Behavioral Activation for Depression

  BA treatment for depression was developed by Neil Jacobson and colleagues (N. S. Jacobson, Martell, & Dimidjian, 2001; Martell, Addis, & Jacobson, 2001), although other BA protocols have also been developed (e.g., Lejuez, Hopko, & Hopko, 2001). An early dismantling study revealed that BA alone had comparable efficacy to cognitive therapy, which included both BA techniques and cognitive restructuring (N. S. Jacobson et al., 1996). Building on these findings, N. S. Jacobson and colleagues developed BA as a treatment in its own right, aimed at helping depressed individuals increase their contact with positive reinforcers and decrease patterns of avoidance and inactivity. In a randomized controlled trial, Dimidjian et al. (2006) found that BA was comparable with medication and cognitive therapy in the treatment of all levels of depression, with evidence for enhanced efficacy compared with cognitive therapy in the treatment of severe depression.

The conceptual model for BA is based on Ferster’s (1973) radical behavioral model of depression. Factors external to the individual (i.e., environmental factors) are seen as potential causal and maintaining factors for depression, and intervention is aimed at these factors. Consistent with other behavioral models of depression, N. S. Jacobson et al. (2001) noted that the inactivity characteristic of depressed individuals leads to decreased contact with potential positive reinforcers, thus reducing opportunities for action to be reinforced. In addition, they noted that the inertia and withdrawal typical of depressed individuals serve a negatively reinforcing function, similar to avoidance behaviors characteristic of anxiety disorders. Despite the short-term relief that likely results from inactivity (by reducing experiences with nonreinforcing environments), these avoidance behaviors can lead to secondary problems (e.g., occupational or relational difficulties) and also limit opportunities for contact with positive reinforcers. Moreover, these avoidance patterns likely lead to disruptions in routines, which are thought to play an etiological and maintaining role in depression (Ehlers, Frank, & Kupfer, 1988).

BA directly targets avoidance behavior and routine disruptions. Therapy begins with a focus on establishing a therapeutic relationship and presenting the model of depression. Therapists work with clients to establish a goal of changing behavior rather than altering mood; clients’ tendency to believe they cannot engage in an action until they feel better is gently challenged behaviorally by requesting that they try to engage in planned behaviors regardless of how they feel. Therapists and clients develop collaborative treatment goals, with a distinction made between short-term goals, many of which will be addressed during therapy, and long-term goals, only a few of which will be directly addressed during the course of treatment.

A focus on functional analysis is a critical element of this treatment. Therapist and client explore the nature of depressive symptoms, identify the triggers for depressive episodes, note how the client responds to depressive symptoms, and identify avoidant behaviors and routine disruptions. Clients are gradually taught to conduct their own functional analyses, with encouragement to do so particularly after therapy ends to prevent relapse. Drawing from the collaboratively derived functional analysis, the client and therapist develop targets for focused activation. Rather than encouraging general activity, as many behavioral approaches do, BA focuses on idiographic identification of activities that the client believes will be beneficial. Monitoring forms are used to track actions engaged in, triggers, and consequences, and assignments are modified on the basis of ongoing refinements to functional analyses.

Modification of avoidance behaviors is achieved by helping clients to identify the function of these behaviors (both the immediate relief and the longer term problems) and choose alternative coping responses. The acronym TRAP is used to help identify triggers, responses, and avoidance patterns, whereas the acronym TRAC (trigger, response, alternative coping) is used to help generate alternative coping responses to the same triggers and responses. Alternative coping responses frequently involve approach, rather than avoidance, behaviors. Therapist and client also work to regulate the client’s routines and integrate activation strategies into regular routines, to be able to fully evaluate their impact. To maximize the impact of activation strategies, clients are encouraged to attend to their experience, particularly their immediate environment, as they engage in activities. Jacobson et al. (2001) noted that this is somewhat similar to mindfulness training in its emphasis on present-moment experience. This attention to experience is thought to increase the impact of present-moment contingencies (leading to more flexible and adaptive responding) and also to help circumvent ruminative thinking, which is thought to interfere with engagement in life. A case example using BA is presented later in this chapter.