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A formal therapy for depression, behavioural activation focuses on activity scheduling to encourage patients to approach activities that they are avoiding and on analysing the function of cognitive processes (e.g. rumination) that serve as a form of avoidance. Patients are thus refocused on their goals and valued directions in life. The main advantage of behavioural activation over traditional cognitive-behavioural therapy for depression is that it may be easier to train staff in it and it can be used in both in-patient and out-patient settings. This article describes the theory and rationale of behavioural activation, its evidence base and how to develop a formulation that guides the strategy.
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Advances in Psychiatric Treatment (2008), vol. 14, 29–36 doi: 10.1192/apt.bp.107.004051
Over three decades ago, Ferster (1973) developed
a model of depression based on learning theory: it
stated that when people become depressed, many
of their activities function as avoidance and escape
from aversive thoughts, feelings or external situa tions.
Depression therefore occurs when a person develops a
narrow repertoire of passive behaviour and efficiently
avoids aversive stimuli. As a consequence, someone
with depression engages less frequently in pleasant
or satisfying activities and obtains less positive
reinforce ment than someone without depression.
Lewinsohn et al (1976) developed the first behavioural
treatment of depression, in which patients increased
the number of both pleasant activities and positive
interactions with their social environment. Several
promising trials were conducted but these were
forgotten with the emergence of cognitive therapy
for depression in the 1980s.
Jacobson et al (1996) set up an important study
to assess the value of the components of cognitive
therapy. They randomised 150 people with depression
to three groups: activity scheduling; activity schedul-
ing plus cognitive challenges to automatic thoughts;
and activity scheduling plus cognitive challenges to
automatic thoughts, core beliefs and assumptions
(full cognitive therapy). They found no statistically or
clinically significant differences between the groups
and concluded that the cognitive component was
redun dant. This outcome remained at 2-year follow-
up (Gortner et al, 1998). Subsequent meta-analyses of
17 studies involving over 1000 participants (Cuijpers
et al, 2006; Ekers et al, 2007) found no difference
in efficacy between behavioural approaches and
cognitive therapy in the treatment of depression in
adults. Activity scheduling has also been used with
success in people with dementia, after the training
of their caregivers (Teri et al, 1997), and in psychiatric
in-patients with depression (Hopko et al, 2003a).
In a literature review Longmore & Worrell (2007)
found little evidence that challenging the content
of thoughts significantly increased the effectiveness
of cognitive–behavioural therapy (CBT) and little
empirical support for the causative role of cognitive
change in the symptomatic improve ments achieved
in the therapy. The review did not, however, include
some of the more recent studies in anxiety disorders,
which have found cognitive approaches to enhance
graded exposure and response prevention.
Theory and rationale
of behavioural activation
Behavioural activation is a development of activity
scheduling, which is a component of cognitive
therapy. Introduced by Martell et al (2001), it has
two primary focuses: the use of avoided activities as a
guide for activity scheduling and functional analysis
of cognitive processes that involve avoidance (a
glossary of terms appears in Box 1). A simpler version
of activity scheduling without a functional analysis
of cognitive processes is described by Hopko et al
Behavioural activation is grounded in learning
theory and contextual functionalism. It is not about
scheduling pleasant or satisfying events (as in the first
stage of cognitive therapy). It does not focus on an
internal cause of depression such as thoughts, inner
conflicts or serotonergic dysfunction. The focus is on
the whole event and variables that may influence
the occurrence of unhelpful responses – both overt
behaviour and cognitive processes. Contextualisation
Behavioural activation for depression
David Veale
Abstract A formal therapy for depression, behavioural activation focuses on activity scheduling to encourage
patients to approach activities that they are avoiding and on analysing the function of cognitive processes
(e.g. rumination) that serve as a form of avoidance. Patients are thus refocused on their goals and valued
directions in life. The main advantage of behavioural activation over traditional cognitive–behavioural
therapy for depression is that it may be easier to train staff in it and it can be used in both in-patient
and out-patient settings. This article describes the theory and rationale of behavioural activation, its
evidence base and how to develop a formulation that guides the strategy.
David Veale is an honorary senior lecturer at the Institute of Psychiatry, King’s College London and a consultant psychiatrist in cognitive–
behavioural therapy at the South London and Maudsley Trust (Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, 99
Denmark Hill, London SE5 8AF, UK. Email:; website: and the Priory Hospital North
London. He is currently President of the British Association of Behavioural and Cognitive Psychotherapies.
Advances in Psychiatric Treatment (2008), vol. 14.
takes a pragmatic approach, looking at what predicts
and maintains an unhelpful response by various
reinforcers that prevent the person from reaching
their goals.
During their first sessions the rationale behind
the therapy is outlined clearly for the patient. The
therapist gives positive explana tion for the patient’s
symptoms and seeks feedback to illustrate how the
patient’s solutions are the problem, maintaining their
distress and handicap. For example, a patient might
be told that their depression is highly understand-
able given the context in which they find themselves
(perhaps a conflict in a relationship or a significant
loss). The experience of depression is regarded as a
consequence of avoiding or escaping from aversive
thoughts or feelings (called ‘experiential avoidance’).
It is emphasised that this, too, is an entirely under-
standable and natural response.
As therapy progresses, patients are taught how to
analyse the unintended consequences of their ways
of responding, including inactivity and ruminating
(e.g. trying to find reasons for the past or attempting
to solve insoluble problems). They are shown that
the effect of their ways of coping is that they become
withdrawn and avoid both their normal activities
and social interaction. This in turn leads to deeper
depression, more rumination and missing out on
experiences in life that normally bring satisfaction
or pleasure. Furthermore, the way they act affects
their environment and other people in a way that
can aggravate the depression.
Assessment and formulation
A development formulation (Box 2) is made that
focuses on social context and the way in which this
has shaped the patient’s coping behaviours. In each
session, the therapist tries to determine what contex-
tual factors are involved in the way the individual is
thinking and feeling and how that person responds
to whatever factors seem to be maintaining their de-
pressed mood. The key issue in the formulation is
determining the nature of the avoidance and escape,
and using this to guide the planning of alternative
‘approaching’ behaviours.
