Overview
Behavioral Activation (BA) is an approach to addressing depression that considers it a response to an environment that lacks positive reinforcement through meaningful rewards and remedies it by building a plan to engage in behaviors that would naturally lift one’s mood.
Under a radical behaviorist perspective, depression is the result of an initial drop in mood and motivation that spirals into a cycle of withdrawing from pleasurable activities and experiencing worsening moods and motivation levels. Eventually, chronic neuroinflammation and the products of stress hormones like cortisol blunt dopamine signaling pathways in the ventral tegmental area (VTA) and nucleus accumbens. When someone attempts to perform an activity that once brought them pleasure, the brain realizes that it took effort to attempt an activity that underdelivered on the expected dopamine spike. This reward prediction error is then associated with the memory of the activity, and over time, someone might be reasonably convinced that there’s no point to spending an already-diminished level of energy on something that has repeatedly failed to feel rewarding. This also leads to a drop in Brain-Derived Neurotrophic Factor (BDNF), a protein that drives neuroplasticity, so the neural pathways in the brain’s hippocampus and prefrontal cortex being to atrophy. These are distinct physical changes in the brain that make it more rigid and difficult to change thought and behavioral patterns.
The goal of BA is to get the brain’s reward mechanisms to reactivate by scheduling activities that would ordinarily be rewarding even when the motivation to act is lacking. This outside-in approach attempts to stimulate the production of BDNF by structuring small tasks in one’s life that are easily completed with minimal effort while still engaging the body physically in ways that reduce inflammation and force the brain to parse sensory rewards. With an increase in BDNF comes an increase in neuroplasticity, which allows pleasure and reward pathways in the brain to be rebuilt.
Note that this is not the same as saying “do pleasurable things” to someone whose brain is struggling to experience pleasure. Cliches from toxic positivity circles about simply persevering through uncomfortable states of mind or feelings through willpower are not justified with this explanation. The core elements of a successful BA intervention include incrementally replacing avoidance patterns with alternative coping mechanisms that are aligned with one’s long-term values and substantial accomplishments that reduce chronic stress, not just impulsive pleasure-seeking. Hedonism is not a solution to the problem of anhedonia.
For instance, someone with depression may have a messy house. Rather than simply telling them to clean their house so they can feel the pleasure of a tidier and less stressful space, a clinician or therapist might first frame the project as aligned with their values of having an organized environment to operate in and then break it down into steps over a period of time, with regular calibration based on the individual’s capacities. The first level might be as basic as folding a handful of clothes from a laundry pile on a room’s chair, allowing the use of the chair again. The second level, scheduled for the next day, might involve putting all the dirty clothes on the floor into a laundry hamper and experiencing the convenience of walking around without trudging through them. The third level might involve doing dirty dishes that allows someone to eat with clean silverware and plates.
Studies have shown that BA is just as effective at addressing the symptoms of depression as Cognitive-Behavioral Therapy (CBT) that incorporates BA into a larger paradigm of combing through thought patterns for distortions and opportunities to reframe a mental schema towards different outcomes. In other words, directly addressing irrational or unhelpful thinking patterns may not actually do much to improve symptoms of conditions like depression.
Contingency Management (CM) is a behavioral intervention for substance use disorders that is heavily rooted in similar ideas as BA about retraining the brain’s decision-making and thought patterns through direct rewards rather than first challenging one’s mental frameworks.
Commentary
I’m a fan of behaviorist interventions, not necessarily because I think cognitive or psychodynamic approaches are inherently ineffective or harmful, but because any institutional implementation of a modality that privileges a professional as the ultimate determinant of a client’s successful participation is subject to a plethora of biases, prejudices, misinterpretations, and miscommunications that can significantly impact the fidelity of treatment. BA and CM track outcomes that are far easier to measure, like a binary evaluation of the completion of a task, and minimize the role of the professional in interpreting a client’s cognitive state compared to symptoms of depression.