Activation comportementale et dépression : une approche de traitement contextuelle Behavioral Activation and Depression: A Contextual Treatment Approach

Résumé

La dépression comptant parmi les troubles psychologiques ayant les plus hauts taux de prévalence dans le monde, il importe de trouver des interventions efficaces et peu coûteuses afin de faciliter l’accès aux services. On observe, depuis une dizaine d’années, un regain d’intérêt pour les interventions comportementales dans le traitement de la dépression. L’activation comportementale, une composante de la thérapie cognitivo-comportementale, a été développée de manière à constituer un traitement à part entière et depuis, les données probantes qui appuient l’efficacité de ce traitement s’accumulent. Cet article résume d’abord les origines du modèle comportemental de la dépression. Il est suivi d’une explication détaillée des différentes étapes impliquées lors d’une intervention d’activation comportementale. Ses appuis empiriques sont par la suite présentés. L’activation comportementale est ensuite discutée dans le cadre de thérapies de troisième vague, abordant le rôle potentiel de la pleine conscience à travers les objectifs d’activation comportementale. Des suggestions sont faites quant à la façon dont les thérapeutes peuvent inclure des activités basées sur la pleine conscience dans la hiérarchie d’activation comportementale. L’article se conclut par une discussion sur les questions qui devraient être abordées dans les recherches futures.

Mots-clés :

• dépression,
• activation comportementale,
• troisième vague,
• pleine conscience

Abstract

Depression is a widespread psychological disorder that affects approximately one in five North American. Typical reactions to depression include inactivity, isolation, and rumination. Several treatments and psychological interventions have emerged to address this problematic. Cognitive behavioural therapies have received increasingly large amounts of empirical support. A sub-component of cognitive behavioural therapy, behavioural activation, has been shown to in itself effectively treat symptoms of depression. This intervention involves efforts to re-activate the depressed client by having them engage in pleasant, gratifying, leisure, social, or physical activities, thereby counteracting the tendency to be inactive and to isolate oneself. Clients are guided through the process of establishing a list of potentially rewarding social, leisure, mastery-oriented or physical activities, to then establish a gradual hierarchy of objectives to be accomplished over the span of several weeks. Concrete action plans are devised, and solutions to potential obstacles are elaborated. The client is the asked to execute the targeted objective and to record their mood prior to and following the activity. Behavioural activation effectively reverses the downward spiral to depression. Interestingly, studies show that behavioural activation has a positive effect on cognitive activities. It has been shown to reduce rumination and favour cognitive restructuring, without requiring cognitively-based interventions. The advantage of this treatment is therefore that it is simpler to administer in comparison to full-packaged cognitive behavioural therapies, it requires a lesser number of sessions and can be disseminated in a low-intensity format. This article begins by summarizing the origins of the behavioural model of depression, which serves as a basis to the understanding of behavioural activation. This is followed by a detailed explanation of the different phases involved in a behavioural activation intervention. Empirical support for behavioural activation is then presented in regards to depression as well as comorbid physical and psychological health problems. The results of meta-analyses and randomized controlled trials are presented. Behavioural activation is then discussed within the framework of third-wave therapies, discussing the potential role of mindfulness in behavioural activation objectives. Specifically, it is suggested that mindfulness, although not necessarily directly addressed in behavioural activation interventions, is an integral part of this intervention as clients are asked to record their mood and activities and to become cognizant of the relationship between their symptoms of depression and the participation in activities that provide positive reinforcement. This favours self-awareness and allows clients to realize the impact of their actions on their physical and psychological states. In engaging in self-observation and self-recording, and in participating in a variety of tasks and activities, clients are indirectly encouraged to focus on the here and now rather that to succumb to the depressive tendency that is to ruminate. Suggestions are made as to how therapists can include mindfulness-based activities in the behavioural activation hierarchy. It is hypothesized that, due to the calming effect of mindfulness practices on the nervous system, incorporating mindfulness-based activities–such as yoga, tai chi, Qi Gong, or meditation–could for some people enhance the efficacy of behavioural activation interventions and foster a greater sense of well-being. The article concludes by discussing issues that should be addressed in future research. It is suggested that future studies on behavioural activation explore the impacts of incorporating mindfulness-based activities in the behavioural activation hierarchy in comparison to a traditional hierarchy limited to the accomplishment of gratifying or mastery-oriented tasks, social outings, leisure activities and physical activity.

Keywords:

• depression,
• behavioral activation,
• third-wave therapies,
• mindfulness