Abstract
Occupational therapy practitioners provide interventions to promote activity engagement to multiple clinical populations. They help clients develop restorative, adaptive, and compensatory skills to improve their performance in daily activities. The issue addressed in this article is that current clinical frameworks lack translation of learned skills to consistent everyday performance. There is a gap between what clients can do and what clients actually do in everyday life. Behavioral activation provides an explicit, structured, and practical approach that can translate capacity into long-term engagement. This article presents behavioral activation as a transdiagnostic approach that targets populations experiencing chronic illness to bridge the gap between what the client can do in therapy and what the client could do in everyday life.
Occupational therapy practice is wide ranging, serving multiple clinical populations across the life course and in various practice settings. Our practice is characterized by its distinct value, as articulated by the American Occupational Therapy Association (AOTA): “to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life” (AOTA, 2015, para. 5). However, among people with chronic conditions, gaps exist between observed capacities (ability to do an activity) in traditional practice settings (e.g., inpatient rehabilitation, outpatient rehabilitation) and lasting engagement in day-to-day activities (actual execution of daily activities; Kapoor et al., 2017; Karp et al., 2009). This loss of engagement is associated with poor physical health, mental health, and quality of life (Mackichan et al., 2013; Oldridge & Stump, 2004). People with chronic conditions often lack a structure to help them apply their capacity for activity performance to lasting engagement.
Behavioral activation is a structured, theory-based approach that can empower multiple clinical populations to identify, schedule, and engage in therapeutic occupations as a part of their everyday lives long after completion of therapy (Kanter et al., 2010). Behavioral activation started as an approach that focused on scheduling and monitoring engagement in meaningful activities to increase the frequency of pleasurable experiences and reduce depressive symptoms in people with major depressive disorder (Lewinsohn, 1974; Martell et al., 2001). However, it can be used as a practical tool in occupational therapy practice to provide a client-led, explicit, repeatable process for participating in meaningful activities.
Four primary essential elements of behavioral activation are (1) values identification and goal setting, (2) activity scheduling, (3) activity monitoring, and (4) skills training (Table 1; Cuijpers et al., 2007; Kanter et al., 2010). Like the occupational therapy process (AOTA, 2014), behavioral activation involves structured assessment of clients’ values to derive meaningful activities. Clients are taught to schedule meaningful activities, to engage in those activities, and to monitor the pleasure associated with them. This iterative process is supported by therapist-directed, skill-based training to ensure the client’s mastery and assimilation of the process.
Essential Elements of Behavioral Activation
In combination with other intervention tools, behavioral activation enacts client-driven processes to overcome engagement barriers after the discontinuation of therapeutic services. Behavioral activation organizes intervention principles used by occupational therapy practitioners into a structured delivery system that can be administered with high fidelity. These principles elicit self-awareness (Goverover et al., 2007) and help train clients in strategies to bridge learned skills in therapy to applications in daily life. At the same time, behavioral activation explicitly transforms clients from passive learners to self-driven leaders because it was designed to foster activity engagement outside of (or between) therapy sessions. We propose that behavioral activation may be a potential transdiagnostic treatment approach (McEvoy et al., 2009) to stimulate client engagement in daily life. We believe behavioral activation provides a manageable therapeutic package to narrow the gap between innate capacities and lasting engagement across the care continuum. To illustrate our point, we describe current applications in occupational therapy research addressing cancer, stroke, and mild cognitive impairment (MCI).
Behavioral Activation: Selected Applications
Cancer
Cancer survivorship is associated with multiple sequelae (Baxter et al., 2017) that act as barriers to completing daily routines (Lyons, Newman, Kaufman, et al., 2018), fulfilling work responsibilities, and balancing interpersonal relationships (Hwang et al., 2015). Behavioral activation was used in two pilot studies to accelerate cancer survivors’ recovery and resumption of valued activities (e.g., work, parenting, socializing) and wellness activities (e.g., exercise, meditation, nutrition; Lyons et al., 2015, 2019). The interventions in both studies included behavioral activation elements: personally selected activities, skills training regarding activity adaptation, action planning to achieve goals, and activity monitoring through 7-day goal setting. The behavioral activation intervention process was enhanced by additional essential and structural elements.
In the first study, a modified version of behavioral activation was delivered remotely to breast cancer survivors by telephone (Lyons et al., 2015). The intervention was augmented by specific skills training to elicit problem solving to help participants overcome barriers impeding goal achievement. In the second study, a modified version of behavioral activation was delivered in the home to older adults who either were receiving or had completed cancer treatment (Lyons et al., 2019). Participants were provided opportunities to practice the desired activity, obtain adaptive equipment, or modify the environment as supplemental intervention elements (Lyons, Newman, Adachi-Mejia, et al., 2018). In both studies, trained occupational therapists provided skills-based training regarding activity adaptation, energy management, and wellness education.
Study results showed that behavioral activation increased participants’ engagement in instrumental activities of daily living (IADLs), work, exercise, leisure, and socialization. The interventions helped participants attain 7-day and 6-wk engagement goals, with goal achievement ranging from 62% to 69% (Lyons et al., 2015; Lyons, Newman, Kaufman, et al., 2018). Both studies were feasibility studies (Lyons et al., 2015, 2019). Participants were satisfied with the intervention (Lyons et al., 2015). Outcomes related to quality of life and disability favored behavioral activation in comparison to cancer survivors receiving usual care alone (Lyons et al., 2019). Behavioral activation offered a structured way to help cancer survivors learn to be strategic and purposeful about increasing activity engagement amid residual sequelae.
