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Behavioral activation came about in the 1990’s as a challenge to the CBT model of depression. The basic strategy behind this therapy blends well with brief medication visits, and we explain how to use it in this professional guide. Check out the patient companion to this edition in the Pocket Psychiatrist podcast.

Published On: 2/1/2021

Duration: 9 minutes, 23 seconds

Rough Transcript:

We’ve set a date on our calendar: On the first Monday of each month we’ll bring you clips from our patient edition – the Pocket Psychiatrist. Today, An Antidepressant Calendar, otherwise known as Behavioral Activation.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Behavioral Activation

Neil Jacobson knew a thing or two about marriage. He spent the 1980’s watching couples fighting, arguing, and sometimes getting along in John Gottman’s famed “Love Lab” at the University of Washington. From that work he figured out that couples did better when they accepted each other than when they tried to change each other, and he turned those insights into an effective marital therapy: Integrative Behavioral Couples Therapy.

Dr. Aiken: In 1990 Dr. Jacobson had just turned 40, and he turned his insights acceptance toward depression. He knew that cognitive behavioral therapy – CBT – was very effective for depression, but he wondered if all the effort spent on changing cognitions was really necessary. After all, his couples had made significant gains when they accepted their differences and moved toward more positive actions with each other through a behavioral approach. What if people with depression accepted all the noise in their head – the automatic, negative thoughts – and moved toward more meaningful action? Instead of weighing all the evidence to figure out how likely it is that they were unlovable, the therapist could help them get in touch with how they were living day to day, get them “out of their heads and into their lives,” doing things that were in line with their goals and values or at least bring a chance of pleasure.

To answer this question, the great marital therapist would have to initiate a divorce – separating the cognitive part of CBT from the behavioral side in what is called a dismantling study. He and his colleagues randomly assigned 150 patients with major depression to one of 3 therapies:

• Pure Cognitive therapy with a focus on challenging negative thoughts and core beliefs behind those thoughts
• Behavior therapy with a touch of cognitive work – in this therapy they focused on getting active – behavioral activation – but the therapist also worked to change the patient’s negative thoughts a little without working on the core beliefs behind those thoughts
• Pure behavior therapy, using what’s come to be known as behavioral activation. Here the focus is on what the patient is doing every hour of the day. Are they doing it to avoid painful emotions? Or to create something positive?

KELLIE NEWSOME: After 6 months, there was no detectable difference in the 3 therapies. All worked equally well at treating depression and at changing depressive cognitions. The study, which was published in 1996, became a classic in psychology. It launched a new way of thinking about therapy – sometimes called contextual psychology or third-wave behavior therapy – along with like-minded approaches like mindfulness, dialectical behavior therapy, and acceptance and commitment therapy. All of these share in common the idea that people don’t need to change their beliefs or thoughts to improve their mental health – they can accept all that stuff and focus on how their actions shape their lives.

Dr. Aiken: Now, you could say – if all these therapies worked equally well, why not just stick with CBT? Why rock the boat? Dr. Jacobson believed that behavioral activation was simpler – it was easier for therapists to learn and easier for patients to do. And we agree – if you’re working with medications in short visits, you’ll get a lot more mileage out of these behavioral steps than you will challenging automatic thoughts. The behavioral approach also makes sense for patients with severe depression who may have cognitive impairments that make it hard for them to engage in traditional CBT. This may be why behavioral activation worked better than cognitive therapy in a 2006 study of severe depression.

KELLIE NEWSOME: If you’d like to learn this therapy, a good introduction is Behavioral Activation by Jonathan Kanter in the CBT Distinctive Features series. He gives a down-to-earth explanation of the philosophy behind the therapy, which is basically this: Everything we do is a behavior. Our actions, but also our thoughts and emotions. “But wait,” you say. “We choose our actions, but we certainly don’t choose our emotions, and we don’t have much control over our thoughts.” Well, I got news for you… there’s no proof that any of this is willful.  Behavior therapists are interested in what happens and what reinforces it, in other words – what makes it habitual. When a police officer pulls up behind you, you start driving more carefully, and you start to feel a little anxious, because it reminds you of the times that the red lights flashed and you got a ticket. Both your actions behind the wheel – and the anxiety inside your chest – are reinforced by the same thing – and behavior therapists work to figure out what’s reinforcing their clients behaviors so they can help them change.

Dr. Aiken: Well, all that is just to say that behavioral activation is a bit more complicated than just asking patients to schedule activities on a calendar. But activity scheduling can still work, particularly with patients who don’t have severe or chronic depression. In our patient edition, we talk with Brett Stevens about how these techniques helped him get out of depression. And it was actually his psychiatrist – who was doing medication management – who got him started on it.

Brett was also seeing a therapist, who gave him a simple technique to accept his first thought – the automatic, depressive one – and more toward action:

Dr. Aiken: You can listen to the full episode in our patient edition – just search for Pocket Psychiatrist in your podcast store. Share it with your patients, and join us next week for an interview with Swapnil Gupta on how to taper psychiatric medications.

KELLIE NEWSOME: Brett Stevens’ is the author of Crossover: A Look inside a Manic Mind, and the follow up book Crossing Back Over: The Practice of Owning and Accepting Bipolar Disorder, both released in 2020. 

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