1. Treating Depression with Behavior Therapy: The Implementation of Behavioral Activation
Christopher Martell, Ph.D., ABPP
Independent Practice and University of Washington
Sona Dimidjian, Ph.D.
University of Colorado
as told by
Steven D. Hollon, Ph.D.
Vanderbilt University

2. Acknowledgements Research Team: Research Staff: Clinical Staff:
Michael Addis
Sandra Coffman
David Dunner
Robert Gallop
Steve Hollon
Bob Kohlenberg
Christopher Martell
Karen Schmaling
Research Staff:
David Atkins
Patty Bardina
Carolyn Bea
Chris Budech
Jackie Gollan
Eric Gortner
David Markley
Melissa McElrea
Joe McGlinchey
Evelyn Mercier
Kim Nomensen
Shireen Rizvi
Lisa Roberts
Elizabeth Shilling
Mandy Steiman
Dan Yoshimoto
Clinical Staff:
Linda Cunning
Steve Dager
Kerri Halfant
Helen Hendrickson
Ruth Herman-Dunn
David Kosins
Tom Linde
Peggy Martin
Steve Sholl
Alan Unis
Support:
NIMH & GlaxoSmithKline

3. 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 escape and avoidance behaviors and ruminative thinking

4. A Brief History of the Evidence Base for Behavioral Activation
Peter M. Lewinsohn
1970s

5. Lewinsohn
Early models highlighted the role of lack of response-contingent reinforcement for non-depressed behavior
Decrease in frequency or range of reinforcing stimuli or increase in frequency of punishment  depression

6. Brief History: Ferster
“I think the conceptual formulation as well as the treatment of depression really depend upon focusing on the behaviors the patient is not engaged in … the most obvious aspect of depression is a marked reduction in the frequency of certain kinds of behavior and an increase in the frequency of others, usually avoidance and escape”
Ferster, 1974

7. Peter M. Lewinsohn
Aaron T. Beck
1970s
1979

8. BA subsumed within CT
“…the ultimate aim of these techniques in cognitive therapy is to produce change in the negative attitudes” (Beck et al., 1979, p.118).
“The key point is that even when cognitive therapists are focusing on behaviors, they do so within the context of a larger model that relates those actions to the beliefs and expectations from which they arise and view them as an opportunity to test the accuracy of those underlying beliefs” (Hollon, 1999, p.306).
Positive outcomes in CT may be dependent on competence level of therapist (DeRubeis et al., 2005; Elkin et al., 1989)

9. Peter M. Lewinsohn
Aaron T. Beck
Neil S. Jacobson
1996
1970s
1979

10. 1996 1970s 1979 What accounts for the efficacy of cognitive therapy?
Peter M. Lewinsohn
Aaron T. Beck
Neil S. Jacobson
1996
1970s
1979

11. Cognitive Therapy for Depression
Facilitative Strategies
Automatic Thought Strategies
Core Belief Strategies
Behavioral Activation Strategies

12. Component Analysis of Cognitive Therapy
Behavioral Activation
Vs.
Full CT Package
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)

13. Component Analysis of CT
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)

14. Component Analysis of CT
Therapists were biased toward CT
BA mostly the proscription from doing cognitive interventions
No control group
No comparison with other standard treatments (i.e. medication)
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)

15. Behavioral Activation
Findings of the component analysis study led to an expansion of BA into a stand-alone model, not solely defined by proscription of cognitive interventions (Jacobson et al., 2000; Martell et al., 2001)
Linked to earlier behavioral work on depression (Ferster, 1973; Lewinsohn, 1974)

16. Acute and Follow-up Design
Acute Phase
Continuation Phase
Follow-Up Phase
Intake
Wk. 8
Wk. 16
Month 12
Month 24 BA
Follow-up evaluations
(N=43) CT
(N=45)
Follow-up evaluations
Placebo withdrawal
Follow-up evaluations
Participants on antidepressant medications were re-randomized at wk 16
All medication was withdrawn at month 12
Limits in the design: No augmentation therapy allowed for medication
Some have criticized for allegiance effects…although the CT therapists were strong adherents to CT as were two of the PIs
Psychotherapy participants were not allowed to continue with study therapists which may have lessened effectiveness for some who needed a longer course of treatment
ADM-CM
(N=100)
ADM continuation
Follow-up evaluations
PLA-CM
(N=53)

17. Assessment of Treatment Adherence

18. Rates of Attrition by Condition by Phase
Medication attrition was higher than in other studies…however, medications were provided by competent, experienced psychiatrists and the medication management component was led by an international expert in clinical drug trials
The percentage of people who were “no shows” in the PLA and ADM condition may suggest that this particular sample of people were more interested in psychotherapy than medication.

