1. Behavioral Activation

2. What is Behavioral Activation?
Structured, brief psychosocial approach
Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments
Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems
Focuses directly on activation and on processes that inhibit activation, such as avoidance behaviors and ruminative thinking
So What is behavioral activation?
BA is a structured, brief psychotherapy that can be implemented in an individual or group format. A typical course of BA would average around 15 weekly sessions. Though it was originally developed as a treatment for depression, it has also been applied to other disorders that are associated with behavioral withdrawal and avoidance, such as PTSD, and is a component of other treatments, such as CBT and Barlow’s Unified Protocol.
BA posits that certain risk factors, environments, and behaviors can limit the experience of positive reward, and that paucity of reward can contribute to the development and maintenance of depression.
BA aims to counteract that narrowing of reward opportunities by systematically and hierarchically increasing activation to increase the probability that patients will experience more frequent and meaningful rewarding contexts
Rather than relying on the development of insight on the part of patients, BA targets activation directly, by encouraging goal-driven behavior and by working to reduce barriers such as avoidance behaviors and rumination.
I should mention that several of the slides I’m going to share today are borrowed or modified from a presentation by Martell and Dimidjian, who are two of the key developers of BA
Martell, & Dimidjian (2007) Treating Depression with Behavior Therapy: The Implementation of Behavioral Activation.

3. Behavioral Activation Therapy for Depression (BAT-D) Lejuez et al
Behavioral Activation Therapy for Depression (BAT-D) Lejuez et al., 2001; Hopko et al., 2003)
Manualized behavioral activation intervention
Orientation to treatment rationale
Monitoring of daily activities
Assessment of values and construction of goals hierarchy
Establishment of short and long term behavioral goals
Engagement with and monitoring of weekly goals
BATD is a manualized, validated behavioral activation intervention for depression. It was designed to be a streamlined version of behavioral activation that would be implementable by counselors with a wide training background. It has demonstrated effectiveness in reducing symptoms in inpatient populations as well as populations with both psychiatric and medical comorbidities.

4. A brief history of a brief behavioral treatment for MDD
Lewinsohn: Increase
positive events to decrease depression
Ferster: Functional
analysis of depression;
Importance of avoidance
The most immediate roots of current-day BA began in the 1970s with work by behaviorists who applied principles of reinforcement to the question of how depression works and might be treated. One of those clinical researchers, Peter Lewinsohn, posited that depression arises when one’s actions do not result in positive reinforcement. When one’s environment is filled with low rates of positive reinforcement and increasing rates of punishment, depressive behaviors are elicited. Lewinsohn developed a treatment protocol that focused on increasing rates of pleasant events, as well as developing an appreciation for the contingencies that lead to the arising of those pleasant events.
At around the same time, Charles Ferster, a student of BF Skinner’s, proposed a functional analytic model of the development and maintenance of depression as a function of negative reinforcement. Avoidance behaviors are seen as gaining strength through negative reinforcement, and these behaviors are emitted to the exclusion of behaviors that might result in positive reinforcement. Ferster made the link that like anxiety disorders, depression is based in avoidance behaviors.
So in the ‘70’s there was Lewinsohn…
Peter Lewinsohn (1974)
• Depression arises when one’s actions do not result in positive reinforcement
• One’s environment is filled with low rates of positive reinforcement and increasing rates of punishment
• Treatment focuses on increasing rate of pleasant events as well as an appreciation for the contingencies that lead to the arising of those pleasant events
Charles Ferster (1973)
• Proposed functional analytic model for the arising and maintenance of depression
• Emphasized that depression arises and is maintained through negative reinforcement as behaviors
– Behaviors gain strength in a repertoire for their escape and avoidance function
– These behaviors are emitted to the exclusion of behaviors likely to result in positive reinforcement
– Like anxiety disorders, depression is based in avoidance
1970s

