May 2011  << Back  

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Behavioral activation for depression. A clinician’s guide

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Christopher R. Martell, Sona Dimidjian, and Ruth Herman-Dunn. New York, NY: The Guilford Press; 2010; ISBN 978-1-60623-515-7; pp 220; $35 (hardcover).

I have to admit that, looking at this book’s title, I wondered, perhaps like some readers, what “behavioral activation for depression” really was. I will start with the definition so there is no confusion. Behavioral activation (BA) “is a brief structured treatment for depression that aims to activate clients in specific ways that will increase rewarding experience in their lives” (p 21). It “is a structured action-oriented therapy” (p 58) that was developed in the “context of clinical trial comparing the behavioral aspects of cognitive therapy to the full cognitive therapy protocol” (p 35). Eo ipso, in simple terms for me, cognitive-behavioral therapy (CBT) stripped of the cognitive part (maybe not totally) and a bit more developed and structured subsequently. In the Foreword, Peter Lewinsohn states that “If one thinks of psychological treatments as being on a continuum with regard to how structured they are, BA would be placed toward the structured end of the continuum” (p xi). He also suggests that a BA therapist should be directive, yet nonjudgmental, and collaborative with clients…the effective BA therapist is not passive (p xi) as “passivity is inherent to depression” (p 30). Now that we know now what the BA is, let us get to the book about it.

The book contains a Foreword, a Preface, 9 chapters, and 4 appendices. Chapter 1, “Introduction. The development of behavioral activation,” discusses the origins and development of BA, active ingredients of various therapies for depression (mostly CBT and BA), and the work of some of the people BA is built on (Charles B. Ferster, Peter M. Lewinsohn, Lynn P. Rehm, and Aaron T. Beck). This chapter emphasizes that BA is a problem-solving therapy and that “A general aim of BA is to help the client to activate in ways that will increase the likelihood that his or her behavior will be positively reinforced” (p 9). Chapter 2, “The core principles of behavioral activation,” points out that “In order to alleviate depression, BA assumes clients must be assisted in engaging in behavior that they will ultimately find pleasurable or productive, or that will improve their life situations in such a way as to provide greater rewards” (p 21). The text also emphasizes that within its structured framework, BA is highly individualized (p 21).

The chapter then lists 10 core principles of behavioral activation: 1) The key to changing how people feel is helping them change what they do; 2) Changes in life can lead to depression, and short-term coping strategies may keep people stuck over time; 3) The clues to figuring out what will be antidepressant for a particular client lie in what precedes and follows the client’s important behaviors; 4) Structure and schedule activities that follow a plan, not a mood; 5) Change will be easier when starting small; 6) Emphasize activities that are naturally reinforcing; 7) Act as a coach; 8) Emphasize a problem-solving empirical approach and recognize that all results are useful; 9) Don’t just talk, do!; 10) Troubleshoot possible and actual barriers to activation (p 23). The chapter also cites 1 patient who skillfully summarized the difference between cognitive and BA approaches as follows, “So, you are saying that cognitive therapists believe that the head teaches the hands, whereas the BA approach assumes that the hands teach the head?” (p 25).

The third chapter, “The structure and style of therapy,” discusses the structure of every session, emphasizing that “activation is the guide” (p 39) and pointing out that during early sessions it is important to explain some of the key elements of the structure” (p 38). The authors also mention a self-help manual that could be given to patients to read. The chapter expounds on the cardinal rule of any behavioral or cognitive-behavioral therapy—reviewing of any assigned homework during the following session (homework mentioned include activity and mood monitoring, activity scheduling, activity structuring/grading tasks, attention-to-experience exercises, and maintaining an activation focus). The authors also list frequently asked questions by patients and sample answers. Chapter 4, “Identifying the ingredients of behavioral antidepressants,” discusses the assessment of goals; defining and describing the key problems and behavior; antecedents and behaviors; and behaviors and consequences and then gets to activity charts and monitoring. Patients can monitor activities hour-by-hour or blocks of time during the day, or they can use time-sampling procedures. They can monitor activities, mood, emotions, mastery and pleasure, and intensity of all. The authors provide useful questions to facilitate the review of activities, etc. Finally, the chapter discusses assessing the risk of suicide (which should be routine during the initial interview).

Chapter 5, “Activity scheduling and structuring,” gets “to the heart of behavioral activation, namely scheduling and structuring activities” (p 90). It discusses how to activate patients, how frequently the tasks should occur, their duration and intensity, and timing. The text also cautions against the “all-or-nothing activation.” Chapter 6, “Solving problems and countering avoidance,” reviews problems addressed in BA (eg, losses, daily hassles, injury with subsequent pain). It also talks about how countering patient avoidance is a critical part of solving problems in BA. Chapter 7, “How thinking can be problematic behavior,” brings back some cognitive issues. The authors write that “thinking is not a separate category of behavior that follows its own special rules but rather is “private behavior” and yet is subject to the same learning principles, such as reinforcement and punishment” (p 130). They emphasize that “BA approaches negative thinking or rumination in a manner consistent with behavioral principles” (p 131). The title of chapter 8, “Troubleshooting problems with activation,” summarizes its content well. Finally, chapter 9, “Tying it all together: relapse prevention and beyond” notes that “BA follows a logical course over time” (p 170) and that “relapse prevention is programmed into BA from the beginning and is increasingly a central focus of sessions as the course of treatment comes to a close” (p 171). The authors also note that “booster sessions” could be helpful after the course of BA is finished. The rest of the chapter “ties it all together” or summarizes BA.

Appendix 1 provides charts and worksheets for depressed clients; Appendix 2 presents “Notebook and weekly therapy plan”; Appendix 3 includes “Notebook and posttherapy plan”; and Appendix 4 is an “ACTIVATE reference sheet for therapists.”

Because the book tries to be easily clinically applicable, all chapters start with a discussion of a fictive BA patient, Alicia. The text includes further clinical examples.

This is a bit wordy (for behavioral therapy), but useful text. In a way, all clinicians treating depressed patients should practice some kind of behavioral activation, eg, having patients schedule physical activities and reviewing their gradual increments with patients. Thus, this text could help us in this practice. Those practicing behavioral therapies or those collaborating with or supervising BA therapists will also find this volume informative and useful.