What is behavioural activation?

This article discusses the theory and rationale behind behavioural activation (a therapy for depression), as well as its evidence base and how to develop a formula that guides the strategy.

In 1973, Ferster developed a model of depression, which was based on the classic learning theory. In this model it is stated that, when people become depressed, many of their daily activities function as avoidance and escape from aversive thoughts, feelings, or situations. Examples of avoidance behaviour of depressed people are:

• Social withdrawal: not answering the phone, avoiding friends.
• Non-social avoidance: not taking on challenging tasks, sitting around the house, spending a lot of time in bed.
• Cognitive avoidance: not thinking about relationship problems, not taking opportunities, not being serious about work or education.
• Avoidance by distraction: gambling, comfort-eating, excessive exercise, watching rubbish on television, playing computer games all day.
• Emotional avoidance: substance abuse.

Behavioural activation is a formal therapy for depression which was introduced by Martell and colleagues in 2001. In behavioural therapy, the focus is on using avoided activities as a guide for activity scheduling. This is done to encourage patients to approach activities that they are usually avoiding. In addition, a contextual functional analysis is performed: a way of identifying antecedents and consequences of a response, used to determine the factors that cause to maintain the depressed mood. In the simpler version, described by Hopko and colleagues (2003), only the activity scheduling is done, thus leaving out the functional analysis. Behavioural activiation, thus, enables patients to refocus their goals and valued directions in life.

What is the structure of behavioural activation therapy?

Generally, the therapy consists of between 12 and 24 sessions. In the first sessions, the rationale behind the therapy is explained to the patient. It is emphasized that depression is regarded as a consequence of avoidance or escape from aversive thought, feelings, or situations, and that this is an entirely understable and natural process. In the next sessions, patients are taught how to analyse the unintended consequences of their way of responding. Their ineffective ways of coping and the consequences thereof are illustrated in consequative circles. Sometimes, an activity log may be kept to determine the individual's pattern of responding and its association with mood changes. Next, all patients should have clearly defined goals in the short, medium, and long term, which are related to their avoidance and escaping behaviour. These goals are then integrated into the activity scheduling and regularly monitored.

The most frequently encountered obstable to implementing behavioural activation concerns the individual's belieds about avoidance. Often, people them themselves that they will engage in a certain activity because they are motivated to do so or they "feel like it". The solution here is that people should always act according to the plan or activity schedule – not according to how they feel at the time. This is something that should be stressed explicitly by the therapist.

In addition to activity scheduling, the therapy usually consists of a contextual function analysis. This analysis is structured according to the ABCDE format.

• A: antecedents or contexts
  • In what situations in the past have you thought that you were worthless?
• B: behaviour and cognitive processes in response
  • What do you do next when you think you are worthless?
  • Does your way of responding include a pattern of avoidance (e.g. staying home, not answering the phone, going to bed and ruminating?
• C: consequences
  • What immediate effect does this activity have?
  • Does it make you feel more comfortable?
  • Does it stop you feeling or thinking something painful?
• D: directions
  • What alternative activities could you choose that are in line with your goals and valued life directions?
• E: effect
  • What effect did the following your goal or valued direction in life have?

In addition to behavioural activation, several complementary approaches are beneficial: exercise and healthy eating, problem-solving therapy (PST), sleep management, counseling, family or couple therapy, compassionate mind training (CMT), mindfulness training, acceptance and commitment therapy (ACT). All of these can be integrated into behavioural activation.

What are the main advantages of behavioural activation over cognitive behavioural therapy?

When comparing behavioural activation to the traditional cognitive behavioural therapy (CBT), two main advantages are: (1) it may be easier to train staff in it, and; (2) it can be used in both in-patient and out-patient clinical settings.