Figure 1 shows the formulation for a 45-year-old
married man who has been made redundant and is
avoiding seeking a new job and making any deci-
sions. His depression is explained as a consequence
of his avoidance or escaping from thoughts of fail-
ure and feelings of shame. Avoidance leads to low
levels of positive reinforcement and a narrowing of
his normal repertoires. The diagram highlights the
various secondary coping strategies that maintain the
Box 1 Glossary of terms
Activity scheduling In behavioural activation,
this a way of structuring one’s day according
to activities that are avoided and which is
consistent with one’s valued directions
Behavioural activation An evidence-based
treat ment for depression by Martell et al (2001).
One of the family of behavioural and cognitive
Cognitive fusion Ways in which thoughts,
images or associations from the past become
fused with reality and guide one’s behaviour
Contextual functional analysis Analysis of the
function of typical cognitive processes and
behaviours: a way of identifying antecedents
and consequences of a response, used to de-
termine the factors that maintain depressed
mood (see Box 3)
Development formulation Similar to a standard
psychiatric formulation, but with the emphasis
on the social context factors such as loss,
interpersonal conflict or changes in role – and
the way in which these factors have led the
patient to cope
Valued direction What is important in one’s
life. Values are not goals – they are more like
a guiding compass and must be lived out by
committed action
Box 2 Examples of avoidance in depression
Social withdrawal
Not answering the telephone
Avoiding friends
Non-social avoidance
Not taking on challenging tasks
Sitting around the house
Spending excessive time in bed
Cognitive avoidance
Not thinking about relationship problems
Not making decisions about the future
Not taking opportunities
Not being serious about work or education
Ruminating on trying to explain the past or
solve insoluble problems
Avoidance by distraction
Watching rubbish on television
Playing computer games
Excessive exercise
Emotional avoidance
Use of alcohol and other substances
Advances in Psychiatric Treatment (2008), vol. 14. 31
Behavioural activation for depression
domains. Any activity may be subject to a contextual
functional analysis, and individuals are taught to
conduct their own analysis of their way of coping
with a situation to determine whether it is helpful and
what is being avoided. They are shown that they do
have a choice. If they choose to use avoidance, they
should monitor its effect on their mood. They can
be encouraged to conduct a behavioural experiment
to compare the effect of avoidance or rumination
with that of approaching behaviours, perhaps on
alternate days, and to record the effect on their mood
and distress.
Goals and valued directions
All patients should have clearly defined goals in
the short, medium and long term that are related to
their avoidance and can be incorporated into activity
scheduling and regularly monitored. Sometimes the
goals will compete and then only some of them will
be met. Goals should include a return to normal work
and social roles as soon as possible. For those who
have been out of work for a long period, part-time
work in a voluntary capacity or retraining might be
Avoid getting a job
Watch rubbish on TV
Play on internet
Unintended consequences
Nothing changes
I get annoyed with myself
My home is a mess
More arguments
Avoid friends
Don’t answer the
or open post
Unintended consequences
Feel more isolated
Friends get frustrated
and ignore me
Worry I shall be alone
Sleep more during
the day or
watch TV
Unintended consequences
Feel more tired
Partner criticises me
Further arguments
Experience of
feeling depressed
Fatigue, crying, poor
concentration, irritability,
thinking negatively about
being a failure
Comfort eat with
lots of crisps and
Unintended consequences
I feel lethargic
Put on weight and I’m
disgusted with myself
Get more withdrawn
Ruminate on
why I’m feeling
so depressed and
attack myself for
being such a loser
Unintended consequences
Feel more depressed
Feel more ashamed
and avoid more
Fig. 1 A formulation of depression in a married man who has been made redundant and is avoiding seeking a new
job and making decisions.
experience of being depressed. These appear in the
circles surrounding the central, shaded circle, much
as petals on a flower. Behavioural activation aims to
break off each of these ‘petals’, to help the individual
to use approaching rather than avoiding behaviours
and to become active despite their negative feelings
or lack of motivation.
Secondary coping behaviours are targeted in all
types of depression, but especially when the in-
dividual is unaware of precipitating factors or, in
chronic depression, when there is no obvious trigger
or onset. In individuals who have a biological vulner-
ability, whose depression may come ‘out of the blue’
(without any apparent context), the formulation still
focuses on their reaction to the experience of being
depressed and their escape from aversive thoughts
and feelings, which are the immediate reinforcers
of their illness.
An activity log may be kept to assess the
individual’s pattern of responding and the link with
alterations in mood. It may also be used to assess
the breadth or restriction of activity, which can then
be discussed during sessions. Avoidance can take
many forms (Box 2) and the Cognitive– Behavioural
Avoidance Scale (Ottenbreit & Dobson, 2004) can help
in assessing the degree of avoidance across different
Advances in Psychiatric Treatment (2008), vol. 14.
A feature borrowed from acceptance and commit-
ment therapy (Hayes et al, 1999) is to identify the
individual’s valued directions and what they want
their life to stand for. The activity schedule that they
draw up can then be focused not only on what they
are avoiding but also on what is important to them
(although the two often overlap).
The Valued Living Questionnaire (Hayes et al,
1999) is a useful instrument for helping individuals
identify their valued directions. It offers prompts for
different types of value (‘areas’), about which the
individual writes a brief statement. Patients should
be warned not to follow values simply because others
will approve.
Values (valued directions) are not goals they
are more like a compass and must be lived out by
committed action. Thus, getting married is a goal,
but being a good partner is a value: you never reach
your destination as there is always something more
you can do. If a valued direction in life is to be a good
parent, then the first goal for a depressed patient
might be to spend a specified time each day playing,
reading or talking with their child.
