Behavioral Activation Techniques for Depression in a variety of settings: Groups, Peer-to-Peer and Non-Clinical Settings

by Susan L. Bandy, M.A., QMHP, LPC Chestnut Health Systems Granite City, Illinois

Order of Topics

Group Dynamics Therapeutic Factors Group Therapy Basics Problem Severity Behavioral Activation Techniques & Definition Good Research Model

Order of Topics

The Two Manuals: Original Form & Group Form Treatment Techniques & the Forms Assessments Uses of the Forms Overview of Tasks to be Accomplished Within the Group Session by Session Outline

Universal Group Dynamics

4 Stages all groups go through to be cohesive and successful

Forming: Group members become oriented toward one another. Storming: Conflicts surface in the group as members vie for status & the group sets its goals. Norming/Performing: Group members move beyond disagreement and organizational matters to concentrate on the work to be done.

Universal Group Dynamics

Forming
Initial stage: Members develop an in or out feeling. This highlights the need for the facilitator or, in peer-to-peer, the co- facilitator to maintain a basic posture of concern, acceptance, genuineness and empathy toward the group members.

***Nothing takes precedence over this attitude!

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Universal Group Dynamics

Forming cont
If possible, individually meet with group members to orient them to the therapy i.e., relay the efficacy of the intervention and determine if they are suitable for the intervention (e.g., presence of personality disorders that can disrupt the group process).

Universal Group Dynamics

Forming cont
Facilitator, or in the case of peer-to-peer, the co-facilitator must recognize and deter any situation that might disrupt the formation of group cohesion i.e., continued tardiness, absences, subgrouping, disruptive extra-group socialization and scapegoating*.

Universal Group Dynamics

Forming cont
*Scapegoating: a process whereby anger and aggression are displaced onto another, usually less powerful group or persons not responsible for the aggressors frustration (aka displacement or projection)
Corsini, R. (Ed.). (2002). The dictionary of psychology (pp. 863). New York: Brunner-Routledge.

Universal Group Dynamics

Forming cont
During this stage there is hesitancy among the members and they will be sizing up one another and the group. They are wondering if they will be liked and respected or ignored and rejected. The members will be searching for approval, acceptance, respect, or domination.

Universal Group Dynamics

Forming cont
Members will be wondering what membership entailshow much they must reveal of themselves, what type of commitment they must make. Very important: they will be looking to the leader/facilitator for structure, answers, leadership and for approval and acceptance.
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Universal Group Dynamics

Forming cont
The members search for similarities is very common in early groups and group members will be fascinated that they are not unique in their misery this is part of the foundation for cohesiveness (discussed later).

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Universal Group Dynamics

Storming
Conflicts surface in the group as members vie for status and the group sets its goals.

This is when the group shifts from preoccupation with acceptance, approval, commitment to the group, definitions of accepted behavior, the search for orientation, structure, and meaning, to a preoccupation with dominance, control and power.
The conflict characteristic of this phase is among members or between members and the leader.

Universal Group Dynamics

Storming - cont
Each member attempts to establish his/her preferred amount of initiative and power. Gradually, a control hierarchy, a social pecking order emerges. Negative comments and intermember criticism are more frequent; members often appear to feel entitled to a one-way analysis and judgment of others.

Universal Group Dynamics

Storming - cont
Advice from the facilitator is given in the context of the social code of the group: social conventions are abandoned and members are told to feel free to make personal criticism about a complainers behavior or attitudes. Judgments may be made of past and present life experiences and styles. It is a time of oughts and shoulds in the group or a time when the peer-court is in session. Members will make suggestions or give advice as a part of the process of jockeying for position.

Universal Group Dynamics

Storming - cont
At one time or another there most likely will be an emergence of hostility toward the facilitator this usually arises out of disappointment by the group member in their progress Remember:

Progress takes time.

Another source of resentment toward the facilitator is that the member eventually realizes he/she will not become the leaders favorite child. This does not arise from a function of childlike mentality or psychological naivete.

Universal Group Dynamics

Storming cont
Encourage members to express their anger or annoyance with you or the peer facilitator

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Universal Group Dynamics

Norming/Performing
This is the stage where group cohesiveness will develop: recognition of a common goal, development of group spirit, consensual group action, cooperation, mutual support, group integration, we-consciousness unity, support and freedom of communication as well as the establishment of intimacy and trust between peers.

Universal Group Dynamics

Norming/Performing - cont
In the beginning the group will exhibit much pride in their unity and possibly much condemnation of the members adversaries outside the group. Eventually this glow will pale and the group must be allowed to express difficulties, conflicts and differentiation otherwise the group will fail.

Universal Group Dynamics

Norming/Performing - cont
There are two aspects to this phase:

an early phase of great mutual support (the group against the external world) and,

a more advanced stage of group work or true teamwork in which tension emerges as a result of the members struggle with his or her own resistances.

