Contemporary behavioral activation treatments for depression: Procedures, principles, and progress

doi:10.1016/S0272-7358(03)00070-9

Clinical Psychology Review

Volume 23, Issue 5, October 2003, Pages 699-717

https://doi.org/10.1016/S0272-7358(03)00070-9 Get rights and content

Abstract

In the past decade, there has been renewed interest in the feasibility and efficacy of purely behavioral treatments for clinical depression. Emphasizing the functional aspects of depressive and nondepressive behavior, these treatments focus on the concept of behavioral activation, which guides implementation of procedures aimed at increasing patient activity and access to reinforcement. Although researchers have provided positive preliminary support for behavioral activation-based interventions, many fundamental issues concerning strategies, principles, and change processes involved in behavioral activation have yet to be addressed. In this paper, we compare and contrast contemporary behavioral activation interventions, explore strategies and process of change issues, clarify the basic behavioral principles underlying activation strategies, and outline questions that need to be addressed to improve outcomes and better understand the potential significance of behavioral activation as it pertains to the future of behavior therapy for depression.

Introduction

Over the past decade, there has been increasing interest in behavioral activation as a comprehensive treatment for clinical depression. Behavioral activation may be defined as a therapeutic process that emphasizes structured attempts at engendering increases in overt behaviors that are likely to bring the patient into contact with reinforcing environmental contingencies and produce corresponding improvements in thoughts, mood, and overall quality of life. Although initial outcome studies have generally supported the efficacy of behavioral activation interventions, this program of research is very much in its infancy, with many fundamental questions surrounding the principles and procedures of the behavioral activation approach remaining unanswered. Unexplored issues that need to be addressed include how divergent behavioral activation interventions appear to be producing similar positive outcomes, related questions surrounding the process of change, and conceptual imprecision regarding the basic behavioral principles underlying behavioral activation interventions. In addressing these issues, our objective is to establish a more comprehensive understanding of the behavioral activation approach to treating depression and further stimulate discussion and research essential to improving the implementation and success of activation-based interventions.

Section snippets

Historical context

The basic conceptual foundation for behavioral activation can be traced back to the 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; for a detailed historical account of the roots of behavioral activation, see Jacobson et al., 2001, Martell et al., 2001). Skinner (1953) initially proposed that depression

Returning to basic behavioral principles

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 et al., 2001, Lejuez et al., 2002). Although these two treatment protocols utilize somewhat different strategies, both approaches are based on extensions of traditional behavioral models of the etiology and treatment of depression. As

Behavioral activation treatment

Based on pioneering work suggesting that BA is the active ingredient in the cognitive–behavioral treatment for depression, Jacobson et al. (2001) developed the first BA protocol that focuses on the functional aspects of depressive behavior. 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 depressive affect (Martell et al., 2001)

Strategies and processes of change

Both BA and BATD have firm roots in traditional behavioral theory and therapy Ferster, 1973, Lewinsohn, 1974 and include attention to the functional analysis of behavior, a de-emphasis on attempts to directly modify maladaptive cognitions and schemata, and strategies for addressing avoidance through an emotional acceptance and behavioral change paradigm. The BA method is unique in that it developed from a contemporary contextualistic theory Hayes et al., 1993, Hayes et al., 1999 and was

Fundamental principles of BA

In suggesting that BA requires changes in overt behavior to engender more positive affect, the question arises as to how this process relates to basic behavioral principles. Simply put, BA strategies generally are based on both simple and more complex principles of reinforcement and punishment. The most pertinent strategies that are derived from these principles and used in BA treatments are extinction, fading, and shaping.

Directions for future research

Based on preliminary data, behavioral activation interventions show promise as parsimonious and potentially cost-effective means to treat clinical depression. The pioneering research outlined earlier is only a first step, with significant research and conceptual questions still to be addressed. First and foremost, the comprehensive activation protocols outlined earlier must undergo more rigorous empirical testing to evaluate their efficacy and effectiveness relative to other well-established,

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Contemporary behavioral activation treatments for depression: Procedures, principles, and progress

Abstract

Introduction

Section snippets

Historical context

Returning to basic behavioral principles

Behavioral activation treatment

Strategies and processes of change

Fundamental principles of BA

Directions for future research

Comprehensive Psychiatry

Sport and Exercise Psychology

Clinical Psychology Review

Behavior Therapy

Behaviour Research and Therapy

Cognitive and Behavioral Practice

Clinical Psychology Review

Journal of Affective Disorders

Behavior Therapy

Reasons for depression and the process and outcome of cognitive–behavioral psychotherapies

Journal of Consulting and Clinical Psychology

Diagnostic and statistical manual of mental disorders

The behavioral treatment of unipolar depression in adult outpatients

Cognitive therapy of depression

Handbook of depression

Sleep and psychiatric disorders: A meta-analysis

Archives of General Psychiatry

A psychoeducational approach to the treatment of depression: Comparison of group, individual, and minimal contact procedures

Journal of Consulting and Clinical Psychology

Statistical power analysis for the behavioral sciences

Toward an interactional description of depression

Psychiatry

Depression in primary care: Depressing news, exciting research opportunities

American Psychological Society Observer

A meta-analysis of the efficacy of cognitive therapy for depression

Journal of Consulting and Clinical Psychology

Problem-solving therapies

Depression: Behavioral principles and implications for treatment and relapse prevention

National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments

Archives of General Psychiatry

A functional analysis of depression

American Psychologist

A self-control behavior therapy program for depression

Journal of Consulting and Clinical Psychology

Cognitive–behavioral and pharmacological treatments of social phobia

Archives of General Psychiatry

Cognitive–behavioral treatment for depression: Relapse prevention

Journal of Consulting and Clinical Psychology

Handbook of depression

Varieties of scientific contextualism

Acceptance and commitment therapy: An experiential approach to behavior change

Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment

Journal of Consulting and Clinical Psychology

On the law of effect

Journal of the Experimental Analysis of Behavior

Behavioral activation treatment for depression: A commentary

Clinical Psychology: Science and Practice

Cognitive therapy for depression: Conceptual issues and clinical efficacy

Journal of Consulting and Clinical Psychology

A course for the treatment of depression among adolescents