Behavioral Activation Group Therapy

Behavioral Activation Group Therapy

Therapist Manual

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

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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:

1.  The first step in doing a functional assessment is to identify the behavior of interest.

2.  The second step is to ask ‘what condition(s) immediately preceded the behavior?’.

3.  The third step is to ask ‘what were the consequences or results of the behavior?’.

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.

1.  What is the behavior of interest? Lying in bed all day.

2.  You ask the patient what was going on when he woke up and continued to lie in bed. He responds that he had no energy and that he had nothing to get up for and that he didn’t feel like seeing anybody so he just stayed in bed.

3.  You ask the patient what happened as a result of his laying in bed all day. He tells you that he was depressed and felt like a failure because only failures stay in bed all day and that his wife got mad at him and he felt guilty about being such a lousy husband.

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:

16

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:

16

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:

16

Symptom Reports from Beck Depression Inventory

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:

16

Daily Activity Schedule Review

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:

16

Assessment of In-session Behavior

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.