the origins and current status of behavioral activation ...€¦ · cognitive behavior therapy...

CP07CH01-Dimidjian ARI 2 March 2011 19:7

The Origins and CurrentStatus of Behavioral ActivationTreatments for DepressionSona Dimidjian,1 Manuel Barrera Jr.,2

Christopher Martell,3 Ricardo F. Munoz,4

and Peter M. Lewinsohn5

1Department of Psychology and Neuroscience, University of Colorado, Boulder,Colorado 80309; 2Department of Psychology, Arizona State University, Tempe,Arizona 85287; 3Department of Psychology, University of Washington, Seattle,Washington 98195; 4Department of Psychiatry, University of California, San Francisco,and San Francisco General Hospital, San Francisco, California 94110; 5Oregon ResearchInstitute, Eugene, Oregon 97403; email: [email protected]

Annu. Rev. Clin. Psychol. 2011. 7:1–38

First published online as a Review in Advance onJanuary 18, 2011

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This article’s doi:10.1146/annurev-clinpsy-032210-104535

Copyright c© 2011 by Annual Reviews.All rights reserved

1548-5943/11/0427-0001$20.00

Keywords

behavioral activation, depression, psychotherapy, history, review,cognitive behavior therapy

Abstract

The past decade has witnessed a resurgence of interest in behavioral in-terventions for depression. This contemporary work is grounded in thework of Lewinsohn and colleagues, which laid a foundation for futureclinical practice and science. This review thus summarizes the originsof a behavioral model of depression and the behavioral activation (BA)approach to the treatment and prevention of depression. We highlightthe formative initial work by Lewinsohn and colleagues, the evolutionof this work, and related contemporary research initiatives, such as thatled by Jacobson and colleagues. We examine the diverse ways in whichBA has been investigated over time and its emerging application to abroad range of populations and problems. We close with reflections onimportant directions for future inquiry.

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Contents

INTRODUCTION. . . . . . . . . . . . . . 3WHAT IS BEHAVIORAL

ACTIVATION? . . . . . . . . . . . . . . 3HISTORICAL CONTEXT OF

PIONEERING WORK . . . . . . . 4THEORETICAL AND

EMPIRICALFOUNDATIONS: THEINITIAL BEHAVIORALMODEL OF DEPRESSION . . 5Overview . . . . . . . . . . . . . . . . . . . . . 5Development of the Pleasant

and Unpleasant EventsSchedules . . . . . . . . . . . . . . . . . . 7

Is Depression Associatedwith Low Rates ofResponse-ContingentPositive Reinforcement? . . . . 7

Is Depression Associated withHigh Rates of PunishingEvents? . . . . . . . . . . . . . . . . . . . . 9

Is Depression Associated withLow Reward Value ofPositive Events and HighAversiveness of NegativeEvents? . . . . . . . . . . . . . . . . . . . . 9

Are Social Skill DeficitsAssociated withDepression? . . . . . . . . . . . . . . . . 9

THEORETICAL ANDEMPIRICALFOUNDATIONS: THEINTEGRATIVE MODEL OFDEPRESSION . . . . . . . . . . . . . . . 10Overview . . . . . . . . . . . . . . . . . . . . . 10Central Components . . . . . . . . . . 11

RELATIONSHIP OF THEBEHAVIORAL MODEL TOOTHER CONCEPTUALMODELS OFDEPRESSION . . . . . . . . . . . . . . . 13Psychodynamic Model of

Depression . . . . . . . . . . . . . . . . . 13

Cognitive Models ofDepression . . . . . . . . . . . . . . . . . 14

Summary . . . . . . . . . . . . . . . . . . . . . 15CLINICAL FOUNDATIONS:

BEHAVIORALACTIVATIONAPPROACHES TO THETREATMENT OFDEPRESSION . . . . . . . . . . . . . . . 15Control Your Depression . . . . . . 16The Coping with

Depression Course . . . . . . . . . 16The San Francisco General

Hospital Manuals . . . . . . . . . . 17Contemporary Behavioral

Activation Approaches . . . . . . 18Summary . . . . . . . . . . . . . . . . . . . . . 20

CONTEMPORARY CLINICALRESEACH ONBEHAVIORALACTIVATION . . . . . . . . . . . . . . . 20Extending Behavioral

Activation to Populationswith Psychiatric and MedicalComorbidity . . . . . . . . . . . . . . . 20

Extending Behavioral ActivationAcross the Lifespan . . . . . . . . . 22

Extending BehavioralActivation to Populationsof Ethnic, Racial, andGender Diversity . . . . . . . . . . . 23

Extending the Reach ofBehavioral ActivationUsing NovelDelivery Formats . . . . . . . . . . . 23

Understanding Processesof Change. . . . . . . . . . . . . . . . . . 25

Summary . . . . . . . . . . . . . . . . . . . . . 26REFLECTIONS FOR

FUTURE WORK . . . . . . . . . . . . 26Does Behavioral Activation

Work? . . . . . . . . . . . . . . . . . . . . . 26How Does Behavioral

Activation Work? . . . . . . . . . . 27

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For Whom Does BehavioralActivation Work? . . . . . . . . . . 28

How Long Does BehavioralActivation Work? . . . . . . . . . . 28

What Novel Methods Facilitatethe Dissemination ofBehavioral Activation? . . . . . . 29

SUMMARY . . . . . . . . . . . . . . . . . . . . . 29

INTRODUCTION

Recent years have witnessed a renewed interestin behavioral activation (BA) for the treatmentof depression. Although depression is one ofthe most prevalent and disabling mental disor-ders, the vast majority of depressed patients arepoorly served by our current treatment deliverysystems, with most receiving either no treat-ment or inadequate care (Wang et al. 2005).Multiple elements contribute to this pressingpublic health problem; however, the shortageof transportable, efficacious treatments iswidely recognized to be an important factor.In this context, scientific and clinical attentionhas turned to the potential value of BA as aparsimonious, evidence-based treatment fordepression that may be particularly amenableto broad dissemination.

This recent interest in BA arises within acontext of a long history of innovative clinicalresearch and practice. Specifically, contempo-rary work is rooted in the work of Lewinsohnand colleagues, whose use of an iterativeprocess of theoretical development, clinicalpractice, and empirical investigation led tothe pioneering of both behavioral theory andpractice. In contrast to the ahistorical stancethat often characterizes the field of clinical psy-chology, we suggest here that awareness of theorigins and trajectory of work on BA will enrichcontemporary clinical research and practice.

This review thus summarizes the develop-ment of a behavioral model of depression andthe BA approach to the treatment and preven-tion of depression, highlighting the initial workby Lewinsohn and colleagues and ongoing work

BA: behavioralactivation

in this tradition. We discuss early influences,both theoretical and empirical, and describe theevolution of these models over time, includingcontemporary work by some who collaboratedwith Lewinsohn on seminal research. We alsodiscuss the lines of research initiated more re-cently by Jacobson and colleagues and othercontemporary researchers, which have revivedinterest in the value of BA in the treatmentof depression. We examine the diverse ways inwhich BA has been investigated over time andits extensions to a broad range of populationsand problems. Finally, we close with reflectionson the development of this field and importantdirections for future inquiry.

WHAT IS BEHAVIORALACTIVATION?

Although Lewinsohn and colleagues pioneeredthe development of the behavioral model andthe application of BA strategies to the treatmentof depression, they did not specifically use theterm BA to refer to their clinical approach. Theearliest use of the term behavioral activationappears in the neuroscience literature referringto the consequences of compounds on an or-ganism (e.g., “achieving behavioral activationwith imipramine”) (Mandell et al. 1968). Later,Gray (1982) defined the “behavioral activationsystem” and “behavioral inhibition system”as fundamental motivational systems. To ourknowledge, the first use of the term in thepsychotherapy literature appears in 1990, withHollon & Garber (1990) defining behavioralactivation as a set of clinical procedures usedin cognitive therapy for depression. Jacobsonand colleagues (1996) retained the term todescribe the behavioral interventions that werea focus of the component analysis study ofcognitive therapy and subsequently to de-scribe a stand-alone treatment for depression( Jacobson et al. 2001). Lejuez and colleagues(2001) similarly used the term to describe astand-alone treatment for depression.

We define BA as a structured, briefpsychotherapeutic approach that aims to(a) increase engagement in adaptive activities

www.annualreviews.org • Behavioral Activation for Depression 3

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(which often are those associated with theexperience of pleasure or mastery), (b) de-crease engagement in activities that maintaindepression or increase risk for depression, and(c) solve problems that limit access to rewardor that maintain or increase aversive control.Treatment focuses directly on these targets oron processes that inhibit a focus on these tar-gets (e.g., avoidance). To achieve these primaryaims, therapists may use a variety of behavioralstrategies such as self-monitoring of activitiesand mood, activity scheduling, activity struc-turing, problem solving, social skill training,hierarchy construction, shaping, reward, andpersuasion. A behavioral model of depressionand a process of behavioral assessment guidethe implementation of these strategies, andtreatment is conducted in a collaborative man-ner. Some therapists include covert behaviorsas targets of behavioral intervention (i.e., in-creasing frequency of reinforcing thoughts anddecreasing frequency of punishing thoughts).

In the past four decades, multiple articula-tions of BA have been examined by differentinvestigator groups for use across a range ofsettings and populations. We suggest here,however, that the shared presence of thesefundamental principles and strategies definesthese approaches as BA. Moreover, we suggestthat the principles and strategies of BA are, infact, not unique to BA. Not only are they arecommon to standard behavior therapy (e.g.,Goldfried & Davison 1994), they also maybe a core element of many evidence-basedtreatments for depression (Dimidjian & Davis2009). For example, the behavioral strategiesthat form the core of BA were incorporatedas a fundamental part of cognitive therapyfor depression and are emphasized heavilyearly in cognitive therapy and in the treatmentof more severely depressed patients (Becket al. 1979). Many of these strategies also areconsonant with the emphasis on modifying theinterpersonal context in interpersonal therapyfor depression (Klerman et al. 1984).

BA, thus, is distinguished from other ap-proaches by the reliance on the principlesof a behavioral model, the use of behavioral

interventions, and an exclusive focus on behav-ior change. BA fits squarely within this traditionof behavior therapy, which could justify aban-doning the specific term BA and using simply“behavior therapy.” Such a change in nomen-clature would have undeniable benefits for thefield with respect to countering a problematictrend toward an increasing number of “brands”of psychotherapy (e.g., Rosen & Davison 2003).Moreover, the term BA is problematic in itsoverlapping application to biological processes(i.e., behavioral activation as a neural system),behavioral processes (i.e., a patient engaging inincreased activity), and a set of therapeutic pro-cedures (i.e., behavioral activation as a treat-ment for depression). Nevertheless, after muchreflection, we have elected to retain the specificdesignation “BA” as a treatment for depressiongiven its increasingly widespread recognitionand the frequency of its use in the literature.

HISTORICAL CONTEXTOF PIONEERING WORK

The seminal work on BA as a treatment fordepression emerged at a time when psycho-analysis was the predominant framework forclinical intervention. Although alternativetheories of depression were being articulated,including Beck’s groundbreaking cognitivetheory of depression (Beck 1979) and Ferster’sbehavioral theory of depression (Ferster1973), clinical practice continued to be rootedprimarily in psychodynamic principles. TheBA approach to treatment as developed byLewinsohn and colleagues represented aradical departure from the prevailing paradigmand provided the foundation for the decades ofresearch that have followed.

Lewinsohn began developing a behavioralapproach to the treatment of depression shortlyafter arriving at the University of Oregon in1965. This work thus began in the contextof a period of enormous shifts in the theory,practice, and research of clinical psychology.As Bandura (2004) has explained, “The 1960’sushered in remarkable transformative changesin the explanation and modification of human

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functioning and change” (2004, p. 616). Theculture at the University of Oregon providedthe setting for the initiation of much of thiswork. The prevailing principles emphasized aniterative process of theoretical development,clinical practice, and empirical investigation.All of this was conducted in a stimulating envi-ronment that engaged graduate and undergrad-uate students in key roles. Moreover, it was anexciting time of collaboration with other ex-perts around the country. For example, JeanEndicott was influential in shaping the earlymethods for clinical assessment and diagnosis,as were Grinker and colleagues, who devel-oped the structured diagnostic interview usedin the early clinical research studies (Grinkeret al. 1961). B.F. Skinner also visited the Uni-versity of Oregon early in the development ofBA; members of the clinical faculty presentedemerging work on the clinical application ofbehavioral theory, which Skinner greeted withenthusiasm.

