Question 1

If someone presents with depression, should you aim to activate first or focus on cognitions or both?

Carl Lejuez · Accepted Answer

I don't think there is one right answer to this and I am not aware of any data to suggest there is. I think it depends on the a) comfort level and word view of the patient, b) the personal circumstances of the patient, c) the theoretical perspective of the therapist, and d) the time available for therapy.

a) Some patients will prefer to get moving on tangible things they can do to recover and for them Id start with activating them with behavioral activation (BA) but for others they may have a strong belief that behavior change is only possible once they are thinking and feeling better in which case I'd start with a cognitive approach.

b) Some patients may be in situations where there is really limited access to opportunities to change behavior and in that case a cognitive approach may be best to start with while for others their situation really requires some tangible action sooner than later in which case BA may be best to start with.

c) The approach you start with can come down to simply your belief about what is the MECHANISM for change.  An extreme behaviorist (like me) believes that if you can impact the patient's behavior and their environment then you eventually will see cognitive and emotional changes over time while an extreme cognitivist believes that if you can change cognition you eventually will see emotional and behavioral changes (and an impact on the environment too). In both cases, all key parts of the equation eventually will change, so where one has a strong theoretical bent its reasonable to start there and consider another angle if its not working.

d) While there are some terrific brief cognitive therapies, i would argue that if time is limited, it might be best to start with BA - and particularly one of the briefer BA approaches.

Question 2

Does behavioral activation include working with values, or is it more about goals?

Carl Lejuez · Accepted Answer

One thing that differentiates behavioral activation from pleasant events from earlier work by Lewinsohn and others is that activities are linked to a higher-level category. In our original manual (Lejuez, Hopko, and Hopko, 2001), we referred to this higher-level category as goals. However, by our revised manual (https://www.researchgate.net/publication/49839614_Ten_Year_Revision_of_the_Brief_Behavioral_Activation_Treatment_for_Depression_Revised_Treatment_Manual), we realized that this higher-level category needed to be as personal, meaningful, and consistently a part of an individual’s life over time. To accommodate this change in thinking, we changed the name of the higher-level category from goals to values. I will add that for some patients, the idea of values can be hard to grasp. In those cases, it might be more useful (at least for a period of time) to simplify the approach and use the idea of goals to organize one’s activities. We discuss several key questions related to values in a paper that provides tips that do not appear in either manual (https://www.researchgate.net/publication/301343109_Therapist_tips_for_the_brief_behavioural_activation_therapy_for_depression_-_Revised_BATD-R_treatment_manual_practical_wisdom_and_clinical_nuance).

Question 3

What is the key target (or mechanism of change) when using BA for depression?

Carl Lejuez · Accepted Answer

As a behaviourist, I would say it’s the change in the way the individual interacts with their environment. This will then lead to further changes in behaviour as well as thoughts and feelings which are all important – but the mechanism is the interaction and change in the interaction with the environment. In fairness, I should also say that one could very easily argue that the mechanism is the change in thoughts or feelings, and the change in behaviour and the interaction with the environment is just a step towards activating that more cognitive mechanism. At this time, we don’t have data to tell us which is right, and research must move beyond just showing an intervention works to testing mediators to show why it works. Until that time, I have chosen to rely on behavioural theory, which led to a focus on behaviour change and not cognitive strategies – but it's important for me to be clear that at this time, we don’t really know.

Question 4

Is BA effective as a standalone treatment for depression, even without the inclusion of cognitive therapy?

Carl Lejuez · Accepted Answer

The short answer is yes!

In case you are interested, here is the long answer:

One of the earliest studies pointing to the efficacy of a behavioral activation (BA) approach to treating depression without a cognitive component was the work of Jacobson et al (1996). In a randomized control trial of adult outpatients diagnosed with major depression, Jacobson et al (1996) compared the treatment outcomes of cognitive-behavioral therapy (CBT) for depression with treatment outcomes for its individual components—activity scheduling and the modification of automatic thoughts. Jacobson et al (1996) randomly assigned participants to one of three treatment conditions: one comprised exclusively of activity scheduling, one comprised of the modification of automatic thoughts, and one comprised of the complete CBT treatment. The results of the study demonstrated that the behavioral component alone was as effective as the complete CBT treatment for depression (Jacobson et al, 1996), and this outcome was maintained through a six-month follow up (Jacobson et al, 1996). While these findings called into question the modification of core schema as the primary change mechanism in CBT, they also paved the way for the reemergence of BA as a viable, stand-alone treatment for depression (Dimidjian et al, 2011; Jacobson et al, 1996).

