Treating Depression with
Behavior Therapy:
The Implementation of
Behavioral Activation
Christopher Martell, Ph.D., ABPP
Independent Practice and University of Washington
Sona Dimidjian, Ph.D.
University of Colorado
as told by
Steven D. Hollon, Ph.D.
Vanderbilt University
Acknowledgements
Research Team:
 Michael Addis
Sandra Coffman
 David Dunner
 Robert Gallop
Steve Hollon
 Bob Kohlenberg
Christopher Martell
 Karen Schmaling
Support:
NIMH & GlaxoSmithKline
Research Staff:
David Atkins
Patty Bardina
Carolyn Bea
Chris Budech
Jackie Gollan
Eric Gortner
David Markley
Melissa McElrea
Joe McGlinchey
Evelyn Mercier
Kim Nomensen
Shireen Rizvi
Lisa Roberts
Elizabeth Shilling
Mandy Steiman
Dan Yoshimoto
Clinical Staff:
Sandra Coffman
Linda Cunning
Steve Dager
Kerri Halfant
Helen Hendrickson
Ruth Herman-Dunn
David Kosins
Tom Linde
Christopher Martell
Peggy Martin
Steve Sholl
Alan Unis
What is Behavioral Activation?
- Structured, brief psychosocial approach
- Based on premise that problems in
vulnerable individuals' lives and behavioral
responses reduce ability to experience
positive reward from their environments
- Aims to systematically increase activation
such that patients may experience greater
contact with sources of reward in their lives
and solve life problems
- Focuses directly on activation and on
processes that inhibit activation, such as
escape and avoidance behaviors and
ruminative thinking
A Brief History of the Evidence
Base for Behavioral Activation
Peter M. Lewinsohn
1970s
Lewinsohn
• Early models highlighted the role of lack of
response-contingent reinforcement for nondepressed behavior
• Decrease in frequency or range of reinforcing
stimuli or increase in frequency of punishment
 depression
Brief History: Ferster
“I think the conceptual formulation as well as the
treatment of depression really depend upon
focusing on the behaviors the patient is not
engaged in … the most obvious aspect of
depression is a marked reduction in the
frequency of certain kinds of behavior and an
increase in the frequency of others, usually
avoidance and escape”
Ferster, 1974
Peter M. Lewinsohn
1970s
Aaron T. Beck
1979
BA subsumed within CT
• “…the ultimate aim of these techniques in cognitive
therapy is to produce change in the negative attitudes”
(Beck et al., 1979, p.118).
• “The key point is that even when cognitive therapists are
focusing on behaviors, they do so within the context of a
larger model that relates those actions to the beliefs and
expectations from which they arise and view them as an
opportunity to test the accuracy of those underlying
beliefs” (Hollon, 1999, p.306).
 Positive outcomes in CT may be dependent on
competence level of therapist (DeRubeis et al., 2005; Elkin et al.,
1989)
Peter M. Lewinsohn
1970s
Aaron T. Beck
Neil S. Jacobson
1979
1996
What accounts for the efficacy of
cognitive therapy?
Peter M. Lewinsohn
1970s
Aaron T. Beck
Neil S. Jacobson
1979
1996
Cognitive Therapy for Depression
Facilitative
Strategies
Behavioral
Activation
Strategies
Automatic
Thought
Strategies
Core Belief
Strategies
Component Analysis of Cognitive Therapy
Behavioral
Activation
Vs.
