Behavioral Activation Therapy
What is Behavioral Activation?
In short Behavioral Activation is a treatment for depression that holds that context rather than internal factors such as cognitions is a more efficient explanation for depression, and a more efficacious realm in which to intervene. In other words, BA seeks to help people understand environmental sources of their depression, and seeks to target behaviors that might maintain or worsen the depression. C. B. Ferster (1973) proposed a behavioral analytic theory of depression providing an alternative to psychoanalytic theory that was prominent at that time. Peter Lewinsohn and colleagues at the University of Oregon were the first to develop Behavioral Activation as a treatment for depression, and developed the treatment to increase pleasant activities for depressed individuals (Lewinsohn, 1994; Lewinsohn, Biglan, & Zeiss, 1976; Lewinsohn & Graf, 1973).
While committed behavior therapists continued to utilize this approach much more research was conducted on cognitive-behavioral treatment for depression, which incorporated behavioral activation but focused mainly on the typical distortions in thoughts and beliefs that are characteristic of depressed individuals. Throughout the 1980s and 1990s CBT became the most widely studied treatment and consistently demonstrated effectiveness in treating depression, anxiety and other disorders.
In 1996 Jacobson and colleagues (Jacobson, et al, 1996) conducted a study of the effective ingredients in CBT for depression. They found that there were no differences in treatment outcome between CBT compared to behavioral activation (BA) alone. Another major study comparing BA, CT, and Antidepressant Medication was conducted by Jacobson and colleagues, and continued after the untimely death of Neil Jacobson in 1999. A description of BA as developed in that study was published in a refereed journal (Jacobson, Martell, & Dimidjian, 2001) and in the book Depression in Context: Strategies for Guided Action (Martell, Addis, & Jacobson, 2001). Results of that study showed BA to be as efficacious as antidepressant medications and to have slight advantage over CT in the treatment of moderate to severe depression (Dimidjian, et al., in press)
The BA model proposes that life events, which can include specific trauma or loss, biological predispositions to depression, or the daily hassles of life, lead to individuals experiencing low levels of positive reinforcement in their lives. Furthermore, many behaviors used to cope with negative feelings that make the individual feel better in the short-run but are detrimental in the long-run increase through a process of negative reinforcement. It is natural for a person that feels sad and is no longer finding pleasure in activities that were previously enjoyed to attempt to cope by withdrawing socially, ceasing to engage in activities and "shutting down". The problem is that such coping strategies do not help alleviate depression, they make it worse.
BA targets inertia. When depression zaps motivation, the BA approach is to work from the "outside-in", scheduling activities and using graded task assignments to allow the client to slowly begin to increase their chance of having activity positively reinforced.
BA targets avoidance. Behavioral analytic theory recognizes that the outcome or function of a behavior is more important than the form of the behavior. Formally, for example, sitting on the front stoop of one's house resting your head in your hands is always just that - sitting. However, you may be sitting there waiting for a friend to pick you up to go to a show or you may be sitting there to escape from a nasty argument with a partner. In those two instances "just sitting" serves very different functions. In the first it functions as an approach behavior, engaging in life. In the second it is an escape or avoidance behavior. Avoidance behavior has not been a primary target of most treatments for depression, in BA it is the primary target.
BA is short-term. In the primary outcome study (Dimidjian, et al., in press) participants had up to 24-sessions of treatment. BA is intended to be a focused, brief treatment for the alleviation of depression.
Questions and Answers about Depression and Behavioral Activation
Is depression an illness that will get worse if not treated?
It is a popular view to consider depression an illness, often compared to diabetes. However, this view is not accepted by everyone in the behavioral health field. Those professionals that seek a biological explanation consider depression an illness, and there are several popular press books that promote this idea, as do television commercials for antidepressant medications. There is little data to support a purely biological perspective on depression. This does not mean that depression is the same as sadness, or that it is not serious. Many people that experience depression suffer tremendously and need not suffer without help.
