Home > Behavioral Activation Group Therapy Therapist Manual Jeffrey F. Porter, Ph.D. and C. Richard Spates, Ph.D. Western Michigan
Jeffrey F. Porter, Ph.D. and C. Richard Spates, Ph.D.
Western Michigan University
Kalamazoo, Michigan
Behavioral Activation (BA) treatment for depression was identified as a viable treatment option based on the results of “A Component Analysis of Cognitive Behavioral Treatment for Depression,” a controlled therapy outcome study conducted at the University of Washington. In that study, Neil Jacobson and colleagues evaluated the components of Cognitive Therapy (CT), developed by Beck et al., (1979), identified as the behavioral component and the behavioral + focus on automatic thoughts component, in comparison with Cognitive Therapy. What they found was that all three treatments were equally effective in reducing patient’s depressive symptoms as measure by BDI scores and clinician Hamilton Rating Scale for Depression scores. Thus, they concluded that interventions aimed at changing cognitions are not necessary to change depressive thoughts and that interventions aimed at changing behaviors are equally effective at changing depressive thoughts and lifting depressed mood.
The theory behind the BA treatment for depression has three components. The first component is that depression results from changes in the patient’s life circumstances because these changes in life circumstances (i.e., changes in the environment) have caused a reduction in reinforcement. Secondly, once the depression occurs, the person’s ways of responding (i.e., coping) to the depression often further deprives her of reinforcement, thus making the depression worse. Finally, not all people are equally vulnerable to depression. Vulnerability is determined by both previous learning history and genetics. Thus, the therapist needs to be aware of (1) the patient’s vulnerability factors due to genes and history, (2) the environmental changes which precipitated the depressive episode and (3) the patient’s methods of coping with the changing environment.
The goal of BA is to activate the patient in such a way as to maximize the opportunities to make contact with reinforcers in the environment. This requires three things: (1) the patient must learn to cope differently, so that opportunities for reinforcement increase, (2) the patient must act as a conduit for modifying her environment so that it will be more reinforcing and (3) the patient will develop the skills necessary for nipping future episodes in the bud by coping more effectively with adverse environments.
It is expected that the therapeutic relationship will be one in which the therapist shows empathy, caring and consideration for the patient. The relationship should be one of collaborative empiricism in which the therapist and the patient work together as a “scientific team”, identifying and systematically helping the patient to modify problematic aspects of her environment through behavior changes. As such, the therapist does not direct the patient as to what to do in order to improve but rather works with the patient to determine which of various possible interventions will be most beneficial for the patient. At times, the therapist will act as an educator, informing the patient about the relationship between loss of reinforcement, a decrease in behavior and depression. Thus, the therapist teaches the patient to become her own therapist, eventually allowing the patient to plan her own treatment interventions.
Since this treatment approach is strictly behavioral, it is necessary to have guidelines in place as to how to handle patients’ thoughts. The therapist is expected to give an empathic response to the patient’s thinking so as not to communicate that the patient’s thinking is unimportant. In some cases, it may be necessary for the therapist to ask a few questions related to thinking in order to develop strategies for dealing with the problems that the patient is experiencing. Such questions should assist the therapist in understanding the eliciting features of different patterns of thinking and function of such patterns. However, while thoughts can be addressed for assessment purposes, interventions aimed specifically at modifying thoughts is prohibited.
BA interventions are based on a functional analysis of how life circumstances have precipitated the depressive episode, how the patient has coped with the experience of depression, and the opportunities available for bringing the patient into contact with aspects of the environment which are likely to relieve the patient of depression. The rationale for treatment given to the patient will be that of the therapist as a personal trainer. The therapist’s job is to help patients identify what is going wrong in their lives and guide them in actions that will help improve their life situations, thereby making them less depressed. Furthermore, the therapist will help the patient become her own trainer, learning to analyze and change life circumstances for the better in the future. Emphasis is put on identifying behaviors and activities that provide the patient with the pleasure and interest that is currently missing from her life. A sense of optimism about the outcome of treatment should be communicated and the patient should be encouraged to consider changes in her behaviors as the key to becoming less depressed.
