Behavioral activation

Behavioral activation is a form of clinical behavior analysis, which is also known as third-generation behavior therapy. Other behavior therapies are acceptance and commitment therapy, dialectical behavior therapy and functional analytic psychotherapy. BA can be integrated into other psychotherapies, and its inclusion in these third-generation therapies reflects its effectiveness and versatility in addressing psychological challenges from different angles. Behavioral activation owes its basis to Charles Ferster'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.{{cite journal | vauthors = Ferster CB | title = A functional anlysis of depression | journal = The American Psychologist | volume = 28 | issue = 10 | pages = 857–870 | date = October 1973 | pmid = 4753644 | doi = 10.1037/h0035605 }}

Ferster's basic model has been strengthened by further development in the study of reinforcement principles which led to the matching law and continuing theoretical advances in the possible functions of depression,{{cite journal |vauthors=Kanter JW, Cautilli JD, Busch AM, Baruch DE |date=2011 |title=Toward a comprehensive functional analysis of depressive behavior: Five environmental factors and a possible sixth and seventh. |journal=International Journal of Behavioral Consultation and Therapy |volume=7 |issue=1 |pages=5–14 |doi=10.1037/h0100920}} as well as a look at behavior analysis of child development in order to determine long-term patterns which may lead to dysthymia. Behavioral activation utilizes positive reinforcements to increase good behavior and reduces negative outcomes from avoidance in order to increase an individual's self-control and personal regulation.{{cite journal |vauthors=Jacobson NS, Martell CR, Dimidjian S |date=2001 |title=Behavioral activation treatment for depression: returning to contextual roots. |journal=Clinical Psychology: Science and Practice |volume=8 |issue=3 |pages=255–270 |doi=10.1093/clipsy.8.3.255}}{{cite journal | vauthors = Boswell JF, Iles BR, Gallagher MW, Farchione TJ | title = Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders | journal = Psychotherapy | volume = 54 | issue = 3 | pages = 231–236 | date = September 2017 | pmid = 28922003 | doi = 10.1037/pst0000119 }}{{cite journal | vauthors = Ferster CB | title = A functional anlysis of depression | journal = The American Psychologist | volume = 28 | issue = 10 | pages = 857–870 | date = October 1973 | pmid = 4753644 | doi = 10.1037/h0035605 }}{{cite journal |vauthors=Kanter JW, Callaghan GM, Landes SJ, Busch AM, Brown KR |date=2004 |title=Behavior analytic conceptualization and treatment of depression: Traditional models and recent advances. |journal=The Behavior Analyst Today |volume=5 |issue=3 |pages=255–274 |doi=10.1037/h0100041}}{{cite book |title=Depression in context: Strategies for guided action. |vauthors=Martell CR, Addis ME, Jacobson NS |date=2001 |publisher=W. W. Norton |location=New York}}

Behavioral activation emerged from a component analysis of cognitive behavioral therapy. This analysis found that any cognitive component added little to the overall treatment of depression.{{cite journal | vauthors = Jacobson NS, Dobson KS, Truax PA, Addis ME, Koerner K, Gollan JK, Gortner E, Prince SE | title = A component analysis of cognitive-behavioral treatment for depression | journal = Journal of Consulting and Clinical Psychology | volume = 64 | issue = 2 | pages = 295–304 | date = April 1996 | pmid = 8871414 | doi = 10.1037/0022-006X.64.2.295 | s2cid = 6052170 }} The behavioral component had existed as a standalone treatment in the early work of Peter Lewinsohn and thus a group of behaviorists decided that it might be more efficient to pursue a purer behavioral treatment for the disorder.{{cite book |title=Progress in behavioral modification |vauthors=Lewinsohn PM |date=1975 |publisher=Academic |isbn=978-0-12-535601-5 |veditors=Hersen M, Eisler RM, Miller PM |series=Progress in Behavior Modification |volume=1 |location=New York |pages=19–65 |chapter=The behavioral study and treatment of depression. |doi=10.1016/B978-0-12-535601-5.50009-3}} The theory holds that not enough environmental reinforcement or too much environmental punishment can contribute to depression. The goal of the intervention is to increase environmental reinforcement and reduce punishment.

