SUDAK, DONNA M. MD; MAJEED, MUHAMMAD H. MD; YOUNGMAN, BRANDEN DO
Behavioral activation is a well-established, empirically validated treatment for depression. It may be employed regardless of theoretical orientation and is a powerful, efficient means to increase a patient’s ability to participate in activities that are enjoyable or meaningful to him or her. Research on the efficacy of behavioral activation has demonstrated its value as an intervention. This article reviews key elements of behavioral activation and illustrates it use in clinical practice using two fictional case vignettes.
Historical Development and Evidence for the Use of Behavioral Activation
The behavioral activation theory of depression was pioneered in 1973 by Ferster,1 whose theories were based on B.F. Skinner’s2 behavioral principles associating depression with the interruption of healthy behavior. Ferster hypothesized that avoidance, escape, and absence of positively reinforced behavior are the basis for depression. At the same time, also in 1973, Lewinsohn and Graf3 proposed a behavioral activation theory of depression that stipulated that a decrease in pleasant events and an increase in aversive events that a person experiences are associated with depression. In 1984, Lewinsohn et al.4 published “Coping with Depression,” a course based on the premise that a decrease in the frequency of positive reinforcement and an increased frequency of punishment were the basis of depression. This course emphasized the importance of reinforcement contingencies, such as scheduling of pleasant activities, social skills development, assertiveness, and time management training, as a treatment for depression.
Beck et al.’s seminal work, Cognitive Therapy of Depression,5 published in 1979, introduced behavioral activation strategies as a component of cognitive therapy for depression. According to Beck’s theory, “the ultimate aim of these techniques in cognitive therapy is to produce change in negative attitudes.”5
In 1984, Lewinsohn et al.4 described cognitive restructuring to enhance a patient’s ability to engage in fundamental behavioral activation strategies. The boundaries of pure behavioral and pure cognitive therapies became blurred and now overlap substantially. In 1990, “behavioral activation” was defined in the literature as “a group of clinical measures used in cognitive therapy for depression.”6
In 1996, behavioral activation was established as a stand-alone treatment, and the functional analytic framework of behavioral activation was introduced, establishing relationships among behavior, environment, and depression.7 Jacobson and Gortner8 demonstrated that cognitive changes may happen solely as a result of engaging in environment-based manipulation. Other studies9,10 established that significant alleviation of depressive symptoms usually occurs in the initial sessions of cognitive-behavioral therapy, a time when behavioral activation tools are most frequently used, bolstering the case for behavioral activation as a stand-alone treatment.
Empirical evidence supporting the behavioral activation model has expanded rapidly in the past decade. Between 2005 and 2010, the number of publications about behavioral activation doubled, reaching over 130 papers annually.11 A randomized placebo-controlled study of 241 adults with major depressive disorder demonstrated that, in severely depressed patients, behavioral activation was comparable to antidepressant medication and was more efficacious than cognitive therapy alone.12 A 2-year follow-up study of this patient group13 showed no statistically significant difference between the durability of response in behavioral activation and cognitive therapy; both therapies had superior durability compared with antidepressant medication. Coffman et al.14 showed that behavioral activation was effective in treating a subset of severely depressed, functionally impaired patients who were unresponsive to traditional cognitive therapy. In 2003, Hopko et al.15 demonstrated the efficacy of brief behavioral activation treatment for depression in an inpatient setting, which was superior compared with standard supportive treatment. Curran et al.16 recommended behavioral activation in inpatient settings for patients with chronic depression that was refractory to pharmacotherapy and cognitive therapy.
Contemporary evidence-based behavioral activation approaches to treat depression17 include the brief behavioral activation treatment for depression (BATD) developed by Lejuez et al.18–20 as well as the behavioral activation approach developed by Martell et al.17 In clinical practice, these approaches may be combined with cognitive restructuring to facilitate patient participation, with or without the formal use of thought records. For example, a patient who makes a negative prediction about an activity (e.g., “If I take a walk, I will just feel worse”) might be encouraged to test this prediction by trying the activity before accepting his or her conclusion as true.
Contemporary behavioral activation approaches expand behavioral activation to target rumination and avoidance and help patients identify and schedule valued as well as pleasurable activities. Acceptance and commitment therapy21 has influenced many contemporary behavioral activation approaches, so that values assessment may be included as a part of treatment, with activities scheduled that are meaningful and valued as well as pleasurable. Such procedures can expand the usefulness of the technique beyond acute depression and help patients engage in meaningful and important pursuits. Principles of behavioral activation can be useful in patients with problems with procrastination, for patients who have negative symptoms of psychosis, and for anyone who wants a framework to assist with task completion.
