Introduction 1
Part 1 Behavioural Activation: Something old, Something New 2
Chapter 1 The search for internal causes 2
Chapter 2 Creating a coherent framework for behavioural activation 2
Chapter 3 The contextual approach 4
Chapter 4 The principles and essentials of behavioural activation 5
Chapter 5 Beginning to Act like a behavioural activator 7
Chapter 6 Teaching client sto view depression within the context of their own lives 8
Chapter 7 Specific techniques used in behavioural activation 9
Chaper 8 Clinical Examples of Behavioural Activation 12
Introduction
In trials CT and BA are seen as effective as one another.
BA says a person has no defect, be it psychological or
physical, rather they have a problem in living which is understood in terms of
their context, their relation to the world and their history.
Depression is a behaviour context transaction that occurs when
people’s actions are less likely to be met with positive reinforcement and more
likely to be met by punishment. This
statement is rather simple and doesn’t always hold true.
This BA treatment looks to environmental events that created
contextual shifts that have denied the client access to reinforcers. It is difficult to change thoughts and
emotions, it is easier to change behaviours and to note their
consequences. One of the fundamental
lows of actions that are followed by avoidance is that they become more likely
(I don’t understand this).
Gather data about the relationship between activity, context
and mood to provide a good functional analysis. Look to bring out short and
long term consequences. This BA is not
just about increasing pleasant events (Graf 1973). This is an idiographic
approach, that gets some people to spend less time ruminating, some being more
assertive, some criticising themselves less. BA looks at the consequences of
thought, does it help you achieve what you want.
Therapeutic relationship is a critical ingredient of change
(Horvath 1994). The key roles in BA are coach=someone who helps the other learn
and implement a set of skills, consultant=someone who observes, analyses and
advices, trainer=someone who selects a very specific set of skills to work on
and improve.
Part 1 Behavioural Activation: Something old, Something New
Chapter 1 The search for internal causes
Internal causes of depression. Biological then use SSRIs,
psychological, use thought records.
People find it hard to understand human behaviour without an internal
cause. There has been a long history of internal causes for behaviours, e.g.
humours, e.g. spirits, e.g. being
bewitched to explain being in love.
SSRIs can be effective (Blacker 1996) but MDD users will
often relapse (Kupfer 1992). There are no studies showing biological aspects
cause depression, sure there is a correlation but that doesn’t imply causation.
People who are depressed selectively focus on negative
events (Fuchs 1977). Depressive episodes are maintained by rumination
(Nolen-Hoeksema 1993). People who are depressed tend to elicit negative
reactions from others (Hockanson 1989)
However just because drugs or CT makes something better
doesn’t mean that it was caused by it any more than rest and chicken soup makes
depression better but doesn’t cause it.
Seraton depletion is actually rectified in 2 days yet takes
2 months to work, so it can’t be purely depletion of serotonin levels. Likewise
some drugs treat depression but don’t effect serotonin levels, and there have
been studies to support this Valenstein (1998)
The desire to have depression as an illness reduces blame
and increases resources and empathy.
Behaviour is seen as down to the individual and if their depression is
caused by how they act, rather than a biological or psychological reason, then
blame is attached. (persons 1996) no
evidence supporting medication as the first line as CT is as effective.
This book aims to break the idea of internal causation and
to show depression as a process occurring in the context of someone’s life, so
depression is a series of events and actions. A Context is the transaction
between person and environment.
Inactivity is one of the central features of depression
(lewinsohn 1974). However activating someone isn’t easy, the depressed context
supports inactivity, hopelessness, isolation, rumination and withdrawal.
Chapter 2 Creating a coherent framework for behavioural activation
A BA Therapist thinks and acts contextually and
functionally. Internal causes can also
be seen to be behavioural deficits, e.g. skills. Traditional CBT relies on a machine metaphor,
something is broken let’s find and fix it.
In contextualism the person and environment are one object.
Change transactions in the environment by natural
reinforcers.
BA has been previously done by Lewinsohn and Beck. Lewinsohn saw that depression was a depletion
of pleasant and surfeit of unpleasant events.
