Cognitive and Behavioral Treatment of Depression:

A Research Treatment Manual

Behavioral Activation (BA) Condition

Copyright 1999
Center for Clinical Research
University of Washington
Seattle, Washington

Revised: July 1999

 Table of Contents

Overall Rationale and Purpose of This Manual - 3

Standard Issues in BA - 6

Therapeutic Relationship - 7

Collaborative Empiricism - 7

How to Respond to Clients’ Thinking - 9

Structure of Therapy Sessions - 12

Essential Components of Good BA - 15

The Logical Course of BA Treatment - 16

Treatment Review and Relapse Prevention - 18

Attention to Non-standard Issues - 20

Conducting Behavioral Activation Therapy - 21

1. General Issues - 21

2. Specific Techniques - 23

3. Presentation of the Model - 28

4. Common Problems in BA - 31

Applying he BA Model to “Larger” Life Issues - 40

Conclusion - 41

Appendix A: BA Condition Assessment and Intervention

Techniques - 42

Appendix B: “Coping with Depression” BA

Pamphlet - 44

References - 48

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 Overall Rationale and Purpose of This Manual

This treatment manual is being written for a specific psychotherapy project

funded by the National Institute of Mental Health entitled "Cognitive and Activation

therapies for Depression." This research project has several aims, including the desire to

analyze the effective ingredients of Beck's cognitive therapy (CT) for depression, and

compare with other state of the art treatments. Cognitive therapy has been, in several

studies, shown to be a highly effective, short-term therapy for the treatment of

depression. Why is this therapy so successful? In order to answer this question, our

previous study (Jacobson, et. al., 1996) broke cognitive therapy down into its major

components and then compared the relative efficacy of each component against the full

treatment. We found that the "behavioral activation" (BA) component of CT worked as

well as did the entire CT intervention package. In other words, simple behavioral

activation worked as well as did the much more complex CT. Our present study is

designed to replicate and extend these findings to compare the treatments.

The cognitive model of depression clearly states that clients' thinking, generating

ideas, fantasizing, assuming, and believing (generally referred to as "cognitions") are

critical for the development and maintenance of depression. In cognitive therapy,

therefore, a premium is placed upon the therapist's ability to effect change in client's

cognitions, thereby reducing their depression.

A more behavioral view suggests that depression results from changes in the

client's life circumstances. The loss of reinforcement resulting from these changes in the

environment precipitates depression. Once individuals become depressed, their ways of

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responding to their depression often deprive them of reinforcement even more, thus

making the depression worse. So, from the standpoint of a behaviorist, the first factor

involved in depression is comprised of the negative life circumstances, chronic life

stressors, and daily hassles that precipitate depression. The second factor is the method

of coping used by the depressed client. This behavior is frequently avoidance of negative

affect or discomfort, which tends to be self-defeating, by generating even fewer

opportunities for reinforcement and often causing routine disruption. The end result is

that the depression gets worse.

There is a third factor, which is vulnerability to depression. Not all people are

equally vulnerable to depression. Both previous history and genetics determine

vulnerability. Thus, everyone has a unique response to a particular set of life

circumstances, as a function of their genetic make-ups and their life histories. Some

people get depressed when life events of a certain type occur; others don't. In short, a

behavioral activator has to consider three factors when analyzing causality of the

depressive reaction of a given client: the vulnerability factor which varies from person to

person as a function of genes and life histories; the environmental changes which

precipitate the depressive episode; and the client's methods of coping with the changing

environment. Finally, from a behavioral point of view, clients become depressed due to

problems in their lives more than due to problems with their thinking or perception of

their lives. Therefore, the behavioral activator will work from a framework that looks

more at problems in the environment, and at the natural (albeit dysfunctional) ways that a

client would cope given such an environment, rather than from a framework which places

the problem primarily inside the client (in their thinking or biology).

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 The goal of treatment from the standpoint of a behaviorist is to activate clients in

specific ways, to maximize the opportunities that they will make contact with reinforcers

in the environment. In other words, the behavior activator assists the client to engage or

re-engage in their lives. First, clients often must learn to cope differently, so that the

opportunities for reinforcement are expanded. Frequently, this will require that the

therapist and client work together to break the patterns of avoidance which maintain the

disengagement and instead expose the client to situations which may initially bring

discomfort but will, in the long run, help them to contact reinforcement in their

environment. Second, clients must act as a conduit for modifying their environment, so

that it will become more reinforcing. In other words, they must learn to act in ways that

elicit positive reinforcement from their environment. Third, they will, in an ideal world,

develop the skills for nipping future episodes in the bud, by coping more effectively with

adverse environments, and becoming less vulnerable to depression through the

experiences learned in therapy.

In order to have a BA treatment manual that fit the goals of the previous study, it

was critical that the manual be true to the cognitive model and cognitive therapy of

depression as it has been previously stated (J. Beck, 1995; A. Beck & Emery, 1985; A.

Beck, Rush, Shaw & Emery, 1979; Burns, 1980; Emery, 1983; Sank & Shaffer, 1984;

Yost, Beutler, Corbishley & Allender, 1986). In the development of the BA manual, the

above references, as well as others, were used to identify treatment procedures that could

be used in BA. These procedures identified those interventions that were prescribed

within BA, as well as those that were proscribed. The BA manual for the current study

has been modified to reflect a reliance on a theoretical framework more compatible with

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an entire 16-week treatment devoted to BA. Treatment adherence will be monitored by

listening to therapy tapes, and identifying therapeutic interventions used in each of the

two treatment conditions.

When it is used within a CT framework, behavioral activation is generally

oriented towards more depressed, or more behaviorally dysfunctional clients. It

generally consists of interventions whereby the therapist tries to have the person become

more active in his/her environment, more self-sufficient, and more capable of dealing

with significant others on a day-to-day basis. It has been observed that depressed clients

often have dysfunctional interpersonal relationships and/or are not maximally adaptive in

their environment. Thus, cognitive therapy often begins with an assessment of the

person's adaptive functioning, as well as intervening with perceived problems. Our BA

treatment consists of very similar interventions, except we implement them for the entire

16 weeks, instead of moving on to cognitive interventions-as is the case for CT. In our

BA condition, a number of therapeutic interventions will be identified that therapists can

use to remediate problems in living, help clients make contact with potential reinforcers,

and provide clients with the skills they need to do so themselves should they find

themselves in need at some point in the future.

Standard Issues in BA.

Although the principle purpose of this research project is to investigate the

differential effect of various treatments, it is nonetheless the case that all of the treatment

conditions rest upon a therapeutic relationship and will as a consequence have several

issues that are standard. Further, there are several aspects of cognitive and behavior

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therapies that are consistent regardless of whether or not the client is receiving

interventions aimed at changing observable behaviors, or private behaviors such as

thinking. In this section of the treatment manual, standard issues that arise in cognitive

and behavior therapies are identified and discussed.

Therapeutic Relationship

Because cognitive and behavior therapies rest upon an interpersonal relationship,

it is important that the different treatment conditions in this study not differ significantly

with regard to the general quality and nature of that relationship.

In general, it is expected that the therapeutic relationship will be one in which the

therapist shows empathy, caring, and consideration for the client and his/her welfare.

Although therapists are not required to demonstrate "unconditional positive regard"

(Rogers, 1957), they are expected to be compassionate regarding their clients' depression

and possible despair, and to show this compassion both verbally and nonverbally.

During the course of the treatment in the study, therapists' levels of empathy will be

rated, and it is expected that there should be no significant difference between the

treatment conditions on this dimension.