Assessment
and intervention techniques available to the therapist follow.
Assessment Techniques
Functional Assessment
Purpose: A functional assessment is an assessment of the relationships between the environment, a behavior and a behavior’s consequences. The goal of a functional assessment is to understand how the environment set up the behavior and what the consequences of the behavior were.
Method:
Doing a functional analysis of a behavior should help you to understand what behavior occurred, why it occurred and what happened as a result of its occurrence.
Example:
A patient reports that he stayed in bed all day. Being a BA therapist, you want to understand why he stayed in bed all day. In other words, what was controlling this behavior? There are endless possibilities. Perhaps the patient had two broken legs or he was sick or he was obsessed with counting the number or marks on the ceiling. So you investigate and conduct a functional analysis.
You now have a pretty good understanding of why the patient stayed in bed and what effect that had on him. You can help the patient to understand that his laying in bed actually made the depression worse rather than better. You can use this information to suggest changes, either in the environment or in the patient’s behavior.
NOTES:
Mastery and Pleasure Ratings of Activities
Purpose: To assess which activities in the patient’s life provide a sense of pleasure and/or mastery. This is useful for increasing meaningful experiences that are more likely to relieve depression.
Method: Patient keeps a daily activity log of activities and rates the degree of pleasure and mastery (0-5) experienced after completing the activity. At a later time, the patient selects those activities rating high on either scale to increase through homework assignments.
One of the goals is for the patient to schedule activities during the day so that there is some sense of structure and control on the part of the patient. This also helps the patient to identify what s/he is doing and to realize that s/he is not doing “nothing.”
Example: Patient calls an old friend on the phone.
The patient makes a phone call to an old friend and talks for 10 minutes. After the call, the patient feels good about initiating the contact and skillful in her ability to make a social contact. The patient records the activity of making the call and rates it a 1 for Mastery and a 3 for Pleasure.
NOTES:
Verbal Reports of Activities
Purpose: To understand what activities the person is currently engaging in which reflects current functioning. The therapist is able to assess whether the patient is acting in ways that are likely to make the depression worse (i.e., self-defeating behaviors). Also gives the therapist an idea of the patient’s interests.
Method: Ask the patient to report what s/he did yesterday and ask if that was a typical day. If patient replies that s/he did “nothing”, be more specific and ask what s/he did at specific times during the day.
Example:
“What did you do from the time you woke up yesterday until the time you went to bed last night?” Probe to get details of activities if they are not forthcoming.
More specific line of questioning:
“What were you doing at 11:00 AM yesterday? How about at noon?”
It is important to reframe if necessary so that the patient’s report is stated in terms of activity.
Example:
Patient: “I just sat around and did nothing all morning.”
Therapist: “So you sat all morning. What were you doing while you were sitting?
Patient: “Nothing. Just sitting there.”
Therapist: “Sitting there and thinking?”
Patient: “Yeah, thinking about how miserable I was.”
Therapist: “So you spent the morning sitting and thinking about your depression.” (This reframe describes active behavior and creates opportunity for suggesting increased behavior or different behavior.)
Therapist: “How about tomorrow if instead of sitting and thinking about your depression, you sit and organize your recipes?”
NOTES:
Purpose: To understand what symptoms of depression the patient is experiencing so that the therapist can choose appropriate targets for intervention.
Method: Therapist looks over the patient’s BDI at the beginning of the session and focuses primarily on strong behavioral and mood symptoms if they are present.
Example:
The therapist reviews the patient’s BDI and says, “I notice that you circled the statement ‘I have a hard time making decisions.’ Can you tell me what that is like for you?”
The therapist would then help the patient process some recent decision making incident that was difficult and use this information at some later point, perhaps to work on problems solving skills.
