Behavioral Activation Running head: behavioral activation



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Behavioral Activation

Running head: BEHAVIORAL ACTIVATION

Behavioral Activation

Derek R. Hopko, Marlena M. Ryba, Crystal McIndoo, Audrey File



The University of Tennessee - Knoxville

Hopko, D. R., Ryba, M. M., McIndoo, C., & File, A. (in press) Behavioral Activation. In A. M. Nezu and C. M. Nezu (Eds.), The Oxford Handbook of Cognitive and Behavioral Therapies. New York: Oxford University Press.

-It’s not who I am underneath, it’s what I do that defines me-

-Bruce Wayne in Batman Begins

Address correspondence to:


Derek R. Hopko, Ph.D.

The University of Tennessee – Knoxville


Department of Psychology


Austin Peay Building

Knoxville, Tennessee 37996-0900


Phone: (865) 974-3368


Fax: (865) 974-3330

E-Mail: dhopko@utk.edu


Abstract

Considered a third-wave behavior therapy, behavioral activation is a therapeutic process emphasizing structured attempts to increase overt behaviors likely to bring patients into contact with reinforcing environmental contingencies and corresponding improvements in thoughts, mood, and quality of life. In the past two decades, behavioral activation has emerged as an empirically supported treatment for depression that has effectively been provided to patients with diverse clinical presentations and in multiple therapeutic contexts. This chapter focuses on providing a brief historical context of behavioral activation, a description of the principles and procedures underlying contemporary behavioral activation therapies, a review of assessment strategies particularly relevant to this approach, a comprehensive analysis of treatment outcome studies, and a presentation of limitations and future directions that need to be addressed to further solidify the status of behavioral activation as an effective and feasible approach to treating clinical depression and other mental health problems.


Key Words: Behavioral Activation; Behavior Principles; Assessment; Treatment Outcome Review

Behavioral Activation

The National Comorbidity Survey (NCS-R) suggested that Major Depression has a lifetime prevalence of 16% and 12-month prevalence of 7%, is associated with substantial life impairment, and adequate treatment occurs for less than 50% of individuals with depression (Kessler et al., 2003; Wang et al., 2005). Although there are many factors associated with this problem and the dissemination of efficacious and parsimonious treatments for depression in general (Collins, Westra, Dozois, & Burns, 2004; Voelker, 2003), one of the primary barriers is a lack of relatively uncomplicated and highly transportable interventions that have the potential to be administered by a variety of mental health and medical practitioners. Recent depression treatment outcome research shows that briefer and less complicated behavioral activation interventions might be as effective in reducing depression as more elaborate cognitive-behavioral approaches, making them a viable option toward resolving this issue (Dimidjian et al., 2006; Hopko, Armento et al., 2011; Jacobson et al., 1996). Although the term behavioral activation is rooted in the biological basis of behavior (Gray, 1982), behavioral activation as a therapeutic process refers to structured attempts to increase overt behaviors likely to bring patients into contact with reinforcing environmental contingencies and produce corresponding improvements in thoughts, mood, and overall quality of life (Hopko, Lejuez, Ruggiero, & Eifert, 2003). Beginning with the pioneering work of Peter Lewinsohn and colleagues (Lewinsohn, 1974; Lewinsohn & Graf, 1973; Lewinsohn, Sullivan, & Grosscup, 1980), revitalized by the cognitive-behavioral therapy component analysis study (Jacobson et al., 1996), and culminating in its current status as an empirically validated treatment for depression (Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009; Sturmey, 2009), behavioral activation interventions have gained prominent status as an effective treatment modality across a range of clinical samples and settings. This chapter focuses on providing a brief historical context of behavioral activation, a description of the principles and procedures underlying contemporary behavioral activation therapies, a review of assessment strategies particularly relevant to this approach, a comprehensive analysis of treatment outcome studies, and a presentation of limitations and future directions that will need to be addressed to further solidify the status of behavioral activation as an effective and feasible approach to treating clinical depression and other mental health problems in a variety of clinical contexts.

Historical Context of Behavioral Activation.

