Only an Intervention for Treating Depression,
Or An Approach for Achieving a Meaningful Life?
Andrew Hale, MA, BCBA
Western Michigan University
1903 W Michigan Ave
Kalamazoo, MI 49008
C. Richard Spates, PhD
Western Michigan University
1903 W Michigan Ave
Kalamazoo, MI 49008
Behavioral activation is an empirically supported intervention for depression that has demonstrated effectiveness both as a stand-alone treatment and as a component of cognitive therapy. Additionally, there is a growing body of evidence supporting the application of behavioral activation in contexts that do not involve the treatment of clinical depression. This paper introduces the defining features of behavioral activation, describes a series of popular self-help and productivity strategies that employ principles of the treatment, and present contemporary neuroscience research related to clinical and non-clinical applications. Behavioral activation may have important benefits beyond treating depression such as increasing resiliency, fostering well-being, and building a meaningful life.
Keywords: Behavioral activation, effort-based rewards, self-help, resilience
- Identify the core strategies of behavioral activation.
- Describe potential benefits of behavioral activation for non-depressed populations.
- Identify three specific techniques used in popular self-help and productivity strategies that are components of behavioral activation.
- Describe the summary findings of basic animal research comparing the effects of effort-based and non-contingent rewards on resiliency.
Target audience: Psychologists and Social Workers
Program Level: Intermediate
Human suffering is ubiquitous and often takes the form of sadness, hopelessness, and depression. Those who struggle with depression often find it difficult to engage in even the most basic tasks. As a result, their lives may narrow and become restricted until they have trouble doing the things they used to enjoy, leaving the house, or even getting out of bed. Behavioral Activation (BA) is an evidenced-based treatment for depression that focuses a person on re-engaging in activities that are important to him or her despite current mood. Most research to date has focused on using behavioral activation to eliminate symptoms of depression, yet few studies have examined the intervention as a preventive measure or even as a tool to increase happiness and well-being for non-depressed populations. In the following paper, we present a history of behavioral activation and how it is typically applied, interpret several popular self-help strategies through the lens of the intervention, briefly review contemporary neuroscience literature related to the underlying theory, and suggest that behavioral activation may have applications beyond exclusively ameliorating symptoms of depression. The principles of behavioral activation may have merit when broadly applied in non-clinical populations to foster well-being, prevent depression, and help build a meaningful life.
Behavioral activation is an empirically supported treatment for depression that has garnered much attention since its conception. It has been used as both a stand-alone treatment as well as incorporated into the broader cognitive-behavioral treatment framework (Dimidjian et al., 2011). In addition to being an effective intervention for depression, behavioral activation has also shown promise when used as an intervention to increase well-being in non-clinical populations (Mazzuchelli, Rees, & Kane, 2009; Mazzucchelli, Kane, & Rees, 2010). Although several variations exist, behavioral activation is widely regarded as a parsimonious and theoretically consistent behavioral treatment with a strong focus on behavior change through enhanced exposure to positive reinforcement. In a recent review, Dimidjian and colleagues (2011) defined behavioral activation as “a structured, brief psychotherapeutic approach that aims to increase engagement in adaptive activities, decrease engagement in activities that maintain depression or increase risk for depression, and solve problems that limit access to reward or that maintain or increase aversive control.” The principles implied in this core definition have formed the foundation of the treatment for the past 40 years. However, the psychological community did not initially embrace behavioral activation as it emerged in an era dominated by Freudian psychoanalysis. Nor was it embraced later with the arrival of the “cognitive therapy revolution,” where the cognitive features held sway. It was through decades of laboratory and clinical research (Lewinsohn, 1974, Ferster, 1973) that repeatedly demonstrated that the principles of behavior could be used to predict, influence, and treat depression that earned behavioral activation a place among empirically supported treatments in its own right.