Activity scheduling then was the answer to this.
Current BA is contextual and idiographic, it also looks at
the contingent maintaining factors. It
also seeks to block the avoidance patterns that prevents reaching goals.
Becks BA is used early in therapy. BA is used to related
activity to mood. If new activity isn’t achieved then the thoughts that block
this are looked at. As the mood improves
then standard CT methods are used. So BA is to get a client active enough to do
CT. BE’s are used to test beliefs. In CT all behavioural work is about changing
cognitions, with the ultimate aim being to change CBs.
This BA work sees behavioural change as sufficient for
lasting change.
The radical behaviourists see thought and emotions as
behaviours, as verbs, which come from the interaction of self and environment,
or in better words as a function of our context. Variables that can be manipulated
are independent variables.
A behaviour is only understood by its context and how it is
meaningful for the client. One behaviour
can have many meanings, many functions.
A behaviour that is reinforced is increased. A behaviour
that is punished is decreased. Positive
punishment adding something unpleasant, negative punishment taking something
pleasant away.
Reinforcement varies, so you could have a fixed ratio, 10 press-ups
10 sweets. Or it can be variable first 2 press ups 3 sweets, next 5 2 sweets.
So the behaviourist view, is that a radical life event has
meant that previously reinforcing activity has stopped, leading to a lack of
feeling of control in the world.
Depression is a response to a problem in living a sign.
Tact is a Skinnerian word for a unit of verbal
behaviour. Complaint, criticism, demands
for relief or assertions of distress functionally lead to escape and avoidance.
(Ferster 1981) =learning history of depressed people may
contain situations wherein behaviour is reinforced on a relatively fixed ratio
schedule requiring large amounts of activity prior to being reinforced. Also behaviours that are maintained by
negative reinforcement lead to passivity.
So for instance with a child if they coo and gurgle and the parent
always comes then small amount of activity gets reinforced. If however the
parent comes inconsistently then the child has to do a large amount of activity
to get attention and reinforcement. If a
child is punished for minor infractions even though there have been major
successes, they lose the ability to relate behaviours with consequences. This leads to a break down in self-monitoring
which is the self-control theory. When self-monitoring
breaks down the child acts on the basis of their own deprivation as opposed
to acting in response to their
environment. A clients complaints may
serve functionally to draw sympathy.
In BA there is the attempt to increase the behavioural repertoire,
a passive response style has been learnt through an attempt to reduce
deprivation and to not learn the ability to get positive reinforcement from the
environment. In has been a learnt style, there is no inner cause.
According to Fester escape and avoidance are predominant
responses to aversive situations. So a
situation like silence is aversive so it is avoided. Ruminating also seeks to
avoid silence. Depression results as the individual avoids aversive stimuli and
therefore lacks sufficient amounts of positive reinforcement, or that there has
been a sudden removal of positive reinforcement. A passive repertoire is one when negative
reinforcement is higher than positive reinforcement, where avoiding and
escaping from aversive situations is higher than seeking positive situations.
Fester shows that
Depressed people
1.
Respond more to their levels of deprivation,
than to external possibilities
2.
They develop narrow repertoires of behaviour
3.
They utilise escape and avoidance more than non-depressed people do
Details of memory can be obscured by the process of
remembering (Loftus 1980). Getting others to meet your needs is a passive
response.
When my needs, my deprivation is primary, then other people
are there to fulfil my needs, i.e. remove my pain, or don’t and I get angry
Increasing pleasurable events by themselves is not enough to
improve mood (Hammen and Glass 1975). Telling clients simply to increase
pleasant activities without a rationale is likely to be contraindicated. The
activities that must be aimed for are things that make life more fulfilling.
What are my activities motivated an aim to reduce my pain, or an aim to
increase my pleasure or mastery. There is also a difference between doing
pleasant events and increasing the pleasure of events.
With activities they can give pleasure, reduce pain, be
meaningful or give a sense of achievement. BA promotes activity that is
naturally reinforcing that leads to a solution of problems
The overall purpose of BA is to
1.
