Acceptance and commitment therapy and behavioral activation for the treatment of depression: description and comparison

The field of clinical behavior analysis is growing rapidly and has the potential to affect and transform mainstream cognitive behavior therapy. To have such an impact, the field must provide a formulation of and intervention strategies for clinical depression, the "common cold" of outpatient populations. Two treatments for depression have emerged: acceptance and commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest largely redundant intervention strategies. However, at other times the two treatments differ dramatically and may present opposing conceptualizations. This paper will compare and contrast these two important treatment approaches. Then, the relevant data will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.     

Associations Among Smoking,Anhedonia, and Reward Learning in Depression

Depression and cigarette smoking co-occur at high rates. However, the etiological mechanisms that contribute to this relationship remain unclear. Anhedonia and associated impairments in reward learning are key features of depression, which also have been linked to the onset and maintenance of cigarette smoking. However, few studies have investigated differences in anhedonia and reward learning among depressed smokers and depressed nonsmokers. The goal of this study was to examine putative differences in anhedonia and reward learning in depressed smokers (n = 36) and depressed nonsmokers (n = 44). To this end, participants completed self-report measures of anhedonia and behavioral activation (BAS reward responsiveness scores) and as well as a probabilistic reward task rooted in signal detection theory, which measures reward learning (Pizzagalli, Jahn, & O'Shea, 2005). When considering self-report measures, depressed smokers reported higher trait anhedonia and reduced BAS reward responsiveness scores compared to depressed nonsmokers. In contrast to self-report measures, nicotine-satiated depressed smokers demonstrated greater acquisition of reward-based learning compared to depressed nonsmokers as indexed by the probabilistic reward task. Findings may point to a potential mechanism underlying the frequent co-occurrence of smoking and depression. These results highlight the importance of continued investigation of the role of anhedonia and reward system functioning in the co-occurrence of depression and nicotine abuse. Results also may support the use of treatments targeting reward learning (e.g., behavioral activation) to enhance smoking cessation among individuals with depression.     

Extinction after partial reinforcement: predicted vs. judged persistence

The partial reinforcement extinction effect (PREE) (i.e., increased persistence following partial reward) is one of the most important generalizations from experimental studies of learning. Many theories of PREE assume that it involves cognitive and emotional mechanisms, but investigations of PREE have focused almost exclusively on behavioral measures. Four experiments with human adults investigated whether PREE is also reflected in cognitive measures. Independent groups of subjects learned an instrumental response under CRF vs. PRF contingencies, and then predicted (Experiments 1, 2, and 3) and/or judged (Experiments 3 and 4) their own persistence under extinction conditions. Predictions of persistcnce were unrelated to prior continuous or partial reinforcement contingencies (Experiments 1, 2, and 3), but subsequent judgments of persistence behavior were accurate (Experiments 3 and 4). These results indicate that increased persistence due to occasional reward is not well represented cognitively prior to its behavioral manifestation, but it is well represented after that manifestation. Possible explanations and implications of this apparent behavior cognition dissociation are discussed.     

Cognitive and Behavioral Contributions to Depression Severity,Quality of Life,and Functioning Among People Living With HIV in South Africa

Cognitive-behavioral treatments for depression typically address both behavioral (e.g., activation) and cognitive (e.g., rumination) components, and consequently improve quality of life (QOL) and function in high-resource settings. However, little is known about the cross-cultural applicability and relative contribution of these components to depression symptom severity, QOL, and functional impairment in South Africa and other resource-limited global settings with high HIV prevalence rates.Persons with HIV (N = 274) from a peri-urban community outside Cape Town, South Africa, were administered multiple measures of depression (Hamilton Depression Scale, Centre for Epidemiological Studies Depression Scale, South African Depression Scale), cognitive and behavioral components related to depression (Ruminative Response Scale, Behavioral Activation for Depression Scale), and measures of QOL and functioning (Sheehan Disability Scale, Quality of Life Enjoyment and Satisfaction Scale—Short Form). Multiple linear regression models were fit to assess the relative contribution of behavioral and cognitive components to depression severity, QOL, and functional impairment in this population.Models accounting for age and sex revealed that lower levels of behavioral activation (BA) were significantly associated with all measures of depression, as well as with QOL and functional impairment (all ps < .01). Rumination was associated with all measures of depression (all ps < .01), but not with QOL or functional impairment.The consistent and unique association of BA with depression, QOL, and functional impairment bolsters its importance as a treatment target for this population.     

