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  #1  
Unread November 10th, 2006, 10:46 PM
James Pretzer James Pretzer is offline
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Default Is Behavioral Activation More Effective Than CT?

While CT has a good track record as a treatment for depression, questions have been raised regarding whether the "cognitive" component of CT is really necessary. A component analysis of CT (Jacobson, et al, 1996) found that the behavioral activation (BA) component of CT alone produced as much change as the entire CT package and did not have a higher relapse rate over a two-week follow-up (Gortner, et al, 1998). A recent study (Dimidjian, et al, 2006) has followed up on these provocative findings with a randomized trial comparing BA, CT, and antidepressant medication to a pill placebo in treating depression. 241 adults who met DSM criteria for Major Depression were recruited, screened, and then assigned randomly to one of the four conditions.

The BA treatment was based on the behavioral interventions recommended in Beck's CT of Depression but included an additional emphasis on counteracting avoidance behaviors and included behavioral strategies targeting rumination. The central idea behind the BA model is that when individuals avoid distressing situations, the demands of daily life, distressing thoughts and feelings, etc., this may minimize distress in the short term but reduces opportunities to contact potentially antidepressant environmental reinforcers and creates or exacerbates problems as a side effect of decreased activity. Dimidjian et al (2006) write "suppose a patient responds to conflict with a coworker by avoiding work for multiple days. Although this avoidance minimizes aversive interactions with her coworker, the patient also misses the experience of accomplishing tasks at work, which has served an antidepressant function for her in the past. Staying home also creates new problems, such as earning less money and engendering frustration on the part of her supervisor, while doing nothing to address the original problem with the coworker. To interrupt this cycle, the BA model uses focused activation strategies to explicitly target such avoidance patterns and associated functional consequences." Interventions included self-monitoring, structuring and scheduling daily activities, rating the degree of pleasure and accomplishment experienced when engaged in daily activities, exploring alternative behaviors relevant to accomplishing personal goals, and using role-play to address skill deficits. There was an increased focus on assessing and treating avoidance behaviors, establishing and maintaining regularized routines, and behavioral strategies for targeting ruminations. These strategies consisted of an emphasis on the function (and consequences) of rumination and on shifting attention from rumination to a focus on immediate, direct experience. The BA condition did not include any interventions that explicitly attempted to identify dysfunctional cognitions and change their content.

The CT treatment was standard CT for depression as described by A. T. Beck et al (1979) and J. Beck (1995). Therapists could utilize the full range of behavioral activation strategies described in these texts but not the BA strategies targeting avoidance behavior and targeting ruminations described in the previous paragraph. CT strategies were used in the integrative way that they normally are, not the sequential manner that was requires in the Jacobson, et al study. Both treatments met twice weekly for 8 weeks then once weekly for 8 weeks for a maximum of 24 sessions.

It is interesting that no results were reported comparing the effectiveness of the treatments over all of the subjects. Subjects were divided into "high severity" and "low severity" groups on the basis of pre-treatment scores on the Hamilton Rating Scale for Depression (HRSD ≥ 20 and HRSD ≤ 19 respectively). Results were reported separately for the "high severity" group and the "low severity" group. Note that both groups were clinically depressed. The "high severity" group had a mean BDI score of 35.3 while the "low severity" group had a mean BDI score of 27.6. From now on I'll refer to the "high severity" group as severely depressed and the "low severity" group as moderately depressed because those labels seem more accurate to me.

When the data was analyzed in terms of level of depression (BDI scores and HRSD scores), for the moderately depressed group, all treatments were effective (mean post-treatment BDIs ranged from 7.9 to 11) and there were no significant between-treatment differences in effectiveness. For the severely depressed group, all treatments were effective but BA and medication were significantly more effective than CT (post-treatment BDIs were 8.75 and 7.78 respectively compared with CT's 17.44). The poor performance of CT relative to BA and medication was partly due to a sub-group of extreme non-responders. In the severely depressed group, 7 of the CT participants had BDI scores greater than 30 at post-test, the other 18 did much better. The average post-test BDI for the group of severely depressed individuals who responded to CT was not reported but according to my math it should have been less than 12.55.