Group Therapy: Therapeutic Factors

Eleven Primary Therapeutic Factors

Instillation of hope Universality Imparting Information Altruism Corrective Recapitulation of Primary family group Development of Socializing Techniques Imitative Behavior Interpersonal Learning Group Cohesiveness Catharsis Existential Factors

Group Therapy: Therapeutic Factors

Instillation of Hope
Most important at the beginning of the process. Instilling hope in someone is therapeutic even before therapy starts. If you have open enrollment, other members of the group can tell how they have been helped. Facilitator must be very confident and optimistic
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Group Therapy: Therapeutic Factors

Universality
You are not alone in this problem.

Although everyone is unique and has his/her own set of problems, within the early stages of group therapy group members come to realize that others have problems and a welcome to the human race experience or were all in the same boat is a powerful source of relief to the individual.
Despite the complexity of human problems, certain common denominators are clearly evident, and the members of a therapy group soon perceive their similarities.

Group Therapy: Therapeutic Factors

Instillation of Hope
From you to the support group member: they may not be informed about what they have, how common it is or how treatable the disorder is. This is extremely beneficial to the individual. From one support group member to another support group member: it is beneficial to the newcomer or ongoing support group member for the members reflection on what he/she accomplished, e.g., made the right decision. If you understand the problem you can learn to control it.

Group Therapy: Therapeutic Factors

Altruism

Both recipient and provider can benefit. See story below for example there is an old Hasidic story of a rabbi who had a conversation with the Lord about Heaven and Hell. I will show you Hell, said the Lord, and led the rabbi into a room containing a group of famished, desperate people sitting around a large circular table. In the center of the table rested an enormous pot of stew, more than enough for everyone. The smell of the stew was delicious and made the rabbis mouth water. Yet no one ate. Each diner at the table held a very long-handled spoon long enough to reach the pot and scoop up a spoonful of stew, but too long to get the food into ones mouth. The rabbi saw that their suffering was indeed terrible and bowed his head in compassion. Now I will show you heaven, said the Lord, and they entered another room identical to the first-same large, round table, same enormous pot of stew, same long-handled spoons. Yet their was gaiety in the air: everyone appeared well nourished, plump and exuberant. The rabbi could not understand and looked to the Lord. It is simple, said the Lord, but it requires a certain skill. You see, the people in this room have learned to feed each other!

Group Therapy: Therapeutic Factors

The Corrective Recapitulation of the Primary Family Group

Male and female therapists/facilitators become mother and father to the group members who in turn become the children or siblings. Re-evokes situations in a setting where one can work on it i.e., make the person/group member more conscious (give insight).

Group Therapy: Therapeutic Factors

Development of Socializing Techniques

Can be explicit e.g., develop social skills in the group: developing vocabulary is one tool for social skills.
Can be implicit e.g., learning to become comfortable talking about personal relationships helps to learn to do this outside of the group setting.

Group Therapy: Therapeutic Factors

Imitative Behavior
Use of models in the group e.g., explicit: how it is done; implicit: how to do it. Building a consensus: when a group member brings up something they need to discuss and is cutoff or disrupted by another group member:

Ask the rest of the group (his/her peers) if this person (disruptee) is wrong or what they want to do, Use of the Socratic method: what do you (rest of the group) think about this situation? Be careful not to hide behind the group decision if it is the wrong decision (aka: consensus building).

Group Therapy: Therapeutic Factors

The development of gratifying interpersonal relationships

The group is a social microcosm (i.e. a miniaturized representation of each members social universe), a place to learn lessons and then generalize them to the outside world (they may have problems relating to other people that are contributing to their psychopathologies). Through feedback from other group members and selfobservation the members become aware of significant aspects of their interpersonal behavior: their strengths, limitations, their interpersonal distortions and the maladaptive behavior that elicits unwanted responses from other people.

Group Therapy: Therapeutic Factors

The development of gratifying interpersonal relationships

Interpersonal sequence:

Display of pathology (behavior) Feedback from other members & self observation result in:
Better witnesses of his/her own behavior Appreciate the impact of this behavior on: Feelings of other people Opinions others have of them Opinions he/she has of himself/herself

Group Therapy: Therapeutic Factors

Gaining Insight
Insight occurs when one discovers something important about oneself about ones behavior, ones motivation, or ones unconscious.

Results: individual realizes they have the power to change their behavior.

Group Therapy: Therapeutic Factors

Group Cohesiveness
The most common factor (this is the same as the therapeutic relationship)

Cohesiveness broadly defined:

The result of all the forces acting for all the members to remain in the group, or more simply: It refers to the condition of members feeling warmth and comfort in the group, feeling they belong, valuing the group and feeling, in turn, that they are valued and unconditionally accepted and supported by other members. In conditions of acceptance and understanding, members will be more inclined to express and explore themselves to become aware of and integrate hitherto unaccepted aspects of self, and to relate more deeply to others.