BA is now considered an evidence-based treatment for depression due to accumulated empirical studies demonstrating its effectiveness in reducing depression symptoms (Cuijpers, van Straten and Warmerdam, 2007; Dimidjian et al, 2006; Dobson et al, 2008; Ekers, Richards and Gilbody, 2008; Mazzucchelli, Kane and Rees, 2009; Sturmey, 2009). In a meta-analysis of 16 studies that examined the efficacy of activity scheduling for the treatment of depression, Cuijpers et al (2007) reported a pooled effect size of 0.87, indicating a large difference between the treatment outcomes for activity scheduling as compared to control. Activity scheduling performed similarly to other evidence-based psychological interventions in the treatment of depression (Cuijpers et al, 2007). In a meta-analysis of 34 studies, Mazzucchelli et al (2009) reported a pooled effect size of 0.78 for BA as compared to controls for participants presenting with depression symptoms, and a pooled effect size of 0.74 for BA as compared to controls for participants who met diagnostic criteria for major depressive disorder. In this meta-analysis, there was again no significant difference between BA and a full CBT package for the treatment of depression (Mazzucchelli et al, 2009). Another meta-analysis of 17 randomized controlled trials (RCTs) of BA found it more effective than controls , brief psychotherapy, and supportive therapy , and equal in efficacy to cognitive-behavioral therapy for the treatment of depression (Ekers et al, 2008). In a similar review of the literature on the use of BA for depression, Sturmey (2009) concluded that BA was consistently more effective in treating depression compared to waitlist and treatment-as-usual controls, and equally as effective as cognitive therapy or CBT for depression based upon empirical support from three meta-analyses (Cuijpers et al, 2007; Cuijpers, van Straten, Andersson and van Oppen, 2008; Ekers et al, 2008). Sturmey (2009) pointed to this accumulation of empirical evidence on BA as justification for its classification as an evidence-based treatment for depression.

Now with all that said, it doesn't mean you cant or shouldn't combine with BA with other approaches including cognitive therapy. It really depends on the time available in therapy and what works for the therapist and patient. So, its absolutely reasonable to use BA as a stand alone treatment but nothing should stop its combination with other approaches by a therapist with skill in each intervention.

References

Cuijpers, P., van Straten, A., Andersson, G., and van Oppen, P. (2008). ‘Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies’, Journal of Consulting and Clinical Psychology, 76(6), pp. 909–922.

Cuijpers, P., van Straten, A., and Warmerdam, L. (2007). ‘Behavioral activation treatments of depression: a meta-analysis’, Clinical Psychology Review, 27(3), pp. 318–326.

Dimidjian, S., Barrera, M., Martell, C., Muñoz, R.F., and Lewinsohn, P.M. (2011). ‘The origins and current status of behavioral activation treatments for depression’, Annual Review of Clinical Psychology, 7, pp. 1-38.

Dimidjian, S., Hollon, S.D., Dobson, K.S., Schmaling, K.B., Kohlenberg, RJ., Addis, M.E., Gallop, R., McGlinchey, J.B., Markley, D.K., Gollan, J.K., Atkins, D.C., Dunner, D.L, and Jacobson, N.S. (2006). ‘Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression’, Journal of Consulting and Clinical Psychology, 74(4), 658-670.

Dobson, K.S., Hollon, S.D., Dimidjian, S., Schmaling, K.B., Kohlenberg, R.J., Gallop, R., Rizvi, S.L., Gollan, J.K., Dunner, D.L., and Jacobson, N.S. (2008). ‘Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression’, Journal of Consulting and Clinical Psychology, 76(3), 468-477.

Ekers, D., Richards, D., and Gilbody, S. (2008). ‘A meta-analysis of randomized trials of behavioural treatment of depression’, Psychological Medicine, 38(5), pp. 611–623.

Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Koerner, K., Gollan, J.K., Gortner, E., and Prince, S.E. (1996). ‘A component analysis of cognitive-behavioral treatment for depression’, Journal of Consulting and Clinical Psychology, 64(2), pp. 295-304.

Mazzucchelli, T., Kane, R., and Rees, C. (2009). ‘Behavioral activation treatments for depression in adults: a meta-analysis and review’, PubMed Health, 16(4), pp. 383-411.

Sturmey, P. (2009). ‘Behavioral activation is an evidence-based treatment for depression’, Behavior Modification, 33(6), pp. 818-829.

Question 5

I find behavioural activation so challenging. Especially when trying to convey empathy and at the same time finding a way to push clients. What would be your best tip for getting started?

Carl Lejuez · Accepted Answer

I have found the introduction and weekly review of monitoring can really impact the connection between the therapist and client, including the opportunity to develop and show empathy for the client. As we outline in a paper that provides tips that do not appear in either manual (https://www.researchgate.net/publication/301343109_Therapist_tips_for_the_brief_behavioural_activation_therapy_for_depression_-_Revised_BATD-R_treatment_manual_practical_wisdom_and_clinical_nuance), it starts from the very first time monitoring is mentioned. In our earlier work, we discussed (and often approached) monitoring as homework without a lot of attention to building personal meaning behind it. We came to understand that it wasn’t really homework, but instead an opportunity for a client to share with the therapist so much of what their life is like outside of therapy that there simply isn’t time to address in session. This then conveys further in weekly review such that the therapist can really use this time to fully step into the shoes of the client outside of session and get to know them and their struggles and successes better. It means a much longer time spent reviewing monitoring at the start of each session, but the resulting stronger connection and understanding that results feels well worth the time. Once we started to view this part of the therapy to be as much about connecting with and understanding the client, and not just simply the first step of behavioural activation, it really changed our ability to build empathy and also build motivation for the client in completing monitoring.

Behavioral Activation for Depression