The engagement of students in the researchprocess was a core element of the context andculture that predominated at the Universityof Oregon during the early years of Lewin-sohn’s work. Notably, a similar culture also wasto characterize work on BA decades later, ledby Neil Jacobson at the University of Wash-ington. In the “Oregon Model” of graduatetraining, each clinical psychology faculty mem-ber taught year-long courses that integratedpracticum training and clinical research on thatfaculty member’s specialty area (e.g., depressionwith Peter Lewinsohn, childhood disorderswith Stephen Johnson, marital distress withRobert Weiss, sexual dysfunction with JosephLoPiccolo, smoking cessation with Ed Licht-enstein, and social anxiety with Hal Arkowitz).Graduate students sampled from these inte-grated practica/research teams and typicallyspecialized in one over the last two years oftheir on-campus training. With the strong be-havioral orientation that permeated the entireclinical program came an appreciation for thevalue of innovation through N = 1 research,behavioral observation, development of treat-ment manuals, and outcome research.

Students who worked with Lewinsohnbecame key members of the treatment devel-opment and investigation team. They learnedhow to use structured clinical interview anddiagnostic measures, daily self-monitoring,and home observation for assessing depressedclients. They developed skill in implementingtherapy procedures by conducting joint ses-sions with Lewinsohn or by being supervisedclosely by him using a two-way mirror andvideotapes. After they had been trained in theessentials of assessment and treatment, studentsassisted in clinical research studies by screeningprospective research participants, conductingoutcome assessments, and serving as therapists.The team experimented with methods toapply the behavioral theory of depression inclinical practice, and it was in this context thatmany of the core intervention techniques weredeveloped. Because each cohort of students wasaware of the basic theoretical framework andthe research that Lewinsohn and students haddone before them, there existed a continuallyevolving understanding of what researchneeded to be done to add to the programmatic,incremental understanding of a behavioralapproach to depression.

The studies from this era of work laid thefoundation for innovative and rigorous ap-proaches to clinical assessment, intervention,and research, all of which continue to influ-ence powerfully the key questions and methodsused in clinical practice and research on BA to-day. Moreover, the integrated model of studenttraining, theoretical development, interventiondevelopment, and empirical investigation con-tinues to stand as a guide for how to advancethe future evolution of this field.

THEORETICAL ANDEMPIRICAL FOUNDATIONS:THE INITIAL BEHAVIORALMODEL OF DEPRESSION

Overview

BA as a treatment approach is rooted ina theoretical conceptualization of depression,


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POTENTIALLY REINFORCING EVENTS

Quantitative Qualitative • how many • how gratifying

• type • function

INDIVIDUAL INSTRUMENTAL BEHAVIOR

AVAILABILITY OF REINFORCEMENT

LOW RATE OF POSITIVE

REINFORCEMENT“DEPRESSION”

SOCIAL REINFORCEMENT

SOCIAL AVOIDANCE

Figure 1Lewinsohn’s Behavioral Model of Depression. (Adapted from Lewinsohn 1974.)

including its causes, correlates, consequences,and maintaining processes. Lewinsohn artic-ulated an initial behavioral model in 1971(Lewinsohn & Shaffer 1971) that was refined in1974 (Lewinsohn 1974, Lewinsohn et al. 1979;see Figure 1).

The initial behavioral model was basedon three assumptions; specifically that (a) lowlevels of response-contingent positive rein-forcement were eliciting stimuli for depressivebehavior (mood and somatic experiences),(b) low levels of response-contingent positivereinforcement were a sufficient explanationfor depression, and (c) the total amount ofresponse-contingent reinforcement was afunction of the number of events that arepotentially reinforcing for an individual, theavailability of such events in the environment,and the instrumental behavior of the individualin eliciting such reinforcement from theenvironment. Moreover, it was assumed thatdepression covaries with amount of responsecontingent reinforcement and is preceded bya reduction in such reinforcement. Response-contingent positive reinforcement was a phraseintroduced by Lewinsohn into the behav-ioral model to address two issues: (a) a keycharacteristic of depressed individuals is that

the rate with which they engage in behaviorsis low, and (b) some episodes of depressionfollow the achievement of major goals andaccomplishments.

This initial behavioral model served as theorganizing framework for a systematic programof empirical research. This research was con-ducted in the clinical science tradition describedpreviously, including measurement develop-ment, case studies, laboratory studies, compar-ative research with depressed and nondepressedclinical subsamples, and treatment outcome re-search (Lewinsohn 1974). In case studies andoutcome research, procedures were designed tochange depressed clients’ engagement in plea-surable activities and to improve social skillsas mechanisms for decreasing depression. Thewisdom of grounding much of the initial em-pirical research in accessible clinical practiceswould subsequently translate into interventiondevelopments that were diverse, practical, andbroad in scale.

The review of early empirical work isorganized around the primary theoreticalpropositions of the initial behavioral modelof depression (Lewinsohn 1974, Lewinsohnet al. 1979). Because the measurement ofpleasant and unpleasant events was so integral

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to foundation research, a description of twocentral measures, the Pleasant Events Sched-ule (PES) and Unpleasant Events Schedule(UES), precedes the review of research on thetheoretical propositions.

Development of the Pleasantand Unpleasant Events Schedules

Clinical research on a behavioral model ofdepression necessitated the measurement ofreinforcement that individuals receive fromtheir natural social environments. Lewinsohnand his collaborators were well aware thatin laboratory paradigms of learned behavior,reinforcing events were identified in moment-to-moment transactions by the effects they hadon subsequent behavior (see Lewinsohn et al.1979, pp. 293–295). Nevertheless, for mea-suring reinforcement in natural environments,it was assumed that pleasurable events wouldhave reinforcing properties and that individ-uals’ self-reports of pleasurable events wouldapproximate the amount of reinforcement theyreceived. The PES, a 320-item self-reportmeasure, had central importance in foundationresearch that was conducted as early as 1971(MacPhillamy & Lewinsohn 1982). Initial itemgeneration was done with university students;however, efforts to strengthen the contentvalidity of the PES led to studies with more di-verse samples of adults who nominated pleasantevents, and these items subsequently replacedoriginal items that were reported infrequentlyor that had low enjoyability ratings.

The PES was an extremely versatile mea-sure. It not only assessed event frequency dur-ing the past month, the potential reinforcementvalue of events (subjective enjoyability ratings),and obtained reinforcement (the product ofenjoyability and event frequency), but it alsowas used as the source of information foractivity schedules. Activity schedules weresubsets of PES items that became the specialfocus of intervention efforts to boost thereinforcement that depressed clients receivedin their daily lives (Lewinsohn & Youngren

PES: Pleasant EventsSchedule

UES: UnpleasantEvents Schedule

1976, Lewinsohn et al. 1980). Development ofthe PES, derivations of subscales, and studiesto establish psychometric properties havebeen summarized in several papers (Hammen& Kratz 1985, Lewinsohn et al. 1979,MacPhillamy & Lewinsohn 1982). The PESand activity schedules were used in much ofthe research conducted by Lewinsohn and hiscolleagues in tests of behavior theory tenets andtreatment procedures derived from that model.

The UES is a 320-item measure of thefrequency and aversiveness of unpleasantevents that is similar to the PES in its structureand development (Grosscup & Lewinsohn1980, Lewinsohn et al. 1985b, Lewinsohn& Talkington 1979). Items were generatedby asking diverse samples of adults to (a) listevents that they had experienced that werehigh, medium, and low on unpleasantness,and (b) self-monitor unpleasant events that oc-curred during a seven-day period (Lewinsohn& Talkington 1979). Conceptually, aversiveevents were linked to depression throughseveral mechanisms (Lewinsohn et al. 1979):Aversive events punish behaviors that couldhave been sources of pleasure, the occurrenceof aversive events elicits dysphoria, and the en-joyability of pleasant events is diminished whenthey occur shortly after aversive events. Likethe PES, the UES was used to create subsets ofunpleasant events that were monitored daily toidentify aversive events that were most highlyrelated to mood (Grosscup & Lewinsohn 1980,Lewinsohn & Talkington 1979).

Is Depression Associated with LowRates of Response-ContingentPositive Reinforcement?

Perhaps the most fundamental assertions ofearly behavioral models of depression speci-fied associations of depression and low ratesof response-contingent positive reinforcement(see Figure 1). The central hypotheses werethat low levels of reinforcement were key an-tecedents to the onset of depression, that fluc-tuations in depressed mood covaried with the


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receipt of positive reinforcement, and thattreatment-induced increases in positive rein-forcement led to reductions in depression.

Basic research directed at these core as-sertions used several strategies. One approachwas to conduct home observations of clinicalcases during which behavioral transactions be-tween depressed clients and their family mem-bers were coded to assess the nature of behav-iors emitted and the consequences of those be-haviors (Lewinsohn & Shaffer 1971, Lewinsohn& Shaw 1969). The paper by Lewinsohn &Shaffer (1971) was a prime illustration of be-haviorally oriented clinical research in whichhome observations were used to inform the se-lection of intervention goals, evaluate treatmenteffectiveness, and test theory. Case descriptionsand home observation data from five familiesshowed that the depressed partner received lesspositive reinforcement than the nondepressedpartner in family interactions prior to the initi-ation of treatment and that reinforcement con-tingencies could be changed through assess-ment feedback to family members and othertreatment interventions.

Another research strategy was to conductfield studies in which participants monitoredthe daily occurrence of pleasant activitiesand depressed mood. Results of those studiesshowed that there was, in fact, an association be-tween depressed mood and number of pleasantactivities that were experienced daily (Grosscup& Lewinsohn 1980, Lewinsohn & Graf 1973,Lewinsohn & Libet 1972). Mood was related topleasant activities for depressed, nondepressedpsychiatric controls, and normal controls(Lewinsohn & Graf 1973, Lewinsohn & Libet1972). Comparative research also showed thatdepressed individuals reported engagementin fewer pleasant activities than did nonde-pressed normal controls and nondepressedpsychiatric controls (Lewinsohn & Graf 1973,MacPhillamy & Lewinsohn 1974). Additionalsupport for the link between depression andreinforcement came from treatment effortsthat increased pleasant events as a means of re-ducing depression. In summarizing the resultsfrom three treated samples, Lewinsohn et al.

(1979) observed that depressed individuals whodecreased depression the most also showed thegreatest increases in obtained reinforcement(the cross-products of PES event frequency andenjoyability). Illustrative case studies and threesamples treated with strategies for increasingpleasant activities also all showed substantialreductions in depression (Lewinsohn et al.1980). One randomized controlled study thatused a group therapy format found evidencethat an initial phase of self-monitoring moodand pleasant events boosted the depression-reduction effects of treatment methods forincreasing pleasant events (Barrera 1979).

Unfortunately, these early studies were con-ducted before quantitative methods for eval-uating mediation were available (MacKinnon& Luecken 2008). Even though studies showedthat pleasant events interventions increasedpleasant events and decreased depression, theylacked methods for testing the theory-basedhypothesis that increases in pleasant eventsaccounted for (i.e., mediated) reductions indepression. Moreover, despite the strongsupport for the covariation of reduced pleasantevents and depressed mood, research directedat specifying the temporal relationship betweenresponse-contingent positive reinforcement(as operationalized by the PES) and depressionwas less convincing. In the study by Lewinsohn& Libet (1972), the strongest relationshipbetween depressed mood and pleasant eventswas found when those two variables were as-sessed on the same day. However, correlationscalculated when depressed mood and activityscores were lagged by one or two days failed toshow clear evidence for temporal precedence.The relation of pleasant activities to next-daydepressed mood was similar to the relation ofdepressed mood to next-day pleasant activities(Lewinsohn & Libet 1972). Studies by Rehm(1978) used measures of daily pleasant eventsand daily mood that differed from those used byLewinsohn, but the results also demonstratedrelations between mood and pleasant eventsthat are assessed on the same day and littleassociation between mood and pleasant eventsthat were lagged by a day.

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Is Depression Associated with HighRates of Punishing Events?