Like standard CBT, a typical behavioural activation
session has a structured agenda to review the home-
work and the progress towards the goals, to discuss
feedback on the previous session and to focus on one
or two specific issues. The number of sessions to treat
depression would be between 12 and 24. Homework
is more likely to be carried out if the individual is
actively engaged in setting it and if there are agreed
times or places when it will be carried out. Sessions
are collaborative and the patient is expected to be
active and to try to generate solutions. Like CBT,
behavioural activation is not didactic but takes the
form of a Socratic dialogue. Sessions are best video-
or audio-taped for the patient to listen to again and
for therapist supervision.
The context of the relationship with the therapist is
important. Techniques of functional analytic psycho-
therapy (Kohlenberg et al, 2004) introduce learning
theory into the therapeutic relationship, showing how
it can enhance change towards the goals. It brings
the patient’s attention to what they are currently
thinking, feeling and doing about the therapist and
the therapeutic relationship. The therapist identifies
behaviours within the session that are examples of
the patient’s problems and uses their own behaviour
to decrease these; likewise, the therapist identifies
improvements in the patient’s daily life and responds
to reinforce these. The effect of the therapist’s
behaviour on the patient would be observed and
the reinforcement adjusted as necessary.
Activity scheduling
The core of behavioural activation is gradually to
identify activities and problems that the individual
avoids and to establish valued directions to be
followed. These are set out on planned timetables
(activity schedules). Individuals are encouraged to
start activity scheduling with short-term goals and
to treat their timetables as a series of appointments
with themselves. A major mistake is for a patient
to try to tackle everything at once. The aim is to
introduce small changes, building up the level of
activity gradually towards long-term goals. Days
should not be filled with activity for activity’s
sake. The activities chosen must relate to what the
individual has been avoiding and help them to act in
accordance with their valued directions. Individuals
are, however, encouraged to include activities that
are soothing and pleasurable, as rewards.
Individuals should monitor the effect of their
scheduled activities (and deviations from their plan)
on their mood. They should also evaluate whether
what they did was in keeping with their goals and
valued directions. They are encouraged to note,
and the therapist should assess, areas that are still
avoided and activities that are overused to avoid
problematic or painful thoughts and feelings. The
therapist might assist with problem-solving or use
role-play to practise activities during a session.
What does one do with cognitions?
In behavioural activation, therapists tend not to
become engaged in the content of the patient’s
thinking. Instead they use functional analysis to
focus on the context and process of the individual’s
response (Box 3). The most common cognitive
responses are rumination, fusion and self-attack.
Rumination frequently involves trying to answer
questions that cannot be answered, constantly seek-
ing reasons for the depression, fantasising (‘If only
I’d found a way to make him different’) or self-pity
(‘What have I done to deserve being treated this
Individuals with chronic depression and low
self-esteem may attack themselves verbally (‘You
fat, useless piece of shit’) or frequently compare
themselves to others.
Both rumination and self-attack serve to avoid
aversive situations such as silence or provide escape
from thinking about interpersonal problems or feel-
ings. The therapist encourages the individual to be
aware of the context (the antecedents) in which these
responses occur and the consequences of engaging
in them. These consequences usually involve some
form of avoidance and non-goal-directed activity.
Advances in Psychiatric Treatment (2008), vol. 14. 33
Behavioural activation for depression
Individuals are helped to turn ‘Why or ‘If only’
questions intoHow’ questions that relate to attaining
their goals and following their valued directions
and that can be incorporated into their activity
Cognitive fusion describes the way in which
thoughts or images from the past become fused with
reality, and information about the world is obtained
from this revised internal reality. Patients are taught
to become more aware of their surroundings and
to see events for what they are, rather than what
their mind is telling them. This process is akin to
mindfulness and involves separating the thought
of an event from the experiencing of it. Patients are
taught to distance themselves from thoughts and no
longer to engage with or ‘buy into’ them. A metaphor
for thoughts and urges that I like is traffic on a road.
Engaging with thoughts is akin to standing in the
road and trying to divert the cars (and getting run
over) or trying to get one and find a parking space
for it. However, even if one manages to divert or
park one car there are always more to be dealt with.
The goal is to acknowledge the thoughts but not to
attempt to stop or control or answer back at them.
The aim is to accept fully aversive thoughts and to
‘walk along the side of the road’, engaging with life
despite the traffic, which one can quietly ignore
(Wells, 2006; Veale, 2007).
Obstacles to activity scheduling
The most common obstacle to implementing
behavioural activation are the individual’s beliefs
about avoidance: people tell themselves that they
will engage in a particular activity when they feel
motivated or when they ‘feel like it’. The solution is
that they should always act according to the plan or
activity schedule – not according to how they feel
at the time. Individuals are told that the longer they
wait, the greater the likelihood that they will become
even less motivated: if necessary, the task should be
done now, even in an unmotivated way. ‘Just doing it’
leads to differences in the way the individual thinks
and feels, which in turn increases motivation and
changes the way others view them.
Other approaches consistent
with behavioural activation
A number of approaches recommended by the
National Institute for Health and Clinical Excellence
for mild to moderate depression (National Collabo-
rating Centre for Mental Health, 2004) are consistent
with behavioural activation and can, if needed, be
woven into therapy (Box 4).
Exercise and healthy eating
Becoming fitter is not important in behavioural
activation but increasing activity levels is. A key issue
is trying to find an activity that fits the individual’s
personality, for example their degree of competi-
tiveness or sociability (Veale & Willson, 2007).
Box 3 Contextual functional analysis: the
The following questions might be asked of a
patient who believes they are worthless.
Antecedents or context
In what situations in the past have you thought
that you were worthless?
Behaviour and cognitive processes in response
What do you do next when you think you
are worthless? Does your way of responding
include a pattern of avoidance (e.g. staying
home, not answering the phone, going to bed
and ruminating)?
What immediate effect does this activity have?
Does it make you feel more comfortable? Does
it stop you feeling or thinking something
What unintended effects does this activity
have? Does it make you feel more hopeless,
tired or depressed? What effect does this
activity have on others? Do they get annoyed
and critical?
What alternative activities could you choose
that are in keeping with your goals and valued
What effect did following your goal or valued
direction have?