When the data for the severely depressed group was analyzed in terms of rates of response to treatment and rates of remission rather than in terms of level of depression, there were no significant differences between treatments but there was a non-significant trend for BA to produce superior results on one of two measures. With the moderately depressed group, there were no significant differences between treatments.

There are several things that would be useful to know in trying to interpret the relevance of these findings to clinical practice. First, it would be interesting to know if BA was superior to CT overall, but unfortunately that result is not reported. It also would be very interesting to know something about the characteristics of the subgroup of the severely depressed individuals who did not respond to CT but that data is not reported. It also would be really, really interesting to know if the CT received by the non-responders differed in any identifiable way from the CT received by the responders. Finally, it would be useful to know what the CT therapists did with the individuals who were not responding to CT after six sessions or so. Normally, when a depressed individual is not responding to CT we'd revisit our conceptualization, we'd focus more on behavioral interventions, and we'd consider antidepressant medication. We know that therapists in this study didn't add antidepressant medication (since that wasn't allowed) but there is no mention of how they did deal with non-responders.


So, do these findings mean that we should quit doing CT and switch to BA? Note that BA was only superior with the seriously depressed individuals and was no better than CT with the moderately depressed individuals. Also note that a small sub-group of non-responders seems to account for much of the difference in effectiveness between BA and CT with the severely depressed individuals. The authors suggest that "The results underscore the value of sustained use of simple behavioral strategies, such as goal setting, self-monitoring, activity scheduling, problem-solving, and graded task assignment in the treatment of depression." They also observe that "A. T. Beck and colleagues (1979) have long suggested that therapists focus on behavioral strategies early in treatment when patients are more depressed and return to that emphasis later if patients start to worsen." I would agree whole-heartedly. It may be that the CT therapists became so enamored of thought sheets and rational responses that they overused these interventions and short-changed the behavioral interventions that are likely to be more effective with severe depression. However, if this happens, I'd argue that it isn't a shortcoming of CT, it is a poor implementation of CT.

It's not that I have a low opinion of BA. It clearly is an effective treatment for depressed individuals and some of the interventions that have been added in the current iteration would be useful to keep in mind when doing CT. We've focused on the role of avoidance in anxiety disorders for decades and more recently we've recognized the role of avoidance behavior in other problems. Before this article, I don't remember seeing much of a discussion of the role of avoidance behavior in depression. However, the example in paragraph 2 of this post is a good one (the individual who has a conflict with a coworker and therefore stays home from work). In situations such as this it seems obvious that we need to address the avoidance of conflict and help the individual deal with the situation in more adaptive ways. I would hope that cognitive therapists would have more sense than to spend their time generating rational responses without addressing the avoidance.

The strategies BA uses for dealing with depressive ruminations (assessing their function, pointing out the consequences of rumination, having the individual shift their focus of attention from the ruminations to immediate experience) seem like a fine way to deal with ruminations. In my mind, it raises the question of how the CT therapists in this study dealt with depressive rumination. If they were trained only in CT of depression and didn't have any training in CT for OCD or GAD (this is possible for 2 of the 3 CT therapists), they may have tried using rational responses as a way of dealing with rumination. Unfortunately, doing so usually is quite counter-productive. The BA approach is a fine way to deal with ruminations in CT but there are a number of other good options. The approach I prefer is to assess the function of the rumination, address any beliefs that encourage rumination, and then to teach the individual to replace prolonged periods of rumination with focused periods of problem-solving. Again, if CT therapists were trying to deal with ruminations by generating rational responses, this isn't a short-coming of CT, it is a poor implementation of CT.

One of the selling points of BA is that it is intended to be easier to learn than CT. Certainly, if it turns out that CT produced worse results because the CT therapists were under-utilizing behavioral interventions, over-using rational responses, or dealing with ruminations in counter-productive ways, this would support the idea that one of CT's shortcomings is that it is hard for therapists to master. The therapists in this study were trained and supervised by Steve Hollon and Keith Dobson and were certified by the Academy of Cognitive Therapy. The idea of developing a treatment protocol that is easy to teach to ordinary practitioners makes a lot of sense.