Determine the patterns of coping that have
exacerbated the depression
2.
Develop a treatment plan for improving the
coping patterns and providing access to more reinforcing activities
When developing a treatment plan you need to know
1.
What is important to this individual
2.
What gives them a sense of purpose in their life
One way to stop ruminating is to be mindful of the minute
detail of the activity you are involved in.
Chapter 3 The contextual approach
The past and the future exist in the ongoing action (Hayes
1988). This makes meaning heavy as a situation is only understood in its context,
so I am depressed, there is the context of what depression means, context of
what it means to be a man, context of my learning history etc. Uncertainty then
is something contextualists need to get used to. BA uses the pragmatic version
of truth, so don’t dispute CT or medical model, but how useful is it to believe
this given the problems that you face.
Principles of BA
1.
Meaning\function of an action needs its past and
present understood (Christ meaning is going to be hard)
2.
Claims about the nature of things gain meaning
from the context in which they occur. Truth has a purpose and that is defined
in its context
3.
Behavioural analysis is based in pragmatism not
realism. BA sees thinks as true on a
scale, depending on the explanatory power of the idea.
Operant is defined as the relationship between behaviour and
stimulus events
Mental\emotional causes end up being circular. I am angry as
I can experience mental or private events, but then to say I am angry because I
have a lot of anger inside doesn’t make sense.
However if we say someone is angry as due to the history of
reinforcement in such a context, then we get an opportunity to change the
context.
To get all of the context of behaviour would be impossible
so behavioural analysis, functional analysis takes the form of broad classes of
activities. So if a client says they are a failure what is the major group of
events that would be seen as a failure.
BA conceptualisation looks at what are the conditions under
which you have not failed, and what are the conditions under which you
failed. If someone says I’m an x, how,
when and where. Likewise when are you
not an x. I’m an x is a predictor
The same behaviour can have different functions for
different people, indeed the same behaviour can have different functions at
different times for the same person!
People’s behaviours affect their context, so if I have been
distracting myself the world seems muted.
Critical elements of a conceptualisation
1.
How is their depression manifesting itself
2.
Symptoms of depression may have become problems
in themselves, i.e. secondary problems, avoidance, escape
Avoidance is behaviour that stops the client contacting
aversive stimuli be it internal or external.
Feel sad, drink alcohol. Sleep can function as avoidance of problem
solving, or dull work. Not all avoidance is bad, e.g. avoiding getting a
speeding ticket.
BA is a coaching in minutiae, looking at what happens, what
they feel and think, how they react and what the consequences are.
Nouns are continually used as verbs, when you think I’m an
x, what do you do next.
Chapter 4 The principles and essentials of behavioural activation
Four principles of BA
1.
People are vulnerable to depression for a number
of reasons
2.
Secondary coping behaviours play a significant
role in depression
3.
BA is not simply about increasing pleasant
activities
4.
Clients should pay close attention to the
context they are in on the context of their mood
The onset of depression can be obvious, i.e. loss of job,
partner etc., or there may be nothing in particular. People who have depression
maintain it in common ways. Avoidance keeps people depressed.
Many people do pleasant activities and ones that bring
mastery but are still depressed. BA says
this is because it is the function of an activity, which in this case may be to
avoid something they really need to do.
Behaviour reoccurring means there is reinforcement we just don’t know if
it’s positive or negative. BA aims to
get clients experts in ABC, so when I do x, its consequences are y. So
behaviours affect mood, behaviour affects energy levels. Each consequence is
the antecedent of something else.
Motivation is something that comes from action, so my previous action,
helps me be more motivated. Act according to a plan not according to feelings.
Clients don’t need to win the total war against
psychological problems, sometimes it is enough to think what you think, feel
what you feel and put one foot in front of the other to do what needs to be
done. Taking small steps that are part
of routine can help achieving goals.
Helping a client approach not avoid is therapeutic.
BA when dealing with thinking looks again at the ABC, what
was the situation that got you thinking like this, what type of thinking were
you do and what was the consequence.
Primary question for a BA therapist is
1.