19. Mean BDI across acute treatment

20. Mean HRSD across acute treatment

21. Extreme Non-Response (BDI)

22. Prevention of Relapse Following Successful Treatment- all treatment conditions
Recurrence

23. Cumulative Direct Costs of Continuation ADM and BA/CT
Note: These costs are based on $100/ session in BA and CT, versus $75/ session in Continuation ADM, plus drug costs of $125/ month; ADM sessions occurring x2/ month for 2 months & monthly thereafter.

24. Putting it all together…
BA emerges as a strong and promising treatment
Challenges the idea that medication is required to treat moderately to severely depressed patients
Challenges the idea that directly modifying cognition is necessary to treat depression
Limitations (BA, CT, ADM)

25. Points of Convergence
Consistent with earlier behavioral literature (e.g., Lewinsohn; Ferster), more recent behavioral and activation oriented studies (e.g., Hopko et al., 2003; Stathopoulou et al., 2006 ), and dismantling studies across other disorders/ages (e.g., Scogin et al., 1989)
Consistent with early emphasis in CT on behavioral strategies for more severely depressed patients (Beck et al., 1979)
Consistent with key components of other behavioral treatments (DBT; Linehan, 1993; ACT; Hayes, Strosahl, & Wilson, 1999) and recent conceptualizations of integrative treatments for Axis I disorders (Barlow, Allen, & Choate, 2004)

26. Putting it into practice

27. Key elements of BA Stylistic strategies
Structuring strategies (including orienting to treatment)
Assessment strategies (individualizing primary treatment targets through behavioral assessment)
Activation strategies (activity structuring and scheduling)
Targeting avoidance, routine disruption, rumination

28. Course of BA Orient to treatment Develop treatment goals
Treatment rationale, including conceptualization of depression and primary treatment strategies
Role of therapist/patient
Develop treatment goals
Individualize treatment targets
Repeated application and troubleshooting of activation and engagement strategies
Reviewing and consolidating treatment gains

29. Stylistic Strategies Validating:
Interested; Accurately reflects; Genuine; Maintains hope and optimism about change
Reciprocal/responsive to client
Collaborative; Open to the client’s influence; Awake to client’s behavior in session and modifies interventions as appropriate; Warm
Non-judgmental and matter of fact in interactions with client
Everything is useful, provides information; Curious—holds a problem solving mindset in relation to all new behavior

30. Structuring
Strategies

31. Structure of Sessions Set collaborative agenda Review homework
Review weekly activities
Troubleshoot problem behaviors
Assign new homework
Ask for feedback

32. Treatment Rationale
Emphasize relationships between environment, mood, and activity
Highlight vicious cycle that can develop between depressed mood, withdrawal/avoidance, and worsened mood
Suggest activation as a tool to break this cycle and support problem solving
Emphasize an “outsidein” approach: act according to a plan or goal rather than a feeling or internal state

33. BA Case Conceptualization
Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.
Sad, tired, worthless, indifferent, etc.
Less Rewarding Life
Life events

34. BA Case Conceptualization
Stay home, stay in bed, watch TV, withdraw from social contacts, ruminate, etc.
Sad, tired, worthless, indifferent, etc.
Less Rewarding Life
Life events
Loss of friendships, conflict with supervisor at work, financial stress, poor health, etc.

36. Address common myths about activation and change
Will-power or “Nike” model of change

37. Address common myths about activation and change
Will-power or “Nike” model of change
Emphasize
Role of the therapist
Focused activation based on careful behavioral analyses
Graded task assignment
Difficulty of change

38. Assessment
Strategies

40. Individualizing activation targets
Conduct detailed examination of what is getting in the way of feeling better
Sounds simple, and yet in practice, we often lack awareness of these relationships

41. Key Assessment Strategies
Identify and set goals
Define and specifically describe problems in behavioral terms
Assesses consequences of behavior
Examine behavioral patterns

42. Goal Setting Ultimate goal of treatment
Clients modify their behavior to increase contact with sources of positive reinforcement
Typical goals relate to changing avoidance patterns and routine disruption and to changing environmental context
Focus on acting from the “outside in”
Set priorities for long and short-term goals
Figure out what behaviors are needed to reach goal—what, when, where, etc. Be focused, specific, and concrete!

