Definition, theoretical basis, effectiveness, advantages, practice approach, resources
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Information
What is Behavioural Activation?
Behavioural Activation (BA) is a psychological therapy that appears to be one of the approaches used in Cognitive Behavioural Therapy. In the early 2000’s it was adopted as an approach that could be used by people without formal CBT study. Put simply, the aim of BA is to reverse the cycle of depression by increasing engagement in valued activities, which increases our chances of deriving pleasure and a sense of achievement from life (McEvoy, 2016). Other writers put more detail around the BA approach.
Tindall et al. (2017) describe BA as a structured, brief psychotherapeutic approach that aims to (1) increase engagement in adaptive activities (which often are those associated with the experience of pleasure or mastery), (2) decrease engagement in activities that maintain depression or increase risk for depression, and (3) solve problems that limit access to reward or that maintain or increase aversive control. The focus of BA has been on relieving depressive symptoms, but research suggests its focus has been broadened in recent years other areas.
Oates, Moghaddam, Evangelou and das Nair (2020) suggest BA is a relatively simple, easy to understand, intervention that does not require a highly trained therapist or complex skills from the patient and may be suitable for individuals with cognitive and physical difficulties. It can be delivered in several formats such as telephone, face-to-face, and carer supported, with varying number and length of sessions.
When comparing BA to CBT, Ekers et al. (2014) suggest skills to deliver BA may be acquired after 5 days of training compared to the 1 to 2 years of intensive training required for CBT.
How does it work? (A brief outline)
BA encourages people to re-engage with activities that are meaningful for them and give them satisfaction. These activities are used to break the cycle of depression that people may find themselves in. The therapy involves examining activities and behaviours that are contributing to depression (or another issue). Therapists and clients then work collaboratively to establish tasks and activities to change these behaviours / situations with the aim of increasing opportunities for positive reinforcement. A therapist may support people in person, over the phone, or online, usually over multiple sessions (Ritschel, Ramirez & Cooley, 2016; Uphoff et al., 2020).
Effectiveness (research findings)
Most of the research on the effectiveness of BA as a therapy has been conducted with individuals with depression. There have been several recent reviews of research. Overall these reviews find BA to be an effective treatment for depression. The reviews included:
Meta-analyses by Stein et al. (2021), Uphoff et al. (2020) and Ekers et al. (2014).
A systematic review by Oates, Moghaddam, Evangelou and das Nair (2020) applying BA to individuals with cognitive and physical difficulties.
A pilot BA program, 8-hours over 8-weeks and run by volunteers, in a residential care home (Bryant et al., 2020).
A study comparing BA and guided physical activity (PA) finding both the self-help BA program and a guided physical activity (PA) program significantly improved mild to moderate depressive symptoms in adults, when comparted to the control (Soucey et al., 2017).
A 2017 randomised control trial by Richards et al. to compare BA and CBT on both alleviating depression and cost-effectiveness. The trial found BA was a clinically effective and cost-effective alternative psychological therapy to CBT for the treatment of patients with depression. Both CBT and BA groups improved with those receiving BA no worse after 6, 12 and 18 months in terms of depression. The total costs of health and care were lower for those receiving BA. The study concluded that BA could be a front line treatment for depression.
A pilot study by Ritschel, Ramirez and Cooley (2016) examined BA with depressed adolescents. Results suggested that BA was an effective treatment for depressed adolescents. Follow-up assessments indicated that treatment effects were sustained.
Some research reviews suggests that BA may not always be effective.
A systematic review of BA on substance use and depression (Martinez-Vispo et al., 2018) found mixed results with effect sizes small and not statistically significant.
After a meta-analysis of 10 studies with young people, Tindall et al. (2017) showed BA may be effective in the treatment of depression in young people. However, the review indicated several methodological problems in the included studies meaning that the results and conclusions should be treated with caution.
A systematic review and meta-analysis of 18 studies by Orgeta, Brede and Livingston (2017) found that BA significantly reduces depressive symptoms in older people in the community; however, most studies were small and with significant bias.
