What is behavioral activation and when is it used? - Chapter 9

What is the rationale behind behavioral activation (BA)?

Behaviorists see positive reinforcement (PR) as fundamental to human experiences. It is a first and continuous influence on behavior, emotion and cognition. When one is under the influence of PR one feels uncontrolled, unforced, so free. According to behaviorists, the meaning of behavior is found in the reinforcers, consequences and antecedents of behavior. A meaningful life consists of contact with diverse, stable and personally meaningful positive reinforcers. The goal of behavioral activation (BA) is to bring someone into contact with these reinforcers, thereby reducing symptoms and giving more meaning to life. BA uses primary (activity scheduling to get in touch with PR) and secondary techniques (overcoming obstacles, choosing good activities).

How does BA work?

There are many different treatment protocols for BA, but one element that is commonplace is activity scheduling. Activity scheduling is characterized by a number of principles / characteristics, the definitions of which are criticized:

1. Scheduling specific activities (this poses problems in the definition of BA, as much use is also made of techniques such as activity monitoring, skills training, etc.).

2. The focus is on activating behaviors to contact positive reinforcers (problem: excludes that BA also focuses on avoidance reduction and negative reinforcers).

3. The term "reinforcement" allows BA theory to piggyback on the vast amount of knowledge about reinforcement, while the term "reward" could be better used

4. The reinforcement must be stable, diverse and personally meaningful, so that not all reinforcers are treated equally.

Manos et al. Have made a BA model for the development of psychopathology, consisting of various parts:

• R: positive reinforcement. Reinforcers can be lost due to, say, loss of your job or a loved one. In addition, reinforcers are different for everyone, the differences can be due to genetic, biological or cognitive factors (Lewinsohn). There is also the possibility that positive reinforcers are present in someone's environment, but that someone has not developed the ability to contact / maintain contact with the reinforcer or that reinforcers are being taken from someone (e.g. child being abused, financial problems).

  • R-: increased negative reinforcement. Avoiding bad things also prevents you from coming into contact with positive reinforcers. This can cause and maintain disorders such as depression.

  • R +: Increased positive reinforcement. Positive reinforcement also exists for problematic behavior. An example is a depressed husband who receives positive attention from his wife for staying home from work. To find out about these factors, a function analysis must be performed.

• M: mood. Mood and reinforcers are taken together in a matching box in the model because they often covariate together. When positive reinforcements disappear, complaints arise in mood.

• B: behavior. When positive reinforcement decreases, the behavior retained by the reinforcement decreases or disappears. To the extent reinforcers were generalized and large, we also expect large, generalized decreases in behavior (Activation). At the same time, the environment is characterized by more negative and positive reinforcement for depressed behavior, leading to avoidance and depressive behavior. When behavior is changed in response to the environment, the environment will change more (no more socializing through avoidance - loss of positive reinforcers - more depression - more reduction in behavior). This is indicated in the model by the arrow from B to R.

• D: depression. Depression, according to the model, is not explained by a reduction in positive reinforcement and reduced behavior, but the result of a vicious circle between reinforcers, mood and behavior.

The model can also be adapted to treatment goals (T). Activity scheduling immediately increases behavior and secondary techniques reduce avoidance and depressive behavior. Techniques (especially contingency management) change the environment directly instead of via the client's behavior. This change in environment, together with the change in environment due to change in the client's behavior, ensures the breaking of the vicious circle and the creation of a healthier circle characterized by:

• positive reinforcement of activating behavior -> strengthening and preserving environmental influences (arrow from R to B) -> improvement in mood -> less depression.

What kind of challenges and problems do you encounter with BA?

Research on BA's model of psychopathology has made use of the Pleasant Events Schedules (PES). PES measures reinforcement over time, but this model is not entirely correct. PES confuses R and M, only pleasant items were included in the model and the model uses M as an indicator for R, this is just not possible because R and M cannot be separated. Current models use activities as measurements of R. In addition, PES confuses R with B, the BA model looks at behavior that follows R (R -> B), the PES looks at behavior that leads to R (B -> R). Although the model is not perfect, results from studies using PES are consistent with results from BA studies. For example, it is found in both that there is a relationship between R and D, but it is not clear whether D leads to a reduction in R or whether a reduction in R leads to D. Many studies have made use of diaries. These studies have shown that many relationships exist from the BA model, but causality cannot be established. For example, Carvalho and Hopko found that R is a mediator between avoidance behavior and depression (B -> R -> D: the line from B to R in the model), but causality cannot be established here either.

