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Contemporary behavioural treatments for clinical depression

Behavioural Interventions have been long recognized as effective interventions for those with depression and other disorders.

Brief Behavioural Activation Therapy is an evidence based intervention that is gaining recognition as an effective treatment choice for clinical depression.

In the case of clinical depression, an individual may display depressed behaviours such as avoidance, withdrawal from social situations or work responsibilities, crying, or excessive sleeping and eating. In addition, in clinical depression it is often the case that positive and healthy behaviours decrease, such as socializing, exercising, meeting up with family, going to work, taking care of their health, and having a positive self-esteem.

A functional view of clinical depression is that depressive behaviours can be maintained by their consequences, ie. there may be increased reinforcement of depressed behaviours and reduced reinforcement of non-depressed behaviours in the case of an individual with clinical depression.

The ‘Matching Law’ is a theory that summarises this view. The ‘Matching Law’ proposes that the likelihood or frequency of depressed behaviour is in direct proportion to the frequency of non-depressed behaviour. In other words, if depressed behaviour continues, it is likely that there is some form of reinforcement for this and proportionately, there is less reinforcement available for non-depressive behaviour.

When we speak of depressed individuals receiving reinforcement for their depressed behaviour, we simply mean that there may be some sort of benefit to their behaviour. For example, avoidance of social situations may remove certain stressful situations; other people may take on their responsibilities; or the person may receive more sympathy and attention from family members.

In accordance with the ‘Matching Law’, it is presumed that non-depressed behaviours are being less reinforced or are not attainable. For example, attempts to work on a friendship may not be reciprocated; involvement in difficult work projects may not be rewarded; sickness may make exercise and activity difficult and hence the benefits normally obtained are inaccessible.

Contrary to popular belief, Brief Behavioural Activation Therapy does not ignore emotional and cognitive aspects. This therapy simply aims to increase the activity level of the individual in order for them to access reinforcement for positive and healthy behaviours. Cognitive processes are expected to become more adaptive following behavioural activation.

In this treatment, it is hoped that positive reinforcement for non-depressed behaviour can be accessed, thereby increasing the likelihood of this behaviour recurring.

This approach to therapy must create an environment that encourages and supports behaviour change. Behavioural activity may be difficult for the individual in the initial stages. During the initial phase, the clinician may be quite directive and the sessions and methods may be quite structured.

The individual must make careful observations and take data on their depressed behaviours over the course of one week to create a baseline. The individual must record their activity hour by hour, recording what activities were engaged in, and for how long. It is important for the individual to become aware of what has maintained any avoidance or withdrawal behaviour also.

The individual must then start working towards creating a healthy and supportive environment. They should utilize the support of their family and friends to keep them accountable in attempting healthy behaviours. This may include creating a contract between the individual and their spouse or family member. This may also include asking family and friends to disallow them to focus on negative and depressive behaviours, and instead to focus on positive seeking behaviours. The goal is not to let the depression be the main source of interaction between the individual and their close ones.

The next goal in therapy is to work out what activities will be targeted. This may involve exploring the possible enjoyable activities that the individual would like to engage in, related to areas such as family relationships, educational goals, community involvement, exercise, career, spirituality and emotional issues. The goals should involve easy to achieve targets and also more difficult to achieve. These can then be ranked on level of difficulty and achievability.

After choosing appropriate targets, the individual should then attempt to engage in these activities as frequently as possible, or as is decided between the individual and therapist. The individual must record how many activities he/she has completed on any given day using an activity chart. These can also be graphed to display the improvement made over time. Simultaneously, the therapist can graph the individual’s depression levels using a tool such as the Beck Depression Inventory. The individual is encouraged to accomplish the goals, regardless of aversive thoughts, moods and motivation.

When activity targets are achieved, it is important that there are rewards. It is best that this is not done using another activity on the targeted list.

This method is simple and straightforward for both the therapist and the individual. It is hoped from the therapy that there will be an increase in the activity level of the individual, and a decrease in depressed affect through the process of reinforcement.

References:

Hopko, D; Hopko, S & Lejeuz, C (2001) A Brief Behavioural Activaton Treatment for Depression: Treatment Manual, Behaviour Modification, Vol 25, No2, pp255-286.

Hopko, D; Lejeuz, C; Ruggiero, K & Eifert, G. (2003) Contemporary behavioral activation treatments for depression: Procedures, principles, and progress, Clinical Psychology Review, 23,pp699-713.

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