One question I have is how broadly applicable BA is. It seems to work well as a treatment for depression but many individuals seeking treatment for depression have other problems as well. For example, in this study 23.7% of participants had a concurrent anxiety disorder, 42.3% had a history of substance abuse, and 20.3% had concurrent avoidant, dependent, obsessive-compulsive, or depressive personality disorder. Does BA produce improvement on these disorders as well or do we need to train therapists in other treatment protocols if these problems are to be treated? One advantage of CT is that it is a versatile approach that can be used effectively with a wide range of problems.

What do you think about all this? (also see the thread "Is it improtant to change the client's dysfunctional cognitions? " in this forum.)

Last edited by James Pretzer; January 10th, 2008 at 10:14 PM.
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  #2  
Unread January 7th, 2008, 11:05 PM
James Pretzer James Pretzer is offline
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Default Follow-up on: Is Behavioral Activation More Effective Than CT?

A post-hoc analysis by Coffman et al (2007) examines some of the questions I raised in my initial post about Behavioral Activation. It is clear that the apparent superiority of BA is due to a sub-group of severely depressed and chronically depressed individuals. For these individuals CT had virtually no benefit while BA had some benefit (but they were still clinically depressed).

I recommend taking a look at Coffman et al's study for a discussion of the characteristics of this sub-group, they go into quite a bit of detail. I'll think it over as i have time and hopefully post more about it in the near future.
Coffman, S. R., Martell, C. R., Dimidjian, S., Gallop, R. & Hollon, S. D. (2007). Extreme nonresponse in cognitive therapy: Can behavioral activation succeed where cognitive therapy fails? Journal of Consulting and Clinical Psychology, 75, 531-541.
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  #3  
Unread January 10th, 2008, 11:30 PM
James Pretzer James Pretzer is offline
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Default Re: Is Behavioral Activation More Effective Than CT?

I've had time to think about Coffman, et al's (2007) paper and a number of points seem important:
  • The sub-group of individuals who did not respond to CT were characterized by severe depression, greater functional impairment and problems with primary support group. Many had major interpersonal problems or major stressors, or both. Most described themselves as having long-standing depressive propensities.
  • With the individuals who did not respond to CT, both therapist and client rated the therapeutic alliance less positively as early as the second session and this continued throughout treatment.
  • With the individuals who did not respond to CT, both therapists and clients became demoralized.
  • The CT therapists did not have access to on-site expert supervision. They often sought expert consultation regarding the individuals who did not respond to CT but there often was a delay in receiving the consultation.

The authors suggest that the CT therapists may have shifted from behavioral interventions to cognitive interventions too soon and it appears that this was the case. When I teach CT (which is quite often) I teach that when treating severely depressed clients one should start with behavioral interventions, begin some of the more concrete cognitive interventions once the client's mood has improved somewhat and wait until the client's depression is substantially improved before addressing dysfunctional beliefs and assumptions. None of the individuals who failed to respond to CT had improved enough for it to make sense to shift from behavioral interventions to cognitive interventions yet therapists in the CT condition spent more than half of their time on cognitive strategies.

Also, the authors suggest that many of the individuals who did not respond to CT would have met DSM criteria for an Axis II disorder. However, it appears that the CT therapists were trained in CT for depression and were not trained in using CT with Axis II disorders. This it particularly salient in light of the observation that problems with the therapeutic alliance were evident with the individuals who did not respond to CT. In CT with personality disorders there is an increased emphasis on dealing with problems with the therapeutic relationship. It appears that the CT therapists in this study did not know how to deal with some of the complexities they encountered.

The authors of this paper make some valuable recommendations for CT therapists who are faced by clients who appear similar to those who did not respond to CT:
  1. Do not abandon behavioral interventions too soon. If the client is not responding to treatment, spend extra time on behavioral interventions.
  2. Don't attempt too much in short-term treatment. If the time is limited, don't get into deep or complex issues that you won't have time to resolve.

To these I would add:
3. If there is a poor therapeutic alliance, address this immediately rather than trying to plow ahead anyway.

