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 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. 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 Lewinsohn

6. “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 Brief History: Ferster

7. Peter M. Lewinsohn Aaron T. Beck 1970s 1979

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 Aaron T. Beck Neil S. Jacobson 1996 1970s 1979

10. What accounts for the efficacy of cognitive therapy? Peter M. Lewinsohn Aaron T. Beck Neil S. Jacobson 1996 1970s 1979

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 (N=43) CT (N=45) Follow-up evaluations Placebo withdrawal Follow-up evaluations ADM-CM (N=100) ADM continuation Follow-up evaluations PLA-CM (N=53)

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 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

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.

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

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 goal—what, 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 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 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?