A Bayesian formulation of behavioral control

Helplessness, a belief that the world is not subject to behavioral control, has long been central to our understanding of depression, and has influenced cognitive theories, animal models and behavioral treatments. However, despite its importance, there is no fully accepted definition of helplessness or behavioral control in psychology or psychiatry, and the formal treatments in engineering appear to capture only limited aspects of the intuitive concepts. Here, we formalize controllability in terms of characteristics of prior distributions over affectively charged environments. We explore the relevance of this notion of control to reinforcement learning methods of optimising behavior in such environments and consider how apparently maladaptive beliefs can result from normative inference processes. These results are discussed with reference to depression and animal models thereof.     

Does learning behavior augment cognitive ability as an indicator of academic achievement?

Measures of cognitive ability have a rich history of accounting for meaningful levels of achievement variance. In contrast to other student characteristics, however, they are somewhat limited in terms of their intervention relevance and treatment validity. Alternatively, children's observable learning behaviors are believed to enhance both treatment validity and the predictions afforded by cognitive ability. This study examined student learning behaviors in the context of cognitive ability and academic achievement. Three structural models were evaluated on a sample of 1304 students ranging in age from 6 to 17 years. Results supported the unique relationship between learning behavior and academic achievement, beyond cognitive ability. Multi-group structural equation modeling (SEM) analysis revealed that these findings were invariant across groups differing by gender and ethnicity. These findings are consistent with previous observations that children's behavioral features in learning situations will supplement the outcome-oriented standardized tests of cognitive ability.     

Disorder-specific Effects of CBT for Anxious and Depressed Youth: A Meta-analysis of Candidate Mediators of Change

The commonalities between anxiety and depression have been discussed before, but few have delineated the potentially different mechanisms through which treatments work for these populations. The current study conducted a comprehensive review of child and adolescent randomized clinical trials that tested cognitive-behavioral therapy (CBT) for anxiety or depression. All studies were required to have assessed both treatment outcomes and at least one theory-specific process target, including behavioral, physiological, cognitive, and coping variables. Using a meta-analytic approach, CBT demonstrated positive treatment gains across anxiety, depression, and general functioning outcomes. CBT for anxiety also produced moderate to large effects across behavioral, physiological, cognitive, and coping processes, with behavioral targets demonstrating potentially the greatest change. CBT for depression produced small effects for cognitive processes but nonsignificant effects for behavioral and coping variables. Findings were generally consistent with CB theory but suggest potentially different mediators in the treatment of anxiety and depression. Results are discussed in terms of implications for mechanisms research, theories of change, and treatment development.     

Clinical Guidelines for Improving Dialectical Thinking in DBT

Cognitive dysregulation, often characterized by extreme, nondialectical thinking, is a core problem area identified in dialectical behavior therapy (DBT) and is posited to contribute to pervasive emotional and behavioral dysregulation. However, cognitive flexibility is understudied and rarely considered a direct treatment target in DBT. This paper provides clinical guidelines for increasing dialectical thinking with patients in DBT. We review the historical context of dialectical thinking in DBT and present the results of a survey examining DBT therapists’ perspectives on nondialectical thinking as a treatment focus. We describe cognitive restructuring strategies from cognitive therapy models, and compare these with techniques targeting cognitive dysregulation in DBT. We highlight the rationale for incorporating dialectical thinking as a direct treatment focus in DBT, and offer strategies derived from cognitive restructuring to incorporate directly targeting dialectical thinking in conceptualization, treatment planning, and in session. These strategies are demonstrated with clinical vignettes and examples.     

A comparative outcome study of four cognitive therapies in the treatment of social anxiety

This clinical outcome study compared four separate cognitive behavioral and one behavioral treatment for reducing social anxiety with a waiting list control. Subjects were adults who responded to advertisements for treatment. In the cognitive-behavioral conditions, subjects were trained to modify their disruptive cognitions and/or emit adaptive cognitions relevant to interpersonal behavior with the specific content and techniques determined by the particular cognitive therapy. In the behavioral condition, subjects modeled and rehearsed appropriate social interpersonal behaviors. Subjects were assessed pre and post-treatment on self-report measures of social anxiety, measures of general anxiety, clinical scales of anxiety, depression and hostility, and behavioral, and physiological concomitants of social anxiety. Subjects in all active treatment conditions showed improvement on the measures of social anxiety and the behavioral measure. However, only those in the cognitive treatment conditions, demonstrated treatment effects on general anxiety and the clinical scales. The results indicate the efficacy of both cognitive and behavioral approaches to the reduction of social anxiety. However, they fail to demonstrate clear distinctions between the various cognitive therapies.     