What environmental factors are involved to why
the client is feeling the way they do
and what ways does the client behave that maintain these feelings
2.
What is the clients method of responding that is
maintaining the feelings
Primary attitude
1.
Act on the basis of a plan or a goal, not an
internal state
2.
When you do an ABC analysis then sometimes people might put
down the situation, feeling angry, behaving, shout, consequences feel guilty.
Thus they see the anger, a magical internal state as causing the behaviour.
However look at the negative reinforcement, of the behaviour reducing the
anger.
Important that therapists develop a good case formulation
(Persons 1989).
Four targets of BA therapy
1.
Avoidance
2.
Passive coping
3.
Routine disruptions
4.
Context of client problems
Avoidance is like giving a thirsty man in a desert a bottle
of vodka. Sometimes relationally depressed client might blame the other, my girlfriend
doesn’t love me anymore, when they are irritated and sullen with them, and this
leads the other to withdraw. Or friends
don’t phone me anymore because I’m a loser, when the client hasn’t been phoning
them.
There is the initial problem of depression, so bad events
happen, you feel sad, have low energy, then you get responses to them, which
are avoidance, rumination, self-criticism.
It is the secondary problems which are maintaining the depression.
Context is everything including the WA. You think if you’re
kind empathetic etc. a good WA will ensue. But if the client has experienced
kind, empathy mixed with cruelty, then this might lead them to mistrust the
relationship as they were waiting for the cruelty to come. A good WA is one that seeks to encourage
client disclosure and trust, and the context should be modified accordingly to
accommodate this.
Complaints historically were a call to the care giver to fix
their needs. Modern complaints though
aren’t reinforced and no one responds to them, they become in a way magical
behaviour, that if I say it, it will magically get fixed.
Selling an activity schedule, I’d like to get a good sense
of what is going on in your life, so I can understand your difficulties, I can’t
follow you, so here’s an activity schedule.
Activity schedules are used to
1.
Assess general activity levels
2.
Assess activity and mood connections
3.
Range of feelings: i.e. clients says I’m
depressed all day
4.
Mastery and pleasure ratings, good to see how behaviours
that give M or P relate to feelings
5.
Observe breadth or restriction of behaviour
6.
Guided activity, i.e. when you’ve spotted the
positive behaviours and negative behaviours to do more\less of them, and be
guided by the plan, and the mood will follow
7.
Helping the client monitor avoidance behaviour
(measuring avoidance, does this activity bring you closer or further away from
your goal)
8.
Evaluating progress toward overall life goals
Avoidance patterns are important in the development and
maintenance of depression. Disruption in
normal routine may precede depression. People’s
mood is dependent on social\environmental routines. Light, meals, sleep cycles,
working week. (Ehlers 1993).
Depressed people tend to react to life rather than to act.
Chapter 5 Beginning to Act like a behavioural activator
Things to do
1.
Good TA
2.
Monitor relationship between situation, action
and mood (ABC)
3.
New coping strategies, i.e. a search for meaning
4.
Lapse and relapse prevention
As you find out about the client find out how they have
withdrawn in this current episode, things they used to do when not depressed.
BA final sessions
1.
List red flags and triggers with the TRAP
framework, trigger, response, avoidance pattern
2.
List helpful elements of treatment
3.
Build activation strategies into routines
Homework has dubious connotations, exercises, practice or
experiments work better. Developing a
plan to implement a task makes the actualizing intention more likely
(Gollwitzer 1999)
It is not important to know the exact causes of depression
as causes can only be hypothesised, what is important though is to know what
keeps it going. Asking open ended questions
can be useful to concretize and not be confrontational, so I can see that…in
what way….here’s some rationale, how does that sound to you. Again important to
ask how models, theories apply to their lives, what they like about it what
they don’t. As you look for history of
behaviours, when you find times that the client doesn’t act like that then you
start getting an idea of their behavioural repertoire.
The conceptualisation is
Life Events=>life less rewarding=> depressive feelings,
e.g. sad, low energy, negativity=> response to depressive feelings=>
avoidance, rumination=>
Life events can either be a specific episode or an
accumulation of life events over the years, so it’s a progressive onset of
depression as opposed to a specific incident, like losing my job.