4. The "Cognitive Therapy for Depression" protocol is designed for uncomplicated unipolar depression. If there are co-morbid disorders (i.e. anxiety disorders, substance abuse, personality disorders, etc.) they probably will need to be addressed as well. That means knowing how to apply CT with anxiety, substance abuse, personality disorders, etc. rather than only knowing CT for depression
This last point highlights one of the drawbacks of CT. It is complex to learn and apply effectively with the wide range of clients one encounters in clinical practice. One of Behavioral Activation's selling points is that it is supposed to be easier to learn than CT. If it does indeed turn out to be easier to learn while remaining equally effective, that would make me a big proponent of BA. However, I must admit that I remain skeptical.

It appears that CT performed more poorly than BA because there was a sub-group of individuals that the CT therapists did not know how to treat effectively. It also appears that simple improvements in how CT is applied would result in much better outcomes for CT with these clients (the authors cite some unpublished data from DeRubeis to support this point). We'll see if this is the case when subsequent research is published.

Last edited by James Pretzer; January 11th, 2008 at 09:46 PM.
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Unread November 21st, 2008, 11:01 PM
James Pretzer James Pretzer is offline
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Default Is Behavioral Activation More Effective Than CT? (Round 3)

Bottonari et al (2008) present another interesting contribution to the question of whether Behavioral Activation (BA) is superior to Cognitive Therapy (CT) in a single-case study they present in Cognitive and Behavioral Practice. A 62-year-old man seeking treatment for chronic, treatment-resistant depression and comorbid personality pathology received 21 sessions of CT, which was ineffective, then the therapist switched to an equal amount of BA, which was effective. That shows that BA is better than CT, right?

The therapist was a grad student in her second year of practicum training. She had training in individual and group CBT for depression and had a supervisor with expertise in empirically-supported treatments. She began CT by working to help the client "identify, track, and evaluate his dysfunctional cognitions" and there also was "a lesser focus on increasing pleasant activities in order to challenge dysfunctional beliefs." Even though an agenda was set for each session, the discussion often strayed from the topic despite the therapist's efforts to redirect Mr. X back to the agenda. "Discussions were interrupted by Mr. X's long stories about his life and his thoughts about God's role in his depression with subsequent crying spells." When the therapist focused on Mr. X's negative cognitions, "his mood spiraled down in response to the content of his thoughts." He also "repeatedly denied memory of the material discussed in prior sessions and stated that he had forgotten to monitor thoughts between sessions."

As I think about the article's description of how CT was implemented, a number of thoughts occur to me:
  1. From the beginning of treatment, the focus was on monitoring and challenging dysfunctional thoughts. With a seriously depressed client, Beck recommends an emphasis on behavioral interventions until there is some improvement in the client's mood.
  2. When attempts were made on behavioral interventions, the emphasis was on increasing pleasant activities rather than on identifying activities that improved the client's mood and working to increase those activities.
  3. The client's noncompliance (both within the session and between sessions) does not appear to have been addressed effectively.
  4. The client was prone to depressive rumination. "Rational responses" often are ineffective or counterproductive in dealing with rumination. Despite the observation that the client had difficulty using cognitive restructuring effectively between sessions, the therapist persisted with this approach rather than trying other ways of dealing with rumination.
  5. While the impact of comorbid dependent personality traits is mentioned, there is no mention of any attempt to address these traits (even though the authors cite at least one reference that has a detailed discussion of CT with dependent personality disorder).
  6. The client reported that he was unable to remember what had been covered in previous sessions but there is no mention of any steps to address problem (i.e. summarizing the major points that were covered at the end of the session, providing the client with a written summary or supplemental readings, using written forms such as Greenberger and Padesky's "Action Plan" form and the "Behavioral Experiment" form, etc.).
  7. There is no mention of attempts to address the client's avoidance

When the therapist finally switched to BA "Mr. X was encouraged to look at his daily behaviors and to observe differences between times when he was engaged in pleasant activities and times when he was inactive and/or ruminating on negative themes." He began to get up earlier, participate in planned activities, and participate in new activities. This is exactly what CT should have started with given Mr. X's level of depression! Cognitive interventions should have been introduced after "Activity Scheduling." When the therapist did address Mr.X's negative thinking when trying a BA approach "rather than challenging the content of his thoughts, the therapist asked him how his ruminative thinking influenced his mood and had him consider engagement in negative thinking as a chosen behavior." This is a much more promising way of dealing with rumination than the therapist tried when attempting CT. It is an approach often used in CT (I don't remember if Beck discusses it but I believe that Burns does).

