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Changing Avoidance (Behavioral Activation)

Behavioral activation (BA) is a structured psychotherapeutic approach effective for a range of disorders, including depression (Ekers et al., 2014), anxiety (Stein et al., 2021), and PTSD (Etherton & Farley, 2022). It aims to help clients engage in adaptive activities and decrease their engagement in activities that maintain their distress. Recent approaches to behavioral activation have highlighted the role of avoidance in perpetuating low mood (Martell et al., 2022). Accordingly, clients are encouraged to functionally assess their avoidance behaviors and implement alternative coping responses. This Changing Avoidance (Behavioral Activation) worksheet is designed to help clients identify and evaluate avoidance behaviors that are maintaining their difficulties (i.e. maladaptive coping) and implement more adaptive ways of coping.

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Introduction & Theoretical Background

Drawing on early behavioral theories of depression (e.g., Lewinsohn, 1974), BA assumes that depressed individuals obtain less positive reinforcement because they engage in fewer pleasant activities and enjoy them less. Modern approaches to BA expand on these ideas by adopting a functional contextualistic perspective (Hayes et al., 1999): the aim is not simply to schedule pleasurable or satisfying events (as with the activity scheduling approach used in cognitive therapy; Beck et al., 1979), but to understand the variables that generate and maintain unhelpful responses, including overt behavior and cognitive processes (Veale, 2008). Furthermore, scheduled activities in BA extend beyond rewarding ones, and may include actions related to personal goals, values, unaddressed problems, and areas of avoidance (Kanter et al., 2010).

Several variants of BA have been developed over recent decades, all of which share a basis in activity monitoring and planning (Kanter et al., 2010). For instance, Lejuez and colleagues (2001, 2011) have developed a relatively brief treatment for depression (BATD) that utilizes behavioral activation alongside other behavioral interventions. According to this approach, depression results from the increased reinforcement of depressive behaviors (e.g., social withdrawal) and the decreased reinforcement of non-depressive behaviors. The aim of this treatment is to shift this ratio in favour of non-depressive behaviors using interventions such as activity monitoring and scheduling, values assessment, enlisting support (i.e., the use of contracts), and contingency management (Kanter et al., 2010; Lejuez et al., 2011).

Similarly, the approach outlined by Martell and colleagues (2001, 2022) utilizes activity scheduling to overcome deficits in positive reinforcement while emphasizing the need to overcome avoidance behavior and activate competing behaviors (Ferster, 1973). This is achieved using several interventions alongside activation, including avoidance modification, problem-solving, values exploration, and a limited focus on ruminative thinking.

Behavioral activation and avoidance modification

Martell and colleagues’ (2022) version of BA targets avoidance modification most comprehensively. While activity monitoring and scheduling are the primary interventions in this approach, avoidance-focused procedures are used to maximize the success of activation.

Many clients begin therapy stuck in patterns of avoidance. These patterns are characterized by coping strategies of passivity, avoidance, or withdrawal… As avoidance is one of the most frequent barriers to recovering from depression, countering client avoidance is a critical part of BA.

Martell et al., 2022, p.110

According to the authors, avoidance behaviors are often a means of coping with depressed feelings. This can become a vicious cycle: whilst avoidance alleviates discomfort in the short term (e.g., staying in bed might feel like a relief if certain social situations are dreaded), it tends to increase depression in the long term due to unimproved negative life situations and/or the emergence of secondary problems (Jacobson et al., 2001; Martell et al., 2022). Accordingly, clients are encouraged to functionally assess their avoidance behaviors and implement alternative coping behaviors (i.e. ‘approach’ behaviors). In this context, functional analysis can help clients:

  • Identify avoidance behaviors that maintain their depression.
  • Evaluate the positive and negative consequences of these behaviors.
  • Explore and implement different behavioral choices.
  • Generate adaptive behaviors that alleviate depression and orientate them toward their values.

Jacobson and colleagues (2001) recommend using visual depictions for functional analyses, as this allows for a direct modification of the client’s environment context, helping them to understand how they can prevent the downward spiral of depression. The authors begin by exploring the function of avoidance behaviors using the acronym ‘TRAP’:

  • T: What triggered the client’s depressive response?
  • R: What was the depressive response?
  • AP: What avoidance pattern followed, that might be maintaining their depression?

Following a costs-benefits discussion of avoidance behaviors, alternative coping behaviors are then explored using the acronym ‘TRAC’:

  • T: What triggered the client’s depressive response?
  • R: What was the depressive response?
  • AC: What alternative coping response could replace their avoidance pattern?

Finally, clients are encouraged to test out their alternative coping responses and reminded that while desisting from avoidance is likely beneficial in the long run, it might not lead to immediate improvements in mood (McCauley et al., 2016).

This Changing Avoidance (Behavioral Activation) worksheet guides clients through a series of steps that involve identifying their depressive responses, ways of coping with them, and the relative costs and benefits of these response patterns. It can be used to explore the antecedents and consequences of avoidance patterns (typically negative and unintended), and to plan alternative coping strategies that lead to more adaptive long-term outcomes.

