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Title: Treating Depression with Behavior Therapy: The Implementation of Behavioral Activation


1
Treating Depression with Behavior Therapy The
Implementation of Behavioral Activation
Christopher Martell, Ph.D., ABPP Independent
Practice and University of Washington Sona
Dimidjian, Ph.D. University of Colorado as told
by Steven D. Hollon, Ph.D. Vanderbilt University
2
Acknowledgements
Research Team Michael Addis Sandra Coffman David Dunner Robert Gallop Steve Hollon Bob Kohlenberg Christopher Martell Karen Schmaling Research Staff David Atkins Patty Bardina Carolyn Bea Chris Budech Jackie Gollan Eric Gortner David Markley Melissa McElrea Joe McGlinchey Evelyn Mercier Kim Nomensen Shireen Rizvi Lisa Roberts Elizabeth Shilling Mandy Steiman Dan Yoshimoto Clinical Staff Sandra Coffman Linda Cunning Steve Dager Kerri Halfant Helen Hendrickson Ruth Herman-Dunn David Kosins Tom Linde Christopher Martell Peggy Martin Steve Sholl Alan Unis
Support NIMH GlaxoSmithKline
3
What is Behavioral Activation?
  • Structured, brief psychosocial approach
  • Based on premise that problems in vulnerable
    individuals' lives and behavioral responses
    reduce ability to experience positive reward from
    their environments
  • Aims to systematically increase activation such
    that patients may experience greater contact with
    sources of reward in their lives and solve life
    problems
  • Focuses directly on activation and on processes
    that inhibit activation, such as escape and
    avoidance behaviors and ruminative thinking

4
A Brief History of the Evidence Base for
Behavioral Activation
Peter M. Lewinsohn
1970s
5
Lewinsohn
  • Early models highlighted the role of lack of
    response-contingent reinforcement for
    non-depressed behavior
  • Decrease in frequency or range of reinforcing
    stimuli or increase in frequency of punishment ?
    depression

6
Brief History Ferster
  • I think the conceptual formulation as well as
    the treatment of depression really depend upon
    focusing on the behaviors the patient is not
    engaged in the most obvious aspect of
    depression is a marked reduction in the frequency
    of certain kinds of behavior and an increase in
    the frequency of others, usually avoidance and
    escape
  • Ferster, 1974

7
Peter M. Lewinsohn
Aaron T. Beck
1979
1970s
8
BA subsumed within CT
  • the ultimate aim of these techniques in
    cognitive therapy is to produce change in the
    negative attitudes (Beck et al., 1979, p.118).
  • The key point is that even when cognitive
    therapists are focusing on behaviors, they do so
    within the context of a larger model that relates
    those actions to the beliefs and expectations
    from which they arise and view them as an
    opportunity to test the accuracy of those
    underlying beliefs (Hollon, 1999, p.306).
  • Positive outcomes in CT may be dependent on
    competence level of therapist (DeRubeis et al.,
    2005 Elkin et al., 1989)

9
Peter M. Lewinsohn
Neil S. Jacobson
Aaron T. Beck
1996
1979
1970s
10
What accounts for the efficacy of cognitive
therapy?
Peter M. Lewinsohn
Neil S. Jacobson
Aaron T. Beck
1996
1979
1970s
11
Cognitive Therapy for Depression
Facilitative Strategies
Automatic Thought Strategies
Core Belief Strategies
Behavioral Activation Strategies
12
Component Analysis of Cognitive Therapy
Behavioral Activation
Vs.
Full CT Package
Jacobson, N.S., et al. (1996) Gortner, E.T., et
al. (1998)
13
Component Analysis of CT
Jacobson, N.S., et al. (1996) Gortner, E.T., et
al. (1998)
14
Component Analysis of CT
Jacobson, N.S., et al. (1996) Gortner, E.T., et
al. (1998)
15
Behavioral Activation
  • Findings of the component analysis study led to
    an expansion of BA into a stand-alone model, not
    solely defined by proscription of cognitive
    interventions (Jacobson et al., 2000 Martell et
    al., 2001)
  • Linked to earlier behavioral work on depression
    (Ferster, 1973 Lewinsohn, 1974)