Assessing Outcome in Cognitive Behavior Therapy for Child Depression: An Illustrative Case Series

Recent meta-analytic data suggest a need for ongoing evaluation of treatments for youth depression. The present article calls attention to a number of issues relevant to the empirical evaluation of if and how cognitive behavior therapy for child depression works. A case series of 6 children and a primary caregiver received treatment—individual CBT for the child and behavioral parent training involving the caregiver and caregiver–child dyad. The effects were generally promising and illustrate how selection of inclusion criteria, measures, measurement intervals, and informants can alter conclusions. These areas warrant attention in studies of child depression and are important not only in interpreting treatment outcome data but also for conducting sound clinical practice.     

The behavioral activation for depression scale-short form: development and validation

Following a landmark component analysis of cognitive therapy by Jacobson and colleagues (1996), there has been renewed interest in behavioral activation (BA) treatments for depression. The Behavioral Activation for Depression Scale (BADS) was developed to measure when and how clients become activated over the course of BA treatment. Multiple studies have provided initial support for the BADS but have also identified several potential problems. Four studies were conducted in order to develop and provide initial evaluation of a short form of the BADS that addresses these concerns. In Study 1, an exploratory factor analysis was conducted on existing data using the original BADS in order to identify items to retain for the short form. In Study 2, these items were administered to a new sample of college students with elevated depressive symptoms and were analyzed with exploratory and confirmatory factor analyses. Study 3 examined the predictive validity of the BADS-SF by examining the BADS-SF and depression scores in relation to activity tracking and reward-value ratings over the course of 1 week. Study 4 examined BADS-SF data over the course of BA treatment for two clients using cross-lagged panel correlations. With one client, changes in BADS-SF scores led changes in depression scores by 1 week, whereas with the other client changes in BADS-SF and depression scores occurred concurrently. These studies resulted in a nine-item scale that demonstrated good item characteristics as well as acceptable internal consistency reliability, construct validity, and predictive validity.     

Trajectories of Change in a Group Behavioral Activation Treatment for Severe,Recurrent Depression

Depression is a common and costly problem. Behavioral Activation (BA) is an effective treatment for depression when delivered 1:1, but group treatments often do not perform as well as 1:1 treatments. One way to begin to understand how group treatments perform is to assess the process of change during treatment. This study examined trajectories of change across 10-session group BA for individuals with severe, chronic, or recurrent forms of depression. We also tested whether individuals who had associated sudden gains or depression spikes had better outcomes than those who did not have these change patterns. We examined psychological and sociodemographic predictors of the patterns of change. Participants were 104 individuals who met diagnostic criteria for major depressive disorder and participated in one of 10 BA groups, provided over a 2-year period. A linear, but not quadratic or cubic, rate of change fit the data and the effect size for the change in mood symptoms from baseline to posttreatment was large, Cohen’s d = 1.25. Although 34% (26 of the 77 who provided outcome data) of individuals had a sudden gain and 10% (7/77) had a depression spike, neither sudden gains nor depression spikes predicted posttreatment outcomes. None of the demographic or psychological factors (rumination, behavioral activation) predicted the pattern of change. These results suggest that although group BA may help to reduce depressive symptoms in individuals with severe, recurrent, and/or chronic forms of depression, the overall linear pattern of change is different from quadratic patterns of change reported for 1:1 BA.     

Dissociable influences of reward motivation and positive emotion on cognitive control

It is becoming increasingly appreciated that affective and/or motivational influences contribute strongly to goal-oriented cognition and behavior. An unresolved question is whether emotional manipulations (i.e., direct induction of affectively valenced subjective experience) and motivational manipulations (e.g., delivery of performance-contingent rewards and punishments) have similar or distinct effects on cognitive control. Prior work has suggested that reward motivation can reliably enhance a proactive mode of cognitive control, whereas other evidence is suggestive that positive emotion improves cognitive flexibility, but reduces proactive control. However, a limitation of the prior research is that reward motivation and positive emotion have largely been studied independently. Here, we directly compared the effects of positive emotion and reward motivation on cognitive control with a tightly matched, within-subjects design, using the AX-continuous performance task paradigm, which allows for relative measurement of proactive versus reactive cognitive control. High-resolution pupillometry was employed as a secondary measure of cognitive dynamics during task performance. Robust increases in behavioral and pupillometric indices of proactive control were observed with reward motivation. The effects of positive emotion were much weaker, but if anything, also reflected enhancement of proactive control, a pattern that diverges from some prior findings. These results indicate that reward motivation has robust influences on cognitive control, while also highlighting the complexity and heterogeneity of positive-emotion effects. The findings are discussed in terms of potential neurobiological mechanisms.     

