CBI – Literatuur college 3
Experiential and Behavioral interventions in Depression
Voorbereiding
Chapter 9 – Behavioral activation (O’Donohue & Fisher, 2012).
Chapter 13 – Principles of positive psychology (O’Donohue & Fisher, 2012).
Chapter 14 – Acceptance and cognitive-behavior therapy (O’Donohue & Fisher,
2012).
Chapter 9 – Behavioral activation
In behaviorism, the principle of positive reinforcement is fundamental, and contingencies
indicate meaning. This means that the meaning of a behavior can be derived from the
reinforcers (consequences of the behavior) or from the antecedents of the behavior. This
notion of positive reinforcement embodies the core principle of Behavioral Activation (BA)
as a treatment for depression. The goal of BA is to increase client contact with diverse, stable,
and personally meaningful positive reinforcement, to reduce depressive symptoms and
increase purpose and meaning in life. BA regulates this core principle through a specific set of
primary treatment techniques, aimed at scheduling specific activities for the client to engage
in to contact positive reinforcement. These primary techniques are supplemented by several
secondary techniques to identify the right set of specific activities to schedule, maximize the
chance of successful activity completion, and troubleshoot obstacles and problems when
activities are not completed.
Definition of the principle of Behavioral Activation
There are many versions of BA treatment, each with varying and overlapping techniques and
treatment mechanisms. The common core treatment element across all different variants of
BA appears to be activity scheduling, to contact positive reinforcement. Thus, the principle
of BA may be defined as the therapeutic scheduling of specific activities for the client to
complete in his or her daily life that function to increase contact with diverse, stable, and
personally meaningful sources of positive reinforcement. Several elements of this definition
require elaboration;
First, the focus on scheduling of specific activities sort of excludes certain commonly
used BA techniques, such as activity monitoring, contingency management, and skills
training techniques. These techniques are certainly important within BA treatment,
with the only distinction being that activity scheduling is seen as a primary BA
technique, and the rest as secondary techniques. These secondary techniques will also
be discussed, later on.
Secondly, another important component of BA are the techniques that focus on
reducing escape and avoidance behaviors that are negatively reinforced. These
techniques are important components of BA, but ‘only’ as a means of the fundamental
goal, namely increasing contact with positive reinforcement. The ultimate focus on
increasing positively reinforced behavior rather than decreasing negatively reinforced
behavior highlights that BA is a constructive therapy, with a goal to help clients
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, create rich, meaningful lives, and not just simply reduce symptoms or eliminate
problem behavior.
Thirdly, the definition specifically employs the behavioral term positive
reinforcement rather than other similar terms, such as rewarding experiences or
pleasant events. Use of the term reinforcement allows BA’s fundamental principle to
benefit from the vast body of knowledge behind the principle of reinforcement,
providing a strong theoretical foundation to guide (future) research. However, the term
reward, which is preferred by neuroscientists, is often used as a synonym, which also
isn’t a problem, seeing as the scientific knowledge on the reward circuitry of the brain
and its dysregulation in depression is highly relevant to (and supportive) of BA.
Fourth, an important note in the definition of BA, is that it seeks positive
reinforcement that is diverse, stable and personally meaningful. Not all positive
reinforcement is wanted and used in BA, because the goal of BA is not a hedonistic
search for pleasure. For example, heroin can also be seen as a positive reinforcement,
but it’s not a substance that’s going to change your life for the better. Reinforcement is
defined as ‘an environmental event that increases the frequency of behavior’. The
question shouldn’t be ‘what reinforcers do we want to use’, but ‘what client behaviors
do we want to increase in frequency’. Emphasizing diverse, stable, and meaningful
reinforcers therefore implies that the goal is for the client’s behavioral repertoire to be
diverse, stable, and meaningful to the client.
