Over the past 10 years there has been a resurgence of interest in behavioral treatments for depression
that were originally proposed in the early 1970s with the theoretical formulations of C. B. Ferster (1973,
1981) and the applied work of Peter Lewinsohn and colleagues (Lewinsohn, 1974; Lewinsohn, Biglan, &
Zeiss, 1976; Lewinsohn & Graf, 1973). The basic idea of the behavioral theory of depression was that
individuals become depressed when there is an imbalance of punishment to positive reinforcement in
their lives. According to Ferster (1981), when an individual responds primarily to deprivation and the
removal of an aversive, deprived state, he or she develops behaviors that function primarily as
avoidance behaviors and there is little access to positive reinforcement built into the behavioral
repertoire of the individual. Treatment for depression would, therefore, consist of a process that would
increase the individual’s access to positive reinforcers.
Following the analysis of Ferster, Lewinsohn and colleagues focused on increasing pleasant events and
pleasurable activities in order to treat depression (Lewinsohn & Graf, 1973). These researchers
developed the use of activity logs and activity scheduling to help depressed patients increase positive
activities that would combat their lethargy and bring them into contact with positive reinforcers. During
this same time, cognitive therapy for depression was also being formulated (Beck, 1976) and utilized the
activity scheduling elements of Lewinsohn’s approach but focused on changing the negative content of
depressed patients’ beliefs. Cognitive therapy was studied extensively and empirically validated as a
treatment for depression, and the field of behavior therapy took on a distinctively cognitive profile
throughout much of the 1980s and 1990s. The idea of increasing pleasant events alone, without
cognitive interventions, was questioned (Hammen & Glass, 1975), and cognitive behavior therapy was
seen as a psychosocial treatment of choice for depression.
A recent meta-analysis (Ekers, Richards, & Gilbody, 2007) suggests that behavioral treatments are
efficacious for treating depression. A component analysis of cognitive therapy for depression (Jacobson
et al., 1996) demonstrated that depressed participants treated with behavioral activation alone
improved as well as those subjects treated with a full cognitive therapy treatment. Their results were
maintained at follow-up (Gortner, Gollan, Dobson, & Jacobson, 1998). The results of the component
analysis study opened the door for a larger study of the treatment of depression, which compared
cognitive therapy, behavioral activation, paroxetine, and pill placebo (Dimidjian, Hollon, Dobson, et al.,
2006). For moderately to severely depressed clients, behavioral activation performed as well as
antidepressant medication and outperformed cognitive therapy in the acute treatment. Both behavioral
activation and cognitive therapy were efficacious in the prevention of relapse (Dobson, Hollon,
Dimidjian, et al., in press).
Behavioral activation is a structured, behavior analytic approach that borrows heavily from earlier
behavioral formulations of depression (Jacobson, Martell, & Dimidjian, 2001; Martell, Addis, & Jacobson,
2001). Through functional analyses, client behavior is understood according to its setting and
consequences rather than the particular form it takes. The emphasis is, indeed, on the function of a
behavior rather than the form and the treatment is not just about getting depressed clients to be more
active. For example, while chatting with a friend on the phone may formally appear to be a positive
behavior for a depressed individual, one must understand the contexts and consequences prior to
From O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive
behavior therapy. Wiley.
coming to such a conclusion. If chatting with the friend serves to keep the individual from working on a
project that is overdue, thus making her or him more depressed, it functions as avoidance and has
negative consequences. The treatment is theory driven rather than protocol driven with a focus on
targeting avoidance behavior as a primary treatment goal with depressed clients.
WHO MIGHT BENEFIT FROM THIS TECHNIQUE
Behavioral activation (BA) is currently a treatment for depression and has undergone evaluation in that
arena. A small pilot study has suggested that BA may be useful in the treatment of veterans with
posttraumatic stress disorder (Jakupcak, Roberts, Martell, Mulick, Michael, Reed, et al., 2006). The BA
focus on avoidance places it in the realm of other exposure-based treatments that have been used for
the treatment of anxiety and other disorders. However, no data are yet available to demonstrate the
utility of the approach in these areas. Participants in Jacobson’s lab met criteria for major depressive
disorder and were screened out only if there was presence of a thought disorder or active substance or
chemical dependence. No other comorbid disorders were excluded. Therefore, the participant pool on
which the treatment was tested had at least an Axis I major depressive disorder, but could have had
comorbid Axis I or Axis II disorders (other than psychosis or substance dependence).