A Behavioral Approach to Mood and Emotion
Skinner (1953) proposed a behavioral analysis of emotions in which he stressed that emotions themselves are not causes of behavior. Emotions commonly co-occur with other behaviors of interest (e.g., escape and avoidance), and he argued that both the emotional and behavioral responses, when they co-occur, are often products of the same contingencies. However, because of their co-occurrence and co-variation it is common to find one of these constituents of depression, an emotional response, being used as an explanatory variable for decreases in overt behavior when at best it is part of the very behavior to be explained. From this perspective, it is useful to focus on the circumstances that evoke the collection of constituent responses (antecedents), including a detailed description of behaviors associated with these emotions and on the specific consequences that immediately follow. Based on this analysis, changes in mood, emotion, and behavior will likely be best accounted for by observed changes in both environment and motivative variables. In other words, we need to ask what events precede the experience of depression, what the depression looks like, and what are the consequences that occur after these behaviors? Modifying these antecedents and consequences will in all likelihood lead to a change in mood along with associated behaviors. Thus, although mood is one obvious and prominent feature of depression, the increase in avoidance and escape behaviors associated therewith are undeniable.
Brief Review of the Development of a Behavioral Treatment for Depression
Ferster (1973) continued the Skinnerian tradition and suggested more specifically that depression is largely engendered and maintained by negative reinforcement of avoidance and escape behaviors. Generally, when life is bad or aversive, any behavior that leads directly to termination or reductions in these circumstances is considered negatively reinforcing. The reward/reinforcement comes by virtue of terminating an existing aversive context. While in the aversive state, escape behaviors consisting of withdrawal reduce the opportunity for making contact with potential positive reinforcement. Further, a person is likely to increase focus on aversive feelings as interaction with the external environment (a potential source of positive reinforcement) decreases. The effect is often compounded as “success” at avoidance leads to more avoidance-driven behaviors and additional symptom exacerbation. For example, a depressed individual tends to quickly perceive circumstances that have previously caused aversive social or interpersonal feelings, and reacts quickly to prevent these from arising in the current context. In successful avoidance, the person isolates him or herself from a multitude of situations that may be experienced as aversive. In doing so, however, they also eliminate the possibility of receiving positive reinforcement from constructive, adaptive, or helpful activities and interpersonal relationships. Importantly, Ferster’s conceptualization of depression placed a spotlight on the function of a client’s behavior rather than the topography or form of the response alone. The emphasis on the function of avoidance and the importance of a functional analysis are Ferster’s main contributions to behavioral activation. He focused particularly on the role of avoidance and escape contingencies as they give rise to depression in the first place. This in turn provided a path for understanding how to reverse such avoidance and escape patterns based on established behavioral science. These contingencies were well understood, as was how to intervene to reduce, disrupt, or eliminate their influence.
Lewinsohn (1974) expanded on the model by proposing that loss or decreased contact with response-contingent reinforcement plays a large role in the development of depression (we will later refer to this as ‘effort-based reward’). Response-contingent reinforcement is reinforcement that is made effective through some level of effort or action by the person. In Lewinsohn’s analysis of depression, once an avoidance pattern becomes well established the person finds him or herself isolated and depressed. In order to counter this situation, he identified activity scheduling as an important component of the behavioral treatment of depression. By scheduling pleasant activities throughout the week, people begin to engage in behaviors they had previously enjoyed, or that led to positive reinforcement, but stopped once they became depressed. This results in renewed sources of reinforcement. This would be particularly true if the activities were related to the very situations that had been avoided or escaped and that led to the isolation and depression. But in order to achieve this end, activity scheduling involves a few other strategies to serve the person well. Merely “scheduling” such activities that were once pleasant is often not enough. The person must be guided to engage or re-engage with the interpersonal or social world by taking very small steps, acknowledging successes in those small steps, really experiencing the reward value of the achievements toward full re-engagement, and be supported and encouraged by others. These approach efforts are arranged so that there is a low probability of failure (punishment) for the patient, and a high probability of success (positive reinforcement). All of these techniques have become part and parcel of the Behavioral Activation intervention. Additionally, other behavioral scientists noted that when a person selects activities to engage in, it is helpful if these activities are also consistent with his or her personal values (Hayes, Strosahl, & Wilson, 2012; Kanter, Busch, &Rusch, 2009; Lejuez, Hopko, &Hopko, 2011; Martell, Addis, & Jacobson, 2001). This, in an important way, might assure that the new approach behaviors (scheduled activities) will be automatically reinforced/rewarded when they occur, because the behaviors are instantly meaningful to the individual and not merely pleasant in a trivial way.