Box 4 Approaches complementary to behav-
ioural activation
Exercise and healthy eating
Problem-solving therapy
Sleep management
Family or couple therapy
Compassionate mind training
Acceptance and commitment therapy
Advances in Psychiatric Treatment (2008), vol. 14.
People with depression may also eat chaotically,
neglect to eat or live off junk food. The function of
this may be to numb themselves emotionally. Eating
healthily can be incorporated into activity schedul-
ing (e.g. growing and buying food, preparing meals,
eating at set times and occasionally eating out).
Problem-solving therapy
Problem-solving therapy (D’Zurilla & Nezu, 2006)
identifies the problems to be solved and the steps a
person might take to try to solve them. Most people
do not lack problem-solving skills, but they may be
avoiding their problems. This is where the therapy
becomes integral to behavioural activation. For
example, a woman who is being physic ally abused by
her partner can be given informa tion on a women’s
shelter and could be encouraged to do a cost–benefit
analysis on using it.
Problem-solving should not be used with non-
existent problems or worries of the ‘What if’ type,
as it would merely generate further questions and
Sleep management
Sleep management (Wilson & Nutt, 1999) is integral
to behavioural activation. Many individuals with
depression have a chaotic sleep pattern or use sleep
to avoid activity. It is important to do a functional
analysis on the pattern of sleep and, if necessary,
integrate a sleep routine into an activity schedule.
Counselling is consistent with behavioural activation
provided that it is supportive in helping people to
move on in their lives and solve their problems.
Analytical counselling, trying to find reasons in the
past for current problems – ‘getting to the bottom of
it all’ may be counterproductive and can encourage
rumination and further depression.
Family or couples therapy
Sometimes partners and other family members
reinforce an individual’s avoidance; they can be
over protective, aggressive or sarcastic; they may
minimise the problem or avoid the individual.
Different members of the family may use different
ways of coping with a depressed relative, leading to
further discord on the ‘best way’.
Assessment should focus on the way different
members of the family cope with the patient’s
depression, their attitudes to treatment and how their
response affects the patient. Behavioural activation
might be used to help the family to be consistent
and emotionally supportive, perhaps helping the
individual to follow their activity schedule.
Compassionate mind training
Compassionate mind training (CMT; Gilbert, 2005)
is a newer development that can be integrated into
behavioural activation with individuals who have
chronic problems associated with shame, self-criticism
or self-attacking. Like behavioural activation, CMT
is based on a functional analysis of the self-directed
behaviour and teaches individuals to develop self-
compassion and soothing behaviours.
Acceptance and commitment therapy
Acceptance and commitment therapy (ACT; Hayes
et al, 1999) is another newer development within the
family of behavioural and cognitive psychotherapies
and it has an increasing evidence base. Its principles
overlap with those of behavioural activation, and
its focus is on the way individuals perpetuate their
difficulties through the language they use and on
how they can learn to act in a valued direction despite
their feelings. There is rich use of metaphors and
detached mindfulness of one’s thoughts without
challenging their content.
In-patients and day patients
with depression
Behavioural activation programmes can be developed
for in-patients and day patients with more severe
depression but they will depend on the enthusiasm
and leadership of a psychiatrist and supervised
staff trained in the technique (Rogers et al, 2002a,b).
Patients’ actual and planned goals and activity
levels, their avoidance profile and valued directions
might be reviewed by nursing staff in a group or
individually at the beginning and end of each day.
In their daily interactions with patients, nursing staff
would discourage avoidance and reinforce approach
Creativity may be required to ensure that
individuals act in their valued directions during
their in-patient stay. In tackling avoidance of friends,
for example, the patient might first be encouraged
to make contact by text message, followed up by
telephone calls or a meeting and making plans for
the future. A valued direction for friendship that is
honest and caring might be explored by sharing with
a friend what it is like to be depressed and asking
about the friend’s experience of the depression; this
might open up the opportunity to give and receive
emotional support.
Advances in Psychiatric Treatment (2008), vol. 14. 35
Behavioural activation for depression
Antidepressant medication
It is more scientifically correct to tell patients that
neurotransmitter abnormalities are not causes of
depression so much as associations with it, and that
an antidepressant may enhance neural transmission
rather than correct a defect. Antidepressant medi-
cation can be combined with behavioural activation
in moderate to severe depression, although no data
exist on whether the combination increases efficacy
or cost-effectiveness of treatment, especially in the
long term.
It can sometimes be helpful to consider identify-
ing the function of psychotropic medication for a
patient and whether they are seeking medication
to avoid aversive thoughts and feelings. It might
be said that the goal of antidepressant medication
is to feel better, whereas the goal of behavioural
activation is to help the individual both to develop
better feelings and to do the things they value in life
including whatever they are avoiding despite the
way they feel. Philosophically, behavioural activation
teaches patients that depression is a natural response
to an aversive environment, rather than a brain
dysfunction, although it does accept that there is
a stronger biological component in some forms of
A big problem is patient choice and access to
evidence-based psychological therapies: individuals
are more likely initially to be offered medication,
whereas they would have been more likely to have
chosen an evidence-based psychological treatment,
had it been offered (Veale, 2008).
The evidence base for behavioural
A key evaluation of behavioural activation as a
treat ment for depression occurred in a randomised
controlled trial in which it was compared with
stan dard CBT, an antidepressant (paroxetine) and
a drug placebo in 214 out-patients (Dimidjian et al,
2006). Participants receiving behavioural activation
or CBT attended a maximum of 24 × 50-minute
sessions over 16 weeks. Depression, therapist
adherence, therapist competence, response and
remission were measured. In the participants with
more severe depression, behavioural activation was
found to be as efficacious as paroxetine and more
efficacious than CBT. Compared with paroxetine,
behavioural activation brought a greater percentage
of participants to remission and retained a greater
percentage in treatment.
Thus, behavioural activation is effective across
the spectrum of illness severity, as a low-intensity
treatment for mild to moderate depression in the
community up to intensive treatment for day patients
and in-patients with severe depression. It is there-
fore a very suitable therapy for use in stepped care.
