As highlighted above, behavioural theory places the person‟s depressed condition firmly within an interrupted relationship with their environment.
in contrast to other approaches that explain depression as an internal deficit due to faulty thinking, neurotransmitter problems or unconscious conflict (Martell et al. 2001). Behaviourists do not believe depression to be due to something being „wrong‟ inside but that it is an understandable pattern emerging based upon events changing reinforcement contingencies; thus if these are explored, understood and manipulated, then the depression will
remit. Therefore treatment does not endeavour to resolve internal feelings or thoughts prior to behavioural change, but instead uses behavioural change to manipulate person-environment interactions, with the aim of subsequently improving those internal feelings. Simply put, behavioural therapy asks people not to „wait to feel right to do things‟ but „to do things to feel right‟. When planning BA treatment, the goal is to develop sources of positive reinforcement in a person‟s life that are stable (the activity and reinforcing effects are repeatable) and diverse (what Kanter describes as
„not putting all of one‟s eggs into one basket‟) (Kanter et al. 2009). If this is achieved, it is more likely that the person will maintain contact with one or more sources of value/positive reinforcement, even in the face of future problematic life events.
2.3.1 The therapeutic relationship in BA
Across all cognitive behavioural therapies establishing a good therapeutic alliance is essential. The patient is being asked to give up well-practised, safe and reinforced behaviours and to replace them with activities of uncertain outcome. Results are then evaluated and reflected upon in an approach to develop new meanings or beliefs. This collaborative
empiricism is also present in BA via the patient‟s dropping of negatively reinforced coping, replacing it with an alternative response and observing the consequences. It is crucial, then, that the therapist develops trust early in the treatment by demonstrating empathic understanding of the patient‟s experience. These non-specific factors are common across therapies (Rogers 1961) and reflect good clinical skills. The therapist also offers a clear understanding of the patient‟s problem, developing a behavioural formulation that is non-judgemental and derived collaboratively. This behavioural case formulation is then linked to a clear rationale for the treatment proposed. This approach helps the patient to realise that they can have an influence on how they feel, which can provide positive
reinforcement within sessions and thus increase ongoing engagement with therapy (Kanter et al. 2009). Throughout the course of behavioural
activation the therapist will observe and identify behaviours within the
session that may be examples of the patient‟s problem, and use their own behaviour (verbal and non-verbal) to try to decrease the frequency of these behaviours through operant methods. Similarly the therapist will attempt to identify desired changes in the patient‟s behaviour within sessions and to reinforce these. This is an approach used commonly in Functional
Analytical Therapy (FAP) and models behavioural principles which are the basis of the treatment within each session (Kanter et al. 2010).
2.3.2 BA models of delivery
Kanter et al (Kanter et al. 2010) conducted a narrative review of
behavioural therapy studies and identified several key techniques which have commonly been incorporated into treatment packages since the 1970s.
The techniques used in these studies were activity monitoring, assessment of goals and values, activity scheduling, skills training, relaxation training, contingency management, procedures targeting verbal behaviour (i.e.
cognition) and procedures that target avoidance. It is of note that the only components appearing consistently over all seven treatment manuals reviewed were activity monitoring and scheduling. This raises some interesting questions, which are yet to be addressed, as to the „active‟
components in BA (Kanter et al. 2010). While Kanter‟s helpful narrative review was not published at the time of the development of the intervention study outlined later in this thesis those studies it highlights were.
There are two main approaches to the application of behavioural theory as described earlier in this chapter used currently that have a body of
published data on their use in clinical settings; these are outlined below.
The first is known commonly as Behavioural Activation (BA) (Martell et al. 2001). This approach was derived from the BA intervention in the Jacobson (1996) study. The treatment focuses on the functional aspects of depressive behaviour, identifying environmental triggers to ineffective coping responses which are then linked to the maintenance of depression.
Primary symptoms as such (tiredness, low mood) are not the key focus of
BA. Instead, the patient is directed to pay attention to their responses to such symptoms and to their negatively reinforced attempts to cope; these are the targets of BA techniques. Thus in this model behavioural avoidance and its function is central. Treatment is delivered in 24 sessions over 16 weeks (Dimidjian 2006).