CONTRAINDICATIONS OF THE TREATMENT
Understanding the possible contraindications of this treatment requires clinical hypothesis rather than
hard data. The treatment does not seem to be contraindicated for most people suffering from major
depression. Although it is a context-based, nonpharmachological treatment that encourages clients to
look outward at their life context rather than at hypothesized internal defects, it has even been used
with clients who maintain a need for psychotropic medication (implying a flaw in the machine). We
would caution clinicians, however, from using this technique with depressed individuals who may be
involved in a domestic violence situation, where activating may expose them to greater harm from an
abusive partner. Clinicians should be cautious not to encourage a client to engage in behavior that could
result in any such harmful interpersonal interaction.
OTHER DECISIONS IN DECIDING WHETHER TO USE BEHAVIORAL ACTIVATION
The data suggest that BA alone, without evaluation of the content of clients’ thinking, works well in the
treatment of a major depressive episode. However, outside of the research setting, there is no
prohibition against using cognitive restructuring although recent investigations into methods for treating
client rumination (see, e.g., Watkins, Scott, Wingrove, Rimes, Bathurst, Steiner, et al., 2007) are more
consistent with the behavioral formulation. Some clients maintain strong beliefs that their thinking is
the problem. We would recommend that, rather than arguing with a client, therapists incorporate the
very behavioral aspects of BA with a cognitive conceptualization. The two treatments are
complementary and provide a bridge for some clients (and therapists). For example, the context and
consequences of clients’ thinking (where and when it occurs, and what effect it has on how the client
feels and what he or she does next) can be incorporated into BA without focusing on the content.
HOW DOES THE TECHNIQUE WORK?
At this time, we can only make assumptions about the factors that make BA work. Primarily, the
therapist takes the role of a coach, encouraging clients to become active even when they feel as if they
From O’Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive
behavior therapy. Wiley.
cannot possibly complete tasks or get any pleasure from life. Because BA works to help clients establish
a regular routine, it breaks the destructive process of routine disruption that often accompanies
depression (Ehlers, Frank, & Kupfer, 1988). Activity in BA means getting engaged rather than just doing
something for the sake of being busy or living under a Calvinist work ethic.
STEP-BY-STEP PROCEDURES
The treatment is based on the theory, described earlier, that depression often results from changes in a
vulnerable individual’s life that decrease the person’s access to positive reinforcement. Basically, the
treatment consists of strategies that increase activity and block avoidance so that the client can come in
contact with natural reinforcers in his or her environment. In order to do this in a manner that is
idiographic and not merely applying broad classes of pleasant activities that may or may not actually be
reinforcing, the therapist needs to do a good functional analysis.
Conducting a Functional Analysis
Whereas the laboratory provides much control over conditions that can lead to accurate understanding
of contingencies at work in the behavior of organisms under study, the clinical setting does not provide
the same level of control. When we speak of functional analysis we are speaking of the best hypotheses
that the therapist and client can develop about the antecedents, behaviors, and consequences that form
elements of the client’s repertoire contributing to depression. In BA we are interested in the function of
the behavior and not the form of the behavior. Therefore, we are less concerned with what popular
opinion may be about a certain behavior (e.g., people may think that going for a run early in the
morning is a good and healthy thing to do) that with the function of a particular behavior for particular
person (e.g., the runner may actually be out early in the morning because she does not want to remain
at home to have a discussion with her partner about having neglected to pay an expensive bill).
Functional analysis is the heart of BA, and it will be conducted throughout the treatment. The first step,
however, is to develop general case conceptualization from a behavior analytic perspective.
There are several questions that the therapist needs to ask about the depressive episode that the client
is experiencing. First, the therapist should understand the client’s history and gather information about
significant life events, positive or negative, that influence the client’s current life context. To do this, the
therapist simply need ask the client to recount such events, with questions like “What is your family
like? What kinds of things have been good in your life? What has hurt you or has been distressing?” It is
also important, second, to understand how the client behavior during a depressive episode is different
from his behavior at other times. Asking the client “What is your life like when you are not depressed?
Are there things that you are not doing now that you typically do when you are not de pressed? What
do you hope to accomplish in you life? Are you taking steps toward accomplishing, these things?” can
help to gather a picture of what problems the client may be experiencing.
Gathering this information helps the therapist to develop a case conceptualization of the client’s
depression. We express the case conceptualization in terms of the life events that may have contributed
to the depression by making the client’s life less rewarding, and we then look at how the client has tried
to cope with the symptoms of depression. Often the client’s attempts at coping become problems in
themselves, and we refer to these as secondary problem behaviors. For example, the runner mentioned
earlier might be coping with feelings of hopelessness and inadequacy by engaging in a fervent exercise