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Group Therapy: Therapeutic Factors

Catharsis
A strong emotional reaction often due to sudden insight of the nature and causes of deeply hidden painful memories. An episode of emotional release and discharge of tension associated with bringing into the conscious recollection previously repressed of unpleasant experiences.

Group Therapy: Therapeutic Factors

Existential Factors
Recognizing that life is at times unfair and unjust.

Recognizing that ultimately there is no escape from some of lifes pain and from death.
Recognizing that no matter how close we get to other people, we must still face life alone.

Group Therapy: Therapeutic Factors

Existential Factors cont

Facing the basic issues of our life and death, and thus living our lives more honestly and being less caught up in trivialities. Learning that we must take ultimate responsibility for the way we live our lives no matter how much guidance and support we receive from others.

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

Group Therapy: Basics

Ideally, no more than 7 to 8 in each group

Decide if you want an open group or a closed group Sometimes you must sacrifice one member for the good of the group It is the group that is the agent of change (this is the norm to strive for)

Group Therapy: Basics

Your group will have its own culture with norms, expectations, behaviors and mores.
You build the outcome you want. Norms of your culture:
active involvement in the group, nonjudgmental acceptance of others, extensive self disclosure, dissatisfaction with present modes of behavior, desire for self-understanding, and eagerness for change.

Group Therapy: Basics

Safety you can say what you want without ridicule, harassment, or being looked down upon.
Respect of member to member. **Attendance. Paying Attention. Food and drinks maybe not is best (when these are present serious conversations rarely take place = not conducive to therapeutic goals).

Problem Severity

Recent statistics show 15% of both sexes aged 65-years and older suffer with clinically relevant depressive symptoms
19.6% of both sexes aged 85-years and older suffer with same symptoms
(Federal Interagency Forum on Aging-Related Statistics. 2006. Older Americans Update 2006: Key Indicators of Well-Being. Pp. 27)

Behavioral Activation Techniques for Depression

A parsimonious, multidimensional holistic approach to treating depression.

Easily adaptable to a variety of practical uses. Behavioral techniques concentrate on:

Increasing positive reinforcement Reducing or undermining punishment from the environment Activation is the direct target for change

Definition

Behavioral activation techniques involve the following:

Identification of individualized target behaviors, goals and rewards that serve to reinforce nondepressive or healthy behavior Increase exposure to positive consequences of healthy behavior thereby increasing likely reoccurrence of such behavior and reducing likelihood of future depressed behavior

Adapted from Lejuez et al. (2001), p. 257

A Good Research Model

Behavioral Activation Group Therapy in Public Mental Health Settings: A Pilot Investigation. Porter, J., Spates, C., & Smitham, S. (2004). Participants met criteria for DSM-IV diagnosis for major depressive disorder.
Exclusion Criteria:
diagnosis of bipolar or psychotic sub-types of depression, panic disorder, current alcohol abuse, past or present schizophrenia, schizophreniform disorder, organic brain syndrome and mental retardation.

A Good Research Model

Treatment modality:
BAGT (Behavioral activation group therapy) sessions:
Group format, 95-minute sessions, weekly for 10 weeks 2 Cotherapists Group size 6 10 participants Mean age = 44-yrs old BDI-II administered at every therapy session to monitor progress on a weekly basis

A Good Research Model

Treatment modality:
BAGT therapy sessions In The Beginning:

Explain and define the therapeutic agent of positive reinforcement and its importance. Explain the use of the forms utilized within the treatment. Explain the importance of homework on the clients part. Explain the importance of not trying to change the cognition of the client. Explain the importance of the client picking out activities that he/she enjoys and not being directed by the facilitator. To show the emphasis on this modality is on the identification of behaviors and activities that provide the client with pleasure and interest that is currently missing from his/her life.

A Good Research Model

Treatment modality:
BAGT therapy sessions - in the beginning cont:

Obtain a baseline from which to measure progress i.e., the Geriatric Depression Scale (is in the public domain) when working with individuals aged 55 years and older (you do not have to use the BDIII with older adults, the GDS is much more efficacious).

A Good Research Model

Treatment modality:
BAGT therapy sessions cont:

Cotherapists/cofacilitator (you) should review BDIII scores (GDS or Geriatric Depression Scale is

better for older adults and one can switch between short form and long form to combat practice effects, may also use the CUDOS) at
Forms are in your handouts in the back as well as scoring instructions.

beginning of each session to monitor progress.

A Good Research Model

Treatment modality:
BAGT therapy sessions - cont:

Group discussions focused on BA principles

To explain and define the therapeutic agent of positive reinforcement and its importance. BA is based on the premise that increased activity (i.e., activation) and the resulting contact with positive consequences is sufficient for the reduction of depressive symptoms and the subsequent increase of positive thoughts and feelings.
(Hopko et. al. (2003). A brief behavioral activation treatment for depression: A randomized trial within an inpatient psychiatric hospital. Behavior Modification, 27(4), 458-469.)

