9a) Behavioural Activation

Question 1

Provide a brief historical account for BA treatment for Depression (4)

Answer 1

• Early behavioural theories of depression (e.g., Ferster,1973; Lewinson and Graf,1973) were based on behavioural principles of B. F. Skinner (1957).
• Aaron Beck incorporated into his ‘Cognitive Therapy of Depression’ (Beck, Rush, Shaw and Emery, 1979).
• Seligman’s theory of learned helplessness
  o Experiments on dogs – similar symptoms as depression
• Jacobson, Martell and Dimidijian (2001). ‘Behavioral Activation Treatment for Depression: Returning to Contextual Roots’.

Question 2

Provide a rationale for BA.

Answer 2

• Symptoms of depression often include a motivation and fatigue, anhedonia, sad mood
• Patients cope with these symptoms and feeling unwell by withdrawal and avoidance behaviours
  o From activity –> inactivity; stay in bed
  o From social interactions –> isolation
  o From selfcare –> poor eating, hygiene
  o From work –> stay home
  o From pleasurable activities
• Cognitive components
  o Increased rumination
  o Negative cognitive triad
  o Increased self-criticism
• Explain relationship between our activity and mood

Question 3

What is the vicious cycle of depression?

Answer 3

The combination of inactivity and avoidance and negative cognitive processing creates a vicious circle

Inactivity = lack of motivation and fatigue, anhedonia, sad mood leading to withdrawal and avoidance

Negative cognitive processing = increased rumination, increased self-criticism, negative cognitive triad (self, world, future)

Question 4

What is the relationship between mood and activity?

Answer 4

Downwards spiral of depression: trigger –> response -> avoidance pattern

Event/thought/feeling –> lower of mood –> decreased activity –> less positive reinforcement –> further decrease in activty –> worsening of mood –> increased lethargy/withdrawal –> etc.

When we are feeling good we spend time with people whose company we enjoy, do activities that make us feel good, and take on new tasks and adventures that challenge us as individuals. All of this activity has positive feedback effects:
* Doing things we enjoy gives us feelings of pleasure
* Challenging ourselves means that we have a chance to grow and develop, and gives us a sense of mastery
* Having positive relationships with other people makes us feel connected and valued

People who are depressed tend to do less overall and so they have fewer opportunities to feel pleasure, mastery, and connection

Question 5

Provide empirical support (3) for BA - short term (3) and long term (4)

Answer 5

Dimidjian et al., 2006: RCT
* BA vs. CT vs. SSRI vs. control
* 16 weeks active treatment
* ‘Usual’ exclusions led to 241 participants (62%) from 388 diagnostic assessments.

Short term
* BA, CT and SSRIs are all evidenced based treatments for depression.
* BA and SSRIs may be superior to CT for more severely depressed individuals.
* BA may result in higher rates of remission for severely depressed individuals.

Long term
* Psychotherapies appear to have a more enduring effect than SSRIs
* CT may have an advantage in preventing relapse for 1-2 years after treatment, though the difference between the psychotherapies was not significant
* SSRIs have the highest rates of relapse when treatment is ceased

Question 6

When comparing treatment costs for depression, which is cheaper - medication or psychotherapies?

Answer 6

short term = medication
medium, long-term = psychotherapies

Question 7

Outline the principles of Activity Scheduling. (4)

Answer 7

• Introduce pleasant activities in a Graduated program
• Reduce self-criticism
• Enhance potential for positive impact
• All of the above will lead to a reversal of vicious circle
• Activities will lead to re-experiencing of pleasure in a graduated way
   greater involvement and socialisation
   less self criticism and reduced symptoms

Question 8

When can BA be used (apart from depression)?

Answer 8

• Patients with diverse socio-cultural backgrounds that are not responsive to cognitive interventions
• Chronic pain
• Anxiety, especially associated with chronic disease/illness (e.g., cancer)

Question 9

What types of activities should be selected? (5)

Answer 9

• Essential activities = maintain biorhythms (e.g., healthy nutrition, sleep, personal hygiene)
• “Can do” activities = Adapt activities to fit constraints imposed by depression
  o Systematic and graduated schedule
  o Reduced concentration may make reading a novel impossible
  o Slow psycho motor activity may rule out competitive tennis
• Pleasurable activities
  o Differentiate between chores (must do) and pleasurable activities (like to do)
  o Analogy of a gift/cheque e.g., one hour a day - pamper yourself
• Choose activities that are meaningful and value-based
  o Will successful attainment of tasks contribute to changes in appraisal of self/others/future in an important way.
  o E.g., quality time with children in woman who pins self worth to being a good mother
  o E.g., work readiness in man who is sees self as financial provider for family
• ‘Can’t lose’ activities = some benefit even if clients don’t enjoy them
  o “Healthy” activities such as walk, swim, walking dog, doing something for kids?
  o Humour: Cartoons, videos, books?

