Behavioral Activation (BA) is a form of short-term outpatient therapy that engages individuals in rewarding activities of their own choosing as a way to counter the negative feelings and withdrawal that are typical of depression. Increasingly, BA is being applied in the treatment of anxiety as well. Behavioral Activation is a basic component of Cognitive Behavioral Therapy, but, applied intensively, it is also used as a treatment in its own right and can be incorporated into many other types of therapy.
BA is a way of changing from the outside in—jump-starting individuals back to the kind of life they once enjoyed. Evidence suggests that even in small doses, engaging in a constructive activity is positively reinforcing, not only rekindling interest in and energy for the activity but providing a sense of achievement—enough to disrupt the negative feelings, avoidant behavior, and disturbed mood that keep people trapped in depression, and the avoidant behavior that is the hallmark of anxiety.
Under the active guidance of a therapist, individuals are assigned to activities they themselves select—whether meeting a friend for coffee, listening to a podcast, or going for a walk in the park—and learn to formulate and accomplish behavioral goals.
The changes in overt behavior are accompanied by changes in thoughts and mood. A number of studies suggest that Behavioral Activation is the component of CBT most responsible for its effectiveness and that it is at least as effective as antidepressant medication, even among the severely depressed.
BA is suitable for people with depression who are not at immediate risk of self-harm. Studies indicate that it may be especially useful for those who are chronically depressed. It is also suitable for those with depression or anxiety who do not want to take medication, or who can’t tolerate medication or its side effects, or for whom medication has failed to relieve symptoms.
Studies show that BA is at least as effective as antidepressant medication, even for people with severe depression. Moreover, because it is action-oriented, it can be used to help people who are reluctant to talk about their feelings or do not have the language to do so
BA usually takes place in weekly sessions for anywhere from eight to 24 weeks, depending on depression severity and response to treatment. One of the essential ingredients of BA is understanding that depression works in vicious cycles. A stressful or negative event—such as ending a relationship or losing a job—triggers negative thoughts and feelings and behavioral shutdown. People withdraw from pleasurable social and other activities; the isolation amplifies negative feelings and provides no relief from them, intensifying depression.
The first step in BA is activity monitoring. Individuals are provided with worksheets on which they note daily activities and rate the moods each is associated with. Next, individuals identify their life values and goals—whether related to work, learning, health and fitness, family, friendship, intimacy, entertainment, or more—as a guide to choosing concrete activities they will focus on adding to their days. They select a mix of those they find meaningful and those that build a sense of mastery, as well as those that bring pleasure.
Then, usually one week at a time, individuals create daily schedules in which they build in both meaningful activities and enjoyable ones. The activities deemed pleasant and those delivering mastery will be different for each person, as will the balance of the two kinds of activities.
In sessions, individuals discuss how to problem-solve, especially how to motivate themselves when they feel stuck. Between sessions, individuals can expect assignments that focus on workarounds for any specific obstacles they encounter in getting things done. And while no one activity will alleviate depression, the effects of building routines of activities and accomplishing goals will build over time.
BA is based on the knowledge that inactivity leads to depression, which leads to more inactivity and deeper depression. BA provides a way of feeling better quickly, directly stimulating improvement in mood through action.
In depression, people generally disengage from their routines and withdraw from their environment; as a result, there is no source of pleasant or rewarding experiences to draw on to motivate continued engagement. With BA, the activity itself generates changes in body physiology and chemistry that are mood-enhancing.
BA works in more sustaining ways as well—participating in valued activities provides a sense of achievement that counters the negative thinking that keeps depressed people stuck. Over time, individuals build a sense of mastery that helps make them emotionally resilient.
Two regimens of BA are in general use—standard BA, presented in 20 to 24 sessions, and a brief form, lasting eight to 12 weeks, called Behavioral Activation Treatment for Depression (BATD). Both focus on activity monitoring and scheduling in accordance with what people value, and both address obstacles to activity and problem-solving.
A BA therapist can be a licensed mental health professional who has additional training and experience in BA or a community health worker who has also undergone training in BA. The training in BA may be stand-alone or embedded in classic training for Cognitive Behavior Therapy, as BA is one of the component skills of CBT. All CBT therapists have had some training in BA.
While BA therapists follow standardized treatment protocols, experience counts. It is advisable to seek a therapist who has not just training but experience using BA to treat people presenting with concerns such as yours.
As with all forms of therapy, it is important to find a BA therapist with whom you feel comfortable. Look for someone with whom you can establish clarity of communication and a sense of good fit.
You might ask a prospective therapist such questions as:
- How often have you dealt with problems such as mine before?
- How do you know whether my situation is a good candidate for BA?
- How does BA work?
- What is a typical plan of treatment, and how long is a typical course of therapy?
- How do you measure progress?