Collaborative Empiricism

Collaborative empiricism refers to the expectation that the client and therapist

work together as a "scientific team", identifying and then systematically helping the

client modify problematic aspects of his or her environment through changes in behavior.

Collaborative empiricism does not mean that the therapist and client simply talk about

the problems; however, there is an explicit demand to gather data related to certain

potential problems that the client might have. Such data gathering may include the

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completion of diaries, various types of records, review of actual experiences of the client,

or the assignment of homework in which the client will gain new information about him

or herself. This endeavor is collaborative because the therapist does not direct the client

as to what he or she must do in order to improve, but rather works with the client to

determine which of various possible interventions will be most beneficial to the client.

The therapist will use questions to understand the client and to determine the potential

value of various interventions. In addition to questions, the therapist also builds

collaboration by using an educational format; he or she will inform the client about the

relationship between loss of reinforcement, a decrease in behavior, and depression and

will encourage the client to adopt a "scientific" perspective on their own problems. By

enjoining the client to help with his/her own treatment and even to plan treatment

interventions to some extent, the therapist is necessarily being collaborative and

empirical at the same time.

In the current treatment manual, it is expected that collaborative empiricism

should be constant across the two therapy conditions, although it is obvious that the

nature of this collaborative empiricism will be somewhat different. Thus, in the BA

condition the therapist will educate the client about the relationship between behavior,

depression, and the environment. The therapist will also consider how the client may

inadvertently maintain his or her depression by using coping strategies that block contact

with environmental reinforcers, for instance the avoidance of triggers that provoke

negative emotions. The therapist and client will develop homework assignments that

reinforce that conceptualization.

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How to Respond to the Client's Thinking

Although therapists will be allowed to assess negative thinking related to client’s

behavior, the interventions that they employ will not include those aimed specifically at

modification of dysfunctional thinking. Further, while the therapist may engage in some

brief assessment of basic beliefs or assumptions on the part of the client, such assessment

will only be permitted to the extent that it is tied to specific behavioral interventions. For

example, although the identification of a belief such as “it is important to be productive

in order to be happy with oneself” helps to identify the types of behaviors that clients

may successfully employ to be less depressed, therapists in this treatment condition will

not be able to examine the basis for that belief, the alternatives to such a belief, or

generally to attempt to modify that belief.

The therapist is responsible for showing her or his understanding and appreciation

of the client's problems in BA. Furthermore, since clients will spontaneously make

observations about their own thinking processes regardless of the treatment condition to

which they may be assigned, it is important that therapists in the current study understand

that they are able to respond to client's verbalizations about their thoughts. Indeed, not to

respond to clients' descriptions of their thinking is itself a communication, as the client

may learn that their thinking is unimportant, trivial, or not being understood. Therapists

in BA are expected to give an empathic response to clients' thinking.

The form of the response that the therapists give to clients' verbalizations of their

thinking will, of course, vary with the statements themselves. Therapists in the BA

condition in particular, must be aware that although they can offer understanding or ask

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clarifying questions, they may not conduct formal cognitive change interventions. In

many instances, a simple "uh-huh" will be sufficient, as this will indicate to the client that

the statement has been heard, and at least at some level, appreciated. In some instances,

such as when there is considerable affect associated with statements about thinking, it

may be appropriate for the therapist to give an empathic response such as "This means a

lot to you," or "I see that this really hurts you." In other situations, it may be necessary to

ask a few questions related to thinking, as these assessments may permit the therapist to

develop strategies for dealing with the problems that the client is experiencing.

Questions that are acceptable include: "When does this idea (thought, notion, etc.) come

to you?", "Do you have other ideas that are like this?", "When you get this idea, how do

you feel?" or, “What were you doing when you were thinking about that?”

Another useful BA intervention is to ask the client under what circumstances they

tend not to think this way. This allows for an understanding of the environmental and

behavioral stimuli that trigger such thinking. It is also acceptable to talk about the

client's thinking and feeling as an operant, i.e. as a behavior that is reinforced which

continues to elicit further behavior that is reinforced. For example, a client may begin to

think about their future as hopeless as a result of some environmental stimuli, such

hopeless thinking may then lead to overt behavior of avoiding basic daily chores, which

then leads to more hopeless thinking, which leads to more inactivity. Thus the hopeless

thinking in this example is maintained by the inactivity which is maintained by the

reinforcement value of reduced responsibility and becomes part of a chain reaction. Such

questions regarding thinking allow the therapist to understand the eliciting features of

situations for different patterns of thinking, and the function of such patterns. From a

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behavioral perspective, the client's ideas about themselves may simply be a pattern of

verbal behaviors that have been consistently reinforced through their life experience, or

the covert verbalizations may serve some other function, such as avoidance of

punishment or other aversive situations (Ferster, 1981). So, in the BA condition, if the

client were to say "I just feel like I am a worthless person, that I add nothing to the

world", the therapist would have several choices:

1. Simply say "Um hmm".

2. Make an empathic response such as "This is very important to you".

3. Question the connection with feeling "When you have this idea, how do you

feel?”

4. Focus on the circumstances eliciting the thinking by asking questions such as

"are there certain times when you think this way? Have there been times during the last

week when you did not think this way? What was going on during those times, what

were you doing that was different?" So the therapist looks for ways that the thinking

makes sense given the context rather than looking for distortions.

5. Ask questions to determine possible functions of the thinking. E.g. "When

you have this idea, do you ever tell others? How do they typically respond?" or "When

you are engaging in this type of thinking, is there anything that it prevents you from

doing?"

In many circumstances, choice numbers 4 & 5 are preferred because they focus

the conversation back to environmental situations or client behaviors that the therapist

and the client can then work to modify.

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 In the CT condition the therapist is free to further explore the client's cognitions,

either at the level of automatic thoughts or general beliefs and assumptions. For

example, if a client states "I am a total failure," it would be entirely reasonable for the

therapist in both conditions to say something like "Can you give me an example of a

situation or time when you thought you were a total failure?" Such questions will lead to

exploration of specific events and the thinking associated with those events. In contrast,

only a therapist working in the CT condition could ask something like "Why is being a

failure important to you?, or "What does being a 'total failure' mean to you?", since these

questions deal with the thinking at an abstract, assumptive level. It should also be noted

that in the CT condition the therapist is also able, if appropriate, to further develop

homework assignments that could permit assessment or intervention of the client's

thinking identified during the course of the treatment session.

Structure of Therapy Sessions

In the standard application of CT (Beck, et al, 1979; Dobson & Shaw, 1988;

Elkin, et al, 1985), there is a consistent structure to the overall application of cognitive

therapy. This structure of up to 24 sessions over sixteen weeks has been adopted in the

current treatment protocol. Appointments are scheduled twice a week during the first

eight weeks, and once a week for the final eight weeks. Although 24 sessions are

possible, appointments that are canceled or for some other reason do not occur during the

16 week period (e.g. because the therapist is on vacation or gets sick) may be

rescheduled, but must occur during the 16 week period. Therefore, a rescheduled

appointment will add a session to a particular week of treatment. Therapists are

encouraged to offer all clients the possibility of rescheduling, so that all clients are

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treated equally in the study. However, therapists should simply state that this is a

possibility, but not force the client to reschedule. It is expected that clients will miss

some sessions and that many appointments will not be rescheduled. Under no

circumstances should a client be seen more than twice a week. In all cases, regardless of

the number of sessions, treatment ends after 16 weeks.

Within each session, there is a typical (albeit not essential) structure. It is

expected that therapists in the current study will adopt this standardized structure, and

that the treatment conditions will not be significantly different on this dimension.

