Behavioral Activation

Distinctive Features

Jonathan W. Kanter, Andrew M. Busch, Laura C. Rusch

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134064298
• Edition: 1
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

Behavioral activation theory indicates that much clinically relevant human behavior is a function of positive reinforcement, and that when positive reinforcement is reduced, lost, or chronically low depression results. Behavioral activation encourages clients to obtain and nurture the skills that allow them to establish and maintain contact with diverse, stable sources of positive reinforcement. This creates a life of meaning, value and purpose.

Behavioral Activation: Distinctive Features clarifies the fundamental theoretical and practical features of behavioral activation, integrating various techniques into a unified whole that is efficient and effective. The book includes numerous case examples and transcribed segments from therapy sessions and outlines behavioral concepts using straightforward terms and examples so that all therapists can see the utility and practical value of this approach.

This book will provide essential guidance for students and new therapists, as well as more experienced clinicians wanting to know more about what makes behavioral activation a distinct form of cognitive behavior therapy.

Part 1
THE DISTINCTIVE THEORETICAL FEATURES OF BEHAVIORAL ACTIVATION

1
A distinctive history

The history of Behavioral Activation (BA) is a true success story. It had its seeds in the early writings of B.F.Skinner (e.g., 1953). Skinner’s radical behavioral approach focused scientists and clinicians on environmental factors in depression and how people are sensitive and responsive to their environments. In the early 1970s, prominent behaviorists, trained by and following in the footsteps of Skinner, such as C.B.Ferster and Peter Lewinsohn, elaborated Skinner’s writings into a behavioral model of depression. This early theory emphasized the basic behavioral premise that humans are responsive to reinforcement, and when stable sources of positive reinforcement are lost, depression will result. Briefly, Lewinsohn (1974) suggested that, if an individual loses major sources of positive reinforcement, treatment should focus on re-establishing contact with positive reinforcement (activity scheduling), and teaching the skills necessary to obtain and maintain contact with stable sources of positive reinforcement (social skills training).

Dozens of research studies were conducted that were supportive of the basic tenets of this model as well as the corresponding techniques. But with the cognitive revolution well underway by the mid-1980s, progress on the behavioral model had stalled. With the exception of a few hard core behaviorists, behavior therapy for depression came to be seen as inadequate and ill-conceived despite the lack of data to support this view.

The shift to cognitive therapy

What happened? Here we will highlight two prominent events. First, Peter Lewinsohn and his students developed separate treatment manuals for activity scheduling, social skills training, and cognitive restructuring, and compared these three treatment components to a waitlist control condition (Zeiss, Lewinsohn, & Muñoz, 1979). They found that all three treatments performed better than the waitlist control. There were no differences, however, in the effectiveness of the three treatments relative to each other. Lewinsohn concluded from this study that the three treatments should be combined into an integrated cognitivebehavioral treatment approach, which subsequently was published as the self-help book Control your depression in 1978 (Lewinsohn, Muñoz, Youngren, & Zeiss, 1978) and the therapy manual The coping with depression course in 1984 (Lewinsohn, Antonuccio, Steinmetz-Breckenridge, & Teri, 1984). This marked the end of Lewinsohn’s focus on a purely behavioral approach to the treatment of depression.

A second, related event was the ascendance of cognitive approaches to depression treatment, initially fueled by the efforts of pioneers such as Aaron Beck, through his book Cognitive therapy of depression (CT; Beck, Rush, Shaw, & Emery, 1979), and Albert Ellis, through his book Reason and emotion in psychotherapy (Rational Emotive Behavior Therapy, REBT; Ellis, 1962), as well as many others. Both Beck and Ellis recognized the value of behavioral techniques and incorporated them into their treatments. For example, Beck folded behavioral activation strategies into the original 1979 CT manual, devoting one of its 18 chapters to them. This chapter, Chapter 7, outlined specific techniques for activity scheduling that essentially duplicated Lewinsohn’s version of activity scheduling, and suggested that these techniques should be used in the early stages of treatment and specifically with severely depressed clients.

Most importantly, these behavioral techniques were to be used in the context of an overarching cognitive model of depression. Beck and Ellis both suggested that behavioral activation homework assignments were valuable as small experiments designed to challenge underlying assumptions or irrational beliefs. The overall goal became cognitive as opposed to behavioral change. Thus, while behavioral techniques continued to be employed in cognitive therapy approaches, the underlying behavioral theory upon which those techniques were originally based was lost.