The Importance of Behavior in Cognitive Therapy for Depression
In 1979, Beck, Rush, Shaw, and Emery published Cognitive Therapy of Depression. Over the next several years, cognitive therapy became one of the most widely used and empirically supported brief treatment packages for depression. In addition to the importance placed on challenging and changing maladaptive thoughts, cognitive therapy also included a behavioral activation component. However, while Beck and colleagues understood the importance of incorporating behavioral change in the treatment, the original rationale was lost; that being the direct positive reinforcement exposure. In cognitive therapy, behavioral activation is viewed as an experiment to test the validity of distorted cognitions or their more adaptive replacements, and the replacement of dysfunctional thoughts is seen as a principle goal. In this context, behavioral activation is a tool used by clients to place themselves in situations with social opportunities to test the validity of the negative thoughts.
Importantly, a therapist utilizing behavioral activation based on the behavioral rationale would not disregard the client’s thoughts. In fact, the thoughts may still play an important role in the analysis (as further constituents of depression). However, the focus would shift from the content of the thoughts to the function that they serve to support maladaptive avoidance or escape.
The cognitive therapy package remained the gold standard of brief depression treatment for many years and largely overshadowed behavioral activation as a stand-alone treatment. It gave therapists a specific set of intervention techniques on which to focus their assistance to patients, and in that respect contrasted positively with many less focused or less specific therapies available at the time (i.e. client centered therapy, psychoanalytic therapy, and several newly arriving idiosyncratic pop psychology interventions). The empirical evidence supported cognitive therapy to the degree that it contained the behavioral activation component implemented along with the cognitive manipulations. This connection led many to assume however that it was the cognitive elements that comprised the essential ingredient of CT, as it was the center of therapists’ action. It seemed quite intuitive. However, in 1996, Jacobson and colleagues, who themselves were among the true believers in CT and the essential role played by cognitive elements, conducted a component analysis of cognitive therapy (otherwise known as a dismantling study) that provided evidence that behavioral activation alone is a powerful and effective treatment for depression, and may in fact constitute the core ingredient of CT. In this study, three treatment groups were used to examine the differential effects of each component. These groups were behavioral activation alone, behavioral activation with cognitive restructuring of automatic thoughts and the full cognitive therapy package including core belief modification along with these other components. The results of the study revealed that all of the assigned experimental conditions produced similar outcomes both at the end of the study and at 2-year follow-up. Importantly, these outcomes were not just on behavioral symptoms of depression, but on measured cognitive features of depression (negative thoughts), even though these were not specifically targeted in the behavioral activation intervention. In other words, negative cognitions changed in the positive direction through only the behavioral intervention. Appealing to the scientific principle of parsimony the authors concluded that behavioral activation strategies alone might be enough for the treatment of depression. At the practical level, the implications were very important because it laid the foundation for an intervention that did not have to begin by identifying irrational, illogical, or maladaptive thinking as the key feature of the depression even if these were noted in the process of conducting a thorough assessment. Instead the therapist or change-agent who assists depressed individuals need only identify personally relevant goals, any escape or avoidance behaviors that block engagement with (usually) interpersonal or social situations that promote success in achieving those goals, and help the clients by structuring activities and small steps that lead directly to such achievements.