Multiple groups have developed and tested treatment modules in primary care for collaborative treatment of depression that incorporate behavioral activation approaches for major depression in adults, adolescents, and elderly persons.22–24 These studies demonstrate the beneficial effects of behavioral activation in combination with medication. Because a significant number of patients with depression are treated in primary care and the response to treatment in the primary care setting is often incomplete, successful implementation and dissemination of behavioral activation in primary care has the potential to have a substantial impact on public health. A pilot study of behavioral activation service delivery by mental health nurses in primary care showed significant improvements in patients’ scores on the Beck Depression Inventory and in quality-adjusted lifeyears. The treatment was also cost-effective.25 Given the significant differences in durability of behavioral activation relative to antidepressant medication, recovery could be extended if behavioral activation treatment were provided as an adjunct to routine medication management in psychiatric practice.
Behavioral activation can be a very effective adjunct to antidepressant medication in chronic depression to combat the social avoidance and occupational deficits that often substantially detract from patients’ quality of life. The behavioral activation model explains that avoidance occurs because of the normal tendency to avoid activities that are associated with painful or stressful stimuli. Patients who are chronically depressed thus develop life habits that are less socially oriented; withdrawal and lack of assertiveness may lead them to have impaired or unsatisfying relationships. Cumulative skill deficits and narrowed scope of activities further damage the patient.
Unemployment is more frequent in patients with chronic depression.26 Several authors have developed a form of behavioral activation that targets the social and occupational impairments associated with chronic depression.27 This variation of behavioral activation targets chronic maladaptive interpersonal coping styles that interfere with the development of satisfying relationships. It uses functional analysis to determine a patient’s persistent areas of avoidance and inactivity even in patients who have recovered. Patients are also encouraged to develop routines to manage activities of daily living and learn methods of combating rumination. Although this particular modification of behavioral activation needs further research, an important “take-home” principle from its use is the need to provide effective rehabilitation to patients with chronic depression as they begin to improve, and the value of behavioral activation as a means of increasing interpersonal contact and reinforcement in depressed patients.
Behavioral activation incorporates specific techniques to target and combat rumination, which some researchers consider a risk factor for future depression.28 Patients are taught to recognize rumination and to respond to it as a cue to take some form of action, such as problem solving or engaging in activities. This method does not employ tools to evaluate cognitive content; thoughts are identified as “verbal behavior” and the function of thinking and the consequences of rumination are delineated. Rumination is often less responsive to cognitive restructuring, so that this approach has particular value in patients who cannot disengage from ruminative thinking. A recent randomized controlled trial employed a manualized form of cognitive-behavioral therapy employing the functional-analytic and contextual principles and techniques of behavioral activation compared with treatment as usual to target rumination and avoidance in residual depression that was refractory to medication.29 Individuals who received the active treatment had significantly improved rates of remission (62% vs. 25% among those receiving treatment as usual).
Case Vignette: Behavioral Activation to Treat Chronic Depression
The patient is a 47-year-old woman in outpatient treatment for depression. Her depression began when she started college and was so severe that she withdrew and returned home. Since that time, the patient has had three psychiatric hospitalizations, all after suicide attempts via overdose. Her illness remains only partially responsive to treatment despite multiple different adequate antidepressant trials. Her current episode of depression started after the death of her sister 3 months ago and is characterized by the full complement of neurovegetative symptoms and suicidal ideation with no plan or intent.
She lives alone, has never married, and has no children. She is currently collecting disability income owing to her chronic depression and she spends most of her time at home alone. She sleeps at least 12 hours per night. Her only other activities are watching television and eating. She leaves the house only to go grocery shopping, despite the fact that her family lives in the area and would like more of a relationship with her.
Her new psychiatrist initially explains the ideas behind behavioral activation therapy and how the avoidance of certain enjoyable behaviors and activities could be contributing to her depression. The patient and the psychiatrist collaboratively create a baseline activity log to better assess how she spends her time. They then develop a list of activities that she is avoiding and discuss how changes in mood states can result from activity. One avoidance pattern they identify is her reluctance to engage in challenging tasks. She has avoided looking for a part-time job because she believes it would be too challenging. She identifies cognitive avoidance patterns that result in her avoiding active decision-making about her future; at the start of treatment, she had no shortor longterm goals in her life. She avoids social interaction and refuses invitations to family functions. The main distraction strategies she identifies are excessive sleeping and watching television.
In collaboration with the psychiatrist, the patient develops short-, medium-, and long-term goals addressing her areas of avoidance. Her short-term goals include visiting her family more often and finding volunteer work, and her long-term goals include participating in regular social activities and getting a part-time job. The patient and psychiatrist together employ activity scheduling to help her attain her goals. First she plans to have dinner with a family member once a week and to go to the local hospital to inquire about volunteer work. Together she and the psychiatrist organize a hierarchy of activities, arranged from the easiest to the most difficult. She begins to increase her social contacts, sending emails and telephoning family. Eventually she meets family and friends in social settings. Her mood gradually improves. Currently, she is working part time at a hospital as a receptionist and is regularly engaging in social activities with both her family and coworkers at the hospital.