In essence, the structure of the therapy session involves a distinctive beginning,

middle, and end, each having separate features. In the beginning of each session, the

therapist will greet the client and often ask some general question such as "How have you

been since I last saw you?" Any problems raised by the client would be briefly explored

for possible further discussion later in the session. The Beck Depression Inventory

completed by the client just prior to the session should be quickly reviewed for other

potential problems (particularly items 2 and 9, related to hopelessness and suicide), or for

signs of progress. This review may also suggest issues for discussion. The results of any

assigned homework should be briefly noted, and likely will become an issue for

discussion in the middle part of the session. Finally, the client should be asked if any

major issues, concerns, or ideas have occurred to them that they want to have discussed.

If appropriate, these may also be placed on the "agenda" for the session.

In summary, the beginning part of the session involves a "rejoining" of client and

therapist, a time to monitor progress, and a time to establish issues for an agenda to be

further discussed in the middle part of the session. The agenda should be based upon a

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collaborative process, in which the therapist and client completely agree on the most

important topics for the week, limit the number of topics to some manageable number,

and possibly assign time limits for each topic.

The middle part of the session, which will typically begin about 10 minutes into

the session, consists of work on the items that have been decided upon in the agenda.

There may be as few as one item on the agenda, in which case a full and in depth

discussion of a particular issue may occur or the agenda may involve a number of

relatively small and specific issues. Topics not on the agenda will typically not be

discussed, although extraordinary issues (e.g. suicidality) that come to the therapist’s

attention during the session may warrant some examination. In any event, the middle

part of the session is used to work on issues of importance, and often will lead to some

decisions about what homework the client should attempt between this session and the

next.

Towards the end of the session, it is appropriate for the therapist to briefly review

the topics that have been discussed and the decisions regarding homework that have been

made, or to have the client conduct this review. Regardless of the task assigned to the

client for completion between sessions, the therapist and client should be clear about the

nature of the task. Typically this can be confirmed by brief review, but in some cases the

therapist may ask the client to write the homework assignment down. In later stages of

treatment the client may assume responsibility for reviewing the session and/or assigning

homework to him/herself. In addition, it is often appropriate to ask the client for

feedback or comments regarding the session that has just been held. In addition, at

certain points of the therapy, an extended discussion of the client's response to the

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treatment may be appropriate. Finally, the session ends with a plan for when the next

session will occur, and saying goodbye.

Essential Components of Good BA Treatment

BA is a relatively easily learned therapeutic tool. There are several things that are

essential to conducting competent BA. First, the focus is always on client behavior and

the environmental context in which those behaviors occur. The therapist must be vigilant

always to think in terms of a functional analysis. In other words, the primary question in

the therapist's mind should be “what environmental factors are involved in how the client

is feeling right now, and how is the client responding to these environmental factors that

may be maintaining negative feelings?” Second, it is important that the therapist teach

the client how to get activated regardless the client’s internal feeling state. Hence the

client is taught that he or she does not need to act according to his or her internal feelings,

but rather they he or she can act according to a goal or plan.

In BA problems are not seen as being primarily within the client. Rather, clients

learn through current and past environments certain problematic behaviors. Individual

learning histories may also leave clients lacking certain skills (e.g. activating oneself,

solving problems) that help to prevent or alleviate depression. The BA therapist looks at

the history and the environment for causes, and then looks to the client as the source of

change, teaching any skills that may be lacking in the client’s repertoire. Skills are

taught on an idiographic, functional basis. The client is taught to do what works, so even

skills training should take place in the context of a current situation in the client’s life and

the client is asked to experiment with new behaviors in real life in addition in-session.

15
Finally, it is important that the therapist assist clients in re-establishing normal routines in

their daily lives. This provides consistency and structure to daily life that may otherwise

be unstable. Research has shown that the routine disruption found in the lives of clients

with mood disorders may significantly impact their depression. Often such routine

disruption precipitates a depressive episode, e.g. change of a job, graduation, seasonal

changes, retirement, etc. (see activity scheduling and the idea of ACTION below).

The Logical Course of BA Treatment

Although Behavioral Activation is a contextual therapy and is, therefore, more

idiographic that either CT or standard Behavior Therapy, there is a logical structure to the

course of treatment. This structure is one that is usually naturally occurring in most

cases, and should not be imposed on any client. In the same fashion that CT usually (but

not always) begins with behavioral activation, then focuses on restructuring automatic

thoughts, turning to the modification of underlying assumptions and core beliefs and

finally, attending to relapse prevention, BA has several "stages", namely:

1. Establishing a good therapeutic relationship and presenting the model. Early on in

therapy the therapist should clearly dispel the myth that changes in mood need to

occur before changes in behavior. Instead the goal to emphasize is that external

structures and plans can be utilized regardless of mood state. The relationship

between mood, activity and environment is not only explained early in treatment, but

should be reiterated and discussed regularly whenever a new intervention is

introduced. It is particularly important that clients begin to understand that action

need not be mood dependent, and that both client and therapist not become

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 discouraged if objective measures of depressed mood do not improve. The therapist

must continue to encourage the client to take the very difficult step of re-engaging in

life nevertheless.

2. Monitoring the relationship between situation/action and mood and doing fine-

grained analysis of day-to-day coping as it relates to mood. Targeting specific coping

behaviors or avoidance patterns that may prevent clients from making contact with

reinforcers in their environment. This is the mainstay of BA and is what the therapist

will focus on the most with most clients. This process in therapy will also focus on

environmental factors such as a negative work environment or poor family relations

that may need to be attended to in order to change the circumstances that either

precipitated or maintain the depression. Clients will be encouraged to try new coping

strategies.

3. Applying new coping strategies to “bigger” life issues. This is by far the most

difficult therapeutic situation for the BA therapist. When clients are searching for

meaning in their lives, the pitfalls for the therapist to make cognitive interventions are

enormous. Therefore, dealing with these issues will be addressed in detail below.

4. Treatment review and relapse prevention. Many of the therapies below will be

started early in therapy but are particularly important to emphasize in the last

sessions. In the final sessions of treatment the therapist and client should:

A: Review initial presenting problems.

B: List red flags and triggers within the TRAP framework (see below)

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 C: List the most helpful elements of treatment.

D: Formulate a relapse prevention/response plan.

E: Build activation strategies into routines

F: Discuss client feelings about termination as indicated.

G: The research therapist should mention the importance of compliance

with follow-up evaluations.

It is essential that the BA therapist recognize that this is a general format, but that she or

he must not rigidly apply any structure to the therapy that does not naturally occur. The

above stages are presented as a guideline for the therapist to know that they are within the

parameters expected for competent BA.

Treatment Review and Relapse Prediction

A standard part of BA consists of a review toward the end of the therapy process,

as well as planning for possible difficult situations that may arise in the future and

predispose the client to relapse. Although the exact content of the treatment review will,

of course, vary from client to client; it is expected that the therapist and client will review

the nature of the treatment that the client has received, what has been beneficial or not,

and the client's progress from the beginning of treatment until the end. This review may

involve the identification of specific techniques or activities that have been particularly

helpful to the client, and it is conceivable that the therapist and client may even develop a

list of such techniques that the patient may take away with them at the conclusion of

therapy.

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 Predicting relapse is another important part of termination in BA, as it is almost

certain that clients will experience, at some point in the future, similar kinds of conditions

that led them to be depressed in the first instance. Clients should be educated about this

possibility, and the coping strategies for this eventuality should be discussed. In the

event that some known difficulty is going to occur, (e.g., a dying family member who is

getting progressively worse) specific plans for how to deal with this difficult situation

can be pursued, and again the client can be given specific directives to take away with

them at the conclusion of therapy.