16
Acute and Follow-up Design
Continuation Phase
Follow-Up Phase
Acute Phase
Intake
Wk. 8
Wk. 16
Month 12
Month 24
BA
Follow-up evaluations
(N43)
CT
Follow-up evaluations
(N45)
Placebo withdrawal
Follow-up evaluations
ADM-CM
(N100)
ADM continuation
Follow-up evaluations
PLA-CM
(N53)
17
Assessment of Treatment Adherence
18
Rates of Attrition by Condition by Phase
19
Mean BDI across acute treatment
20
Mean HRSD across acute treatment
21
Extreme Non-Response (BDI)
Extreme Non-Response
22
Prevention of Relapse Following Successful
Treatment- all treatment conditions
Relapse
Recurrence
23
Cumulative Direct Costs of Continuation ADM and
BA/CT
Note These costs are based on 100/ session in
BA and CT, versus 75/ session in Continuation
ADM, plus drug costs of 125/ month ADM sessions
occurring x2/ month for 2 months monthly
thereafter.
24
Putting it all together
  • BA emerges as a strong and promising treatment
  • Challenges the idea that medication is required
    to treat moderately to severely depressed
    patients
  • Challenges the idea that directly modifying
    cognition is necessary to treat depression
  • Limitations (BA, CT, ADM)

25
Points of Convergence
  • Consistent with earlier behavioral literature
    (e.g., Lewinsohn Ferster), more recent
    behavioral and activation oriented studies (e.g.,
    Hopko et al., 2003 Stathopoulou et al., 2006 ),
    and dismantling studies across other
    disorders/ages (e.g., Scogin et al., 1989)
  • Consistent with early emphasis in CT on
    behavioral strategies for more severely depressed
    patients (Beck et al., 1979)
  • Consistent with key components of other
    behavioral treatments (DBT Linehan, 1993 ACT
    Hayes, Strosahl, Wilson, 1999) and recent
    conceptualizations of integrative treatments for
    Axis I disorders (Barlow, Allen, Choate, 2004)

26
Putting it into practice
27
Key elements of BA
  • Stylistic strategies
  • Structuring strategies (including orienting to
    treatment)
  • Assessment strategies (individualizing primary
    treatment targets through behavioral assessment)
  • Activation strategies (activity structuring and
    scheduling)
  • Targeting avoidance, routine disruption,
    rumination

28
Course of BA
  • Orient to treatment
  • Treatment rationale, including conceptualization
    of depression and primary treatment strategies
  • Role of therapist/patient
  • Develop treatment goals
  • Individualize treatment targets
  • Repeated application and troubleshooting of
    activation and engagement strategies
  • Reviewing and consolidating treatment gains

29
Stylistic Strategies
  • Validating
  • Interested Accurately reflects Genuine
    Maintains hope and optimism about change
  • Reciprocal/responsive to client
  • Collaborative Open to the clients influence
    Awake to clients behavior in session and
    modifies interventions as appropriate Warm
  • Non-judgmental and matter of fact in interactions
    with client
  • Everything is useful, provides information
    Curiousholds a problem solving mindset in
    relation to all new behavior

30
Structuring Strategies
31
Structure of Sessions
  • Set collaborative agenda
  • Review homework
  • Review weekly activities
  • Troubleshoot problem behaviors
  • Assign new homework
  • Ask for feedback

32
Treatment Rationale
  • Emphasize relationships between environment,
    mood, and activity
  • Highlight vicious cycle that can develop between
    depressed mood, withdrawal/avoidance, and
    worsened mood
  • Suggest activation as a tool to break this cycle
    and support problem solving
  • Emphasize an outside?in approach act according
    to a plan or goal rather than a feeling or
    internal state

