Behavioral Activation Treatment for Depression: Returning to Contextual Roots

Jacobson, N., Martell, C., & Dimidjian, S. (2001). Behavioral Activation Treatment for Depression: Returning to Contextual Roots.Clinical Psychology: Science And Practice, 8(3), 255-270.

In 1990, an experiment by Jackson et al. was done to determine the extent to which the behavioural activation (BA) component of cognitive therapy (CT) could account for the benefits of CT in depressed patients. The results were consistent with activation theory, and long-term follow-up results suggested that BA was as effective at preventing relapse as CT. This article provides an overview of the current BA model and its underlying principles.

A Brief History of Behavioural Activation

Study results indicated that the BA component of Ct was just as effective as the entire CT process, which led researchers to investigate the topic further. The previously accepted cognitive theory of depression required clients to confront and modify negative core schemas in order to effect change in depression was under question, as it appeared that BA was not only necessary, but may also be sufficient.

This led scientists to go back and study the literature on depression. Based on the principles of Skinner, Ferster proposed a completely behavioural model of depression, placing an emphasis on a functional analysis of behaviour in the understanding of depression. Additionally, he highlighted the importance of increased avoidance and escape behaviours and decreased positively reinforced behaviours in depressed people. Lewinsohn, on the other hand, proposed a behavioural model in which depression comes form an increase in aversive events or a decrease in pleasurable events. In this model, depression was assumed to be causally related to an increase in punishment or a decrease in reward.

These models did not lead to purely behavioural treatments. Over time, cognitive aspects were added into the treatment regime, including cognitive resrtucturing interventions in combination with relaxation therapy. Behavioural treatments were viewed as components of cognitive treatments, with the aim of modifying cognitive structures, and behavioural therapy had strayed from it's original intended roots.

While CT had been shown to be effective in the treatment of depression in laboratory studies, many researchers in the field were still skeptical and wanted to look at the therapy in more detail. This led to the development of BA as a treatment in its own right.

Behavioural Activation and the Demedicalisation of Depression

The BA model for the treatment of depression is unlike other conventional models, as it places a significant importance on context and individual, internal dysfunction. These individual defect models are representations of the science of our times, and include biological, genetic, and cognitive defects. Individual illness models focus on pathology within the organism, whereas a functional models look outside of the organism to establish relations between behavior and environment. However, it is important to note that functional models do not exclude genetic or biological components of depression. While many studies have investigated the relationship between neurotransmitter imbalance and depression, studies remain inconclusive about the specific biological dysfunction that may account for the success of treatments, as well anything related to causation on this topic.

The BA model, similarly, does not discount biological or genetic factors related to depression, but suggests that an emphasis placed solely or largely on biology ignores many important factors of consideration, such as contextual factors. This is evident in the doubling of the incidence of depression since the Second World War, which cannot be explained by biology and genetics alone, as well as the existence of various sub-types of depression, where genetics plays a greater role in some, but not others.

Looking at the demographics on depression, it is clear that contextual external factors are an important part of the pathology of depression. Traumatic life events, life stressors, and whether or not one is married all play a role in an individual's relationship to depression, concluding that depression cannot be explained by purely biological factors. Common treatments often include the use of anti-depressants, which come with their own set of side-effects and may not be the best method of treatment for depression.

The Basics of Behavioural Activation

BA begins with the assumption that triggers for depression are more often found in the lives or environment of the sufferer, rather than within the sufferer himself. Thus, BA is based fundamentally on a distinctly behavioural model of depression, one where external factors play a causal role in depression. BA looks at events in an individual's life and his or her responses to those events once the individual has become depressed. Depressed individuals often express avoidance behaviours, as they try to cope with unconditioned responses to events in their lives. Inactivity, withdrawal, and inertia are also common symptoms of depression. BA takes these symptoms and pays attention to the role of these behaviours in the context of an individual's life.

For example, avoidance behaviours, such as staying in bed due to lethargy, prevents people with depression from the potential of coming into contact with anti-depressive situations and behaviours. The results of this avoidant behaviour are often secondary behaviours, such as not showing up to work on time. BA works to counter both primary and secondary behaviours, by working toward guided activities to increase the probability of clients contacting positive reinforcements in their lives.

Closely related to avoidance patterns are routine disruptions, which have also been shown to have a negative impact on people with depression. The concept of social zeitgebers, refers to indicators in our lives that regulate our biological rhythms. Zeitstörers, on the other hand, are time disruptors, things that disrupt this routine. This concept may be highly relevant in the treatment of depression, as our bodies eventually become dependent on these routines. Disruption of these routines can cause us to be out of sync with our environments, and can negatively contribute to already existing depression within an individual. One important part of BA is returning to, or redefining these routines.

Course of Treatment

Within one general structure, BA has several components, as outline below:

Establishing a therapeutic relation between client and therapist and presenting the model

In the first session of therapy, the treatment model is presented to the client, both in discussion and in a written letter. The client is then encouraged to express any concerns about the model or as any questions. While this model presentation occurs early in treatment, it is often the case that the presentation of the model must be repeated in subsequent sessions.