Behavioral Activation: A Treatment for Depressed Individuals
Since the Jacobson, et al. (1996) study, several additional iterations of behavioral activation have emerged and have been refined. While some of these packages have slight variations, it is possible to abstract the common elements. First, a key principle in the treatment is teaching clients the skill of activity monitoring to increase their self-awareness and identify mood patterns in their weekly routines. This process creates a visible record of activity to which the client can be taught to respond differentially. It is well-established that depressed individuals tend to view the world, themselves, and their futures in very negative ways, no matter the genuine circumstances (Beck, 1976). They also fail to notice the relationship between their behaviors and their moods, especially in instances where there is little variation in their behavior during depressed moods (i.e., where total avoidance and escape prevail and their mood may in fact be low and largely unchanging). It is common for clients to retrospectively report an activity as not being very enjoyable, yet through activity monitoring and/or through direct questioning by a therapist in a very specific time course analysis of their day, they discover their mood generally improved while engaging in some types of activities. Second, clinicians work with their clients to generate enjoyable values-consistent activities and schedule activation as homework. The purpose of this is to increase the client’s contact with positive reinforcement, either by engaging in new activities or by revitalizing old ones. Importantly, the activity scheduling is done using a graded approach to start small so as to not discourage, overwhelm, or set clients up to fail. Sometimes and for some clients, this may involve teaching new skill sets since some difficulties may have arisen due to defective or ineffective social and interpersonal skills in the first place. Further, clients are encouraged to follow the schedule and plans, not their moods. Mood dependent behavior (e.g., “I didn’t feel like it” or “I was not motivated to engage” or “I didn’t think it would do any good anyhow”) is specifically discouraged. A “do it anyway, despite present mood” approach is preferred inasmuch as such resistance is viewed as a by-product of the recent history of reinforced avoidance and practice is needed to move the client to experience potentially reinforcing events. Third, client avoidance patterns are identified and undermined and countered through problem-solving, validating and accepting the difficulties of change, and using specific behavioral descriptions to increase the saliency of the target behaviors. Problem-solving strategies can be used to collaboratively address barriers. For example, making plans in advance, role-playing difficult social interactions, and even acquiring requisite social skills in some instances can increase the probability of success in the goal of extracting reinforcement from the environment. Further, validating the client’s difficulties helps strengthen the therapeutic alliance by demonstrating that the therapist can take the client’s perspective. Finally, skills training, stimulus control procedures, and contingency management are used to increase the chances of client success. The principles of behavioral activation can be described colloquially as being aware of what you’re doing, intentionally selecting and planning goal-relevant activities, doing more of the things you once liked that service those well-chosen goals, doing things that are meaningful or values-consistent even when you don’t feel like it, and doing things that make you happy while using tools such as post-it notes, weekly planners, and social contracting to maximize your chances of being successful.
Behavioral Activation: An Intervention for Non-Depressed Individuals
While much of the discussion, up this point, has been in the context of behavioral activation for depression in order to illustrate the principles and procedures involved, a central thesis to this paper is these principles are application-neutral and have relevance to clinical and non-clinical uses alike. As previously mentioned, a significant portion of the behavioral activation intervention is concerned with increasing reinforcing activities and decreasing avoidance behaviors. Ferster and Lewinsohn’s conceptualization of depression provided a model of how these two components assisted an understanding of and led to steps toward the alleviation of symptoms of the disorder. However, the question raised by the present article is whether the experience of depression is a prerequisite to achieving personal benefit from behavioral activation. In other words, do the principles hold promise of benefit for non-depressed populations as well and to what end? There are several examples that suggest the application of BA may be well-suited to assisting the achievement of non-clinical personal life goals. The remainder of this article sketches the broad outlines of just such applications, usually by other names.
“Go for No” is a popular book that recommends utilizing BA type strategies to address strong tendencies to avoid based on punishment history (Fenton & Waltz, 2010). The authors suggest that people often treat success and failure as opposite ends of a continuum and will go to great lengths to avoid moving in the direction of failure – often at the expense of engaging in activities that are important to their goals. The “Go for No” approach emphasizes doing more of the things we tend to avoid, independent of mood (e.g., tired, afraid, unmotivated), when doing them will lead to beneficial/positive outcomes (reinforcement). The salesman who fails to make a particular sale and then withdraws and misses the next few opportunities to connect with potential buyers exemplifies the problem, and commends the solution to achieving desired goals; to wit, face the thing you tend to avoid, and, in fact, the book recommends, counting and increasing the frequency of potential purchasers saying “no” to a sale. By doing so you are enormously more likely to increase sales and thus make progress towards the desired outcome (or life goal).
7: How Many Days of the Week Can Be Extraordinary? is a self-help book that also recommends strategies for life that are akin to behavioral activation (Zadra, 2012). The book is essentially a montage of inspirational quotes and stories, thought-provoking questions about life, and suggestions for taking action. For example, the book uses a metaphor to compare our lives and what we fill our time with to a container that can be filled with rocks, pebbles, and sand. The rocks represent the things that matter most to us (our values, in psychological terms), the pebbles are things that are important but don’t dictate our happiness (e.g., work, house), and the sand is everything else in our lives (all of the small, busy things). Many of us have the tendency to fill our containers with the sand, and we do so at the expense of having room for the more important rocks. An attached worksheet encourages readers to think about what their “rocks” are and to prioritize fitting those into their lives before the less important things. In behavioral activation terms, the authors are recommending identifying your values and prioritizing behaviors consistent with them before adding in less important things that often find a way to dominate our lives. Further, the book contains recommendations that are strikingly similar to activity scheduling, making it a good example of how BA strategies can be used in everyday life.
