Behavioral Activation Treatment for Depression: Returning to Contextual Roots

Behavioral Activation Treatment for Depression: Returning to Contextual Roots Neil S. Jacobson, Christopher R. Martell, and Sona Dimidjian University of Washington Behavioral activation (BA), as a stand-alone treatment term follow-up results suggested that BA was as effective for depression, began as a behavior therapy treatment at preventing relapse as CT (Gortner, Gollan, Dobson, & condition in a component analysis study of the Beck, Jacobson, 1998). Rush, Shaw, and Emery version of cognitive therapy.BA Based on these results, we, in collaboration with attempts to help depressed people reengage in their Michael Addis and Keith Dobson, have spent the past 2 lives through focused activation strategies.These strate- years developing a new and more comprehensive model of BA designed as a treatment in its own right (Martell, gies counter patterns of avoidance, withdrawal, and in- Addis, & Jacobson, 2001). Although there is significant activity that may exacerbate depressive episodes by gen- overlap between the techniques used in the previous study erating additional secondary problems in individuals’ and those currently used, our work has placed BA in a lives.BA is designed to help individuals approach and broader contextual framework. Whereas in the last trial access sources of positive reinforcement in their lives, BA was defined by what could not be done (i.e., the pro- which can serve a natural antidepressant function.Our scription of cognitive interventions), BA as it is currently purpose in this article is to describe BA and the history practiced has been developed to maximize the potential of of its development. a functional analytic treatment, which is epistemologically Key words: behavioral activation, contextualism, rooted in the philosophy of contextualism (Jacobson, major depression, cognitive-behavioral therapy, psycho- 1994; Pepper, 1942) and a distinctly behavioral theory of therapeutic techniques. [Clin Psychol Sci Prac 8:255– depression (Ferster, 1973). ffi 270, 2001] A large clinical trial is underway comparing the e cacy of our BA model to CT (overseen by Sandra Coffman, Keith Dobson, and Steven Hollon) and pharmacotherapy In 1990, Jacobson and colleagues at the University of (overseen by David Dunner) for individuals diagnosed Washington began a dismantling study where they tested with current major depressive disorder.1 competing hypotheses about the basis for the effects of Participants in cognitive therapy ( Jacobson et al., 1996). In particular, the BA and CT conditions receive a maximum of 24 ther- they isolated the behavioral activation (BA) component apy sessions over a 16-week period. The pharmacother- of cognitive therapy (CT) to determine whether simply apy is administered under double-blind conditions and activating depressed people, and thereby helping them includes 3 groups: (a) 16weeks of paroxetine (trade name make contact with potentially reinforcing experiences, Paxil) followed by 1 year continuation paroxetine treat- could account for the benefits of CT. The initial findings ment, (b) 16weeks of paroxetine followed by 1 year of pill were consistent with the activation hypothesis, and long- placebo, and (c) eight weeks of pill placebo. This design is calibrated with previous trials to demonstrate the drug Address correspondence to Christopher R. Martell, Ph.D., responsiveness of our sample (acute Paxil vs. acute pill pla- Department of Psychology, University of Washington, 1107 cebo; Klein, 1996) and to establish the relapse potential of N. E. 45th St., #310, Seattle, WA 98105–4631. the psychotherapies (BA vs. CT vs. discontinued Paxil). It ᭧ 2001 AMERICAN PSYCHOLOGICAL ASSOCIATION D12 255 also allows for a direct comparison of the acute and long- The component analysis results led to our effort to term efficacy among BA, CT, and Paxil when mainte- develop BA into a treatment in its own right, a process nance medication is used (Jacobson & Gortner, 2000). that in turn led us back to the behavioral literature. A num- The purpose of this article is to provide an overview of ber of behavioral theories of and treatments for depression the current BA model, focusing in particular on the origin have been proposed and evaluated during recent decades. and history of our laboratory’s interest in BA, the under- In fact, nearly 30 years ago, Ferster (1973) proposed a dis- lying principles of the model, and its primary interven- tinctly behavioral theory of depression, based largely on tion strategies. We discuss both the theory and practice of the radical behaviorist principles of B. F. Skinner (1957). BA. In so doing, we illustrate how the epistemologi- Ferster (1973) emphasized the importance of a functional cal assumptions as well as the underlying theory differen- analysis of behavior in the