The Role of BA’s Principle in BA’s Theory of Psychopathology
BA’s model of psychopathology (by Manos et al., 2010), contains several interactive
elements;
The first element, labeled R, is positive reinforcement. According to BA, depression
begins with losses of (or chronically low levels of) positive reinforcement. This gets
depicted as ‘↓R+ for healthy behavior’. Examples of losses of positive reinforcers are
the loss of a family member or the possibility that positive reinforcers are available in
the environment of the person, but the person does not possess the right skills to
acquire it (say, a person gets invited to a party, but doesn’t have the social skills to
interact with others). Individual differences also make it more or less likely certain
environments will be reinforcing, for example one person finds parties reinforcing,
while the other likes going for walks.
Next to loss of positive reinforcement, there can also be an increase in negative
reinforcement, depicted as ‘↑R- for depressed behavior’ in the model. It’s normal to
want to escape the adversities of life (such as unpleasant situations). But when you’re
busy trying to avoid aversive situations, it’s usually difficult to contact positive
reinforcement as well. A socially anxious person who avoids a social event
successfully avoids the anxiety but also avoids opportunities for positive social
reinforcement. Many forms of psychopathology, including depression and suicidal
behavior, are often functions of unhealthy efforts to avoid negative emotions,
thoughts, memories, and social interactions. Research shows that people with
depression tend to use avoidance coping to deal with stressors in the environment and
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, that avoidance plays a significant role in the maintenance of depression. In the BA
model, avoidance increases the chance of reduction of positive reinforcement. In other
words, the already available positive reinforcers in the environment cannot be attained
because depressed individuals avoid the necessary non-depressed activities to gain the
reinforcers.
Another process in the model, is positive reinforcement of depressed behavior
(‘↑R+ for depressed behavior’ in the model). Some environments provide positive
reinforcement, but for problematic behavior. For example when a man is reinforced by
his wife with positive attention for staying at home from work, and his parents even
offer financial support for the lost income. Such responses from friends and family of
depressed individuals are quite common, as they are behaving lovingly in genuine
efforts to provide comfort and support to those in need. From a behavioral perspective,
however, they are contributing to the problem, by reinforcing the wrong behavior and
contributing to an environment in which healthy behavior is not prompted or
reinforced. BA’s behavioral theory of depression suggests that in many cases, a
functional analysis of the individual’s life circumstances will reveal a fundamental
deficit in contact with diverse and stable sources of positive reinforcement.
When contact with positive reinforcement is reduced (or lost altogether), the primary
affective disturbances in depression, anhedonia and increased negative mood, will
result. This is depicted in the model with M (mood) or more specifically, ‘↑depressed
mood.’ These primary processes, reinforcement and mood, are grouped together in a
larger box to suggest that reinforcement and mood may covary together. This makes it
difficult to disentangle the two in measurement attempts. Technically, when
reinforcement occurs, the mood reaction simultaneously occurs as a respondent
byproduct of the change in contingencies. Less technically, we may say that when
reinforcers are lost, people feel bad.
When contact with positive reinforcement is reduced, the person’s behavior will
change as well. This is labeled as B (behavior) in the model. Reinforcement maintains
behavior, so when reinforcement is lost, the behavior that was maintained by that
reinforcement will reduce in frequency or extinguish. The behavioral reductions often
seen in depression are that the depressed individual stops going to work, stops
socializing, perhaps even stops taking care of basic hygiene. This is depicted in the
model as ‘↓ activation’. Likewise, when the individual’s environment is characterized
by increased negative reinforcement and positive reinforcement for depressed
behaviors, increases in avoidance and depressed behavior will follow. This is depicted
with ‘↑ avoidance and depressed behavior’.
According to BA, when these initial changes in behavior occur in response to the
environment, the environment is further changed. For example, if one has stopped
socializing because of avoidance, one has effectively lost social events as possible
positive reinforcements, which in turn may increase depressed mood and reduce
behavior even further. This is depicted in the model by the arrow from Behavior back
to the Reinforcement box. This cycle is seen as fundamental to depression by BA.
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