Behavior Activation

Description of the Strategy

A number of theoretical perspectives have been outlined with regard to factors most critical in understanding the etiology and maintenance of clinical depression; biological theorists implicate decreased levels of the neurotransmitters serotonin and norepinephrine; cognitive psychologists highlight dysfunctional thoughts and maladaptive core schemas; while interpersonal psychotherapists associate clinical depression with impaired interpersonal functioning. From the behavioral perspective provided here, depression results from decreased response-contingent reinforcement for nondepressive (healthy) behavior, a process that results from unavailability of reinforcement in the environment, inability to access reinforcement (e.g., skill deficits), and/or an increased frequency of punishment. Depressive behaviors such as passivity or lethargy also may be maintained through positive (e.g., expressed sympathy) and/or negative reinforcement (e.g., avoidance of responsibilities). In other words, depressed behavior results from some combination of reinforcement of depressed behavior and a lack of reinforcement or even punishment of more healthy alternative behavior.

Based on this model, conventional behavioral therapy for depression was aimed at increasing access to pleasant events and positive reinforcers, as well as decreasing the intensity and frequency of aversive events and consequences. Additional strategies included teaching relaxation skills, social and problem-solving skill training, and a focus on increasing self-control through self-monitoring and self-reinforcement. With increased interest in cognitive theory in the latter quarter of the 20th century, interventions based exclusively on operant and respondent principles, once thought adequate, had begun to be viewed as insufficient to address the complex nature of clinical depression. As such, the treatment of depression began to include direct cognitive manipulations, including cognitive restructuring and self-instructional training.

Within the past decade, there has been a revitalized interest in traditional behavior therapy as conducted without specific attention to cognitive processes and intervention. This resurgence can be attributed to a number of factors, including pressure to develop and implement psychosocial interventions that are both time limited and empirically validated (i.e., in response to managed care organizations), and recent data that suggest significant therapeutic benefits can be achieved without comprehensive cognitive-behavioral treatment packages. In response to these issues, behavior activation research programs have evolved to evaluate the feasibility, effectiveness, and efficacy of purely behavioral interventions for depression.

Behavior activation (BA) may be defined as a therapeutic process that emphasizes structured attempts at increasing overt behaviors that are likely to bring the patient into contact with reinforcing environmental contingencies and produce corresponding improvements in thoughts, mood, and overall quality of life. This strategy is a central component of contemporary behavioral interventions, although the fundamental philosophy and specific behavior activation methods are somewhat distinct across therapies. Neil Jacobson and his colleagues developed a 20- to 24-session behavior activation protocol designed to address the functional aspects of depressive behavior. This intervention focuses on evolving transactions between the person and environment and the identification of environmental triggers and ineffective coping responses involved in the etiology and maintenance of depressed mood. Much like traditional behavioral therapy, this approach conceptualizes depressed behavior (e.g., inactivity, withdrawal) as a coping strategy to avoid environmental circumstances that provide low levels of positive reinforcement or high levels of aversive control. Behavioral avoidance is thus a core feature of this treatment model, and the initial treatment objective is to increase a patient's awareness of how an internal or external event (trigger) results in a negative emotional (response) that may effectively establish a recurrent avoidance pattern (i.e., TRAP: trigger, response, avoidance pattern). Once patient and clinician establish recognition of this pattern, the principal objective becomes one of helping the patient to reengage in healthy behaviors through developing alternative coping strategies (i.e., TRAC; trigger, response, alternative coping). Along with increased patient awareness and progression from a TRAPto a TRAC-based philosophy, the primary therapeutic technique of BA involves teaching patients to take action. To reduce escape and avoidance behavior, patients are taught to assess the function of their behavior, and then to make an informed choice to continue escaping and avoiding or instead integrate alternative behaviors into their lifestyles that may improve their moods. Additional treatment strategies used to facilitate development of active coping include rating mastery and pleasure of activities, assigning activities to increase mastery and pleasure, mental rehearsal of assigned activities, roleplaying behavioral assignments, therapist modeling, periodic distraction from problems or unpleasant events, mindfulness training or relaxation, self-reinforcement, and skills training (e.g., sleep hygiene, assertiveness, communication, problem solving).

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