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New Directions in Behavioral Activation Clinical Psychology Review 79 (2020) 101860 Contents lists available at ScienceDirect Clinical Psychology Review journal homepage: www.elsevier.com/locate/clinpsychrev Review New directions in behavioral activation: Using findings from basic science T and translational neuroscience to inform the exploration of potential mechanisms of change Courtney N. Forbes Department of Psychology, University of Toledo, Mail Stop 948, 2801 West Bancroft Street, Toledo, OH 43606, USA HIGHLIGHTS • Understanding mechanisms of change can facilitate improvements in BA treatments. • BA treatments may work by targeting (low) reward responsiveness directly. • Basic science findings can inform hypotheses about potential mechanisms of change. ARTICLE INFO ABSTRACT Keywords: Interest in behavioral activation treatments for depression has increased over the past two decades. Behavioral Behavioral activation activation treatments have been shown to be effective in treating depression across a variety of populations and Reward responsiveness settings. However, little is known about the mechanisms of change that may bring about symptom improvement Depression in behavioral activation treatments. Recent developments in the theoretical and empirical literature on beha- Mechanisms of change vioral activation treatments have coincided with advances in basic science and translational neuroscience re- Translational neuroscience garding the mechanisms underlying individual differences in responsiveness to reward. Attenuated reward re- sponsiveness has been associated with depression and related clinical outcomes at the self-report, behavioral, and neural levels of analysis. Given that behavioral activation treatments are focused on increasing individuals' contact and engagement with sustainable sources of reward in their environment, it is plausible that behavioral activation treatments bring about improvements in depression symptoms by targeting (low) reward respon- siveness directly. This paper integrates findings from the clinical research literature on behavioral activation treatments with insights drawn from basic science and translational neuroscience in order to propose hypotheses about potential mechanisms of change in behavioral activation. Conceptual issues and recommendations for future research on behavioral activation treatments are discussed. 1. Introduction et al., 1996) of cognitive-behavioral therapy for depression (CBT; Beck, Rush, Shaw, & Emery, 1979) demonstrated that the behavioral activa- The past two decades have seen a resurgence of interest in treat- tion (BA) component of CBT was as efficacious as the full CBT package ments that are rooted in behavioral and contextual theories of psy- in improving depression symptoms and preventing depression relapse chopathology. Behavioral and contextual theories emphasize the in- for up to two years following the initial treatment (Gortner, Gollan, fluence of idiographic contextual factors, such as the environmental Dobson, & Jacobson, 1998). Results of the component analysis study antecedents and consequences of behavior, on the development and inspired the development of several novel BA treatments (e.g., Lejuez, maintenance of psychological disorders (Ferster & Skinner, 1957; Hopko, Acierno, Daughters, & Pagoto, 2011; Lejuez, Hopko, & Hopko, Jacobson, 1994; Skinner, 1953). In particular, there has been a renewed 2001; Martell, Addis, & Jacobson, 2001) based on this parsimonious interest in behavioral activation treatments for depression, which focus approach. These BA treatments have been shown to be effective for primarily on increasing individuals' engagement with “rewarding” ac- treating depression across a variety of populations and settings. tivities; that is, sustainable sources of positive reinforcement in their The renewed interest in the development and dissemination of BA environment. In the late 1990s, a component analysis study (Jacobson treatments over the past several decades has occurred concurrently E-mail address: [email protected]. https://doi.org/10.1016/j.cpr.2020.101860 Received 25 December 2019; Received in revised form 3 March 2020; Accepted 1 May 2020 Available online 05 May 2020 0272-7358/ © 2020 Elsevier Ltd. All rights reserved. C.N. Forbes Clinical Psychology Review 79 (2020) 101860 with advances in basic science and translational neuroscience research Furthermore, this review builds upon Nagy et al.'s (2020) work by on biobehavioral mechanisms underlying psychological disorders. One conceptualizing relations between basic science findings on reward mechanism of particular relevance to depression and other disorders functioning and BA treatment strategies within the framework of spe- characterized by attenuated motivation and