Behavioral Activation Powerpoint Slides - Centerstone Research

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					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
Research Team:            Research Staff:         Clinical Staff:
    Michael Addis           David Atkins            Sandra Coffman
   Sandra Coffman           Patty Bardina           Linda Cunning
    David Dunner            Carolyn Bea             Steve Dager
    Robert Gallop           Chris Budech            Kerri Halfant
   Steve Hollon             Jackie Gollan           Helen Hendrickson
                             Eric Gortner            Ruth Herman-Dunn
    Bob Kohlenberg
                             David Markley           David Kosins
   Christopher Martell
                             Melissa McElrea         Tom Linde
    Karen Schmaling
                             Joe McGlinchey          Christopher Martell
                             Evelyn Mercier          Peggy Martin
                             Kim Nomensen            Steve Sholl
NIMH & GlaxoSmithKline       Shireen Rizvi           Alan Unis
                             Lisa Roberts
                             Elizabeth Shilling
                             Mandy Steiman
                             Dan Yoshimoto
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
     A Brief History of the Evidence
     Base for Behavioral Activation

Peter M. 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
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
Peter M. Lewinsohn   Aaron T. Beck

   1970s               1979
 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.,
Peter M. Lewinsohn   Aaron T. Beck   Neil S. Jacobson

   1970s               1979              1996
                          What accounts for the efficacy of
                          cognitive therapy?

Peter M. Lewinsohn   Aaron T. Beck    Neil S. Jacobson

   1970s               1979               1996
Cognitive Therapy for Depression

       Strategies                  Automatic

                                   Core Belief
       Behavioral                  Strategies
Component Analysis of Cognitive Therapy

         Behavioral   Vs.           Full CT Package
                            Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
                Component Analysis of CT
                Acute Findings


           30                    Cognitive
           25                    Activation
Mean BDI





                Pre               Post
                                              Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
                Component Analysis of CT
                Acute Findings                                                 Follow Up Findings

           35                                                            100
                                 Cognitive                               90                   Cognitive
           30                                                                                 Therapy
                                                                         80                   Behavioral

                                                % Survival (Two Years)
           25                    Activation                              70                   Activation

Mean BDI

           15                                                            40
           10                                                            30
           0                                                              0
                Pre               Post
                                              Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
 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)
Acute and Follow-up Design
 Acute Phase           Continuation Phase         Follow-Up Phase

Intake      Wk. 8   Wk. 16                    Month 12          Month 24

    BA   (N=43)                Follow-up evaluations

   CT    (N=45)                 Follow-up evaluations

                         Placebo withdrawal      Follow-up evaluations
                         ADM continuation        Follow-up evaluations
                    Assessment of Treatment Adherence
                           8.65                                    BEH
                                                                   COG             8.06
                    7.00                             6.07
Mean Scale Score

                    6.00                      5.01




                                  0.58 0.57                          0.22
                                                            0.06            0.06
                                  BA                 CT                     ADM
Rates of Attrition by Condition by Phase

             0.45               Second 8 weeks
             0.40         8%
                                First 8 weeks
                                Randomized No-Show


             0.25         22%
             0.20   8%
                                2%               7%
                    15%   14%                    2%
             0.00               2%
                    PLA   ADM   CT               BA
Mean BDI across acute treatment
                            CT Hi
35                          CT Lo
                            BA Hi
30                          BA Lo
                            ADM Hi
                            ADM Lo




     Intake     Mid-Tx    Post-Tx
Mean HRSD across acute treatment
                            CT Hi
                            CT Lo
                            BA Hi
                            BA Lo
                            ADM Hi
                            ADM Lo


      Intake    Mid-Tx    Post-Tx
                    Extreme Non-Response (BDI)
                                         ADM (N=57)                           Non-Response
             0.50                48%
                                         CT (N=25)
                                         BA (N=25)
             0.40   37%

             0.30                                                                   28%


             0.10                      7% 8%     8%                      8%
                                                                  0%                        0%
                          0-10           11-20                   21-30              31-63
Prevention of Relapse Following Successful
Treatment- all treatment conditions
                         Relapse                       Recurrence

               0.8                                                              (n=21)
                                                                                ADM-ADM (n=28)
  % Survival

                                                                                Prior BA (n=27)
                                                                                Prior CT (n=30)












                             Months (following end of active treatment)
Cumulative Direct Costs of
Continuation ADM and BA/CT

                    3500           BA/ CT

                    3000           ADM-ADM
  Cost in Dollars





                           1   2    3   4    5   6   7   8   9   10 11 12 13 14 15 16
                                                 Months in Treatment
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.
Putting it all together…
• BA emerges as a strong and promising
• 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
• Limitations (BA, CT, ADM)
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)
Key elements of BA
• Stylistic strategies
• Structuring strategies (including orienting to
• Assessment strategies (individualizing primary
  treatment targets through behavioral
• Activation strategies (activity structuring and
• Targeting avoidance, routine disruption,
 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
Stylistic Strategies
•  Validating:
  – Interested; Accurately reflects; Genuine;
      Maintains hope and optimism about
• Reciprocal/responsive to client
  – Collaborative; Open to the client’s
      influence; Awake to client’s behavior in
      session and modifies interventions as
      appropriate; Warm
• Non-judgmental and matter of fact in
   interactions with client
  – Everything is useful, provides information;
      Curious—holds a problem solving
      mindset in relation to all new behavior
Structure of Sessions
•   Set collaborative agenda
•   Review homework
•   Review weekly activities
•   Troubleshoot problem behaviors
•   Assign new homework
•   Ask for feedback
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
     BA Case Conceptualization