The presentation of the model includes explanations of the relationship between mood, activity, and environment, as well as the vicious cycle of depressed mood, decreased activity level, and subsequent consequences, outlined previously in this paper. In part of this explanation, it is important for the client to understand that increased activation is a way to break out of this cycle, and that theraoeutic goals must be goal-directed, rather than mood-directed. That is, one of the goals of introducing the BA model is to dispel the myth that changes must first happen in mood in order for behavioural changes to occur.

Another emphasis of BA is the importance of focused activation, that is, simply increasing activity at random is not an effective course of treatment for depression. Instead, BA encourages clients to increase behaviours that are positively reinforcing, activities that are likely to disrupt the spiral of depression. BA must, thus, be tailored to each individual client's life in order to be effective.

Conveying optimism is also important in the presentation of the BA model. By conveying a sense of understanding for the difficulties caused my depression, such as a lack of energy and motivation, therapists can establish a sense of empathy, and at the same time, allow the client to see that waiting for his or her mood to change will likely result in being trapped in a depressive spiral.

Finally, the role of the therapist is explained to the client. In BA, it is emphasised that the therapist serves as a coach or trainer, someone who works collaboratively with clients to solve the client's problems, rather than the therapist just prescribing tools for the client to use, or the client figuring it out on his or her own.

Developing treatment goals

As mentioned above, BA therapy should be a collaboration between therapist and client. After the model has been presented to the client, therapist and client work together to identify secondary problem behaviours (such as avoidance patterns,) as well as larger life issues that may contribute to the client's depression. This information is then used to form both short term and long term goals.

Clients often have non-specific goals, such as "feeling better' or "being more social." It is the therapist's job to guide the client towards focused, specific, and operational goals that are more achievable and measurable than these initial vague goals.

They also often have difficult distinguishing between long- and short term goals. A long-term goal can be defined as a goal that cannot be attained through immediate action, and that requires progressive steps to achieve. Within a 16-week treatment period, it is only possible to focus on one or two long term goals. Most of BA focuses on helping clients increase their activation with short-term goals by detailing the steps required i order to reach these goals and acting as a coach or mentor to the client as they follow these steps.

Conducting a functional analysis of daily events

In conducting a functional analysis of the client's behaviours, BA focuses on the specific triggers for depression and the client's responses to those triggers. It is important to not environmental influences and past learning histories characterised by low levels of positive reinforcement and/or aversive control. In general, the functional analysis seeks to answer five questions:

• What triggered the depression?

• What particular depressive symptoms does the client experience?

• What is the client's coping response to depression?

• To what extent do avoidance patterns exacerbate the depression?

• What routines are disrupted?

This functional analysis guides the course of treatment and teaches clients how to conduct functional analyses on themselves.

Treatment review and relapse prevention

After some time spent in therapy, clients will have learned how to determine environmental factors that influence their depression. In order to remain an effective course of treatment, it is important that the original goals formed are reviewed. In the final session of therapy, therapists sit with the clients, assess the progress made over the therapeutic period, and formulate a relapse prevention/response plan with the client.

Activation Strategies in a Typical BA Regimen

Simply encouraging clients to be more active will not work as a form of therapy. In BA, clients sit with therapists t o identify which activities would be helpful to the client in increasing positive reinforcement. The client and therapists try out several activities in a "trial an error" manner, and if an activity appears to help improve the client's mood, the client is encouraged to do more of that activity.

Activity logs monitoring the activity performed, the time spent on that activity, and the client's mood/observations during that activity are often used in BA. When activities appear to have an impact on mood, therapists discuss why that may be, allowing the client to delve deeper into what kinds of solutions may help in their depression.

Assignments usually follow a gradient of difficulty, beginning with easy tasks, such as keeping an activity log, and moving on to more complicated goals, such as joining a social group.

Avoidance Modification

As mentioned above, people with depression often get stuck in avoidance patterns in order to alleviate their immediate discomfort. This usually falls under the TRAP model: a trigger, such as demands at work, illicit a response, such as a depressed mood or a sense of helplessness, which in turn, causes an avoidance pattern, such as staying at home. In encouraging a client to break the avoidance pattern, the client is encouraged to replace avoidance patterns with alternate coping mechanisms, such as using graded tasks to improved the situation.

Routine Regulation

Many clients resist the notion that disruptions in routines make depression worse. Clients are encouraged to take an experimental approach to determining a set routine and schedule. This often involves the use of activity logs, previously mentioned in this article.

Attention to Experience

For many clients with depression, a great deal of time and energy is spent on focusing on the misery in his or her life. In BA, this behaviour is addressed, however it is addressed in a manner that continues to focus on activating the client. Instead of using cognitive interventions to challenge the client's beliefs, BA focuses on developing interventions that block ruminative behaviours and maximise exposure to naturally-occurring positive environmental reinforcement.

Overcoming Obstacles in Treatment

Depressed clients are often passive and may experience difficulties in taking action on goals developed in therapy. In such cases, the therapist must work with the client to get over the hump. One fundamental step is to ensure that the client agrees with the model of treatment. If the client does not agree, it is very unlikely that BA therapy will be effective, as the client must take in active role in his or her therapy. The strategies mentioned above, using activity logs, and graded tasks can encourage a client to be an active contributor to his or her treatment.