Full CT Package
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
Component Analysis of CT
Acute Findings
35
Cognitive
Therapy
Behavioral
Activation
30
Mean BDI
25
20
15
10
5
0
Pre
Post
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
Component Analysis of CT
Follow Up Findings
Acute Findings
100
35
Mean BDI
25
20
15
10
90
80
% Survival (Two Years)
Cognitive
Therapy
Behavioral
Activation
30
70
60
50
40
30
5
20
10
0
0
Pre
Cognitive
Therapy
Behavioral
Activation
Post
Jacobson, N.S., et al. (1996); Gortner, E.T., et al. (1998)
Behavioral Activation
 Findings of the component analysis study
led to an expansion of BA into a standalone model, not solely defined by
proscription of cognitive interventions
(Jacobson et al., 2000; Martell et al., 2001)
 Linked to earlier behavioral work on
depression (Ferster, 1973; Lewinsohn, 1974)
Acute and Follow-up Design
Acute Phase
Wk. 8
Intake
BA
CT
(N=43)
(N=45)
Continuation Phase
Wk. 16
Follow-Up Phase
Month 12
Month 24
Follow-up evaluations
Follow-up evaluations
Placebo withdrawal
Follow-up evaluations
ADM continuation
Follow-up evaluations
ADM-CM
(N=100)
PLA-CM
(N=53)
Assessment of Treatment Adherence
10.00
9.00
8.65
BEH
COG
PHARM
8.00
Mean Scale Score
7.00
8.06
6.07
6.00
5.01
5.00
4.00
3.00
2.00
1.00
0.58 0.57
0.06
0.22
0.06
0.00
BA
CT
ADM
Rates of Attrition by Condition by Phase
0.50
0.45
Second 8 weeks
8%
0.40
First 8 weeks
Percentage
0.35
Randomized No-Show
0.30
22%
0.25
0.20
8%
0.15
2%
0.10
15%
0.05
14%
9%
2%
0.00
PLA
ADM
CT
7%
2%
7%
BA
Mean BDI across acute treatment
40
CT Hi
35
CT Lo
BA Hi
30
BA Lo
25
ADM Hi
ADM Lo
20
15
10
5
Intake
Mid-Tx
Post-Tx
Mean HRSD across acute treatment
25
CT Hi
CT Lo
BA Hi
20
BA Lo
ADM Hi
ADM Lo
15
10
5
Intake
Mid-Tx
Post-Tx
Extreme Non-Response (BDI)
0.60
Extreme
Non-Response
ADM (N=57)
48%
Percentage
0.50
0.40
37%
CT (N=25)
BA (N=25)
36%
28%
0.30
0.20
7% 8%
0.10
8%
8%
4%
0%
2%
0%
0.00
0-10
11-20
21-30
BDI
31-63
Prevention of Relapse Following Successful
Treatment- all treatment conditions
Relapse
Recurrence
1
ADM-Placebo
(n=21)
ADM-ADM (n=28)
0.6
Prior BA (n=27)
0.4
Prior CT (n=30)
0.2
Months (following end of active treatment)
24
22
20
18
16
14
12
10
8
6
4
2
0
0
% Survival
0.8
Cumulative Direct Costs of
Continuation ADM and BA/CT
Cost in Dollars
4000
3500
BA/ CT
3000
ADM-ADM
2500
2000
1500
1000
500
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16
Months in Treatment
Note: These costs are based on $100/ session in BA and CT, versus $75/ session in Continuation ADM,
plus drug costs of $125/ month; ADM sessions occurring x2/ month for 2 months & monthly thereafter.
Putting it all together…
• BA emerges as a strong and promising
treatment
• Challenges the idea that medication is
required to treat moderately to severely
depressed patients
• Challenges the idea that directly
modifying cognition is necessary to treat
depression
• Limitations (BA, CT, ADM)
Points of Convergence
• Consistent with earlier behavioral literature (e.g.,
Lewinsohn; Ferster), more recent behavioral and
activation oriented studies (e.g., Hopko et al., 2003;
Stathopoulou et al., 2006 ), and dismantling studies
across other disorders/ages (e.g., Scogin et al., 1989)
• Consistent with early emphasis in CT on behavioral
strategies for more severely depressed patients (Beck
et al., 1979)
• Consistent with key components of other behavioral
treatments (DBT; Linehan, 1993; ACT; Hayes,
Strosahl, & Wilson, 1999) and recent
conceptualizations of integrative treatments for Axis I
disorders (Barlow, Allen, & Choate, 2004)
Key elements of BA
• Stylistic strategies
• Structuring strategies (including orienting to
treatment)
• Assessment strategies (individualizing primary
treatment targets through behavioral
assessment)
• Activation strategies (activity structuring and
scheduling)
• Targeting avoidance, routine disruption,
rumination
Course of BA
• Orient to treatment
– Treatment rationale, including conceptualization of
depression and primary treatment strategies
– Role of therapist/patient
• Develop treatment goals
• Individualize treatment targets
• Repeated application and troubleshooting of
activation and engagement strategies
• Reviewing and consolidating treatment gains
Stylistic Strategies
•
Validating:
– Interested; Accurately reflects; Genuine;
Maintains hope and optimism about
change
• Reciprocal/responsive to client
– Collaborative; Open to the client’s
influence; Awake to client’s behavior in
session and modifies interventions as
appropriate; Warm
• Non-judgmental and matter of fact in
interactions with client
– Everything is useful, provides information;
Curious—holds a problem solving
mindset in relation to all new behavior
Structure of Sessions
•
•
•
•
•
•
Set collaborative agenda
Review homework
Review weekly activities
Troubleshoot problem behaviors
Assign new homework
Ask for feedback
Treatment Rationale
• Emphasize relationships between
environment, mood, and activity
• Highlight vicious cycle that can develop
between depressed mood,
withdrawal/avoidance, and worsened mood
• Suggest activation as a tool to break this
cycle and support problem solving
• Emphasize an “outsidein” approach: act
according to a plan or goal rather than a
feeling or internal state
BA Case Conceptualization
Life
events
Less
Rewarding
Life
Sad, tired,
worthless,
indifferent,
etc.
