Behavioural Therapy and Behavioural Activation

What is behavioural therapy?

Behavioural therapy works on what you do, more than on what you think. You and your therapist plan small changes, try them out and look at what happens.

It is one of the two roots of cognitive behavioural therapy, which adds work on thoughts. This page covers three behavioural methods: behavioural activation, exposure and habit reversal.

Exposure and response prevention, used for obsessive-compulsive disorder, has its own page.

How it works

What you do and how you feel shape each other. Behavioural therapy looks for the patterns that keep a problem going. Then it changes them, one planned step at a time.

Avoidance is often part of the pattern. The NHS says avoiding a fear can bring relief in the short term, but it can make the fear grow.

Source: NHS: facing your fears

Behavioural activation

Behavioural activation (BA) is a talking therapy for depression. It focuses on the links between what you do and your mood, rather than on thoughts and feelings.

NICE describes it as helping you spot patterns and plan practical changes that reduce avoidance. The plan leans on activities linked to a better mood. The work is structured, with clear goals, and deals with problems you face now.

NICE lists BA among the treatments to discuss for a new episode of depression. It can be one to one or, for less severe depression, in a group.

NICE says a course usually runs to eight sessions for less severe depression. For more severe depression, it is usually twelve to sixteen. NHS Talking Therapies offers BA at both its lower and higher intensity levels.

Sources: NHS: depression treatment, NICE NG222, NHS England: talking therapies manual

Exposure for fears and phobias

Exposure means facing something you fear on purpose, in small steps and with support. NHS inform says treating simple phobias involves gradually becoming exposed to what causes your fear. This is also called desensitisation.

You list the situations you fear, from the least to the most difficult. Then you face them one at a time, starting with the easiest. Your therapist helps you plan each step and stay with it.

For obsessive-compulsive disorder, exposure is paired with holding back the compulsion. That is exposure and response prevention.

Sources: NHS inform: phobias, NHS: facing your fears

Habit reversal

Habit reversal is a behavioural method for tics and hair pulling. The NHS names habit reversal therapy as one of the main therapies for tics. It says trichotillomania, or hair pulling, is commonly treated with habit reversal training.

The NHS calls that training a type of CBT. Behavioural methods and CBT overlap, and many therapists use both.

You learn to notice when the urge comes, and to respond in a new way. For a shoulder shrug, that might mean stretching your arms until the urge passes. Our Tourette's page covers tics in more depth.

Activation works with activity and mood. Exposure works with avoidance, while habit reversal develops another response to an urge.

Sources: NHS: tics treatment, NHS: trichotillomania, NHS: depression treatment, NHS: facing your fears

Who is it best suited to?

NICE says BA may be helpful when depression has led to pulling away from people, doing fewer things or inactivity. It says the same when depression followed a change in circumstances or routine.

Behavioural therapy can be a good fit if you:

• Have stopped doing things you used to enjoy, and the days have gone flat
• Avoid a place, an object or a situation because of fear
• Prefer practical steps to talking about the past
• Want to see progress in what you do from week to week

NICE also notes that BA asks you to be willing to do homework between sessions.

Source: NICE NG222

Behavioural therapy or CBT?

CBT joins behavioural methods to work on thoughts. A 1996 trial compared full CBT for depression with its behavioural activation part alone. It found no sign that the full treatment did better.

Many CBT therapists use behavioural methods, and some specialise in them. If that matters to you, ask a therapist how much of their work is behavioural.

Source: Jacobson et al. 1996

The evidence

Most of this research is about BA for depression. In the COBRA trial, 440 adults with depression in Devon, Durham and Leeds had either BA or CBT. Junior mental health workers gave the BA, and psychological therapists gave the CBT.

BA did no worse than CBT, and it was more cost-effective. The authors concluded that workers with less costly training can deliver BA with no loss of effect.

A 2014 review pooled 26 trials of BA for depression. It found BA did better than the control groups in those trials.

For fears, a 2008 review of 33 trials looked at specific phobias. Exposure did much better than no treatment. It also did better than placebo and than other talking therapies.

Sources: Richards et al. 2016, Ekers et al. 2014, Wolitzky-Taylor et al. 2008

Where the evidence stops

The trials above studied depression and specific phobias. They do not test BA for other problems, such as anxiety or long-term illness.

For depression, our low mood and depression page covers the other options NICE names.