Two particularly difficult situations arise when either the client has problems with

termination, or the therapy is not yet complete. In the first of these instances, it is simply

worth noting that certain clients have difficulty with both making and ending

relationships. Some may even have responses that are not adaptive (missing sessions

towards the end of therapy, being angry at the therapist, becoming worse towards the end

of therapy). Therapists should be sensitive to such possibilities, and reinforce the fact

that this is a research study that necessitates the conclusion of therapy after 16 weeks. If

it is anticipated that a client will have difficulty with such a situation, it may be

advantageous to begin discussing termination relatively early in the therapy process.

Indeed, it is often helpful to spend some time after eight weeks briefly reviewing the

progress that has been made to that point and planning the second half of therapy. This

not only serves as a partial review of treatment, but also will anticipate potential

termination problems.

With regards to clients who are not yet improved, there are guidelines for

referring clients to other therapists after 16 weeks. These decisions are not to be made

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until after the post-test interview. Clients still meeting DSM-IV criteria for Major

Depression will be provided with a list of referrals of non-study treatment providers.

Those clients who do not meet diagnostic criteria will be encouraged to wait prior to

seeking further treatment, even if they still have some depressive symptoms. These

clients, along with those who are no longer depressed at all, will be followed according to

the research protocol.

Attention to Non-Standard Issues

Regardless of the treatment condition that therapists are administering, it is

important in the current research study that there is standardized attention to several non-

standard issues in the course of treatment. In the case of a client who is suicidal, for

example, a suicide assessment and intervention protocol that meets standard of care

should be implemented, regardless of treatment condition. Therapists should,

parenthetically, be routinely assessing clients' level of suicidal thinking and should be

sensitive to thoughts that may be indicative of suicidal planning. If clinical deterioration

is such that the therapist thinks the client should be considered for termination from the

study, they should immediately notify the program coordinator.

Another non-standard issue that may arise in the course of therapy is when the

client expresses severe reservations about the nature of therapy, or expresses intention to

drop out of treatment. When this occurs, the therapist should first try to reestablish a

therapeutic relationship with the client, and discuss the merits of staying in the treatment

plan. The therapist should also carefully review the problems that the client is

experiencing, his/her thoughts about the therapy, and attempt to determine if there is

something that can be improved that would make it a better working relationship. In the

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eventuality that the client is not willing to continue treatment, however, the therapist

must attempt to get the client to submit to a post-therapy evaluation, and appropriate

steps should be taken in this direction. Termination should then be handled as

respectfully as possible.

A third type of non-standard issue that may arise in the course of therapy is a

personal crisis. This may arise as a result of some family or interpersonal situation, or

some difficulty that the client experiences (e.g., a motor vehicle accident or other

trauma). Therapists should attempt to deal with these crises consistent with the condition

that they are applying. Although such crises warrant immediate attention, it is the

expectation that therapists should be able to generate a treatment plan that primarily

involves BA.

Conducting Behavioral Activation Therapy

1. General Issues

The overall purpose of the BA Condition is: a) to provide an hypothesis regarding the

life circumstances that have precipitated the depression; b) to elucidate the coping

patterns that have exacerbated the depression; c) to create a treatment plan for improving

the coping patterns and providing access to more reinforcing life circumstances - -

frequently these treatment plans will include teaching clients to approach rather than

avoid situation. These new approach behaviors may initially lead to discomfort but will

eventually facilitate more adaptive functioning and improved mood. BA therapy for

depression is a therapy in which clients’ levels of adaptive functioning are assessed and

modified.

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 In the current treatment study, BA will consist of a series of interventions that have

their basis in a functional analysis of how life circumstances have precipitated the

depressive episode, how the client has coped with the experience of depression, and the

opportunities available for bringing the client into contact with aspects of the

environment that are likely to relieve the client of depression. The therapist must keep in

mind that the functional analysis in outpatient therapy is never as fully developed as it

can be in a laboratory setting where most variables are controlled. Therefore, therapists

must keep in mind that their assessment is a working hypothesis about what precipitates

and maintains the client’s depression, and that the functional analysis is fluid and must

change as new information is gathered.

Therapists working in the BA Condition will need to be aware that certain treatment

goals are more easily accomplished than are others. Clients who believe themselves to

be depressed due to their inability to meet certain standards, for example, can be helped

to set new goals and try new strategies to achieve them, learn new competencies, etc. It

will be more difficult to work with clients who have treatment goals that are not easy to

trace to an environmental precipitant. In addition, it is particularly difficult when the

therapist believes it is perhaps not in the best interests of the client to work towards

particular goals, which for reasons of ethics, practicality, or clinical judgment, the

therapist believes are misguided. For example, a depressed man who insists that

achievement is the path to personal happiness may see his goal as the attainment of ever

greater success, even though his pursuit of success is driving friends and family away. A

therapist confronted with this situation in the BA condition is not permitted to directly

confront the client’s belief. He/she is permitted, however, to determine the benefits (and

22
problems) that are likely to derive from additional success, and whether or not, based on

a functional analysis, achievement is likely to get the client what he wants – freedom

from depression. Such assessment will allow the therapist the opportunity to determine if

the goal is achievable and worthwhile. If not, other goals may need to be pursued in the

early stages of therapy, and this goal re-examined at a later point. A typical exchange

between client and therapist in this situation may look something like this:

Client: I know that I would be less depressed if I could just get the advancement
at work that I was turned down for last year.
Therapist: What might happen if you got that advancement?
Client: I’d feel better about myself. I wouldn’t feel like such a failure.
Therapist: How might you be acting differently if you got the advance?
Client: I don’t know, I just would like myself better.
Therapist: Well, although I know how much you would like to get this job
advancement, I don’t know that our work can guarantee that sort of
success. However, what would be good for us to look at is what types of
things you are currently doing to cope with not having gotten the
advancement, or achieved the level of success you were hoping for. What
might those things be?
Client: Well, I don’t think I am coping, I just go to work and do the bare
minimum, and feel like dirt and go home.
Therapist: So, one goal might be to change how you currently engage in work so
that you don’t feel like dirt at the end of the day?
Client: Well, maybe that would be good.

This idealized interaction shows how the therapist in the BA condition can use

questioning to focus the client on a more reasonable goal without challenging the client’s

belief about achievement and personal happiness.

2. Specific Techniques

Clients that are assigned to the BA Condition of this treatment study, as with all other

clients, will require a rationale regarding their treatment. Therapists in this treatment

condition will provide a rationale to clients, which uses the metaphor of therapist as

23
personal trainer (i.e., consultant). Your job is to help clients identify what is going wrong

in their lives, and guide them in actions that will help improve their life situations, and

thereby make them less depressed. Furthermore, in the process of helping them to

alleviate their depression, they will also develop the ability to analyze and improve their

life circumstances that they can use in subsequent depressogenic life circumstances.

Among other things, you will emphasize finding activities and behaviors that provide

them with the pleasure and interest that are currently missing from their lives. But we do

not recommend a simple random increase in the experience of typically pleasurable

events. Rather, our focus will be on events that will undo their depressing life

circumstances, and eventually bring them into contact with aspects of their environment

that will be more rewarding. This is an idiographic approach, and the events and

activities will differ for each client. These activating events will depend upon a joint

analysis of actions that are likely to break the depressive cycle. The therapist may use

the following schematic to demonstrate the depressive cycle as seen by a BA therapist:

Precipitating Events ----Æ Depression ----Æ Secondary Problems

(List Known Events, or
mark a “?” if precipitating
life events are unknown).
(May list associated (List behaviors that you know
mood states) are problematic for client, e.g.
Staying in Bed, Not talking to
Family).
|
^ |
^ |
Å-----------------------

The therapist can show the client how life events may lead to depression but that it is the

secondary problem behaviors that the clients find themselves repeating while trying

desperately to cope with their depression that worsen the depression.