Therapist’s attention and concern can be a reinforcer to
shape behaviour (kohlenberg & Tsai 1991). (Addis and Carpenter 2000), if
clients want to vent, stick it on the agenda.
A client may see that if their behaviour maintains and
creates their depression that they are to blame for it. The vodka analogy can be useful, but I’m not
quite sure how to use it. Important to
present therapeutic rationale without jargon and make it personally relevant to
the client (Addis and carpenter 2000). Asking questions keeps a dialogue going
without turning into a lecture.
Clients treated with BA improve their measures on depression
(Jacobson 1996). Act according to a plan, not according to mood and your mood
will follow.
In BA depression is natural and part of life events and not
something to be got rid of or fought, It is the secondary reaction, the
avoidance, rumination and self-criticism that cause the problems and these are
the things that make the natural feelings worse.
Clients wait for motivation to do stuff, but if they were
motivated they wouldn’t be depressed. The quickest way to feel like an x person
is to act like one. Clients are more
likely to do things if they form a plan (Wegner 1999). Waiting to will something
into action is based on the illusory relation between thought and action.
Depressed clients wait to do things until the feel like doing it, but then they
wait a long time, do less and feel worse.
Act according to a plan, act according to environmental cues
(trainers left out in the morning, call a friend).
Social skills can be useful to teach to someone who is
depressed. When they are depressed they focus very much on themselves and not
on the other person, this makes the other person less likely to want to engage
with them. The depressed person acts
more on their own deprivation rather than what is offered to them in the
world\situation. When a depressed person
gets things off their chest there is negative reinforcement but for the other
person then in some ways they are left with their crap, complaints and problems
which leads them less likely to want to engage more. It is therefore important
that the client act like they are not depressed (????).
Acting as if.
1.
How would you act if you weren’t depressed,
posture, eye contact, what type of things would you talk about
Chapter 6 Teaching clients to view depression within the context of their own lives
Doing an ABC analysis A is the event be it internal a
thought or an external event.
TRAP= Trigger response avoidance pattern
TRAC=Trigger response alternative coping
Action= Assess, Choose avoidance or activation, Try out,
Integrate, Observer, Never give up
Trigger= being ignored by a friend
Response= sad
Avoidance pattern=avoid friends in the future
The avoidance above is to avoid any discomfort with asking
the friend what’s going on for them, which would also provide an opportunity to
problem solve the situation.
When you’re doing activity charts, then notice when the client’s
mood decreases or increases so that you can learn what behaviours effect mood.
You can notice you are avoiding something when you do x and
there is something facing them that they do no want to do. Alternatively if
they are ruminating or anxious then this may well point to some task that needs
to be done.
You can’t be definitive about behaviour as it can serve
different functions. That’s why when you
do an activity sheet you must see what the emotion was afterwards to understand
what the behaviour represented.
ACTION
1.
Assess how behaviours serve you
a.
I.e. do a detailed ABC analysis
2.
Choose to avoid or activate
a.
Make this choice in terms of moving towards your
target goal. This can be difficult as to choose here means that if you are
getting the worse outcome then you are choosing depression, and therefore you
are to blame. However frame it in the sense of control or passivity. Choose
without judgement, observe the outcome and learn.
3.
Try out whatever behaviour has been chosen
a.
This enables you to become an expert in your
life
4.
Integrate your new behaviour into a routine
a.
Disruptions of routine are seen to be precursors
to depression and continuing new behaviour becomes more likely when it is
embedded in a routine.
5.
Observer the outcome
a.
If you don’t get the outcome you want, then
adjust
6.
Never give up
BA Therapists think functionally and contextually, what is
the context, what is the behaviour and what is its function.
Chapter 7 Specific techniques used in behavioural activation
Many techniques are ABC, TRAP, TRAC and action. Pleasure and
mastery scales in activity schedules can be used but only as a precursor to a
more fine grained analysis. Indeed pleasure and mastery might not more the
client closer to their goals. Other tools, graded task assignment and
shaping. Doing one small thing changes things,
changes the environment, changes your mood.