NOTES:
Purpose: To assess the type and quantity of activities to better understand the patient’s routines and regular activities. This helps the therapist to better understand why the person is receiving little pleasure from life.
Method: Introduce the Daily Activity Schedule to the patients during a group and explain that it can be very valuable to keep a record of one’s activities throughout the day so that suggestions for changes in behavior, based on this information, can be made.
Example:
A patient completes a Daily Activity Schedule during the second week of therapy and brings it to the session. The therapist reviews it during the session and notices that the patient engages in very few activities that provide and sense of mastery or pleasure. Yet the patient does essentially the same activities day after day. The therapist might bring this to the patient’s attention and make some suggestions for changing the patient’s routine so that it includes activities that are more likely to produce pleasure.
NOTES:
Purpose: To observe first-hand both the depressive behaviors, as well as the healthy behaviors, that the patient engages in during the therapy session. These observations can be brought up as they are made or at a later time. This is an effective way of demonstrating the functional relationships between environment, behavior and its consequences.
Method: Observe the patient’s behavior in terms of the typical symptoms of depression as well as in terms of generally unhealthy behavior. Observe the patient’s behavior in terms of healthy and productive behavior. Examine what is happening when problem behaviors or healthy behaviors occur and what the results of the behaviors are.
Example:
A patient is talking during the session and is interrupted by another group member. The patient who was interrupted begins pouting and crying during the session. The therapist notes to her/himself what occurred and how the patient reacted. This information can be used at a later time to demonstrate the functional relationships between the environment, behavior, and its consequences.
NOTES:
Intervention Techniques
Assigning Activities to Increase Sense of Mastery or Pleasure
Purpose: To activate the patient in such a way that s/he feels more effective in her/his environment and consequently receives more pleasure from activities.
A) Activities that are likely to improve negative aspects of the environment or ones that were previously (prior to the onset of the depression) reinforcing.
Example: The patient used to enjoy playing the piano but since being depressed, has stopped playing. The therapist might contract with the patient to play again and discuss possible obstacles to playing that may hinder performance. Such obstacles might be decreased skills due to not playing for a long time or due to the depression. The patient might also have more difficulty than usual concentrating for a prolonged period. It is important to communicate that these obstacles are to be expected and that they are normal due to the current depressed condition.
B) High probability activities: activities that are likely to occur, initially solitary activities that are within the patient’s control. It is important to set the patient up for success, not failure.
Example: The patient contracts to take a 15-minute walk each day before the next session. Or the client agrees to bake herself a favorite meal for dinner Thursday night.
Activities that involve the cooperation and participation of others should be used cautiously at first, as they present a greater risk for failure due to their dependence on another person(s).
C) Activities from lists of pleasurable events, either ones currently pleasurable or ones that at least at one time have been pleasurable. This information can be obtained from having the patient complete a Pleasant Events Schedule (possible homework assignment).
NOTES:
Purpose: To help the patient to understand the relationship between her/his behavior and moods and between the environment and moods. This helps the patient understand how s/he can make meaningful changes to improve moods. This requires explaining the ABC model to the patient.
A represents the antecedent to the behavior. This is whatever was happening just prior to the behavior that set up the behavior to occur.
B represents the behavior of interest. This is an observable behavior on the part of the patient.
C represents the consequences resulting from acting out the behavior. Consequence does not imply something bad. All behaviors have some consequence, whether good or bad.
It is important to focus on what the patient actually does (active behavior) rather than on what s/he failed to do.
Example: The patient describes a situation in which she stayed in bed all day and “did nothing.” It is important to put this incident in terms of what he did (actively) so that there is some behavior that occurred to focus attention on. Instead of talking about the behavior as doing nothing (as the patient talked about it), you might talk about it as staying home and sleeping and lying in bed all day starring at the ceiling.
