Andrew M. Busch

A critical review of assessment strategies to measure the behavioral activation model of depression

Behavioral activation (BA) treatments for depression are based on a model of psychopathology indicating that losses of, reductions in, or chronically low levels of positive reinforcement produce behavioral and emotional changes in depression. The corresponding mechanism theory is that using BA techniques to increase activation will lead to a subsequent increase in positive reinforcement, which will decrease depressive symptoms. We attempt to review BA literature relevant to its psychopathology and mechanism models, paying particular attention to attempts to measure activation as conceptualized within BA treatments and attempts to measure reinforcement. Suggestions on ways in which to improve these measurements in order to better evaluate the psychopathology and mechanism models are provided.

A Micro-Process Analysis of Functional Analytic Psychotherapy's Mechanism of Change

This study sought to clarify the micro-process of Functional Analytic Psychotherapy (FAP) by using the Functional Analytic Psychotherapy Rating Scale (FAPRS) to code every client and therapist turn of speech over the course of successful treatment of an individual meeting diagnostic criteria for depression and histrionic personality disorder. Treatment consisted of cognitive behavioral therapy alone followed by the addition of FAP techniques in a unique A / A+B design. In-session client behavior improved following the shift to FAP techniques, and micro-process data suggested that client behavior was effectively shaped by in-vivo FAP procedures. These results support FAPs purported mechanisms of change and highlight the advantages of utilizing molecular coding systems to explore these mechanisms.

Acceptance-Enhanced Behavior Therapy (AEBT) for Trichotillomania and Chronic Skin Picking: Exploring the Effects of Component Sequencing

This pilot study examined the utility of acceptance-enhanced behavior therapy (AEBT) for trichotillomania (TTM) and chronic skin picking (CSP) and the impact of altering treatment sequence on overall treatment efficacy. Participants referred to a TTM and CSP specialty clinic were assessed by an independent evaluator within separate, nonconcurrent, multiple-baseline designs across participants. The first group of three participants received habit-reversal training (HRT) followed by acceptance and commitment therapy (ACT), and the second group of two participants received ACT followed by HRT. Results indicated that AEBT greatly reduced pulling/picking for all five participants and that the order in which ACT and HRT were implemented made little or no difference in short-term treatment outcome. Conclusions, limitations, and future areas of research are discussed.

Initial Outcomes of a Culturally Adapted Behavioral Activation for Latinas Diagnosed With Depression at a Community Clinic

Latinos demonstrate high rates of depression, often do not seek treatment, and terminate prematurely for a variety of reasons, including lack of sensitivity to contextual and cultural factors in treatment approaches. For decades researchers have suggested a behavioral approach to Latinos diagnosed with depression because such an approach targets the complex environmental stressors experienced by these populations with a simple, pragmatic approach. Recently, behavioral activation has been culturally and linguistically adapted for Latinos/Latinas diagnosed with depression (BA-Latino or BAL). The current study consists of a pilot evaluation of BAL at a bilingual (Spanish—English) community mental health clinic (N = 10 Latinas). Results provide preliminary support for the feasibility and effectiveness of BAL for Latinas in a community setting in terms of treatment adherence, retention, and outcomes. Implications and future directions are discussed.

Randomized controlled trial of behavioral treatment for comorbid obesity and depression in women: the Be Active Trial

Objective:Depression is associated with increased risk for obesity and worse weight loss treatment outcomes. The purpose of the present study was to test the hypothesis that delivering evidence-based behavior therapy for depression before a lifestyle weight loss intervention improves both weight loss and depression.Design:In a randomized controlled trial, obese women with major depressive disorder (N=161, mean age=45.9 (s.d.: 10.8) years) were randomized to brief behavior therapy for depression treatment followed by a lifestyle intervention (BA) or a lifestyle intervention only (LI). Follow-up occurred at 6 and 12 months. Main outcome measures included weight loss and depression symptoms.Results:Intention-to-treat analyses revealed both conditions lost significant weight, but no differences between conditions in weight change at 6 months (BA=−3.0%, s.e.=−0.65%; LI=−3.7%, s.e.=0.63%; P=0.48) or 12 months (BA=−2.6%, s.e.=0.77%; LI=−3.1%, s.e.=0.74%; P=0.72). However, the BA condition evidenced significantly greater improvement in Beck Depression Inventory-II scores relative to the LI condition at both 6 months (BA mean change=−12.5, s.d.=0.85; LI mean change=−9.2, s.d.=0.80, P=0.005) and 12 months (BA mean change=−12.6, s.d.=0.97; LI mean change=−9.9, s.d.=0.93; P=0.045). Participants who experienced depression remission by 6 months (61.2%) lost greater weight (mean=−4.31%; s.e.=0.052) than those who did not (39.7%; mean=−2.47%, s.e.=0.53; P=.001).Conclusion:Adding behavior therapy to a lifestyle intervention results in greater depression remission but does not improve weight loss within 1 year. Improvement in depression is associated with greater weight loss.

