Behavioral Activation

Summary

Behavioral activation was developed as a specific CBT for depression, for which it has shown to be a very effective treatment in numerous clinical trials. Its principles can be used in every cognitive behavior therapy where low mood plays a role. Behavioral activation is based on the understanding that depression develops because the patient is less and less in contact with experiences that gives him or her a sense of pleasure, competence or fulfillment, leading to feelings of emptiness, low mood and inactivity. The core principle of behavioral activation is therefore to help the patient more actively engage with life again. This is done through the reintroducing of positively reinforcing experiences in the patient’s life (which one can call “natural antidepressants”). The role of the therapist is to be engaging, supporting and focused on helping the patient identify and implement activities and experiences that are meaningful and valued in his or her life.

Background

Behavioral activation has its roots in early behavioral approaches for depression (Charles Ferster, Peter Lewinsohn) that was eventually incorporated into Aaron Beck’s cognitive therapy for depression. Beck’s therapy was an early example showing that a “talking therapy” could be an effective treatment for clinical depression, and one could say that it actually established CBT as a proper psychotherapy, starting its dissemination within psychiatry and mental health. In the 1990s, a series of clinical trials were performed that showed that behavioral activation alone was as effective as the whole “package” of cognitive therapy (including its module on behavioral activation). The clinical researchers behind these studies (Neil Jacobson, Christopher Martell, Michael Addis and Sona Dimidjian) then conceived of Behavioral Activation as a contextual, behavioral psychotherapy for depression in its own right. It is considered to be part of the so called “third wave of CBT” (see separate article).

Core principles

Behavioral Activation is based on learning theory and on a functional analysis (see separate article) of depression. That means that it is not, as cognitive therapy, primarily focused on how the patient thinks about (interprets) events in life, but rather focuses on what the patient does (or does not do) and how this affects his or her mood. It is thus based on the empirical observation that depressed patients are often relatively passive or have a low degree of experiences that they value or that procure them pleasure or fulfillment. In functional terms, this means that the patient is less and less in contact with positively reinforcing experiences, leading to feelings of emptiness, low mood and inactivity.

The overarching principle of Behavioral Activation is therefore to help the patient engage more actively with life again. This is done through the gradually reintroducing of positively reinforcing (“naturally antidepressant”) experiences in the patient’s life. The role of the therapist is to be engaging, supporting and focused on helping the patient identify and implement activities and experiences that are meaningful and valued in his or her life.

Establishing the link between behavior and emotions

The first principle in therapy is to help the patient observe his or her everyday life and to enable him or her to see the link between what _she does_ (or does not do) and how _she feels_. This link is usually obvious for the non-depressed person and the family or entourage of the patient. It is however an empirical fact that the depressed person (especially the more severely depressed) partly or completely loses the ability to perceive this link. A common subjective experience of the depressed person is that he or she is like a “leaf in the wind” – that is, that he or she is not at all in control of how she feels, in essence that her depression would be solely caused by external factors (what is called an “external locus of control”). If it is true that depression is often preceded by what epidemiological studies of depression call “major negative life events” (such as loss of employment or close relationship or somatic illness), what distinguishes those that develop depression compared to others with similar life experiences is that the depressed person reacts to the negative emotions caused by the event in an avoidant way (for instance by engaging less in certain everyday activities, like social activities).

That is, what Behavioral Activation helps the patient to see is that the often rather passive behavior patterns in his or her everyday life (often lonely “pastime” activities like watching TV or social media, instead of reaching out or opening up to a friend, or not seeking out new meaningful activities) _maintains_ low mood, and hinders the patient to experience the positive reinforcement in for instance the moral support of a friend or a meaningful family activity. This can be done by giving the patient the homework of noticing and writing down what he or she does during the week and its related feeling (in a so called “activity schedule” – see Clinical tool page).