(Stepped care is a way of using limited resources
to greatest effect. For most people, complex inter-
ventions are given only when simpler and cheaper
ones have been shown to be inadequate.) Behavioural
activation lends itself to manualised self-help
although the long-term cost-effectiveness of self-help
books for the intervention (Addis & Martell, 2004;
Veale & Willson, 2007) with or without the support
of a low-intensity worker has yet to be evaluated.
Another potentially fruitful possibility would be
computerised behavioural activation with minimal
support for mild depression.
Why choose behavioural
Behavioural activation may be currently unpopular
because it lacks the complexity of other psycho-
therapies (e.g. cognitive therapy’s challenging of core
beliefs and schemas). For some, it has associations of
reward and punishment or a therapist who is cold
and unresponsive. Some think it a simple therapy
suitable only for mild illness. The principles may be
relatively simple but it is still hard for the patient to
carry out. Furthermore, the therapist must still make
an individual formulation of the factors maintaining
the patient’s depression and must have good super-
vision and training. Complex problems often require
the therapist to carry out simple procedures well –
rather than undertaking ever more complex ones.
An advantage of behavioural activation over tradi-
tional cognitive therapy for depression is that it may be
easier to train staff in its use. And as discussed above,
it may have greater efficacy in severe depression.
Among its advantages over antidepressants is that
patients may find it more acceptable and it may be
more cost-effective in the long term.
The priority for research is to determine the cost-
effectiveness of behavioural activation for both mild
to moderate depression with low-intensity workers
in stepped care and for severe depression either alone
or in combination with antidepressant medication.
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MCQ answers
1 2 3 4 5
a F a F a F a F a F
b F b T b T b T b F
c F c F c F c F c F
d F d F d F d F d F
e T e F e F e F e T
1 Functional analysis:
ignores cognitive processes such as ruminationa
cannot be used for the therapeutic relationshipb
cannot be taught to patientsc
is concerned with challenging the function of an d
aims to determine whether an activity is immediately e
reinforcing and more likely to occur again and the
unintended consequences in the long term.
2 Cognitive processes in depression include:
thought dissociation a
rumination to find reasons for being depressed b
over-inflated sense of responsibility for harmc
cognitive fissiond
3 Activity scheduling involves:
scheduling only pleasant and satisfying activitiesa
scheduling activities that have been avoided b
negative reinforcementc
buzzers to prompt the patientd
starting an activity only when a person feels e
4 Assessment for behavioural activation in depression
beliefs about the self, world and the future a
types and degree of avoidanceb
understanding a detailed developmental history and d
the causes of depression
ignoring the context of interpersonal relationships. e
5 Behavioural activation:
should be used only for simple cases of depression a
is linked to operant conditioning of rewards and b
has, for some, an incorrect association of reward and c
punishment or a cold, unresponsive therapist
is a preliminary to cognitive or ‘deeper’ therapy d
can be used in people with severe depression as an e
alternative to antidepressants.
... This approach has been widely used in behavior modification (e.g., Magidson et al., 2014) as well as in settings relevant to procrastination, for example, in organizations (e.g., Wilder et al., 2009) and schools (e.g., Vargas, 2013). Notably, in the analysis and treatment of depression, a method based on functional analysis, the behavioral activation for depression model (e.g., Veale, 2008), has been found to be a viable approach, and randomized clinical trials have documented this approach to be comparable to CBT (Cuijpers et al., 2007;Dimidjian et al., 2014;Simmonds-Buckley et al., 2019;Stein et al., 2020). Martell et al. (2022) provide an in-depth clinical overview of this approach. ...
... Fourth, as the behavior that is procrastinated often will occur at a lower frequency than is needed for proper goal attainment, an understanding of how to increase the frequency of goal-relevant behavior is necessary. Here, behavioral activation (e.g., Veale, 2008;Kanter et al., 2010;Martell et al., 2022) presents well-documented techniques. In fact, research on behavioral activation for depression indicates that the use of simple strategies to increase behavioral frequency may also have a positive impact on the mood associated with the target behaviors. ...
... Activity monitoring and subsequent activity scheduling are the first steps in behavioral activation (Kanter et al., 2010). For example, in the monitoring of depression (Veale, 2008), daily activities are initially monitored using a detailed coding system that, hour by hour during the day, specifies the concrete activities done as well as the mood associated with the activity. In the case of academic procrastination, a similar approach may be used (e.g., Suh et al., 2021;Martell et al., 2022). ...
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Academic procrastination – habitually delaying work with academic tasks to the extent that the delays become detrimental to performance, wellbeing, and health – represents a substantial personal, systemic, and societal problem. Still, efforts to prevent and reduce it are surprisingly scarce and often offered as treatment regimens rather than preventive efforts. Based on the principles of functional analysis and a broad examination of factors that are important for academic procrastinatory behaviors, this paper aims to describe a strategy for analyzing individual controlling conditions for procrastination and give parallel advice on how to change those controlling conditions. Both are ideographic, allowing for individual and dynamic analyses of factors responsible for instigating and maintaining procrastination, as well as tailor-made remedies that address controlling conditions in preventive and curative efforts to reduce procrastination. Although functional analysis integrates well with important research findings in the procrastination field, this approach suggests new criteria for identifying procrastinatory behaviors and an alternative model for analyzing their control conditions. We conclude that a functional approach may supplement procrastination research and efforts to prevent and alleviate this detrimental habit.
... ej., sensación de identidad grupal, interacción con el resto), al logro de habilidades motrices (p. ej., sensación de autoeficacia), a la mejora de la apariencia física y al efecto evasivo frente a estresores y pensamientos rumiativos Veale, 2008). En tercer y último lugar, la hipótesis comportamental incluye otros factores que estarían positivamente influidos por la actividad física, como puede ser la duración y calidad del sueño, los cuales a su vez mejorarían la salud mental del individuo . ...