positive affect is respon- cific Positive Valence Systems (PVS) sub-domains. siveness to rewarding stimuli, which is thought to be driven by dopa- minergic activity in the brain's mesolimbic pathway (Nestler & 2. Early models of reward functioning in depression: Gray, Carlezon, 2006). The neural reward system is thought to govern goal- Ferster, and Lewinsohn directed behavior related to seeking out primary rewards, such as food and sex; as well as secondary rewards, such as monetary gain and po- Individual differences in reward-seeking behavior and responsive- sitive social feedback (Arias-Carrión, Stamelou, Murillo-Rodríguez, ness to reward have long been recognized. The Reinforcement Menéndez-González, & Pöppel, 2010). Thus, the reward system is Sensitivity Theory of Personality (RST; Gray, 1972, 1990) proposes that thought to play a critical role in human motivation as well as hedonic behavior is influenced by two primary motivational systems: thebe- enjoyment of rewards (Berridge & Robinson, 2003). Abnormalities in havioral activation system (BAS) and the behavioral inhibition system the functioning of this system, which governs behavioral responsiveness (BIS). The BAS is thought to govern reward sensitivity (i.e., interest in to positive stimuli (i.e., reward functioning), have been associated with and responsiveness to reward) and approach motivation. Atypically low symptoms of major depressive disorder (MDD) including reductions in functioning of the BAS and other personality constructs related to po- motivation, activity level, and the ability to experience pleasure sitive emotionality (e.g., positive affect, extraversion) has been asso- (Treadway & Zald, 2011). ciated with depression symptom severity cross-sectionally and long- The activity of the reward system may be particularly relevant to BA itudinally across a variety of populations, and has been shown to treatments for depression, given that the primary emphasis of BA predict the maintenance of depression symptoms over time (Kasch, treatments is on increasing patients' activity level and engagement with Rottenberg, Arnow, & Gotlib, 2002; McFarland, Shankman, Tenke, rewarding activities. Robust associations have been observed between Bruder, & Klein, 2006; see Khazanov & Ruscio, 2016, for a meta-ana- depression and attenuated reward functioning (Pizzagalli et al., 2009; lysis). In addition to highlighting associations between reward func- Smoski et al., 2009; Treadway, Bossaller, Shelton, & Zald, 2012). By tioning and depression, Gray's work has influenced the development of increasing patients' contact with rewarding stimuli, BA treatments may contemporary conceptualizations of approach motivation in relation to bring about improvements in depression symptoms by targeting (low) the PVS domain (Olino, McMakin, & Forbes, 2018), and is reflected in reward functioning directly. However, research on mechanisms of PVS sub-domains including Reward Anticipation, Initial Responsive- change in BA treatments has been limited. Despite their conceptual ness, and Effort Valuation. overlap, the literature on the efficacy of BA treatments has, for the most Theoretical understanding of the role of approach motivation in part, developed independently of basic science and translational neu- depression was advanced by a seminal behavioral theory proposed by roscience research on biobehavioral processes involved in reward Charles Ferster (1973, 1974), a colleague of B.F. Skinner's who applied functioning. the principles of radical behaviorism (Skinner, 1953, 1957) to a func- The purpose of this paper is to integrate the clinical literature on BA tional analysis of behaviors associated with depression. Specifically, treatments with research on biobehavioral processes involved in reward Ferster proposed that behaviors associated with depression are driven functioning in order to use insights from basic science and translational by both positive reinforcement, or the presentation of a positive sti- neuroscience research to inform hypotheses about potential mechan- mulus following a behavior; and negative reinforcement, or the removal isms of change in BA treatments. The development of novel hypotheses of an aversive stimulus following a behavior. Ferster observed that in- informed by basic science may pave the way for future research focused dividuals with depression often exhibit a reduction in overall activity on identification of the mechanisms in BA treatments that drive level, which may be influenced by the absence of positive reinforce- symptom change. Increased knowledge of these mechanisms of change ment for adaptive behaviors in work, social relationships, and other life may, in turn, facilitate the development and refinement of future BA domains. Ferster also suggested that
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