Behavioral Activation for Major Depressive Disorder

  Santiago-Rivera et al. (2008) suggested that BA (Martell et al., 2001) may be an effective intervention for depression among Latinos and Latinas because of its emphasis on environmental factors and behavior change. They reviewed literature that details the number of environmental causes that may be associated with depression among Latinos and Latinas and also noted that depressive symptoms in this population may be associated with realistic appraisal of lack of control rather than cognitive distortions that could be the target of intervention. This case illustration draws from their suggestions for cultural adaptation of BA in the treatment of depression in a Latino client.

Pedro was a 38-year-old bilingual Latino man who presented for treatment reporting depressive symptoms, hopelessness, loss of interest in things he used to enjoy, and increased appetite and weight gain. He was married, with 10- and 12-year-old daughters and a 14-year-old son. He and his wife had immigrated to the United States from Mexico 15 years prior; his sister and brother-in-law lived nearby, and the rest of his family still lived in Mexico. He was going to school to complete his bachelor’s degree while also working a part-time job to help support his family. He reported difficulties keeping up with his school work and growing distance in his marriage. His wife was also working part time to help support the family. He also reported feeling distant from his children. In the initial session, Pedro expressed a lot of disappointment in himself for his current level of functioning and a great deal of self-criticism and rumination about the ways he was not living up to his own expectations. He expressed feelings of guilt for not enjoying the opportunities available to him when other family members did not have the same benefits he had.

Treatment with Pedro began with a clinical assessment that included self-report measures, initial monitoring of depressive symptoms, and an extensive intake that assessed symptoms and contextual factors that might be associated with presenting problems. Pedro’s expectations about therapy, including his hopes and fears, were also assessed. His therapist also asked about Pedro’s experiences of acculturative stress (e.g., what the process of moving to the United States was like for him, any challenges he faced in adjusting), as well as experiences of racism and discrimination he had experienced during his time in the United States, using open-ended questions that sensitively addressed these topics and conveyed her understanding that these kinds of experiences are common among immigrants and members of ethnic minority groups. Efforts were made to focus on specific goals that Pedro had for therapy, with attention to cultural values. The therapist used her general knowledge of values that might play a role in Pedro’s experience given his identity as a Mexican American immigrant (e.g., acculturative stress, experiences of discrimination, values of family connectedness [familismo], and the male role of providing for the family and being responsible [machismo]) but was careful to ask about the specific role of these values in Pedro’s life, rather than assuming the importance of each issue because of his ethnic background. To get a sense of the routines in his life and his level of activity or lack thereof, the therapist asked Pedro to describe a typical day. She also acknowledged cultural differences between herself and Pedro and invited him to let her know if she seemed to be misunderstanding his experience in any way.

Pedro’s symptoms met criteria for major depressive disorder. Through the clinical interview, he recognized that although he had experienced some dysphoric feelings since moving to the United States, his symptoms had become more severe during the past year when he had begun pursuing a degree and left his job. Exploration of other environmental changes that had accompanied this change in jobs revealed that Pedro had worked with several Mexican Americans, whom he had known for many years, whereas he was now taking classes with people he did not know and with whom he did not interact. He reported experiences of discrimination in the context of school. In addition, his daily routine had changed when he started school; he had gone from a very regular routine to a more erratic one. Some nights he stayed up late doing work for his classes and then slept late in the morning, and other nights he went to bed earlier so that he could wake up in time for a morning class. On weekends, he regularly stayed up late studying and slept late in the mornings. Staying up late and subsequently sleeping late, particularly on the weekends, also reduced his time with his family because he missed family activities, such as attending church on Sundays.

Review of monitoring forms helped to identify the patterns of responding that were contributing to Pedro’s depression and isolation. For instance, demands from school were a significant trigger. When he perceived these demands (trigger), he responded with hopelessness, depressed feelings, and self-criticism (response). This typically led to his procrastinating by surfing the Internet or watching television (avoidance pattern). This avoidance further fueled his self-criticism and sense of hopelessness and also resulted in his staying up late to get his work done, which disrupted his sleep routine and reduced his time with his family. Pedro also described cognitive triggers, such as thoughts that he was not supporting his family well, which led to feelings of sadness and shame, which in turn led him to avoid interpersonal interactions with his family and friends.

A central focus in the beginning of therapy was developing a shared understanding of Pedro’s depressive symptoms that emphasized the role of environmental factors and learned avoidance patterns in his continued distress. The therapist pointed out the numerous stressors that Pedro was facing in his pursuit of his degree (including experiences of discrimination) and highlighted the learned avoidance patterns that had naturally evolved in response to these triggers, but were perpetuating the cycle of depression. This model was a novel way of understanding depression for Pedro; however, he could see the way it described the pattern of his experience. He reported experiencing relief as he began to see his depressive symptoms as resulting from environmental factors rather than from his own limitations. Although he was concerned he would not be able to change his behavior patterns, he responded to the idea of taking action from the “outside in” rather than waiting to feel like engaging in a particular action. Pedro’s wife was also invited to a session, and Pedro shared this conceptualization with her and described the treatment approach so that she was able to better understand his experience and support his efforts at behavior change.

Over the course of treatment, Pedro and the therapist worked together to identify activities for focused activation, including making plans to see his brother-in-law and friends from his old job, whom he had been avoiding; waking up to go to church with his family; planning activities with his wife and children, regardless of how he was feeling; initiating social contact with people in his class; and engaging in regular exercise. By monitoring his activities and responses, Pedro was able to determine which activities were associated with improvements in his mood, or improved functioning despite his mood, and made these activities part of his regular routine. Attention was also paid to routine regulation; the therapist suggested that Pedro try to go to sleep at a set time each night and wake up at a set time to reduce the dysregulation that was likely resulting from his erratic sleep pattern. Pedro was initially reluctant to alter his patterns for fear that it would negatively affect his ability to do his school work. The therapist validated his concern and asked him whether he would be willing to try out a more regular routine for a few weeks to see whether it had the feared effects, while also addressing his avoidance pattern regarding his school work to minimize any risk to his academic performance (described in the next paragraph). Because Pedro could see the way in which his sleep pattern might be making his mood more problematic, he agreed to give this a try temporarily.

Pedro learned to notice when he was having responses to triggers of school stress and made the choice to approach his school work instead of avoiding it. He found that approaching his work, even when he really did not feel like it, actually improved his mood. Over time, he was able to complete his school work during a set period and leave time at the end of the night to spend with his wife, which began to reduce the distance and conflict in their relationship. Gradually, Pedro noted significant improvements in his mood, a renewed interest in activities, and a renewed sense of connection with his family members.