24
 Therefore, the therapist will help the client to modify these problem behaviors first,

and then they will try to tackle the primary precipitants of the depression. The therapist

may tell them that clients who are able to activate themselves in this way typically

experience an improvement in their level of self-esteem, feel better about themselves, and

become less depressed. A sense of optimism about the outcome of the treatment should

be communicated to clients, and they should be encouraged to consider changes in

behavior, which in turn are expected to favorably modify their environment, as the key to

becoming less depressed. This rationale should be provided to the clients no later than

the second session. In session one, the therapist should give the BA version of the

booklet “Coping with Depression” (Appendix B) to be discussed with the client in

session two. The treatment rationale needs to be repeated regularly as support for various

interventions. The client should always understand why particular behavioral changes

are being attempted, and how such changes relate to current and long-term therapeutic

goals.

Some clients will resist the idea that they can make significant changes in their lives

without either understanding the historical (e.g., early childhood) causes of their

depression or first improving their level of mood. Such clients should be informed that

although their tendency to get depressed may be rooted in early childhood, research has

shown that corrective experiences can occur without extensive focus on such early

experiences. They can also be told that, just as changes in mood can activate people, so

can activation – especially the directed activation that we advocate – have the effect of

modifying thinking and feeling, which in turn leads to greater opportunity for behavior

change. Since we have no direct way of changing their mood without first activating

25
them, we make the pragmatic choice of doing it the other way around. While anti-

depressant drugs may act directly on mood, they leave people vulnerable to depression in

the future, or as soon as the drugs are withdrawn. Why? Because drugs do not work

directly on the situations and coping strategies that may precipitate and/or maintain

depression. Many clients will readily understand that withdrawal from the world

exacerbates the deprivation of rewarding experiences, and the logic of reversing that

process is easy to impart. It can be useful to tell clients that in BA we deal with the

problems from the outside – in, rather than from the inside – out. Since we can’t directly

change moods, we help them to modify the activities and behaviors that seem to be

connected to their mood. Further, it can be pointed out that feeling sluggish and lethargic

doesn’t necessarily have to lead to inactivity; that activity can begin however one feels,

although this is not usually easy. Once goals have been defined, and a functional

analysis has been conducted, clients should be encouraged to attempt to make some

small, concrete changes consistent with the analysis and to observe the consequences of

those changes. In this way a collaborative and “scientific” relationship can be started

with the client, in which the client and therapist work together to determine the

effectiveness of the strategies.

Appendix A lists the assessment and treatment interventions that are specific to the

BA condition of the treatment study. It will be noted that the assessment techniques that

are specific to this treatment condition are all aimed at the collection of data regarding

clients’ behavior and the contingencies suspected of controlling their behavior. The

majority of these assessment techniques are identified in the Cognitive Therapy of

Depression textbook (Beck, et. al., 1979) and will not be repeated here in detail except

26
where specific modifications have been suggested in the current treatment. Therapists are

encouraged to limit their exploration of symptom improvement to general descriptions of

depression, analyses of mood and overt behavior change, as well as vegetative symptoms.

Furthermore, since BA encourages clients to act in spite of their mood, any impression

that the BDI needs to improve before clients can take action is contraindicated. However,

when the BDI does improve, and the client is activated, the BA therapist can use graphs

of BDI scores to indicate to the client the ups and downs of their moods, and links

between activation and symptom improvement. In very few other ways, however, is the

therapist limited in his/her assessment of behavioral aspects of depression.

Appendix A lists a total of 20 specific interventions that the therapists are permitted

to use. In general, these interventions can be broken down into the subcategories of:

1) determining environmental targets for change, and the modes of activation

necessary to change them;

2) assessing and improving behavioral competencies; and

3) enhancing behavioral coping strategies.

The BA therapist should attempt, whenever possible, to conceptualize problems as

behavioral, and to anticipate tasks that might lead to lower depression on the part of the

client. Optimal activation tasks are those that are likely to reduce punishment and

increase positive reinforcement.

Remember, in a behavioral view, it is considered probable that a pattern of

negative reinforcement is associated with the development and exacerbation of

depression. Therefore, techniques that require the client to behave in a certain way in

order to avoid aversive consequences or bring the cessation of aversive experience are to

27
be used sparingly. For example, although it is perfectly acceptable for a therapist to call

a client to remind him or her to do homework assignments, and this call may in fact be

aversive to the client (embarrassing, etc.), using such a technique to reinforce (i.e.

increase) compliance with homework should be used only after other more positive

techniques have been exhausted. Thus, while most of the behavioral interventions listed

in Appendix A for the BA Condition are appetitive (that is, attempting to increase

positive reinforcement or pleasant experiences), some are also aimed at lowering the

likelihood of negative experience. Thus, some behavioral strategies for coping with

problems are to avoid them, or to distract oneself from their occurrence. Although these

strategies are listed in Appendix A and are available tools for the therapist, in general

these strategies are considered less likely to be effective strategies for dealing with

depression, and should largely be reserved for those cases in which more pleasure

oriented interventions are not successful, or where the problem is clearly one where the

client needs relief in the form of avoidance, escape, or distraction.

3. Presentation of the Model

Since client education in the form of collaborative empiricism is essential in BA, it is

important that clients understand the notion of a functional analysis. Clients need not

ever understand the jargon, however. Therefore, several simple acronyms have been

developed to assist clients in understanding the principles and methods of a functional

analysis. These acronyms are useful in educating clients about the important aspects of

the overall BA treatment and in analyzing specific situations that occur in the client’s life

during therapy.

28
 The first and second acronyms are used specifically when avoidance is a problem in

the client’s life and are related to daily events that occur. They are that the client may

often get stuck in a TRAP, and need to get back on TRAC. Thus these acronyms serve

mnemonic purposes and function as metaphors that may be useful for the client. They

are defined in the following ways:

TRAP =

T = Trigger (an environmental or private event that occurs. Hence it can be

observable such as a fight with a spouse, or private, such as remembering

a humiliating experience).

R = Response (Usually emotion; increased depression, anger, anxiety, etc.)

A = Avoidance –

P = Pattern (The secondary behaviors that the client uses to try to cope with the

negative emotion, but which lead the client to feel worse).

Clients are thus taught to recognize the connection between environmental events,

emotional reactions, and coping behaviors. Note that in BA the focus is on thinking as a

private behavior rather than on the content of particular thoughts or beliefs. Thus, the

therapist should attempt to assess the situations in which particular thinking occurs in

order to understand the function of that behavior. For example, negative ruminations can

be used as a way of avoiding active problem solving. The BA therapist would never

discuss the meaning of the memory, or try to modify the client’s perception of the

experience, as these would be CT interventions proscribed in BA.

29
 Once the client recognizes that he or she is in a situation that fits the TRAP, they are

encouraged to get back on TRAC. With the same Trigger and Response, they are

encouraged to find Alternative Coping behaviors.

The third acronym is the word “ACTION”, which can be used to detail the overall

BA approach to clients’ problems. It stands for the following:

A = Assess, is what I am doing going to make me more depressed? Am I avoiding?

What are my goals in this situation?

C = Choose, I know that activating myself will increase my chances of improving my

life situation and my mood. Therefore, if I do not self-activate, I am choosing to

take a break and remain depressed for now. Otherwise, I will choose to engage in

activities that may increase the likelihood of improvement.

T = Try, the behavior that I have chosen.

