Values-based Behavioral Activation - A Clinical Review


Behavioral activation is a therapeutic module developed by Lewinsohn (Lewinson, 1971) which posits that depression is caused by one or several negative events leading to avoidance of reward-contingent behaviors as well as an increase in negative affects, which leads to a negative spiral of avoidance of rewarding behaviors and increasing negative affect over time, where behaviors generating negative affects are reinforced whilst naturally rewarding behaviors stop being reinforced. The main causal mechanism in this form of treatment is thus breaking this negative spiral by increasing patients' contact with reward-contingent behaviors, whilst decreasing avoidance. This is posited as increasing positive affects which in turn puts the patient in position to re-learn maladaptive cognitions and further engage in activities such as learning valuable skills or other important therapeutic factors. Since its original formulation, several updates have been proposed to this model, including an increased focus on not just increasing frequencies of rewarding behaviors, but also on analyzing the context in which they are rewarded as well as the function of current negative behaviors, as well as techniques such as identification of avoidance patterns, teaching functional assessment of behavior, guided activity, mental rehearsal, periodic distraction, mindfulness training, rumination-cued activation, and skills training (Lejeuz et al.,2011).

Behavioral activation is often used in a modules-based approach within standard Cognitive Behavioral Therapy, but there are studies indicating its effectiveness as a sole intervention for treating major depressive disorder. Jacobson et al (1996) found that behavioral components of CBT treatment performed as well as behavioral and cognitive interventions combined, in regards to treating major depressive disorders - able to significantly alter cognitive variables otherwise explicitly treated with cognitive interventions.

A meta-analysis by Stein (et al.,2020) showed that behavioral activation had large effect sizes ranging in comparison to inactive control - however there was a potential of publication bias, and an adjusted effect size of 0.49 was calculated based on this. However, compared to active control groups, BA still had a small but significant effect size. Interestingly, BA was also shown to have a small effect size on anxiety disorders - although there was a negligible effect size in comparison to an active control. A values-component as a module to increase BA effectiveness has been proposed as an added mechanism for change, but the authors conclude only 6 studies could be found with this approach - too few to draw any strong conclusions from the results. The authors reported significant heterogeneity in relation to different modes of BA-interventions, number of participants and number of sessions, weakening the generalisability of the analysis.

There are - however - some results indicating the effectiveness of values-based interventions in relation to BA. Values van be defined as ““freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself” (Hayes et al., 2012). These often take inspiration from Acceptance and Commitment Therapy - a form of therapy with the implicit goal of values-based action, and are never achieved - in relation to goals - and are approach-based patterns of activity that are freely chosen (Harris et al., 2010). Values are in this way defined as intrinsically motivating according to Self Determination Theory - the most widely accepted motivational framework (Desi et al., 2000).

Doi (et al., 2016) investigated how ACT-based values work affected activation, reinforcement and avoidance of behaviors during behavioral activation. A total of 314 Japanese undergraduate students from a non-clinical sample, rated their personal values, rates of depression, behavioral activation and commitment to their identified values. A series of analyses were then conducted in order to first identify whether - controlling for depressive affect - values-based action would be positively correlated with behavioral reinforcement and activation, and negatively correlated with avoidance. Secondly, whether the hypothesised correlations would be mediated by behavioral commitment to values - rather than goals. And thirdly, whether the first hypothesis would be mediated by values, rather than goals. Results did indicate that values-based actions were associated with increased behavioral commitment, which was in turn associated with completion of daily scheduled activities. However, there was no clear mediation in terms of behavioral commitment to values - indicating some other factor was involved in this association. Results also did not show that values-based action was associated with avoidance of engagement with negative states or rumination. All in all, the researchers did conclude that values-based work could contribute to the effectiveness of behavioral activation - however studied in a non-clinical population in this study.