Therapist Guidance

Being active and doing the things that matter to you is an effective way to overcome low mood. Unfortunately, certain things can get in the way of becoming more active, including how you try to cope with feeling low. Avoidance is a coping strategy that can take many forms, including shutting down and withdrawing, procrastinating, or dwelling on problems. These ways of coping might give you a sense of relief in the short term, but they tend to prolong distress in the long run. Can we use this worksheet to explore your ways of coping?

Therapists should first use this worksheet to analyze the antecedents and consequences of avoidance patterns that appear to contribute to the client’s distress. In this context, avoidance encompasses both avoidance behaviors (i.e., acting to prevent something) and escape behaviors (i.e., taking oneself out of an undesirable situation; Martell et al., 2022). If the client acknowledges that these avoidance patterns come with costs (which are often most apparent in the long-term), more adaptive coping strategies are generated and their likely consequences analyzed. These alternative coping strategies can then be tested.

Step 1: Situation

Begin by identifying a recent situation that triggered the client’s depressive or avoidant response. For example:

  • "Let’s start by identifying a recent time when your mood worsened, or you used the avoidance behaviors we have discussed."
    • "Where were you?"
    • "Who was involved?"
    • "What happened?"

Step 2: Thoughts and emotions

Explore the client’s cognitive and emotional responses to the trigger. Clinicians will find it helpful to assist their clients to make links between their appraisals and their emotional reactions. Consider asking:

  • "What did you think and feel in response to that situation?"
  • "When that happened what was going through your mind?"
  • "How did that experience make you feel?"

Step 3: Current way of coping

Identify the client’s coping response(s), including any forms of avoidance. These responses can be framed as an active attempt to solve the problem or elevate distress:

  • "How did you try to cope with that situation?"
  • "What did you do to avoid those feelings"
  • "It might have been something you started to do, like brooding, or postponing something you didn’t want to do, like getting out of bed."

Step 4: Describe the short-term and long-term consequences of the current coping strategy

Explore the costs and benefits of the client’s coping response(s) in the short and long term. Consider how avoidance impacts the client’s natural positive reinforcers (e.g., reduced contact with supportive friends), existing problems (e.g., accumulating household chores), and long-term goals (e.g., overcoming their depression):

  • "What are the consequences of coping in this way, both in the short-term and the long-term?"
  • "Does it have any payoffs?"
  • "In the long run, is avoidance likely to help with your mood, or will it contribute to a downward spiral?"

Step 5: New way of coping

Help the client identify more helpful ways of coping with their depressive response. This might include working toward an activity, goal, or value, or using problem-solving to address the situation. You might ask:

  • "How could you get out of this avoidance pattern and cope in a more helpful way? One option might be taking a step toward an activity, goal, or value that’s important to you. Another option is addressing the problem directly using problem-solving."
  • "If a friend were in this situation, what would you recommend they try?"

Step 6: Describe the short-term and long-term consequences of coping in this way

Explore the costs and benefits of alternative coping in the short- and long-term. Consider how these responses are likely to benefit the client’s natural positive reinforcers, current problems, and long-term goals. This can be an opportunity to remind the client that reduced avoidance might not lead to immediate improvements in their mood, and may make them feel slightly worse in the short-term. Consider asking:

  • "If you coped in this way, what are the short-term and long-term consequences likely to be?"
  • "Can you think of any ways it would benefit you?"
  • "What impact is likely to have on your goals or the problems you are experiencing in the long run?"

Step 7: Test out the new way of coping

Encourage the client to implement their alternative coping strategy and record the results, including how it impacted their mood:

  • "It looks like your new way of coping might be more helpful than avoiding things. Are you willing to test it out and see what happens? Write down what happened and the impact it had on your mood."

References And Further Reading

  • Barlow, D. H., & Craske, M. G. (2006). Mastery of your anxiety and panic. Oxford University Press.
  • Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training: A manual for the helping professions. Research press.
  • Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.
  • Clark, D. M., Salkovskis, P. M. (2009). Panic disorder: Manual for improving access to psychological therapy (IAPT) high intensity CBT therapists.
  • Ehlers, A. (1993). Interoception and panic disorder. Advances in Behaviour Research and Therapy, 15(1), 3-21.
  • Limmer, J., Kornhuber, J., & Martin, A. (2015). Panic and comorbid depression and their associations with stress reactivity, interoceptive awareness and interoceptive accuracy of various bioparameters. Journal of Affective Disorders, 185, 170-179.
  • Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018). Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis. 
    Psychological Medicine, 48(12), 1945-1953.
  • Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417.
  • Seligman, M. E. P. (1988). Competing theories of panic. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological Perspectives (pp. 321-330). Hillsdale,NJ.: Lawrence Erlbaum Associates.
  • Taylor, S. (2001). Breathing retraining in the treatment of panic disorder: Efficacy, caveats and indications. Scandinavian Journal of Behaviour Therapy, 30(2), 49-56.
  • Wegner, D. M. (1994). Ironic processes of mental control. Psychological Review, 101(1), 34.
  • Yoris, A., Esteves, S., Couto, B., Melloni, M., Kichic, R., Cetkovich, M., ... & Sedeño, L. (2015). The roles of interoceptive sensitivity and metacognitive interoception in panic. Behavioral and Brain Functions, 11(1), 1-6.