Stay home,
stay in bed,
watch TV,
withdraw
from social
contacts,
ruminate,
etc.
BA Case Conceptualization
Life
events
Less
Rewarding
Life
Sad, tired,
worthless,
indifferent,
etc.
Stay home,
stay in bed,
watch TV,
withdraw
from social
contacts,
ruminate,
etc.
Loss of friendships,
conflict with supervisor
at work, financial stress,
poor health, etc.
Adolescents Taking Action
Sessions 1 & 2: Getting Started
What Does Behavioral Activation Mean?
Depression is a vicious cycle
BUT Behavioral Activation can
break this cycle by:
1st by identifying what makes
you feel down
2nd by learning how to tackle
problems
Depression
Your life is more stressful. You
begin to feel tired, bored….life
gets harder, you do less, pull away
and may blame yourself for not
doing more….it gets harder to do
things. This can create more
problems with school, parents,
friends…….
3rd by working together with
your therapist to take small
steps, get active, accomplish
your goals, and
BUILD THE
LIFE YOU
WANT!
TG 1-2, 2-2
Address common myths about
activation and change
• Will-power or “Nike”
model of change
Address common myths about
activation and change
• Will-power or “Nike”
model of change
• Emphasize
– Role of the therapist
– Focused activation
based on careful
behavioral analyses
– Graded task
assignment
– Difficulty of change
Individualizing activation targets
• Conduct detailed examination of what is
getting in the way of feeling better
• Sounds simple, and yet in practice, we
often lack awareness of these
relationships
Key Assessment Strategies
•
•
•
•
Identify and set goals
Define and specifically describe
problems in behavioral terms
Assesses consequences of behavior
Examine behavioral patterns
Goal Setting
• Ultimate goal of treatment
Clients modify their behavior to increase contact with
sources of positive reinforcement
• Typical goals relate to changing avoidance
patterns and routine disruption and to changing
environmental context
• Focus on acting from the “outside in”
• Set priorities for long and short-term goals
• Figure out what behaviors are needed to reach
goal—what, when, where, etc. Be focused,
specific, and concrete!
Key Assessment Strategies
• Basic questions:
– What is maintaining the depression?
– What is getting in the way of engaging and
enjoying life?
– What behaviors are good candidates for
maximizing change?
• Activity/mood monitoring provides the
essential information
• Utilize basic behavioral principles to
answer these questions
Behavioral Assessment
ANTECENDENT
BEHAVIOR
• Assess the circumstances
eliciting the behavior
• Assess the function of the
behavior: How is the behavior
reinforced or punished? Does it
garner a reward? Does it allow
escape or avoidance of an
aversive stimulus?
• Emphasis on function vs. form
CONSEQUENCES
Two Types of Conditioning
• Classical Conditioning: paired stimuli take on
similar functions
– a neutral stimulus such as a hospital paired with
grief following a loved one’s death in the hospital
takes on the properties of grief, such that seeing a
hospital evokes similar feelings
• Operant Conditioning: behavior is learned
according to the consequences that maintain
it
Understanding consequences
• Negative reinforcement: the likelihood of a behavior
is increased by the removal of something from the
environment (usually an aversive condition)
– Watching television is negatively reinforced by reduction of
painful emotions
– Negative reinforcement contingencies are frequently targets
in BA for depression
• Positive reinforcement: the likelihood of a behavior is
increased by the addition of something in the
environment
– Going to bed early is positively reinforced by family member
offering empathy and support
• Punishment: the extinguishing of a behavior by the
addition of an aversive consequence in the
environment
– Asking for help is punished by a judgmental and critical
reaction from others
Nuts and bolts of behavioral
analysis in BA…
• The Activity Chart – Central tool!