I = Integrate, any new activity that allows me to re-engage into my daily routine

and/or solves problems.

O = Observe the result. Do I feel better or worse after doing this activity (or not

doing it)? Did this action allow me to take steps toward improving my situation?

N = Never give up, taking a “scientific” approach means trying and trying once again.

I have taken action and observed the results of putting it into my routine.

Therapists may use this acronym (but are not required to). It can assist clients to

understand that they must make a choice toward action. It also emphasizes that

establishing a routine is important in the treatment of depression and that one shot at any

activity is not enough. This is important in combating the routine disruption that

frequently occurs in depression that can exacerbate the mood disorder. Teaching clients

30
to use the ACTION acronym emphasizes that paying close attention to the relationship

between mood, situation, and behavior is essential to learning effective ways of coping.

Finally, therapists can also use a simple ABC model to show clients that there are

Antecedents to their Behavior and the behavior leads to certain Consequences. It is

difficult to use “ABC” without using jargon, and therapists may find it easier to teach

clients about TRAPS or TRACS.

Besides looking at functional analyses of specific problems, it is important for the BA

therapist to help clients differentiate between short-term and long-term goals. It is

common for people who are depressed to try to alleviate immediate distress (short term),

but for the behaviors used to do so to block future improvements (long term). Clients

must learn to decide whether the costs to long-term goals are worth short-term gains.

Furthermore, it is important for clients to break long-term goals into graded (short-term)

steps in order for them to self-activate and begin to see success along the way. Over and

again, the BA therapist must coach the client to integrate new behaviors into a daily

routine. The disruption of normal routines is detrimental to depressed individuals.

Therefore, the establishment of routine can be helpful in the activation process.

4. Common Problems in BA

One of the potential problems with clients assigned to the BA Condition is that it may

be difficult to determine what homework is appropriate. Remember, homework is an

essential part of transferring treatment to the client’s life outside of therapy. This problem

may arise because the therapist may think that he/she does not have the opportunity to

investigate the client’s thinking that is related to the behavior. In response to this

potential problem, it should first be noted that therapists have the opportunity to

31
investigate thoughts related to specific behaviors. It should be noted, however, that

should the client present disordered thinking related to the homework that is being

discussed, the therapist may identify this type of thinking, but he/she may only intervene

behaviorally.

For example, suppose that a client agrees that doing some sports activity will make

her feel better, and a homework assignment is planned in which she will go for a swim

twice in the week between one appointment and the next. When she returns for her next

appointment, however, she reports that although she went swimming once, she did not

enjoy it, but rather found the experience depressing. She noticed how “fat” she was, and

how she has lost “all” of her swimming ability. Normally, a cognitive therapist might

engage in cognitive assessment of these types of thoughts, and might try to have the

client see how her exaggeration and all-or-nothing thinking may contribute to her

negative feelings about swimming. In contrast, within the BA model the assessment of

these thoughts is permissible (as long as the assessment is limited to the homework

assignment), however, attempts to directly intervene with regard to these thoughts are not

permissible. There are, however, a large number of possible interventions. A partial list

of such interventions includes:

1) reassuring the client that it is normal to feel somewhat unsure after being away

from an activity for a while, and that probably her abilities will improve.

2) having a discussion with the client about how difficult it is to try new activities or

activities in which one has not engaged for some time, and

32
 3) emphasizing that it is important to persist at situations that may make one feel

worse initially in order not to repeat behavior that increases depression (e.g.

avoidance).

4) reviewing the swimming incident in detail: exactly what did the client do?

5) When she noticed she was “fat” what did she do (e.g. did she leave the pool, an

avoidance maneuver)? Was there any pleasure associated with the activity?

6) coaching her not to look at herself in the mirror if this was upsetting.

7) suggest that she buy a new, and more flattering, swimsuit.

8) swimming at times when the pool was less busy, thus minimizing social

embarrassment.

9) concentrating on a swim stroke in which she feels most proficient (see “Attention

to experience or mindfulness” in Appendix A), to reinforce the competence of her

activity.

10) graded task assignment regarding swimming.

11) swimming with a friend.

12) taking a swim course.

13) Clarifying what the goal is – feeling better immediately? Taking steps towards a

new routine? Getting healthy? Looking your best?

It should also be noted that if the treatment rationale has been successfully explained

to the client, he or she should understand the necessity of finding activities that are truly

important to increasing the probability that they will be reinforced. The client will also

understand the importance of integrating these activities into a routine before observing

33
the results. If this has been done, the above situation may be less likely to occur, or less

problematic if it does.

Obviously, the type of intervention attempted will need to be carefully fitted for the

client in question, but the above demonstrates that if a homework assignment fails, there

may be a number of behavioral strategies that can be attempted to overcome the

problem(s).

Another homework related problem that may emerge is one in which clients will not

comply with their homework agreement. In this circumstance, the therapists are free to

fully investigate the environmental contingencies that may have prevented the homework

from being completed. Should it appear, however, that the client’s thinking got in the

way of adherence, the therapist should again proceed to briefly assess this type of

thinking, but only as it pertains to the behavioral homework. Again, the BA therapists

are not permitted to directly intervene to modify this thinking, but the information

gathered in the assessment of thinking related to homework can be used in the planning

of future homework assignments.

For example, a client agrees to call a friend he hasn’t seen for some time, and this is

set as homework. When he gets home, however, he has thoughts such as “She doesn’t

want to see me,” “She’s too busy,” and “If she wanted to see me, why hasn’t she called?”

He puts the call off and in the end, does not make the telephone call. Clearly the pattern

of thinking in this situation may be dysfunctional, and might be a target for intervention

in the CT Condition. In the BA condition, however, the therapist cannot directly

challenge the content of the client’s thinking, but must find a behavioral strategy for

change. The BA therapist may also look at the context of the thinking and the function

34
that it served. In this example, the thinking served the function of allowing the client to

avoid an activity that created some level of discomfort. The BA therapist can certainly

discuss this functional assessment of the thinking with the client. They can also look at

the context in which the thinking occurred, e.g. spending time thinking about calling (the

“inside”) rather than calling (the “outside”), and the client would be encouraged to work

from the outside-in rather than the inside-out and not wait to feel like calling or

convincing himself to call or not to call before simply doing it. It is essential that clients

begin to separate action from the internal desire to act. In BA, the therapist tries to get

the client to commit to doing activities because they increase the likelihood of improving

the depression, rather than because the client feels like doing the activity. Another idea

here might be to re-open the idea of phoning, and be sure that this really would be

rewarding, if completed. If so, the therapist and the client can contract not only that the

client will call, but also exactly when, or even that he will call the therapist shortly after

the appointed time to report the results of the assignment. Alternatively, the therapist

may decide, based upon the brief cognitive assessment that calling a female is too

challenging for the client at this point in time, and another less threatening person might

be identified for telephoning. Or it may be that rather than phoning someone the client

might agree to stop off at someone’s house for a coffee or chat. The point is, though, that

a behavioral strategy, rather than a cognitive one, must be employed. In most instances

the therapist should be able to derive an alternative homework assignment, which is

acceptable to the client, able to be completed, and antidepressant in its effects.