As highlighted in previous works (Hopko et al., 2003; Dimidjian, Barrera, Martell, Munoz, & Lewinsohn, 2011; Jacobson, Martell, & Dimidjian, 2001), the basic conceptual foundation for behavioral activation can be traced back to original behavioral models of depression that implicated decreases in response-contingent reinforcement for nondepressive behavior as the causal factor in eliciting depressive affect (Ferster, 1973; Lewinsohn, 1974; Lewinsohn & Graf, 1973). Detailed historical accounts of the evolution of behavioral activation have been nicely articulated (Jacobson at al., 2001; Kanter, Manos, Bowe, Baruch, Busch, & Rusch, 2010; Martell, Addis, & Jacobson, 2001), including an interesting narrative depicting its initial development in the laboratory of Peter Lewinsohn at the University of Oregon (Dimidjian et al., 2011). Although Peter Lewinsohn should be considered the father of behavioral activation, his work was clearly influenced by B. F. Skinner, who initially proposed that depression was associated with an interruption of established sequences of healthy behavior that had been positively reinforced by the social environment (Skinner, 1953). In subsequent expansions of this model, the reduction of positively reinforced healthy behavior was attributed to a decrease in the number and range of reinforcing stimuli available to an individual for such behavior, a lack of skill in obtaining reinforcement, and/or an increased frequency of punishment (Lewinsohn, Antonuccio, Breckenridge, & Teri, 1984; Lewinsohn & Shaffer, 1971; Lewinsohn, 1974).

A functional analytic view of this paradigm suggests that continued engagement of depressed behavior must result from some combination of reinforcement for depressed behavior and/or a lack of reinforcement or even punishment of more healthy alternative behavior (Ferster, 1973; Hopko et al., 2003; Kanfer & Grimm, 1977; Kazdin, 1977). As degree of social reinforcement was an integral component of Lewinsohn’s model (1974), it was also indicated that although depressed affect and behavior could initially may be maintained through positive social reinforcement, depressed behavior also could ultimately result in aversive social consequences in the form of negative responses from significant others (Coyne, 1976). Accordingly, this behavioral model of depression highlighted the quantitative (number, level of gratification) and qualitative (type, function) aspects of reinforcing events, their availability, and an individual’s instrumental behaviors as critical toward decreased levels of response contingent positive reinforcement, particularly as it pertained to one’s social environment (and related social avoidance). Using a number of research designs, these fundamental assertions generally have been strongly supported. For example, using home observations (Lewinsohn & Shaffer, 1971; Lewinsohn & Shaw, 1969) and self-monitoring paradigms (Grosscup & Lewinsohn, 1980; Lewinsohn & Graf, 1973; Lewinsohn & Libet, 1972), it was demonstrated that depressed mood was related to decreased positive reinforcement for healthy behaviors and less engagement in pleasurable activities. In a recent daily diary study, self-reported depression was inversely related to general activity level as well as the amount of reward or pleasure obtained through overt behaviors (Hopko, Armento, Chambers, Cantu, & Lejuez, 2003). Another study showed that mildly depressed college students also engaged less frequently in social, physical, and educational behaviors (Hopko & Mullane, 2008).

In terms of other model assertions, several studies demonstrated that depressed mood also was associated with an increased frequency of aversive events and experiences (Grosscup & Lewinsohn, 1980; Lewinsohn & Talkington, 1979; MacPhillamy & Lewinsohn, 1974; Rehm, 1977). Also supporting Lewinsohn’s emphasis on decreased social reinforcement as a catalyst for depression, several studies highlighted the premise that social behaviors of depressed individuals were less likely to be reinforced relative to non-depressed individuals (Libet & Lewinsohn, 1973; Lewinsohn & Shaffer, 1971; Rehm, 1988; Youngren & Lewinsohn, 1980). Important to acknowledge, although it has accurately been pointed out that conclusions regarding the causal relationship between decreased response contingent positive reinforcement and depression are limited due to the unavailability of statistical mediation analyses decades ago (Dimidjian et al., 2011), at least two recent studies support this causal association (Carvalho & Hopko, 2011; Carvalho, Trent, & Hopko, 2011). Similarly, although decreased social skills and diminished social reinforcement have been associated with depression (Dimidjian et al., 2011; Segrin, 2000), support for the causal link is equivocal (Cole & Milstead, 1989; Segrin, 1999, 2000).