• What does a BA therapist focus on when
reviewing activity schedules?
Typical Questions to Guide Review
• What would the client be doing if he or she were not
depressed (e.g., working, managing family
responsibilities, exercising, socializing, engaging in
leisure activities, eating, sleeping, etc.)?
• What is being avoided or from what is the client pulling
away? How are these patterns related to mood?
• What is the relationship between specific activities and
mood?
• What is the relationship between specific life contexts
or problems and mood?
• Is the client engaging in a wide variety of activities or
have his or her activities become narrow?
• Are there disruptions in normal routines?
Exercise #2: Activity Monitoring
1. Recording: Write down your activities
and moods for 1-2 typical days over the
past week; include enough detail to
allow your partner can begin to notice
some relationships
2. Role Play: Practice being the therapist
and reviewing the completed log;
identify “if…then” relationships between
activity and mood; look for variability;
help your client begin to notice these
relationships
The challenge!
“There is only a modest correlation
between intention and behavior. Most
often, people have good intentions and
fail to act on them.” (Gollwitzer, 1999)
Problem Solving
• Problem definition
• Generate and evaluate solutions
• Practice new behaviors in session as
appropriate
• Skills training as appropriate
• Troubleshooting
Activity Scheduling
• Increase pleasure
• Increase mastery
• Increase approach (vs. avoidance)
Activity Scheduling
Mood/Activity
M
T
W
Th
F
S
S
Mood (0-10*)
6
5
5
7
3
3
2






Walking dog
Bed by 10pm




Auto meeting

Call friend

Gardening
List to wife



* 0=mild/no depressed mood  10=intense depressed mood


Activity Structuring: Grading Tasks
• Break down activities into parts
• Assign simple to more complex tasks in
a stepwise fashion
• Design assignments so that early
success is guaranteed
• Goal is not to accomplish all parts of the
activity—rather, to get started, increase
activation, disrupt avoidance
• Completing one component will
increase likelihood of completing others
Qualities of Effective Action Plans:
Opposite Action (Linehan, 1993)
 Emotions love themselves
– All emotions have “action urges” – what one wants to
do or say when feeling an emotion
– Action urges tend to maintain or intensify emotions
 If you want to change an
emotion, act opposite
to the action urge
 Opposite action works best
if you do it “ALL THE WAY” –
throwing yourself into and
participating fully in
the opposite action
Qualities of Effective Action Plans
• Clearly tied to the essence of the problem
(not random or arbitrary)
• Target avoidance, withdrawal, approaching
important problems/modifying life context
• Includes activities that are opposite to the
action urges accompanying depression
• Based on creative and collaborative
problem solving
• Utilizes contingency management as
needed to promote change
Qualities of Effective Action Plans
• Clear and specific (adequately detailed
information about what, when, where, etc.);
do you and the patient know what the plan
is when the session ends?
• Do-able (adequately graded into
component parts, assigning simple to more
complex parts in a stepwise fashion,
structured so that early success is nearly
guaranteed)
Qualities of Effective Action Plans
• Informed by adequate troubleshooting-consideration of potential barriers; anything
that might get in the way?
• Informed by what’s needed to maximize
commitment to implementation -- public
commitment, getting started in session,
reminders during the week, explicit linking
to long-term goals
• Includes plans for how to make new
behaviors routine
• Returns to treatment rationale as needed
Acronyms to Organize Action Plans
• TRAP/TRAC
• ACTION
TRAP/TRAC
• T- Trigger (demands
at work)
• R- Response
(depressed
mood/hopelessness)
• AP- Avoidance
Pattern (leave work;
stay at home)
• T-Trigger (demands
at work)
• R- Response
(depressed
mood/hopelessness)
• AC- Alternative
Coping (approach
behaviors using
graded tasks)
Trigger
Response
AvoidancePattern
Trigger
Response
Alternative
Coping
ACTION Strategy
• A=Assess
How will my behavior affect my depression?
