Behavioural Activation For Depression: Martell, Dimidjian, Herman Dunn

Behavioural Activation For Depression: Martell, Dimidjian, Herman Dunn

Contents

1.      Introduction: The development of behavioural activation. 3

2.      The core principles of behavioural activation. 4

The 10 Core principles of BA.. 4

Principle 1: The key to changing how people feel is helping them change what they do. 5

Principle 2: Changes in life can lead to depression, and short term coping strategies may keep people stuck over time   5

Principle 3: The clues to figuring out what will be antidepressant for a particular client lie in what precedes and follows the client’s important behaviours. 5

Principle 4: Structure and schedule activities that follow a plan and not a mood. 5

Principle 5: Change will be easier when starting small 5

Principle 6: Emphasise activities that are naturally reinforcing. 5

Principle 7: Act as a coach. 6

Principle 8: Emphasize a problem-solving empirical approach, and recognise that all results are useful 6

Principle 9: Don’t just talk do it. 6

Principle 10: Troubleshoot possible and actual barriers to activation. 6

3.      The structure and style of therapy. 6

4.      Identifying the Ingredients of the Behavioural Antidepressant. 7

Assessing goals. 7

The basics of behavioural assessment. 8

Antecedents and Behaviours. 8

Behaviours and Consequences. 8

Assessment How to: The activity Chart. 8

When to monitor. 9

What to monitor. 9

Emotional recording. 9

Monitoring Mastery and Pleasure. 9

Monitoring intensity. 9

Reviewing Activity Monitoring. 9

Useful questions to facilitate the review.. 9

Assessing Risk. 10

Making an effective choice of activities. 10

What to target after reviewing the activity chart. 11

Basics of Identifying treatment targets. 11

5.      Activity Scheduling and Structuring. 11

How to activate clients. 12

Structuring and scheduling activities for BA.. 13

6.      Solving problems and countering avoidance. 13

Problem solving. 13

Types of problems addressed in BA.. 14

Validating the natural tendency to avoid and the challenge of change. 14

BA Problem Solving and Avoidance modification. 14

7.      How thinking can be problematic behaviour. 15

Assessing Rumination. 16

Targeting depressive rumination in BA, Don’t just talk, Do!. 17

Five ways to deal with rumination. 17

Interventions for dealing with ruminations. 18

8.      Troubleshooting problems with activation. 18

The challenges of activation. 18

The Therapists style and stance in troubleshooting. 18

Graded tasks. 19

The absence of inadequacy of activity monitoring. 19

Limited information about mood or emotions. 19

Problems with cue control 19

Problems with contingency management. 19

Problems with classically conditioned behaviours. 19

9.      Tying it all together: Relapse prevention and beyond. 20

The importance of relapse prevention. 20

Generalisation. 20

Ingredients of the behavioural antidepressant. 20

Expanding Activation to new life contexts and goals after treatment ends. 20

Identifying and preparing for high risk situations. 20

Booster and spaced sessions. 20

Putting it all together. 21

Summary. 22

1.     Introduction: The development of behavioural activation

Scepticism and compassion are two essential ingredients in psychotherapy research and possibly in psychotherapy.

There are three strategies in CBT

1.       Change how people think about specific situations

2.       Change how people behave

3.       Change how people think generally about themselves, their future and others.

Theorists:

Ferster:

·         Believed  activity depressed people choose is to avoid aversive feelings, e.g. watch TV, thus controlled by negative reinforcement, thus their behaviour is not being positively reinforced and they are lacking any feel good

Lewinsohn

·         Believed lack of focus on the environment rather than the self-caused is a major feature of depression, where an individual focusses more on themselves than how to enjoy the world

·         Key to fixing depression is to find more positively reinforced activities not negatively reinforced ones

·         Depressed people are more sensitive to emotional and physical pain, and react worse to aversive events.

Rehm

Depression is accounted for by a deficit in self control

1.       Selective monitoring of negative events

2.       Selective monitoring of immediate rather than more long term events

3.       Stringent self-evaluative criteria

4.       Inaccurate attribution of responsibilities

5.       In sufficient self-reward

6.       Excessive self-punishment

If you can rewards yourself in such a way that you are immune to aversive environmental events then you can be protected against the environment of course you need to listen to the environment but not be knocked off course by it

Beck

·         Start with activation and then do cognitive restructuring

·         Uses pleasure and mastery scale such that if client rates vacuuming as a 3 then they can think about dusting in comparison to this

CT & BA

Behavioural techniques in CT always serve the goal of changing how people think which is considered necessary to lasting change, however BA sees that it is positive reinforcement that does that.

BA does experiments to test the outcome of behaviour on mood, CT does behavioural activation to challenge thoughts.

Problem solving is an incompatible behaviour to rumination and can be an antidote to depression.

2.     The core principles of behavioural activation

·         BA aims to increase rewarding activities in people’s lives, increasing activation, i.e. energy, and increasing engagement with the world, i.e. purpose

·         Targets activities that prevent activation e.g. avoidance and escape behaviours

·         BA asserts that depression is the result of not getting positive rewards from their environment

·         Passive behaviours which tend to create dull negative feelings

o   Drinking alcohol

o   Watching TV

o   Sleeping excessively

Some clients are very busy but involve themselves in ruminative thinking which means they don’t enjoy what they do

The 10 Core principles of BA

1.       The key to changing how people feel is helping them change what they do

2.       Changes in life can lead to depression, and short term coping strategies may keep people stuck over time

3.       The clues to figuring out what will be antidepressant for a particular client lie in what precedes and follows the clients important behaviours

4.       Structure and schedule activities that follow a plan not a mood

5.       Change will be easier when starting small

6.       Emphasise activities that are naturally reinforcing

7.       Act as a coach

8.       Emphasise a problem solving empirical approach, and recognise that results are useful

9.       Don’t just talk, do

10.   Troubleshoot possible and actual barriers to activation

Principle 1: The key to changing how people feel is helping them change what they do

Typically people wait until they feel better before doing something, but this means they are a victim of their moods, and in fact their moods will be better if they actually got out and did something. Their motivation is inside out, if feel good then do.  However there are some necessary tasks around the house, or at work that you do regardless of how you feel. This is outside in motivation, and often even if you don’t feel like doing it, through doing it, you get some pleasure out of doing it.

