Behavioral Activation Therapy

Depression often occurs as a reaction to adverse life events such as the break-up of a relationship, the death of a loved one, loss of a job, or serious medical illness (Hammen, 2005). A study by Frank, Anderson, Reynolds, and Ritenour (1994) revealed that 65% of people with depression reported a negative life event in the 6 months prior to the onset of their depression. Moreover, people with depression are more likely to than nondepressed people to have chronic life stressors, such as financial strain or a bad marriage, and these people also tend to have a history of traumatic life events, particularly events involving loss (Hammen, 2005). These observations led Lewinshon and Gotlib (1995) to propose the behavioral theory of depression, which suggests that life stress can lead to depression by reducing positive reinforcers in a person’s life. As a result, the depressed person begins to withdraw, causing further reduction in positive reinforcers, leading to more withdrawal, and thus creating the self-perpetuating cycle of depression. Therefore, it is not surprising that depression is characterized by feelings of sadness, misery, and a sense of apathy, resulting in pervasive impairment of the capacity to experience pleasure or to respond positively to the anticipation of pleasure. Such inhibitions of the mechanism of pleasure lead to diminished interest and investment in the environment. Consequently, depressed patients are unable to enjoy or participate in once pleasurable activities such as hobbies, eating, sex, or social interaction. In this chapter, I describe behavioral, physical, and hypnotherapeutic methods for dealing with avoidance and inactive behaviors. The methods include (a) techniques for dealing with avoidant behaviors, (b) physical exercise, (c) active-interactive training, and (d) hypnotherapeutic strategies for dealing with avoidance behaviors.

Techniques for Dealing with Avoidant Behavior

According to Lewinshon and his colleagues (1974, 1986), when behavior decreases due to nonreinforcement, other symptoms of depression such as low energy and low self-esteem are likely to follow. In general, research has provided some support for the behavioral theory of depression (e.g., Rehm & Tyndall, 1993). Similarly, Rehm (1977) described depression as a deficit state characterized by lack of adaptive self-reinforcement. However, Willner (1991) believes the neurobiological changes accompanying prolonged stress may underpin such dampened hedonic capacity, and therefore the fundamental problem may be decreased reward salience rather than decreased exposure to rewarding activities. This view complements Seligman’s (1975) learned helplessness model of depression. To counteract behavioral inactivation and
avoidance, the weekly activity schedule and behavioral activation training are used.

Behavioral techniques are combined with CBT to counteract the behavioral inactivation component of depression, which includes anhedonia, lethargy, and lack of motivation. Friedman, Thase, and Wright (2003) have proposed a useful guiding principle for using behavioral technique within the CBT framework. They suggest that the greater the degree of the patient’s behavioral inactivation, the greater the need for using behavioral techniques. The behavioral activation strategies include activities scheduling, graded task assignments, and mastery-pleasure exercises. These techniques help to actively overcome the lethargy cycle of depression, in which amotivation and indecisiveness, fatigue, lethargy, and anhedonia reinforce the automatic negative thoughts and beliefs of inadequacy and failure. This cycle becomes self-reinforcing, because worry and inactivity lead to sleep-cycle disintegration, which promotes further biological dysregulation that compromises the subjective appraisals of well-being (Friedman, et al., 2003). Friedman et al. believe behavioral techniques ameliorate both the behavioral and the biological components of the depression.

Weekly Activity Schedule

An effective way to reverse this cycle is to utilize the weekly activity schedule (see Appendix 13A), which engages the patient in planned activities that substantially increase access to reinforcement. The weekly activity schedule is a calendar-like template that allows the patient to document how he spends time and to schedule activities. The patient is instructed to fill in the hourly grid with his activities and, in the next session, the therapist reviews the activities the patient engaged in over the past week. The patient is taught to appraise realistically the mastery and pleasure experienced while performing these activities. In so doing, the patient comes to see that an adequate degree of mastery can be achieved even when little pleasure is derived from an activity. Conversely, some activities, in the absence of complete mastery, can also be very pleasurable. By self-monitoring his hedonic capacity with the weekly activity schedule, the patient learns how expectations and predictions lead to specific mood states and behavioral outcomes. Martell (2003) has listed several reasons for using the weekly activity schedule:

It reveals the patient’s level of activity.
It highlights restrictions imposed by negative mood.
It shows the connection between activity and mood.
It provides ratings for mastery and pleasure.
It assists the patient in monitoring avoidance behaviors.
It facilitates guided activity.
It underscores steps the patient is taking to achieve stated life goals.

Behavioral Activation Training

Although the weekly activity schedule can help depressed patients increase daily activities, some patients still continue to avoid some activities or situations. Behavioral activation training
(BAT) provides a strategy for helping patients change their behaviors in such a way as to bring them into contact with positive reinforcers in their natural environment. However, for such treatment to succeed, the therapist must take an idiographic approach. Merely applying broad classes of pleasant activities may not be reinforcing to every depressed patient, and thus a good functional analysis is required. BAT is adapted from Martell (2003), and it consists of three steps for dealing with avoidance. These steps are illustrated by three acronyms utilized by Martell: ACTION, TRAP, and TRAC.

APPENDIX 13A: Weekly Activity Schedule

Time	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Date: Week Starting_______ Week Ending_______
Please grade activities M for mastery and P for pleasure and rate them on a scale of 0–10; 0 = no mastery or pleasure and 10 = full mastery or pleasure; Monday 9–10 and 10–11 completed as examples
8–9	Got out of bed M7
9–10	Read P8
10–11
11–12
12–13
13–14
14–15
15–16
16–17
17–18
18–19
19–20
20–21
21–22
22–23
23–24