... ej., sensación de identidad grupal, interacción con el resto), al logro de habilidades motrices (p. ej., sensación de autoeficacia), a la mejora de la apariencia física y al efecto evasivo frente a estresores y pensamientos rumiativos Veale, 2008). En tercer y último lugar, la hipótesis comportamental tiene en cuenta otros factores que estarían positivamente influidos por la actividad física, como puede el sueño nocturno, el cual a su vez mejoraría la salud mental . ...
Adolescence is a key life stage in relation to health habits due to the convergence of two main aspects. On the one hand, is common to observe a decrease in different indirect and direct health indicators throughout adolescence. On the other hand, it seems to be a critical period for the establishment of lifestyle behaviors in later years. Under these premises, there is a need to understand in depth the complex variables network that surrounds health during adolescence in order to provide useful information for prevention and/or improvement policies. As part of such a broad undertaking, the present doctoral research included the following four objectives: 1) To know the link between body dissatisfaction and other health, psychology and sociology variables. 2) To evaluate the bidirectional/temporal associations between wakefulness movement and sleep. 3) To investigate the longitudinal relationship between wakefulness movement and mental health. 4) To observe the evolution of wakefulness movement and sleep throughout adolescence. In order to achieve these goals, a longitudinal cohort study was carried out with three repeated measurements over 3 consecutive years. A convenience sample technique was used with voluntary participation in the city of Avilés (Asturias, Spain). In total, 246 students in the 2nd year of Compulsory Secondary Education were initially involved (x̄ = 13 years, 46% girls). In each annual measurement, adolescents wore an Actigraph GT3x+ triaxial accelerometer for a full week and completed several validated questionnaires. Taking into account the results: first, body dissatisfaction seems to be a highly prevalent phenomenon, especially among girls. Moreover, it appears to be related to BMI, psychological well-being, physical self-concept, and sleep efficiency. Second, the bidirectional and temporal relationships between wakefulness movement and night sleep are partial, depending on the constructs and the number of days analyzed. It is possible that physical activity exerts benefits in night sleep, whereas sedentary behavior could harm it. On the other hand, night sleep could help to be more physically active. Lastly, the relationships between wakefulness movement and nocturnal sleep could be highly influenced by factors such as school schedules and other diary routines. Third, it seems changes in physical activity levels at all three measured intensities (light, moderate, vigorous) are positively associated with psychological well-being, at least in girls. Finally, except for the small increase in vigorous physical activity, adolescence appears to be a period marked by a progressive impairment of wakefulness movement and sleep. In addition, cross sectional results showed in all measurements a low compliance with the official physical activity and sleep guidelines. The present research provides new useful information for the necessary subsequent studies in each of the topics explored, as well as for the development of intervention policies by the health competent authorities.
... Despite this, healthcare services usually fail to detect or treat depression in people with NCDs, particularly in LMICs (World Health Organisation, 2014). Behavioural Activation (BA) is a simple, flexible and effective psychological therapy for depression and has shown to be portable across cultures (Kanter et al., 2012;Veale, 2008). BA focusses on the link between behaviour and mood rather than thoughts and low mood (Kanter et al., 2012;Veale, 2008). ...
... Behavioural Activation (BA) is a simple, flexible and effective psychological therapy for depression and has shown to be portable across cultures (Kanter et al., 2012;Veale, 2008). BA focusses on the link between behaviour and mood rather than thoughts and low mood (Kanter et al., 2012;Veale, 2008). Focussing on behaviour change sidesteps alternative beliefs about depression, such as having a faith/spiritual basis (for example, being punished by God, being possessed by a demon) without the therapist being required to support the depressed person to tackle associated negative stigmatising thinking patterns (cognitive restructuring). ...
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The cultural tailoring of interventions is a cost-effective approach to reach underserved populations. There are multiple frameworks for intervention adaptation, however, information on their use in practice, and sources to guide the adaptations is limited. The aim of this paper is to describe our experience using intervention adaptation frameworks and illustrate the adaptation process of a behavioural activation intervention for depression in people with type 2 diabetes in Bangladesh and Pakistan. We were guided by the intervention mapping adaptation framework for development and evaluation of health interventions and the Bernal and the Escoffery frameworks to address the cultural components of the adaptation. We performed a needs assessment, developed a logic model and systematically searched for available evidence-based interventions. To obtain evidence to guide the adaptations, we conducted a literature review, a qualitative study and workshops with community, expert advisory panels and a co-design group which systematically fed into the adaptation process. We co-produced the materials (training manual and booklet) with stakeholders. Finally, an implementation and evaluation plan was produced to test the feasibility and effectiveness of the intervention. We selected 3 interventions that had a good fit for our target population. Guided by the logic model, we identified core components of these interventions that could not be changed. We made changes in the language, pictures, illustrations, intervention dose and delivery (self-guided versus facilitator), inclusion of carers and/or family members, and training intensity. We developed a protocol to test the feasibility and effectiveness of the intervention considering key changes from the original intervention and the characteristics of the new setting and target population. Intervention adaptation frameworks proved to be valuable tools to guide the intervention process, and ensure the inclusion of multiple sources of evidence and key stakeholders.
... Low mood referrals were significantly more likely to generate 'personal or hobby-related goals'. Behavioural theories of depression state when one becomes depressed, many of their behaviours function to avoid and escape aversive thoughts, feelings or external situations (Veale, 2008). Consequently, those with low mood or depression engage less frequently with rewarding or satisfying activities and receive less positive reinforcement than those without depression, further exacerbating their symptoms. ...
Full-text available
Clinical goal setting is an important area of practice within mental health interventions for children and young people (CYP). The present research aimed to explore the type of intervention goals set by CYP during mental health interventions. Further, changes in goal progress from pre-to post-intervention were compared between externally observed behavioural goals and subjective feelings-based goals. The relationship between therapeutic goal achievement and changes in symptoms of depression and anxiety (measured using the Revised Children's Anxiety and Depression Scale) was also investigated. Data were collected from 792 participants aged 3 to 18 years (mean age: 13.8, SD: 2.85) across all gender identities and ethnicities, who received low-intensity cognitive behavioural therapy interventions from Children's Wellbeing Practitioners in the Southwest of England. A mixed methods approach involving conceptual content analysis, correlational analysis, and group comparisons was utilised. Eleven categories of child-rated goals were identified. The most commonly developed goals focused on understanding, managing, and expressing emotions and feelings. No significant differences were found between behavioural and feelings-based goals (p = 0.061). Partial correlations demonstrated that improvements in goal progress were significantly associated with reductions in depression and anxiety symptoms (rs > −0.157, p < 0.001), even when controlling for the number of sessions attended (rs > −0.146, p < 0.001). Integrating goal-based outcomes with standardised measures could enhance a comprehensive approach to service delivery and evaluation.