A: feeling no motivation or interest to get out of bed to do anything; tired; wanting to avoid seeing others; no commitments to keep get you out of bed
B: slept and laid in bed
C: felt more depressed; felt worthless, tired, isolated, guilty; lower self-esteem
NOTES:
Encouraging an Active, Rather than a Passive Approach in
Specific Situations
Purpose: To focus the patient on the function of a behavior in terms of being productive or destructive.
Active behaviors are those behaviors that:
1) Serve to create pleasurable or meaningful experiences;
2) Serve to ameliorate aversive or unpleasant experiences.
Passive behaviors are those behaviors that:
1) Produce aversive or unpleasant experiences
2) Fail to ameliorate aversive or unpleasant experiences.
Example of Active Behavior: Problem solving is active behavior as it serves to remediate a problem, thereby lessening an aversive condition.
Example of Passive Behavior: Complaining is a passive behavior inasmuch as it rarely changes the aversiveness of a situation.
Example: The patient has a conflict at work with a coworker over job duties.
Passive response: The patient complains to family and friends. Results: the situation at work does not change; patient receives attention from family/friends; family/friends get annoyed and avoid patient.
Active response: The patient goes to the supervisor and asks for a clarification of her job duties.
NOTES:
Tasks of Increasing Difficulty
Purpose: To ensure success and combat the patient’s feelings of overwhelm. Make problems manageable and assignment doable.
Method:
1) Problem definition: useful definition of the problem in behavioral terms. Be very concrete and specific.
2) Stepwise assignment of tasks from simpler to more complex
3) Immediate and direct observation by the patient that s/he is successful in reaching a specific objective. If the patient does not know whether or not s/he has completed a goal, then the definition of the goal needs to be more concrete and specific.
4) Ventilation of doubts, reactions and belittling of achievement.
5) Celebration of achievements. It is important that the client recognizes and be recognized (particularly early in therapy) for successful completion of goals.
This intervention requires the therapist to break down a task into doable parts.
Example: A patient reports that he is no longer able to keep up with the housework because he cannot get himself to clean. Instead of focusing the client on cleaning the entire house, the therapist shifts the focus to doable tasks that make up cleaning the entire house. For example, the therapist might start with encouraging the patient to vacuum one room the first day. On the second day his goal would be to vacuum two rooms, etc. Within a short amount of time the patient is able to clean a substantial portion of the house. This approach works because it breaks the big task into many manageable little tasks that provide successes at short intervals. It is important for the therapist to emphasize to the patient that he complete one task before moving on to the next otherwise they tend to run together into one big task, which was the initial problem.
NOTES:
Purpose: To anticipate pitfalls that might occur while completing certain activities.
Method: Talk through the steps of a planned activity with the patient, probing when necessary and helping the patient to problem solve when problems arise.
Example: The patient’s assignment is to call a friend and invite her to lunch. The patient describes this from the time that she picks up the phone until she hangs up. Therapist asks “What if…?” types of questions and helps the patient solve these small problem situations.
Examples:
“What if there is no answer the first time you call?”
“What if your friend cannot talk but asks you to call back later?”
“What if your friend says that she has plans that day?”
NOTES:
Purpose: To help the patient learn from experiences how to better handle problem situations (i.e., how to better cope).
Method: Examine the incident of interest and generate alternative options for ways to behave. The goal is to identify behaviors to use in the future when a similar situation arises.
Example: A patient reports that he had an argument with his wife in which he lost control and began yelling and calling her names. The therapist’s job is to help the patient generate alternative ways that he could have handled the situation. For example, he might have told her that he was too angry to talk and that he needed time to cool down. Or he might have withdrawn and said nothing. Or he might have physically assaulted her. Each alternative is rated on its merits in terms of getting the patient’s needs met and being generally healthy.
**It is important to include worse alternatives to what the patient actually did so that the patient can see things in a realistic perspective. Thus, in most cases, while there are many things that he could have done differently that would have been healthier, there are also worse things that he could have done. This is important in that it shifts the patient’s focus on himself as a terrible person to a person who could have made a better choice.