Cognitive Behavioral Therapy for HIV-Negative Heterosexual Meth Users: The FASTLANE II Intervention

The purpose of this paper is to provide clinicians with a theoretical roadmap and practical toolkit for the FASTLANE II intervention, a 9-session behavior change intervention for HIV-negative meth-using heterosexual men and women that simultaneously targets depressive symptoms, meth use, and sexual risk behavior. The intervention was grounded in cognitive behavioral therapy (CBT), social cognitive theory (SCT), and the theory of reasoned action (TRA), and utilized a variety of cognitive and behavioral techniques. Examples of those techniques are provided, as well how those techniques map onto core theoretical elements of CBT, SCT, and TRA. We present three case studies with sample counseling session dialogue. Techniques and skills from FASTLANE II may be of use to clinicians interested in targeting depression, meth use, and high-risk sexual behavior.     

A test of the regulatory fit hypothesis in perceptual classification learning

This article builds a bridge between research on regulatory focus in motivation and classification learning. It tests the hypothesis that a fit between the situational regulatory focus and the reward structure of the task leads to greater cognitive flexibility than does a mismatch between situational focus and the reward structure and that the fit between the regulatory-focus-induced processing characteristics and the nature of the environment influences performance. In Experiment 1, we used a classification task for which cognitive flexibility should be advantageous and examined both gains (Experiment 1A) and losses (Experiment 1B) reward structures. In Experiments 2 and 3, we used a classification task for which cognitive flexibility should be disadvantageous. In Experiment 2, we used a gains reward structure, and in Experiment 3, we used a losses reward structure. As was predicted, when cognitive flexibility was advantageous, the participants in a regulatory fit showed faster learning and more quickly shifted toward the optimal response strategy. Also as was predicted, when cognitive flexibility was disadvantageous, the participants in a regulatory mismatch showed faster learning and more quickly shifted toward the optimal response strategy. Implications for current theories of motivation and classification learning are discussed.     

Hoarding

This commentary highlights areas of research during my career that have been very positively influenced by Dr. Aaron T. Beck’s work on cognitive theory, assessment, and treatment of behavioral disorders. These include collaborative efforts to develop assessment of beliefs and interpretations, as well as cognitive therapy for obsessive-compulsive disorder, and especially recent work on assessing, understanding beliefs about possessions, and cognitive behavior therapy for hoarding disorder.     

Treatment of a Case Example With PTSD and Chronic Pain

This commentary reviews the case of GH, a survivor of a road traffic collision, who has chronic pain and posttraumatic stress disorder (PTSD). The case formulation, assessment strategy, and treatment plan are informed by the relevant experimental literature and empirically supported treatments using a cognitive behavioral perspective. Given this framework, the commentary includes a focus on the treatment of PTSD with an eye toward generalizing the therapeutic strategies to chronic pain problems. Psychoeducation, imaginal exposure to the traumatic event, in vivo exposure to avoided activities, and cognitive interventions including coping self-statements, correction of logical errors, decatastrophizing and developing alternative explanations are all included in the recommendations as part of a standard cognitive behavioral treatment for PTSD. Added to this standard PTSD protocol is the suggested use of interoceptive exposure to address GH’s feared bodily sensations. In the assessment domain, standard measures for pain and PTSD assessment are suggested along with tracking of depression and anxiety sensitivity. Some recognition of more recent approaches to cognitive behavioral therapy (e.g., Acceptance and Commitment Therapy) is given in considering potential obstacles to treatment.     

Behavioral Activation as a Mechanism of Change in Residential Treatment for Mood Problems: A Growth Curve Model Analysis

Research on the efficacy, effectiveness, and dissemination potential of behavioral activation (BA)-focused interventions for depression and comorbid disorders has expanded rapidly. However, research that examines how BA interventions work has seen less growth. A primary purported mechanism of BA is activation, which reflects a person’s meaningful (re)engagement in life. BA theory posits that depression will decrease as activation increases, and that changes in the mechanism variable will lead to changes in outcome. The current study aims to investigate activation as a potential mechanism of change in the context of a BA-focused residential treatment intervention for mood problems using repeated measures of self-reported activation and depression from a large comorbid sample (N = 578). Growth curve modeling was used to examine between-person differences in within-person change over time. Findings suggest that self-reported activation increases and depression decreases over time. Moreover, results show both linear and quadratic growth and that the rate of change in activation predicts the rate of change of depression. BA-focused residential treatment may facilitate activation, which exerts an effect on depression among residents with diagnostically complex presentations.