BEHAVIORAL ACTIVATION TREATMENT FOR DEPRESSION

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