Avoiding things being passive doesn’t change much but deepens passivity.
Activity breeds activity, inactivity
breed inactivity.
As the activity cycle increases it is important to get the
client not to take on too much and go through a boom and bust cycle.
It could be useful for the client to send you a message when
they have finished their task, ask them.
Imaginal rehearsal of tasks can help. If a client describes
a negative feeling then ask them what they would do if they felt that, can do
the same cognitively. If the end result would be they would stop the task then
ask them if you were to continue with your goal, what would you do?
When setting homework, ask the client to suggest things that
will make the homework more likely, e.g. trainers out for the gym. Arbitrary reinforcers are questionable as
they get in the way of natural reinforcers which is the aim of BA. However some behaviours e.g. being assertive
to a horrible boss, may not have any obvious reinforcers so an arbitrary reward
for this would be tantamount to good self-care.
There is nothing wrong with arbitrary reinforcement so long as it
doesn’t block natural reinforcement.
When you look for alternative coping responses e.g. trigger
response alternative coping. You can keep within the same form but different
content, watching TV talk shows, watch a comedy, reading Sylvia Plath read um,
frankl. Play computer games, play them online.
As much as new behaviour can be imaginally rehearsed so you
can role play. When doing role play the
client plays themselves, get them to give you an idea of the type of response
they expect. So do it this way until you
get a car crash, then debrief the situation to see if there is any other way
that outcome.
Committed action in ACT is acting according to their goal,
so it’s acting as if, you can also see this in DBT. One way to do this is when they tell a story
in depressed mode, get them to retell it as if they were fine. Find out what
the difference is between the two positions.
Acting as depressed has one outcome, acting as not depressed has another
outcome, both become self-fulfilling.
You can also look at how others react to the client when in depressed
mode or when not. You can sell this as
getting greater control over your behaviour, try it out, see what behaviour
suits, you may well find that quite naturally you start adopting the behaviour
that suits.
Techniques that bring temporary relief, but are not a long
term solution
1.
Distraction
a.
Useful when people have to deal with things they
can’t change, it can give them relief
2.
Limiting contact with unpleasant people
a.
Again be careful of the consequences
3.
Behaviour stopping
a.
E.g. rubber band, shouting stop
Dealing with ruminative thinking.
Rumination a common occurrence in depression (Ferster 1981).
(Nolen-Hoeksema 1994) show people who ruminate have longer periods of
depression. So what is the effect of rumination? What can you do instead that
will move you towards, or at least not away from your life goals. Rumination keeps the client separated from
others and detracts from problem solving.
Sometimes you can reduce rumination by looking at the trigger and
working out different ways to respond, do you feel upset, or lonely, what can
you do about it. Rumination is negatively
reinforced, so if you can find out what is the trigger and how it reduces the
impact of that then this can be put up as a problem to be solved. The situation of rumination might give a
clue, i.e. only do it at work.
Rumination and self-criticism might be a form of counter control to
anger, so originally when angry they were punished and so they self-criticise
to negatively reinforced by the avoidance of punishment which is associated
with anger, so to reduce anger is a negative reinforcer. Rumination is reminding yourself how bad
things are and wishing (magic) it could be different. When someone is ruminating, get them to
notice it, then to ask themselves is this helping me, what are my other
options. One way to avoid, ha, worrying
is to focus on the present, notice how your body feels, what the room looks
like, be mindful and just describe your present experience in detail.
Mindfulness training is seen in (linehan 1993). Mindfulness is an incompatible
behaviour with self-talk. This self-talk,
rumination, self-criticism etc. is often situational, people who are socially
anxious get this and it is impossible to be with the other when you are
absorbed in your own thoughts. Sometimes clients will do their assignments but
will be distant from them in some way, ruminating or physically distant, again
if they do a task and it doesn’t go well, check for this.