... CBT may reduce rumination through the introduction of cognitive restructuring that encourages more adaptive thinking, problem-solving to address current stressors, and behavioral activation, which may increase opportunities to learn information incompatible with depressive cognitions (Veale, 2008). Indeed, CBT has been shown to be effective in reducing rumination (Spinhoven et al., 2018;Wilkinson and Goodyer, 2008). ...
Background: Rumination is strongly associated with depressive symptom severity and course. However, changes in rumination during outpatient cognitive behavioral therapy (CBT), and their links to baseline features such as distress tolerance and clinical outcomes, have received limited attention. Methods: 278 outpatients with depression received group or individual CBT. Measures of rumination, distress tolerance, and depression symptom severity were assessed at baseline and periodically during treatment. Mixed effect and regression-based models evaluated changes over time, and associations between rumination, distress tolerance and depression severity. Results: Depression and rumination decreased throughout acute treatment. Rumination reduction was concurrently associated with depressive symptom reduction. Lower levels of rumination at each time point prospectively predicted lower depressive symptoms at the next time point. Distress tolerance measured at baseline was positively associated with depression symptom severity; the indirect effect on post-treatment depression symptoms via rumination measured mid-treatment was nonsignificant when rumination at baseline was unaccounted for. Changes in and associations between depression and rumination were replicated in sensitivity analyses; although changes in depression and rumination were smaller in magnitude in patients receiving treatment during COVID-19. Limitations: Additional assessment points would permit a more nuanced assessment of the role rumination may play in mediating the associations between distress tolerance and depression severity. Additional investigation of treatments in community settings may also further our understanding of variability in rumination during depression treatment. Conclusions: The current study provides unique real-world support for variability in rumination as a key indicator of change over the course of CBT for depression.
... It might be that in the CBT delivery there was a greater focus on altering ruminative thinking processes than the content of negative thoughts and self-beliefs themselves. 31 For both treatments, self-beliefs may represent an important target as we found an indirect effect of treatments on depressed mood via thoughts of being a failure. ...
Full-text available
Background Cognitive–behavioural therapy (CBT) and counselling for depression (CfD) are recommended first-line treatments for depression. While they approach change differently, there is little understanding of the impact those approaches have on change during treatment. Objectives This study aimed to identify whether CBT and CfD target different symptoms and explore the implications of modelling choices when quantifying change during treatment. Methods Symptom-specific effects of treatment were identified using moderated network modelling. This was a retrospective cohort study of 12 756 individuals who received CBT or CfD for depression in primary/community care psychological therapy services in England. Change was modelled several ways within the whole sample and a propensity score matched sample (n=3446). Findings CBT for depression directly affected excessive worry, trouble relaxing and apprehensive expectation and had a stronger influence on changes between suicidal ideation and concentration. CfD had a stronger direct influence on thoughts of being a failure and on the associated change between being an easily annoyed and apprehensive of expectation. There were inconsistencies when modelling change using the first and second appointments as the baseline. Residual score models produced more conservative findings than models using difference scores. Conclusions CfD and CBT for depression have differential effects on symptoms demonstrating specific mechanisms of change. Clinical implications CBT was uniquely associated with changes in symptoms associated with anxiety and may be better suited to those with anxiety symptoms comorbid to their depression. When assessing change, the baseline should be the first therapy session, not the pretreatment assessment. Residual change scores should be preferred over difference score methods.
... First, physiological factors may improve the brain structure and function (e.g., new capillaries growth, increased gray matter activation, greater BDNF production) through mechanisms such as the natural opiates secretion (e.g., serotonin, dopamine, endorphins, norepinephrine), the stress hormones inhibition (e.g., cortisol) and an improved blood supply Rodriguez-Ayllon et al., 2019;Schuch et al., 2016). Second, psychosocial factors may improve the person´s mood and life satisfaction through mechanisms such as social interaction (e.g., sense of identity, community participation), psychomotor skills achievement (e.g., learning new movements, achieving goals), and the distracting effect against stressors, negative and ruminative thoughts (Morgan et al., 2016;Veale, 2008). Third, the behavioral hypothesis highlights the possible PA benefits on factors such as sleep quality and duration, which that in turn would affect mental health outcomes . ...
Full-text available
There is a lack of studies that examine the longitudinal relationship between physical activity (PA) and mental health with accelerometers in adolescent populations. The current study aimed to investigate whether changes in PA intensities and sedentary time (ST) are associated with mental health in a cohort of adolescents. 246 (130 boys, 116 girls) high school adolescents aged 13-15 years old (13.28 ± .57) were recruited in a city from the north of Spain. PA and ST levels were assessed by accelerometry. Psychological well-being (PWB) was measured using a self-reported validated questionnaire. Regression linear models were implemented by including PWB as the dependent variable and PA intensities and ST as predictors. Girls who increased light, moderate, and vigorous PA had significantly better PWB at follow-up, whereas no longitudinal associations were found for boys. No association between ST and PWB was identified. The results suggest changes in PA, but no in ST, have an association with PWB in adolescents. Nevertheless, the associations were stronger in girls than in boys. Because girls showed worse PWB at both time points, an optimal threshold for PA influence on mental health could explain the results. Future research is warranted.