Interestingly, BATD-R - one of the most revised manuals for behavioral activation treatment from the previous forms of BA, has emphasized scaling sessions down to 10 in number, whilst putting a greater emphasis on patients values - diverging slightly from previous more behaviorally focused manuals with the underlying assumption that values are an important part of directing action towards optimally rewarding behaviors that increase positive affect and thus create more consistent behavioral and emotional change (Lejeuz et al.,2011). A recent study tested the effectiveness of this revised BA-manual (Lee et al., 2020). 80 participants 38 healthy participants received no treatment, in contrast to 42 participants qualifying for major depressive disorder through online screening receiving BATD-R for a total of 10 weeks. Pre-and post measures were then taken for both groups, whilst comparing results. Results indicated significant alleviations of depressive symptoms for the clinical group after treatment, as well as at a 3-month follow up, whilst the healthy control group indicated no significant change. Two previous smaller studies have also tested the effects of BATD-R - showing positive indications (Collado et al.,2016; Collado et al.,2014). This supports the suggestion that values-based interventions are compatible with standard behavioral activation interventions.

An interesting detail in regards to BA interventions is that he number of behavioral activation sessions do not seem to significantly moderate its effectiveness as an intervention, according to one study (Ekers et al.,2014) Several studies also point to the effectiveness of increasing homework compliance as a mechanism for increased behavioral activation (Burns & Spangler, 2000; Busch, Uebelacker, Kalibatseva, & Miller,2010 ; Kazantzis, Deane, & Ronan, 2000; Mausbach et al.,2010; Ryba & Hopko, 2012). With BA being a heavily data-and frequency focused intervention, paper forms are often used several times within treatment - thus there is a potential of optimizing this process in a patient-centric way.

In conclusion, behavioral activation has evidence as a viable intervention for major depressive disorder, and has some efficacy for comorbid anxiety disorders where depression is conceptualised as preceding and thus causing anxious symptoms. Beginning as a strictly behavioral intervention - recent research has increased emphasis on integrating values-based interventions to increase its effectiveness, and this has so far shown promising results.


References:


Lewinsohn PM, Shaffer M. 1971. Use of home observations as an integral part of the treatment of depression: preliminary report and case studies. J. Consult. Clin. Psychol. 37:87–94


Lejuez CW, Hopko DR, Acierno R, Daughters SB, Pagoto SL. Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised Treatment Manual. Behavior Modification. 2011;35(2):111-161. doi:10.1177/0145445510390929


Jacobson,N.,Dobson,K.,Truax,P.,Addis,M.,Koerner,K.,Gollan,J.K.,...Prince,S.E. (1996). A component analysis of cognitive-behavioral treatment for depression.Journal of Consulting and Clinical Psychology, 64, 295-304.


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(9), 1491-1504. doi:10.1017/S0033291720000239


Hayes, S. C., Strosahl, K., Wilson, K. G. (2012) Acceptance and commitment therapy: the process and practice of mindful change, New York: Guilford Press.


Harris, R. (2006). Embracing your demons: An overview of acceptance and commitment therapy. Psychotherapy in Australia, 12(4), 70.


Deci, E. L., Ryan, R. M. (2000) The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychological Inquiry 11: 227–268.


Doi S, Yokomitsu K, Sakano Y. Relationships Among Valued Action, Behavioral Activation, Avoidance, and Reinforcement in a Sample of College Students. Psychological Reports. 2016;118(1):5-22. doi:10.1177/0033294115625272


Lee, J., Ford, C.G., McCluskey, D.L. et al. Testing the Effectiveness of Brief Behavioral Activation Treatment for Depression—Revised: Changes in Depression, Anxiety, Dysfunctional Attitudes, and Mindfulness. J Psychopathol Behav Assess (2021). https://doi-org.ezproxy.its.uu.se/10.1007/s10862-021-09938-4


Collado, A., Calderón, M., MacPherson, L., & Lejuez, C. (2016). The efficacy of behavioral activation treatment among depressed Spanish-speaking Latinos. Journal of Consulting and Clinical Psychology, 84, 651–657. https://doi-org.ezproxy.its.uu.se/10.1037/ccp0000103


Collado, A., Castillo, S. D., Maero, F., Lejuez, C. W., & MacPherson, L. (2014). Pilot of the brief behavioral activation treatment for depression in Latinos with limited English proficiency: Preliminary evaluation of efficacy and acceptability. Behavior Therapy, 45, 102–115. https://doi-org.ezproxy.its.uu.se/10.1016/j.beth.2013.10.001


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(9), 1491-1504. doi:10.1017/S0033291720000239




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