By Michael D. Anestis, M.S.
This article will serve as the first of a series detailing specific components of cognitive behavioral therapy (CBT). Lora Rose Hunter's excellent article on cognitive behavioral group therapy (CBGT) for social anxiety disorder provides a more thorough description of CBT as a whole. The initial posts in this series will focus on CBT as designed to treat depression.
The focus of this initial post will be behavioral activation. As a therapist, this can be a very enjoyable component of CBT, but, for reasons I will explain, it can also be fairly challenging. Put simply, behavioral activation involves planning a combination of productive and rewarding behaviors. As Peter Lewinsohn first described (Lewinsohn & Graf, 1973), individuals who are feeling depressed tend to engage in fewer rewarding activities. This alteration in behavior causes a reduction in the amount of positive reinforcement in that individual's life, thus further increasing his or her depressive symptoms. Essentially, the individual gets stuck in a depressive cycle not unlike the one described in our article on rumination, with this particular cycle being driven by changes in behavior.
There are many reasons a client will report for engaging in fewer rewarding and productive behaviors. Anhedonia, the loss of interest in or pleasure from previously enjoyable activities, is one of the two central symptoms of depression (along with depressed mood) and is typically at the root of these behavioral changes. The client may report that there is no point in engaging in previously rewarding activities because there is no hope that he or she will enjoy them as they did before becoming depressed. Alternatively, the client will report that engaging in such behaviors is frivolous and that he or she does not deserve to experience any pleasure that might result. These are obviously distorted cognitions, but they feel entirely real to the client. As such it is imperative that the therapist utilize a behavioral intervention that allows the client to examine the evidence for and against his or her distorted hypothesis, thus allowing for a change in the way he or she views the situation. In the end, the client may be right in that the amount of pleasure and mastery felt in response to the behavior may be dampened relative to pre-depression levels. Even if this is the case, however, such information can serve as an opportunity for the therapist to work on diminishing the client's dichotomous thinking by asking whether muted enjoyment might be better than a complete absence of pleasure and if this might represent slow progress worth further examination.
Behavioral activation first requires the client to monitor his or her activities, hour by hour, each day for the week between sessions and to note the amount of pleasure and mastery that he or she experiences in response to each activity. This serves several purposes. First, the therapist can get a more accurate and detailed description of the client's behaviors than is possible by simply asking for a retrospective report on the week. It is hard for anyone to remember a week's worth of activities and behaviors, and this is particularly true when an individual is in a depressive episode. Additionally, it provides the client with irrefutable evidence regarding what has transpired during the course of the previous seven days and how he or she felt in each moment, thus precluding the client's current depressed mood from influencing his or her memory of what has transpired.
Based off this initial report, the therapist and client then work together to determine which activities from the previous week were the most and least rewarding. Additionally, they create a list of activities, both fun and productive (although not necessarily both at the same time), that the client used to engage in regularly but have become rare or entirely absent in his or her life. Next, the therapist and client work together to fill out a prospective schedule for the following week that includes planned positive events. Oftentimes, the therapist will have the client plan a series of productive activities aimed at increasing mastery (e.g., Saturday 9:00-9:30am, pay bills), and then plan a rewarding activity immediately after the productive activity (e.g., Saturday 9:30am-10:00am, take a walk around lake). The idea behind this approach is to train the client to reward him or herself for engaging in productive behaviors rather than simply dismissing them as things her or she should have been doing anyway. The word "should," in fact, will be a target in cognitive restructuring, another CBT component that will be described in a future post. Care must be taken in planning activities to ensure that success is probable and the activity is not likely to result in ruminative thinking. To do this, a priority should be placed on active behaviors (e.g., going for a walk, reading) as opposed to passive ones (e.g., watching television), although this does not have to be a universal pattern throughout the week.
Behavioral activation has the ability to improve a client's mood and outlook extremely quickly, as the experience of positive affect not only improves mood, but also tends to increase hope. As such, this component of CBT should be utilized very early in treatment, as it can be invaluable with respect to increasing motivation for treatment. In order to avoid common pitfalls, the therapist can also include cognitive components to this behavioral task by having the client compare his or her expected outcome (e.g., "this won't be any fun for me and I'll probably fail") to actual outcomes (e.g., "I enjoyed this quite a bit, even if it wasn't quite as fun as before") in order to diminish dichotomous thinking and fortune telling. The client can then learn that initial gut feelings about the potential utility of engaging in certain behaviors are not as reliable as tangible evidence from prior examples.
Ultimately, behavioral activation serves as a way for clients to break rumination, experience positive emotions, and take control over their symptoms. The client must continue to monitor and schedule their behaviors throughout treatment in order to ensure that they remain engaged in this component of treatment, but eventually the structure can be relaxed and spontaneity can return to the client's life.
For more information on behavioral activation in particular and CBT in general, please refer to PBB contributor Robert Leahy's manual Treatment Plans and Interventions for Depression and Anxiety Disorders, available on Amazon.com through our online store.
Mike Anestis is a doctoral candidate in the clinical psychology program at Florida State University.
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