What is Clinical Behaviour Analysis?

Introduction

Clinical behaviour analysis (CBA; a third-generation behaviour therapy) is the clinical application of behaviour analysis (ABA). CBA represents a movement in behaviour therapy away from methodological behaviourism and back toward radical behaviourism and the use of functional analytic models of verbal behaviour – particularly, relational frame theory (RFT).

Current Models

CBA therapies include acceptance and commitment therapy (ACT), behavioural medicine (such as behavioural gerontology and paediatric feeding therapy), community reinforcement approach and family training (CRAFT), exposure therapies/desensitisation (such as systematic desensitisation), functional analytic psychotherapy (FAP, such as behavioural activation (BA) and integrative behavioural couples therapy), and voucher-based contingency management.

Acceptance and Commitment Therapy

Acceptance and commitment therapy is probably the most well-researched of all the third-generation behaviour therapy models. Its development co-occurred with that of relational frame theory, with several researchers such as Steven C Hayes being involved with both. ACT has been argued to be based on relational frame theory, although this is a matter of some debate within the community. Originally this approach was referred to as comprehensive distancing. Every practitioner mixes acceptance with a commitment to one’s values. These ingredients become enmeshed into the treatment in different ways which leads to ACT being either more on the mindfulness side or more on the behaviour-changing side. ACT has, as of May 2021, been evaluated in over 600 randomised clinical trials for a variety of client problems. Overall, when compared to other active treatments designed or known to be helpful, the effect size for ACT is a Cohen’s d of around 0.6, which is considered a medium effect size.

Behavioural Activation

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching law model of reinforcement. A recent review of the research supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Community Reinforcement Approach and Family Training

Community reinforcement approach and family training (CRAFT) is a model developed by Robert Meyer and based on the community reinforcement approach (CRA) first developed by Nathan Azrin and Hunt. The model focuses on the use of functional behavioural assessment to reduce drinking behaviour. CRAFT combines CRA with family therapy.

Functional Analytic Psychotherapy

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. The basic FAP analysis utilises what is called the clinically relevant behaviour (CRB1), which is the client’s presenting problem as presented in-session. Client in-session actions that improve their CRB1s are referred to as CRB2s. Client statements, or verbal behaviour, about CRBs are referred to as CRB3s. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Integrative Behavioural Couples Therapy

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couples relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Clinical Formulation

As with all behaviour therapy, clinical behaviour analysis relies on a functional analysis of problem behaviour. Depending on the clinical model this analysis draws on B.F Skinner’s model of Verbal Behaviour or relational frame theory.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group in clinical behaviour analysis ABA:I. ABA:I serves as the core intellectual home for behaviour analysts.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis.

The Association for Contextual Behavioural Science is devoted to third-generation therapies and basic research on derived relational responding and relational frame theory.

What is Behavioural Activation?

Introduction

Behavioural activation (BA) is a third generation behaviour therapy for treating depression.

It is one functional analytic psychotherapy which are based on a Skinnerian psychological model of behaviour change, generally referred to as applied behaviour analysis. This area is also a part of what is called clinical behaviour analysis (CBA) and makes up one of the most effective practices in the professional practice of behaviour analysis. The technique can also be used from a cognitive-behaviour therapy (CBT) framework.

Overview

The Beck Institute describes BA as “getting clients more active and involved in life by scheduling activities that have the potential to improve their mood.”

Theoretical Underpinnings

Behavioural activation emerged from a component analysis of cognitive behavioural therapy. This analysis found that any cognitive component added little to the overall treatment of depression. The behavioural component had existed as a stand-alone treatment in the early work of Peter Lewinsohn and thus a group of behaviourists decided that it might be more efficient to pursue a purer behavioural treatment for the disorder. The theory holds that not enough environmental reinforcement or too much environmental punishment can contribute to depression. The goal of the intervention is to increase environmental reinforcement and reduce punishment.

The theoretical underpinnings of behavioural activation for depression is Charles Ferster’s functional analysis of depression. Ferster’s basic model has been strengthened by further development in the study of reinforcement principles which led to the matching law and continuing theoretical advances in the possible functions of depression, as well as a look at behaviour analysis of child development in order to determine long-term patterns which may lead to dysthymia.

