Making Behavioral Activation 1 Running head: MAKING BEHAVIORAL ACTIVATION MORE BEHAVIORAL Making Behavioral Activation More Behavioral

Behavioral Activation (BA; Martell, Addis & Jacobson, 2001), an efficacious treatment for depression, presents a behavioral theory of depression—emphasizing the need for clients to contact positive reinforcement—and a set of therapeutic techniques—emphasizing provision of instructions rather than therapeutic provision of reinforcement. An integration of BA with another behavioral treatment, Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991), addresses this mismatch. FAP provides a process for the therapeutic provision of immediate and natural reinforcement. This paper presents this integration and offers theoretical and practical therapist guidelines on its application. Although the integration is largely theoretical, we present empirical data in its support when available. We end with a discussion of future research directions. Making Behavioral Activation 4 Making Behavioral Activation More Behavioral Recent interest in Behavioral Activation (BA) for clinical depression (Martell, Addis, & Jacobson, 2001) stems from several sources. The component analysis of Cognitive Therapy (CT; Beck, Rush, Shaw, & Emery, 1979) by Jacobson and colleagues (1996) suggested that the BA component of CT alone produced equivalent outcomes to the full CT package at the end of acute treatment (Jacobson et al., 1996) and at a 2-year follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998). This grabbed the attention of prominent cognitive therapists (Hollon, 2000) and sparked the development of a full BA treatment package (Jacobson, Martell, & Dimidjian, 2001; Martell et al., 2001). Current BA recently performed equivalently to Paroxetine and better than CT for moderate-to-severe depression in a large randomized trial (Coffman, Martell, Dimidjian, Gallop, & Hollon, 2007; Dimidjian et al., 2006). Simultaneously an alternate BA treatment was developed by Lejeuz, Hopko, and Hopko (2002), referred to as Brief Behavioral Activation Treatment for Depression (BATD). BATD showed promise in a smaller randomized trial on an inpatient unit (Hopko, Lejuez, LePage, Hopko, & McNeil, 2003) and in several case studies (Hopko, Bell, Armento, Hunt, & Lejuez, 2005; Hopko, Lejuez, & Hopko, 2004; Hopko, Sanchez, Hopko, Dvir, & Lejuez, 2003; Lejuez, Hopko, LePage, Hopko, & McNeil, 2001). Cuijpers, van Straten and Warmerdam (2007) recently published a meta-analysis of BA-related treatments that showed, with some exceptions (e.g., Hammen & Glass, 1975), that these treatments have performed quite well over several decades of research. A final source of interest in BA may be its inclusion in several descriptions of a growing “third wave” of behavior therapies that place less emphasis on cognitive change, revisit and elaborate on earlier behavioral theories, and emphasize mindfulness and acceptance processes (Hayes, 2004; Hayes, Follette, & Linehan, 2004). Currently, BA and BATD are being Making Behavioral Activation 5 evaluated by several independent research groups for diverse problems including post traumatic stress disorder, depression in Latinos, depression in cancer patients, obesity, and addiction (Kanter & Mulick, 2007). BA is based on early functional descriptions of depression by Lewinsohn (1974) and Ferster (1973) that emphasized basic behavioral principles, particularly positive and negative reinforcement (Hopko, Lejuez, Ruggiero, & Eifert, 2003). The current paper offers an important clarification of how reinforcement is, and is not, incorporated into BA’s model of depression and purported mechanism of action. This clarification expresses BA’s strengths and exposes possible limitations. We then suggest an integration of BA with another behavioral treatment, Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991) to address an important limitation. In both BA and FAP, therapists are expected to learn the underlying principles rather than a session-by-session set of techniques (BATD, in contrast, offers more structure). The integration presented herein is offered in this spirit; in conjunction with the BA and FAP manuals it should provide a sufficient therapist guide to the delivery of FAP-Enhanced BA (FEBA). Although the integration is largely theoretical, we present empirical data in its support when available. Behavioral Activation A vast body of research supports the basic principle of reinforcement (Catania, 1998) that states that a given behavior will increase when followed by certain environmental changes. When this given behavior no longer produces these environmental changes or is punished, the behavior will decrease in frequency. Lewinsohn (1974) first described depression as such a decrease in behavior, with naturally elicited sequelae such as sad mood, anhedonia and other dysphoric emotional reactions, due to losses of, reductions in, or chronically low levels of positive reinforcement. Lewinsohn’s resulting treatment focused on pleasant events scheduling Making Behavioral Activation 6 to increase rates of positive reinforcement and social skills training to increase the client’s ability to obtain and maintain positive reinforcement (Zeiss, Lewinsohn, & Muñoz, 1979). Current BA (Martell et al., 2001) retains this basic emphasis on activation and skills training strategies to increase contact with positive reinforcement but, based on Ferster’s (1973) functional description of depression, adds a new emphasis on the role of negative reinforcement (i.e., escape and avoidance behavior) in depression. Specifically, negative events occur, these negative events produce aversive emotional responses, and the individual’s repertoire becomes dominated by efforts to escape and avoid these aversive emotions. Such emotion-focused coping is often quite passive (e.g., staying in bed, withdrawing from or passively attending social situations, neglecting housework) or interpersonally or physically destructive (e.g., alcohol or drug use, excessive eating). Furthermore, most of these avoidance behaviors do not function to resolve the original problems or deficits that contributed to the negative events or lack of positive reinforcement in the first place. Thus, when an individual responds to the original negative events and resulting negative affective states with avoidance, a spiral into clinical depression may occur. This relation between avoidance and depression is supported by considerable research (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Ottenbreit & Dobson, 2004). In BA (Martell et al., 2001) this basic model is presented to the client as the acronym TRAP (Trigger, Response, and Avoidance Pattern). Triggers are broadly defined, including sudden, major negative life events, stimuli related to past negative life events, or the accrual of smaller negative events over a long period of time. Responses to triggers are respondent behaviors or conditioned emotional responses and include some (but not all) of the symptoms of depression, including anhedonia, negative affect and crying, and loss of energy. Key to the model is that these responses are natural, unavoidable and not sufficient by themselves (in most Making Behavioral Activation 7 cases) to constitute major depression or otherwise require clinical attention. Instead, the presence of Avoidance Patterns in response to these symptoms is emphasized. The goal in BA is to “get out of the TRAP and get on TRAC” (Martell, et al., 2001, p. 102) by replacing the avoidance patterns with Alternate Coping behaviors that address the original triggers and bring the individual into contact with diverse and stable sources of positive reinforcement. The client in BA would be activated to get out of bed, leave home, go to work, and interact socially even when feeling sad, tired, worthless, indifferent and hopeless.