A second potential problem may emerge when significant others in the client’s

35
life punish improvements, reinforce behavior that maintain clients’ depression, or are

generally unrewarding for the client. In BA, it is acceptable to bring a spouse, partner, or

any significant person in the client’s life, in for one or several therapy sessions. Such

sessions are useful to educate the significant other generally about depression and

specifically about behavioral activation as a treatment for depression. Such sessions also

provide a good opportunity for the client to teach their partner, and for the therapist to

observe the client describe the model and fill in any gaps in the client’s understanding or

correct any misconceptions about the treatment. These sessions also provide useful

opportunities to enlist the partner’s cooperation in the treatment process. Sometimes

getting the partner actively engaged can encourage him or her to act in more rewarding

ways toward the client. The BA therapist can also point out the contingencies that

maintain interactions between the client and their spouse/partner, i.e. “when you get

upset that your partner is depressed and keep trying to encourage him to do things around

the house that he doesn’t want to do, he feels badgered and more hopeless.” This would

be pointing out that the spouse has involvement in the problem, but the intervention takes

place between the therapist and the client. For example, the therapist could teach the

client how to better communicate with the spouse in these situations.

There are several restrictions regarding conjoint sessions that must be kept in mind.

First, the BA therapist does not do couple therapy, and the client remains the only client

in the room. This must be disclosed clearly to the spouse prior to the session, and it is a

good idea for the therapist to identify the client in writing and spell out the parameters of

the session. Second, clients should never be badgered about bringing in a spouse or

partner. If they collaboratively agree to a conjoint session, then the therapist should

36
proceed and should try to be flexible about scheduling a time that will accommodate both

client and spouse/partner. An added benefit to conjoint sessions is that they provide

more information regarding the context in which the client’s behaviors occur.

A third potential problem that may emerge in the BA Condition is when the client

uses his or her thinking as a reason for not becoming active. For example, a client might

hold the idea that she/he cannot change because of deep depression. Similarly, clients

may undermine their homework assignments by verbalizing thoughts that are then used

to explain their noncompliance (e.g., a client who fails some interpersonal task and insists

that the task failed because of their belief that the task is doomed to failure). Behavioral

interventions may include identifying and modifying some basic skill in the area related

to the client’s thoughts in order to begin the activation process. It may be that a more

graded approach to the particular problem is necessary, one that involves more precise

and small steps that the client may complete and feel some sense of accomplishment and

encouragement to move to the next step. The therapist should be very empathic toward

the client’s struggle and may reassure the client that he or she completely understands

that engaging in activity when one is very depressed is extremely difficult. The therapist

should also remind the client that waiting for internal change is unlikely to lead to

improvement but that taking the difficult step of activating (from the “outside”) might

ultimately improve the client’s mood and situation. Finally, it may be that the therapist

will be forced to switch strategies, and rather than focus on the behavioral target that they

have previously identified, move to a different target, or one that is only slightly related,

coming back to the first target at a later point in the therapy. Essentially, this kind of

37
problem will pose a challenge to the therapist, and will require ingenuity in order to

derive a behavioral strategy for overcoming the difficulties.

A fourth potential, although low likelihood, problem for clients assigned to the BA

condition, is the situation where the client presents with no problems in their life, and no

apparent reduction in activity. Such clients may be already relatively active in their life,

relatively effective problem-solvers, and have few behavioral deficits. In most of these

cases, the problem can be traced either to a chronically negative environment, or an

inability on the part of the client to accurately track recent changes, or to find personally

meaningful goals and pursue them.

These clients pose especially difficult challenges. It is suggested that under this

circumstance the therapist proceed relatively slowly and methodically, beginning with an

in-depth exploration of environmental events, chronic stress, and daily hassles; followed

by monitoring of daily activities, potentially reinforcing events, and the setting of tasks

that will enhance the client’s coping capacity to improve life circumstances. The

therapist might also focus on what the client is doing that might make current activities

less pleasing than they might optimally be. For example, a client may be engaged in

activities at an overt behavioral level, but covertly ruminating about how bad life is. In

this case, the client is not allowed contact with all of the possible reinforcement inherent

in the activity. The BA therapist, though not allowed to address the content of the

thinking, can again address the context and function. In this case teaching the client to be

mindful of the activity, using all of his or her senses to experience the activity fully may

be a useful intervention (see Attention to Experience/Mindfulness Appendix A). Since

depressed clients almost invariably engage in at least some self-defeating behavior in

38
response to their life circumstances or the early stages of their depression, the therapist

must not accept a claim that no problems exist at face value, but must instead conduct a

thorough functional analysis. Should this analysis bear fruit, therapists in this treatment

condition will have the opportunity to conduct an in-depth training sequence, in which

the clients’ ability to scrutinize their lives and respond competently can be fully detailed

and improved upon.

In any treatment, clients might become frustrated and disappointed, particularly if

change is slow or not forthcoming. Clients in the BA Condition may notice that there are

many things that the treatment protocol does not permit (e.g. use of medication).

Therapists should explain that there are different approaches to treating depression, and

that the one being used with them focuses on activation. Clients can be told that both

clinical experience and research evidence supports the value of this treatment approach,

and a sense of optimism should be communicated about the effectiveness of this

treatment approach. Therapists should attempt to work collaboratively with the client to

select behavioral targets of maximal import to the client. The therapist can present this

treatment as “fine tuning” of the client’s ability to relate to others and the world in

general, through action that both breaks the depressive cycle and creates a more

reinforcing environment. Clients who continue to express frustration about this treatment

should be encouraged to complete their course of therapy, since time may be needed to

change life-long habits and extremely aversive environments.

One of the problems that therapists may need to contend with is when the client

presents with insights into his or her own behavior, or a pet theory as to what causes and

maintains the depression. Clients may present these insights or ideas in a relatively

39
spontaneous way, or they may actually present these as items that they want to discuss

with the therapist. Insights and thoughts should not be ignored or brushed aside, but

should be dealt with in a concrete, problem solving way, since such insights may provide

valuable information about how to intervene behaviorally. Thus, if a client presents an

insight, an appropriate response on the part of the therapist would be to ask what kind of

activating strategy this insight relates to. The therapists may explore briefly the nature of

thoughts that their clients present, with a focus on behavioral referents and an attempt to

derive behavioral interventions.

It should be recognized that in some instances therapists may inadvertently

attempt to intervene with a thought that is presented to them, by contrasting behavior

with the thought. For example, a client who agreed to confront her boss on an issue

related to how he handled her, and then actually did so with some success, might

spontaneously report that her cognition prior to speaking to her boss was that “He will

harass, or even maybe fire me.” In light of her success, however, she may realize that

those thoughts were irrational and unwarranted, and may say so directly to the therapist.

Therapists should not, in response to such an opening, explore her earlier thinking and

contrast her behavior and its outcome with that thinking as a way of reinforcing her

challenging such negative predictions, as this is a technique for cognitive therapy. A

more appropriate response would be to say something like “Uh, huh– so when you do

things, even things that are difficult for you to do, you sometimes get pleasantly surprised

and feel good for doing them!” Such a response clearly indicates that the client has been

heard, but reinforces the behavioral activation aspect of the homework rather than the

change in cognitions reported by the client.

40
Applying the BA Model to “Larger” Life Issues

Frequently clients will want to draw the therapist’s attention to larger issues in their

lives once they have experienced some symptomatic relief. The model can and should be

applied to such general areas in a client’s life. Once the therapist and client have

conducted a good functional analysis of the depression and of instances of

environment/behavior interactions that affect the client mood, there should be some

established patterns of behavior noted. These patterns thus become themes that can be

applied to many areas of the client’s life. For example, if a client has difficulty breaking

down tasks into concrete, reasonable steps, the client and therapist would work on doing

so with a number of daily tasks that the client may wish to complete in order to improve

his or her depression. Should that same client have difficulty deciding what to do with

his or her life (an existential dilemma), the therapist can use the same theme developed in

a functional analysis (difficulty breaking things into steps) and apply the training to the

larger dilemma. Similarly, a client who believes that a predominant problem is a general

questioning of the sense of meaning in life would be helped to use the functional analysis

to deal with this type of problem. Although this is a problem that is typically dealt with

using cognitive interventions, it is easily addressed within a BA model. For example, if it

were clear that the client frequently engaged in avoidance of aversive tasks, and

consistently kept her or himself from accomplishing things that seemed too difficult, a

pattern of approach behavior could be targeted toward situations that the client believes

would make his or her life feel more meaningful. The “big” issues of life must be

41
approached in BA, but the BA therapist is expected to find ways to help the client change

their behavior that will lead to the possible resolution of these larger issues.