Theoretical basis
Behavioural Activation is based on the well-researched understanding that depression often keeps peoople from doing the things that bring enjoyment and meaning to their lives. This “downward spiral” causes people to feel even worse. BA therapy works to reverse this cycle using an individual’s actions and choices (University of Michigan, n.d.).
BA attempts to refocus a depressed individual on activities that have a positive impact on the person’s life. Negative life events such as grief, trauma, daily stressors, or a genetic predisposition to depression can lead to a person having too little positive reinforcement and can lead to unhealthy behaviours such as sleeping in, social withdrawal, drug use, etc. These behaviours sometimes provide temporary relief, but ultimately cause negative outcomes. Therefore BA aims to increase positive experiences for a person and end negative behaviour patterns (Therapist Aid, 2014).
This sounds easy, but usually takes time and persistence. When depressed a quick fix is often more appealing that an approach that will help long-term, e.g. staying bed can be more appealing than getting up to engage in physical activity or see friends. BA is about helping people see that avoidant behaviour (staying in bed) is causing depression to worsen. For example, sleeping until noon every day to avoid stress and negative feelings has immediate consequences and long-term consequences. Immediate consequences could be missing breakfast, lack of time to exercise and not meeting daily responsibilities. Long term consequences could include increased stress due to unaddressed responsibilities, guilt about worsening health due to little activity and reduced energy due to inadequate diet (Therapist Aid, 2014).
There are tools to assist with the process and these form part of the sessions with the client. It is important to start with changes that are relatively easy and will provide something positive for the individual. As things start to improve, more challenging positive and achievement-based activities can be included in the program (McEvoy, 2016; Therapist Aid, 2014).
Advantages of Behavioural Activation
BA is no panacea, but it can be very effective at treating depression for many people. It has no side effects, which is a common concern with medications. Simplicity is its major advantage over many other treatments. Simpler treatments can be taught more quickly and cheaply and are more likely to be delivered with greater fidelity than more complex treatments. Simple treatments overcome poor concentration, a common symptom of depression (McEvoy, 2016).
Practice Approach
The following information is a synthesis of the approaches to BA from the following sources: McEvoy (2016), Therapist Aid (2014), University of Michigan (n.d.), and Lejuez, Hopki and Hopki (2001). All sources follow a similar pattern, outlined in brief on the left.
Step One: Conduct a biopsychosocial-spiritual assessment with particular emphasis on social and family relationships, employment, leisure/recreational activities, substance use, personal goals, and self-abuse intent.
Step Two: Discuss the two cycles of depression (on the left, from University of Michigan, n.d.). Educate the person about the reasoning behind BA (Therapist Aid):Turning to unhealthy behaviours is not uncommon, but they only provide temporary relief. Use the person’s BPSS to illustrate. Over time BA replaces negative behaviour with positive alternatives, but this takes effort.But failure to tackle depression makes it worse. Again, use the person’s BPSS to illustrate.
Step 3: Three of the sources above suggest the person be sent off to monitor their daily activities over the course of a week and rate their depression level (0 to 10) when engaged in these activities. The Activity Monitoring Worksheet (University of Michigan) could be used for this. However if the person is not likely to return, then a discussion about activities that cause low mood and those that do not should occur.
Step 4: Use the completed personal discussion and/or Activity Monitoring Worksheet and/or an Activity List, available from Therapist Aid, at https://www.therapistaid.com/therapy-worksheet/activity-list, to identify positive behaviours that can replace the negative behaviours. Choose both pleasurable and achievement-based activities.
Step 5: Lejuez et al.suggest placing these in order from easiest to difficult.Work with the person to choose and then plan how and when to complete the positive behaviours. Complete the Weekly Schedule for BA page, available from Therapist Aid, 2014 at https://www.therapistaid.com/therapy-worksheet/activities-behavioral-activation. Be specific: identify when, where, and how the tasks will be performed. Examine obstacles that may arise and how to overcome them. (The Barriers and Resources Worksheet from Michigan University may be of use.) Possibly modify the tasks to ensure success.It is appropriate at this stage to see if social support for the person is feasible—Can a family member or friend help the person successfully accomplish the tasks? Finally, discuss the reward that the person can attain for successful completion of the scheduled activity.Natural rewards are best.