Principle 2: Changes in life can lead to depression, and short term coping strategies may keep people stuck over time

Dysphoria=A state of unease or generalized dissatisfaction with life.

There are events such as poor jobs, relationship break up etc. that can cause depression. A short term coping strategy may be to withdraw from activity that was once pleasurable and engage in escape and avoidant behaviour. The trouble is that this keeps the client in their depressed state as there are low levels of positive reinforcement and then there are low levels of feelings of mastery, then there is a sense of inability to cope or problem solve.  So whilst depressive responses may make sense in the short term, as a regrouping position, in the long term they maintain the depression.

Principle 3: The clues to figuring out what will be antidepressant for a particular client lie in what precedes and follows the client’s important behaviours

So do an antecedent, behaviour and consequence analysis on depressed behaviour. Look at behaviours that used to give pleasure and see what has stopped them. You can use this analysis to see how depression is maintained, by creating unpleasant feelings through avoidance, or through stopping doing things that previously made you feel good.

Principle 4: Structure and schedule activities that follow a plan and not a mood

Acting from the inside out is not a good strategy when you are depressed.  When depressed you don’t want to do anything and this maintains depression.  Try acting according to a plan or a goal and not according to your mood, e.g. activities that solve problems, i.e. reduce stress, increase mastery, or activities that used to bring pleasure can improve mood. Activity scheduling and structuring is the backbone of BA and all other strategies emerge from here

Principle 5: Change will be easier when starting small

Change when ok is hard, but when depressed is even harder, so start small.  Some clients get frustrated if the goal is either too small, or they don’t get it completely right. So the trick is to select the right sized goal, that is challenging without being daunting. Failing a task can give a sense of hopelessness.

Principle 6: Emphasise activities that are naturally reinforcing

Natural reinforcement is when someone smiles when you talk then you continue talking, arbitrary reinforcement is getting a sweet after you have cleaned your room.  Quite often when someone has been withdrawn the environment initially punishes activity, so talking to co-workers they can give you the brush off as you haven’t been engaging with people and therefore haven’t got many stories or confidence etc. etc. In this case then you need to give yourself arbitrary reinforcement until as such time as the natural ones become available.

Dieting is naturally reinforcing after you see results but needs arbitrary reinforcement up until that point.

Principle 7: Act as a coach

Good coaches plan strategies, make suggestion, keep up morale and motivates. Coaching has an encouraging component, that is vital to the depressed client.

Principle 8: Emphasize a problem-solving empirical approach, and recognise that all results are useful

If getting activated and engaged were easy a client would do it themselves.  Effective therapy is an on-going process of developing, evaluating and trying out potential solutions.  Finding out what is positive reinforcing is vital to this work.

When a client tries a plan and it doesn’t have a desired outcome, then still remain positive and hopeful as we can learn from our successes and our failures.  So what you need to do is to analyse why it didn’t work so that you can avoid that, or incorporate that next time.

Principle 9: Don’t just talk do it

Activity is key to BA so you need to do homework every session. Homework must be done in collaboration with clients, and must have a good rationale as to why it is worthwhile. Tasks should be broken down so they can be seen to be able to be done, and what is involved in doing it is thought about as well as contingencies thought about too.  Homework is reinforced by reviewing it the next week.

Principle 10: Troubleshoot possible and actual barriers to activation

Yep, there are going to be problems!!! Use them to learn about the client and the activity schedule and tailor both your relationship and the activity schedule accordingly.

3.     The structure and style of therapy

BA shows that low activity produces depression. Most people are motivated inside out and this means in depression that the depression is going to maintain. What you need to do here is work outside in and to become active no matter how you are feeling and soon the motivation will come. To help with depressed clients then tasks are broken down into small units and structure is added to their days to help them towards achieving the tasks. Depression is the act of pulling back from life, which can be the case when something bad happens, however if you stay depressed and pulled back from life more bad things happen because of your depression.

BA Therapists need to understand what are the situations that motivate the client to action.

Doing a BDI or a PHQ9, will structure the time as we can see how the client’s scores are changing in response to treatment, and gives us a focus for treatment. It also connects last week to homework to this week.

There are 5 key aspects to BA work

1.       Activity and mood monitoring

2.       Activity scheduling

3.       Activity structuring\grading tasks

4.       Attention to experience exercises

a.       Helps stop rumination

5.       Maintaining an activation focus

In therapy style, there is a problem solving attitude, what can the client do to get what they want, what is stopping them getting what they want.

Style and session structure

1.       Maintain session structure

2.       Remain action orientated

3.       Validate client experiences

a.       This is so important, people need strokes, people need to feel close to other people and to do this

4.       Work collaboratively with client

5.       Be non-judgemental

6.       Express warmth and be genuine with client

7.       Reinforce reports or examples of adaptive behaviour

4.     Identifying the Ingredients of the Behavioural Antidepressant

Life consists of penetrating the unknown, and fashioning our actions in accord with the new knowledge thus acquired: Leo Tolstoy

Working with clients: find the behaviours and situations that create depressive feelings or reduce it . Clients may well feel they are depressed all the time, but if you analyse the situation then you will find during their day that their depression is higher and lower in different situations.

The bedrock of BA is assessment, here the therapist works out what is maintaining depression and what is likely to improve it.