The second approach, Behavioural Activation Treatment for Depression (BATD) was developed by Lejuez and colleagues (Lejuez et al. 2001).
BATD is based on behavioural matching theory (Hernstein 1970). This model focuses on increased contact with the reinforcement of healthy (non-depressed) behaviour and reduced contact with reinforcers of depressed behaviour with the aim of decreasing depressed behaviour and increasing non-depressed behaviour. (Hopko et al. 2003). The BATD model is delivered in a 8-15 session protocol (Hopko et al. 2003).
2.3.3 Components of BA interventions
Behavioural Activation (Martell et al. 2001, Martell et al. 2010). The first sessions of BA are used to develop a therapeutic relationship with the patient, introduce the formulation and link to the treatment rationale. This aims to develop an increased awareness on the part of the patient of their attempts to cope with symptoms of depression, resulting in only short-term relief and longer-term maintenance of the condition. Initially BA uses activity and mood monitoring to build on this awareness and
understanding. Patients keep a daily diary of their activities on an hourly basis with a corresponding statement and rating of mood. This information is gradually incorporated into the initial case formulation and is used to assess general activity level and range of emotion. Associations between specific activities and mood are explored through functional analysis and related to development of understanding of the maintenance of depression.
This antecedent-behaviour-response (ABC) is developed and an acronym TRAP: Trigger, Response, Avoidance Pattern used to facilitate a shared language between the therapist and patient. Once patterns of avoidance are understood, the focus of treatment moves to re-establishing healthy
behaviours by developing new alternative coping mechanisms aimed at contact with valued goals. The BA goal is to create new opportunities for encountering positive reinforcement from the person‟s environment, again using an acronym, TRAC: Trigger, Response, Alternative Coping. BA then uses scheduling and functional analysis to reduce avoidance and increase contact with positive reinforcement throughout treatment. Identification of specific goals and alternative coping strategies are collaborative, seeking to link the patient to their particular set of values. To support this process, BA incorporates techniques such as grading activities, therapist modelling, skills training, problem-solving and mental rehearsal as methods of connecting with positive reinforcement and replacing avoidance with
„healthy behaviours‟ which is the aim of BA.
BATD (Lejuez et al. 2001, Hopko et al. 2003). As in BA, initial sessions of BATD are used to help establish a therapeutic relationship. It again seeks to identify the changes in reinforcement patterns, using these to describe the treatment rationale. BATD then employs “systematic activation” with the goal of increasing frequency and reinforcement of healthy behaviour.
As in BA, patients are asked to monitor their activities but not mood.
Activity monitoring is used to emphasise the quality and quantity of a patient‟s range of activities, and from this to provide possibilities for new behaviours to focus on in treatment. BATD then identifies goals in valued areas such as relationships, education, employment, hobbies and recreation, general health issues, spirituality etc. Within these areas, patients select 15 activities which are organised into a hierarchy of difficulty of achievement, and are then supported to work progressively through the hierarchy.
Specific weekly goals are set in relation to frequency and duration of each activity. Additional positive reinforcement is integrated by introducing rewards for completing weekly goals.
2.3.4 Using behavioural theory to improve concordance Often problems are encountered in activation approaches, moving people from patterns of negatively reinforced avoidance. Functional assessment
procedures can be used to explore obstacles to client progress and resolve problems (Kanter et al. 2009). By returning to basic behavioural principles it is possible to develop an understanding of the difficulties that may arise in therapy and developing approaches to resolve these.
In all approaches to behavioural treatments of depression all patients have clearly defined goals that reverse patterns of avoidance and introduce a sense of pleasure or accomplishment. Values differ from goals in that the term is used to describe a direction for life rather than an end point or target (Hayes et al. 1999). In order to reintegrate positive reinforcement, goals need to be linked to an individual‟s particular set of values, or they will not achieve that purpose. This means that, in order to effectively overcome potential obstacles, each set of goals used in therapy must be individually negotiated in order to correspond with each patient‟s particular set of values.
2.4 BA and improving access to the psychological treatment of