Depression is best seen as a syndrome, or a compilation of behavioral patterns. Certainly some people are predisposed to depression by family history and so on. Having depressed parents or grandparents not only transfers genetic material, but also models of coping with life that become a part of a person's repertoire. A bio-psycho-social perspective on depression considers biology, individual behavior patterns and environmental variables rather than any of these in isolation as potential causal factors. In other words the entire context of a person's life is taken into account rather than focusing on one specific area such as biology or environment. Statistically, depression in many people lasts for six months or less and remits on its own, even without treatment. For others depression can last for years and become chronic.
It is true that a person that has had one major depressive episode is more likely to have a second, and after a second the odds of a third increase. Roughly 60% of people that have been depressed once will be depressed again. Some consider this as partial evidence that there is a medical illness occurring. However, the same pattern has been found for divorce. Second marriages are less likely to succeed than first marriages, and the odds get worse for third or fourth marriages. One would never conclude that divorce is a disease that will repeat itself if untreated through medicine! Rather, it may also be the case that certain patterns of behavior and thinking occur that become habitual, and because people do not consist of separate minds and bodies, but of a physical body including a brain and central nervous system, changes may also occur in the brain that interact with these behavioral patterns. Once a person has experienced a certain way of coping with life, even if it feels bad, it may become engrained as a method for coping.
Treatments for depression can help, and provide structure and support to allow an individual to recover more quickly.
What causes depression?
There are several differing views on the cause of depression. As mentioned above, the bio-psycho-social view considers heritability, individual behavior patterns and environmental variables as causes for a person becoming depressed. From a behavioral perspective, the feelings one experiences following losses, disappointments, daily difficulties with money, family, or jobs, and so on are natural feelings. People vary in their levels of tolerance for negative feelings, and their sensitivity to them. When life is unrewarding or when one has to work extremely hard for very little reward, the result can be feeling sad, losing interest in activities, and decreased energy. When one feels low energy, fatigued or has no interest in activities it is understandable that a person may cope by sleeping longer hours, staying at home more often than usual, or isolating from friends and loved ones. The life events or the behaviors that follow may have an impact on biochemical changes in the body, the decrease in activity will prompt less activity, and a person may begin to feel hopeless and focus on all that is wrong in his or her life. This has been referred to as the vicious cycle or downward cycle of depression.
What is wrong with considering depression a medical illness?
Modern psychiatry has discovered many helpful medications that alleviate suffering for many people who experience variety of problems. At the same time, psychological and behavioral research has also validated psychotherapeutic and behavioral therapy methodologies that relieve suffering. The idea that depression is a "medical illness" suggests that it requires a medical cure. This is more than a question of semantics. From a psychological perspective there is much that a person can do, often with the help of a professional, to cope with and treat depression besides taking medication. Psychotropic medication does not work for everyone, and some people do not tolerate the side effects of medication. Depression can be considered a behavioral disorder that often requires treatment by a mental health professional. However, there are treatment options, including antidepressant medication, cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), and behavioral activation therapy (BA), that have all been studied and supported by randomized clinical trials. The problem with thinking of depression as an illness is that it implies that the depressed person is helplessly in the grasp of something completely uncontrollable. This is not the case, and one should have hope that changes in activity, life situations, long-held beliefs about self and world can all help to alleviate the suffering involved in depression.
For further reading see:
Antonuccio, D. W., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26(6), 574-585.
Valenstein, E. S. (1998). Blaming the brain: The truth about drugs and mental health. New York: Free Press.
How do I know if I'm depressed?
Behavioral health problems are not as clear-cut as biological diseases like a clogged artery or a broken bone. Diagnostic criteria change through the decades and are based on research and consensus of psychiatrists, psychologists and other mental health researchers and practitioners. The diagnoses are listed in a publication called the Diagnostic and Statistical Manual of Mental Disorders, which is now in its fourth edition:
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (1994, 2000). Washington, D.C.: Author.
Commonly called the DSM-IV, the manual provides the following criteria for diagnosing depression, considering that five or more of the symptoms have been present during a consecutive 2-week period: (DSM-IV-TR, pp. 356)
- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all or almost all activitities most of the day, nearly every day.