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 mood.
Therefore, if I choose not to self-activate, I am choosing to
take a break.
• T=Try
• I=Integrate
• O=Observe
Try the behavior I have chosen.
Integrate any new activity into my daily
routine.
Observe the result. Do I feel better or worse?
Did this action allow me to take steps toward improving
my situation?
• N=Never
Never give up.
Experiential Avoidance (Hayes et al., 1996)
• BA is not a one-size-fits-all therapy
• Not all clients will be inactive
• Need to look for subtle forms of
avoidance
• Engagement as activation
• Experiencing rather than avoiding
negative feelings
Routine Regulation
• Work with patient to develop and follow
regular routine for basic life activities—
eating, working, school, sleeping.
• Can only evaluate new behaviors after
implemented for a period of time—make
them routine, then evaluate
– Use activity logs
– Use the ACTION strategy
Exercise #3:
Modifying Avoidance
•
•
Break into pairs
Help your partner…
•
•
•
•
•
Identify a goal for learning at ABCT (or more
broadly getting the most out of your experience)
Identify an avoidance pattern that might typically
become a barrier to moving in the direction of this
goal
Identify an action plan for alternative coping that
can be implemented over the next 3 days
Troubleshoot potential problems that would
interfere with the action plan
You can use the TRAP/TRAC form or a blank
activity schedule if useful
The Trouble with Ruminating
Nolen-Hoeksema, 2000
• What is ruminating?
– “People with a ruminative response style think
repetitively and passively about their negative
emotions, focusing on their symptoms of distress
("I feel so lousy," "I just can't concentrate") and
worrying about the meanings of their distress
("Will I ever get over this?“).”
• Ruminative response styles predict higher
levels of depressive symptoms over time,
onset of new episodes, and episode
chronicity
Targeting Ruminating
• Monitor and assess
• Focus on context and consequences of
ruminating, not on the content of
ruminative thoughts
Targeting Ruminating
• Practice with “attention to experience”
strategies
• Notice colors, smells, noises, sights, relation to others, etc.
• Notice elements of tasks (parenting, work)
• Select activities that are associated with high
engagement
• Highlight negative consequences of ruminating
• Be alert for partial activation and identify
specific behaviors that would maximize full
engagement
A Focus on the Content of Thinking
“I was depressed all day yesterday because I
was thinking about how my sister really
doesn’t love me.”
* What is the evidence that this thought is accurate?
* What would it mean if it were true?
* Can you think of another way to interpret what your
sister said?
* Why must everyone love you?
A Focus on the Context and
Consequences of Thinking
“I was depressed all day yesterday because I was thinking
about how my sister really doesn’t love me.”
* When did you start thinking that?
* How long did it last?
* What were you doing while you were thinking that?
How engaged were you with the activity, context, etc.?
* What were consequences of thinking about that? What
might be the function?
Relapse Prevention
• Consolidate Treatment gains
– What has been helpful
– What has been learned
• Plan for future problems
– What targets have been identified
– What new responses to targets are practiced
Additional Resources





Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral
activation treatment for depression: Returning to contextual roots.
Clinical Psychology: Science and Practice, 8, 255-270.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in
context: Strategies for guided action. New York: Norton and Co.
Addis, M.E., & Martell, C.R. (2004). Overcoming Depression One Step
at a Time: The New Behavioral Activation Approach to Getting Your
Life Back. New York: New Harbinger Press.
Dimidjian, S., Hollon, S.D., Dobson, K.S., Schmaling, K.B.,
Kohlenberg, R., Addis, M., Gallop, R., McGlinchey, J., Markley, D.,
Gollan, J.K., Atkins, D.C., Dunner, D.L., & Jacobson, N.S. (2006).
Randomized trial of behavioral activation, cognitive therapy, and
antidepressant medication in the acute treatment of adults with major
depression. JCCP, 74 (4), 658-670.
Dimidjian, S., Martell, C.R., Addis, M.E., Herman-Dunn, R. (in press).
Behavioral activation. In D. H. Barlow (Ed.), Clinical Handbook of
Psychological Disorders, 4th Edition. NY: Guilford Press.