The nature of clinical depression: symptoms, syndromes, and behavior analysis.

In this article we discuss the traditional behavioral models of depression and some of the challenges analyzing a phenomenon with such complex and varied features. We present the traditional model and suggest that it does not capture the complexity of the phenomenon, nor do syndromal models of depression that dominate the mainstream conceptualization of depression. Instead, we emphasize ideographic analysis and present depression as a maladaptive dysregulation of an ultimately adaptive elicited emotional response. We emphasize environmental factors, specifically aversive control and private verbal events, in terms of relational frame theory, that may transform an adaptive response into a maladaptive disorder. We consider the role of negative thought processes and rumination, common and debilitating aspects of depression that have traditionally been neglected by behavior analysts.

Making Behavioral Activation More Behavioral.

Behavioral Activation, an efficacious treatment for depression, presents a behavioral theory of depression—emphasizing the need for clients to contact positive reinforcement—and a set of therapeutic techniques—emphasizing provision of instructions rather than therapeutic provision of reinforcement. An integration of Behavioral Activation with another behavioral treatment, Functional Analytic Psychotherapy, addresses this mismatch. Functional Analytic Psychotherapy provides a process for the therapeutic provision of immediate and natural reinforcement. This article presents this integration and offers theoretical and practical therapist guidelines on its application. Although the integration is largely theoretical, empirical data are presented in its support when available. The article ends with a discussion of future research directions.

Time-Varying Smoking Abstinence Predicts Lower Depressive Symptoms Following Smoking Cessation Treatment

INTRODUCTION The question of whether abstinence during the months following a planned quit attempt exacerbates or improves depressive symptoms is an important clinical issue. Extant research has primarily modeled between-person covariation between postquit abstinence and depressive symptom trajectories. However, this approach cannot account for potential third variables between participants that may affect both smoking and depression. Accordingly, the current study examined within-person covariation between time-varying abstinence and depressive symptom in a multilevel model (MLM), which allowed for transitions between smoking statuses within a participant. METHODS Participants were 236 heavy drinking smokers in a randomized clinical trial testing the efficacy of incorporating brief alcohol intervention into smoking cessation treatment. Depressive symptoms and biochemically verified abstinence were assessed 1 week prior to and 2, 8, 16, and 26 weeks after quit date. RESULTS MLMs indicated a slight increase in depressive symptoms over time in the sample as a whole. However, there was an inverse relation between time-varying abstinence (vs. smoking) and concurrent level of depressive symptoms, indicating that transitions from smoking to abstinence within individuals were associated with reductions in depressive symptoms. CONCLUSIONS During the first 6 months following a planned quit attempt, being abstinent in a particular week appears to be associated with lower levels of concurrent depressive symptoms. These results are not concordant with the view that intentional smoking abstinence exacerbates depressive symptoms. Efforts to promote smoking cessation should highlight that individuals are likely to feel more rather than less psychologically healthy when they successfully quit smoking.

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.

Translating the Theoretical into Practical: A Logical Framework of Functional Analytic Psychotherapy Interactions for Research, Training, and Clinical Purposes.

Functional analytic psychotherapy (FAP) provides a behavioral analysis of the psychotherapy relationship that directly applies basic research findings to outpatient psychotherapy settings. Specifically, FAP suggests that a therapist’s in vivo (i.e., in-session) contingent responding to targeted client behaviors, particularly positive reinforcement of a client’s effective behavior, should be a powerful mechanism of change. However, much of the previous literature on FAP has been theoretical, broadly defining FAP techniques rather than explicating them with the precision necessary for replication and training. In this article, the authors explicate a logical framework for turn-by-turn interactions between the client and therapist that may guide research, training, and dissemination of FAP. This molecular behavioral description of the events of the proposed logical interaction lends itself to microprocess research methodology, and a discussion of potential hypotheses to explore follows. Prescriptive, direct guidance for the application of FAP for training and dissemination purposes is given.