Similar to the research on pleasant events, stud-ies on daily fluctuations in depressed mood andstudies that compared diagnostic groups foundrelations between depression and the frequencyof aversive events. Some of the relevant re-search was done to establish the reliability andvalidity of the UES (Lewinsohn et al. 1985b,Lewinsohn & Talkington 1979). Lewinsohn &Talkington (1979) used 30-day self-monitoringdata from a mixed group of depressed clients,nondepressed psychiatric controls, and normalcontrols to show that the daily occurrenceof negative events and mood were related.A similar association between fluctuationsof unpleasant events and depressed moodwas found in daily self-monitoring data ofdepressed clients in treatment (Grosscup &Lewinsohn 1980) and college students (Rehm1978). Rehm’s studies added robustness tothese findings because, as noted previously,they relied on measures of mood and unpleas-ant events that differed from those used byLewinsohn and colleagues.

In research that contrasted diagnosticgroups, the frequency of unpleasant eventsdifferentiated depressed and nondepressedcontrol participants even after accounting forthe frequency of pleasant events (Lewinsohnet al. 1985b). In research by Lewinsohn &Talkington (1979), three subgroups wereformed on the basis of the Minnesota Mul-tiphasic Personality Inventory (MMPI) andstructured interviews: depressed, nondepressedwho scored high on other dimensions ofpsychopathology (high-MMPI controls), andnormals. Compared to normal controls, thedepressed and nondepressed high-MMPI con-trols showed small but statistically significantelevations on total unpleasant events.

Is Depression Associated with LowReward Value of Positive Events andHigh Aversiveness of Negative Events?

Early behavioral models included the proposi-tions that depression stemmed not only from

inadequate engagement in pleasurable activityand excessive experience of aversive events,but also from the diminished reward value ofpotentially pleasant events and the heightenedaversiveness of unpleasant events. As notedpreviously, the PES calls for ratings of bothevent frequency as well as the event enjoyabil-ity. Consistent with behavioral theory, studiesusing the PES found that the subjective enjoy-ability of events for depressed individuals waslower than for nondepressed normals and non-depressed psychiatric controls (MacPhillamy& Lewinsohn 1974). It is interesting thatmore contemporary research that integratesneuroscience and laboratory paradigms forstudying the effects of reward and punishmenthas found that depressed individuals are lessresponsive to reward than nondepressed indi-viduals, and that such differences are correlatedwith hypoactivation of brain regions indicativeof a deficit in approach-related behavior(Henriques & Davidson 1991, Henriques et al.1994, Pizzagalli et al. 2005). Studies suggestinggenetic associations to differential levels ofpositive affect in response to pleasant eventsare also intriguing (Wichers et al. 2008).

The UES instructs participants to rate thefrequency and subjective aversiveness of un-pleasant events. Also consistent with theory,depressed participants rated unpleasant eventsas more aversive than did normal controlsand nondepressed “psychiatric” controls whohad high scores on MMPI scales (Lewinsohn& Talkington 1979). Grosscup & Lewinsohn(1980) found that there was a decrease in theexperienced aversiveness of events that was as-sociated with clinical improvement in depres-sion. In addition, two laboratory studies foundthat compared with nondepressed controls, de-pressed participants showed a greater auto-nomic response during the presentation of anaversive stimulus (electric shock) (Lewinsohnet al. 1973).

Are Social Skill Deficits Associatedwith Depression?

In Lewinsohn’s (1974) initial behavioral for-mulation of depression, low rates of positive


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reinforcement were determined by three fac-tors: (a) the extensiveness of events that werepotentially reinforcing for an individual, (b) theavailability of those events in the environment,and (c) an individual’s instrumental skillsin obtaining reinforcement (see Figure 1).Social skills had special importance within thebroader domain of instrumental skills becauseperturbations in social relationships havesuch prominence in theories of depression, asarticulated in later work such as that of Gotliband Hammen (e.g., Gotlib & Hammen 1992).Social skill was defined as “the complex abilityboth to emit behaviors which are positively ornegatively reinforced and not to emit behaviorswhich are punished or extinguished by others”(Libet & Lewinsohn 1973, p. 304).

The hypothesis that depressed individualshave less social skill than nondepressed indi-viduals received substantial research support inearly studies. Studies of depressed and nonde-pressed people in quasi-therapy (“self-study”)groups (Libet & Lewinsohn 1973), home en-vironments (Lewinsohn & Shaffer 1971), andgroup and dyadic interactions in laboratory set-tings (Youngren & Lewinsohn 1980) demon-strated that depressed individuals are less likelyto be positively reinforced by others for thebehaviors that they emit. Similar results werefound in an analog study in which college stu-dents interacting with a depressed confederateresponded with more silences, direct negativecomments, and less overall verbal respondingcompared to those who interacted with non-depressed confederates (Howes & Hokanson1979). In addition, daily reports of one partic-ular social skill, assertiveness, were negativelycorrelated with daily ratings of depressed mood(Sanchez & Lewinsohn 1980). That study alsofound that assertiveness was prospectively re-lated to depressed mood, but depressed moodwas not prospectively related to assertiveness.

A study by Youngren & Lewinsohn (1980)was a multifaceted investigation of the relationbetween depression and interpersonal behav-ior. Observational measures of verbal behav-ior (speech rate and volume) and nonverbal be-havior (eye contact, facial expressions) showed

some evidence of impairment for depressedparticipants who differed from normals, but notfrom nondepressed participants who showed el-evations on MMPI scales. Deficits that wereunique to depression were found on ratings ofsocial skill during group interactions when par-ticipants, group members, and nonparticipantobservers were the raters.

THEORETICAL ANDEMPIRICAL FOUNDATIONS:THE INTEGRATIVE MODELOF DEPRESSION

Overview

Informed by some of the limitations of the ini-tial behavioral model of depression, Lewinsohnexpanded the initial model into an integrativemodel of depression in 1985 (see Figure 2).The integrated model recognized both the ex-istence of four primary models of depressionat the time (i.e., the behavioral, interpersonal,cognitive, and biological models) and the limi-tations of each in fully accounting for the etiol-ogy of depression.

Proposing that depression is a heteroge-neous disorder caused by the interplay of a mul-tiplicity of factors, Lewinsohn and colleaguescontended that a useful model of depressionneeded to explain recent scientific advances,to articulate the way in which variables in-teract to produce depression, and to generatenovel tractable hypotheses. Lewinsohn and col-leagues identified 10 contributions of prior re-search on depression that must be addressed inan explanatory model: (a) the heterogeneity ofdepression with respect to symptom patternsand severity, (b) the centrality of dysphoria asthe only symptom that is experienced by nearlyall depressed individuals, (c) the broad impact ofdepression on a multiplicity of behavioral andcognitive domains, (d ) the high prevalence andincidence of depression in the general popula-tion, (e) the relationship between age and preva-lence of depression (assumed at that time tobe curvilinear), ( f ) the increased risk amongfemales and people with prior histories of

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Figure 2Lewinsohn’s integrative model of depression. (Reproduced with permission from Lewinsohn et al. 1985a.)

depression, ( g) the lack of differences betweenpreviously depressed and never depressed in-dividuals and the possible importance of con-ditions that activate risk, (h) the time-limitednature of depression suggesting that there aremultiple pathways for recovery, (i ) the poten-tial effectiveness of many interventions and thenonspecificity of treatment effects, and ( j) theunique role of stress and low social support asprecipitating factors.

Central Components

In line with the stated aims of a useful modelof depression, the integrative model reflectedgreater complexity with respect to the re-lationship between cognition, behavior, andmood. Specifically, Lewinsohn and colleaguesexplained that “we would argue that past cog-nitive and reinforcement positions have offeredtoo simplistic views; in particular, we contendthat while the cognitive models have overem-phasized cognitive dispositional factors, thereinforcement models have, in turn, over em-phasized situational factors” (Lewinsohn et al.1985a, p. 343). For example, early studies onthe PES were intended to test predictions aboutpositive reinforcement. Criticisms of defining

reinforcement in terms of pleasant events havebeen made historically (Sweeney et al. 1982)and more recently (for a review, see Abreu &Santos 2008). Empirically, in prospective stud-ies conducted by Lewinsohn and colleagues,the PES did not predict occurrence of depres-sion or sufficiently explain gender differences inepisodes of depression (Amenson & Lewinsohn1981, Lewinsohn et al. 1988). Studies like thesehelp to inform the need for a revised behavioralapproach to depression.

The integrated model was intended toexplain the interacting nature of dispositional(including cognitive) and environmental fac-tors. As illustrated in Figure 2, environmentalstressors (A) were identified as the primarytriggers of the depressogenic process. Theassertion continues to be supported empirically(Lewinsohn et al. 1994, Risch et al. 2009).Stressors such as the death of a close relative,disabling physical illness, or serious failuresto accomplish important goals can disrupt anindividuals’ behavioral repertoire, includinginteracting with others, working, and otherroutine behaviors, and result in initial negativeaffect (B). The degree to which these changesproduce depression is related to the degree towhich they reduce positive reinforcement or


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increase aversive control (C). Efforts to copewith the effects of the stressors also are includedin the model and failures to influence the stres-sor through use of such efforts are hypothesizedto increase self-focused attention (D). Thecombination of increased self-focused attention(D) and dysphoria (E) are presumed to result inthe cognitive, behavioral, and emotional corre-lates of depression (F), which themselves serveto maintain and exacerbate depressive states.Finally, all parts of the process are influencedby both individual and environment vulner-ability factors (G), such as gender, age, priorhistory, low coping skills, increased sensitivityto aversive events, poverty, self consciousness,accessibility of a depressive self schema, highinterpersonal dependency, and presence ofyoung children in the home. The behavioralresponse of others in one’s environment alsowas highlighted as a potential vulnerabilityfactor. Finally, duration and severity of depres-sive episodes were understood as influenced byfeedback loops among the various elements ofthe model, yielding the possibility of “vicious”or “benign” cycles serving to exacerbate orreverse the depressogenic process.

Lewinsohn’s increased focus on the roleof cognition in the integrative model wasinfluenced, in part, by the collaboration of hisgraduate student team. Although Lewinsohnhad included cognitions as reinforcing and pun-ishing activities from the start (e.g., “Thinkingabout something good in the future” is an itemon the PES), until Lewinsohn began workingwith Munoz, who joined his team as a graduatestudent in 1975, cognitions were not addressedexplicitly as part of the theory or treatment fordepression. Munoz began his graduate trainingwith Lewinsohn already having been greatlyinfluenced by working with Albert Banduraand his students and colleagues at Stanford.Bandura and colleagues, within the contextof what was then known as Social LearningTheory (1977a; later described as Social Cog-nitive Theory; Bandura 2001), were extendingbehavioral approaches to “covert behaviors,”that is, thoughts, memories, and expectations,and other cognitions (Mahoney 1970). Homme

(1965) had coined the term “coverants” to referto “the operants of the mind.” Case studiespublished in the journal Behavior Therapyspecifically focused on “the self-managementof covert behavior” (Mahoney 1971) or “cov-erant control of self-evaluative responses inthe treatment of depression” (Todd 1972).The approach taken by Munoz in his disser-tation reflected this perspective: “Thinking isbehavior—it is something one does. Thinkingcan have stimulus properties. . . . It can alsohave operant-response properties. . . . One canthink without being aware one is thinkingjust as one can act without being aware oneis acting. . . . It is assumed here that covertbehavior and overt behavior are most easilymodified when brought to awareness. . . .Covert events comprise a very special kind ofenvironment . . . potentially modifiable at anytime by the individual. . . . This plasticity makesthe internal environment a potentially greatsource of adaptive influence” (Munoz 1977,pp. 9–11).

Results from studies intended to testwhether depressed individuals did indeed re-port lower levels of self-reinforcing cognitionsand higher levels of self-punishing cognitionsyielded support for this hypothesis (Lewinsohnet al. 1982, Munoz 1977). Similar results werefound when cognition was operationalized asexpectations (according to Beck’s hypothesisthat depressed individuals have negative viewsof the self and the world) and as “irrational be-liefs” (according to Ellis’s model) (Lewinsohnet al. 1982, Munoz 1977). The integrative the-ory of depression was proposed to incorporatesuch complexities. Negative cognitions (F inFigure 2) were conceptualized as leading toantecedents (A) (i.e., depression-evokingevents) and as predisposing vulnerabilities (G).

