior, which develops when rewards are inconsistent (non-contingent), and an individual either doesn't learn effective behavior or doesn't believe effective behavior will be rewarded; and
  3. Escape and avoidance – behavior such as lying in bed or ruminating causes individuals to escape or avoid potentially rewarding, but initially unpleasant experiences, such as meeting new people or trying new activities.

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.

Part 2 - Behavioral Activation Therapy

Hoping that you are now intrigued, let me describe BA in practice. Several general concepts direct the therapist:

  1. Encourage patients to be active regardless of how they feel. BA therapists call this "working from the outside in."
  2. Encourage patients to increase activities that lead to experiences of mastery and pleasure. These activities will produce natural reinforcement.
  3. Address escape and avoidance. Symptoms of depression function as escape and avoidance of activities that are unpleasant in the short run, but potentially rewarding in the long run. For example, procrastination avoids feelings of failure when learning a new skill. Procrastinations avoids feelings of rejection when applying for a new job. Distracting oneself from memories of a loved one's death avoids sadness and tears in the short run, but impedes the normal grief process. Ruminating instead of being engaged in life is an escape from potentially rewarding relationships and activities.
  4. Think about the consequences of a behavior, thought, or emotion. BA therapists do not address the content of a patient's rumination. Instead, BA therapists address the function of rumination, when and where it occurs, and what precedes and follows it. Rumination usually causes depression to worsen. Rumination does not result in feelings of pleasure or mastery, therefore rumination should be replaced with another activity that does lead to positive consequences. When this is difficult, being mindful or attending to experience is a helpful alternative to rumination
  5. Always be specific and concrete. When patients articulate a goal, find out how, when, and under what conditions they want to achieve it.

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.

The BA Therapist Evaluates the Consequences
of Cognitions, Behaviors, and Emotions,
and Ignores the Content of Cognitions.

In BA patients learn two acronyms that facilitate their treatment:

  1. TRAP – Trigger, Response, Avoidance Pattern (a catchy variant of the ABCs that highlights the central, defeating role of avoidance); and
  2. ACTION – Assess how the behavior serves you, Choose to activate, Try out a different behavior, Integrate the new behavior into routines, Observe the outcome, and Never give up. This is a good summary of BA philosophy. Behavioral techniques that facilitate activation include:
    1. Graded assignments – starting with the least stressful task, or breaking up a large task into smaller components.
    2. Verbal and imaginal rehearsal that includes specific details of the task to be performed, the steps required to perform it, and the setting in which it will occur.
    3. Modeling by the therapist and role-playing by the patient.
    4. Acting toward the goal is behaving in a way that is designed to achieve a stated goal, or behaving in accordance with how patients would like to be perceived by themselves and others.

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.

Part 3 - Modifications to Behavioral Activation

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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