                                    Stay home,
                     Sad, tired,    stay in bed,
         Less        worthless,
Life                                watch TV,
         Rewarding   indifferent,
events                              withdraw
         Life        etc.           from social
     BA Case Conceptualization

                                          Stay home,
                     Sad, tired,          stay in bed,
         Less        worthless,
Life                                      watch TV,
         Rewarding   indifferent,
events                                    withdraw
         Life        etc.                 from social

                                Loss of friendships,
                                conflict with supervisor
                                at work, financial stress,
                                poor health, etc.
Adolescents Taking Action
Sessions 1 & 2: Getting Started

                                   What Does Behavioral Activation Mean?

                                                            BUT Behavioral Activation can
  Depression is a vicious cycle                             break this cycle by:

                                                                1st by identifying what makes
                                                                you feel down

                                                                2nd by learning how to tackle

                                                                3rd by working together with
                         Depression                             your therapist to take small
                                                                steps, get active, accomplish
                                                                your goals, and
 Your life is more stressful. You
 begin to feel tired, bored….life
                                                                                 BUILD THE
 gets harder, you do less, pull away
                                                                                  LIFE YOU
 and may blame yourself for not
 doing more….it gets harder to do
 things. This can create more
 problems with school, parents,
                                                                                TG 1-2, 2-2
  Address common myths about
     activation and change
• Will-power or “Nike”
  model of change
  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
  – Difficulty of change
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
    Key Assessment Strategies
•   Identify and set goals
•   Define and specifically describe
    problems in behavioral terms
•   Assesses consequences of behavior
•   Examine behavioral patterns
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
  goal—what, when, where, etc. Be focused,
  specific, and concrete!
  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
    Behavioral Assessment

• Assess the circumstances
  eliciting the behavior
• Assess the function of the          CONSEQUENCES
  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
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 one’s 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
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
   – 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
   – Asking for help is punished by a judgmental and critical
     reaction from others
Nuts and bolts of behavioral
analysis in BA…

• The Activity Chart – Central tool!

• What does a BA therapist focus on when
  reviewing activity schedules?
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
• 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?
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 “if…then” relationships between
   activity and mood; look for variability;
   help your client begin to notice these
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)
Problem Solving

• Problem definition
• Generate and evaluate solutions
• Practice new behaviors in session as
• Skills training as appropriate
• Troubleshooting
Activity Scheduling
• Increase pleasure
• Increase mastery
• Increase approach (vs. avoidance)
  Activity Scheduling
Mood/Activity       M       T        W         Th        F   S   S

Mood (0-10*)        6       5        5         7         3   3   2

Walking dog                                                   
Bed by 10pm                                                  
Auto meeting                                                     
Call friend                                                     
Gardening                                                       
List to wife                                           
* 0=mild/no depressed mood  10=intense depressed mood
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
  activity—rather, to get started, increase
  activation, disrupt avoidance
• Completing one component will
  increase likelihood of completing others
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 an
  emotion, act opposite
  to the action urge
 Opposite action works best
  if you do it “ALL THE WAY” –
  throwing yourself into and
  participating fully in
  the opposite action
 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
 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
 Qualities of Effective Action Plans
• Informed by adequate troubleshooting--
  consideration of potential barriers; anything
  that might get in the way?
• Informed by what’s 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
Acronyms to Organize Action Plans

• T- Trigger (demands    • T-Trigger (demands
  at work)                 at work)
• R- Response            • R- Response
  (depressed               (depressed
                         • AC- Alternative
• AP- Avoidance            Coping (approach
  Pattern (leave work;     behaviors using
  stay at home)            graded tasks)
Trigger   Response   Avoidance-
Trigger   Response   Alternative
   ACTION Strategy
• A=Assess      How will my behavior affect my depression?
                 Am I avoiding? What are my goals in this

• C=Choose      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.

• T=Try         Try the behavior I have chosen.

• I=Integrate   Integrate any new activity into my daily

• O=Observe     Observe the result. Do I feel better or worse?
                Did this action allow me to take steps toward improving
                my situation?

• N=Never       Never give up.
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
• Engagement as activation
• Experiencing rather than avoiding
  negative feelings
Routine Regulation
• Work with patient to develop and follow
  regular routine for basic life activities—
  eating, working, school, sleeping.
• Can only evaluate new behaviors after
  implemented for a period of time—make
  them routine, then evaluate
  – Use activity logs
  – Use the ACTION strategy
                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
    •     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
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
      Targeting Ruminating

• Monitor and assess
• Focus on context and consequences of
  ruminating, not on the content of
  ruminative thoughts
        Targeting Ruminating
• Practice with “attention to experience”
     • Notice colors, smells, noises, sights, relation to others, etc.
     • Notice elements of tasks (parenting, work)
• Select activities that are associated with high
• Highlight negative consequences of ruminating
• Be alert for partial activation and identify
  specific behaviors that would maximize full
A Focus on the Content of Thinking
“I was depressed all day yesterday because I
was thinking about how my sister really
doesn’t 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?
       A Focus on the Context and
       Consequences of Thinking
“I was depressed all day yesterday because I was thinking
about how my sister really doesn’t 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?
        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
    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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