Behavioral Activation: How to
Get Motivated When You Are
Depressed
Campus Mind Works
Ricks Warren, Ph.D., ABPP
Department of Psychiatry
University of Michigan
Tuesday, March 18, 2013
Acknowledgements
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
What is Behavioral Activation
• Psychosocial treatment
• Focuses on the relationship between life
events, our actions, and our moods
• Goal is to increase activities and actions
associated with increased mood and
decrease those that are associated with
lower moods.
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)
Treatment Rationale
• Emphasizes relationships between
environment, mood, and activity
• Highlights vicious cycle that can develop
between depressed mood,
withdrawal/avoidance, and worsened mood
• Suggests activation as a tool to break this
cycle and support problem solving
• Emphasizes 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.
SELF-ASSESSMENT
Behavioral Activation for Depression Scale
Common Myths About Activation
and Change
• Feeling motivated
must precede action
Just do it!
ACTION LEADS TO
MOTIVATION
GOAL DIRECTED VS. FEELING
DIRECTED
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
result in a reward? Does it allow
escape or avoidance of an
aversive stimulus?
• Emphasis on function vs. form
CONSEQUENCES
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.
– Surfing the internet is likely to increase in frequency if it
removes you from a difficult homework assignment.
– Negative reinforcement contingencies are frequently targets
in BA for depression
Understanding Consequences
• Positive reinforcement: the likelihood of a behavior is
increased by the addition of something in the
environment
– Initiating contact with a friend is positively reinforced when
your friend is happy to hear from you and suggests getting
together.
– Studying consistently is positively reinforced by getting a
good grade
Understanding Consequences
• Punishment: the likelihood of a behavior is decreased
when it is followed by an aversive consequence in
the environment
– Asking for help will be less likely if it receives a judgmental
and critical reaction from others.
– Social interactions will be less likely if they result in rejection
(or perceived rejection).
Nuts and bolts of behavioral
analysis in BA…
• The Activity Chart – Central tool!
• What to focus on when reviewing activity
schedules?
Typical Questions to Guide Review
• What would you be doing if you were not depressed
(e.g., working, managing family responsibilities,
exercising, socializing, engaging in leisure activities,
eating, sleeping, etc.)?
• What did you used to enjoy and find meaningful that
you are no longer doing?
• What is being avoided or from what are you pulling
away? How are these patterns related to mood?
Typical Questions to Guide
Review
• What is the relationship between
specific activities and mood?
• Are you engaging in a wide variety of
activities or have your activities become
narrow?
• Are there disruptions in your normal
routines?
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)
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
• Go from 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
The Pleasure Prediction Method
• Estimate on a scale of 0 to 100 how much
pleasure or enjoyment you predict you will
get from engaging in a planned activity.
• Engage in the activity
• Rate from 0 to 100 how much pleasure or
enjoyment you actually obtained.
• Remind yourself of this next time you
predict the activity will not be satisfying.
•
Burns, 1980
The Antiprocrastination Method
• Break down a task into small steps.
• Rate down on a scale from 0 to 100 how
difficult you predict the task to be and how
much satisfaction you will get from
completing the task.
• After task completion make actual difficulty
and satisfaction ratings (0 to 100).
•
Burns, 1980
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
Opposite Action All the Way
•
•
•
•
•
•
1. Actions
2. Thoughts
3. Facial Expressions
4. Posture
5. Words
6. Voice Tone
Acronyms to Organize Action Plans
•
•
TRAP/TRAC
Trigger
Response
AvoidancePattern
Trigger
Response
Alternative
Coping
TRAP/TRAC
• T- Trigger
(homework)
• R- Response
(depressed
mood/hopelessness)
• AP- Avoidance
Pattern (stop working
on it / skip class
• T-Trigger
(homework)
• R- Response
(depressed
mood/hopelessness)
• AC- Alternative
Coping (divide and
conquer, one step at
a time / go to class)
Routine Regulation
• Work on developing and following 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
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)
• Mindfulness Meditation (Kabat-Zinn, 1980)
TARGETING RUMINATION
• 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?
Readings: Self-Help

Self-help:

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.

Burns, D.D. (1980). Feeling Good: The New Mood Therapy. New York:
HarperCollins.

Kabat-Zinn, J. (1980). Full Catastrophe Living.

Lewinsohn, P. M., Munoz, R. F., Youngren, M.A., & Zeiss, A. M.
(1992). Control Your Depression. New York: Fireside

Siegel, R. (2010). The Mindfulness Solution. New York: Guilford
Readings: Profesional/Academic

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.
Journal of Consulting and Clinical Psychology, 74,, 658-670.

Martell, C. R., Dimidjian, s., & Herman-Dunn, R. (2013,
paperback version). Behavioral activation for depression: A
clinician’s guide. New York: Guilford.

Dichter et al. (2009). The effects of psychotherapy on neural
responses to rewards in major depression. Biological
Psychiatry, 66, 886-897.