Behavioral activation
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Behavioral activation (BA) is a third generation
behavior therapy Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or oth ...
for treating depression. It is one form of
functional analytic psychotherapy Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session continge ...
, which is based on a
Skinnerian Burrhus Frederic Skinner (March 20, 1904 – August 18, 1990) was an American psychologist, behaviorist, author, inventor, and social philosopher. He was a professor of psychology at Harvard University from 1958 until his retirement in 1974. C ...
psychological model of behavior change, generally referred to as
applied behavior analysis Applied behavior analysis (ABA), also called behavioral engineering, is a psychological intervention that applies empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. ...
. This area is also a part of what is called
clinical behavior analysis Clinical Behavior Analysis is one of several ABA subspecialty fact sheets produced by the BACB in partnership with subject matter experts (SMEs). Clinical behavior analysis (CBA; also called clinical behaviour analysis or third-generation behavior ...
(CBA) and makes up one of the most effective practices in the professional practice of behavior analysis. The technique can also be used from a
cognitive-behavior therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (su ...
framework.


Overview

The Beck Institute describes BA as ''"getting clients more active and involved in life by scheduling activities that have the potential to improve their mood."''


Theoretical underpinnings

Behavioral activation emerged from a component analysis of
cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
. This analysis found that any cognitive component added little to the overall treatment of depression. The behavioral component had existed as a stand-alone treatment in the early work of Peter Lewinsohn and thus a group of
behaviorists Behaviorism is a systematic approach to understanding the behavior of humans and animals. It assumes that behavior is either a reflex evoked by the pairing of certain antecedent stimuli in the environment, or a consequence of that individual' ...
decided that it might be more efficient to pursue a purer behavioral treatment for the disorder. The theory holds that not enough environmental reinforcement or too much environmental
punishment Punishment, commonly, is the imposition of an undesirable or unpleasant outcome upon a group or individual, meted out by an authority—in contexts ranging from child discipline to criminal law—as a response and deterrent to a particular acti ...
can contribute to depression. The goal of the intervention is to increase environmental reinforcement and reduce punishment. The theoretical underpinnings of behavioral activation for depression is
Charles Ferster Charles Bohris Ferster (1 November 1922 – 3 February 1981) was an American behavioral psychologist. A pioneer of applied behavior analysis, he developed errorless learning and was a colleague of B.F. Skinner's at Harvard University, co-authorin ...
's
functional analysis Functional analysis is a branch of mathematical analysis, the core of which is formed by the study of vector spaces endowed with some kind of limit-related structure (e.g. Inner product space#Definition, inner product, Norm (mathematics)#Defini ...
of depression. Ferster's basic model has been strengthened by further development in the study of reinforcement principles which led to the
matching law In operant conditioning, the matching law is a quantitative relationship that holds between the relative rates of response and the relative rates of reinforcement in concurrent schedules of reinforcement. For example, if two response alternatives A ...
and continuing theoretical advances in the possible functions of depression, as well as a look at behavior analysis of child development in order to determine long-term patterns which may lead to
dysthymia Dysthymia ( ), also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with lon ...
.


Methods

One behavioral activation (BA) approach to depression was as follows: participants were asked to create a hierarchy of reinforcing activities which were then rank-ordered by difficulty; participants tracked their own goals along with clinicians who used a
token economy A token economy is a system of contingency management based on the systematic reinforcement of target behavior. The reinforcers are symbols or tokens that can be exchanged for other reinforcers. A token economy is based on the principles of op ...
to reinforce success in moving through the hierarchy of activities; participants were measured before and after by the
Beck Depression Inventory The Beck Depression Inventory (BDI, BDI-1A, BDI-II), created by Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. Its development mark ...
(BDI) and a great effect on their depression was found as a result of their treatment. This was then compared to a control group who did not receive the same treatment. The results of those who received behavioral activation treatment were markedly superior to those of the persons in the control group. Multiple clinics have since piloted and developed the treatment. Another behavioral activation approach utilized a different methodology: clients are asked to develop an understanding of the relationship between actions and emotions, with actions being seen as the cause of emotions. An hourly self-monitoring chart is created to track activities and the impact on the mood they create for a full week. A rating scale from 1 to 10 is used for each mood change per hour. The goal is to identify depression loops. A depression loop is when a temporary coping method reduces the overall depression, such as the temporary relief provided by alcohol or other drugs, escape or avoidance or rumination. When patterns of dysfunctional responding, or loops, are identified alternative coping responses are attempted to break the loop. This method is described with the acronym "TRAP" (Trigger, Response, Avoidance Pattern) which is to be replaced with a "TRAC" (Trigger, Response, Alternate Coping response). Particular attention is given to rumination, which is provided with its own acronym RCA (Rumination Cues Action). Rumination is identified as a particularly common avoidance behavior which worsens mood. The client is to evaluate the rumination in terms of it having improved the thing being ruminated about, providing understanding, and its emotional effects on the client. Attending to experience is suggested as an alternative to rumination as well as other possible distracting or mood improving actions. The general program is described with the acronym ACTION (Assess behavior/mood, Choose alternate responses, Try out those alternate responses, Integrate these alternatives, Observe results and (Now) evaluate). The goal being the understanding of the relationship between actions and emotional consequences and a systematic replacement of dysfunctional patterns with adaptive ones. Additionally, focus is given to quality sleep, and improving social functioning.