In his book released in 2010 titled The Compound Effect, Darren Hardy outlines a strategy for helping people become successful and implicitly find happiness. The main principle underlying The Compound Effect is small changes can produce massive results over the long-run. For example, a person who wants to lose weight may construct a complex and intense workout plan. The person may stick with it for a few weeks, get frustrated with the lack of immediate results, lose motivation, and quit. In our analysis, this individual has now been successful at escape and avoidance to the point of abandoning a meaningful life goal of losing weight, with its many health benefits. Alternatively, that person could commit to doing one set of push-ups and sit-ups every morning before showering. While it may not seem like much, that person is more likely to stick with the small change and by the end of the year he or she will have done thousands of repetitions of the exercises and will be in better shape. Many benefits come from this. These people may feel better about themselves, be more confident, increase their success with potential dating relationships, and be in good enough shape to go hiking with friends. In other words, one small change can multiply opportunities to experience reinforcement throughout many areas of life. Hardy uses the example of three friends whose different approaches to life reveal the compound effect, and thereby the implementation of, BA-consistent strategies. The first of the three friends is making poor choices in his life. He is increasing the amount of TV-watching per day by an hour and increasing his alcohol consumption by at least one drink per week. The second friend is happy with the status quo and is not making changes in either direction. The third friend has decided to make some positive, but fairly minor, changes in his life. He is going to listen to an instructional podcast on his 30-minute commute to and from work, and cut 125 calories from his diet each day by drinking one fewer can of soda. Monitoring these three individuals over the next six months may or may not reveal any significant differences. However, if we continue monitoring them for another year the cumulative effect of these changes will become apparent, and even more so after a second year. In fact, after 31 months the first friend, according to Hardy, has gained 33.5 pounds due to the extra alcoholic drink per day, while the third friend has lost 33.5 pounds, creating a difference between them of 67 pounds. The first friend has also watched 940 hours of television, while the third friend has listened to 940 hours of instructional podcasts that have helped him in both his personal and professional life. Meanwhile, the second friend has not made any changes and is roughly in the same condition he was in 2.5 years ago. The third friend has significantly improved his quality of life through relatively small changes.
Consistent with the rationale for activity-monitoring in behavioral activation, Hardy says the first step toward change is awareness and suggests his readers track every behavior related to an area of life they wish to improve. He suggests that many people are simply sleepwalking through life and thus may be unaware of the default choices they are making and the consequences their choices have. Consistent with the current psychological literature on values, Hardy highlights the importance of identifying one’s “core values” and making sure that life choices align with those values. Again, similar to behavioral activation’s goal, this strategy is to increase the probability that the behaviors being emitted are likely to receive automatic positive reinforcement, be maintained over a longer period of time, and lead to increased happiness. His descriptions of “game changers” also bear a striking similarity to the core principles of behavioral activation. For example, he recommends identifying triggers for bad habits and removing things from the environment that enable them (stimulus control), easing in to new behaviors (graded tasks), and using public displays of accountability (social contracting). Stimulus control is a term used in behavioral sciences to describe how the presence or absence of a stimulus makes it more likely that a particular behavior will occur in a given context. The third friend in the earlier example is attempting to reduce his soda intake and may implement a stimulus control procedure by skipping the purchase of soda at the grocery, or obscuring it from view behind healthier alternatives in the refrigerator so it is not the first beverage seen when the door opens. Graded tasks refers to breaking larger tasks down into smaller, more manageable pieces to make the task less overwhelming, to assist with project planning, and to provide opportunities to obtain reinforcement as steps are completed along the way to the larger goal (Hardy’s “easing into new behaviors”). This strategy is often utilized in behavioral therapies, but is also seen in popular task management and productivity systems such as David Allen’s Getting Things Done (Allen, 2002). While writing “Clean and organize basement” on your to-do list is certainly an identification of a worthwhile project, the immensity of the task is more likely to evoke anxiety and avoidance than to motivate you to begin the work. Alternatively, breaking the project down into smaller steps increases the probability that you will initiate the task. If the first item on a to-do list is, “Assemble10 cardboard boxes to use as storage/organization,” then a person is much more likely to go down to the basement and spend the 15 minutes assembling the boxes. Once finished, this person gets to cross the item off of the list, feel productive and motivated, and are also in the right position to capitalize on the momentum and begin the next graded task. Social contracting is a strategy that has been shown to increase the likelihood that a behavior change plan will be implemented consistently and with integrity. Research has shown that once people have publically made a commitment to performing an action, they are more likely to behave in a manner that is consistent with their remarks (Hayes & Wolf, 1984; Zettle& Hayes, 1983). Social contracting has often been used with clients to increase the probability that they will follow through with elements of the treatment plan (e.g., engaging in difficult exposures, completing “homework”). A coach might say, “We’ve talked about how difficult this assignment is for you, and also how much it would mean for you to accomplish it – can you commit to giving it your best this week even though it may be difficult?” Change agents may even encourage the client to employ family or close friends to help hold them accountable for certain tasks to increase the probability that they will engage in a difficult task even if they want to avoid it at the moment. Committing to completing tasks and following through is important, but is simply finishing a task all that is necessary to achieve the experience of satisfaction, pleasure, or accomplishment? Or are there other important factors to consider, such as the amount of effort required to achieve the goal and the steps employed along the way?