Behavioral Theory into Practice. Based on behavioral theories of depression, conventional behavioral therapy for depression was aimed at increasing access to pleasant events and positive reinforcers as well as decreasing the intensity and frequency of aversive events and consequences (Lewinsohn & Graf, 1973; Lewinsohn, Sullivan, & Grosscup, 1980; Sanchez, Lewinsohn, & Larson, 1980). In these pioneering efforts to examine the efficacy of behavioral activation strategies, Lewinsohn and colleagues demonstrated that through daily monitoring of pleasant/unpleasant events and corresponding mood states as well as behavioral interventions that included activity scheduling, social skills development and time management training, depressive symptoms often were alleviated. Importantly, these early studies documented the potential efficacy of activation-based approaches in multiple contexts, including individual, group, family, and marital therapy settings (Brown & Lewinsohn, 1984; Lewinsohn & Atwood, 1969; Lewinsohn & Shaffer, 1971; Lewinsohn & Shaw, 1969; Zeiss, Lewinsohn, & Munoz, 1979). The study by Brown and Lewinsohn (1984) found that the efficacy of individual, group, and minimal contact (telephone) conditions was superior to a delayed contact control condition. Fundamental behavioral activation strategies (i.e., pleasant event scheduling) also were as effective as cognitive and interpersonal skills training approaches in treating depressed outpatients (Zeiss et al., 1979). Based on several of these early studies, what could be considered the first behavioral activation treatment manual was developed (Lewinsohn, Biglan, & Zeiss, 1976).

As support for behavioral therapies for depression accumulated, increased attention was being given to biological, interpersonal, and cognitive factors as etiologically associated with depression. For example, with increased interest in cognitive theory in the latter quarter of the twentieth century, interventions based exclusively on operant and respondent principles, once thought adequate, were viewed as insufficient, and the absence of direct cognitive manipulations was widely regarded as a limitation of behavioral treatment. These changing perspectives, along with three highly influential studies, contributed to the de-emphasis of purely behavioral interventions as stand-alone treatments. In the first of these studies, Hammen & Glass (1975) demonstrated that mild to moderately depressed college students who increased their participation in events they had rated as pleasurable did not become less depressed. Second, Shaw (1977) published a multi-method assessment study with depressed college students and suggested the potential superiority of cognitive techniques over behavioral strategies in attenuating depression symptoms. In a third study published two years later, a component analysis revealed no differential effectiveness between activity scheduling, skills training, and cognitive techniques (Zeiss, Lewinsohn, & Munoz, 1979). In response to these studies and the changing zeitgeist that reflected a more integrative multi-dimensional model of depression, purely behavioral interventions generally were abandoned in favor of more comprehensive cognitive-behavioral approaches (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985). The increasing popularity of cognitive therapy culminated in its inclusion (and exclusion of behavioral therapy) in the Treatment of Depression Collaborative Research Program (TDCRP; Elkin et al., 1989) funded by the National Institute of Health. This transition stated, however, the distinction among interventions for depression considered purely “cognitive” or “behavioral” has become blurred because of their significant conceptual and technical overlap (Barlow, Allen, & Choate, 2004; Hollon, 2001). Indeed, cognitive strategies have been integrated into more traditional behavioral approaches (Fuchs & Rehm, 1977; Rehm, 1977; Lewinsohn, et al., 1980, 1984; Lewinsohn & Clarke, 1999; Lewinsohn, Munoz, Youngren, & Zeiss, 1986) and vice versa (Beck, Rush, Shaw, & Emery, 1979).



Despite the documented efficacy of cognitive and cognitive-behavioral therapies for depression (DeRubeis & Crits-Christoph, 1998; Hollon & Ponniah, 2010; Hollon, Thase, & Markowitz, 2002; Westen & Morrison, 2001), several recent findings along with evolving socioeconomic and professional developments raise the question as to whether “purely” behavioral approaches to treating clinical depression were abandoned too hastily. For example, managed care organizations and academic counseling centers have established the need to develop and utilize psychosocial interventions that are both time-limited and empirically validated (Peak & Barusch, 1999; Voelker, 2003), which are features typifying the behavioral model. Second, empirical data from carefully conducted clinical studies demonstrate that cognitive change may be just as likely to occur using environment-based manipulations or cognitive interventions (Jacobson et al., 1996; Jacobson & Gortner, 2000; Simons, Garfield, & Murphy, 1984; Zeiss, Lewinsohn, & Munoz, 1979). Third, it has been demonstrated that behavioral activation interventions have been effective with even difficult-to-treat medical and psychiatric samples (Dimidjian et al., 2006; Ekers et al., 2011; Hopko et al., 2011; MacPherson et al., 2010; Pagoto et al., 2008). Fourth, therapeutic benefits of cognitive-behavioral treatment packages for depression most often occur in the initial sessions of the treatment course (Hopko, Robertson, & Carvalho, 2009), a period in which behavioral components often are more prominent (Hollon, Shelton, & Davis, 1993; Otto, Pava, & Sprich-Buckminster, 1996). In response to these issues, research programs have continued to evolve that evaluate the feasibility, effectiveness, and efficacy of purely behavioral interventions for depression.