A Good Research Model

Treatment modality:
BAGT therapy sessions - cont:

Soliciting group member disclosure

Involve members to talk about activities they have not done and why e.g., too hard, too depressed, etc.

Planning & evaluating interventions

This is the time to review individuals chosen activities e.g., were they too hard?, not feasible, etc (try to monitor this at the very beginning when they are choosing activities to avoid upset. In other words, they should not try to reach for the moon make sure activities are easy enough to be accomplished.

Providing feedback to group members.

The BATD Manual for Group Therapy

Porter, J., Spates, C. R., & Smitham, S. (2004). Behavioral activation group therapy in public mental health settings: A pilot investigation. Professional Psychology: Research and Practice. 35(3), 297-301. Email: jeffreyporter@yahoo.com for BAGT manuals (both Therapist manual and client workbook). It is fundamentally important for you to obtain this manual.

The BATD Manual in its original form

A Brief Behavioral Activation Treatment for Depression: Treatment Manual. Lejuez, C., Hopko, D., & Hopko, S. (2001)
Excellent, easily implemented structured treatment manual useful for individual treatment and modifiable to group modality. Treatment manual Can be downloaded from: http://web.utk.edu/~dhopko/BATDmanual.pdf Again, of extreme importance to obtain this manual so that you have a good understanding

Treatment Techniques & The Forms

Orientation to therapy
Daily Activity Record
Establish baseline

Instillation of hope & explanation of how therapy works

Functional Assessment Life Activities Checklist Life Areas Assessment Behavior Contract Activity Hierarchy

Establish pattern of activity for previous 7 days

Treatment Techniques & The Forms

Activity Identification Ranking Rewards List Weekly Behavioral Checkout Master Activity Log Activity Graph Depressive Symptom Severity Graph

Types of Assessment

Therapist/Facilitator-administered assessments
Interview to determine suitability for group membership (see previous criteria i.e., exclusion criteria). Mental Health Assessment presence of depressive symptomology (see functional assessment)

Types of Assessment Cont.

Self-report measures to establish baseline and/or suitability for group membership (i.e., MMSE and/or SLUMS)
Beck Depression Inventory (BDI-II) Clinically Useful Depression Outcome Scale (CUDOS; available online), or Revised Hamilton Rating Scale for Depression (RHRSD) Geriatric Depression Scale (GDS) Mini Mental Status Exam (MMSE) and/or St. Louis University Mental Status Exam (SLUMS; available online)

Overview of Session Interventions: Functional Assessment

Purpose:
Establish daily activity/routine
To assess which activities in the clients life provide a sense of pleasure and/or mastery. Client keeps a daily activity log of activities. Teach the client the role of self-defeating behavior and Aversive Environments in Negative Moods.

To help the client to understand the relationship between his/her behavior and moods and between the environment and moods. This helps the client to understand how he/she can make meaningful changes to improve moods.

Session Interventions Overview cont: Mastery and Pleasure Ratings of Activities

Purpose:

To assess which activities in the clients life provide a sense of pleasure and/or mastery. Client keeps a daily activity log of activities and rates the degree of pleasure/mastery (0-5) experienced after completing the activity.

Later in the therapy the client selects those activities rating high on either side of the scale to increase via homework assignments. Goal: for the client to schedule activities during the day so that there is some sense of structure and control on the part of the client. This also helps the client to identify what he/she is doing and to realize that he/she is doing nothing.

Adapted from Behavioral Activation Group therapy; therapist manual by Porter, J. & Spates, R. (2004)

Session Interventions Overview cont: 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 client is acting in ways that are likely to make the depression worse (i.e., selfdefeating behaviors). Also gives the therapist an idea of the clients interests.

Ask the client to report on what he/she did at specific times during the day.

Adapted from Behavioral Activation Group therapy; therapist manual by Porter, J. & Spates, R. (2004).

Session Interventions Overview cont: Symptom Reports from Depressive Measure (GDS)

Purpose:
To understand what symptoms of depression the client is experiencing so that the therapist can choose appropriate targets for intervention.

Look over the measure at the beginning of the session and focus primarily on strong behavioral and mood symptoms if they are present.

Adapted from Behavioral Activation Group therapy; therapist manual by Porter, J. & Spates, R. (2004).

Session Interventions Overview Cont: Daily Activity Schedule Review

Purpose:
To assess the type and quantity of activities to better understand the clients routines and regular activities. This helps the therapist to better understand why the person is receiving little pleasure from life.

Introduce the Daily Activity Schedule to the group members during a group and explain that it can be very valuable to keep a record of ones activities throughout the day so that suggestions for changes in behavior, based on this information, can be made.

