Behavioral Activation

Behavioral activation as a treatment for depression originated from instrumental conditioning models, in which depressed mood was attributed to proportionately more punishers than positive reinforcers. As a way of counteracting this disproportionate reinforcement schedule, Lewinsohn and colleagues (e.g., Lewinsohn, 1974) encouraged increased access to positive reinforcers by using activity logs and activity scheduling from a standard list of activities to increase engagement in pleasant activities. More recently, Jacobson and colleagues (Jacobson, Martell, & Dimidjian, 2001) took a more idiographic approach to identifying the types of activities that would increase positive reinforcement by relying on a functional analysis for a given individual. They also emphasized the importance of behavioral activation as a way of countering avoidance of life challenges and associated negative emotions. Such avoidance is presumed to contribute to ongoing depression. For example, requesting to speak to one’s boss to make amends for an error made at work would serve as an activity that counters avoidance of the negative emotions anticipated to arise during the interaction with the boss. By this kind of emphasis on counteracting avoidance, behavioral activation overlaps with problem solving and with exposure therapy for anxiety disorders.

Behavioral activation begins with a functional analysis of the antecedents and maintainers of the lack of behavior, which informs the way to structure behavioral activation in a given individual’s context. A functional analysis is essential since the same behavior, or lack thereof, may serve a very different function for different people. For example, arranging to have coffee with friends may be an adaptive socialization, or a maladaptive avoidance of other responsibilities. Understanding the context of depression includes broadly assessing significant life events, and ways in which behavior has altered since being depressed, as well as the methods that have been used to cope with depression that may be in themselves problematic (e.g., avoidance behaviors). This information is then used for a conceptualization of the life events that have contributed to depression by making the client’s life less rewarding and ways in which attempts to cope with depression by avoidance have contributed to depression.

Activity charts then are used to assess current levels of activity and the connections between activity and mood, and to help clients monitor avoidance behaviors as well as steps that are being taken toward accomplishing stated life goals (Martell, 2003). Clients then are encouraged to become aware of their own avoidant strategies and to choose between continuing to be avoidant and depressed or to engage in activities that will eventually lead to improved mood. An acronym ACTION is used to help clients assess when they are being avoidant:

Assess – is my behavior avoidant?

Choose – whether to activate or continue to avoid.

Try – the chosen behavior.

Integrate – new activity into regular routine.

Observe – the outcome; does the new behavior lift mood or life situation?

Never – give up. (Martell, 2003)

The purported mechanisms underlying behavioral activation are that by increasing activity and blocking avoidance, clients come into contact with more natural positive reinforcers from their environment. Also, behavioral activation establishes a regular routine and encourages functionality. Furthermore, behavioral activation helps clients learn to become active even when they feel they cannot possibly complete tasks or get any pleasure from life (Martell, 2003). By encouraging approach to previously avoided situations, behavioral activation may contribute to the extinction of CRs. Also, self-efficacy may be effectively raised and in turn contribute to further motivation for behavioral activation. Finally, although behavioral activation treatment does not attempt to change the content of cognition, performance accomplishment is likely to provide evidence that disconfirms overly negative appraisals about the self and the world.

Behavioral activation was developed specifically for the treatment of depression. There are no clear contraindications for the person who is depressed, with the exception of situations in which activating the client may place them at risk of harm due to an abusive partner or violent living circumstances (Martell, 2003). Given the contextual basis of behavioral activation, in which the goal is to encourage clients to look “outward at their life context rather than at hypothesized internal defects” (Martell, 2003, p. 29), behavioral activation is not usually combined with a cognitive therapy focus on the content of negative cognitions. Instead, cognitions are addressed in terms of their function, such as by evaluating where and when these negative cognitions occur and what is the effect of the cognition on what the person feels and does next. Then, the treatment refocuses on how to behave differently, in a way that is not guided by the negative cognitions. In certain cultural contexts, behavioral activation may be modified to include activities with family members.