NOTES:
Purpose: To practice certain behaviors in a controlled and safe environment before using them in a real life situation.
**This intervention has much potential for use in a group therapy setting.
Method: Identify a task or skill to practice and construct the necessary situation using the members of the group as participants.
Example: A group member complains that she cannot control her kids and that they run the house. Using group members as actors, a likely scenario might be played out that allows the group member to practice being assertive and setting limits with the kids.
NOTES:
Purpose: To help the client process possible outcomes of different behaviors before they occur. This assists the patient in making a decision in a situation when it does occur. It also gets the patient in the mindset of thinking about the effects of her/his behavior so that better decisions can be made.
Method: Talk through a particular situation with the patient and ask questions to help the patient explore the possible effects of engaging in certain behaviors. Important to explore best case and worst-case outcomes so that the patient is prepared for either extreme if it occurs.
Example: The weekend is coming and the patient is concerned about what to do during the weekend. The first step is to generate ideas of what the patient could do (e.g., stay in bed, do yard work, have lunch with a friend, watch a movie). The next step is to process likely outcomes if each behavior were to occur and how the patient would feel. An emphasis on the qualities that would make an activity healthy should be made so that the activities do not seem random but rather have some consistency.
NOTES:
The Likelihood of Homework Success
Purpose: To avoid obstacles to successful completion of homework in advance of doing the homework so that they do not prevent the homework from being successfully completed.
Method: Talk about the homework assignment and possible pitfalls. Help the patient problem solve by creating a homework assignment with a high probability of success.
Example: A patient’s homework is to exercise every morning for one hour. However, mornings are very busy for the client because she has to take care of her children and get them off to school. Therefore, there is a high probability that this assignment would fail due to her busy morning schedule. As a therapist you might suggest that this might be a problem and suggest setting aside time in the afternoon for exercise when the likelihood of interruption is lower.
NOTES:
Purpose: To shift a patient’s focus from some problem or unpleasant experience to something more productive and healthy. Often times depressed patients perseverate on a problem and distracting them from the problem helps them to loosen their stronghold on the thought.
Method: Assist the patient in coming up with alternative behaviors to engage in when a problem situation arises. Ideally, this distraction behavior should be one that is incompatible with the problem behavior.
Example: The patient reports that she sat around all weekend thinking about a fight she had with her mother and persecuting herself for being such a terrible person. The therapist might suggest some activities that would serve to take her mind off of the event. Such activities might include visiting a friend, talking with someone about the fight or reading a book.
NOTES:
Purpose: To prevent self-defeating behavior that sets a person up to be hurt. The goal is to teach the patient to avoid situations that are likely to lead to painful or unpleasant experiences.
Method: Teach the person specific coping skills for getting out of unpleasant situations.
Example: The patient reports that every time he visits his mother she tells him how much potential he has and how he is wasting his life being a writer. Yet the patient continues to see his mother regularly and therefore sets himself up to be hurt. He doesn’t see confronting her as a viable option. So the therapist may suggest to the client that he avoid seeing his mother for a while or only see her with other family present, when she is not as likely to make these hurtful comments towards him.
NOTES:
Purpose: To teach the client alternative behaviors to those that are self-damaging.
Method: The therapist helps the client identify behaviors that, while still allowing the patient to get her needs met, are healthier (i.e., less self-damaging).
Example: The patient reports that when she gets extremely upset she cuts on her arms and legs with a knife until she bleeds. The therapist’s goal is to identify alternative behaviors to do in the place of cutting. These behaviors should make cutting incompatible. This might mean writing in a journal or on a computer. Such activities are healthy because they allow for self-expression and they occupy the patient’s hands so that she cannot cut on herself.
NOTES:
Purpose: To teach the patient skills that he is deficient in. This allows a demonstration and practice of these skills in a safe setting.