Assessing goals

The overall goal of BA is to get the client to experience greater contact with sources of reward in the world and to solve life’s problems. What these are the client will define.

The client has been told a 1000 times to get busy, get active do something don’t just mope around and hasn’t listened. So a big question is, what does the client want? Standardly the client wants to feel better, and BA state that it is increased activity that will do this. Knowing what a client values may help in identifying goals.

So a client wants to feel better, you say then you need to increase activity in the world, doing what you value, doing what gives you pleasure and solving problems. So you need to find out what the client values to select the behavioural goals for the client.  Explain the difference between values and goals to the client and get the client to select goals that accord with their values.  ACT can give more information about selecting values. In BA it can be useful to restrict the domain of values to family, interpersonal relationships, work and leisure.

The basics of behavioural assessment

Finding out about the situation, the antecedents of an important behaviour are key to finding out what motivates a client and what their goals are. Sometimes they act in antidepressant ways, through getting clear about what it was in that situation that was antidepressant, provides the key to their behavioural antidepressant.

First of all do an ABC analysis on the problem behaviour. Look at one incident and do the ABC, then look to do others and look to get a pattern of behaviour, in some ways, get the commonality out of the ABC.

When looking to analyse the B, then do so in concrete terms, if a client says I was depressed, what does this mean? What did they feel like, what did they do, what were they thinking about? Often it is helpful to think of in terms of behaviours to be increased or decreased. The behaviours to be increased are those that bring positive reinforcement, those that bring pleasure or add competence, or solve problems. Another behaviour that needs to be increased is defining problems and applying problem solving.  The behaviours that need to be decreased are the avoidant and escapist behaviours that give a short term gain, but a long term problem, such behaviours are rumination, drinking etc.

Antecedents and Behaviours

Antecedents and behaviours can be connected via respondent conditioning. If they are then you need to extinguish this pairing through exposure.

Behaviours and Consequences

Relationship between consequence and behaviour is by reinforcement. This can be positive or negative. There can also be punishment which relates consequence and behaviour. Punishment can be positive or negative.

Behaviour has a function of increasing or decreasing the likelihood of behaviour. Behaviour has a consequence, a function that means it will increase or decrease the likelihood of it being repeated. It is important to see the function of a behaviour, some benign looking behaviours may actually be avoidant.

Assessment How to: The activity Chart

The activity chart is the primary mode of assessment for the client. Urge the client to act like a scientist recording data as soon after it has happened, examine your life in detail, and closely examine even the smallest detail.

Activity monitoring is a client’s activity for the week prior to the session.

There are a few different ways of doing it

When to monitor

1.       Hour by hour

a.       Provides most data but can be impractical due to the commitment needed.

2.       Blocks of time

a.       E.g. morning, afternoon and evening, less detail but easier to collect

3.       Time sampling

a.       Select time slices and record at these points during the day, so this should give examples of different time periods and be easier to collect, although there could be some difficulty in remembering what time to collect the data

What to monitor

1.       Activity

2.       Mood\Emotion

3.       Intensity of mood\emotion

4.       Levels of pleasure\accomplishment

It can be useful to guide the client in terms of not recording too little or too much. So at work 8 hours bored, is too little, and what you want to capture is the hour’s shift, the talking to colleagues good, the reading emails bad. Ideally you would want to capture major shifts in moods, and then you can look at what precipitated it. What we are trying to find out is what makes us happy and what makes us sad and that the information is out there in our activity chart. Sometimes the situation can be external, such as boss shouts at me, sometimes it can be internal, such as ruminating.  Be aware that you can do two things at the same time, so you can talk to the neighbour and be ruminating.

Emotional recording

To start off get the client to rate a single depressed mood as none or full on, later on then you can look at specific emotions, sad, guilty, ashamed etc.

Monitoring Mastery and Pleasure

As an alternative to monitoring mood you can monitor mastery and pleasure, so mastery is the feeling of accomplishment that you can do something.

Monitoring intensity

To start monitoring intensity of emotions then it is helpful to get a client to anchor this scale. So get them to do a 0 ,25,50, 75 and 100. Some clients don’t like using a numeric scale, in which case you can use a little a lot etc. Prior to sending a client home with the chart then they can practice in session to see how they get on.

Reviewing Activity Monitoring

First of all get the client to say what they learnt from doing the monitoring. Have they seen any connections between activity and mood. What they find out about what makes them happy, what makes them unhappy.

Useful questions to facilitate the review

1.       What are the connections between the clients activities and moods

a.       Aim to notice what maintains their mood

b.      It is important to notice when there are shifts in mood

c.       Describe the context as two identical activities can have two different moods

                                                               i.      When you understand what makes for a better mood, you can look to increase these activities

                                                             ii.      When you understand what makes for a worse mood, then you can look to decrease these activities

d.      Look at regular routines, like sleeping, eating and working. It can hard to  tackle life’s problems without proper nutrition or sleep

2.       What is the clients overall mood and specific emotions experienced during the week

a.       A client can engage in a range of activities but yet experience only a limited set of emotions

                                                               i.      Can the client correctly articulate all emotions

3.       Has there been disruption in the clients routine

a.       What would your typical day be when you weren’t depressed, or if you weren’t depressed

b.      Does this provide a sense of things being abnormal, would having  a structure and predictability add some structure, some security and feeling of being in control

c.       Dysregulation of routine can add to a feeling of depression

4.       What avoidance patterns are present

a.       Some avoidance is obvious, drinking, or staying in bed, but others are subtle so avoiding a situation that provokes shame

b.      Avoidance adds to passivity and so problems get larger and you get weaker

5.       Where should one start making changes?

a.       What activities motivate and what activities demotivate

b.      When you make change, make small doable changes

Assessing Risk

If the client reports suicidal ideation then a safety assessment should be done.  It is not uncommon for people with depression to want to escape these feelings and there can be thoughts of self-harm or suicide, do you ever have these. On the basis of this you need to know if they want to escape the feelings or would prefer to be dead, this says is this an active or passive choice, i.e. I want to be dead, or I just don’t want to feel like this, which would be passive. If the former then find out if they have planned it, if they have got the means of doing it.  To assess the severity of the suicide intent, then you need to establish what the protective factors are, i.e. what stops you, has stopped you to date from suicide. These are potentially contingent so should be monitored, i.e. my parents stop me, but then when you have a row with your parents, or they die does this make it more likely.

