Is Behavioral Activation Effective in Treating Depression?
Behavioral activation treatment is a behaviorally based treatment for depression that proposes that the internal factors often associated with the treatment of depression in such therapies as Cognitive Behavioral Therapy are not as important as the context or environmental conditions that foster depression.
What this means is that behavioral activation assumes that focusing on thoughts and irrational beliefs is not as effective as focusing on overt behavior or actions. Behavioral activation uses an applied behavioral analysis approach, which operates on behavioral learning principles and is implemented according to the principles of operant conditioning set forth by B.F. Skinner.
What Is Behavioral Activation?
Behavioral activation is a behaviorally focused approach that seeks to understand environmental sources that contribute to an individual’s depression. The basic approach is to have individuals who suffer from depression engage in positive and reinforcing activities as a means to treat their depression. The approach is basically half of the overall cognitive-behavioral approach to depression, such that the intense cognitive component is ignored and instead the behavioral component of the treatment is emphasized.
The behavioral analytic theory of depression was proposed in the early 1970s as an alternative to Freudian-based models of depression that were very prominent at the time. Behavioral activation treatment of depression was developed in the 1970s, and its main focus was to increase pleasant activities for individuals diagnosed with depression as opposed to having them focus on their beliefs, feelings, and other cognitive issues. However, the Cognitive Behavioral Therapy (CBT) approach became much more prominent in the late 1970s as originally publicized by high-level practitioners, such as Albert Ellis and Aaron Beck.
Despite the emphasis that is given to CBT, there are a number of research studies finding no differences in treatment outcomes between treatment with cognitive therapy, CBT, and behavioral activation. All of these techniques have been found very effective in treating clinical depression. These findings are consistent even in very stringent research methodologies such as meta-analysis. Meta-analysis is a statistical technique that combines the results of many different similar studies to determine if there is an overall treatment effect for a specific intervention. Meta-analytic research is considered to be more reliable and valid than the results of single studies. Meta-analytic studies have indicated that behavioral activation is a viable treatment for depression.
For example, a 2007 meta-analytic study reported in Clinical Psychology Review included 16 studies. There were large effects observed for behavioral activation techniques in its effectiveness for the treatment of clinical depression, and there were no differences between behavioral activation and cognitive therapy for depression in terms of treatment effectiveness. A 2009 meta-analytic study reported in the journal Clinical Psychology: Science and Practiceanalyzed 34 studies with over 2,000 total participants. Again, behavioral activation was found to be effective in the treatment of depression, and there were no differences regarding the treatment effectiveness of behavioral activation and cognitive therapy. Finally, a 2014 study reported in the journal PLoS ONE reported a meta-analysis of over 26 studies and 1,500 participants, indicating that behavioral activation was effective in the treatment of depression. Thus, the research does indicate that behavioral activation is an effective treatment for depression.
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Behavioral activation is based on the idea that as people become more depressed, they will also perform activities and behaviors that lead to avoidance and isolation. As these individuals become more isolated, they become more depressed, and as they become more depressed, they continue to engage in avoidance behaviors. This is a vicious cycle that can result in serious issues.
The goal of behavioral activation is to gradually assist these people in decreasing their movement toward isolation and avoidance, and to get them to become more active and perform activities that are known to enhance mood. Often, these are activities that the individual enjoyed before they became depressed. The activities vary from person to person and may include very simple activities, such as engaging in personal hygiene, showering, doing household chores, engaging in forms of exercise, taking classes, going out to dinner, or anything that the individual finds personally rewarding.
Since its original conception, behavioral activation has undergone a number of alterations in its theory and delivery. Many of the tenets of behavioral activation are explained in the book Overcoming Depression: One Step at a Time. Contemporary models of behavioral activation typically begin with assessing the individual’s level of depression, assessing any function or benefit that the individual receives from being depressed, and establishing rapport with the patient. Other functional activity, such as the amount of sleep the individual gets, their dietary habits, and any substance abuse, should also be assessed in this stage.
Once there is a full assessment and understanding of the individual’s condition, the behavioral activation program is implemented. There are a number of different models that can be used. In one model, patients are asked to create a list of positive activities from the easiest to most difficult to perform. The patient then begins to perform the easiest activities in an effort to deal with their depression, and they move up the hierarchy to the more difficult activities systematically. Performing more difficult but rewarding activities encourages the patient and helps relieve their depression. The patient’s progress is monitored throughout the process. Patients are seen multiple times per week by a therapist for short periods to monitor progress, check that they are engaging in the positive behaviors, and answer any questions or provide any encouragement. Over time, the individual’s depression is significantly reduced as a result of engaging in positively reinforcing activities.
The acronym ACTION is often used to describe the general process associated with behavioral activation:
- A: Assess behavior and mood.
- C: Choose a list of alternate reinforcing responses.
- T: Try out the alternate responses to make sure they will function properly.
- I: Integrate the behavioral alternatives into one’s routine.
- O: Observe the results of the program.
- N: Now evaluate the results as they relate to one’s goals.
In some cases, certain concrete goals are set, and the patients can collect tokens as they reach their goals. The tokens can be exchanged for certain types of rewards; in behavioral psychology, this process is often referred to as a token economy. The specific rewards/reinforcers will vary from individual to individual. Over time, individuals engaging in the behaviors experience a reduction in their depression.
A number of other methods using behavioral activation also exist; however, the general approach in behavioral activation is to use positively reinforcing activities to replace the symptoms of depression. It should be noted that behavioral activation is a formal form of psychotherapy and should only be attempted by trained and licensed therapists who are competent in the technique.
Any number of complications can occur in individuals with depression. Therefore, only licensed and trained therapists should use the technique. In addition, there are some caveats to using BA, outlined below.
- Individuals who are extremely depressed and suicidal may require more strict supervision and often require the use of medications and other treatments. These individuals require special considerations, and behavioral activation may not be appropriate for them.
- Individuals who have serious mental health disorders in addition to being depressed, such as substance use disorders, bipolar disorder, schizophrenia, post-traumatic stress disorder, etc., also need to be thoroughly assessed for their suitability to engage in behavioral activation.
- Many individuals with severe personality disorders suffer a component of depression along with aspects of their personality disorder. Many of these individuals may not be appropriate for behavioral activation unless it is accompanied by other forms of treatment suited for their mental health condition.
Thus, despite the relative simplicity of the paradigm, it is in fact a very complicated and difficult paradigm to implement effectively. In many instances, depression is accompanied by other mental health conditions that also need to be addressed. Any individual who wishes to seek treatment for depression should consult with a licensed professional mental health provider.