What is behavioral activation?: A review of the empirical literature

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Abstract

Behavioral Activation (BA) for depression is an empirically supported psychotherapy with a long history dating back to the 1970s. To date there have been no systematic reviews of how BA treatment packages and their accompanying components have evolved over the years. This review sought to identify and describe the specific treatment components of BA based on the descriptions of techniques provided in empirical articles on BA and referenced treatment manuals when available. The following component techniques were identified: activity monitoring, assessment of life goals and values, activity scheduling, skills training, relaxation training, contingency management, procedures targeting verbal behavior, and procedures targeting avoidance. The implementation of these techniques is reviewed, along with their empirical support both as stand-alone components and as components of larger treatment packages. Whereas activity scheduling, relaxation, and skills training interventions have received empirical support on their own, other procedures have shown effectiveness as parts of larger treatment packages. Although BA interventions differed in tools used, activity monitoring and scheduling were shown to be constant components across interventions. Possible directions for the future evolution of BA are discussed.

Introduction

Behavioral activation (BA) treatments for depression have a long history, spanning from early pleasant events scheduling of Lewinsohn (1974), to several treatments developed in the 1970s, to BA as a component of Cognitive Therapy (CT; Beck, Rush, Shaw, & Emery, 1979), to more contemporary approaches of Martell et al., 2001, Lejuez, Hopko & Hopko, 2001. Several recent meta-analyses (Cuijpers et al., 2007, Ekers et al., 2008, Mazzucchelli et al., 2009) have comprehensively documented the efficacy of BA treatments. In fact, Mazzucchelli et al. evaluated BA's empirical support in light of standards developed by the American Psychological Association's Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (Chambless et al., 1998, Task Force on Promotion and Dissemination of Psychological Procedures, 1995) and concluded that BA should be designated a “well-established empirically validated treatment.”

The specific treatment components of current versions of BA and guidelines for their implementation are available in several manuals, primarily Martell et al., 2001, Lejuez et al., 2001; also see Addis and Martell, 2004, Hopko and Lejuez, 2007, Lejuez et al., in press, Martell et al., 2010) and the principles underlying these two interventions also have been clearly outlined (Hopko, Lejuez, Ruggiero, & Eifert, 2003). Research on these current versions of BA, while rapidly growing, however comprises only a small subset of the accumulated evidence for BA evaluated in recent meta-analyses (Cuijpers et al., 2007, Ekers et al., 2008, Mazzucchelli et al., 2009); only 6 of the 52 trials reviewed in these meta-analyses incorporated the Martell et al., 2001, Lejuez, Hopko & Hopko, 2001 manuals. There has yet to appear a comprehensive catalog and description of BA techniques that have been employed over its entire history.

With this extensive history and empirical support, the term “activation” has entered the mainstream clinical psychology lexicon as a component of depression treatment and often the assumption by those without specific training in BA is that activation consists primarily or exclusively of the scheduling of pleasant activities. For example, the American Psychological Association, on the public information pages of its website, notes that one of the four aspects of effective depression treatment is to help clients “gradually incorporate enjoyable, fulfilling activities back into their lives” (the other three aspects briefly describe problem-solving, interpersonal and cognitive approaches; APA, 2009).

Examining BA's diverse history in more detail, it becomes clear that BA has included variants on the theme of scheduling of pleasant activities but is in fact much more than this and a variety of component techniques and strategies have been employed under the umbrella of BA for depression. This review begins with a short history of BA and a summary of its empirical support. Following this history, the empirical studies analyzed in the three published meta-analyses of BA are reviewed to 1) catalog the various BA component techniques, 2) describe their implementation, 3) review the research on them as components of the larger packages, and 4) review the research on them as stand-alone interventions. The intention is to provide readers with a clear overview of exactly what components make up BA and the empirical support for each component. The review ends with suggestions for implementing the full arsenal of BA techniques to maximize the efficacy and efficiency of the general approach and suggestions for future research directions.

Section snippets

History of behavioral activation

Lewinsohn (1974) provided the seminal description of the behavioral theory of depression in which depression is a function of 1) low rates of response-contingent positive reinforcement and 2) inadequate social skill. In 1976, he consolidated a number of previous intervention studies based on this theory into a comprehensive treatment manual (Lewinsohn, Biglan, & Zeiss, 1976). This manual primarily encouraged activity scheduling to address environmental deficits in positive reinforcement and

Identifying behavioral activation techniques

To identify the full range of BA techniques included in trials of BA, first the three comprehensive meta-analyses of BA by Cuijpers et al., 2007, Ekers et al., 2008, Mazzucchelli et al., 2009 were reviewed. These analyses conducted comprehensive database searches to identify trials of BA, resulting in the identification of 44 trials across the three reports. Eight of these trials were excluded from the current analysis because they were unpublished dissertations (Barlow, 1986, Besyner, 1979,

Behavioral activation techniques

The review is organized roughly according to how techniques might be applied over treatment with a given client, beginning with assessment techniques (activity monitoring and values assessment), followed by activation techniques (activity scheduling and procedures targeting avoidance), and concluding with a range of procedures that function to increase the likelihood of successful completion of activation.

Integration and discussion

The primary points of this review are that BA, as applied over the last 30 years, consistently includes activity monitoring and scheduling but is often more than these and is quite diverse with respect to the specific techniques included and the manner in which these techniques are employed. From an empirical standpoint it is unclear which components, or what combination of components, are necessary or maximally effective at decreasing depressive symptoms. Several of the techniques often

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