Conclusion

BA can be a creative and exciting treatment for depression. Although the BA

therapist in the current study is proscribed from using cognitive interventions in the

course of treatment, they are encouraged to experiment with a range of behavioral

interventions (see Appendix A) within the model. This can be a process filled with

challenge and great hope for clients whose lives have been impacted by the narrowing of

behavior resulting from depression.

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Appendix A: BA Condition Assessment and Intervention Techniques

Assessment Techniques

A1. Conducting functional analyses

A2. Mastery and Pleasure ratings of activities

A3. Verbal report of activities

A4. Symptom reports from BDI

A5. Daily Activity Schedule review

A6. Assessment of in-session behavior

Intervention Techniques

I-1. Assigning activities to increase sense of Mastery or Pleasure

-activities likely to improve negative aspects of the environment (determined by

the functional analysis), or ones that were previously reinforcing (prior to
the onset of depression).

-high probability activities, or activities that the client has demonstrated will
occur
with little effort on a regular basis.

-activities from lists of pleasurable events, either ones currently pleasurable or

ones that had at least at one time been pleasurable. These lists must be developed
between client and therapist and the therapist must not use any currently available
“generic” lists of pleasant activities.

I-2. Teaching client the role of self-defeating behavior and aversive environments in
negative moods.

I3. Encouraging an active, rather than passive approach in specific situations

I-4. Graded task assignment

I-5. Mental rehearsal of assigned tasks or activities (used in order to help clients plan
behavioral steps that they need to take, and to plan the activity).

I-6. Examining alternative behaviors in different situations

43
I-7. Role-playing behavioral assignments that involve other people

I-8. Examining potential outcomes of different behaviors

I-9. Managing situational contingencies to maximize likelihood of homework success,

e.g. encouraging a client to go to a quiet room in their house to write activities in
a log, suggesting that a client telephone a friend with the television off so that he/she
can remain adequately engaged in the call.

I-10. Therapist modeling of activation strategies

I-11. Distraction from problems or unpleasant events (Use sparingly)

I-12. Avoiding or limiting exposure to unpleasant situations or people (Again, use

sparingly)

I-13. Behavioral stopping – not acting in self-damaging ways

I-14. Direct behavioral instruction by therapist

I-15. Attention to Experience or “mindfulness” training. In BA, the therapist teaches the
client to actively engage in all sensory properties of an experience. What is the olfactory
experience? What does one notice visually? How do the objects, people, animals you
touch feel? Note the experience fully.

I-16. Teaching client to give themselves rewards for behavioral achievements

I-17. Dealing with specific behavioral problems (e.g., sleep) using only behavioral
interventions, regardless of cognitive components in certain treatment protocols.

I-18. Training to overcome skill deficits (e.g. assertion, communication, and problem
solving). Again, the therapist must focus on what the client does -- not on what the client
thinks -- in these situations despite the frequent inclusion of cognitive interventions in
Behavior Therapy for skill deficits.

I-19. Covert flooding and extinction

I-20. Teaching the client to conduct a functional analysis using either an ABC or TRAP
model, and presenting the idea of ACTION.

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 Appendix B
Coping with Depression: A Manual for Self-Help

The Problem

Depression is a vicious cycle. When you first experience it, your body is telling

you that something is not going well in your life. Someone once described the experience

as a bad case of the flu. It slows you down, mentally and physically. Everything

becomes an effort, and you tire easily. You do less, and then blame yourself for doing

less. You come to believe that you can do nothing, and that you will never get over your

depression. Then you feel even more depressed. It becomes even more difficult to do

things. And so it goes on.

It is important to recognize that your depression does not reflect some personal

defect within you. It is a signal that something needs to be done to change your life.

Either things have changed recently to make your life worse, or you life hasn’t been right

for a long time, and you body has only begun to tell you recently. The problem is that

when people get depressed, instead of changing their lives in ways that are likely to

improve their well being, they tend to blame themselves, withdraw from the world, and

their lives get worse. Gradually, they feel even more depressed. Now they have two

problems. They still have lives that are not going well. And now they have added the

retreat from the world, which has made them even more depressed.

Overcoming the Problem

There are a number of possible ways to overcome depression, and with your

therapist, you will have the opportunity to use one of the most effective, which we call

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self-activation. Activity breaks the cycle of depression. But not just any activity. With

your therapist, you will first identify the two sets of problems that are contributing to

your depression: those aspects of your life that need to be changed: and those actions

you have taken to remove yourself further from the world, thus making you more

depressed. The activity is aimed specifically at positioning yourself to change your life,

and then actually changing it. This guided activity is an excellent way to break the

vicious cycle of depression. It has a number of advantages.

1. Guided activity makes you feel better. It can give you a sense that you are

taking control of your life again, and achieving something worthwhile. You

may even find that there are activities that you highly enjoy, once you try

them. At the very least, becoming more active is an effective way to take

your mind off your worries and your depressed feelings. Initially, it places

you in a state of readiness to make positive changes in your life. Then, with

the help of your therapist, your activity can be directly oriented toward

making those life changes.

2. Guided activity makes you feel less tired. Normally, when you are tired, you

need rest. When you are depressed, the opposite is usually true. You need to

actually do more. Doing nothing will only make you feel more lethargic and

exhausted. Doing nothing also leaves your mind unoccupied, so you are more

likely to brood on difficulties and your lack of ambition, and to feel even more

depressed.

3. Guided activity motivates you to do more. Many depressed people have the

thought that if they only had the motivation, they would do more and

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 overcome their depression. What has been clearly learned, however, is that

being active itself is the most effective way to increase motivation. The more

you do, the more you feel like doing.

4. Guided activity improves your ability to think. Once you get started,

problems that you thought you could do nothing about come into perspective.

The unmanageable becomes manageable, and your mood will improve.

In spite of the advantages of getting more active, getting going again when you

are depressed is not easy. When you are depressed, you may think that you are doing

nothing, achieving nothing, and enjoying nothing. It may be difficult to organize your

time productively, or to involve yourself in things you would normally enjoy. Sometimes

you can’t even imagine doing things that were once basic and easy.

The treatment we will be working with will help you with all of the problems in

your life that inhibit your productive activity, and it will help you overcome those

problems, and in that way get rid of your depression. Working with your therapist, you

will learn how to monitor your life, and how your actions affect your overall level of

involvement in life. You will learn what activities oriented toward improving the quality

of your life might make you feel less depressed, either because they make you more

productive or because they are simply enjoyable. You will learn how to plan activities,

how to monitor the effects of activities on your mood, and how to get the most benefit

out of the things you do. You will learn about typical problems that people encounter

when they try to change their activities, and how not to fall into these problems yourself.

You and your therapist will work out a plan uniquely tailored to your situation to

optimize your daily activity schedule to make you less depressed. You will learn how to

47
get the most out of your day’s activities. Above all, you will learn how to operate

effectively in the world, and make the world a better place for you. It may be easier than

you think.

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Yost, E., Beutler, L., Corbishley, M. A. & Allender, J. (1986). Group
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