Question 10

What are best practice principles when assigning activities for BA? (6)

Answer 10

• Follow best practice principles of HW assignments
• Task is clear (what, when, where, how long, how often)
• SMART goals (Specific, Measurable, Achievable, Relevant, and Time-Bound)
• Write down tasks (cognitive issues in depression)
• Initiate activities in session before generalising
• Collaborative approach

Question 11

List some challenges when doing BA with clients with severe or complex problems. (6)

Answer 11

• Lack of optimal collaboration and engagement
• Severe clinical symptomatology - especially hopelessness
• 2nd order beliefs about symptoms, techniques, therapeutic approach, prognosis, outcomes.
  o Secondary gains.
   Are there benefits to remain depressed?
   Are there fears that prevent recovery?
• Family and social context may be undermining therapeutic gains
• Network of negative beliefs that make specific intermediate beliefs particularly hard to change
• Therapist factors
  o Unhelpful beliefs and reactions by therapist
  o Developing skills

Question 12

What qs can you ask to combine BA with CT? (8)

Answer 12

• Did my mood change during the week? How? What patterns do I notice?
• Did my activities affect my mood? How?
• What activities made me feel better? Why? Are these activities in my best long-term interest? What other activities could I do that might also make me feel better?
• What activities helped me feel worse? Why? Are these activities in my best interest to do?
• Were there certain times of the day (e.g., mornings) or week (e.g., weekends) when I felt worse?
• Can I think of anything I could do to feel better during these times?
• Were there certain times of the day or week I felt better?
• Looking at my answers to Q3 and Q4, what activities can I plan in the coming week to increase the chances that I will feel better this week? Over the next few months?

Question 13

What are some general strategies when encountering challenges during BA? (6)

Answer 13

• Re-check assessment and conceptualisation
• Do a CB assessment of problem encountered (resistance, hopelessness, etc. )
• Look at formulation, beliefs to be changed, barriers
• Obtain clinical supervision
• Analyse recorded session
• Think laterally - can you use different methods; are you trying to change an ‘unchangeable’ belief?

Question 14

What are some strategies to deal with resistance? (10)

Answer 14

• Identify beliefs - resistance is the C in ABC. A is therapist’s expert help to resolve problems
• Revise formulation
• Clarify reinforces and meanings of reinforcing activities with client
• Use validation techniques
• Greater focus on therapeutic relationship
• Break down unsolvable problems into simpler components that are more manageable
  o Build milestones
  o Use problem solving strategies
  o Bargain for time/trial
• Help client access support from others to resolve barriers

Question 15

When does hopelessness occur?

Answer 15

• our goals, pathways, and agency (i.e., hope) are tested and
• when change is seen as impossible
• during times of adversity/challenging times

Question 16

Why is it important to address hopelessness?

Answer 16

strong predictor of suicidal behaviours

Question 17

Define hope

Answer 17

A way of thinking.
Trilogy of: goals, pathway, agency

Question 18

What are some interventions for dealing with hopelessness? (13)

Answer 18

• Dissect hopelessness into more manageable, specific automatic thoughts and assumptions
• Examine automatic thoughts and assumptions about
  o depression’s course, prognosis, impact on current and future functioning e.g., I’ll never be happy again
  o Some symptoms of depression (e.g., cognitive impairments, or anhedonia) e.g., never recover from losing cog abilities
  o Self and other cognitions e.g., My neglect has damaged my children that they’ll never recover from this trauma. AND, Being a good mother was the thing I most valued
  o About therapy e.g., therapy is too hard for me.
• Validate the client’s experience
  o You don’t have to Agree with client’s appraisal
• Disrupt ruminations
• Use cognitive restructuring to deal with these thoughts.
  o Target assumptions rather than core beliefs
  o Coping statements and cards sometimes helps if depression is severe
• Be patient. Hang tough.
• Set smaller goals.
• Use behavioural strategies
• Become self-aware of your reaction:
  o Impatient and Angry? Hopelessness?

Question 19

What are 10 key points to address when presenting the BA treatment model?

Answer 19

• BA is based on the idea that the events in your life and how you respond to such events influence how you feel
• BA assumes that one reason people get depressed is that their lives are providing too few rewards and too many problems
  o Sometimes it is possible to identify easily stressors/problems
  o Other times, there are no clearly identifiable stressors but there is still not adequate reward from the environment
• When one’s life context is difficult, it is common to experience feeling sad, down, discouraged, anxious, fatigued, drained, and so forth
• When feeling these ways, it is also common to do (or not to do) particular actions
  o People often pull away from the world around them and find that basic routines in their lives become disrupted
• Pulling away from the world when feeling down is natural and understandable.
  o The problem is that is also can initiate downward spirals with how you feel (e.g., the less you do, the worse you feel, and the worse you feel, the less you do).
• Acting (or not acting) in such ways also can maintain depression by making it hard to solve life problems effectively
  o This initiates another downward spiral in which what you do or don’t do makes the context of life harder or keeps you from improving it
• In this treatment, we will work together to focus on specific things you can do to help shift these downward spirals and help you become more active and engaged in your life
• BA is not just about “doing more”
  o If feeling better were that easy, you would have already done it
  o We can work together to identify the activities that would be most helpful and the small and manageable steps you can take to get started
  o You can think of me as your coach/consultant in the process of change
• Each session will involve developing practical and do-able steps to engage in activities that improve mood and to solve specific life problems
  o Between sessions, you will work on HW assignments that we develop together
  o These assignments are an essential part of therapy and will focus on re-connecting/building parts of your life that increase feelings of pleasure/accomplishment and bring you closer to important life goals
• Activating and engaging in specific ways can help you experience more reward and effectively solve life problems
  o When you are active, engaged, and solving problems effectively, it is likely that you will be moving toward important life goals and feeling better