Making an effective choice of activities

So you can either increase behaviours that make life better or decrease behaviours that make life worse. The place to start is the behaviours that temporarily ease distress , rather than the more major items, so increase physical activity prior to looking for a job.

What to target after reviewing the activity chart

Many times there are so many problems with a client’s activities it’s difficult to know where to start, like having 5 doors open and not knowing which one to walk through. This is very similar to a client who doesn’t know what to do. The key to working out what will be a behavioural antidepressant is to look at what happens before a behaviour and what happens after.

Lethargy breeds lethargy, the more passive you are the more you feel passive the less you want and feel capable of doing things. Likewise with activity, the more active you are the more you feel like being active.

Some changes you can make are improving a situation to make a behaviour more likely, for instance putting your sports clothes out on the bed to encourage you to go to the gym. The other thing about BA is to take a problem solving approach, so if you are down because you have nothing to do, take this as a problem to be fixed.

Basics of Identifying treatment targets

1.       Define and describe the key problems the client experiences

2.       Assess patterns of behaviour

3.       Use functional analysis to understand what motivates behaviour and what its consequences are

4.       Utilise the activity chart

5.       Monitor activities

6.       Monitor mood and opinion

7.       Monitor mastery and pleasure

8.       Monitor intensity

9.       Identify routine disruption and avoidance patterns

10.   Assess client risk

11.   Collaboratively choose activities that are likely to break the depressive cycle

12.   Identify initial steps for making change

5.     Activity Scheduling and Structuring

Part of the activity monitoring is to see that

1.       Depression isn’t something you suffer like a cold but is something that comes from certain situations

2.       That you aren’t depressed all the time, there are better and worse times

3.       That your depression can be maintained by your activity

As you start to make changes, then make small changes that you can be successful in to increase confidence. When making plans look to see what might get in the way.

The heart of BA is activity scheduling and structuring. Once you have a baseline from monitoring, and made a functional analysis of it, then you can see how behaviour functions what keeps the depression, what makes it better.

The model here is that depression is the result of low levels of positive reinforcement, so what does this mean, that I don’t do things that make me want to do them again, I don’t get pleasure or mastery out of what I do, so I stop doing things, this means I don’t get pleasure, I don’t think well about myself, my self-esteem goes down, as my self-esteem goes down so does my ability to get pleasure and mastery in the world.

How to activate clients

Clients know they should do more, clients have been told this by people, they have tried themselves, and this is the paradox of BA that we are asking them to do precisely what is hardest. When we are down we tend to act in ways that keep us down, emotions love themselves as Linehan once said. What BA wants is to act according to a plan not according to an emotion. BA asks clients to act outside in. Some clients feel this is phony or fake, but a useful analogy can be if you break your right hand you have to use your left hand to do things, at first it feels awkward and clumsy but after a while it feels comfortable and natural, it’s a process of learning, that to start off with it doesn’t feel comfortable.

Some clients also see their depression as biological or genetic, so what is the point. They need drugs, or indeed take them. However research shows that drugs only take away the feeling of depression and when they stop, unless change has been made in how they live, then it will come back. Again changing your mood can change your body chemistry.

Studies show that increased physical activity promotes well-being, having a meaningful job, having leisure activities as well.

Principle 4: Structure and schedule activities that follow a plan, not a mood

Identifying a time and place to do something will increase its chance of getting done. This tends to make it less mood dependent, so it’s not the case I will do it when I feel like, but rather I will do it at 12 o’clock and when 12 comes around then it becomes the thing to do.  You may well want to specify the frequency and duration of the task, keeping in mind that the client might overestimate what they can do, as they are returning from a depressed state, so best to stay small and achievable.

The more specific an activity is made, where when, why, how, the more likely it is to get done. When scheduling activities then think about the energy levels during the day and if there are any times that are more likely to have the requisite energy to do the task.

Principle 5: Change will be easier when starting small

Break tasks down into graded task assignments, here you break tasks down into small pieces so you can get a sense of accomplishment from finishing each task. It has also been seen that challenging task are motivating and that challenging specific tasks are more motivating than challenging vague tasks. It is easier to work towards positive targets rather than negative ones, so easier to run 3 miles, as opposed to lose 3 pounds.

When you start the baseline and set goals you need to be aware how long a client has been depressed, so whilst they might set goals on how they did things when they weren’t depressed so they might be overly ambitious.

If you’re not feeling motivated to do a task remember, outside in, that if we act regardless of how we are feeling, we will feel better. The other point is to start small but also build from there, you can see a scenario where loads of little things that are unconnected are done, which doesn’t provide much satisfaction. There needs to be some positive reinforcement of the task done, this can be a natural reinforcement, which would be preferable or an arbitrary one, such as the praise of the therapist?

Countering all or nothing thinking

The point of BA is to activate the client, to get them feeling better through doing.  It also helps with avoidance. So on the basis of this, it is not necessary to complete the whole task. So the point of activity is to see how it affected mood. A client may not feel immediate pleasure out of doing the tasks, but it can be looked at as an incremental process  that may be pleasurable over time. The other aspect is did you feel more mastery, to increase your sense of your own capability to get out and do things, fix problems, will make life more manageable.  So not seeing the emotional goods immediately we can see that these are small steps, that if we stick with we will get better.