The work on behavioral approaches todepression provided a valuable foundationfor understanding the causes and maintainingfactors in depression and possible targets forintervention. A return to these historical rootsis important in highlighting studies that oftenare neglected in contemporary discussionsof depression. In addition, this discussion

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illustrates the evolution of behavioral ap-proaches to depression over time, highlightingkey elements of the early models and the waysin which such work has paved the way forcontemporary and future efforts.

RELATIONSHIP OF THEBEHAVIORAL MODEL TOOTHER CONCEPTUAL MODELSOF DEPRESSION

In a retrospective account of the developmentof behaviorally oriented approaches, Bandura(2004) characterizes the response within thefield in dramatic terms. He explains, “Thetransformative changes followed the pre-dictable sequence of all fruitful innovations.Outright rejection was the first reaction. Behav-ior therapy was regarded not only as superficialsymptom removal but dangerous” (2004,p. 617). Although certainly not all perceivedemerging behavioral approaches as potentiallyharmful, there is no doubt that a strong contrastexisted with the prevailing model of depressionoffered by psychodynamic theory. The behav-ioral model of depression was viewed primarilyin relation to this theory, and early presen-tations of the behavioral model frequentlyaddressed core psychodynamic constructs,presenting these in alternative behavioralformulations. Over time, cognitive models ofdepression gained prominence and increasinglybecame key reference points for the behavioralmodel. Here, we discuss the relationship of thebehavioral approach to depression to each ofthese major alternative models of depression.

Psychodynamic Model of Depression

The psychodynamic understanding of depres-sion focused on fixations at stages during whichthe individual relies on external sources to reg-ulate self-esteem (e.g., early development) orduring periods of time when feelings of guiltcause regression to such early stages (Fenichel1945). The psychodynamic position suggestedthat depressions followed either experiencesthat resulted in a loss of self-esteem or a lossof the external supplies that an individual had

hoped would maintain or enhance self-esteem(Fenichel 1945).

The idea of “external supplies” seemedto resemble the idea of access to reinforcersin the environment, yet the psychodynamicmodel stressed the importance of internal-ized development of self-esteem rather thanreliance on external supply. The behavioralmodel represented a radical departure from theprevailing psychodynamic views of depression.In contrast to the psychodynamic emphasison the construct of self-esteem, the behavioralmodel did not highlight the centrality of self-esteem or the loss thereof. In fact, Flippo &Lewinsohn (1971) undermined the purportedrole of self-esteem with results that failedto confirm the hypothesis that depressed, ascompared to nondepressed, participants wouldevidence greater worsening of self-esteemin response to failure experience. Althoughdepressed individuals do evidence greatersensitivity to aversive experiences than nonde-pressed individuals and may be more likely towithdraw from such experiences (Lewinsohnet al. 1973), there was little evidence to supportthat the construct of “self-esteem” was central.

The psychodynamic model of depressionalso included the idea that hostility, originallydirected at others who did not meet the pa-tient’s narcissistic needs, was redirected againstthe ego through a process of introjection(Fenichel 1945). Thus the idea of depressionbeing defined as anger turned against the selfwas predominant in the psychodynamic con-ceptualization. Other psychodynamic modelsalso proposed different types of depression,including a dependent type and a self-criticaltype (Blatt 1974, Blatt et al. 1982).

The behavioral model of depression ac-counted for many of these core psychodynamicpropositions by emphasizing schedules ofreinforcement. Ferster wrote most directlyin response to the psychodynamic constructs,and his work influenced the early thinking ofLewinsohn, who overlapped with him at the In-diana University Medical Center. According toFerster (1974), “ the low frequency of positivelyreinforced behaviors in the depressed person’s


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repertoire might perpetuate the incompleteor distorted perception of the environment”(p. 35). Ferster argued that the decrease infrequency of many different kinds of positivelyreinforced activities was characteristic of thedepressed client. Fenichel theorized failure todevelop self-esteem independent of a relianceon external supply. Similarly, Ferster (1981)explained that early environments lacking con-sistent positive reinforcement would occasionverbal behaviors that were avoidant responsesto the individual’s deprivation schedule ratherthan responses to the presence of a listener whocould “minister to the distress” (p. 185). Thus,Ferster did not appeal to the construct of poordevelopment of self-esteem but rather to a lim-ited behavioral repertoire that did not enablethe individual to engage his or her environmentin such a way that behavior would be positivelyreinforced. Ferster argued that depressedindividuals emitted responses based on a senseof need, which temporarily provided relief butultimately perpetuated avoidance behaviors.

Ferster also provided a behavioral accountfor the psychodynamic notion of hostility to-ward the self in depression. He suggested thatnegative statements about the self resulted froma process of counter control over behaviors,which when emitted publicly, such as angryoutbursts, are punished. In order to avoid pun-ishment, the individual performs the behaviorcovertly. Such covert behavior is maintainedthrough negative reinforcement, because itprovides temporary relief from distress (Ferster1981). Unfortunately, such covert behavioralso results in a limited repertoire, maintaininga pattern of activity, or inactivity, that does notresult in manipulation of the environment insuch a way as to obtain positive reinforcement.Similarly, Lewinsohn and colleagues describedthe phenomena of low self-esteem and pes-simism in terms of an attempt by the individualto describe an unpleasant feeling state that heor she is experiencing. The hostility that washeld to be a central aspect of depression inpsychodynamic theory as “anger turned in-ward” was described behaviorally as secondaryto the low rate of response-contingent positive

reinforcement in an individual’s transactionswith his/her environment (Lewinsohn 1974).Lewinsohn, like Ferster, understood that theexpression of an aggressive response servesto alienate other people and leads to furtherisolation; it is therefore punished, and theindividual “learns to avoid expressing hostiletendencies by suppressing (or repressing)them” (Lewinsohn 1974, p. 161).

Cognitive Models of Depression

Lewinsohn’s early work developed in thecontext of two emerging cognitive models ofdepression. Ellis’s work on Rational EmotiveBehavior Therapy (Ellis 1962) was anchoredin an emphasis on the ways in which irrationalthinking leads to problematic emotions andbehaviors. Ellis’s work had a strong influenceon Lewinsohn, who adapted Ellis’ basic A-B-Cmethod with clients. Specifically, Ellis taughtthat “A” stands for “activating event” (theevent about which one feels distress, e.g., beingrejected by someone, doing poorly on the task).“C” is the emotional consequence of the events,which includes specific emotions (e.g., sadness,anger) and nonconstructive self-talk (e.g., Ishould have been much more successful). “B”refers to the belief about “A” (e.g., I am afailure, nobody loves me). Under Lewinsohn’ssupervision, Munoz developed a self-reportmeasure, the Personal Beliefs Inventory,which was used in the early Lewinsohn studies(Lewinsohn et al. 1982), and adopted strategiesfrom Ellis (Ellis & Harper 1961, 1975) andKranzler (1974) for disputing irrational beliefsand nonconstructive self-talk and for replacingirrational beliefs with more constructive beliefs.

Beck’s cognitive model of depression wasarticulated at approximately the same timeas the early behavioral model. Specifically,Beck and colleagues (1979) proposed thatdepression resulted from cognitive distortionsand that depressed individuals in particularwere prone to viewing themselves, the world,and the future in negative terms. Being in a de-pressed mode of thinking led the individual tomisperceive much of his or her experience in a

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way that confirmed negative biases. This modelchallenged the behavioral conceptualizationof depression by situating particular forms ofdepressogenic thinking as a causal factor indepression (Beck 1967, Beck et al. 1979).

The past four decades have witnessed anexplosion of research on Beck’s early and otherrelated cognitive models, and many studieshave provided partial evidential support. In fact,even early work by Lewinsohn and colleaguesreported support for cognitive biases amongdepressed individuals (Lewinsohn et al. 1982).Depressed participants had negative expectan-cies for present and future events pertainingto the self; specifically, they had negativeexpectancies about their ability to perform insituations that required competence. This find-ing was consistent with Bandura’s (1977b) self-efficacy theory and also with Rehm’s assertionthat depressed individuals reinforce themselvesless and punish themselves more (Rehm 1977).

The cognitive model guided the devel-opment of cognitive therapy for depression(Beck et al. 1979), which included behavioralstrategies as a core component. In fact, BAis heavily emphasized in the beginning ofcognitive therapy and with more severelydepressed patients in particular. In keepingwith the emphasis on cognition as the principaletiological factor in depression, however,behavioral strategies are used not solely for theexplicit purpose of overt behavior change but asa means to test thoughts and beliefs. As Hollon(1999) has explained, “The key point is thateven when cognitive therapists are focusingon behaviors, they do so within the contextof a larger model that relates those actionsto the beliefs and expectations from whichthey arise and views them as an opportunity totest the accuracy of those underlying beliefs”(p. 306). Thus, although cognitive therapy andBA share many elements, they diverge on thepoint of cognition as a privileged causal factorin depression and as an essential therapeutictarget. The initial behavioral model postulatedthat negative cognitions accompany depressionbut that they are not necessarily antecedent to adepressive episode. The subsequent integrative

model (Lewinsohn et al. 1985a) proposed achain of events that included environmentaland dispositional factors. As described pre-viously, antecedent events were assumed tobe environmental stressors that disruptedrelatively automatic behavior patterns of theindividual. Cognitive biases were conceptual-ized as correlates of depression that could serveto maintain and exacerbate depressive states.Such problems could lead to antecedents andcould constitute predisposing vulnerabilities.

Summary

BA was developed during a period whenthe prevailing paradigm emphasized psycho-dynamic constructs and interventions, and itsdevelopment contributed significantly to thetransformative process by which behavioral ap-proaches gained ascendance (Bandura 2004).This model also was developed in parallel withBeck’s cognitive theory of depression, whichshares many components but diverges on thequestion of the causal nature of cognition andthe importance of targeting cognitive processesdirectly during treatment.

CLINICAL FOUNDATIONS:BEHAVIORAL ACTIVATIONAPPROACHES TO THETREATMENT OF DEPRESSION

BA as a treatment approach is defined, mostfundamentally, by reliance on the principlesof a behavioral model and an exclusive focuson behavior change. Since the seminal work ofLewinsohn and colleagues in the 1970s, multi-ple investigator groups, including members ofthe original Lewinsohn team and independentinvestigator groups, have articulated and inves-tigated specific BA versions. Two broad linesof research emerged initially from Lewinsohn’sinitial behavioral model of depression. Oneline branched from the randomized controlledtrial conducted at the University of Oregon byZeiss et al. (1979) that concluded that pleasantactivities, social skills, and cognitive approacheswere comparable in effectiveness and mer-ited integration. This work resulted in the


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CYD: Control YourDepression

Control Your Depression (CYD) self-help book(Lewinsohn et al. 1978), which subsequentlyled to the Coping with Depression course andthe San Francisco General Hospital manuals.Another line branched from outcome researchaddressing treatments specifically described asBA. A major initiator of this research was thework of Jacobson et al. (1996, Gortner et al.1998) suggesting that a behavioral approachcould stand on its own and was not moreeffective with the addition of cognitive meth-ods. Parallel work by Hopko and colleaguessimilarly supported the stand-alone status ofa BA approach to depression (Hopko et al.2003a). Here, we summarize briefly the coreBA treatment approaches and their evolutionover time. In the following section, we detailthe empirical studies that extend these coreapproaches across populations and settings.

Control Your Depression

Originally published in 1978 and revisedin 1986, CYD (Lewinsohn et al. 1978) waswritten as a self-help manual based on theinterventions used in the seminal treatmentoutcome study conducted by Lewinsohnand his doctoral students (Zeiss et al. 1979).This study was a randomized controlled trialcomparing three treatments that specificallytargeted only one of three potential goals:(a) increasing mood-related pleasant activities,(b) increasing assertiveness, positive socialimpact, and social interaction, and (c) changingcognitions to increase mental reinforcers toimprove patients’ internal reality. Patientsreceived individual therapy three times a weekfor four weeks, either as immediate treatmentor after a one-month delay. Those receivingimmediate treatment were less depressed atpost assessment than those receiving delayedtreatment, with no differences across the threetypes of treatment. Patients who improvedin each treatment condition also exhibitedchanges across all the hypothesized targets (ac-tivities, interpersonal variables, and cognitions)rather than only those explicitly addressed bythe treatment approach.

