The Science of Cognitive Behavioral Therapy

Stefan G. Hofmann, Gordon J. G. Asmundson, Stefan G. Hofmann, Gordon J. G. Asmundson

• Editorial: Academic Press
• Año: 2017
• ISBN:
  9780128034583
• Categoría: Psychologie
• Categoría: Psychologie clinique

The Science of Cognitive Behavioral Therapy describes the scientific approach of CBT, reviews the efficacy and validity of the CBT model, and exemplifies important differences and commonalities of CBT approaches.

The overarching principle of CBT interventions is that cognitions causally influence emotional experiences and behaviors. The book reviews recent mediation studies, experimental studies, and neuroimaging studies in affective neuroscience that support the basic model of CBT, as well as those that clarify the mechanisms of treatment change.

Additionally, the book explains the interplay of cognition and emotion in CBT, specifies the treatment goals of CBT, discusses the relationship of cognitive models with medical models and associated diagnostic systems, and provides concrete illustrations of important general and disorder-specific considerations of CBT.

• Investigates the scientific foundation of CBT
• Explores the interplay of emotion and cognition in CBT
• Reviews neuroscience studies on the mechanisms of change in CBT
• Identifies similarities and differences in CBT approaches for different disorders
• Discusses CBT extensions and modifications
• Describes computer assisted applications of CBT

Section III

Problem-Focused Approaches

Outline

Chapter 12 Behavioral Activation Treatments for Depression

Chapter 13 Posttraumatic Stress Disorder

Chapter 14 Eating Disorders: Transdiagnostic Theory and Treatment

Chapter 15 Transdiagnostic Treatment for Anxiety Disorders

Chapter 16 Cognitive Behavioral Therapy for Sleep Disorders

Chapter 17 Cognitive Behavioral Therapy for Somatoform Disorders and Pain

Chapter 18 Dialectical Behavior Therapy: Overview, Characteristics, and Future Directions

Chapter 12

Behavioral Activation Treatments for Depression

Leanne Quigley and Keith S. Dobson, University of Calgary, Calgary, AB, Canada

Abstract

Behavioral activation (BA) is a time-limited, evidence-based psychotherapy for depression. Based on a behavioral model of depression, BA aims to increase behaviors that are positively reinforced by the environment and decrease behaviors that function to maintain depression. There are two major contemporary BA protocols, namely BA and brief BA treatment for depression (BATD). The primary therapeutic techniques of BA and BATD are activity monitoring and scheduling, through which the client increases active and approach-oriented behaviors. Other techniques include an assessment of goals and values, contingency management, skills training, and targeting avoidance. Research indicates that BA is as efficacious for the treatment of depression as other established therapies, including cognitive and cognitive behavioral therapies. Extant issues and directions for future inquiry are discussed, including research on the cost-effectiveness, active treatment components, and psychopathology and treatment model of BA.

Keywords

Behavioral activation; brief behavioral activation treatment for depression; behavior therapy; activity monitoring; activity scheduling; activation; depression

Major depressive disorder (MDD) is defined as a period of decline in mood and functioning, during which an individual experiences persistent low mood and/or decreased interest in formerly enjoyed activities for a minimum of 2 weeks, as well as at least four additional depressive symptoms, which may include a significant change in appetite or weight, insomnia or hypersomnia, psychomotor agitation or slowing, low energy, feelings of worthlessness or excessive guilt, impaired thinking, concentration, or decision-making, and suicidal ideation or behavior (American Psychiatric Association, 2013). Evidence suggests that the annual prevalence rate of MDD is 5%–7%, and that approximately 13%–18% of individuals will meet criteria for MDD in their lifetimes (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler et al., 2003; Williams et al., 2007). The high prevalence of MDD is paralleled by its high burden. The majority of individuals with MDD report significant role impairment (Kessler et al., 2003; Williams et al., 2007), and depression is the fourth-leading cause of disability worldwide (Üstün, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004). The estimated annual cost of depression in the United States was $210 billion dollars in 2010, comprised of 45%–47% treatment costs, 5% costs related to suicide, and 48%–50% costs related to reduced productivity and absenteeism in the workplace (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015).

Despite the tremendous costs of depression, treatment among individuals with MDD remains low. Greenberg et al. (2015) reported that about 50% of individuals with MDD received treatment between 2005 and 2010. Furthermore, only about one in five individuals with MDD receive treatment considered adequate according to duration and intensity guidelines (Kessler et al., 2003). The high prevalence and burden of depression combined with the rising costs of health care has led to pressure to determine cost-effective methods of treating depression. Cost-effective interventions are likely to be those that are brief in duration, simple to deliver, and show rates of efficacy that are comparable with other established treatments for depression.

One seemingly parsimonious and cost-effective intervention for depression is behavioral activation. Behavioral activation has a long history, beginning with early behavioral models of depression (Ferster, 1973; Lewinsohn, 1974). Over the past 20 years, there has been a renewed interest in behavioral activation approaches, evident in the development of two protocols, namely behavioral activation (BA)¹ developed by Jacobson, Martell, and colleagues (Martell, Addis, & Jacobson, 2001), and brief behavioral activation treatment for depression (BATD) developed by Lejuez, Hopko, and Hopko (2001). This chapter reviews the history of behavioral models of depression, key principles of contemporary behavioral activation therapies, and the outcomes associated with these treatments. Extant issues and directions for the future are discussed at the end of the chapter.