Adapted from Behavioral Activation Group therapy; therapist manual by Porter, J. & Spates, R. (2004).

Session Interventions Overview Cont: Assessment of In-Session Behavior

Purpose:

To observe first-hand both the depressive behaviors, as well as the healthy behaviors, that the client 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 the environment, behavior and its consequences.

Observe the clients behavior in terms of typical symptoms of depression as well as in terms of generally unhealthy behavior. Observe the clients 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.

Adapted from Behavioral Activation Group therapy; therapist manual by Porter, J. & Spates,

Session Interventions Overview Cont: Assigning Activities to Increase Sense of Mastery or Pleasure Purpose:
To active the client in such a way that he/she feels more effective in his/her environment and consequently receives more pleasure from activities.

Activities that are likely to improve negative aspects of the environment or ones that were previously (before the depression) reinforcing.

Session Interventions Overview Cont: Teach Client Role of SelfDefeating Behavior & Aversive Environments in Negative Moods

Purpose:

To help the client to understand the relationship between his/her behavior and moods and between the environment and moods. This helps the client understand how he/she can make meaningful changes to improve moods.

It is important to focus on what the client actually does (active behavior) rather than on what he/she failed to do.
You must explain the ABC model to the client

A is the antecedent to the behavior. This is what was occurring just prior to the behavior that set up the behavior to occur. B is the behavior of interest. This is an observable behavior on the part of the client. C is the consequences resulting from acting out the behavior. Does not imply something bad. All behaviors have some consequence, whether good or bad.

Session Interventions Overview Cont: Encouraging An Active, Rather than a Passive Approach in Specific Situations Purpose:
To focus the client on the function of a behavior in terms of being productive or destructive.

Active behaviors are those that:

Serve to create pleasurable or meaningful experiences. Serve to ameliorate aversive or unpleasant experiences.

Passive behaviors are those that:

Produce aversive or unpleasant experiences. Fail to ameliorate aversive or unpleasant experiences.

Session Interventions Overview Cont: Graded Task Assignment: Progressive Assignment of Tasks of Increasing Difficulty

Purpose:
To ensure success and combat the clients feelings of being overwhelmed. Make problems manageable and the assignment doable.

Problem definition: useful definition of the problem in behavioral terms. Be very concrete and specific. Stepwise assignment of tasks from simpler to more complex. Immediate and direct observation by the client that he/she is successful in reaching a specific objective. If the client does not know whether or not he/she has completed a goal, then the definition of the goal needs to be more concrete and specific.

Session Interventions Overview Cont: Graded Task Assignment: Progressive Assignment of Tasks of Increasing Difficulty Purpose - cont:
Ventilation of doubts, reactions and belittling of achievement. Celebration of achievements. It is important that the client recognizes and be recognized (particularly early in therapy) for successful completion of goals.

Session Interventions Overview Cont: Mental Rehearsal of Assigned Tasks or Activities

Purpose:
To anticipate pitfalls that might occur while completing certain activities.

Talk through the steps of a planned activity with the client, probing when necessary and helping the client to problem solve when problems arise.

Session Interventions Overview Cont: Examining Alternative Behaviors in Different Situations

Purpose:
To help the client learn from experiences how to better handle problem situations (i.e., how to better cope).

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.

Session Interventions Overview Cont: Role-playing Behavioral Assignments that Involve Other People Purpose:
To practice certain behaviors in a controlled and safe environment before using them in a real life situation.****

Identify a task or skill to practice and construct the necessary situation using the members of the group as participants.

***Extremely beneficial intervention in the group setting.

Session Interventions Overview Cont: Examining Potential Outcomes of Different Behaviors

Purpose:

To help the client process possible outcomes of different behaviors before they occur. This assists the client in making a decision in a situation when it does occur. It also gets the client in the mindset of thinking about the effects of his/her behavior so that better decisions can be made.

Talk through a particular situation with the client and ask questions to help the client explore the possible effects of engaging in certain behaviors. Important to explore best case and worst-case outcomes so that the client is prepared for either extreme if it occurs.

Session Interventions Overview Cont: Managing Situational Contingencies to Maximize 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.

Talk about the homework assignment and possible pitfalls. Help the client problem solve by creating a homework assignment with a high probability of success.

Session Interventions Overview Cont: Distraction from Problems or Unpleasant Events

Purpose:
To shift a clients focus from some problem or unpleasant experience to something more productive and healthy. Often times depressed clients perseverate on a problem and distracting them from the problem helps them to loosen their stronghold on the thought.

Assist the client 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.

Session Interventions Overview Cont: Avoiding or Limiting Exposure to Unpleasant Situations or People

Purpose:
To prevent self-defeating behavior that sets up a person to be hurt. The goal is to teach the client to avoid situations that are likely to lead to painful or unpleasant experiences.