One behavioral activation approach to depression had participants create a hierarchy of reinforcing activities, rank-ordered by difficulty. Participants then tracked goals along with clinicians who used a token economy to reinforce success in moving through the hierarchy of activities, being measured before and after by the Beck Depression Inventory. A markedly greater effect on their depression was found as a result of their treatment, as compared to a control group who did not receive the same treatment.{{cite journal | vauthors = Hopko DR, Lejuez CW, LePage JP, Hopko SD, McNeil DW | title = A brief behavioral activation treatment for depression. A randomized pilot trial within an inpatient psychiatric hospital | journal = Behavior Modification | volume = 27 | issue = 4 | pages = 458–469 | date = September 2003 | pmid = 12971122 | doi = 10.1177/0145445503255489 | url = http://web.utk.edu/~dhopko/BAinpatient.pdf | s2cid = 30950124 | archive-url = https://web.archive.org/web/20150402162244/http://web.utk.edu/~dhopko/BAinpatient.pdf | archive-date = 2 April 2015 }} Multiple clinics have since piloted and developed the method of treatment.{{cite journal | vauthors = Cullen JM, Spates CR, Pagoto S, Doran N | title = Behavioral activation treatment for major depressive disorder: A pilot investigation. | journal = The Behavior Analyst Today | date = 2006 | volume = 7 | issue = 1 | pages = 151–165 | doi = 10.1037/h0100150 | s2cid = 41079284 | url = https://escholarship.umassmed.edu/prevbeh_pp/112 }}{{cite journal | vauthors = Spates CR, Pagoto SL, Kalata A | title = A qualitative and quantitative review of behavioral activation treatment of major depressive disorder. | journal = The Behavior Analyst Today | date = 2006 | volume = 7 | issue = 4 | pages = 508–518 | doi = 10.1037/h0100089 | s2cid = 3337916 | url = https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1106&context=prevbeh_pp }}

Another behavioral activation approach is known as ACTION (Assess behavior/mood, Choose alternate responses, Try out those alternate responses, Integrate these alternatives, Observe results and (Now) evaluate).{{rp|74}} The goal of ACTION is 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.{{rp|117}}

The ACTION method has clients develop an understanding of the relationship between actions and emotions, with actions being seen as the cause of emotions.{{cite book | vauthors = Addis ME, Martell CR | title = Overcoming depression one step at a time: The new behavioral activation approach to getting your life back. | publisher = New Harbinger Publications, Incorporated | date = 2004 | isbn = 978-1-57224-367-5 }}{{rp|21}} An hourly self-monitoring chart is created to track activities and the impact on the mood they create for a full week, with the intention of identifying depression loops.{{rp|37}} When patterns of dysfunctional responding, or loops, are identified, alternative coping responses are attempted to break the loop.{{rp|39}} This method is described with the acronyms "TRAP" (Trigger, Response, Avoidance Pattern) and "TRAC" (Trigger, Response, Alternate Coping response). As rumination is identified as a particularly common avoidance behavior which worsens mood, another common acronym is RCA (Rumination Cues Action).{{rp|97}} 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.{{rp|101}}

Reviews of behavioral activation studies for depression found that it had a positive measurable effect and that policy makers should consider it an effective treatment.{{cite journal | vauthors = Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S | title = Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis | journal = PLOS ONE | volume = 9 | issue = 6 | pages = e100100 | date = 2014-06-17 | pmid = 24936656 | pmc = 4061095 | doi = 10.1371/journal.pone.0100100 | doi-access = free | bibcode = 2014PLoSO...9j0100E }} A large-scale treatment study found behavioral activation to be more effective than cognitive therapy and on par with medication for treating depression.{{cite journal | vauthors = Dimidjian S, Hollon SD, Dobson KS, Schmaling KB, Kohlenberg RJ, Addis ME, Gallop R, McGlinchey JB, Markley DK, Gollan JK, Atkins DC, Dunner DL, Jacobson NS | title = Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression | journal = Journal of Consulting and Clinical Psychology | volume = 74 | issue = 4 | pages = 658–670 | date = August 2006 | pmid = 16881773 | doi = 10.1037/0022-006X.74.4.658 | s2cid = 31098108 }} 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.{{cite journal | vauthors = Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S | title = Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis | journal = PLOS ONE | volume = 9 | issue = 6 | pages = e100100 | date = 2014-06-17 | pmid = 24936656 | pmc = 4061095 | doi = 10.1371/journal.pone.0100100 | doi-access = free | bibcode = 2014PLoSO...9j0100E }} A 2009 meta-analysis showed a medium post-treatment effect size compared to psychotherapy and other treatments.{{cite web | vauthors = Mazzucchelli T, Kane R, Rees C | work = Centre for Reviews and Dissemination | publisher = University of York |url=http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?AccessionNumber=12010001298|title=Behavioral activation treatments for depression in adults: a meta-analysis and review |access-date=2016-03-08}} In a 2020 Cochrane review covering fifty-three studies and 5495 subjects it was suggested (limited confidence) that behavioral activation was more effective than treatment as usual and medication and no less effective than CBT, psychodynamic therapy or being placed on a waiting list.{{cite journal | vauthors = Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, Samaan Z, Richards D, Meader N, Churchill R | title = Behavioural activation therapy for depression in adults | journal = The Cochrane Database of Systematic Reviews | volume = 7 | issue = 7 | pages = CD013305 | date = July 2020 | pmid = 32628293 | pmc = 7390059 | doi = 10.1002/14651858.CD013305.pub2 | collaboration = Cochrane Common Mental Disorders Group }} A meta-analysis from 2017 showed that behavioral activation can reduce depressive symptoms in older adults.Orgeta, V., Brede, J., & Livingston, G. (2017). Behavioural activation for depression in older people: Systematic review and meta-analysis. The British Journal of Psychiatry, 211(5), 274–279. https://doi-org.ezproxy.its.uu.se/10.1192/bjp.bp.117.205021