Principle 6 Stay with activities that are naturally reinforcing

You can try to enhance this by when a client finishes a task, just to take a couple of quiet moments to look over what they have done and see what they think and feel about it. Slightly like when you have finished eating some food you really like that you sit contented. In some ways that makes you think of looking how to enjoy the things that you need to do, if you find washing dishes an aversive experience it’s not going to get done that much but if you look to enjoy and get some reinforcement out of it, then it will get done.

So with tasks the BA looks to find things that are naturally reinforcing.  So if you want to exercise then look to exercise with a friend, then you get social pleasure and you get a public commitment. Another way to do this is to email the therapist when the task is done although this leads to possible shame and failure, although it can be motivating, or demotivating depends which way it swings.

Structuring and scheduling activities for BA

1.       What task frequency will be most effectual for the client

2.       What duration or intensity will be most effectual for the client

3.       What days and what times should the client do the activity

4.       Have you and the client started small

5.       Have you and the client countered all or nothing activation

6.       Have you and the client targeted activities that are naturally reinforcing.

6.     Solving problems and countering avoidance

Solving problems can be one pathway out of depression. Remember all results from tasks are useful.

Problem solving

1.       Define problem clearly

a.       This can reduce feeling overwhelmed by adding structure

b.      Define problem in behavioural terms

c.       Define problems contextually

2.       Brainstorm solutions without judging them

3.       Evaluate ideas from brainstorming using pros and cons

4.       Define the solution in behavioural terms and implement, define goals

5.       Evaluate outcome

Types of problems addressed in BA

There are generally two types of problem Primary and Secondary. Primary problems are beyond the client’s control, so an event happens, job loss, death of family and secondary problems are client’s responses to the primary problems. Primary problems are the problems that cause the initial depression, then secondary problems maintain it.  You should always address the secondary problems first, as the client will be then be stronger to face the primary problems. So the secondary problems keep the depression going and are problems in themselves. So the etiology is something bad happens, a relationship break up, an irritating neighbour,  this creates sad feelings, feelings of loss of love, the combination of these are unpleasant feelings, the client then turns away from these avoids these feelings through isolation and passivity. This can be a useful strategy to regroup but if instead of regrouping it stays as behaviour then it causes a problem in itself and needs to be addressed first. Primary and secondary problems can only be understood by function, for instance losing your job could be a primary problem due to a declining economy or it could be because you are depressed, passive and always turn up to work late.

Validating the natural tendency to avoid and the challenge of change

To get stuck in a short term approach to an unpleasant event, that then turns into a vicious cycle has many reasons to explain why a client gets stuck like that. To break out of this is not easy, the main shift needs to be from avoidance to activation.

The therapist needs to validate the difficulty of the clients struggle with what seems a cycle that cannot get out of, but they must remain hopeful and optimistic in the face of this struggle.  Remember keeping a problem solving approach and that all results are useful.

It is harder to solve your problems when depressed than normally, depression affects your executive functions, depression impairs your problem solving skills.

Validating how a client feels, and how they feel stuck is an important and useful tool in moving them forward. Validation reduces shame and anxiety which in turn facilitates collaboration.

BA Problem Solving and Avoidance modification

To address avoidance, you need to concretely specify what is being avoided.

To validate a client who avoids or escapes it is important to remember:

1.       People tend to avoid when attempts to solve problems are not reinforced or are punished in some way

2.       When a given behaviour is negatively reinforced through the avoidance of something it is likely this behaviour will increase

3.       Increased effort to overcome fatigue, poor concentration or other depressive symptoms is needed to activate and to be productive when depressed. It is easier to be aversive to making this extra effort, thus avoiding making the effort is negatively reinforced

4.       Cognitive impairment is a symptom of people with depression.

5.       It is difficult to counter avoidance and activate oneself when depressed. Activating feels unnatural and avoiding feels natural, and this is the hard thing to counter

Defining a problem in behavioural terms in the first stage in solving it. By behavioural terms, it means how often, when, how, with whom etc. etc., really specific, so define the antecedents, the behaviour and the consequences.  Fully define the situation and work out, what it is in the situation that is significant.

The Action Acronym, working out if something is avoidance behaviour

Assess the behaviour: is the action serving the client, short, medium and long term. Does the action accord with the clients values

Choose an action. Clients may feel they have no agency in their lives, but showing that they do and that they can choose, will result in more ability to choose what they want to do

Try: if you have been avoiding and choose a different action, then try it. BA is about action

Integrate: the new behaviour into a routine.  Trying a new behaviour once is not sufficient after a long bout of depression, rather the behaviour needs to be repeated regularly to see benefits.

Observe the results. See how in the client’s activity schedule their moods have changed

Never give up, developing a new habit requires a lot of practice.

Summary

You need to validate the client in their difficulty, their cognitive impairment, their avoidant activity.  Whenever something doesn’t work, ask what we can learn from this. Ruminating is an avoidance technique as it can stop clients trying to find solutions to their problems, or to undertake tasks that are uninteresting or overwhelming.

7.     How thinking can be problematic behaviour

Thinking is private behaviour, if you instead of seeing thinking as thinking but rather talking to yourself, then would that change your approach to seeing it as a behaviour.

Two problems with rumination, firstly it disengages you with your environment, which is where you can get positive reinforcement, secondly it prevents effective problem solving

Thinking as a behaviour follows the similar behavioural principles, some styles of thinking are rewarded some are punished, and this locks in the type of thinking. It can also be content of thought gets reinforced, and certain thoughts get paired with certain emotions. What would be the resultant emotion if someone says to you the things you say to yourself?  So maybe what you say to yourself has an emotional impact, indeed what has been said to you publically or privately has a long lasting impact, and can set up a mood.