Reinforcement in Context – Importance of Effort-Based Reward
In Enjoy Old Age (Skinner & Vaughan, 1983), recommendations are made to increase the well-being of older adults in spite of physical deterioration and major life changes, such as retirement. Relevant to this analysis is the chapter on “keeping busy.” Skinner and Vaughan point out that retirement is a relatively new concept and is often conceptualized as an escape from “the labors of life.” However, many people find that they are escaping from things they actually enjoyed doing, losing an avenue of social contact, and simply creating an abundance of down-time. These changes can result in boredom or depression. Skinner and Vaughan suggest that the process that leads to these symptoms may be a function of increased free time, in which having “nothing to do” is a common complaint. The occurrence of this problem is not only restricted to retirees. They, like Lambert (2006) (see summary of Lambert’s position below), indicate that this problem has been exacerbated by the industrialization of agriculture and technological advances that lead to improved methods of production. These changes ultimately have had the effect of reducing the availability of effort-based rewards.
A possible side effect of our rapid technological growth is we may have taken reinforcement out of its context. Food, of course, functions as a primary reinforcer to a food-deprived organism. However, is the process that is used to obtain that reinforcer an important, and often overlooked, part of the equation? More specifically, is entering a keystroke on a computer to order food delivery completely equivalent to emitting the gathering and cooking behaviors oneself? Skinner and Vaughan (1983) state, “The long-term effect of the completed work is one thing; what happens when the brush touches the canvas or a phrase is tested on the keyboard is another.” They suggest that there is more to reinforcement than just being able to obtain it; the process through which it is obtained is relevant. In the case of the artist, each brush stroke on the page provides satisfaction as the painting moves another step closer to completion, while simultaneously setting the occasion for the next stroke to be made. In other words, the cumulative effect of repeated conditioned reinforcement for making progress towards achieving a moderate to long-term goal may be as important as – or, in reference to Skinner and Vaughn’s example – more important than – the terminal reinforcer at the end of the long chain of behavior.
Social psychologist Jonathan Haidt reaches a similar conclusion in his book The Happiness Hypothesis (Haidt, 2006). Haidt points out that humans often set ambitious long-term goals and strive to achieve them. However, the reward or pleasure that results from finally attaining the long-term goal tends to be fleeting. For example, a person may work hard for several years to get a promotion, yet only experience pride and satisfaction for a short period of time before thinking, “What’s next?” and then setting sights on the next long-term goal. In many cases, the feeling may even be one of relief rather than one of achievement or accomplishment. Instead, Haidt suggests that making progress towards goals, the small steps along the way, are often more important to happiness than the final product. This effect, called the “progress principle,” emphasizes the reinforcing experience of taking each step in the right direction in the process of achieving a goal, and is about the cumulative effect these rewarding experiences have on human happiness.