Teach the person specific coping skills for getting out of unpleasant situations.

Session Interventions Overview Cont: Behavioral Stopping Not Acting in Self-damaging Ways

Purpose:
To teach the client alternative behaviors to those that are self-damaging.

The therapist helps the client identify behaviors that, while still allowing the client to get his/her needs met, are healthier (i.e., less self-damaging).

Session Interventions Overview Cont: Direct Behavioral Instruction by the Therapist

Purpose:
To teach the client skills that he/she is deficient in. This allows a demonstration and practice of these skills in a safe setting.

A particular skill can be identified and practiced by the client. Other group members can participate and the therapist is present to stop action if necessary and make suggestions and give feedback in order to

Session Interventions Overview Cont: Sensate Focus

Purpose:
To help the client overcome sexual arousal or performance problems.

This is achieved by shifting the clients focus from some sexual act to something less critical. This typically involves asking the client to focus on non-sexual touching with his/her 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.

Session Interventions Overview Cont: Teaching the Group to Give Themselves Rewards for Behavioral Achievements

Purpose:

To increase the amount of pleasure in the clients life by having him/her reward themselves for accomplishments. This is particularly important when the clients 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.

Help the client to define tasks in terms that will allow him/her to easily determine whether a task has been completed or not. Then, help the client identify things that he/she can provide that are likely to give some pleasure.

Session Interventions Overview Cont: Dealing with Specific Behavioral Problems (e.g., sleep)

Purpose:
To address problems involving overt behaviors.

Do a functional analysis of the behavior and determine what changes can be reasonably made that are likely to alleviate the problem behavior.

Session Interventions Overview Cont: Training to Overcome Skills Deficits (e.g., assertion, communication) Purpose:
To teach skills that the client is deficient in which are contributing to the depression. Often time these are basic communication skills.

The therapist can talk about certain skills and what makes them effective and the therapist can model these skills for the group.

Session 1

Welcome group members and express optimism about their decision to attend
Briefly state ground rules common to all groups

Confidentiality no one outside of group should be mentioned by name to anyone outside of the group (may discuss experiences with family/friends but are prohibited from discussing other group members experiences or identity). No acting out: if emotions get out of control, the group member should discuss his/her feelings or leave the room temporarily if he/she cannot control themselves.

Session 1
Ground Rules cont:
No interruptions: every member deserves the same respect and everyone will have a chance to participate. Participation: everyone is expected to participate. Homework: between sessions activities are expected. Co-therapist dialogue: comment on co-therapist dialogue so that when it is utilized the process does not confuse members of the group.

Session 1
Ground Rules cont:

Describe some of the benefits of group therapy:

Learn from others who have similar experiences. Opportunity to interact with others in a safe environment. Peer support and feedback.

Introduction of group members:

Name, personal information. What do you want to be different at the end of this group experience?

Introduce the basics (theory) of behavioral activation for depression (i.e., how it works and its efficacy).

Session 1

Basics Cont:
Depression is characterized by feeling terrible, losing interest or pleasure in most activities, change in weight and eating habits, change in sleep pattern, feeling exhausted all the time, feeling worthless or guilty much of the time, difficulty concentrating, and thoughts of death or dying. Depression occurs when changes in a persons life occur that reduce the number of pleasurable & meaningful experiences. This reduction causes people to experience some of the symptoms of depression (the blues). Once the person becomes depressed, his/her way of responding to the depression often make the depression worse. For example, instead of working to restore the level of pleasurable experiences, the person often withdraws and further reduces pleasurable experiences.

Session 1

Basics Cont:
A final factor is that not all people are equally vulnerable to depression. What causes one person to become depressed may not cause another person to become depressed. Whether or not a person becomes depressed is determined by his/her genes, his/her history of experiences, and his/her loss of physical functioning including chronic illnesses/diseases.

The goal of behavioral activation is to assist the client in making changes in behavior that will maximize the opportunities for pleasurable or meaningful experiences.

Session 1

The goal of behavioral activation cont

This is accomplished by learning to cope differently in a way that increases these opportunities. Also, group members are helped to change parts of his/her environment so that it will become more pleasurable. Finally, the group member will learn to nip future episodes in the bud by coping better with adversity, thereby making him/herself less vulnerable to depression.

Session 1
The goal of behavioral activation cont
It is important to communicate to the group members that while behavioral activation has been shown to be effective in reducing depression, there is no magic change that takes place. Group members should expect difficulties in completing homework assignments, particularly early in therapy. Depression can be relieved through continued use of behavioral activation over a period of several weeks.

Role of the therapists: The therapist is a personal trainer, their job is to help clients identify what is going wrong in their lives and guide them in actions that will help improve their life situations, and thereby make them less depressed.