What happened before and after ruminating? Does it help problem solve or is it spinning the wheels. Rumination is the process of chewing over negative things that have happened to you and its outcome is to increase depression.

There could well be two types of ruminative process

1.       Reflection

2.       Brooding

Reflection entails cognitive problem solving, whereas brooding entails rehashing the difference between how you are and how you were, how others are, how you would like to be etc.

It is more than likely the brooding component that makes you feel worse.

Ruminating can be positive and you can see that when it  focusses on specific concrete detail.

Ruminating is negative when it is abstract and general and evaluative because you can’t act on generalities.

Dysphonia: A state of unease or generalized dissatisfaction with life.

Depression is summed up by a focus on the self that is repetitive.

Assessing Rumination

You can firstly assess rumination by working out if a client is engaging in overt behaviour that should make a difference but they are not enjoying it as their minds are elsewhere. There is a difference between public and private behaviours, as people can be at a party publically but sitting there having a go at themselves privately.

Throwing the ball with your dog and being with that is a completely different activity from throwing the ball with your dog, ruminating how depressed you feel.

What then are the contingencies that maintain rumination? So find out what happened before rumination, and then look for an alternative that would make the client less susceptible to rumination

Sometimes it’s the consequences that maintain rumination. Sometimes people think they are doing something about their problems when they are thinking about them, which is positive reinforcement.  Sometimes ruminating can be a way of avoiding feeling emotion as when you engage the cognitions then you disengage the emotions.

Sometimes rumination happens out of habit, it used to be reinforced but now it is a conditioned response.  Rumination may give the feeling of activity, without any of its difficulty or potential for failure.

To prevent rumination then give the client the 2 minute rule, if after 2 minutes ask themselves have they moved any closer to solving the problem, if not then try another tack. Also they need to ask themselves are they less self-critical or depressed after 2 minutes, unless one of the answers is yes, they should use an alternative technique to interrupt thinking.

You can also get them to create a worry window. So the exercise is set up thus. I need you to record what you worry about, now it’s probably going to be difficult during your day so let’s create a time during the day half an hour when you’re by yourself when you can worry. Do this every day. Then you review the worries, and you will generally see that the same things are worried about and that no progress is made. Ask the client what they think of their worries when they look at them, how it made them feel every day, how worrying is helping them. Then ask if there are any other ways to get what they want.

Targeting depressive rumination in BA, Don’t just talk, Do!

Sometimes you can perpetuate a client’s rumination through engaging with the content of it.  Sometimes a client will talk publically in therapy, in the same way that they talk to themselves when they ruminate.

Five ways to deal with rumination

1.       Highlight the consequences of rumination

2.       Problem solve

3.       Attending closely to sensory experience

4.       Refocusing on the task at hand

5.       Distracting oneself from rumination

Highlight the consequences of rumination

Look at what the effect of rumination is, the consequence of a situation. What does rumination prevent you from doing?

Problem solving

Problem solving is a natural antidote to ruminating. One way to counter it is to take the problem that is ruminated on, and to engage in active problem solving on it.  Some times on reflection there is no easy, or obvious answer to a problem, in this instance the best idea may be to tolerate a difficult circumstance.

Attending closely to sensory experience

Mindfulness can help, ruminating takes one out of the present moment, mindfulness keeps one in. So as rumination is an internal process, clients are asked to pay attention to what is happening outside them, to use all the senses to engage with the outside world. Rumination happens about the past or the future, so to change attention to the present can help.

Whilst problem solving and attention to the moment are good antidotes to rumination they are hard to put into practice. One way to practice mindfulness, is to look at all the different colours and shapes in the space in front of you, this will take you out of your mind and into the world. If you find yourself drifting off and thinking, just come back, refocus and start noticing the colours in front of you.

Refocusing on the task at hand

Here what clients do is to realise that they are not focussing on the task at hand, instead they are ruminating and then to gently point themselves back to the task at hand. This is easier to do where there is a complicated task, or one that has many steps. However if the client isn’t doing anything then this can be difficult. RCA can be a useful acronym, rumination cues action. When you find yourself ruminating then find some action to involve yourself in.

Distracting oneself from ruminative thoughts

Whilst refocusing moves your attention to a task, and mindfulness refocuses you on what is happening in the present, distracting yourself, brings something new into the environment, for instance turning on the radio station whilst driving. Think of every animal through the alphabet, can be a distraction.

Interventions for dealing with ruminations

1.       Highlight the consequences of ruminating

a.       Does it help my mood

b.      Is it helpful

c.       Does it problem solve

d.      Does it have short term or long term benefits

2.       Problem solving

a.       Define a concrete problem that is being ruminated about and generate solutions

3.       Attend closely to experience

a.       Direct your attention repeatedly to the sensory experience of seeing, hearing, smelling, touching or tasting in the moment

4.       Refocusing on the task at hand

a.       Identify what tasks are necessary to complete a task, bring your attention back to these

5.       Distract yourself from ruminating

a.       Bring something new into the environment, turn the radio on, think of every animal in the alphabet, and describe in detail a favourite scene.

8.     Troubleshooting problems with activation

The challenges of activation

In the early stages of therapy, clients will be frustrated and disappointed at their inability to do assignments.  Clients may feel guilty when they haven’t done their homework.  Clients can often operate on mood dependent behaviour.

The Therapists style and stance in troubleshooting

Above all you need to get the clients buy in to BA to make activation work.  Validating the client will help. Always have a problem solving approach even when things go wrong, learn from it. If something hasn’t been done on a certain time, I notice you didn’t get around to doing x at y, I was wondering how your afternoon went for you. Change is not going to be quick and often can be 2 steps forward and one step back.  Use optimism and persistence. Look for opportunities to reinforce progress.

Graded tasks

Success reinforces the ability to take another step, so make sure steps are small enough to succeed with.