Contemporary Behavioral Activation Strategies

The revitalization of behavioral approaches to treating depression has been most evident in the development of two new interventions: Behavioral Activation (BA; Martell et al., 2001) and the Brief Behavioral Activation Treatment for Depression (BATD; Lejuez, Hopko, & Hopko, 2001; BATD-R; Lejuez, Hopko, Acierno, Daughters, Pagoto, 2011). Although these treatment protocols utilize somewhat different strategies, both are based on traditional behavioral models of the etiology and treatment of depression (Ferster, 1973; Lewinsohn, 1974) and to a greater or lesser degree include conventional behavioral therapy strategies designed to increase response-contingent positive reinforcement. These strategies include increasing pleasant or rewarding events, teaching relaxation skills, social and problem solving skill training, contingency management, decreasing behavioral avoidance, and the incorporation of cognitive-behavioral methods such as self-instructional training and rumination-cued activation (Antonuccio, Ward, & Tearnan, 1991; Hersen, Bellack, Himmelhock, & Thase, 1984; Lewinsohn et al., 1986; Nezu, Nezu, & Perri, 1989). These treatment components, sometimes enhanced using exposure-based therapy techniques for co-existent anxiety conditions (Hopko Armento et al., 2011; Hopko, Robertson, & Lejuez, 2006; Jakupcak, Roberts, Martell, Mulick, Michael, & Reed, 2006) collectively fall under the rubric of behavioral activation.

Although contemporary behavioral activation approaches are consistent with the original etiological formulation and treatment approaches, these newer protocols entail important advancements over early behavioral approaches. First, current activation approaches are more idiographic, giving more attention to unique environmental contingencies maintaining depressed behavior, and in the case of BATD, also incorporate an individualized life areas and value assessment (LAVA) that provides the foundation for activity identification and structured activation. Second, there has been a concerted movement from targeting pleasant events alone (Lewinsohn & Graf, 1973) toward understanding the functional aspects of behavior change (Martell et al., 2001). So rather than increasing exposure to events and behaviors presumed to be pleasant or rewarding, this functional analytic approach involves a detailed assessment of contingencies maintaining depressive behavior, idiographic assessment of patient values and goals, and the subsequent targeting of behavior that functionally is likely to attenuate depressive affect and improve quality of life. Accordingly, the appropriateness of any particular behavioral change is determined by ongoing assessment of whether the frequency and/or duration of that behavior increases over time and leads to a corresponding reduction in depressive symptoms. Although this process may involve several strategies as outlined above, the critical mechanism of change is to decrease avoidance behavior and increase reward via principles of extinction, fading, shaping, and differential reinforcement of healthy behaviors (Hopko et al., 2003). Third, as elucidated in other works (Manos et al., 2010), unlike traditional behavioral treatments, BA focuses significantly more on the role of negative reinforcement in maintaining depressive symptoms. Consistent with the perspective that individuals with depression often experience aversive or punitive environmental events and stimuli, negative affect resulting from such experiences may result in extreme escape and avoidance behavior that cyclically may exacerbate depression and further increase the likelihood of avoidance behavior. Important to highlight, however, at this stage of research, behavioral activation methods more strongly focus on increasing response contingent positive reinforcement and in a much less structured manner address aversive environmental events and the “de-activation” of patient behaviors that may elicit such events.