Historical and Theoretical Foundations

The conceptual foundations of behavioral activation can be traced to the work of early researchers who first developed behavioral models of depression. Ferster (1973) noted that depressed individuals engaged in increased avoidance and escape behaviors and displayed fewer behaviors that resulted in positive reinforcement. He emphasized the importance of the function rather than the overt form of behavior in terms of understanding depression. Lewinsohn (e.g., Lewinsohn & Graf, 1973; Lewinsohn, 1974) also articulated a behavioral theory of depression in which depression results from a decline in or consistently low rates of response-contingent positive reinforcement. As a function of a lack of or reduction in adequate environmental reinforcers and/or the individual’s inability to obtain those reinforcers, the individual receives low positive reinforcement for his or her behavior. Healthy behavior is consequently extinguished through the lack of reinforcement, and the individual’s behavior becomes increasingly restricted and passive, which reduces future opportunities for positive reinforcement. Further, low positive reinforcement is proposed to have a direct negative effect on mood. Based on this theory, Lewinsohn developed a treatment protocol to increase access to response-contingent positive reinforcement through participation in pleasant events and social skills training (Lewinsohn, Biglan, & Zeiss, 1976).

Despite early attention to the behavioral mechanisms of depression, and related research support, behavioral treatments were soon integrated with or subsumed within cognitive treatments for depression. In a direct comparison of cognitive therapy and behavioral therapy for depression, Shaw (1977) found an advantage for cognitive therapy, which contributed to the rise of cognitive approaches. Lewinsohn incorporated cognitive techniques into his treatment protocol over time (Lewinsohn, Muñoz, Youngren, & Zeiss, 1978). After the introduction of cognitive therapy for depression (Beck, Rush, Shaw, & Emery, 1979), cognitive and cognitive behavioral approaches became the most widely used and studied evidence-based interventions for depression (Butler, Chapman, Forman, & Beck, 2006; Dobson, 1989). Cognitive therapy did incorporate some behavioral strategies, but primarily with the aim to facilitate cognitive change by providing the client with opportunities to test and challenge negative beliefs (Jacobson, Martell, & Dimidjian, 2001).

Interest in a purely behavioral treatment for depression was renewed with the publication of a component analysis of cognitive therapy conducted by Jacobson et al. (1996). This study compared the behavioral activation component of cognitive therapy to the full cognitive therapy protocol and found that behavioral activation alone was as efficacious as cognitive therapy for reducing depression. Furthermore, at a 2-year follow-up, behavioral activation alone remained equivalent to cognitive therapy for the prevention of relapse to depression (Gortner, Gollan, Dobson, & Jacobson, 1998). These findings challenged the notion that cognitive interventions were necessary for optimal depression treatment (Jacobson et al., 1996). Jacobson et al. argued that, given equivalent outcomes, behavioral activation may be preferred over cognitive therapy for depression treatment because of its potential for wider dissemination. The relative parsimony of behavioral activation may allow it to be easily delivered by therapists with less training and/or experience, as well as transported into cost-effective delivery formats including self-help.

These seminal findings led to the development of two contemporary models of behavioral activation. Jacobson, Martell, and colleagues expanded their behavioral activation treatment into a stand-alone intervention for depression, termed BA (Martell et al., 2001). Also recognizing the potential of a parsimonious, easily accessible, and purely behavioral treatment for depression, Lejuez et al. (2001) developed BATD in an independent research endeavor (see also Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011). The following section describes these two major contemporary models of behavioral activation for depression.

Contemporary Behavioral Activation Approaches

Behavioral Activation (BA)

Consistent with the earlier behavioral theories of depression (e.g., Lewinsohn, 1974), BA views depression as primarily a consequence of reduced or low levels of positive reinforcement (Martell et al., 2001; Martell, Dimidjian, & Herman-Dunn, 2010). Low positive reinforcement directly depresses mood and also extinguishes healthy behaviors, leading to a pattern of avoidance, passive coping, and disruption of regular behavioral routines. BA addresses the depressed client’s reduced engagement in healthy behaviors through the scheduling of activities that increase opportunities for positive reinforcement.

The BA model emphasizes a contextual understanding of depression (Jacobson et al., 2001). Efforts are directed to understand the conditions in which an individual’s depression developed and the environmental factors that maintain and/or worsen the condition. BA assumes that the causes for depression lie in life circumstances rather than in intrapersonal factors or deficits. Thus, therapy focuses on the client’s ongoing life events and responses to those events. BA views depressive behavior as primarily avoidance behavior that is an attempt to cope with aversive emotions and life circumstances. BA also attends closely to the function of behavior (Jacobson et al., 2001; Martell et al., 2001, 2010). Behaviors are determined to be adaptive or maladaptive based on their effects on mood and future behavior. A functional analysis of behavior is, therefore, essential to BA and is explicitly taught to the client as a component of therapy.

In addition to the focus from earlier models on the role of low positive reinforcement, the BA model highlights the role of negative reinforcement of avoidance behavior in depression (Martell et al., 2001, 2010). To provide relief from the negative emotion that results from an environment with low rates of positive reinforcement, the depressed individual avoids activities, situations, and responsibilities. Although avoidance provides temporary relief, it ultimately sustains depression by preventing future opportunities for positive reinforcement and contributing to secondary problems that arise from avoiding responsibilities. As avoidance is negatively reinforced through a temporary reduction in negative affect, the depressed individual becomes increasingly fixed in a pattern of restricted, inactive, and passive behavior. BA explicitly addresses avoidance by teaching the client to recognize avoidance patterns and employ alternative coping strategies.

BA draws on acceptance-based approaches (Hayes, Strosahl, & Wilson, 1999), as it encourages the client to act despite low motivation, negative emotions, and desires to avoid (Martell et al., 2001, 2010). The BA therapist acknowledges lack of motivation and energy as common features of depression but coaches the client to work from the “outside-in” instead of the “inside-out,” with the rati...