The absence of inadequacy of activity monitoring

You must have an activity chart to conduct a behavioural analysis to be able to set assignments and to problem solve them. Some clients say focussing on what they do or don’t do makes them feel worse. You can address this by just getting an activity chart, without how it made them feel as well. You can also reduce the window when the client monitors their activity, so you can do what did you do Monday for instance.

Limited information about mood or emotions

Clients bring back activity charts without mood information, then they say I was depressed all the time. You can explain that one of the aspects about depression is that subtle changes tend not to get noticed. If you put the microscope on your moods then you will notice these subtle shifts and then we can start maximising them. You can often work with this by getting the client to recall what they have done in the few hours up until therapy.

Problems with cue control

Sometimes clients will not do homework, not because they are apathetic but because there was nothing in the environment to remind them of doing it. To work with this then you can ask what interfered with completing this assignment. A simple way of doing this is to do a behavioural analysis of when the task should have occurred, you can ask did the you remember the homework at any time during the week.  If they didn’t remember, then you could ask them what they could do to remind themselves of the task.

Problems with contingency management

Contingency management is to arrange ones immediate environment to maximize the likelihood of desired consequences.  So what makes a behaviour more likely and what makes it less likely

Problems with classically conditioned behaviours

Depressed people often have things that have gone wrong in their lives and they associate with their current situation.

Troubleshooting

1.       Maintain a non-judgemental stance when clients have problems with activation

2.       Consider contextual factors that have impacted activities and barriers to success

3.       Assess problems with activation

a.       A client hasn’t understood the task

b.      A client may require a smaller task

c.       A client may require more skills to do the task

d.      A client may require more cues to remember to do the task

e.      A client may have a conditioned response around the task

9.     Tying it all together: Relapse prevention and beyond

The start of relapse prevention is to establish what the client used to do and what skills they have now learned to combat these. During treatment the client and the therapist identify what may be an antidepressant behaviour or set of behaviours that can be reused after treatment ends. They both work to find naturally reinforcing behaviours in the environment and target secondary behaviours like withdrawal and avoidance.  The secondary behaviours are avoidance and rumination and some clients only focus on these and still leave primary problems intact.  The BA process is to monitor, structure, schedule activities, problem solve and troubleshoot.

The importance of relapse prevention

One way to get relapse prevention is to find out the active ingredient of the behavioural antidepressant and to generalise to other situations. This is done by once the key ingredient is identified to look at other contexts where it can be applied.  You can also look for high risk situations which might threaten well-being and to develop escape hatch routines.

Generalisation

There are two types of generalisation, stimulus and response generalisation.  Stimulus generalisation is where the same stimulus occurs in different situations, and likewise response generalisation is where the same response is generated in other situations. Stimulus generalisation occurs where the same response is used with different situations. So being assertive with therapist, co-worker, and friends. With response generalisation then the response varies in different situations (I don’t quite get this). I guess it’s when you slightly vary the response but still get a good outcome. So stimulus is the same response to different stimulus, response generalisation is slightly different responses to similar stimuli.

The therapist can encourage this, by asking the client practice the same skills in different situations for homework.  The more a client can generalise the less chance they have of relapse.

Ingredients of the behavioural antidepressant

Encouraging a client to keep a handbook of what they have learnt in therapy can help

Expanding Activation to new life contexts and goals after treatment ends

Teaching clients to activate in the face of depression, to recognise avoidance behaviours and to maintain healthy routines are the core of BA.

Identifying and preparing for high risk situations

Ask the client when they are most likely to relapse into depression, what the high risk situations are.  On the basis of this identification then ask what they can do to reduce the impact. What was the essence of what took them into depression this time, and how could it reoccur can be a useful question. You can also chart the BDI scores over time and use this to identify vulnerabilities.

Booster and spaced sessions

It can be useful for clients to know if they start to relapse then they can book booster sessions. It can be useful as the sessions come to an end to space the time between sessions, so the client gets used to not having therapy and also to check on their resilience.

Putting it all together

ACTIVATE:

Assess

Counter avoidance with structured activation and effective problem solving

Take time to get specific

Include Monitoring

Validate

Assign Activities

Troubleshoot

Encourage

Assess

Assess the frequency and range of client activities as well as their function, use an activity diary. Understand the life circumstances of the client and what contributed to their depression and how they have attempted to cope. Through assessment then you know which activities you want to see more of and which less of

Counter avoidance

Avoidance is a useful short term measure but depletes pleasure and mastery in the longer term. Plan activities rather than be mood dependent, act outside in.

Take time to be specific

Always be behaviourally specific. It increases the likelihood of compliance. Behaviours to increase are those that offer natural positive reinforcement.

Include monitoring

Monitoring makes clear the situations that make clients activity most likely, the activity chart should almost be a regular weekly assignment. Activity chart is the mainstay of BA. It provides information about behaviour, mood, and situation.  It also gives the situation which indicate which behaviours are likely from certain situations, you can modify situations as much as you can modify behaviours. You can identify the situational patterns which are the precursor to behaviour.

Validate

Being depressed is being stuck in a dark place with little hope, you must acknowledge this. You must see that change is difficult and be empathic with this. Validating the clients experience of being in a place where they feel hopeless, unable to change and very unhappy.  You need to provide warmth, understanding and encouragement

Assign activities

Activity scheduling is the primary ingredient of BA. This requires creating a plan to follow as opposed to falling into mood dependent activity.  Activity scheduling provides more opportunity to come into contact with positive reinforcement from the environment and to take control over stressors.  Activities need to be graded to ensure success and its positive reinforcement.

Troubleshoot

Clients will probably struggle with activation and feel frustration. Use this as the opportunity to refine activation schedules, belief in the efficacy of BA and the potential of the client is important. All outcomes are useful!!!