43. Key Assessment Strategies
Basic questions:
What is maintaining the depression?
What is getting in the way of engaging and enjoying life?
What behaviors are good candidates for maximizing change?
Activity/mood monitoring provides the essential information
Utilize basic behavioral principles to answer these questions

44. Behavioral Assessment
ANTECENDENT
Assess the circumstances eliciting the behavior
Assess the function of the behavior: How is the behavior reinforced or punished? Does it garner a reward? Does it allow escape or avoidance of an aversive stimulus?
Emphasis on function vs. form
BEHAVIOR
CONSEQUENCES

45. Two Types of Conditioning
Classical Conditioning: paired stimuli take on similar functions
a neutral stimulus such as a hospital paired with grief following a loved one’s death in the hospital takes on the properties of grief, such that seeing a hospital evokes similar feelings
Operant Conditioning: behavior is learned according to the consequences that maintain it

46. Understanding consequences
Negative reinforcement: the likelihood of a behavior is increased by the removal of something from the environment (usually an aversive condition)
Watching television is negatively reinforced by reduction of painful emotions
Negative reinforcement contingencies are frequently targets in BA for depression
Positive reinforcement: the likelihood of a behavior is increased by the addition of something in the environment
Going to bed early is positively reinforced by family member offering empathy and support
Punishment: the extinguishing of a behavior by the addition of an aversive consequence in the environment
Asking for help is punished by a judgmental and critical reaction from others

47. Nuts and bolts of behavioral analysis in BA…
The Activity Chart – Central tool!
What does a BA therapist focus on when reviewing activity schedules?

48. Typical Questions to Guide Review
What would the client be doing if he or she were not depressed (e.g., working, managing family responsibilities, exercising, socializing, engaging in leisure activities, eating, sleeping, etc.)?
What is being avoided or from what is the client pulling away? How are these patterns related to mood?
What is the relationship between specific activities and mood?
What is the relationship between specific life contexts or problems and mood?
Is the client engaging in a wide variety of activities or have his or her activities become narrow?
Are there disruptions in normal routines?

51. Exercise #2: Activity Monitoring
Recording: Write down your activities and moods for 1-2 typical days over the past week; include enough detail to allow your partner can begin to notice some relationships
Role Play: Practice being the therapist and reviewing the completed log; identify “if…then” relationships between activity and mood; look for variability; help your client begin to notice these relationships

52. Activation
Strategies

53. The challenge!
“There is only a modest correlation between intention and behavior. Most often, people have good intentions and fail to act on them.” (Gollwitzer, 1999)

55. Problem Solving Problem definition Generate and evaluate solutions
Practice new behaviors in session as appropriate
Skills training as appropriate
Troubleshooting

56. Activity Scheduling Increase pleasure Increase mastery
Increase approach (vs. avoidance)

58. Activity Scheduling ü Mood/Activity M T W Th F S Mood (0-10*) 6 5 7 32
Walking dog ü
Bed by 10pm
Auto meeting
Call friend
Gardening
List to wife
* 0=mild/no depressed mood  10=intense depressed mood

59. Activity Structuring: Grading Tasks
Break down activities into parts
Assign simple to more complex tasks in a stepwise fashion
Design assignments so that early success is guaranteed
Goal is not to accomplish all parts of the activity—rather, to get started, increase activation, disrupt avoidance
Completing one component will increase likelihood of completing others

60. Qualities of Effective Action Plans: Opposite Action (Linehan, 1993)
Emotions love themselves
All emotions have “action urges” – what one wants to do or say when feeling an emotion
Action urges tend to maintain or intensify emotions
If you want to change an emotion, act opposite to the action urge
Opposite action works best if you do it “ALL THE WAY” – throwing yourself into and participating fully in the opposite action

61. Qualities of Effective Action Plans
Clearly tied to the essence of the problem (not random or arbitrary)
Target avoidance, withdrawal, approaching important problems/modifying life context
Includes activities that are opposite to the action urges accompanying depression
Based on creative and collaborative problem solving
Utilizes contingency management as needed to promote change

62. Qualities of Effective Action Plans
Clear and specific (adequately detailed information about what, when, where, etc.); do you and the patient know what the plan is when the session ends?
Do-able (adequately graded into component parts, assigning simple to more complex parts in a stepwise fashion, structured so that early success is nearly guaranteed)