Contemporary approaches to behavioral activation are far more sophisticated than identifying and assigning multiple pleasurable events. Patients are more likely to respond to treatment and engage in activities that are custom-tailored to them and that they find either important or meaningful. Patients who understand the rationale for treatments are more likely to participate and will be more capable of integrating the principles of treatment into day-to-day life now and in the future. This is a key principle of all cognitive-behavioral treatments. Therefore, when initiating behavioral activation, clinicians must explain to patients that the natural tendency in depression is to feel “shut down,” lacking energy, interest, and a sense of enjoyment. The key concept patients must learn is that, when we plan enjoyable or important activities and follow such a plan, we can recover from depression and also have a more meaningful life.
Case conceptualization in behavioral activation entails a specific assessment of the behaviors that the patient has stopped doing that either produce pleasure or are of importance, as well as behaviors that are essential to self-care or which would produce crises if neglected (e.g., bill paying). This assessment can be particularly difficult in patients with chronic depression, because such patients frequently cannot remember any pleasurable activities. Chronically depressed individuals may also lack predictable routines for self-care and need coaching and instruction as to why and how to develop these skills. Skills from cognitive- behavioral therapy that are vital to this process include empathy, validation, and Socratic questioning (i.e., “If you were feeling and functioning better, how would you spend your day? What would you be doing for enjoyment? What did you do before you became depressed that you are not doing now?”). Patients with severe anhedonia or loss of energy may think it is not possible that any activity will change the profound decrement in enjoyment that they are experiencing. Frequently, it helps to educate patients that they may need to be more active for a substantial period before they experience a shift in their sense of pleasure.
Activity monitoring provides treatment targets and leads to the case conceptualization in behavioral activation. Activity monitoring consists of using charts, forms, or other prompts to track the relationship between activities and other variables (e.g., mood, enjoyment). Creative, contemporaneous use of these tools leads to an activity hierarchy. Patients with depression have a limited ability to recall positive experiences when their mood is negative, so it is very important to avoid this bias by getting mood data on activities as they happen. Self-generated scales or benchmarks for achievement or pleasure can focus attention on such experiences, resulting in increased enjoyment. Functional magnetic resonance imaging studies in major depression suggest that improving responses to rewarding stimuli by engagement in behavioral activation may correct abnormalities in striatal brain regions.30
Scheduling activity is the most important procedure in each form of behavioral activation.31 A wide variety of tasks may be targeted depending on the patient formulation. The essence is to plan a stepwise approach to such activities in assignments of a manageable size. The psychiatrist and patient must make certain that assigned tasks are the right size and that they are important, concrete, and specific and they must build sufficient behavioral reminders into the plan. A thorough discussion of obstacles that could potentially interfere with planned activities is essential. A list of typical behavioral activation tasks is presented in Table 1.
An example of breaking activities into smaller steps is the task of doing laundry. The steps could include sorting clothes, getting quarters for the machine, buying detergent, bagging sorted clothes, taking a bag to the basement, starting the machine, putting clothes into the dryer, bringing dried clothes upstairs, folding clothes, and putting away clothes. Planning activities in this level of detail, with written action plans and troubleshooting obstacles, is critical for success. One common obstacle is the idea that the patient “doesn’t feel like” doing the activity. Validation of avoidance as a natural and common response when anticipating negative stimuli often enlists patient cooperation. Thereafter, the psychiatrist can make clear the tremendous long-term consequences of avoidance. Finally, planning rewards for activities is another strategy that may be fruitful, particularly when the planned activity is aversive. This works well with procrastination regarding tedious or difficult tasks (e.g., thesis writing, studying for the bar exam).
Behavioral activation helps patients with the social withdrawal common to depression. Improvement occurs both by encouraging patients to engage in interpersonal activities that are pleasurable and by remediating any social skills deficits. Patients overcome social isolation in a stepwise fashion. When social isolation is severe, one might start with activities that are not too threatening, such as sending emails or chatting online. Social activities are then gradually reintroduced, thus remediating the isolation and loneliness that are part of the core symptoms of major depressive disorder.