Stroke
Stroke has shifted from an acute condition with high mortality to a chronic condition with high morbidity and disability (Benjamin et al., 2018). Most people who experience stroke live with residual impairments (Wolf et al., 2009). Although some impairments may improve over time, few people experience restoration of prestroke levels of engagement (Kapoor et al., 2017). Behavioral activation, in combination with elements of metacognitive instruction, has shown promise for reducing residual impairments and disability after stroke (McEwen et al., 2015; Skidmore et al., 2015; Wolf et al., 2016). Behavioral activation and metacognitive instruction share many essential elements in that they train clients in strategies to identify and assess challenging activities, schedule and perform these activities, and monitor behavior to resolve challenges through skills-based training (Skidmore et al., 2014). The core feature of these approaches is the iterative practice of the strategy, which culminates in a greater awareness of and confidence in eliciting engagement.
In interventions for stroke survivors, behavioral activation elements have been augmented by the metacognitive element of guided discovery. Guided discovery, in contrast to direct skill instruction, is a therapist-facilitated process that elicits clients’ own insights (Mayer, 2004). Behavioral activation with guided discovery has been shown to enhance activity outcomes among people with stroke-related cognitive impairment (Skidmore et al., 2015, 2017). Examined collectively, behavioral activation approaches that include guided discovery have shown promise for improving activity engagement. Benefits in motor function, cognitive functions (in particular, executive functions), mood, motivation, activities of daily living, and self-efficacy have also been observed (McEwen et al., 2017). These approaches have been studied across phases of stroke recovery, levels of stroke severity, and practice settings (McEwen et al., 2017).
Mild Cognitive Impairment
MCI is a stage between normal cognitive aging and dementia. Older adults with MCI have evidence of cognitive deficits that are not attributable to delirium or explained by another mental disorder. Older adults with MCI can engage in daily activities but may require additional effort or time to complete them (American Psychiatric Association, 2013). Recent research has suggested that people with MCI demonstrate subtle changes in performance, including difficulties with IADLs and work (Rodakowski et al., 2014).
A few studies have begun to examine the feasibility and efficacy of interventions that use essential elements of behavioral activation in older adults with MCI to maximize performance of daily activities.These studies have applied the essential elements of behavioral activation: participant-derived, self-selected activity goals (Rodakowski et al., 2018); activity monitoring to provide information on baseline daily engagement and its value; activity scheduling to increase social contact and engagement; and skills-based training in problem solving to identify solutions to problems and strategies to overcome barriers. The interventions were delivered in homes and communities to encourage real-world application.
These preliminary studies using behavioral activation have shown promising outcomes among older adults with MCI. The findings suggest that the intervention was easy and feasible to administer (Rodakowski et al., 2019), that people with MCI liked the intervention (methods are under review), and that it helped people achieve meaningful activity-based goals (mean = 4.23 goals, standard deviation = 1.00; Rodakowski et al., 2018). Behavioral activation is sustainable because the participants focus on what they want to do and how they want to do it, and therefore it may be used as a clinical intervention to activate long-term engagement in older adults with MCI (Fernández-Ballesteros et al., 2003).
Discussion
Behavioral activation and occupational therapy practice have a natural synergy. Behavioral activation stimulates the primary outcome of occupational therapy practice: promotion of occupational engagement to promote health and quality of life. Although many of these concepts are not new to occupational therapy, one could argue that occupational therapy practitioners are not providing the essential elements of behavioral activation in a structured way that maximizes prolonged engagement outside of therapy. Unlike traditional directed therapy and fragmented use of individual elements, behavioral activation maximizes clients’ expertise by training them to actively engage in their treatment. Therefore, they learn to identify challenging daily activities, generate individualized strategies, and generalize these skills to other performance challenges after the intervention program has ceased (Skidmore et al., 2017). In essence, clients learn to drive their own change and daily engagement. Behavioral activation is an implementable package that can be effectively delivered with similar effects both in person (Rodakowski et al., 2018; Skidmore et al., 2015) and remotely (Lyons et al., 2015).
Implications for Occupational Therapy Education, Practice, and Research
We argue for incorporation of behavioral activation into occupational therapy education, practice, and research on the basis of currently available research, as follows:
We recommend that occupational therapy education programs review behavioral activation in curricula and case study applications. This way, novice therapists possess a transdiagnostic framework and knowledge of essential elements that activate lasting engagement.
We selected three exemplars of behavioral activation application. Although the science is emerging, we see value in behavioral activation for multiple populations, including people with mental health conditions, those with severe physical impairments, and clients in pediatric-based practice. It will be important to investigate how behavioral activation approaches are augmented by additional intervention elements in new populations.
We must evaluate feasibility and acceptability benchmarks by therapists and researchers to optimize the structural elements of behavioral activation. As evidence is reported, we must synthesize the literature for refinement of unified and unique intervention elements.
Conclusion
Behavioral activation appears to be an implementable transdiagnostic approach for occupational therapy intervention. Behavioral activation shows promise for promoting lasting engagement in meaningful, client-centered activities in populations with chronic illness. Further research is warranted to evaluate feasibility, acceptability, and translation to everyday practice.
Footnotes
Acknowledgments
We acknowledge the following funding sources: Rachelle Brick and Elizabeth Skidmore are supported by the National Center for Medical Rehabilitation Research (Grant R01 HD074693). Kathleen Doyle Lyons is supported by the National Cancer Institute (Grant R01 CA225792-01A1). Juleen Rodakowski is supported by the National Institute on Aging (Grant R01 AG056351).