Applied behavior analysis (ABA) has long been part of an overall psychotherapeutic approach for the treatment of clinical depression and the anxiety that is so often associated with it. However, it has more recently enjoyed a solid reputation as a stand-alone intervention, thanks to a better understanding of behavioral treatments for depression amid a growing consensus of the shortcomings of traditional interventions, and for those who are averse to using pharmaceutical anti-depressants.
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Depression is characterized by a wide variety of symptoms that include:
- Persistent anxious or sad mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, helplessness, or worthlessness
- Loss of interest or pleasure in activities and hobbies
- Decreased energy or fatigue
- Difficulty concentrating, remembering, or making decisions
- Appetite or weight changes
- Thoughts of death or suicide
Applied behavior analysis as an integral approach to mental health services expands the range of available interventions and improves therapeutic outcomes. It can be used to teach and motivate adaptive behavior through any number of ABA techniques, although behavioral activation (BA) has certainly garnered the most attention.
BA helps people reengage in their lives through focused strategies designed to counter patterns of withdrawal, avoidance, and inactivity that stem from depression.
The Birth of Behavioral Activation: A Third-Generation Behavioral Therapy for the Treatment of Depression
Major depression and the anxiety so often associated with it is an illness that affects a person’s thoughts, feelings, behaviors, and functioning, and is very often associated with feelings of intense anxiety. Depression is also among the most common mental disorder in the United States. According to the Anxiety and Depression Association of American, in 2014 about 15.7 million adults ages 18 and over experienced at least one major depressive episode in the past year—that’s 6.7 percent of all American adults. Further, about 2 out of 100 young children and 8 out of 100 teens may also suffer from major depression.
Applied behavior analysts work to understand the nature of emotions and their place in the science of behavior. Most behavioral models of depression view depression as deprivation or lack of positive reinforcement. They also recognize that behavior that is seldom positively reinforced will slow or stop altogether.
In 1953, B.F. Skinner proposed that emotions themselves are not causes of behavior; instead, they co-occur with along with related behaviors. Based on his analysis, changes in mood, emotion, and behavior can be better understood by observing changes in both environment and in the variables that motivate people. Later, Skinner’s close collaborator, Charles Ferster, identified that slowing or stopping a positively reinforced activity was the “common denominator” among patients with depression.
In addition to finding that individuals with depression and anxiety engaged in fewer behaviors that provide pleasure or enjoyment, Ferster outlined a functional analysis of depression, finding that individuals with depression and engaged in many behaviors that served to escape or avoid stimuli they found difficult. For example, staying in bed all day or avoiding social outings.
Although these behaviors may temporarily alleviate discomfort, the further reduction in activities lead to continued depression and anxiety since reducing or stopping normal and healthy behaviors leads to feelings of depression-uncertainty, reduced confidence, and helplessness.
By the 1970s, psychologists had developed a comprehensive behavioral treatment that followed a schedule of activities that the patient described as pleasant or enjoyable. In 1998, Jacobson and colleagues working on cognitive behavioral therapy (CBT) found that the behavioral component of CBT alone was as effective as CBT in both the treatment of depression and the prevention of its relapse.
Using these findings, Jacobson and colleagues developed a behavioral activation (BA) treatment model that stressed the importance of identifying individual needs and goals and using components like guided activity scheduling, mood and activity monitoring, and value-based behavioral goal setting to stop avoidance behaviors.
They used Ferster’s functional assessment model to identify the patient’s overall current living environment and depressive behaviors, including:
- Overt Behavior: Is the patient avoiding social situations, changing eating or sleeping patterns?
- Private Events: Does the patient have feelings of worthlessness or anxiousness?
- Affective Responses: Does the patient have outward signs of depression, such as crying episodes?
- Verbal Behavior: Does the patient make self-critical statements?
Behavioral activation (BA), now largely considered the third generation of behavior therapy for the treatment of depression, is just one of many functional analytic psychotherapies based on applied behavior analysis.
Applied behavior analysts use BA to help patients understand the environmental sources of their depression and then seek to target (and eventually eliminate) behaviors that may worsen or maintain feelings of dread or hopelessness.
The BA model proposes that a number of factors such as biological predispositions to depression, a specific trauma or loss, and the daily hassles of life can all lead to individuals experiencing low levels of positive reinforcement in their lives. Coping strategies, such as avoidance, may help short-term but only aggravate feelings of depression and anxiety over the long-term.
Even Better Than Anti-Depressants: Applied Behavior Analysis in the Treatment of Depression
Applied behavior analysts target avoidance using behavioral activation. They schedule activities and use graded task assignments to encourage clients to slowly begin increasing positive reinforcement. BA recognizes that the outcome of a behavior is more important than the behavior itself. It targets the inertia that often occurs with depression, helping patients take steps to begin re-engaging in life, despite their lack of motivation or negative feelings.
This treatment is designed to be a focused, brief (usually no less than 24 treatments) treatment for the alleviation of depression.
In order to achieve the benefits of BA, applied behavior analysts guide patients to slowly engage or re-engage in activities that were once pleasant. They structure activities carefully as to produce a low probability of failure for the patient and a high probability of success. Applied behavior analysts help patients select activities that are consistent with their personal values, thereby increasing the likelihood that the newly approached behaviors will be automatically reinforced or rewarded when they occur because they are meaningful to the patient.
They acknowledge patient successes in these small steps and help them experience the reward value of the achievements. As they move toward full re-engagement, applied behavior analysts support and encourage their efforts.
A 2006 trial focused on the treatment of adults with major depression found that BA is as effective as antidepressants and more effective than CBT during acute treatment. The study also found that BA is comparable to CBT in the prevention of relapse and most cost-effective and long-lasting than antidepressants.
Ongoing studies are being conducted to identify the merits of BA, not only for those with depression but also in non-clinical populations to foster well-being and help build a meaningful life.