33
BA Case Conceptualization
Stay home, stay in bed, watch TV, withdraw from
social contacts, ruminate, etc.
Sad, tired, worthless, indifferent, etc.
Less Rewarding Life
Life events
34
BA Case Conceptualization
Stay home, stay in bed, watch TV, withdraw from
social contacts, ruminate, etc.
Sad, tired, worthless, indifferent, etc.
Less Rewarding Life
Life events
Loss of friendships, conflict with supervisor at
work, financial stress, poor health, etc.
35
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36
Address common myths about activation and change
  • Will-power or Nike model of change

37
Address common myths about activation and change
  • Will-power or Nike model of change
  • Emphasize
  • Role of the therapist
  • Focused activation based on careful behavioral
    analyses
  • Graded task assignment
  • Difficulty of change

38
Assessment Strategies
39
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40
Individualizing activation targets
  • Conduct detailed examination of what is getting
    in the way of feeling better
  • Sounds simple, and yet in practice, we often lack
    awareness of these relationships

41
Key Assessment Strategies
  • Identify and set goals
  • Define and specifically describe problems in
    behavioral terms
  • Assesses consequences of behavior
  • Examine behavioral patterns

42
Goal Setting
  • Ultimate goal of treatment
  • Clients modify their behavior to increase
    contact with sources of positive reinforcement
  • Typical goals relate to changing avoidance
    patterns and routine disruption and to changing
    environmental context
  • Focus on acting from the outside in
  • Set priorities for long and short-term goals
  • Figure out what behaviors are needed to reach
    goalwhat, when, where, etc. Be focused,
    specific, and concrete!

43
Key Assessment Strategies
  • Basic questions
  • What is maintaining the depression?
  • What is getting in the way of engaging and
    enjoying life?
  • What behaviors are good candidates for maximizing
    change?
  • Activity/mood monitoring provides the essential
    information
  • Utilize basic behavioral principles to answer
    these questions

44
Behavioral Assessment
ANTECENDENT
  • Assess the circumstances eliciting the behavior
  • Assess the function of the behavior How is the
    behavior reinforced or punished? Does it garner a
    reward? Does it allow escape or avoidance of an
    aversive stimulus?
  • Emphasis on function vs. form

BEHAVIOR
CONSEQUENCES
45
Two Types of Conditioning
  • Classical Conditioning paired stimuli take on
    similar functions
  • a neutral stimulus such as a hospital paired with
    grief following a loved ones death in the
    hospital takes on the properties of grief, such
    that seeing a hospital evokes similar feelings
  • Operant Conditioning behavior is learned
    according to the consequences that maintain it

46
Understanding consequences
  • Negative reinforcement the likelihood of a
    behavior is increased by the removal of something
    from the environment (usually an aversive
    condition)
  • Watching television is negatively reinforced by
    reduction of painful emotions
  • Negative reinforcement contingencies are
    frequently targets in BA for depression
  • Positive reinforcement the likelihood of a
    behavior is increased by the addition of
    something in the environment
  • Going to bed early is positively reinforced by
    family member offering empathy and support
  • Punishment the extinguishing of a behavior by
    the addition of an aversive consequence in the
    environment
  • Asking for help is punished by a judgmental and
    critical reaction from others

47
Nuts and bolts of behavioral analysis in BA
  • The Activity Chart Central tool!
  • What does a BA therapist focus on when reviewing
    activity schedules?

48
Typical Questions to Guide Review
  • What would the client be doing if he or she were
    not depressed (e.g., working, managing family
    responsibilities, exercising, socializing,
    engaging in leisure activities, eating, sleeping,
    etc.)?
  • What is being avoided or from what is the client
    pulling away? How are these patterns related to
    mood?
  • What is the relationship between specific
    activities and mood?
  • What is the relationship between specific life
    contexts or problems and mood?
  • Is the client engaging in a wide variety of
    activities or have his or her activities become
    narrow?
  • Are there disruptions in normal routines?