As is often the case in clinical psychology, paradigm shifts are larger than science, as the shift from behavioral to cognitive treatments was not based on scientific findings. In fact, Cuijpers and colleagues (2007) conducted a meta-analysis of 15 studies that had been conducted on behavioral techniques from the 1970s to 1990s, and found that these techniques were very effective for adult outpatient depression compared to waitlist or no treatment controls. Cuijpers and colleagues also found that these techniques were as effective as CT across several studies, and this lack of differential effectiveness extended to follow-up periods as well.

The cognitive therapy component analysis

This subjugation of behavioral techniques to the cognitive model was the final nail in the coffin of a purely behavioral approach to depression for quite some time. Then, in 1996, Neil Jacobson and his colleagues at the University of Washington published a component analysis of CT that resuscitated behavioral techniques. Jacobson and colleagues examined Beck’s 1979 CT book and argued that CT could be split into three additive component conditions: (1) activity scheduling (which Jacobson labeled Behavioral Activation), (2) a cognitive restructuring condition that included activity scheduling and restructuring automatic thoughts, and (3) the full CT treatment that included activity scheduling, cognitive restructuring, and core belief modification.

Results were quite surprising. Jacobson and colleagues (1996) found no evidence that the full CT package produced better outcomes than the cognitive restructuring or BA conditions, despite a large sample, excellent adherence and competence by clinicians in all conditions, and a clear bias by the study clinicians favoring CT. Also, CT was no more effective than BA at preventing relapse at a 2-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998). Jacobson concluded from this study that, because BA was as effective in treating depression as were the other components, this could be taken as evidence that cognitive theory and interventions were unnecessary in the treatment of depression. Simple behavioral activation strategies, he concluded, may be enough.

It may be interesting to compare the Jacobson and colleagues (1996) component analysis study to the Zeiss and colleagues (1979) study described above. Both studies tested several active treatment components against each other, and both found all components to be equally effective. While Lewinsohn interpreted this result as suggesting that the interventions should be combined, Jacobson reasoned, if all interventions are equally effective, why not promote the simplest and easiest-to-train intervention? Why unnecessarily complicate treatment with additional components that, empirically, do not enhance outcomes?

Modern BA

Jacobson and colleagues’ (1996) component analysis catalyzed the field and sparked several developments. First, Jacobson and colleagues, not satisfied to refer interested individuals to Chapter 7 of the CT manual, set out to develop a stand-alone BA package, resulting in the book Depression in context: Strategies for guided action by Christopher Martell, Michael Addis and Neil Jacobson, published in 2001. In an effort to reestablish a behavioral theoretical foundation for activation techniques, these authors were heavily influenced by the writings of C.B.Ferster (1973), who emphasized the role of avoidance in depression—it is not just that depressed individuals have lost major sources of positive reinforcement, it is also that they may be inactive due to passive avoidance of aversive situations. Thus, the BA techniques described by Martell and colleagues included simple behavioral activation techniques and techniques for identifying and overcoming avoidance. The book was written to emphasize the flexible application of treatment techniques rather than presenting a highly structured approach.

Second, Carl Lejuez and his colleagues Derek Hopko and Sandra Hopko developed a different version of BA which they titled Brief Behavioral Activation Treatment for Depression (BATD; Lejuez, Hopko, & Hopko, 2001, 2002). They looked to matching law (Herrnstein, 1970) for theory, which highlights the importance of looking at the entire context in which behavior occurs, not just at specific reinforcers that follow specific behaviors. Treatment techniques of BATD are highly structured and focused on creating and completing activation assignments, with some additional attention paid to arranging for others in the client’s life to effectively support activation. Unlike the Martell version, however, no specific techniques are offered to target avoidance.

Hopko, Lejuez, Ruggiero, and Eifert (2003) have provided an excellent discussion and comparison of BA and BATD. They highlighted that both treatments are much more idiographic than their predecessors, focusing more on how depressed individuals differ from each other in terms of unique environmental situations and histories. Both treatments make an attempt to understand the client’s behavior functionally and schedule activities based on function, rather than simply scheduling generally pleasant events. Also, both treatments are much more inclusive of factors traditionally seen as non-behavioral, such as biological, genetic, and cognitive variables.