Empirical Support for BA as a Strategy for Achievement of Life Goals
In addition to these popular accounts of the application of BA strategies for positive life change, there is direct empirical support concerning the pertinence of BA for life. Mazzuchelli et al. (2009) applied a group BA intervention to a non-clinical sample of adults. This study examined the effects on well-being of a group intervention consisting of a four-week behavioral activation component followed by a three-week mindfulness component, and ending with an integrating closure session. In addition to reducing psychological distress, the intervention also increased several measures of well-being. Better than 50% of participants additionally reported being happier after the full intervention. In a well-conducted meta-analytic investigation, these investigators reviewed extant literature between 1970 and 2008, addressing behavioral activation’s impact on one or more components of psychological well-being that included positive affect, happiness, life satisfaction, quality of life, or self-esteem. They found moderate effect sizes for BA on these quality of life and well-being measures, regardless of depression status. These effects were reportedly comparable to effects achieved with Positive Psychology interventions in their own right (Sin &Lyubomirsky, 2009) for similar dependent measures. The BA interventions also demonstrated maintenance of effects for up to the 3-month follow-up, which proved better than comparison interventions in the review.
Seligman’s description of a happy life includes “positive emotion, engagement and meaning” (Seligman, 2002). The present article illustrates that BA targets all three of these objectives through reduced negativity and enhanced pleasurable emotions, enhanced activity scheduling that accomplishes constructive engagement, and meaning through implementation of values-consistent behaviors. These life goals are not limited to clinical samples, although they are certainly relevant to those populations. It is argued here that BA constructs are equally relevant to anyone wishing to achieve personally relevant and meaningful life goals with an increased likelihood of success. With regard to clinical populations, however, it is reasonable to suggest that whatever symptom reduction strategies are called for, supplementation of a treatment plan with BA strategies for achieving well-being might be worth considering. Symptom reduction alone may not automatically lead to an improved quality of life or to well-being. For this reason, behavioral scientists are increasingly assessing quality of life indicators in addition to and separate from symptom reduction in many clinical trials (Spates, Kalata, Ozeki, Stanton, & Peters, 2013; Roy-Byrne et al., 2005). In addition to the empirical evidence just summarized, further conceptual support for BA principles is derived from neuroscience work that addresses “effort-based reward.” This work is briefly outlined next.
Converging Evidence from Neuroscience
Lambert (2006) puts forth a convincing argument that effort-based reward has been lost to technological advancement, which removes the effort from the equation and extracts only the reward. Skinner and Vaughn (1983) made a similar argument and both strongly implicate the contribution of this shortcut to psychological ills faced by the world today, including steady increases in diagnosed depression and anxiety disorders. Lambert further offers that neuroscience research supports the notion of an effort-based reward circuit in the central nervous system, consisting of the accumbens–striatal–cortical network and its modulating neurochemicals. This circuit is thought to be critical for connecting movement, emotion, and thinking. In the book Lifting Depression: A Neuroscientist’s Hands-on Approach to Activating Your Brain’s Healing Power (Lambert, 2008), Lambert provides evidence from human and non-human literature implicating effort-based rewards in the prevention of depression. These data suggest that by engaging in effort-driven activities, the effort-based rewards circuit is fully activated, resulting in a strong sense of emotional satisfaction and well-being. Strongly established in the course of our evolution, this circuit has been shortened by our increased ability to meet our needs and ordinary demands of life with steadily decreasing effort. In other words, technological advances have somewhat reduced the number of opportunities to engage in effort-driven behaviors and the resulting decrease in effort-based rewards may be negatively impacting mental health. It is argued accordingly that, “If physical activity is indeed important in the maintenance of mental health, increased emphasis on behavioral and behavioral/cognitive preventative life strategies” is called for to meet the challenges posed by contemporary existence (Lambert, 2006). Therefore, strategies that target increases in effort-based rewards, including behavioral activation, may be clinically indicated in the prevention and treatment of depression. In fact, Lambert (2008) suggests, “It appears that the effort-driven brain reward circuit facilitates the neural implementation of behavioral activation therapy.” Lambert contrasts this approach with that seen in the ever-expanding promotion of drugs as the solution to life challenges, and points to evidence that strongly suggests failure of the latter, given the steady rises in both application of drugs and symptoms of depression and anxiety.