Step 6: At the next session (or suggest the person repeat each week if this is a one-off session) evaluate the week. Praise success and problem-solve failures. Repeat steps 4 and 5 choosing a mixture of pleasurable and achievement-based activities. Remind the person it can be a long-term process. As mood and motivation improve, transition to more challenging activities with long-term payoffs.
Supporting Material
(Available on request)
Bryant, C., Brown, L., Polacsek, M., Batchelor, F., Capon, H., & Dow, B. (2020). Volunteer-led behavioural activation to reduce depression in residential care: A feasibility study. Pilot and Feasibility Studies, 6(95). https://doi.org/10.1186/s40814-020-00640-y
Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., Gilbody, S. (2014). Behavioural activation for depression; An update of meta-analysis of effectiveness and sub group analysis. PLoS ONE, 9(6), e100100. doi:10.1371/journal.pone.0100100
Lejuez, C. W., Hopki, D. R., & Hopki, S. D. (2001). A brief Behavioural Activation treatment for depression: Treatment manual. Behaviour Modification, 25(2), 255-286. Retrieved from https://www.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf
McEvoy, P. (2016). Explainer: What is behavioural activation for depression? Retrieved from https://theconversation.com/explainer-what-is-behavioural-activation-for-depression-62910
Martinez-Vispo, C, Martinez, U., Lopez-Duran, A., Fernandez del Riio, E., & Becona, E. (2018). Effects of behavioural activation on substance use and depression: A systematic review. Substance Abuse Treatment, Prevention, and Policy, 13(36). https://doi.org/10.1186/s13011-018-0173-2
Oates, L. L., Moghaddam, N., Evangelou, N., & das Nair, R. (2020). Behavioural activation treatment for depression in individuals with neurological conditions: a systematic review. Clinical rehabilitation, 34(3), 310–319. https://doi.org/10.1177/0269215519896404
Orgeta, V., Brede, J., & Livingston, G. (2017). Behavioural activation for depression in older people: Systematic review and meta-analysis. The British Journal of Psychiatry, 211, 274-279. doi: 10.1192/bpj.bp.117.205021
Richards, D., Rhodes, S., Eckers, D., McMillan, D., …Warner, F.,& Woodhouse, R. (2017). Cost and Outcome of BehaviouRal Activation (COBRA): A randomised controlled trial of behavioural activation versus cognitive behavioural therapy for depression. Health Technology Assessment, 21(46). https://doi.org/10.3310/hta21460
Ritschel, L., Ramirez, C., & Cooley, J. (2016). Behavioral activation for major depression in adolescents: Results from a pilot study. Clinical Psychology Science and Practice, 23(1), 39-57. doi: 10.1111/cpsp.12140
Soucy, I., Provencher, M., Fortier, M., & McFadden, T. (2017). Efficacy of guided self-help behavioural activation and physical activity for depression: A randomized controlled trial. Cognitive Behaviour Therapy. http://dx.doi.org/10.1080/16506073.2017.1337806
Stein, A., Carl, E., Cuijpers, P., Karyotaki, E., &Smits, J. (2021) Looking beyond depression: A meta-analysis of the effect of behavioral activation on depression, anxiety, and activation. Psychological Medicine, 51, 1491-1504. https://doi.org/10.1017/ S0033291720000239
Therapist Aid. (2014). Behavioural Activation. Retrieved from https://www.therapistaid.com/therapy-guide/behavioral-activation-guide
Tindall, L., Mikocka-Walus, A., McMillan, D., Wright, B., Hewitt, C., & Gascoyne, S. (2017). Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis. Psychology and Psychotherapy: Theory, Research and Practice, 90, 770-796. doi:10.1111/papt.12121
University of Michigan. (n.d.). Behavioural Activation for depression. Retrieved from https://medicine.umich.edu/sites/default/files/content/downloads/Behavioral-Activation-for-Depression.pdf
Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, Samaan Z, Richards D, Meader N, Churchill R. (2020). Behavioural activation therapy for depression in adults. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD013305. doi: 10.1002/14651858.CD013305.pub2.