Treatment outcome research shows good effect sizes for BA, it is equivalent to cognitive therapy. Treatment process research investigates the working mechanism, this shows that T leads to change in R, M, B and D, because use was made of the PES model, no direction can be indicated. The studies also show that BA's mechanism of change is specific to BA treatments. Other forms of treatment also show improvement in mood, increased activity, and elements seen as R. This suggests that the relationship between M and R can also run differently than in the BA model (R -> M), namely from M -> R. This is not a problem for the BA model, as long as the model is seen as one possible model and not as the only model. This is confirmed by a number of single-subject studies in which the BA model was valid for a number of clients, but not for all.

Much research is consistent with the BA model. For example, it has been shown in the ARMDA model (Activity Restriction Model of Depressed Affect) that stressful life events can lead to depression. Life events are seen here as R and consisted of illnesses or caring for sick loved ones (R -> D). According to this model, life events reduce activities perceived as rewarding, such as exercise, leading to depressive symptoms (R -> B -> D).

Control theory suggests that depression is due to a hindrance to goal achievement. BA mentions the goal of activity scheduling as "coming into contact with diverse, stable and personally meaningful sources of positive reinforcement." It has been found that the best way to maintain mental health over the long term is to pursue various higher-order goals, which gives activities a purpose to work towards. A disruption in someone's ability to achieve these goals predicts depression.

In people with depression, the reward circuit in the brain is disrupted. This is related to the BA model because changes in environmental reinforcement must bring about changes in mood and behavior, as well as in the underlying reward circuit that mediates mood and behavior. Disturbances in the reward circuit have been found to normalize (R) after BA therapy.

Skinner was the first to explore the relationship between depression and disruptions in positive reinforcement. Lewinsohn took this further and developed a treatment manual that included techniques such as activity scheduling and social skills training. Later the manual was expanded with cognitive and relaxation training. In this early phase of BA, it became clear that both behavioral and cognitive therapy were effective for depression and many forms of BA emerged (all with activity scheduling as a central component). In the 1970s / 1980s, there was an increasing trend towards combined cognitive-behavioral therapy. Beck's cognitive therapy had a major impact on this. Activity scheduling was included as a secondary technique aimed at facilitating cognitive change (instead of behavioral change). However, a component analysis showed that activity scheduling without cognitive techniques was sufficient for the treatment of depression, after which it became a stand-alone therapy.

Based on the component analysis, two forms of behavioral therapy have been developed: BA and BATD (behavioral activation treatment for depression). Both assume that depression is due to too little positive reinforcement, but they also differ in several areas. BA is based on Lewinsohn's model, which focuses on activity scheduling and activation techniques that are also found in CT (activity monitoring, contingency management, skills training). It is theoretically based on the functional contextual perspective and Fernster's idea that depressives also use many avoidance strategies leading to a reduction in positive reinforcement. BA focuses on avoidance and teaches people functional analytical techniques to understand their behavior. BATD is based on the matching law, which not only looks at positive reinforcement, but the ratio between reinforcement for depressed behavior versus reinforcement for non-depressive behavior. BATD is more structured than BA, it starts with an assessment in which a hierarchy of specific activities is established, after which the therapy focuses on activity scheduling and contingency management (to involve the family for support and change the environment). BA and BATD have been shown to be effective in many populations.

Although component analysis has shown that BA is sufficient and CT does not need to be added, the results are not one-sided. Other studies show that CT techniques do contribute to better results. It is difficult to determine what will lead to change because the two components (CT and BA) are intertwined and often confused in measurements. It can be concluded that behavioral activation is an active component in most cases in both CT and BA, the mechanism of action is not yet clear.

Besides activity scheduling, there are other techniques used in BA. These techniques are considered consistent with BA if they cooperate with the goal of planning activities to interact with positive reinforcement, if new behaviors are learned that are positive reinforcing. For example, relaxation aims to reduce anxiety (not consistent with BA) and is seen as part of BA when the anxiety prevents a person from engaging in activities.

Behaviorists see positive reinforcement (PR) as fundamental to human experiences. It is a first and continuous influence on behavior, emotion and cognition. When one is under the influence of PR one feels uncontrolled, unforced, so free. According to behaviorists, the meaning of behavior is found in the reinforcers, consequences and antecedents of behavior. A meaningful life consists of contact with diverse, stable and personally meaningful positive reinforcers. The goal of behavioral activation (BA) is to bring someone into contact with these reinforcers, thereby reducing symptoms and giving more meaning to life. BA uses primary (activity scheduling to get in touch with PR) and secondary techniques (overcoming obstacles, choosing good activities).