Methods

One behavioural activation approach to depression was as follows: participants were asked to create a hierarchy of reinforcing activities which were then rank-ordered by difficulty; participants tracked their own goals along with clinicians who used a token economy to reinforce success in moving through the hierarchy of activities; participants were measured before and after by the Beck Depression Inventory (BDI) and a great effect on their depression was found as a result of their treatment. This was then compared to a control group who did not receive the same treatment. The results of those who received behavioural activation treatment were markedly superior to those of the persons in the control group. Multiple clinics have since piloted and developed the treatment.

Another behavioural activation approach utilised a different methodology: clients are asked to develop an understanding of the relationship between actions and emotions, with actions being seen as the cause of emotions. An hourly self-monitoring chart is created to track activities and the impact on the mood they create for a full week. A rating scale from 1 to 10 is used for each mood change per hour. The goal is to identify depression loops. A depression loop is when a temporary coping method reduces the overall depression, such as the temporary relief provided by alcohol or other drugs, escape or avoidance or rumination. When patterns of dysfunctional responding, or loops, are identified alternative coping responses are attempted to break the loop. This method is described with the acronym “TRAP” (Trigger, Response, Avoidance Pattern) which is to be replaced with a “TRAC” (Trigger, Response, Alternate Coping response). Particular attention is given to rumination, which is provided with its own acronym RCA (Rumination Cues Action). Rumination is identified as a particularly common avoidance behaviour which worsens mood. The client is to evaluate the rumination in terms of it having improved the thing being ruminated about, providing understanding, and its emotional effects on the client. Attending to experience is suggested as an alternative to rumination as well as other possible distracting or mood improving actions.

The general program is described with the acronym ACTION (Assess behaviour/mood, Choose alternate responses, Try out those alternate responses, Integrate these alternatives, Observe results and (Now) evaluate). The goal being the understanding of the relationship between actions and emotional consequences and a systematic replacement of dysfunctional patterns with adaptive ones. Additionally, focus is given to quality sleep, and improving social functioning.

Research Support

Depression

Reviews of behavioural activation studies for depression found that it has a robust effect and that policy makers should consider it an effective treatment. A large-scale treatment study found behavioural activation to be more effective than cognitive therapy and on par with medication for treating depression. A meta-analysis study comprising 34 Randomised Control Trials found that while Behavioural Activation treatment of adults with depression showed significantly greater beneficial effect compared with control participants, compared to participants treated with CT/CBT, at post treatment there were no statistically significant differences between treatment groups. A 2009 meta-analysis showed a medium post-treatment effect size compared to psychotherapy and other treatments.

Anxiety

A 2006 study of behavioural activation being applied to anxiety appeared to give promising results. One study found it to be effective with fibromyalgia-related pain anxiety.

In the Context of Third Generation Behaviour Therapies

Behavioural activation comes under the heading clinical behaviour analysis or what is often termed third generation behaviour therapy. Other behaviour therapies are acceptance and commitment therapy (ACT), as well as dialectical behaviour therapy (DBT) and functional analytic psychotherapy (FAP). Behavioural activation owes its basis to Charles Ferster’s Functional Analysis of Depression (1973) which developed B.F. Skinner’s idea of depression, within his analysis of motivation, as a lack of reinforcement.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group for practitioner issues, behavioural counselling, and clinical behaviour analysis. The association has larger special interest groups for behavioural medicine. It also serves as the core intellectual home for behaviour analysts.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis.

Doctoral level behaviour analysts who are psychologists belong to the American Psychological Association’s division 25 -Behaviour analysis. APA offers a diplomate in behavioural psychology.

BA in Virtual Reality

Due to a lack of access to trained providers, physical constraints or financial reasons, many patients are not able to attend BA therapy. Researchers are trying to overcome these challenges by providing BA via Virtual Reality. The idea of the concept is to enable especially elderly adults to participate in engaging activities that they would not attend it without VR. Possibly, the so-called “BA-inspired VR protocols” will mitigate the lower mood, life satisfaction, and likelihood of depressions.