Behavioral activation (AC) for depression is a procedure that has no less than 30 years of history, but in recent years it has regained interest in the field of psychotherapies for depression.
Like any good idea, it is based on a simple premise: no matter how depression is generated, one of its main characteristics is inaction, a lack of activity, which in turn leads to worse mood and thoughts ( and often adds guilt to existing sadness), which in turn makes action difficult. In colloquial language, this is the main characteristic that we identify when saying that a person “is depressed”: it is difficult for them to fulfill their obligations, they spend a lot of time locked up, they do not seem to enjoy any activity, etc.
With this in mind, a possible treatment could be aimed at “activating” the person, that is, using learning and reinforcement principles so that the depressed person gradually performs activities that are pleasant, important, or that give them a sense of mastery. about his life, and in this way the circuit of “sadness-inaction-sadness-inaction”. This is precisely the proposal made by Behavioral Activation (CA).
AC is based on the work of Ferster, who made the first conceptualizations of depression using functional analysis, and the early developments of Lewinsohn and his collaborators, who were the first to apply behavioral principles to the treatment of depression (although the term “ behavioral activation” is later).
Despite considerable research and development effort in the behavioral wing, the approach became popular mainly thanks to its inclusion as a treatment component in the Cognitive Therapy (CT) of depression developed by Aaron Beck, a treatment model that included, In addition to cognitive interventions as the central axis of the treatment, the planning of pleasant or mastery activities as part of the protocol.
If you value articles like this, consider supporting us by becoming a Pro subscriber. Subscribers enjoy access to members-only articles, materials, and webinars.
Beck’s model
In the case at hand, TC is the standard of treatment for depression, a solid model with a lot of evidence in favor of its effectiveness. TC includes several interventions, some cognitive and some behavioral, that is, it includes several “ingredients.” A full discussion of Beck’s model is beyond the scope of this article, but suffice it to mention that CT treatment for depression posits that people acquire certain cognitive schemas (also called core beliefs), which are stable ways of viewing the world. , as a result of his early experiences.
It does not require discussion or modification of the depressed patient’s thoughts.
These cognitive schemes predispose people to negatively interpret life events (the so-called cognitive distortions or automatic thoughts), and this in turn leads the person to act in a depressive manner. In research and in the clinic, CT proved to be highly effective for depression, achieving good results with relatively brief treatments, and soon became the standard of treatment for depression, being today one of the most popular approaches in clinical practice. guided by evidence. However, not everything was said yet.
Jacobson’s research
Towards the mid-90s, Neil Jacobson’s team conducted a component analysis of CBT for depression. A component analysis is a type of research intended to find out that is effective in a given treatment. Most psychological therapies include different interventions, and the question is which of these “ingredients” best leads to change and improvement. For example, it is common that during the psychological treatment of a depressed patient, physical activity is recommended, perhaps an antidepressant is also prescribed, and all this while continuing with psychotherapy. Now, the question is: if the patient improves after six months, do we attribute it to the physical activity, to the psychotherapy, to the medication, to the combination of all of these or to some factor external to the therapy (for example, the mere passage of time or the resolution of a conflict in the person’s life)? That’s the kind of question a component analysis attempts to answer. By comparing the effectiveness of the treatment components with each other, it is possible to know which is the active element, or to what degree it is, in each case. And knowing which are the active components and which are unnecessary in a treatment allows you to improve it, making it simpler and more effective.
The research carried out by Jacobson’s team was carried out with 152 patients diagnosed with Major Depressive Disorder, who were randomly assigned to one of three possible treatment conditions, following Beck’s treatment model:
-
The first treatment condition included only the behavioral activation component of Beck’s CT for depression. This included semi-structured activities aimed at activating people in their everyday environment.
-
The second treatment condition included, in addition to the AC component, the detection and modification of dysfunctional automatic thoughts (AP) or cognitive distortions, as performed in traditional CT.