- Significant weight loss when not dieting or a decrease or increase in appetite nearly every day.
- Difficulty sleeping, or sleeping too much nearly every day.
- Noticeably physically agitated or slowed down, as observed by others nearly every day.
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive guilt nearly every day.
- Diminished ability to concentrate or make decisions nearly every day.
- Recurrent thoughts of death or suicide.
If you believe that you are experiencing these symptoms or if others have told you that they observe these patterns, you might consider seeking an evaluation from a licensed behavioral healthcare provider. Your primary care physician can also diagnose depression. Keep in mind, however, that you have options regarding treatment. For some people medication is a simple solution, for others cognitive-behavioral therapy, behavioral activation therapy or interpersonal psychotherapy is a better option, and for others a combination of therapy and medication can help.
Is depression ever normal?
There is a reason for all human feelings and behavioral propensities. If we did not have a panic reaction to life threatening situations we would never get out of harms way and would not have survived as a species. All of the feelings that are part of depression are normal in that they are part of the human repertoire. However, only in an ideal world would they not be problematic. We do not live in an ideal world, but in one that is filled with violence, social inequities, oppression, loss, and social isolation. As the world has become more complex our extended families have become fragmented, sleep cycles are disrupted, and we are faced with an overwhelming array of choices. Rates of depression have nearly tripled since World War II. It is possible that not only are we living in a less than ideal world, but that the world in which we live has become increasingly depression inducing.
Some people believe that depression or other behavioral health problems may have a positive impact on creativity. Artists like Vincent Van Gogh, who was diagnosed with Manic-Depressive Disorder, are often cited as examples. Yet there is no data to suggest that such talented artists would not have been more creative had they been treated for their disorder. Some level of melancholy may help one create, but when depression becomes severe to the point that a person is unable to get out of bed or concentrate, it is hard to say that depression is a necessary condition under which creativity flourishes.
How is behavioral activation therapy different from other therapies?
The main difference between behavioral activation treatment for depression and other treatments is that the focus is on the problems you are experiencing in your life rather than on a problem with your thinking or your biology. While depression itself is not considered a "normal condition" that is in any way desirable, the depressive reactions to a life that brings few rewards are considered understandable and not the "fault" of the sufferer. Behavioral activation first targets the inertia that occurs in depression, helping you to begin to take steps to re-engage in life despite the lack of motivation or the negative feelings.
I don't think I'm depressed, but I have trouble getting anything done. Can BA help?
Behavioral activation therapy has been empirically studied in the treatment of depression, and that is the primary use for this therapy. Smaller studies are being conducted by researchers using the therapy with other problems, but the data are not yet available. In so far as a behavioral activation therapist serves as a coach, helping clients to break down activities into small, achievable tasks it may be helpful for those that are not depressed, but have trouble getting things done. Good BA therapists encourage their clients to experiment with various means to accomplishing tasks, setting up weekly goals and structuring activities to achieve the goals.
How do I find a BA therapist?
While the interest in behavioral activation therapy waned for several decades, it has reemerged among psychologists and other behavioral health specialists since the late 1990s. However, basic behavioral activation strategies have always been a part of cognitive behavioral therapy for depression. You can find therapists that have training in behavioral or cognitive-behavioral therapy by going to the related cites and clicking on the Association of Behavioral and Cognitive Therapies (ABCT, formerly AABT). You can also contact local State Psychological Associations or other referral services and ask for a therapist that specializes in behavior therapy or CBT.
If I am on medication, can I still use behavioral activation treatment for depression?
Yes. Behavioral activation treatment can help you to engage in activities that you may have avoided and to address problems in your life with the help of a therapist/coach when medication alone will not help you to do so. Studies have shown that a combination of medication and cognitive-behavioral therapy produces good results. Although there have not yet been studies of combination treatment with behavioral activation, logic suggests that similar results would be found.
Please see the related sites page for additional resources about behavioral activation and related therapies.