Additional evidence indicating the importance of effort-based reward is provided by other non-human basic neuroscience investigations. For example, Bardi and colleagues (2012) examined the effect of effort-based reward training on behavioral and neurological measures. In this study, Long-Evans rats that were trained with effort-based rewards engaged in an appetitive problem-solving task longer than rats from a non-contingent training group even after controlling each rat’s predisposed coping strategy. Further, the ratios of dehydroepiandrosterone (DHEA), a naturally occurring steroid associated with adaptive responses to stress, to corticosteroid levels were higher in the contingency trained rats. Higher ratios of DHEA/corticosteroid have been associated with improved resilience and adaptive responses to stress (Charney, 2004). In another study, Bardi and colleagues (2013) trained one group of rats to dig for food while a control group received the food independent of digging. After training, the rats were exposed to a Dry Land Maze task in which they searched an open field for wells that were baited with food. Results of the study suggested that rats exposed to contingent training were 50% more efficient than the non-contingent training rats in locating and obtaining food, and showed 20% less c-fosimmunoreactivity cells in the insular cortex, retrosplenial cortex, and dentate gyrus of the hippocampus, areas associated with emotional and cognitive processing. The researchers conclude, “Thus, our data support the hypothesis that the EBR (effort-based reward) training enhances both cognitive functioning and emotional regulation during challenging events. Considering the ongoing controversy about the efficacy of pharmacological interventions in treating depression, the EBR model provides a valuable alternative for the investigation of the neurobiology of mood disorders.”
There is a growing body of literature with converging evidence from behavioral, cognitive, and neurological sciences suggesting that strategies focusing on increasing effort-based rewards may not only achieve symptom reduction in clinical populations but may also increase resiliency against unexpected or stressful events. This evidence adds to our argument that BA-based strategies may have valuable uses in non-clinical populations. BA places strong emphasis on personal effort and well-chosen activities over avoidance, escape, and unplanned or non-purposeful activity (“drift”) in service of achieving meaningful life goals. Therefore, BA may be an effective strategy for multiple applications and contexts including treatment, prevention, and increasing quality of life.
In this review, we have introduced Behavioral Activation as a well-established stand-alone intervention for clinical depression, but have posited that it is a potentially useful intervention for achieving non-clinical goals on the part of non-depressed persons. The support for this hypothesis was drawn from popular accounts (Hardy, 2010; Skinner & Vaughn, 1983; Fenton & Waltz, 2010), review of pertinent literatures (Mazzuchelli et al., 2010), and direct empirical evidence (Bardi, et al., 2013; Lambert, 2005; Mazzuchelli et al., 2009). We suggest that, as an intervention for non-clinical samples, BA holds promise for assisting with the achievement of meaningful life goals. But more generally, and beyond the treatment of depression, BA might supplement therapy strategies in achieving a higher quality of life for participants beyond symptom reduction. The implications for the use of BA in non-clinical populations are intriguing. We raise the question: “Can the use of behavioral activation strategies act as a preventive measure with regard to the development of depression?” Imagine, for example, a classroom of children in middle school who are taught the importance of planned and systematic activity-scheduling, choosing values-based activities, breaking down complex tasks into manageable pieces, and following through with activities regardless of mood. Perhaps these students would be better equipped to navigate the inevitable obstacles and stressors that appear across a person’s lifetime. While this notion has not been empirically tested, it is offered here as a consideration for future research to assess its possible contributions to the prevention of depression and the achievement of meaningful life goals in the general population.
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Andrew Hale is earning his Ph.D. in the clinical psychology program at Western Michigan University. His interests include the treatment of anxiety and depressive disorders and the investigation of telehealth applications of evidence based interventions. In addition to his ongoing training in clinical psychology, Andrew holds a master’s degree in applied behavior analysis and BCBA certification.
C. Richard Spates, Ph.D. is a clinical psychologist and Professor of Psychology at Western Michigan University. He received his Ph.D. from the University of Illinois at Urbana and worked for 12 years with the Michigan Department of Mental Health as a Senior Mental Health Executive. Among the roles at MDMH he was Director of Evaluation Design and Analysis, and Director of Clinical Policy, Standards, & Behavioral Services. He spent the last 27 years as Professor of Psychology at Western Michigan University where he has additionally served as Director of Clinical Training for 20 of those years and Department Chairperson for 3 years. He engaged in private practice for approximately 8 years and as a legal expert witness for the past 30 years. He has serve as the principal advisor for 27 Ph.D. Clinical Psychology graduates over the past 25 years and is widely published in the areas of anxiety, depression and PTSD interventions.
Published by Dr. Robert O' Block in The Annals of Psychotherapy March, 2015