Behavioral activation strategies are utilized for clients who primarily experience anxiety. The core focus of these strategies is to address and disrupt patterns of anxious avoidance, which can often manifest as excessive worry. The ultimate goal is to motivate and encourage clients to actively engage in rewarding experiences and positive behaviors.{{cite journal | vauthors = Boswell JF, Iles BR, Gallagher MW, Farchione TJ | title = Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders | journal = Psychotherapy | volume = 54 | issue = 3 | pages = 231–236 | date = September 2017 | pmid = 28922003 | doi = 10.1037/pst0000119 | id = {{ProQuest|1940533236}} }} A 2006 study of behavioral activation being applied to anxiety appeared to give promising results.{{cite journal | vauthors = Hopko DR, Robertson S, Lejuez CW | title = Behavioral activation for anxiety disorders. | journal = The Behavior Analyst Today | date = 2006 | volume = 7 | issue = 2 | pages = 212–224 | doi = 10.1037/h0100084 }} One study found it to be effective with fibromyalgia-related pain anxiety.{{cite journal | vauthors = Lundervold DA, Talley C, Buermann M | title = Effect of Behavioral Activation Treatment on fibromyalgia-related pain anxiety cognition. | journal = International Journal of Behavioral Consultation and Therapy | date = 2006 | volume = 2 | issue = 1 | pages = 73–78 | doi = 10.1037/h0100768 }} In another, researchers observed a notable improvement in the quality of life and a reduction in anxiety levels as a result of BA treatment.{{cite journal | vauthors = Hopko DR, Robertson S, Lejuez CW |date=2006 |title=Behavioral activation for anxiety disorders. |url=http://doi.apa.org/getdoi.cfm?doi=10.1037/h0100084 |journal=The Behavior Analyst Today |language=en |volume=7 |issue=2 |pages=212–232 |doi=10.1037/h0100084 |issn=1539-4352|url-access=subscription }}

Due to a lack of access to trained providers, physical constraints or financial reasons, many patients are not able to attend BA therapy.{{cite web | author = Virtual Human Interaction LAB, Stanford University |title=Medical Virtual Reality |url=https://vhil.stanford.edu/projects/2020/medical-virtual-reality-research/ |website=VHIL.Stanford |date=February 20, 2020 |publisher=VHIL LAB |access-date=20 November 2020}} Researchers are trying to overcome these challenges by providing BA via Virtual Reality. 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.

One strategy is exposure therapy, VR can be utilized to create realistic and controlled environments where individuals can gradually confront situations that trigger anxiety or avoidance. By exposing individuals to these situations in a virtual setting, therapists can help them develop more adaptive coping strategies and reduce anxiety.{{cite journal | vauthors = Paul M, Bullock K, Bailenson J | title = Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial | journal = JMIR Mental Health | volume = 9 | issue = 5 | pages = e35526 | date = May 2022 | pmid = 35404830 | pmc = 9123544 | doi = 10.2196/35526 | doi-access = free }} Another strategy is through role-playing and social skills training, VR environments can be used to facilitate role-playing exercises, helping individuals practice and improve their social skills and interactions in a safe and non-threatening space.

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Category:Behavior therapy

Category:Behavior modification

Category:Cognitive behavioral therapy

Category:Depression (mood)