Fourth, behavioral activation approaches are unique from traditional behavior therapy in that along with dialectical behavior therapy (DBT; Linehan, 1993), acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), mindfulness-based therapies (MBT; Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002), and the cognitive behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), behavioral activation adheres to principles consistent with third-wave behavioral therapies. Where first and second wave therapies focused primarily on behavior modification of immediate problems, third wave methods emphasize the broad constructs of values, spirituality, relationships, and mindfulness. Indeed, when the acceptance and mindfulness-based philosophies of behavioral activation are recognized in the context of emphasizing value-based behavior, and through overt behavioral change, reducing the discrepancy between the perceived and ideal self, it is not unreasonable to suggest behavioral activation shares many fundamental assertions of traditional humanistic therapy (Rogers, 1951). On many levels, activating is congruent with strides toward self-actualization. Third wave behavioral therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tend to emphasize contextual and experiential change strategies in addition to more direct and didactic ones (Hayes, 2004). So where a second wave cognitive-behavior therapist might identify and restructure cognitive errors, a third wave therapist might focus more on encouraging patients to understand and accept the cognitions, learn their function, and how they associate with the patient’s value system. Accordingly, differing from early behavioral therapies for depression, behavior activation is much more focused on a balanced acceptance-change model (Hayes, Strosahl, & Wilson, 1999). Based on this paradigm, behavioral activation partially involves teaching patients to formulate and accomplish behavioral goals irrespective of certain aversive thoughts and mood states they may experience. This focus on action makes it unnecessary to attempt to control and change such thoughts and mood states directly, as was more common with traditional behavioral interventions (Lewinsohn, Munoz et al., 1978; Rehm, 1977). Instead, changes in patterns of overt behavior are likely to coincide with changes in thoughts and mood, in most instances following rather than preceding behavior change.

Behavior activation models acknowledge that there continues to be significant controversy surrounding cause-effect relations among biological, cognitive, and behavioral components in the etiology and maintenance of depression (Eifert, Beach, & Wilson, 1998; Hopko et al., 2003; Martell et al., 2001; Plaud, 2001). As with other pathogenic models of depression, the importance of cognition in the genesis and maintenance of depression is acknowledged in activation-based approaches, but cognitions are not regarded as proximal causes of overt behavior to be targeted directly for change. Thus, behavioral activation procedures address cognitions and emotions indirectly by bringing the individual into contact with more positive consequences for overt behavior. In doing so, behavioral activation addresses the environmental constituent of depressive affect, a component deemed more external, observable, measurable, and capable of being modified. Finally, relative to traditional behavioral therapies, contemporary behavioral activation approaches are designed to more systematically address co-existent anxiety conditions (Hopko, Robertson, & Lejuez, 2006). In large part due to high rates of comorbidity and shared symptom patterns (Kessler et al., 2003; Barlow, Allen, & Choate, 2004), the contention has been made that heterogeneity of anxiety and depressive symptom patterns is but an inconsequential variant of what is more importantly a broader general neurotic or negative affect syndrome (Barlow, 2002; Barlow et al., 2004). Based on this functional analytic framework in which depressive and anxiety based symptom patterns are viewed as conceptually parallel, behavioral avoidance is targeted within behavioral activation both as a means to increase response contingent positive reinforcement and systematically extinguish anxiety-related fears and phobias. For a comprehensive review of treatment components of traditional and contemporary behavioral activation interventions, as well as a thoughtful discussion of the construct of behavioral activation and whether effective psychotherapies such as self-control therapy (Rehm, 1977) should fall under this category, the reader is referred to the work of Jonathan Kanter and colleagues (2010).



Behavioral Activation (BA) or Washington BA. BA directly evolved from a component analysis study comparing cognitive-behavioral therapy for depression, behavioral activation supplemented with automatic thought restructuring, and behavioral activation alone. Data indicated that the behavioral activation condition was just as effective as the comprehensive intervention in terms of both overall treatment outcome and the modification of negative thinking and dysfunctional attributional styles (Jacobson et al., 1996). Longer-term maintenance of gains also was noted in that at 24-month follow-up, BA and the comprehensive cognitive-behavioral treatment were equally effective in preventing relapse (Gortner, Gollan, Dobson, & Jacobson, 1998). Predictor analyses indicated that positive outcome of BA was associated with pretreatment expectancies and inversely related to “reason giving,” or the tendency to offer multiple explanations with respect to the etiology and maintenance of depression (Addis & Jacobson, 1996). Several years later, a BA treatment manual was published that clearly highlighted the underlying philosophy and treatment components of BA (Addis & Martell, 2004; Martell et al., 2001). The focus of BA is on the evolving transactions between the person and environment over time and the identification of environmental triggers and ineffective coping responses involved in the etiology and maintenance of depression (Martell et al., 2001). Much like traditional behavioral therapy, this approach conceptualizes depressed behavior (e.g., inactivity, withdrawal) as a coping strategy to avoid environmental circumstances that provide low levels of positive reinforcement or high levels of aversive control (Jacobson et al., 2001). Behavioral avoidance is central to the BA treatment model. Within the context of a collaborative patient-therapist relationship, the initial treatment objective is to increase patient awareness of how internal and external events (triggers) result in a negative emotional (response) that may effectively establish a recurrent avoidance pattern (i.e., TRAP; trigger, response, avoidance-pattern). Once this pattern is recognized, the principal therapeutic objective is to assist the patient in reengaging in healthy behaviors through the development of alternative coping strategies (i.e., TRAC; trigger, response, alternative coping).