Introducing new elements to everyday life

The second principle in Behavioral Activation is therefore to introduce such positively reinforcing experiences, that the patient has lost sight of. To identify such activities, it is useful to help the patient see what he or she did in her everyday life _before_ she became depressed (that is, what experiences in the patient’s everyday life that has been lost). Apart from previous activities, it is also helpful to guide the patient in finding _new_ goals, that they wish to introduce in their life (see separate article on Goal formulation).

As soon as these goals have been identified, the task is to introduce them in the activity schedule for the coming week. An example: “You said that an important goal for you is to be a parent that is more present in your child’s life and have more ‘quality time’ with him, and that one specific goal could be to drive your son to football practice or play ball with him next to your house. When could you do that this coming week?”)

During this active phase of therapy, it is continuously important to help the patient observe what she does and what impact it has on her mood. When patients reengage with everyday activities that are meaningful to them, and when they pursues goals in life that really matter to them, they will gradually become less and less depressed.

Challenges in Behavioral activation

If the patient consistently, over several Behavioral Activation-exercises, does not report a change in mood related to those experiences, it is most probably due to subtle avoidance during the activity. The most common type of such avoidance is rumination (repeated negative thinking). If the person ruminates heavily during his ‘quality time’ with his child (not fully engaging with the child but staying a bit withdrawn while ruminating about “How bad of a father he is”), or doing something similar during time spent with cherished friends (“They are more successful than me, I’m a loser”) he or she is not _really_ engaging in the experience, which will hinder its anti-depressant effect. One could say that the patient is physically present but psychologically absent (avoiding). The role of the therapist is to help the patient identify such subtle avoidance behaviors, and to help him or her to change this pattern (Therapist: “It seems like you withdraw into yourself when you are with your friends. Next time, could you try to be more fully present, and talk about things that are meaningful to you?”) Relatively often, rumination also occurs during a therapy session, which is a good occasion for the therapist to help the patient see what he or she is doing (not being fully present in therapy) and guides her to engage in the present moment (Therapist: “When I look you in the eyes now, it feels like you’re not really there… Are you ruminating now? I know it’s difficult, but try to come back to me now when we’re talking. What could be something important for you that we could focus on now together?”)

Active depression and emotional avoidance

The negative effects of rumination and of other subtle depressive avoidance can also explain what has been called atypical or “active” depression: That is, when the person is not typically withdrawn or passive, but has a rather active social life and a full everyday agenda. In a sub-group of patients, this is the case, and what can be seen when the activities and experiences are functionally analyzed closer, is usually the pattern of being physically active but psychologically detached, as was described above (often because of heavy rumination). The goal of Behavioral Activation with such patients stays the same (to introduce more positively reinforcing experiences in the patient’s life), but the therapy will also have to include a more subtle analysis of what the patient actually does, also in his or her mind, in the many everyday situations that “should” be reinforcing for her. Much of these are things that the patient does that could be called emotional or interpersonal avoidance: The depressed person is socially active, but emotionally distant and doesn’t really engage in an authentic way in interpersonal relations (he or she often says that she “wears like a mask” with others). This is particularly common when depression becomes chronic. The specific evidence-based CBT for chronic depression is called CBASP (Cognitive Behavioral Analysis System of Psychotherapy), which could be considered as an “Interpersonal behavioral activation”.

What we just highlighted underscores that all Behavioral Activation is actually not about what the patients does, but rather about the function of what the patient does. If the patient is busy with a lot of everyday activities whose primary function is to “feel less bad”, “holding up a mask” or just being temporarily distracted from low mood, he or she will stay depressed.

Again, all Behavioral Activation sets out to help the patient find experiences that are truly meaningful for him or her. This is closely linked to value-based goals (see specific article).

Behavioral Activation has strong empirical support. Its effect has been shown in several clinical studies, where a majority of patients are no longer clinically depressed after therapy. The effect of treatment also seems to be maintained over time. This is also important to convey to the depressed patient: As a therapist, you will have to maintain the hope that the patient has lost.