Session 1

Go-Around:
Each member gets 5-10 minutes to tell his/her story about why he/she is in the group and what his/her life has been like recently. Therapists take turns processing information for group member and assist them by using openended probes, clarifications, and empathetic responses. After each group member finishes, allow for vicarious sharing (not advice) from other group members.

Session 1

Co-therapist dialogue to introduce concept of homework:

Introduce activity schedules and explain rationale for them and ask all group members to keep one for the next weeks session. Introduce workbooks for group members. Explain the purpose of having each group member become familiar with the different treatment techniques. Ask each group member to read his/her workbook and be able to describe how and why the technique is used to the group during the next session. Spend a few minutes with each group member contracting for one additional homework assignment that will begin the activation process.

Session 1

Closure:
Thank all members for their participation and acknowledge the difficulty of sharing personal feelings in a group. Be encouraging about the first sessions progress. Explain that in future sessions, group members will be asked for more feedback to peers.

Session 1

Daily Activity Record Homework

Session 1

Begin collaborative assessment of Life Activities Checklist - Homework

to identify enjoyable activities and activities of possible future interest

Session 2

Warm up exercise (progressive muscle relaxation, imagery, etc). Other therapist reviews clients GDS (Geriatric Depression Scale).
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.

Session 2

Go-Around:
Each group members gets approx. 5 minutes to talk about the past weeks experiences and the therapists should assist by reflecting, probing and clarifying with the mindset of identifying behaviors to target for intervening upon with a balance between in-session interventions and homework assignments At this early stage of treatment, the therapists will be the primary resources for intervention for the group members. Therapists should deflect duties to group members when appropriate and when there is good reason to believe that the group member can handle the task.

Session 2

Closure:
Firm up homework assignments with each group member and get a verbal commitment of homework from each group member.

Session 2

Create formalized agreements, behavior contracts, outlining specific ways family/friends can help client to achieve his/her goals
Homework

Session 3 - 6

Warm-up exercise Other therapists review GDSs Go-around

Each group member reports on homework experiences. In-session interventions are utilized more often as treatment progresses and more information about each group member is obtained. Increase homework assignments in terms of assignments that may be more difficult and have more potential antidepressant value.

Session 3 - 6

Go-around - cont
As treatment progresses, the therapists should be deflecting increasing amounts of responsibility to the group members and should be functioning as facilitators more than interventionists. This involves having clients take on more responsibility for their own treatment as well as for helping other group members with treatment.

Closure
Firm up homework assignments.

Sessions 3-6

Identify potential activities, Life Areas Assessment homework

Sessions 3-6
client determines activities he/she would like to target

Family Relationships (e.g., what type of

brother/sister, father/mother does he/she want to be? What qualities are important to the client in their relationship with various family members?)

Social Relationships (e.g., what would an ideal

friendship be like to the client? What areas could be improved in his/her relationships with friends?)

Sessions 3-6

Intimate Relationships (e.g., what would

constitute clients role in an intimate relationship? Is he/she currently involved in this type of relationship, or would he/she like to be?)

Education/Training (e.g., would client like to

pursue further education or receive specialized training? What would he/she like to learn more about?)

Employment/Career (e.g., what type of work

does he/she like to do? What kind of worker would he/she like to be?)

Sessions 3-6

Hobbies/Recreation (e.g., are there any

special interests client would like to pursue, or new activities he/she would like to experience?)

Volunteer Work/Charity/Political Activities

(e.g., what contribution would client like to make to the larger community?)

Physical/Health Issues (e.g., does client wish

to improve his/her diet, sleep, exercise, etc.?)

Sessions 3-6

Spirituality (e.g., what, if anything, does

spirituality mean to him/her? Is client satisfied with this area of his/her life?)

Psychological/Emotional Issues (e.g., what are

clients goals for this treatment? Are there other issues besides depression that he/she would like to explore?)

Sessions 3 6 Cont.

VIP: Activities must be observable by others and measurable

A general goal such as thinking more positively is NOT appropriate Select activities of varying degrees of difficulty and only a few should be the more difficult long-term projects Important to select activities across a wide range of life areas - from social contact to the completion of life responsibilities This is where the data collected on the Life Activities Checklist can facilitate choice of activities to work on

Sessions 3 6 Cont.

To improve likelihood of initial success and ease transition into the program, three of the activities should be taken from those activities client is already completing on a regular basis (see Daily Activity Record from initial homework)
In total, client should select 15 activities personalized to his/her own needs and desires as much as possible (collaborative effort)

Sessions 3 6 Cont.

The initial 15 activities chosen should be listed on the Activity Identification Ranking Sheet

Add activities to this sheet in no particular order Next rank them from 1 (least difficult) to 15 (most difficult) Homework

Sessions 3 6 Cont.