Along with increased patient awareness and progression from a TRAP to TRAC based coping philosophy, BA involves teaching patients to take ACTION. To reduce escape and avoidance behavior, patients are taught to assess the function of their behavior, and then to make an informed choice as to whether to continue escaping and avoiding or instead engage in behavior that may improve their mood, integrate such behavior into their lifestyle, and never give up. Additional treatment strategies are used to facilitate action and development of active coping including rating mastery and pleasure of activities, assigning activities to increase mastery and pleasure, mental rehearsal of assigned activities, role-playing behavioral assignments, therapist modeling, periodic distraction from problems or unpleasant events, mindfulness training or relaxation, self-reinforcement, and skills training (e.g., sleep hygiene, assertiveness, communication, problem solving) (Martell et al., 2001). Rumination-cued activation also is an important intervention component in which patients are taught to recognize negative cognitions and to use this identification as a cue to reengage with the environment and behaviorally activate. The treatment duration of BA typically is between 20-24 sessions.



Behavioral Activation Treatment for Depression (BATD) or Morgantown BA. At approximately the same time the BA treatment manual was released, our research team at West Virginia University published the brief behavioral activation treatment for depression (BATD: Lejuez, Hopko, & Hopko, 2001) based on behavioral matching theory. Applied to depression, matching theory suggests that the frequency and duration of depressed relative to nondepressed (or healthy) behavior is directly proportional to the relative value of reinforcement obtained for depressed versus nondepressed behavior (Herrnstein, 1970; McDowell, 1982). When the value (e.g., accessibility, duration, immediacy) of reinforcement for depressed behavior is increased through environmental change (e.g., increased accessibility to social attention, increased opportunity to escape aversive tasks), the relative value of reinforcement for healthy behavior decreases, increasing the likelihood of depressive behavior. Similarly, when the value of reinforcement for healthy behavior is decreased through environmental change (e.g., decreased availability of peers), the relative value of reinforcement for depressed behavior is simultaneously increased. The BATD model predicts that increased contact with reinforcement for healthy behavior (or reduced contact with reinforcement for depressed behavior) would have the effect of decreasing depressed behavior and increasing healthy behavior.

Based on this paradigm, BATD generally is conducted over an 8-10 session protocol, although two-session BATD has recently been shown to be effective in reducing symptoms of depression among moderately depressed undergraduate students (Armento, McNulty, & Hopko, in press; Gawrysiak, Nicholas, & Hopko, 2009). Initial sessions consist of assessing the function of depressed behavior, efforts to weaken access to positive reinforcement (e.g., sympathy) and negative reinforcement (e.g., escape from responsibilities) for depressed behavior, establishing patient rapport, identifying the pros and cons of behavioral change, and introducing the treatment rationale. Patients begin with a weekly self-monitoring exercise that serves as a baseline assessment of daily activities, orients patients to the quality and quantity of their activities, and generates ideas about activities to target during treatment. The emphasis then shifts to the life areas and value assessment (LAVA), in which ideographic life values are identified and behavioral goals are established within major life areas: family, peer, and intimate relationships, daily responsibilities, education, employment, hobbies and recreational activities, physical/health issues, spirituality, and anxiety-eliciting situations (Hayes et al., 1999). Such goal setting has long been considered an important component in the behavioral treatment of depression (Rehm, 1977). Subsequent to goal selection, an activity hierarchy is constructed in which 15 activities are rated ranging from “easiest” to “most difficult” to accomplish. Using activity logs to monitor progress, the patient progressively moves through the hierarchy. For each activity, the therapist and patient collaboratively determine what the weekly and final goals will be in terms of the frequency and duration of activity. At the start of each session, the monitoring form is examined and discussed, with the following weeks goals are established as a function of patient success or difficulty with goals for the prior week. The BATD treatment manual recently was revised to simplify and clarify treatment components, procedures, and forms, with an additional emphasis on therapeutic alliance issues and applications of BATD for the cognitively impaired (Lejuez, Hopko et al., 2011).