Empirical support

These two alternate versions of Behavioral Activation (which we will call BA and BATD) have generated much interest and empirical support.

First, a major study recently compared BA, CT, paroxetine and a medication placebo (Dimidjian et al., 2006). All treatments performed well for mildly depressed clients, but BA performed surprisingly well for the traditionally difficult-to-treat moderately-to-severely depressed clients, outperforming CT and performing equivalently to paroxetine. In addition, paroxetine evidenced a large drop-out rate and problems with relapse and recurrence when the medication was discontinued (Dobson et al., 2004), so BA appears to be the superior treatment in this study when all is considered.

Two other studies of BA have been conducted, including a study supporting a group therapy version of BA in a public mental health setting (Porter, Spates, & Smitham, 2004) and a version of BA adapted for Posttraumatic Stress Disorder (Jakupcak et al., 2006; Mulick & Naugle, 2004). Several other studies are ongoing.

BATD, in turn, has been evaluated through a small randomized controlled trial on an inpatient unit (Hopko, Lejuez, LePage, Hopko, & McNeil, 2003). In this study, BATD produced significantly greater Beck Depression Inventory (BDI) score reductions from pre-treatment to post-treatment compared to general supportive therapy.

The current book

This brief history suggests that there are at least four versions of Behavioral Activation: (1) Lewinsohn’s early version, (2) the version incorporated into CT and tested in Jacobson and colleagues’ component analysis, (3) the current BA by Martell and colleagues, and (4) BATD by Lejuez and colleagues. The current book aims to unify and clarify the diverse and overlapping set of theoretical positions and clinical techniques that are subsumed under the general label Behavioral Activation. In Part 1 of this book, we present the distinctive overarching theory of behavior and depression that guides BA techniques. In Part 2, we outline a unified and clearly articulated set of BA techniques.

2
A distinct definition of human behavior

This Point starts at the very beginning with a simple question: What is behavior? The answer is quite broad—it is everything a person does. Behaviorism has often been viewed as a theory that is most applicable or even only applicable to animals, children, and adults with cognitive disabilities. The modern behavioral theory upon which BA is based, however, allows for the full range of human experience to be relevant to BA.

Traditionally, human psychological functioning has been partitioned into three categories: cognition, affect, and behavior. Modern behavior theory treats all three categories as behavior. Making this shift to an inclusive view of behavior is easy and simply involves changing nouns to verbs. Cognition becomes thinking, affect becomes feeling, and behavior (as traditionally defined) becomes overt acting. According to BA, thinking, feeling and acting are all things people do and thus all can be treated as behavior in any analysis.

To many non-behaviorists, the idea that behaviorists treat private experiences (thinking and feeling) as behavior is puzzling because they were taught that behaviorists deny the existence or relevance of private experiences outright. In fact modern behavioral theory seeks to explain private experiences of all types, including thinking, feeling, loving, dreaming, wishing, remembering, and even the experience of self (Kohlenberg and Tsai, 1991). Modern behavioral theory takes into account the whole range of human experiences. The key difference between the behavioral view and most other schools of thought in psychology is that these private experiences are seen as private behaviors, not the causes of behaviors. Private and public behaviors differ in terms of scale and accessibility, in that private behaviors may be very subtle and only observable to the person engaging in the behavior. But, private behaviors can be accounted for with the same learning principles and change processes as can public behaviors.

While behaviorists do not deny the existence of private behaviors, they do object to substituting mental entities for private behaviors, and then using these entities to explain the behaviors. Examples of this are quite prevalent. We remember well (behavior, verb) because we have a good memory (noun, mental entity). We act intelligently (behavior, verb) because we have high intelligence (noun, mental entity). We think in certain ways (behavior, verb) because of our schemas (noun, mental entity). Behaviorists refer to such mental entities as explanatory fictions. To a behaviorist, the concepts of memory, intelligence, and schemas ultimately are circular, do not explain much at all and obscure the search for more useful causes. If you acted intelligently because of your intelligence, what have we learned about you, other than that you act intelligently? If you remembered something because of your good memory, what have we learned, other than that you remember things well? We now need another set of analyses to understand the factors that cause high intelligence and good memory. Thus, behaviorists instead seek to understand the current and historical variables that lead individuals to engage in the behaviors of remembering, acting intelligently, and thinking about specific things. It is ultimately believed...