Behavioral Strategies

Behavioral Component of CT

The seminal formulation of CT suggested a strong emphasis on the use of behavioral strategies with more severely depressed patients (Beck, Rush, Shaw, & Emery, 1979). As Beck and colleagues (1979) noted:

The behavioral techniques are clearly indicated with severely depressed patients. An individual with severe depression commonly has considerable difficulty focusing on more abstract conceptualizations. His attention span may be limited to well-defined concrete suggestions. Research findings in the area suggest "success" experiences on concrete behavioral tasks are most effective in breaking the vicious cycle of demoralization, passivity and avoidance, and self-disparagement. (p. 140)

And, as discussed in greater detail below, research by our group has suggested that purely behavioral treatments demonstrate comparable or possibly superior outcomes to CT among more severely depressed patients (Dimidjian et al., 2006; Jacobson et al., 1996).

When working with severely depressed patients, therefore, therapists are advised not to abandon prematurely the behavioral strategies in favor of the more purely cognitive interventions. Key behavioral interventions in CT include activity monitoring and scheduling, mastery and pleasure ratings, and graded task assignments. These strategies are used with more severely depressed patients in a format similar to that used with less depressed patients; however, therapists may need to pace interventions at a level that is appropriate to the patient's degree of depression. The aim of these strategies is to increase patient activity, specifically, those activities associated with mastery and pleasure, while decreasing activities found to be associated with depression (Beck et al., 1979). This early focus on behavior change is important to increase the patient's readiness for more direct exploration and evaluation of cognition. Activity monitoring and scheduling assignments can also be used to elicit and address patient beliefs about activity. Specifically, early behavior change can be critical in providing some of the early evidence required to evaluate specific depressive and hopeless thoughts (e.g., "I fail at everything, nothing will help me. I've tried everything. What is the point?"). Such thoughts may be targeted directly in the course of planning and debriefing behavioral homework assignments. Thus, although early homework assignments in CT for patients with more severe depression are heavily behavioral, discussion of these assignments during sessions often integrates a behavioral and cognitive focus.

In general, patients are initially asked to complete monitoring assignments in which they keep track of their moods and activities, and specific experiences of mastery or pleasure. Typically, patients are invited to record specific activities each hour of the day and to rate their level of depression on a 10-point scale that is associated with each activity. Therapists working with patients with particularly acute depression associated with significant functional impairment may move quickly to activity scheduling assignments. They may ask patients, "What might you do tomorrow if you were not depressed?" Then, using graded task assignment (as discussed below), therapists may ask patients to schedule small, specific behaviors to complete prior to the next contact with the therapist. Later, monitoring assignments can be superimposed on tasks that patients have been doing as they work to follow the scheduled activities.

Completed activity logs are then reviewed in session; discussion ofthese logs frequently emphasizes activities or interactions that are associated with increased depression. In addition, the logs provide essential information about the patient's daily schedule, including sleep, nutrition, and social isolation. The practice of keeping the schedule also helps to activate patients and begins training them to notice and label moods, and the specific relationships between activities and moods. Activity scheduling strategies involve inviting patients to plan specific activities during sessions and/or to plan activities each night for the following day. Therapists may emphasize that it is common for people not to accomplish everything that they plan, and tasks that are left undone can be scheduled for another day.

The use of graded task assignment is particularly important with more severely depressed patients, who may believe that even seemingly simple tasks are impossible to complete. The aim of graded task assignment is to program success into scheduled activities. Rather than trying to accomplish a large task all at once, tasks are broken down into component parts. As each successive step is completed, the patient has a success experience and makes concrete progress toward solving problems or developing a more fulfilling daily routine. Moreover, the patient gathers evidence that he/she can succeed at something, which may provide evidence against negative and overgeneralized beliefs about the self.