BA and BATD: Similarities and Differences. The most important similarity in BA and BATD is their direct focus on behavioral avoidance as the primary target of therapy. Both interventions strongly emphasize that behavioral avoidance is the pathognomonic feature of depression that inhibits exposure to response contingent reinforcement and extinction of anxiety-related symptoms and behaviors. Based on this conceptual similarity, a primary and common treatment focus is facilitating approach behavior. In the context of BA, activities in graded task assignments are designed based on current activity level, likelihood of success, and importance of activities in meeting life goals. This process is quite open and the therapist has significant flexibility in assigning activities, how to assess life goals, and determining whether (and when) the remaining treatment components are to be implemented. With BATD, following the LAVA assessment and based on a model forwarded by Hayes and colleagues (1999), an activity hierarchy is systematically constructed that directly reflects life values and is followed by systematic movement through the hierarchy to achieve value-consistent life goals. The course of therapy is held relatively constant across all patients. Second, both BA and BATD researchers and clinicians would suggest that affective change and cognitive modification are directly attributable and secondary to relative increases in reinforcement for healthy relative to depressive behavior patterns. Third, both interventions focus on functional assessment of depressive behaviors to varying degrees. In the BA model, the TRAP/TRAC strategies are used to identify avoidance patterns and teach a functional analytic style of understanding and modifying behavior. In contrast, and consistent with traditional behavior therapies for depression, the BATD model does not focus significantly on assisting patients with functional analytic interpretations of behavior as precise functional analyses are difficult for even highly trained clinicians (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Consequently, functional analytic strategies in BATD are deemed secondary to the primary overt activation component. Beyond the theoretical distinctions explicated above, the primary difference in the two approaches is that BA includes many strategies generally not incorporated within BATD, such as mental rehearsal, periodic distraction, mindfulness training, and skill-training procedures. BATD is based on the premise that systematic activation toward positive activities and situations will allow patients to develop skills in the natural environment, enhance generalizability of treatment gains beyond the clinic, and maximize maintenance of gains over time. That stated, the question of whether a multimodal strategy is superior to a pure activation-based approach must be answered empirically, and to date, the incremental benefits of treatment approaches included in BA beyond those of BATD is unstudied. In terms of practical applications, a clinician who desires a greater range of intervention strategies might prefer the BA method, whereas therapists and patients desiring greater structure and decreased interest in strategies beyond direct activation might prefer BATD. This is not to suggest, however, that BA cannot be organized more systematically or that BATD cannot be used flexibly. We merely assert that such efforts are less easily accomplished within the framework of the particular approaches and therefore likely would require greater practical and conceptual skill on the part of the therapist.

The Focus of Behavioral Activation: Behaviors Amenable to Activation. When discussing behavioral activation interventions, it is important to clearly operationalize the scope of behaviors amenable to activation. Toward this objective, it is useful to distinguish between nondepressive or healthy overt behaviors we are striving to activate, and the depressive behaviors we are attempting to eliminate or deactivate. Nondepressive behavior is defined as overt behaviors that are generally value-based, directed toward improving quality of life and life functioning, minimize aversive response-consequence contingencies, and are directed toward the attainment of some objective or rewarding consequence. Nondepressive behavior is directly incompatible and the antithesis of depressive behavior. Depressed behavior may occur as a function of some reward via positive (e.g., sympathy from friend or family member) or negative reinforcement (escape from responsibility), or in response to decreased availability of reinforcers for healthy behavior. Depressed behavior also is often a direct consequence of aversive or unpleasant life events or experiences, some of which are beyond human control and unpredictable (e.g., sexual or physical trauma, natural disasters, chronic medical illness, death of a loved one) and others where human accountability is more apparent (e.g., alcoholism and substance abuse, gambling, aggression and other social indiscretions). In contrast with healthy behavior, depressive behavior generally is not consistent with one’s value system and generally does not function to improve functioning or quality of life. Depressive behavior generally refers to responses associated with major depressive disorder (DSM-IV-TR; American Psychiatric Association, 2000).