Even in brief office visits, it is possible to ask a patient to brainstorm about one or two activities that could improve her mood if she were to try them, identify a time for her to attempt them, troubleshoot obstacles, and implement reminders for this plan. This can “jump start” recovery prior to the onset of action of antidepressants when patients are receiving combined treatment, and it enhances well-being and the breadth of symptoms that improve. Effective engagement in behavioral activation early in medication management sessions may enhance the therapeutic alliance and thus improve adherence to antidepressant medication regimens. Although there are no treatment studies comparing the efficacy of behavioral activation combined with antidepressant medication versus either modality alone, data from combined treatment studies with CBT and antidepressant medication show a clear advantage for the combination.32,33 It is therefore likely that for the patient with depression, behavioral activation, CBT, and antidepressant management would be synergistic, or at least that the combination would not be less effective than if either treatment were provided alone. In addition, behavioral activation is clearly more durable than antidepressant medication,13 and it is easy to include behavioral activation in sessions involving antidepressant management, thus conveying multiple advantages to the patient. Psychiatrists can make it feasible to add this intervention in briefer sessions by having forms available to use and by planning treatment targets in advance. In patients with complicated or chronic conditions, or in patients who are being treated with behavioral activation alone, a formal list of activities is generated and then arranged according to a hierarchy of difficulty, which then becomes the roadmap for treatment. As patients engage in pleasurable and valued pursuits, more adaptive behavior is reinforced, increasing engagement in therapy.
Another illness that may benefit from the use of behavioral activation is schizophrenia. Negative symptoms may be addressed by employing a gentle functional analysis, and by planning activities after patient and therapist have formed a good therapeutic alliance. If patients with schizophrenia are found to be avoiding activities because positive symptoms have emerged, such symptoms can be addressed. Then patient and therapist can identify and plan alternative activities that are less stressful but provide more interesting and rewarding experiences for the patient.
The patient can also be encouraged to make realistic plans and therapy time may be structured to help him or her plan and execute meaningful pursuits.
Finally, the tools of behavioral activation are ideally suited to assist individuals who are struggling with procrastination or who wish to accomplish more positive, purposeful activities. Task completion is far easier when there is a plan to engage in a stepwise progression of activity, with behavioral rewards and a commitment to the task.
Case Vignette: Behavioral Activation to Treat Procrastination
The patient is a 42-year-old college chemistry professor who has recently been hired by a small community college. Although he was a successful student in college, his graduate and postgraduate careers have been significantly hampered by chronic difficulties with paperwork and task completion. He finished his master’s degree 18 months later than scheduled, both because he neglected to register for classes in a timely way, and because he could not complete his thesis on time.
The patient sought treatment after he was asked to leave a teaching position at a prestigious university, which he had held for 2 years. He was reprimanded several times for his lack of timeliness and attention to paperwork before he was dismissed.
The patient is dysphoric but does not meet criteria for other Axis I or Axis II disorders. He had never sought psychiatric treatment prior to his dismissal. On assessment, he describes having lifelong difficulties with organizing routine tasks and with postponing “mundane” activities in favor of things he believes are more interesting or important. He often schedules time to finish certain tasks, but then he becomes distracted by another “more pressing concern” (such as completing a scientific paper) or becomes demoralized by the amount of work that he faces.
The psychiatrist begins by asking the patient to keep an activity monitoring chart so that together they can determine how the patient spends his time. They quickly discover that the patient has extremely irregular sleep and eating habits and that, except for his classes, he does not have any method of keeping a predetermined regular schedule. The patient is willing to try to follow a schedule for 1 week, although he is concerned that he will find it “too confining.” He is quite surprised, however, by the sense of freedom he feels when a schedule permits him to know what to expect in the day ahead.
Next, the patient and his psychiatrist plan for the patient to list all the tasks he delays in a given week. The patient is again surprised to find how many items he postpones. His psychiatrist reviews with him how normal it is for people to want to avoid things that they anticipate will be unpleasant. Together they develop a list of reasons to pursue such tasks. The patient realizes that he would have a better life if he could more easily and quickly accomplish tasks such as bill paying, grading papers, completing student evaluations, and filing his income taxes. He also describes chronic lateness in responding to phone and email messages as a substantial drain on his social and professional relationships. Together the patient and psychiatrist arrange these tasks in a list from most to least difficult, and together they break each task into component parts. Bill paying, for example, becomes a multistep task: gathering all the unpaid bills, putting them in a file, adding new bills to the file daily, setting aside 2 hours on Saturday to pay the bills, setting up reminders with a calendar and phone alarm to pay the bills on Saturday, and, finally, rewarding himself with a new music download after the task is completed. Once this is accomplished and bill paying has become a routine part of the patient’s week, they tackle the next item on the hierarchy.
As this case example illustrates, the collaboration between patient and psychiatrist works to identify valued activities and proceeds to systematically assign these and resolve problems with targeted behavioral analysis and feedback.
Behavioral activation is a useful and empirically based method of treatment for depression. Activity monitoring and scheduling and targeting rumination and avoidance in the context of an empathic and validating relationship have the potential to improve patients’ lives. Psychiatrists can employ these techniques in a number of different contexts and improve care. Avoidance patterns are common to a wide variety of psychiatric disorders. Identifying and educating patients about avoidance patterns and then implementing behavioral activation therapy can produce meaningful and enduring change. Strategic use of this modality should be a part of the skill set of psychiatrists.
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