understanding and treatment of tiate BA from CT and traditional behavior therapy but depression, which he described as an analysis in which link BA more closely with a functional analysis of “the significance of a person’s activities is understood by depression. the way it operates on the environment, including, of course, both sides of his skin . behavioral significance A BRIEF HISTORY OF BEHAVIORAL ACTIVATION is largely derived from the reinforcers maintaining them, Interest in our new model of BA evolved from the empir- rather than their overt form” (p. 868). In addition to high- ical findings of the component analysis study (Gortner et lighting the functional analysis, Ferster also emphasized al., 1998; Jacobson et al, 1996). Results from this study the centrality of increased avoidance and escape behaviors suggested that the behavioral activation component of CT and decreased positively reinforced behaviors among performed as well as the full CT package in the acute depressed individuals. Although avoidance behavior was treatment of depression and the prevention of relapse over an essential feature of Ferster’s early behavioral model of a 2-year follow-up period. These results demanded care- depression and is firmly established as a process that com- ful scrutiny of the cognitive theory of depression and the plicates anxiety disorders (Barlow, Blanchard, Vermilyea, prevailing treatment technology. It challenged the notion Vermilyea, & DiNardo, 1986), it has largely been over- that one must directly confront and modify negative core looked in the literature on depression prior to our new schemas to effect change in depression and suggested that BA model (Dobson et al., 1999). activating clients may, in fact, be not only necessary but Lewinsohn and colleagues (e.g., Lewinsohn & Graf, also sufficient. 1973; Lewinsohn & Libet, 1972) also postulated a behav- The component analysis study was not the first study to ioral theory of depression in which a decrease in pleasant challenge the cognitive explanation for the documented events or an increase in aversive events was associated with success of CT. Cognitive therapy for depression has been the onset of depression. In this way, particular reinforcing demonstrated to be an efficacious treatment for depression qualities of a person’s environment, such as low rates of in multiple clinical trials since the 1980s (DeRubeis, Gel- positive reinforcement or increased rates of punishment, fand, Tang, & Simons, 1999; Dobson, 1989; Hollon, were assumed to be causally related to depression (Lewin- Shelton, & Loosen, 1991). However, a number of investi- sohn, Antonuccio, Breckenridge, & Teri, 1984). Lewin- gators have questioned whether cognitive interventions, sohn’s original treatment (Lewinsohn & Graf) generally in fact, account for the positive outcome of cognitive sought to increase large classes of self-defined “pleasant therapy (see, e.g., Beidel & Turner, 1986; Latimer & events” to increase the positive reinforcement for de- Sweet, 1984; Sweet & Louizeaux, 1991; Wilson, Gol- pressed clients. din, & Charbonneau-Powis, 1983). The component anal- Lewinsohn’s treatment was significant for its emphasis ysis study highlighted the surprising efficacy of a purely on the importance of reinforcement contingencies in the behavioral approach and, from a pragmatic standpoint, treatment of depression and as such provides an important raised the question of whether BA, a more parsimonious foundation for our BA model. Lewinsohn’s treatment treatment, would be more amenable to dissemination, model, however, relied primarily on a nomothetic particularly via less experienced therapists and/or self- approach in the identification and classification of rein- administered or peer support treatments. forcing events. In contrast, we conceptualize BA as more CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V8 N3, FALL 2001 256 idiographic and do not make a priori assumptions that an behavior therapy for depression back to these early con- event is reinforcing until we have seen that it increases textual roots. behavior or has a positive effect on mood. In addition to Lewinsohn’s model, other behavioral BEHAVIORAL ACTIVATION AND THE models have been developed with the aim of addressing DEMEDICALIZATION OF DEPRESSION the difficulties with problem solving often observed The functional analytic framework of BA is radically dif- among depressed individuals (Nezu, 1989). The behav- ferent from models that regard depression purely as a iorally focused therapy developed by D’Zurilla and Gold- medical illness. In this way, BA is part of a larger effort fried (1971) trained clients in five steps of problem to provide an alternative to treatment models that have solving: problem orientation, problem definition and for- underemphasized

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