What is behavioral activation?: A review of the empirical literature
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
References (0)
Cited by (280)
Cognitive Behavioral Therapy for Anxiety and Depression in Children and Adolescents
2024, Psychiatric Clinics of North AmericaEscaping through video games: Using your avatar to find meaning in life
2023, Computers in Human BehaviorDoes reward processing moderate or mediate the link between childhood adversity and psychopathology: A longitudinal study
2023, Development and Psychopathology