... Behavioural Activation (BA) is an established therapy for acute unipolar depression [10] that seeks to re-establish healthy patterns of activity and replace behaviours that function to avoid or manage distress with more adaptive behaviours that are rewarding, or constructive in the longer term [11]. An advantage of BA in unipolar depression is that is appears to be as effective as Cognitive Behavioural Therapy (CBT), whilst arguably being simpler to train and to deliver [12]. ...
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Behavioural Activation (BA) is associated with a substantial evidence base for treatment of acute unipolar depression, and has promise as an easily disseminable psychological intervention for bipolar depression. Using a randomised multiple baseline case series design we examined the feasibility and acceptability of an adapted version of BA in a U.K. outpatient sample of 12 adults with acute bipolar depression. Participants were allocated at random to a 3–8 week wait period before being offered up to 20 sessions of BA. They completed outcome measures at intake, pre- and post-treatment and weekly symptom measures across the study period. Retention in therapy was high (11/12 participants completed the target minimum number of sessions), and all participants returning acceptability measures reported high levels of satisfaction with the intervention. No therapy-related serious adverse events were reported, nor were there exacerbations in manic symptoms that were judged to be a result of the intervention. The pattern of change on outcome measures is consistent with the potential for clinical benefit; six of the nine participants with a stable baseline showed clinically significant improvement on the primary outcome measure. The findings suggest adapted BA for bipolar depression is a feasible and acceptable approach that merits further investigation.
... Thus, preferred medications may be those which are effective and have a favorable side effect profile, i.e., low risk of gaining weight. Psychotherapeutic interventions that increase activity, such as cognitive behavioral therapy (62), acceptance and commitment treatment (54,63), or behavioral activation (64,65), have shown efficacy in the treatment of depression but may also be beneficial for cardiac health although evidence in this regard is currently lacking. Other psychological interventions have also shown effectiveness particularly in patients with underlying ACE, such as the cognitive behavioral analysis system of psychotherapy (CBASP) (66,67). ...
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Background and aim: Adverse childhood experiences (ACEs) are a major risk factor for unfavorable behavioral, mental and health outcomes later in life. However, the precise pathway via which ACEs convey these risks, in particular regarding health outcomes such as cardiovascular disease, remains unknown. Here, we combined psychiatric and cardiac methods to investigate the pathway via which childhood adversities may lead to adult adverse cardiovascular health, with a focus on epicardial adipose tissue (EAT) as a risk marker. Methods: 210 adult congenital heart disease outpatients (mean age 35.5 y, 43% female) completed a thorough cardiac and psychiatric evaluation. Psychiatric measurements included an expert interview, the childhood trauma questionnaire (CTQ), Beck's depression inventory II (BDI-II), quality of life and the global scale of functioning, amongst others. All patients completed a full cardiac workup including EAT assessment using echocardiography. We then computed bootstrapping mediation models using ACEs as a predictor, depression and physical activity as mediators and EAT as dependent variable in PROCESS. Results: CTQ scores had a significant indirect effect on EAT via a serial mediation of BDI and physical activity [a*b2*d = 0.0260, 95% BCa CI [0.0047, 0.0619]]. Conclusion: Using mediation analyses, we show that adverse childhood events are linked to increased depressive symptoms, which are linked to decreased physical activity, which in turn are linked to a higher amount of epicardial adipose tissue. While other pathways most certainly exist and replication is needed, this suggests a meaningful pathway via which ACEs lead to adverse cardiovascular health, with several potential targets for health interventions across time.
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In the UK, the National Institute for Health and Clinical Excellence's guidelines on obsessive - compulsive disorder (OCD) recommend cognitive - behavioural therapy, including exposure and response prevention, as an effective treatment for the disorder. This article introduces a cognitive - behavioural model of the maintenance of symptoms in OCD. It discusses the process of engagement and how to develop a formulation to guide the strategies for overcoming the disorder.
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Depression is a significant public health issue and many researchers have suggested that modifications to conventional cognitive-behavioral therapy (CBT) are required to address infrequent help-seeking in men and counter negative effects of traditional masculinity on therapeutic engagement. This narrative review summarizes recommended alterations to CBT in the areas of therapeutic setting, process, and content. Key themes from this literature include a focus on behavioural interventions, and harmful cognitions that orginate from the traditional male gender stereotype. This literature is marked by limited empirical support for many of the recommended treatment modifications, and several options for future research are outlined.
This two-part Continuing Professional Development article presents the treatment of behavioural activation as a justifiable treatment intervention for depression. Part one will set the scene by examining the nature and assessment of depression. Then we review the evidence for psychosocial and medical interventions. Third, we explore the strengths and limitations of current psychological interventions, taking into account their efficacy, costs and training requirements. Finally, we will summarise behavioural theories of depression.
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
Human beings use language to shape their world: to structure it and give it meaning. Language builds our skyscrapers, imparts the strength to our steel, creates the elegance of our mathematics, and forms our art’s depiction of beauty. Language has been the source of so much human achievement that it is only natural that we look to it first to identify a problem and craft a solution. But it is precisely because language can be so useful that it can also be problematic. Language not only enables human achievements, but also our ability to project fearsome futures, to compare ourselves to unrealistic ideals and find ourselves wanting, or to torment our souls with the finitude of life itself. Language is at the core of the remarkable human tendency to suffer in the midst of plenty.
One-third of our lives is spent asleep, but the reasons why we sleep are not yet fully understood. Sleep is a state of inactivity accompanied by a loss of awareness and a markedly reduced responsive ness to environmental stimuli. When a recording is made of an electroencephalogram (EEC) and other physiological variables such as muscle activity and eye movements during sleep (a technique called polysomnography) a pattern of sleep consisting of five different stages emerges. This pattern varies from person to person, but usually consists of four or five cycles of quiet sleep alternating with paradoxical (active) sleep, with longer periods of paradoxical sleep in the latter half of the night. A representation of these various stages over time is known as a hypnogram, and one of these derived from a normal control subject is shown in Figure 1. The quiet sleep is divided further into four stages, each with a characteristic EEC appearance, with progressive relaxation of the muscles and slower, more regular breathing as the deeper stages are reached. Most sleep in these deeper stages occurs in the first half of the night.