-
The third treatment condition included the complete CT treatment: AC, the modification of cognitive distortions, and also the identification and modification of stable thought patterns: the cognitive schemas or core beliefs, which are hypothetically the cause of negative thoughts and depressive behavior.
The results were solid and unexpected: there was no difference in efficacy in the results at the end of the experiment or in the two-year follow-up of the patients. The complete CT modality It was just as effective. than the other two conditions (AC only, or AC+PA). The discoveries (quite unexpected for Jacobson’s team) called into question the need for cognitive interventions for the treatment of depression. That is, if the entire TC packet has the same effectiveness than AC (which is only part of it), what would be the usefulness of adding cognitive interventions? Additionally, this research questioned Beck’s premise regarding the cause of depression, namely that central beliefs or schemas and distorted thoughts are the cause of depression.
Incorporates elements of functional analysis and tools to deal with rumination
All of this led to renewed interest in AC as a stand-alone treatment (that is, not as part of another treatment but as a treatment in itself) for depression, as it offers a number of advantages:
-
It does not require discussion or modification of the depressed patient’s thoughts, a procedure that is usually difficult to learn and apply.
-
It is a simpler treatment for the therapist to carry out.
-
It is an easier treatment to teach therapists.
Based on Jacobson’s research, research has begun to focus exclusively on AC, comparing it with other interventions (psychological and pharmacological), and the results have been favorable, particularly with the most severe cases of depression.
Behavioral Activation Models
AC has its own conceptualization of depression, which involves behavioral principles and functional analysis of the behaviors that constitute depression.
Currently there are two formats or models of behavioral activation for therapy: the BA (Behavioral Activation) model, promoted by Addis and Martell (who were collaborators of Jacobson), and the BATD (Brief Activation Treatment for Depression) model. Behavioral Activation for Depression; Lejuez, Hopko et al.). The differences between the two are relatively small: they are based on different learning principles; BATD is more structured than BA; BA incorporates elements of functional analysis and tools to deal with rumination, while BATD focuses exclusively on behavioral activation. But in any case, both models share more similarities than differences.
BATD
BATD is of particular interest in our Latin American context, in which economic resources do not usually allow for prolonged and complex treatments, and access to training for therapists is usually limited, since it is a brief protocol, accessible to therapists. on its theoretical basis, and with good empirical references regarding its effectiveness,,,.
The BATD model proposes the identification and performance of activities that are closely connected with the personal values of each patient, in various vital areas, and although the model does not ignore the patient’s emotions and thoughts, it places emphasis on behavior modification. as a means for change. For example, suppose a patient states as a value “being a good father to my children,” in that case, the BATD model will focus on collaboratively identifying activities appropriate to the patient’s activity level, activities that embody that value, such as Play with your children, go pick them up from school, help them with homework, etc. Motivation is put here as a result, not as a requirement: motivation does not arise in a vacuum, but we feel more motivated as we interact with the world.
BATD proposes the identification and performance of activities that are closely connected to the personal values of each patient.
The BATD model consists of few treatment elements: the recording of daily activities, the evaluation of the patient’s vital areas and personal values, the prioritization and planning of selected activities, and the use of social resources accessible to the patient.
The BATD procedure, organized in this way, can be learned in a few hours, and provides a tool that can be used in the clinic, either as a sole treatment for depression, or as a complement to another treatment (something that usually happens in practice). is to dedicate half of the session to the BATD protocol and the other half to other work styles). In addition to this, AC can be used as a treatment axis in a wide range of disorders (there is some initial research on the application of BA in various anxiety disorders, see Hopko et al, 2004). That is: get the patient moving and then work on the difficulties that arise when moving in a certain direction (negative emotions, thoughts, memories, etc.), with other procedures.
In short, it is a treatment with empirical support, extremely interesting for our socio-economic context, and which sheds new light on the treatment of people suffering from depression.
Recommended book: .
For more…