5. A brief history of a brief behavioral treatment for MDD
Lewinsohn: Increase
positive events to decrease depression
Beck: Use of behavioral activation as a tool to modify cognitive beliefs
Ferster: Functional
analysis of depression;
Importance of avoidance
As the cognitive revolution in psychotherapy took hold beginning with the 1979 publication of Beck’s Cognitive Therapy of Depression, Behavioral activation was subsumed as one of the tools within cognitive therapy.
1970s
1980s

6. “The term behavioral techniques may suggest that the immediate therapeutic attention is solely on the patient’s overt behavior; that is, the therapist prescribes some kind of goal-directed activity. In actuality, the reporting of the patient’s thoughts, feelings, and wishes remains critical for the successful application of the behavioral techniques. The ultimate aim of these techniques in cognitive therapy is to produce change in the negative attitudes so that the patient’s performance will continue to improve.” -- Beck et al., 1979, p 118
Rather than behavioral change itself functioning as the key mediator of depression symptom change, Beck used behavioral activation as a tool to elicit thoughts and feelings on the part of the patient, and used behavioral experiments as a way of eliciting and solidifying changes in beliefs and attitudes. Goal-directed behavior was used in behavioral experiments to test the validity of thoughts, rather than as an end in itself.
And that seemed to work pretty well. Cognitve therapy for depression developed a strong evidence base for the treatment of depression, and was expanded in various forms to treat other disorders such as anxiety and somatization disorders.

7. A brief history of a brief behavioral treatment for MDD
Lewinsohn: Increase
positive events to decrease depression
Beck: Use of behavioral activation as a tool to modify cognitive beliefs
Jacobson: Component analysis of CBT: the B wins
Ferster: Functional
analysis of depression;
Importance of avoidance
But fast-forwarding again to the 1990s, Neil Jacobson and others began to ask the question about the active ingredients of cognitive behavioral therapy. Was it actually necessary to modify cognitiions and schemas in order to reduce depression, or might some other aspects of CBT bring about reductions in symptoms without cognitive modifications?
1970s
1980s
1990s

8. Sad, tired, worthless, indifferent, etc. Less Rewarding Life
Behavioral model of depression: disengagement is negatively reinforced, contributing to a narrowing of positive contexts
Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.
Sad, tired, worthless, indifferent, etc.
Less Rewarding Life
Life events
The problem comes in when these behaviors create their own feedback loop. Behavioral withdrawal contributes to further symptoms, and the long-term consequences of withdrawal start to accrue, such as stress in one’s professional life and other relationships, which further limits the potential for positive reward as the individual’s world narrows. The point of intervention becomes the behavioral response to the emotional consequences of low reward – countering the behavioral tendency to withdraw and putting in place alternative behaviors that break this cycle, and increase the potential for reward in the patient’s environment.
Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

9. Two Manuals: Hopko & Lejuez Martell/Addis/ Jacobson/Dimidjian
Obviously we’re not going to cover all or most of what quality treatment with BA is going to look like, so I refer you to these two manuals, which reflect the two current “flavors” of BA available at present. The Martell book provides quite a bit of theoretical background and concepts of treatment, especially around doing a thorough functional analysis of behaviors. It’s less structured and more about teaching the principles of BA. The other manual developed by Hopko, Lejuez and colleagues, is for the BATD approach, or brief behavioral activation treatment for depression. This is a more structured, formally manualized approach, that has the benefit of requiring perhaps less psychological sophistication on the part of either the therapist or the patient, with a growing literature supporting its implementation by paraprofessionals, or for example, nursing staff on inpatient units. What I discuss today is going to be cherry-picking from both approaches, and the forms I passed out are drawn from the BATD manual.