The authors concluded that all three treat-ments may have produced a change in self-efficacy (Bandura 1977a) and that treatmentsthat meet the following criteria should be effec-tive in overcoming depression: (a) begin witha well-planned, convincing rationale; (b) pro-vide training in skills that are effective, havepersonal significance, and fit with the rationale;(c) emphasize the use of the skills outside of thetherapy context, that is, in the patient’s dailylife; and (d ) encourage the patient to attributeimprovement in mood to their use of these skills(Zeiss et al. 1979, pp. 437–438).

Thus, the components of treatment in CYDinclude a clear description of depression and arationale for treatment based on social learningtheory, an emphasis on the developmentof a plan by the reader, and recognition ofthe importance of making a decision aboutsteps to take in the future for the depressedindividual’s ongoing recovery and relapse pre-vention. Several sets of skills were presentedincluding creating a personal plan, relaxation,increasing pleasant activities, social skills,controlling thoughts, constructive thinking,and self-instructional techniques. The chapterson pleasant activities address how to gatherbaseline data, identify an individualized set ofpleasant activities to increase, set specific goals,engage in self-reward and self-evaluation, andmonitor and modify the plan over time. Thechapters on social skills address how to act as-sertively, in socially skillful ways, and how to useself-monitoring of progress and self-reward.The chapters on controlling thoughts use avariety of techniques, including self-assessmentof thinking patterns, thought interruptions,worry time, self-rewarding thoughts, cognitiverestructuring, using Albert Ellis’s A-B-Cmethod for evaluating and disputing negativethoughts (Ellis 1962, Ellis & Harper 1961)and self-instructional methods (Meichenbaum1974).

The Coping with Depression Course

Written for clinicians and published in 1984,the Coping with Depression (CWD) course was

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intended as a group treatment for depressionor as a psychoeducational community outreachapproach. The course consists of 12 two-hoursessions that are conducted over eight weeks.Initial sessions were conducted twice weeklyin order to promote engagement in treatmentand alliance building among the group and withthe therapist. Setting a limited number of ses-sions was hypothesized to maximize the likeli-hood that participants would engage in the pro-cess and work on their problems. The coursealso included follow-up sessions called “classreunions,” which were held at one month andsix months.

The CWD course begins with two ses-sions identifying the ground rules for treatmentand providing instruction in the social learn-ing view of depression and model for change.These orienting sessions are followed by eightsessions devoted to learning skills in the fourareas of increasing relaxation, increasing pleas-ant activities, changing negative cognitions,and improving social skills. Participants be-gin by learning basic principles for designinga plan of self-change and then learning re-laxation techniques. Behavioral strategies con-sist of monitoring the impact of specific ac-tivities on mood and then developing a planfor increasing pleasant activities. The sessiondealing with negative thinking explains howthoughts can be rewarded and punished andteaches a basic ABC model for understandingthe consequences of particular thoughts and be-liefs, as drawn from Rational Emotive Therapy(Ellis & Harper 1975). The sessions thatfocus on cognitive change explain the impor-tance of constructive self-talk and also usebehavioral strategies such as planning “worrytime” and thought stopping. It is not assumedthat all depressed individuals have poor socialskills, but there is an emphasis on using effec-tive social skills and particularly on being prop-erly assertive. The final two sessions are devotedto maintaining treatment gains and preventingrelapse. Participants in the course are expectedto complete homework assignments and collectbaseline and ongoing data relevant to the tar-geted skill. The course clearly emphasizes bet-

CWD: Coping withDepression

ter functioning in life rather than simply feelingbetter.

The course also provides a specific sessionstructure for each of the two-hour sessions,which includes setting an agenda for each ses-sion, reviewing the previous session, providinga rationale for the current session, and preview-ing the following session and homework. In-tended for broad use in community outreach,the CWD course also includes recommenda-tions for advertising and ethical considerationsas well as self-assessment measures and formsto be used by participants.

A program for adolescents was developedlater (Lewinsohn et al. 1990), which consistedof 16 two-hour sessions over 18 weeks. Theadolescent course was modified to reduce theamount of leader presentations and homeworkassignments and to emphasize group activitiesand role-play exercises. Clarke (1998) reporteda 10-item fidelity scale that highlights thecore components of the program: (a) review-ing previous session material, (b) providingstructured practice for skills and techniques,(c) delivering the entire presentation as outlinedin the manual, (d ) clearly assigning homework,(e) monitoring the tone of session, ( f ) allow-ing equal time for participants, ( g) clearlyexpressing ideas and pacing appropriately,(h) being organized, (i ) staying on task, and( j) assessing the difficulty of the group.Although simplified and presented in a lessdidactic fashion for adolescents, these elementswere important for the adult course as well,and the session structure remained the same.

The San Francisco GeneralHospital Manuals

Around the time the CYD book was pub-lished, Christensen et al. (1978) published aframework designed to help structure meth-ods to increase mental health service delivery.The framework recommended that, in additionto professionals providing treatment, the fieldshould expand its focus to prevention and main-tenance interventions and interventions pro-vided by agents other than professionals, such as


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paraprofessionals (paid staff trained to providespecific interventions under professional super-vision), partners (volunteers providing supportto those being helped), peers (individuals en-gaging in mutual support), print, and parapher-nalia (electronic and other methods of deliv-ering interventions, such as mass media andcomputers).

This framework helped structure the evo-lution of interventions based on CYD, par-ticularly at San Francisco General Hospital(SFGH), where Munoz directs the Latino Men-tal Health Research Program. The SFGHadaptations have used the “healthy manage-ment of reality” perspective (Munoz 1996),which was developed in response to the majorpsychosocial challenges facing public sector pa-tients (Le et al. 2010b). This approach is rootedclearly in the work of Lewinsohn and the em-phasis on the need to change the reinforcementfrequency in people’s daily lives in order to cre-ate lasting mood changes. It also is informedby the work of Bandura and the key concepts ofself-efficacy and reciprocal determinism; specif-ically, focusing on how patients and preventionparticipants can modify their internal (mental)reality using cognitive methods and their exter-nal (physical) reality using behavioral methods.This approach has been adapted for use withpopulations that are culturally different fromthe ones in which it was developed in Eugene,Oregon (Munoz & Mendelson 2005).

The first major articulation of this emergingresearch program occurred with the Depres-sion Prevention Course (Munoz 1984). TheCYD book was adapted for use as an eight-session intervention intended to prevent majordepressive episodes in a public sector primarycare population. The Depression PreventionCourse was used in the first randomizedcontrolled depression prevention trial (Munoz& Ying 1993, Munoz et al. 1995). This coursealso has been adapted to prevent postpar-tum depression (The Mothers and BabiesCourse; Munoz et al. 2001, 2007) and to beadministered via the Internet. The DepressionPrevention Course also has been translated intoSpanish, Chinese, Japanese, Korean, German,

Finnish, and Dutch. A recent meta-analysisof the CWD course for both prevention andtreatment shows that it is effective for bothpurposes (Cuijpers et al. 2007a). It also hasbeen tested with psychiatric inpatients (Alvarezet al. 1997) and was adopted as one of theinterventions for the Outcomes of DepressionInternational Network study in Finland, theRepublic of Ireland, Norway, Spain, and theUnited Kingdom (Dowrick et al. 1998, 2000).

The depression prevention research projectrevealed the large number of currently clin-ically depressed primary care patients at theSFGH. In 1985, a cognitive-behavioral depres-sion clinic was founded at SFGH by Munoz andclinical psychology training program fellowsSergio Aguilar-Gaxiola and Jeanne Miranda.They adapted the Depression PreventionCourse to a 12-session treatment manual(Munoz et al. 1986, Munoz & Miranda 1986)designed for public sector primary care patientsin Spanish and English. The manual retainedthe CYD focus on activities, people, andthoughts, with four sessions dedicated to eachof these elements. The manual has subsequentlybeen used by Miranda and colleagues in a seriesof studies showing its effectiveness as part ofquality-improvement efforts in primary careclinics (Wells et al. 2000, 2004) and in otherpublic sector settings (Miranda et al. 2003).In 2000, the manual went through a majorrevision (Munoz et al. 2000a,b). A four-sessionmodule on depression and health was added,as well as an extensive instructor’s manual.These manuals are available for downloadingat no charge from the UCSF/SFGH LatinoMental Health Research Program Web site(http://www.medschool.ucsf.edu/latino/).

Contemporary BehavioralActivation ApproachesThe contemporary BA approach articulatedby Jacobson and colleagues (Dimidjian et al.2007; Jacobson et al. 2001; Martell et al.2001, 2010) was developed initially as partof an effort to identify the active ingredientsof cognitive therapy for depression (Becket al. 1979). Specifically, in 1996, Jacobson

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and colleagues published the componentanalysis study, which aimed to identifythe causally active ingredients of cognitivetherapy for depression. The component designcompared three conditions: (a) behavioralactivation only, (b) behavioral activation pluscognitive restructuring focused on automaticthoughts, and (c) the full cognitive therapypackage, including behavioral activation andcognitive restructuring focused on automaticthoughts and core beliefs. The prevailing no-tion at the time was that the full cognitive ther-apy package would outperform the componentconditions in the acute treatment of depressionand the prevention of relapse ( Jacobson &Gortner 2000). Surprisingly, however, themost parsimonious condition—behavioralactivation only—performed as well as the mostcomplex condition—the full cognitive therapypackage. This lack of significant differencesheld true not only for the treatment of acutemajor depression ( Jacobson et al. 1996) but alsofor the prevention of relapse over a two-yearfollow-up period (Gortner et al. 1998).

On the basis of these findings, the BA com-ponent was articulated as an independent treat-ment, linked explicitly to the behavioral modelof depression articulated by Lewinsohn andcolleagues, which provided the framework forcase conceptualization and selection of partic-ular behavioral strategies. BA was comparedagainst cognitive therapy and pharmacother-apy in a placebo controlled design (Dimidjianet al. 2006). In this trial, BA performed com-parably to pharmacotherapy (paroxetine), evenamong more severely depressed patients, anddemonstrated superior rates of retention. BothBA and pharmacotherapy significantly outper-formed cognitive therapy among more severelydepressed patients. Follow-up results demon-strated again the promise of BA, not only withregard to acute effects but also relapse preven-tion (Dobson et al. 2008). These findings con-tributed to the emerging evidence base for BAas a viable treatment choice among the rangeof available options (including antidepressantmedication) and revitalized interest in clinicalresearch on BA.

BA is characterized by a flexible course thatbegins with the presentation and discussion ofthe rationale for treatment followed by heavyemphasis on behavioral assessment throughactivity and mood monitoring in order todetermine targets for intervention. In essence,therapists work with clients using monitoring toidentify the ingredients of a “behavioral antide-pressant.” The bulk of the therapy then utilizesactivity structuring and scheduling to increasesuch “antidepressant” activities and utilizesproblem solving to alter contextual problemsthat may be eliciting or maintaining depressedmood. The final stage of treatment focuses onconsolidating treatment gains and planning forrelapse prevention. BA also includes a substan-tial focus on identifying barriers to activation,and when barriers to activity arise, therapistsand clients assess the function of behavior andgenerate solutions for future activation assign-ments. The focus on barriers often emphasizesbehaviors that function as avoidance. Clientsmay behave in ways that allow them to avoidparticular contexts, for example staying inbed late to avoid going to work, or emotions,for example using substances to avoid feelingsadness. Therapists work with clients to breakdown activities into small, achievable tasksand to take gradual steps toward approachrather than avoidance. BA also has focused ontargeting the process of depressed thinking,or ruminating, which is conceptualized ascovert behavior or as mental activity, parallelto observable physical activity. To counterruminating, clients are taught either to engagein problem solving or to use “attention toexperience” exercises (Martell et al. 2001) tofully engage in an activity rather than act in anautomatic fashion while ruminating.