49
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51
Exercise 2 Activity Monitoring
  1. Recording Write down your activities and moods
    for 1-2 typical days over the past week include
    enough detail to allow your partner can begin to
    notice some relationships
  2. Role Play Practice being the therapist and
    reviewing the completed log identify ifthen
    relationships between activity and mood look for
    variability help your client begin to notice
    these relationships

52
Activation Strategies
53
The challenge!
  • There is only a modest correlation between
    intention and behavior. Most often, people have
    good intentions and fail to act on them.
    (Gollwitzer, 1999)

54
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55
Problem Solving
  • Problem definition
  • Generate and evaluate solutions
  • Practice new behaviors in session as appropriate
  • Skills training as appropriate
  • Troubleshooting

56
Activity Scheduling
  • Increase pleasure
  • Increase mastery
  • Increase approach (vs. avoidance)

57
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58
Activity Scheduling
Mood/Activity M T W Th F S S
Mood (0-10) 6 5 5 7 3 3 2
Walking dog ü ü ü ü
Bed by 10pm ü ü ü ü ü
Auto meeting ü
Call friend ü ü
Gardening ü ü
List to wife ü ü ü
0mild/no depressed mood ? 10intense depressed
mood
59
Activity Structuring Grading Tasks
  • Break down activities into parts
  • Assign simple to more complex tasks in a stepwise
    fashion
  • Design assignments so that early success is
    guaranteed
  • Goal is not to accomplish all parts of the
    activityrather, to get started, increase
    activation, disrupt avoidance
  • Completing one component will increase likelihood
    of completing others

60
Qualities of Effective Action Plans Opposite
Action (Linehan, 1993)
  • Emotions love themselves
  • All emotions have action urges what one wants
    to do or say when feeling an emotion
  • Action urges tend to maintain or intensify
    emotions
  • If you want to change anemotion, act opposite
    to the action urge
  • Opposite action works best if you do it ALL THE
    WAY throwing yourself into andparticipating
    fully inthe opposite action

61
Qualities of Effective Action Plans
  • Clearly tied to the essence of the problem (not
    random or arbitrary)
  • Target avoidance, withdrawal, approaching
    important problems/modifying life context
  • Includes activities that are opposite to the
    action urges accompanying depression
  • Based on creative and collaborative problem
    solving
  • Utilizes contingency management as needed to
    promote change

62
Qualities of Effective Action Plans
  • Clear and specific (adequately detailed
    information about what, when, where, etc.) do
    you and the patient know what the plan is when
    the session ends?
  • Do-able (adequately graded into component parts,
    assigning simple to more complex parts in a
    stepwise fashion, structured so that early
    success is nearly guaranteed)

63
Qualities of Effective Action Plans
  • Informed by adequate troubleshooting--consideratio
    n of potential barriers anything that might get
    in the way?
  • Informed by whats needed to maximize commitment
    to implementation -- public commitment, getting
    started in session, reminders during the week,
    explicit linking to long-term goals
  • Includes plans for how to make new behaviors
    routine
  • Returns to treatment rationale as needed

64
Acronyms to Organize Action Plans
  • TRAP/TRAC
  • ACTION

65
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67
TRAP/TRAC
  • T- Trigger (demands at work)
  • R- Response (depressed mood/hopelessness)
  • AP- Avoidance Pattern (leave work stay at
    home)
  • T-Trigger (demands at work)
  • R- Response (depressed mood/hopelessness)
  • AC- Alternative Coping (approach behaviors using
    graded tasks)

68
TRAP
Trigger
Response
Avoidance- Pattern
69
TRAC
Trigger
Response
Alternative Coping
70
ACTION Strategy
  • AAssess How will my behavior affect my
    depression?
  • Am I avoiding? What are my goals in
    this
  • situation?
  • CChoose I know that activating myself will
    increase my
  • chances of improving my life situation and
    mood.
  • Therefore, if I choose not to self-activate, I
    am choosing to take a break.
  • TTry Try the behavior I have chosen.
  • IIntegrate Integrate any new activity into my
    daily routine.
  • OObserve Observe the result. Do I feel better
    or worse?
  • Did this action allow me to take steps toward
    improving my situation?
  • NNever Never give up.