10. Phases of Treatment
Psychoeducation about depression and orientation to treatment
Behavioral monitoring and functional analysis
Selection of behavioral goals
Implement goals hierarchy and problem-solve barriers
Relapse prevention

11. Examine logs for:
Regularity/variability
Degree of overall activity
Balance of enjoyment and importance
Mood contingencies
Overall ratings vs. hour-by-hour

12. Which Behaviors to Activate?
Values-consistent
Regulating and routine
Self-reinforcing
One of the most common conceptualizations, and I would say mis-conceptualizations, I hear about BA is that at the core, BA is about getting patients to do pleasant or fun things. Tell your patient to go watch a sunset or eat an ice cream cone and call it a day. While that may be a piece of it, it misses some very important components of behavioral activation. Our goal isn’t just to get our patients to do more, but to act in a way that increases the rewarding context of their everyday lives. To do that, we first need to establish what is actually rewarding, or important, to the patient. That way we can establish goals that are values-consistent [click] for that particular person. One way to think about this is to think about the difference between someone’s ideal and real senses of themselves. The more the person can act as the person they want to be, the less discrepant their sense of real and ideal selves, and the less distress, hopelessness, and helplessness they will experience.
We also want to target activities that are regulating. [click] By this I mean activities that give a sense of regularity and consistency to one’s daily and weekly schedule. One thing we know about depression is that it can mess with our biological rhythms – sleep can be affected, and with appetite disruptions, regular eating times can be disrupted. Exercise and activity become less regular, which takes away the distiction between active and rest times, which can contribute to fatigue and low energy. We thus talk about zeitgebers, or time-givers, as activities that can help get a person back on schedule. This includes consistent wake times, regular meals, and ideally, a regular pattern of exercise. It can also extend to less biological but equally important regular activities, like consistently going to work or other regularly scheduled activities.
Finally, we want the activities that we focus on to become self-reinforcing over time. We want to help our patients establish regular activities that become habitual, and don’t need as much external reinforcement over time. So for example, a patient may get benefit from calling an old friend and reconnecting, but that won’t necessarily lead to consistent change in the same way as, say, establishing a weekly coffee meetup would. Typically activities that are values-consistent and occur regularly will end up being self-reinforcing and will need less and less support by you as the therapist to keep them going.

13. Values domains Family Relationships Social Relationships
Romantic Relationships
Education/Training
Employment/Career
Hobbies/Recreation
Volunteer Work/ Charity/ Political Activities
Physical and Psychological Health Issues
Spirituality
Daily Responsibilities

14. Values assessment Value 1: Form 2. Activities Checklist (3/10)
Life Area: Romantic Relationships
Value 1:
Enjoyment (0-10)
Importance (0-10)
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Value 2:
Enjoyment (0-10)
Importance (0-10)
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:

15. Values assessment
Form 2. Activities Checklist (3/10)
Life Area: Romantic Relationships
Value 1: Open, honest communication
Enjoyment (0-10)
Importance (0-10)
Activity 1: Have dinner together regularly 7
Activity 2: Talk about future plans 4 10
Activity 3: Actively listen when Sweetie describes day 8
Activity 4: Bring up issues that are bothering me 3
Activity 5: Play “I Never…”
Value 2: Companionship
Enjoyment (0-10)
Importance (0-10)
Activity 1: Have dinner together regularly 7
Activity 2: Take walks together in the evening 8
Activity 3: Go antique-shopping together 4 6
Activity 4: Go to basketball games together 10
Activity 5:

16. Function of monitoring changes from assessment to include scheduling and self-monitoring of goals

17. Structure of Sessions Work together to set an agenda
Review homework/progress on goals
Troubleshoot unmet goals and barriers
Assign new goals for homework

18. BA Therapy Strategies

19. Forms of Avoidance Under-activity Over-activity
Experiential avoidance vs. engagement
Note that it is the FUNCTION of the activity, not the FORM, that defines avoidance

20. Rumination

21. Rumination Identify as a “mental behavior”
Context and consequences (functional analysis)
Turning the mind/mindfulness skills
Identify and implement incompatible behaviors

22. Rumination Example thought:
“I’m just a total failure. I’ll never get anything right.”
Ask:
“When do you tend to have this thought?”
“Are there times that you don’t think this way?”
“What are the consequences of thinking this way?”
“What do you tend to do when you think this way?”
“If you weren’t thinking this way, what might you do?”
“What else could you do instead of thinking this thought?”

23. Relapse Prevention By the end of treatment, BA aims to foster:
Greater clarity of values and goals
Ability to schedule and monitor activities
Basic functional analysis skills
Established positive habits