In addition to the BA approach articulatedby Jacobson and colleagues, the team of Lejuezand colleagues (2001, 2011) articulated a BAapproach that similarly shares grounding in theprinciples of a behavioral model, the use of be-havioral interventions, and an exclusive focuson targeting behavior change. This approach,behavioral activation treatment for depression,is based on the propositions that depression


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ensues when the value of reinforcers for de-pressed behaviors is increased due to environ-mental change and the value of reinforcers fornondepressed behaviors is decreased (Hopkoet al. 2003b). The protocol consists of 8 to 15sessions that utilize self-monitoring and activ-ity scheduling to accomplish goals based on ahierarchy of activities ranked from easiest tomost difficult. Clients work through the hier-archy until weekly and final goals are achieved.Hopko and colleagues (2003b) investigated thisBA model compared to usual care in an inpa-tient psychiatric setting, with results indicat-ing that the effect size for improvement in de-pressive severity in BA was large and greaterthan that observed for usual care. Subsequentresearch, as discussed in the next section, hasexamined this approach in a range of settingsand patient populations.

Summary

Four major programs of intervention researchhave been conducted since Lewinsohn’soriginal work in the 1970s. These include(a) research leading to the CYD book,(b) research based on the CWD course, (c) re-search at SFGH initially inspired by the CWDcourse, and (d ) research on contemporaryBA approaches including those articulated byJacobson and colleagues and by Hopko and col-leagues. Although some of these programs werenot specifically identified as “BA” at the timeof their inception, and some later evolved toinclude an emphasis on cognitive restructuring,we classify each within the historical traditionof research on BA as a treatment for depression.Moreover, although unique elements of theapproaches at times have been emphasized(e.g., BA versus behavioral activation treatmentfor depression), in our opinion the shared com-ponents of these models eclipse differences.

CONTEMPORARY CLINICALRESEACH ON BEHAVIORALACTIVATION

Research on BA has expanded rapidly in recentdecades. Figure 3 illustrates the number of

publications relevant to BA over the past fourdecades. Within the larger context of researchon behavior therapy for depression that wasgrowing in the 1970s and early 1980s (e.g.,McLean & Hakstian 1979, McNamara &Horan 1986, Shaw 1977, Taylor & Marshall1977, Wilson 1982, Wilson et al. 1983),clinical trials investigating BA were initiatedas reviewed in the previous section. Empiricalattention then remained relatively modestthroughout the 1980s and 1990s. By the endof the 1990s, however, interest in the BAmodel for treating depression was revitalized,and since that time, clinical research hasexpanded rapidly. Studies have extended thecore research on the efficacy of BA to novelpopulations, including populations that havemedical and psychiatric comorbidity, that existacross the lifespan, and that are culturallydiverse. In addition, researchers are testing thelimits of the transportability of BA, examiningthe use of innovative delivery formats forpatients and methods of training of clinicians.Finally, research is beginning to address theprocess of change in BA and connections tobehavioral models of depression.

Extending Behavioral Activationto Populations with Psychiatricand Medical Comorbidity

Much of the renewed interest in BA has fo-cused on extending BA to novel populations.Although this work is in the early and ex-ploratory stage, with heavy reliance on casestudies and small open-trial designs, as a col-lection these studies suggest that BA may havebroad applicability as a parsimonious and trans-portable intervention. As such, these studiespave the way for future rigorously controlledclinical research on the transportability of BAto a range of populations with psychiatric andmedical comorbidity.

Given the high comorbidity between majordepression and other psychiatric disorders,many studies have addressed the value of BAin treating patients with comorbid diagnoses.Promising directions have been reported in

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Figure 3Cumulative number of behavioral activation–relevant publications.

the context of case studies with patients withborderline personality disorder and suicidalideation (Hopko 2003) and mixed anxiety anddepression (Hopko et al. 2004). Three studieshave examined the use of BA among patientswith PTSD or comorbid PTSD and depres-sion. A case report of an 11-session course of BAwith a police officer/military veteran diagnosedwith PTSD and major depressive disorderreported positive change in both PTSD anddepression (Mulick & Naugle 2004). A smallopen trial (N = 11) with military veterans diag-nosed with PTSD reported positive change inPTSD but not depressive symptoms ( Jakupcaket al. 2006). Finally, a small randomized trial(N = 8) with motor vehicle accident survivorscompared a brief course of BA to care as usual,with evidence of significant improvement inPTSD severity but not depression (Wagneret al. 2007). Although preliminary, these find-ings raise interesting questions regarding theimportance of specific targeting in treatmentand the modifications that may be requiredto treat comorbid disorders. The DepressionPrevention Course also was adapted at SFGHas a mood-management intervention formethadone maintenance patients in pilot studywith 11 Spanish-speaking Latino individuals(Gonzalez et al. 1993). Other recent inves-tigations also have shown strong results forthe use of BA to target comorbid substance

use disorders and depression (Daughterset al. 2008, MacPherson et al. 2010). Finally,reflecting an interest in psychiatric severity inaddition to comorbidity, Curran and colleagues(2007) broadly discussed issues that arise inthe extension of BA to inpatient settings andreported favorable outcomes for a patientwith chronic depression who was refractory topharmacotherapy and cognitive therapy.

Interest in the value of BA in targeting med-ical comorbidity has been reflected in recentstudies as well. A 12-week intervention, whichalso included nutritional counseling, demon-strated promise in reducing depression andweight in a small open trial with patients withdepression and obesity (Pagoto et al. 2008).Hopko and colleagues reported promising out-comes in a series of case studies with patientswith cancer and depression treated in primarycare and an oncology clinic (Armento & Hopko2009, Hopko et al. 2005). This work has beenextended recently in a randomized controlledtrial design that demonstrates promise for BAamong depressed women with breast cancer(Hopko et al. 2010). Finally, Uebelacker et al.(2009) developed a 10-session protocol for usewith depressed patients in primary care set-tings. In a small open trial (N = 12), depressiveseverity declined significantly over time, withpromising trends indicated for social function-ing, pain, and general health.


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Extending Behavioral ActivationAcross the Lifespan

Developmental adaptations of BA across thelifespan also have been a focus of recent em-pirical attention. Given the high prevalence ofdepression among older adults, multiple in-vestigator groups have examined the extensionof BA with older adults in both communityand residential settings. This research buildson the foundation of early work in the 1980s(e.g., Breckenridge et al. 1987, Gallagher 1981,Gallagher & Thompson 1982), which alsohas been extended more recently (Gallagher-Thompson et al. 2000). Although a wide rangeof specific models has been tested in this area ofresearch on BA, each includes activity schedul-ing as a central component.

Meeks and colleagues developed a BA-consistent approach called BE-ACTIV, a10-week activity-based behavioral treatmentdelivered as a collaborative effort between nurs-ing home staff and mental health providers.An initial case report highlighted the potentialvalue of this approach (Meeks et al. 2006). Insubsequent treatment development (N = 5)and feasibility studies (N = 20), Meeks andcolleagues (2008) reported promising results,with indications that patients, families, andstaff were receptive to the intervention and thatdepressive severity and activity levels improvedover the intervention period.

Sood and colleagues (2003) examined theGeriatric Wellness Program (GWP), whichwas based on the Depression in Older UrbanRehabilitation Patients Treatment Programaimed at treating depression among geriatricnursing home patients receiving rehabilitationservices (e.g., Lichtenberg et al. 1998). Non-mental health personnel (i.e., occupationaltherapists) deliver the intervention over thecourse of approximately eight weeks. Each ses-sion included teaching relaxation and visualiza-tion, mood monitoring, positive reinforcementfor progress, and participation in pleasantevents as guided by responses to the PES. Ina small, randomized trial (N = 14), Sood andcolleagues compared participation in the GWP

to standard occupational therapy among nurs-ing home residents. The study demonstratedthe feasibility of implementing the GWPprogram in a nursing home setting, and dif-ferences in depressive severity between controland GWP groups were in the hypothesizeddirections, though not statistically significant.

In contrast to the emphasis on nursing homesettings, Teri and colleagues (1997) conducteda randomized clinical trial among community-dwelling older adults with depression and de-mentia. Patient and caregiver dyads (N = 72)were randomly assigned to a BA condition, acaregiver problem-solving condition, wait-listcontrol, or usual care. The nine-session BAprotocol included both patient and caregiverand emphasized teaching caregivers to help in-crease pleasant events and modify contingen-cies that maintain depression. Both of the be-havioral conditions (BA and problem solving)demonstrated superiority over the control con-ditions in the improvement of depressive symp-toms and diagnosis at the end of the interven-tion. Caregivers also improved in their ownsymptoms of depression. Patient and caregivergains were maintained through a six-monthfollow-up.

Quijano and colleagues developed thecommunity-based Healthy IDEAS program(Identifying Depression, Empowering Activi-ties for Seniors; Quijano et al. 2007). This six-month program is composed of four compo-nents (assessment, education, referral, and BA)and is delivered via in-person and telephonesessions by community agency case managers(versus specialty mental health professionals).In a large open trial with frail, high-risk elders(N = 94), participation in Healthy IDEAS wasassociated with improvements in both depres-sive severity and pain.

At the other end of the age spectrum, Clarkeand colleagues (1995, 2001) have developed in-terventions to prevent depression in adoles-cents based on CWD, although some of theseinterventions evolved to include componentsof cognitive therapy (e.g., Garber et al. 2009).Similarly, McCauley and colleagues (2011)are investigating an adapted version of the

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contemporary BA model among depressed ado-lescents, which includes a greater focus on col-laboration with family members as well as morestructured homework assignments and moni-toring forms. A preliminary randomized trialcomparing this approach with usual care iscurrently under way. Ruggerio and colleagues(2005) also described a positive course of BAwith a 17-year-old girl in foster care with de-pressive symptoms.

Extending Behavioral Activationto Populations of Ethnic, Racial,and Gender Diversity

Munoz and colleagues at San Francisco Gen-eral Hospital have conducted extensive workadapting the CYD approach to multiculturalpublic sector populations, with a special focuson Spanish-speaking Latinos (Le et al. 2010,Munoz et al. 1997, Munoz & Mendelson2005, Organista et al. 1994, Perez & Munoz2008). Kanter and colleagues (2010) also areexploring the application of BA with Latinopopulations. They report that BA may haveparticular relevance for depressed ethnicminority clients given the relative emphasis inBA on environmental contextual variables (e.g.,unemployment, displacement) as opposed tointernal, individual pathology. Such workbuilds on earlier studies with Puerto Ricanpatients (Comas Diaz 1981). Additionally,recent case studies also highlight the promiseof a modified form of BA with Latina popu-lations (Kanter et al. 2008, Santiago-Riveraet al. 2008). A recent small open trial (N = 10)reported positive findings for retention and de-pressive severity improvement for a culturallyand linguistically adapted form of BA admin-istered by bilingual clinicians in a communitymental health clinic (Kanter et al. 2010).

Multiple investigators also are examiningextensions to understudied populations ofdepressed women. In particular, extensionsof the CWD course to perinatal women andmothers of young children have been a focus ofattention. A study of a Web-based modificationof the CWD course for depressed mothers of

children in Head Start programs was recentlycompleted by Sheeber and colleagues, and aWeb-based modification of CWD for post-partum depression is underway currently byDanaher and colleagues. These studies build onearlier work by Meager & Milgrom (1996) inextending the CWD course to perinatal popula-tions and the work on prevention of postpartumdepression by Munoz and colleagues (Munozet al. 2001a,b; 2007). Dimidjian and colleaguesare launching a multisite study of BA adminis-tered in obstetric clinics, over the telephone, orin homes for women with perinatal depression.

Extending the Reach ofBehavioral Activation UsingNovel Delivery Formats

The potential for broad dissemination has beenone of the hallmarks of interest in BA. In fact,some of the earliest work on BA models high-lighted dissemination to traditionally under-served populations, including racial and ethnicminority populations as discussed previously aswell as geographically underserved individuals(e.g., Padfield 1976). Recent work suggests thatthe relative parsimony of BA as compared toother evidence-based psychotherapies may beparticularly conducive to dissemination usingnovel delivery formats. Studies have examinedthe use of brief group-based formats, telephonedelivery, bibliotherapy, and the Internet. Also,investigators are exploring ways to train clini-cians efficiently or to rely on the use of parapro-fessionals to provide BA. Overall, these studiesemphasize novel formats as a means of increas-ing access to evidence-based treatment.