BA therapists teach goal setting, problem solving, activate
and approach behaviours, acting to a plan not a mood. Problem solving skills training has a long history in
BT (D’Zurilla 1982). D’Zurilla teaches to distract attention from mood, and
focus on the environmental factors associated with their response and find all
the facts relevant to the problem and then set an appropriate goal.
Problems in real life are not as clear cut as those in the
literature (Biglan and Dow 1981) recommend depression treatment should be
problem specific.
Problems may not be approached, through passivity and
avoidance or skills deficit. When you look for solutions to the client’s
problems and what behaviours do get positively reinforced, the result may not
be the obvious one. To get short term goals, you can assess what worked and
what didn’t. When you look at behaviours
think both about classes of responses and specific detail. Clients can often be
unclear about goals or indeed have goals that once they get they don’t
want. Clients can have conflicting
goals, situational goals, so really the question is not what is the true goals,
but what is the client will to commit themselves to. To understand conflicting goals, see both
what the stated desire is and what action there is the tension may show other
goals.
So BA says
1.
What are you doing and what are its
consequences, does this help you towards your goals
2.
If not then problem solving and ACTION
(Skinner 1953) suggest that social environment was the
primary mediator of positive reinforcement so (Follette 1988), so involving
significant others can be crucial.
(Coyne 1976) recognised that people may find interactions
with someone who is depressed to be aversive, indeed depressed people may find
a less supportive environment, one that supports their depression (Coyne 1999).
It has been suggested that social context needs to be integrated into
assessment procedures (Billings 1984). Twice as many women suffer depression
than men (Russo 1990). It has been suggested that marriage serves as a buffer
against depression for men but the opposite for women. (Hanmen 1991).
Treat marital problems to treat depression when
1.
Client is more concerned about marital problems
than depression
2.
Marital problems preceded depression
3.
Cognitive errors relate to the marriage and not
the client
Depression is related to a decrease in activity that brings
reward.
If you bring in the significant other, be aware that they
may want to put on a good face, make themselves seem fine and the other with
the problem.
Chapter 8 Clinical Examples of Behavioural Activation
BDI
9 or below sub clinical depression
10-19 mild
20-29 moderate
30-39 severe
40 and above consider hospitalisation
Stage 1
1.
Client sees relation between behaviour and mood,
mood and behaviour
Formulating a problem list (Persons 1989)
When there’s something you need to do but don’t want to,
when you’re depressed you wait for the feeling to come, when you feel
motivated, you act from the inside, out. But a way that clients have found
useful is to act from the outside in, so act and then find that the feeling
comes afterwards. So you can act you way into a new way of feeling, rather than
feeling your way into a new way of acting.
If you act maybe the feeling will follow, if it doesn’t, at least you
have done your task.
Encourage your client to act rather than philosophize. Does
a question like if I could just figure out why I got depressed then I could do
something about it, mean that you don’t need to do anything about my depression
until I have an answer, which leads to not doing anything about your
depression. Does curiosity act
avoidantly so you don’t need to act?
Self-therapy is spending 30-60 minutes planning activities
and using the tools learnt in therapy.
With clients get a problem list, ask what you would be doing
if you weren’t depressed, ask what your life goals for the next 2 years are.
When a client gets angry, do they do something about it, or
do they ignore it. Same question applies
to other emotions. Why is this the case, have you always done this. With
avoidance sometimes say with interpersonal issues it can be good to avoid, to
avoid a fight, but not always, and if a fight can happen once, would it happen
all the time?
When depressed there are biological changes and serotonin is
one but there are also behavioural changes. Whilst there is something in
changing serotonin levels that makes a difference we aren’t sure what it is, as
the chemical change happens within 2 days but it takes 2 months for mood to
change. If a client doesn’t do an
activity chart for homework, maybe do it in session.
Depressed clients have skill at getting out of bad, or
reducing bad situations but less skill in finding good situations indeed to
endure something uncomfortable is sometimes necessary to find something
good. Sometimes useful mindfulness, e.g.
description of the present to stay in a situation that you find aversive and
want to escape from. Relying on luck is
passive, other people have all the luck is a passive response.