71
Experiential Avoidance (Hayes et al., 1996)
  • BA is not a one-size-fits-all therapy
  • Not all clients will be inactive
  • Need to look for subtle forms of avoidance
  • Engagement as activation
  • Experiencing rather than avoiding negative
    feelings

72
Routine Regulation
  • Work with patient to develop and follow regular
    routine for basic life activitieseating,
    working, school, sleeping.
  • Can only evaluate new behaviors after implemented
    for a period of timemake them routine, then
    evaluate
  • Use activity logs
  • Use the ACTION strategy

73
Exercise 3 Modifying Avoidance
  • Break into pairs
  • Help your partner
  • Identify a goal for learning at ABCT (or more
    broadly getting the most out of your experience)
  • Identify an avoidance pattern that might
    typically become a barrier to moving in the
    direction of this goal
  • Identify an action plan for alternative coping
    that can be implemented over the next 3 days
  • Troubleshoot potential problems that would
    interfere with the action plan
  • You can use the TRAP/TRAC form or a blank
    activity schedule if useful

74
Engagement
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77
The Trouble with Ruminating
Nolen-Hoeksema, 2000
  • What is ruminating?
  • People with a ruminative response style think
    repetitively and passively about their negative
    emotions, focusing on their symptoms of distress
    ("I feel so lousy," "I just can't concentrate")
    and worrying about the meanings of their distress
    ("Will I ever get over this?).
  • Ruminative response styles predict higher levels
    of depressive symptoms over time, onset of new
    episodes, and episode chronicity

78
You'll never plow a field by turning it over
in your mind...
79
Targeting Ruminating
  • Monitor and assess
  • Focus on context and consequences of ruminating,
    not on the content of ruminative thoughts

80
Targeting Ruminating
  • Practice with attention to experience
    strategies
  • Notice colors, smells, noises, sights, relation
    to others, etc.
  • Notice elements of tasks (parenting, work)
  • Select activities that are associated with high
    engagement
  • Highlight negative consequences of ruminating
  • Be alert for partial activation and identify
    specific behaviors that would maximize full
    engagement

81
A Focus on the Content of ThinkingI was
depressed all day yesterday because I was
thinking about how my sister really doesnt love
me. What is the evidence that this thought is
accurate? What would it mean if it were
true? Can you think of another way to
interpret what your sister said? Why must
everyone love you?
82
A Focus on the Context and Consequences of
ThinkingI was depressed all day yesterday
because I was thinking about how my sister really
doesnt love me. When did you start thinking
that? How long did it last? What were you
doing while you were thinking that?How engaged
were you with the activity, context, etc.?
What were consequences of thinking about that?
What might be the function?
83
Relapse Prevention
  • Consolidate Treatment gains
  • What has been helpful
  • What has been learned
  • Plan for future problems
  • What targets have been identified
  • What new responses to targets are practiced

84
Additional Resources
  • Jacobson, N. S., Martell, C. R., Dimidjian, S.
    (2001). Behavioral activation treatment for
    depression Returning to contextual roots.
    Clinical Psychology Science and Practice, 8,
    255-270.
  • Martell, C. R., Addis, M. E., Jacobson, N. S.
    (2001). Depression in context Strategies for
    guided action. New York Norton and Co.
  • Addis, M.E., Martell, C.R. (2004). Overcoming
    Depression One Step at a Time The New Behavioral
    Activation Approach to Getting Your Life Back.
    New York New Harbinger Press.
  • Dimidjian, S., Hollon, S.D., Dobson, K.S.,
    Schmaling, K.B., Kohlenberg, R., Addis, M.,
    Gallop, R., McGlinchey, J., Markley, D., Gollan,
    J.K., Atkins, D.C., Dunner, D.L., Jacobson,
    N.S. (2006). Randomized trial of behavioral
    activation, cognitive therapy, and antidepressant
    medication in the acute treatment of adults with
    major depression. JCCP, 74 (4), 658-670.
  • Dimidjian, S., Martell, C.R., Addis, M.E.,
    Herman-Dunn, R. (in press). Behavioral
    activation. In D. H. Barlow (Ed.), Clinical
    Handbook of Psychological Disorders, 4th Edition.
    NY Guilford Press.
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