Practitioners of behavioral activation conceptualize depressive behavior from a contextual perspective, which: (a) considers behavior as a function of the environmental contingencies that shape and maintain its occurrence, and (b) encourages the identification of environment-behavior relations that may be measured objectively and reliably. For example, lethargic and passive behavior associated with anhedonia as well as suicidal behavior largely is understood with reference to operant principles. Although these forms of behavior primarily occur as a function of environmental context, they also are considered “choice” behaviors insofar as the person has some degree of control over whether situations are approached or avoided. Social withdrawal, substance abuse, and other maladaptive actions (antagonistic social behavior, lack of work productivity) associated with depressive behavior may well be considered in the same category. Neurovegetative symptoms such as decreased eating and sleeping, on the other hand, though still a function of environmental contingencies, are perhaps more biologically-based responses and less directly controllable (Benca, Obermeyer, Thisted, & Gillin, 1992). Yet even in this example “choice” (in a stochastic rather than mentalistic sense) plays a certain role in whether one eats or decides to sleep or awaken. Finally, symptoms such as negative cognitions and psychomotor agitation/retardation primarily are viewed as private (non-observable) responses to environmental stimuli that are less controllable, difficult to manipulate therapeutically, and in the latter case biologically based. In conducting behavioral activation, patients and therapists target behavior that is within the realm of patient control and where the environmental context can be modified. In the case of BATD, multiple life domains are focused on simultaneously as a guideline to structured activation. Private behaviors (thoughts, feelings) do not fall into this category, are more difficult to observe and measure, and consequently are less often the focus of behavioral activation methods. Such behavior is not ignored, however, but rather is expected to alleviate following overt behavior modification that increases environmental reward. For example, although cognitions often are not targeted directly in behavioral activation strategies, covert change has been directly implicated as a transfer effect of activation (Jacobson, et al., 1996; Simons, et al., 1984). That stated, it is noteworthy that rumination-cued activation is a BA treatment component that focuses on recognition of maladaptive cognitions, their impact on life functioning, and the incorporation of activation as a viable coping mechanism by which ruminative behavior is replaced via engagement in rewarding overt behaviors (Addis & Martell, 2004).



Behavioral Activation as a Mechanism for Anxiety Exposure. As indicated earlier, behavioral activation provides a framework in which exposure strategies can easily be implemented. The theoretical basis for this integration has been highlighted in earlier works (Hopko, Robertson, & Lejuez, 2006) and is largely based on a unified model of internalizing disorders (Barlow, 2002; Barlow et al., 2004). Indeed, in addition to several case studies, a few randomized trials have demonstrated preliminary support for the efficacy of both BA and BATD in attenuating symptoms of anxiety (Hopko et al., 2011; Jakupcak et al., 2006). Nonetheless, the process of behavioral activation should be differentiated from that of in vivo exposure. In the latter procedure, exposing individuals to aversive conditioned stimuli while preventing an avoidance response is an application of extinction within a classical conditioning framework. Without experiencing the anticipated aversive or traumatic event, over time anxious responding in the presence of the conditioned stimuli is likely to extinguish. Although exposure strategies are not fundamental to the behavioral activation process, avoidance behaviors characteristic of depressed individuals may partially be a function of aversive contextual stimuli (e.g., situations or individuals). To the extent that avoidance behavior functions to minimize anxiety elicited by these contexts, the therapeutic effects of guided activity (or activation) and graduated systematic exposure might be functionally similar. Exploration of the relevance of behavioral activation in treating anxiety disorders is worthy of further investigation because of the inter-relatedness of anxiety and depressive conditions (Barlow et al., 2004; Kessler et al., 2003; Mineka, Watson, & Clark, 1998), the potential transfer effects of treating one condition on the other (Hopko et al., 2011; Stanley et al., 2003), and increased focus on refining treatments for patients with mixed anxiety-depressive disorders (Barlow & Campbell, 2000). More systematic research clearly is needed to examine how activation strategies supplemented with graduated fear hierarchies, progressive muscle relaxation, and other behavioral strategies may enhance treatment of patients with co-existent anxiety and depressive symptoms.
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