Research support


Depression

Reviews of behavioral activation studies for depression found that it has a robust effect and that policy makers should consider it an effective treatment. A large-scale treatment study found behavioral activation to be more effective than cognitive therapy and on par with medication for treating depression. A meta-analysis study comprising 34 Randomized Controlled Trials found that while Behavioral Activation treatment of adults with depression showed significantly greater beneficial effect compared with control participants, compared to participants treated with CT/CBT, at post treatment there were no statistically significant differences between treatment groups. Another meta-analysis comprising 25 Randomized Controlled Trials found a large effect size for behavioral activation compared to controls at post-treatment. A 2009 meta-analysis showed a medium post-treatment effect size compared to psychotherapy and other treatments.


Anxiety

A 2006 study of behavioral activation being applied to anxiety appeared to give promising results. One study found it to be effective with fibromyalgia-related pain anxiety.


In the context of third generation behavior therapies

Behavioral activation comes under the heading
clinical behavior analysis Clinical Behavior Analysis is one of several ABA subspecialty fact sheets produced by the BACB in partnership with subject matter experts (SMEs). Clinical behavior analysis (CBA; also called clinical behaviour analysis or third-generation behavior ...
or what is often termed third generation
behavior therapy Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or oth ...
. Other behavior therapies are
acceptance and commitment therapy Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of psychotherapy, as well as a branch of clinical behavior analysis. It is an empirically based psychological intervention that uses acceptance and mindfu ...
(ACT), as well as dialectical behavior therapy (DBT) and
functional analytic psychotherapy Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session continge ...
(FAP). Behavioral activation owes its basis to
Charles Ferster Charles Bohris Ferster (1 November 1922 – 3 February 1981) was an American behavioral psychologist. A pioneer of applied behavior analysis, he developed errorless learning and was a colleague of B.F. Skinner's at Harvard University, co-authorin ...
's ''Functional Analysis of Depression'' (1973) which developed B.F. Skinner's idea of depression, within his analysis of motivation, as a lack of reinforcement.


Professional organizations

The
Association for Behavior Analysis International The Association for Behavior Analysis International (ABAI) is a nonprofit organization dedicated to promoting behavior analysis. The organization has over 9,000 members. The group organizes conferences and publishes journals on the topic of appl ...
has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis. The association has larger special interest groups for behavioral medicine. It also serves as the core intellectual home for behavior analysts. The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. Doctoral level behavior analysts who are psychologists belong to the
American Psychological Association The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States, with over 133,000 members, including scientists, educators, clinicians, consultants, and students. It ha ...
's division 25— Behavior analysis. APA offers a diplomate in behavioral psychology.


BA in Virtual Reality

Due to a lack of access to trained providers, physical constraints or financial reasons, many patients are not able to attend BA therapy. Researchers are trying to overcome these challenges by providing BA via
Virtual Reality Virtual reality (VR) is a simulated experience that employs pose tracking and 3D near-eye displays to give the user an immersive feel of a virtual world. Applications of virtual reality include entertainment (particularly video games), educ ...
. The idea of the concept is to enable especially elderly adults to participate in engaging activities that they would not attend it without VR. Possibly, the so-called "BA-inspired VR protocols" will mitigate the lower mood, life satisfaction, and likelihood of depressions.


References

{{DEFAULTSORT:Behavioral Activation Behavior therapy Behavior modification Cognitive behavioral therapy Depression (mood)