Some investigators are beginning to exam-ine using BA in brief formats or with groupmodels. A recent study compared a one-sessionBA protocol to a no-treatment control amongcollege students with moderate depressivesymptoms (Gawrysiak et al. 2009). The one-session intervention was followed by two weeksof activation assignments, to which participantsreported adhering at a high level (approximately72% of assigned activities). The BA conditionevidenced significantly greater improvement in


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depression and access to environmental rewardas compared to the control condition. Althoughthe extent to which these findings generalizeto other populations is uncertain, the potentialpromise of brief BA interventions clearly de-serves attention. Another recent trial exploredthe delivery of BA in a group format. Porterand colleagues (2004) examined the feasibilityof this format in a small, randomized trial con-ducted in rural community mental health cen-ter settings. All participants met criteria for ma-jor depressive disorder and were randomized toBA or wait-list control, with results suggestingpromising improvement in depressive symp-toms. Houghton et al. (2008) conducted an un-controlled trial of a group BA treatment basedon the Addis & Martell (2004) self-help man-ual and theoretically congruent interventionsbased on Acceptance and Commitment Ther-apy (Hayes et al. 1999) with 42 participants. Thegroup intervention was accepted by patients andwas effective in improving self-reported symp-toms of depression, lending further support tothe importance of future, more rigorously con-trolled studies of group BA treatment.

An early study by Brown & Lewinsohn(1984) utilized a telephone delivery conditionin which therapists called patients weekly to in-quire about how they were doing, what theymight need, what problems they had experi-enced, and so forth. Sessions lasted between 10and 60 minutes. The telephone condition wasas effective as the two active treatments and su-perior to the wait-list control. This study wasan early forerunner of the extensive work thathas investigated telephone-based applicationsof cognitive behavioral treatments for depres-sion (e.g., Mohr 1995) and highlights the po-tential value of telephone delivery of BA.

Bibliotherapy formats also have been a fo-cus of attention. The CYD book was testedby Scogin et al. (1989) in a randomized con-trol trial in which it was used as a behav-ioral printed intervention and compared witha cognitive printed intervention and a wait-list control. The CYD book and the cognitivebibliotherapy conditions produced significantlylarger reductions in depressed mood than did

the wait-list control and were not different fromeach other, a benefit that was retained acrossa two-year follow-up. A simplified version ofthe mood management approach based on in-creasing pleasant activities was also used in asmoking-cessation trial conducted via surfacemail with Spanish-speaking smokers (Munozet al. 1997). The study compared a formerlytested smoking-cessation guide versus the guideplus the Tomando Control de su Vida (TakingControl of Your Life) intervention based onCYD, with the combined condition yieldingdouble the quit rate. This intervention hasbeen included in the National Cancer InstituteWeb site as one of its research-tested inter-vention programs (Programa Latino para De-jar de Fumar; http://rtips.cancer.gov/rtips/programDetails.do?programId=105455).

A series of studies also has explored the useof media to disseminate BA interventions. In1978, when the first edition of CYD was pub-lished, Art Ulene, a physician producing health-related programming for the NBC televisionnetwork, contacted the authors and proposedpreparing a series of 10 four-minute segmentsto present during the news program through-out the country. The segments were created andtelevised, and, when shown in the San Franciscoarea, evaluated using phone surveys of a randomsample of San Francisco residents before andafter the two-week period when the segmentswere aired. Results showed that individualswith initially high depression symptom scoreswho watched the segments had significantlylower post-assessment scores than those whodid not watch the segments (Munoz et al. 1982).Though not a randomized trial, this study pro-vided evidence that the skills taught in the CYDbook were associated with clinical benefit whenwidely disseminated using mass media.

A range of Internet media adaptations alsohave been developed and tested. Web-based ex-tensions have been investigated using BA withadolescents (Van Voorhees et al. 2009) andthe CWD course with adults with depressivesymptoms (Warmerdam et al. 2008) and olderadults (Spek et al. 2007, 2008). Munoz andcolleagues adapted the CYD book as part of a

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http://rtips.cancer.gov/rtips/programdetails.do?programId=105455


stop-smoking Internet intervention now testedin a series of worldwide, randomized controltrials in Spanish and English; over 800,000visitors from over 200 countries have cometo the site, and over 60,000 of them havesigned consent and entered the outcome stud-ies. Smoking-cessation rates have been 20% to21% at 12 months (Munoz et al. 2009) and ashigh as 26% at six months (Munoz et al. 2006),which is comparable to the rates associated withthe nicotine patch. Moreover, the SFGH man-uals for prevention and treatment of depressionare currently being adapted for depression pre-vention and management studies via the Web,and the Mothers and Babies Course is currentlybeing tested in an Internet study. An iPhoneapplication (UCSF SFGH Stop Smoking) us-ing a mood management intervention focusedon increasing activity has been launched and isavailable via iTunes.

Additionally, the University of California,San Francisco/SFGH Latino Mental HealthResearch Program established the InternetWorld Health Research Center in 2004. Thecenter is dedicated to systematically developingevidence-based Internet interventions to tar-get gaps in our knowledge base. The processis guided by a grid composed of columns repre-senting health problems (smoking, depression,diabetes, pain, and so on) and rows representinglanguages (English, Spanish, Chinese, and soon). The center focuses on targeting cells withinthis grid representing health problems thathave been understudied and for which cogni-tive behavioral interventions may be beneficial.Delivery methods also are being expanded touse such technologies as MP3 players (e.g.,recording depression manual messages so pa-tients can listen throughout the week) and textmessages (so patients can monitor their mood,activity levels, and thoughts throughout theweek) (Aguilera et al. 2010). The aim of theseinnovative dissemination methods via the Inter-net is to contribute to the reduction of healthdisparities worldwide (Munoz 2010).

Finally, investigators are examining the useof the Internet to train clinicians to be com-petent practitioners of BA. The feasibility and

preliminary outcomes of using an online train-ing format to teach clinicians the core principlesand strategies of BA was tested in a recent pilotstudy, with promising results (Dimidjian et al.2011). Moreover, as discussed previously, muchof the work with older adults has effectively uti-lized non-mental health specialists to providecare. A subsequent iteration of the DepressionPrevention Course for smoking cessation alsoused master’s-level counselors (e.g., Hall et al.1994). The 2000 version of the CBT GroupTherapy manual (based on CYD; Munoz et al.2000a, p. vi) has been adapted for administra-tion by substance abuse counselors for popu-lations of depressed substance abusers and al-cohol abusers, with encouraging results (Osillaet al. 2009). Finally, Ekers and colleagues (2011)have reported promising findings in a random-ized clinical trial using nonspecialists to imple-ment BA with depressed patients, and Cullenand colleagues (2006) reported favorable find-ings in a study of BA using graduate studentclinicians. These studies suggest that BA maybe amenable to widespread transportability viause of novel methods of training mental healthclinicians or reliance on a range of individuals,mass media, or the Internet for service delivery,as suggested by Christensen et al. (1978).

Understanding Processes of Change

Few studies to date have addressed the ques-tion of how beneficial effects are obtained inBA. Some studies have examined the role ofpatient activation specifically. For example,Hopko and colleagues, using daily diarymethods, have provided some evidence forthe relationship between activation and mood(Hopko et al. 2003c, Hopko & Mullane 2008).Similarly, T.P. Andrusyna (unpublished data),using observational coding of BA treatmentsessions, reported a correlation betweenpatient reports of increased activation anddepressive symptom reduction. A similarobservational coding study replicated thefinding that patients report more pleasure andmastery activities during intervals of significantsymptom reduction and also demonstrated


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an association between increased activationover three sessions and pre- to post-treatmentchange in Beck Depression Inventory-II scores(Hubley et al. 2009). None of these studies,however, provide information about the tem-poral relationship between change in activationlevel and mood. In exciting new lines ofresearch, other investigators are exploring pos-sible neural correlates of change in BA (Dichteret al. 2009), providing preliminary evidence ofactivation in brain structures associated withreward processing among responders to BA.

Summary

Contemporary research on the clinical applica-tion of BA is proceeding rapidly across multiplelines, including use with patient populationswith complex and comorbid conditions, olderadults and adolescents, ethnic and racial mi-norities that have been traditionally understud-ied, and perinatal women. In addition, inno-vative methods for delivering BA and trainingclinicians in BA are the focus of an increasingnumber of studies. Overall, the contemporaryresearch highlights extensive promise of BA,but as discussed in the next section, requiresgreater methodological rigor in testing efficacyas well as expanded efforts to test empiricallycomponents of the behavioral model of depres-sion and change in the context of clinical trials.

REFLECTIONS FORFUTURE WORK

There has been a substantial increase inthe clinical and scientific interest in BA asa treatment for depression in recent years.This work, which has its roots in the historyof behavior therapy broadly and the earlymodels and methods developed by Lewinsohnand colleagues specifically, has established astrong evidence base for BA as a treatment fordepression and has highlighted the diversityof settings and clinical populations for whichBA holds promise. As we look to the futureevolution of this work, we identify here fiveimportant questions to guide the field.

Does Behavioral Activation Work?

An increasing number of clinical trials supportthe efficacy of BA, and recent reviews have con-cluded that BA is an efficacious treatment fordepression (e.g., Cuijpers et al. 2007b, Ekerset al. 2008, Mazzucchelli et al. 2009). BA alsohas been included as an evidence-based treat-ment for depression in guidelines released bythe National Institute for Health and ClinicalExcellence (2009). Despite this strong support,a greater number of methodologically rigorousstudies is required to answer definitively thequestion of whether BA works. For example,the study conducted at the University ofWashington is the only study of BA to date toinclude pharmacotherapy and placebo controlconditions. Given that pharmacotherapy iswidely considered to be the standard of carefor depression in the United States, such com-parisons are essential from a policy standpoint.Moreover, they provide the most rigorousapproach for testing causal efficacy given thecomplexities in designing credible psychosocialplacebo controls. Although the Universityof Washington study provides an essentialcomponent of the BA evidence base and alignswith converging evidence from a host of otherefficacy studies, the value of replication cannotbe overstated. In addition, many of the otherstudies of BA have suffered from small samplesand failure to document fully clinical samples ofdepressed patients (e.g., reliance on elevated de-pressive symptom scores rather than diagnosticassessments). The relatively young area ofresearch extending BA to novel or specificpopulations also relies heavily on case studiesor small open trial designs. Such recommen-dations are relevant for dissemination researchas well. For example, studies on BA with agingpopulations provide emerging evidence thatBA can be delivered in a range of settingsby nonspecialist providers; however, futurerandomized clinical trials are necessary tomake causal inferences regarding efficacy withsuch providers. In general, it will be essentialfor future studies of BA to employ rigorousmethods, including control conditions, reliable

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and valid assessments of depressive diagnosesand severity by independent blind raters, andmeasurement of treatment integrity, as wellas standard reporting requirements such aspatient flow diagrams, with clear informa-tion about retention and attrition, treatmentexposure, and so forth.

How Does BehavioralActivation Work?

There has been little systematic research clar-ifying the processes that account for the effi-cacy of BA in the treatment and prevention ofdepression. During the foundation research onBA therapies, quantitative methods for studyingmediation were not practiced routinely. Earlystudies laid some of the conceptual groundworkby reporting the relation of BA to hypotheticalaffective, behavioral, and cognitive mechanismsand showing the relation of these to depression(e.g., Jacobson et al. 1996). However, future re-search will benefit from an increased focus ontesting conceptually based mediators of changeand employing rigorous quantitative methodsto do so (e.g., Kraemer et al. 2002). As Kazdin(2007) has highlighted, the benefits of identify-ing mediators of change are multiple, includingthe potential of optimizing efficacy, maximiz-ing parsimony, and highlighting ways in whichchange may occur in natural, nontherapeuticcontexts as well. Understanding mediators ofchange in BA can promote depression theorytesting through the conduct of therapy outcomeresearch (cf. Howe et al. 2002).

Multiple potential mediators may be valu-able to address in future work. To do so, it willbe necessary to ground inquiry in a conceptualunderstanding of the psychopathology of de-pression. Thus, continued work on the investi-gation and refinement of behavioral and inte-grative models of depression is important. Suchresearch will need to employ multiple methodsof investigation. Traditionally, clinical researchhas relied heavily on self-report and clinicianinterview methods. Future work would ben-efit from integrating such methods with the

use of laboratory task paradigms and biologi-cal methods, such as neuroimaging, in a trans-lational approach to the question of how BAworks.