63. Qualities of Effective Action Plans
Informed by adequate troubleshooting--consideration of potential barriers; anything that might get in the way?
Informed by what’s needed to maximize commitment to implementation -- public commitment, getting started in session, reminders during the week, explicit linking to long-term goals
Includes plans for how to make new behaviors routine
Returns to treatment rationale as needed

64. Acronyms to Organize Action Plans
TRAP/TRAC
ACTION

67. TRAP/TRAC T- Trigger (demands at work)
R- Response (depressed mood/hopelessness)
AP- Avoidance Pattern (leave work; stay at home)
T-Trigger (demands at work)
R- Response (depressed mood/hopelessness)
AC- Alternative Coping (approach behaviors using graded tasks)

68. TRAP
Trigger
Response
Avoidance-
Pattern

69. TRAC
Trigger
Response
Alternative
Coping

70. ACTION Strategy A=Assess How will my behavior affect my depression?
Am I avoiding? What are my goals in this
situation?
C=Choose I know that activating myself will increase my
chances of improving my life situation and mood.
Therefore, if I choose not to self-activate, I am choosing to take a break.
T=Try Try the behavior I have chosen.
I=Integrate Integrate any new activity into my daily routine.
O=Observe Observe the result. Do I feel better or worse?
Did this action allow me to take steps toward improving my situation?
N=Never Never give up.

71. Experiential Avoidance (Hayes et al., 1996)
BA is not a one-size-fits-all therapy
Not all clients will be inactive
Need to look for subtle forms of avoidance
Engagement as activation
Experiencing rather than avoiding negative feelings

72. Routine Regulation
Work with patient to develop and follow regular routine for basic life activities—eating, working, school, sleeping.
Can only evaluate new behaviors after implemented for a period of time—make them routine, then evaluate
Use activity logs
Use the ACTION strategy

73. Exercise #3: Modifying Avoidance
Break into pairs
Help your partner…
Identify a goal for learning at ABCT (or more broadly getting the most out of your experience)
Identify an avoidance pattern that might typically become a barrier to moving in the direction of this goal
Identify an action plan for alternative coping that can be implemented over the next 3 days
Troubleshoot potential problems that would interfere with the action plan
You can use the TRAP/TRAC form or a blank activity schedule if useful

74. Engagement

77. The Trouble with Ruminating
Nolen-Hoeksema, 2000
What is ruminating?
“People with a ruminative response style think repetitively and passively about their negative emotions, focusing on their symptoms of distress ("I feel so lousy," "I just can't concentrate") and worrying about the meanings of their distress ("Will I ever get over this?“).”
Ruminative response styles predict higher levels of depressive symptoms over time, onset of new episodes, and episode chronicity

78. You'll never
plow a field
by turning it over
in your mind...

79. Targeting Ruminating Monitor and assess
Focus on context and consequences of ruminating, not on the content of ruminative thoughts

80. Targeting Ruminating
Practice with “attention to experience” strategies
Notice colors, smells, noises, sights, relation to others, etc.
Notice elements of tasks (parenting, work)
Select activities that are associated with high engagement
Highlight negative consequences of ruminating
Be alert for partial activation and identify specific behaviors that would maximize full engagement

81. A Focus on the Content of Thinking “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * What is the evidence that this thought is accurate? * What would it mean if it were true? * Can you think of another way to interpret what your sister said? * Why must everyone love you?

82. A Focus on the Context and
A Focus on the Context and Consequences of Thinking “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * When did you start thinking that? * How long did it last? * What were you doing while you were thinking that? How engaged were you with the activity, context, etc.? * What were consequences of thinking about that? What might be the function?

83. Relapse Prevention Consolidate Treatment gains
What has been helpful
What has been learned
Plan for future problems
What targets have been identified
What new responses to targets are practiced

84. Additional Resources
Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8,
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton and Co.
Addis, M.E., & Martell, C.R. (2004). Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back. New York: New Harbinger Press.
Dimidjian, S., Hollon, S.D., Dobson, K.S., Schmaling, K.B., Kohlenberg, R., Addis, M., Gallop, R., McGlinchey, J., Markley, D., Gollan, J.K., Atkins, D.C., Dunner, D.L., & Jacobson, N.S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. JCCP, 74 (4),
Dimidjian, S., Martell, C.R., Addis, M.E., Herman-Dunn, R. (in press). Behavioral activation. In D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders, 4th Edition. NY: Guilford Press.