Next, create the Activity Hierarchy

After construction of ranked list of activities, assign the first 3 activities to Level 1 the 4th through 6th activities to Level 2 the 7th through 9th activities to Level 3 the 10th through 12th activities to Level 4 the 13th through 15th activities to Level 5.
*Remember Level 1 activities should include those the client is already engaging in to some degree (see Daily Activity Record) Homework

Sessions 3 - End

Behavioral Checkout Week ___

Homework

Sessions 3 - End

Behavioral Checkout Week ____

This form records progress on a daily basis Similar to Master Activity Log, write the frequency and duration goals in the appropriate columns for each activity selected that week Each day client is to circle Y if he/she completed the activity and N if he/she did not Once desired frequency and duration goal is completed for the week, client is to circle G as well as Y or N

Circling G acknowledges that regardless of whether he/she engaged in that activity on that day, he/she met their goal for the week

Sessions 3 - End

Behavioral Checkout Week ____ - cont

After the given week, the data should be transferred to the Master Activity Log and therapist/counselor should record the number of times the client met both frequency and duration goals for a particular activity in the Do column If client met or exceeded his/her goals the activity may be increased (frequency/duration) for the following week (assuming they have not met the ideal goal)

Use professional judgment to determine if goal was too high or unreasonable Once same weekly goal has been met 3 weeks in a row, the activity will be considered mastered

Sessions 3 - End

Behavioral Checkout Week ____ - cont

After given activity has been mastered it is no longer charted each week, instead, may simply write M under goal and Do on the Master Activity Log Use the mastery of an activity as a cue to add a new activity to be charted. Always be aware of moving too fast for the client should be based on individual circumstances

(see samples in your packet for the way completed forms appear)

Sessions 3 - End

Master Activity Log

Therapists work

Sessions 3 - End

Master Activity Log

This is where weekly activities are planned In the columns next to the activity the following should be listed:
Number of times he/she would eventually like to complete the activity in a 1-week period and Duration of the activity (may use UF to signify the activity will continue until finished regardless of the duration) Number of activities for any one week should range from 3 to 5 activities per week

Sessions 3 - End

Master Activity Log cont

Extremely important for counselor and client to determine weekly goal selection collaboratively so as to prevent client from becoming overwhelmed by challenging themselves too much too quickly For each activity selected for a given week, write down the frequency (#) and duration (time) goals in the appropriate columns

Sessions 3 - End

Rewarding Progress

- Homework
VIP that client reward self for achieving weekly goals Rewards should be attainable and within the clients control Pick items that are enticing enough to motivate client to work toward attaining goals and, that he/she will engage in only if goal has been completed (consider Life Activities Checklist for reward ideas)

Session 7 - 9

Warm-up exercise Go-around

Group members report on their own significant GDS items. Group members report on their homework experiences. In-session interventions and homework assignments become increasingly more substantial. Group members are taking the majority of the responsibility for their own treatment and the treatment of other group members.

Session 7 - 9

Relapse Prevention

Provide rationale for relapse planning. Begin reviewing the types of experiences each person has had during treatment that have been successful in relieving the depression. Emphasize the role that the client has played in that he/she has done all of the work and that the therapists and group members have only assisted.

Closure

Firm up homework assignments.

Last Session Agenda

Warm-up exercise Brief Go-around

Group members share any meaningful experiences they have had during the past week.

Relapse Prevention
Therapists spend time with each group member identifying significant experiences that have occurred during treatment with an emphasis on those types of homework experiences that have been particularly effective with each individual. Each individual is encouraged to use the knowledge and skills that he/she has gained from therapy to manage difficult situations in the future and defend against future depression.

Last Session Agenda

Closure
Therapists summarize the gains that have been made by the group members and highlight some of the most meaningful examples of Behavioral Activation success.

Sessions 3 - End

Depressive Symptom Severity Graph

Therapists work

Sessions 3 - End

Activity Graph
Therapists Work

References

Cullen, J., Spates, C., Pagoto, S., & Doran, N. (2006). Behavioral activation treatment for major depressive disorder: A pilot investigation. The Behavior Analyst Today, 7(1), 151-166.
Federal Interagency Forum on Aging-Related Statistics. (2006, May). Older Americans Update 2006: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics, Washington, DC: U.S. GPO. Hopko, D., Lejuez, C., LePage, J., Hopko, S., & McNeil, D.
(2003). A brief behavioral activation treatment for depression: A randomized pilot trial within an inpatient psychiatric hospital. Behavior Modification, 27(4), 458-469.

References

Lejuez, C., Hopko, D., & Hopko, S. (2001). A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification, 25(2), 255-286. (Treatment manual available online at: http://web.utk.edu/~dhopko /BATD manual.pdf)

Porter, J., Spates, C. R., & Smitham, S. (2004). Behavioral activation group therapy in public mental health settings: A pilot investigation. Professional Psychology: Research and Practice. 35(3), 297-301. Email: jeffreyporter @yahoo.com for BAGT manuals.

References

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.