Recent work on the potential mediatorof reward processing is instructive. In theirbasic research on the structure of affectivestates, Watson et al. (1988) found that neg-ative affect was related to both anxiety anddepression. Positive affect, on the other hand,showed greater specificity with its relation todepression only. They concluded “that theloss of pleasurable engagement is a distinctivefeature of depression” (p. 346). Consistentwith such work and the behavioral modelsdiscussed previously, it would follow then thatreward processing could be a critical elementof effective depression treatment. The work ofDichter and colleagues (2009) is paradigmaticof the type of research that examines suchtheory-based variables incorporating multiplemethods of investigation. Other particularlypromising processes to examine in futurestudies include, for example, avoidance orbehavioral control, which also have stronggrounding in basic research (Maier et al. 2006).

Finally, future research could addresswhat specific elements of BA are critical.Although BA is parsimonious compared toother evidence-based treatments for depres-sion, it too contains multiple elements. Someof the studies included in the precedingreview focused specifically, for example, onactivity scheduling, whereas others includeda wider range of behavioral strategies. More-over, even within the narrow domain ofactivity-scheduling interventions, treatmentfrequently focuses on a range of targets,including increasing activation in routine,pleasant, mastery, interpersonal, and physicalactivities. It is not clear whether it is importantfor activation to target specific domains orwhether any increases in activity can interruptdepressogenic cycles. Moreover, the degreeto which an idiographic versus nomotheticapproach to activation maximizes clinicalefficacy is not known. Future research could


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address such questions through the use of thetypes of dismantling designs that Jacobsonand colleagues applied to cognitive therapy orthrough the use of analog laboratory designs.

For Whom Does BehavioralActivation Work?

Recent years have witnessed increasing atten-tion to the potential promise of personalizingtreatments for depression. There is no doubtthat a heterogeneous disorder such as depres-sion requires multiple approaches that are opti-mally suited for particular patient populations.Future trials are needed to test formally vari-ables that may predict or moderate treatmentresponse.

For example, advancements in behavioralneuroscience and genetics have relevance toour understanding of depression (Caspi et al.2003, Monroe & Reid 2008) and, more specifi-cally, possible sources of individual differences(e.g., Henriques & Davidson 2000, Pizzagalliet al. 2005, Wichers et al. 2008). The work ofWichers and colleagues (2008) on the geneticmoderation of the daily experience of pleas-ant events may have special relevance for BAbecause their methodology for assessing dailyevents and mood resembled that used in thefoundation research on a behavioral model ofdepression. A natural extension of this workwould be to determine whether the findingsfrom neuroscience and behavioral genetics thathave linked reward systems to depression havepractical implications for understanding differ-ential responsiveness to BA.

Clinical research and practice guidelinesalso highlight possible moderators to in-vestigate in future trials. Recent work hasunderscored the role of depressive severityin moderating pharmacological responseto antidepressants (Fournier et al. 2010).Moreover, the use of BA strategies in cognitivetherapy has been emphasized heavily with moreseverely depressed patients (Beck et al. 1979),and results suggest that BA is comparable topharmacotherapy even among more severely

depressed patients (Dimidjian et al. 2006).Thus, BA may hold particular advantage formore complex, severe depression. On theother hand, it also is possible that BA mightbe aimed profitably at those who are relativelymildly depressed and may not require theinvolvement of a mental health professional.In such a stepped care model, mildly depressedindividuals may be treated by paraprofessionalsor self-administered formats of BA as an initialtreatment option, followed by more intensiveformats if necessary. To test formally suchvariables as moderators of treatment willrequire large randomized clinical trials; suchwork, however, has the potential to identifyvariables that may be used to personalizetreatments, thereby maximizing treatmentresponse for given subgroups of patients.

The question of for whom BA works also un-derscores the importance of extending futureresearch to novel populations that have beenunderemphasized in prior studies. Much of therecent research on BA has examined extensionsof BA beyond the treatment of outpatient de-pression. There are indications of promise withdepressed individuals across the lifespan, withethnically and culturally diverse populations,and with populations for whom few evidence-based treatments have been studied, such asperinatal women or individuals with comorbidpsychiatric or medical illness. Although studiesdemonstrate the promise of BA for these pop-ulations, future research will require more rig-orous methods to substantiate efficacy for thesepopulations.

How Long Does BehavioralActivation Work?

Given the often chronic and relapsing na-ture of depression, it is important forevidence-based treatments to address not onlythe acute treatment of depression but also therelapse-prevention effects. The meta-analyticreview by Mazzucchelli and colleagues (2009)observed that very few studies provided follow-up data that permitted evaluations of BA

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maintenance effects beyond 1–3 months follow-ing the end of treatment. The ability to provideenduring benefits beyond treatment termina-tion is one of the unique benefits of cognitivetherapy with respect to pharmacotherapy. Al-though the studies conducted to date suggestthat BA has beneficial long-term effects (Dob-son et al. 2008, Gortner et al. 1998), it is criticalfor future studies to study the long-term effectsof BA and ways that its beneficial effects mightbe maintained.

What Novel Methods Facilitatethe Dissemination ofBehavioral Activation?

Much of the enthusiasm for BA relates to itspotential for widespread dissemination. Asmuch of the contemporary work suggests, BAappears to be compatible with a range of noveldelivery formats. Investigators are extendingBA through the use of computers, Internet, andtelephone technologies. BA approaches may bewell-suited for patient self-guided applicationsusing media that provides readily accessibleinformation, vehicles for self-monitoring, thedelivery of prompts for engaging in goal-directed behavior, and other BA components.Additionally, such novel methods may be usedprofitably to train practitioners to administerBA. Initial work demonstrates that it is feasibleto use Web-based approaches to train mentalhealth professionals in BA; future work isimportant to test the limits of such trainingwith respect to the efficacy of treatment deliv-

ered by clinicians trained with such methodsand with respect to the range of providersfor whom such methods are useful (e.g.,paraprofessionals).

SUMMARY

In describing the evolution of BA, we often relyon the classic quote from William Faulkner(1951): “The past is never dead. It’s not evenpast.” The pioneering work of Lewinsohnand colleagues initiated lines of research thatcontinue to expand today. Behavioral modelsof depression as proposed by Lewinsohnand colleagues evolved according to newresearch findings and will continue to do so.An understanding of the history of researchon behavioral models and approaches todepression enhances our ability as a field toidentify important directions for the future.Depression is a complex and heterogeneousdisorder for which current treatment deliveryefforts are insufficient. The majority of patientsare without access to even the chance of as-sistance from evidence-based psychotherapiessuch as BA. Clearly, there is more work to bedone. In this review, we have highlighted keytheoretical, empirical, and clinical componentsof the work that has informed contemporaryresearch on BA. We also have identifiedimportant questions for future inquiry, whichwe hope will support the field in understandingthe nature of depression and providing themost powerful treatments in the most efficientways for the greatest number in need.

SUMMARY POINTS

1. Contemporary research on BA treatments for depression is rooted in a long history ofresearch on behavioral approaches to depression.

2. Contemporary research on BA has expanded rapidly in recent decades, examining theuse of BA across a wide array of patient populations and clinical settings.

3. Interest in BA derives in part from its potential as a transportable intervention for depres-sion, and recent research has examined novel methods of delivery and clinician training.


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4. Future research needs to increase methodological rigor and address key questions relevantto theoretical models of depression as well as concerns and priorities of routine clinicalcare settings.

FUTURE ISSUES

1. Advancing clinical research requires testing theory in the context of intervention studies,particularly focusing on identifying mediators and active ingredients of BA. Future workin these areas would enhance understanding of the processes by which BA achieves clinicalbenefit and may help to optimize treatment outcome and dissemination.

2. The promise of personalized treatments requires identifying potential moderators ofchange, specifying who is likely or unlikely to respond to BA.

3. The use of multiple methods, including self-report, behavioral observation, laboratorytask paradigms, and biological, are important to include in future studies to examinemediators, moderators, and active ingredients of change.

4. Extensions of BA to novel populations are critical to address clinical needs of populationsthat have not been studied extensively or that are not well served by current interventionmodels. Particular populations of interest include racial and ethnic minority individuals,adolescents, geriatric individuals, perinatal women, and those with mental or physicalhealth comorbidities.

5. Given the often chronic and relapsing nature of depression, it is essential for future studiesto include longer-term follow-up periods in order to examine the potential relapse-prevention effects of BA.

6. Future research should continue to innovate new methods of treatment delivery andshould employ rigorous methods to examine the efficacy of such methods.

7. The transportability benefits of BA require direct investigation that focuses on outcomessuch as cost-effectiveness.

8. Given the promise of BA as a parsimonious and transportable intervention, there is astrong need for empirically based models of clinician training that are robust and cost-effective. Innovative methods, such as the use of Web-based approaches, to train cliniciansin BA should be investigated.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings thatmight be perceived as affecting the objectivity of this review. The authors receive royalties forsome of the treatment manuals and books referenced in this manuscript.

ACKNOWLEDGMENTS

The authors wish to acknowledge gratefully the collaboration of Samuel H. Hubley in preparingthis manuscript for publication and contributing to advancing the scope and quality of researchon BA.

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CP07-FrontMatter ARI 8 March 2011 4:13

Annual Review ofClinical Psychology

Volume 7, 2011 Contents

The Origins and Current Status of Behavioral Activation Treatmentsfor DepressionSona Dimidjian, Manuel Barrera Jr., Christopher Martell, Ricardo F. Munoz,

and Peter M. Lewinsohn � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Animal Models of Neuropsychiatric DisordersA.B.P. Fernando and T.W. Robbins � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �39

Diffusion Imaging, White Matter, and PsychopathologyMoriah E. Thomason and Paul M. Thompson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �63

Outcome Measures for PracticeJason L. Whipple and Michael J. Lambert � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �87

Brain Graphs: Graphical Models of the Human Brain ConnectomeEdward T. Bullmore and Danielle S. Bassett � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 113

Open, Aware, and Active: Contextual Approaches as an EmergingTrend in the Behavioral and Cognitive TherapiesSteven C. Hayes, Matthieu Villatte, Michael Levin, and Mikaela Hildebrandt � � � � � � � � 141

The Economic Analysis of Prevention in Mental Health ProgramsCathrine Mihalopoulos, Theo Vos, Jane Pirkis, and Rob Carter � � � � � � � � � � � � � � � � � � � � � � � � � 169

The Nature and Significance of Memory Disturbance in PosttraumaticStress DisorderChris R. Brewin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 203

Treatment of Obsessive Compulsive DisorderMartin E. Franklin and Edna B. Foa � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229

Acute Stress Disorder RevisitedEtzel Cardena and Eve Carlson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 245

Personality and Depression: Explanatory Models and Reviewof the EvidenceDaniel N. Klein, Roman Kotov, and Sara J. Bufferd � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 269

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Sleep and Circadian Functioning: Critical Mechanismsin the Mood Disorders?Allison G. Harvey � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 297

Personality Disorders in Later Life: Questions About theMeasurement, Course, and Impact of DisordersThomas F. Oltmanns and Steve Balsis � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 321

Efficacy Studies to Large-Scale Transport: The Development andValidation of Multisystemic Therapy ProgramsScott W. Henggeler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 351

Gene-Environment Interaction in Psychological Traits and DisordersDanielle M. Dick � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 383

Psychological Treatment of Chronic PainRobert D. Kerns, John Sellinger, and Burel R. Goodin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 411

Understanding and Treating InsomniaRichard R. Bootzin and Dana R. Epstein � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 435

Psychologists and Detainee Interrogations: Key Decisions,Opportunities Lost, and Lessons LearnedKenneth S. Pope � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 459

Disordered Gambling: Etiology, Trajectory,and Clinical ConsiderationsHoward J. Shaffer and Ryan Martin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 483

Resilience to Loss and Potential TraumaGeorge A. Bonanno, Maren Westphal, and Anthony D. Mancini � � � � � � � � � � � � � � � � � � � � � � � 511

Indexes

Cumulative Index of Contributing Authors, Volumes 1–7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 537

Cumulative Index of Chapter Titles, Volumes 1–7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 540

Errata

An online log of corrections to Annual Review of Clinical Psychology articles may befound at http://clinpsy.annualreviews.org

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the origins and current status of behavioral activation ...€¦ · cognitive behavior therapy...

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