Encourage

Clients ask for help when they feel discouraged and demoralised

Summary

Behavioural activation states that depression is maintained by two aspects. Firstly low levels of activity that accord to a person’s values and give low levels of feelings of pleasure and mastery.  Secondly high level so of avoidance behaviour.

So when working with a client I guess the first thing to do is to see if they believe this BA position too.  In the first session as you are getting to know them and about their problem, you can start to get a feeling for their life. To add to this position then for homework you should be doing an activity chart. The rationale for doing this should be to get to understand your problems better then it will be very useful to understand what your life is like generally and to see the relation between what you do and how you feel. If we can understand what you enjoy and what you don’t enjoy, then we can look to start increasing the former and decreasing the latter. Setting this homework will take at least 15 minutes, as you’d need to do an example of how this should be filled in and you can use as an example the few hours before coming to therapy.

The thing is how do  you do this collaboratively, well you could ask would it be useful to get a general understanding of what you do and how you feel during the week, so that we can both (assumption) increase our understanding of your moods and behaviours.

On the basis of getting the activity sheet returned, although this may not happen. You can from there start to see what activities bring pleasure or displeasure, likewise what activities might be filling in space for something else. So TV, beer, over eating and sleep, if you were feeling good would you be doing these things, if not, then look to do an ABC to look at the situation before, came in, feeling bored, then watched TV, boredom goes down a bit, to reinforce it, but it doesn’t really make you feel that good afterwards, and it certainly doesn’t help the next time you are in a similar situation as it hasn’t increased your repertoire of what to do. To be client focussed then ask them what the antecedents and consequences are and see what the reinforcement is. Then take the problem solving approach of I am bored, how can I solve this problem, how does TV help, it is avoidant.

Once a good understanding of what activity produces unhelpful results and what activity produces helpful results then the time comes to activity schedule. I think at this point we can also add in what inactivity produces helpful\unhelpful results. So not paying the bills is an inactivity that leads to stress, so whilst reviewing the activity chart it can be useful to at the end and getting an understanding of what was done, to also ask what wasn’t done, as this is in an odd way a result of behaviour.

So on the basis of the activity chart then you look at activity scheduling looking to produce a highly concretised piece of action, what, when, where and how. Then you can start think about roadblocks, things that could get in the way, it is possible out of this that mood might come up. In this case some questions about how mood is going to affect behaviour. So if you’re down, and one of the reasons you are down is that you aren’t doing much you enjoy, then it would seem you will stay down, at some point if you act according to a plan and not a mood, then your mood will recover.

On the basis of the results of the first behavioural activation then we will get some results and chance are that they won’t be that good. A depressed person  is likely to find it harder to change than when they’re not depressed. Likewise there may well be a feeling of hopelessness and lack of belief in self to achieve. At this point you need to firstly problem solve and see what you can learn about what wrong, empathise in terms of finding things difficult and how if you have been a bad place for some time it can be hard.  Some useful steps here to think about :

1.       Was the goal too big

2.       Did something get in the way

3.       Is there something that we can do in terms of the situation to make the behaviour more likely

4.       Brain storm ways to fix the problem

Other work that you can do early on, is to understand when the depressive episode came on, and what the difference between now and then is. Doing this can establish the primary problem, my brother died, and then secondary problems of passivity and isolation. It makes more sense to target the secondary problems, firstly as they are maintaining problems and secondly they are easier so can be easier targets to get success with. Nothing breeds success like success.

Clients may avoid doing new tasks, as it requires energy they don’t feel they have. Validating this position is important, I can understand how it must be difficult for you to take on new tasks given how you are feeling and what you are going through. What can be useful to work on with avoidance is the ACTION acronym.

Assess, what’s the effect of what you did and what you didn’t do, in terms of short and medium term

Choose an action that would be better in such situations

Integrate, when you have a new action that works for you better, make a routine out of it

Observe the outcomes of this new action

Never give up, new habits take practice

Sometimes a client may do the activity and not have the required result. There are a couple of reasons for this, firstly they may need to practice it to get the reward, secondly they may be cognitively avoiding.  Indeed they may have been ruminating before.

To work with rumination then do an ABC analysis of it to see what its outcome is, and both assess the outcome on a short and medium term basis. If rumination looks produces a bad outcome, in both emotional and functional terms then you can try the following, when ruminating which is a combination of reflection and brooding, brooding being the evaluative comparison of different personal states, or yourself with another, everyone else is happier than me, I should be happy etc., is noticed then label it, that is the first stage awareness. When you are aware of it, then you can ask yourself after 2 minutes is it useful for me emotionally or functionally, and if it’s not working do something else. You can also use distraction techniques, so be mindful, or count all the animals you know for every letter in the alphabet. The other thing is a daily worry window, assess mood before and after and the content of thought. Allow the client to see if worrying has worked, what its effects are.

Apart from distraction techniques then you can also use, focussing on the task in hand, and take a problem solving approach to what you are ruminating about?

Sometimes a client may not do an activity as they didn’t remember to do it, here you can again work with the situation, so leaving themselves reminders, encouragements etc.

So every session you should be looking to schedule activity, with every session then you should have two pieces of homework, one the activity chart to assess how you are doing and the second should be an activity schedule to plan new activity.

At the point where the activation starts working and the client sees positive results, then you should consolidate this position and ensure the new behaviour is integrated into their routine.

At this point a review needs to happen where you establish what the active ingredient for the behavioural antidepressant is. On the basis of this understanding then you can then start getting them to generalise this to other situations which will have a greater beneficial effect and prevent relapse.

Relapse prevention can also look to think about high risk situations and develop escape hatch routines.

I guess the final point to make about this, is that it is entirely possible that you only deal with secondary problems in your brief sessions and it leaves the primary problem undone. This being the case then you can develop with the client and action plan with the client to use what they learnt to apply to the primary problem.