Method: A particular skill can be identified and practiced by the patient. Other group members can participate and the therapist is present to stop action if necessary and make suggestions and give feedback in order to shape the behavior into a productive behavior.
Example: The patient has difficulty communicating with his spouse and fights between them are common. The therapist can model some communication skills and then help the patient practice the skills with other group members, providing feedback throughout the exercise.
NOTES:
Purpose: To help the patient overcome sexual arousal or performance problems.
Method: This is achieved by shifting the patient’s focus from some sexual act to something less critical. This typically involves asking the patient to focus on non-sexual touching with her/his partner and not to have sex. This tends to reduce the amount of attention focused on the act, which reduces anxiety and often leads to sexual activity.
Example: The patient complains that she has no interest in sex anymore. She states that she cannot even get herself to have sex with her husband. The therapist might suggest that on some evening this week she lay in bed with her husband and each of them gives the other a back or body massage. The therapist further suggests that the patient not have sex at this point but rather just focus on the pleasurable feelings of massage. If the patient follows these directions, then she has successfully completed a homework assignment and a first step towards restoring physical intimacy has been taken. If the patient ends up having sex after the massaging, then the patient has failed the homework but the larger goal of sexual activity has been achieved.
NOTES:
For Behavioral Achievements.
Purpose: To increase the amount of pleasure in the patient’s life by having her/him reward self for accomplishments. This is particularly important when the patient’s environment does not provide a lot of pleasure on its own. The rationale to provide is that often times depressed persons do not acknowledge their accomplishments because they are so focused on negatives. Rewarding oneself is a way of increasing pleasure and acknowledging accomplishment.
Method: Help the patient to define tasks in terms that will allow the patient to easily determine whether a task has been completed or not. Then, help the patient identify things that s/he can provide that are likely to give some pleasure.
Example: A patient complains that she is unable to start a project at home that she has wanted to do for a long time. The therapist suggests that the patient break the project into manageable steps and that after the completion of each step, she reward herself by buying herself a new tool.
NOTES:
(e.g., sleep)
Purpose: To address problems involving overt behaviors
Method: Do a functional analysis of the behavior and determine what changes can be reasonably made that are likely to alleviate the problem behavior.
Example: The patient complains that she cannot sleep at night but that she can sleep during the day. The therapist might explain the importance of a routine in sleeping and suggest strategies to develop a routine that enables nocturnal sleeping.
NOTES:
(e.g., assertion, communication)
Purpose: To teach skills that the patient is deficient in which are contributing to the depression. Often time these are basic communication skills.
Method: The therapist can talk about certain skills and what makes them effective and the therapist can model these skills for the patients.
Example: The patient reports that he cannot talk to his wife without a fight breaking out. Through listening to self-report and through direct observation of in-session behavior the therapist has reason to believe that the patient’s communication skills are part of the problem, as the patient has a very accusatory communication style. The therapist can model less accusatory communication and the patient can practice and get feedback from group members.
NOTES:
BAGT First Session Agenda
I.
(About 5-10 minutes)
II.
(About 10 minutes)
III.
(About 15 minutes)
IV.
(About 50 minutes)
(About 5 minutes)
BAGT Second Session Agenda
I. Warm-up exercise (progressive muscle relaxation, imagery, etc.)
Other therapist reviews the clients’ BDIs
II. Group members each have a turn presenting the treatment techniques from their workbooks. The therapists assist by prompting the clients with questions or expanding on the clients’ descriptions when needed.
III. Go-Around
IV. Closure
BAGT Sessions 3-6 Agenda
I. Warm-up exercise
Other therapist reviews BDIs
II. Go-around
III. Closure
BAGT Sessions 7-9
I. Warm-up exercise
II. Go-around
III. Relapse Prevention
IV. Closure
BAGT Last Session Agenda
I. Warm-up exercise
II. Brief go-around
III. Relapse Prevention
IV. Closure
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