To the degree that severity also overlaps with hopelessness, it is also essential that therapists address this skillfully early in treatment. Therapists must take care not to get caught in the patient's despair, which may be associated with unwillingness to try new approaches and strategies. Therapists can provide hope and repeatedly encourage an experimental approach by inviting the patient to try a variety of strategies to improve mood and by emphasizing the importance of repeated, small steps. Although flexibility and persistence are core features of standard CT, with more severely depressed and hopeless patients, modeling both may be particularly important. At the same time, it is necessary to do so in a way that does not rely on false promises or guarantees; the essence of encouraging experiments is to find out whether something works, not simply to assume that it will. It is important that the patient learn to test things out rather than to assume the worst (or the best) in advance of action.

The Behavioral Activation Approach

Early work by Jacobson and colleagues (1996) suggested that the behavioral component of CT performed as well as the full CT package in the treatment of major depression. This work led to the evolution of the behavioral component of CT into a stand-alone treatment approach, called simply behavioral activation (BA; Jacobson, Martell, & Dimidjian, 2001; Martell, Addis, & Jacobson, 2001). This approach is based heavily on the behavioral component of CT, but, it also includes additional clinical innovations and a purely behavioral rather than a cognitive conceptualization that draws heavily from early behavioral work of Ferster (1973) and Lewinsohn (1974). The additional strategies and conceptualization of the BA approach may be of value in informing the practice of CT with more severely depressed patients.

In BA, behavior change is pursued for its direct impact on mood; it is not assumed that it is necessary to change thinking to treat depression.

Moreover, when utilizing the activity schedule, BA therapists emphasize the function of the patient's activity. In other words, activity serves many purposes. Staring out the window on a rainy day as one waits for a loved one to come home to a lovely dinner is different than staring out the window at the rain as one thinks about the dreariness of life. The form of the behavior is similar (i.e., staring out the window), but the function differs. The emotional outcome is quite different: in the first case, hopeful anticipation of the loved one's return; in the second, hopeless despair.

The BA therapist generates hypotheses about the function of the patient's activity and notes particularly behaviors that function as avoidance; these behaviors are hypothesized to maintain or exacerbate depression and, as such, are the initial targets of treatment. Depressed patients often engage in behaviors that may provide some temporary relief and yet have negative long-term consequences for mood and quality of life. Staying in bed, for example, may be reinforced by the relief of not having to address problems at work or in one's family. Therapy focuses on monitoring the short- and long-term consequences of such behaviors, and using graded task assignment and activity scheduling to interrupt avoidance patterns and increase activation. Essentially, patients learn to approach and engage rather than to avoid and withdraw. The acronym TRAP (Trigger, Response, Avoidance Pattern) can be used to teach patients to recognize situations that lead to negative feelings (or thoughts) to which the patients respond with avoidance behavior. Although, from a cognitive perspective, avoidance behavior may result from patients' negative beliefs (e.g., "What is the point of trying?"), the BA therapist does not address the validity of such beliefs directly. Instead, the emphasis in BA remains on the function or consequences of patient behavior, and as such, is very consistent with a focus on the "utility" of thoughts or behaviors in CT (e.g., asking "What is the utility of thinking that way?" as opposed to "What is the validity of that thought?").

We are not advocating that therapists do away with cognitive components in the treatment of severely depressed patients. Certainly, our results (described below) supporting the promise of the BA approach do not negate a cognitive conceptualization; approaching rather than avoiding an aversive situation may indeed provide important evidence to contradict patients' negative or global beliefs. However, our data and clinical experience suggest that in treatment of severely depressed patients, it may be ill-advised to rush through the behavioral component of CT in an effort to devote the majority of clinical time to addressing beliefs directly. Particularly in the context of time limited treatment, it may be more efficacious for therapists to concentrate on more concrete goals and to use simpler, more specific behavioral interventions for a longer period of time (Coffman, Martell,

Dimidjian, Gallop, & Hollon, 2007). In a sense, CT therapists may do more for their severely depressed patients by trying to cover less over the course of treatment. The importance of a systematic, graded, and prolonged focus on monitoring and scheduling activities is highlighted in the treatment of more severely depressed patients.

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