Behaviour Therapy Rationale

Behaviour therapies for depression are underpinned by learning theory as a means of explaining the decline into and resolution of the depressive state and are primarily aimed at engaging or re-engaging the patient in pleasurable and consequently positively reinforcing behaviours. Relative to psychotherapy, behaviour therapy concentrates more on behaviour itself and less on a presumed underlying cause. The basic premise of behavioural treatments is that depression is a learned response in light of low rates of positively reinforcing behaviours and insufficient positive reward from routine behaviour. The aim therefore is to increase the reward experience through behavioural activation. Interventions combine skills based learning such as relaxation skills and problems solving with distress tolerance for negative emotions.

Evidence Base

Behaviour therapy approaches generally follow the framework developed by Lewinsohn (1975), with no trials evaluating behavioural interventions based on classical conditioning. Despite the emphasis on empirical evidence there are very few studies supporting the preferential use of behaviour therapy as a treatment for depression. National Institute for Clinical Excellence (NICE) guidelines accepted only two (Gallagher, 1983 and McLean & Hakstian, 1979) and concluded that there was insufficient evidence to support clinically significant differences in outcome between behaviour therapy and other psychotherapies.

Two studies have shown this approach to outperformed control conditions. Shaw (1977) found that although behaviour therapy patients did not outperform those in CT, they did improve more than a waiting-list condition. Treatment gains were maintained at one month but failure to follow up the waiting-list group prevented comparison. McLean & Hakstian (1979) reported a relatively short-lived advantage for behaviour therapy in a comparative study with psychotherapy, relaxation therapy and amitriptyline. The clearest finding was for behaviour therapy over psychotherapy, with some advantage recorded over Amitriptyline at the end of treatment. At the three-month follow-up, the mean difference in depression scores was no longer significant.

Jacobson & Hollon (1996) conducted a dismantling study with 152 depressed subjects, in which behavioural activation (BA) alone was compared with BA plus cognitive coping skills and full CT. No significant differences were found between the three treatment formats on a range of outcome measures at the end of treatment or over a two-year follow up (Gortner et al., 1998), with all treatments producing significant (58 % to 68 %) and sustained improvement.

As with other models of therapy for depression, behaviour therapy has also been employed as a couples therapy. When compared with individual CBT (Jacobson et al., 1991) found no difference in capacity to reduce depressive symptoms and reported that only those receiving behavioural marital therapy (BMT) demonstrated a significant improvement in marital adjustment. Similarly, Beach & O'Leary (1992) found BMT and CT to be equally effective in reducing depression and superior to waiting list controls but only BMT improved the marital relationship. Both studies found that depressive symptoms were mediated by marital adjustment, suggesting a specific mechanism of change whereby depression reduces with increase marital satisfaction.

Clinical Practice

Behaviour therapy concentrates on the present and sets specific, clearly defined treatment goals within a time-limited and structured intervention. Given the emphasis on engaging patients in rewarding behaviours and reducing punishing behaviours, one of the initial tasks is collaboratively identifying the impact of behaviour on depressive symptoms. Specific interventions are then scheduled to elucidate patterns of reinforcement, for example through monitoring daily activities and rating the associated mastery and pleasure. Tasks are then assigned to gradually increase mastery and pleasure and decrease negatively reinforcing patterns. Progress may be made through imaginal or in vivo exposure to problematic situations with the ultimate aim of identifying and implementing behavioural techniques for managing identified difficulties. Specific areas of difficulty are addressed through appropriate skills training, for example assertiveness or social skill training.

Behavioural marital therapy progresses through three stages, employing social learning, behavioural change and cognitive techniques. The initial phase concentrates on the patterns of reinforcement that exist within the couple and aims to eliminate the stressors and reestablish or introduce positive interactions through agreed homework tasks that promote mutually satisfying activity. The potential for mood elevation through successful completion of these tasks is used as a foundation for the second phase, which focuses more closely on the mechanics of the relationship, tackling communication patterns, problem-solving strategies and day-to-day interactions. These tasks further aim to tip the balance of reinforcement in favour of patterns through more effective problem resolution. This is achieved by supporting the couple to make expression of emotion safe and acceptable and enhancing perceived capacity to cope, mutual trust, dependability and closeness. Negotiating tasks in advance is used to make responses more predictable and to increase the opportunity for a positively reinforcing cycle. By default the reduction in uncontrolled conflict will also diminish the potential for negatively reinforcing patterns to be repeated. From this stronger position the couple then prepares for termination in the final stage. This concentrates on relapse prevention, tolerating transitory return of conflict or symptoms and promoting early response to high-risk situations.

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