In short, I think that the therapist did better CT when she was attempting BA than she did when she was attempting CT. I don't intend any disrespect towards BA, I think BA is a promising approach. However, it seems as though CT's biggest problem is that therapists are trying to do CT without knowing how to do it well. If the client is seriously depressed, don't start with cognitive restructuring, start with activity scheduling and introduce cognitive interventions once the client's mood begins improving. If attempts at "cognitive restructuring" make the client's mood worse rather than better, don't perseverate for weeks, try one of the alternative approaches. If there are comorbid conditions that complicate treatment, address them rather than trying to plow ahead despite the complications.
Bottonari, K.A., Roberts, J. E., Thomas, S. N., & Read, J. P. (2008) Stop thinking and start doing: Switching from Cognitive Therapy to Behavioral activation in a case of chronic treatment-resistant depression. Cognitive and Behavioral Practice, 15, 376-386.
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Unread January 7th, 2009, 10:51 PM
sk8rgrl23 sk8rgrl23 is offline
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Default Re: Follow-up on: Is Behavioral Activation More Effective Than CT?

Quote:
Originally Posted by James Pretzer View Post
A post-hoc analysis by Coffman et al (2007) examines some of the questions I raised in my initial post about Behavioral Activation. It is clear that the apparent superiority of BA is due to a sub-group of severely depressed and chronically depressed individuals. For these individuals CT had virtually no benefit while BA had some benefit (but they were still clinically depressed).

I recommend taking a look at Coffman et al's study for a discussion of the characteristics of this sub-group, they go into quite a bit of detail. I'll think it over as i have time and hopefully post more about it in the near future.
Coffman, S. R., Martell, C. R., Dimidjian, S., Gallop, R. & Hollon, S. D. (2007). Extreme nonresponse in cognitive therapy: Can behavioral activation succeed where cognitive therapy fails? Journal of Consulting and Clinical Psychology, 75, 531-541.
I think that BA may be more effective with the most severely depressed because it is simple, concrete, nonjudgmental and therefore it is a good approach to getting the most depressed to a point where they can think functionally and benefit from CT.

DBT (Dialectical Behavior Therapy-Linehan) is well-known for its benefits for those with Borderline PD, and made up of skills in 4 separate categories, including Distress Tolerance. I thought of DT when reading your phrase about ruminating and using activities and mental redirection as a way of combatting that. When I lead a DBT group, I prefer to start with Distress Tolerance. As with Borderline PD, depression can lead a person to be overly sensitive to perceived criticism, and I find the Distress Tolerance the most User Friendly in this regard.

It makes absolute sense to use a multi-stage approach, and also perhaps there is no one approach that works for everyone. Some clients ruminate because of past trauma, and simply having the chance to tell their story helps many to unload some of that emotional memory and become more aware of trauma triggers (and ultimately able to sidestep them).

What about research that suggests that a combination of medication and therapy is the most effective?
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Unread January 29th, 2009, 10:38 PM
James Pretzer James Pretzer is offline
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Default Re: Is Behavioral Activation More Effective Than CT?

On the question regarding studies that show that a combination of medication and therapy is the most effective, I haven't reviewed that literature lately but the last time I looked there were some studies showing that medication plus CT was more effective than either alone and there were some studies showing that medication plus CT was no more effective than either alone (see http://www.behavior.net/forums/cogni...996/msg83.html). While there are plenty of people (both clients and practitioners) who assume that the combination medication and therapy is best with depression, I don't think that is what the data shows. In fact, I think that there is a study or two suggesting that a combined approach has a higher drop-out rate and thus actually ends up being less effective. Obviously more research is needed.

My clinical experience leads me to think that there may be some people for whom a combined approach is best, some people for whom either approach will work well, some people for whom medication works better than CT, and some people for whom CT works better than medication. (There may well be some people for whom neither approach will work but I don't run into very many of those.) Unfortunately, we haven't figured out how to predict who will need a combined approach and who won't. The "state of the art" is "try it and see."

As we develop a better understanding of the genetics of serotonin metabolism and the role it plays in depression, that may help us predict who needs medication and who doesn't. It will be interesting to see how that research turns out.
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